25CS0058_-_Sample_Insurance_Template.pdf
PDF 802 KB Posted
- Solicitation number
- 0000037258
- Issued by
- Imperial County, Los Angeles County, Orange County, Riverside County, San Bernardino County, San Diego County, Orange Cove City, Imperial City, East Los Angeles CDP, Lake Los Angeles CDP, Los Angeles City, Orange City, Lake Riverside CDP, Riverside City, Orangevale CDP, San Bernardino City, Imperial Beach City, Rancho San Diego CDP, San Diego City, San Diego Country Estates CDP, Orange Blossom CDP, California
About this file
This is a sample Certificate of Insurance template issued by the State of California, Department of Veterans Affairs for solicitation number 25CS0058, which pertains to Window and Window Screen Repair and Replacement Services at the Veterans Home of California, Chula Vista. The certificate template provides a standardized format for contractors to document their insurance coverage across multiple policy types, including General Liability, Automobile Liability, Garage Liability, Excess/Umbrella Liability, and Workers Compensation and Employers' Liability. The template specifies that the State of California, its officers, agents, employees, and servants must be named as additional insured parties, but only with respect to work performed for the State of California. The certificate is issued solely as a matter of information and confers no rights upon the certificate holder; it does not amend, extend, or alter the coverage afforded by the actual insurance policies.
The template requires contractors to complete details including policy numbers, effective dates, expiration dates, and coverage limits for each insurance type. Contractors must provide information on their insurance companies, producers, and special items or operations related to the work. The insurance carrier must provide thirty days' written notice of cancellation prior to policy expiration; however, failure to provide such notice imposes no obligation or liability upon the insurance company or its representatives. This certificate template establishes the baseline insurance requirements that bidders on solicitation 25CS0058, which is restricted to certified Disabled Veteran Business Enterprise (DVBE) firms only, must satisfy as part of their contractual obligations with the State of California.
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Text version
SAMPLE
State of California Solicitation Number: 25CS0058 Department of Veterans Affairs
CERTIFICATES OF INSURANCE
DATE (MM/DD/YY) / /
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
NO RIGHT UPON THE CERTIFICATE HOLDER. THIS COVERAGE DOES NOT AMEND,
EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANY
A
INSURED COMPANY
B
COMPANY
C
COMPANY
D
COVERAGES
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 CONDIDTION 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.
TYPE OF INSURANCE POLlCY NUMBER
POLICY
EFFECTIVE
DATE
(MM/DD/YY)
POLICY
EXPIRATION
DATE
(MM/DD/YY)
LIMITS
GENERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS - COMP/OP AGG $
CLAIMS
MADE
OCCUR PERSONAL & ADV INJURY $
OWNER AND CONTRACTOR’S PROT EACH OCCURRENCE $
FIRE DAMAGE (Any one fire) $
MED EXP (Any one person) $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO
ALL OWNED AUTOS BODILY INJURY (Per person) $
SCHEDULED AUTOS
HIRED AUTOS BODILY INJURY (Per accident) $
NON-OWNED AUTOS
PROPERTY DAMAGE $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
WORKERS COMPENSATION AND
EMPLOYERS’ LIABILITY STATUTORY LIMITS
THE PROPRIETOR/ EACH ACCIDENT $
PARTNERS/ EXECUTIVE
OFFICERS ARE:
INCL DISEASE - POLICY LIMIT $
EXCL DISEASE - EACH EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
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
ATTENTION:
BID NO.
STATE OF CALIFORNIA
P.O. Box 4038 Sacramento, CA 95812-4038
CANCELLATION
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 TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE
NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR
RESPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
I hereby certify under penalty of perjury that the foregoing is true and correct.
X
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