HomeMy WebLinkAboutNak Concrete LLC 05-18-20 A !�D® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DI7✓YYY1)
07/30/2019
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 Cindy
NAME: Casey
Thiel Insurance Group, LLC PHONE FAX
IA/C.
620 N Richmond Street E-M
No.EMI: (A/C,No):
A cindyc®thielinsurancegroup.Corn
ADDRESS:
INSURERS)AFFORDING COVERAGE NAIC 0
Appleton WI 54911 INSURER A: Y Heritage Herita a Insurance 14184
INSURED
INSURER B:
Nak Concrete LLC
INSURER C:
537 Marcella Ave
INSURER D:
INSURER E:
Combined Locks WI 54113
INSURER F:
COVERAGES CERTIFICATE NUMBER: CL1973001340 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.
NSA ADDL-SUER POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INS() WVD- POLICY NUMBER (MM/DD/YYYY) (MMIDD/YYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X OCCUR DAMAGE TO RENTED 100,000
PREMISES(Ea occurrence) $
MED EXP(Any one person) S 5,000
A Y Z72472 05/18/2019 05/18/2020
PERSONAL&ADV INJURY $ 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER 2,000,000
POLICY n PRO- GENERAL AGGREGATE f
JECT LOC
PRODUCTS-COMP/OPAGG S 2,000,000
OTHER:
S
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) S 500,000
OWNED SCHEDULED BODILY INJURY(Per person) $
A AUTOS ONLY XY Z72472
AUTOSHE05/18/2019 05/18/2020 BODILY INJURY(Per accident) S
X HION-OWND PROPERTY DAMAGE
AUTOSRED ONLY _� N
AUTOS ONLY X 1 g (Per accident) S
Underinsured motorist BI $ 500,000
UMBRELLA LIAB
_ OCCUR EACH OCCURRENCE S
EXCESS LIAB CLAIMS-MADE
AGGREGATE S
DEO I I RETENTION S
-WORKERS COMPENSATION E
AND EMPLOYERS'LIABILITY PER I OTH-
ANY Y/N STATUTE I ER
A OFFICER/MEMBEREXCLUDED?ECUTIVE N N/A Z72472 100,000
(Mandatory In NH) 05/18/2019 05/18/2020 E.L.EACH ACCIDENT S
If yes,describe under E.L.DISEASE-EA EMPLOYEE s 100,000
DESCRIPTION OF OPERATIONS below
E.L.DISEASE-POLICY LIMIT S 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
Work being performed at: 3930 Sandhill Court,Oshkosh,WI 54904
Additional insureds per attached endorsements:COI acceptable to the City of Oshkosh shall be submitted prior to commencement of the work to the
applicable City department. These certificates shall contain a provision that coverage afforded under the policies will not be canceled or non renewed until
at least 30 days poor written notice has been given to the City Clerk-City of Oshkosh.
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, Attn: City Clerk ACCORDANCE WITH THE POLICY PROVISIONS.
215 Church Avenue
P O Box 1130 AUTHORIZED REPRESENTATIVE
Oshkosh WI 54903-1130
CORD 25(2016/03) t 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD