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„ DATE (MMIDD/Y(YY)
<br />AC ” CERTIFICATE OF LIABILITY INSURANCE
<br />4/16/2019
<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.
<br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
<br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
<br />'.. PRODUCER CONTACT
<br />NAME:
<br />The Horton Group PHONE FAX
<br />708-845-3917
<br />340 Columbia Place (AIANa,_stt� """" {Aac,,,pe) 8a„i12 nk17
<br />E-MAIL
<br />South Bend IN 46601 ADmR$,,,tfaCtitI1,I1rJttollgruy.cam
<br />INSURERISI, AFFORDING COVERAGE
<br />INSURER A: FCCI INS CO 10178
<br />INSURED INSURER B
<br />Ancon Construction Co., Inc. ...
<br />2146 Elkhart Road wsURERc
<br />Goshen IN 46526 INSURERo
<br />COVERAGES
<br />CERTIFICATE NUMBER:793021816
<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..
<br />NSI I ., TYPE OF INSURANCE .......... ... .. AjNS1D ISWVD P POLICY NUMBER ,I ,(MM/DDY/YYYY) gMMPDpfY'YY'NY) LIMITS
<br />LTR
<br />A X COMMERCIAL GENERAL LIABILITY Y Y CPP 0024250 6/1/2018 6/1/2019 EACH OCCURRENCE $1000,000
<br />DAMAGE YURENM ._. ...,....,.
<br />CLAIMS -MADE X,.; OCCUR PREMISFSIE@,ocuorrenoaj„ $ 100,,000
<br />XCU
<br />ED EXP (Any one person)
<br />$ 5,000
<br />X Contractual „
<br />PERSONAL & ADV INJURY
<br />...... .,.,.,...
<br />$ 1 000 000
<br />, .
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />GENERAL AGGREGATE
<br />$ 2,000,000
<br />.,. .... PRO-
<br />POLICY �" X JECT X LOC
<br />-
<br />PRODUCTS - COMPIOP AGG
<br />$ 2 000 000
<br />U1p1P,:H^
<br />PD Deduct per claim
<br />$ 500
<br />A
<br />AUTOMOBILE LIABILITY
<br />Y
<br />Y
<br />CA 100014159
<br />6/1/2018
<br />6/1/2019
<br />UO't`1RIf'Irt"I""tNG EL1FrCIT
<br />$1,000,000
<br />X ANY AUTO
<br />BODILY INJURY (Per person)
<br />$
<br />OWNED SCHEDULED
<br />BODILY INJURY (Per accident)
<br />$
<br />AUTOS ONLY ............ AUTOS
<br />..,,.
<br />HIRED NON -OWNED
<br />PROPERTY DAMAGE
<br />$
<br />AUTOS ONLY ..-. AUTOS ONLY
<br />kper accident)
<br />Comp & Coll Deduct:
<br />$ 500 each
<br />A
<br />UMBRELLA LIAB X OCCUR
<br />Y
<br />Y
<br />UMB 100014161
<br />6/1/2018
<br />6/1/2019
<br />EACH OCCURRENCE
<br />$ 10,000,000
<br />EXCESS LIAB CLAIMS-MADE
<br />AGGREGATE
<br />$ 10,000,000
<br />DFD X RETENTION $ in nnn$
<br />A
<br />WORKERS COMPENSATION
<br />Y
<br />WC 000/14410
<br />6/1/2018
<br />6/1/2019
<br />X PER OTH
<br />STATUTE... FR„....
<br />AND EMPLOYERS' LIABILITY YrI1M
<br />.. ,,,
<br />ANYPROPRIETOR/PARTNER/EXECUTIVE
<br />E,L EACH ACCIDENT
<br />$ 1 000 000
<br />OFF ICER/M EMBER EXCLUDED? J
<br />NIA
<br />(Mandatory in NH)
<br />E..L.. DISEASE -EA EMPLOYEE.
<br />'
<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 />A
<br />Leased/Rented Equipment
<br />Y
<br />CPP 0024250
<br />6/1/2018
<br />6/1/2019
<br />Deduct. $1,000
<br />250,000
<br />A
<br />Installation Floater
<br />Y
<br />CPP 0024250
<br />611/2018
<br />6/1/2019
<br />Deduct: $1,000
<br />100,000
<br />Y
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required)
<br />Additional insured on a primary and non-contributory basis with respect to general liability and auto liability only when required by written contract. Waivers of
<br />subrogation applies to the general liability, auto liability and workers compensation in favor of the stated additional insureds only when required by written
<br />contract.
<br />RE: Project No. 118-010A, Historic Leeper Park Improvements
<br />Additional Insured: CITY OF SOUTH BEND
<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 ACCORDANCE WITH THE POLICY PROVISIONS.
<br />INDIANA BOARD OF PUBLIC WORKS
<br />227 West Jefferson Blvd. AUTHORIZED REPRESENTATIVE
<br />SOUTH BEND IN 46601 '
<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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