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TRUCRUS-01 MCOFFEI,
<br />AC7"l?" DATE (MMIDDfYYYY)
<br />CERTIFICATE OF LIABILITY INSURANCE
<br />2/20/2020
<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 />. ........... . . ............
<br />IMPL)K I AN 1: It the certiticate holder is an ADDITIONAL INSURED, the policy(les) 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 r�qh!s,!q,,�he certificate holder in lieu of such endorsement(s),
<br />.... . . . ............ ... ... ..... . ..... .......... .. .........................
<br />__ ........... . . ..................... . . . .....
<br />PRODUCER
<br />6TCOACT'
<br />OA4...
<br />Miller Insurance Group
<br />..... ... .... .................... . . . ......
<br />PHONE
<br />(MC, No, Pxqy (574) 546-3341
<br />I iz-A X — -------
<br />q546-2687
<br />PO Box 229
<br />Bremen, IN 465067
<br />DI rifi?@T illerins ura nceg,irp.com
<br />1 op .
<br />�A . ......
<br />�,.Np?0574)
<br />_!NqPERsAFFORDING COVERAGE
<br />. ... ......
<br />NAIC #
<br />IpSUjR,ER_A_:,0hi _S ;M rityInsurance Co
<br />INSURED
<br />INSURER 13: West Bend Mutual Insurance
<br />....... . .....................
<br />15350
<br />Trucks R Us, Inc.
<br />Lake Effect Snow Excavating
<br />23300 State Road 23
<br />South Bend, IN 46619
<br />INSURER F
<br />DO,VERAGES CERTIFICATE NUMBER: REVISION NUMBER-
<br />---- ---- - ---------- ...... . ........... . . . ...........
<br />-I HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY K:RIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 10 WHICH TI IIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL I'IIE'IF-RMS
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />. . . ............. .. A-6-M SUIBIR ------ p655Y EF'� XF
<br />'S`R TYPE , ,OF INSURANCE POLICY NUMBER IppryE LIMITS
<br />YYY
<br />Wyl), IMM L TS
<br />C-C ------
<br />X COMMERCIAL GENERAL LIABILITY EA-C.110 ------ LRRF 11, 1,000,000
<br />CLAIMS -MADE [ X ] 0 KS56685229 7/512019 7/5/2020 DAMAGE TO RENT['[) 300,000
<br />_ IF
<br />PREMISES (Eaaccu"rrolca� [S
<br />A 16-W
<br />OCCUR [B
<br />I, AGO, W(AIC LIMIT APPLIES PER
<br />PRO -
<br />POLICY _X] JECT I OC
<br />B
<br />AUTOMOBILE LIABILITY
<br />X
<br />ANY ALTO
<br />OWNED
<br />SCHEDULED
<br />ALTOS ONLY
<br />AUTOS
<br />HIRED
<br />NON -OWNED
<br />AUTOS ONLY
<br />AUTOS ONLY
<br />OCCUR
<br />EXCESS LIABAB ._ j CLAIMS -MADE
<br />UMBRELLA LI
<br />RETENTION $
<br />B WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY Y_?_N
<br />ANY PROPRIETORIPARTNER/EXECUTIVE
<br />OFFICERIMEMBER EXCLUDED? NIA
<br />(Mandatory in NH)
<br />If yes, describe under
<br />DEmSCRIPTION OF OPERATIONS below
<br />bMotor Truck Cargo
<br />137
<br />149
<br />137
<br />7/5/2019 N 7/5/2020
<br />7/5/2019 II 7/5/2020
<br />7/5/2019
<br />GENERALAGGREGATE .
<br />PRODUCTS - COMP/DP A
<br />COMBINFD SINGLE LIMP
<br />CEO
<br />BODILY -1 URY (Fgrp,!s,
<br />--------- _N41
<br />B 0 1 JN JURY (Per arcu
<br />PROPL'A rY DAMAGE
<br />FACH OCCURRIFNCE
<br />AGGREGATE
<br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />HOLDER
<br />City of South Bend / St Joseph County
<br />Board of Public Works 125 S. Lafayette Bid, #1100
<br />South Bend, IN 46601
<br />TION
<br />PER � OTH-
<br />5TATUTE F4_
<br />F_ACFtA.(',..CUDFNT___
<br />PI§E-A�S EA EMPI_OYF.
<br />DISEASE - POIACY 1, IML
<br />ao
<br />15,000
<br />1,000,000
<br />2,000,000
<br />2,000,000
<br />1,000,000
<br />500,000
<br />500,000
<br />500,000
<br />100,000
<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 />� �dpL
<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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