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Opening of Applications - 2024 Water Works Utility Service Line Repair Program - Niezgodski Plumbing
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Opening of Applications - 2024 Water Works Utility Service Line Repair Program - Niezgodski Plumbing
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2/13/2024 3:04:08 PM
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2/13/2024 3:02:22 PM
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Board of Public Works
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Projects
Document Date
2/13/2024
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A�� CERTIFICATE OF LIABILITY INSURANCE 02101120244118: 8 ` <br />THIS CERTIFICATE 1S 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 endorsement(s). <br />PRODUCER CONTACT <br />NAME.• <br />Kelley, Jacob PHONE (574) 40p-4389 FAX <br />2410 Edison Rd, Suite 400 E MANa Ext : AIE Nat <br />ADDRL Jacob.Kelley@infarmbureau.com <br />South Bend, IN 46615 ` <br />INSURED <br />NIEZGODSKI PLUMBING, INC <br />232 N MAYFLOWER RD <br />SOUTH BEND, IN 46619-1534 <br />INSURER B : <br />INSURER C : <br />INSURER(S) AFFORDING COVERAGE NAICA <br />United Farm Family Mutual Insurance Company 15288� <br />COVERAGES CFRTIFIr ATF NI IIUIFtFR• oC71I0InKi Rn IRAaco. <br />THIS IS TO CERTIFY THAT THE POLIGIES 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 />INSR ADDL'SUBR i POLICY EFF POLICY EXP <br />LTR TYPE OF INSURANCE POLICY NUMBER MMIDD I MMIDDNYYYI LIMITS <br />X <br />COMMERCIAL GENERAL LIABILITY <br />� OCCUR <br />I <br />EACH OCCURRENCE $1,000,000 <br />—OAMCLAIMS-MADF <br />E O R TE <br />PREMISES Ea occurrence $ 50 000 <br />ME❑ EXP (Anyyne person) `. $10 000 <br />�... <br />PERSONAL&ACV INJURY $1,000, 00 <br />A <br />BOP8236911 <br />08/21/2023 <br />08/21/2024 <br />GEN'L <br />X <br />AGGREGATE LIMIT APPLIES PER: <br />POLICY j a C� LOC <br />I <br />? <br />GENERAL AGGREGATE <br />PRODUCTS- COMPfOPAGG I $2000 00 <br />1 $ <br />OTHER: <br />AUTOMOBILE <br />- <br />LIABILITY <br />j <br />COMBINED SINGLE LIMIT <br />Ea accident $ 1,OD0,00D <br />BODILY INJURY (Per person) r $ <br />[ <br />ANY AUTO <br />1 <br />AFOWNED <br />{ X SCHEDULED <br />AUTOS ONLY � AUTOS <br />CAPS524976 <br />08121 /2023 08121 /2024 i <br />BODILY INJURY Per accident) <br />( <br />$ <br />HIRED ? NON -OWNED <br />AUTOS ONLY XAUTOS ONLYPROPERTYDAMAGE <br />i <br />Per accident <br />$ <br />i <br />$ <br />A <br />X <br />UMBRELLALIAB <br />EXCESSLIM <br />OCCUR <br />i_CLAIMS_-M_A_D_1= <br />UMB8609087 <br />08/21/2023 <br />I <br />08/21/2024 <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$2,000,000 <br />DED RETENTION$10.000 <br />$ <br />A <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY YIN <br />ANYPROPRIETORIPARTNERfEXECUTIVE <br />OFFICERfMEMBEREXCLUDEO? <br />N!A <br />WC 834164b .08/2112D23 <br />08/21/2024 <br />X STATLITE ERH <br />`—'— <br />$1 000 000 <br />-- <br />E.L. EACH ACCIDENT <br />E.L. DISEASE -EA EMPLOYER <br />- -- -- -- --- --- <br />F.L. <br />$1,000,000 <br />(Mandatory in NH) <br />l yes, descdde under <br />DESCRIPTION OF OPERATIONS below <br />DISEASE -POLICYLI�$ <br />1,non nri0 <br />i <br />II <br />DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) <br />CFRTIFIrATF i4ni ITFR relurr-1 I ATInKi <br />City of South Bend Board of Pubiic Works <br />227 W Jefferson BLVD <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 />South Bend 46601- <br />AUTHORIZED REPRESENTATIVE <br />Kelley, Jacob <br />C71988-2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />
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