1-E. Certificate of Liability Insurance - SAMPLE.pdf
PDF 618 KB Posted
- Attached to
- Custodial Supplies & Small Equipment
- Solicitation number
- RFP 26-27-12
- Issued by
- Cameron County, Texas
About this file
This is a sample Certificate of Liability Insurance form (ACORD 25) applicable to the Los Fresnos CISD's Custodial Supplies & Small Equipment procurement in Texas. The certificate serves as proof of insurance coverage and is issued for informational purposes only, conferring no rights upon the certificate holder. The form is designed to document various types of insurance coverage including General Liability, Commercial General Liability, Automobile Liability, Umbrella Liability, and Workers Compensation and Employers' Liability. The certificate includes fields for policy details such as policy numbers, effective and expiration dates, and coverage limits across multiple insurance categories. Importantly, the document specifies that if the certificate holder is designated as an additional insured or if subrogation is waived, the underlying insurance policies must include appropriate endorsements to provide those protections.
The sample certificate is part of a broader vendor packet required by Los Fresnos CISD for participation in the custodial supplies procurement process. Prospective vendors must submit this insurance documentation along with other required forms including a New Vendor Request Form, ACH form, Form W-9, vendor certifications, Form 1295, and a Conflict of Interest Questionnaire. The certificate template provided demonstrates the minimum documentation standards vendors must meet to qualify as approved suppliers for the district's custodial products and equipment needs. This insurance requirement protects the district by ensuring vendors maintain adequate liability coverage throughout the contract period.
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Text version
SAMPLE
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
mm/dd/yyyy 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).
PRODUCER
CONTACT
NAME:
PHONE
(A/C, No, Ext): ###-###-####
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A : SAMPLE
INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND
ITS PARTICIPATING MEMBERS
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: USS311713 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 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
LTR TYPE OF INSURANCE
ADDL
INSR
SUBR
WVD POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY) LIMITS
A
GENERAL LIABILITY
SAMPLE
EACH OCCURRENCE $
X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (ANY ONE FIRE) $
CLAIMS-MADE X OCCUR MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $
X POLICY
PRO-
JECT LOC $
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
(Ea accident) $
ANY AUTO BODILY INJURY (Per person) $
ALL OWNED
AUTOS
SCHEDULED
AUTOS BODILY INJURY (Per accident) $
HIRED AUTO
NON-OWNED
AUTOS
PROPERTY DAMAGE
(Per accident) $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
N / A
WC STATU-
TORY LIMITS
OTH-
ER $
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L. EACH ACCIDENT $
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
DETAILS of EVENT INSURANCE IS ISSUED FOR
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
| New Vendor Request Form 11-15-23.pdf |
| _New Vendor Packet 11-1-23.pdf |
| New Vendor Request Form 11-1-23.pdf |
| ACH form 11-1-23.pdf |
| Form W-9.pdf |
| Vendor Certifications, CIQ, 1295, & COLI 11-1-23.pdf |
| _LFCISD Required Proposal Forms Template for Bids2.pdf |
| The following provisions are required and apply when federal funds are expended by Los Fresnos CISD, and/or its cooperative members, for any contract resulting from this procurement process. |
| _Form 1295.pdf |
| Form 1295 Changes.pdf |
| _Form CIQ Conflict of Interest Questionaire.pdf |
| coi-example.pdf |
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