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COMMERCIAL UMBRELLA DECLARATION <br />INDIANA FARM <br />fflow"M BUREAU INSURANCE(D <br />Zi'-yNO. Transaction R=E TAL BUSINESS <br />B 8609087 01 <br />From 0 8 / 21 / 2 0 2 3 to 0 8 / 2 2 -_2 ' at I2:01 a.m. Standard Time at the described location <br />Agent: Name and Phone Address <br />JACOB KELLEY 2410 EDISON RD, SUITE 400 <br />574-400-4389 SOUTH BEND IN 46615-3518 <br />7601102 762 <br />Named Insured <br />NIEZGODSKI P-_��3-:;^, - <br />2 3 2 N 1M1AYE=O a <br />SOUTH BE _:C--. __ <br />Business Description Type of Business <br />PIrt MRIL:C v `,=_K C-="- CORPORATION <br />LIMIT OF INSURANCE <br />Policy Aggregate Limit 2, c, c o 0 <br />Self -Insured Retention s, -; , 000 <br />SCHEDULE OF UNDERLYING INSURANCE REQUIREMENTS <br />If policies providing the required "underlying insurance' indicated by "X" in Column A are either reduced, cancelled, <br />discontinued or non-existant, the named insured's minimum "retained limit" is equal to the following: <br />Type of <br />A <br />Liability Insurance Limits of Insurance <br />x <br />General Liability <br />General Aggregate $2, 000, 000 <br />Products - Completed Operations Aggregate 2 000 <br />Personal and Advertising Injury <br />Each Occurrence $1, floor coo_ <br />_x. <br />Auto Liability <br />Each Accident <br />or <br />Bodily Injury Each Person <br />Bodily Injury Each Accident <br />Property Damage Each Accident <br />or <br />Combined Single Limit BI Liability/PD Liability <br />Uninsured/ <br />Bodily Injury Each Person: <br />Underinsured <br />Bodily Injury Each Accident: <br />Motorist Liability <br />x <br />Employer's Liability <br />Bodily Injury Each Accident $500, 000 <br />Bodily Injury By Disease Policy Limit $500 , 000 <br />Bodily Injury By Disease Each Employee 5500, 000 <br />Forms and Endorsements Applicable to this policy: See Attached Schedule <br />TOTAL PREMIUM: $2, 65C . 00 <br />Issued Date: 07/04/2022 <br />Authorized Representative <br />22-27212-93 INSURED 00154-00003 Page 1 of 1 <br />