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CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 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 certifi cate 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 certifi cate does not confer rights to the certifi cate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: PHONE (A/C, NO, EXT): FAX (A/C, NO): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME 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. INSR LTR TYPE OF INSURANCE ADDTL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY)LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea Occurrence)$ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN’L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ POLICY PROJECT LOC PRODUCTS - COMP/OP AGG $ OTHER:$ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident)$ ANY AUTO BODILY INJURY (Per person) $ OWNED AUTOS ONLY SCHEDULED AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS ONLY NON-OWNED AUTOS ONLY PROPERTY DAMAGE (Per accident)$ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $$ WORKERS COMPENSATION AND EMPLOYERS ‘ LIABILITY N/A PER STATUTE OTHER $ ANY PROPRIETOR/PARTNER/ EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y/N E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All Rights Reserved The ACORD name and logo are registered marks of ACORD ACORD 25 (2016/03) 31-1769 11-15 ELIVERED IN ACCORDANCE WITH THE PO 015ACORDCORPORATION Al Lafayette Jenna Isch(3670363) 2606 Veterans Memorial Pkwy S Ste 6 765-838-2781 03/05/2021 888-670-9912 jisch@farmersagent.comIN 47909-9192 LAFAYETTE Truck Insurance Exchange 21709 Allied World Surplus Lines Insurance Co 24319 TOTAL HOME BY DJ, L.L.C.LM Insurance Corporation 33600 3510 US HIGHWAY 52 S STE 2 IN 47905 B 1,000,000 50,000 5,000 N 1,000,000 2,000,000 N 5057-4409 01/14/2020 01/14/2021 2,000,000 A 1,000,000 N N 605449660 04/01/2021 C Y N WC539S373186020 500,000 500,000 500,000 B Contractor's Pollution Liability N N 5057-4409 01/14/202 01/14/2021 Each Occ./Agg.1,000,000 City of South Bend c/o Board of Public Works 227 West Jefferson Blvd South Bend IN 46601 04/01/2020 07/18/202107/18/2020