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    Sample: Certificate of Liability Insurance

    Uploaded by

    Jude Tucker
    This document is an ACORD certificate of liability insurance that provides information about insurance policies held by an insured party. It lists the types of insurance coverage provided, including general liability, automobile liability, workers' compensation, and excess/umbrella liability. For each type of coverage, it provides the policy number, effective and expiration dates, and coverage limits. It also notes that the certificate does not confer any rights to the certificate holder and is being provided for informational purposes only.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Sample: Certificate of Liability Insurance

    Uploaded by

    Jude Tucker
    101 views2 pages
    This document is an ACORD certificate of liability insurance that provides information about insurance policies held by an insured party. It lists the types of insurance coverage provided, including general liability, automobile liability, workers' compensation, and excess/umbrella liability. For each type of coverage, it provides the policy number, effective and expiration dates, and coverage limits. It also notes that the certificate does not confer any rights to the certificate holder and is being provided for informational purposes only.

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    ac

    Original Title

    c Coi Acord25

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    This document is an ACORD certificate of liability insurance that provides information about insurance policies held by an insured party. It lists the types of insurance coverage provided, including general liability, automobile liability, workers' compensation, and excess/umbrella liability. For each type of coverage, it provides the policy number, effective and expiration dates, and coverage limits. It also notes that the certificate does not confer any rights to the certificate holder and is being provided for informational purposes only.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    101 views2 pages

    Sample: Certificate of Liability Insurance

    Uploaded by

    Jude Tucker
    This document is an ACORD certificate of liability insurance that provides information about insurance policies held by an insured party. It lists the types of insurance coverage provided, including general liability, automobile liability, workers' compensation, and excess/umbrella liability. For each type of coverage, it provides the policy number, effective and expiration dates, and coverage limits. It also notes that the certificate does not confer any rights to the certificate holder and is being provided for informational purposes only.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    ACORD

    PRODUCER

    TM

    CERTIFICATE OF LIABILITY INSURANCEClear

    Save

    DATE (MM/DD/YYYY)

    THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC #

    INSURED

    INSURER A: INSURER B: INSURER C: INSURER D: INSURER E:

    COVERAGES
    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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
    INSR ADDL LTR INSRD

    TYPE OF INSURANCE GENERAL LIABILITY

    POLICY NUMBER

    POLICY EFFECTIVE DATE (MM/DD/YY)

    POLICY EXPIRATION DATE (MM/DD/YY)

    LIMITS

    COMMERCIAL GENERAL LIABILITY CLAIMS MADE

    OCCUR

    GENL AGGREGATE LIMIT APPLIES PER: PROPOLICY LOC JECT


    AUTOMOBILE LIABILITY

    Sample

    EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurence) MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP/OP AGG

    $ $ $ $ $ $

    ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS

    COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident)

    $ $ $ $ $ $ $

    GARAGE LIABILITY

    AUTO ONLY - EA ACCIDENT OTHER THAN AUTO ONLY: EA ACC AGG

    ANY AUTO

    EXCESS/UMBRELLA LIABILITY

    EACH OCCURRENCE AGGREGATE

    OCCUR

    CLAIMS MADE

    DEDUCTIBLE RETENTION $ WC STATUTORY LIMITS OTHER

    $ $

    WORKERS COMPENSATION AND EMPLOYERS LIABILITY


    ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS below

    OTHER

    DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS

    Sample
    CANCELLATION
    REPRESENTATIVES. AUTHORIZED REPRESENTATIVE

    E.L. EACH ACCIDENT

    E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $

    CERTIFICATE HOLDER

    SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN

    NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR

    ACORD 25 (2001/08)

    ACORD CORPORATION 1988

    IMPORTANT

    If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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).

    DISCLAIMER
    The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.

    ACORD 25 (2001/08)

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