Fillable Certificate Of Insurance Template printable pdf download

Indiana Grain Buyers & Warehouse

CERTIFICATE OF INSURANCE

Licensing Agency

State Form 23447 (R2 / 4-97)

OFFICE USE ONLY

ISTA Center, Suite 416

Approved by State Board of Accounts, 1997

150 West Market Street

RECYCLED PAPER

FILE #:

Indianapolis, Indiana 46204-2810

Telephone: (317) 232-1356 FAX: (317) 232-1362

ISSUED BY: (name of insurance company)

Home office address: (number and street, city, state, ZIP code)

THIS IS TO CERTIFY THAT there is now in effect an insurance policy(ies) issued by this company, policy numbers(s) as

listed below, insuring all grain contained, in the name of the indicated business firm against loss by fire, internal explosion,

lightning, and windstorm.

Monthly reporting required?

Name of insured business firm:

9 Yes

9 No

Headquarters address: (number and street, city, state, ZIP code)

POLICY NO.

EFFECTIVE

NAME & LOCATION OF INSURED FACILITY

EXPIRATION

LIMIT OF LIABILITY FOR

GRAIN

POLICY DATE

This certificate is furnished as a matter of information only and covers no rights upon the holder. It is issued with the understanding that the

rights and liabilities of the parties will be governed by the original policy as it may be lawfully amended by endorsement from time to time.

Insurance is afforded only with respect to such and so many of the above policies and coverages thereunder as are indicated by a limit of

liability applicable thereto. The limit of the Company’s liability under each coverage shall not exceed the amount stated therein, subject to all

terms of the policy having reference thereto.

This further certifies that, pursuant to Indiana law, the Company will not cancel or reduce the limit of liability of the above listed policy(ies)

except after the expiration of a thirty (30) day period from the mailing, by registered or certified mail, to the holder of this certificate, of notice

of intent to do so. A copy of such notice will be mailed to the insured firm on the same day the notice is mailed to the certificate holder. The

cancellation or reduction in the limit of liability shall not affect the liability accrued or which may accrue under such insurance policy before

the expiration of the thirty-day period.

It is understood that the insured firm may not cancel or reduce the limits of the policy(ies) listed above without the prior written approval of

the Director of the Agency identified below, and the Director’s approval of substitute insurance.

Signature of Licensed agent

CERTIFICATE HOLDER:

Director, Indiana Grain Buyers &

Date of issue of certificate

Warehouse Licensing Agency

DISTRIBUTION: White - Licensing File; Canary - Travel File

Certificate Of Insurance Template

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