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HomeMy WebLinkAboutDale Van Groll Concrete Creations 2-1-19 AC� DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/23/2018 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 CONTACT NAME: Vicky Verhasselt Van Dyn Hoven Insurance laic°.No.Extt: (920)788-3530 lac,Nol: (820)788-15948 534 Pine Street ADDRIESS: VIcky@nvdhinsUrance.Com Little Chute, WI 54140 INSURER(S)AFFORDINOCOVERAGE NAIL/ INSURERA: Wilson Mutual INSURED INSURERB: Dale Van Groll Concrete Creations LLC INSURER C: N4084 Mary Joan Ct. INSURERD: Appleton,WI 54913 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-664146 REVISION NUMBER: 67 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 ADDLISUBR POUCY EFF POLICY EXP UNITS LTR INS('WVD POUCY NUMBER IMM/DD/YYYYI IMM/DDfYYYY) A X COMMERCIAL GENERAL LIABILITY 3200625180 02/01/2018 02/01/2019 EACH OCCURRENCE $ 1,000,000 DAMAGE TO CLAIMS-MADE _ OCCUR PREMISES(EaENTED occurrence) $ 100,000 MED EXP(Any one person) S 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POUCY 1 JE LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: S A AUTOMOBILE LIABILITY 3200625180 02/01/2018 02/01/2019 ((EaMxaNl SINGLE LIMIT S 1,000.000 ANY AUTO BODILY INJURY(Per person) S - OWNED SCHEDULED BODILY INJURY(Per accident) S - AUTOS ONLY X AUTOS X AUTOS ONLY X AUOTOCANNEL'? PROP(PeraacEcidentDAMAGE S A X UMBRELLA UAB _ OCCUR 3200625180 02/01/2018 02/01/2019 EACH OCCURRENCE _ $ 1,000,000 EXCESS UAB CLAIMS-MADE AGGREGATE S 1,000,000 DED RETENTIONS 0 S A WORKERS COMPENSATION 3200625180 02/01/2018 0210112019 STATUTE OT ER H AND EMPLOYERS'UABIUTY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? y N/A (Mandatory In NH) E.L_.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY UNIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION 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. 215 Church St Oshkosh,WI 54903 AUTHORIZED REPRESENTATIVE (VIC) ©`'1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by VIC on April 23.2018 at 08:38AM