Quote Opening - Randolph Street Basin Emergency Repairs Proj No. 116-083D - HRP Construction

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O CERTIFICATE OF LIABILITY INSURANCE DATE/n216 %."'�� 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). PROWLER Gibson Insurance Agency, Inc. 130 S Main St, Ste 400 CONT"ME A Stacy Christlieb PHONE (800)814-2122 FAX A/C No Ext: (A/C Na:(8001836-2122 ADIEDRSS. schristlieb@gibsonins. com PO BOX 11177 South Bend IN 46601-0177 INSURER(S) AFFORDING COVERAGE NAICi INSURERA Amerisure Mut Ins Cc 23396 INSURED INSURER B HRP Construction Inc. INSURERC: 5777 Cleveland Rd INSURERD: PO BOX 266 INSURERS: South Bend IN 46624-0266 wsURERF ..vv eRramw l.CK11 rIl:A1G NUMt3tK:y-1-1�/1/ Devi elms ur u.n,-n. SCR. 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. LTIRR TYPE OF INSURANCE POLICY NUMBER POLICY EFF MOLIC YYYV POLICY EXP FOLIC YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000, 000 PREMISES Eeoccunenoe $ 1,000,000 A CLAMS -MADE X�OCCUR X MEDEXP(Any one person) $ 10, 000 XCD CPP20316441202 9/1/2016 9/1/2017 X Contractual Liability PERSONAL &ACV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000, 000 PRO- POLICY LOC PRODUCTS - COMP/OP AGG $ 2,000, 000 JECT OTHER AUTOMOBILE LIABILITY COM N N L Ea acgtlent $ 1,000,000 X BODILY INJURY (Per person) $ A ANYAUTO AUTOS AUTOS CA20316451202 9/1/2016 9/1/2017 BODILY NJURYlRereceident) $ NON-OX HIRED AUTOS N AUTOS NED AUTOS PROPERTY DAMAGE Per accident $ $ X 11 UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10 000,000 A EXCESS LIAB CLAIMS -MADE AGGREGATE $ 10 000,000 DED X RETENTION$ 0 CU20316431102 9/1/2016 9/1/201] $ WORKERS COMPENSATION _ X AND EMPLOYERS' LIABILITY YIN STATUTEERH E.L. EACH ACCIDENT $ 1, 000,000 ANY PROPRIETORPARTNERIEXECUTIVE OFFICEMMEMBER EXCLUDED] 4]N/A A Manager, in NH) Ifyes, describe under NC203164211 9/1/2016 9/112017 EL. DISEASE - EA EMPLOYE $ 1,000,000 EL DISEASE -POLICY LIMIT I $ 1 000,000 DESCRIPTION OF OPERATIONS below States of I6 6 Mx DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, AddlUonal Remarks Schedule, maybe spooned If more space Is requlred) Project: Randolph Street Basin Emergency Repairs Project No. 116-083D 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 Ins Agency/STACYC r,nHew rwwnr .A ACORD 25 (2014f01) The ACORD name and logo are registered marks of ACORD INS025 (201401)