Insurance CGL Acord Form

INSURANCE CGL ACORD FORM

Producer / Agent

Producer Name:

Insured

Contact Phone:    Email:

Date of Birth:

Insurer(s) / Carrier Information

Insurer A:

Insurer B:

Policy Information

Policy Type:

Policy Number:

Policy Period From:    To:

Limits of Liability

General Aggregate:

Products — Comp/Op Aggregate:

Each Occurrence:

Damage to Rented Premises (Each Occurrence):

Medical Expenses (Any one person):

Personal & Advertising Injury:

Deductible / Self-Insured Retention:

Coverage Features & Endorsements

Occurrence    Claims-Made    Contractual Liability

Additional Insured Endorsement    Waiver of Subrogation    Primary & Noncontributory

Exclusions

The following standard exclusions apply unless otherwise endorsed. If additional exclusions apply, list them in the Description section below.

Description of Operations / Locations / Vehicles

Provide specific operations, limits applicable by location, and any project-related information required for the certificate.

Certificate Holder / Additional Insured

Cancellation / Notice

Should any of the above-described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions requiring notice to the certificate holder.

Notice Period (if different than policy):

Declaration and Certification

By signing below, the insured certifies that the information provided on this Certificate is true and complete to the best of the insured's knowledge. This Certificate is issued as a matter of information only and confers no rights upon the certificate holder. Coverage afforded under the policies described is subject to all terms, exclusions and conditions of such policies. The issuance of this Certificate does not amend, extend or alter the coverage afforded by the policies listed herein.

Applicant represents that any person or organization shown as a certificate holder is included as an insured only if specified by endorsement issued to the policy. Applicant acknowledges the duty to promptly notify the Producer of any material changes affecting coverage.

Premium / Payment

Claims Notification

All claims, occurrences, or potential claims relating to this Certificate should be reported to the insurer or producer as required by the policy. Failure to provide timely notice may prejudice coverage.

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