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T Ft0' CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYI)
03/18/2019
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 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 CNAMEACT Brent Jetton,AAI,CIC
Silverstone Insurance Services PHONE FAX
Jetton&Assoc Ins Svs Inc 211 ANEo.Exr):909-980 4211 (NC No). 909-980-4785
P.O. Box 1200(Lk #0004829) ADDRESS:
Rancho Cucamonga„ CA 91729-1200
Brent Jetton,AAI,CIC INSURER(S)AFFORDING COVERAGE NAIC S
INSURER A:Federal Insurance Company _ 20281
INSURED Wisconsin Technology INSURER B:Great American E&S Ins Co 37532
Networking, LLC INSURER c:Underwriters Lloyds London IL 15792
660 Newport Center Dr.#200
Newport Beach, CA 92660 INSURER D:
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 TYPE AnnSUBR T POLICYEFF POLICYEXP LIMITS
LTR INSR WVO POLICY NUMBER (MMIDD)YYYY) (MMIDDIYYYY)
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A X C.-:MMERCIAL GENERAL LIABILITY Y Y 36036868 11/11/2018 11/11/2019 DAMAGE TORENrEL)
PREMISES(Ea occurrence) $ 1,000,000
CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000
PERSONAL 8 ADV INJURY $ 1,000,000
CONTRACTUAL LIAB GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY n PECT n LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000
(Ea accident) $
A X ANY AUTO y y 73591570 11/1112018 11/11/2019 BODILY INJURY(Per person) $
ALL S OWNED AUTOS
BODILY INJURY(Per accident) $
— NON-OWNED PROPERTY DAMAGE --
HIRED AUTOS _ AUTOS (PER ACCIDENT)
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000
A EXCESS LIAB CLAIMS-MALE 79897229 11/11/2018 11/11/2019 AGGREGATE $ 10,000,000
DED REF_ $ $ Follow Form
WORKERS COMPENSATION X WC STATU- 0TH-
AND EMPLOYERS'LIABILITY TORY LIMITS ER
A wr.,i- uP-E _ FAhr,ER/EXECU11VE YrN
- 71749062 11/11/2018 11111/2019 E.L.EACH ACCIDENT $ 1,000,000
OFFICERIMEMBER EXCLUDED? N N/A
(Mandatory In NH) E L DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $ 1,000,000
B Pollution Liab r PRE315985703 11/11/2018 11/11/2019 EaClmfAgg 5,000,000
C Professional Liab PMOBI000918 11(1112018 11111/2019 EaClmlAgg 5,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORO 101,Additional Remarks Schedule,If more space Is required)
RE: Annual Right-of-Way Obstruction License.
City of Oshkosh, its officers, council members, agents, employees and
authorized volunteers are additional insured where required by written
contract or agreement. *30 Days NOC to the City Clerk.
CERTIFICATE HOLDER CANCELLATION
CITOSHK
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
215 Church Ave. AUTHORIZED REPRESENTATIVE
PO Box 1130 ( r.
Oshkosh,WI 54903-1130
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