In the intricate world of insurance, the Commercial Liability Insurance Certificate form serves a pivotal function in the realm of risk management and verification of coverage. Essentially, this certificate acts as a snapshot, providing crucial information on the insurance policies held by a business, including types of coverage, policy numbers, effective dates, and limits. It's pertinent to understand that this document does not modify the coverage in any way; instead, it affirms the existence and specifics of the insured's policies as issued by Farmers Agency or other insurers. Notably, the form stresses that it is not a contract and does not confer any rights to the certificate holder beyond what is stipulated in the actual insurance policies. The liabilities covered, such as general liability, automobile liability, and workers’ compensation, are outlined with their respective limits, offering peace of mind to third parties or financial institutions requiring proof of insurance. Conditions such as the notification of cancellation and the requirement for certain endorsements, like additional insured or waiver of subrogation, are highlighted to ensure all parties are aware of these critical details. Through this document, stakeholders can swiftly verify coverage details without delving into the full policies, streamlining processes that require evidence of insurance.
| Question | Answer |
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| Form Name | Commercial Liability Insurance Certificate Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | blank small business insurance certificate, state farm insurance template, farmers certificate liability, farmers certificate insurance form |
Commercial Certificate of Liability Insurance |
FARMERS |
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Agency |
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Issue Date (MM/DD/YY)____________________ |
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Name |
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This certificate is issued as a matter of information only and confers no rights |
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upon the certificate holder. This certificate does not affirmatively or negatively |
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amend, extend or alter the coverage afforded by the policies shown below. |
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This certificate of insurance does not constitute a contract between the issuing |
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insurer(s), authorized representative or producer, and the certificate holder. |
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Insured |
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Companies Providing Coverage (NAIC #): |
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Company Letter A Truck Insurance Exchange 21709 |
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Company Letter B |
Farmers Insurance Exchange 21652 |
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Company Letter C |
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Company Letter D |
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Coverages
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.
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Type of Insurance |
Policy Number |
Policy Effective |
Policy Expiation |
Policy Limits |
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Insrd. |
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i M/DD,Yv) |
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General Liability |
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LJANCE |
Each Occurrence |
$ |
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Commercial General Liab. |
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Q INI |
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Damage To Rented |
$ |
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Businessowners Liability |
A |
&TIt, TX bS |
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Premises (Ea. Occur.) |
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$ |
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R 0 V E D |
Medical Expens s |
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— Ciaims Made |
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P |
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(Any one persone) |
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EC 2 (j Z 0 |
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Personal & Adv. Injury |
$ |
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.__ Occurrence |
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1 |
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General Aggregate Limit Applies |
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General Aggregate |
$ |
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Per Location |
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Prod/Comp. Ops. Aggr. $ |
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Per Project |
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Automobile Liability |
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Combined Sin le Limit |
$ |
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Any Auto |
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(Each accidenJ |
$ |
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Au Owned Autos |
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Bodily Injury |
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— Scheduled Autos |
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(Per person) |
$ |
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Bodily Iniury |
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Hired Autos |
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(Per accident) |
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Property Damage |
$ |
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(Per accident) |
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Garage Liability |
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Auto |
$ |
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Any Auto |
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Other Than Each Accident $ |
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Auto Only: |
$ |
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Aggregate |
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Umbrella Liability |
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Limit |
$ |
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Retention $ |
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Workers’ Compensation and |
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Statutory |
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Employers’ Liability |
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Each Accident |
$ |
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Disease - Ea. Employee $
Disease - Policy Limit $______________________
Description of Operations/Vehicles/Restrictions/Special items:
Certificate Holder |
Cancellation |
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Should any of the above described policies be cancelled |
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Name |
before the expiration date thereof, notice will be delivered In |
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accordance with the policy provisions. |
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Address |
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Authorized Representative |
C2492201 PAG( 1 OF 2 |
IMPORTANT
If the certificate holder is an additional insured, the pollcy(ies) must be so endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Commercial Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer, authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by any policies listed thereon.
C2492202 PAGf 2 Of 2 |