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HomeMy WebLinkAboutBoldt Company 12-31-19 Page 1 of 3 A` DATE(MM/ Y) CERTIFICATE OF LIABILITY INSURANCE 03/O1/2019/2019 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 NAME: Willis Towers Watson Midwest, Inc. fka Willis of Minnesota, Inc. PHONE 1-877-945-7378 FAX 1-888-467-2378 c/o 26 Century Blvd (A/C.No.Ext.): (A/C.No): P.O. Box 305191 ADDRESS: certifi cat eaerrillin.com Nashville, TN 372305191 USA EC 1-)V EL- INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Travelers Indemnity Company 25658 INSURED MAK — 2��J INSURER B: Travelers Property Casualty Company of Ame 25674 The Boldt Company INSURER C: Travelers Casualty Insurance Company of Am 19046 PO Box 419 Appleton, WI 549120419 DEPT-,OF i, i, , ,I INSURER D• Charter Oak lire Insurance Company 25615 I I OSl IhW•5I i INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:R10292304 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 EFF POLICY EXP W LIMITS LTR INSD, VD POLICY NUMBER IMMIDD/YYYY) (MM/DD/YYYYI X COMMERCIAL GENERALUABILITY EACH OCCURRENCE S 5,000,000 DAMAGE TO CLAIMS-MADE X OCCUR PREMISES(EaENTED occurrence) $ 500,000 A MED EXP(Any one person) $ 10,000 VTC2K-CO-3992B816-IND-19 01/01/2019 12/31/2019 PERSONAL BADVINJURY S 5,000,000 GEN'L AGGREGATE LIMB APPLIES PER: GENERAL AGGREGATE S 5,000,000 POLICY X JE: X LOC PRODUCTS-COMP/OPAGG S 5,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 2,000,000 (Ea accident) X ANY AUTO BODILY INJURY(Per person) S B OWNED SCHEDULED VTJ-CAP-3510A098-TIL-19 01/01/2019 12/31/2019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED sNO'iN-OWNt�ELDy PROPERTY DAMAGE �I OS ONLY Obl710p.mig {1 ooc (Per accident) X bode S1,000 X f UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMS-MADE AGGREGATE S DED RETENTIONS $ WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY MUTE ERA YIN C ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? No NIA VTC2J-DB-46888552-19 01/01/2019 12/31/2019 1,000,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S B Excess Workers Compensation VTWXJ-UB-9497L73-2-19 01/01/2019 12/31/2019 Bee Below Michigan DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Re: Annual Right-of-Way Excavation License. SEE ATTACHED CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Oshkosh Attn: City Clerk 215 Church Avenue AUTHORIZED REPRESENTATIVE P 0 Box 1130 vi6fiTL Oshkosh, WI 54903-1130 ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 17599780 BATCH: 1091237