E Insurance Certificate Instructions (5-28-21).pdf

Insurance Certificate Instructions

Insurance Certificate Instructions (5/28/21)

1. The selected subcontractor will be required to obtain the required insurance coverage, and submit insurance certificates, endorsements, copies of policy pages for blanket coverage, and other documentation confirming the required insurance coverage as stipulated in the subcontract, prior to commencing performance at a worksite other than the Subcontractor's or lower-tier subcontractor's facilities. The Subcontractor shall provide the University Procurement Representative with documentation to demonstrate full compliance with the subcontract insurance requirements, unless otherwise stated within the subcontract.

2. Submission of insurance documentation is the responsibility of the Subcontractor, and shall be submitted to the email address for the University Procurement Representative identified on the subcontract, or mailed to:

The Regents of the University of California and the U.S Government Lawrence Berkeley National Laboratory

Attn: [University Procurement Representative’s Name] One Cyclotron Road Berkeley, CA 94720

3. The dollar limits for each type of insurance must be equal to or higher than the minimum dollar limits specified in the Subcontract, and the policy coverage dates must be current for all the types of insurance. The minimum dollar limits may be met through Excess/Umbrella Liability Insurance. The Subcontractor shall be responsible for all deductibles and self-insured retentions (SIR) applicable to the insurance policies.

4. Normally, the liability insurance should be written on a "per occurrence" basis. If written on a "claims made" basis, it shall continue for three years following completion or termination of the subcontract and provide for a retroactive date of placement prior to or coinciding with the effective date of the subcontract.

5. The Subcontractor or its insurers must provide written notification at least 30 days in advance of any modification, change, or cancellation of any of the insurance coverage. Any statement on the insurance certificate regarding such notification shall not affect the Subcontractor’s obligation in this regard.

6. If any of the required insurance will expire prior to completion or expiration of the Subcontract, the Subcontractor is responsible for submitting a replacement insurance certificate to the University immediately after the policy expiration date.

7. The insurance certificates may be able to be applied to future University subcontracts, and it is preferred that it not be made applicable, or reference, a specific subcontract.

CERTIFICATE HOLDER

© 1988-2010 ACORD CORPORATION. All rights reserved.

ACORD 25 (2010/05)

AUTHORIZED REPRESENTATIVE

CANCELLATION

DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE

LOCJECT

PRO-POLICY

GEN'L AGGREGATE LIMIT APPLIES PER:

OCCURCLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

GENERAL LIABILITY

PREMISES (Ea occurrence) $

DAMAGE TO RENTED

EACH OCCURRENCE $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

$RETENTIONDED

CLAIMS-MADE

OCCUR

AGGREGATE $

EACH OCCURRENCE $UMBRELLA LIAB

EXCESS LIAB

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

INSR

LTR TYPE OF INSURANCE POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

WC STATU-

TORY LIMITS

OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

ANY PROPRIETOR/PARTNER/EXECUTIVE

If yes, describe under DESCRIPTION OF OPERATIONS below

(Mandatory in NH)

OFFICER/MEMBER EXCLUDED?

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y / N

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED SCHEDULED

HIRED AUTOS

NON-OWNED

AUTOS AUTOS

AUTOS

COMBINED SINGLE LIMIT

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE $

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

ADDL

WVD

SUBR

N / A

(Ea accident)

(Per accident)

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).

The ACORD name and logo are registered marks of ACORD

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

INSURED

PHONE

(A/C, No, Ext):

PRODUCER

ADDRESS:

E-MAIL

FAX

(A/C, No):

CONTACT

NAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

KLJurgensen Typewritten Text

SAMPLE

KLJurgensen Typewritten Text [Insurance Representative's Name and Address]

KLJurgensen Typewritten Text [Subcontractor's Name and Address]

KLJurgensen Typewritten Text A

KLJurgensen Typewritten Text B

KLJurgensen Typewritten Text C

KLJurgensen Typewritten Text D

KLJurgensen Typewritten Text E

KLJurgensen Typewritten Text [For General Liability Insurance]

KLJurgensen Typewritten Text [For Automobile Liability Insurance]

KLJurgensen Typewritten Text [For Excess/Umbrella Liability Insurance]

KLJurgensen Typewritten Text [For Workers Comp/Employer's Liability Insurance]

KLJurgensen Typewritten Text [For Other Liaibility Insurance]

KLJurgensen Typewritten Text X

KLJurgensen Typewritten Text X

KLJurgensen Typewritten Text X

KLJurgensen Typewritten Text

KLJurgensen Typewritten Text

KLJurgensen Typewritten Text

KLJurgensen Typewritten Text

KLJurgensen Typewritten Text

KLJurgensen Typewritten Text

MM/DD/YY

KLJurgensen Typewritten Text

MM/DD/YY

KLJurgensen Typewritten Text

MM/DD/YY

KLJurgensen Typewritten Text

MM/DD/YY

KLJurgensen Typewritten Text

MM/DD/YY

KLJurgensen Typewritten Text

MM/DD/YY

KLJurgensen Typewritten Text

MM/DD/YY

KLJurgensen Typewritten Text

MM/DD/YY

KLJurgensen Typewritten Text 1,000,000

KLJurgensen Typewritten Text 1,000,000

KLJurgensen Typewritten Text 2,000,000

KLJurgensen Typewritten Text 2,000,000

KLJurgensen Typewritten Text 1,000,000

KLJurgensen Typewritten Text

KLJurgensen Typewritten Text 1,000,000

KLJurgensen Typewritten Text 1,000,000

KLJurgensen Typewritten Text 1,000,000

KLJurgensen Typewritten Text The attached endorsements, or the terms of the general liability and automobile insurance policies provide coverage for each of the certificate holders as an additional insured, and include a waiver of subrogation provision in favor of the certificate holders, and require the insurance be primary and noncontributory.

[If Professional Liability Insurance is required the following statement should be included in the Description of Operations section] The Professional Liability insurance policy includes Contractual Liability coverage for liability that would exist in the absence of the subcontract.

KLJurgensen Typewritten Text The Regents of the University of California and the U.S Government Lawrence Berkeley National Laboratory One Cyclotron Road Berkeley, CA 94720

KLJurgensen Typewritten Text [Signature Required]

KLJurgensen Typewritten Text

MM/DD/YY

KLJurgensen Typewritten Text X

KLJurgensen Typewritten Text

KLJurgensen Typewritten Text

KLJurgensen Typewritten Text

DEDUCT $

KLJurgensen Typewritten Text X

KLJurgensen Typewritten Text X

KLJurgensen Typewritten Text X

KLJurgensen Typewritten Text

DEDUCT $