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HomeMy WebLinkAboutMiller Masonry & Concrete 12.1.19 A CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY( 11/19/2018 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 policy(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 CONTANAME: Patti VandenBosch Ansay&Associates, LLC. FV PHONE - FAX 4351 W College Ave =mac.Lo.Ext.):920-560-7016 (NC,No):920-560-7079 Suite 310 ADDRESS: patti.vandenbosch@ansay.com Appleton WI 54914 INSURER(S)AFFORDING COVERAGE NAIC INSURER A:ACUITY,A Mutual Insurance Company 14184 INSURED MILLMAS-01 Miller Masonry&Concrete Inc INsuRERe:__ PO Box 6 INSURERC: Little Chute WI 54140 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:236987617 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 IADDLISUBR POUCY EFF POUCY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MMIDD/YYYY) IMM/DD/YYYY) LIMITS A GENERAL LIABILITY V Y Z30801 12/12018 12/1/2019 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $250,000 I CLAIMS-MADE X OCCUR MED EXP(Any one person) S 10,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $3,000,000 GENL AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OP AGG $3,000,000 POLICY X JECT LOC S A AUTOMOBILE LIABILITY Z30001 12/12018 12/12019 COMBINED SINGLE LIMIT (Ea accident) $1.000.000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOX HIRED SAUTOS X �N OWNED PROPERTY DAMAGE $ AUTOS (Per accdent) a A UMBRELLA LIAB X OCCUR Z30801 12/12018 12/1/2019 EACH OCCURRENCE $5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION S 0 S A WORKERS COMPENSATION Z30801 12/1/2018 12/1/2019 X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100,000 'OFFICER/MEMBER EXCLUDED'? N N/A -- (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes.yes,descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 A Inland Marine Z30801 12/1/2018 12/1/2019 Rented Equipment 550,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) City of Oshkosh,and its officers,council members,agents.employees and authorized volunteers shall be Additional Insureds on the General Liability by endorsements CB7191A and CB7245A if required in a written contract. Waiver of Subrogation Included on the general liability #CB7268 if required in a written contract. RFCEA/FD NOV 26201 CERTIFICATE HOLDER CANCELLATION j 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 PO Box 1130 AUTHORIZED REPRESENTATIVE Oshkosh WI 54902 U , l ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD