Sample_Insurance_Template.pdf
PDF 308 KB Posted
- Attached to
- 26LS0005 - Temporary Relief Physician Services
- Solicitation number
- 0000039962
- Issued by
- Los Angeles County, California
About this file
This is a Certificate of Insurance template issued by the State of California, Department of Veterans Affairs, for Solicitation Number 26LS0005 regarding temporary relief physician services at the Veterans Home of California - Lancaster. The certificate serves as proof of insurance coverage and does not confer any rights upon the certificate holder or amend existing policy coverage. The template accommodates multiple insurance companies and requires documentation of various coverage types including general liability, commercial general liability, automobile liability, garage liability, excess liability/umbrella coverage, and workers' compensation and employers' liability insurance. The certificate must identify policy numbers, effective dates, expiration dates, and coverage limits for each insurance type.
The document requires that the State of California, its officers, agents, employees, and servants be named as additional insureds with respect to work performed for the state. The certificate holder is identified as the State of California, P.O. Box 4038, Sacramento, CA 95812-4038, and must reference the applicable bid number. The issuing insurance company agrees to provide 30 days' written notice of policy cancellation to the certificate holder, though failure to provide such notice imposes no obligation or liability upon the company or its representatives. The authorized representative must certify under penalty of perjury that all information provided on the certificate is true and correct.
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Text version
State of California Solicitation Number: 26LS0005 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.
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