Fillable CERTIFICATE OF LIABILITY INSURANCE (Merced College)

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CERTIFICATE OF LIABILITY INSURANCE (Merced College)

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ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
INSR
LTR
DATE (MM/DD/YYYY)
INSURED
POLICY EFFECTIVE
DATE (MM/DD/YY)
POLICY EXPIRATION
DATE (MM/DD/YY)
POLICY NUMBER LIMITS
TYPE OF INSURANCE
GENERAL LIABILITY
AUTOMOBILE LIABILITY
GARAGE LIABILITY
EXCESS/UMBRELLA LIABILITY
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
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 OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
INSURER A:
INSURER B:
INSURER C:
INSURER D:
INSURER E:
EACH OCCURRENCE $
DAMAGE TO RENTED
PREMISES (Ea occurence)
COMMERCIAL GENERAL LIABILITY $
CLAIMS MADE OCCUR MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $
PRO-
JECT
POLICY LOC
COMBINED SINGLE LIMIT
(Ea accident)
$
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY
(Per person)
$
SCHEDULED AUTOS
HIRED AUTOS
BODILY INJURY
(Per accident)
$
NON-OWNED AUTOS
PROPERTY DAMAGE
(Per accident)
$
AUTO ONLY - EA ACCIDENT $
ANY AUTO EA ACC $
OTHER THAN
AUTO ONLY:
AGG $
EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE $
RETENTION $ $
WC STATU-
TORY LIMITS
OTH-
ER
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT $
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 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.
THIS CERTIFICATION 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.
INSURERS AFFORDING COVERAGE NAIC #
COVERAGES
CERTIFICATE HOLDER CANCELLATION
ACORD 25 (2001/08)
© ACORD CORPORATION 1988
CERTIFICATE OF LIABILITY INSURANCE
ADD'L
INSRD
PRODUCER
$
City of Los Angeles
Office of the City Administrative Officer, Risk Management
200 North Main Street, Room 1240
Los Angeles, CA 90012
Clear All
Policy must be valid at
time of the event.
Endorsement letter
MUST BE submitted.
Merced College
3600 M. Street
Merced CA 95348
1,000,000
$500,000
Must include the following statement: “Merced Community College District are named as additional insured on general
liability policy per attached endorsement letter for the event held on month/date(s)/year.”
ACORD 25 (2001/08)
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statment on this
certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
The Certificate of Insurance on the reverse side of this form does not constitute a contract between the
issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively
or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
DISCLAIMER
IMPORTANT
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu
of such endorsement(s).
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CERTIFICATE OF LIABILITY INSURANCE (Merced College)

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Completed 5 September 2020

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