Sudbury Certificate Of Insurance Form PDF Details

In navigating the intricacies of hosting special events, securing a robust insurance plan emerges as a non-negotiable cornerstone to safeguard against unforeseen liabilities and risks. At the heart of this preparatory step lies the Sudbury Certificate of Insurance for Special Events—a pivotal document designed to offer a comprehensive snapshot of the insured party's coverage specifics. This certificate underscores the mandatory completion and signature requirement from an insurer or insurance broker, delineating the coverage in explicit detail, including the insured's name, policy number, effective and expiry dates, along with the limits of liability across various categories like Commercial General Liability and Excess Commercial General Liability. It highlights a requirement for proof of liability insurance exclusively through this form, without any amendments, and insists that any facsimile transmission be subsequently followed by the original certificate. The form meticulously outlines coverage inclusiveness for scenarios from liquor liability to fireworks and even potential sub-limits or limitations, demanding disclosure of any such conditions. Additionally, it necessitates the inclusion of the City of Greater Sudbury as an additional insured party, thus extending a protective umbrella over the city's interests relative to the insured's operations. The form also spells out the protocol for notifying the city in the event of cancellation or material changes to the policies, thereby ensuring that the City of Greater Sudbury remains well-informed and shielded against potential risks tied to the insured special events. Through this structured format, the certificate acts as a critical bridge between the insurer and the insured, embedding a layer of security and transparency essential for event planning and execution within Sudbury.

QuestionAnswer
Form NameSudbury Certificate Of Insurance Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesSpecial_Events_ Certificate certificate of insurance special event fillable form

Form Preview Example

Certificate of Insurance – Special Events

This is to certify that the insured, named below is insured as described below.

*** This form must be completed and signed by your insurer or insurance broker.***

Note: 1. Proof of liability insurance will be accepted on this form only (with no amendments). 2. If a facsimile has been transmitted, the original certificate must follow

Name of Insured:

Insured’s Address:

Telephone Number

(Area Code)

⏐

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Postal Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of

 

Insurer’s Name

Policy Number

 

Effective Date

 

 

Expiry Date

 

Limits of Liability

 

 

 

Insurance

 

 

 

 

 

yr

mo

day

 

 

yr

mo

day

 

(Bodily Injury & Property

Deductible

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Damage-Inclusive)

 

 

 

Commercial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

General Liability

 

 

 

 

 

 

⏐

⏐

 

 

⏐

 

⏐

 

$

$

 

 

Umbrella

 

 

 

 

 

 

⏐

⏐

 

 

⏐

 

⏐

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

$

 

 

Excess

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commercial General Liability

 

Occurrence Basis, including Personal Injury, Property Damage, Broad Form Property Damage, Contractual Liability,

 

(including):

 

 

 

Non-Owned Automobile Liability, Work Performed on Behalf of the Named Insured by Sub-Contractors, Products –

 

 

 

 

 

Completed Operations, Contingent Employers Liability, Cross Liability Clause and Severability of Interest Clause.

 

DOES COVERAGE INCLUDE:

 

 

 

 

 

 

 

 

 

 

 

Limits ($)

 

 

•

Liquor Liability

NO

YES

$

•

Tenants Legal Liability

NO

 

YES

$

•

Injury to Participants

NO

 

YES

$

•

Fireworks

NO

 

YES

$

•

Watercraft

NO

 

YES

$

 

 

 

 

 

 

 

•

Sub-limits or Limitations

NO

 

YES

PLEASE INDICATE

The CITY OF GREATER SUDBURY has been added as an additional insured but only with respect to their interest in the operations of the Named Insured.

This is to certify that the policies of insurance as described above have been issued by the undersigned to the Insured named above and are in force at this time.

If cancelled or materially changed in any manner that would affect the CITY OF GREATER SUDBURY as outlined in coverage specified herein for any reason, so as to affect this certificate, thirty (30) days prior written notice, by registered mail or facsimile transmission will be given by the insurer(s) to:

CITY OF GREATER SUDBURY

ATTENTION: RISK MANAGEMENT / INSURANCE OFFICER

200 BRADY STREET, P.O. BOX 500, STATION A

SUDBURY, ON, P3A 5P3

FAX: (705) 673-0344

This certificate is executed and issued to the aforesaid City of Greater Sudbury, the day and date herein written below.

Name of Insurance Company or Broker (completing form)

Telephone Number with Area Code

 

⏐

 

 

Address

Fax Number with area code

 

 

⏐

 

 

Name of Authorized Representative or Official (Please Print)

Signature of Authorized Representative or Official

Date (Year, Month, Day)

 

 

⏐

⏐

Revised July 11/03

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Stage # 1 of completing Sudbury Certificate Of Insurance Form

2. Soon after the previous section is filled out, go to enter the applicable details in these: YES, YES, YES, YES, Injury to Participants, Sublimits or Limitations, Fireworks Watercraft The CITY, Please indicate, CITY OF GREATER SUDBURY, ATTENTION RISK MANAGEMENT, BRADY STREET PO BOX STATION A, SUDBURY ON PA P, FAX, This certificate is executed and, and Name of Insurance Company or.

How to complete Sudbury Certificate Of Insurance Form stage 2

3. Completing Telephone Number with Area Code, Name of Authorized Representative, Signature of Authorized, Date Year Month Day, and Revised July is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Stage no. 3 for filling out Sudbury Certificate Of Insurance Form

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