Sample Certificate of Liability Insurance.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 AMEND, EXTEND OR ALTER THE

COVERAGE AFFORDED BY THE POLICIES BELOW.

PRODUCER

[INSERT NAME AND ADDRESS OF THE AGENCY ISSUING THE POLICY]

INSURERS AFFORDING COVERAGE NAIC #

INSURER A: [NAME OF INSURANCE COMPANY] NAIC #

INSURER B:

INSURER C:

INSURER D:

INSURED

[INSERT CONTRACTOR’S NAME AND ADDRESS]

INSURER E:

COVERAGES

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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE

DATE (MM/DD/YY)

POLICY EXPIRATION

DATE (MM/DD/YY) LIMITS

EACH OCCURENCE $500,000

DAMAGE TO RENTED

PREMISES (Ea occurrence) $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $500,000

GENERAL AGGREGATE $500,000

PRODUCTS - COMP/OP AGG $500,000

GENERAL LIABILITY

COMMERICAL GENERAL LIABILITY

CLAIMS MADE OCCUR

GEN’L AGGREGATE LIMIT APPLIES PER:

POLICY PROJECT LOC

<<POLICY #>> <<EFFECTIVE

DATE>>

<<EXPIRATION

DATE>>

COMBINED SINGLE LIMIT

(Each Occurrence) $

BODILY INJURY

(Per person) $200,000

BODILY INJURY

(Per accident) $500,000

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED AUTOS

SCHEDULED AUTOS

HIRED AUTOS

NON-OWNED AUTOS

<<POLICY #>> <<EFFECTIVE

DATE>>

<<EXPIRATION

DATE>>

PROPERTY DAMAGE

(Per accident) $20,000

AUTO ONLY - EA ACCIDENT $

EA ACC $

GARAGE LIABILITY

ANY AUTO OTHER THAN

AUTO ONLY: AGG $

EACH OCCURRENCE $

AGGREGATE $

EXCESS/UMBRELLA LIABILITY

OCCUR CLAIMS MADE

DEDUCTIBLE

RETENTION $ $

WC STATU-

TORY LIMITS

OTH-

ER

E.L. EACH ACCIDENT $

E.L. DISEASE - EA EMPLOYEE $

WORKERS COMPENSATION AND

EMPLOYERS’ LIABILITY

ANY PROPRIETOR/PARTNER/EXECU-

TIVE OFFICER/MEMBER EXCLUDED?

If yes, describe under SPECIAL PROVISIONS below

E.L. DISEASE - POLICY LIMIT $

OTHER

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS

[INSERT CONTRACT NUMBER, PROJECT TITLE, LOCATION]

THE UNITED STATES OF AMERICA, ACTING BY AND THROUGH THE GENERAL SERVICES ADMINISTRATION, IS AN ADDITIONAL INSURED.

CERTIFICATE HOLDER CANCELLATION

ANY CANCELLATION OR ANY MATERIAL CHANGE ADVERSELY AFFECTING THE

GOVERNMENT’S INTEREST SHALL NOT BE EFFECTIVE (1) FOR SUCH PERIOD AS THE LAWS

OF THE STATE IN WHICH THIS CONTRACT IS TO BE PERFORMED PRESCRIBE OR (2) UNTIL

30 DAYS AFTER THE INSURER OR THE CONTRACT GIVES WRITTEN NOTICE TO THE

CONTRACTING OFFICER, WHICHEVER PERIOD IS LONGER..

General Services Administration Mid-Atlantic Region, Public Buildings Service 20 N. 8th Street Philadelphia, PA 19107 Attn: [NAME OF CONTRACTING OFFICER]

AUTHORIZED REPRESENTATIVE

ACORD 25 (2001/08) © ACORD CORPORATION 1988

INSR

LTR

ADD’L

INSRD

IMPORTANT

If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

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).

DISCLAIMER

The Certificate of Insurance on the reverse side of this form does not constitute a contact between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.