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HomeMy WebLinkAboutAl Dix Liability Ins. DATE tMMIDDInm) CERTIFICATE OF LIABILITY INSURANCE 3/14/2016 THIS CERTIFICATE 1S 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 PORGY(les) 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 endorsements . coNTACT Mary McLennan PRODUCER NAME: Spectrum Insurance Group GO PHONE 920-884-2850 FA920-884-2851 920-884-2851 fAtC,-NQ,ExU• 303 Packerland Dr., Ste C E-MAIL Mary.McLennan@spectruminsgroup.com Green Bay WI 54307ADDRESa NAtca INSURERS AFFORDING COVERAGE INSURER A:Acus 14184 INSURED ALDIX-1 INSURER B: Al Dix Concrete, Inc. INsuRERc: W4437 Schmidt Rd INSURER P Kaukauna W154130 INSURERS: INSURER F: COVERAGES CERTIFICATE NUMBER: 1958207103 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 DED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFOR EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IL7R POLICYNUMBER SUER POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE INSD WVD MMIDDIYYYY MMfDDNYYY X90139 3/1/2016 3/1/2017 EACH OCCURRENCE $1,000,000 A X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS-MADE El OCCUR PREMISES Ea occurrence $250,000 LIED EXP(Any one person) $10,000 PERSONAL&ADVlt,JURY 51,000,000 GENERAL AGGREGATE $3,000,000 GEITLAGGREGATE LIMIT APPLIES PER: POLICY PRO- [j]LOC PRODUCTS-COMPIOPAGG 53,000,000 JECT $ . OTHER: A AUTOMOBILE LIABILITY X90139 3!112016 3!112017 Ea ardent E 51,000,000 BODILY INJURY(Per WWI) $ X ANY AUTO AllOOSVNED SCHEDULED BODILY INJURY DAMPeraccldent) $ ALIT NON-OWNED P�acddentDAMAGE y HIREDAUTOS AUTOS $ A UMBRELLA LtA6 Tfl�CCUR X90139 3/1/2016 3!1/2017 EACH OCCURRENCE $3,000,000 AGGREGATE 53,000,000 EXCESS LIAa lAlh1S-0.1ADE $ DED X RETFNTIONSO A WORKERS COMPENSATION X90139 3!1!2016 3/1/2017 X STATUTE JERH AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT $100,000 ANY PROPRIETORrPARTNERIEXECUTI= ❑ N I A OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $100,000 {Mandatory In NH} If yyes,describe under F.L.DISEASE-POLICY LIMIT $500,000 DESCRIP710N OF OPERATIONS Dekvu DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Sahedule,may bo attached If more space Is required) The City of Oshkosh, its officers, council members, agents,employees or authorized Volunteers are included as Additional Insured on a primary and non-contributory basis with a 30 day notice of cancellation subject to insurance laws for the State of Wisconsin 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 ACCORDANCE WITH THP_POLICY PROVISIONS, 215 Church Ave Oshkosh WI 54903-1130 AUTHORIZED REPRESENTATIVE >0a.� -� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD W3 ACUITYBIS-PAKID COVERAGE PART It —� A LWIVOI 141Maae 04rcPany I Renewal Declarations First Named Insured and Address: Agency Name and Number: AL DIX CONCRETE INC SPECTRUM INSURANCE GROUP 500 DRAPER ST 7674-AA KAUKAUNA WI 64130 • Po[Icy Number; X90139 Policy Period: Effective pate: 03-01-16 Expiration Date: 03-01-17 in return for the payment of the premium and subject to 12:01 A.M. standard time at all the terms of the policy, we agree to provide the your mailing address shown insurance'coverage as stated in the same, it) the declarations COVERAGE FORMS AND ENDORSEMENTS APPLICABLE TO THIS COVERAGE PART Form Number Form Title Premium CB-0006 (12-12) Bls-Pak Business Liability and Medical Expenses Coverage Form . . . . $ CB-0009 (09.04) Bis-Pak Common Policy Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . CB-1416 (01-10) Snovi Plow Products-Completed Operations Hazard Coverage . . . . . . . t CB-7201 (04-10) Property in the Course of Construction . . . . . . . . . . . . . . . . . . . . . • • 196.00 IL-7002 (10-90) Notice of Cancellation Indorsement . . . . . . • . . . • • • • • • • • • • • • • • • CB-7048 (04.10) Additional Insured - Owners, Lessees or Contractors -Scheduled 150,00 Person . