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DATE(MNJODl1'1'YY) <br />AC"M � CERTIFICATE OF LIABILITY INSURANCE <br />3/l/2017 <br />L� <br />CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />THIS <br />DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />CERTIFICATE <br />DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <br />BELOW. THIS CERTIFICATE OF INSURANCE <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to <br />may require an endorsement. A statement on this certificate does not confer rights to the <br />the terms and conditions of the policy, certain policies <br />certificate holder in Ileu of such endomement(s). <br />N A <br />PRODUCER NAME: <br />ROCKSTROH INSURANCE AGENCY INC PHONE, (574)233-5136 ac.No(574)232-2991 <br />333 N Lafayette Blvd AooiEss:rockagcy3@outlo0k.com <br />South Bend, IN 46601-1208 INSURERIS) AFFORDING COVERAGE NAICN <br />INSURER A: Auto -Owners Insurance i <br />INSURED South Bend Cinco LLC <br />INSURER B: <br />INSURER C: <br />DBA Cinco <br />INSURERD: <br />709S. Carlisle St. <br />INSURER E: <br />South Bend, IN 46619 <br />INSURER f <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br />BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED <br />OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM <br />AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE <br />CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />EXCLUSIONS AND <br />NSR TYPE OF INSURANCE INSO Me POLICY NUMBER I MM/D�� MM/DDY� LIMITS <br />LTR OOO OOO <br />. <br />A COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 6 1 <br />CLAIMS OCCUR I PREMISES Ea occurrence I s 50 000 <br />-MADE <br />i <br />10/16/2017 MEG EXP(Any one person) S 5,000 <br />09150919 1,0001000 <br />I10/16/2016 <br />PERSONAL& ADV INJURY 15 <br />GENERAL AGGREGATE s 2 , OOO , O00 <br />GEN'L AGGREGATE LIMIT APPLIES PER: <br />PRO- �LOC PRODUCTS-COMP/OPAGG s 2,000,000 <br />A <br />POLICY JECT S <br />OTHER: i S <br />LIABILITY Ea axitlent <br />�'. <br />�AUTOMOBILE <br />BODILY INJURY (Per person) 6 <br />I ANYAUTO <br />ALL OWNED SCHEDULED BODILY INJURY (Per aocidenp , s <br />AUTOS NOWOWNED P OPER DAMA <br />Per acudent $ <br />LL HIRED AUTOS t— AUTOS i S <br />1 <br />UMBRELLA LIAR <br />OCCUR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />°+ <br />EXCESS LIAR <br />CLAIMS -MADE <br />S <br />DED RETENTION $ <br />WORKERS COMPENSATION <br />STATUTE ER <br />EL EACH ACCIDENT <br />I S <br />AND EMPLOYERS' LIABILITY <br />ANYPROMEMSERRIPARTNEF✓E%ECUTIV'c <br />Y�I <br />( <br />EL DISEASE - EA EMPLOYEE, <br />s <br />I <br />OFFICEFIMEMBER EXCWDEDi <br />(nlanaamm in Nm <br />N/A <br />E.L. DISEASE - POLICY LIMIT <br />s <br />it yes, desalbe under <br />DESCRIPTION OF OPERATIONS below <br />I <br />i <br />C DES RIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101. Additional Remarks Schedule, may ce attached rf more space 1a required) <br />Additional Insured -City of South Bend <br />I I <br />I <br />CERTIFICATE HOLDER CANCELLATION <br />Board of Public Works <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />1oar Count lit Building <br />County -City g <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />227 W. Jefferson Boulevard <br />—�—y <br />AUTHO�¢EO RR`EP'fR�'E�S�'EN�lTATQN�E�,//% <br />South Bend, Indiana 46601 <br />U iBBd-ZUI4AUUK000 1v U"IIUrv. nN nglus roam vcu. <br />ACORD25(2014101) The ACORD name and logo are registered marks of ACORD <br />