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HomeMy WebLinkAboutJacobson Contracting LLC 5-1-18 ��'1 JACOCON-01 MHOBBS ACORU' CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `.� 12/05/2017 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 CONMTEACT NA The Diedrich Agency PHONE 920 232-4090 FAX 920 748-5044 303 High Avenue (AA,No,Ext):( ) (NC,No):( Oshkosh,WI 54902 Flloss: INSURER(S)AFFORDING COVERAGE NAIC A INSURER A:Acuity 14184 INSURED INSURER B: JACOBSON CONTRACTING LLC INSURER C: 6403 E Decorah Avenue INSURER D: OSHKOSH,WI 54904 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 SUBR POLICY NUMBER POLICY EFF POLICY EXP UNITS LTR INSD WVD IMM/DD/YYYY) (MMIDD/YYYY► A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE r X I OCCUR X41856 05/01/2017 05/01/2018 DAMAGE TO RENTED 100,000 X PREMISES(Ea occurrence) $ 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 PRO-JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 (Ea accident) $ ANY AUTO X41856 05/01/2017 05/01/2018 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY X AUTOS y Ep BODILY INJURY(Per accident) $ X AUTOS ONLY X AUTOS ONLY 1 PROPERTY a�een) $ . $ A X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE X41856 05/01/2017 05/01/2018 AGGREGATE $ DED RETENTIONS Aggregate $ 1,000,000 - WORKERS COMPENSATION STATUTEPER ERH AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) — C��l`1 City of Oshkosh and its officers,council members,agents,employees and authorized volunteers -lit'1e1i.1 y.Fy----- 1 ---- LAN 02 NIL CITY C CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oshkosh THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN tyACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1120 Oshkosh,WI 54903 AUTHORIZED REPRESENTATIVE .-atildW ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD