Sample Certificate - Commodities Delivered (Common Carrier)~1.pdf

The Ducey Agency, Inc 43 South Liberty Drive Stony Point, NY 10980

COMMODIITIES DELIVERED BY

COMMON CARRIER

123 MAIN STREET

NEW CITY, NY 10956

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

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).

CONTACT

NAME:PRODUCER

PHONE

(A/C, No, Ext):

FAX

(A/C, No):

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 ADDL

INSD

SUBR

WVD

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)TYPE OF INSURANCE POLICY NUMBER LIMITSLTR

X 1 ,000,000COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE X OCCUR

EACH OCCURRENCE 1

DAMAGE TO RENTED

PREMISES (Ea occurrence) 50,000A X X A

5,0001MED EXP (Any one person)

1 ,000,000PERSONAL & ADV INJURY 1

2 ,000,0001GEN'L AGGREGATE LIMIT APPLIES PER:

x I PRP-^ JECT

GENERAL AGGREGATE

2 ,000,000POLICY LOC 1PRODUCTS - COMP/OP AGG

OTHER: $

COMBINED SINGLE LIMIT

(Ea accident)AUTOMOBILE LIABILITY

B ANY AUTO

OWNED

AUTOS ONLY

HIRED

AUTOS ONLY

1BODILY INJURY (Per person)

SCHEDULED

AUTOS

NON-OWNED

AUTOS ONLY

1BOI IJURY (Per accident)

DAMAGEPER

1;pf dent)

UMBRELLA LIAB OCCUR EACH OCCURRENCE 1

EXCESS LIAB CLAIMS-MADE AGGREGATE $

RETENTION $DED $

PER OTH-WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

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

STATUTE ER

Y / N

$E.L. EACH ACCIDENTN / A

E.L. DISEASE - EA EMPLOYEE $

E.L. DISEASE - POLICY LIMIT $

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.County of Rockland

50 Sanatorium Road, Bldg. A Pomona, NY 10970

AUTHORIZED REPRESENTATIVE

akhterr Typewriter The Certificate Date of issuance must be within 6 months of Request akhterr Typewriter Required akhterr Typewriter Required akhterr Typewriter Required akhterr Typewriter Rating as Required by Contract or Solicitation akhterr Typewriter Submit a Valid Certificate of Liability Insurance with the coverage and limits provided on this sample Name of Insured must be that of contract Holder akhterr Typewriter Required akhterr Typewriter Required if applicable akhterr Typewriter Required akhterr Typewriter Required akhterr Typewriter Required akhterr Typewriter NYS Wokrs' Comp. Certificate Provide Form c-105.2 or u-26.3 NYS Disability Certificate - Provide Form DB 120.1 Or Attestation of Exemption akhterr Typewriter Description of Operations/Locations/Vehicles (ACORD 101, Additional Remarks Schedule, may be attached if needed) akhterr Typewriter The County of Rockland including its employees, its officials, volunteers and Rockland County Sewer District #1 are named as additionally Insured.

akhterr Typewriter Signature is Required akhterr Highlight akhterr Highlight akhterr Highlight akhterr Typewriter Language Required naming County of Rockland as additionally insured.

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