Date

Certi cate of Liability Insurance Template

22/7/20
21

Producer Contact Person Phone Number ☎

Email

Insurers Affording Coverage

Insured
vganesh@example.com

Coverages

Type of Insurance Limits

Insr Ltr General Liability Policy Number Each Occurrence

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augue. Aliquam erat volutpat. Policy Effective Date

Policy Expiration Date Medical Expense (Any Person)

General Aggregate Limit Applies Per Personal and Advertising Injury

General Aggregate

Bodily Injury (Per accident)

Insr Ltr Automobile Liability Policy Number Combined Single Unit (ea
accident)

Bodily Injury (Per person)

Policy Effective Date

Property Damage (Per Accident)

Policy Expiration Date

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 Date
Certi cate of Liability Insurance Template
22/7/20
21

Garage Liability Limits

Insr Ltr Garage Liability Policy Number Auto Only - EA Accident

Policy Effective Date Other than Auto Only (Agg)

Other than Auto Only (ea acc)

Policy Expiration Date

Aggregate

Insr Ltr Excess/Umbrella Liability Policy Number Each Occurrence

Policy Effective Date

Policy Expiration Date

Deductible amount Retention amount

Workers compensation and employer's liability

Insr Ltr Any proprietor / partner / executive member excluded? Policy Number WC Statutory Limits

Policy Effective Date

E.L. Each Accident

Policy Expiration Date

E.L. Disease - Ea Employee

E.L. Disease - Policy Limit

Description of Details / Special Provisions

Certi cate Holder Name Authorized Representative

signature

Certi cate Holder Address

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