Standard Certificate Of Insurance - Niagara Region Page 2
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2Automobile Liability (“Auto”) Policy:
Insurer A
Insurer B
Insurer C
Policy #:
Effective date:
Expiry date:
Limit of Liability ($):
All owned automobiles
All leased automobiles
Standard excess automobile
Excess/Umbrella Liability Policy:
Insurer A
Insurer B
Insurer C
Policy #:
Effective date:
Expiry date:
Limit of Liability ($):
Deductible/SIR:
Excess policy
Umbrella policy
Occurence basis
Follows form to:
CGL policy (as above)
Auto policy (as above)
All insurance coverages indicated above comply with the contract except as specified below:
Section 3: Provisions/Amendments/Endorsements
a.
The above noted Additional Insured(s) has/have been added as the Additional Insured except for the Auto Policy and the Professional
Liability Policy, but only with respect to liability arising out of operations of the Named Insured.
b.
The Policies identified above shall apply as primary insurance and not excess to any other insurance or self insurance available to the
Additional Insured(s).
c.
Any failure to comply with any of the terms and conditions of the Policies of the Named Insured shall not affect coverage provided to the
Additional Insured(s).
d.
In the event that there is a material change in the foregoing Policies or coverage affecting the Additional Insured(s) or cancellation of
coverage before the expiration date of any of the foregoing Policies, the undersigned will give thirty (30) days prior to written notice
(fifteen (15) days for auto liability) by registered mail or facsimile transmission to: The Regional Municipality of Niagara Attention:
Legal Division, 1815 Sir Isaac Brock Way, Thorold, Ontario, L2V 4T7 Fax: 905-685-7931
This is to certify that the policies of insurance as described above have been issued by the
undersigned to the Named Insured and are in force at this time. This Certificate of Insurance is
executed and issued to the Additional Insured(s) on the date written below.
Name of insurer or broker issuing certificate:
Address:
Phone:
Fax:
Email:
Name of authorized representative or official:
Signature of authorized representative or official:
Date:
Standard Certificate of Insurance | Revised July 2017
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