Loading...
HomeMy WebLinkAboutDorner 6-1-19 ® DATE(MM/DD/YYYY)AC� �� CERTIFICATE OF LIABILITY INSURANCE 2/13/2019 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 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: an Hauge,CISR Ansay&Associates, LLC. PHONE FAX 1710 Lawrence Drive (A/C.No.Ext):800-236-8652 (A/C,No):920-437-4179 De Pere WI 54115 ADDREss: bri.hauge@ansay.com EC L-I V E D INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:Sentry Insurance a Mutual Company 24988 INSURED DORNINC-01- 1 8 2019 INSURER B:Middlesex Insurance Company 23434 Dorner Inc& — 1 Dorner Stahl Trucking LLC INSURERC: _ PO Box 129 DEPT OF PUBLIC WORKS INSURERD: Luxemburg WI 54217 OSHKOSII. W'ISCONSIN INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 168004936 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 SUBR POLICY EFF POLICY EXP LIMITS LTR INSD, VO POLICY NUMBER (MM/DD/YYYY) (MM/DO/YYYY) B X 1 COMMERCIAL GENERAL LIABILITY Y A0103044004 6/1/201S 6/112019 EACH OCCURRENCE $1,000,000DAMAGE I RENTED CLAIMS-MADE X OCCUR PREM SESO(Ea occurrence) $500,E ___ MED EXP(My one person) $10,000 PERSONAL 8 ADV INJURY $1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $3,000,000 POLICY X PECOT- I 1 LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER $ B 1 AUTOMOBILE LIABILITY A0103044001 6/1/2018 6/1/2019 COMBINED SINGLE LIMIT $ B A0106391001 6/1/2018 6/1/2019 (Ea accident) 1.000,000 I X ANY AUTO BODILY INJURY(Per person) $ I ALL OWNED SCHEDULED • BODILY INJURY(Per accident) $ AUTOS , AUTOS ED PR0R DAMAGE $X HEDAUTOS X , AUTOS ( e accident) $ 8 X UMBRELLA LIAB X OCCUR ` A0103044001 6/1/2018 6/1/2019 EACH OCCURRENCE $10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED X RETENTION S 0 $ A WORKERS COMPENSATION A0103044005 6/1/2018 6/112919 X AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? N N/A - -- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 6100,000 If yes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 B Motor Truck Cargo A0103044003 6/1/2018 6/1/2019 limit: 760,000 Deductible 5,000 Builders Risk/Installation Float Limit: 6,000,000 Deductible. 2,500 Leased/Rented Equipment Limit: 400.000 Deductible 2,500 I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE: Right-of-Way City of Oshkosh, and its officers, council members, agents,employees and authorized volunteers are included as additional insured's on a primary and noncontributory basis for general liability per form CG2010 04/13&CG2037 04/13 when required by written contract. 30 day notice of cancellation provided 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, Attn: City Clerk PO Box 1130 AUTHORIZED REPRESENTATIVE Oshkosh WI 54903-1130 r-4 ; . i ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD