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A C.CORD CERTIFICATE OF LIABILITY INSURANCE � 03/08/019
03108/'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 POUCIES 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: CLIENT CONTACT CENTER
FEDERATED MUTUAL INSURANCE COMPANY PHONE FAX
HOME OFFICE: P.O. BOX 328 RECEIVED (A/C,No,Ext):888-333-4949 (A/C,No):507-446-4664
OWATONNA, MN 55060 E-ADDRESS:CLIENTCONTACTCENTER( FEDINS.COM
INSURER(S)AFFORDING COVERAGE NAIC#
MAR 1 4 2019 INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935
INSURED 1 INSURER B:
J.C. SANTY CONSTRUCTION, LLC DEPT OF NU L�LI� `�'� INSURER C:
3184 S SAINT AUGUSTINE DR OSHKOSH, WISCONSIN
PULASKI,WI 54162-8949 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:4 REVISION NUMBER:0
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 SUBR POLICY NUMBER POUCY EFF POLICY EXP LIMITS
LTR INSR WVD IMMIDDIYYYY) IMM/DD/YYYY)
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000
DAMAGE TO ED
CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $100,000
MED EXP(Any one person) EXCLUDED
A Y N 6076803 01/18/2019 01/18/2020 PERSONALS ADV INJURY $1,000,000
OEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
POLICY X JECT LOC PRODUCTS-COMP/OP AGG $2,000,000
OTHER:
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000
(Ea accident)
X ANY AUTO BODILY INJURY(Per person)
OWNED AUTOS ONLY SCHEDULED AUTOS_ACHES Y N 6076803 01/18/2019 01/18/2020 BODILY INJURY(Per accident)
HIRED AUTOS ONLY NON-OWNED PROPERTY DAMAGE
AUTOS ONLY (Per accident)
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $1,000,000
A �• EXCESS LIAR •�CLAIMS-MADE N N 6076804 01/18/2019 01/18/2020 AGGREGATE $1,000,000
DED RETENTION
WORKERS COMPENSATION OTH-
X PER STATUTE ER
AND EMPLOYERS'LIABILITY
YI ANY PROPRIETOR/PARTNER/EXECUTIVE N E.L.EACH ACCIDENT $500,000
A OFFICER/MEMBER EXCLUDED? NIA N 6076805 01/18/2019 01/18/2020
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000
II yes,describe under
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required)
SEE ATTACHED PAGE
CERTIFICATE HOLDER CANCELLATION
156-988-8 4 0
CITY OF OSHKOSH ATTN:CITY CLERK SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE
215 CHURCH AVE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
PO BOX 1130 ACCORDANCE WITH THE POUCY PROVISIONS.
OSHKOSH,WI 54903-1130
AUTHORIZED REPRESENTATIVE
11444,,,f,.,i KA,
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