ACORD ™ CERTIFICATE OF LIABILITY INSURANCE - SAMPLE         DATE: 05/05/2000

 

NOTE: Set your printer margins for .25 on all sides before printing.

               

PRODUCER

Agency

Address

City, State, Zip

 

 

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

INSURED

Sample

Address

City, State, Zip

 

INSURER A:  LEMIC INSURANCE COMPANY

INSURER B: 

INSURER C: 

INSURER D: 

INSURER E:

COVERAGES

THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.  AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

INSR

LTR

TYPE OF INSURANCE

POLICY NUMBER

POLICY EFFECTIVE

DATE (MM/DD/YY)

POLICY EXPIRATION

DATE (MM/DD/YY)

LIMITS

 

GENERAL LIABILITY

 

 

 

 

EACH OCCURRENCE

$

o COMMERCIAL GENERAL LIABILITY

FIRE DAMAGE (Any one fire)

$

o CLAIMS MADE

o OCCUR

MED EXP 

(Any one person)

$

 

o______________________________

 

PERSONAL & ADV INJURY

$

 

o______________________________

 

GENERAL AGGREGATE

$

GEN’L AGGREGATE LIMIT APPLIES PER:

PRODUCTS – COMP/OP AGG

$

o POLICY

o PROJECT

o LOC

 

 

 

AUTOMOBILE LIABILITY

 

 

 

COMBINED

SINGLE LIMIT

(Ea accident)

$

o ANY AUTO

o ALL OWNED AUTOS

BODILY INJURY

(Per person)

$

o SCHEDULED AUTOS

o HIRED AUTOS

BODILY INJURY

(Per accident)

$

o NON – OWNED AUTOS

 

o______________________________

PROPERTY DAMAGE

(Per accident)

$

o______________________________

 

 

GARAGE LIABILITY

 

 

 

AUTO ONLY – (Ea Accident)

$

o ANY AUTO

OTHER THAN AUTO ONLY:

EA ACC

 

AGG

 

$

o______________________________

 

$

 

EXCESS LIABILITY

 

 

 

EACH OCCURRENCE

$

o OCCUR  o CLAIMS MADE

AGGREGATE

$

 

$

o DEDUCTIBLE

 

$

o RETENTION

 

$

A

WORKER’S COMPENSATION AND EM PLOYER’S LIABILITY

777-XXXXX-XX-XXX

01/01/2000

01/01/2000

X/WC STATUTORY

LIMITS / OTHER

 

E.L. EACH ACCIDENT

$10000

E.L. DISEASE – EA EMPLOYEE

$10000

E.L. DISEASE – POLICY LIMIT

$50000

 

OTHER

 

 

 

 

 

DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS

XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

CERTIFICATE HOLDER / ADDITIONAL INSURED; INSURER LETTER___               CANCELLATION 10-Day Notice for Non-Payment of Premium

 

Sample

123 ABC Street

Baton Rouge, LA 70815

 

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER 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 LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.

AUTHORIZED REPRESENTATIVE