HomeMy WebLinkAboutAl Dix Concrete 3-1-19 A CERTIFICATE OF LIABILITY INSURANCE DATE04/17/018
04/17I2018
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
FEDERATED MUTUAL INSURANCE COMPANY NAME: CLIENT CONTACT CENTER
PHONE HOME OFFICE: P.O. BOX 328 (A/CC,No,Ext):888-3334949 FAX
No):507-446-4664
OWATONNA, MN 55060 E-MAIL
CLIENTCONTACTCENTER(aFEDINS.COM
INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A:FEDERATED MUTUAL INSURANCE COMPANY 13935
INSURED 399-196-5 INSURER B:FEDERATED SERVICE INSURANCE COMPANY 28304
AL DIX CONCRETE, INCORPORATED INSURER C:
401 GERTRUDE ST
KAUKAUNA,WI 54130-1423 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:6 REVISION NUMBER: 1
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 INSR WVD (MM/DDIYYYYI (MM/DD/YYYY)
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $1,000,000
DAMAGE TO RENTED
CLAIMS-MADE X OCCUR PREMISES Ea occurrence) $100,000
MED EXP(My one person) $5,000
A Y N 6068617 03/01/2018 03/01/2019 PERSONAL&ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
POLICY X ECT 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
A AUTOS N N 6068617 03/01/2018 03/01/2019 BODILY INJURY(Per accident)
HIRED AUTOS ONLY NON-OWNED PROPERTY DAMAGE
AUTOS ONLY (Per accident)
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $3,000,000
—A EXCESS LIAB CLAIMS-MADE N N 6068618 03/01/2018 03/01/2019 AGGREGATE $3,000,000
DED RETENTION
WORKERS COMPENSATION OTH-
AND EMPLOYERS'LIABILITY Y/N X PER STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000
B OFFICER/MEMBER EXCLUDED? NIA N 6068619 03/01/2018 03/01/2019
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000
If yes,describe under
OE SCRIPTION OF UPE RM1 IONS below E.I- OISFASE-POLICY LIMIT $500,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may he attached if more space is required)
RE: PUBLIC WORKS CONTRACT# 18-06
CITY OF OSHKOSH, AND ITS OFFICERS, COUNCIL MEMBERS, AGENTS, EMPLOYEES, AND AUTHORIZED VOLUNTEERS ARE ADDITIONAL
INSURED FOR GENERAL LIABILITY.
CERTIFICATE HOLDER CANCELLATION
399-196-5 6 1
CITY OF OSHKOSH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
215 CHURCH AVE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
PO BOX 1130 ACCORDANCE WITH THE POLICY PROVISIONS.
OSHKOSH,WI 54903-1130
AUTHORIZED REPRESENTATIVE
6 )4AA
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