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HomeMy WebLinkAboutDale Van Groll Concrete Creations LLC 02-01-20 ACORU CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYVV) 16.---- 07/02/2019 I 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: Sue Schommer Van Dyn Hoven Insurance PHNE (IA/C.No.Ext): (920)788-3530 FAX(A/C.No):(820)788-6946 534 Pine Street E-MAIL ADDRESS: 4ueevdhInsurance.com _ Little Chute,WI 54140 INSURER(S)AFFORDING COVERAGE NAICX INSURERA: Motorists Insurance 13331 INSURED INSURER B: Dale Van Groll Concrete Creations LLC INSURER C:_ _ _ _ _ N4084 Mary Joan Ct INSURERD: Freedom,WI 54913-8983 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000-823202 REVISION NUMBER: 92 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. IItER TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LMITS LTR Inn WV") POLICY NUMBER (MM/DDIYYYY1 IMM/DD/YYYYI A X.COMMERCIAL GENERAL LIABILITY 5000025514 02/01/2019 02/01/2020 EACH OCCURRENCE $ 1,000,000 DAMAGE RENTED CLAIMS-MADE X OCCUR PREM SESO(Ea occurrence) $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPUES PER: GENERAL AGGREGATE $ 2,000,000 POLICY X Ter. LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE UABIUTY 5000025514 02/01/2019 02/01/2020 (EeMaccidEDtSINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY X AUTOS BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE $ X AUTOS ONLY X AUTOS ONLY (Per accident) A X. UMBRELLA UAB H OCCUR 5000025588 02/01/2019 02/01/2020 EACH OCCURRENCE _ $ 1,000,000 EXCESS UAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED RETENTION$ 0 $ A WORKERS COMPENSATION I 5000025584 02/01/2019 02/01/2020 PER STATUTE OTH- ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N/A — (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000 1 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Oshkosh as additional insured CERTIFICATE HOLDER CANCELLATION 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 St Oshkosh,WI 54903 AUTHORIZED REPRESENTATIVE �h �c 11- (SMS) ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD Printed by SMS on July 02,2019 at 02:02PM