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Client#: 21954 HARRLLC2
<br />ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
<br />1 /09/2020
<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 be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />certificate holder in lieu of such endorsement(s).
<br />PRODUCER AfiC N E1 863 686-2113 �(
<br />NAME Renee' Pa ne
<br />Lamer Upshaw,Inc. oNE� 863 682 6292
<br />1115 US Hwy 98 South MAIL °""' Arc
<br />ADDRESS:,_ Re_n_ee_.Payne@LaiiierUpshiaw.com erUpsh
<br />P.O. Box 468
<br />Lakeland, FL 33802 ; AIG Speciality insurance R(S) AFFORDING COVERAGE NAIC #
<br />INSURE.R.�............................ INSURER(S)
<br />Co...............__._..,....,....,.,.,..,,...............................�.........----
<br />26883
<br />Harrell's LLC, Harre
<br />......__ _..... ........ INSURER C
<br />.... .,._ ...
<br />INSURED
<br />INSURER B Nat'l Union Fire Ins Co of Pittsburgh 79445
<br />ll'$, Inc. Markel American InsuranceCc 28932
<br />P.O. Box 807
<br />INSURER D Axis Surplus Insurance Company 26620
<br />Lakeland, FL 33802 - .......... __.
<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 CONTRACTOR 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 />A
<br />.,
<br />TYPE OF INSURANCE POLICY NUMBERNtVraii,<DtiFXYXY. iMM/DD/YXXX), ..__ LIMITS
<br />AL LIABILITY
<br />EG13/01/2019 7937835 03/01/202 EACH
<br />COMMERCIAL GENER LENTPO OCCURRENCE
<br />9 ....
<br />CLAIMS MADE X OCCUR ?,A,,MA( C�Yei,d.irrH3cte„s)
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />POLICY PRO-
<br />JECT t I LOC
<br />OTHER
<br />..............._..................................................
<br />B
<br />AUTOMOBILE LIABILITY
<br />X ANY AUTO
<br />B ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />HIRED AUTOS lx NON -OWNED
<br />Auros
<br />UMBRELLA
<br />OCCUR
<br />A X� EXCESS ABAB X CLAIMS -MADE
<br />CA4489811
<br />All States
<br />CA4489812
<br />MA Only
<br />EGU17915146
<br />MED EXP (Any one person)
<br />PERSONAL & ADV INJURY
<br />GENERAL AGGREGATE
<br />PRODUCTS - COMP/OP AGG_
<br />Deductible
<br />/20 M 03/01
<br />$1
<br />0
<br />$2
<br />$1
<br />1,000
<br />BODILY INJURY (Per person) $
<br />PR $
<br />/2019 03/01/202 BODILY INJURY (Per accident) $
<br />PERTY
<br />OAMAGE'. ...
<br />PIi _....-.....................
<br />qu��p
<br />PIP $$1
<br />/2019 03/01/2020 EACH OCCURRENCE
<br />AGGREGATE $15
<br />.....(....PE.D L. �.l-.RETENTION $U ,,, ,,.. .,.,..., ...... $
<br />B WORKERS COMPENSATION Y/N WCO25893850 3/01/2019 03I01/202 X PER IbTH
<br />OFFICERIMEMBEREXCLUDED? N/A All States 17F $1 O
<br />B (Mandatoryin NH WCO25893851 3/01/2019 03/01/202 E.L, Dlsl A ovEE $1 000,000
<br />D EMPLOYERS' LIABILITY
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE EACH
<br />If yes, describe under ACCIDENT .. 00f000
<br />RIPTION OF OPERATIONShelow .. ...... .., ,..... ..... ................ .............. .EL_.DISEASE- POLICY , LIMIT � ....� ..
<br />) SE EA EMPL
<br />MIT $1000,000
<br />A Pollution Liabili EG17937835 3/01/2019 03/01/202 $2,000,000/$50,000 Ded
<br />C Rented/Leased Eqp MKLM31MOO501 3/01/2019 03/01/202 $500,000 Per Item/Occur
<br />D Prof Liabilit EMP1900056101 3/01I2019 03/01/202 $1,000,000/$10 000 Ded
<br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />RE Bid Name: Venues Parks & Arts 2020 Chemical Supply
<br />Certificate holder, City of South Bend, their affiliates and or assigns are included as additional
<br />insured in respects to general liability on a primary and noncontributory basis and auto liability as
<br />required by written contract. Waiver of subrogation applies to additional insured(s) for general liability,
<br />auto liability and workers compensation. Umbrella follows form of general liability, auto liability and
<br />workers compensation.
<br />City of South Bend Office of the
<br />Board of Public Works
<br />227 W. Jefferson Blvd, Ste 1316
<br />South Bend, IN 46601
<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 />ACORD 25 (2014/01) 1 of 1
<br />#S470303/M466402
<br />©1988-2014 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />SRP
<br />
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