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NIEZPLU-01 —.._..........,._------ ..
<br />CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
<br />08/161201' 8
<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 />.....................................�._...... .... _...
<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
<br />Dan Berry Insurance Agency Inc.
<br />54101 Ironwood Road
<br />South Bend, IN 46637
<br />255-6222
<br />254-2630
<br />INs RER A :West BendITmMutUal Insurance Co IT�IT_� 15350 ,....._
<br />INSURED INSURER B IiS1CPt �11Sll�r'1IIC %OA 1�Bn ..................IT. ITIT. ._; 27626
<br />Nleigodski.Plumbing,Inc. INSURERc: .._ ............
<br />PO. Box 3096 INSURER D . __._..
<br />South.Bend, IN 46619�
<br />INSURER. E '...
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: . ................. 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 />INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
<br />LTR AMMMIYYM AlRmlopficnn . ........ ..�
<br />A X COMMERCIAL'GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
<br />...�
<br />CLAIMS -MADE [:] ��AMA�
<br />OCCUR A495062 08/21/2018 0812l/2019 D $ 300,0001
<br />MED, P.4?...(nr�M one Persnn $ OO..
<br />5,
<br />1,000,0
<br />PERSONAL 8 ADV I
<br />� 00
<br />_. m... �............. ...... --- --- N URY S -..-r-r-�
<br />GEN
<br />—XI T AGGREGATE LIMIT APPLIES PER. GENERALAGGREGATE $ 2,000,000
<br />JECT LOC PRODUCTS COMP/OP AGG _ A-- 2,000,000
<br />OTHER_......�..... .��. .... _....... .... ._ � OO
<br />A AUTOMOBILE LIABILITY
<br />COMIINEO'R7viGL. LNMIT
<br />(R-ami rd} 1,000,0
<br />X ANY AUTO A495062 08/21/2018 08/21 /2019 BODILY IN lURY/PerpersonJ_ _$ IT _mm m mm
<br />OWNED SCHEDULED URY PeraccWent $
<br />AUTOS ONLY AUTOS BODILY INJ { _
<br />AURED ( q . _ ......�
<br />TOS ONLY A41ONY P/�NnOaP7kISJAMAGE $
<br />__ _.M.�-. _ ...._...._............__ ..$......_...... ......................
<br />A X UMBRELLA LIAB X OCCUR EACH O�,C,URRI? N E_ $ 2,000,000
<br />EXCESS LIAB CLAIMS -MADE A495062 08/21/2018 08/21/2019 AGGREGATE $ 2,000,0001
<br />..........
<br />D RETENTION $ $
<br />B WORKERS COMPENSATION X PER OTH-
<br />MPLOYERS' LIABILITY STA_TUIIE . E
<br />AND E 08/21/2019 500,000
<br />ANY PROPRIETORIPARTNER/EXECUTIVE ❑ E L EACH ACCIDENT
<br />FBIER/M M E EXCLUDED NIA -' ..'—
<br />Yilan5atory.n �itij Y / N WC0190699-01 08121/2018 I E ,L DISEASE -Eo,, En�I�Lp1-� 500,000
<br />IF es, describe under 500,000
<br />....._-'.. D m;,,_ RJa BON OF OPERATIONS below .. ,,. ,_, .�,ITIT. ,,,,,, E,L. DISEASE - POLICY LIMIT
<br />- —.1- L I L.---
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Addltlonal Remarks Schedule, may be attached If more space is required)
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />Department of Public Works THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />p ACCORDANCE WITH THE POLICY PROVISIONS.
<br />1046 W. Sample St.
<br />South Bend, IN 46619 ... -- -�
<br />AUTHORIZED REPRESENTATIVE
<br />�... ........�.....,,
<br />ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks ofACORD
<br />
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