Certificate of Liability Insurance

Certificate of Liability Insurance
Name of Producer
Address of Producer
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Name of Insured
Address of Insured
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Contact Information
Contact Person
First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Insurers affording Coverage
Rows Name NAIC No.
Insurer A
Insurer B
Insurer C
Coverage
Type of Insurance
General Liability
General Aggregate Limit Applies Per
Insr Ltr
Policy Number
Policy Effective Date
MonthDayYear
Date
Policy Expiration Date
MonthDayYear
Date
Limits
Each Occurrence
Damage to Rented Premises
Medical Expense (Any Person)
Personal and Advertising Injury
General Aggregate
Automobile Liability
Insr Ltr
Automobile Liability
Policy Number
Policy Effective Date
MonthDayYear
Date
Policy Expiration Date
MonthDayYear
Date
Limits
Combined Single Unit (ea accident)
Bodily Injury (Per person)
Bodily Injury (Per accident)
Property Damage (Per Accident)
Garage Liability
Insr Ltr
Garage Liability
Policy Number
Policy Effective Date
MonthDayYear
Date
Policy Expiration Date
MonthDayYear
Date
Limits
Auto Only - EA Accident
Other than Auto Only (ea acc)
Other than Auto Only (Agg)
Excess/Umbrella Liability
Insr Ltr
Excess/Umbrella Liability
Deductible amount
Retention amount
Policy Number
Policy Effective Date
MonthDayYear
Date
Policy Expiration Date
MonthDayYear
Date
Limits
Each Occurrence
Aggregate
Workers compensation and employer's liability
Insr Ltr
Any proprietor / partner / executive member excluded? If yes, describe in Description of Operations below
Policy Number
Policy Effective Date
MonthDayYear
Date
Policy Expiration Date
MonthDayYear
Date
WC Statutory Limits
Other
E.L. Each Accident
E.L. Disease - Ea Employee
E.L. Disease - Policy Limit
Description of Operations / Locations / Vehicles / Exclusions added by Endorsement / Special Provisions
Certificate Holder Name
First NameLast Name
Certificate Holder Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Authorized Representative
Should be Empty:

Rows	Name	NAIC No.
Insurer A
Insurer B
Insurer C

Certificate of Liability Insurance

Limits

Limits

Limits

Limits