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.4CORa'a <br />CERTIFICATE OF LIABILITY INSURANCE <br />DATE (MMIDDIVYM <br />0411112023 <br />THIS CERTIFICATE 13 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 poiicy(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 rights to the certificate holder in lieu of such endorsement(*). <br />PRODUCER <br />NAM£: NTAGT Jessica Roush <br />PHaRE . (574) 231-6574 IrAX <br />NC p (574) 25MI77 <br />Synergy LLC <br />ED"DRE roush s nor insuran. <br />oDREss• 3 L Y 9Y oBgroup,com <br />13800 Jackson Road <br />INSURER 8 AFFORDING COVERAGE <br />NAIL/ <br />INSURER A. K& K INSURANCE <br />Mishawaka IN 46544 <br />INSURED <br />INSURER D: INDIANA FARMERS MUTUAL INS Co <br />22624 <br />St. Joseph County 4-H Fair, Inc. <br />INSURER <br />INSURERD: <br />5117 Ironwood Road <br />INSURER E: <br />South Bend IN 46614 <br />INSURER <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NA ALD A30VF FOR THE POLICY PERIOD <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT <br />TO WHICH THIS <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DE9CRIHFD HEREIN IS SUBJECT TO ALL <br />THE TERMS, <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM'S. <br />POLICY E:XP <br />I <br />LTR TYPEorINSURANCE JNSD WVDBURR! ICYNUMBER - pwn�E JIM'DDYYYY <br />LIMITS <br />X COrrE41ERCIALCENERALLIABR•ITY <br />CLAIMS -MADE FRI OCCUR <br />EACHOCCURRENGE <br />SE 0 RENTED a occurren <br />$ 1,000,000 <br />$ tX},aQt} <br />MED EXP Any one perwin) <br />$ 10,000 <br />A _ KKO0000026396700 3/1912023 311912024 <br />PER80NAL&ADV INJURY <br />3 1.000,000 <br />CEN'LAGGREGATELIMITAPPLIESPER, <br />X POLICY L0C <br />GENERAL AGGREGATE <br />PRODUCTS <br />PRODUCTS-COMProP AGO <br />$ 5.000,000 <br />$ 5,000,000 <br />OTNER: <br />$ <br />AUTOMOBILE <br />LIABILITY <br />GVMBINED SINGLE LIMIT <br />jEa accident] <br />$ 1 ��•OD� <br />X <br />_ <br />BODILY INJURY [Per person] <br />AW AUTO <br />$ <br />B <br />OWNED AU_0S.1LED <br />ALITOSONLY AV-05 <br />CAP1012112 <br />3/19/2023 <br />311912024 <br />BODILY INJURY Per accldent) <br />� <br />$ <br />FRO TYDAMAGE <br />$ <br />HIRED NON-U I,'dNED <br />ALrrOSONLY AUTOS ON LY <br />UMBRELLALL4B <br />OCCUR <br />EACH OCCURRENCE <br />$ 5,000,000 <br />AGGREGATE <br />S 5,000,000 <br />A <br />EXCESS LIAR <br />CLAIPAS-MADE <br />XK00000025396900 <br />3/1912023 <br />311912024 <br />DEU RETENTION $ <br />$ <br />g <br />WORKERSCOMPENSATION <br />AND EMPLOYERS' LIABILITY <br />&NYFRCPaIETORrARTNER;EXECUTIVE YIN <br />r.FFICERWE.MBEREXCLUDED9 <br />(Mandatory in NH) <br />NIA <br />WCP1008824 <br />3/1912023 <br />311912024 <br />� STA STATUTE ER <br />E.L. EACH ACCIDENT <br />$ 50o,000 <br />E-L. DISEASE - EA EMPLOYEE <br />$ 500,000 <br />I <br />If yes, nescribe under DESCRIPTION <br />DESCRIPTION OF OPERATIONS below <br />E.L. DISEASE- POLICY LIMIT <br />$ <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additi01lal RB111anc9 Schedu 10, may Be attached it more Space is required) <br />L.CISIIr7L.fLIC NVLUCK %HJANk. CLLAI I IUN <br />S H O U L D AN Y O F TN E ABOVE DESC RIB ED POLICIES BE CAN CELLE D H E FO R E <br />THE= EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />City of South Bend ACCORDANCE: WITH THE POLICY PROVISIONS. <br />227 West Jefferson BIVd. AUTHORIZEDREPRESENTATIVE <br />South Bend IN 46601 <br />©1988-2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25(2016103) The ACORD name and logo are registered marks ofACORD <br />