SAMPLE CERTIFICATE OF LIABILITY INSURANCE

1 INITIAL GC _____ INITIAL SUBCONTRACTOR _____ SAMPLE CERTIFICATE OF LIABILITY INSURANCE PAGE 1 DATE (MM/DD/YYYY) 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 Your Broker Address City, State, Zip INSURERS AFFORDING COVERAGE INSURER A: A. M. Best rating of A- or better INSURER B: INSURER C: INSURER D: insured Sub Contractor s Name Address City, State, Zip 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.

2 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE POLICY EXPIRATION DATE LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Any one fire) $ 50,000 CLAIMS MADE X OCCUR MED EXP (Any one person) $ 5,000 PERSNAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS COMP/OP AGG $ 2,000,000 A GENERAL AGGREGATE LIMIT APPLIES PER: POL-ICY X PRO-JECT LOC Policy Number Must Include.

3 - additional insured Including Completed Ops - Primary & Non-Contributory - Per Project Aggregate - Waiver of Subrogation (MM/DD/YY) (MM/DD/YY) AUTOMOBILE LIABILITY X ANY AUTO COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per person) $ X HIRED AUTOS X NON-OWNED AUTOS BODILY INJURY (Per accident) $ _____ A Policy Number (MM/DD/YY) (MM/DD/YY) PROPERTY DAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY EA ACCIDENT $ ANY AUTO EA ACCIDENT $ OTHER THAN AUTO ONLY AGGREGATE $ A EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 5,000,000 X OCCUR CLAIMS MADE AGGREGATE $ 5,000,000 DEDUCTIBLE RETENTION Policy Number Must follow form of: - GL, Auto & WC Policies (MM/DD/YY) (MM/DD/YY) X WC STATU-TORY LIMITS OTHER WORKERS COMPENSATION AND EMPLOYERS LIABILITY Policy Number Must Include.

4 (MM/DD/YY) (MM/DD/YY) EACH ACCIDENT $ 500,000 INCL - Waiver of Subrogation DISEASE EA EMPLOYEE $ 500,000 A THE PROPRIETOR/ PARTNERS/EXECUTIVE OFFICERS ARE EXCL DISEASE POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS All operations performed under Project <Insert Project Name> by or on behalf of Subcontractor. (See attached description) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION ATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TOMAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS ORREPRESENTATIVES.

5 General Contractor Name Street Address City, State, Zip AUTHORIZED REPRESENTATIVE SIGNATURE EXHIBIT G SAMPLE CERTIFICATE INITIAL GC _____ INITIAL SUBCONTRACTOR _____ SAMPLE CERTIFICATE PAGE 2 DATE (MM/DD/YYYY) DESCRIPTIONS (Continued from previous page) additional insured : The following are included as additional Insureds (per ISO endorsement Form CG2010 0704 and CG 2037 0704) with respects to General LIABILITY .

6 Primary & Non-Contributory INSURANCE : As respects the General LIABILITY Policy, the additional insured coverage afforded shall be Primary & Non Contributory for all additional Insureds, and any other INSURANCE maintained by such additional Insureds shall be excess only and shall not be called upon to contribute with this INSURANCE . Waiver of Subrogation: Waiver of Subrogation is also provided in favor of the following additional Insureds with respects to General LIABILITY & Workers Compensation. additional Insureds, including their directors, officers, employees, subsidiaries and affiliates: 1.

7 General Contractor 2. Job specific additional insureds ( Owner, Architect, etc.)