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ACORO® CERTIFICATE OF LIABILITY INSURANCE <br />ilr.. <br />DATE(MMIDD/YYYY) <br />7'/18/2016 <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 be endorsed. If SUBROGATION IS WAIVED, subject to <br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the <br />certificate holder in lieu of such endorsement(s). <br />PRODUCER <br />CONTACT NAME: ZZBllsiness Group <br />PHONE 10 Ex,(800)814-2122 ac No:1e00)936-2122 <br />Gibson Insurance Agency, Inc. <br />130 S Main St, Ste 400 <br />E-MAIL <br />ADDRESS: <br />INSURERS AFFORDING COVERAGE <br />NAIL If <br />PO Box 11177 <br />INSURERA:Cincinnati Specialty Underwriter <br />13037 <br />South Bend IN 46601-0177 <br />INSURED <br />INSURER B <br />Urban Adventure Games <br />INSURERC: <br />PO Box 63 <br />INSURER D <br />NSURER E <br />Granger IN 46530 <br />1. URERF: <br />COVERAGES CERTIFICATE NUMBER:7-29-16 to 7-30-16 REVISION NUMBER: <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 />INSR <br />LTR <br />TYPE OF INSURANCE <br />AD L <br />SUBR <br />POLICY NUMBER <br />POLICY EFF <br />(MMIDDnYYYYI <br />POLICY E%P <br />IDDIYYYYMOCCURRENCE <br />LIMITS <br />X <br />COMMERCIAL GENERAL LIABILITY <br />NCE <br />$ 11000,000 <br />A <br />CLAIMS -MADE �X OCCUR <br />NTED <br />ccurrence <br />100,000 <br />$CSUOOe7023 <br />ne person) <br />$ Excluded <br />7/29/2016 <br />7/30/2016 <br />V INJURY <br />$ 11000,000 <br />GEN'L <br />AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />$ 2,000,000 <br />X <br />POLICY [:]JEBT r7 LOG <br />PRODUCTS-COMP/OP AGG <br />$ 2,000,000 <br />$ <br />OTHER <br />AUTOMOBILE <br />LIABILITY <br />COMBINED SINGLE LIMIT <br />Ea..itlent <br />$ _ <br />BODILY INJURY (Per person) <br />ANVAUTO <br />$ <br />ALL OWNED SCHEDULED <br />AUTOS AUTOS <br />BODILY INJURY Per accitlent <br />( ) <br />$ <br />HIRED AUTOS NON -OWNED <br />AUTOS <br />PROPERTY DAMAGE <br />Peraccitlent <br />$ <br />is <br />UMBRELLA LIAB <br />OCCUR <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />EXCESS LIAB <br />CLAIMS -MADE <br />DED I I RETENTION <br />$. <br />WORKERS COMPENSATION <br />PER OTH- <br />AND EMPLOYERS'LIABILITV YIN <br />STATUTE ER <br />E.L. EACH ACCIDENT <br />$ <br />ANY PROPRIETORRARTNERIEXECUTIVE <br />OFFICER/MEMBER EXCLUDED? <br />NIA <br />E.L. DISEASE - EA EMPLOYE <br />$ <br />(Mandatory in NH) <br />If yes, describe under <br />E.L. DISEASE -POLICY LIMIT 1 <br />$ <br />DESCRIPTION OF OPERATIONS below <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) <br />South Bend Parks Department <br />321 E. Walter St. <br />South Bend, IN 46614 <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 />AUTHORIZED REPRESENTATIVE <br />Ins Agency/JAIMIE <br />CORPORATION. All rights reserved. <br />ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD <br />INS02512m4nn <br />