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HomeMy WebLinkAboutStafford Construction 4-20-20 ,�.--•, STAFCON-01 MHOBBS ACORL) CERTIFICATE OF LIABILITY INSURANCE DATE YY) �� 5/20/2019 20/2 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). CONTACT PRODUCER NAME: The Diedrich Agency 303 High Avenue (arc,PHONEL,Eat):(920)232-4090 FAX No):(920)748-5044 Oshkosh,WI 54902 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Sheboygan Falls Insurance Company 15148 INSURED INSURER B: STAFFORD CONSTRUCTION RANDY STAFFORD DBA INSURER C: 4237 ST RD 21 INSURER D: OSHKOSH,WI 54904 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 SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR JNSD WVD ,(MM/DD/YYYY1 (MM/DD/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR CPP9196748 4/20/2019 4/20/2020 DAMAGE TO RENTED 250,000 X PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10'000 PERSONAL 8 ADV INJURY $ 1,000,000 GENIIAGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 3,000'000 POLICY Tel' LOC PRODUCTS-COMP/OP AGG $ 3,000,000 OTHER $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO CAY9196748 4/20/2019 4/20/2020 BODILY INJURY(Per person) $ OWNED � SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY(Per accident) $ X HIRED X NON-OWNED PROPERTY DAMAGE AUTOS ONLY , AUTOS ONLY (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N WCY9196748 ANY4/20/2019 4/20/2020 100,000 OFFICER/M�MBER(EXCLUDED?ECUTIVE i N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under 500,000 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,emplohyees and authorized volunteers Randy Stafford is excluded from coverage under workers compensation have additonal insured status under general liability form CGD 20 33 when required by written contract. A 30 Day Notice has been added for 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. 420 Jackson Street Oshkosh,WI 54901 AUTHORIZED REPRESENTATIVE ..4:,-X,pY ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD