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ACa CERTIFICATE OF LIABILITY INSURANCE L:�21112023 <br />( YVY) <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 rights to the certificate holder in lieu of such aendorsement s . <br />PRODUCER NAME <br />PHONE FAX <br />ROCKSTROH INS AGENCY INC IAIc, No, Ext): (574)233-5136 (A//C, No): (574)232-2991 <br />E-MAIL <br />333 N Lafayette Blvd ADDRESS: rockagcyl@outlook.com <br />South Bend, IN 46601-1208 INSURER(S) AFFORDING COVERAGE NAIC p <br />INSURER AUTO -OWNERS INSURANCE <br />INSURED INSURER B <br />SOUTH BEND CINCO LLC INSURER C. <br />dba CINCO 5 INSURER D: <br />112 W COLFAX AVE INSURER E. <br />SOUTH BEND IN 4&601 INBURERF: <br />REVISION NUMBER: <br />M <br />COVERAGES CERTIFICATE NUBER: <br />TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED <br />OR OTHER <br />DOCUMENT WITH RESPECT TO WHICH THIS <br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT <br />POLICIES DESCRIBED <br />HEREIN IS SUBJECT TO ALL THE TERMS, <br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFOROCO BY THE <br />LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS <br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES <br />POLICY EFF POLICY EXP <br />LIMITS <br />lNSfi 'ADDLSUBR, <br />t FR TYPE OF INSURANCE POLICY NUMBER MMft7DI1rYYY MMlDDryWY <br />$ 1,000,000 <br />X COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />DAMAGE TO 5O 000 <br />CLAIMS -MADE OCCUR <br />PREMISESS((Ea occurrence) - r <br />MED EXP (Any one person) + i 5,000 <br />09150919-22 10/1612022 10/16/2023 <br />PERSONAL a ADV INJURY $ 1,000,000 <br />A <br />GENERAL AGGREGATE S 2,000,000 <br />GEN'L AGGREGATE LIMIT APPLIES PER <br />PRODUCTS - COMPIOP AGG $ 2,000,000 <br />PRO_ C <br />X POLICY JCCT LO <br />$ <br />- <br />OTHER — - — <br />COMBINED SINGLE UM IT S <br />AUTOMOBILE LIABILITY <br />lea accldurtl) <br />BODILY INJURY (Per person) $ <br />ANY AUTO <br />I BODILY INJURY (Per accldenl) $ <br />1 OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />PROPERTY DAMAGE $ <br />HIRED NON -OWNED <br />(PeracGdb0t) <br />All TOS ONLY AUTOS ONLY <br />$ <br />I <br />EACH OCCURRENCE S <br />UMBRELLA LIAR OCCUR <br />S <br />EXCESS LIAR CLAIMS -MADE <br />1 AGGREGATE <br />3 _ <br />CE13 Rr. TENTIONS, — - <br />PER <br />STATUTE ER <br />WORKERS COMPENSATION <br />, <br />AND EMPLOYERS' LIABILITY YIN <br />E.L. EACH ACCIDENT S <br />J, <br />ANY PROPRIETORIPARTNERrEXECUTIVE <br />N I A <br />OFFICFRIMEMBER EXCLUDED? J <br />�J <br />E L. DISEASE- EA FAIPLOYE $ <br />(Mandatory in NH) <br />LIMIT l S <br />II ves, descebe ure161 _ <br />E L QSSEI1See - POLICY <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) <br />ADDITIONAL INSURED - CITY OF SOUTH BEND <br />C ERTIF <br />Tc Lint nsr-P <br />BOARD OF PUBLIC WORKS <br />1316 COUNTY CITY BUILDING <br />227 W JEFFERSON BLVD <br />SOUTH BEND, IN 46601 <br />ACORD 25 (2016/03) <br />N <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 />The ACORD name and logo are registered <br />© 9 -2015 ACORD CORPORATION. All rights reserved. <br />narks of ACORD <br />