10-12 sample - CERTIFICATE OF INSURANCE.pdf

ACORD

CERTIFICATE OF LIABILITY INSURANCE I

DATE (MM/DD/YYYY)

� 7/31/2020 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 "u",�"' (Your Agents Contact Info) NAME:

(Agency Name and Address) f.��N.;o "•"· I

FAX

fA/C Nol:

E-MAIL

ADDRESS:

INSURERfSI AFFORDING COVERAGE INSURERA: {A- or hiaher rated Insurance Carrier}

INSURED (Your Business Name and Address, including OBA INSURER B :

This MUST match the name on your application) INSURER C:

INSURER D:

INSURER E:

INSURER F:

COVERAGES CERTIFICATE NUMBER:Vender Sample 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

A

A

A

TYPE OF INSURANCE

X COMMERCIAL GENERAL LIABILITY -:J CLAIMS-MADE GJ OCCUR ---

GEN'L AGGREGATE LIMIT APPLIES PER: Fl □ PR� POLICY JECT

OTHER:

AUTOMOBILE LIABILITY

ANY AUTO

- ALL OWNED -

X

AUTOS ,__

X HIRED AUTOS X

UMBRELLA LIAB

OLoc

SCHEDULED

AUTOS

NON-OWNED

AUTOS

EXCESS LIAB

HOCCUR

CLAIMS-MADE

OED I I RETENTION $

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y/N

ANY PROPRIETOR/PARTNER/EXECUTIVE □ OFFICER/MEMBER EXCLUDED?

(Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

�DDL SUBR

,:�ito� ,:��l 1,u�n ,_,n POLICY NUMBER

(Policy #, not "Binder") 2020 2021 x (If business owna autos) 2020 2021

(If you have NO employees, supply copy of your Waiver) 2020 2021

NIA

LIMITS

EACH OCCURRENCE

DAMAGE TO RENTED

PREMISES IEa occurrence\ MED EXP (Any one person)

PERSONAL & ADV INJURY

GENERAL AGGREGATE

PRODUCTS - COMP/OP AGG

������d��trlNGLE LIMIT

BODILY INJURY (Per person) BODILY INJURY (Per accident) r ROPERTY DAMAGE Per accidentl

EACH OCCURRENCE

AGGREGATE

XI �ffrnTE I I OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) [ Project Name ] City of St George is listed as an Additional Insured; Primary & Non-Contributory endorsement applies, including Ongoing and Completed Operations; Waiver of Subrogation applies; 30 day notice of Cancellation required, except 10 days for non-payment of premium.

CERTIFICATE HOLDER CANCELLATION

NAIC #

{reauiredl

1,000,000

300,000

5,000

1,000,000

3,000,000

3,000,000

1,000,000

100,000

100 000

500 000

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

City of St George

Attn:

175 E. 200 N.

St George, I

ACORD 25 (2014/01)

INS025 1201401)

UT 84770

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

(Agents Signature)

© 1988-2014 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD x x x x x x 1,000,000

1,000,000

2020 2021 (Policy #)

* If use umbrella or excess liability, then must include language that shows these are also primary & non-contributory and waiver of subrogation applies for additional insured.