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- Sample Certificate of Liability SECTION 00620 p Insurance CERTIFICATE OF LIABILITY INSURANCE PRODUCER 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. COMPANIES AFFORDING COVERAGE INSURED COMPANY A - COMPANY B - COMPANY C - COMPANY D - COMPANY 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 ACCORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY POLICY EFFECTIVE POLICY EXPIRATION MSRTYPE OF INSURANCE NUMBER DATE MMIDD DATE MMID LIMITS LTR $ 11000,000 GENERAL LIABILITY EACH OCCURRENCE $ 50,000 A [3 COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Any One Fire $ 5,000 ❑ CLAIMS MADE - ❑OCCUR MED. EXP. (Any One Person ❑ PERSONAL & ADV INJURY $ 1 ,000,000 ❑ GENERAL AGGREGATE $ 11000,000 ❑ PRODUCTS — COMP/OPAGG. $ 11000,000 ❑ $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 10000,000 A ❑ ANY AUTO (Ea. Occurrence) ❑ ALL OWNED AUTOS BODILY INJURY $ ❑ SCHEDULED AUTOS (Per Person) ❑ HIRED AUTOS BODILY INJURY $ ❑ NON-OWNED AUTOS (Per Accident) ❑ PROPERTY DAMAGE $ GARAGE LIABILITY AUTO ONLY — EA ACCIDENT i ❑ OTHER THAN EA ACC $ ❑ AUTO ONLY AGG $ A EXCESS LIABILITY EACH OCCURRENCE ❑ ❑ CLAIMS MADE ❑ DEDUCTIBLE AGGREGATE $ ❑ RETENTION $ $ $ WORKER'S COMPENSATION AND ❑WC STATUTORY LIMITS A EMPLOYER'S LIABILITY E.L. EACH ACCIDENT $ 100,000 THE E.L. DISEASE — EA $ 500,000 PROPRIETOR/PARTNERS/ ❑ INCL E.L. DISEASE-POLICY LIMIT S 1009000 EXECUTIVE OFFICERS ARE: ❑ EXCL OTHER: FULL REPLACEMENT COST BUILDER'S RISK OF THE WORK DESCRIPTION OF OPERATIONS/LOCATIONS VEHICLESISPECIAL ITEMS CERTIFICATE HOLDER ADDITIONAL INSURED; INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ADDITIONAL INSURED: INDIAN RIVER COUNTY 1840 2e STREET, VERO BEACH, FL 32960 00620 - Sample Certificate of Liability Insurance REV 04-07.doc 00620 - 1 F:\Engineering\Speoial Projects\Eagle Trace Phase 2\Contract Documents\Eagle Trace Subdivision Phase 11\00620 - Sample Certificate of Liability Insurance REV 04-07.doc Rev. 05/01