Laserfiche WebLink
DATE (MMIDDIYYYY) <br />AiC"R" CERTIFICATE OF LIABILITY INSURANCE <br />`� 01 r17/24 <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 policy(ies) must have ADDITIONAL 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 endorsements . <br />PRODUCER CONTACT <br />_mV41— - <br />ROCKSTROH INSURANCE AGENCY INC W"57 1F 4)232-2991 <br />333 INLafayette Blvd Ea"'I�p L ro_ekaa r5@sbcglobal.net <br />South Bend, IN 46601-1208 INSURERIS) AFFORDING COVERAGE NAIL u <br />_License #: _ WWRERA_ Auto Owners Insurance _ <br />INSURED INSURER B : <br />Early Bird Eatery <br />Four Stones LLC <br />INSURER C : <br />INSURER D : <br />117 E Wayne St <br />INSURER E : <br />South Bend IN 46601 <br />INSURER F: <br />r n�IGo A r_cc rcorrClr AYr us tuoCo. <br />RFVI-QlnM NI INIRFR• <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 <br />PAID CLAIMS. <br />^.AD�LSV6R^ <br />INSR <br />1 MMND EFF <br />EXP <br />TYPE OF INSURANCE pOLICYNUMBFJt <br />MMILg6 LIMITS <br />COMMERCIAL GENERAL LIABILITY <br />EACH OCCURRENCE <br />$_ 2 O� OO 000 <br />/ <br />O-#1=hI <br />50 000 <br />CLAIMS -MADE OCCUR <br />rrI_,- <br />$ <br />X 09375078 <br />06125/23 <br />MED EXP (Any one person) <br />06/25/24 PERSONAL 8 ADV INJURY <br />$ _ 5:000_. <br />S 2,000,000 _ <br />A <br />AGGREGATE LIMIT APPLIES PER: <br />GENERAL AGGREGATE <br />$ 4,000,000 <br />�IEEN'L <br />�✓\ POLICY jE O I LOC <br />�. - -- <br />,,. PRODUCTS - COMPIOP AGG <br />$ 4 01000 <br />— <br />OTHER! <br />$ <br />AUTOMOBILE LIABILITY <br />Cv4IBlNED SINGLE LIMIT <br />a�cckdnnl) <br />$ <br />ANY AUTO <br />I <br />BODILY INJURY (Per person) <br />j $ <br />OWNED I SCHEDULED <br />I <br />BODILY INJURY (Per accident) $ <br />AUTOS ONLY AUTOS <br />HIRED I NON -OWNED <br />II <br />PROPERIYOAMAQE <br />S <br />.. AUTOS ONLY 1 AUTOS ONLY <br />{$I <br />) - <br />$ <br />I111 <br />UMBRELLA LIAO OCCUR <br />EACH OCCURRENCE <br />$ <br />EXCESS LIAB_ CLAIMS -MADE <br />I <br />AGGREGATE <br />$ <br />DED RETENTION S <br />1 $ <br />WORKERS COMPENSATION <br />j STATUTE i t3T1i <br />AND EMPLOYERS' LIABILITY <br />Y❑ <br />ANY PROPRIETORIPARTNER/EXECUTIVE <br />E.L EACH ACCIDENT <br />S <br />OFFICERIMEMBER EXCLUDED? <br />NIA <br />(Mandatory In NH) <br />E.L. DISEASE - EA EMPLOYEE <br />S <br />If yes, describe under <br />DESCRIPTION OF OPERATIONS iwJow <br />EL. DISEASE - POLICY LIMIT <br />S <br />IEI <br />DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) <br />Ut:NIIt- IL,RIlz "ULULK I..NNL.tLLAIIUr4 <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />City of South Bend THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />227 W Jefferson Blvd ACCORDANCE WITH THE POLICY PROVISIONS. <br />South Bend, IN 46601 AUTHORIZED REPRESENTATIVE <br />t <br />©1988-2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD <br />