Opening of Bids - 2023 Water Works Utility Service Line Repair Program - Niezgodski Plumbing Inc.

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DATE (MMIDDIYYYY) A�oRo CERTIFICATE OF LIABILITY INSURANCE 01/041202308:48 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). PRODUCER Galvan, Brandon CONTACT NAME: _ PHONE (574)400-4389 Fax AIC Na '� E-MAIL Brand on.Galvan@infarmbureau ,com ADDRESS: 2410 Edison Rd, Suite 400 INSURERS AFFORDING COVERAGE NAIL# South Bend, IN 46615 IIVSURERA:—United Farm Family Mutual Insurance Company 15298 INSURED _ INSURER B : INSURERc_— NIETGODSKI PLUMBING, INC 23214 MAYFLOWER RD SOUTH BEND, IN 46619-1534 INSURER D: INSURER E : INSURER F : rrVERAr_Ec GERTIFICATiF NUMRFR: 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. INSR LTR TYPE OF INSURANCE ADDL SUBR V POLICY NUMBER POLICY EFF MMfDDlYYYY POLICY EXP MMIDD LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_1 OCCUR ; BOP8236911 08121 /2022 08121 /2023 €€ EACH OCCURRENCE I $ 1 000 000 DAMAGE TO RENTED PREMISES (Ea occurrence $ 50 000 MED EXP (Any one person) $10000 PERSONAL & A➢v INJURY $1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER: X � PRO - POLICY u LOG OTHER: GENERAL AGGREGATE $ 2 000 000 PRODUCTS - COMPIOP AGG $ 2 000 000 A AUTOMOBILE LIABILITY ANY AUTO OWNED X SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED X AUTOS ONLY X AUTOS ONLY CAP8524976 0912112022 08/21 /2D23 EO BINEDtSINGLE LIMIT $1,000,000 BODILY INJURY (Per person) $ BODILY INJi1RY (Peraccidenl) $ PROPERTY DAMAGE Per accident $ I $ A X UMBRELLALIAB EXCESS LIAB OCCUR CLAIMS -MADE UMBS609087 08/21/2022 I �08/21/2023 EACH OCCURRENCE $ Ll AGGREGATE $2,000,000 -- DED RETENTION $10,000 ! $ A WORKERS COMPENSATION ANU EMPLOYERS' LIABILITY ANYPROPRIETORIPARTNER1EXECUTiVE YIN OFFICER/MEMBEREXCLUDEO? (Mandatary in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NrA WC 8341646 08l21/2022 08I2112023 X, PER OTH- STATUTE ER -- -" ""--"- E.L. EACH ACCIDENT $ 1 000 000 ; E.L. DISEASE - EA EMPLOYEE $ 1,0 D0,000 E.L. ➢ISEASE - POLICY LIMIT $ 1.000.000 I DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) L"=Iz41I2LMl 3 City of South Bend Board of Public Works 227 W Jefferson Blvd #1316 South Bend, IN 46601 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 13E DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Galvan, Brandon v raoV-cV r.. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD