Certificate of Liability Insurance.pdf
PDF 573 KB Posted
- Attached to
- PSC - Library Boiler Replacement
- Solicitation number
- RFB202690000713
- Issued by
- Mingo County, West Virginia
About this file
This is an ACORD Certificate of Liability Insurance and Certificate of Property Insurance document issued for a contractor performing work on the Mary F. Shipper Library boiler replacement project at Potomac State College in Keyser, West Virginia. The certificates confirm that the contractor maintains comprehensive insurance coverage as required for the project. The liability insurance includes general liability coverage with limits of $1,000,000 per occurrence and $50,000 medical expense coverage, commercial auto coverage, umbrella liability with limits of $5,000,000 per occurrence and aggregate, and workers' compensation with employer's liability coverage of $500,000 per accident and disease limits. The property insurance certificate covers building, personal property, business income, and inland marine transit coverage with a 20 percent coinsurance clause noted. Both certificates require that the Owner, Architect, and Architect's Consultants be named as additional insureds, and special provisions mandate compliance with West Virginia Code 23-4-2 regarding employer's liability coverage.
The certificates indicate that the issuing insurance companies will provide thirty days' written notice to the state agency prior to cancellation of any policies. All coverage is subject to the terms, exclusions, and conditions of the underlying policies, and aggregate limits may have been reduced by paid claims. The document serves as written confirmation of the insurance requirements for contract performance and confers no rights upon the certificate holder. The specific policy numbers, effective dates, expiration dates, and names of the insured contractor and insurance companies are not fully completed in this template version of the certificates.
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Text version
ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DONYYY)
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
INSURANCE AGENCY'S NAME AND ADDRESE 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 C: INSURER'S NAME
INSURER D:
I INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVvlTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 'MTH 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.
·~~ ~: TVDC ns:u•A••-•••.-- POLICY NUMBER ~C_Y_ ~FFECTlVE ~1:!.9Y EXPIRATION LIMITS
~NERAL LIABILITY EACH OCCURRENCE sl, 000, 000 l] COMMERCIAL GENERAL LIABILITY ~E~I:."!!.~~--· $ 50,000
D CLAIMS MADE [xi OCCUR MEO EXP IAnv one 1><raonl $ 5 000
A f-
PERSONAL & ADV INJURY $ 1 000 000
GENERAL AGGREGATE $ 2 000 ooc f-s2,000,000 nLAGGR~E LIMIT APnS PER: PRODUCTS • COMP.()P AGG
POLICY ~f9; LOC
~TOIIOBILE LIABILITY COM81NED SINGLE LIMIT sl,000,000 lX. /'JfYAUTO
(Ea acddenl)
- ALL ~ED AUTOS BODILY INJURY
(Per pellOO)
SCHEDULED AUTOS
A [x HIRED AUTOS OOOILY INJURY $ .x_ NON-0\'.NED AUTOS (Per acddenl)
~ PROPERTY DAMAGE
(Per .eddenl) $
GARAGE LIABILITY AUTO 0NL Y • EA ACCIDENT $
1>HYAUTO OTHER THAN EAACC S
AUTO ONLY: AGG s
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE s5 000.000 :xi OCCUR D CLAIMS MADE AGGREGATE s5 , 000,000
B s R DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION x I T~~T~J.V;, I 10.w·
AND EMPLOYERS' LIABILITY Y/N 500,000
c ANY PROPRIETOR/PARTNER/EXECUTIVE D E.L. EACH ACCIDENT s
OFFICER/MEMBER EXCLUDED?
E.L. DISEASE - EA EMPLOYEI $ 500,000 {MlndAlory In NH) mMt~~1~s l)elq;, E.L. DISEASE - POLICY LIMIT $ 500 000
OTHER
OESCRIPTION OF OPERATIONS I LOCA TIDNS I VEHICLES I EXCLUSIONS ADDED BY ENDORSE II ENT I SPECIAL PROVISIONS
Employer s liability includes coverage for w. Va . Code §23-4-2 (Mandolidis) .
Owner, Architect and Architect's Consultants are to be named as additional insureds. (Insert project's name and address)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE AJIOVE DESCRIBED POLICIES BE CAHCELLEO BEFORE TliE EXPIRATION
DATE TliEREOF, TliE ISSUING INSURER WIU. ENDEAVOR TO MAIL ...3Jl_ DAYS WRJmN
STATE AGENCY'S NAME AND ADDRESS NOTICE TO n!E CERT1F1CATE HOLDER NAMED TO TliE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIAB1UTY OF ANY KIND UPON TliE INSURER, tn AGENTS OR
REPRESENTATIVES.
AUTHORIZED R.EPRESENTA TIVE
I
ACORD 25 (2009/01) © 1988·2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
ACORD,., CERTIFICATE OF PROPERTY INSURANCE I DATE
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER 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.
COMPANIES AFFORDING COVERAGE
COMPANY
A INSURER'S NAME
INSURED
COMPANY
B
CONTRACTOR' S NAME AND ADDRESS
COMPANY
c
COMPANY
D
COVERAGES
THIS 15 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.
co TYPE Of INSURANCE POLICY HUMBER POLICY EFFECTIVE POLICY EXPIRATION COVERED PROPERTY LIMITS LTR DATE (NIIIDDl't'Y) DATE (MM/00/'t'Y)
LJ PROPERTY - BUILDING s ~USES OF LOSS - PERSONAL PROPERTY s
- BASIC BUSINESS INCOME s -BROAD - - EXTRA EXPENSE s SPECIAL BLANl(ET BUil DiNG s - - EARTHQUAKE Bl»IKET PERS PROP s - - FLOOD Bl»IKET BLDG & PP s - -s - -s
_x INI..ANDNARIHE L BUILDING CONTRACT AM' ~ lYPE OF POLICY x.... TRANSIT $ ?n!lc
A I ns t / Bu ilder' s Ri sk (if applicabl e ) x.... OFF-S ITE $ 20%
CAUSES OF LOSS
>-- - STORAGE s ._ NAMED PERILS s -OTHER s
CRIME - ._ s lYPE OF POllCY - s
_J 8011..!!R&MACHINERY ._ s
_j OTHER
LOCATION OF PREMISES/DESCRIPTION OF PROPERTY
PROJECT NAME AND ADDRESS
SPECIAL CONDITIONS/OTHER COVERAGES
Owner is t o be na me d as additional insured .
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY Of TIIE ABOVE DESCRIBED POLICIES BE CANCELU:O BEFORE THE
EXPIMTION DATE THElll!Of, Tiii! ISSUING COMPANY WILL l!NDl!AVOR TO MAIL
STATE AGENCY'S NAME AND ADDRESS ..1Q_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOU>ER NAMED TO TIIE LEFT, BUT FAILURE TO NAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABlllTY
Of' ANY KIND UPON THE COMPANY, rrs AGENTS OR REPRESENTATIVES.
AUTHORIZl!D Rl!l'Rl!UNTATM!
ACORD 24 (1/95) © ACORD CORPORATION 1995
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