5-E. Certificate of Liability Insurance - SAMPLE.pdf
PDF 618 KB Posted
- Attached to
- Charter Bus and Transportation Services
- Solicitation number
- RFP 26-27-10
- Issued by
- Cameron County, Texas
About this file
This is a Certificate of Liability Insurance sample form issued by ACORD, applicable to the Los Fresnos Consolidated Independent School District (CISD) charter bus and transportation services procurement in Texas. The certificate serves as documentation of insurance coverage for vendors providing transportation services, including field trips, employee shuttles, event transportation, and other designated travel requirements. The sample document outlines the standard insurance coverage types required, including General Liability, Automobile Liability, Umbrella Liability, and Workers' Compensation and Employers' Liability insurance. The certificate is issued for informational purposes only and does not confer rights upon the certificate holder unless specific endorsements are added to the underlying policies, such as additional insured status or waiver of subrogation provisions.
The certificate template specifies that vendors must maintain appropriate insurance limits across multiple coverage categories, with fields for policy numbers, effective and expiration dates, and coverage limits for each insurance type. The document indicates that cancellation notice will be provided in accordance with policy provisions should any described policies be cancelled before expiration. This insurance requirement is part of the broader vendor onboarding process for Los Fresnos CISD, which includes completion of additional forms such as the New Vendor Request Form, W-9, ACH form, conflict of interest questionnaire, and Form 1295, ensuring compliance with both state and federal requirements when federal funds are utilized for the contract.
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Text version
SAMPLE
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
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 AFFIRMATIVELY OR NEGATIVELY AMEND, 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 OR 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
(A/C, No, Ext): ###-###-####
ADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A : SAMPLE
INSURED SPORTS AND RECREATION PROVIDERS ASSOCIATION (PURCHASING GROUP) AND
ITS PARTICIPATING MEMBERS
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: USS311713 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
ADDL
INSR
SUBR
WVD POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY) LIMITS
A
GENERAL LIABILITY
SAMPLE
EACH OCCURRENCE $
X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (ANY ONE FIRE) $
CLAIMS-MADE X OCCUR MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $
X POLICY
PRO-
JECT LOC $
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
(Ea accident) $
ANY AUTO BODILY INJURY (Per person) $
ALL OWNED
AUTOS
SCHEDULED
AUTOS BODILY INJURY (Per accident) $
HIRED AUTO
NON-OWNED
AUTOS
PROPERTY DAMAGE
(Per accident) $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
N / A
WC STATU-
TORY LIMITS
OTH-
ER $
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L. EACH ACCIDENT $
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
DETAILS of EVENT INSURANCE IS ISSUED FOR
CERTIFICATE HOLDER CANCELLATION
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
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
| New Vendor Request Form 11-15-23.pdf |
| _New Vendor Packet 11-1-23.pdf |
| New Vendor Request Form 11-1-23.pdf |
| ACH form 11-1-23.pdf |
| Form W-9.pdf |
| Vendor Certifications, CIQ, 1295, & COLI 11-1-23.pdf |
| _LFCISD Required Proposal Forms Template for Bids2.pdf |
| The following provisions are required and apply when federal funds are expended by Los Fresnos CISD, and/or its cooperative members, for any contract resulting from this procurement process. |
| _Form 1295.pdf |
| Form 1295 Changes.pdf |
| _Form CIQ Conflict of Interest Questionaire.pdf |
| coi-example.pdf |
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