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CB-0497F (01-06) Waiver of Transfer of Rights of Recovery Against Others To Us . . . . . 48.00 CB-0413 (01-06) Additional Insured - Engineers, Architects or Surveyors . . . . . . . . . . . . CB-7333 (04-10) Additional Insured- Owners, Lessees or Contractors- Completed50 00 Operations . . . . . . , • . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . , . CB-1604(06-14) Exclusion-Access of Confidential or Personal Info/Data with Limited ei . . . . . . . . . . . . . . . , . . . . . . . . . . . . . . . . . . . . . . . . . . . CB-0417 (07-02) Employment-Rotated Practices Exclusions . . . . . . . . . . . . . . . . . . . . CB-7021 (09.04) Wisconsin Changes . . . . . . . . . . . . . . . . . . . . . • • • • . • • • • CB-0577 (04-10) Fungi or Bacteria Exclusion (Liability) • . . . • • IL-7012 (03-14) Asbestos Exclusion . . . . . . . . . . . . . . . . . . : . . . . . . • • . • • • • • • • GB-7105 (06-13) Contractor's Equipment . . . . . . . . . . . . . . . . . . • . • • • 2,254.00 CB-1004(01-07) Exclusion of Certain Computer-Related Losses . . . . . . . . . . . . . . . . . . CB-0601 R (01-07) Exclusion of Loss Due to Virus or Bacteria . . . . . . . . . . . . . . . . . . . . . CB-0664 (01-16) Conditional Exclusion of Terrorism (Relating to Disposition of Federal Act) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CB-0002 (09-14) Deluxe 1318-Pale Property Coverage Form . . . . . . . . . . . . . . . . . . . . . CB-7262 (04.10) ACUITY Advantages - Property Coverages . . . . . . . . . . . . . . . . . . . . . ( CB-7268 (11.14) ACUITY Enhancements - Liability Coverages . . . . . . . . . . . . . . . . . . . 116.00 CB-7344(12-11) Additional Insured - Owners, Lessees or Contractors -Primary and 300.00 Noncontributory . , . . . . . . . . . . . . . . . . . • . • . . . . . . . . . . . . CB-700002-08) Policyholder-Original so 01 03102/16 IIl1 Page 2 Policy Number; X90139 Effective Date: 03-01-16 i Premium Form Number Form Title CB-1203 (01-06) Loss Payable Provisions . . . . . . . ss.ors Promi • . , . ; , . . ` . . . • . . CB-0402 (01-87) Additional Insured - Managers or lessors of Premises . . ; 36,00 CB-7297 (01-15) Exclusion of Certified Acts of Terrorism • . , • • • • Advance Endorsement Premium . . , . . . . . . • . . . . . . . . . I . . . . . . .. . . . . . . . . . . . . . $ 3,149.00 PREMIUM SUMMARY . . . , . . • . . . . . . $ 3,397,00 Advance Premium . . . . . . . . . . . . . . . . . . . . . . . • , . 3,149.00 Advance Endorsement Premium . . . . . • • . • • • • • • . • • • • ` • . . • ` . . • • . • • ----- $ 6,546.00 Total Advance Premium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . ated at the me this The Total Advance Premium shown above is based o thedance with the BisnPakp L ability andrModlcal coverage part began. We will audit this coverage part in Expenses General Condition entitled Premium Audit- Business Liability at the close of the audit period, PROPERTY COVERAGES pROVIDED { Form: Deluxe Premises Building Limit of Automatic Coverage Insurance Increase Item Number Number Percentage 001 Replacement Cost $ 337,080 6% Building 001 001 Buslness Personal Property 001 pp1 Replacement Cost 50,000 Deductible: $500 001 0Q2 Replacement Cost 22,472 Building10,000 NIA Business Personal Property 0071002 Replacement Cast Deductible: $500 6% 001 003 Replacement Cost 67,416 Building 003 Flep]acement Cost 20,000 NIA Business Personal Property 001 Deductible: $500 Go/.X01 004 Replacement Cost 168,540 Building25,000 NIA Business Personal Property 001 004 Replacement Cost Deductible: $500 DESCRIPTION OF PREMISES So 01 03102/16 CB-7000(12.06) pet c Pago 3 Policy Number, X90939 Effective Date: 03-01-16 i Premises Building Constructlon, Number Number Occupancy and Location 001 001 NONCOMBUSTIBLE CONCRETE FLATWORK 500 DRAPER ST KAUKAUNA WI 001. 002 FRAME CONCRETE FLATWORK 500 DRAPER ST KAUKAUNA WI 001 003 NONCOMBUSTIBLE CONCRETE FLATWORK 500 DRAPER ST KAUKAUNA WI 001 004 FRAME CONCRETE FLATWORK 500 DRAPER 8T KAUKAUNA Wl MORTGAGEHOLDER NAME AND ADDRESS Premises Building Mortg�geholder Lean Number Number dumber 001 001 FIRST MERIT BANK 4321 W COLLEGE AVE STE 101 APPLETON W154914 001 002 FIRST MERIT BANK 4321 W COLLEGE AVE STE i01 APPLETON W154914 001 003 FIRST MERIT BANK 4321 W COLLEGE AVE STE 101 APPLETON WI 64914 001 004 FIRST MERIT BANK 4321 W COLLEGE AVE STE 101 APPLETON W€54914 LIABILITY COVERAGES PROVIDED Coverage Item Limit of Insurance Liability and Medical Expenses (Each Occurrence) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 11000,000 Medical Expenses (Any One Person) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10,000 l CB-7000(12.08) 80 01 03102116 Ii66 Page 4 I Policy Number; X90139 Effective Data: 03.01-16 (. s Rented to You . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250,000 Damage to Premises . . . . . � , • . . . . . . . . . . . . . . Products-Completed Operations Aggregate Limit . . . • . , . • • • • • • • • ' ' ' ' . ' ' . ' . ' 3,000,000 3,000,000 General Aggregate Limit (Other Than Products-Completed Operations) . . . . . . . . , . - • • ses Bullding Prom[ classification Class Premium Rate Number Number Description Code Basisi opt col Driveway Parking Area or Sidewalk 92215 . 363,200 PA 6.59 Paving i I PA = Payroll- date Applies Per$1,000 of Payroll OPTIONAL COVERAGES PROVIDED Limit of Coverage Item Insurance Forgery and Alteration . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . ' 2,600 Scheduled Contractors' Equipment -Actual Cash Value . . . . . . . . . . . . . • • • • • ' . ' ' ' ' ' ' See CE35,0006 Business income from Dependent Properties . . . . . . . . . . . • . . . . • . ' ' ' . ' ' ' . . . . . . . .. 10,000 Electronic Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10,000 Interruption of Computer Operations . . . . . . . . . . . . • • . . . • , . • • • • . • • • • • • • • . . . . . Outdoor Signs , . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10,000 Property in the Course of Construction . . . . . . . . . . ... . . . . . . . . . . . . . . ' . . . . . . , . See 6&7201 ACUITY Advantages- Property Coverages . . . . . . . . . . . • • • • • • . . ' ' ' ' ' ' ` . ' . ' . . . . . . See CB-7262 See CB-7262 ACUITY Enhancements - Liability Coverages . . . . . . . . . , • • • • • • • • • . • • • . • • ' ' ' ' ' ' ' Premises 13ullding Limit of Coverage Item Number Number Insurance Business Income and Extra Expense . . . . . . . . . . . . . . . . . • • • • • • . 001 001 Actual Lass Sustained Landlord as an Additional insured . . . . . . . . . . . . . . • • 001 001 Sams asLiability Limit Money and Securities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 001 001 . . . . Inside the Premises . . , , . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10,000. . . . . 5,000 Outside the Prem€sos . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . 001 001 25,000 AccountsReceivable . . . . . . . . . . . . . . . . . . . . . . ' . . . . . . . . . . I 10,000 Valuable Papers . . . . , . . . . . . • . . . . . . . . . . . . . . . • . . . • . . • . . • 001 001 Business Income and Extra Expense . . . . . . . . . . . . . . . . . • • • • • • • 001 002 Actual Loss Sustained Money and Securl#!es . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 001 002 10,000 Inside the Premises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5,000 Outside the Premises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . Accounts Receivable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • • . . . 001 002 25,000 10,000 Va[uable Papers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . 001 002 Business Income and Extra Expense . . . . . . . . . . . . . . . . • • • • • • 001 003 Actual Loss Sustained so 01 0=2116 OB-7000(12-08)