Change Order No 1 - Small Drainage & Design Repair - Sampson & Overlook Proj No. 118-063 - HRP Construction, Inc.

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DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 08/06/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER Theresa Burns NAME: FAX PHONE Gibson Insurance Agency, Inc.(800) 814-2122(800) 836-2122 (A/C, No): (A/C, No, Ext): E-MAIL 202 S.Michigan St., Suite 1400tburns@gibsonins.com ADDRESS: INSURER(S) AFFORDING COVERAGENAIC # South BendIN46601National Trust Ins Co20141 INSURER A : INSURED FCCI Ins Co10178 INSURER B : G. E. Marshall, Inc.Travelers Prop Cas Co of Amer25674 INSURER C : 1351 Joliet Road INSURER D : PO Box 242 INSURER E : ValparaisoIN46384 INSURER F : 7-15-20/21 Liab Updated COVERAGESCERTIFICATE NUMBER:REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDLSUBR INSRPOLICY EFFPOLICY EXP TYPE OF INSURANCELIMITS POLICY NUMBER LTR(MM/DD/YYYY)(MM/DD/YYYY) INSDWVD COMMERCIAL GENERAL LIABILITY 2,000,000 EACH OCCURRENCE$ DAMAGE TO RENTED 2,000,000 CLAIMS-MADEOCCUR$ PREMISES (Ea occurrence) XCU10,000 MED EXP (Any one person)$ AContractual LiabilityCPP10005076907/15/202007/15/20212,000,000 PERSONAL & ADV INJURY$ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$ PRO- 2,000,000 POLICYLOCPRODUCTS - COMP/OP AGG$ JECT Per Project AggregateIncluded $ OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY 1,000,000 $ (Ea accident) ANY AUTOBODILY INJURY (Per person)$ OWNEDSCHEDULED ACA10000392807/15/202007/15/2021 BODILY INJURY (Per accident)$ AUTOS ONLYAUTOS HIREDNON-OWNEDPROPERTY DAMAGE $ (Per accident) AUTOS ONLYAUTOS ONLY $ UMBRELLA LIAB 5,000,000 OCCUREACH OCCURRENCE$ B EXCESS LIAB UMB10004968507/15/202007/15/20215,000,000 CLAIMS-MADEAGGREGATE$ 0 DEDRETENTION$$ PEROTH- WORKERS COMPENSATION STATUTEER AND EMPLOYERS' LIABILITY Y / N 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT$ BN N / A WC010005936107/15/202007/15/2021 OFFICER/MEMBER EXCLUDED? 1,000,000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE$ If yes, describe under 1,000,000 DESCRIPTION OF OPERATIONS belowE.L. DISEASE - POLICY LIMIT$ Limit$14,000,000 Excess Liability CZUP16N5664020NF07/15/202007/15/2021Deductible$10,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: Small Drainage Design & Repair project #118-063 GEM #3098; Certificate holder is additional insured (primary) with respect to general liability and auto liability coverages regarding work performed by the insured. OID 1-3-18 CERTIFICATE HOLDERCANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of South Bend, Indiana 227 W Jefferson Blvd AUTHORIZED REPRESENTATIVE South BendIN46601 © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03)The ACORD name and logo are registered marks of ACORD