|
Client#: 99762 CHICCAF
<br />ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
<br />06/19/2020
<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 />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 any rights to the certificate holder in lieu of such endorsement(s).
<br />PRODUCER kRAJ4CTAbby Grim
<br />ONI Risk Partners
<br />O y
<br />(A 260 625 7216 (AIC 260 625 7525
<br />1111 Chestnut Hills Parkway E-MAIL
<br />abb grim@onirisk.com
<br />com
<br />Fort Wayne, IN 46814
<br />INSURER(S) AFFORDING COVERAGE NAIC 0
<br />- ---- _ .. �
<br />INSURER A: SOCIETY INSURANCE, a mutual company 15261
<br />— — INSURER ....... ... ......
<br />INSURED INSURER g Zenith Insurance Company 13269
<br />Chicory of South Bend, Inc. dba Chicory .......... .. ........ .
<br />Cafe C '
<br />INSURER Dr
<br />105 E Jefferson Blvd. ...... .....
<br />South Bend, IN 46601 INSURER E
<br />COVERAGES CERTIFICATE NUMBER:
<br />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 CONTF(ACT OR OTHER DOCUMENT WITH RESPECT
<br />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
<br />BEEN REDUCED BY PAID CLAIMS.
<br />INSR
<br />TYPEOFINSURANCE
<br />ADDLSUBRT
<br />INSR
<br />MP
<br />NM
<br />POLICY UBER
<br />PMY VY
<br />(LTR
<br />POL P
<br />LIMITS
<br />A
<br />X
<br />COMMERCIAL GENERAL LIABILITY
<br />BP20004925
<br />3/01/2020
<br />03/01/2021
<br />EACH OCCURRENCE
<br />$1 'OOOiOOO
<br />.............
<br />lIY
<br />..... CLAIMS -MADE XI OCCUR
<br />'..., ;...
<br />P�CSF,,Qr„Ha„Er,�,ct.a�ec0emna)„
<br />$ _._
<br />„------,,,-----_
<br />,,,,,,
<br />MED EXP fAny one person)
<br />$ 5,000 ......
<br />PERSONAL & ADV INJURY
<br />$1,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />_
<br />G
<br />GENERAL AGGREGATE
<br />$2a000,000
<br />PRO -
<br />POLICY JECT LOC
<br />PRODUCTS COMP/OP
<br />_
<br />OTHER.
<br />^,
<br />$
<br />A
<br />_.,.
<br />AUTOMOBILE LIABILITY
<br />CA20004926
<br />3/01/2020
<br />03/01/2021
<br />COMBINED SINGLE LIFT
<br />1 000 000
<br />X
<br />ANY AUTO
<br />BODILY INJURY (Per person)
<br />$
<br />OWNED
<br />AUTOS ONLY
<br />_
<br />SCHEDULED
<br />AUTOS
<br />- ................................................
<br />BODILY INJURY (Per accident)
<br />------
<br />$
<br />X
<br />AUTOS ONLY
<br />X
<br />NON -OWNED
<br />AUTOS ONLY
<br />`P
<br />PROPER DAMAGE
<br />(PeracddeM1
<br />A
<br />UMBRELLA X
<br />..�
<br />I
<br />occuR
<br />1
<br />UM20004928
<br />3/01/2 020
<br />03/01 /2021
<br />/01 /2
<br />EACHOCCURRENCE
<br />E
<br />000 OO
<br />, Q
<br />Excess LwBIAe
<br />CLAIMS MApE
<br />A
<br />$1
<br />X�
<br />,OOO,OOO
<br />DED REThdTINI'
<br />........... .........
<br />$
<br />B
<br />WORKERSCOMPENSATION
<br />Z136559701
<br />3/01/2020
<br />03/01/2021
<br />PER GTH
<br />11mF
<br />ED1
<br />ACCIDENT
<br />ECUTIVEFW
<br />4WF EX
<br />N / A
<br />EL, EACH
<br />$1001000
<br />(Mandatory In NH)
<br />E.L. DISEASE - EA EMPLOYEE
<br />$100 000
<br />If descptbe under
<br />.............a .. .,.,- ,,,
<br />as,
<br />DESORIPTpOA OF OPERATIONS below
<br />E L DISEASE POLICY LIMIT
<br />s500,000
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />** Supplemental Name **
<br />Chicory of South Bend, Inc. dba Chicory Cafe
<br />City Of South Bend SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />227 W Jefferson Blvd ACCORDANCE WITH THE POLICY PROVISIONS.
<br />South Bend, IN 46601
<br />AUTHORIZED REPRESENTATIVE
<br />©1988-2015 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2016/03) 1 of 1 The ACORD name and logo are registered marks of ACORD
<br />#S2536972/M2536971 AGRI1
<br />
|