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CMc Proposal for City of South Bend — Four Winds Renovation and Expansion Project u 30
<br />CERTIFICATE OF INSURANCE AND BONDING
<br />INSR ADDL SUBRLTRINSRWVD
<br />DATE (MM/DD/YYYY)
<br />PRODUCER CONTACTNAME:FAXPHONE(A/C, No):(A/C, No, Ext):
<br />E-MAILADDRESS:
<br />INSURER A :
<br />INSURED INSURER B :
<br />INSURER C :
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />POLICY NUMBER 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/EXECUTIVEOFFICER/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 $(Ea accident)
<br />BODILY INJURY (Per person)$ANY AUTO
<br />OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS
<br />AUTOS ONLYHIRED PROPERTY DAMAGE $AUTOS ONLY (Per accident)
<br />$
<br />OCCUR EACH OCCURRENCE $
<br />CLAIMS-MADE AGGREGATE $
<br />DED RETENTION $$
<br />PER OTH-STATUTE ER
<br />E.L. EACH ACCIDENT $
<br />E.L. DISEASE - EA EMPLOYEE $If yes, describe under 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 />Zurich American Insurance Co.
<br />Travelers Property Casualty Co. of Amer
<br />AGCS Marine Insurance Company
<br />8/31/2023
<br />MJ Insurance, Inc.
<br />PO Box 3430
<br />Carmel, IN 46082-3430
<br />317 805-7500
<br />MJ Insurance, Inc.
<br />317 805-7542 317 805-7515
<br />certificate@mjinsurance.com
<br />Hagerman, Inc.
<br />P.O. Box 11848
<br />Fort Wayne, IN 46861-1848
<br />16535
<br />25674
<br />22837
<br />A X
<br />X
<br />X XLU
<br />X CONTRACTUAL LIAB
<br />X X
<br />Y Y GLO9809049 04/01/2023 04/01/2024 2,000,000
<br />1,000,000
<br />10,000
<br />2,000,000
<br />4,000,000
<br />4,000,000
<br />A
<br />X
<br />X X
<br />X PHYS DAMAGE
<br />Y Y BAP9809048 04/01/2023 04/01/2024 2,000,000
<br />B X X
<br />X 10,000
<br />Y Y CUP1T96253722NF 04/01/2023 04/01/2024 25,000,000
<br />25,000,000
<br />A
<br />N
<br />Y WC9809047
<br />3A STATES INCL
<br />TX
<br />3C STATES EXCL
<br />04/01/2023
<br />IN IA KS
<br />ND OH WA
<br />04/01/2024
<br />KY MI MO
<br />WY
<br />X
<br />1,000,000
<br />1,000,000
<br />1,000,000
<br />C
<br />C
<br />INSTALL MATERIALS
<br />TEMP LOC &TRANSIT
<br />PROP - OWNED LOCS
<br />MZI93085362
<br />MZI93085362
<br />04/01/2023
<br />04/01/2023
<br />04/01/2024
<br />04/01/2024
<br />500,000 LIMIT; 5000 DED
<br />NON-OWNED LOCATIONS
<br />450,000 LIMIT; 5000 DED
<br />The additional insured and waiver of subrogation boxes above are marked based on the policy information
<br />shown below.
<br />The Certificate Holder and others as defined in the written agreement and the General Liability additional
<br />insured endorsement UGL2162ACW 02/19 (see attached endorsement) and Automobile Liability endt CA2048 10/13
<br />(See Attached Descriptions)
<br />City of South Bend
<br />Office of the Board of Public Works
<br />County-City Building, Room 1316
<br />227 W Jefferson Blvd
<br />South Bend, IN 46601-0000
<br />1 of 2#S1536083/M1499210
<br />HAGECONClient#: 12550
<br />DMD11of 2#S1536083/M1499210
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