HomeMy WebLinkAboutOshkosh LaCrosse/06-07
CERTIFICATE OF INSURANCE CLUB# 220 ISSUE DATE (MM/DDIYY)
2-27-06 sah
PRODUCER THIS CERTIFICATE IS EVIDENCE OF COVERAGE ISSUED AS A
SADLER & COMPANY, INC. MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS
P.O. BOX 5866 UPON THE CERTIFICATE HOLDER. IT DOES NOT AMEND,
COLUMBIA, SOUTH CAROLINA 29250-5866 EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
(800) 622-7370 Email: soda@sadlersports.com POLICIES BELOW.
INSURED COMPANIES AFFORDING COVERAGE
ERS Risk Purchasi 19 Gnql.Associatiori;-hc., db'a COMPANY
SporIspIex OpemIotsAnd DeveIopersAssocialion LETTER A GREAT AMERICAN ASSURANCE COMPANY
OSHKOSH LACROSSE
1064 HUNT AVE COMPANY
NEENAH, WI 54956 LETTER B AIG Life Insurance Company (AIG Life)
COMPANY
LETTER C
COVERAGES
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.
POLICY POLICY
CO. EFFECTIVE EXPIRATION
LTR TYPE OF INSURANCE POLICY NUMBER DATE DATE LIMITS
(MMlDDIYY) (MMlDDIYY)
General Liability General Aggregate NONE
Rr Commercial General Liability Products-Comp/ops $2,000,000
~ggregate
12:01 AM 12:01 AM Personal & Advertising $2,000,000
A r Claims Made P1 Occur. GLOOOO05662233-02 Injury
Each Occurrence $2,000,000
C1 Owners & Contractors Prot 02-16-06 01-01-07 Fire Damage (Anyone $ 300,000
fire)
f~~: Medical Expenses (Any $ 5,000
one person)
Participant Legal liability $2,000,000
12:01 AM 12:01 AM Excess Medical $100,000
B Participant Accident AMS9010006 02-16-06 01-01-07
REFERENCE #: SRG8710411 AD&D $ 5,000
DESCRIPTION OF OPERATlONSlLOCATIONSNEHICLESlRESTRICTIONSlSPECIAL ITEMS
COVERED SPORT: ONE (1) TEAM (Maximum TWENTY-FOUR (24) Players per Team) YOUm LACROSSE
(NOTE: Participant Accident has a $250.00 Deductible per claim)
NOTE: The Participant Accident policy shown above is issued to Sportsplex Operators & Developers Association and is not a
part of the ERS Risk Purchasing Group Association, Inc.
With respect to the General liability, the Certificate Holder is added as an Additional insured solely in its capacity as a
property owner or sponsor, but only with respect to liability arising out of the insured's operations. This insurance does not
apply to the sole negligence of the Additionallnsurecl.
CERTIFICATE HOLDER CANCELLATION
PROPERTY OWNER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY
CITY OF OSHKOSH WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE
215 CHURCH AVE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL
PO BOX 1130 SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY
OSHKOSH, WI 54903-1130 KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES
AUTHORIZED REPRESENTATIVE (Company A)
,. . ('4',~~ ~.o?~
AUTHORIZED REPRESENTATIVE (Company B)
~ ,S:.+A 4...
. .
~.. ..~-,-,.~- "'.-'."-,,---,- t." ~O.'lDA I
~. fC'~ ~r~~ n ,,0.. ~
i iE l,.~,.j_ f'"'1, I
L_..:3 "":' ..'_1 '" ~ \
I.' r-..----".-'--.---,-", ~ i j',
d" 'Ii': 11 i
~'111! JAN 2 9 ZOG? 111.)j I
I ~ ,. ~ . ,,' ,,1/
Uc' l":r"y' .;,., r-';i-"'~:;:::----' "'~'" j
. ~ &--r,~'~,' '4w,
V l.-..... I 1'\ ,~~ '. I
- . ~"f;;_,;;;.,"~"'~)';'~~"':'~'~'..t~;. ~~ '''" ;,..'._~._~; .~", ", ~......w. ~.... _~;___,~
PLEASE PRINTr _ ~
Field Requested cS.~k~j/MY ~ ~ ~ ~O~FIELDPERFORM)
t:1('~ /!uS h Utrf;$/U
Name of Organization (BE sPEcmq f/ )'I"L' .
Person in Charge j,J/0ko/{S !J.tl1fttrtcJ Title ~./ ~ ~~
. /
Address If) 6'1 ~J h.e ~,~ City ,dzt!./fA.,A- Zip pYf7,rG
Home Phone 1ZtJ tp ~ 9 - c3 7 ') 7 Business Phone
. '. . . . '. . ?ti1C/'OS.s:.e ~
E-Mail Address ~actt/)U1#t;;l r&J.Il t15"Akl/. . Fax Number
1 a.-'~' -:
. ,..~. ..L:::.....; I.
2. ~ I 'IYI &6 ~5
3. ~' 1_
4. ~ I_
S. --1 1_
6. _I 1_
7. ____I I~
8. I I
- -
_ 9. Ji!/ -L! () ? Ifllin tL
10. _1--1---;- _
11.--1_1_
12.--1--1_
13._1--1_
DO NOT USE
.RED INKU
Base Path Distance
OSHKOSH AREASCHOOL DISTRICT
RECREATION DEPARTMENT
FIELD RESERV ATIONREQUEST FORL~
(This ReQuest is subject to Final Anproval by the Recreation Department)
(Upon final 'approval. a cop v of this form will be sent to yon for your records)
Pitcher's Mound Distance
(Y1V11 - 1=""..- ~
~;'f
f/
SEE BACK OF FORM FOR FIELD RESERV AllON RULES
PERSON RESPONSIBLE SIGNATURE ~fJ(j1~
DATE: (1/ (7/~b
( ." ( . ..' .
*******~*****************************************************************************~****
INCOMPLETE FORMS WILL BE RETURNED. All cancellations MUST be reported to the Recreation Department.
Violation of the following shall be sufficient reason to revoke this permit, and to deny future permits to the same individual or group.
I. Destruction of properl)': 4. No smoking in the buildings or on school grounds.
2. Profane or indecent language or conduct.
3. Failure to abide by the orders of the proper constituted authority.
5. No use of intoxicating liquors on premises.
The Department of Recreation assumes no risk of injury to anyone.
BOOKED X.
-OFFIQj: USE ONL y-
aRD INITIALS -L. c.r' DATE SENT
I / ~.3 /$