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HomeMy WebLinkAboutJohn Skotzke Concrete Construction 12-31-19 ___....--..N JOHNSKO-01 BARIBMA ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDM YY) `..------- 6/6/2019 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 Mary Beth Baribeau The McClone Agency,Inc. PHONE PO Box 389 (Arc,No,Ext):(920)725-3232 1 FAX WC,No):(920)725-3233 Menasha,WI 54952 ADDRESS:marybeth.baribeau@mcclone.com INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:Employers Mutual Casualty Co 21415 INSURED INSURER B:Middlesex Insurance Co 23434 John Skotzke Concrete Construction Inc. INSURERC: 7203 State Rd.76 INSURER D: Neenah,WI 54956 INSURER E 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD INVD POLICY NUMBER (MM/DD/YYYY) IMM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE I X J OCCUR X 9D49967 12/31/2018 12/31/2019 pREMISES IEaEN7rrence) $ 300,000 MED EXP(Any one person) $ 5'000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE JE LIMITRa APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X CT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ X ANY AUTO X 9Z49967 12/31/2018 12/31/2019 BODILY INJURY(Per person) $ OWNED SCHEDULED - AUTOS ONLY _ AUTOS{ BODILY INJURY(Per accident) $ AUTOS ONLY _ AUUTOS ONLYY (Per accident)DAMAGE $ $ A X UMBRELLA LIAB X OCCUR I EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE 9J49967 12/31/2018 12/31/2019 AGGREGATE $ 5,000,000 DED I X I RETENTIONS 0 $ B I WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY STATUTE ER A0120966001-1 12/31/2018 12/31/2019 500,000 ANY EXCLUDED?ECUTIVE YNN N/A E.L.EACH ACCIDENT $ Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) The City of Oshkosh,its employees,council members,agents,authorized volunteers and officers are included as additional insureds as per General Liability Blanket Additional Insured Form CG7482.3 10-13 attached.30 days notice of cancellation applies for all reasons except non-payment. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF OSHKOSH ATTN:CITY CLERK THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 215 CHURCH AVENUE P.O.BOX 1130 OSHKOSH,WI 54902-1 1 30 AUTHORIZED REPRESENTATIVE ' ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD