HomeMy WebLinkAboutGit R Done Paving 01-08-20 •
��-� p DATE(uMrDDiYYYY)
® RECEIVrr
A f.. CERTIFICATE OF LIABILITY INSURANCE , 08(M8/2019
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON!LIB: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. i' i',r .,y
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the poliey(iee)moat be endorsed. If SU GA`1..okIIS WAIL 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 endorsament{e),
PRODUCER COON IEACT
PHONE I FAX
LAIC_No_gm: I(A/C,No):
Dan Yanak Ins Agency Inc E-MAIL :
127 W Perry St • INSURER(B)AFFORDING COVERAGE NAJC#
Port Clinton _ pH 43482 INsuRERA: NATIONWIDE MUTUAL INSURANCE COMPANY 23787
INSURED INSURER B: AMCO INSURANCE COMPANY 19100
CHARLES SWARTZ wSVRER C I
DBA GIT R DONE PAVING iNsuRER D;
3322 STATE HWY 13 INsuRMR E: /
WISCONSIN DELLS WI 53985-8923 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 VNTH 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.
ILS_ TYPEOFINEuRANCE i p yy,m sten POLICY NUMBER tMMOl01DIYW 1 tMMWD!Y AT UNITE
X COMMERCIAL GENERALUAU{LITY EACH OCCURRENCE s 1,000,000
DAMAGE it)HEN TED
1 CLAIMS-MADE X OCCUR PREMISES[Ea owyenoe) S 100,000
MED EXP(Any ono person) 3 5,000
A X ACP GU)5794327319 01/08/2019 01/08/2020 PERSONAL 5AOVINJURY S 1,000,000
,
OEN'.AGGREGATE LIMB APPLIES PER: GENERAL AGGREGATE s 2,000,000
xLIC POY JECT 1 LOC PRODUCTS-COMP/OP AGG $ 2,000,000
_ OTHER: 5
AUTONOBILEUAE1LRY CE8 illiVSINGLELIMIT S 1,000,000
_ ANY AUTO eOonY INJURY(Per person) E
A AuT D x ULED X ACP BA 5794327319 01/08I2010 01/08/2020 pBODILYINJURY(Perooridert) b
X HIRED AUTOS X AUTOS ED rParOaoEd4TMerKD1 � $ -
$
x UMBRELLA UAB X'OCCUR tiEACHOCCURRENCE s 2,000,000
B EXCESS LIAR CLAMS-MADE X ACP CAA 5794327319 01/05/2019 01/08/2020 AGGREGATE $ 2,000,000
DED RETENTIONS $
WORKERS cam PEN$ATION �� PER TFL
AND EMPLOYERS'LABILITY Y 1 N STATUTE ER .
ANYPROPRIErORIPARTNERIEXECUTIVE 7 N f A EA_EACH ACCIDENT ;
OFFICER/ME/MEP(EXCCLUDEo7
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $
If yyes,dezaibe undv -
DESCRIFrtON OF OPERA;IONS below E.L,DISEASE-POLICY OMIT S
•
DESCRIPTION OF OPERATIONS,LOCATONS I VEHICtES(ACORD 101,Additional Remarks Schedule,may be ai aatmd If more apace le 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 rd 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
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Oshkosh,Attu:City Clerk AUTHORIZED REPRESENTATIVE
PO Box 1130 Nationwide Mutual Insurance Co
Oshkosh WI 54903-1130
I
ID 1988.2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD