Sample Certificate of Liability Insurance~36.pdf

PDF 812 KB Posted

Attached to
26AL2015 Rend Lake S. F. W. A. Farm Lease
Solicitation number
26-422DNR-REALT-B-49026
Issued by
Jefferson County, Illinois

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This document is a Sample Certificate of Liability Insurance for the Illinois Department of Natural Resources (IDNR), located in Springfield, Illinois. The certificate is an ACORD standard form that provides information about insurance coverage for a tenant farmer, serving as a formal record of insurance policies without actually conferring rights to the certificate holder.

The insurance certificate shows commercial general liability coverage with a policy limit of $1,000,000 per occurrence and a $2,000,000 general aggregate limit. The document includes sections for various types of insurance coverage, including automobile liability and workers' compensation. A key note at the bottom of the document clarifies that this certificate is intended for informational purposes only and does not supersede the requirements of any executed farm lease between the tenant farmer and the IDNR. The form is designed to provide a standardized overview of insurance coverage, with specific fields for policy numbers, coverage dates, and insurance limits.

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SAMPLE CERTIFICATE OF LIABILITY INSURANCE.

POLICY NUMBER START

DATE

END DATE

POLICY NUMBER START

DATE

END DATE

POLICY NUMBER

(IF APPLICABLE)

START

DATE

END DATE

nicole.thomas Line nicole.thomas Text Box This box MUST be completed, even if the response is "N".

nicole.thomas Text Box Minimum amount required by law, if applicable.

nicole.thomas Line nicole.thomas Line nicole.thomas Line nicole.thomas Text Box IDNR should be listed as additional insured.

nicole.thomas Line nicole.thomas Line nicole.thomas Text Box Minimum contract requirement. Additional coverage/info may be included.

nicole.thomas Line nicole.thomas Line nicole.thomas Line nicole.thomas Text Box This document does not supersede the requirements of any executed farm lease. This document is intended for informational purposes only. Contractual terms of an executed farm lease between the tenant farmer and the IDNR control.

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