Certificate of Insurance Specimen

CERTIFICATE OF INSURANCE SPECIMEN

Producer:   Phone:

Insurer(s) Affording Coverage:

Named Insured:

Mailing Address:

WHEREAS

WHEREAS, the Named Insured identified above has requested written assurance that insurance policies described herein are in force for the benefit of certain third parties and for work to be performed under applicable contracts; and

WHEREAS, the Producer and Insurer(s) have issued or bound the insurance policies described below to afford the coverages, limits and provisions set forth in this specimen certificate; and

WHEREAS, this Certificate of Insurance Specimen is furnished to document the existence of coverages and specific policy provisions as requested by the certificate holder and does not alter, extend or affect the policy terms, conditions, exclusions or endorsements.

CERTIFICATION

This is to certify that the policies of insurance listed below have been issued to the Named Insured and are in full force on the date of issuance of this certificate. Limits shown are the limits applicable to the policy period and are subject to all policy provisions, endorsements and exclusions. Coverage afforded under each policy is subject to the terms, conditions and exclusions of the respective policy.

SCHEDULE OF INSURANCE

Commercial General Liability

Policy Number:   Effective:   Expires:

Each Occurrence Limit:   General Aggregate:

Automobile Liability

Policy Number:   Effective:   Expires:

Combined Single Limit:

Workers' Compensation and Employers' Liability

Policy Number:   Effective:   Expires:

Employers' Liability:

Professional / E&O Liability (if applicable)

Policy Number:   Retroactive Date (if any):   Limit:

ADDITIONAL COVERAGE PROVISIONS

Additional Insured:  Yes    Waiver of Subrogation:  Yes    Primary and Noncontributory:  Yes

Cancellation Provision: The insurer shall endeavor to provide advance written notice to the certificate holder of cancellation or material change in coverage, but such notice shall be governed by the terms of the policy and statutory requirements; this Certificate does not amend, extend or alter the coverage afforded by the policies listed.

SCOPE OF WORK

PAYMENT TERMS (CONTRACTUAL SECTION)

Contract Price / Value of Work:

Late Payment Fee: . Any unpaid amounts shall bear interest or fees as stated above and are subject to contract remedies.

TERM AND TERMINATION

Agreement Start Date:   Agreement End Date:

Termination for Convenience with Notice of days by either party; termination for cause shall be effective upon written notice if a material breach is not cured within the cure period set forth in the underlying contract.

CONFIDENTIALITY

Each party shall maintain in confidence all nonpublic information disclosed by the other party that is designated confidential or that reasonably should be understood to be confidential given the nature of the information and the circumstances of disclosure. Confidential information shall not include information that is: (a) publicly available through no fault of the receiving party; (b) rightfully received from a third party without an obligation of confidentiality; or (c) independently developed without use of the other's confidential information. Obligations of confidentiality shall survive termination or expiration for a period of three (3) years unless otherwise stated.

GOVERNING LAW

This specimen and any dispute arising out of or relating to these documented assurances and the associated contract obligations shall be governed by and construed in accordance with the laws of , without regard to conflicts of laws principles.

ENTIRE AGREEMENT

This Certificate of Insurance Specimen, together with any endorsements or attachments specifically referenced herein, constitutes the entire written understanding as to the existence and scope of the insurance coverages represented and supersedes any prior written representations concerning coverage. Nothing in this specimen shall create duties or obligations on the part of the Producer or Insurer not otherwise contained in the underlying insurance policies.

Issuer Contact Name:   Title:

Issuer Address:

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