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HomeMy WebLinkAboutBIG FOUR LIABILITY BIGFOUR-01 DGROSECLOSE C-CARE, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDYYYY) 05/23/2018 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 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(s). PRODUCER CONCT Dawn Groseclose NAME:TA Cincinnati Insurance Company PHONE FAX Cincinnati Customer Care Center (NC,No,Ext):(877)687-1291 (ac No):(513)881-8114 P.O.Box 145496 E-MAIL ADDRESS:CincinnatiCerts@cinfin.com Cincinnati,OH 45250-5496 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Cincinnati Insurance Company 10677 INSURED INSURER B:Cincinnati Casualty Company 28665 Big Four Restaurant LLC; BFM NA LLC DBA Big Four Burgers INSURER C: &Beer PO BOX 257 INSURER D: NEW ALBANY,IN 47151-0257 INSURERE: 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. INSR ADDL SUBR, POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMM/DD/YYYYI (MM/DD/YYYYI LIMITS _ A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X J OCCUR X ECP 0438040 05/08/2017 05/08/2020 PREMISESO(Ea occurrence) $ 1,000,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GE 'L AGGREGATE LIMB-APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY X ECT X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY �. COMBINED SINGLE LIMIT 1,000,000 (Ea accident) ANY AUTOED SCHEDULED ECP 0438040 05/08/2017 05/08/2020 BODILY INJURY(Per person) $ AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ _ X AUTOS ONLY X AUT (Pfter accident5)AMAGE UMBRELLA LIAB OCCUR - EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATIONIPER OTH- AND EMPLOYERS'LIABILITY Y/N X_1 STATUTE ER - ANY PROPRIETOR/PARTNER/EXECUTIVE N N/A EWC 0438046 05/08/2018 05/08/2019 E.L.EACH ACCIDENT 500,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) 500,000 E.L.DISEASE-EA EMPLOYEE.$ _ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Liquor Liability ECP 0438040 05/08/2017 05/08/2020 GA539 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF JEFFERSONVILLE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 500 QUARTERMASTER CT#205 JEFFERSONVILLE,IN 47130-3672 AUTHORIZED REPRESENTATIVE %7Y ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 1. Designation of Premises(Part Leased to You): 114 E MAIN STREET NEW ALBANY, IN 47150 2. Name of Person or Organization (Additional Insured): CITY OF JEFFERSONVILLE 500 QUARTERMASTER CT # 205 JEFFERSONVILLE, IN 47130-3672 SECTION II -WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1. Any'occurrence"which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person or organization shown in the Schedule. 3. "Bodily injury', "property damage"or"personal and advertising injury"arising out of the sole negligence or willful misconduct of the additional insured or its"employees". .1400, Includes copyrighted material of Insurance GA 4079 10 01 Services Office, Inc., with its permission. THE CINCINNATI INSURANCE COMPANY A Stock Insurance Company LIQUOR LIABILITY COVERAGE PART DECLARATIONS Attached to and forming part of POLICY NUMBER: ECP 043 80 4o Named Insured is the same as it appears in the Common Policy Declarations Legal Entity/Business Description LIMITED LIABILITY COMPANY LIMITS OF INSURANCE Each Common Cause Limit $ 100 , 000 Aggregate Limit $ 200 , 000 CLASSIFICATION CODE NO. PREMIUM BASE RATE ADVANCE PREMIUM RESTAURANTS, TAVERNS , 58162 320 , 000 1 . 011 324 HOTELS , MOTELS TOTAL PREMIUM $ 324 FORMS AND/OR ENDORSEMENTS APPLICABLE TO LIQUOR LIABILITY COVERAGE PART: GA115 12/04 LIQUOR LIABILITY COVERAGE FORM CG0305 01/96 DEDUCTIBLE LIABILITY INSURANCE GA 539 07 08 ECP 043 80 40 Page 1 of 1 /....N BIGFOUR-01 DGROSECLOSE A`O'RL7 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 05/23/2018 _ 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 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(s). PRODUCER CQNTACT Dawn Groseclose NAME: Cincinnati Insurance Company PHONE FAX Cincinnati Customer Care Center (ac,No,Ext):(877)687-1291 I(NC,No):(513)881-8114 P.O.Box 145496 ADDRESS;CincinnatiCerts@cinfin.com Cincinnati,OH 45250-5496 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Cincin nati Insurance Company 10677 INSURED INSURER B:Cincinnati Casualty Company 28665 Big Four Restaurant LLC;BFM NA LLC DBA Big Four Burgers INSURER C: &Beer PO BOX 257 INSURER D: NEW ALBANY,IN 47151-0257 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. INSR ADDL SpBR1 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR D 1 POLICY NUMBER IMM/DD/YYYYI (MM/DD/YYYYI LIMITS A X COMMERCIAL GENERAL LIABILITY ' ; �; EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X °'(" =ECP 0438040 05/08/2017 05/08/2020 DAMAGE S(REEa oocurrDPREMISEence) $ 1,000,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENt AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY X S'eT, X LOC PRODUCTS-COMP/OP AGG.,__J 2,000,000 OTHER: $ BILITY COMBINED SINGLE LIMIT 1,000 000 A AUTOMOBILE LIA (Ea accident) $ ANY AUTO ECP 0438040 05/08/2017 05/08/2020 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS i BODILYOINJURY(Per accident) $ X AUTOS ONLY X AUTOS ONLY (Peri accidentFAMAGE $ UMBRELLA LIAB OCC ' EACH OCCURRENCE $ EXCESS LIAB CLAII DE AGGREGATE is DED RETENTION$ $ B WORKERS AND EMPLOYERS'LI LIABILITY SATION , �_X STATUTE EEPER RH- ANY PROPRIETOR/PARTNER/EXECUTIVE v/N EWC 0438046 05/08/2018 05/08/2019 E.L.EACH ACCIDENT $ 500,000 FFICER/MEMBER EXCLUDED? N 1 N/A Mandatory In NH) 500,000 E.L.DISEASE-EA EMPLOY If yes,describe under " I DESCRIPTION OF OPERATIONS below "` , E.L.DISEASE-POLICY LIMIT 500'000 A Liquor Liability EC'04381(- 05/08/2017 05/08/2020 GA539 x DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CLUCKERS LLC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN W RIVERSIDE DR ACCORDANCE WITH THE POLICY PROVISIONS. 100JEFFERSONVILLE,IN 47130-3114 AUTHORIZED REPRESENTATIVE (r ACORD 25(2016/03) ®1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 1. Designation of Premises(Part Leased to You): 114 E MAIN STREET NEW ALBANY, IN 47150 2. Name of Person or Organization (Additional Insured): CLUCKERS LLC 100 W RIVERSIDE DR JEFFERSONVILLE, IN 47130-3114 11111640 SECTION II -WHO IS AN INSURED is amended to include as an insured the person or organization shown in the Schedule but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exdusions: This insurance does not apply to: 1. Any 'occurrence"which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person or organization shown in the Schedule. 3. "Bodily injury', "property damage"or"personal and advertising injury"arising out of the sole negligence or willful misconduct of the additional insured or its"employees". Includes copyrighted material of Insurance GA 4079 10 01 Services Office, Inc., with its permission. THE CINCINNATI INSURANCE COMPANY A Stock Insurance Company LIQUOR LIABILITY COVERAGE PART DECLARATIONS Attached to and forming part of POLICY NUMBER: ECP o43 8o 4o Named Insured is the same as it appears in the Common Policy Declarations Legal Entity/Business Description LIMITED LIABILITY COMPANY LIMITS OF INSURANCE Each Common Cause Limit $ 100 , 000 Aggregate Limit $ 200 , 000 CLASSIFICATION CODE NO. PREMIUM BASE RATE ADVANCE PREMIUM RESTAURANTS , TAVERNS , 58162 320 ,000 1 . 011 324 HOTELS, MOTELS TOTAL PREMIUM $ 324 FORMS AND/OR ENDORSEMENTS APPLICABLE TO LIQUOR LIABILITY COVERAGE PART: GA115 12/04 LIQUOR LIABILITY COVERAGE FORM CG0305 01/96 DEDUCTIBLE LIABILITY INSURANCE 400 GA 539 07 08 ECP 043 80 40 Page 1 of 1