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

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A� oO CERTIFICATE 4F LIABILITY INSURANCE DATE 08/20/202418.44 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 INSURERJS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: Ifi the certificate holder Is an ADDITIONAL INSURED, the poiicy(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 endorsement($). PRODUCER CONTACT NAME: Kelley. Jacob PHaNE . (574) 400-4389 FAX AIC a E AIC No - Ewalt ADDRESS: Jacab.Keuey@infarmbureau.cam 2410 Edison Rd, Suite 400 South Bend, IN 46615 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A. United Farm Family MUtuat Insurance Company 15288 INSURED INSURERS: NIEZGODSKI PLUMBING, INC 232 N MAYFLOWER RD INsuRERc SOUTH BEND, IN 46619-1534 INSURER D, INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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, ILTR TYPE OF INSURANCE ADRL SUBR POLICY NUMBER Pro DO EFF MPNMiDOLIY YY I LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR I BOP8236911 108/21/2024 i 08/2112025 I EACH OCCURRENCE $1 000 000 PREMISES Ea occurrence S50,006 MED EXP (Any one Person) $ 10 000 PERSONAL& ADV INJURY $1 000 000 GEN'L AGGREGATE LIMIT APPLIES PER X POLICY ❑PRO ❑ JECT LOG OTHER: GENERAL AGGREGATE 1 $ 2,000,000 PRODUCTS - COMPIOP AGG $ 2.000 000 $ A AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEpU"rD AUTOS ONLY X AUT05 HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY i CAP8524976 I 08/21 /2024 I 108/21/2025 COMBINED SINGLE LIMIT Ea a cent $ 1,00fl,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ $ A X UMBRELLALWB EXCESS LIAB OCCUR HCLAIMS-MAOEE i UMB8609087 0812112024 08/21/2025 EACH OCCURRENCE $ AGGREGATE $2.00fl,000 DED REiENTION $10.006 g A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPER ROPRf"TOR1PARTNSRIEXECUTIVE OFFICERIMEMBEREXCLUDED? ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A WC8341646 �08/2112024 08/21/2025 X SPER TATUTE OTH $ 1 00(),000 E,E., EACH ACCIDE1�kT ' E.L. iJISEASE - EA EMPLOYEE $1.000.000 EJ_ DISEASE -POLICY LIMIT $1.000,000 DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) City of South Bend Board of Public Works 227 W. Jefferson Blvd South Bend, IN 46601 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL. BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Kelley, Jacob Q 1$a8-2015 ACOR17 CORPORATION. All rights reserved, ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD