Opening of Applications - 2025 Sewer Insurance Lateral Repair Program - Niezgodski Plumbing

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tr`orro® CERTIFICATE 4F LIABILITY INSURANCE 8Y' 08/201202418� 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(les) 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 endorsements . PRODUCER CONTACT NAME: W PHONE (574) 400-4389 FAX (AIC.No _ A!C No - Kelley. Jacob E-MAIL Jacob.Ketley@infarmbureau.eom ADDRESS: 2410 Edison Rd, Suite 400 South Bend, IN 46615 INSURER(S) AFFORDING COVERAGE NAtC# INSURER A: United Farm Family Mutual Insurance Company 15288 INSURED INSURER B NIEZGODSKI PLUMBING, INC 232 N MAYFLOWER RD INSURERC : SOUTH BEND, IN 46619-1534 INSURERD: INSURER E : INSURER F . 1 COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A80VE 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. ILTR TYPE OF INSURANCE I S L S I POLICY NUMBER PMOIDDY EFF POMLICY f:7CP LIMITS A X I COMMERCIAL GENERAL LIABILITY I CLAIMS -MADE OCCUR I Ij BOP8236911 i 08/21/2024 I0812112025 EACH OCCURRENCE $ 1 000 000 PREMISE=ce $50 000 MED EAP (Any one per S 1 p pQQ PLRSONAL & ADV INJURY i $1 000 ao0 GEN'L x AGGREGATE LIMIT APPLIES PER: POLICY E PRO- JECT LOC OTHER: I GENERAL AGGREGATE $2000000 PRODUCTS - COMP/OP AGG $ 2 fl©O tIOO $ A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY X AUTOS HIRED X AUTOS AU SY ! ! CAP8524976 I I08/21/2024 i I I 108/2112025 I CUMSkNEDSINGLELIMIT Ee accident $ 1.00fl,00fl BODILY INJURY (Per person) $ X BQDILYINJURY (Per ar;ddent) $ F'erOacntlenDAMAGE S A x UMSRELLAL" EXCESsLIAH HOCCUR CLAIMS -MADE jj I UMB8609087 I i08121/2132410812112025 LEACH OCCURRENCE S AGGREGATE $2,000,00 DED RETENTION$f4000 I $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRFrTORIPARTNERIEXECUTivrz Y I N OFFiCERWEMBEREXCLUDED? (Mandatory-inNN) If yea, describe under DESCRIPTION OF OPERATIONS hekaw NIA f ! WC8341646 08/21/2024 �0812112025 , PER OTH- ` STATUTE ER I EL, EACH ACCIDENT ' S 1 001) 000 ES..DISEASE -EA EMPLOYEE $1,QOQ,000 EL DISEASE - POLICY LIMIT $ 1.000,000 I I � f DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 401, Additional Remarks Schedule, maybe attached If more space Is required) Certificate holder is an Additional Insured as provided by form 03-151 when required by written contract applies to general liability which includes ongoing operations and products and completed operation and primary R non-contributory City of South Bend 227 W. Jefferson Blvd Ste 1316 South Bend, IN 46601 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Kelley, Jacob %11988 2015 ACORD CORPORATION!. All rights reserved. ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD