|
BOKOMAS-01
<br />FDATE(MM/DD/YYYY)
<br />CERTIFICATE OF LIABILITY INSURANCE o2o
<br />.......�... ....� ........ ........ . .........
<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 />.....
<br />PRODUCER CONTACT
<br />The Healy Group, Inc. PHONE
<br />NAME:
<br />Bendr, IN466D5D" Afss
<br />Drive xt). (574) 271-6000 _._. ITmmm _........ el TO'� 74 243-3214
<br />South m`
<br />INSURED
<br />Bokon Masonry Inc.
<br />56571 Pear Rd
<br />South Bend, IN 46619-9801
<br />14176
<br />COVERAGES
<br />....... CERTIFICATE
<br />NUMBER
<br />REVISION NUMBER:
<br />THIS
<br />IS TO CERTIFY THAT THE POLICIES
<br />OF
<br />INSURANCE
<br />LISTED BELOW HAVE BEEN
<br />ISSUED
<br />TO THE INSURED
<br />NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED,
<br />NOTWITHSTANDING ANY REQUIREMENT,
<br />TERM OR CONDITION OF ANY
<br />CONTRACT
<br />OR OTHER
<br />DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE
<br />MAY BE ISSUED OR MAY
<br />PERTAIN,
<br />THE INSURANCE AFFORDED BY
<br />THE POLICIES
<br />DESCRIBED
<br />HEREIN IS SUBJECT TO ALL THE TERMS,
<br />_ EXCLUSIONS
<br />AND CONDITIONS OF SUCH
<br />POLICIES.
<br />LIMITS SHOWN MAY HAVE BEEN
<br />REDUCED BY
<br />PAID CLAIMS.
<br />TYPE OF INSURANCE
<br />ADO L
<br />SUOR
<br />w
<br />POLICY NUMBER
<br />mmmPOLICYFF E
<br />JMMI
<br />POLICY EXP
<br />dM117%DD/YYXYI
<br />_ LIMITS �.. ..._ .
<br />�
<br />A
<br />X COMMERCIAL GENERAL LIABILITY
<br />EACH OCCU 1,Q0o,o0Q
<br />CLAIMS -MADE CD OCCUR
<br />X
<br />CPP9874827
<br />8/17/2019
<br />8/17/2020
<br />A-6E WEEff ..
<br />RLND $ 100 000
<br />PN
<br />MEDwEXP (Any one erson $ 5,000
<br />,........
<br />PERSONAL B ADV INJLIRY $._ 1,000,000
<br />GLN AIE APPLIESPER:
<br />GENERAL AGREGATE $ 2,000,000
<br />POLICYDt Pj CT LOC
<br />PRODUCTSGCOMP/OP mmmm WWW ^2,000,000
<br />AGG $
<br />A
<br />OTHER
<br />AUTOMOBILE LIABILITY
<br />---
<br />OMUINFI} SINGLE LIMIT
<br />�Fa_ �I,4s:�I . $ 500,000
<br />X ANY AUTO
<br />ACV9874840
<br />8/17/2019
<br />8/17/2020
<br />BODILY INJURY-(Per,perSgPJ. $
<br />OWNED SCHEDULED
<br />r
<br />AUTOS ONLY AUTOS
<br />RY (Pgrc deal),, $
<br />UOA(LY(N,IIJ,,,,m,
<br />Ep C�Dy ����
<br />AUTOS ONLY AUO,Y
<br />mmw„
<br />Peic rAhGeLGL
<br />__WWW_W
<br />w
<br />$
<br />A
<br />X UMBRELLA LIAB X OCCUR
<br />........
<br />EACH OCCURRENCE $ 1,000,000
<br />LIAB CLAIMS -MADE
<br />ULC9874849
<br />8/17/2019
<br />8/17/2020
<br />_
<br />AGGREGATE _m mITmm mmm 1,000,000
<br />_.m.. .... ........
<br />]:EXCESS
<br />DED RETENTION $
<br />$ ... w
<br />A
<br />WORKERS COMPENSATION
<br />PER OTH
<br />_X
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PR PRIETORIPARTNERIEXECUTIVE
<br />OR/PARLUDED�
<br />N/A
<br />WC 9874841
<br />8/17/2019
<br />8/17/2020
<br />EACHmA C $ 500,000
<br />FkCE Bfal M
<br />W arida oryi n NH)
<br />_ _
<br />500,000
<br />EL DISEASECIDENT
<br />- EA EMPLOYEE $
<br />If yes, describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E L. DISEASE POLICY L` mm ........_ __._
<br />LIMIT $ 500 000
<br />DESCRIPTION OF OPERATIONS. / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required)
<br />City of South Bend Is Ilsted as Additional Insured.
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />City of South Bend THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />125 South Lafayette Blvd, Suite 100
<br />South Bend, IN 46601
<br />AUTHORIZED REPRESENTATIVE
<br />ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
|