Application For An "Isp" Independent Service Provider & Irs Form W-9 & Njs Verification Form (Page 3 of 3) in pdf

NOTIFICATION OF REQUIRED INSURANCE

Must be in compliance with Master Service Agreement, Insurance & Provisions section

DATE (MM/DD/YYYY)

and

Submitted prior to any work performed for NJS

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE

DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF

INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE

CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS

WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to

the certificate holder in lieu of such endorsement(s).

Broker contact name

CONTACT

PRODUCER

NAME:

Broker phone #

PHONE

FAX (A/C,

(A/C, No, Ext):

No):

Broker email address

E-MAIL

ISP's Insurance Agent

ADDRESS:

INSURER(S) AFFORDING COVERAGE

NAIC #

Insurance Company

INSURER A :

INSURED

Insurance Company

INSURER B :

Insurance Company

INSURER C :

ISP Legal Name

Insurance Company

INSURER D :

ISP Full Legal Address

INSURER E :

INSURER F :

COVERAGES

CERTIFICATE NUMBER:

REVISION NUMBER:

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD

INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS

CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,

EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

ADDL

SUBR

POLICY EFF

POLICY EXP

INSR

TYPE OF INSURANCE

LIMITS

POLICY NUMBER

LTR

(MM/DD/YYYY)

INSD

WVD

COMMERCIAL GENERAL LIABILITY

1,000,000

EACH OCCURRENCE

DAMAGE TO RENTED

CLAIMS-MADE

OCCUR

PREMISES (Ea occurrence)

x Contractual Liability Included

MED EXP (Any one person)

PERSONAL & ADV INJURY

2,000,000

GENERAL AGGREGATE

GEN'L AGGREGATE LIMIT APPLIES PER:

PRO-

PRODUCTS - COMP/OP AGG

POLICY

LOC

JECT

OTHER:

COMBINED SINGLE LIMIT

1,000,000

AUTOMOBILE LIABILITY

(Ea accident)

ANY AUTO

BODILY INJURY (Per person)

OWNED

SCHEDULE

BODILY INJURY (Per accident) $

AUTOS ONLY

D AUTOS

PROPERTY DAMAGE

NON-OWNED

HIRED

(Per accident)

AUTOS ONLY

UMBRELLA LIAB

EACH OCCURRENCE

OCCUR

EXCESS LIAB

AGGREGATE

CLAIMS-MADE

DED

RETENTION $

PER

OTH-

WORKERS COMPENSATION

STATUTE

AND EMPLOYERS' LIABILITY

Y / N

1,000,000

E.L. EACH ACCIDENT

ANYPROPRIETOR/PARTNER/EXECUTIVE

N / A

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMIT

DESCRIPTION OF OPERATIONS below

D Third Party Crime Coverage

(if required)

10,000

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES

Additional Insured Endorsement Example

“Named Insured’s policy includes a blanket automatic endorsement that provides Additional Insured status to Certificate

Holder for any and all work performed under written contractual agreement”

Polices that do not contain blanket additional insured statement shown above requires CG2010 endorsement with this certificate.

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

National Janitorial Solutions ("NJS") and

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

Expert Janitorial, LLC

ACCORDANCE WITH THE POLICY PROVISIONS.

14000 Commerce Parkway, Suite D

Mount Laurel, NJ 08054

Sample only, actual verification will be submitted with the contract.

Must be an ACORD Form

Rev. 10-19-2016

Application For An "Isp" Independent Service Provider & Irs Form W-9 & Njs Verification Form Page 3

Related Articles

Related forms

Related Categories