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NIEZPLU-01 ,,,
<br />AA" DATE (MM/DD/YYYY)
<br />CEWRTIFICATE OF LIABILITY INSURANCE 8f20P2019
<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 />IMPORT
<br />ANT: 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 to the certificate holder in lieu of such endorsement(a .
<br />.. .... ...__ _--...... -- ..-__
<br />PRODUCER .HCR# CT. ..... ...
<br />Dan Berry Insurance Agency Inc. PHONE FAX
<br />54101 Ironwood Road (NC„ No! Ext) 574) 255-6222 1/uc, rva/;(574) 254-2630
<br />'South Bend, IN 46637 .SS,.1MSS, r6s1ness6dbfsll c ...cortll.............................. �.
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />INSURERA:West Bend Mutual Insurance Co 153-- . .....................
<br />INSURED .INSURERSFirstComp Insurance Company,_ ___, ,_,._ „27626 ...,
<br />Niezgodski Plumbing, Inc. iNsuRER,c
<br />PO Box 3096 INSURER0
<br />South Bend, IN 46619 .._,...... ...... ..._-------- .... ------ . _ __ ..-------_-
<br />INSURER E .
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER: REVISIONNUMBER:
<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 _ ADDL SUER: POLICY EFF POLICY EXP
<br />LTR TYPE OF INSURANCE POLICY NUMBER LIMITS
<br />A X COMMERCIAL GENERALLIABWTY-�� 1 000,000
<br />,EACH OCCl1RRENCE ___ $
<br />CLAIMS -MADE X occuR A495062 8/21/2019 8/21l2020 DAMAGE Tea RIrN r10 300,000
<br />PI �IAfl4d�[Eaisl
<br />nnEDxP (nny one,erso�? ...... 5,000
<br />..
<br />_ PERSONAL & ADV IN„ URY $ 1,000,000
<br />,.
<br />TE
<br />C LN OLGuCY1ATEjE T APPLIES PER: P $ 2 000,000
<br />� PRODUCTS 7 COMP/OP,AGG ,$ 2 000,000
<br />OTHER` $
<br />A AUTOMOBILE LIABILITYOMBINI.D SINGLF umi'r 1,000,000
<br />_(9A"o%W llt..
<br />X ANY AUTO A495062 8/21/2019 8/21/2020
<br />BODILXINJURY(Perperson�j $....... ...
<br />OWNED ITOS
<br />HEDULED
<br />AUTOS ONLY �p7BQD14 YINJURY (Per accident] $ ..... ...._—
<br />AUTOSONLY 'COS��%� RNt3PECTY AMAGE S -.- .,.., ,,.,..... PR PE i�nR ..... _ .
<br />...
<br />A 1........... _._ ...._......_
<br />....�...WWmmWW�
<br />UMBRELLA LIAB OCCUR EAGH pCGURRENCE....___ .. 2,000 000'
<br />EXCESS IJAB CLAIMS MADE A495062 8/21/2019 8/21/2020 AGGREGATE
<br />DED RET ENTIGN $ 2,000,000
<br />ANY PROPMETOMPAR I N RI LIABILITY Y/ N STATUTE J RH ...
<br />PER
<br />WC0190699-07 8/27I2019 8/21/2020 500,000.
<br />WORKERS�RryCOMPENSATIONAND ERJL'XECUTIVE � N / A E.L.EACH ACCIDENT,..., ..... $ ....... , ... .500,000
<br />rci etta Lln EXCLUDED^r
<br />y E.L, pISEASE - EA EMPLOYE E..$ _
<br />If
<br />DESCRIPOI^i OF OPERATIONS b. aw...................ww..._.,... _._................................_........_........m.,:.................................... ..E L DI6 -,_.. .-...... - ---
<br />EASE -POLICY LIMIT $ 500,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached U more space is required)
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of South Bend Board of Public Works THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />tY ACCORDANCE WITH THE POLICY PROVISIONS.
<br />227 W. Jefferson Blvd.
<br />South Bend, IN 46601
<br />AUTHORIZED REPRESENTATIVE
<br />ry ' ;i,,
<br />ACORD 25 2016/03 ©1988-2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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