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a =E,(/MMJ/DDfYYYY) <br />AC"R" CERTIFICATE OF LIABILITY INSURANCE 0 272 <br />019 <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 Danielle Hunt <br />NAME: <br />. .......... . <br />Gibson Insurance Agency, Inc PHONE (800) 814-2122 FAX <br />(AIC, No, Ext): (AJC, No): (800) 836-2122 <br />130 S Main St, Ste 400 ADORn L�MAIL dhunt@gibsonins corn <br />. ... . ..... <br />PC Box 11177 INSURER(S) AFFORDING COVERAGE NAIC # <br />South Bend IN 46601-0177 NSURERA.. i�risure Mut Ins Co 23396 <br />. .......... . . ..................... <br />INSURED INSURER B; <br />......................... <br />HRP Construction Inc INSURER C: <br />5777 Cleveland Rd INSURER D <br />. . . . . . .......... . ..................... <br />PO Box 266 INSURER E; <br />South Bend IN 46624-0266 IN SURER F <br />COVERAGES CERTIFICATE NUMBER: 9-1-19/20 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 CONTRACTOR OTHER DOCUMENT <br />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 <br />A <br />WM <br />I` Y - <br />LTR <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />(MM DDfyyyy) <br />IVYVY <br />LIMITS <br />X <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />1,000.000 <br />OCCUR CLAIMS -MADE <br />19 <br />=9 =RrRTM,_ <br />PREMISES (Ea occurrence) <br />1,000,000 <br />X <br />XCU <br />MED EXP (Any one Person) <br />­- <br />16,066 <br />A <br />X <br />Contractual Liability <br />CPP20316441502 <br />09/01/2019 <br />09/01/2020 <br />....... ............... <br />1.000,000 <br />PERSONAL &ADV INJURY <br />$ <br />GEN'LAGGREGATE LIMITAPPLIES PER: <br />Rt2EE��Aa�LR CATE <br />�LG <br />$ 2.000,000 <br />PRO, <br />POLICY19 JECT D LOC <br />PRODUCTS-COMP/OP AGO <br />$ 2,000,000 <br />OTHER <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT <br />$ 1,000,000 <br />(Ea accident) <br />X <br />ANY AUTO <br />BODILY INJURY (Per person) <br />$ <br />A <br />OWNED <br />SCHEDULED <br />CA20316451502 <br />09/01/2019 <br />09/01/2020 <br />BODILY INJURY (Per accident) <br />$ <br />AUTOS ONLY <br />LIT <br />AUTOS <br />HIRED <br />X <br />X <br />0 <br />NON -OWNED <br />.15—ROP C TWID.-A.—M-A G—E ............. <br />AUTOS ONLY <br />AUTOS ONLY <br />. . <br />I X <br />. ....... <br />UMBRELLA71AB <br />X OCCUR <br />. .. <br />.............. <br />.. . .. . ............... ... ....... <br />EACH OCCURRENCE <br />.000.000 <br />$ 1 1 <br />A <br />EXCESS LV <br />CLAIMS -MADE <br />CU20316431402 <br />09/01/2019 <br />09/01/2020 <br />AGGREGATE <br />F1­1­0_1 j'o 0, 060 <br />J1111 LET�Wn.. $ <br />L_J.�5L _ .............. . <br />_. <br />­­­.­­.­­­­ <br />. ...... ......... <br />............... . <br />............... <br />$ <br />COMPENSATION <br />...... <br />}S5T�R 0 - - H <br />. ..... <br />,AND EMPLOYERS' LIABILITY Y/N <br />AT. <br />LITE ER <br />ANY PROPRIETOR/PARTNER/EXECUTIVE <br />NIA <br />WC203164214 <br />09/01/2019 <br />09/01/2020 <br />E L EACH ACCIDENT <br />$ 1,000.000 <br />OFFICER/MEMBER EXCLUDED? <br />IMandatory in NH) <br />E.L.DISEASE- EA EMPLOYEE <br />$ 1,000,000 <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />... . ............ . . <br />E L DISEASE - POLICY LIMIT <br />1,000,000 <br />DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if mom space is required) <br />City of South Bend Board of Public Works <br />227 West Jefferson, 13th Floor <br />South Bend <br />IN 46601 <br />CANCELLATION <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 />@ 1988-2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />