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HomeMy WebLinkAboutFour Way Construction 3-31-19 t:Mary Meyer CISR FaxID'920-748-5044 Date 4/6/2018 9:56 05 AM Paae:2 of 2 ____......p/� � FOURCON-01 .__ MMEYER AL O/l 0' DATE(MM/DDIYYYY) �� CERTIFICATE OF LIABILITY INSURANCE oaros/zols 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). CONTACT PRODUCER _NAME; The Diedrich Agency (A/C, Eat): (920)748-2811 Fi/C 222 Blackburn St 1E��p,�L� (A/C,No):(920)748-5044 I Ripon,WI 54971 .9PBgF SI_ _• INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:QBE rt24414 INSURED INSURER B:West Bend Mutual Insurance Company 15350 Four-Way Construction Co _INSURER C: ,„„_, ••,,,__,,,,,,__ PO Box 133 INSURER 0: Berlin,WI 54923 _. 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 ADDL SUER �^ I POLICY EFF POLICY EXP ..LIB. TYPE OF INSURANCE IN . . POLICY NUMBER INLMIDD(YYYYLIMM1PD/YYYYI LIMITS A X COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE 1 X OCCUR A407659 03/31/2018 03131/2019 DAMAGE TO RENTED 300,000 X PREMISF$!Ea/rramenpel S MED.EXP(A.9.y one rson S 5,000 PERSONAL&ADV INJURY S 1,000,000 _GEM_AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE_••_••••••.„$ 2,000,000 1 POLICY X 71t0 LOC PRODUCTS-COMP/OP AGG S 2,000,000 OTHER: S•,_._....,._......_._,__ —•-•----• --•—••••-•- -• COMBINED SINGLE LIMIT 1,000,000 B AUTOMOBILE LIABILITY •(Ea.asskleIltl. S X 1 ANY AUTO '407859 03/31/2018 03/31/2019 BODILY INJURY(Per person) $ OWNED 1 SCHEDULED AUTOS ONLY I AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY AMAGE 1 AUTOS ONLY AUTOS ONLY Per acodentg $ S B X UMBRELLA UAB X OCCUR EACH OCCURRENCE S 2,000,000 EXCESS UAB I CLAIMS-MADE •407659 03/31/2018 03/31/2019 AGGREGATE $ 2,000,000 DED X RETENTION$ 0 S B WORKERS COMPENSATION X I PER T OTH- AND EMPLOYERS'UABILITY ..SIALITE. ER •407661 03/31/2018 03/31/2019 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE NN NIA E.L.EACH ACCIDENT S OFFICER/MEMBER EXCLUDED? (- (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE S 100,000 H yea,describe under '---_---.—.—.—•_M__.._._......_......_ DESCRIPTION OF•OPERATIONS below •••-_••• I El,DISEASE-POLICY LIMIT S 500,000 .......... _ ---� . ......_...,.. _ DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Y Additional insureds include: City of Oshkosh and its officers,council members,agents,employees and authorized volunteers. I APR 0 6 2018 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Oshkosh THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1130 Oshkosh,WI 54903 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD