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HomeMy WebLinkAboutEgbert Excavating Inc 3-9-18 �....moN EGBEEXC-01 MMEYER ACORO CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) �� 10/30/2017 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 have ADDITIONAL INSURED provisions or 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: The Diedrich Agency PHONE (920)748-2811 FAX 222 Blackburn t (AlC,No,Ext): (An,No):(920)748-5044 E-MAIL Ripon,WI 54971 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:United Fire&Casualty 13021 INSURED INSURER B: Egbert Excavating Inc INSURER C: PO Box 462 INSURER D: Green Lake,WI 54941 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 OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MMIDDIYYYYI IMMIDD/YYYYI A X COMMERCIAL GENERAL LABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR X 60428021 03/09/2017 03/09/2018 PREMISES Ea occurrence( $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X P X LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ COMBINED SINGLE LIMIT 1,000,000 A AUTOMOBILE LIABILITY (Ea accident) $ X ANY AUTO X 60428021 03/09/2017 03/09/2018 BODILY INJURY(Per person) $ — OWNED SCHEDULED — AUT OS ONLY AUTOS BODILYO INJURYp (Per accident)_$ _ HIREDTO ONLY �. AUTOS ONLDY (Per accident)AMAGE $ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE 60428021 03/09/2017 03/09/2018 AGGREGATE $ 5,000,000 ' DED X RETENTION$ 10,000 $ A WORKERS COMPENSATION X STATUTE ERH- AND EMPLOYERS'LIABILITY 60428021 03/09/2017 03/09/2018 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? r NIA NN E.L.DISEASE-EA EMPLOYEE $ 100 000 (Mandatory in N ) � � If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Dan Egbert is excluded from Workers Compensation. CERTIFICATE HOLDER C11:1 CANCELLATION JAN 02 2018 I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cit of Oshkosh THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN am'ici yACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1130 - Oshkosh,WI 54902 c,_ (- ' �— AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD