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<br />,a►coRO CERTIFICATE OF LIABILITY INSURANCE
<br />`�
<br />DATE(MMIDDIYYYY)
<br />1 12/15/2017
<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($), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />PRODUCER
<br />Gregory & Appel Insurance
<br />1402 N Capltol Suite 400
<br />Indianapolis, IN 46202
<br />C2€4TEACT
<br />AICNNo, Ext)i (317) 634-7491 WC, No):(317) 634-6629
<br />E_M €
<br />DD°1hss: Corp@gregoryappel.com
<br />INSURERS AFFORDING COVERAGE
<br />NAIC N
<br />INSURER A: ACUITY A Mutual insurance Company
<br />14184
<br />INSURED
<br />RJE Interiors, Inc.
<br />ATTN. Denny Sponsel
<br />621 East Ohio Street
<br />Indianapolis, IN 46202
<br />INSURER B: Accident Fund Insurance Company of America
<br />10166
<br />INSURERC:
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />0C111alf1m IUIIMFtFR•
<br />v THIS, IS TO~CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />INSR
<br />TYPE OF INSURANCE
<br />ADDL
<br />SUBR
<br />POLICY NUMBER
<br />POLICY EFF
<br />DO
<br />POLICY EXP
<br />b
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,000
<br />CLAIMS -MADE OCCUR
<br />Z59934
<br />1211212017
<br />121121201$
<br />DAMAGE TO RENTED
<br />PRE S Ea RENTED
<br />500,000
<br />MED EXP Ljkny one also:
<br />10,000
<br />PERSONAL& ADV INJURY
<br />$ 1,000,000
<br />GENT
<br />AGGREGATE LIMIT APPLIES PER:
<br />POLICY F JECT PRO- ❑ LOC
<br />GENERAL AGGREGATE
<br />3,000,000
<br />PRODUCTS - COMP/OP AGG
<br />S 3,000,000
<br />OTHER:
<br />A
<br />AUTOMOBILE LIABILITY
<br />Ea accciden SINGLE LIMIT
<br />$ 1,000,000
<br />BODILY INJURY Per erson
<br />$
<br />X ANYAUTD
<br />Z59934
<br />12112/2017
<br />12/12/2018
<br />BODILY INJURY Per acc dent
<br />$
<br />OWNED AUT08 ONLY AUTOS
<br />HIRED NON-OWNEp
<br />AUTOS ONLY AUTOS ONLY
<br />PROPERTY AMAGE
<br />Per..
<br />$
<br />A
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />OCCUR
<br />CLAIMS -MADE
<br />59934
<br />12/12/2017
<br />12/12/2018
<br />EACH OCCURRENCE
<br />$ 5,000,000
<br />X
<br />M
<br />AGGREGATE
<br />$ 5,000,000
<br />DED I X I RETENTION $ Q
<br />B
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS` LIABILITY
<br />ANY PROPRIETORIPARTNERIEXECUTiVE YIN
<br />OFFICERIMEMBE, EXCLUDED? NJ
<br />(Mandataryin NHj
<br />NIA
<br />CV5015849
<br />12/12/2017
<br />12/12/2018
<br />X STATUTE ERH
<br />E.L. EACH ACCIDENT
<br />500,000
<br />$
<br />E.L. DISEASE - EA EMPLOYEE
<br />500,000
<br />E.L. DISEASE - POLICY LIMIT
<br />500,000
<br />It es, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />A
<br />Errors & Omissions
<br />IZ59934
<br />12112/2017
<br />12l1212018
<br />Per Claim
<br />1,000,000
<br />A
<br />Errors & Omissions
<br />Z59934
<br />12112/2017
<br />12/12/2018
<br />Aggregate
<br />2,000,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is requtred)
<br />City of South Bend Department of Public Works are included as additional insureds as defined in policy form FIG-7274 05-13 & CG-7194 05-13 with respects to
<br />General Liability according to the terms, conditions and exclusions within the policy.
<br />^A►t^01 1 ATIl K[
<br />vin 1 lrlvr„ �
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of South Bend Department of Public Works
<br />y p
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />227 W Jefferson Blvd., Room 1316
<br />South Bend, IN 46601
<br />AUTHORIZED REPRESENTATIVE
<br />Y�JCA
<br />ACORD 25 (2016103) V 1!3tR$-XU10 AI;UKLJ UUKYUKAI IUN. mu rlgnis reserver.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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