HomeMy WebLinkAboutNaslund, Richard 4-13-19 AC4RE)
`ram CERTIFICATE OF LIABILITY INSURANCE DATE
Yrr)10/02/2018
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:lithe 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:
' Martin TeLindert(345037V) PHONE FAX
303 Pearl Ave Ste E (A/C,NO,EXT):920-651-3031 I (A/C,NO):920-651-9933
E-MAIL
Oshkosh WI 54901-4774 ADDRESS: mtelindert@farmersagent.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: Truck Insurance Exchange 21709
INSURER B: Farmers Insurance Exchange 21652
NASLUND, RICHARD INSURER c: Mid Century Insurance Company 21687
301 N SAWYER ST
INSURER D:
INSURER E:
OSHKOSH WI 54902
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME 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 ADDTL SUER POLICY NUMBER POLICYEFF POLICYEXP LIMITS
LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY)
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
CLAIMS-MADE X OCCUR PREMISES(Ea Occurrence) $ 100,000
MED EXP(Any one person) $ 5,000
C 606625566 04/13/2018 04/13/2019 PERSONAL&ADVINJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY PROJECT LOC PRODUCTS-COMP/OP AGG $ 1,000,000
OTHER: $
AUTOMOBILE LIABIUTY COMBINED SINGLE LIMIT $
(Ea accident)
ANY AUTO BODILYINJURY(Perperson) $
OWNED AUTOS SCHEDULED • `
ONLY AUTOS BODILY INJURY,(Peraccident)$
HIRED AUTOS NON-OWNED PROPERTY DAMAGE $
ONLY AUTOS ONLY (Per accident)
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION PER OTHER $
AND EMPLOYERS'LIABILITY STATUTE
ANY PROPRIETOR/PARTNER/ V/N N/A E.L.EACH ACCIDENT $
EXECUTIVE OFFICER/MEMBER
EXCLUDED?(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE
If yes,describe under DESCRIPTION OF
OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
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.
AUTHORIZED REPRESENTATIVE
ACORD 25(2016/03) ! 1988-2015 ACORD CORPORATION.All Rights Reserved
31-1769 11-15 The ACORD name and logo are registered marks of ACORD