|
ACOROCERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
<br />7/3/2019
<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 />_..........
<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 />1st Source Insurance, Inc.
<br />6909 Grape Road
<br />Mishawaka, IN 46545
<br />nda S.
<br />271-5200 ( r� ^ wloy (574) 271-5240
<br />wskll@lstsource.com
<br />INSURER n : West Bend Mutual Ins. Co.
<br />INSURED
<br />�15350
<br />INSURER B_:
<br />South Bend Civic Theatre, Inc.
<br />INSURER c ......._.,e ......___ .......___ ... ...___........._. J ..
<br />403 N. Main Street
<br />INSURER D
<br />South Bend, IN 46601
<br />I -
<br />INSURER E
<br />INSURER F ;
<br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER; ..,_ ___....._
<br />THIS IS TO CERTIFY THAT THE POLICIES
<br />OF INSURANCE LISTED BELOW HAVE BEEN ISSUED
<br />TO THE INSURED
<br />NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED, NOTWITHSTANDING ANY REQUIREMENT,
<br />TERM OR CONDITION OF ANY CONTRACT
<br />OR OTHER
<br />DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY
<br />PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES
<br />DESCRIBED
<br />HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH
<br />POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY
<br />PAID CLAIMS..
<br />INS-LIR._........ .. .... ,,. ...........................................I.
<br />TYPE OF INSURANCE
<br />t I POLICY NUMBER F
<br />Y..._.............�................................................ .........,POLW'EF ..................(POLICY
<br />E#R
<br />� .., ........ ..... LIMITS ...........
<br />A X�COMMERCIAL GENERAL LIABILITY
<br />1,000,000
<br />EACH OCCURRENCE I
<br />CLAIMS -MADE X OCCUR
<br />�( A294330 7/1/2019
<br />7/1/2020
<br />-IS
<br />DAMAGE To RENTED 300,000
<br />P6�FIhoII�L� ((rs �iccurracAla�ep $
<br />1
<br />1 O,00O
<br />MED EXP IAny one person) $
<br />PERsoNAL AOV INJURY I $.. 1,000,000
<br />C:EN AGGREGATE LIMIT APPLIES
<br />GENERAL AGGREGATE $
<br />,
<br />PRO-L
<br />X POLICYJEC7 LUC:
<br />m,
<br />2,000,000
<br />PRODUCTS'- COMP/OP AGG $oTIJER: 0
<br />...A._. AUTOMOBILE LIABILITY
<br />-. ITITIT �__....___,..�.�..
<br />��_..._......�.._
<br />COMBINEDNG SILE LIMIT 1,000,000
<br />I
<br />(Ep accade $
<br />ANY AUTO
<br />A294330 7/1/2019
<br />7/1/2020
<br />BODILY INJURY (Perp_ersong l$
<br />OWNED SCHEDULED
<br />AUTOS ONLY AUTOS
<br />I
<br />BODILY INJURY (Per acadent) $
<br />XHIRED I NON -OWNED
<br />1 AUTOS ONLY X J AUTOS ONLY
<br />,,
<br />PIROPERT"+ AMAe E I
<br />(Per acc Jec t $,,,, , , , , ,, ,,,,
<br />A X I UMBRELLA LIAB X OCCUR
<br />EACH OCCURRENCE
<br />is 1,000,000
<br />LIAB CLAIMS MADE
<br />A294330
<br />7/1/2019
<br />7/1/2020 AGGREGATk
<br />$ 1,000,000
<br />.,�Excess
<br />X I,RETENTLO.N.$. ..................o..-;
<br />I•.,,.,,,, ,,,,,,,
<br />($....
<br />DED I
<br />_
<br />_._....... ER
<br />A WORKERS COMPENSATION
<br />.
<br />_.... � .... _ H
<br />PER ORH
<br />X
<br />AND EMPLOYERS LIABILITY
<br />Yl�u
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />� '
<br />B nrLcRm ary in NH} EXCLUDED. (N,.l
<br />N/A
<br />A294331
<br />7/1/201.......
<br />9
<br />E.L�EACHATE
<br />1
<br />7/1/2020 _CCIDENT
<br />E,L DISEASE - EA EMPLOYEE;
<br />1 $ 500'000
<br />000
<br />6_ '
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E L DISEASE - POLICY LIMIT
<br />I $ 500 000
<br />DESCRIPTION OF OPERATIONSI LOCATION'S/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />City of South Bend, Indiana is additional insured as respects to general liability when required in written contract or agreement.
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of South Bend, Indiana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />Y ACCORDANCE WITH THE POLICY PROVISIONS.
<br />227 W. Jefferson Blvd
<br />South Bend, IN 46601 - .... ..... _—_-. ......
<br />AUTHORIZED REPRESENTATIVE
<br />Wit. s
<br />..........
<br />ACORD25 (2016/03) .... .�..�.. �..._...........m... ....�__......_._._.__� im9 ..................._................................................... ....
<br />�w
<br />88-2015 ACORD CORPORATION. All rights reserved,
<br />
|