Form 0788 - Certificate Of Insurance - Standard
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1Certificate of Insurance - Standard
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 liability insurance will be accepted on this form only (with no amendments).
E-mail address
Named Insured
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
Aggregate
Liability
$
Occurrence
$
Umbrella
Aggregate
Excess
$
Other
Occurrence
(Explain.)
$
Aggregate
$
Commercial General Liability: Occurrence Basis, Including Personal Injury, Property Damage, Broad Form Property Damage, Contractual
Liability, Non-Owned Automobile Liability, Owner's and Contractor's Protective Coverage, Products -
Completed Operations, Contingent Employers Liability, Cross Liability Clause and Severability of Interest
Clause.
$
Tenant's Legal Liability:
NO or
YES. . . (Limit)
____________________
Liquor Liability:
NO or
YES
THE CORPORATION OF THE CITY OF LONDON, the London Convention Centre, Covent Garden Market Corporation, Museum
London o/b London Regional Art & Historical Museums, London Public Library Board, London Police Service, Housing
Development Corporation, London and London Middlesex Housing Corporation 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
Insurance Company
Policy Number
Effective Date
Expiry Date
Limits of Liability
$
vehicle
(YYYYMMDD)
(YYYYMMDD)
liability
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.
Telephone number
Name of insurance company or broker (completing form)
Fax number
Address
Name of authorized representative or official (Please print.)
E-mail address
Date
Signature of authorized representative or official
(YYYY-MM-DD)
Form no. 0788 (rev.2016.09)
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