6-1 Sample Risk 2.pdf
PDF 25 KB Posted
- Attached to
- ARC Clean Up Services for Special Events
- Solicitation number
- 505-26
- Issued by
- Dallas County, Texas
About this file
This is a Certificate of Liability Insurance (ACORD 25 form) for the City of Richardson, Texas, related to a contract opportunity for clean up services for special events. The certificate documents insurance coverage requirements for a mid-level risk contractor providing services to the City. The contractor must maintain General Liability coverage with limits of $1,000,000 per occurrence and $2,000,000 general aggregate, Automobile Liability coverage with combined single limits of $1,000,000 per accident, and Workers Compensation coverage with statutory limits and Employers Liability limits of $1,000,000 per accident and disease. All policies must be issued by insurers with an AM Best Rating of A- or better and must include the City of Richardson as an additional insured with a 30-day notice of cancellation requirement.
The insurance policies are effective as of April 1, 20XX, with all coverage written on a primary and non-contributory basis. A waiver of subrogation must apply to all policies, and the contractor's General Liability and Automobile Liability policies must include no care, custody, and control (CCC) exclusion for any work involving City property. The certificate holder is the City of Richardson, P.O. Box 830309, Richardson, Texas 75083, and the insurance broker contact is John Smith at 1234 Main Street, Richardson, Texas 75083, with phone number 123-456-7889 and email john.smith@agency.com. This certificate is issued for information purposes only and confers no rights upon the certificate holder unless policies are properly endorsed as required.
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Text version
ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD
CERTIFICATE OF LIABILITY INSURANCE RISK 2
DATE (MM/DD/YYY)
04/01/20XX
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
Agency Name 1234 Main Street Richardson, TX 75083
CONTACT
NAME: John Smith
PHONE
(A/C, No. Ext): 123-456-7889
FAX
(A/C, No):
ADDRESS: john.smith@agency.com
INSURER(S) AFFORDING COVERAGE NAIC#
INSURED
SAMPLE COI
For Risk 2 – mid-level risk offering City some type of service or product auto liability would typically be required as autos would be on City property or used to transport City people or property – All other coverage as indicated for Risk 2 required
INSURER A : AM Best Rating of A- or better
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F:
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
ADDL
INSR
SUBR
WVD
POLICY
NUMBER
POLICY EFF
(MM/DD/YYY)
POLICY EXP
(MM/DD/YY)
LIMITS
A
GENERAL LIABILITY
Y
123456
04/01/20XX
EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY
DAMAGES TO RENTED
PREMISES(Ea occurrence)
$ 50,000
CLAIMS-MADE X OCCUR MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN’L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP
AGG
$2,000,000
X POLICY PRO-
JECT
LOC
A
AUTOMOBILE LIABILITY
787899
COMBINED SINGLE LIMIT
(Ea accident)
$1,000,000
X ANY AUTO BODILY INJURY(Per person) $
ALL OWNED
AUTOS
SCHEDULED
AUTOS
BODILY INJURY(Per accident) $
HIRED AUTOS
NON-OWNED
AUTOS
PROPERTY DAMAGE
(Per accident)
UMBRELLA LIAB OCCUR
EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
A WORKERS COMPENSATION AND
EMPLOYERS ‘ LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below
Y/N
N
N/A
595966
X
WC STATU-
TORY
LIMITS
OTH-
ER
E.L. EACH ACCIDENT $1,000,000
E.L. DISEASE – EA
EMPLOYEE
$1,000,000
E.L. DISEASE – POLICY
LIMIT
$1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 30-day Notice of Cancellation, Waiver of Subrogation, Additional Insured shall apply to all policies. General Liability and Auto policies shall be written on a Primary and Non-Contributory basis. Workers Comp policy shall name COR as an alternate employer (for any risk required if temporary employment service or COR controls actions of others employees). No CCC exclusion permitted on General Liability and Auto policies on any risk where city property is in their care, custody or control to provide service.
CERTIFICATE HOLDER CANCELLATION
City of Richardson P. O. Box 830309 Richardson, TX 75083
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
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