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HomeMy WebLinkAboutOmni Glass & Paint 1-1-19 1 �...IN OMNIG-3 OP ID: DK ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) kiii.....----- 12/21/2017 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 920-725-3232 CONTACTNAME: Troy Carlson McClone PHONE FAX 920-725-3232 I 920-725-3233 150 Main Street,Ste 300 (ac,No,Ext): (A/c,No): Menasha,WI 54952-0389 E-MAIL troy.carlson@mcclone.com mcclone.com Troy Carlson ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Zurich American Insurance Co. 16535 INSURED Omni Glass&Paint(CERTS) INSURER B: 3530 Omni Drive PO Box 2186 INSURER C: Oshkosh,WI 54903 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: I 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 NUMBER POLICY EFF : POLICY EXP LIMITS LTR INSD WVD IMM/DD/YYYYI,IMM/DO/YYYY1 A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE i X OCCUR GL05525127 01/01/2018 01/01/2019 DAMAGE TO RENTED 500,000 X PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ COMBINED SINGLE LIMIT 1,000,000 A AUTOMOBILE LIABILITY (Ea accident) $ X ANY AUTO X BAP5525128 01/01/2018 01/01/2019 BODILY INJURY(Per person) $ — OWNED — SCHEDULED AUTOS ONLY _ AUTOS 1n/ BODILY INJURY(Per accident) $ AURTOS ONLY � AUUTOS ONLYY (Per PROPERTY DAMAGE $ • A X UMBRELLA LIAR _ OCCUR EACH OCCURRENCE $ 10,000,000 EXCESS LAB CLAIMS-MADE X AUC5956035 01/01/2018' 01/01/2019 AGGREGATE $ 10,000,000 DED I X I RETENTION$ None $ A WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER WC5525129 01/01/2018 01/01/2019 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N N I A 1,000'OOO (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 1 1.000.000 uw,. PTiON OF OFCRAT iOI.3 Loire c L.Di3EA3C-FOLiGY LirvMtT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CITY OF OSHKOSH, AND ITS OFFICERS, COUNCIL MEMBERS,AGENTS, EMPLOYEES & RECEIVED AUTHORIZED VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED ON GENERAL LIABILITY& UMBRELLA AS PER FORM U-GL-1175-F CW(04/13),WHICH IS EQUIVALENT TO CG2037, ANDINSURED IS ON A PRIMARY AND NON-CONTR BU ORYY MOBIL BASISE 0 DAYITY.NOTICE OFO CANCELLATION PPLIES. [DEC29 2017 CITY CLERK'S OFFICE CERTIFICATE HOLDER CANCELLATION CITOSH2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CITY OF OSHKOSH ATTN: CITY CLERK PO BOX 1130 AUTHORIZED REPRESENTATIVE OSHKOSH,WI 54903-1130 Troy Carlson ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD