Attach 19 - Sample Certificate of Insurance (COI).pdf

CERTIFICATE OF LIABILITY INSURANCE 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 AMEND, EXTEND OR ALTER THE

COVERAGE AFFORDED BY THE POLICIES BELOW.

PRODUCER

INSURERS AFFORDING COVERAGE NAIC #

INSURER A:

INSURER B:

INSURER C:

INSURER D:

INSURED

INSURER E:

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.

TYPE OF INSURANCE POLICY NUMBER

POLICY EFFECTIVE

DATE (MM/DD/YY)

POLICY EXPIRATION

DATE (MM/DD/YY)

LIMITS

EACH OCCURENCE $

DAMAGE TO RENTED

PREMISES (Ea occurrence) $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

GENERAL LIABILITY

COMMERICAL GENERAL LIABILITY

CLAIMS MADE OCCUR

GEN’L AGGREGATE LIMIT APPLIES PER:

POLICY PROJECT LOC

COMBINED SINGLE LIMIT

(Each Occurrence) $

BODILY INJURY

(Per person) $

BODILY INJURY

(Per accident) $

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED AUTOS

SCHEDULED AUTOS

HIRED AUTOS

NON-OWNED AUTOS

PROPERTY DAMAGE

(Per accident) $

AUTO ONLY - EA ACCIDENT $

EA ACC $

GARAGE LIABILITY

ANY AUTO

OTHER THAN

AUTO ONLY: AGG $

EACH OCCURRENCE $

AGGREGATE $

EXCESS/UMBRELLA LIABILITY

OCCUR CLAIMS MADE

DEDUCTIBLE

RETENTION $ t

WC STATU-

TORY LIMITS

OTH-

ER

E.L. EACH ACCIDENT $

E.L. DISEASE - EA EMPLOYEE $

WORKERS COMPENSATION AND

EMPLOYERS’ LIABILITY

ANY PROPRIETOR/PARTNER/EXECU-

TIVE OFFICER/MEMBER EXCLUDED?

If yes, describe under SPECIAL PROVISIONS below

E.L. DISEASE - POLICY LIMIT $

OTHER

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 INSURER AFFORDING COVERAGE WILL ENDEAVOR TO

MAIL 30 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

ACORD 25 (2001/08) © ACORD CORPORATION 1988

INSR

LTR

ADD’L

INSRD

Text1: Architect of the Capitol U.S. Capitol Building, Room SB-15 Washington, DC 20515

*combined single limit coverage providing the limits shown is acceptable

NOTE: The United States of America, acting by and through the Architect of the Capitol shall be included as an additional insured with respect to operations under this contract.