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Non Res Block Party - Kite Realty - Car Show
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Non Res Block Party - Kite Realty - Car Show
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Last modified
3/31/2025 4:11:36 PM
Creation date
7/11/2017 2:47:47 PM
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Board of Public Works
Document Type
Permit Applications
Document Date
7/11/2017
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310178 <br />A� " CERTIFICATE QF LIABILITY INSURANCE <br />DAT5/912'0 7YYY) <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 have ADDITIONAL INSURED provisions or be endorsed. <br />If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on <br />this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). <br />PRODUCER <br />Commercial Lines - (404) 923-3700 <br />Wells Fargo Insurance Services USA, Inc. <br />CONTACT Kimberlee KOM <br />NAME: <br />PHONE 404-923-3532 FAX 877-362-9069 <br />A!C NoExl : A1C No <br />E-MAIL O.comllik l b meree.m.owellsfar <br />ADDRESS: kiGay g <br />INSURERS AFFOROING COVERAGE <br />NAIL # <br />3475 Piedmont Road NE, Suite 800 <br />INSURER A. LM Insurance Corporation _ <br />33600 <br />Atlanta, GA 30305-2886 <br />_ <br />INSURED <br />INSURER B: Allied World National Assurance Co. <br />10690 <br />Kite Realty Group Trust <br />INSURER C <br />INSURERD: <br />30 S. Meridian St., Ste. 1100 <br />INSURER E : <br />INSURER F : <br />Indianapolis IN 46204 <br />COVERAGES CERTIFICATE NUMBER: 11760500 REVISION NUMBER: See below <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 />AUDL <br />NSD <br />SUHR <br />WVD <br />POLICY NUMBER <br />POLICY EFF <br />MM1D0fYYYY <br />POLICY EXP <br />MMfnD1YYYY <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS -MADE OCCUR <br />1- - 1 <br />TB5791453740077 <br />No Deductible/Retention <br />03/01/2017 <br />03/01/2018 <br />EACH OCCURRENCE <br />$ 1,000,000 <br />DAMAGE TO <br />PREMISES Ea Doccur RENTED <br />nce <br />S 500,000 <br />MED EXP (Any one person) <br />S Excluded <br />Applies to GL <br />-- <br />PERSONAL & ADV INJURY <br />S 1,000,000 <br />GEN'L <br />AGGREGATE LIMIT APPLIES PER: <br />GENERALAGGREGATE <br />S 2.000,000 <br />POLICY PRO LOC <br />JECT <br />PRODUCTS - COMPIOP AGG <br />S 2.000,000 <br />.,._- <br />5 <br />OT HER: <br />A <br />AUTOMOBILELIA131LITY <br />AS5Z91453740067 <br />03/01/2017 <br />03/01/2018 <br />COMBiNEDSINGL.ELIMIr <br />Ea eocdenl <br />g 1,DDo,rsoD <br />BODILY INJURY (Per person) <br />5 <br />X ANY AUTO <br />NO deductible <br />OWNED SCHEDULED <br />AUTOS ONLY AUTOS <br />on Auto Liability <br />y <br />BODILY INJURY (Per accidenl) <br />5 <br />PROPERTY DAMAGE <br />Per accident <br />$ <br />X HIRED X NON <br />AUTOS ONLY AUTOS ONLY <br />$ <br />B <br />X <br />UMBRELL.ALIAa <br />X <br />OCCUR <br />3088008 <br />03/01/2017 <br />03/01/2018 <br />EACH OCCURRENCE <br />S 25,000,000 <br />AGGREGATE <br />S 25.000,000 <br />EXCESS LIAR <br />CLAWS -MADE <br />DED I X RETENTION$ 5,000 <br />S <br />A <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />ANYPROPRIETORfPARTNERfEXECUTIVE Y 1 N <br />OFFICERIMEMBEREXCLUOED7 C <br />(Mandatory In NH) <br />NIA <br />WC5Z91453740087 <br />03/01/2017 <br />03/01/2018 <br />X STATUTE ERH <br />E.L. EACH ACCIDENT <br />$ 1,OOD,000 <br />E.L. DISEASE - EA EMPLOYEE <br />$ 1,000,000 <br />E.L. DISEASE -POLICY LIMIT <br />S 1,000,000 <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS below <br />DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) <br />Re: KRG Eddy Street Commons, LLC , Eddy Street Commons 1044-1234 Eddy Street, South Bend, IN 46601 <br />CERTIFICATE HOLDER CANCELLATION <br />City of South Bend <br />Department of Public Works, Engineering Division <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 />227 W Jefferson Blvd., Suite 1316 <br />AUTHORIZED REPRESENTATIVE <br />South Bend, IN 46601 <br />9e 01 <br />The ACORD name and logo are registered marks of ACORD ©1988-2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016103) <br />(rhls cer0fiwte replsos ce4fralak 11740495 issuad on 51912047l <br />
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