HomeMy WebLinkAboutDeGirolamoAPPLICATION FOR MRAINLA fET S"LI-CENS•E � ?
MANSFIELD, MA C!
DATE
Name and/or Corporation:_. d
7 l+/r)n�/��
& Address:
Emergency 24 hour telephone #
Please attach the following:
1. Valid Heavy Equipment operators License (copy);
2. Insurance Certificate (Town must be listed as additionally
insured);
3. Performance Bond;
4. Three references who are familiar with your work with
telephone numbers;
5. Application fee of $250.00.
The undersigned hereby acknowled es receipt, understanding of the
Drainlayer's Regula1tions, an hat he/ahe has read the entire
document. II
Signature:
DPW APPROVED:
DATE: 6/20/95
$250.6
T40002 TRAH 096982 06/20/95
hc:'�IPT 16671` C 1 $25i1.i
';11�".
TISSUE DATE (MMIDF"
06/13/95
PRODUCER
•• THIS CERTIFICATE IS ISSUED AS A`MATTER OF INFORMATION ONLY AND <:
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
NEW ENGLAND SECURITY INSURANCE AGENCY
INCI DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
200 CHADNCY STREET - SIIITE 100
POLICIES BELOW,
MANSFIELD, MA 02048
COMPANIES AFFORDING COVERAGE
COMPANY THE TRAVELERS INSURANCE COMPANY
A
LETTER
.._._CHARTER OAK FIRE INSURANCE COMPANY
COMPANY THE TRAVELERS INSURANCE COMPANY
8
NsufleO
LETTER TRAVELERS INDEMNITY COMPANY
PETER DEGIROLAMO AND SONS, INC.
COMPANY
C INSURANCE COMPANY OF NORTH AMERICA— CIGNA
631 EAST STREET
LETTER
MANSFIELD, MA 02048
COMPANY
D
LETTER
_._
._.___._.—_._.__.__......__.....,___...__......_..�.____...___.__._.____..,_...._ ..... ...
COMPANY E
LETTER
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.
co
Lj TYPE OF INSURANCE POLICY NUMBER j POLICY EFFECTIVE POLICY EXPIRATIONI LIMITS
LTRj DATE (MM/OD/YY) I DATE (MM/DD/YY)
i GENERAL LIABILITY
! GENERAL AGGREGATE '$1,000,00
A; $ COMMERCIAL GENERAL LIABILITY. 660-874EO698—COF94'
,.._..__._..
10/11/94 10/11/95 PRODUCTS COMP/OP AGO. E1,000>OOO
.....'—.
!CLAIMS MADE'$ `OCCUR.
................ ___.... _._._._ ...:__._.
PERSONAL B AOV. INJURY $ 500,000_
DOWNER'S & CONTRACTOR'S PROT)
- EACH OCCURRENCE E 500,000_
.._...
FIRE DAMAGE (Any one fire) $
_._.._ ._..
? :� MED. EXPENSE (Any one person)$ 5,000
AUTOMOBILE LIABILITY
;COMBINED SINGLE
$
ANY AUTO
LIMIT .
!ALL OWNED AUTOS
BODILY INJURY
g j g ISCHEDULED AUTOS AO—BAP259K562-8-94 i 09/21/94 09/21/95 �IPerperson) 500,000
_
$ i HIRED AUTOS
BODILY INJURY E
$ I NON -OWNED AUTOS
i(Pot eccldenl) 500,000
GARAGE LIABILITY
s
PROPERTY DAMAGE $ 100,000
{
EXCESS LIABILITY
j j EACH OCCURRENCE 'l S 2,000,000
B j $ ;UMBRELLA FORM 'PSMCUP-674F674-6-IND-1 10/12/94 i 10/12/95 AGGREGATE 1$2,000,000
OTHER THAN UMBRELLA FORM
94
$. STATUTORY LIMITS t
WORKER'S COMPENSATION
- EACH ACCIDENT 1 $ 100,000
C : AND C4 1482412
:03/31/95 03/31/96 DISEASE—POLICYLIMIT $ 500,000._
EMPLOYERS' LIABILITY
_.
DISEASE —EACH EMPLOYEE ;$ 100,000
_ OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
TOWN OF MANSFIELD IS AN ADDITIONAL INSURED ATIMA.
PAVING CONTRACTOR
,
TOWN OF MANSFIELD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
DEPARTMENT OF PUBLIC WORKS
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
BOB SWANSON
MAIL _ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
50 WEST STREET
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
MANSFIELD, MA 02048
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTFrjREPZSENjtTlLES.
AUTHORIZED REPRESENTATIVEor
00,14
NEW ENGLAND SECURITY n C.
A 9.
_ ' RATtiI4N'eoY