Form no. 0888 (rev.2021.01)
www.london.ca
Name of insurance company or broker (completing form)
Address
E-mail address
Telephone number Fax number
Name of authorized representative or official Signature of authorized representative or official
Date (YYYY-MM-DD)
Named Insured
E-mail address Telephone number Fax number
Insured's address (street name, city, province and postal code)
Insurance Company Policy Number Effective Date Expiry Date Limits of Liability
(full legal name) (YYYYMMDD) (YYYYMMDD)
(bodily injury & property damage - inclusive)
Annual - $
Budget - $
Claims made? No Yes
Limit is inclusive of damages and claims expenses? No Yes
Deductible? No Yes…(Amount) $
Self-Insured Retention? No Yes…(Amount) $
Is the full limit of coverage available on today’s date? No Yes
Certificate of Insurance – Professional Liability
This is to certify that the Insured named below is insured as described:
*** This form must be completed and signed by your insurer or insurance broker. ***
Note: Proof of insurance will be accepted on this form only (with no amendments).
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
Mailing address: P O Box 5035
London, ON N6A 4L9
Fax: 519 661-4631
E-mail: certificates@london.ca
This certificate is executed and issued to the aforesaid Corporation of the City of London, the day and
date herein written.
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.
