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HomeMy WebLinkAboutJeff Foust Excavating 4-1-19 __�1 7 FOUST-1 OP ID: RG AcoRO CERTIFICATE OF LIABILITY INSURANCE DATE IMM/DD YYYYi ilk.,------- 03/17/2016 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 920-233-4000 NAME cT Brian McClone McClone-Oshkosh PHONE 920-233-4000 1FAX 920-725-3233 505 North Westfield Street (NC,No,Eztl: 1(A/c,No): Oshkosh,WI 54902-4105 itakSS,brian.mcclone@mcclone.com Brian McClone INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:West Bend Mutual Insurance Co. 15350 INSURED Jeff Foust Excavating Inc. INSURER 8: 2824 Clairvllle Rd. Oshkosh,WI 54904 r INSURER C: INSURER D: 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 TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMIT'S LTR INSR NIVD IMMIDDIYYYYI IMM/DD/YYYYf A X COMMERCIAL GENERAL UABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR A419383 04/01/2018 04/01/2019 DAMAGES(RENTED 300,000 X PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 5,000 X Aggr Per Prof CG7 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMITRCTp APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JE LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINEDa LIMIT $) 1,000,000 X ANY AUTO X A419383 04/01/2018 04/01/2019 BODILY INJURY(Per person) $ —_ OWNED EONS ONLY SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY _ AUTO O Y PFtter acade nt;AMAGE $ ( ) $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2,000,000 EXCESS LIAB CLAIMS-MADE X A419383 04/01/2018 04101/2019 AGGREGATE a 2,000,000 DED X I RETENTIONS 10000 s A WORKERS COMPENSATION X STATUTE ERH- AND EMPLOYERS'LIABILITY A419404 04/01/2018 04/01/2019 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT , $ QFFICERJMEMBEREXCLUDED? N/A (Mandatory n NH( E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes.describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Il LIVET) City of Oshkosh,its officers, council members, agents,employees and authorized volunteers are Additional Insured on a Primary and Non Contributory Basis with respects to General Liability including Ongoing and JAN j g Completed Operations when required by written contract and Additional D Z0r9 Insured with respect to Auto Liability on a Primary & NonContributory (cont) OS T Or pi, 1 HKOSH' WISCON ICS CERTIFICATE HOLDER CANCELLATION OSHCI-1 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 215 Church Avenue AUTHORIZED REPRESENTATIVE PO Box 1130 Brian McClone Oshkosh,WI 54903-1130 ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD