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HomeMy WebLinkAboutMiller Masonry & Concrete Inc 12-1-18 ACORN® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYVY) 11/30/2017 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 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: Patti VandenBosch Ansay&Associates, LLC. FV PHONE IINC.No.Ext):920-560-7000 FAX No):920 560 7079 4351 W College Ave E-MAIL Suite 310 ADDREss:patti.vandenbosch@ansay.com Appleton WI 54914 INSURER(S)AFFORDING COVERAGE NAIC INSURER A:ACUITY.A Mutual Insurance Company 14184 INSURED MILLMAS-01 INSURER B: Miller Masonry& Concrete Inc INSURERC: PO Box 6 Little Chute WI 54140 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1888714495 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 INSR WVD POLICY NUMBER IMMIDD/YYYY) (MM/DD/YYYY) LIMITS A GENERAL LIABILITY Y Y Z30801 12/1/2017 12/1/2018 EACH OCCURRENCE $1,000,000 X DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $250,000 CLAIMS-MADE X OCCUR MED EXP(Any one person) $10,000 PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE $3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $3,000,000 POLICY X j7 X LOC $ A AUTOMOBILE LIABILITY Z30801 12/1/2017 12/1/2018 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X X NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) A UMBRELLA LIAB X OCCUR Z30801 12/1/2017 12/1/2018 EACH OCCURRENCE $5,000,000 X EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X RETENTION$0 $ A WORKERS COMPENSATION Z30801 12/1/2017 12/1/2018 X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED", N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes.describe under --- DESCRIPTION OF OPERATIONS below E L DISEASE-POLICY LIMIT S500,000 A Inland Marine Z30801 12/1/2017 12/1/2018 Rented Equipment $50,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) City of Oshkosh, and its officers, council members, agents, employees and authorized volunteers shall be Additional Insureds on t eneral Liability by endorsements CB7191A and CB7245A if required in a written contract. Waiver of Subrogation Ind I liability by #CB7268 if required in a written contract. DEC 0 4 2017 CERTIFICATE HOLDER CANCELLATION CITY co` SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oshkosh THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn: City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1130 Oshkosh WI 54902 USA AUTHORIZED REPRESENTATIVE 10ZWA: ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD