Insurance Performance Certificate of Insurance

INSURANCE PERFORMANCE CERTIFICATE OF INSURANCE

Insurer and Producer

Producer / Broker:

Contact Phone:    Email:

Insured / Contractor (Applicant)

Date of Birth:    Phone:    Email:

Entity Type: Individual Partnership Corporation LLC

Certificate Holder & Project

Policy Information and Coverage Limits

This certificate attests that the policies described below are in force for the insured named herein for the period and limits indicated. Coverage provided is subject to all terms, conditions, limitations and exclusions of the policies.

Commercial General Liability

Policy Number:    Policy Period From:   To:

Each Occurrence: $    General Aggregate: $    Deductible: $

Automobile Liability

Policy Number:    Policy Period From: To:

Combined Single Limit (or BI/PD): $    Vehicles Covered:

Workers' Compensation & Employers' Liability

WC Policy Number:    Policy Period From: To:

Employers' Liability Limits: $

Umbrella / Excess Liability

Policy Number:    Limit: $

Professional Liability (if applicable)

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

Endorsements, Additional Conditions, and Waivers

The insurer attests that the following endorsements are: (check if provided)

Additional Insured endorsement in favor of the Certificate Holder
Waiver of Subrogation in favor of the Certificate Holder
Primary and Non-Contributory wording applies
Cross-Liability / Severability of Interest applies

Exclusions and Limitations

The coverage afforded under the policies described herein is subject to all exclusions and limitations contained in the policies. Typical exclusions may include, but are not limited to: punitive damages where not insurable, contractual liability beyond policy wording, loss arising from intentional acts, pollution unless specifically endorsed, and professional services unless specifically endorsed. This certificate does not alter, extend, or validate the coverage afforded by the policies.

I acknowledge that the Certificate Holder relies on the full policy language for rights and obligations and that the certificate is issued as a matter of information only.

Beneficiary Designation (If applicable)

Beneficiary Name:    Relationship:

Beneficiary Percentage:

Claims and Notice Information

Phone:    Email:

Declaration and Certification

The undersigned certifies that the policies described above are in full force and effect on the date of issuance; that the insurer named above is authorized to issue this Certificate of Insurance; and that the information set forth herein is true and correct to the best of the undersigned's knowledge. This certificate is issued as a matter of record and does not confer any rights to the certificate holder beyond those provided by the underlying insurance policy(ies). The insurer will provide notice of cancellation or material change as required by the policy language, subject to the policy provisions regarding notice periods and permissibility of such notices.

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