Sample Insurance Certificate

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:

PHONE

(A/C, No, Ext):

E-MAIL

ADDRESS:

PRODUCER

FAX

(A/C, No):

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

LTR

ADDL SUBR

INSD WVD

TYPE OF INSURANCE

POLICY NUMBER

POLICY EFF

POLICY EXP

(MM/DD/YYYY) (MM/DD/YYYY)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE

OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

PROPOLICY

LOC

JECT

LIMITS

EACH OCCURRENCE

DAMAGE TO RENTED

PREMISES (Ea occurrence)

$

MED EXP (Any one person)

$

PERSONAL & ADV INJURY

$

GENERAL AGGREGATE

$

PRODUCTS - COMP/OP AGG

$
$

OTHER:

COMBINED SINGLE LIMIT

(Ea accident)
BODILY INJURY (Per person)

AUTOMOBILE LIABILITY

ANY AUTO

OWNED

AUTOS ONLY

HIRED

AUTOS ONLY

$

SCHEDULED

AUTOS

NON-OWNED

AUTOS ONLY

$
$

BODILY INJURY (Per accident) $

PROPERTY DAMAGE

(Per accident)

$
$

UMBRELLA LIAB

OCCUR

EACH OCCURRENCE

$

EXCESS LIAB

CLAIMS-MADE

AGGREGATE

$

DED

RETENTION $

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

ANYPROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)
If yes, describe under

DESCRIPTION OF OPERATIONS below

$
PER

STATUTE

Y/N

OTHER

E.L. EACH ACCIDENT

N/A

$

E.L. DISEASE - EA EMPLOYEE $

E.L. DISEASE - POLICY LIMIT

$

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