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HomeMy WebLinkAboutScott Lamers Construction 6-25-19 O e DATE(MM/DD/YYYY) AC `C) CERTIFICATE OF LIABILITY INSURANCE 02/08r2019 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. ,t.v 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: Theresa Vorpahl Fox Cities Insurance Agency Inc We tiLs.lul- (920)739-0424 FAX No):(920)739-3536 1204 N Mason St ADDRESS: Theresav@foxcitiesinsurance.com Appleton,WI 54914 INSURERjS)AFFORDING COVERAGE NAIC0 INSURER A: West Bend Mutual Ins.Co. 15350 INSURED INSURER a: Scott Lamers Construction LLC INSURER C: W4527 County Road Kk INSURERD: Kaukauna, WI 54130-8795 INSURER E: INSIIRFR F: COVERAGES CERTIFICATE NUMBER: 00000000-832550 REVISION NUMBER: 7 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 ADO_SUER POLICY EFF POLICY EXP LTR IN MI cD WV. POLICY NUMBER IMDO/YYYYI (MMIDOIYYYYT LIMITS A X COMMERCIAL GENERAL LIABILITY 0917123 06/25/2018 06/25/2019 EACH OCCURRENCE 5 1,000,000 CLAIMS-MADE X OCCUR PREMISES lEa cwe ncel S 200,000 MED EXP(Any one person) S 5,000 PERSONAL P ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER' GENERAL AGGREGATE S 2,000,000 POLICY X I PR - POLICY LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY 091 71 23 06/25/2018 06/25/2019 (Ea accident SINGLE LIMIT S 1,000,000 X ANY AUTO • BODILY INJURY(Per person) I$ OWNED SCHEDULED BODILY INJURY(Per accident)(- AUTOS ONLY _ AUTOS HIRED NON-OWNED PROPERTY DAMAGE S x AUTOS ONLY X AUTOS ONLY (Per accident) I S A )( UMBRELLALIAB OCCUR 0917123 6/25/2018 6/25/2019 EACH OCCURRENCE $ 1,000,000 EXCESS LIAB —r CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION S $ A WORKERS COMPENSATION 0917124 06/25/2018 06/25/2019 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE I ER Y!N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? Y N!A (MyyaeeRIPT ON uOndatory In NH) E.L.DISEASE-EA EMPLOYE S 1,000,000 DESCF OPERATIONS below E.L.DISEASE-POLICY LIMIT$ 1,000,000 A Equip Loaned,Leased, 0917123 06/2S/2018 06/25/2019 Limit I $100,000 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) City of Oshkosh,&its officers,council members,agents,employees&authorized volunteers shall be Additional Insureds. 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 ACCORDANCE WITH THE POLICY PROVISIONS. 106 Washington , Oshkosh,WI 54901 AUTHORIZED REPRESENTATVE ��j (TMV) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by TMV on February 08,2019 at 04:23PM