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A4CCPR1:> CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) <br />08/20/2021 <br />THIS E TIFI T IS ISSUED AS A MATTER OF INFORMATION L CONFERS 1 TS UPON THE CERTIFICATE HOLDER. THIS <br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND, EXTEND LT THE COVERAGE AFFORDED BY THE POLICIES <br />BELOW. THIS CERTIFICATE F INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), TH IZE <br />REPRESENTATIVE OR PROUCE , AND THE CERTIFICATE HOL E . <br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, thepolicy(les) must have ADDITIONAL INSURED provisior s or -be endorsed. <br />If SUBROGATIONIS WAIVED, subject to the terms and conditions of the policy, certain policies may require anendorsement. A statement on <br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />PRODUCER CONTACT <br />AME CT Danielle Hunt <br />Gibson insurance Agency, Inc. PHONE {800) 814-2122 FAX {800 836-2122 <br />A/C No. Ext): A/C No : <br />202 S Michigan St, Suite 1400 E ®AIEss: dhunt@thegibsonedge.com <br />South Bend <br />INSURED <br />HRP Construction Inc. <br />PO Box 266 <br />South Bend <br />INSURER(S) AFFORDING COVERAGE NAIC <br />IN 46601 INSURER A: Amerisure Ins Co 19488 <br />INSURER B: Amerisure Mut Ins Co 23396 <br />INSURER C: <br />INSURER D: <br />INSURER E: <br />IN 46624-0266 1 INSURER F: <br />CERTIFICATE E a 9-1-21/22 Liability <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_ I IMITS SHMM UAV WA1/F Rl=;=Kf Rl=rni ir`r:rn Rv DAM r-1 ®IRAQ <br />INSR <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />INSD <br />SUBR <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MM/DD <br />POLICY EXP <br />MM/DD/YYYY <br />LIMITS <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE $ 1,000,000 <br />I -] CLAIMS -MADE OCCUR <br />1,000,000 <br />PREMISES Ea occurrence $ <br />XCU <br />MED EXP (Any one arson) $ 10,000 <br />A <br />Contractual Liability, <br />CPP20316441701 <br />09/01/2021 <br />09/0112022 <br />PERSONAL&ADV INJURY $ 1,000,000 <br />GEN'LAGGREGATE LIMITAPPLIES PER: <br />GENERAL AGGREGATE $ 2,000,000 <br />POLICY PRO- <br />JECT a LOC <br />PRODUCTS-COMP/OPAGG $ 21000,000 <br />$ <br />OTHER: <br />AUTOMOBILE LIABILITY <br />E aBINED SINGLE LIMIT $ 1,000,000 <br />ANY AUTO <br />BODILY INJURY (Per person) $ <br />B <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />CA20316451702 <br />09/01/2021 <br />09/01/2022 <br />BODILY INJURY (Per accident) $ <br />HIRED X NON -OWNED <br />AUTOS ONLY AUTOS ONLYpeC <br />PROPERTY DAMAGE <br />accident <br />$ <br />UMBRELLA UAB <br />XOCCUREACH <br />OCCURRENCE $ 10,000,000 <br />B <br />EXCESS LIAB <br />CLAIMS -MADE <br />CU20316431602 <br />09/01/2021 <br />09/01/2022 <br />AGGREGATE $ 10,000,000 <br />DED I X RETENTION $ 0 <br />$ <br />WORKERS COMPENSATION <br />X1 <br />AND EMPLOYERS' LIABILITY Y / N <br />SPER TATUTE EOTTH <br />E.L. EACH ACCIDENT $ 1,000,000 <br />A <br />ANY PROPRIETORIPARTNER/EXECUTIVE <br />OFFICERIMEMBEREXCLUDED? N <br />N/A <br />WC203164216 <br />09/01/2021 <br />09/01/2022 <br />E.L. DISEASE - EA EMPLOYEE $ 1,000,000 <br />(Mandatory In NH) <br />If yes, describe under <br />E.L. DISEASE - POLICY LIMIT $ 1,000,000 <br />DESCRIPTION OF OPERATIONS below <br />•••>•••••••,• ...+•� v. v. ..."r Swivv a ( Vr_n1%A_r_7 kM%.'Vr%U 9u t, muumDnai memarKs bcneauie, may tie attacnea it more space is required] <br />City of South Bend Board of Public Works <br />227 West Jefferson, 13th Floor <br />South Bend <br />IN 46601 <br />AUTHORIZED REPRESENTATIVE <br />@ 1988-2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD <br />