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HomeMy WebLinkAboutHousworth, Jeremiah 09-09-20 A ® DATE(MMIOD YYYY) CERTIFICATE OF LIABILITY INSURANCE 08/27/2019 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 JON BERGER,AGENT NAME: RURAL MUTUAL INSURANCE COMPANY HONE Extl 920-230-6886 _ FAX 920-230-6887C. _ Jon Berger Agency ADpAREss: cgonzales@ruralins.com 1730 Algoma Blvd Suite A INSURERS)AFFORDING COVERAGE NAIC Oshkosh WI 54901 INSURER A: RURAL MUTUAL INSURANCE 15091 INSURED INSURER B: INSURER C: JERAMIAH HOUSWORTH INSURERD: 1721 OHIO ST INSURERE: OSHKOSH WI 54902 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 l - ADDL SUER POLICY EFF POLICY EXP LTR 1 TYPE OF INSURANCE INSD WVD POLICY NUMBER JMM/DD/YYYY) IMM/DD/YYYY) moTS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ _ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JET LOC PRODUCTS-COMP/OP AGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ I r AUTOS ONLY AUTOS ONLY (Per accident) $ I X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 _ A EXCESS LIAB CLAIMS-MADE Y HOMG126312 09/09/2018 09/09/2020 AGGREGATE $ 1,000,00.0 I DED X RETENTION$ 1,000 $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY YIN STATUTE ERH ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Each Occurrence $300,000 A HOMEOWNERS LIABILITY Y HOMG126312 09/09/2018 09/09/2020 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached it more space is required) Additional Insureds per attached endorsements. Certificates of Insurance 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'prior 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 Ave AUTHORIZED REPRESENTATIVE PO Box 1130 Oshkosh WI 54903 JON BERGER.AGENT ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD