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HomeMy WebLinkAboutGM Bauman Concrete & Masonry 10-3-20 AWR CERTIFICATE OF LIABILITY INSURANCE DATE IMM/DD/YYYY) 9/3/2019 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 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 Ansay &Associates, LLC. FV PP ONE Doreen Janssen FAX 4351 W College Ave (A/C.No.EIR):920-560-7000 (Arc,No):920-560-7079 Suite 310 RECEIVED - A►oonEss: doreen,janssen©ansay.com Appleton WI 54914 - -- INSURER(S)AFFORDING COVERAGE NAICM S E P -6 2 1�MBAUMA-01 INSURER A:ACUITY,A Mutual Insurance Company 14184 INSURED INSURER B GM Bauman Concrete&Masonry LLC &Masonry LLC DEPT OF PUBLIC WORKS INSURERC: N3502 12 Corners Road OSHKOSH, WISCONSIN INSURER 0: Appleton WI 54913 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1692786625 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 TYPE OF INSURANCE ADOL SUBR POUCY EFF POLICY EXP W MI UNITS LTR INSR VD POLICY NUMBER (MDDIYYYY) (MMIDD/YYYY) A GENERAL LIABILITY Z81916 10/3/2019 10/3/2020 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $250,000 _ CLAIMS-MADE X OCCUR MED EXP(Any one person) S 10,000 PERSONAL&ADV INJURY $1,030,000 GENERAL AGGREGATE S 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER' PRODUCTS-COMP/OP AGG $3,000,000 POLICY X jT LOC $ A AUTOMOBILE LIABIUTY Z81916 10/312019 10/3/2020 COMBINED SINGLE LIMIT (Ea accident) $1.000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ ,AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS X AUTOS (Per accident) $ $ A X • UMBRELLA LIAB X OCCUR 281916 10/3/2019 10/3/2020 EACH OCCURRENCE S 2,000,000 ' EXCESS UAB CLAIMS-MADE AGGREGATE S2,000,000 DED RETENTIONS $ A WORKERS COMPENSATION Z81916 10/3I2019 10/3/2020 X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y l N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $100,000 OFFICER/MEMBER EXCLUDED" NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 I 1 I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) City of Oshkosh is listed as additional insured per form CB7191 and a 30 day notice of cancellation is in favor of the City of Oshkosh. 10 Day notice for cancellation of non payment. 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/City Clerk ACCORDANCE WITH THE POLICY PROVISIONS. 215 Church Avenue PO Box 1130 AUTHORIZED REPRESENTATIVE Oshkosh WI 54903-1130 /? ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD