HomeMy WebLinkAboutB&L Construction 8-10-19 BLCON01 OP ID:CMW
ACORD• DATE(MMIODIYYVY)
CERTIFICATE OF LIABILITY INSURANCE 10/03/2018
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 920-734-3110 NNper BRANDON HEISE
ADEMINO 920-734-6027
DAVID ADE ASSOCIATES INC PHONE 920-734-3110 FAX MINO (PJC,No,Ext): I(A/C,No):
1001 TRUMAN P 0 BOX 99 R))itss:bheise(ademino.com
KIMBERLY, WI 54136-0099
BRANDON HEISE INSURER(S)AFFORDING COVERAGE NAM#
INSURERA:SELECTIVE INSURANCE 19259
INSURED B&L CONSTRUCTION LLC INSURER B:
BRAIN WILKE
4822 RIVERMOORE RD INSURER C:
OMRO,WI 54963 INSURERD:
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 SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR INSR WYD (MMIDDN YYYI (MMIDDM'YY1
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X OCCUR Y S 2348075 08/10/2018 08/10/2019 PREMISES(Ea oc TO RENTED ence) $ 500,000
MED EXP(Any one person) $ 15,000
PERSONAL&ADV INJURY $ 1,000,000
GENII_AGGREGATE LIMIT APPLIES PER- GENERAL AGGREGATE $ 3,000,000
POLICY X j X LOC PRODUCTS-COMP/OP AGG $ 3,000,000
OTHERCOMBINED $
A AUTOMOBILE LIABILITY Ea accident) GLE LIMIT $ 1,000,000
X ANY AUTO Y S 2348075 08/10/2018 08/10/2019 BODILY INJURY(Per person) $
- OWNED SCHEDULED
AUTOS ONLY _ AUTOS BODILY
R� INJURY� (Per accident) $
AUTOS ONLY _ AUTOS ONLY (Per accRident) GE $ .
$
A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000
EXCESS LIAB CLAIMS-MADE S 2348075 08/10/2018 08/10/2019 AGGREGATE $ 1,000,000
DED X RETENTION $ 0 $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANY
Y FROO�PMRFIEMTgOERRARTNE EXCLUDED?ECLMVE N/A E L.EACH ACCIDENT $
.laudatory In NH) E L DISEASE-EA EMPLOYEE $
It yes.describe under
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule.may be attached if more space Is required)
SEE ATTACHED
CERTIFICATE HOLDER CANCELLATION
OSCIT-1
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF OSHKOSH ACCORDANCE WITH THE POLICY PROVISIONS.
ATTN: CITY CLERK
215 CHURCH ST AUTHORIZED REPRESENTATIVE
OSHKOSH,WI 54901
ACORD 25(2016/03) O 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD