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E (MM/DDIYYYY)D
<br />CERTIFICATE OF LIABILITY INSURANCE AT3/1/2018
<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 />3ELOW. 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 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 CONTACT
<br />The DeHayes Group n1HONE „Karen Wallace FAX
<br />5150 West Jefferson Boulevard lAtc .14.1z,,15ty, 260
<br />Fort Wayne IN 46804,poEMAIL REss, kaleNlwdehayes.com
<br />INSURED ORTMDRI-01
<br />Ortman Drilling, Inc.
<br />241 North 300 West
<br />Kokomo IN 46901-3984
<br />D:
<br />E:
<br />!_AFFORDING
<br />and Casual
<br />COVERAGES CERTIFICATE NUMBER: 1586676728 REVISION NUMBER:
<br />86
<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 ICE 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 />INTRR TYPE OF INS ANS L w VD POLICY NUMBER
<br />INSURANCE
<br />..
<br />POLICY EFF POLICI EXP
<br />- MMIDOII (Y� MMIOD/YYYY LIMITS
<br />A X COMMERCIAL GENER11 AL LIABILITY 5X0 41 1817
<br />.
<br />3/1/2018 3/1/2019 EACH OCCURRENCE $ 1,000,000
<br />CLAIMS OCCURC`KMAA6E11".
<br />A �h�Nyr0 . ... .. ...
<br />� -MADE _X
<br />r)"vF WE*} IF $ 100 000
<br />_ME D EXP (Any one person) $ 5,000
<br />PERSONAL & ADV INJURY $ 1,000.000
<br />,.e. .-.- ,_
<br />GEN I AGGREGAT EJECT AF I I IES PER:
<br />..
<br />GENERAL AGGREGATE $ 3,000 o00
<br />X PRO (
<br />POLICY LOC
<br />PRODUCTS - COMP/OP AGO $ 3 000 000
<br />X
<br />_ d:DTI^Ip%R" XC4JndNa%�G!tiAderti
<br />., . ....
<br />$ ..
<br />AUTOMOBILE LIABILITY 5X04118
<br />3/1/2018 3/1/2019 IE�Ghtl�rI Ir LIIrwNIT
<br />{gyp aCxIda„�1�,s $
<br />X ANY AUTO
<br />er Perperson)
<br />BODILY INJURY ( p on} $
<br />t ALL OWNED µ„--"" SCHEDULED
<br />_ AUTOS AUTOS
<br />~BODILY INJURY Perac _
<br />( accident) $
<br />X HIREDAUTOS X NON -OWNED AUTOS
<br />tTKdD'PERTY't:1AMAG'L ....,.�.... .-.-_..-,...
<br />$
<br />A X UMBRELLA
<br />'"X`"' OCCUR 5X041 1817
<br />3/1/2018 3/1/2019 EACH OCCURRENCE $ 10,I.01)Xto
<br />EXCESS LIABAB
<br />CLAIMS -MADE.........
<br />---- ..... .__.--
<br />- ....-.......
<br />AGGREGATE
<br />.,.,,,, ....
<br />DIED X RETENTION $
<br />,,, , �
<br />A WORKERS COMPENSATION 5X0411897
<br />3/1/2018 3/1/2019 X PER r}I"H
<br />AND EMPLOYERS' LIABILITY Y t N
<br />.....__. STADt TF F;k3,
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED? N q NIA
<br />E.L EACH ACCIDENT $ 1,000 000
<br />---- .....• ....
<br />(Mandatory In NH) """
<br />E.L DISEASE EA EMPLOYEEi:. $ 1,000 000
<br />If yes, describe under
<br />---- . ... -.
<br />'.. DESCRIPTION OF OPERATIONS below
<br />I E.L. DISEASE -POLICY LIMIT $ 1.100,000
<br />A Inland Marine 5X0411817
<br />Inland Marine
<br />3/1/2018 3/l/2019 Leased/Rented Equip 120,000
<br />Pollution Liability
<br />Installation Floater 150.000
<br />Limit $500,000
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) _
<br />CERTIFICATE; HOLDER
<br />CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />City of South Bend Dept of Public Works
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />1316 City County Bldg
<br />South Bend IN
<br />AUTHORIZED REPRESENTATIVE
<br />USA
<br />�77.
<br />© 1988-2014 ACORD CORPORATION. All rights reserved,
<br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
<br />
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