Standard Certificate Of Insurance - Niagara Region
Download a blank fillable Standard Certificate Of Insurance - Niagara Region in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Standard Certificate Of Insurance - Niagara Region with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Standard Certificate of Insurance
This form must be completed and signed off by your insurer or insurance broker. Proof of liability
insurance will be accepted on this form only. Note: Checked boxes confirm coverage in place.
Section 1: Insurer Information
Location and nature of operation to which this Certificate of Insurance applies (“the contract”):
Named Insured:
Address:
Phone:
Fax:
Insurers affording coverage (exact F.S.C.O. licensed name):
Insurer(s) licensed to conduct business in Ontario and/or Canada
Insurer A:
Insurer B:
Insurer C:
Additional Insured as required by the contract:
The Regional Municipality of Niagara
Niagara Regional Police Services Board
Niagara Regional Housing
Other additional insureds as required by the contract:
Section 2: Types of Insurance
Commercial General Liability (“CGL”) policy:
Insurer A
Insurer B
Insurer C
Policy #:
Effective date:
Expiry date:
Each occurence ($):
Deductible/SIR ($):
CGL Policy on a per occurence basis including: Bodily Injury, Death and Property Damage, Cross Liability
and Severability of Interest, Blanket Contractual Liability, Premises and Operations, Personal and Advertising
Injury, Broad Form Property Damage, Products and Completed Operations, Owner’s and Contractors
Protective, and Non-owned Automobiles.
Check which of the following are also included in the CGL Policy:
Employer’s liability
No sexual abuse or molestation exclusion
Tenant’s legal liability
Other
Standard Certificate of Insurance | Revised July 2017
1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal