Sample_Insurance_Template.pdf
PDF 256 KB Posted
- Attached to
- 26BS0003 - Temporary Relief - Medical Director, Physician, and Physician Assistant Services
- Solicitation number
- 0000039015
- Issued by
- California
About this file
This is a Certificate of Insurance template issued by the State of California Department of Veterans Affairs for Solicitation Number 26BS0003 related to temporary relief medical services at the Veterans Home of California - Barstow. The template establishes insurance requirements that contractors must meet when providing Medical Director, Physician, and Physician Assistant Services to the facility. The certificate serves as proof of insurance coverage and specifies that the State of California, its officers, agents, employees, and servants are named as additional insureds with respect to work performed for the state.
The template outlines mandatory insurance coverages including General Liability with specified aggregate and per-occurrence limits, Commercial General Liability covering products and completed operations, Automobile Liability for any owned, hired, or non-owned vehicles, Excess Liability or Umbrella coverage, and Workers Compensation and Employers' Liability with statutory limits. All policies must include 30 days' written notice of cancellation to the Certificate Holder at the address provided. The certificate specifies that insurance coverage does not amend, extend, or alter the actual policies issued and that all terms, exclusions, and conditions of the underlying policies apply. Coverage limits may have been reduced by paid claims, and the authorized representative must certify under penalty of perjury that the information provided is true and correct.
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Text version
State of California Solicitation Number: 26BS0003 Department of Veterans Affairs
CERTIFICATES OF INSURANCE
DATE (MM/DD/YY) / /
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
NO RIGHT UPON THE CERTIFICATE HOLDER. THIS COVERAGE DOES NOT AMEND,
EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANY
A
INSURED COMPANY
B
COMPANY
C
COMPANY
D
COVERAGES
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 CONDIDTION 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.
TYPE OF INSURANCE POLlCY NUMBER
POLICY
EFFECTIVE
DATE
(MM/DD/YY)
POLICY
EXPIRATION
DATE
(MM/DD/YY)
LIMITS
GENERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS - COMP/OP AGG $
CLAIMS
MADE
OCCUR PERSONAL & ADV INJURY $
OWNER AND CONTRACTOR’S PROT EACH OCCURRENCE $
FIRE DAMAGE (Any one fire) $
MED EXP (Any one person) $
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO
ALL OWNED AUTOS BODILY INJURY (Per person) $
SCHEDULED AUTOS
HIRED AUTOS BODILY INJURY (Per accident) $
NON-OWNED AUTOS
PROPERTY DAMAGE $
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY
EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
WORKERS COMPENSATION AND
EMPLOYERS’ LIABILITY
STATUTORY LIMITS
THE PROPRIETOR/ EACH ACCIDENT $
PARTNERS/ EXECUTIVE
OFFICERS ARE:
INCL DISEASE - POLICY LIMIT $
EXCL DISEASE - EACH EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
The State of California, its officers, agents, employees and servants are hereby named as additional insured but only with respect to work performed for the State of California.
CERTIFICATE HOLDER
ATTENTION:
BID NO.
STATE OF CALIFORNIA
P.O. Box 4038 Sacramento, CA 95812-4038
CANCELLATION
SHOULD ANY OF THE ABOVE-DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE
THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE
NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR
RESPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
I hereby certify under penalty of perjury that the foregoing is true and correct.
X
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