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INSR ADDL SUBR
<br />LTR INSR WVD
<br />DATE (MM/DD/YYYY)
<br />PRODUCER CONTACT
<br />NAME:
<br />FAXPHONE
<br />(A/C, No):(A/C, No, Ext):
<br />E-MAIL
<br />ADDRESS:
<br />INSURER A :
<br />INSURED INSURER B :
<br />INSURER C :
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />POLICY NUMBER
<br />POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY)
<br />COMMERCIAL GENERAL LIABILITY
<br />AUTOMOBILE LIABILITY
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />AUTHORIZED REPRESENTATIVE
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />Y / N
<br />N / A
<br />(Mandatory in NH)
<br />ANY PROPRIETOR/PARTNER/EXECUTIVE
<br />OFFICER/MEMBER EXCLUDED?
<br />EACH OCCURRENCE $
<br />DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR
<br />MED EXP (Any one person)$
<br />PERSONAL & ADV INJURY $
<br />GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:
<br />PRODUCTS - COMP/OP AGG $
<br />$
<br />PRO-
<br />OTHER:
<br />LOCJECT
<br />COMBINED SINGLE LIMIT
<br />$(Ea accident)
<br />BODILY INJURY (Per person)$ANY AUTO
<br />OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS
<br />AUTOS ONLY
<br />HIRED PROPERTY DAMAGE $AUTOS ONLY (Per accident)
<br />$
<br />OCCUR EACH OCCURRENCE $
<br />CLAIMS-MADE AGGREGATE $
<br />DED RETENTION $$
<br />PER OTH-
<br />STATUTE ER
<br />E.L. EACH ACCIDENT $
<br />E.L. DISEASE - EA EMPLOYEE $
<br />If yes, describe under
<br />E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below
<br />POLICY
<br />NON-OWNED
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<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 />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 />COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:
<br />CERTIFICATE HOLDER CANCELLATION
<br />© 1988-2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)
<br />ACORDTM CERTIFICATE OF LIABILITY INSURANCE
<br />National Fire Insurance Co of Hartford
<br />The Continental Insurance Company
<br />Valley Forge Insurance Company
<br />Berkley Insurance Company
<br />American Casualty Co of Reading, PA
<br />10/14/2022
<br />EPIC Insurance Midwest
<br />P.O. Box 80159
<br />Indianapolis, IN 46280
<br />Brian Hopton
<br />812-478-6041
<br />Brian.Hopton@epicbrokers.com
<br />American Structurepoint, Inc.
<br />9025 River Road
<br />Suite #200
<br />Indianapolis, IN 46240
<br />20478
<br />35289
<br />20508
<br />32603
<br />20427
<br />A X
<br />X
<br />X X
<br />X X 6050367892 11/01/2022 11/01/2023 1,000,000
<br />1,000,000
<br />15,000
<br />1,000,000
<br />2,000,000
<br />2,000,000
<br />E
<br />X
<br />X X
<br />X X 6050364572 11/01/2022 11/01/2023 1,000,000
<br />B X X
<br />X 10000
<br />X X 6050364555 11/01/2022 11/01/2023 10,000,000
<br />10,000,000
<br />C
<br />N
<br />X 6050364569 11/01/2022 11/01/2023 X
<br />1,000,000
<br />1,000,000
<br />1,000,000
<br />D Professional
<br />Liability
<br />AEC905502406 05/29/2022 05/29/2023 $5,000,000 Per Claim
<br />$5,000,000 Aggregate
<br />Anyone person or organization, as required by written contract or agreement requiring insurance, is
<br />included as additional insured with respect to the General Liability and Automobile Liability policies.
<br />Coverage on the General Liability and Automobile policies is primary and non-contributory where required by
<br />written contract or agreement.
<br />A waiver of subrogation in favor of any person or organization, signed prior to a loss, as required by
<br />(See Attached Descriptions)
<br />City of South Bend Department of
<br />Public Works
<br />227 W. Jefferson Blvd. 13th
<br />Floor
<br />South Bend, IN 46601-0000
<br />1 of 2
<br />#S4332762/M4330913
<br />AMERSTRClient#: 34734
<br />BHOPT
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