Insurance_Certificate_Sample.pdf

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

INSR ADDL SUBR

LTR INSD WVD

PRODUCER CONTACT

NAME:

FAXPHONE

(A/C, No):(A/C, No, Ext):

E-MAIL

ADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

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

AUTHORIZED REPRESENTATIVE

EACH OCCURRENCE $

DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence)

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $

PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT

OTHER: $

COMBINED SINGLE LIMIT

$(Ea accident)

ANY AUTO BODILY INJURY (Per person) $

OWNED SCHEDULED

BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

HIRED NON-OWNED PROPERTY DAMAGE

$AUTOS ONLY AUTOS ONLY (Per accident)

OCCUR EACH OCCURRENCE

CLAIMS-MADE AGGREGATE $

DED RETENTION $

PER OTH-

STATUTE ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below

INSURER(S) AFFORDING COVERAGE NAIC #

COMMERCIAL GENERAL LIABILITY

Y / N N / A

(Mandatory in NH)

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

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.

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 have ADDITIONAL INSURED provisions or 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).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

© 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03)

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

The ACORD name and logo are registered marks of ACORD

03/30/2017

(703) 827-2277 (703) 827-2279

20508

TLC Engineering for Architecture, Inc.

255 South Orange Ave Ste 1600 Orlando, FL 32801

20427 20443 19437

A 1,000,000

X 4029282666 03/30/2017 03/30/2018 1,000,000 15,000

1,000,000 2,000,000 2,000,000

1,000,000B 4029282778 03/30/2017 03/30/2018

10,000,000C 6024385012 03/30/2017 03/30/2018 10,000,000

10,000 A

4029282814 03/30/2017 03/30/2018 1,000,000 N 1,000,000

1,000,000 D Professional Liab. 027015035 03/30/2017 Per Claim/Aggregate 8,000,000

Sarasota County Government is included as additional insured as respects to General Liability, but solely in regards to work being performed by or on behalf of the Named Insured in connection with the project described herein as required by written contract. 30-day Notice of Cancellation will be issued in accordance with policy terms and conditions.

Sarasota County Government Attn: Risk Management 1660 Ringling Blvd, 4th Floor Sarasota, FL 34236

TLCENGI-01 KCOLLINS

Ames & Gough 8300 Greensboro Drive Suite 980 McLean, VA 22102 admin@amesgough.com

Valley Forge Insurance Company A(XV) American Casualty Co of Reading, PA A(XV) Continental Casualty Company (CNA) A, XV Lexington Insurance Company A, XV

X

03/30/2018

X X

X X

X

X

X

X dcapella Highlight dcapella Highlight dcapella Highlight dcapella Callout Additional Insured status - X or Y dcapella Highlight dcapella Highlight dcapella Highlight dcapella Highlight dcapella Highlight dcapella Highlight dcapella Highlight dcapella Highlight dcapella Highlight dcapella Highlight dcapella Highlight dcapella Highlight dcapella Highlight dcapella Highlight dcapella Highlight dcapella Highlight dcapella Callout Specialized coverage info dcapella Callout Additional Insured Status dcapella Highlight dcapella Callout Should use Admin Agent as contact and Dept. address dcapella Typewritten Text dcapella Typewritten Text dcapella Typewritten Text dcapella Typewritten Text dcapella Typewritten Text dcapella Typewritten Text dcapella Typewritten Text dcapella Typewritten Text dcapella Typewritten Text dcapella Typewritten Text dcapella Typewritten Text dcapella Typewritten Text dcapella Typewritten Text dcapella Typewritten Text dcapella Typewritten Text

Acord Certificate Reference

1. INSURED – Must be legal name of contracting party.

2. COMMERCIAL GENERAL LIABILITY – Verify that coverage is included, there is a policy number with a current policy period, and the “Each Occurrence” limit is equal or greater than the limits required per the contract or insurance matrix. Also look for additional insured status indicated as an X or Y in the “Addl Insd” box or referenced in the Description of Operations.

3. AUTOMOBILE LIABILITY – If required, verify that coverage is included, there is a policy number with a current policy period, and the “Combined Single Limit” limit is equal or greater than the limits required per the contract or insurance matrix. In the case of transportation related services (i.e. charters, towing, hauling, etc.) we require additional insured insured status for auto liability as indicated by an X or Y in the “Addl Insd” box or referenced in the Description of Operations.

4. UMBRELLA LIABILITY – If required, verify that coverage is included, there is a policy number with a current policy period, and the “Each Occurrence” limit is equal or greater than the limits required per the contract or insurance matrix.

5. WORKERS COMPENSATION & EMPLOYERS LIABILITY - If required, verify that coverage is included, there is a policy number with a current policy period, the “Statutory” box is checked and there are limits listed in the EL category boxes. If USL&H coverage is required, the certificate must reference that this coverage is included.

6. BLANK – This space is available for identifying any coverages beyond GL, AL, UMB and WC. If required, verify that the specific coverage is referenced here or elsewhere on the certificate and that the limits are equal to or greater than what is required in the contract or insurance matrix.

7. DESCRIPTION OF OPERATIONS, et al. - This section is typically used for a wide variety of functions, including a description of the contract or work being performed, additional remarks concerning some aspect of coverage, or for indicating additional insured status. Look for additional insured status here if not otherwise indicated in “Addl Insd” box.

8. CERTIFICATE HOLDER – This should reflect Sarasota County Government as a default. If the contract or agreement utilizes some other entity name, that should be reflected as certificate holder. Our standard contract language calls for certificates to be sent to the administrative agents. Your location address should be used.