Exhibit C - COI Template.pdf

City and County of Denver Contractor

DENVER

THE MILE HIGH CITY

Certificate of Insurance

Contractors, please provide this sample certificate to your insurance agent or broker

Certificates must mirror this sample

Note the Additional Insured special instructions below

Contractor’s Legal Name

Types of insurance required in contract

If other insurance (Builders’ Risk, Professional Liability, for example) is required, please list it here

Only project/contract info and additional insured in this box*

Verify correct address & contact information

Tituruimo flrtcr NAmo & Adifrco U

11062)AFFORIP*O COAfl500 Cant

.,aA monO

Cctruilors to.oI Stan .ini AddYosY PalICO a ps—n’

COVERAGES CERTIFICATE NUUBER: REVISION NUMBER:

THIS ii. ... THAT TIlE POJCIES OF .* ,.,.. .. •...

IC3TED TOTWTH5TAICOIG ANT REOIJREVEIfl TERM OR COCOTION OF AMY CONTRACT OR OTHER OOCI*RIW RITE RESPECT To MUCH OHS CERTiFICATE MAY BE ISSUED OH MAY PERTAIN THE IIinURfiOICE AFFORORD BY THE POliCIES COSORRED HEREIN IS R5.ISCT TO Au. 0€ TERMS EECWUOMA AVE CONOOl4S OF SUCH POliCIES ClEATS 5HDMI MAY HAVE SEEN REELICED BY PAID CI.AJUS.

,_............_ AAOLSOEA

1eaaUALltv E,U,OCCLOS*s • I

.,. .HEpo’alur •.9! Mi!

IIUALJM rt. 0 Cm,. •93 $

• Aces LAO •ia AS.$LA”( I ma mn, COCaIF$flT HES’! 0!.

*%Lp0nO Wan fl Lit A CA

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MACAPTOUD! OPIRAYOAIILOCATUAI!VSC.fl tAsa! Acopo RI. SAWa Rain. IOA. SMAcCI.,. mnq*ndI

Contrnci N:imeNionber

As reuuired by written contract, the City and County olDenvcr, is Elected and Appointed Officials. Employees and Volunteers arc included us Additional Insured us respects the Commercial tieneral Liability and llnainess AtSo

ISIS

must be same or greater than

Z required in the contract

Policy start date

/ must be prior to effective date of the contract

*The ‘description’ box must only contain project/contract detail such as the contract name and number and “As required by written contract, the City and County of Denver, its Elected and Appointed Officials, Employees and Volunteers are included as Additional Insured” with regards to the appropriate policies ONLY.

QUALIFYING LANGUAGE SUCH AS “SUBJECT TO THE TERMS AND CONDITIONS OF THE POLICY”

and “IF REQUIRED PER WRITTEN CONTRACT” CAN NOT BE ADDED.

DO NOT ATTACH ADDITIONAL INSURED ENDORSEMENTS OR POLICIES

If any additional language is added to this section, the certificate will be rejected. If the requirements can not be complied with, we reserve the option to move on to another contractor

ACQRD CERTIFICATE OF LIABILITY INSURANCE I

ThIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATiON ONLY AND CONFERS NO RIGHTS UPON TEE CERTTFICATE 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 TUE ISSUING INSURER(SI. AUThORIZED

REPRESENTATIVE OR PRODUCER. AND TEE CERTIFICATE UOLDER

IISPORIANI: A .,o m.,on n..a, ,* pnnnoG. ON polmypeat nO.515. eHAo,s.IF ,,.ornn,A,. ,.co.. USING Is Re lINen d COndfllse. .5 ON polIcy. Anile poW... may mqsSn I. pndon.mnd. A AstemaIN O0 PUB nHIRORO doss fbI noldn UgNA Is ON

Policy limits

C d C’ r . . WOULD ANY CF TIlL ABOVE DESCSISOD POLICIES BE CANCELLED I€Fii> an OUnO It THE EXPRMTIGN OATS THEREOF. NOTICE WILl. BE ECI.XUCRED WI l)tpartmeni oI — AECOWOUBEC am s.€ PoliCY PWoVEDCNS tAddee&s) - Dept Denver. (‘olorudo --

C TBU.DETD ACORO CORPORATiON. AU Ughts tRIp,V.d.

ACORD 25 1201 Q1QU) The ACORO name and logo me r.giBRr.d mains of ACORD

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