Sample Insurance Certificate.pdf

PDF 52 KB Posted Aug 31, 2026

Attached to: Operation and Maintenance of Arkansas Lakes Project
Solicitation number: W912EE26RA015
Issued by: Department of the Army Corps of Engineers Engineering District Vicksburg

About this file

Written by GovTribe AI · Aug 31, 2026

This document is an ACORD 25 Certificate of Liability Insurance template, a standard form used to provide proof of insurance coverage to third parties.

The certificate serves as informational documentation only and confers no rights upon the certificate holder. It is not a contract between insurers, representatives, producers, and the certificate holder. The form accommodates multiple insurers and allows documentation of various coverage types including Commercial General Liability, Automobile Liability, Workers Compensation and Employers' Liability, Umbrella Liability, and Excess Liability. Key data fields include policy numbers, effective and expiration dates, coverage limits for bodily injury per person and per accident, property damage, combined single limits, medical expense, general aggregate, products/completed operations aggregate, and damage to rented premises. The certificate includes options to indicate additional insured status, subrogation waivers, hired and non-owned auto coverage, and workers compensation officer/member exclusions. The form requires specification of policy limits in dollar amounts and distinguishes between occurrence and claims-made policies. A cancellation notice provision requires notification to the certificate holder if policies are cancelled before expiration. Space is provided for description of operations, locations, and vehicles, with reference to ACORD 101 Additional Remarks Schedule if additional documentation is needed. The template includes fields for producer contact information, authorized representative signature, and certificate holder identification.

View the file

Other files

File	Type	Posted
Amended_Ark Lakes_SeedTaskOrder BidSchedule.xlsx	XLSX spreadsheet	Oct 8, 2026
Amended_Seed Task Order SOW_Ark Lakes.pdf	PDF	Oct 8, 2026
Amended Attachment 2_Mowing.pdf	PDF	Oct 8, 2026
Solicitation Amendment_W912EE26RA0150002.pdf	PDF	Oct 8, 2026
Amended Attachment 3_Dumpster Maps.pdf	PDF	Oct 8, 2026
Amended_Ark Lakes OM_Parent IDIQ Bid Schedule_Amendment 0002.xlsx	XLSX spreadsheet	Oct 8, 2026
Ark Lakes Operations Presentation.pptx	PPTX presentation	Sep 25, 2026
Ark Lakes Site Visit_PP.pptx	PPTX presentation	Sep 25, 2026
Ark Lakes Site Visit Sign in Sheet.pdf	PDF	Sep 25, 2026
Solicitation Amendment W912EE26RA0150001 SF 30.pdf	PDF	Sep 25, 2026
Ark Lakes OM_Parent IDIQ Bid Schedule.xlsx	XLSX spreadsheet	Aug 31, 2026
Solicitation - W912EE26RA015.pdf	PDF	Aug 31, 2026
Attachment 3 Trash Collection Maps-OUACHITA.pdf	PDF	Aug 31, 2026
Attachment 5 Past Performance Questionaire.pdf	PDF	Aug 31, 2026
Attachment 4 Debris Dump Sites.pdf	PDF	Aug 31, 2026
__Attachment_1___Facilities_by_Area___2026.xlsx	XLSX spreadsheet	Aug 31, 2026
Attachment 2 Mowing.pdf	PDF	Aug 31, 2026
CBA for Ark Lakes.pdf	PDF	Aug 31, 2026
Wage Rates for Ark Lakes OM.pdf	PDF	Aug 31, 2026
Ark Lakes_SeedTaskOrder_BidSchedule.xlsx	XLSX spreadsheet	Aug 31, 2026
Seed Task Order SOW_Ark Lakes.pdf	PDF	Aug 31, 2026

Show all 21

On GovTribe

Work with this file

Download the original file
Contacts named in this file
Similar government files
Ask GovTribe AI about this file

Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

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).

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.

OTHER:

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSD

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.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

OTH-

STATUTE

PER

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

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

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY

PRO-

JECT LOC

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).: ACORD 0025 2016-03

Enter date: The date on which the form is completed. (MM/DD/YYYY) :

Enter text: The full name of the producer / agency. :

Enter text: The mailing address line one of the producer / agency. :

Enter text: The mailing address line two of the producer / agency. :

Enter text: The mailing address city name of the producer / agency. :

Enter code: The mailing address state or province code of the producer / agency. :

Enter code: The mailing address postal code of the producer / agency. :

Enter text: The name of the individual at the producer's establishment that is the primary contact. :

Enter number: The producer's contact person's phone number. If applicable, include the area code and extension. :

Enter number: The fax number of the producer / agency. :

Enter text: The producer's contact person's e-mail address. :

Enter text: The named insured(s) as it / they will appear on the policy declarations page. :

Enter text: The named insured's mailing address line one. :

Enter text: The named insured's mailing address line two. :

Enter text: The named insured's mailing address city name. :

Enter code: The named insured's mailing address state or province code. :

Enter code: The named insured's mailing address postal code. :

Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name. As used here, this is Insurer A.:

Enter code: The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). As used here, this is Insurer A.:

Enter code: The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). As used here, this is Insurer B.:

Enter code: The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). As used here, this is Insurer C.:

Enter code: The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). As used here, this is Insurer D.:

Enter code: The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). As used here, this is Insurer E.:

Enter code: The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). As used here, this is Insurer F.:

Enter identifier: The producer assigned number for the certificate. :

Enter number: The producer assigned revision number for the certificate. :

Enter code: The Company Letter of the insurer, as identified in the "Insurer(s) Affording Coverage" form section, associated with the general liability policy. :

Check the box (if applicable): Indicates the claims made or occurrence option applies for the general liability policy. :

Check the box (if applicable): Indicates the "claims made" option applies on the general liability policy. :

Check the box (if applicable): Indicates the general liability policy, occurrence basis applies. :

Check the box (if applicable): Indicates other coverage not found on the form exists for the general liability policy. :

Enter text: The description of other coverage (not the limit) on the general liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). :

Check the box (if applicable): Indicates other coverage not found on the form exists for the general liability policy. :

Check the box (if applicable): Indicates the general liability policy, general aggregate limit applies per policy. :

Check the box (if applicable): Indicates the general liability policy, general aggregate limit applies per project. :

Check the box (if applicable): Indicates the general liability policy, general aggregate limit applies per location. :

Check the box (if applicable): Indicates the general liability policy, general aggregate limit applies to option is other than those listed on the form. :

Enter text: The description of the other option to which the general liability policy, general aggregate limit applies. :

Enter Y for a “Yes” response. Input N for “No” response. Indicates if the certificate holder has been named as an additional insured on the general liability policy. :

Enter Y for a “Yes” response. Input N for “No” response. Indicates if subrogation has been waived on the general liability policy. :

Enter identifier: The identifier assigned by the insurer to the general liability policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. :

Enter date: The effective date of the general liability policy. The date that the terms and conditions of the policy commence. :

Enter date: The date on which the terms and conditions of the general liability policy will expire. :

Enter limit: The general liability, each occurrence limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy.:

Enter limit: The general liability, damage to rented premises each occurrence limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy.:

Enter limit: The general liability, medical expense each person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy.:

Enter limit: The general liability, personal and advertising injury limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy.:

Enter limit: The general liability, general aggregate limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy.:

Enter limit: The general liability, products and completed operations aggregate limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy.:

Enter limit: The general liability, other coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). :

Enter code: The Company Letter of the insurer, as identified in the "Insurer(s) Affording Coverage" form section, associated with the policy. :

Check the box (if applicable): Indicates the commercial vehicle policy covers any auto. As used here, complete this section only if you are certifying automobile liability. Check all appropriate boxes to correspond with the covered auto symbols found on the policy declarations page. If the certificate is being issued to the owner of a leased vehicle, DO NOT USE THIS FORM. Use ACORD 23, Vehicle or Equipment Certificate of Insurance.:

Check the box (if applicable): Indicates the commercial vehicle policy covers owned autos only. :

Check the box (if applicable): Indicates the vehicle policy covers hired autos only. :

Check the box (if applicable): Indicates the vehicle policy covers autos other than those listed. :

Enter text: The description of the other covered autos. :

Check the box (if applicable): Indicates the vehicle policy covers scheduled autos. :

Check the box (if applicable): Indicates the vehicle policy covers non-owned autos only. :

Check the box (if applicable): Indicates the vehicle policy covers autos other than those listed. :

Enter text: The description of the other covered autos. :

Enter Y for a “Yes” response. Input N for “No” response. Indicates if the certificate holder has been named as an additional insured on the automobile liability policy. :

Enter Y for a “Yes” response. Input N for “No” response. Indicates if subrogation has been waived on the automobile policy. :

Enter identifier: The identifier assigned by the insurer to the automobile liability policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. :

Enter date: The effective date of the automobile liability policy. The date that the terms and conditions of the policy commence. :

Enter date: The date on which the terms and conditions of the automobile liability policy will expire. :

Enter limit: The vehicle combined single limit liability each accident amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy.:

Enter limit: The vehicle policy, bodily injury per person limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy.:

Enter limit: The vehicle policy, bodily injury per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). :

Enter limit: The vehicle policy, property damage per accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy.:

Enter text: The description of the coverage. :

Enter limit: The limit amount of the other coverage. :

Enter code: The Company Letter of the insurer, as identified in the "Insurer(s) Affording Coverage" form section, associated with the commercial excess or umbrella liability policy. :

Check the box (if applicable): Indicates the type of policy is umbrella. As used here, if evidencing an umbrella coverage, underlying policy number(s), term(s) and line(s) of business may be listed on an ACORD 101.:

Check the box (if applicable): Indicates the type of policy is excess. As used here, if evidencing an excess coverage, underlying policy number(s), term(s) and line(s) of business may be listed on an ACORD 101.:

Check the box (if applicable): Indicates "coverage trigger" is on an occurrence basis on an excess or umbrella liability policy. :

Check the box (if applicable): Indicates the "coverage trigger" is on a claims-made basis on an excess or umbrella liability policy. :

Check the box (if applicable): Indicates a deductible amount applies to the excess or umbrella liability policy. :

Check the box (if applicable): Indicates a retention amount applies to the excess or umbrella liability policy. :

Enter deductible: The excess or umbrella liability deductible or retention amount. :

Enter Y for a “Yes” response. Input N for “No” response. Indicates if the certificate holder has been named as an additional insured on the umbrella/excess liability policy. Place a "Y" next to each coverage where an additional insured endorsement has been issued or for umbrella / excess where there is an additional insured on the underlying primary policy and this umbrella / excess is follow form. :

Enter Y for a “Yes” response. Input N for “No” response. Indicates if subrogation has been waived on the excess policy. For umbrella / excess, place a "Y" next to each coverage where subrogation has been waived on the underlying primary policy and this umbrella / excess is follow form. :

Enter identifier: The identifier assigned by the insurer to the excess liability policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. :

Enter date: The effective date of the excess liability policy. The date that the terms and conditions of the policy commence. :

Enter date: The date on which the terms and conditions of the excess liability policy will expire. :

Enter limit: The excess or umbrella liability each occurrence limit. As used here, the limit should be listed as a whole dollar amount, as governed by the policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s).:

Enter limit: The excess or umbrella liability aggregate limit should be listed as whole dollar amount, as governed by the policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). :

Enter text: The description of other coverage (not the limit) on the excess or umbrella liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). :

Enter limit: The excess or umbrella liability other coverage limit should be listed as a whole dollar amount, as governed by the policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). :

Enter code: The Company Letter of the insurer, as identified in the "Insurer(s) Affording Coverage" form section, associated with the commercial workers compensation and employers liability policy. :

Enter Y for a “Yes” response. Input N for “No” response. Indicates whether the workers compensation and employers liability policy excludes any proprietor, partner, executive officer, or member. As used here, the DESCRIPTION OF OPERATIONS section is available, if needed, to provide details of any "Yes" response. In NH, if "Yes" response is indicated, it is mandatory to provide corresponding details in the DESCRIPTION OF OPERATIONS section.:

Enter Y for a “Yes” response. Input N for “No” response. Indicates if subrogation has been waived on the workers compensation policy. :

Enter identifier: The identifier assigned by the insurer to the workers' compensation and employers liability policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. :

Enter date: The effective date of the workers' compensation and employers liability policy. The date that the terms and conditions of the policy commence. .:

Enter date: The date on which the terms and conditions of the workers' compensation and employers liability policy will expire. :

Check the box (if applicable): Indicates that workers compensation coverage is per statute. :

Check the box (if applicable): Indicates that additional coverage above the workers compensation statutory limits applies (permitted in some states). :

Enter text: The description of other coverage (not the limit) on the workers compensation and employers liability policy. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the DESCRIPTION OF OPERATIONS section is available if more space is required.:

Enter limit: The workers compensation and employers liability policy, employers liability each accident limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). :

Enter limit: The workers compensation and employers liability policy, employers liability disease each employee limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy.:

Enter limit: The workers compensation and employers liability policy, employers liability disease policy limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). :

Enter code: The Company Letter of the insurer, as identified in the "Insurer(s) Affording Coverage" form section, associated with the other policy. :

Enter text: The description of the other policy not listed on the form. :

Enter Y for a “Yes” response. Input N for “No” response. Indicates if the certificate holder has been named as an additional insured on the other policy. :

Enter Y for a “Yes” response. Input N for “No” response. Indicates subrogation has been waived on the other policy. :

Enter identifier: The other policy number exactly as it appears on the policy, including prefix and suffix symbols. :

Enter date: The date on which the terms and conditions of the other policy commence. :

Enter date: The date on which the terms and conditions of the other policy expires. :

Enter code: The coverage code for the other policy. :

Enter limit: The other policy, coverage limit amount. Any questions about appropriate limits or applicable policy coverage(s) should be answered by the issuing insurer(s). As used here, the limit should be listed as a whole dollar amount, as governed by the policy.:

Enter code: The coverage code for the other policy. :

Enter text: The Certificate Of Liability Insurance general remarks. The additional comments or special conditions that may exist upon the policy. ACORD 101, Additional Remarks Schedule, may be attached if more space is required. As used here, records information necessary to identify the operations, locations and vehicles for which the certificate was issued.:

Enter text: The certificate holder's full name. :

Enter text: The certificate holder's mailing address line one. :

Enter text: The certificate holder's mailing address line two. :

Enter text: The certificate holder's mailing address city name. :

Enter code: The certificate holder's mailing address state or province code. :

Enter code: The certificate holder's mailing address postal code. :

Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent, broker, etc.) of the company(ies) listed on the document. This is required in most states. :

File details come from the government source that posted it. Updated Sep 23, 2026.