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HomeMy WebLinkAboutRobert J Immel Excavating Inc 10-10-18 A�ORD� DATE(MMlDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 11/13/2017 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 CONTACT NAME: Spectrum Insurance Group GB PHONE 920-884-2850 FAX 920-884-2851 303 Packerland Dr., Ste C 4A1C.No E•l) ie(c.Not; Green Bay WI 54303 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC I/ INSURER A:Sentry Insurance INSURED IMMEL01 INSURER B:Sentry Insurance 21180 Robert J Immel Excavating Inc INSURER C: PO BOX 135 Greenville WI 54942 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1527078399 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 IDOL BR' , POLICY EFF POLICY EXP LTR i INSD WVD I POLICY NUMBER (MMIDDIYYYY) (MM/DDIYYYY) LIMITS A x COMMERCIAL GENERAL LIABILITY A0090058004 '10/10/2017 10/10/2018 EACH OCCURRENCE $1,000,000 GE TO RENTED CLAIMS-MADE X OCCUR PREMISES Ea occurrence) S200,000 MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 X POLICY PRO- JECT LOC PRODUCTS-COMP/OPAGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY A0090058001 10/10/2017 10/10/2018 C.OMBINED SINGLE LIMIT $ (Ea accident) •1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ B X UMBRELLA LIAB OCCUR A0090058007 10/10/2017 10/10/2018 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X I RETENTION$10,000 $ B WORKERS COMPENSATION 1 x A0090058006 10/10/2017 10/10/2018PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100,000 OFRCER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 1 DESCRIPTION OF OPERATIONS/LOCATIONS 1 VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Annual Excavation,Work in right-of-way City of Oshkosh,and its officers,council members, agents,employees and authorized volunteers are additional insured when required by written contract subject to policy terms and conditions. t� 1 S VTEI Itl' ',CANCELLATION CERTIFICATE HOLDER BAN �..0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Oshkosh �I1 'C THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 215 Church Sl ACCORDANCE WITH THE POLICY PROVISIONS. Oshkosh WI 54901 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD