Transcription of CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
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CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
CERTIFICATE HOLDERANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED?(Mandatory in NH)If yes, describe underSPECIAL PROVISIONS below 1988- 2009 ACORD CORPORATION. All rights 25 (2009/09)AUTHORIZED REPRESENTATIVECANCELLATIONDATE (MM/DD/ yyyy ) CERTIFICATE OF LIABILITY INSURANCELOCJECTPRO-POLICYGEN'L AGGREGATE LIMIT APPLIES PER:OCCURCLAIMS-MADECOMMERCIAL GENERAL LIABILITYGENERAL LIABILITYPREMISES (Ea occurrence)$DAMAGE TO RENTEDEACH OCCURRENCE$MED EXP (Any one person)$PERSONAL & ADV INJURY$GENERAL AGGREGATE$PRODUCTS - COMP/OP AGG$$RETENTIONDEDUCTIBLECLAIMS-MADEOCCUR $$AGGREGATE$EACH OCCURRENCE$UMBRELLA LIABEXCESS LIABDESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)INSRLTRTYPE OF INSURANCEPOLICY NUMBERPOLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITSWC STATU-TORY EACH DISEASE - EA DISEASE - POLICY LIMIT$$$WORKERS COMPENSATIONAND EMPLOYERS' LIABILITYY / NAUTOMOBILE LIABILITYANY AUTOALL OWNED AUTOSSCHEDULED AUTOSHIRED AUTOSNON-OWNED AUTOS$COMBINED SINGLE LIMIT(Ea accident)BODILY INJURY (Per person)BODILY INJURY (Per accident)PROPERTY DAMAGE(Per accident)$$$$THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED.
(mm/dd/yyyy) limits wc statu-tory limits oth-er e.l. each accident e.l. disease - ea employee e.l. disease - policy limit $ $ $ workers compensation and employers' liability y / n ... expiration date thereof, notice will be delivered in accordance with the policy provisions.
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