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�,"���QD nATE (MW-DFYYYY] <br />CCERTIFICATE OF LIABILITY INSURANCE 4/25/2017 <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 pallcy(las) must have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br />this certiflcate does not center rights to the certificate holder In Ileu of such endorsemont(s), <br />PRODUCER <br />Surplus Insurance Brokers <br />P . 0. BOX .14 g <br />South Bend IN <br />4 6 624 --0� 4 9 <br />CO AC * * * <br />NAME: <br />AFCNNo' Exl : FAX Ho <br />E-MAIL <br />ADDMS$: <br />WSURERIS AFFORDINGCOVERAGE <br />NA€C# <br />_ <br />INSURER A! CAPITOL SPECIALTY INS CORM <br />10328 <br />_ <br />INSURED SOUTH BEND MEMORIAL DAY <br />PARADE <br />14985 ADAMS RD <br />INSURERR: <br />INSURERD: <br />GRANGER IN 46530 <br />INSURER E : <br />INSURERF; <br />COVERAGES CERTIFICATE NUMBER: 00087675 REVISION NUMBER: 00087897 <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDUCED BYPAID CLAIMS, <br />INSR <br />LTR <br />TYPE OF INSURANCE <br />IN <br />3 <br />POLICY NUMBER <br />IdMI�OFYYY PP <br />MMIODIYYYY <br />LIMITS <br />A <br />i <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE EX]OCCUR <br />IMPOO13001000481 <br />5/29I2p1'! <br />5/36/201! <br />.EACHOCCURR♦:NCE <br />PREMISES(Eaocrencel_ <br />3 1,000,000 <br />S 100,00Q <br />IAEDEXP(An onope[aon) <br />$ 5,000 <br />_ <br />PERSONAL& ADV INJJRY <br />$ 1,000,000 <br />GEMLAGGREGATE LIMIT AP€OESPER: <br />GENERALAGOREGATE <br />$ 2,000,000 <br />- <br />X POLICY ❑ P O LOC <br />PRODUCTS -COMPIOPACG <br />$ INCLUDED <br />$ <br />OTHER' <br />AUTOMOBILE LIAWLITY <br />COM8INEDS€N LELUdIT <br />En acgdenl <br />$ <br />BODILY INJURY (Per poison) <br />S <br />ANY AUTO <br />T UWi9ED SCHEDULED <br />AUTOS ONLY AUTOS <br />HIRED NON-OV55JED <br />AUTOS ONLY H AUTOS ONLY <br />BOD€LY II4JURY (Pet aocidont) <br />$ <br />PROPERTY€IAMAGE <br />Per accidonl <br />$ <br />i <br />UhIRRELLALIAB <br />OCCUR <br />EACH OCCURRENCE <br />; <br />AGGREGATE <br />EXCESS LIAB. <br />CLAIMS-IADC <br />_ <br />TIED RETENTION$ <br />3 <br />WORKERSCOMPENSATION <br />AND EMPLOYEW LIAB14ITY Y/N <br />ANYFROPRIETORIPARTNUVE) :CUTIVE <br />STATUTE ER <br />E.L. EACH ACCIDENT <br />4 <br />OFFICEMMEMBERD(CLULkM <br />(Mandatory In NH) <br />NIA <br />F..I..DISFASE-EAEMPLOYEE <br />—..-.__,.__._.....__.._..._ <br />$ <br />E.L. DISFASE -POLICY LIMIT <br />$ <br />IfYes, deser�h0 under <br />DESCRIPTION OF OPERATIONS be€or, <br />DESCRIPTION OF OPERAT€ONS I LOCATIONS F VEHICLES (ACORD 101, Additional Remarks Schedule, may be altae hod Irmoro space Is required) <br />SOCIAL GATHERINGS/MEETINGS <br />CITY OF SOUTH BEND <br />BOARD OF PUBLIC WORKS <br />227 W JI FFERSON BLVD <br />ROOM 1316 <br />SOUTH BEND IN 46601 <br />UTAN ULLIAI INN <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHOR€tE3 REPRESENTATIVE <br />Co] <br />ON. All rights reserved. <br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD (OMNI7 CERT004-170113l1704251120) <br />