LIABILITY INSURANCE CERTIFICATE
STREET ACTIVITIES
NOTE: INSURANCE COMPANIES MUST BE LICENSED TO CONDUCT BUSINESS IN BRITISH COLUMBIA
1. THIS CERTIFICATE IS ISSUED TO: City of Vancouver – Engineering Services, Street Use, Street Activities
320 – 507 West Broadway, Vancouver, BC, V5Z 0B4
Fax: (604) 873-7255 Email: street.activities@vancouver.ca
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: Check additional extension where applicable:
√ Personal Injury √ Blanket Contractual Liability Host Liquor Liability
√ Employees as Additional Insureds √ Broad Form Products & Completed Operations
√ Cross Liability or Severability of Interest √ Broad Form Property Damage incl. Loss of Use
√ Contingent Employer’s Liability √ Non-Owned Auto Liability
Limits of Liability (Bodily Injury and Property Damage Inclusive)
INSURER: Per Occurrence $
POLICY NUMBER: Aggregate $
POLICY PERIOD: From to Deductible per occurrence $
MM/DD/YY MM/DD/YY
4. 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 $
MM/DD/YY MM/DD/YY
5. 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
MM/DD/YY
NAME OF THE INSURER OR ITS AUTHORIZED REPRESENTATIVE,
AGENCY NAME, COMPLETE ADDRESS, POSTAL CODE & PHONE NUMBER
COV Liability Insurance Certificate – Merchandise - 06-11-2014.dotx
