Certificate Of Liability Insurance Template - Free Download
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Certificate Of Liability Insurance Template
Certificate Of Liability Insurance Template
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
Month/Date/Year
PRODUCER
Insurnce Agent/Broker Name
Insurnce Agent/Broker Street Address or P.O. Box
Insurnce Agent/Broker City, State & Zip Code
Contact & Phone Number
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
Vendor Name
Vendor Street Address or P.O. Box
Vendor City, State & Zip Code
INSURER A: Name of Insurance Company
Enter NAIC#
INSURER B: Name of Insurance Company (if applicable)
Enter NAIC#
INSURER C: Name of Insurance Company (if applicable)
Enter NAIC#
INSURER D: Name of Insurance Company (if applicable)
Enter NAIC#
INSURER E: Name of Insurance Company (if applicable)
Enter NAIC#
COVERAGES
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MM/DD/YY)
POLICY EXPIRATION
DATE (MM/DD/YY)
LIMITS
A
GENERAL LIABILITY
COMMERICAL GENERAL LIABILITY
CLAIMS MADE OCCUR
GEN’L AGGREGATE LIMIT APPLIES PER:
POLICY PROJECT LOC
Enter Policy #
Enter Effective
Date
Enter Expiration
Date
EACH OCCURENCE
$1,000,000
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$100,000
MED EXP (Any one person)
$N/A
PERSONAL & ADV INJURY
$1,000,000
GENERAL AGGREGATE
$2,000,000
PRODUCTS - COMP/OP AGG
$1,000,000
$
A
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
Enter Policy #
Enter Effective
Date
Enter Expiration
Date
COMBINED SINGLE LIMIT
(Each Occurrence)
$1,000,000
BODILY INJURY
(Per person)
$
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
A
GARAGE LIABILITY
ANY AUTO
Enter Policy # (if
required)
Enter Effective
Date
Enter Expiration
Date
AUTO ONLY - EA ACCIDENT
$1,000,000
OTHER THAN
AUTO ONLY:
EA ACC
$
AGG
$
A
EXCESS/UMBRELLA LIABILITY
OCCUR CLAIMS MADE
DEDUCTIBLE
RETENTION $Enter Amount
Enter Policy # (if
required)
Enter Effective
Date
Enter Expiration
Date
EACH OCCURRENCE
$Enter Limit
AGGREGATE
$Enter Limit
$
$
$
A
WORKERS COMPENSATION AND
EMPLOYERS’ LIABILITY
ANY PROPRIETOR/PARTNER/EXECU-
TIVE OFFICER/MEMBER EXCLUDED
If yes, describe under
SPECIAL PROVISIONS below
Enter Policy #
Enter Effective
Date
Enter Expiration
Date
WC STATU-
TORY LIMITS
OTH-
ER
E.L. EACH ACCIDENT
$500,000
E.L. DISEASE - EA EMPLOYEE
$500,000
E.L. DISEASE - POLICY LIMIT
$500,000
OTHER
CERTIFICATE HOLDER
CANCELLATION
The Board of Trustees of the University of Alabama
Attn: Risk Management Dept. (or requesting party/department)
P.O. Box 870119 (or address of requesting party/department)
Tuscaloosa, AL 35487-0119
Facsimile Number: (205) 348-3312
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO
MAIL 30 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 REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2001/08) © ACORD CORPORATION 1988
INSR
LTR
ADD’L
INSRD
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