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HomeMy WebLinkAboutEgbert Excavating 3-9-20 �....41 EGBEEXC-01 MMEYER AC'ORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDlYYYY) 11.------- 3/7/2019 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 CONTACT _NAME: The Diedrich Agency PHONE Ert°N (920)748-2811 1 F c Ne 920 748-5044 222 Blackburn 54971 St MAR - S 2019 E-MAIL ) ) ADDRESS: DEpT O F I'U I3 L i C WORKS INSURER(S)AFFORDING COVERAGE NAIC• QSHK©SH INSURED > W ISCONSIN INSURER A:United Fire&Casualty 13021 INSURER B:Axis Egbert Excavating Inc INSURER C: PO Box 462 INSURER D: Green Lake,WI 54941 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 SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMM/DD/YYYYI (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 1EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X 60428021 3/9/2019 3/9/2020 DPREMSES(EaEoccu ence) t_ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X YE& X LOC PRODUCTS-COMP/OP AGG $_ 2,000,000 OTHER: $ _ COMB aBINED SINGLE LIMIT $ 1,000,000 A AUTOMOBILE LIABILITYCF,a X ANY AUTO X 160428021 3/9/2019 3/9/2020 BODILY INJURY(Per person) _s_ OWNED SCHEDULED _ AUTOS ONLY _ AUTOSpNNyyyy��EEpp BODILY INJURY(Per accident) $ AUTOS ONLY Al)TOS ONLY (PerR PROPERTY DAMAGE $ $ A _ UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,000 X EXCESS UAB CLAIMS-MADE 60428021 3/9/2019 3/9/2020 AGGREGATE $ 5,000,000 DED X RETENTION$ 10,000 $ A WORKERS COMPENSATION X STATUTE ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 60428021 319I2019 3/9/2020 E.L EACH ACCIDENT $ 100,000 OFFIC l In NH)EXCLUDED? Y N/A 100,000 ((�M NN E.L.DISEASE-EA EMPLOYEE S It yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ B Prof.Errors&Omiss CP002547-02-2018 6/20/2018 6/20/2019 Pollution Liab. 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) Dan Egbert is excluded from Workers Compensation. City of Oshkosh is an Additional Insured per CG2010(0704)and CG2037(0704)equivalent. See attached. 30 day cancel notice will be given to the City of Oshkosh. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Oshkosh THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1130 Oshkosh,WI 54902 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD