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HomeMy WebLinkAboutMidstate Asphalt 6-11-19 ACo® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `� 3/25/2019 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(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: RADTKE RHONE INSURANCE IA/CNo.Ext): (920)982-3048 FA//CC.No): (920)982-2584 EMAIL PO Box 210 RECEIVED ADDRESS: radtkerhone@radtkerhone.com New London,WI 549 61-0 21 0 _ INSURE (S1AFFORDINGCOVERAGE NAICi't MAR �y r7 JT r' INSURER A: State Auto INSURED F 7 '1 9 INSURER B: MIDSTATE ASPHALT LLC INSURER C: DEPTOh' PUBLIC' WOi; Corey Prinsen nS►IKOSH, WISCON�, INSURER D: 519 N. SHAWANO STREET INSURER E: NEW LONDON, WI 54961 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 EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER I_MMIDD/YYYY),JM JY M)DDYYYL X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO RENTED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $ 500,000.00 MED EXP(Any one person) $ 5,000.00 A Y SOC 2564193 6/11/2018 6/11/2019 PERSONAL&ADVINJURY $ 1,000,000.00 GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ 2,000,000.00 X POLICY PRO- JECT LOC PRODUCTS-COMPiOPAGG $ 2,000,000.00 OTHER. _ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) 1,000,000.00 ANY AUTO BODILY INJURY(Per person) $ OWNED A AUTOS ONLY X AUTOSULED BAP 2295035 6/11/2018 6/11/2019 BODILY INJURY(Per accident) $ XAUTOS HIRED ONLY /�X/ NON-AUTO OWNED SONLY PROPERTY DAMAGE (Per accident) $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000.00 A EXCESSLIAB CLAIMS-MADE SOC 2564193 6/11/2018 6/11/2019 AGGREGATE $ 5,000,000.00 DED RETENTION$ _ $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY STATUTE X EERH Y/N ANY PROPRIETOPARTNER/EXECUTIVE R; E.L.EACH ACCIDENT $ 1,000,000.00 A OFFICERMEMBER EXCLUDED? y N/A WCP 2261209 6/11/2018 6/11/2019 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000.00 If yes,describe under DESCRIPTION OF OPERATIONS below _ E.L.DISEASE-POLICY LIMIT $ 1,000,000.00 Leased or Rented Equipment A SOC 2564193 6/11/2018 6/11/2019 up to $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The City of Oshkosh is listed as an additional insured for the general liability as required by written contract for any and all jobs done in the City of Oshkosh CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oshkosh THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1130 AUTHORIZED R*PRESENTATIGE Oshkosh, WI 54903-1130 1 ©1988-20 5 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD