19._ACORD-Certificate_of_Liability_Sample.pdf

ACORD C E R T I F I C A T E O F LIABILITY I N S U R A N C E DATE (MM/DD/YY)

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, OR 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 OF 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 E-Mail

INSURER(S) AFFORDING COVERAGE

COMPANY A

INSURED

COMPANY B

COMPANY C

COMPANY D

COVERAGES CERTIFICATE NUMBER 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 POLICY NUMBER

POLICY EFFECTIVE

DATE (MM/DD/YY)

POLICY EXPIRATION

DATE (MM/DD/YY) LIMITS

A

GENERAL LIABILITY EACH OCCURRENCE $

X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Any one fire) $

CLAIMS MADE X OCCUR MED EXP (Any one person) $

PERSONAL & ADV. INJURY $

GENERAL AGGREGRATE $

GEN’L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COM/OP AGG $

POLICY PROJECT LOC

B

AUTOMOBILE LIABILITY

COMBINED SINGLE LIMIT

(Each Accident)

$ X ANY AUTO

ALL OWNED AUTOS

BODILY INJURY

(Per Person)

SCHEDULED AUTOS

HIRED AUTOS

BODILY INJUSRY

(Per Accident)

□ Non-Owned Auto

PROPERTY DAMAGE

(Per Accident)

OTHER THAN

AUTO ONLY:

EACH ACC $

AGG $

EXCESS/MBRELLA LIABILITY EACH OCCURRENCE $

OCCUR CLAIMS MADE AGGREGATE $

DEDUCTIBLE

WORKERS COMPENSATION AND

EMPLOYERS’ LIABILITY X STATUTORY

LIMITS

C Any Proprietor,/Partner Executive

Officer/member excluded? Y / N

EACH ACCIDENT $

If yes, describe under DISEASE-POLICY LIMIT $

Description of Operations Below DISEASE-EACH

EMPLOYEE

OTHER $ Occurrence D Medical Professional $ Aggregate

DESCRIPTION OF OPERATIONS/LOCATIONS/VECHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS

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.

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 below, but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives.

CERTIFICATE HOLDER CANCELLATION

State of California California Department of Corrections and Rehabilitation (CDCR) California Correctional Health Care Services (CCHCS) Direct Care Contracts Section, Building D P.O. Box 588500 Elk Grove, CA 95758

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

Signature or Signature Stamp