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HomeMy WebLinkAboutGit R Done Paving 1-8-18 DATE(MM/DDIYYYY) ACC)RCP CERTIFICATE OF LIABILITY INSURANCE 06/08/2017 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 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: PHONE FAX IA/C.No.Eat): (A/C,No): IL RICK A NEMECEK ADDRESS: 127 W PERRY ST INSURER(S)AFFORDING COVERAGE NAILX PORT CLINTON OH 43452-1039 INSURER A: NATIONWIDE MUTUAL INSURANCE COMPANY 23787 INSURED INSURER B: CHARLES SWARTZ INSURER C: DBA GIT R DONE PAVING INSURER D: _ 3322 STATE HIGHWAY 13 INSURERE: Wisconsin Dells WI 53965 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 TPOLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER IMMIDD/YYYY)I IMM/DDIYYYY). UMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 '� DAMAGE TO RENTED CLAIMS-MADE f X i OCCUR PREMISES(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 A X ACP GLO 5774327319 01/08/2017 01/08/2018 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JE T LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ A ALL OWNED X SCHEDULED AUTOS AUTOS X ACP BA 5774327319 01/08/2017 01/08/2018 BODILY INJURY(Per accident) $ X HIRED AUTOS X N -OWNED PROPERTY DAMAGE $ AUTOS (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER Y/N ANVPROPRIETOR/PARTNER/EXECUTIVE NIA E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED7 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Additional insureds per attached endorsements.Certificates of insurance acceptable to the City of Oshkosh shall be submitted prior to work to the applicable city rd department.These certificates shall contain a provision that coverage afforded under the policies will rot betfriikEp renewed until at least 30 days prior written notice has been given to the City Clerk-City of Oshkosh JUN 16 2017 CITY CLERK'S OFFICE CERTIFICATE HOLDER CANCELLATION 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 AUTHORIZED REPRESENTATIVE PO Box 1130 Nationwide Mutual Ins Co 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