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AC D� CERTIFICATE OF LIABILITY INSURANCE [_DA7E(MMIDDIYYYY) �� 01 /06/2023 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 CONTACT Katie Miller NAME: Synergy LLC PHONE� (574) 231-6566 F4� No . (574) 258-9177 13800 Jackson Road EMAIL. ADDRESS: clservice@synergyinsurancegroup.com INSURERIS) AFFORDING COVERAGE NAIC N Mishawaka INSURED Woochi Japanese Fusion & Bar Inc 119 N Michigan St IN 46544 I INSURERA: SOCIETY INS GROUP INSURER B1 INSURER D: South Bend IN 46601 INSURER F' CGVFRAGFS CFRTIFICATF NI IMRFR• PFVIQIn KI MI VVICZFr?- 15261 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 LTR TYPE OF INSURANCE N DI. $lJ D POLICY NUMBER MMfDD(YYYY MM/DDIYY P LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 PREMISES lEaoccurrence) $ CLAIMS -MADE FXI OCCUR MED EXP Any one persop $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 A 22038904 12/31/2022 12/31/2023 GEN'LAGGREGATE LIMIT APPLIES PER : POLICY f PRO- LOC JECT I GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP/OP AGG $ 2,000,000 COMBINED SINGLE LIMIT �Ea accidenlj $ $ 071�IE�.1•: AUTOMOBILE LIABILITY BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTYDAMAG Aar aDIt $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? ANYPROPRIETORIPARTNERIECUTIVE Y ] (Mandatory in NH) N/A 22038928 12/31/2022 12/31/2023 X PTAVllTE FOR EL. EACH ACCIDENT $ 100,000 E,L,DISEASE - EA EMPLOYEE $ 100,000 If yes, describe under DESCRIPTION OF OPERATIONS below E-L, DISEASE - POLICY LIMIT $ 500.000 Liquor Liability 12/31/2022 12/31/2023 Aggregate $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) RECEIVED :.N , N . t F o.�U Div. of Engineering CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of South Bend ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 227 West Jefferson Blvd South Bend IN 46601 @ 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD