Acord_25__Certificate_of_Liability_Insurance_(Sample).pdf

ACORD® CERTIFICATE OF LIABILITY INSURANCE I

DATE (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:

Name, Address , Telephone Number PHONE I r~~ Nol: ' A l,.. u,.. Cvt\ • of Insurance Agent Goes Here E-MAIL

ADDRESS :

PRODUCER

' ,..,, ... ._ .... aa- ... ln:i·

INSURER(S) AFFORDING COVERAGE NAIC #

INSURED INSURER A : Name of Insurer Number of Name of Vendor (As required by Permit, Agreement)

INSURER B : Insurer

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

TYPE OF INSURANCE

ADDL SUBR POLICY EFF POLICY EXP

LTR l lN~I> l wvn POLICY NUMBER IMM/DD/YYYYl IMM/DD/YYYYl LIMITS

GENERAL LIABILITY EACH OCCURRENCE s i:;nn nnn ~ Add Policy# lJAMA{jt:: I lJ r< t: N I t:U x COMMERCIAL GENERAL LIABILITY I I PREMISES IEa occurrence\ $

~ CLAIMS-MADE D OCCUR MED EXP (Any one person) $

PERSONAL & ADV INJURY $ 100 000 -

GENERAL AGGREGATE $ -

GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ n n PRO-POLICY JECT n LOC $

AUTOMOBILE LIABILITY Add Policy# COMBINED P" '\GLE LIMIT $ - (Ea accident) 1

ANY AUTO I I BODILY INJURY (Per person) $ 200,000 -

ALL OWNED AUTOS

BODILY INJURY (Per accident) $ 500,000 -

SCHEDULED AUTOS

PROPERTY DAMAGE - $ 20,000 HIRED AUTOS (Per accident) - NON-0 1/'vNED AUTOS $ - $

UMBRELLA LIAB H OCCUR EACH OCCURRENCE $ - EXCESS LIAB CLAIMS-MADE I I AGGREGATE $

DEDUCTIBLE $ -

RETENTION $ $

WORKERS COMPENSATION

I T~iitJNs I IOTH-

AND EMPLOYERS' LIABILITY Add Policy# ER Y/N

ANY PROPRIETOR/PARTNER/EXECUTIVE D I E.L. EACH ACCIDENT $ 100 000

OFFICER/MEMBER EXCLUDED? N/A

f Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $ f yes, describe under

E.L. DISEASE - POLICY LIM IT $ ~n~r tAI ·-·-· I I

DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

Contract Number and Description of Services. Add the following statemeni'exactly as written : "Any cancellation or material change in the coverage adversely affecting the government's interest shall not be effective unless the insurer or the contractor gives thirty (30) days written notice of cancellation or change to the contracting officer."

CERTIFICATE HOLDER CANCELLATION

USDA-Rural Development SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE

EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE

654 Plaza, Suite 601 , Mui'\oz Rivera Ave. POLICY PROVISIONS.

San Juan, PR 00918

AUTHORIZED REPRESENTATIVE

I

© 1988- 2009 ACORD CORPORATION. All rights reserved .

ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD

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