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HomeMy WebLinkAboutGM Bauman Concrete & Masonry ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MWDDMWY) 4/23/2019 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(les) 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; Doreen Janssen Ansay&Associates, LLC. FV PHONE FAA 4351 W College Ave wc..NenE4:920-580-7000 1 taq,t020.580.7079_ E•MA IL Suite 310 AooREss: doreen.janssen®ansay.com _ Appleton WI 54914 INSURERS'AFFORDING COVERAGE NAUCS INsuRER A:ACUITY.A Mutual Insurance Company 14184 INSURED GMBAUMA-01 INSURER B_ GM Bauman Concrete&Masonry LLC —&Masonry LLC INSURER C: N3502 12 Corners Road INSURER Appleton WI 54913 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER:961297616 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.t LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IlTBRR t TYPE OF INSURANCE IPDSR isWNQ Y .-.__ POLICY HUNGER I AIWEN>IYYYYI IMM/DOIYYYYI! UIMITS A GENERAL UABILITY Z81918 10/312018 10/3/2010 EACH OCCURRENCE $1,1300,000 X COMMERCIAL GENERAL LIABILITY OiiFdAGETORErvrf•J PREMJSES.(Eawursx&l_- S2E0800 CLAIMS•MADE X OCCUR MED EXP(Any one person) 510,000 PERSONALS ADV INJURY S 1,000,000 GENERAL AGGREGATE S3,000,000 REBATE LIMIT APPUES PRODUCTS-COMP/OP AGO S 3p00(700 PO ac A AUTOMOBILE LIABILITY Z131018 1013/2018 1013/2019 COMBINED SINGLE LIMIT (EA espda70 35.091; ANY AUTO BODILY INJURY(Per person)— S ALL OWNED X SCHEDULED BODILY INJURY(Per occident) S AUTOS AUT03 AUTO X HIRED AUTOS X NON-0WNEDS _ AGE S A X UMBRELLA LUB X OCCUR ZEI1918 10/32018 10/3/2019 !EACH OCCURRENCE S 2JI00A00 EXCESS LIAR CLAIMS-MADE AGGREGATE $2.000.000 DEC I 1 RETENTIONS v S A WORKERS COMPENSATION Z81918 10/3/2018 10J312019 X WC$TA TU--l�l f{OTH- AND EMPLOYERS'UABILITY Y/N T.�.y-SAIAII:.1--` ANY PROPRIETORIPARTNER/EXECUTiVE E L EACH ACCIDENT S 100.000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E L DISEASE-EA EMPLOYEE]S 100,000 If es,describe under DESCRIPTION OF OPERATIONS below , E L DISEASE-PQIJCY OMIT S 500 000 DESCRIPTION OF OPERATIONS!LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Raman('Scnaduta,If more space Is required) City of Oshkosh Is listed as additional insured per form C87191 and a 30 day notice of cancellation is in favor of the City of Oshkosh. 10 Day notice for cancellation of non payment. 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/City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. 215 Church Avenue PO Box 1130 AUTHORIZED REPRESENTATIVE Oshkosh WI 54903-1130 ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD