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'``C- "NCERTIFICATE OF LIABILITY INSURANCE °ATE(MMDDYYYY) 7/l/2016 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(ies) must 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(s). PRODUCER Gibson Gibson Insurance Agency, Inc. 130 S Main St, Ste 400 NAMichelle Wasoaki PHONE (800)814-2122 FAX 1800)836-2122 NC No: Xi7r�eSS,�asoski@gibsoninB.com PO Box 11177 South Bend IN 46601-0177 INSURERS AFFORDING COVERAGE NAIC II INSURER A:Cincinnati Ina Cc 10677 INSURED La Casa de Amistad, Inc. 746 S Meade Street INSURERS Accident Fund Com an INSURERC: INSURER D: INSURER E South Bend IN 46619 INSURER F: THIS IS TO CERTIFY THAT THE POLICIES UINSURANCE 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. INTR TYPE OF INSURANCE DL SUBR POLICY NUMBER MM/DCVIYYYY MM%DCDYITEYYPY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR ETD 0234312 2/15/2016 2/15/2017 EACH OCCURRENCE $ 11000,000 DAM E TO RENTED PREMI E Ea occur r nee $ 11000,000 MED EXP(Any one person) $ 10,000 PERSONAL S ADV INJURY $ 11000,000 GEML X AGGREGATE LIMIT APPLIES PER: POLICY PRO- E]LOC JECT OTHER: GENERAL AGGREGATE $ 11000,000 PRODUCTS - COMP/OP AGG $ 11000,000 A AUTOMOBILE LIABILITY ANY AUTO AOSCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS ETD 0234312 2/ 15/2016 2/15/2017 COMBINED SING Ea accident LE LIMIT $ 11000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) -PROPERTY $ -DAMAGE Per accident) $ B UMBRELLA LIAB EXCESS LIAB OCCU CLAIMSR -MADE WCV6098384 2/15/2016 2/15/2017 EACH OCCURRENCE $ AGGREGATE $ DIED I RETENTION WORKERS COMPENSATION ANDEMPLOYERS'LIABILITV YIN ANY PROPRIETORIPARTNEWEXECUTIVE OFFICERIVEMBER EXCLUDED? ❑N/A (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below X PER OTH- STATUTE ER $ E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE -EA EMPLOYE $ 500, 000 E.,.'A. . DISASPLLIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is additional insured with respect to general liability coverages as required by written contract. Board of Public Works 1316 County -City Building 227 West 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 Ins Agency/MWASOS Al. V mu LD (ZU l4/Ul ) INS025 nm4nv 1988-2014 The ACORD name and logo are registered marks of ACORD All riahts reserved