HomeMy WebLinkAboutPublic Parking Facility - Beacon Health SystemsINTER -OFFICE MEMORANDUM
BOARD OF PUBLIC WORKS
DATE SENT: 4/10/2017
TO: �Federico
ndy Wilkerson, Code Enforcement
Rodriguez, Fire Department 4
Ott Longfellow, Engineering
tjChris Dressel, Community Investment
FROM: Linda M. Martin, Clerk
SUBJECT: License Application for Public Parking Facility
Beacon Health Systems/ Memorial Hospital Parking
Garage
707 N Michigan StJ Bartlett Garage
LOCATION: 621 Memorial Dr./ Centennial Garage
100 Navarre StJ Navarre Parking Garage
DATE DUE: April 18th, 2017
FAX OR E-MAIL TO:
235-9171 1 Imartin@southbendin.gov
RECOMMENDATIONS AND COMMENTS:
By Date
For all municipal business license quest€ons, contact: City of South Bend • Department of Community Investment
227 west Jefferson Blvd • Suite 1400 S -South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION -4-39
Ill. PERSONAL DATA
A. Applicant's Legal Name:
B. Residential Address:
City:
C. Residential Telephone Number:
D. Residential Fax Number:
E. Cellphone Number:
F. Position with Business:
State: Zip:
IV. OWNERSHIP
A. Type of ownership (check one):
Sole Proprietorship (If sole proprietorship, proceed to 1).
Partnership (if partnership, proceed to 2).
Corporation (If corporation, proceed to 3).
1. Sole Proprietor
Name:
Residential Address:
City: State:
Telephone Number:
2. Partnership (List at least two (2) partners)
Name #1:
Residential Address:
City:
Telephone Number:
Zip:
State: Zip:
Name #2:
Residential Address:
City: State:
Telephone Number:
Zip:
3. Corporation
Legal name of corporation: vrr�� ;!)`
Date and state of incorporation:
is
I
For all municipal business license questions, contact: City
of South Bend - Department of Community Investment
227 West Jefferson Blvd - Suite 1400 S -South Bend, Indiana 46601 - 574.235.5912 - F: 574.235.9021
I
LICENSE APPLICATION FOR -
PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION -4-39
I
IV. OWNERSHIP (Continued)
A. Type of ownership (continued):
j
3. Corporation (continued)
Resident Agent:
/ ff_
f
Name: ! .iT7i �All�iiN'`eic3
r ��;;
Title: `j.I,Y� � ct
I
4c%'rv-m f,4) ��0Se Ee-� j
I r "'e _
Business Address:
i
City:
State:
Zip:
Officers:
�
Name #1:
Title:aeC;Cf LCi�
Business Address:
i
City:
State:
Zip:
Residential Address:
City:
State:
I
Zip:
Name #2-.
i
Title:
Business Address:
City:
State:
Zip: i
Residential Address:
City:
State:
Zip:
Name #3:
Title:
Business Address:
I
City:
State:
Zip:
Residential Address:
City:
State:
zip:
E E
i
3
For all municipal business license questions, contact: City of South Bend •Department of Community investment
227 west Jefferson Blvd • Suite 1400 S -South Bend, Indiana 46601 • 574.235.5917 • r:574.235,9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY'
MUNICIPAL CODE SECTION -4-39
V. INCLUDE COMPLETE RATE AND HOUR SCHEDULE WITH APPLICATION
VI. INCLUDE A CURRENT INSURANCE POLICY OR BOND
VII. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION
VIII. AFFIRMATION .
I, hereby, certify and affirm that all of the information I have given in this application is true and
accurate to the best of my knowledge. I further certify that I have in noway attempted to
mislead the City in this application by omitting facts known to me. I have read and understand
the regulations of the Public Parking Facility license found in the City of South Bend Municipal
Code, Section 4-39.
ui
(A14AAl- lAre"'4 _,(
S' nature
Po-&'Ck
4e
4
-3 /M// -)
Date
03/22/2018 12:08 M
Hours of 0[)era—tf(fin
Oartfatt Garage: Monday Friday 10:00 am- 8;00 pm
Centannial Garage; Monday Friday ILWO am- 8:00 pm
Navarro Garage: Monday- Friday 9:00 am-6:00 pm
Rate Schedule
0 Ihr$L00
1-3 hr $2,00
3- 6hr $3,00
6- 8hr $6,00
8- 24h r $9,00
Fax Server
4/6/2017 9:37:38 AM PAGE 2/002 Fax Server
CERTIFICATE OF LIABILITY INSURANCE
PATE [MM10P1YYYY)
1416/2017
THIS CERTIFICATE IS 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 poltcy(ies) must 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 endorsemen s ,
PRODUCER
The Horton Group
340 Columbia Place
South Bend IN 46601
NR or Thomas R. Cassad Jr.
PHONE 574-334500 nAo a .574-334-5600
E-MAIL
INSURER 5 AFFORDING COVERAGE
NAIL 0
INSURERA:Medlcai Protective
11843
INSURED BEACHEA-02
INSURERB:Arnerisure Mutual Insurance Co.
23396
Beacon Health System, Ino,
Memorial Hospital of South Bend, Inc,
615 N. Michigan Street
INSURER C:
INSURERD:
INSURERE:
South Bend IN 46601
INSURER F :
COVERAGES CERTIFICATE NUMBER, 289626112 REVISION NUMBER;
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE ISTED BELOW HAVE 13EEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDINO 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
LTR
TYPE OFINSURANCE
INSD
WVD
POLICY NUMBER
POLICYEFF
MMlDDNYYY
POLICY EXP
{NMIDDIYW
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE ❑ OCCUR
H002223
12/1/2016
12/112017
EACH OCCURRENCE
$1,000.000
PREM SESOEa occurrOence
$50 000
MED EXP(Aq one person)
$6,000
PERSONAL &ADV INJURY
$1,000,000
GENt AGGREGATE LIMIT APPLES PER:
X POLICY ❑ JE`CT ❑ Lac
OTHER:
GENFRX- AGGREGATE
$3.000,000
PRODUCTS-GOMPIOP AGG
$3,000,000
5
B
AUTOMOBILE
X
X
LIABILITY
ANYAUTO
ALLOWNED SCHEDULED
AUTOS AUTOS
HIRED AUTOS)( NOX OWNED
AUTOS
CA13212592102
811312016
8/1312017
EOMB �E..D0SiNGLE LIMIT
$1,000,000
HDDLYINJURY(Per person)
5
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Pet acddenl)
$
$
A
X
UMBRELLA LIAR
EXCESSLIAB
X
OCCUR
CLAIMS -MADE
E002223
12/1/2016
12/112017
EACH OCCURRENCE
s25,000,000
AGGREGATE
s25,000,000
DEO IX I RETENTION325000
$
WORKERS COWENSATION
AND EMPLOYERS' LIABILITY YIN
ANY OFFICERIMEMBER EXCLUDED? PROPRIETOMPARTNERJO(ECUTIVE ❑N!A
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONSbetow
PER OTH-
STATUTE ER
E.LEACH ACC�NT
$
EL DISEASE -EA EMPLOYE
$
E.LDISEASE •POLICYLIMIT
$
❑ESCRIPTI ON OF OPERATIONS 1 LOCATIONS I VEHICLES (ACRRD 101, Additional Remarks Schedule, may be attached if mote space is required)
Annual Parking Garage License: Centennial, Bartlett and Navarre Garages
EL"04kil 11120.11r■Jq: PJSh'L"aAr-115IIL•J4
City of South Bend
227 W. Jefferson Blvd.
Suite 1400 South
South Bend IN 45601
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
O 1988-2014ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) TheACORD name and logo are registered marks ofACORD
:�
i
I
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 Westlefferson Blvd • Suite 1400 S •South Bend, Indiana 46601 • 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION - 4-39
Ill. PERSONAL DATA
A. Applicant's Legal Name:
B. Residential Address:
City:
C. Residential Telephone Number:
D. Residential Fax Number:
E. Cellphone Number:
F. Position with Business:
State: Zip:
IV. OWNERSHIP
A. Type of ownership (check one):
Sole Proprietorship (If sole proprietorship, proceed to 1),
Partnership (If partnership, proceed to 2).
Corporation (If corporation, proceed to 3).
1. Sole Proprietor
Name:
Residential Address:
City:
Telephone Number:_
2. Partnership (List at least two (2) partners)
Name #I. -
Residential Address:
City:
Telephone Number:
Name #2:
Residential Address:
s 'City: -
Telephone Number:_
State: Zip:
State:
State:
Zip:
Zip:
3. Corporation
Legal name of corporation: �
Date and state of incorporation:
2
For all municipal business license questions, contact: City of South Bend - Department of Community Investment
227 West Jefferson Blvd - Suite 1400 S •South Bend, Indiana 46601 - 574.235.5912 - F: 574.235.9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION - 4-39
IV. OWNERSHIP (Continued)
A. Type of ownership (continued):
3. Corporation (continued)
Resident Agent-
Namf
Title:
Business Address:
City:
Officers:
NamE
Title:
Business Address:
City:
Residential Address:
City:
Name #t2:
Title:
Business Address:
City:
Residential Address:
City:
Name #3:
Title:
Business Address:
City:
Residential Address:
City:
3
State:
State:
State:
State:
State:
State:
State:
Zip:
Zip:
Zip:
Zip:
Zip:
Zip:
Zip:
For all municipal business license questions, contact: City of South Bend • Department of Community Investment
227 West Jefferson Blvd * Sulte 1400 5 -South Bend, Indiana 46601 •574.235.S912 • F: 574.235.9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION - 4-39
V. INCLUDE COMPLETE RATE AND HOUR SCHEDULE WITH APPLICATION
VI. INCLUDE A CURRENT INSURANCE POLICY OR BOND
VII. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION
Vill. AFFIRMATION
I, hereby, certify and affirm that all of the information I have given in this application is true and
accurate to the best of my knowledge. I further certify that I have in no way attempted to
mislead the City in this application by omitting facts known to me. I have read and understand
the regulations of the Public Parking Facility license found in the City of South Bend Municipal
Code, Section 4-39.
Si ature
3
Date
03/22/2013 12:08 FAX
Hours of Operation
Bartlett Garage: Monday- Friday 10:00 am- 8:00 pro
Centennlal Garage: Monday Friday10.00 am-8:00 pm
]Navarre Garage. Monday- Friday 9:00 am-6:00 pm
Rate Seheduie
0 -Ihr $1.00
1-3 hr $2.00
3-- 6hr$3,00
6- 8hr $6,00
8- 24hr $9,00
[a 0014/0014
Fax Server
f
4/6/2017 9:37:38 AM PAGE 2/002 Fax Server
I
��. CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDDIYYYYI
4i6/2017
THIS CERTIFICATE IS 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 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 endorsemen s .
PRDDUCER
The Horton Group
340 Columbia Place
South Bend IN 46601
CONTACT
NAIVE: Thomas R. Cassady, Jr.
PHONE 574-334-5500 FAA574-334-5600
E-MAIL
INSURERS AFFORDING COVERAGE
NAIC to
INSURER A: M edloal Protective
11843
INSURED BEACHEA-02
iNsuRERB:Amerisure Mutual Insurance Co,
23396
INSURERC:
Beacon Health System, Inc.
Memorial Hospital of South Bend, Inc.
615 N. Michigan Street
INSURERD:
South Bend IN 46601
tNSURERE:
€NSURER F :
r^IIMMAr_r=o rcoTlerrAY= nutneeco• 7R9R9R119 RRVf.R1nM MIIMRr=R-
THIS IS TO CERTIFY THAT THE POLICIES 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.
TN —SR
LTR
TYPE OF INSURANCE
INSD
WVD
POLICY NUMBER
POLICY EPF
MMlODNYYYI
POLICY £XP
(MWDD)YYYYI
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
H002223
12/1/2016
12/112017
EACH OCCURRENCE
$1,000,000
CLAIMS -MADE 0 OCCUR
PREM SES Ea occu rneMg
$50 000
MED FXP (Any one person)
$6,000
PERSONAL&ADV$NJURY
$1,000,000
GENL AGGREGATE LIM IT APPLES PER:
GENERAL AGGREGATE
$3,000,000
PROI7UGTS-COMPIOPAGG
$3,000,000
X POLICY ❑ 5EGT ❑ LOC
$
OTHER:
B
AUTOMOBILE LIABILITY
CA13212592102
8/13/2016
8/13/2017
(C a a Iu dn8 I G MIT
$1 000,000
ODDLYINJURY(Perperson)
$ALL
ANY AUTO
OWNED SCHEDULED
AUTOS
BODILY IWURY(Per accident)
$
PROF[]ZTY PRMAGE
Per acddent
$
H Rt77 AUTOS NON-MNED
X AUTOS
Ix
A
X
UMBRELLA LIAB
X
OCCUR
E002223 -
12/1/2016
12/112017
EACH OCCURRENCE
$25,000,000
AGGREGATE
$25,000,000
EXCESSLIAS
CLAIMS -MADE
REp IX 1RF.TFNTIDNS25,000
$
WORKERS COMPENSATION
AND EMPLOYERS LIABILITY YIN
ANY PROPRIETORPARTNERIE)ECUTNE ❑
OFFICERIMEMBER EXCLUr
...
STATUTE ER
E.L EACH ACCIDENT
$
(MandamryInNH)
E.LDISUASE- EAEMPLOYE
$
E.L 01SEASE • POLIGY LIM Ir
$
If yes, describe under
QESCRIPT#ON C>= OPERATIONS below
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required)
Annual Parking Garage License: Centennial, Bartlett and Navarre Garages
4CK I lrR.H I C r7U LUCK �.Fa�ra.cLr-r+ I IWIM
City or South Bend
227 W. Jerferson Blvd,
Suite 140G South
South Bend IN 46601
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHOMZED REPRESENTATIVE
Q;� 191313-2014 ACQKD CORPOKA l ION. AN rights reserves.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
For all municipal business license questions, contact: City of South Bend -Department of Community Investment
227 West Jefferson Blvd -Suite 1400 S. -South Bend, Indiana 46601 • 574.235.5912 - F: 574.235.9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION - 4-39
III. PERSONAL DATA
A. Applicant's Legal Name:
B. Residential Address:
City:
C. Residential Telephone Number:
D. Residential Fax Number:
E. Cellphone Number:
F. Position with Business:
State:
13
IV. OWNERSHIP
A. Type of ownership (check one):
Sole Proprietorship (If sole proprietorship, proceed to 1).
Partnership (If partnership, proceed to 2).
Corporation (If corporation, proceed to 3).
1. Sole Proprietor
Name:
Residential Address:
City:
Telephone Number:_
2. Partnership (List at least two (2) partners)
Name #1:
Residential Address:
City:
Telephone Number:
Name #2:
Residential Address:
City:'
Telephone Number:.
State:
Zip:
State: Zip:
State :• Zip:
3. Corporation {
Legal name of corporation:
Date and state of incorporation:
2
For all municipal business license questions, contact: City of South Bend - department of Community Investment
227 West Jefferson Blvd - Suite 1400 S -South Bend, Indiana 46601 - 574-235.5912 - F: 574.235.9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION -4-39
IV. OWNERSHIP (Continued)
A. Type of ownership (continued):
3. Corporation (continued)
Resident Agent:
Name: "
Title: L
Business Address:
City: State: Zip:
Officers:
Name #1: �_1_4Ir
Title: es', Alen
Business Address:
City:
Residential Address:
City:
Name #2:
Title:
Business Address:
City:
Residential Address:
City:
Name #3:
Title:
Business Address:
Citv:
Residential Address:
City:
3
State:
State:
State:
State:
State:
State:
Zip:
Zip:
Zip:
Zip:
Zip:
Zip:
For all municipal business license questions, contact: City of South Bend - Department of Community Investment
227 West Jefferson Blvd - Suite 1400 S -South Bend, Indiana 46601 - 574.235.5912 • F: 574.235.9021
LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY
MUNICIPAL CODE SECTION - 4-39
V. INCLUDE COMPLETE RATE AND HOUR SCHEDULE WITH APPLICATION
VI. INCLUDE A CURRENT INSURANCE POLICY OR BOND
VII. INCLUDE $5.00 PROCESSING FEE WITH APPLICATION
VIII.-AFFIRMATION
I, hereby, certify and affirm that all of the information I have given in this application is true and
accurate to the best of my knowledge. I further certify that I have in no way attempted to
mislead the City in this application by omitting facts known to me. I have read and understand
the regulations of the Public Parking Facility license found in the City of South Bend Municipal
Code, Section 4-39.
Signatur
4
312-7(('2
Date
03/22/2013 1.2:08 )PAX
Hours ofOperation
Bartlett Garage: Monday- Friday 10:00 am- 8:00 pm
Centennial Garage: Monday- %riday 10.00 am- B:00 pm
!Navarre Garage: Monday- Friday 9:00 am- 6:00 pm
Rate Schedule
0 -4hr $1.00
1-3hr $2,00
3- 6hr $3.00
6� 8hr $6,00
8- 24h r $9,00
Fax Server
4/6/2017 9:37:38 AM PAGE 2/002 Fax Server
CERTIFICATE OF LIABILITY INSURANCE VATEIMfd1U01YYYY)
ift s 4/612017
THIS CERTIFICATE IS 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 INSURE;R(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must 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 endorsemen s .
PRODUCER
The Horton Group
340 Columbia Place
South Bend IN 46601
NaN1TT^., CT Thomas R. Cassad Jr.
PHONE 574-334-5500 FAX 574-334-5500
rc No
E-MAIL
INSURERS AFFORDING COVERAGE
NAIGR
INSURERA, Medical Protective
11843
INSURED BEACHEA-02
INSURER B :Arnerisure Mutual Insurance Co,
23396
Beacon Health System, [no.
Memorial Hospital of South Bend, Inc.
615 N. Michigan Street
INSURERC:
INSURERO.,
INSURER E :
South Bend IN 46601
INSURER F ;
COVERAGES CERTIFICATE NUMBER:289626112 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE tISTEI) 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 )-ypg OF POLICYEFF POLICYEXP LIMITS
LTR 1N50 WVD POLICY NUMBER MMVODIYYYY MrNowyYY
A
X
COMMERCIAL GENERAL UABIL17Y
1H002223
12111201 G
12/112017
EACH CCCURWNCE
S1,000,000
CLAIMS -MADE OCCUR
AMAGETO
URITITED
P REMISE- Ea 11G 1 e a
$50 000
MED EXP (Any one person)
$5,000
PERSON LKADVINJURY
$1,000,000
GEN'L AGGREGATE UM€F APPLES PER:
GENERAL AGGREGATE
$3,000,000
X POLICY ❑JE'Gry- LUC
PRODUCTS-COMPIOPAGG
$3,000,000
$
OTHER:
B
AUTOMOBILE
LIABILITY
CA13212592102
81131201E
8/13/2017
COM131NEDSING
(Ea aWdenq
$ 1,00mo0
ODDLY INJURY (Per person)
$
X
ANY AUTO
ALL OWNEDSCHEAUTDULED
aODLYINJURY (Per accident)
S
X
Fi1RFAAUT05 X NON -OWNED
AUTOS
PROF�RTYDAMAGE
(Per acddet?t
$
A
X
UMBRELLALIAR N
OCCUR
E002223
12/112016
1211/2017
EACH OCCURRENCE
s25,000,000
AGGREGATE
$25,000,000
EXCESS LIAR
CLAIMS-MADF1
DED X RETENTION$25000
$
WORKERS COMPENSATION
AND EMPLOYERS'LIABILITY YIN
ANYPROPRIETOR/PARTNER)E)ECUrIVE ❑
OFFrER/MEMBER EXCLUDED?
NIA
PER OTT -
STATUTE lwR
E.LEACH ACCIDENT
S
E.L DISEASE • EA EMPLOYE
$
(Mandatory In NH)
if yes, deser€he under
DESORPTION OFOPERATIONS below
F,LDISEASE -POLICYLIMIT
$
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule. maybe attached if more space is required)
Annual Parking Garage License: Centennial, Bartlett and Navarre Garages
City of South Band
227 W. Jefferson Blvd.
Suite 1400 South
South Bend IN 46601
SHOULD ANY OF THE ABOVE➢ESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THEPOLICY PROVISIONS.
AUTHORIZE!] REPRESENTATIVE.".
O 19B6-2014 ACORD CORPORATION. All rights reserved.
ACORD 215 (2014101) The ACORN name and logo are registered marks of ACORD