Standard Insurance Certificate Template - County Of Erie
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1
2County of Erie Standard Insurance Certificate
LAW-1 INS (Rev. 3/06)
This certificate does not amend, extend or alter the coverage afforded by the standard form policies listed below.
I
III Companies Affording Coverages
Insured
Name
A
Address
Zip
B
Phone No.
II
Name
C
Issuing
Address
Agency
Zip
D
Phone No.
IV
This is to certify that the policies listed below have been issued to the insured named above and are in force at this time.
Indicate Type of Insurance By Checking the Box
Policy
Effective Date
Limits of Liability in Thousands
Number
& Expiration
Check the Box
Occurrence
Aggregate
Company
1. General Liability
Bodily Injury
Letter -
Comprehensive Form
Property Damage
from III above
Premises and Operations
Products/Completed Operations
OR
Independent Contractors
Contractual
Personal Injury
Combined Single Limit
Broad Form Property Damage
Explosion, Collapse
Underground Hazard
2. Automobile Liability
Comprehensive Form
Bodily Injury
OR
Property Damage
OR
Schedule Form
owned
Combined Single Limit
hired
non-owned
3. Excess Liability
Umbrella Form
Bodily Injury & Property
OR
other than umbrella
Damage Combined
$
auto
general
both
Self Insured Retention $
4. Worker's Compensation &
Statutory
Employer's Liability
Disability Benefits
Statutory
5. Other
V. County of Erie is included as an additional Insured under the following Policy numbers:
VI. Description of Operations: It is understood that this coverage on behalf of the insured is for all locations in the County of Erie, NY.
VII. Cancellation/Non-Renewal: Should any of the policies noted above be cancelled before expiration thereof or not renewed by the
Insured, the issuing company will endeavor to mail ________ days advance written notice to the Certificate Holder, but failure to mail
such notice shall impose no obligation or liability of any kind upon the company, its agents or representatives.
Date Issued
VIII. Name and Address of Certificate Holder
& Recipient of Notice:
County of Erie
Auth. Representative
c/o Department of Law
69 Delaware Avenue Suite # 3 00
Firm name & address
Buffalo, NY 14202
716-858-2200
FOR COUNTY USE ONLY:
Name of County Dept. Requesting Certificate
Purchase Order or Contact Number
Vendor Insurance Classification
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