C-2_Acord_Certificate_of_Insurance_Sample_.pdf
PDF 153 KB Posted
- Solicitation number
- 2026-036
- Issued by
- Polk County, Florida
About this file
This is a Certificate of Liability Insurance issued by Insurance Agency, Inc. on September 25, 2020, for the City of St. Cloud, Florida in connection with Project #123. The certificate documents insurance coverage for Contractors, Inc., with the City of St. Cloud designated as an additional insured for the period of October 1, 2020 through November 1, 2021. The insurance certificate covers multiple types of liability protection through four insurers: ABC Company provides Commercial General Liability with limits of $1,000,000 per occurrence and $2,000,000 general aggregate, along with Automobile Liability with combined single limits of $1,000,000; DEF Company provides Workers Compensation and Employers' Liability with statutory limits and $100,000 per accident and $500,000 disease limits; ABC Company also provides Umbrella/Excess Liability coverage with $2,000,000 limits; and GHI Company provides Professional Liability coverage with $1,000,000 per claim and $2,000,000 aggregate limits. All policies are effective January 1, 2020 through January 1, 2021, with coverage subject to all terms, exclusions, and conditions of the underlying insurance policies.
The certificate confirms that all insurance policies have been issued and are in force as of the certificate date. The producer contact is John Doe at Insurance Agency, Inc., located at 123 Main Street, Small Town, Florida 34769, with telephone 555-555-5555 and email jdoe@insuranceagency.com. The certificate holder and additional insured is the City of St. Cloud, Attention: Procurement Services Department, 1300 9th Street, Building A, 2nd Floor, St. Cloud, Florida 34769. The certificate is issued for information purposes only and confers no rights upon the certificate holder; however, it confirms that the insured contractor maintains adequate liability protection for the specified project. Any cancellation of the policies described will be delivered in accordance with the policy provisions.
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Text version
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
| 50,000 |
| X X ABC123 |
| X X ABC456 01/01/13 |
| ABC789 01/01/13 01/01/14 |
| 2,000,000 |
| 100,000 |
| 500,000 |
| C Professional Liability GHI123 01/01/13 01/01/14 |
File details come from the government source that posted it. Updated .