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Exhibit G - 3 pages
<br />CERTIFICATE OF LIABILITY INSURANCE DATE(MM12018 YY)
<br />,,,, SI201 B
<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. If
<br />SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this
<br />certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />oo.,ni r.onI CONTACT
<br />Hon Services southwest, Inc.
<br />'..Houston TX Office
<br />..._
<br />POE E.at � 8662837122 F" (800) 363-0105
<br />iAIc° No . • Na.
<br />E-MAIL
<br />ADDRESS:
<br />5555 San Felipe
<br />Suite 1500
<br />INSURER(S) AFFORDING COVERAGE
<br />NAIC #
<br />Houston TX 77056 USA
<br />'.INSURED
<br />INSURER A: LeXington Insurance Company
<br />19437
<br />cardno, Inc.
<br />10004 Park Meadows Drive
<br />'.. Suite 300
<br />INSURERB: Zurich American Ins co
<br />16535
<br />INSURER C: American Guarantee & Liability Ins co
<br />26247
<br />'..Lone Tree CO 80124 USA
<br />INSURERD: Ironshore Specialty Insurance Company
<br />25445
<br />INSURER E:
<br />..............._.----.....----_....--....._._.._.__...--_..._._._.�......_.-
<br />...........
<br />INSURERF:
<br />COVERAGES CERTIFICATE NUMBER: 570073915296
<br />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 BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested
<br />LTyt
<br />TYPE OF INSURANCE
<br />ADD
<br />' D
<br />O
<br />POLICY NUMBER
<br />hUMP47DCYYY .POLICY EFF
<br />POLICY
<br />mMODA"1�YVtNSR '
<br />LIMITS
<br />X
<br />COMMERCIAL RNE'RALLIABILITY
<br />GLO
<br />EACH OCCURRENCE
<br />$1,000,000
<br />CLAIMS -MADE OCCUR
<br />PREMISES Ea occurrence..
<br />$1,000,000
<br />Per Pr*cl. Agg $2M
<br />MED EXP (Any one person)
<br />$10 , 000
<br />PERSONAL B ADV INJURY
<br />$1,000,000
<br />m
<br />GEN'LAGGREGATE
<br />LIMITAPPLIES PER:
<br />GENERAL AGGREGATE
<br />110 000 000
<br />in
<br />X
<br />POLICY ❑T LOCJLC
<br />PRODUCTS- COMPIOP AGG
<br />$2 000 000
<br />n
<br />OTHER:
<br />_.
<br />or
<br />B
<br />AUTOMOBILE LIABILITY
<br />BAP 0183962-03
<br />06/30/2018
<br />06/30/2019
<br />COMBINED SINGLE LIMIT
<br />$1,000,000
<br />a PSoft
<br />X ANYAUTO
<br />BODILY INJURY ( Per person)
<br />O
<br />Z
<br />OWNED SCHEDULED
<br />BODILY INJURY (Per accident)
<br />r
<br />•• AUTOS ONLY AUTOS
<br />HIREDAUTOS NON -OWNED
<br />PROPERTY DAMAGE
<br />19
<br />v
<br />ONLY AUTOS ONLY
<br />Per accident.
<br />tE
<br />a,
<br />d
<br />C
<br />X
<br />UMBRELLA LL4B X I OCCUR
<br />AUC018392703
<br />06/30/2018
<br />06/302019
<br />EACH OCCURRENCE
<br />$10,000,000
<br />IL)
<br />EXCESS LIAR CLAIMS -MADE
<br />AGGREGATE
<br />$10,000,000
<br />-__,_,_,_,_,_,_,_,
<br />DED RE�,ENTNON
<br />B
<br />WORKERS COMPENSATION AND
<br />wcO1839660A
<br />0673072618
<br />6671672619
<br />TH-
<br />EMPLOYERS' LIABILITY Y I N7
<br />ANY PROPRIETOR / PARTNER I EXECUTIVE
<br />N'
<br />E.L. EACH ACCIDENT
<br />$1,000,000
<br />OFFICERWEMBER EXCLUDED?
<br />(Mandatory in NH) L
<br />N I A
<br />E.L, DISEASE -EA EMPLOYEE
<br />$1,000,000
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE -POLICY LIMIT
<br />$1,000,000
<br />D
<br />Env Site Liab
<br />0 7 4
<br />06/30/2018
<br />06/30/2019
<br />Occurrence
<br />$16,000,00
<br />Pollution Liability
<br />Aggregate
<br />$10,000,000
<br />DESCRIPTION OF OPERATIONS I ONS I CLES (ACORD 101, Additional Remarks Schedule, may be attached if mom space is required) 8;;.w
<br />city of south d of Public works re Additional ired ut
<br />en tcommercial
<br />cluded sthe
<br />Indiana/ rllanured
<br />sendorsemenured as tuwith
<br />limited underapplicable rrespecttto the
<br />ht, saabalottnactper
<br />totheiOpa AttonLilof
<br />GeneralY Y Y policy.
<br />CERTIFICATE HOLDER CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
<br />EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
<br />POLICY PROVISIONS.
<br />city of South Bend, Indiana
<br />AUTHORIZED REPRESENTATIVE
<br />Board of Public works
<br />Attn: Kara M Boyles
<br />227 West Jefferson Blvd
<br />s ��a�
<br />South Bend IN 46601 USA
<br />e..(y4YO/si
<br />©1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
<br />
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