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ACORE) CERTIFICATE OF LIABILITY INSURANCE DATE RAEE 018
THIS ERTIFICATE 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(les) 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).
CONTACT
PRODUCER NAME:______
Ansay& Associates, LLC.-OSH PHONE 9V0-235 2764 I(AAiC,No):920 23S 2694
430 NI. Koeller Street E is NNo.Emu:
Oshkosh WI 54902 ADDRESS; infagansay.corn
INSURER(9)AFFORDING COVERAGE _ -_ NAIC 0
INSURER A:Sheboygan Falls Mutual 15145
INSURED FOXVALL-32 INSURER B:
Fox Valley Asphalt&Maintenance, LLC
7526 Hwy 76 INSURER C:
Neenah WI 54956 INSURER 1):
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:391327480 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 I ADDL SUER POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE IN5p POLICY NUMBER (MM/DDIYYYYI IMMIDDIYYYY)
A X COMMERCIAL GENERAL LIABILITY Y CPP2002.181 11R2/2017 1ii.:'/201H EACH OCCURRENCE $1 DOO.non
DAMAGE TO RENTED S1'O� O.N
CLAIMS-MADE X OCCUR PREMISE jEa occurrences r _
MED EXP(My one person) $5.00u
PERSONAL&ADV INJURY S 1.009,009
GEN'L AGGREGATE LIMIT APPIJES PER: GENERAL AGGREGATE S 2,0013.00u
POLICY JPER� I LOC PRODUCTS.COMP/OP AGG 8 2.000,000
OTHER: $
A ,AUTOMOBILE LIABILITY Y` CA20031J1 12/n4017 12(22/2018 COMBINED SINGLE UMI f S
(Ea student) 1 000 OOn
X ANY AUTO BODILY INJURY(Per person) S
ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $
OP
ERT
X HIRED AUTOS X AUTOSWNED (PPerr( an)nt)AMAGE $
S
X•UMBRELLA LIAB X OCCUR CX1200315I '12/22/2017 12/22/2018 EACH OCCURRENCE 51,000,000
r.__ EXCESS LIAB CLAIMS-MADE AGGREGATE $
TIED RETENTION$ $
WORKERS COMPENSATION WCJOO(Ih1 12(22/2017 12/22/2019 X PER OTH-
AND EMPLOYERS'LIABILITY YIN STATUTE ER _
ANY PROPRIETOR/PARTNER/EXECUTIVE 1 NIA E L.EACH ACCIDENT S 100.050
'OFFICER/MEMBER EXCLUDED?
'(Mandatory In NH) EL DISEASE-EA EMPLOYEE S 190AC0
If yes describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S500.000
DESCRIPTION OF OPERATIONS 1 LOCATIONS i VEHICLES (ACORD 101,Additional Remarks Schedule.may he attached If more space Is re Brad) REC El Y Ell
MAY 04 2018
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.
AUTHORIZED REPRESENTATIVE ENT
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