NIEZPLU-01 _... ._...�..
<br />�� � CERTIFICATE DATE (MMIDDIYYYY)
<br />ICATE OF LIABILITY INSURANCE 812012019
<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 olic ies HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED the must have AD............._�...........__...d..
<br />_..._.__...__........... _....... _._ p Y( )..........................DITIONAL 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 />Dan Berry Insurance Agency Inc.
<br />54101 Ironwood Road
<br />South Bend, IN 46637
<br />255-6222
<br />254-2630
<br />----.._ ._.. .... _.... --
<br />INSURER A : West Bend Mutual Insurance Co 153,,,, ,
<br />--------- 5
<br />INSURED
<br />INSURERµ8 ,.FirstCom „-Insurance Com ,man
<br />P P ... .... _ ..__..
<br />276,
<br />Niezgodski Plumbing, Inc.
<br />InIsuRFltc_ ....,.
<br />PO Box 3096
<br />INSURER D :
<br />South Bend, IN 46619
<br />......,
<br />.�.
<br />INSURER F :
<br />I�E�"IFI�G�1TmNUMBER: REVISION"(."OVERAC_....� �.._ m m I(!(tlMI3ER:
<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,
<br />THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
<br />LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />m _
<br />ADDL SUBR
<br />IAaR. TYPE OF INSURANCE .� ...
<br />A� ICY EFF JL POLICY EXP
<br />POLICY NUMBER LIMITS
<br />__....
<br />A X COMMERCIAL GENERAL LIABILITY
<br />EACH OCCURRENCE
<br />00
<br />1,000,000
<br />CLAIMS -MADE I X OCCUR
<br />D
<br />A495062 8/21/2019 8/21/2020 DAMAGE 0 RENTED
<br />300,000
<br />_
<br />.MEDEIAnyP( Xonepperso0
<br />5,000
<br />PER,SQNAL &wADV INJU,F2Y
<br />1,000,000
<br />GEN L AGGREGATE LIMIT APPLIES PER:
<br />GENFRAL_AGGI�EGATE $.
<br />2,000,000
<br />POLICY Loc
<br />PRODUCTS COMPIOPAGG $
<br />,W.m..,...
<br />2,000,000
<br />OTHEW
<br />$
<br />COMBINED SINGLE LIMIT
<br />1,000,000
<br />AUTOMOBILE LIABILITY
<br />CLA AWOM - ., .........
<br />X ANYAUTO
<br />A495062 8/21/2019 8/21/2020 BODILY INJURY (Perperson)
<br />OWNED 1 SCHEDULED
<br />AUTODS ONLY AUTOS
<br />BRORD�LY INJURY (Per accadent) $
<br />HIRED
<br />ONLY _,I A8%T %NaI�i.
<br />„(Pate ms r DAMAGE
<br />_ A � ....._C.....�. . _._
<br />UMBRELLA LUIB OCCUR
<br />._.....__. ..................._...� a-_..._ �.
<br />EACH OCCURRENCE,,,
<br />2,000,00p
<br />EXCESS LIAB CLAIMS -MADE
<br />A495062 8/21/2019 8/2112020 ATE
<br />AGGREGATE $
<br />DED RETENTION $_.
<br />_�
<br />� ..... .. i ..,.... - $
<br />2,000,0001
<br />..._
<br />"'
<br />B WOR ERS COMPENSATION
<br />.-.......
<br />PER
<br />ID I RH
<br />AND EMPLOYERS' LIABILITY
<br />YIN
<br />C0190699-01 812112019 8/2112020
<br />n
<br />SOO,000
<br />O PARTNER/EXECUTIVE
<br />t ExcLUDED� N / A
<br />ANaPRO
<br />E L EACH ACCIDENT $
<br />iC RIMI,MgER
<br />do
<br />DISEASE EA EMPLOYEE $ ,,..
<br />500,000
<br />.
<br />If yes, devAbe under
<br />DESCRIPTtON OF OPERATIONS below ......_.IT,�„
<br />..._ _
<br />.........„„„_.... „„„.. �_....... _...... E,L DISEASELIME- - POLICY ' A_,,,
<br />0�'()00..
<br />e attached if more space Is required)
<br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be
<br />_ ..._... _.__.... .._._.. _ ..._._ .. _ _ .......-..--
<br />......... ....... _
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF,
<br />City of South Bend ACCORDANCE WITH THE POLICY PROVISIONS. NOTICE WILL BE DELIVERED IN
<br />227 W. Jefferson Blvd.
<br />South Bend, IN 46601-1830 - - __.......-� ��--
<br />AUTHORIZED REPRESENTATIVE
<br />................... ---- —_.----,___-,-,_................-....
<br />ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
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