6-E. Certificate of Liability Insurance Sample.pdf
PDF 618 KB Posted
- Attached to
- CTE Center IP Intercom System Replacement
- Solicitation number
- RFP 25-26-19
- Issued by
- Cameron County, Texas
About this file
This is a Certificate of Liability Insurance sample form (ACORD 25) applicable to the Los Fresnos Consolidated Independent School District (CISD) in Texas for the CTE Center IP Intercom System Replacement procurement. The document serves as a template demonstrating required insurance coverage specifications that vendors must obtain and provide as part of their proposal submission. The sample certificate outlines the standard format and information fields that bidders must complete, including insured party identification, producer contact details, policy effective and expiration dates, and coverage type designations. The form indicates that this certificate is issued for informational purposes only and does not confer rights upon the certificate holder; however, it establishes the baseline insurance requirements vendors must satisfy to be considered for award of this contract.
The Certificate of Liability Insurance sample specifies multiple coverage categories that vendors must maintain, including General Liability (with limits for each occurrence, fire damage, medical expense, and personal and advertising injury), Commercial General Liability, Automobile Liability (covering any auto, bodily injury, and property damage), Umbrella Liability, and Workers Compensation and Employers' Liability. The document notes that additional insured status may be required and that subrogation waivers may be necessary depending on policy terms and conditions. Vendors are required to ensure proper policy endorsements are in place and must provide a completed certificate as part of their response to the procurement. The form references supporting documentation including New Vendor Request Forms, ACH forms, Form W-9, and various vendor certification documents (Forms 1295, CIQ, and COLI) that must accompany insurance documentation.
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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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