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Certificate of Insurance ]
THIS CERTIFICATE IS ISSUED AS A MATTER OF IN.FOR. MATION ONLY A.N.!D CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER.
THIS CERTlI'ICATE IS NOT AN INSURANCE POLlCY AND DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES LISTED BELOW.
This is to Certify that
Insured:
CABULANCEINC
1402 MT VERNON
OSHKOSH WI 54901-3038
Producer of Record:
KAREN E NEMITZ
BURKHART-HEISDORF INS AGENCY
1807 ERIE AVE
SHEBOYGAN WI 53081
At the issue date of this certificate, insured by the Company under the policy(ies) listed below. Thc insurance afforded by the
to all thcir terms, exclusions and conditions and is not altered by any requirement, term or condition of any contract or other document
which this certificate may be issued.
POLICY
TYPE OF POLICY DATES POLICY NUMBER LIMITS OF LIABILITY
Coverage Afforded Under WC Law of the Following
States:
WORKERS Bodily Injury By Each
COMPENSATION N/A N/A Accident $ Accident
Bodily Injury By Each
Disease $ Person
$ Policy
Limit
General Aggregate-Other than Procl!Completed Ops
$
Products/Completed Operations Aggregate
$
GENERAL LIABILITY N/A N/A Bodily Injury and Property Damage Liability
$
Per Person/Organization
AUTOMOBILE
LIABILITY
D O\VNED Each Accident - Single Limit
12/26/04 ASl-341-433661-014 $500,000 CSL B. 1. And P. D. Combined
00 NON-OWNED TO Each Person
00 SCHEDULED Each Accident or Occurrence
VEHICLES 12/26/05
00 HIRED Each Accident or Occurrence
U ANY AUTO
YOU WILL NOT BE NOTIFIED ANNUALLY OF THE CONTINUATION OF COVERAGE. YOU WIlL BE NOTIFIED IF COVERAGE IS TERMINATED
OR REDUCED BEFORE THE CERTIFICATE EXPIRATION DATE.
NOTICE OF CANCELLATION: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TIlE EXPIRATION DATE
THEREOF, TIlE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTlFICA TE HOLDER NAMED BELOW,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION 0 ILITY OF ANY KIND UPON THE COMPANY, IT'S AGENTS OR
REPRESENTA1lVES.
CERTlFICA TE
HOLDER CITY OF OSHKO
215 CHURCH A V
PO BOX 1130
OSHKOSH WI 549
W AUSAU, WI AB
OFFICE
BS 772R6