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TRANS-3 OP ID: CH <br />A9_'L "J?6 <br />16-�CERTIFICATE OF LIABILITY INSURANCE <br />DATE(MWDD/YYYY) <br />04/27/2017 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED <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 />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsements . <br />PRODUCER <br />CONTACTNAMEi Ben Nehls <br />R.S. Miller & Sons, Inc. <br />P.O. Box 229 <br />PHONE--- ---- - FAX <br />-(ArC No. Exl ; 574-546-3341 _ _A/( C, No); 574.546-2687 <br />109 W. Plymouth Street <br />E-MAIL <br />Bremen, IN 4t3506 <br />-ADDRESS; <br />Ben Nehls <br />INSURERS) AFFORDING COVERAGE NAIC 11 <br />INSURERA Pekin Insurance Company ,24228 <br />INSURED Transformation Industries, LLC <br />INSURER B <br />dba Greater Impact Lawncare <br />- -__ ..._--...._ .. .._ _.-- .__ ..____ _ _. -1 _ - <br />Kory Lantz <br />INSURER C , <br />------------------------...__...._....... _ _ -- --— <br />615 GUSHING ST <br />INSURERD: <br />INSURERE: <br />South Bend, IN46616 <br />INSURER F <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />--._._..............._.....-.. <br />LTR <br />TYPE OF INSURANCE <br />DDL <br />INSD <br />SUER <br />WVD <br />__.._ <br />POLICY NUMBER <br />POLICY EFF <br />MWDD/YYYY <br />POLICY EXP <br />MWDDlYYY <br />LIMITS <br />A <br />X <br />i COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />$ 1,000,000 <br />CLAIMS -MADE U OCCUR <br />I <br />CL0199239 <br />04/17/2017 <br />04/17/2018 <br />-DAMAGETO RENTED _ ..- - <br />PREMISES Ea occurrence <br />.-_._ __... __._. ---- <br />S 100,000 <br />MED EXP (Anyone person) <br />S 5,000 <br />, <br />PERSONAL & ADV INJURY <br />S 1,000,000 <br />GENERAL AGGREGATE <br />$ 2,000,000 <br />GEN'L <br />AGGREGATE LIMIT APPLIES PER: <br />PRODUCTS -COMPIOPAGO <br />S 2,000,000 <br />X <br />POLICY �� PRO LOG <br />JECT <br />OTHER: <br />AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT <br />;Ea accident)—.. . <br />S <br />BODILY INJURY (Per person) <br />S 1,000,000 <br />A <br />ANY AUTO <br />i <br />�00OP702340 <br />04/17/2017 <br />04/17/2018 <br />ALL OWNED I X SCHEDULED <br />I <br />BODILY INJURY (Per accident) <br />S 11,000,000 <br />AUTOS I AUTOS <br />X NON -OWNED <br />j <br />-- <br />PROPERTY DAMAGE <br />Par accident)_--_..-_.- <br />-- - - .,_._.,.-.. <br />g j 000 00 <br />' ' _ <br />WIRED AUTOS AUTOS <br />S <br />I <br />I <br />! <br />- <br />UMBRELLA LIAB <br />OCCUR <br />EACH OCCURRENCE <br />- - ---- - <br />S - - _ . .. <br />EXCESS LIAB <br />CLAIMS -MADE <br />AGGREGATE--.. _.. <br />S -- --- - <br />DEO I RETENTIONS <br />S <br />WORKERS COMPENSATION <br />X STATUTE ER <br />A Ii <br />AND EMPLOYERS' LIABILITY <br />ANY PROPRIETORIPARTNER/EXECUTIVE YINN <br />EXCLUDED? <br />1 A <br />WC0010342 <br />04/17/2017 <br />04/17/2018 <br />_ <br />E.L. EACH ACCIDENT <br />_ <br />S 500,000 <br />E.L. DISEASE EA EMPLOYE <br />.............._.._. <br />S 500,000 <br />,--------- — ---. <br />1 <br />OFFICER/MEMBER <br />(Mandatory €n NH) <br />E <br />I <br />II y©s, describe under <br />DE5CRtPTION OF OPERATIONS below <br />--------------- <br />E.L. DISEASE - POLICY LIMIT <br />5 500,000 <br />E <br />E <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space Is required) <br />r'l=r1TIFIr_ATF HOLDER CANCELLATION <br />SOUTHBE <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 13E CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS, <br />City of South Bend <br />Parks Dept. <br />321 E. Walter St. <br />AUTHORIZED REPRESENTATIVE <br />Ben Nehis <br />South Bend, IN 46614 <br />01988-2014 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD <br />