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HomeMy WebLinkAboutFour Way Construction Co 3-31-18 FOURCON-01 MMEYE- CORO" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/00/VYYY) 11/17/2017 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 IC2NTACT __ The Diedrich Agency PHNE/CC,,No,Ext):(920)748-2811 FAX No):(920)748,5044 222 Blackburn 5t Ripon,WI 54971Miss: INSURER(S)AFFORDING COVERAGE __.NAIC fi INSURER A:QBE 24414 INSURED INSURER B:Accident Fund 10166 Four-Way Construction Co INSURER C: - PO Box 133 INSURERD: Berlin,WI 54923 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD I WVD POLICY NUMBER (MM/DDIYYYYI (MMIDDIYYYYI UNITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE 1,000,000 S CLAIMS-MADE X OCCUR CCI0104162 03/31/2017 03/31/2018 PRERI ETORENTED 100,000 X PREMISES(Ea ocanence�_.__ S MED EXP(Any one person) $ 6'000 PERSONAL&PDV INJURY $ 1'0'000_ GEN'L AGGREGATE LIMpIT.APPLIES PER: GENERAL AGGREGATE 1; 2,000,000 POLICY X JECT [ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: COMBINED SINGLE LIMB : 1,000,000 A AUTOMOBILE LIABILITY _ . ...(Ea_ecdden0-- i , X ANY AUTO CBA0104162 03/31/2017 03/31/2018 BODILY INJURY(Per person) SO - AUTOS EONS ONLY SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUT0.S ONLY (( erPcadent)AMAGE S A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 2,000,000 EXCESS LIAB CLAIMS-MADE CCU0104162 03/31/2017 03/31/2018 AGGREGATE S 2,000,000 DED X RETENTIONS 10,000 $ B AND EMPLOYERS'LIABIUTY X STATUTE OTH- ER I N WCV5004770 03/31/2017 03/31/2018 100,000 ANY PROPRIETOR/PARTNER/EXECUTIVEN 1, NIA E.L.EACH ACCIDENT ( FICdEa�IMi NH EXCLUDED? 100,000 E.L.DISEASE-EA EMPLOYEE $ If yes,describe order 500,000 DESCRIPTION OF OPERATIONS below i - _ _ 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) Additional insureds include: City of Oshkosh and its officers,council members,agents,employees and authorized volunteers. RECEIVED I. JAN 02 2018 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cityof Oshkosh THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1130 Oshkosh,WI 54903 AUTHORIZED REPRESENTATIVE „./ ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD