1-Blank Template - Acord 25 Cert of Liability Insurance (1).pdf

CERTIFICATE HOLDER

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH) If yes, describe under SPECIAL PROVISIONS below

© 1988- 2009 ACORD CORPORATION. All rights reserved.

ACORD 25 (2009/09)

AUTHORIZED REPRESENTATIVE

CANCELLATION

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

LOCJECT

PRO-POLICY

GEN'L AGGREGATE LIMIT APPLIES PER:

OCCURCLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

GENERAL LIABILITY

PREMISES (Ea occurrence) $

DAMAGE TO RENTED

EACH OCCURRENCE $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

$RETENTION

DEDUCTIBLE

CLAIMS-MADE

OCCUR

AGGREGATE $

EACH OCCURRENCE $UMBRELLA LIAB

EXCESS LIAB

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

INSR

LTR TYPE OF INSURANCE POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

WC STATU-

TORY LIMITS

OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y / N

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED AUTOS

SCHEDULED AUTOS

HIRED AUTOS

NON-OWNED AUTOS

COMBINED SINGLE LIMIT

(Ea accident)

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE

(Per accident) $

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.

INSR

ADDL

WVD

SUBR

N / A

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 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).

The ACORD name and logo are registered marks of ACORD

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

INSURED

PHONE

(A/C, No, Ext):

PRODUCER

PRODUCER

CUSTOMER ID #:

ADDRESS:

E-MAIL

FAX

(A/C, No):

CONTACT

NAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE

EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE

POLICY PROVISIONS.

D:20090923104633- 05'00' D:20090927213529- 04'00'

CERTIFICATE HOLDER

ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED?

(Mandatory in NH) If yes, describe under SPECIAL PROVISIONS below © 1988- 2009 ACORD CORPORATION. All rights reserved.

ACORD 25 (2009/09)

AUTHORIZED REPRESENTATIVE

CANCELLATION

DATE (MM/DD/YYYY)

CERTIFICATE OF LIABILITY INSURANCE

The title of the form. ACORD 25, Certificate of Liability Insurance, 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 policies".

The above information is included in the opening statement of the form.

If the receiver of the form wants to verify that liability coverage exists on a policy and has no direct interest in the policy, use the certificate of insurance. However, if the receiver of the form does have a verifiable interest in the policy, such as an additional insured, the liability policy must be amended by endorsement, to provide the appropriate coverage for the interested party prior to issuing a certificate of insurance (since the certificate confers no rights upon the holder and does not amend the policy).

ACORD 25 was designed to collect policy limit information based on the ISO commercial lines program. It addresses both Claims Made and Occurrence policies.

Purpose of the Certificate of Insurance

The purpose of the Certificate of Insurance has been the topic of frequent discussions throughout the industry. Attention centers around the true purpose of a certificate and the rights, if any, it conveys to a certificate holder.

In a 1974 court decision (United States Pipe & Foundry Co. v United States Fidelity & Guar. Co, 505 F. 2d 88 (5th Cir. 1974), the court ruled that a certificate is not a contract between the holder and the insurer. It only provides information to an interested third party that insurance is in force at the time of issuance. The court also stated: "The provision regarding notification in the event of cancellation is a mere promise, unsupported by any consideration." Although many companies provide notice of cancellation to certificate holders, they are not obliged to do so, since the holder is not a party to the contract.

The Certificate of Liability Insurance is used for most casualty situations in which the insured has requested certification to a third party of issued casualty coverages.

The uses of the Certificate can include large and small contracting or manufacturing risks, lessor/lessee agreements, or other areas of liability certification.

The ACORD Certificate should be issued only in compliance with company instructions.

ACORD recommends that the Certificate NOT be used in the following situations:

* To waive rights

* To provide information to the owner of a leased motor vehicle or the lender about both liability and physical damage coverages applying to the vehicle (ACORD 23, Automobile Certificate of Insurance, should be used for this)

* To quote wording from a contract

* To attach to an endorsement

* To quote any wording which amends a policy unless the policy itself has been amended

IMPORTANT

Kansas, Kentucky, Minnesota, Missouri, North Carolina, Oklahoma and Wisconsin require the filing of certificate of insurance forms. ACORD has filed all of its certificates in these states. In these states, the text of ACORD's certificates cannot be modified, unless the modified form is filed for approval by the respective state Department of Insurance.

Additionally, virtually every other state will not allow any change in a certificate of insurance that would attempt to modify a policy unless the revised certificate is filed and approved. In these states, this form can only be changed to reflect the terms and conditions of the policy on which it is reporting. Such change(s) must be approved in advance by the insurance carrier that issued such policy.

LOC

JECT

PRO-

POLICY

GEN'L AGGREGATE LIMIT APPLIES PER:

OCCUR

CLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

GENERAL LIABILITY

PREMISES (Ea occurrence)

DAMAGE TO RENTED

EACH OCCURRENCE

MED EXP (Any one person)

PERSONAL & ADV INJURY

GENERAL AGGREGATE

PRODUCTS - COMP/OP AGG

RETENTION

DEDUCTIBLE

CLAIMS-MADE

OCCUR

AGGREGATE

EACH OCCURRENCE

UMBRELLA LIAB

EXCESS LIAB

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

INSR

LTR

TYPE OF INSURANCE

POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

LIMITS

WC STATU-

TORY LIMITS

OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

Y / N

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED AUTOS

SCHEDULED AUTOS

HIRED AUTOS

NON-OWNED AUTOS

COMBINED SINGLE LIMIT

(Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident)

PROPERTY DAMAGE

(Per accident) 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.

INSR

ADDL

WVD

SUBR

N / A 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 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).

The ACORD name and logo are registered marks of ACORD

COVERAGES

CERTIFICATE NUMBER:

REVISION NUMBER:

INSURED

PHONE

(A/C, No, Ext):

PRODUCER

PRODUCER

CUSTOMER ID #:

ADDRESS:

E-MAIL

FAX

(A/C, No):

CONTACT

NAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.

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primary contact.

Enter number: The producer's contact person's phone number. If applicable, include the area code and extension.

agency or brokerage).

policy. This is not the insurer's group name or trade name. As used here, this is Insurer A.

policy. This is not the insurer's group name or trade name. As used here, this is Insurer B.

policy. This is not the insurer's group name or trade name. As used here, this is Insurer C.

policy. This is not the insurer's group name or trade name. As used here, this is Insurer D.

policy. This is not the insurer's group name or trade name. As used here, this is Insurer E.

policy. This is not the insurer's group name or trade name. :

Coverage" form section, associated with the commercial general liability policy.

holder has been named as an additional insured on the policy. As used here, place a check mark next to each coverage where an additional insured endorsement has been issued.

Enter Y for a “Yes” response. Input N for “No” response. Indicates subrogation has been waived on the policy.

Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced. If required for self-insurance, the self-insured license or contract number. As used here, the general liability policy number exactly as it appears on the policy, including prefix and suffix symbols.

about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.

Enter limit: The general liability policy, damage to rented premises each occurrence limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.

Enter limit: The commercial general liability policy, medical expense each person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.

Enter limit: The general liability policy, personal and advertising injury limit amount.

Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.

Enter limit: The commercial general liability policy, general aggregate limit amount.

Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.

Enter limit: The general liability policy, products and completed operations aggregate limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.

Enter text: The description of other coverage (not the limit). Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).

Enter limit: The general liability, other coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).

Enter code: The Company Letter of the insurer, as identified in the "Insurers Affording Coverage" form section, associated with the commercial vehicle policy.

Check the box (if applicable): Indicates the commercial vehicle policy covers any auto. As used here, complete this section only if you are certifying automobile liability. Check all appropriate boxes to correspond with the covered auto symbols found on the policy declarations page. If the certificate is being issued to the owner of a leased vehicle, DO NOT USE THIS FORM. Use ACORD 23, Automobile Certificate of Insurance.

: 0

holder has been named as an additional insured on the policy. As used here, place a check mark next to each coverage where an additional insured endorsement has been issued.

Enter Y for a “Yes” response. Input N for “No” response. Indicates subrogation has been waived on the policy.

Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced. If required for self-insurance, the self-insured license or contract number. As used here, the automobile liability policy number.

Enter date: The effective date of the policy. As used here, the automobile policy effective date.

Enter date: The date on which the terms and conditions of the policy will expire. As used here, the automobile policy expiration date.

Enter limit: The vehicle combined single limit liability amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.

Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.

Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).

Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.

Coverage" form section, associated with the commercial garage liability policy.

on an excess or umbrella liability policy.: 0

holder has been named as an additional insured on the policy. As used here, place a check mark next to each coverage where an additional insured endorsement has been issued.

Enter Y for a “Yes” response. Input N for “No” response. Indicates subrogation has been waived on the policy.

Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced. If required for self-insurance, the self-insured license or contract number. As used here, the automobile liability policy number.

Enter date: The effective date of the policy. As used here, the automobile policy effective date.

Enter date: The date on which the terms and conditions of the policy will expire. As used here, the automobile policy expiration date.

Enter limit: The excess umbrella liability limit each occurrence limit. As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.

Enter limit: The excess/umbrella liability aggregate limit should be listed as whole dollar amount, as found on the policy declarations page. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as whole dollar amount, as found on the policy declarations page.

Enter text: The description of other coverage (not the limit) on the excess umbrella liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).

Enter limit: The excess umbrella liability limit other coverage limit. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as whole dollar amount, as found on the policy declarations page.

Enter text: The description of other coverage (not the limit) on the excess umbrella liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).

Enter limit: The excess umbrella liability limit other coverage limit. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as whole dollar amount, as found on the policy declarations page.

Enter code: The Company Letter of the insurer, as identified in the "Insurers Affording Coverage" form section, associated with the commercial garage liability policy.

been waived on the policy.

Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced. If required for self-insurance, the self-insured license or contract number. As used here, the automobile liability policy number.

Enter date: The effective date of the policy. As used here, the automobile policy effective date.

Enter date: The date on which the terms and conditions of the policy will expire. As used here, the automobile policy expiration date.

Check the box (if applicable): Indicates that workers compensation statutory limits apply.

: 0 Check the box (if applicable): Indicates that additional coverage above the workers compensation statutory limits applies (permitted in some states). Describe the additional coverage in Special Provisions section.

: 0 Enter text: The description of other coverage (not the limit) on the workers compensation and employers liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).

Enter limit: The workers compensation and employers liability policy, employers liability each accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).

Enter limit: The workers compensation and employers liability policy, employers liability disease each employee limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.

Enter limit: The workers compensation and employers liability policy, employers liability disease policy limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).

Enter code: The Company Letter of the insurer, as identified in the "Insurers Affording Coverage" form section, associated with the commercial garage liability policy.

holder has been named as an additional insured on the policy. As used here, place a check mark next to each coverage where an additional insured endorsement has been issued.

Enter Y for a “Yes” response. Input N for “No” response. Indicates subrogation has been waived on the policy.

Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced. If required for self-insurance, the self-insured license or contract number. As used here, the automobile liability policy number.

Enter date: The effective date of the policy. As used here, the automobile policy effective date.

Enter date: The date on which the terms and conditions of the policy will expire. As used here, the automobile policy expiration date.

Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).

As used here, the limit should be listed as a whole dollar amount, as found on the policy declarations page.

Enter text: The Certificate Of Liability Insurance general remarks. As used here, records information necessary to identify the operations, locations and vehicles for which the certificate was issued.

agent, broker, etc.). by all companies to issue Certificates. As used here, the authorized representative by all companies to issue Certificates.

ClearAll: