1-B-2616LM Insurance Certificate Requirements with Sample.pdf

Insurance Certificate Requirements

Service Provider must provide an insurance certificate meeting the below requirements prior to providing services at any GCPS location.

INSURANCE. CONTRACTOR, from the time of commencement of Work hereunder until completion of Work and removal of all personnel from the premises, shall provide and maintain, in effect, the following types and amounts of insurance with insurance companies satisfactory to the DISTRICT and CONTRACTOR:

A. The following minimum insurance must be maintained by CONTRACTOR over the duration of this Agreement:

1. Commercial General Liability Insurance Commercial General Liability Insurance with at least One Million Dollars ($1,000,000) each occurrence; at least One Million Dollars ($1,000,000) damage to premises and operations limit; at least One Million Dollars ($1,000,000) personal and advertising injury limit; and general aggregate limit (other than products/completed operations) of at least Two Million Dollars ($2,000,000). Insurance shall not contain any restrictive endorsements other than those restrictive endorsements normally included in the State of Georgia.

2. Automobile Liability Insurance Contractual Automobile Liability for any auto furnished or used in the course of performance of CUSTODIAL LABOR AND OPERATIONS SERVICES of awarded contract of at least Five-Hundred Thousand Dollars ($500,000) combined single limit per accident.

3. Worker's Compensation and Employer’s Liability Worker's Compensation and Employer Liability Insurance which shall comply with the statutory requirements of the State of Georgia with limits of not less than One Million Dollars ($1,000,000) per occurrence and shall apply to all persons employed by CONTRACTOR.

B. Certificates: CONTRACTOR shall furnish Certificates of Insurance evidencing the insurance required hereunder and upon request shall furnish true copies of the actual policies. Each Certificate shall provide that thirty (30) days prior written notice shall be given the DISTRICT in the event of cancellation or material change in the policies. In order to avoid delays in commencing Work, Certificates and/or copies of policies shall be addressed as follows, or to any person or department requesting same – Send one (1) copy to:

Gwinnett County Public Schools Attn: Department of Purchasing and Property Management 437 Old Peachtree Road Suwanee, Georgia 30024-2978

C. Named Insured: Gwinnett County Public Schools shall be named as additional insured on CONTRACTOR's policies for liability insurance required hereunder and such liability policies shall be endorsed to make such insurance primary to any liability insurance carried by the DISTRICT.

D. Certificate Holder: Must state:

Gwinnett County Public Schools 437 Old Peachtree Road Suwanee, Georgia 30024-2978

E. Insurance Premiums Responsibility: All policies shall be endorsed to provide that there will be no recourse against the DISTRICT for payment of premium.

F. Insurance in Force: CONTRACTOR shall not commence services at PROJECT until all of the insurance, that CONTRACTOR is required to provide, are in full force and the necessary certificates and statements have been received by the DISTRICT.

SAMPLE

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD WVD

CONTACT

NAME:

FAXPHONE

(A/C, No):(A/C, No, Ext):

E-MAIL

ADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

AUTHORIZED REPRESENTATIVE

EACH OCCURRENCE $

DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence)

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $

PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT

OTHER: $

COMBINED SINGLE LIMIT

$(Ea accident) ANY AUTO BODILY INJURY (Per person) $

OWNED SCHEDULED

BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

HIRED NON-OWNED PROPERTY DAMAGE

$AUTOS ONLY AUTOS ONLY (Per accident)

OCCUR EACH OCCURRENCE

CLAIMS-MADE AGGREGATE $

DED RETENTION $

PER OTH-

STATUTE ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below

INSURER(S) AFFORDING COVERAGE NAIC #

COMMERCIAL GENERAL LIABILITY

Y / N

(Mandatory in NH)

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

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.

THIS CERTIFICATE IS 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 policy(ies) must have ADDITIONAL INSURED provisions or 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 endorsement(s).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

© 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03)

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)

The ACORD name and logo are registered marks of ACORD

Vendor Name & Address

A 1,000,000

1234567 11/11/2025 11/11/2026 1,000,000

1,000,000 2,000,000

500,000B 1234567 11/11/2025 11/11/2026

PIP

B

C 1234567 11/11/2025 11/11/2026 1,000,000

D

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

Gwinnett County Public Schools is included as additional insured per general liability.

Gwinnett County Public Schools 437 Old Peachtree Rd Suwanee, GA 30024-2978

PRODUCER

X

X X

XX

X

Y

INSURER(S) MUST HAVE AN A RATING OR HIGHER &

MUST BE REGISTERED IN THE STATE OF GEORGIA

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