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MIKO&AS-01 Kf>T, I <br />CERTIFICATE OF LIABILITY INSURANCE <br />mmmm 4/17/2020 <br />.� DATE (MMIDD/YYYY) <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 />If the certificate <br />IS WAIVED, subject to the terms and conditions of the policy, certain policies mmmmm �mmm mmITITITITITITo statement �� nt WW <br />holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. <br />J � p y, may require an endorsement. A statement on <br />this certificate does not confer r18hts to the certificate holder in lieu of such endorsement(s) <br />1 ilyrick and tDrive A/ No ExKI(309) 664I1800 I I. <br />PRODUCER O TACT <br />Sn der & Sn der Agency, Inc. PHONE -1885 <br />N� O 664 m <br />Bloomington, IL 61701 EµMAIL <br />9 ADDRE'SR, <br />INSURED <br />Mikolajewski & Associates Inc <br />325 S Summit Dr <br />South Bend, IN 46619-2336 <br />A. <br />COVRAGE_. <br />.....CERTIFICATE NUMBER: R: _...... REVISION NUMBER- <br />.. ......... <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 �..-- TYPE OF INSURANCE ADDL SUBR .... .... _._........ ,... .. ........ _... - ,........... .... __. <br />._... ---- . . <br />�M POLICY NUMBER POLICY EFF POLICY EXP LIMITS <br />........ I�.�Iz .ar�!a.._ .......__..�. MAai�'�...iAei�ala <br />COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE <br />CLAIMS -MADE [- <br />OCCUR DAMAGE TO RENTED Pr)' t$E$ V9uik.IS ) 1.. ...,.,, <br />MEN EXP, An one -person) <br />...-... �.- _.m PERSONAL & ADV INJURY $ <br />POLICY AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE <br />PRO- <br />�... .� JECT" LOC PRODUCTS - GOMP/OP AGG $ <br />_. .. <br />OTHER: <br />AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT <br />I ss7Grl ) $. ..... ... <br />ANY AUTO <br />BODILY I . Per erson $, . <br />AUTOS ONLY _ AUTOS BODILY INJURY (Per,acadenI) - -_ <br />AUti ti ONLY A4J� NFeAiEudetAhti/ GF.... $ <br />UMBRELLA LIAB OCCUR EACH OCCUENCE RR $ <br />..... <br />EXCESS LIAR CLAIMS -MADE <br />AGGREGATE $,,... . <br />DE) RETENTION $ $ <br />........ YEN..____... 5300002258201 5/1/20_._ <br />A WORKERS COMPENSATION _ X PER FORTH <br />AND EMPLOYERS' LIABILITY .,TATUTF _ <br />ANY PROPRIETOR/PARTNER/EXECUTIVE � 2O 5/1/2021 500,000 <br />FFPGERIMEMBER EXCLUDED? N / A E.L. DISEASE GEA EMPLOYEE $ <br />(Mandatory in NH)-_.._..-11 500,000 <br />If yes, describe under <br />_�_ <br />DESCRIPTION OF OPERATIONS belowE.L. DISEASE POLICY LIMIT $ 500,00(I <br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />City of South Bend Indiana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />Department of Community Investment <br />227 W. Jefferson Boulevard, Suite 1400 S. --- ........ <br />South Bend, IN 46601 AUTHORIZED REPRESENTATIVE <br />...................... <br />....... ...... _._...._. <br />ACORD 25 (2016/03) ... ©1988 2015 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORD <br />