J.12 Sample Certificate of Liability Insurance.pdf

ACORD

CERTIFICATE OF LIABILITY INSURANCE I

DATE (MM/DD/YYYY)

I.

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).

PRODUCER CONTACT

NAME:

PHONE I FAX

IAJC No Ext\: /AJC Nol:

E-MAIL

ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC#

INSURER A :

INSURED INSURER B:

INSURER C :

INSURER D :

INSURER E :

INSURER F :

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

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

LTR TYPE OF INSURANCE

COMMERCIAL GENERAL LIABILITY

D CLAIMS-MADE □ OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

Fl

□ PRO-

POLICY JECT

OTHER:

AUTOMOBILE LIABILITY

ANY AUTO

� ALL OWNED

AUTOS

DLoc

SCHEDULED

AUTOS

� NON-OWNED

HIRED AUTOS AUTOS

UMBRELLA LIAB

H

OCCUR

EXCESS LIAB CLAIMS-MADE

DED

I I

RETENTION$

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y/ N

ANY PROPRIETOR/PARTNER/EXECUTIVE

□ OFFICER/MEMBER EXCLUDED?

(Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below

ADDL SUBR POLICY EFF POLICY EXP

INSD WVD POLICY NUMBER IMM/DD/YYYYl IMM/DD/YYYYl LIMITS

EACH OCCURRENCE $

DAMAGE TO RENTED

PREMISES (Ea occurrence) $

MED EXP {Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $

BODILY INJURY (Per accident) $

PROPERTY DAMAGE

/Per accident\ $

EACH OCCURRENCE $

AGGREGATE $

I PER I

STATUTE

I OTH-

ER

N/ A

E.L. EACH ACCIDENT $

E.L. DISEASE - EA EMPLOYEE $

E.L. DISEASE - POLICY LIMIT $

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

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

I © 1988-2014 ACORD CORPORATION. All rights reserved.

ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD

NOTE: The United States of America, acting by and through the Architect of the Capitol shall be included as an additional insured with respect to operations under this contract.

CERTIFICATE HOLDER: Architect of the Capitol U.S. Capitol Building, Room SB-15 Washington, DC 20515