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HomeMy WebLinkAboutFahrner Asphalt Sealers 12-1-19 • _ Page 1 of 2 AC�®' DATE(MMIDD/YYYY) `� CERTIFICATE OF LIABILITY INSURANCE 06/06/2019 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 tiiia of Minnesota, Inc. PHONE 1-877-945-7378 FAX 1-BBB-467-2378 c/o 26 Century Blvd RECEIVED -LA/C•No.Eat): - (A/C'Ne) P.O. Box 305191 - A DRIESS: certificatesewillis.com Nashville, TN 372305191 USA INSURER(S)AFFORDING COVERAGE NAIC• J U N -7 2019 INSURER A: Zurich American Insurance Company 16535 INSURED ' IN �i� SURERB: American Guarantee and Liability Insurance 26247 Fahrner Asphalt Sealers, LLC DEPT ()I I'i 113LIC YY O�•' INSURER C 2800 Mecca Drive tf� can _- - - Plover, WI 54467 ()M I h.I /ti I I. �Y ISCON INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:W11567766 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 ADOL SUER POLICY EFF POLICY EXP LIMITS LTRINSD WVD POLICY NUMBER IMMIDD/YYYY) (MMIDDIYYYYI X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 2,000,000 AMAGE TO RENTED 1 CLAIMS-MADE X OCCUR PREM PREMISES(Ea occurrence) $ 500,000 A MED EXP(Any one person) S 10,000 Y GLO 05944711-10 12/01/2018 12/01/2019 2,000,000 PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 4,000,000 POLICY X 7E8- X LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S 5,000,000 _ (Ea accident) X ANY AUTO BODILY INJURY(Per person) S A OWNED SCHEDULED Y I BAP 05944710-10 12/01/2018 12/01/2019 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS _ HIRED HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _AUTOS ONLY (Per accident) $ UMBRELLA LIAR 1 X OCCUR EACH OCCURRENCE S 5,000,000 B -- X EXCESSLIAB 1 CLAIMS-MADE SXS 0271705-01 12/01/2018 12/01/2019 AGGREGATE S 5,000,000 DED X RETENTIONS 0 $ WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY STATUTE ER YIN A ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT S 1,000,000 OFFICER/MEMBEREXCLUDED? 1-7 E.L.INC 05944712-10 12/01/201B 12/01/2019 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 1,000,000 If yes.describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Installation Floater CPP 9383736-10 04/01/2019 04/01/2020 $2,000,000 Off-Site Temporary Storage 1 $2,000,000 Property in Transit I $2,000,000 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 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 PO Box 1130 L- O Oshkosh, WI 54903-1130 . 14,✓--- ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD SR ID. 18075743 BATCH 1231001