Date

Certi cate of Liability Insurance Template

22/11/2
021

Producer Contact Person Phone Number ☎

Email

Insurers Affording Coverage

Insured

Name NAIC No.

Insurer A

Insurer B

Insurer C

Coverages

Type of Insurance Limits

Insr Ltr General Liability Policy Number Each Occurrence

Commercial General Liability Claims Made

Occur Damage to Rented Premises

Policy Effective Date

Policy Expiration Date Medical Expense (Any Person)

General Aggregate Limit Applies Per Personal and Advertising Injury

Policy Project Location

General Aggregate

Bodily Injury (Per accident)

Insr Ltr Automobile Liability Policy Number Combined Single Unit (ea
accident)
Any Auto All owned Autos

Scheduled Autos Hired Autos Bodily Injury (Per person)

Policy Effective Date
Non-owned Autos

Property Damage (Per Accident)

Policy Expiration Date

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 Date
Certi cate of Liability Insurance Template
22/11/2
021

Garage Liability Limits

Insr Ltr Garage Liability Policy Number Auto Only - EA Accident

Any Auto
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

Occur Claims Made Deductible

Retention 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

Yes No

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

Certi cate Holder Address

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