11._Sample_ACORD_Insurance_Form.pdf
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- Solicitation number
- 0000036050
About this file
This document is a Certificate of Insurance form from the State of California Department of Veterans Affairs. The blank form is designed to provide details about insurance policies, including types of coverage such as general liability, automobile liability, excess liability, and workers' compensation. The form allows for documentation of policy numbers, effective and expiration dates, and specific insurance limits across various coverage categories.
The certificate includes a standard provision that the State of California, its officers, agents, employees, and servants are named as additional insured, but only with respect to work performed for the state. The form also contains a cancellation clause indicating that if any described policies are canceled before their expiration date, the issuing company will attempt to mail 30 days written notice to the certificate holder. The document serves as an informational certificate and does not confer any rights upon the certificate holder or amend the underlying insurance policies.
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Text version
State of California Solicitation Number:
Department of Veterans Affairs
CERTIFICATES OF INSURANCE
DATE (MM/DD/YY) / /
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
NO RIGHT UPON THE CERTIFICATE HOLDER. THIS COVERAGE DOES NOT AMEND,
EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANY
A
INSURED COMPANY
B
COMPANY
C
COMPANY
D
COVERAGES
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 CONDIDTION 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.
TYPE OF INSURANCE POLlCY NUMBER
POLICY
EFFECTIVE
DATE
(MM/DD/YY)
POLICY
EXPIRATION
DATE
(MM/DD/YY)
LIMITS
GENERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS - COMP/OP AGG $
CLAIMS
MADE
OCCUR PERSONAL & ADV INJURY $
OWNER AND CONTRACTOR’S PROT EACH OCCURRENCE $
FIRE DAMAGE (Any one fire) $ MED EXP (Any one person) $
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO
ALL OWNED AUTOS BODILY INJURY (Per person) $
SCHEDULED AUTOS
HIRED AUTOS BODILY INJURY (Per accident) $
NON-OWNED AUTOS
PROPERTY DAMAGE $
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY
EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
WORKERS COMPENSATION AND
EMPLOYERS’ LIABILITY
STATUTORY LIMITS
THE PROPRIETOR/ EACH ACCIDENT $
PARTNERS/ EXECUTIVE
OFFICERS ARE:
INCL DISEASE - POLICY LIMIT $
EXCL DISEASE - EACH EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
The State of California, its officers, agents, employees and servants are hereby named as additional insured but only with respect to work performed for the State of California.
CERTIFICATE HOLDER
ATTENTION:
BID NO.
STATE OF CALIFORNIA
P.O. Box 4038 Sacramento, CA 95812-4038
CANCELLATION
SHOULD ANY OF THE ABOVE-DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE
THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE
NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR
RESPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
I hereby certify under penalty of perjury that the foregoing is true and correct.
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