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CENTFOR-01 KKLINE <br />CERTIFICATE OF LIABILITY INSURANCE F0ATE(MMIDDNYYY)10/29/2016 <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(ies) 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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />PRODUCER T cT <br />1st Source Insurance, Inc, PHONE FAX <br />No ; 574 271-5240 <br />6909 Grape Road Arc No, Pad : 674 271-5200 <br />Mishawaka, IN 46545 6 hLAiL__ <br />INSURED <br />Center For Hospice <br />Karl Nolderman <br />$01 Comfort Place <br />Mishawaka, IN 46645 <br />COVERAGIFR f'=10T1=1AAT1T Kit <br />.....".�,�ru�.r.. <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED <br />KtVISIUN NUM13F=R: <br />NAMED ABOVE FOR THE POLICY <br />PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH <br />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 />ILTANSR TYPEOFINSURANCE ADIX SUER PO��CYI FF PO J0 Fa(P <br />D POLICY NUMBER <br />LIMITS <br />MERCIAL GENERAL LIABILITY <br />1,000,000 <br />LAIMS-MADE DcctfR MFL0043331114 <br />EACH OCCURRENCE $ <br />DAMAGE TO RENTED <br />11/01/2016 11/0112017 <br />3 �� , rrene S <br />100,000 <br />TGEItN?'L <br />MED EXP Any one person <br />6,000 <br />PERSONAL S ADV INJU Y $ <br />1,000,000 <br />YR GATE LIMpIT APPLIES PER: <br />JECr LOCPRODUCTS-COMPIOPAGGIncluded <br />GENERRLAGGREGATE g3,000,000 <br />R: <br />A AUTOMOBILE LIABILITY <br />COMBINED SINGLE LIMIT <br />1,000,000 <br />ANY AUTO MFL0043331114 11/01/2016 11/01/2017 <br />SCHEDULED <br />AUTOS <br />gODILYIN URY Per ers n $ <br />ONLY <br />ER�p UpTNOpSyy� pp <br />AtfTOS ONLY AUTOS ON Y <br />rx <br />BR�ODILYMJURY Peraccldent $ <br />AMAGE <br />Per aecit <br />l $ <br />$ <br />UMSRELLALIAS OCCUR <br />EACH OCCURRENCE S <br />EXCESSUAB CIAIMS-MADE <br />DEO RETENTION$ <br />ATE S <br />WORRIERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />OTH- <br />ANYPROPRIErOR1PARINERlEXECUTIVE YIN <br />MFe datorYIM? I EXC UOE09 NIA <br />TU TE <br />ACCII g <br />If yyes des cn'be undo, <br />DE tiR1PTION OF OPERATIONS below <br />- EA EMPLOYE <br />ASE -POLICY LIMIT $ <br />DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, May he attached irmore space is required) <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />City of South Bend, Indiana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />227 W. Jeferson Blvd ACCORDANCE WITH THE POLICY PROVISIONS. <br />South Send, IN 46601 <br />AUTHORIZED REPRESENTATIVE <br />ACORD 26 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />