8-8. Cert of Insurance Example.pdf

LOC

MADE

Date the Certificate is issued

THIS CERTIFICATE IS ISSUED AS 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.

DATE (MM/DD/YY) CERTIFICATE OF LIABILITY INSURANCE ACORDTM

PRODUCER

INSURER(S) AFFORDING COVERAGE

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.

INSR

LTR

GENERAL LIABILITY

TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE

DATE (MM/DD/YY)

POLICY EXPIRATION

DATE (MM/DD/YY)

EACH OCCURRENCE

LIMITS

COMMERCIAL GENERAL LIABILITY

CLAIMS MADE OCCUR

*3

FIRE DAMAGE (Any one fire) $

MED EXPENSE (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

GEN’L AGGREGATE LIMIT APPLIES PER:

POLICY

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED AUTOS

SCHEDULED AUTOS

HIRED AUTOS

NON-OWNED AUTOS

GARAGE LIABILITY

ANY AUTO

EXCESS LIABILITY

PRO-

JECT

These sections show only the coverages provided through the agent or broker identified in “1” above. If the insured uses more than one broker, a separate certificate is needed to show those

These two column shows inception and expiration dates for policies identified. Pay special attention that coverage does not expire before or during your project or lease.

PRODUCTS-COMP/OP AGG

COMBINED SINGLE LIMIT

(Ea accident)

BODILY INJURY

(Per person)

BODILY INJURY

(Per accident)

PROPERTY DAMAGE

(Per accident)

AUTO ONLY–EA ACCIDENT

OTHER THAN

AUTO ONLY:

EACH OCCURRENC

EA ACC $

AGG $

OCCUR CLAIMS

DEDUCTIBLE

RETENTION $

WORKERS’ COMPENSATION AND

EMPLOYERS LIABILITY

*3

OTHER

coverages.

The coverages & limits required in the solicitation, or those which are appliciable to the projects scope of work MUST be included on the certificate.

AGGREGATE

WC STATU-

TORY LIMITS

E.L. EACH ACCIDENT

E.L. DISEASE – EA EMPLOYEE

E.L. DISEASE – POLICY LIMIT

OTH-

ER

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

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE

THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE

CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION

OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.

AUTHORIZED REPRESENTATIVE

ATTN: PM contact or Procurement Team 9 Must be signed by an authorized representative of the brokerage agency.

This block may include contact information for the broker / agency. It’s often helpful to contact the broker directly for clarification, revision requests or renewal certificates. Some agencies will only communicate with their insureds and do not allow or respond to 3rd requests.

INSURER E:

INSURER D:

INSURER C:

INSURER B:

INSURER A:

The Insured is Vendor, Contractor or lessee (the policy holder).

INSURED

The insurance company will be identified here. The insurer letter appears again in the left-hand margin near the center of the page (*3) to show which insurer provides which type of coverage.

[Firm Name] [Address]

Forth Worth Housing Solutions is endorsed as additional insured on the general and auto liability policies on a primary and non-contributory basis.

This block identifies the Agent or Broker and their address.

*3

*3

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, certiain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).