1-E. Certificate of Liability Insurance - SAMPLE.pdf
PDF 618 KB Posted
- Attached to
- Theater & Fine Arts Products or Related Services
- Solicitation number
- RFP 26-27-05
- Issued by
- Cameron County, Texas
About this file
This is a sample Certificate of Liability Insurance document associated with a Theater & Fine Arts Products or Related Services procurement for Los Fresnos Consolidated Independent School District (C.I.S.D.) in Texas. The certificate serves as proof of insurance coverage for vendors participating in this procurement process and is issued for informational purposes only, conferring no rights upon the certificate holder. The document outlines the standard liability insurance requirements that qualified vendors must maintain to provide comprehensive theater and fine arts equipment, supplies, materials, and related services to support the district's performing arts programs, theatrical productions, music performances, and visual arts instruction across all district facilities. The certificate includes fields for general liability, commercial general liability, automobile liability, umbrella liability, and workers' compensation coverage, with specific limits and policy details to be completed by the insured vendor.
The sample certificate indicates that vendors must obtain appropriate insurance endorsements if the district is to be named as an additional insured or if subrogation is waived, as applicable under the policy terms and conditions. The document references the ACORD 25 (2010/05) standard form and cross-references additional required vendor documentation including New Vendor Request Forms, ACH forms, W-9 forms, vendor certifications, conflict of interest questionnaires, and Form 1295. The insurance requirements apply when federal funds are expended by Los Fresnos C.I.S.D. or its cooperative members for any contract resulting from this procurement process, establishing a baseline risk management standard for all vendors seeking to provide theater and fine arts products or related services to the district.
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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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