C-2_Acord_Certificate_of_Insurance_Sample_.pdf

DATE (MM/DD/YYYY)

09/25/2020

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

Insurance Agency, Inc.

123 Main Street Small Town, FL 34769

CONTACT John DoeNAME:

PHONE 555-555-5555 FAX 555-555-5556

ADDRESS: jdoe@insuranceagency.comE-MAIL

INSURER(S) AFFORDING COVERAGE NAIC #

INSURER A : ABC Company 123456

INSURED

Contractors, Inc.

456 Main Street Small Town, FL 34769

INSURER B : DEF Company 456789 INSURER C : GHI Company 101112

INSURER D :

INSURER E :

INSURER F :

X

B

CERTIFICATE OF LIABILITY INSURANCE

(A/C, No, Ext):

(A/C, No):

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

LTR TYPE OF INSURANCE

GENERAL LIABILITYX

ADDL SUBR

INSR WVD POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED

COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ 50,000

A CLAIMS-MADE X OCCUR X X ABC123 01/01/20 01/01/21 MED EXP (Any one person) $ 0

GEN'L AGGREGATE LIMIT APPLIES PER:

PERSONAL & ADV INJURY $ 1,000.000

GENERAL AGGREGATE $ 2,000,000

PRODUCTS - COMP/OP AGG $ 1,000,000

POLICY

PRO-

JECT LOC $

AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT

(Ea accident) $ 1,000,000

X ANY AUTO

A ALL OWNED SCHEDULED

AUTOS AUTOS X X ABC456 01/01/20 01/01/21

BODILY INJURY (Per person) $

BODILY INJURY (Per accident) $

HIRED AUTOS

NON-OWNED

AUTOS

PROPERTY DAMAGE $

(Per accident)

UMBRELLA LIAB OCCUR

EACH OCCURRENCE $ 2,000,000

A X EXCESS LIAB CLAIMS-MADE ABC789 01/01/20 01/01/21 AGGREGATE $ 2,000,000

DED RETENTION $ $

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y / N

WC STATU-

TORY LIMITS

OTH-

ER

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED? N / A X DEF123 01/01/20 01/01/21 E.L. EACH ACCIDENT $ 100,000100,000 (Mandatory in NH) If yes, describe under

E.L. DISEASE - EA EMPLOYEE $ 500,000

DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $

C Professional Liability GHI123 01/01/20 01/01/21 1,000,000 Each Claim 2,000,000 Aggregate

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

The City of St. Cloud is an Additional Insured with respects to Project #123 (10/01/2020 - 11/01/21).

CERTIFICATE HOLDER

City of St. Cloud Attention: Procurement Services Department 1300 9th Street, Building A, 2nd Floor St. Cloud, Florida 34769

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

ACORD 25 (2010/05)

© 1988-2010 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD mailto:jdoe@insuranceagency.com