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A� f �S CERTIFICATE OF LIABILITY INSURANCE <br />08/201202418:08 <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 INSURERJS), AUTHORIZED <br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. <br />IMPORTANT; If the certificate holder is an ADDITIONAL INSURED, the poiicy(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 endorsernertt(s . <br />PRODUCER <br />CONTACT <br />-NAME* <br />Kelley, Jacob <br />F4C Na (574) 400-4389 � No <br />2410 Edison Rd, Suite 400 <br />E-MAIL Jacob.Kelley@infarmbureau_com <br />ADDRESS, <br />South Bend, IN 46615 <br />INSURER(S) AFFORDING COVERAGE <br />NAIC # <br />INSURER A: United Farm Family Mutual Insurance Company <br />15288 <br />INSURED <br />NIEZGODSKI PLUMBING, INC <br />-INSURERS: <br />232 N MAYFLOWER RD <br />INSURER C <br />SOUTH BEND, IN 46619-1534 <br />INSURER D: <br />INSURER E <br />INSURER F <br />COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <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 PAID CLAIMS. <br />INSR <br />LTR <br />TYPE OF INSURANCE <br />A L <br />5 <br />$ 13R <br />POLICYNUMBER <br />POLICY EFF <br />fmmfogynm <br />POLICY W <br />11IVUDD1yyre1LIMITS <br />A <br />X <br />COMMERCIAL GENI RALLIASiLITY <br />CLAIMS -MADE OCCUR <br />j IBOP8236911 <br />0812112CI24 <br />0812112025 <br />EACHO=URRENCE1 <br />$7.DDD 00D <br />DAMAGE TO REM <br />PREMISES JEao=%fenoe <br />$50000 <br />ME[) EXP (Anyone person) <br />$10 000 <br />PERSONAL &ADVINJURY <br />$1 00()000 <br />GENL AGGREGATE LIMIT APPLIES PER: <br />X POLICY PRO- <br />JECT 171 Lo c <br />OTHER: <br />GENERAL AGGREGATE <br />$2,000,000 <br />PRODUCTS - COMPIOP AGG <br />$ 2 000 000 <br />$ <br />pIx <br />AUTOMOBILE <br />1-Mi .ITY <br />ANY AUTO <br />OWNED X SCHEDULED <br />AUTOS ONLY AUTOS <br />HIRFD X NON -OWNED <br />AUTOS ONLY AUTOS ONLY <br />CAPS524976 <br />108/21 /2024 <br />08/2112025 <br />COMBINED SINGLE LEMiT <br />Ea acxident <br />$1.000,00D <br />BODILY INJURY (Per person) <br />$ <br />BODILY INJURY (Per acddenf ) <br />$ <br />PROPERTYDAMAGE <br />Per acadent <br />$ <br />A <br />X <br />UMBRELLAL146 <br />EXCESS LIAR <br />OCCUR <br />CLAIMS -MADE <br />I <br />UMBS609087 <br />( <br />0812112024 <br />If <br />08121 /2025 <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$2,400,13D0 <br />DED RETENTION 10.000 <br />$ <br />A <br />WORKERS COMPENSATION <br />ANDEMPLOYERSLIARILMY YfN <br />ANYPROPRIETORIPARTNERIEXECUTNE <br />OFHCERIMEMSEREXCLUOED? <br />(Mandatory In NH) <br />If yes, dawfta under <br />DESCRIPTION OF OPERATIONS balaw <br />NIA <br />WC 8341646 <br />I <br />111812112024 <br />08/21/2025 <br />PSTEA UrE I ERR- <br />$1 .ODD ODD <br />E-L. EACH ACCIDENT <br />E1. DISEASE- EA EMPLOYEE <br />$1,000,000 <br />E.L. DISEASE -POLICY LIMIT <br />$1 ,000.000 <br />DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If mare space Is required) <br />Certificate holder is an Additional Insured as provided by form D3-151 when required by written contract applies to general liability which includes ongoing <br />operations and products and completed operation and primary & non-contributory <br />CERTIFICATE HOLDER CANCELLATION <br />City of South Bend <br />Bureau of Sewers <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE <br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN <br />731 S. Lafayette Blvd <br />ACCORDANCE WITH THE POLICY PROVISIONS. <br />South Bend, IN 46601 <br />AUTHORIZED REPRESENTATIVE <br />Kelley, Jacob <br />Q 1988 2015 ACORD CORPORATION. All rights reserved. <br />ACORD 25 (23161103j The ACORD name and logo are registered marks of ACORD <br />