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Client#: 99762 CHICCAF ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 4/12/2023 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 any rights to the certificate holder in lieu of such endorsement(g). PRODUCER NA°MT,NTAO'Abby Grim EPIC Insurance Midwest PHONE 260 625-7216 FAX 317 706-9988 1111 Chestnut Hills Parkway J pHo eg ° R°. grim�eplcl,rokers.com Fort Wayne, IN 46814 abby. INSURERJSl AFFMtNe COVERAGE NAIC # INSURER A: SOCIETY INSURANCE, a mutual company 15261 INSURED INSURER B : Zenith Insurance Company 13269 Chicory of South Bend, Inc. dba Chicory 105 E Jefferson Blvd. INSURER C : South Bend, IN 46601 INSURER D : INSURER E: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER - THIS INDICATED. CERTIFICATE EXCLUSIONS IS TO CERTIFY THAT THE POLICIES NOTWITHSTANDING ANY REQUIREMENT, MAY BE ISSUED OR MAY PERTAIN, AND CONDITIONS OF SUCH OF POLICIES. INSRL INSURANCE LISTED BELOW HAVE BEEN TERM OR CONDITION OF ANY THE INSURANCE AFFORDED BY THE LIMITS SHOWN MAY HAVE BEEN ISSUED TO CONTRACT OR POLICIES REDUCED MM/DDIYEY" J.A 03/01/2023 THE INSURED OTHER DOCUMENT DESCRIBED BY PAID CLAIMS. EXP fNMIDDY 03/01/202 NAMED ABOVE FOR THE POLICY PERIOD WITH RESPECT TO WHICH THIS HEREIN IS SUBJECT TO ALL THE TERMS, LIMITS EACH��OC7CURRENCE $1000000 LTRR TYPE OF INSURANCE tfYVD POLICY NUMBER X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR RP70004925 CA20004926 PREMISESOEa EccurrDence _ $ 3OO OOO MED EXP (Any one person) s5,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO - POLICY L7 ECT F-1 LOC OTHER: GENERAL AGGREGATE s2,000,000 PRODUCTS - COMP/OP AGG $2 000,000 $ A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY X AUTOS HIRED AUTOS ONLY X NON -OWNED AUTOS ONLY D3/01/2023 03/01/202 �D$BoINEeBISINGLEUMI 11,000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Pet aCadeirt $ _ $ A X UMBRELLA LIAR EXCESS LIAR NX OCCUR CLAIMS -MADE UM20004928 _ D3/01/2023 03/01/202 EACH OCCURRENCE $4 000 000 AGGREGATE s4.000.000 DED X RETENTION $0 $ B WORKERS COMPENSATION ANO EMPLOYERS' LIABILITY Y / N AFFIANY CERI RIErOR EXCLUD D7 ECUTIVE - (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A Z136559704 _ D3/01/2023 03/01/202 PER OTH- E.L EACH ACCIDENT $100 000 E.L. DISEASE - EA EMPLOYEE $1 OO 000 E.L. DISEASE - POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) ** Supplemental Name ** Chicory of South Bend, Inc. dba Chicory Cafe RE: Sidewalk Caf -105 East Jefferson Blvd The City of South Bend is listed as Additional Insured as respects General Liability as agreed in written contract/agreement. t,CM I It- IL.H I t MULUtIN CANCELLATION City of South Bend Board of Public Works 1316 County -City Building 227 W. Jefferson Blvd South Bend, IN 46601 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 ACORD 25 (2016/03) 1 of 1 #S5479319/M5313172 ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGRI1