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HomeMy WebLinkAboutLicense - Public Parking Facility - 100 Navarre St., 621 Memorial Dr, 707 N. Michigan St.INTER -OFFICE MEMORANDUM BOARD OF PUBLIC WORKS DATE SENT: TO: XTom Anderson, Code Enforcement X Gerald Ellis, Fire Department X Matt Longfellow, Engineering X Chris Dressel, Community Investment X Angela Smith, South Bend Area Plan FROM: Linda M. Martin, Clerk SUBJECT: License Application for Public Parking Facility Mi llikZ0►*1 Memorial Hospital of South Bend / Beacon Health System LOCATION: 707 N. Michigan St. / Bartlett Parking Garage 621 Memorial Dr. / Lafayette Parking Garage 100 Navarre St. / Navarre Parking Garage DATE DUE: August 19, 2020 FAX OR E-MAIL TO: 235-9171 / l hensley o e i. ov RECOMMENDATIONS AND COMMENTS: By Date 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 I. APPLICATION TYPE Check One: New ................... „Renewal x II. BUSINESS DATA A. Business Name: MEMORIAL HOSPITAL OF SOUTH BEND / BEACON HEALTH SYSTEM ZONED CBD 100 NAVARRE ST / NAVARRE PA B. Business Address: PARKING GARAGE ....,. _...�... w.._,.... Cityt,wSOUTH BEND State IN Zip 46601 PROPERTIES tl44ro'^^� C. Mailing Address (If different from above): ADMINISTRATION City: SOUTH BEND State: INN STREET P I HIG Zip: 46601 D. Business Telephone Number: 574-647-1472 574-64-..��........_...�,.........._:......�__ �...............�.,.,.�.:-_........_..,_...�_........._._.,�....._:��.,�................_.. E. Business Fax Number: 7-1473 F. E-Mail Address: SGALLOWAY@BEACON HEALTH SYSTEM. ORG G. Maximum Number of Vehicles that can be parked at facility at onetime: 591 ........... H. Total Number of Parking Spaces atfacility:..591591 I. Hours during which vehicles may be stored: 7 DAYS / 24 HOURS H. Premises are (check one): Leased by Applicant Owned by Applicant If Leased: Owner's Name: Owner's Business Address: City:.,,,. ._...w ___Zip: Owner's Residential Address,.... City: State:...__Zip: J. Insurance Carrier and Amount of Liability Insurance OR Bonding Agent and Amount of Bond: THE HORTON GROUP (ATTACHED) For Office Use Only S.InAo M_ Mm'��i. (:Ink 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: ...�_�........�_ ... v .21p: IV, OWNERSHIP A. Type of ownership (check one): ..............._....., .,...,_.. Sole Proprietorship (If sole proprietorship, proceed to 1). ....... Partnership (If partnership, proceed to 2). X .�,,�...�.,���,., Corporation (If corporation, proceed to 3). 1. Sole Proprietor Name: Residential Address: State: City: te:.........�._.�..�..........���...�......w...�� Telephone Number: 2. Partnership (List at least two (2) partners) Name #1: Residential Address:. City' Telephone Number: Name #2: Residential Address.;. City Telephone Number: p State:--,", ­...­ ....-...,Zip: 3. Corporation Legal name of corporation:, MEMORIAL HOSPITAL OF SOUTH BEND, INC. eye �R .....�x...�._we�� .._ . �,..,_ ...._ Date and state of incorporation: OCTOBE311985 ....................................... 2 For all municipal business license questions, contact: City of South Bend -Department Of Community Investment 227 West Jefferson Blvd - Suite 1400S -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: ANTHONY SHANE GALLOWAY Title., MANAGER, BEACON PROPERTIES ADMINISTRATION ..... . . ..... ­­ ..­­ - - — - — --- Business Address: 100 NAVARRE PLACE SUITE 6645 ... ............. . ..... City: SOUTH BEND IN Zip: 46601 City: Name 42; Title. Business Address: City:----- ,State:Zip: Residential Address: City: Residential Address: City, 3 p: State: Zip. tYM011dbMIMOMMa14�1W�6D!ddIMIMIIIIIIIMVI'1t� UIuMM YrdiVIf�MMIMdIIIMi �ICCMM�iNi I V;f7M;Ml'd CM21M�N�Yf9°dMNifMM M 64MMMY�V MMIIIMM P1 �°�MMifFMtlWINi+MV4M 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 fads 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. �a. 8/6/2020 711 Signature Date BOARD OF PUBLIC�R'ORKS Gary A. G1.t, Pr idunt Lherese J. D. Member Flip I oh A. M—dik.',1 mb, lord.. V. G.Ibu,,, Member Al'I'LS'1': �:;rr,;;, off'wr„ Joseph IL M.1—. Member _ I m& M. M.,fn, Clmlk 4 M 4C iNv99fMIMMMiSf iGi49 2IM9WV � S4 f� t h�UMflMMIVII'WMMMM 7MIY��4TI� Il'MVid�MItlM I/ a a(,, Y� V G w tt J,A/1�,,,,I r.G ILbIAyv/�a!/{,Fr/��� r��,�rvrrf/ia, o, ,,,,,� G,/elLltw�(Il iu�wU✓.lr�an !/:' I�co.:J171,V'auo.,frt✓.aN' IN����l ��� �� s Wqq' y„�, ✓� �� .� Fri"'Ill d a ��"ya �'(,�V! �ah)� t 1; 0-1 hours $1.00 1-3 hours $2.00 3-6 hours $4.00 6-8 hours, $6.00 8-24 hours $9.00 CERTIFICATE OF LIABILITY INSURANCE ! DATE(MMIDD/YYYY) 11 /21 /2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO CERTIF BELOW. THIATES CERTIFICATE N LATE IR INSURANCE DOES NOT YAMEND,CONSTITUTE A CONTRACT BETWEEN THE ISSUING _ .... ,.,_ P IES UPONTHE CERTIFICATE HOLDER. THIS DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. ..� . �w. _FerP ._.y�'.._..)...... m_.... IT.. If IMPORTANT t1ii WAIVED, subjects an AODIi _ ' to the terms and conditions ofthepolicy, certain policiesmayrequire San a endorsement. nt. A statement endorsed. IONAL INSURFO tla ollc es must have ADDITIONALyant. A„statement on vROD!ucI Rrtificate dogs such endorsement s _ not confer rlwgtat to the certificate holder in lieu of d5k� The Horton Group NAME° 340 Columbia Place WC,N,a.Exl1 708-845-3917 NE FAX Nw4 866-202 5917 South Bend IN 46601 E-MAIL ADDRESS. cellificates(f thehortongroup.com INSURER(S)AFFORDING COVERAGE NAIC0 INSIIUREIIII A,: 117rwa".W cM FlimRti; ctive 11843 INSURED BEAOHEA-03 INSURERS: Amerisure Mutual Insurance Co. 23396 Beacon Health Systr�nl lac,; Beacon Medical Group; Memorial Hospital of South Bend, Inc.; Elkhart INSURER C General Hospital Community Hospital of Bremen INSURER D p 615 fit M'ichi an Street IN$UREGNE: South Be'ndN 46601 ES CERTIFICATE NUMBER 1732807401 REVISION NUMBER THIS IS rl1 C.LRTIt'Y THAT THE POLICICS OF INSURANCE LISTED BI,tOW' HAVE BEEN G'"tlED 7O THE INSURED NAMED AE30VE FDft 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. 1GN,' ^ P' lP H002223�.,.. �- .i.., - t ..0 FACHOCCCII�CCNCE IMITS OF .., ... ,...., _ P0480w 12/1I�20 9 _ 1211l2020� ,... ...............�•��.. SR ADOL. S'URR` " O'AMdWGE T4J RCN"q 4:C5 ......... NUMBEtt _ t ._......,-.............. _ ...:.. d4tlM YYYY MRDDJVYY L..._ A X COMMERCIAL GENERAL LIABILITY $1,000,000 CLAIMS -MADE % ......� OCCUR PREMISES, Ea rt:r„uwrenao'. $100,000 MEO EXP (Any one person) $ 5,000 PERSONAL& ADV INJURY $1.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: P,D'NFR,ALA'GGREGATE 53,000,000 JET LOC PRODUCTS -COMP/OP AGG $3,e00„000 POLICY El . ... - OTHER .. ..Aµ .�..... _.,.,....,...... ....... __... B AUTOMOBILE LIABILITY -�---CA13212592802 0/13/2019- a113/2020..dIl`8t�.iLINY6 - $1,000,000 ANY AUTO BODILY INJURY (Per person) $ x OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ x,, HIRED X NON -OWNED TY9:fdtitdtAGE AUTOS ONLY PROPERTY , AUTOS ONLY PE daru9j $ .Ax UM.., .,..�,... ,..,..4-e..e.. $ BRELLALIAR - .........m...,.., ,.-...........,, .....,.... ......... OCCUR E002223 12/l/2019 12/112� F _.. URR� � 020 P.,r4CHOCCURRENCE $25,OOD,000 EXCESS LIAR X CLAIMS -MADE AIJGRCr;ATE. $ 25,000,000 AND EMPLOYERS' L ABILIITY --- h7EU RE"rENrkON WORKERS.. ,.._ Y�� ..... ,,,,. .n......., ,�.....,._.......... ... �....�.....-„-.. ... , �,._, ....,,,,.n., .....w STATUTE..... . .1f... ......,-,.._ dNYPROPRIE"C0RiPAR'1NFwFxIW`CU1nVE N OFrICCRWEMBEAEXCLUDED"P NNA , E.L. EACH ACCIDENT $ (Mondatoly In NI�4) E.L. DISEASE - EA Er,RKOYEI:. $ A Ifs vk,scr9tae under RMedical Malpractice Shared Limits H002223 Of OP OLSORIPB'Nr,?N OPERATIONS &aa@rxrr _ E L DISEASE P`FJI f Y 9 AMn .a.�.,_.. ...�,,., � -..�.. ,.,.... � .-....-,- ....�_.� ....... . �.,.....- ....awrr1211/2019 1211/2.,. ...... -.-. w.. 020 Incident Mad Malpractice Separate Limits =ate UAggragate 15,000,000 500, 000/1, 500, 000 DESCRIPTION OF OPERATIONS I LCh�C:A'tioNS J VEti. CLES(ACORD $01, Ad .,. m... a Schedule, .,.....,...,�. d If rna _m......... is r .............._... ...,,....... .,..wMrv.._...._. w,,,,,..�,�,.... .. dVtaxara�l Rarraarks SoYned�rte array Ire'aNadctuad WN rngre Apace 9s reparured) Additional Named Insureds. Beacon Spedally Surgery Center, L LC; Beacon Health, LLC, Beacon Health Ventures, Inc.: Beacon Occupational Health, LLC. Qualified under the Indiana Patient Compensation Fund. Annual Parking Garage License: Centennial, Bartlett and Navarre Garages CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of South Bend ACCORDANCE WITH THE POLICY PROVISIONS. 227 W. Jefferson Blvd. Suite 1400 South AUTH_D'_ORI2EREPRESENT ATIVE South Bend IN 46601 ACORD 25 (2016/03) The ACORD name and � � � �1 � ACORD �RP reserved. r � ©1988-2015 ACORD CORPORATION. All rights reserved. logo are registered marks of ACORD SS-c-as 'Stale Form 37019 STATE OF INDIANA °w..a M.AI.ICE r ,rfi .x n.Yd4r CRL7 ,5TA'F a,"'-. `. �w " CERTIRCATE OF AMFMDMFNT To Whoni These Pre,serlt.s Come, Greetingr.- j 0 o 1, EDWINI, 51MCOX, Secretary of S'tatap of Indiana, hereby certify that MFJ40RTAL HOSP 11,11M 0-F SOUTH BENDa INC. a corporation duly orgaattazed and existing Header the laws of the Mate of Indiana, has thd.,; day filed era the office Of tNae Secretary of State, Articles of Amendment shoaalarag an aaa,vaendment to the articles of ¢rrcor'pxratiort of said company, in accordance ufitPm q a p�" a y XAMY The Indiana No 1,,'o "-,�'a°c.°fit Corpor'ntirira Ac of a9Y1 �N)"mRLA: 5, capon date examination, I find that they'conform to lauk NOW, 7-FI REFORF,1, EDWI )SIMt"• O , area 'etn at (af Slate, hereby cem turfy that I lma°& e this day endorsed ray approval upon all copse, of A licles m) traa,�w,a.r'ata�a�, and, having recea 'a' d the fees r°eqi r aaa�l by laaaar, In7ve fl)ead arse "MY of tht? A rtickls uta than office and returned the.rern ainin, copg.1e,s beara'rrg the endo?Soraaentofm,y<al""pr-oval to thf," t"'Orpor°aafion. !as Wat¢m.x Whereof, t have hereur8tal set arsy haarrod and affbced the ,setzt of the ,State of tawNaaaar, at ttue Cory of trldsaaraatroR5, ¢.. dray of December 9_ EDWIN J. SIMCOX, Secretlxry of Slate By .. m Deputy For all municipal business license questions, contract: 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 Q,C. . 70 7 b5 VL> LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY MUNICIPAL CODE SECTION - 4-39 I. APPLICATION TYPE Check One: II. BUSINESS DATA Renewal .,x ,,. A. Business Name: MEMORIAL HOSPITAL OF SOUTH BEND / BEACON HEALTH SYSTEM ZONED CBD : 621 MEMORIAL DRIVE I LAFAYETTE�PA K�..�..M . B, Business Address: PARKING GARAGE SOUTH BEND IN. 46601 Zip _ City:,SOUTH -e._� Mate mm C. Mailing Address (if different from above) 615 N MICHIGAN STREET ATTN PROPERTIES ADMINISTRATION City _.. Staie ZI SOUTH BEND IN ...m.� �..�...._...,,__. .�_.. �. _ ... .....m. .�.... P 46601_..,�..n......... � �, D. Business Telephone Number: 74 647-1472 574-647- �.�....._.._..�..,� ... _.._.___m._�. ,�� .. �,...... __�....� .... _ . n... E. Business Fax Number: 1473 F. E-Mail Address: SGALLOWAY@BEACONHEALTHSYSTEM.ORGmm _- . u ..., ,m_..... .a_..... G. Maximum Number of Vehicles that can be parked at facility at onetime:599 H. Total Number of Parkin Spaces atfacilit g p y 599 i. Hours during which vehicles may be stored 4 HOURS H. Premises are (check one): Leased by ApplicantOwned byApplicant ,X, If Leased: Owner's Name: Owner's Business Address: City: State: Zip: Owner's Residential Address: City:____ ....., State: Zip: J. Insurance Carrier and Amount of Liability Insurance OR Bonding Agent and Amount of Bond: THE HORTON GROUP (ATTACHED) For Office Use Only Application Filed AUG 0 6 2020 .. ....�... p..m,_.Public Works Approval e a _ ._.................. ASentApplication Fee Paid.G License Fee Paid to Dept. ...._.. U.G _6_2 w.. License Numb k _ ... i Not Approved Reason 130ARU OI+Yt�t3LIC �40Rk:S 9 a=:t- ( 1 (lot Yirnidaif 1 I oil 1 \ham hk. M ,M", �n n � 11iw:\fanbu 111P,Sf� _. c�.iru/n CI( bi 1 41I NJn�I�n, Uuk For all municipal business license questions, Contact: otV of South Bend °o��m���mm�w/��mc� azvWe^�m��nmw~swe1wms�vv�e�*/"mana*s�z~sr4.aas,ss1u~ps^`ass90o1 LICENSE APPLICATION FOR -PUBLIC PARKING FACILITY MUNICIPAL CODE SECTION -4-39 Ill. PERSONAL DATA IV. OWNERSHIP A.Type ofownership (check woe): Sole Proprietorship (if sole proprietorship, proceed 1u1). Partnership (if partnership, proceedtoZ). x Corporation (if corporation, proceed to3). 1. Sole Proprietor Name:_-_.,-_____ Residential Address: Telephone Number: 2.Partnership (List at least two (2)partners) mume#1: Residential Address: city Telephone Number: Namn#2:______ Residential Address. Telephone Number: State: State: l[orpongion Legal name ofcorporation: MEMORIAL HOSPITAL OFSOUTH BEND, INC. Date and state ofincorporation: _DCTOBER31' 1985 2 l ,!( r r La�UI /JI llllAJJli�ll111///%/.%%r�W„/UNf1flU1111 H1JJVJlEIIG"//dlllll/%/,Uf(KP��I%/fr.1J91,4/rf(�19/ily/IEI.U%i%//!l//!D1/ r� 1! // 1 r r r +i r i J . �Ill///�l/II�J�Il1�rJJG%A(1l/��(//d�f(/�/✓�NlrNr/r/�i�Ypel7JVa�llAA4�'i�J'llr1i11J1r1d�l�Grrli7l�'d17�rgY�T1,S;,�tYNhD�IEMHfIV�'�771�'�IStlt�1/O/��Jd�It�I�N�GwdllliY5d11R�irXJ16[Ji�d1J/�'l/A�rl9lihfJlVl�'�//Y/rl�G�a�Yl�ll>�lU��&�lv�//1�f11Il�J�'ll�d'�ll� 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 I� LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY r MUNICIPAL CODE SECTION - 4-39 IV. OWNERSHIP (Continued) A. Type of ownership (continued): 3. Corporation (continued) Resident Agent: Name: ANTHONY SHANE GALLOWAY 1 Title: MANAGER, BEACON PROPERTIES ADMINISTRATION 100 NAVARRE PLACE Business Address SUITE 6645_ I City SOUTH . ,. BEND ..w_�. ....m IN....... _..�Zip: I p 466 , . ...__.� _.. � State: Officers: Name #1: LARRY TRACY. m�.......� �� ._ .....� �.�_�_�....� ��...._..�_._._.. Title PRESIDENT, MEMORIAL HOSPITAL OF SOUTH BEND Business Address: 615 N. MICHIGAN ST. City SOUTH BEND m .. .. State: IN.....w ,_.... Zip:�46601 01 Residential Address: City:-- ........ ..... �._M.�� ......�___,._�.�State .....�w_._�.._ .......m....m...�.�Zip .._....__.m�._._...__ Name #2: Title Business Address: f City; �.A....... .... _..... State: Zip: Residential Address:. ¢ CitYi State ,Zip Name #3: Title: 1 Business Address:..._. r City=... Stage Zip:__.. Residential Address: .�.�..... ,..... a Cltyr, State Zip: 3 I �`Im»»/�Jr,llrfi�r�rirrlrrrri Jr r r, r� GrGI /✓i � , rr �� r r l � /l hRfffll/Ill%1„/Yr //l , 11 r � r �' P l r��d/� J„✓iJl,y. I �/ Jir . 1 /�l , , p r rr r r , � � ,,, .. r,/%A1,.rlILJJ//,Ul////dll/%all,/,(,m1fN'1�'GrIJ///lflyf/G%%/f,fl�r"11I1//lhNrli/O>.'�/I/lllfll„IAR90JfIIlliNldlJ1,11111/rlll%y�!'(IplII�1Lr�(fKOfUYlI1UAl1//,N1�1101111n11�I)yfdPllfi�Pl/4111�1Wf/GIG'o1/111VflY%lll%%lJi/IL/41�Jr11///Pi,°1/%11D/P4.G. / YY rr %'/ Pl 7, lr J Y U.9�fo�iYViA7,+lIuIURVli7lll/�ll%1LlGplkP,llYO�r�YGAUUA,7d1J17�9}T, 11 - rri�rir�riririillrJf�a�rrlarrr�lu��r.�l!lul�rrl���l�ur�c�uvl,�Y�;�„r�culiluoYl�utr�r���a�+u!'><�lc�l�wi�t�ytfJ�,we>Yu»ugiu�lrnirrtu+wAu�i�l���w�l'rr,+i�il,u!�ir��urra�/�>irr�J>A���clarro��irrrru � �ir����rrrr„�>ir�r,�iuriAY��iii!�u✓��rrJ��rx�+at�w�rmfl�uau��u»�rr�a�+;�i��Q;ua�u� 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 S 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 1 t!g I Vill. AFFIRMATION I, hereby, certify and affirm that all of the information I have given in this application is true and 1 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. u 8/6/2020 Signature Date I BOARD OF PUBLIC WORKS 1 l Gary A. Gilot, President 11irn J. D..,f, Member Elizabeth A Maxadilc, Member Jordan V. Gathers, Member i ATTEST: f .Tsneph R. Molnar, Member fl Linda M. Martin, Clerk I J' i ri +� I' i 4 w(�!�wrrrirrriaiail�ah�d�r��rl, >i�u / / r f r I/'!lY/WIJf(UMW,,�YS'IIJJ)dIIIAP%/rdl'JIIIYNr�IkU;1in°9y1;Y//rrJ19l,J111i(N,rJ!/l�h(�„110;�iAl/)ir{(fkIJN�INNl�J1JJ111P,ll+/rII�IYI(fitVGllll/(N111✓/ADJr,1i,Irill�zhWiy�,„�Ylrll(1�"�';Wrlr1>(/nAY17@1+1VVl1IbJYluaINV/iiP1!;n��lfr�6i/I�i�IiNIIr11V�111��iti"(Illll/li,I4+i1. ( � r J'. ''v ' (I r�I„IU`�i,1dYi�ll�Vr17�f1,9iV�'IIIrlGildJGVd7JOlYD1Yk1lr/An71J�)t�iYJ'Y,dl"Ai11�1dViflfffM4ifY°niW� 6 'Nil � G�Rti,�'Pfo1llN E'^wJ'flNl�P0�4JrRNrr/. fir ri br.,lri /Or mrOlfemr//l!!l7/�(/w YG/4f/r�Xldl,I6imPA/Pn r6G�/,�„LN,.,�rt pl�I �rf��nr���,�'�!//��/Al�rtfaYlf�fwUlydkl.2klf41✓°J/rN/,✓, �G r�Gr/lG 1q�NL.'!i 'JL M Fon N(�Ir(E 9�� ""��,,r" �urrr�""k� y� J1,� 6 W�I� �. / (lIy �uy,.�"I��,r��r UW p�W"k(^e �,i��,�dln,��IY�hG n 0 1 hours $1.00 1-3 hours $2.00 3-6 hours $4.00 6-8 hours $6.00 8-24 hours $9.01 CERTIFICA,m OF LIABILITY INSURANCE aru (uaamDDIYYYY1 THIS CERTIFICATE IS ISSUE11iP AS A MATTER OF INFOVaMATMIV„V ONLY A,NID CONFERS NO IRIGHTS UPON THE CER._I_EV'k..!, HOLDER. THIS CERT 19CAVEM° DOES NOT AFFIRMATIVELY OR NEOA"I"N@11F II Y AMEN[), EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW THB CERTIIFICA'T"'E: OF INSURANCE km DOES NOT' CONSTITUTE A. CONTRACT ISE"("Wl%CEN 'tI"Ifiii ISSUING VNSURVR(S), AOTI"IOINZeD ICI"PRI!:!GF:NTATWE OR PRODUCER, AND THE CERTIFICATE HOLDER, INdPOPTAO T pt PBae c oua'IlVwaale IoE Ndear us an ADE71"TNONAq INS IIALt1, P.ho pualVcy(ies) midst have ADDITIONAL INSURED pprovhjB oras or be endorsed. If SUBROGATION IS 'WAWEI'), subject to the terms and c�ondltions of the ptalley, certain p�ollcies Irnay require an endorsement. A Stateumerit on this aerto doe,, not .confer ._d�Yt st.o, t.ree ca�vw$�uRrA a.te holder .N,.,.e._u of such sc h NwNaipd�oT rsernerftd) PRODUCER �...... �� ..�. PRONE IA%rF"tl � he @ IGrt aru I31rc u,r(a ,ti EIuDMuurlrtr Milraa:a, a a"tw3�g43ai3 J91p' �Ae� pP�p r3tla,�t32 SII1t South Bend IIN 46601 � eraARES� t <I a e tNur' VararrlrP3rerrala.naauwa - _ N �krREauq pr s rr�rel uuwc rt.mYa.ra s<ar NAIL It PCIURER Medicak Iprotective 11693 INSURED EA tEA 02,� MraRER D atrverrslure Nkjtu,fal Iu�,�tP�"�rprru'e �:r":. .. 23396 I'lea+on 4Irak h Sy";N-NPu Inc,,a c;on EuleucficM (Group, Mrbmr'oriW I HospurlA of otdh Bend, IIg1u. E.M tart iIW^URERC a.,rDrtW91 Rdosp[tal, comaYliund'( Hasp i(,q& ofBrerna INSURER a: 615 F9 hP alp Street INSSouth Rend IN46601 URERS _ COVERAGES CtTtlfll Ik1'T' E I TITIEII"A1 NO I'VLIIk 9AR2WIG'PdCWT NUMBER: Y.... ...._..,.. W .. m. K m..,... �. .,.�,..�.., ..�.� " "61II a d";p..It IlI S CIF= ILT pJPfuNgCL LPSYV:II:"t BELOW CVkJ HAVE rebl�C�::V~1 ISSUED rCa 'q'UdV;: IhdSugr,I:M:b Td/%ItaL'L:D l�4rCGy✓Jlf hT"kE Thlp T TTIL. �.. dh �" q'k.IfIIrTL) l� I(A Fu." la I I; NIAY IDt VS~ NDJ II y V'4:MCT ()R 07 1ER E)0CIJN�II.::rla , Nd r I E 6~ E'-,l EC 1 To V^VB Duos H '7" I—ns �aBudC DIl'r.F.b da8C7�'V'WWfll (Ild v' EAI�LrIlt1� lur+!"d T21..GDTYIII�V IkYYc rIi" I Il.frquD u�aBk u�uSNl�d GOi�IT TDp Ft,P�db �,VD➢V OR MAY PERT.�IIa IIIE INSu GJ>dJ+C� .: AFFORDED ,;TD BY THE q"C:)UCIII S I"dl'�:I0:4"�g6 ED k-DILEF�"If'N IS ,;1J BJlliCT "110 .AI..IL "TBDIf" 'I[EIRIrrlS, FXCLUFa tar c..uNr ahCJ dNl)TVJNS 01SIilCndC&S,. IIOIMIS SI C7VN MAY HAVE CaFTN REDdtIIP BY PAID CI AM& .5ultrotV: FrDa.tu r ��T wr7a.drw, an"rS AMA vsa rwSS Euu��al�wrS ._ EEumVE,w saEa .....Lrl��rDgtrd Ir.&EiCAupicr TJ !iVIrs _ �,.. _. _. . �a F", £1BrRJuPo�'C7�r,d)I„ � LWLV'ed.0. 0.16)C"bIa.NPN FUo:YdO2D'/S T,"rr f'�r91 ^J 17/y ID"4D2R! �,aA7 6Po rOr�r, rOtitV��`r',a,ir: _,.......••..•a V,TditYk't o,09,t,ry0 Ir r ra4= X obc u.0 CYfi,MA(I 7 Pip a1 # aB F'tRL, MP r "'Inn p,,d,d'D „.J iXX. itrplr".0 7«PW T,XC 1 Adi'BNr^p plax,,,,InN 5 5.'004) _. r+ER'Tu'ONOQ. rw,17V PPwdd,lRY y I,f k'�IG,. XIu,Jtit .tTr"Yll,tir r Hur.11N' Ml APPLAa I(,-i. ETTfp .Pkifidrrr.XwO IwK`NrtlileTtAiE B,'14,J00,000 .. i1.11)11C, i buFm"LXI11G4, rH-Cd)MP,0HAGG y,30Y'1,000 a'aruu au liAa)4a�0hdCli111I"t G 13� d �59LT¢a 810 w62L G 0 QE),BJ C3 AUTO hAi'➢I"11 i I I Mk J;If°r fl r p are„ n) OW lh4l"I� I Dt P:Vil qm AU t03 ONLY I" P)s I n M d IIN I IY'r I `X aN4 i,1e1a'aa^tk ? x II'{ie'rED X, uIY0,7PSCd'Aa'Ndu CI: ALP7 QS 0NL..Y ro 47'�"P75 ON t Y I 4 0"�mP6�LR'k rV,tAM�B,Avn.wE _ a pY dxt ;ta a ia7's , ......... �.�, .,. ,...w.,. .. ......,,. .... ... � _ ..,..._ ._....._-.�... D° UMBRELLA Y. AA,Gb i li 1 08 La00P'f Y3 .,.._ .w...,„„ 42111d401 l A.)1/2UYQl D°^ tl„4 ,nPV+M,.«AWya'A. ., EACH OCCURRENCE UWQG'kILUWL,a ..... $ Y�r d)TiLI CO Cif) A.G F8L.GMe. `«' a.B,k,P0tD ,0001L aa�rP 4 r & L rd 16t,RIa � ,.. _. .__...,.� ..w_,.......... w.. _.,..,.,,._,._,_,. WORKMCOMPMATI .... �.,.�.. .... .,. m.�...�,.,.��.�_.� w.a� n.»,_,.,.., J6NP7ElPIPr_Cbr Rga II YBN I r T!FA VA't4 ka,4¢. ..... .......,»,...-m,.. ..." rNhp A"Fat lP t9161 Dh fd iG+'p.F._.,...�.... i irate" Nd6A ihYL,V'�,aMrF P,rt3lld'R;.;�IX II,PCrIL.47 P' �....... � Ell. 0.ACPI F,I,UDf IN yGY IM d V AQ,y In MI9p Irvw,-,&aw Y,Ie t,7dol E C- rI~:aPA,E FAfMCIC)YEF p„ —.,... 1, W .ma�.P...�I .,I *N OF, IDPER4 Y.1 ._.0OIbjw.,........_.. .�.,.,.,�.... ..." Gk r•.lr( w$ ........."�e...�.,......�.. ,1, qEuQel acepIacflca Shared iCC�1�3 ,.............. moG,Pw._.,.. �A,»a..u.,.., ...'.C.,>..L,nmZ...Y.e....L..�.k., 12I1!2019 92d'I12020 IrvdrleiP� ...�..n...a. 600,000� IU9r,ra NlnVOuraaisc�Ebepeai-+¢LI.Ilnihs� t,aBDrr{,y�itr 'p5 oco mo Pir:;gCd,, rol/Attyyrc*rLra¢r� SQlQ,C7fJfr'1.�GU(Y.¢3TaPY a•rrauau r�har �rrrJr^& f �r'6'(!C 1 T i �' Y7 hs'.N bTdd"utlk.Jr�d 470 i)i°"Oy N..... ,„ Adw^,e,t8a1Y 111M1„artiitl&IopY,ur as 6i.urraarrrNrn ;,"c lr Ett7t �.,.� ...�..., .,�......,� AEcN tlih lit Vtlibl;46r111� a1Re1 �a Yptl{4Ci IrtrAYY P.YW It�l�afCPPa,1 .. �pclPlur ru;cq C1 rNx a uI Irriallgra t1 1 uac t.rr) Sp iiec a,titp+ ..zurg et r a.Eewos L,I.T,„ Ebu.��aa.1a11 H ,00I , I I C, SaaWXXI I" e aHh ruo�Ytiuffc.:�S, qnc Beacon Occup)adona)II HeaiIh, i_i_C, k 1101IIried 1IFIdo the Indiana T^4k1hp91Aa t h,;o9k pere �,.yW)" Fund, Annual Pal'kInq a raraapea License: Cpint.uara'iaq, HaaMe R and Naauaure GaI arpeS TIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City Of South Bend ACCORDANCE WITH THE POLICY PROVISIONS. 227 W. Jefferson Blvd. Suite 1400 .South AUTHORIZED REPRESENTATIVE_�­ South Bend IN 46601 mm � ©1988-2015 ACORD CORPORATION. All reserved. � " g d. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD S-S-C-35 'Stale Form 37019 M STATE OF INDLANA 0 "ICE OF THE SECUTAIZ-Y OF gj'Aj-� FF CER"FIFICA-IT- OF AMENDMENT DEC 1. 1 198S' F0 Whom These Presents Coppie, Grpeji?jg,,, 01 1, EDWIN I SIMCOX, Secretary of State of Indiana, hereby certify that MEMORIAL HOSPTTA�. OF SOUTH IREND, ING. a Corporation duly gar g ganized and existing . under the laws of the State of Indiana, has this day f0ad in the office of the Secretary of Strafe, Articles of Angendmepir showing an amendment to the articles of incor,poration of said company, in accordance w1th , �� The Indfuna Not-For-Profil C"Orporation Axt of 19 1 23-74J)V PVIIERFRMSp upon due examination, I find that they Conf-brm to law; NOW, 711FRErORE-, 1, EDWIN 11 SfMCOX, Secretary of State, hereb,y certify that I have this rl�ly' endorsed may approval ?,jpon all copips of Artkles.so pl•r..,,gg e VP41 he ees �j�jvit�g i '. t f reqxdred by fr7w, havefiled otlecOPYof gheArtich4qin this office a nd returned Me, rer I arj it,, jpIg copi? 9 bearfn,g, the endoiserne"t 4,`f P)1Y aWVOL)ed to the C"or' poratio1j, hi WiMess Whereof, I have hereunto set a?ty hand and affixed the Seal of the ,State of Indiana, at the CRy of Indiari.apoks, 3 Opi.'5 rd- . . . ....... ... day of 7 19. By. -_ _ - EDWIN 1. SIMCOX, Secretary of State Deputy ��f�iC�✓rill.rr�wr��l��„I�1k�2��fJ'kJff�di/yf��Ui�l��/ilGrrU�f�rM»Atialfll�il�rn„f11�,�1f�(�A,flr��1�1^ui���11N,I�fnu�r,��GA rlbli i r � , NJiDI'6WV,11J1f07U��fiW>lI1NJVMfIJUry�'�P!t!NROtY7„K�plNft!tlfN!�Ad1�liPo1110J((Or9YlYiitl�al�r�/!(n!I!0/50Y11JY�?(I'Pi7l�?°rPl�fP�1�e71:f1�'(itlJllFtfflT�+Udi1�tlY"�YIiVJii�ll�4lJflf��6lfli�Nllw4)�1ytE�(P,'i':&fCii2 '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 • S74.235.5912 • F; 574.235.9021 LICENSE APPLICATION FOR - PUBLIC PARKING FACILITY MUNICIPAL CODE SECTION - 4-39 I. APPLICATION TYPE Check One: New„ T getewal II. BUSINESS DATA A. Business Name: MEMORIAL HOSPITAL OF SOUTH BEND / BEACON HEALTH SYSTEM ZONED CBD -: 707 N MICHIGAN STREE T ! BARTLETTPARKI B. Business Address: PARKING GARAGE City SOUTH BEND State IN �p 46601 C. Mailing Address (If different from above) 615 N MICHIGAN STREET ATTN: PROPERTIES ADMINISTRATION SOUTH BEND City .LN. ... ....... m...w. m .. Zip, 46601 574-647-1472 D. Business Telephone Number: m �i _ E. Business Fax Number: 574-647-1473��.�.�.._.---. OWAY 6 F. E-Mail Address: @ SGALL BEACONHEALTHSYSTEM ORG,....m._ _ ._ .. -. . ....... .. G. Maximum Number of Vehicles that can be parked at facility at onetime: 468 H. Total Number of Parking Spaces at facility 4fi8, I_ Hours during which vehicles may be stored: 7 DAYS ! 24 HOURS H. Premises are check one): Leased b Applicant-- .� ...u.b p�- ( ) Y .. ---.--,Owned by Applicant X If Leased: Owner's Name: .._.._.. ..... .......w.__ .... W Owner's Business Address: City. ...... -.w State Zip: Owner's Residential Address: City:.... State J. Insurance Carrier and Amount of Liability Insurance OR Bonding Agent and Amount of Bond: THE HORTON GROUP (ATTACHED) ® For Office Use Only Application Filed .... —...._ .� ..�. .........w._� Public Works Approval—— , . �.... .. _ ......._.. . u i Application Fee Paid.,--.,, ------ ... _�, ._.... Y License Fee Paid �.......�.... Sent to Dept... �..m . � _ ....�... _.mLicense Number_.._ ...�_� �.......� ....�.. _... �.�._ ._... 1 Not Approved Reason T yl nr. ..... _,mom . .............. .m .....,- i vrm�, i 4 1 It! aUY�Itu31,N(Aff(IA(!fG/1JIJ/�RH`I(fGt, Ul1��111J111D Y 1 � 1, 1( �r YIiN;Y✓T'!YI,�WrikltttU,Nl�x1't1,uG1/„�X6lIl/,IJJddI,�/d�F/llr, /fi�14w it r r iri r Lc9rJb ZVI171��1trl 7GlrllY�l:Jly➢19a��d11�0/�U�JJN111��JGd�G1aG�l>7JG'klr�diN"YDl�1Vf1��,'�aIf,IJrrililE;�1'JuYd2OR�t11tiNIIIt21U1fI�AXJVPniY0i0/�a��d�)�ll%llv]�lllbVl�GYl1�7UII�I�ID/tD116tyU1�lGII6S4VU/1P41I7�lJFI�fiU�Pr�'Tf�(�I�fM�PhU"r�V",'9"II�9dIJPiY��itPIMI For all municipa I business license questions, contact: City of South Bend -Department mCam munxvInvestment U[ENSEAPPUCATONFOR-PUBLIC PARKING FACILITY MUNICIPAL CODE SECTION - 4-39 Ill. PERSONAL DATA IV. OWNERSHIP A.Type ofownership (check one): Sole Proprietorship (If sole proprietorship, proceed tu1). Partnership (if partnership, proceed to2). x Corporation (If corporation, proceed tu3). 1. Sole Proprietor No Residential Address. - [by: ' � Telephone Number 2.Partnership (List atleast two (2)partners) Residential Address: � .Telephone Number: Name#2: Residential Address, Telephone Number:..," 3.[o,pomtnn Legal name ofcorporation: MEMORIAL HOSPITAL OFSOUTH BEND, INC . Date and state ofincorporation: OOTO8ER31.1Q85 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) Name #2: Title:_ Business Address: City; ­ . .... . .. State: Residential Address: City:_ --- Name #3: Title: Business Address: City: State:— .. . ....... Residential Address: City: State:_-. . ... .. ... Zip: 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 ® 574,235.5912 ® 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. ,�. Si nati, e BOARD OF PUBLIC WORKS Q Gry A Gill h.,ida 1 11i,aboh A 11 adil�, MJ he qh R. M I r, Member 4 8/6/2020 Date ]he�ese J. D..., Member 1 -I V. 0A...a, Manbcr Z ST: �ouGr ofTmvu Linda M. M.rIm. Clark ✓.r A l l r>�' I � y )y /r i r �U!��1� N,r/aGyr /G/�, �' � ,fir 41r i �iP /f�'✓ "W'rNmX�Ij [. J/Gl4 LIi NlMrobvi!