Sample COI Template – US Enercorp Ltd/Ageron Energy LLC

DATE (MM/DD/YYYY)
CERTIFICATE OF INSURANCE MM/DD/YYYY
PRODUCER

INSURED INSURER(S) AFFORDING COVERAGE NAIC #

Name of Insured INSURER A : List all insurers (AM Best A- VII or higher) List all NAICs
INSURER B:
Address
INSURER C:
City, State, Zip
INSURER D:

INSR ADDL SUBR EFFECTIVE EXPIRATION

LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER DATE DATE LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY X X Required Required Required DAMAGE TO RENTED PREMISES

CLAIMS-MADE X OCCUR MED EXP (Any one person)

PERSONAL & ADV INJURY 00,000
____________________________ GENERAL AGGREGATE
____________________________ PRODUCTS - COMP/OP AGG

AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $1,000,000

X ANY AUTO X X Required Required Required BODILY INJURY (Per person)
ALL OWNED SCHEDULED
AUTOS AUTOS BODILY INJURY (Per accident)
NON-OWNED
HIRED AUTOS
AUTOS
PROPERTY DAMAGE (Per accident)
Annual Aggregate
EACH OCCURRENCE
$4,000,000
EXCESS / UMBRELLA LIABILITY AGGREGATE
$4,000,000
PER
WORKERS’ COMPENSATION
AND EMPLOYERS’ LIABILITY
X STATUTE
OTHER
Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? N/A X Required Required Required
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000

• Endorsements Required:
o Commercial General Liability Additional Insured (On-Going Operations)
o Commercial General Liability Additional Insured (Completed Operations)
o Commercial General Liability Waiver of Subrogation
o Commercial General Liability Primary & Non-Contributory
o Auto Liability Waiver of Subrogation
o Auto Liability Additional Insured
o Workers Compensation Waiver of Subrogation
• REQUIRED: Signed Master Service Agreement, W9, and Business License

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
US Enercorp LTD, Enercorp LLC, US ACCORDANCE WITH THE POLICY PROVISIONS.
Enercorp LLC, Ageron Energy LLC &
AUTHORIZED REPRESENTATIVE
Ageron Holdings LLC
1250 NE Loop 410, Ste 500
ELECTRONIC OR WRITTEN SIGNATURE REQUIRED
San Antonio, TX 78217

All documents should be emailed to AgeronLLC@bcsops.com or faxed to (210) 855-4690