2-3 - Acord Form Example - Rev 3.3.21.pdf

CERTIFICATE OF LIABILITY INSURANCE

DATE (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

Insurance Company Name

Address

CONTACT NAME: Insurance Company Contact Name

PHONE (A/C No. Ext): Insurance Company Phone # FAX (A/C No): Fax #

EMAIL ADDRESS: Insurance Company Contact Email

INSURER(S) AFFORDING COVERAGE NAIC #

INSURER A : Any Additional Insurance Companies

INSURED

Legal Name of Vendor (Contractor) Legal Address

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

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

INSD

SUBR

WVD POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

COMMERCIAL GENERAL LIABILITY

Enter Policy Number Here Date Date

EACH OCCURRENCE $ 2,000,000

CLAIMS-MADE OCCUR

DAMAGE TO RENTED

PREMISES (Ea occurrence) $ 2,000,000

Contractual Liability MED EXP (Any one person)

PERSONAL & ADV INJURY $ 2,000,000

GEN’L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000

POLICY PROJECT LOC PRODUCTS - COMP/OP AGG

OTHER

AUTOMOBILE LIABILITY

Enter Policy Number Here Date Date

COMBINED SINGLE LIMIT

(Ea accident) $ 1,000,000

ANY AUTO BODILY INJURY (Per person) $ 1,000,000

ALL OWNED

AUTOS

SCHEDULED AUTOS BODILY INJURY (Per accident) $ 1,000,000

HIRED AUTOS NON-OWNED AUTOS

PROPERTY DAMAGE

(Per accident)

$ 1,000,000

UMBRELLA LIAB

EXCESS LIAB

OCCUR

CLAIMS-MADE

EACH OCCURRENCE $

AGGREGATE $

DED RETENTION $ $

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

N / A Enter Policy Number Here Date Date

PER

STATUTE OTHER STATUTORY

E.L. EACH ACCIDENT $

Y / N (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $

If Applicable to Contracted Service:

Cyber Liability - $1,000,000 Medical Liability - $2,000,000 Professional Liability $1,000,000

Columbia County, Georgia is named as an Additional Insured ATIMA in reference to “INSERT PROJECT NAME HERE” under the General, Contractual, and Automobile Liability coverage and will receive (30) thirty days prior written notice of cancellation on this policy.”

Columbia County, Georgia Attn: Procurement Department P. O. Box 498 Evans, Georgia 30809

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.