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ACC>R�� <br />LJ CERTIFICATE 4F LIABILITY INSURANCE <br />DATE (AiY <br />fl8/22/2024 241313:30 <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($), 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 endorsement(s). <br />PRODUCER <br />Kelley, Jacob <br />2410 Edison Rd, Suite 400 <br />South Bend, IN 46615 <br />CONTACT <br />NAME: <br />PHONE (574) 400-4389 FAX <br />Ext : AfC No <br />EA1A L <br />ADDREss: Jacob.Keliey@infarmbureau.com <br />INSURER S)AFFORDING COVERAGE <br />NAIL# <br />INSURER A: United Farm Famity Mutual Insurance Company 115288 <br />INSURED <br />NIEZGODSKI PLUMBING, INC <br />INSURER B : <br />232 N MAYFLOWER RD <br />INSURER C <br />INSURERD: <br />SOUTH BEND, IN 46619-1534 <br />INSURER E ; <br />INSURER F : <br />I <br />I <br />COVERAGES CERTIFICATF NtIMRFR- RFVlgInI4J MIlMul=D- <br />THIS 1S 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 PAID CLAIMS. <br />INSR I <br />LTR <br />TYPE OF INSURANCE <br />ADDL <br />INS11 <br />SUBR <br />wvn <br />POLICYNUMaER <br />POLICY EFF <br />MM1DDNYYY) <br />POLICY EXP <br />JMM1DD0= <br />LIMITS <br />A <br />X <br />COMMERCIAL GENERAL LIABILITY <br />CLAIMS MADE X OCCUR <br />_ <br />! <br />1 <br />I <br />BOPS236911 <br />08f21 /2024 <br />! <br />i <br />08121/2025 <br />EACH OCCURRENCE <br />$1 000 000 <br />G ro—Rg e <br />PREMISES fEa occurrence <br />$ SD.ODO <br />MED EXP (Any one Person) <br />f $10,000 <br />PERSONAL & ADV INJURY <br />$1 000 000 <br />G£N'LAGGREGATE LIMIT APPLIES PER <br />X POLICY PRO- �' <br />JECT a LOC <br />OTHER: <br />GENERALAGGREGATE <br />$ 2,000 000 <br />PRODUCTS -COMPIOPADO <br />$ 2 DDa 0()D <br />$ <br />q <br />AUTOMOBILE <br />LIABILITY <br />ANY AUTO <br />OWNED SCHEDULED <br />AUTOS ONLY X AUTOS <br />HIRED X NON -OWNED <br />AU745 ONLY AUTOS ONLY <br />1 <br />II <br />t <br />CAP8524976 <br />08121/2024 <br />08/21/2025 <br />! <br />j <br />COMBINED SINGLE LIMrf <br />Ea accdent <br />$1,000,004 <br />BODILY INJURY (Per person) <br />$ <br />90t?€LYINJURY (Per aoc#dent) <br />$ <br />X <br />PROPERTY DAMAGE <br />Per accident <br />$ <br />A <br />X <br />UMBRELLALIAB <br />EXCESS LIAB <br />OCCUR <br />CLAIMS -MADE <br />I <br />UMB8609087 108/2112024 <br />108f2112025 <br />1 <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ 2.000.000 <br />DED I I RETENTIONS1D.000 <br />$ <br />A <br />WORKERSCOMPE14SATION <br />AND EMPLOYERS' LIAMn Y Y 1 N <br />ANYPROPRIETOR/PARTNER/EXECUTIVE <br />DFFICERIMEMBEREXCLUDED? <br />(Mandatory in NH) <br />If <br />D eyes <br />SCRIPTION OF OPERATIONS balaw <br />NIA <br />WC 8341646 <br />I <br />08/21/2024 <br />I <br />1011121/2025 <br />X ! UiE EOTRH- <br />E.L, EACH ACCIDENT <br />$1 000 G00 <br />EL. DISEASE - EA EMPLOyerz <br />$ 1,00D,00D <br />E.L. DISEASE - POLICY LIMIT <br />$ 1 .009.000 <br />I <br />DESCRIPTION OF OPERATIONS I LOCATIONS ! VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space Is required) <br />CERTIFICATE HOLDER CANCFLI ATInN <br />South Bend Sewer Department <br />731 S. Lafayette Blvd. <br />South Bend, IN 46601 <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />AUTHORIZED REPRESENTATIVE <br />Kelley, Jacob <br />ID 1988-2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD <br />