Page 257 - Urban Construction Project Management

212 Chapter Ten
Exhibit 10-2
Certificate of liability insurance.

Certificate of Insurance Issue Date (MM/DD/YY)

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.
PRODUCER
INSURERS AFFORDING COVERAGE NAIC #
INSURER A
INSURED
INSURER B
INSURER C
Subcontractor’s Name
INSURER D
INSURER E
COVERAGES
THIS IS TO CERTIFY THAT 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 HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUTIONS AND CONDITIONS OF SUCH POLICIES.
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO POLICY EFFECTIVE POLICY EXPIRATION
LTR. TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY) DATE (MM/DD/YY) Limits
GENERAL LIABILITY POLICY NUMBER
X COMMERCIAL GENERAL LIABILITY PERPROJECT AGGREGATE EACH OCCURRENCE $ 1,000,000
CLAIMS X OCCUR. ENDORSEMENT
MADE 50′ RAILROAD EXCLUSION PRODUCTS-COMP/OP AGG. $ 1,000,000
OWNER’S & CONTRACTOR’S PILOT PERSONAL & ADV INJURY $ 1,000,000
ELIMINATED
X ISO FORM CG0001 GENERAL AGGREGATE $ 2,000,000
(11/BB PR EQUIVALENT)
X CONTRACTL LIAB. FIRE DAMAGE (Any one foto) $ 300,000
GENL AGGREGATE LIMIT APPLIES PER: MED, EXPENSE (Any one person) $ 5,000
POL- PRO-
ICY X JECT LOC
COMBINED SINGLE
AUTOMOBILE LIABILITY POLICY NUMBER $ 1,000,000
LIMIT
X ANY AUTO
BODILY INJURY
ALL OWNED AUTOS (Per person) $
SCHEDULED AUTOS
BODILY INJURY
HIRED AUTOS (Per accident) $
NON-OWNED AUTOS
GARAGE PROPERTY DAMAGE $
EXCESS LIBILITY POLICY NUMBER
X UMBRELLA FORM PER PROJECT EACH OCCURRENCE 2,000,000
ENDORSEMENT
OTHER THAN UMBRELLA AGGREGATE $ 2,000,000
INCLUDED
FORM
WORKERS COMPENSATION POLICY NUMBER X STATUTORY LIMITS
AND EACH ACCIDENT $ *500,000
EMPLOYER’S LIABILITY COVERAGE APPLIES IN STATE DISEASE-POLICY LIMIT $ *1,000,000
OF JOBSITE OPERATION
THE PROPRIETOR, X INCL. UNDER THIS SUBCONTRACT
PARTNERS EXECUTIVE USL&H COVERAGE IS INCL- DISEASE-EACH
EMPLOYEE
OFFICERS ARE EXCL. UDED WHERE NEEDED $ *500,000
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED ** BEFORE THE EXPIRATION
DATE THEREOF , THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO
THE CERTIFICATE HOLDER NAMED TO THE LEFT BUT FAILURE TO MAIL SUCH NOTICE SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR
This must be crossed out REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
** NON-RENEWED OR MATERIALLY CHANGED
Initials__________/_________