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HomeMy WebLinkAboutBlack Teak Properties 11-1-18 AC CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1/5/2018 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: 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 CONTACT NAME: Ann Wehrle Ansay&Associates, LLC.-OSH PHONE FAX 430 N. Koeller Street (A/c.No.Cxli: 920-235-2764 (A/C,No):920-235-2694 Oshkosh WI 54902 AADDRESS: ann.wehrle@ansay.com INSURER(S)AFFORDING COVERAGE NAIC 8 INSURER A:QBE US Agencies ITC INSURED BLACTEA-01 INSURER B: Black Teak Properties PO Box 1099 INSURER C: Oshkosh WI 54903 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:800740732 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 SUER POLICY EFF POLICY NUMBER (MM DD/YYYYI (MM DDY EXP TYPE OF INSURANCE INSO LTR INSD WVD IYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY CF80994495 11/1/2017 11/1/2018 EACH OCCURRENCE $2,000,000 DAMAGE CLAIMS-MADE X OCCUR PREMISESO(Ea occuED ence) $100.000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY 5 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY PET LOC PRODUCTS-COMP/OP AGG $4.000,000 $ OTHER: A AUTOMOBILE LIABILITY CFB0994495 11/1/2017 11/1/2018 COMBINED SINGLE LIMIT $ (Ea accident) 1 000.000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X X NON-OWNED PeraccidTYIDAMAGE $ HIRED AUTOS _ AUTOS UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION CWC0994495 2/2/2017 2/22018 X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/NI N/A E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED? I E.L.DISEASE-EA EMPLOYEE $100,000 (Mandatory In NH) _ If yes,describe under DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS!LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Oshkosh,and its officers,council members,agents,employees and authorized volunteers are additional insured on a primary and noncontributory basis. 30 day cancellation notice applies. Forms CG2010 and CG2037 apply. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Oshkosh ACCORDANCE WITH THE POLICY PROVISIONS. Attn: City Clerk P.O. Box 1130 AUTHORIZED REPRESENTATIVE Oshkosh WI 54903-1130 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD