Project Completion Affidavit - Gemini at Washington-Colfax Apartments Masonry & Stair Repairs Div A Project No 118-080B - Bokon Masonry

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BOKOMAS-01 ROOM A��`a►' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 9/4/2019 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: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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 The Healy Group, Inc. 17535 Generations Drive South Bend, IN 46635 271-6000 243-3214 INSURED Bokon Masonry Inc. 56571 Pear Rd South Bend, IN 46619-9801 COVERAGES CERTIFICATE NUMBER: INSURER A: Hastings Mutual Ins. Co. INSURER B ; INSURER C . ........ INSURER D : INSURER E INSURER F : REVISION NUMBER: 14176wwwww_ .......... 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 _ TYPE OF INSURANCE ADOL S9%BR POLICY NUMBER _ POLICY EFF POLICY EXP - ._....ww.. � LIMITS _ A X COMMERCIAL GENERAL LIABILITY EACH'OCCURRENCE $ 1,000,000' CLAIMS -MADE X OCCUR X CPP9874827 8/17/2019 8/17/2020 WDAMAGE TO RENTED 100,006 SE n $ ..... MED EXP (Any one erson) $ mm 5,000 PERSONAL & ADV INJURY $ 1,000,000 L AGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY vT 0 LOC 2,000,000 t�u PRODUCTS - COMP/OP AGO $ OTHER $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT _. .. 506,066 X ANY AUTO ACV9874840 8/17/2019 8/17/2020 BODILYINJURYPer erson $ OWNED SCHEDULED """. """"' AUTOS ONLY AUTOS BODILY_IN,I_ URY (Per accident! $ App AUTOS OPER�Y AMAGE Port __. 1J ONLY Of accil eAl A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS -MADE ULC9874849 8/17/2019 8/17/2020 AGGREGATE-_, _ 1,000,000 --- . DIED RETENTION $ A WORKERS COMPENSATION OTH AND EMPLOYERS' ANY Y❑ WC 9874841 8/17/2019 6I17/2020 — PROPRIETOR/PARTNER/EXECUTIVE HR EXCLUDED? 1ERI'M �) N / A CEA SOO,OOO .F,1, E,L. DISEASE EMPLOYEE $ If es, describe under DESCRIPTION OF OPERATIONS below _.__a... E,L DISEASE -POLICY LIMIT ....._.. 500,000 $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) City of 'South Bend Is listed as Additional Insured. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of South Bend THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 125 South Lafayette Blvd, Suite 100 South Bend, IN 46601 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) 01988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD