SAMPLE CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YY)

PRODUCER 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.
INSURANCE AGENT OR BROKER COMPANIES AFFORDING COVERAGE
COMPANY
A
INSURED COMPANY
B INSURANCE COMPANY
COMPANY
SUBCONTRACTOR C
COMPANY
D
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 HERIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

CO POLICY EFFECTIVE
TYPE OF INSURANCE POLICY NUMBER LIMITS
LTR DATE (MM/DD/YY)
GENERAL LIABILITY GENERAL AGGREGATE $ 2,000,000
COMMERCIAL GENERAL
X LIABILITY
PRODUCTS-COMP/OP AGG $ 1,000,000

CLAIMS MADE X OCCUR PERSONAL&ADV INJURY $ 1,000,000

B
OWNER’S & CONTRACTORS PROT EACH OCCURANCE $ 1,000,000

X Contractual Liability
FIRE DAMAGE (Any one fire) $ N/A

MED EXP (Any one person) $ 5,000

AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $ 1,000,000
ANY AUTOS

ALL OWNED AUTOS BODILY INJURY $ 250,000

(Per person)

B SCHEDULED AUTOS
BODILY INJURY
$ 500,000
(Per accident)
HIRED AUTOS

NON-OWNED AUTOS
PROPERTY DAMAGE $ 1,000,000

EXCESS LIABILITY EACH OCCURANCE $ 1,000,000

B UMBRELLA FORM AGGREGATE $ N/A

OTHER THAN UMBRELLA FORM $
WC SATU-
WORKER’S COMPENSATION AND
EMPLOYER’S LIABILITY X TORY OTHER $
LIMITS
EL EACH ACCIDENT $ 100,000
B
THE PROPRIETOR/ INCL EL DISEASE – POLICY LIMIT $ 500,000
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL EL DISEASE – EA EMPLOYEE $ 100,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
Job Site:___________________________________ Apartment #:____________________, Name:________________________________________________
With regard to the approved work to be performed by named insured at the above job site, the following are listed as Additional Insureds: Lexington Belvedere, LLC
and Rose Associates, Inc. and all their partners, officers, shareholders, directors, agents, and employees, respective heirs, successors, assignees, and any owned,
controlled, affiliated, subsidiary company or corp. now existing hereafter constituted, as their interest may appear.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE POLICIES BE CANCELLED OR MATERIALLY
Lexington Belvedere, LLC CHANGED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING
COMPANY WILL ENDEAVOR TO MAIL _30_ DAYS (EXCEPT 10 DAYS FOR
c/o Rose Associates, Inc.
NON-PAYMENT) WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED
200 Madison Avenue, 5th Floor TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO
New York, NY 10016-3998 OBILGATION OF ANY KIND UPON THE COMPANY, ITS AGENTS OR
REPRESENTATIVES.

AUTHORIZED REPRESENTATIVE