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- Sample Certificate of Liability SECTION 00620 p Insurance <br /> CERTIFICATE OF LIABILITY INSURANCE <br /> PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO <br /> RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND <br /> OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br /> COMPANIES AFFORDING COVERAGE <br /> INSURED COMPANY A - <br /> COMPANY B - <br /> COMPANY C - <br /> COMPANY D - <br /> COMPANY E - <br /> COVERAGES <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED <br /> NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED <br /> OR MAY PERTAIN THE INSURANCE ACCORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. <br /> LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> POLICY <br /> POLICY EFFECTIVE POLICY EXPIRATION <br /> MSRTYPE OF INSURANCE NUMBER DATE MMIDD DATE MMID LIMITS <br /> LTR <br /> $ 11000,000 <br /> GENERAL LIABILITY EACH OCCURRENCE <br /> $ 50,000 <br /> A [3 COMMERCIAL GENERAL LIABILITY <br /> FIRE DAMAGE (Any One Fire <br /> $ 5,000 <br /> ❑ CLAIMS MADE - ❑OCCUR MED. EXP. (Any One Person <br /> ❑ PERSONAL & ADV INJURY $ 1 ,000,000 <br /> ❑ GENERAL AGGREGATE $ 11000,000 <br /> ❑ PRODUCTS — COMP/OPAGG. $ 11000,000 <br /> ❑ $ <br /> AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 10000,000 <br /> A ❑ ANY AUTO (Ea. Occurrence) <br /> ❑ ALL OWNED AUTOS BODILY INJURY $ <br /> ❑ SCHEDULED AUTOS (Per Person) <br /> ❑ HIRED AUTOS BODILY INJURY $ <br /> ❑ NON-OWNED AUTOS (Per Accident) <br /> ❑ PROPERTY DAMAGE $ <br /> GARAGE LIABILITY AUTO ONLY — EA ACCIDENT i <br /> ❑ OTHER THAN EA ACC $ <br /> ❑ AUTO ONLY AGG $ <br /> A EXCESS LIABILITY EACH OCCURRENCE <br /> ❑ ❑ CLAIMS MADE <br /> ❑ DEDUCTIBLE AGGREGATE $ <br /> ❑ RETENTION $ $ <br /> $ <br /> WORKER'S COMPENSATION AND ❑WC STATUTORY LIMITS <br /> A EMPLOYER'S LIABILITY <br /> E.L. EACH ACCIDENT $ 100,000 <br /> THE E.L. DISEASE — EA $ 500,000 <br /> PROPRIETOR/PARTNERS/ ❑ INCL E.L. DISEASE-POLICY LIMIT S 1009000 <br /> EXECUTIVE OFFICERS ARE: ❑ EXCL <br /> OTHER: FULL REPLACEMENT COST <br /> BUILDER'S RISK OF THE WORK <br /> DESCRIPTION OF OPERATIONS/LOCATIONS VEHICLESISPECIAL ITEMS <br /> CERTIFICATE HOLDER ADDITIONAL INSURED; INSURER LETTER: CANCELLATION <br /> SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE <br /> EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 <br /> DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. FAILURE <br /> TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND <br /> UPON THE COMPANY ITS AGENTS OR REPRESENTATIVES. <br /> AUTHORIZED REPRESENTATIVE <br /> ADDITIONAL INSURED: <br /> INDIAN RIVER COUNTY <br /> 1840 2e STREET, VERO BEACH, FL 32960 <br /> 00620 - Sample Certificate of Liability Insurance REV 04-07.doc <br /> 00620 - 1 <br /> F:\Engineering\Speoial Projects\Eagle Trace Phase 2\Contract Documents\Eagle Trace Subdivision Phase 11\00620 - Sample Certificate of Liability Insurance REV <br />04-07.doc Rev. 05/01 <br />