R2012-160 ACCEPTING THE BID AND AUTHORIZING CONTRACT

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y Ac"" CERTIFICATE OF LIABILITY INSURANCE DATE14/2/Y2 16.� 08/14/2012 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 1-630-773-3800 CONTACT NAME: Morgan Dudzik Arthur J. Gallagher Risk Management Services, Inc. PHONE - - _ _ - -- -- — - -AJC,No Ext 630-285-4459 _ A/C yo�630-285-3922 Two Pierce Place E-MAIL Morgan_Dudzik@a'7 ADDRESS: g.com Itasca , IL 60143-3141 _ _._ INSURER(S)AFFORDING COVERAGE - _ _ NAI_C# _ INSURERA: NATIONAL FIRE INS CO OF HARTFORD -1i20478 INSURED INSURER B: VALLEY FORGE INS CO 20508 A.C. Pavement Striping Co., Inc. GREAT AMER INS CO 16691 INSURER C: _ 695 Church Road INSURER D. Elgin, IL 60123 INSURER E: —I- INSURER F: COVERAGES CERTIFICATE NUMBER: 28676683 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. INSR ADDLSUBR - - POLICY EFF POLICY EXP LTR TYPE OF INSURANCENSR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A GENERALCOMMERCIAL GENERAL LIABILITY 5082704262 02/01/13 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED-- X r 300,000 CLAIMS-MAGE ��' OCCUR 02/01/12 PREMISES Ea occurrence $ X I. _MED EXP(Any one person) $ 5,000 X $2,500 BI & PD Ded. - PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AG;; $ 2,000,000 POLICY-_X_. PRO- I X LOC �— --- i$ B AUTOMOBILE LIABILITY 5082704245 02/01/1 02/01/13 COMBINED SINGLE LIMIT JEa accident)_ 11000,000 X ANY AUTO �- AUTOS �f BODILY INJURY Per person) $ ALL OWNED SCHEDULED III BODILY INJURY(Per accident $ { AUTOS AUTOS '�ROa RTY DAMAGE )T-_- NON-OWNED I $ X HIRED AUTOS X $ C X � UMBRELLA LIAB`II X OCCUR TW001674102 02/01/121 02/01/13`EACH T' EXCESS LAB -_.: -_1.-CLAIMS-MADE j AI GGREOGATERRENCE--- '"$-25 000,000.---_ 'L DED X RETENTION$10,000 $ A WORKERS.AND EMPLOYERSELI LIABILITY Y/N '5082704276 02/01/1 02/01/13 WC STATUOTH- 1 X J TORY T.5 I. Ry1. ANY PROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $ 1,000,000 (Mandatory in NHR EXCLUDED N N/A E .DISEASE-EA EMPLOYEEL.$ 1,000,000 If es,describe under ---- __- - ttt - -- - - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) AC Job# 13854. Project Name: City of Decatur, 2012 Micro-Surfacing Project, City project 2012-24. The City of Decatur, City Project 2012-24, and 2012 Micro-Surfacing Project are shown as additional insureds solely with respect to general liability coverage as evidenced herein as required by written contract with respect to work performed by the named insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Decatur THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Naomi R. Jones #1 Gary K. Anderson Plaza AUTHORIZED REPRESENTATIVE Decatur, IL 62523-1196 USA �•r�t/�.� �• ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD jthackery 28676683