Insurance Certificate – COV Liability – 2010-03
LIABILITY INSURANCE CERTIFICATE
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1. THIS CERTIFICATE IS ISSUED TO: City of Vancouver, 453 W 12
th
Avenue, Vancouver, BC, V5Y 1V4
and certifies that the insurance policy (policies) as listed herein has/have been issued to the Named Insured and is/are in full force and effect
as of the effective date of the agreement described below.
2. NAMED INSURED [must be the same name as the Permittee/Licensee or Party(ies) to Contract and is/are either an individual(s) or a legally
incorporated company(ies)]
BUSINESS TRADE NAME OR DOING BUSINESS AS
BUSINESS ADDRESS
DESCRIPTION OF OPERATION, CONTRACT, AGREEMENT, LEASE, PERMIT OR LICENSE
3. COMMERCIAL GENERAL LIABILITY INSURANCE (Occurrence Form)
Including the following coverages:
√ Personal Injury Check Additional Extensions where applicable and included:
√ Cross Liability or Severability of Interest Work below ground level over 3 metres
√ Employees as Additional Insureds Excavation, shoring, underpinning, pile driving or caisson
√ Blanket Contractual Liability Demolition, removal or weakening of support of property
√ Broad Form Products and Completed Operations Blasting
√ Broad Form Property Damage including Loss of Use Operation of hoist or attached machinery
√ Non-Owned Auto Liability 24 months Completed Operations
INSURER: __________
POLICY NUMBER:
POLICY PERIOD: FROM:
To:
LIMITS OF LIABILITY (Bodily Injury and Property Damage Inclusive):
Per Occurrence $
Aggregate $
Deductible Per Occurrence $
All Risk Tenants’ Legal Liability $
4. AUTOMOBILE LIABILITY INSURANCE for operation of owned and/or leased vehicles
INSURER: LIMITS OF LIABILITY:
POLICY NUMBER: Combined Single Limit: $
POLICY PERIOD: From to If vehicles are insured by ICBC, complete and provide Form APV-47.
5. UMBRELLA OR EXCESS LIABILITY INSURANCE Limits of Liability (Bodily Injury and Property Damage Inclusive) -
INSURER:
Per Occurrence $
POLICY NUMBER:
Aggregate $
POLICY PERIOD: From
to Self-Insured Retention $
6. OTHER INSURANCE (e.g. Conractors Equipment, Crime, etc.) – Please specify Name of Insurer(s), Policy Number, Policy Period, and Limit
7. POLICY PROVISIONS
Where required by the governing contract, agreement, lease, permit or license, it is understood and agreed that:
a) The City of Vancouver, its officials, officers, employees, servants and agents have been added as Additional Insureds with respect to
liability arising out of the operation of the Named Insured pursuant to the governing contract, agreement, lease, permit or license.
b) THIRTY (30) days written notice of cancellation or material change resulting in reduction of coverage with respect to any of the policies
listed herein, either in part or in whole, will be given by the Insurer to the Holder of this Certificate; the exception is cancellation for non-
payment of premiums in which case the applicable statutory conditions will apply.
c) The insurance policy (policies) listed herein shall be primary with respect to liability arising out of the operation of the Named Insured.
Any insurance or self-insurance maintained by the City of Vancouver shall be in excess of this insurance and shall not contribute to it.
SIGNED BY THE INSURER OR ITS AUTHORIZED REPRESENTATIVE
Date
PRINT NAME OF THE INSURER OR ITS AUTHORIZED REPRESENTATIVE, ADDRESS AND PHONE NUMBER
