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HomeMy WebLinkAboutJacobson Contracting 5-1-20 JACOCON-01 MHOBBS ACORO DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 5/1/2019 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 suchpendorsement(s). PRODUCER NAME CT — The Diedrich AgencyPHO 303 High Avenue ( NNo,Ext):(920)232-4090 � FAX No(920)748-5044 Oshkosh,WI 54902 RECEIVED irtAh$S: INSURER(S)AFFORDING COVERAGE NAIC M MAY 1 2019 INSURER A:Acuity 14184 INSURED INSURER B: JACOBSON CONTRACTING LLC )EPT OF PUBLIC WORI�MSURERC: 6403E Decorah Avenue OSHKOSH,WI54904 OSHKOSH, WISCONSI;vNSURERD: 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER POUCY EFF POLICY EXP UMITS LTR INSD WVD IMM/DD/YYYY) /MM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X 1 OCCUR X P DREMIS X41856 5/1/2019 5/1/2020 AMAGEES( RENTEDoccurre $ 100,000 TO Eance) 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 ja LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO X41856 5/1/2019 5/1/2020 BODILY INJURY(Per person) $ OWNED X SCHEDULED AUTOSRE ONLY AUTNOSSy�N BODILY INJURY(Per accident) $ X AUTOS ONLY X AUUTOS ONLY 54:=AMAGE _ $ A UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000 X EXCESSLIAB CLAIMS-MADE X41856 5/1/2019 5/1/2020 AGGREGATE $ 1,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER H AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ (MFandatory In gH N )EXCLUDED? N I A E.L.DISEASE-EA EMPLOYEE S If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Oshkosh and its officers,council members,agents,employees and authorized volunteers have addtional insured status when required by written contract under addtional insured forms CB7332 and CB7245 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CI Of Oshkosh THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1120 Oshkosh,WI 54903 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD