Quote Opening - Ireland Road Storm Repairs Proj No. 116-083G - HRP Construction

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ACOR& CERTIFICATE OF LIABILITY INSURANCE `� DATE(MMIOOIYYYY) 1 10/17/2016 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 endorsement(s). PRODUCER CONTACT Stacy Christlieb NAME: 1 Gibson Insurance Agency, Inc. 130 S Main St, Ste 400 P/C No Est: (BDD) 814-2122 qIC No: (S00)e3fi-2122 EMAIL schristlieb@gibsonins.com ADDRESS PO BOX 11177 INSURER(S) AFFORDING COVERAGE NAIC41 INSURERA.Amerisure Mut Ins Cc 23396 South Bend IN 46601-0177 INSURED INSURERS: IIRP Construction Inc. INSURER C: 5777 Cleveland Rd INSURER 0: PO Box 266 INSURERE: South Bend IN 46624-0266 INSURER F: COVERAGES CERTIFICATE NUMBER:9-1-16/17 REVISION NUMBER: 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. INSR L SI TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIDOIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X�OCCUR EACH OCCURRE�111NCE $ 1,000,000 PREMISES Ea ouU �noe $ 1,000,000 X TeED E`P(Any one person) $ 10,000 xCU CPP20316441202 9/1/2016 9/1/2017 X Contractual Liability PER OONAL 3 ADV INJLWY $ 1,000,000 GENT AGGREGATE LWIT APPLIES PER POLICY 1"' LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS-COMPIOPAGG $ 2,000,000 $ OTHER'. AUTO MOBILE LIABILITY CUNTWNE OLlh L01 1 Ea exitlern $ 1,000,000 BODILY INJURY (Per person) $ A X MY AUTO ALL OWNED SCHEDULED AUTOS AUTOS CA20316451202 9/1/2016 9/1/2017 BODILY INJURY(Peraccident ) $ NON -OWNED HIRED AUTOS X AUTOS X PROPERTY DAMAGE Per accident IT $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10 000 000 A EXCESS LIAB CLAIMS -MADE LED I X I RETENTION$ D $ CU20316431102 9/1/2016 9/1/2017 A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? N❑ (Mandatory in NH) NIA WC203164211 9/1/2016 9/1/2017 X PEATUTE ETH E.L.EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1 000,000 fyes describeurder DESCRIPTION OF OPERATIONS below States of IS 6 MI EL DISEASE -POLICY LIMIT I $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) Project: Ireland Road at High Street Emergency Repairs; Project No. 116-083G Certificate holder is additional insured with respect to general liability coverages regarding work performed by the insured. City of South Bend Board of Public Works 1316 County -City Building 227 West Jefferson Blvd 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. AUTHORIZED REPRESENTATIVE Ins Agency/STACYC © 1988-2014 ACORD ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401)