20._ACORD_Cert._Liab._Ins_(Sample).pdf
PDF 360 KB Posted
- Solicitation number
- 0000035871
- Issued by
- California
About this file
This document is an ACORD Certificate of Liability Insurance for the State of California, specifically involving the California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS). The certificate demonstrates insurance coverage for an unnamed insured entity providing services to the state, with the State of California named as an additional insured party for work performed on their behalf. The insurance includes general liability, automobile liability, workers' compensation, and potentially other coverage types, though specific policy limits are not fully populated in this sample document.
The certificate serves as a standard proof of insurance, indicating that the insured has appropriate liability coverage for work with the state agency. The document is set up to provide notification of insurance policies, with a cancellation clause requiring advance notice of any policy changes. The certificate holder is listed as the State of California, with the Direct Care Contracts Section located in Elk Grove, CA as the specific point of contact. While this is a sample document, it represents a typical insurance verification process for state contractors, ensuring that vendors maintain adequate insurance protection when performing work for government entities.
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Text version
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.
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 adriana.ring Highlight adriana.ring Highlight
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