6._SAMPLE_ACCORD_Exterior_Improvements.pdf
PDF 83 KB Posted
- Solicitation number
- 147063
- Issued by
- San Bernardino County, California
About this file
This is a Certificate of Liability Insurance issued for the City of Chino, California, related to a multiple facilities roof replacement project. The certificate documents insurance coverage provided by Insurance Solutions CA and Insurance Company for the contractor Company XYZ, located at 5555 W Street in Chino, California. The policy period runs from April 1, 2025, through April 1, 2026. The certificate indicates that the City of Chino is named as an additional insured under the policies, with coverage extending to completed operations, ongoing operations, and primary/non-contributory wording as required by written contract.
The insurance coverage includes commercial general liability with limits of $2,000,000 each occurrence and $4,000,000 general aggregate, along with automobile liability coverage of $1,000,000 and workers' compensation coverage. An umbrella liability policy provides $5,000,000 in coverage on a follow-form basis, extending over both general liability and auto liability. The certificate specifies that the umbrella policy is follow form and extends coverage over GL and Auto policies. Additional coverage includes hired autos only and physical damage with collision deductibles of $100/$1,000. All policies are marked as claims-made or occurrence-based as applicable, with certificate holder endorsements attached as required by the underlying written contract between the City of Chino and the contractor.
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Text version
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
INSURER(S) AFFORDING COVERAGE
INSURER F :
INSURER E :
INSURER D :
INSURER C :
INSURER B :
INSURER A :
NAIC #
NAME:
CONTACT
(A/C, No):
FAX
ADDRESS:
PRODUCER
(A/C, No, Ext):
PHONE
INSURED
REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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).
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.
OTHER:
(Per accident)
(Ea accident)
N / A
SUBR
WVD
ADDL
INSD
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.
$PROPERTY DAMAGE
BODILY INJURY (Per accident)
BODILY INJURY (Per person)
COMBINED SINGLE LIMIT
AUTOS ONLY
AUTOSAUTOS ONLY
NON-OWNED
SCHEDULEDOWNED
ANY AUTO
AUTOMOBILE LIABILITY
Y / N
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
DESCRIPTION OF OPERATIONS below If yes, describe under
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. DISEASE - POLICY LIMIT
E.L. DISEASE - EA EMPLOYEE
E.L. EACH ACCIDENT
ER
OTH-
STATUTE
PER
LIMITS(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
POLICY EFF
POLICY NUMBERTYPE OF INSURANCELTR
INSR
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
EXCESS LIAB
UMBRELLA LIAB $EACH OCCURRENCE
$AGGREGATE
OCCUR
CLAIMS-MADE
DED RETENTION $
$PRODUCTS - COMP/OP AGG
$GENERAL AGGREGATE
$PERSONAL & ADV INJURY
$MED EXP (Any one person)
$EACH OCCURRENCE
DAMAGE TO RENTED
$PREMISES (Ea occurrence)
COMMERCIAL GENERAL LIABILITY
CLAIMS-MADE OCCUR
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY
PRO-
JECT LOC
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
CANCELLATION
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03)
© 1988-2015 ACORD CORPORATION. All rights reserved.
CERTIFICATE HOLDER
The ACORD name and logo are registered marks of ACORD
HIRED
AUTOS ONLY
GEC300171702 4/1/2025 4/1/2026
1,000,000
X
UEC006316702 4/1/2025 4/1/2026
X 10,000
Umbrella is Follow Form and extends over GL & Auto
Certificate holder(s) is/are named as additional insured per the attached endorsements as required by written contract subject to the terms & conditions of the policy:
General Liability - Completed Operations per attached General Liability - Ongoing Operations per attached General Liability - Primary/Non-Contributory wording applies per attached See Attached...
City of Chino 13220 Central Avenue Chino CA 91710
Insurance Solutions CA Insurance Tustin CA 92780
Company XYZ 5555 W Street Chino, CA 91763
Insurance Company 22322 Insurance America, Inc 24554 I Insurance Company 36940
4/1/2025
A X 2,000,000 X 100,000
5,000
1,000,000
4,000,000 X
AEC006316502 4/1/2025 4/1/2026
X X
X MCS90 X PHY DAMAGE COMP/COLL DED $100/$1,000
A X 5,000,000 X
SAMPLE
5,000,000
4,000,000
A
A 4/1/2025 4/1/2026 1,000,000 1,000,000 1,000,000
12315454654
Allen, Claudia Rectangle
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