Fillable Certificate of Insurance - Contractors (City of London, Ontario)

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Certificate of Insurance - Contractors (City of London, Ontario)

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Certificate of Insurance - Contractors
Page 1 of 2
This is to certify that the Insured, named below is insured as described below.
*** This is to certify that the Insured, named below is insured as described below. ***
Note: Proof of liability insurance will be accepted on this form only (with no amendments).
Named Insured
Insured's address (street name, city, province and postal code)
E-mail address
Telephone number Fax number
Type of Insurance Insurer's Name Policy Number Policy Period
Limits of Liability
(bodily injury & property
damage inclusive)
Commercial
General Liability
Wrap-up Liability
From 12:01AM
To 12:01AM
Occurrence
Aggregate
Deduction
Umbrella/Excess
Follow Form Auto
Follow Form
Liability
From 12:01AM
To 12:01AM
Occurrence
Aggregate
Deduction
Commercial / General / Liability includes:
Occurrence basis, including Personal Injury, Property Damage, Broad Form Property Damage, Contractual Liability, Non-owned
Auto Liability, Owners & Contractors Protective Coverage, Products-Completed Operations, Contingent Employers Liability,
Cross Liability Clause and Severability of Interest Clause.
Check which of the following are included in the Commercial General Liability Policy:
CCDC compliance
Off-Premises welding limit: $Standard pollution exclusion
Hot process roofing exclusion/restriction
Off-Premises welding exclusion
Demolition coverage
Blasting coverage/ Collapse / Underpinning coverage / Pile driving coverage
Total pollution exclusion Full form pollution
Limited pollution coverage (120 Hr.)
THE CORPORATION OF THE CITY OF LONDON, the London Convention Centre o/a RBC Place, Covent Garden Market
Corporation, Museum London o/b London Regional Art & Historical Museums, London Public Library Board, London Police
Service, Housing Development Corporation, London and London & Middlesex Community Housing have been added as an
additional Insured but only with respect to their interest in the operations of the Named Insured.
This certifies that the policies of insurance described above have been issued by the undersigned to the Insured named above
and are in force at this time. If cancelled or materially changed in any manner that would affect the CITY OF LONDON or other
scheduled additional insured, for any reason, so as to affect this certificate, thirty (30) days prior written notice registered mail or
facsimile transmission will be given by the Insurer(s) to:
The Corporation of the City of London
Attention: Risk Management Division
Office location: 520 Wellington Street, Unit 1
Mailing address: P O Box 5035 Fax: 519 661-4631
London, ON N6A 4L9 E-mail: certificates@london.ca
Form no. 0887 (rev.2021.01)
www.london.ca
Continued on reverse...
Page 2 of 2
Certificate of Insurance - Contractors
for
Type of Insurance Insurer's Name Policy Number Policy Period Limits of Coverage
Motor Vehicle Liability
"All vehicles owned or
operated by the
Insured"
From 12:01AM
To 12:01AM
Amount
Deductible
Builder's Risk
Installation floater
From 12:01AM
To 12:01AM
Amount
Deductible
Environmental
Impairment Liability
From 12:01AM
To 12:01AM
Amount
Deductible
Asbestos Abatement
From 12:01AM
To 12:01AM
Amount
Deductible
Mold Remediation
From 12:01AM
To 12:01AM
Amount
Deductible
Professional Liability
From 12:01AM
To 12:01AM
Amount
Deductible
Watercraft
From 12:01AM
To 12:01AM
Amount
Deductible
Other - specify type below:
From 12:01AM
To 12:01AM
Amount
Deductible
This certificate is executed and issued to the aforesaid Corporation of the City of London, the day and date herein written below.
Yes No
I confirm that the coverage shown above conforms with the minimum requirements of the London Construction
Insurance Program and with the requirements in:
Tender No.:
Project Name:
Name of insurance company or broker completing form certifies that the coverage meets the requirements of the contract
Address
E-mail address
Telephone number Fax number
Name of authorized representative or official Signature of authorized representative or official
Date signed
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Certificate of Insurance - Contractors (City of London, Ontario)

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Completed 26 July 2021

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