Tier I Contractors Sample Certificate of Insurance ...

1 Tier I Contractors Sample Certificate of Insurance Certificate OF Insurance ISSUE date {MM/DD/YY) 3/15/2015 PRODUCER ___J Insurance broker's name 15 Certificate IS ISSUED AS A MATTER OF IN RIGHTS UPON THE Certificate HOLDER Insurance carrier's name; XYZ Insurance Brokerage MmLND, EXTEND OR ALTER THE COVERAGE AFFC letter next to carrier's name 1150 Bridge Street corresponds to individual Berns, PA 19002 '.A policies below to the far left COMPANIES AFFO G 1.,UVLK/-\\:>C COMPANY LETTER A ABC Insurance COMPANY INSURED COMPANY LETTER B Any Vendor Insured/vendor's name appears here r C 1313 Mockingbird Lane I.}

2 "Y D LETTER Mockingbird Heights, CA 90200 COMPANY LETTER 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. OPERATIONS THIS Certificate OF Insurance COVERS ALL OPERATIONS OF THE INSURED NAMED ABOVE FOR THE Certificate HOLDER FOR THE FOLLOWING PROJECT: ? PROJECT# & NAME: co TYPE OF Insurance LTR GENERAL LIABILITY A 0 COMM. GENERAL LIABILITY 0 CLAIMS MADE D OCCUR. D OWNER'S & CONTRACTOR'S PROT. D AUTOMOBILE LIABILITY A 0 ANYAUTO 0 ALL OWNED AUTOS 0 SCHEDULED AUTOS 0 HIRED AUTOS 0 NON-OWNED AUTOS 0 GARAGE LIABILITY EXCESS LIABILITY 0 UMBRELLA FORM 0 OTHER THAN UMBRELLA FORM A WORKERS COMPENSATION AND EMPLOYERS LIABILITY OTHER I OTHER PROVISIONS I Policies must be renewed by this date .

3 / POLICY NUMBER POLICY EFFECTIVE POLICY ' LIMITS date (MM/DDIYY) EXPIRATION date (MM/DD/VY ,,_ GL123456789 12/17/2009 12/17/2010 Tier I contractor general liability minimum Tier I contractor auto liability I \.,AIL.)'100/tl:1 IL/ I IILU iU 12/17/2010 Above Tier I contractor-minimums Imay be satisfied with excess liability oolicv with a minimum limit of $1 M I I NOT APPLICA Statutory Limits box for workers' compensation must be checked WC123456789 12/17/2009 12/17/2010 Tier I contractor employee liability GENERAL AGGREGATE PRODUCTS-COP/GP AGG.

4 PERSONAL & ADV. INJURY FIRE DAMAGE (Anv one fire I (Anv one person) BODILY INJURY /Per Person) BODILY INJURY (Per Accident) PROPERTY DAMAGE EACH - AGGREGATE XO STATUTORY LIMITS EACH A :i" -, L POLICY LIMIT DISEASE -EACH EMPLOYEE $1 000000 $XXXXXXXX $XXXXXXXX $1,000,0000 $XXXXXXXX $XXXXXXXX $1,000,000 $XXXXXXXX $XXXXXXXX $XXXXXXXX $1 000000 $XXXXXXXX $500 000 $500 000 $500,000 Airgas, Inc, and its respective employees, subsidiaries, affiliates, divisions, officers, directors, agents, and all of our subcontractors and their employees are included as additional insureds under all such Insurance , except Workers' Compensation.

5 ___IStatement !!!Y. ! appear as written on Certificate I Certificate HOLDER Airgas SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED OR MATERIALLY CHANGED 123A-dS1 BEFORE THE EXPIRATION date THEREOF, THE ISSUING COMPANY WILL PROVIDE THIRTY (30) Philadelphia, PA 19000 DAYS WRITIEN NOTICE TO THE Certificate HOLDER NAMED TO THE LEFT. AUTHORIZED REPRESENTATIVE: I Airgas company name here with address I I ARG-SM (b) (08/2015)