Named Insured
E-mail address
Insured's address (street name, city, province and postal code)
Telephone number Fax number
Type of
Insurance Company Policy Number Effective Date Expiry Date Limits of Liability
insurance
(full legal name) Year Month Day Year Month Day
(bodily injury & property damage -
inclusive)
Occurrence
Commercial
General
$
Liability
Aggregate
$
Occurrence
Umbrella
$
Excess
Aggregate
$
Other (Explain.)
Occurrence
$
Aggregate
$
Tenant's Legal Liability: NO or
YES. . . (Limit)
Liquor Liability: NO or
$ YES
Certificate of Insurance - Standard
This is to certify that the Insured named below is insured as described:
Commercial General Liability: Occurrence Basis, Including Personal Injury, Property Damage, Broad Form Property Damage,
Contractual Liability, Non-Owned Automobile Liability, Owner's an
d Contractor's Protective
Coverage, Products - Completed Operations, Contingent Employers Liability, Cross Liability Clause
and Severability of Interest Clause.
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, Western Fair Association, 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.
If cancelled or 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 by 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
Fax: 519 661-4631
Mailing address: P O Box 5035 E-mail: certificates@london.ca
London, ON N6A 4L9
Motor Vehicle Liability - must cover all vehicles owned, or operated by, or on behalf of the insured.
This is to certify that the Policies of Insurance as described above have been issued by the undersigned to the Insured named
above and are in force at this time.
This certificate is executed and issued to the aforesaid Corporation of the City of London, the day and date herein written.
Name of insurance company or broker (completing form)
Telephone number
Address
Fax number
Name of authorized representative or official (Please print.)
E-mail address
Signature of authorized representative or official
Date (YYYY-MM-DD)
Form no. 0788 (rev.2021.01)
www.london.ca
*** This form must be completed and signed by your insurer or insurance broker. ***
Note: Proof of liability insurance will be accepted on this form only (with no amendments).
Motor
Insurance Company Policy Number
Effective Expiry Date Limits of Liability
vehicle
Date
(YYYYMMDD)
liability
$
