HomeMy WebLinkAboutZivkovich, Michael 10-30-19 ,CORD CERTIFICATE OF LIABILITY INSURANCE CAI E(MMUD/YYYY)
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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.
tf 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 I NAME:ACT Luke Mongin
Mongin Insurance Agency PHONE
E tl: (920)499-0821 FAX,No):(920)499-1390
501 S. Military Ave E-MAILAppREas:_ Ijmongin@�mail.com
Green Bay,WI 54303 INSURER(S)AFFORDING COVERAGE NAM*
INSURER*= Rockford Mutual Insurance _27065
INSURED INSURER_B:
Michael Zivkovich — -----
Mercedes Zivkovich MSURERc:
1243 Harney Ave INSURERD: _
Oshkosh, WI 54901-5438 INSURERE -
I I INSURER F--
COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 1
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.
ma ADDL SUER 1 POLICY EFF ' POLICY EXP .
LTR TYPE OF INSURANCE WED WVD POLICY NUMBER I TI JM)D/YYYYI LMM'DWTYYYI LIMITS
A COMMERCIAL GENERAL LIABILITY 1-10000030594 11Y30t2018 1Of30f2019 EACH OCCURRENCE a 500,WO
I-IDJAAGE TO
CLAIMS-MADE I OCCUR Pa emistS(taENTED o ounence) i
MED EXP(Any one pasm) i1,
^- - - PERSOIO*L a ADV INJURY *
GEN'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE S
X POLICY f I PROT LOC PRODUCTS-COMP/OP AGO S
JEC -.__-
•
OTHER-. i
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ma accident
ANY AUTO BODILY INJURY(Per Person) i
OWNED SCHEDULED • BODILY INJURY(Pig aodtkrq i
i AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE i
AUTOS ONLY _AUTOS ONLY (Pe(accident)
i
•
UMBRELLA LIAR I OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
IAD RETENTIONS S
WORKERS COMPENSATION
P
ANU EMPLOYERS'LIABILITY YIN I STATUTE I ER
ANY PROPRIETOR/PARTNER/EXECUTIVE f I E.L EACH ACCIDENT ItCE OFHWMEMBER EXCLUDED? 1 N/A
(Mandatory In NH) E.L DISEASE-EA E MPLOYEE S _
B yes,desalbe under
DESCRIPTION OF OPERATIONS Iselaa E.L DISEASE-POLICY LIMIT t
, r
DESCRIPTION OF OPERA I IONS/LOCATIONS/VEHICLES(ACORD 101.Add,tional 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
216 Church Ave ACCORDANCE WITH THE POLICY PROVISIONS.
PO Box 1130
Oshkosh, WI 54903 AUTHORIZED REPRESENTATIVE
1: (LJM)
0 988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
Printed by LJM on May 09,2019 at 01:SOPM