Quote Opening - Chippewa Avenue Emergency Repairs Proj No. 116-083F - HRP

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---44111® A4KL1 CERTIFICATE OF LIABILITY INSURANCE DATE (MMI°DIYYYY) 10/17/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED ATE THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER BYAUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditlons of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements . PRODUCER Gibson Insurance Agency, Inc. 130 S Main St, Ste 400 PO BOX 11177 NAME Stacy Christlieb PHONE (600)814-2122 FAX AID No Ex LAIC Na:(e D0)936-2122 pooRless: schristlieb@gibsonins.com INSURER(S) AFFORDING COVERAGE NAICi South Bend IN 46601-0177 INSURERA Amerisure Mut Ins Cc 23396 INSURED HRP Construction Inc. 5777 Cleveland Rd PO BOX 266 South Bend IN 46624-0266 INSURER B INSURERC: INSURERD: INSURER E: INSURERF: ------- - ViswrY IIUlnocrt: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE AD R POLICY NUMBER MMIfIJ[CiIVVYY MMIDDVrvYYV LIMITS X COMMERCIAL GENERALLIABILRY A CLAIMS -MADE X�OCCUR 0 EACH 0'URRENCE $ 1,000,000 PREMISESOEaopcun'enca $ 1, 000, DOD X XCD CPP20316441202 9/1/2016 9/1/2017 MED EXP (My one person) $ 10,000 Contractual Liability X PERSONAL d ADV IN.URY $ 1,000,000 AGGREGATE LIMIT APPLIES PER POLICY [K P LOC GEN'L GENERAL AGGPDA\TE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 OTHER A AUTOMOBILE X LIABILITY ANY AUTO AUD SULED ATDS IEAAUUTOO HIRED AUTOS X NO NNED CA20316451202 9/l/2016 9/1/2017 MBI SINGL LIMI rEe amman[ $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Par accident) $ X PROPERTY DAMAGE Per accident $ A A X UMBRELLA LIAB EXCESS LIAB X OCCUR anlMs-MADE L20316431102 NC203164211 States of is 6 NI 9/1/2016 9/1/2016 9/1/2017 9/1/2017 EACH OCCURRENCE $ 10,000 000 AGGREGATE $ 10 000 000 BED I X I RETENTION$ 0 WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERiEXECUTIVE OFFICER/MEMBER EXCLUDED LNIA (Mandatory In NH) If yes, dasaibe under DESCRIPTION OF OPERATIONS below PER OTH- X STATUTE ER $ EL EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 EL DISEASE -POLICY LIMIT $ -1,000,000 DESCRIPTION OF OPERATIONS/ LOCATIONS I VEHICLES (ACORD 101, Addl6onal Remark. Schedule, may he attached If more space Is required) Project: Chippewa Avenue at Bowman Creek Emergency Repairs Project No. 116-083F Certificate holder is additional insured with respect to general liability coverages regarding work performed by the insured. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of South Bend THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Board of Public Works ACCORDANCE WITH THE POLICY PROVISIONS. 1316 County -City Building 227 West Jefferson B1Vd AUTHORIZED REPRESENTATIVE South Bend, IN 46601 Ins Agency/STACYC (D 198B-2014 ACORD CORPORATION. All rights NwVmu AD (nrlwlu 1) 1 ne ACOHO name and logo are registered marks of ACORD INS025 (201401)