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UUMIVIL!"VIAL UIVWHI--L.� ULULAHAIIW4 <br />BUREAU INSCIRANCEXty!!i'iia; <br />'{i Cf± '' ti i> k ' r <br />.... <br />.................... ........... ..:::::'•::::':::...._ ..._ ..,._....,_.................,.......:t <br />226 Soutb East Streit • P.A. Rom 12v6r0 • Indianapolis, IN 46206-1260 <br />UMB 8602678 06 <br />12/05/2017 12/05/2018 <br />12.01 AA SiarsdEird Tir04 al the mailing address shown <br />RENEWAL BUSINESS <br />BACKSTROM, JON E 7601404 <br />LIVING STONES CHURCH <br />718 E DONNt-!YER AVE <br />5032 MIAMI ST 760 <br />SOUTH BEND IN 46614 <br />SOUTH BEND IN 46614-3232 <br />Telephone: 57 4- 2 91-3 8 4 0 <br />Business Description <br />Type of Business <br />CHURCH <br />CORPORATION <br />LIMIT OF INSURANCE <br />Policy Aggregate Lirnil $1, 000, non <br />Self -Insured retention $10, 000 <br />SOHEDULE OF UNDERLYING INSURANCE REQUIREMENTS <br />If policies providing the required "underlying insurance" indicated by W in Column A are either reduced, cancelled, <br />discontinued or non-exlstant, the named insured's minimum "retained limit" is equal to the following: <br />X <br />.x <br />General Liability <br />General Aggregate <br />$3, <br />000, <br />000 <br />Products - Completed Operations Aggregate <br />$3,000,000 <br />Personal and Advertining Injury <br />S1, <br />000, <br />gop <br />Each Occurrence <br />5I , <br />000, <br />000 <br />Auto Liability Each Accident <br />or <br />Bodily Injury Each Parson <br />'Bodily Injury Each Accident <br />Property Damage Each Accident <br />or <br />Combined Single Limit BI Liability/PD Liability <br />Uninsured! I Bodily Injury ,Each Person: <br />Underinsured Bodily Injury Each Accident: <br />Motorist Liability <br />$1,000,000 <br />$1,000,000 <br />x Employer's Liability Bodily Injury Each Accident _ Sio0, <br />Bodily Injury By Disease Policy Limit 500 00 <br />Bodily Injury By Disease Each Employee 8100, 000 <br />Forms and Endorsements Applicable to this policy. See Attached Schedule <br />TOTAL PREMIUM: $600.00 <br />Issued Date: 11/07/2017 <br />7 /9444. <br />Authorized Representative <br />22.272I293 INSURED 00093-00009 Page 1 of 1 <br />