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TRANS-3 OP ID: CH <br />AC4C7RO" CERTIFICATE OF LIABILITY INSURANCE <br />DATE03/08/2018DD <br />03/0818 <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 poilcy(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 endorsement(s). <br />PRODUCER <br />R.S. Miller & Sons, Inc. <br />P.O. Box 229 <br />CONTACT Ben Nehls <br />NAME: <br />PHONE E t,574_546-3341 arc No): 574-546-2687 <br />E-MAF <br />ADDRESS: <br />109 W. Plymouth Street <br />Bremen, IN 46506 <br />INSURER(S) AFFORDING COVERAGE <br />NAIL d <br />Ben NEWS <br />1NSURERA:Pekin Insurance Company <br />24228 <br />INSURED Transformation Industries, LLC <br />dba Greater Impact LaWneare <br />Kory Lantz <br />INSURER B <br />INSURER C <br />INSURERD: <br />615 CUSHING ST <br />South Bend, IN 46616 <br />INSURER E3: <br />INSURER P : <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 SEEN REDUCED BY PAID CLAIMS. <br />INSR <br />LTR <br />TYPE OF INSURANCEAD <br />INSD <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MM/DDIYYYY <br />POLICY EXP <br />MM/DD <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS-MADE1­91 OCCUR <br />CL0199239 <br />04/17/2018 <br />04/17/2019 <br />EACW OCCURRENCE <br />$ 1,000,00 <br />PREMISES Ea Occurrence <br />$ 100,00 <br />MED EXP (Any one parson) <br />$ 5,00 <br />PERSONAL&ADVINJURY <br />$ 1,000,00 <br />GENL AGGREGATE LIMIT APPLIES PER: <br />jEc <br />pq POLICY o ❑ LOC <br />OTHER: <br />GENERAL AGGREGATE <br />$ 2,000,00 <br />PRODUCTS - COMP/OPAGG <br />$ Included <br />$ <br />A <br />AUTOMOBILE <br />LIABILITY <br />ANY AUTO <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />�( AUTOSNON-OWNED <br />HIRED AUTOS AUTOS <br />0OP702340 <br />04/17/2018 <br />04/17/2019 <br />COMBINED SINGLE LIMIT <br />twa accident <br />$ <br />BODILY INJURY (Per person) <br />$ 11000100 <br />BODILY INJURY Per accident) <br />( <br />$ 11000,00 <br />Perracriden�AMAGE <br />$ 1,000,00 <br />5 <br />UMBRELLA LIAB <br />EXCESS LIAR <br />OCCUR <br />CLAIMS -MADE <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />DED I I RETENTION $ <br />$ <br />A <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />ANY PRoPnIETORPXCLUDE/E ECUTIVE <br />FYI <br />(Mandatory In NH) <br />If yes, describe under <br />DESCRIPTION OP OPERATIONS below <br />NIA <br />WC0010342 <br />04/17/2010 <br />04/17/2019 <br />PER TH- <br />X STATUTE ER <br />E.L.EACHACCIDENT <br />$ 500,00 <br />E.L. DISEASE - EA EMPLOYEE <br />$ 500,00 <br />E.L. DISEASE • POLICY LIMIT <br />$ 500,00 <br />I <br />_-T <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) <br />f�t•r1T1!'Y/�AYr+11�1 e�r17 <br />SOUTHBE <br />City of South Bend <br />Parks Dept, <br />321 E. Walter St. <br />South Bend, IN 46614 <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 />AUTHORIZED REPRESENTATIVE <br />Ben Nehls <br />v I%P00-ets-14 AI;UHL1 (;UHVUHATION. All rights reserved. <br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD <br />