COI_Requirements.pdf

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CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

PRODUCER

COMPANY / BUSINESS SELLING INSURANCE

ADDRESS HERE

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY

AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS

CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE

COVERAGE AFFORDED BY THE POLICIES BELOW.

INSURERS AFFORDING COVERAGE NAIC #

INSURED

VENDOR NAME MUST MATCH W-9 AND CONTRACT

Include DBA, if Applicable

INSURER A: Insurance Carrier [Minimum Best Rating = A - : VII] xx xxxx

INSURER B: Insurance Carrier [Minimum Best Rating = A - : VII] xx xxxx

INSURER C: Insurance Carrier [Minimum Best Rating = A - : VII] xx xxxx

INSURER D: Insurance Carrier [Minimum Best Rating = A - : VII] xx xxxx

INSURER E: Insurance Carrier

COVERAGES «The types of insurance and limits noted below are for example only. The vendor’s contract will dictate actual coverage required.»

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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

TYPE OF INSURANCE POLICY NUMBER

POLICY EFFECTIVE

DATE (MM/DD/YYYY)

POLICY EXPIRATION

DATE (MM/DD/YYYY) LIMITS

A

GENERAL LIABILITY

COMMERICAL GENERAL LIABILITY

CLAIMS MADE OCCUR

OWNERS & CONTRACTOR’S PROT

CONTRACTUAL LIABIITY COVERAGE

GEN’L AGGREGATE LIMIT APPLIES PER:

POLICY PROJECT LOC

xx xxxxxxxx xx / xx / xxxx xx / xx / xxxx

EACH OCCURRENCE $ 2,000,000

DAMAGE TO RENTED

PREMISES (Ea occurrence)

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $ 2,000,000

PRODUCTS - COMP/OP AGG

B

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED AUTOS

SCHEDULED AUTOS

HIRED AUTOS

NON-OWNED AUTOS

xx xxxxxxxx xx / xx / xxxx xx / xx / xxxx COMBINED SINGLE LIMIT (Each Occurrence) $ 1,000,000

BODILY INJURY

(Per person)

BODILY INJURY

(Per accident)

PROPERTY DAMAGE

(Per accident)

GARAGE LIABILITY

ANY AUTO

AUTO ONLY - EA ACCIDENT $

OTHER THAN

AUTO ONLY:

EA ACC $

AGG $

C

EXCESS / UMBRELLA LIABILITY

OCCUR CLAIMS MADE

DEDUCTIBLE

RETENTION $_________

xx xxxxxxxx xx / xx / xxxx xx / xx / xxxx

EACH OCCURRENCE $

AGGREGATE $

D

WORKERS COMPENSATION AND

EMPLOYERS’ LIABILITY

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH) If yes, describe under SPECIAL PROVISIONS below

Y/N

WC STATU-

TORY LIMITS

OTH-

ER $ 1,000,000

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

OTHER

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

110 N. City Pkwy., Las Vegas, NV 89106 – PH GSA, LLC & PH, LLC

CERTIFICATE HOLDER CANCELLATION

PH GSA, LLC & PH, LLC

c/o Molasky Corporate Center 100 N. City Pkwy., Ste. 140 Las Vegas, NV 89106

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE

EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO

MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT

FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE

INSURER, ITS AGENTS OR REPRESENTATIVES.

AUTHORIZED REPRESENTATIVE

Signature Here

ACORD 25 (2009/01) © 1988-2009 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

INSR

LTR

ADD’L

INSRD

IMPORTANT

If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

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).

DISCLAIMER

This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.

ACORD 25 (2009/01)