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TRANS-3 OP ID: KC
<br />=EDONJYYY)
<br />CERTIFICATE OF LIABILITY INSURANCE 9
<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(lies) 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 />109 W. PI mouth Street
<br />Bremen, ( 4606
<br />Ben Nehls
<br />INSURED
<br />dba Greater Impact Lawncare
<br />Kory Lantz
<br />615 CUSHING ST
<br />South Bend, IN 46616
<br />COVERAGES
<br />CERTIFICATE NUMBER:
<br />Ben Nehls
<br />....._..-....__._w.
<br />574-546-3341
<br />INSURER(S) AFFORDING COVERAGE
<br />INSURER A: Pekin Insurance Company
<br />INSURER B :
<br />INSURER D
<br />1.1 ATItifor771111T I�1 3 _1
<br />574-546-2687
<br />24228
<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.
<br />Pd OC"V-0 .�.. ......._._ ......" ..."""__ ..
<br />.... ....., "OiiL �JS�V ........-_._POLICY
<br />LTA TYPE OF INSURANCE NUMBER MM�'DDfYYYY MMd6DYEYY. LIMITS
<br />NUM.
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />$ 1,000,0O
<br />CLAIMS -MADE X occuR
<br />CL0199239
<br />04/17/2018
<br />04/17/2019
<br />ckClDid
<br />100,.00..
<br />PREhh9Sln rurNGrCJ„
<br />. ... ecnuirrirra(a
<br />$
<br />...—.
<br />—_._.-............................................................
<br />M EXP one (Any person)
<br />..E .,.......... ---__,n...,.,
<br />$ 5,00
<br />.... ........_�..
<br />..-_.-,.:..-..._._
<br />....................................................................................................
<br />PERSONAL & ADV INJURY
<br />$ 1,000,00
<br />..��.. ^�_���
<br />L AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />n'Y_
<br />$ 2,000,00
<br />X
<br />G
<br />PRO • I
<br />G POLICY Ipw;C,T LOC
<br />------.J
<br />PRODUCTS - COMP/OP AG""..
<br />n_�... G
<br />$ Included
<br />__.._,.... .....
<br />OTPiEw
<br />$
<br />AUTOMOBILE
<br />LIABILITY
<br />COdVu'GIFgFD,S[NGLE IS 1WI
<br />$
<br />ANY AUTO
<br />0OP702340
<br />04/17/2018
<br />04/17/2019
<br />BODILY INJURY (Per person)
<br />$ 1,000,00
<br />ALL OWNED X SCHEDULED
<br />AUTOS .....u.. AUTOS
<br />._ e...
<br />BODILY INJURY Per accid nt)
<br />.......... __ .....�,
<br />$ 1,000�00
<br />NON -OWNED
<br />HIRED AUTOS X.. AUTOS
<br />_
<br />i�'@.'i%k ft5lafulA;C'
<br />Rras ac.rddent ...
<br />4., i —
<br />......
<br />OO,00
<br />$..........m 1°0.......................
<br />......._.
<br />UMBRELLA LIAB OCCUR
<br />EACH OCCURRENCE
<br />$
<br />EXCESS 8 LIAB CLAIMS -MADE
<br />, . ,,. ....
<br />- ._..,,_..,,..,. .....
<br />AGGREGATE
<br />._...._... ........m....,.,..,�.
<br />$
<br />DED RETENTION $
<br />$
<br />WORKERS COMPENSATION
<br />-
<br />AND EMPLOYERS' LIABILITY YIN
<br />,FR
<br />E(L_EACH
<br />A
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED?
<br />IN / A
<br />WC0010342
<br />04/17/2018
<br />04/17/2019
<br />ACCIDENT SOO,OO
<br />.. ...
<br />(Mandatory in NH)
<br />E.L.. DISEASE- EA EMPLOYES $ 500160
<br />If describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L, DISEASE- POLICY LIMIT $ 500,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
<br />SOUTHBE
<br />City of South Bend
<br />Board of Public Works
<br />County -City Building
<br />227 W. Jefferson Blvd.
<br />South Bend, IN 46601
<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 />©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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