(ew�JGn„la,Y,,,!a0,nnmi ,d�aDwll6..s(r,/lsm;w � /,.. � "'�,���� 0 1 nn hours NOWN=/I 1/11, CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD[YYYY] 11/21/2019 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� Ii the Certificate holder is an ADDIT161NALINSURED, the policy must have ADDITIONAL INSURED provisions orb 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 ondorsoment(s), m.muff -PRODUcER' The Horton Group 0AME;- P14ONE FAX 340 Columbia Place (A)(„' 708-846-3917 AM No,„ a68-202-5917 South Bend IN 46601 E-MAIL AaoRuSs! cen ifica he y the 11 Orton g roup. com 0.NSURERtSyAFFORDINP COVERAGE NAIC 4 INSURED 8 1 LACHEA-02 INSURER A: Medical Protective 11843 Beacon Health System, inc.; Beacon: Medical Group; Memorial INSURER B: Amerisure Mutual insurance Co. 23396 Hospital of South Bend, Inc,; Elkhart INSURER C General Hospjtal� Community Hospital of Bremen INSURfiR 0 615 N Michi an Street INPlJRER 6 South BendIN 46601 COVERAGES CERTIFICATE NUMBER: 1732807401 R . EVI SIO N - N " UMBER I —is 'IF"'Y 7'H" "AT—T-i-I-E-,-POL—I,C--l-E—S-0-F-I-N--S",U"I-R-A--N--C",E- —LIS--TED BELOW HA-"V-"E-IBE—EN--ISSUED ---- ------ TO THE INSURED NAMED ABOVE FOR THE POI ICY 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 CONDFTIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR t _ __ _', INSURANCE C AUDL 'SuOR POLI,CYQFF POLICYEXPE -!t. 1kiiu liz A X COMMERCIAL GENERAL LIABILITY H002223 -K OCCUR 1211/2019 12/1/2020 FACH OCCURRENCC $ I'"0'000 kA GRAS WIDE L)AMA(f to ALNTEU .. T'1 lion Ann G[N`L AGGREG&TE LIMIT APPLIES PER: RO, Priory 1-1 JECT PLCC 8 AUTOMOBILE LIABILITY ANY ALI jr(j X OWNED SCHrIDULLA) AUTOS OlIll Y AUTOS X HIRED X NON-Ovi AU1 OS ONLY AUTOS ONLY A X UMBRELLALIAB (K=R EXCESS LIAB UlAIM&MADC' AND EMPLOYERS' LIABILITY YIN ANYPROPRIETCRIPARTNER/EXECUTIVE OFFICERWEMBEREXCLUDED? ❑ NIA (Mandatory In NH) A Medical Malpractice Shared Limits Mad Malpractice Separate Limits MED EXP (Any one Person) $5.000 PERSONAL & ADV IN4UAY $ 1,000,000 GENERAL AGGREGATE s 3000'000 PRODUGuS CONiii"OVAGG 3,000,0100 zozoCEa aculdu5 k, 11kr 17 $1,000,000 OCOILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTYDAMAGE $ ex. danl, $ E002223 12/1/2019 12/1/2020 EACH OCCURRENCE S 25,000,000 AGGREGATE S 25,000,000 STATUTE EA E1. EACH ACOOENT $ EJ, OTbEASE-FAFMplow, I E1, DISEASE • POUCY LIMIT3 ;0-02-2"2-3-, 19 1211/2020 riddew 500,000 " 09,1to 15,000,000 JA ',NdanVA9gregae 500,000/1,500,000 ORSCRIPIIQNOFOPERATtONSlLOCATIONS IVtrliCtCS Additional Named Insure4s- Beacon Spe6afty Surgery Cenlev, LLC„ Beacon Health, ILLCBeacon Health Ventures, Inc.; Beacon Occupational Health, LLC. Qualified under the Indiana Patient Compensation Fund, Annual Parking Garage License: Centennial, Bartlett and Navarre Garages CERTIFICATE HOLDER CAN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of South Bend ACCORDANCE WITH THE POLICY PROVISIONS. 227 W. Jefferson Blvd. Suite 1400 South South Bend IN 46601 . . ............... . (9) 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ss-C-35 'State Form 37019 m STAU Or INDIANA OFFICE OFTHE SECRETAjzy oF sTArE CERTRICATE OF AMENDMENT To Whom These hesents co,le, Greefinge 111 LM 1:,-lu I® EDWIN 1, SIA4CQ)( , Secretary of Srate of Indi[ana, hereby certify that 9F-tOUT ,H-BEN'0, VIC. a corporation duly organy zcd and e.,w,istimg, iq,jcjej' tlu2 laws Of the State Of Indiana, has Otis r1f,4Yflied 41 the office of the Secretary of Articles of Amendnwnt showhg an airfendment to the air drat, of' bm"w1joration of sa!4 ccipnapjjrjy 'ij,j a4.coj.dttrlf_2 r with (3 r) X?� x yar, 4 KX nu �,x 6 we NAmm-xx xx x P xrs� X Tire I d if i r, i u Not -P'c) Prof i t co P -Pc'ra t i o A c 1, r a f 19 71 a,, , NPLnv due 0-xaminafiorn, I fipid tjvat they'conform to lauj,, NOW, THERER)RhA EDWINJF"I&ICOIK SMVMT�lof Scvte, hereby cerlij" that I ha tie th)'s'day e) dor5rd 1?7'y Cr)))ieS Of /A reirleg e�,,e P't i - n ed, ffflcl, havbdg receivM tile, ppr, rcqub-edbyl(?-u)0 haveftledomecon of theArifelesim bearimg elie mdorsement of jjzy to the CQrpw,(lt;()n In Witness WhereoLI have heregmto set my hand and affixxel the smP of rt;w state of Indiana, at the City of India this day of December 19 BY EDWIN J. SIMCOX, Secret4ry of State Deputy