HomeMy WebLinkAboutBarrowsAPPLICATION FOR DRAINLAYER'S I}WE%1sq' � A =-_`'jfr-LL0
MANSFIELD, MA
DATE •
95 AUG -2 PM 7: 26
�yL`� `� • ✓ �%y!-� _
Name and/or Corporation:
& Address: S��f �� �! w3/C! - --
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 acknowledges receipt, understanding of the
Drainlayer's Regulations, and that he/she has read the entire
document. .. l
Signature:
DPW Approved: ��•
Date: //23��`�
r
ISSUE DATE (MMIDDIYY)f
07/10/95
-
rN
THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND
ND SECURITY INSURANCE
CONFERS NO RIGHTSUPONTHE CERTIFICATEHOLDERTHISCERTIFICATE
OSNOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
NC.
POLICIES BELOW.
200 CHAUNCY ST. SUITE 100
COMPANIES AFFORDING COVERAGE
MANSFIELD, MA 02048
(508)339-8991
COMPANY THE TRAVELERS INSURANCE COMPANY
LETTER
i
COMPANY ITT HARTFORD INSURANCE COMPANY
LETTER
INSURED
WILLIAM J. BARROWS, JR.
COMPANY
LETTER
519 GILBERT STREET
MANSFIELD, MA 02048
COMPANY
LETTER
COMPANY E
LETTER
l sM�� ,gip
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.
Doi TYPE OF INSURANCE POLICY NUMBER
LTR;
POLICY EFFECTIVE (POLICY EXPIRATION LIMITS
DATE (MM/DD/YY) DATE (MM/DD/VY)
GENERAL LIABILITY
GENERAL AGGREGATE $1 , 0 0 0, 0 0 0
X COMMERCIAL GENERAL LIABILITY
PRODUCTS-COMP/OP AGG. $1 , 000,600
I CLAIMS MADE; X OCCUR. 660-331GI833COF95
03/14/95 03/ 14/96 PERSONAL & ADV. INJURY $ 500,606
OWNER'S & CONTRACTOR'S PROT.
EACH OCCURRENCE $ 500,060
FIRE DAMAGE (Any one fire) $ 50,000
MED. EXPENSE (Anyone person) $ 5 000
AUTOMOBILE LIABILITY
COMBINED SINGLE
$
. ANY AUTO
LIMIT
ALL OWNED AUTOS AOBAP527K245295
01/25/95 01/25/96 BODILY INJURY $ 500,000
(Per person)
! X SCHEDULED AUTOS
X HIRED AUTOS
BODILY INJURY
$
X NON -OWNED AUTOS
(Per accident) 500,000
GARAGE LIABILITY
PROPERTY DAMAGE $ IOO OOO
i .� EXCESS LIABILITY
EACH OCCURRENCE $
UMBRELLA FORM
AGGREGATE $
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION
STATUTORY LIMITS
-
AND 77WZNBO729
11/11/94 1.1/11/95 EACH ACCIDENT $ 100,000
DISEASE —POLICY LIMIT $ 500, 000
EMPLOYERS' LIABILITY
DISEASE —EACH EMPLOYEE $ 100OOO
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
CONTRACTOR
TOWN OF MANSFIELD IS AN ADDITIONAL ATIMA
'.CER 'IFICATE.NOLbER
TOWN OF MANSFIELD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
WEST STREET
'- EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MANSFIELD, MA 02048-
MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
r LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPJJ,ITS ENT R EPRESENTATIVES.
AUTHORIZED PEPflES TIWE
0CACORD=RP,ORATI401980,