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HomeMy WebLinkAboutWolf River Asphalt and Sealcoating 3-16-20 Ace CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYY) 07/01/2019 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 Michele Daniels Family Insurance Center, LLC NAME: PHONE (920)757-1010 FAx (920 757-9710 N1788 Lily of the Valley Dr (A/C.No.EMI; �aC,No): ) Greenville,WI 54942 ADDRESS: michele@familyinsctr.com INSURER(S)AFFORDING COVERAGE NAIC N _ INSURER A: Erie Insurance 26271 INSURED WOLF RIVER ASPHALT AND SEALCOATING,INC INSURER B: CNA Surety CNA N5206 Rexford Rd Shiocton,WI 54170 INSURER C: INSURER D: 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. INSRICY EXP TYPE OF INSURANCE ..dSD SWVD, POLICY NUMBER ,(MMIDUBR' OIYYYY) JMY EFF M1 DIYYYY) LIMITS A J COMMERCIAL GENERAL LIABILITY Y Q39-1650891 03/16/2019 03/16/2020 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE L VI OCCUR PREMISES(Ea Occurrence) S 1,000,000 MED EXP(Any one person) S 5,000 PERSONAL a ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 POLICY I I JP i LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: S A AUTOMOBILE LIABILITY Y Q03-1640079 03/16/2019 03/16/2020 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) _ d ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED BODILY INJURY(Per accident $ AUTOS ONLY AUTOS ) HIRED NON-OWNED PROPERTY DAMAGE — $ AUTOS ONLY AUTOS ONLY (Per accident) A V UMBRELLA LIAB OCCUR y Q27-1670325 03/16/2019 03/16/2020 EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION S _ $ A WORKERS COMPENSATION Q87-1600839 03/16/2019 03/16/2020 VI SPR TATUTE OTH- ER EMPLOYERS'LIABILITY Y 1 N - ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 1,000,000 OFFICER/MEMBER EXCLUDED? n N/A (Mandatory In NH) E.L DISEASE-EA EMPLOYEE 5 1.000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 1,000,000 B Single Site Right-of-Way Excavation 64705248 07/01/2019 12/31/2019 $5000 Bond I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101.Additional Remarks Schedule,may be attached If more space is required) Additional Insureds per the attached endorsements Certificates of insurance acceptable to the City of Oshkosh shall be submitted prior to commencement of the work to the applicable City department. These certificates shall contain a provision that coverage afforded under the policies will not be canceled or non renewed until at least 30 days'prior written notice has been given to the City Clerk-City of Oshkosh Includes ISO Forms CG 20 10 and CG 20 37 Project for Aquire Restoration CERTIFICATE HOLDER CANCELLATION City of Oshkosh SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attn:City Clerk THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 215 Church Ave ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1130 Oshkosh,WI 54903 AUTHORIZED REPRESENTATIVE illy .-a2r I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD