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HomeMy WebLinkAboutJohn Skotzke Concrete 12-31-18 SKOTZ-1 OP ID: DL ACORN DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 04/26r2018 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 920-233-4000 CONTACT Brian McClone McClone-Oshkosh PHONE FAX 505 North Westfield Street (ac,No,Ext,920-233-4000 (A/C,No):920-725-3233 Oshkosh,WI 54902-4105 E-MAIL brian.mcclone@mcclone.com Brian McClone ADDRESS: INSURER(S)AFFORDING COVERAGE _ NAIC# INSURER A:Employers Mutual Casualty Co 21415 INSURED John Skotzke Concrete INSURER B Construction,Inc. 7203 State Rd.76 INSURER C Neenah,WI 54956 INSURER D 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 LIMITS LTR INSD WVD IMM/DD/YYYYI IMM/D D/YYYYI A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR 9D49967 12/31/2017 12/31/2018 DAMAGE TO RENTED 300,000 XPREMISES IEa occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'00()'(]()0 POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER Emp Ben. $ 1,000,000 COMBINED SINGLE LIMIT 1,000,000 A AUTOMOBILE LIABILITY (Ea accident) $ X ANY AUTO 9Z49967 12/31/2017 12/31/2018 BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 EXCESS LIAB CLAIMS-MADE 9J49967 12/31/2017 12/31/2018 AGGREGATE $ 5,000'000 DED RETENTION$ $ A WORKERS COMPENSATION X I STATUTE I I ERH AND EMPLOYERS'LIABILITY Y/N 9N49967 12/31/2017 12/31/2018 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ RECVI-`•'�----- DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule.may be attached if more space is required MAY 0 4 Z018 The City of Oshkosh,its employees and officers,are included as an _ additional as per General Liability Blanket Additional Form, CG7482. . .g OFFICE CITY CLEF CERTIFICATE HOLDER CANCELLATION OSHKOSI SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF OSHKOSH ACCORDANCE WITH THE POLICY PROVISIONS. 215 CHURCH AVENUE P.O. BOX 1130 AUTHORIZED REPRESENTATIVE OSHKOSH,WI 54902-1130 Brian McClone ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD