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HomeMy WebLinkAboutQ3 Contracting 2-28-20 • A` DATE(MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE 05/28/2019 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 MCGRIFF,SEIBELS&WILLIAMS OF TEXAS,INC. PHON: E 818 Town&Country Blvd,Suite 500 (A/CNNo,Eat): 713-877-8975 (AA/C,No):713-877-8974 Houston,TX 77024-4549 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Liberty Mutual Fire Insurance Company 23035 INSURED INSURER B:LM Insurance Corporation 33600 Q3 Contracting,Inc. 3066 Spruce Street INSURER C:Liberty Insurance Corporation 42404 Little Canada,MN 55117 INSURER D:Underwriters At Lloyd's,London 15792 INSURER E: INSURER F: _ COVERAGES CERTIFICATE NUMBER:SHHNPHLW 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. INSRTRPOLICY EFF POLICY EXP TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS C X COMMERCIAL GENERAL LIABILITY TB7-C91 463703-069 02/28/2019 02/28/2020 EACH OCCURRENCE $ 2,000,000 DAMAGE D CLAIMS-MADE X OCCUR PREMISESO(EaENTE occu occurrence) $ 2,000,000 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4.000,000 POLICY X jE LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: $ C AUTOMOBILE LIABILITY AS7-C91-463703-079 02/28/2019 02/28/2020 COMBINED SINGLE LIMIT 2,000,000 (Ea accident) $ X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY ^ AUTOS ONLY (Per accident) Physical Damage Ded. $ 250,000 D X UMBRELLA LIAB X OCCUR AU1900190 02/28/2019 02/28/2020 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED X RETENTION$ $ A WORKERS COMPENSATION WC2-691-463703-039 02/28/2019 02/28/2020 X STARUTE OT B AND EMPLOYERS'LIABILITY Y/N WA5-C9D-463703-049ER C ANY PROPRIETOR/PARTNER/EXECUTIVE WC5-C91-463703-059 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N N/A EW5-69N-463703-029 TX/LA 1,000,000 (Mandatory In NH) WA7-C9D-468237-189 E.L.DISEASE-EA EMPLOYEE $ It yes,describe under EW7-69N-463703-019 CA 1,000,000 DESCRIPTION OF OPERATIONS below $250,000 Ded/SIR applies to all E.L.DISEASE-POLICY LIMIT $ I $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) In the event of cancellation by the insurance companies the policies have been endorsed to provide(30)days Notice of Cancellation(except for non-payment)to the Certificate Holder shown below. City of Oshkosh,and its officers,council members,agents,employees and authorized volunteers are included as Additional Insured as respects the General Liability,Auto Liability and Umbrella Liability policies. A Waiver of Subrogation is provided in favor of the Certificate Holder as respects the General Liability,Auto Liability,Umbrella Liability and Workers'Compensation policies. General Liability,Auto Liability and Umbrella Liability policies are Primary and Non-Contributory. Workers'Compensation policy includes USL&H,Maritime Liability,Defense Base Act,Federal Employers Liability,Outer Continental Shelf Lands Act, Alternate Employer Endorsement and Voluntary Compensation. All as required by written contract and subject to policy terms,conditions and exclusions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Oshkosh Attn:City Clerk AUTHORIZED REPRESENTATIVE 215 Church Ave—PO Box 1130 Oshkosh,WI 54903 Page 1 of 4 ©1988-2015 ACORD CORPORATION. All rights reserved. A r'r Dn OC MMC fn41 Th.. ArnDn nn...s nn.f!noon n.s rsooisfs.sd...o.L.....f Ar^nDn