26YS0027_-_Sample_Insurance_Template.pdf
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- Solicitation number
- 0000038973
- Issued by
- Colusa County, Contra Costa County, Lake County, Marin County, Napa County, Solano County, Sonoma County, Yolo County, Colusa City, Contra Costa Centre CDP, Auburn Lake Trails CDP, South Lake Tahoe City, Shaver Lake CDP, Blue Lake City, China Lake Acres CDP, Lake Isabella CDP, Lake of the Woods CDP, Lakeside CDP, Hidden Valley Lake CDP, Lakeport City, Lower Lake CDP, North Lakeport CDP, Upper Lake CDP, Elizabeth Lake CDP, Lake Hughes CDP, Lake Los Angeles CDP, Lakewood City, Marina Del Rey CDP, San Marino City, Bass Lake CDP, Yosemite Lakes CDP, Lucas Valley-Marinwood CDP, Marin City CDP, Lake Don Pedro CDP, Lake City CDP, Crowley Lake CDP, June Lake CDP, Mammoth Lakes Town, Twin Lakes CDP, Virginia Lakes CDP, Marina City, Napa City, Lake of the Pines CDP, Lake Wildwood CDP, Lake Forest City, Bucks Lake CDP, Lake Almanor Country Club CDP, Lake Almanor Peninsula CDP, Lake Almanor West CDP, Lake Davis CDP, Canyon Lake City, Lake Elsinore City, Lakeland Village CDP, Lake Mathews CDP, Lake Riverside CDP, Lakeview CDP, Big Bear Lake City, Lake Arrowhead CDP, Silver Lakes CDP, Spring Valley Lake CDP, Lake San Marcos CDP, Lake Nacimiento CDP, Emerald Lake Hills CDP, Lakehead CDP, Shasta Lake City, Lake Shastina CDP, Sonoma City, Sonoma State University CDP, Lake California CDP, Phoenix Lake CDP, Pine Mountain Lake CDP, Lake Sherwood CDP, Yolo CDP, Plumas Lake CDP, California
About this file
This is a Certificate of Insurance template issued by the State of California, Department of Veterans Affairs for Solicitation Number 26YS0027, Kitchen Hood Fire Suppression Services at the Veterans Home of California at Yountville. The template serves as a standardized form for bidders to provide proof of insurance coverage as part of their bid requirements. The certificate documents various types of insurance policies that must be maintained by the contractor, including general liability, commercial general liability, automobile liability, garage liability, excess/umbrella liability, and workers' compensation and employers' liability insurance. The form requires bidders to identify specific policy numbers, effective dates, expiration dates, and coverage limits across multiple insurance categories, with all policies subject to standard terms, exclusions, and conditions. The State of California, its officers, agents, employees, and servants are designated as additional insureds with respect to work performed for the state.
The certificate template specifies that the State of California, located at P.O. Box 4038 Sacramento, CA 95812-4038, serves as the certificate holder for the bid. The form includes a cancellation provision requiring issuing insurance companies to provide 30 days' written notice before policy cancellation, though failure to provide such notice imposes no obligation or liability on the insurance company. The authorized representative must certify the information provided under penalty of perjury, indicating that compliance with these insurance requirements is mandatory for all prospective bidders on this Kitchen Hood Fire Suppression Services contract.
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Text version
State of California Solicitation Number: 26YS0027 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
SAMPLE
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