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HomeMy WebLinkAboutComplete Flatwork Specialists LLC 3-30-18 COMPL-1 OP ID:JR ACORO► CERTIFICATE OF LIABILITY INSURANCE DATE IMM/DDIY YYY) 06/06/2017 THIS CERTIFICATE IS IS';UED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOI 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 PkODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endLrsed. 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 ADEMINO&ASSOCIATES INC PHPHONE JYL A RANDERSON FAX DAVID ADEMINO LAIC,No,ExtI:920-734-3119 INC.No):920-734-6027 1001 TRUMAN P O BOX 97 ADDRESS:• jranderson@ademino.com KIMBERLY,WI 54136-0099 JYL A RANDERSON INSURER(S)AFFORDING COVERAGE NAIC t INSURER A:SHEBOYGAN FALLS INS COMPANY 15148 INSURED COMPLETE FL4TWORK SPECIALISTS INSURERB: LLC W1992 INDUSTRIAL DR INSURER C: _ FREEDOM,WI 54130 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTt."DING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE IS3l ED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDIT14i IS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSUR..`!CE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/OD/YYYY) (MM [NY IDYYY A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,00 CLAIMS-MADE X j OCCUR X CPP2004686 03/30/2017 03/30 2018 PRr SES Ea o TE,TD e) $ 100,00 -_ MED EXP(Any one parson) S 5,00 PERSONAL&ADV INJURY S 1,000,00 GEN'L AGGREGATE UNIT APPLIES PER: GENERAL AGGREGATE S 3,000,00 POLICY I jECT LOC PRODUCTS-COMP/OP AGG S 3,000,001 OTHER. f AUTOMOBILE LIABILITY COMBINED SINGLE UMIT S 1,000,001 (Ea accident) A X 'ANY AUTO CA2004686 03/30/2017 03/30/2018 BODILY INJURY(Per person) S ALL OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS -tUTOS .. HIRED AUTOS ''ION-OWNED PROPERTY DAMAGE .YL'TOS (Per accident) _ s X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 1,000,000 A EXCESS LIAB CLAIMS-MADE CXY2004686 03/30/2017 03/30/2018 AGGREGATE $ 1,000,000 DED X RETENTIONS 0 S WORKERS COMPENSATION X PER l OTH- AND EMPLOYERS'LIABILITY STATUTE I ER A ANY PROPRIETOR/PARTNER,EXECUTNE YIN NIA WCY2004686 03/30/2017 03/30/2018 E.L EACH ACCIDENT S 100,000 OFFICER/MEMBER EXCLUDER? (Mandatory in NH) E.L DISEASE-EA EMPLOYEE S 100,000 If yes,describe under ' DESCRIPTION OF OPERATIONS below EL DISEASE-POUCY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) T�. L CC h T �, ,� CITY OF OSHKOSH, ITS OFFICERS,COUNCIL MEMERS,AGENTS,EMPLOYEES AND AUTHORIZED VOLUNTEERS ARE ADDITIONAL INSUREDS WHERE REQUIRED BY WRITTEN 2�1 CONTRACT SUBJECT TO POLICY TERMS AND CONDITIONS. Jl IN 0 17 C[TY C1m -'�OFFiCB CERTIFICATE HOLDER CANCELLATION OSCIT-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF OSHKOSH THE EXPIRATION DAL E THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 215 CHURCH ST OSHKOSH,WI 54901 AUTHORIZED REPRESENTATIVE JYL A RANDERSON ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD