20._ACORD-Certificate_of_Liability_Sample.pdf
PDF 113 KB Posted
- Attached to
- SD23-00088 Ocular Prosthetic Services (Region 4)
- Solicitation number
- 0000032627
- Issued by
- San Bernardino County, California
About this file
This document is an ACORD Certificate of Liability Insurance. It certifies that the insured company has general liability, automobile liability, and workers compensation insurance policies in place to cover operations performed for the State of California, specifically the California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS). The policy provides coverage limits for bodily injury, property damage, and personal/advertising injury. The certificate holder, CDCR/CCHCS, is named as an additional insured with respect to work performed for the state. The policies are subject to standard terms, exclusions, and conditions, and limits may have been reduced by paid claims. The insurance company agrees to endeavor to provide 30 days' written notice to the certificate holder if any of the policies are cancelled prior to the expiration date.
The certificate does not contain any information about a specific state or local contract opportunity. It solely provides evidence of the insured company's required insurance coverage to conduct work for the State of California.
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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
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
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