Certificate of Liability Insurance.pdf

CERTIFICATE OF LIABILITY INSURANCE I ACORD DATE (MMIDOIYYYY)

PRODUCER THIS CERTIFICATION IS ISSUED AS A MAnER OF INFORMATION Insurance Agency's Name and Address ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE

HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR

ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.

INSURERS AFFORDING COVERAGE NAIC#

INSURED INSURER A: Insurer's Name

INSURER B: Insurer's Name Contractor's name and Address

Insurer's Name lNSURERC:

lNSURERD:

INSURERE:

COVERAGES

THE I I ; OF : ,:!~T':o._B.':'!c0_":' HJ\\IE_~E,=-':l. ~s_sy,,!:, :!:<:'. T.':f!'. ·!.?~_T':'~.':.OL~C:!~~~<:o._'. NU ",I, n~' ANU"", ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE lSSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH

~~~~;ES AGG::::, LIMITS SHOWN MAY HAVE B:::c::~~~:D BY PAID ri~'~M~S~. ~~~~~~ I 0'0" UM~S.

I--"'~EIRAL LIABILITY ~ I ;:. 1, non nnn

A IjX~~~~MERCI.'LGENERALLIABILIlY ~ 1$ 50,0(j()

1-1----'1 CLAIMS MADE D OCCUR I MED EXP (My ooe p~e",o"Lo)+I"--$----=~ 5.0

1-

~'L AGGREGATE LIMIT APPLIES PER:

h POLICY rXl j:g.; n LOC

I "

A ANY AUTO

ALL OWNED AUTOS -

SCHEDULED AUTOS

~ HtREDAUTOS

~ NON-OWNED AUTOS

~RAGE LIABILITY

RANYAUTO

I EXCESS' UMBREUA LIABILITY

B I~ OCCUR D CLAIMS MADE

1=1 DEDUC~'BLE

'AND

C EMPLOYERS' LIABILITY Y N

ANY PROPR'ETORlPARTNERlEXECUT'VED

OFFICERIMEMBER EXCLUDED?

NHI

If yes, describe under

OTHER

I ;{ I IADDEDBY

,0.,," "'OY 1$ 1.

1$ I PRODUCTS· cnMPnp Ar.r. I $

I $

COMBINED SINGLE LIMIT $

(Ea accident)

BODILY INJURY $

(Per person)

BODILY INJURY $

(Per accident)

PROPERTY DAMAGE $

AUTO ONLY -EA. I $

OTHER THAN EAACC $

AUTOONLV: AGG $

EACH $

I T'6)<$lfJ,¥s I ~

EL FACH. $

EL DISEASE· FA $

EL DISEASE· POLICY LIMIT $

1,000,000

1 nnn non finn,nnn cnn,non

Employers liability includes coverage for W. Va. Code Section 23-4-2 (Mandolidis).

Owner, Architect and Architect's Consultants are to be named as additional insureds.

(Insert project's name and address)

State Agency's Name and Address

ACORD 25 (2009/01)

nON

SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION

DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN

NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL

IMPOSE NO OBUGA110N OR UABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR

REPRESENTATIVES.

© 1988·2009 ACORD CORPORATION. All rights reserved.

The ACORD name and 10<10 are r.<listered marks of ACORD

ACORD .. CERTifiCATE Of PROPERTY INSURANCE I DA1'E

PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTI'R OF INFORMATION

ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE

INSURANCE AGENCY'S NAME AND ADDRESS

HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR

ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.

COIIIIPANIES AFFORDING COVERAGE

COMPANY

A INSURER'S NAME

INSURED COMPANY

II

CONTRACTOR'S NAME AND ADDRESS

COMPANY

c

COMPANY

COVERAGES

THIS IS m CERTIFY T~ THE POLICiES OF iNSURANCE LISTED BELOW ,HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD lNDICATED<, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ftJoJ.Y CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFlCATE MAY BE ISSUeD OR'MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLlC!ES DESCRIBED HEREIN IS SUBJECT TO AlL THE TERMS, EXCLUSiONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWNMAY HAVE BEEN REDUCED ay PAlOCl.AlMS.

00 TYPE' OF INSURANCE POlICYNU_m flQUCY EFFECTIVE POUC'fEXl1RAifO}rf CovrmEDPROPERTY LIMn'S LTR "" TE (UOIIOOIV'/J DA1'J! IMMiDDf'fY)

..J """""""" ~

""""NG •

.~SESOFL:OSS - PERSONAL PROPERTY • -----

",,"0 BUsINESS INCOME • .~ .-

""""" EXTRA EXPENSE • ~ -

SPECIAL BlANKET BUILDING • - -

- EAlmiQUN<E f-H BlANKET PIERS PR()P • --------c

- FlooO f-H BlANKET SLOG &. PP • .~-l- I-- s

• f-Xl iNLAND IltARINIE lL BUILDING CONTRACT Mi .

TYPE OF POUCY t TRANSIT

• ?fl'k

A InstjBuilder's Risk (if applicable) OFF-SITE • 20% ~sesoFLOss - STORAGE • '- NAMED PeRIlS - • --

OTHER •

OR ... - $

~PEOFf>QUCY • - .. • '.-11i0l1...ER" MACHINERY

-.J OTHS

LOCA"tlON Of' PREM4SESIOESCRlWrlOl'l1 Of PROPERTY

PROJECT NAME AND ADDRESS

SPECIAL COMptTlONSJOTtilER COVERA.GES

Owner is to be named as additional insured.

IF'"'' n,,,,., SHOULD AIff Of THE ABOVE DESCRIBeD POLICIES SE CANCELLED BEFORE THE

EXPJRA1'ION. DAtE" THEREOF, THE lSSUfNG COMPANY WILL ENDEAVOR TO MAIL

STATE AGENCY'S NAME AND ADDRESS ~ IOAYS WRmEN NonCE TO- THE CERTIFICATE HOLDER HAMED 10 'THE lEFT, SUT FAILURE TO MAIL .sucH NOTICE SHAlL IMPOSE NO OBUGATtON OR UABlllTY

~""". mE

ITS .".,.,. OR

) 24(1195) 11995

Check Box1: Yes