Opening of Applications - 2024 Sewer Insurance Lateral Repair Program - Niezgodski Plumbing

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A�� CERTIFICATE OF LIABILITY INSURANCE 02101120244118: 8 ` THIS CERTIFICATE 1S 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 rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: KeUey, Jacob PHONE FAX --_ 2410 Edison Rd, Suite 400 E-MAIL Ext : (574) 400-4389 pdc No : ADDRL Jacob.Ketley@infarmbureau.com South Bend, 1N 46615 ` ENSURED NIEZGODSKI PLUMBING, INC 232 N MAYFLOWER RD SOUTH BEND, IN 46619-1534 _ INSURER(S) AFFORDING COVERAGE INSURERA: United Farm FamilyMutuat Insurance Company _N_AIC_4 15288 INSURERB: ------- -...-- 1NSURERC: INSURERD: _ COVERAGES CFRTIFIr ATF NI II1dr{FR• oC71ICInRI Rn IRAaco. THIS IS TO CERTIFY THAT THE POLIGIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL'SUBR POLICY EFF POLICY EXP !TR TYPE OF INSURANCE POLICY NUMBER MMIDD I(MMIDDNYYYI LIMITS X COMMERCIAL GENERAL LIABILITY I' EACH OCCURRENCE $1,000,0 )0 CLAIMS X OCCUR M O R TE -MADE i I PREMISES Ea acrurrence $ 50 000 MED EXP (Any vne person) ` $10 000 PFRSONAL & AnV INJURY $1,000, 00 A BOP8236911 08/21/2023 08/21/2024 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE X POLICY ja _$2000,000 _1 LOC ? PRODUCTS-COMPfOPAGG $Q 000,000 1 $ OTHER: AUTOMOBILE - - LIABILITY j COMBINED SINGLE LIMIT Ea acciden1��! $ 1,00o,a0a BODILY INJURY (Per person} r $ �— ANY AUTO j A OWNED SCHEDULED AUTOS ONLY X AUTOS CAPS524976 08121 /2023 08121 /2024 j BODILY INJURY (Per accident) $ HIRED ? NON -OWNED X F X PROPERTY DAMAGE - $ - -- AUTOS ONLY AUTOS ONLY i Per accident i $ X UMBRELLALIA6 OCCUR I EACH OCCURRENCE $ $2,D00,000 A EXCESS LIM CLAIMS -MAD= UMS8609087 08/21/2023 08/21/2024 DED RETENTION $10.000 ��REGATE — $ WORKERS COMPENSATION J PER OTH- ANDEMPLOYERS'LIA131UTY YIN XI UTE. ER__ _. E.L. EACH ACCIDENT A ANYPROPRIETORIPARTNERfEXECUTIVE OFFICERfMEMBEREXCLUDEO? ❑ NIA WC 8341646 .08/2112023 08/21/2024 $ 1 000 O0O E.L. DISEASE -EAEMPLOYEF� S1,000,000 (Mandatory in NH) If yes, descride under --- ------ ---- ____ DESCRIPTION OF OPERATIONS below F.L. DISEASE -POLICYLI�$ 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) CFRTIFIrATF i4ni ITFR relurr-1 I ATInlu City of South Bend Board of Pubiic Works 227 W Jefferson BLVD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, South Bend 46601- AUTHORIZED REPRESENTATIVE Kelley, Jacob C71988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD