Certificate_of_Insurance_Sample.pdf

EXHIBIT 1 -- INSURANCE COVERAGE REQUIREMENTS

INDICATES WHAT TYPE OF INSURANCE IS REQUIRED

TYPE OF INSURANCE

LIMITS OF LIABILITY

Each Occurrence

Aggregate

GENERAL LIABILITY

Comprehensive Form Bodily Injury $1,000,000 $1,000,000

Premises - Operations Property Damage $1,000,000 $1,000,000

Explosion & Collapse Hazard

Underground Hazard

OR

Products/Completed Operations Hazard

Contractual Insurance Bodily Injury and Property Damage Combined Single Limit

$1,000,000 $1,000,000

Broad Form Property Damage, Incl. Care, Custody Control

Independent Contractors

Personal Injury Personal Injury $1,000,000 $1,000,000

AUTOMOBILE LIABILITY

Comprehensive Form Bodily Injury (Each Person) $500,000

Owned Bodily Injury (Each Accident) $500,000

Hired Property Damage OR $500,000

Non-Owned Bodily Injury & Property Damage Combined Single Limit

$500,000

EXCESS LIABILITY (Over and above automobile and general liability

Umbrella Form Bodily Injury/Property Damage Combined

$1,000,000

OR

$1,000,000

Excess Liability Gap Layer $500,000 $500,000

WORKER'S COMPENSATION and Statutory

EMPLOYER LIABILITY $1,000,000

OTHER

Builder's All Risk Amount of Contract Price $________________

Errors & Omissions (Professional Liability) $500,000

Please indicate: Claims-Made Form:______________, Occurrence Form:____________, Extending Reporting Provisions Avail. ____________

The Contractor's insurance company must provide a certificate of insurance on the Lewis County form showing the above required coverage and modified to conform to the following endorsement. The following endorsement must also be signed by the insurer.

Authorized Signature

Titl

FORM

12.16.03

CS-FACIL

LEWIS COUNTY, WA

CERTIFICATE OF INSURANCE

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY.

THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE

COVERAGE AFFORDED BY THE POLICIES BELOW.

INSURED (Legal name and business address) CERTIFICATE HOLDER:

LEWIS COUNTY, WASHINGTON

DEPT. OF CENTRAL SERVICES

CONTRACT

NUMBER

LEWIS COUNTY HISTORICAL COURTHOUSE DATE ISSUED:

351 N. W. NORTH STREET

CHEHALIS, WASHINGTON 98532

PROJECT DESCRIPTION / LOCATIONS / VEHICLES / RESTRICTIONS / SPECIAL ITEMS:

This is to certify that policies of Insurance listed below have been issued to the Insured named above for the policy period indicated.

CO

LTR

TYPE OF INSURANCE POLICY NUMBER Date Policy Effective

(MM/DD/YY)

Date Policy Expires

(MM/DD/YY)

ALL LIMITS IN THOUSANDS

GENERAL LIABILITY General Aggregate $

Commercial General Liability Products Comp/Ops Aggregate $ Claims Made Occurrence Personal & Advertising Injury $ Owner’s & Contractors Protection Each Occurrence $ Fire Damage (Any One Fire) $ Deductible $ Medical Expense (Any One Person) $

AUTOMOBILE LIABILITY

CSL $

Any Auto All Owned Autos Bodily Injury

(per person) $ Scheduled Autos Hired Autos Bodily Injury

(per accident) $ Non-Owned Autos Garage Liability Property

Damage $ Deductible $ EXCESS LIABILITY Each Occurrence

Aggregate

Other Than Umbrella Form

WORKERS

COMPENSATION

AND

EMPLOYER’S LIABILITY

STATUTORY

$ (Each Accident) $ (Disease Policy Limit) $ (Disease-Each Employee)

OTHER

ADDITIONAL PROVISIONS

LEWIS COUNTY is included as additional insured as related to the above-mentioned project.

Should any of the above described policies be cancelled before the expiration date thereof, the issuing Company must deliver or mail not less than 45 days written notice to the above Certificate Holder, per RCW 48.18.290

COMPANIES AFFORDING COVERAGE ISSUING COMPANY, AGENT OR REPRESENTATIVE

NOTE: Attach a separate sheet to this certificate giving all the company names and their percentage of coverage, if clarification is needed, NAME:

ADDRESS:

C om pa ny

L et te r

A

B

C

D

E