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HomeMy WebLinkAboutGit R Done Paving 1-8-19 ACCPR C)® DATE(MM/DD/YYYY) `� CERTIFICATE OF LIABILITY INSURANCE 06/21/2018 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 pollcy(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 CONTACTNAME: PHONE : FAX (A/C.No.Ext): I (A/C,No): RICK A NEMECEK A DRIESS: 127 W PERRY ST INSURER(S)AFFORDINGCOVERAGE NAIC# PORT CLINTON OH 43452-1039 INSURER A: NATIONWIDE MUTUAL INSURANCE COMPANY 23787 INSURED INSURER B: CHARLES SWARTZ INSURER C: DBA GIT R DONE PAVING INSURER D: 3322 STATE HIGHWAY 13 INSURER E: Wisconsin Dells WI 53965 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 i TYPE OF INSURANCE ADDL'SUBR POLICY EFF POLICY EXP OMITS LTR INSD WVD POLICY NUMBER '(MM/DD/YYVY) (MMIDWYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I $ 2,000,000 CLAIMS-MADE X OCCUR PREM SESO(EaENT occurrrence) $ 100,000 MED EXP(Any one person) $ 5,000 A X ACP GLO 5784327319 01/08/2018 01/08/2019 PERSONAL a ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 X POLICY PRO JECT LOC PRODUCTS-COMP/OP AGG $ 4,000,000 OTHER: $ AUTOMOBILEUABILITY COMBINED SINGLE LIMIT $ 1 000,000 (Ea accident) — ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED X SCHEDULED X iAUTOS ACP BA 5784327319 01/08/2018 01/08/2019 BODILY INJURY(Per accident) $ �/ NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS (Per accident) $ UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ , DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'UABIUTY Y/N , STATUTE ER ANYPROPRIETOR/PARTNERIEXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below _ E.L.DISEASE-POLICY LIMIT $ I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Additional insureds per attached endorsements.Certificates of insurance acceptable to the City of Oshkosh shall be submitted prior to commencement of the work to the applicable city rd department.These certificates shall contain a provision that coverage afforded under the policies will not be canceled or non renewed until at least 30 days prior written notice has been given to the City Clerk-City of Oshkosh 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 AUTHORIZED REPRESENTATIVE PO Box 1130 Nationwide Mutual Insurance Co Oshkosh WI 54903-1130 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD