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NEW <br />Renewal of Number <br />POLICY DECLARATIONS <br />No. SE 2004000 <br />Mount Vernon Fire Insurance Company <br />1190 Devon Park Drive, Wayne, Pennsylvania 19087 <br />A Member Company of United States Liability Insurance Group <br />NAMED INSURED AND ADDRESS: <br />FAMILY JUSTICE CENTER OF ST. JOSEPH COUNTY <br />533 N NILES AVE <br />SOUTH BEND, IN 46617 <br />POLICY PERIOD: (MO. DAY YR.) From: 06/19/2021 To: 06/21/2021 12:01 A.M. STANDARD TIME AT YOUR <br />MAILING ADDRESS SHOWN ABOVE <br />FORM OF BUSINESS: Limited Liability Company <br />BUSINESS DESCRIPTION: Special Event <br />IN RETURN •- THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE <br />WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. <br />THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. <br />THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. <br />PREMIUM <br />Commercial Liability Coverage Part $253.00 <br />TOTAL: $253.00 <br />Coverage Form(s) and Endorsement(s) made a part of this policy at time of issue <br />See Endorsement EOD (1/95) <br />Agent: GIBSON INSURANCE AGENCY, INC. (SOUTH BEND, IN) (4579) Issued: 04/06/2021 1:13 PM <br />202 S Michigan Street, Suite 1400 <br />South Bend, IN 46601 <br />By: Authorized Represe ati e <br />THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, <br />UPD (08-07) COVERAGE PART COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, <br />COMPLETE THE ABOVE NUMBERED POLICY. <br />