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HomeMy WebLinkAboutNortheast Asphalt Inc 03-01-20 '__---.1 a► DATE(MM/DD/YYYY) ,d.�o CERTIFICATE OF LIABILITY INSURANCE 08/28/2019 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 w certificate does not confer rights to the certificate holder in lieu of such endorsement(s). c CONTACT m PRODUCER 'O NAME: _ Aon Risk Services Central, Inc. PHONE Ent): (920) 437-7123 FAX (920) 431-6345 m Green BayWI Office ( (A/C.No.): RECEIVE,, E-MAILt 111 N. Washington Street, Suite 300 p P. 0. Box 23004 ADDRESS: _ Green Bay WI 54305-3004 USA INSURER(S)AFFORDING COVERAGE NAIL# INSURED �EP INSURERA: The Travelers Indemnity Co. 25658 Northeast Asphalt, Inc �Ejy J1' INSURERS: Travelers Property Cas Co of America 25674 C/0 Mary Jorgensen ` OF PUBLIC jC Ik'1 INSURERC: The Travelers Indemnity Co of CT 25682 PO Box 32 waukesha6WI 53187 USA OSHKOSH, yy/��CO\ INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 570077992434 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. Limits shown are as requested INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) 1MMIDD/YYTY- LIMITS A X COMMERCIAL GENERAL LIABILITY VTC2K-CO-7211B454-IND-19 03/01/2019 03/01/2020 EACHOCCURRENCE S1,000,000 General Liability DAMAGE 10RENrED CLAIMS-MADE X OCCUR PREMISES(Ea occurrence) $300,000 MED EXP(Any one person) S10,000 PERSONAL 8ADV INJURY S1,000,000 A GENT AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE S2,000,000 m POLICY X JECa LOC PRODUCTS-COMP/OP AGG S2,000,000 0 OTHER 0 A VTC2K-CAP-3049P020-IND-19 03/01/2019�03/01/2020�COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY S2,000,000 Automobile (Ea accident) .. X ANY AUTO BODILY INJURY(Per person) 0 Z OWNED SCHEDULED BODILY INJURY(Per accident) tq AUTOS ONLY AUTOS X HIRED AUTOS x NON-OWNED PROPERTY DAMAGE U ONLY AUTOS ONLY (Per accident) ;.= t 0 B X UMBRELLAUAB X OCCUR VTSMJ-CUP-63773169-TIL-19 03/01/201903/01/2020 EACH OCCURRENCE S10,000,000 U Umbrella AGGREGATE S10,000,000 EXCESS LIAB CLAIMS-MADE DED X RETENTION 310,000 B WORKERSCOMPENSATIONAND UB-3L596342-19-25-R 03/01/2019I 03/01/2020rx PER OTH- EMPLOYERS'LIABILITY YIN Workers Compensation - WI STATUTE ER ANY PROPRIETOR I PARTNER I EXECUTIVE E.L.EACH ACCIDENT S1,000,000 C OFFICER/MEMBEREXCLUDED? I N I UB-4L04638A-19-25-K 03/01/2019103/01/2020 (Mandatory in NH) Workers Compensation - Ot E.L.DISEASE-EA EMPLOYEE S1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000- I 2 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) RE: OLD NATIONAL BANK 708461. CITY OF OSHKOSH, ITS OFFICERS, COUNCIL MEMBERS, AGENTS, EMPLOYEES OR AUTHORIZED VOLUNTEERS IS AN ADDITIONAL INSURED ON THE COMMERCIAL GENERAL LIABILITY POLICY PER THE TRAVELERS ADDITIONAL INSURED ENDORSEMENT #CG D3 61 03 05 .- AND CG 20 37 07 04 AND ON THE AUTOMOBILE AND UMBRELLA LIABILITY POLICIES ON A PRIMARY AND NON-CONTRIBUTORY BASIS, IF REQUIRED BY CONTRACT, AND TO THE EXTENT CAUSED BY THE NEGLIGENT ACTS OR OMISSIONS OF THE NAMED INSURED. THE LIMIT OF LIABILITY COVERAGE WILL BE PER CONTRACT OR AS SHOWN ON THE COI, WHICHEVER IS LESS. ENDORSED POLICIES WILL INCLUDE A 30 DAY NOTICE OF CANCELLATION/NONRENEWAL FOR ANY REASON OTHER THAN NONPAYMENT OF PREMIUM, PROVIDED TO THOSE PARTIES INDICATED IN THE WRITTEN �J• CONTRACT. :ram CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE C EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Y. CITY OF OSHKOSH AUTHORIZED REPRESENTATIVE ATTN: CITY CLERK 215 CHURCH AVENUE a. PO BOX 1130 OSHKOSH WI 54903 USA MI ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD