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ACORD 25 — Certificate Header

Date (MM/DD/YYYY)

Certificate Number

Revision Number

Producer (Your Agency)

Producer Name & Address

Contact Name

Phone (A/C, No, Ext)

Fax (A/C, No)

E-Mail Address

Insured

Insured Name & Address

Insurers Affording Coverage

Insurer A

NAIC # (Insurer A)

Insurer B

NAIC # (Insurer B)

Insurer C

NAIC # (Insurer C)

Insurer D

NAIC # (Insurer D)

Insurer E

NAIC # (Insurer E)

Insurer F

NAIC # (Insurer F)

Coverages

Commercial General Liability

Insr Ltr

Policy Number

Policy Eff (MM/DD/YYYY)

Policy Exp (MM/DD/YYYY)

Claims-Made or Occur

Addl Insd (Y/N)

Each Occurrence $

Damage to Rented Premises $

Med Exp (Any one person) $

Personal & Adv Injury $

General Aggregate $

Products – Comp/Op Agg $

Automobile Liability

Insr Ltr

Policy Number

Policy Eff

Policy Exp

Auto Type

Combined Single Limit $

Bodily Injury (Per person) $

Bodily Injury (Per accident) $

Property Damage (Per accident) $

Umbrella / Excess Liability

Insr Ltr

Policy Number

Policy Eff

Policy Exp

Type

Each Occurrence $

Aggregate $

Workers Compensation & Employers’ Liability

Insr Ltr

Policy Number

Policy Eff

Policy Exp

Statute / Other

E.L. Each Accident $

E.L. Disease – Ea Employee $

E.L. Disease – Policy Limit $

Officer/Member Excluded? (Y/N)

Description of Operations / Locations / Vehicles

Authorized Representative

Your Certificate of Liability Insurance

Fields highlighted in blue are editable. All other fields are locked by your agent.

ACORD^®

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

PRODUCER

CONTACT NAME:

PHONE (A/C, No, Ext):

FAX (A/C, No):

E-MAIL ADDRESS:

INSURER(S) AFFORDING COVERAGE

NAIC #

INSURER A :
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :

INSURED

COVERAGES CERTIFICATE NUMBER:

REVISION NUMBER:

THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

INSR LTR	TYPE OF INSURANCE	ADDL INSD	SUBR WVD	POLICY NUMBER	POLICY EFF (MM/DD/YYYY)	POLICY EXP (MM/DD/YYYY)	LIMITS

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

CERTIFICATE HOLDER

CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)