Insurance Certificate of Insurance

CERTIFICATE OF INSURANCE

Producer / Agent

Insurer and Certificate Data

Insurer Name:    Certificate Number:

Issue Date:    Insurer Address:

Named Insured / Applicant

Date of Birth:

Policy Information & Coverages

The following insurance policies have been issued to the Named Insured identified above. Limits shown are per policy unless otherwise stated.

Covered:   Insurer:  Policy #:

Effective:  Expires:  Each Occurrence:  General Aggregate:

Covered:   Insurer:  Policy #:

Effective:  Expires:  Combined Single Limit:

Covered:   Insurer:  Policy #:

Effective:  Expires:  Limit:

Covered:   Insurer:  Policy #:

Effective:  Expires:  Limit:  Deductible:

Covered:   Insurer:  Policy #:

Effective:  Expires:  Employers' Liability:  Jurisdiction:

Covered:   Insurer:  Policy #:

Effective:  Expires:  Limit:  Retroactive Date (if any):

Description of Operations / Additional Insureds

Describe the operations, projects, locations and any parties to be designated as additional insureds. Include any special endorsements or project-specific underwriting conditions below.

Exclusions and Limitations

The coverage described above is subject to all terms, conditions, exclusions and limitations of the policies issued by the insurers. Common exclusions include intentional acts, contractual liability beyond indemnity obligations, punitive damages where not insurable, war, nuclear hazard and pollution unless specifically endorsed. Any deviations from standard policy terms must be noted below.

Cancellation

It is understood and agreed that should any of the above described policies be cancelled before the expiration date, the issuing insurer will endeavor to provide written notice of cancellation to the Certificate Holder identified below in accordance with policy provisions. For the purposes of this certificate, the insurer's obligation is limited to the issuance of notice and does not amend, extend or alter the coverage provided by the policy(ies).

Certificate Holder

Certification

This Certificate of Insurance is issued as a matter of information only and confers no rights upon the certificate holder. The certificate does not modify, extend or alter the coverage, terms, conditions, exclusions or limitations of any policy shown. Coverage afforded under the policies described herein is subject to all the terms, conditions, exclusions and endorsements of such policies. Any statement that the certificate holder is an additional insured or loss payee remains subject to the terms of the applicable endorsement and policy.

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