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OP ID: I
<br />CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYYP
<br />1 0212312018
<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 pollicy(ies) must be endorsed. It SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />certificate holder in lieu of such endorsoment(s). I
<br />PRODUCER
<br />R.S. Miller& Sons, Inc.
<br />P.O. Box 229
<br />109 W. Plymouth Street
<br />Bremen, IN 46506
<br />Gregory S. Miller, CPCU,CIC
<br />regory S'Miller, CPCU,.CIC
<br />574-546-3341
<br />TRUCK-1
<br />57,4-546-2687
<br />SURER S AFFORDING COVERAGE NA$C 9 1
<br />INSURED Trucks R Us, Inc, INSURER A: West Bend Mutual Insurance 15350
<br />Lake Effect Excavating, Inc INSURERS:
<br />Lake Effect Snow Removal INSURERC:
<br />Lake Effect Auto Sales
<br />23300 State Road 23 INSURER D z
<br />South Bend, IN 466114 INSURER E:
<br />I . INSURER F :
<br />f'1=0TIl=!e'ATr- REVISION NUMBER:
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />EFF _J5_0_UCYFxP
<br />ffl�
<br />F R]
<br />LTR
<br />TYPE OF INSURANCE
<br />A7D _gUeR
<br />IN DL
<br />R
<br />V1JVD
<br />POLICY NUMBER
<br />P-0—L16Y
<br />(MM/DDIYYYYI
<br />MMIDDIYYYYI
<br />LIMITS
<br />A
<br />GENERAL LIABILITY
<br />X COMMERCIAL GENERAL LIABILITY
<br />FZ71 OCCUR
<br />CLAIMS -MADE I A ]
<br />A040137
<br />0710512017
<br />0710612018
<br />EACH OCCURRENCE
<br />$ 1,000,00
<br />-UXM—AGETO —RENTEff—
<br />200,000
<br />MED FXP (Any one person)
<br />PERSONAL & ADV INJURY
<br />$ 6,000
<br />A 1,000,000
<br />-GENERAL AGGREGATE
<br />00,
<br />$ 2,00000,00
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />RL] POLICY [ X1 SEC0j LOC
<br />PRODUCTS - COMPIOP AGG
<br />$ 2,000,000
<br />L
<br />$COMBINED
<br />.7
<br />A
<br />AUTOMOBILE
<br />LIABILITY
<br />ANY AUTO
<br />A040137
<br />0710512017
<br />07105/2018
<br />SINGLE LIMIT
<br />(Ea acclident)
<br />BODILY INJURY (Per person)
<br />$ 1,0010,000
<br />$
<br />X
<br />ALL OWNED AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />SCHEDULED AUTOS
<br />HIRED AUTOS
<br />PROPERTY DAMAGE
<br />(PER ACCIDENT)
<br />$
<br />. .... .
<br />NON -OWNED AUTOS
<br />�1
<br />A
<br />—
<br />UMBRELLA LIAR
<br />EXCES!.LLJA8!.=(LAIMS-MADE
<br />I X OCCUR
<br />A040137
<br />0710512017
<br />0710512018
<br />EACH OCCURRENCE
<br />$ 2,000,000
<br />-AG—q—REGATE
<br />$ _ 2,0100,000
<br />$
<br />—
<br />DEDUCTIBLE
<br />X RETENTION $ 10,000
<br />WORKERS COMPENSATION
<br />W
<br />WU- OTH-
<br />C STATOR IMITS_J ER
<br />OR LL 1
<br />1 A
<br />A
<br />AND EMPLOYERS' LIABILITY YIN
<br />ANY PROPRIETORIPARTNER/EXECUTIVF
<br />OFFICERIMEMBER EXCLUDED?
<br />(Mandatory in NH)
<br />If yes describe under
<br />DESCRIPTION OFOPERATIONS.below
<br />Motor Truck Cargo
<br />NIA
<br />7
<br />A040149
<br />040137
<br />r
<br />07105/2017
<br />07105/2017
<br />0710612018
<br />071061201 8
<br />E.L, EACH ACCIDENT
<br />$ 500,000
<br />E.L. DISEASE - EA EMPLOYEE
<br />ICY LIMIT
<br />E. Lr DISEASE -POLICY
<br />IMTCargo
<br />ded
<br />$ 5,0(),000
<br />$ 600,000
<br />100,000
<br />1:,0001
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if mora space Is required) 1
<br />I
<br />SOUTHISE 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 />City of South Bend
<br />Department of Public Works AUTHORIZED, REPRESENTATIVE
<br />13th Floor Gregory S. Miller, CP U,CIC
<br />227 W. Jefferson I I ll
<br />@ *6-200,9 ACORD CORPORATION. All rights reserved.
<br />ACORD 25 (2009/09) The ACORD name and logo are registered marks OT A(;UKU
<br />
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