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Generic Example of Certificate of Liability Insurance. Producer: If you have questions about this form, please call 800-678-5102. Your insurance broker may SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the CERTIFICATE OF LIABILITY INSURANCE THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR 11 Oct 2016 A certificate of liability insurance is used to verify the existence of liability Separate certificate forms are used for property and liability insurance. For example, the General Liability section lists the six separate limits SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE The Certificate of Insurance on the reverse side of this form does not CERTIFICATE HOLDER COMMERCIAL GENERAL LIABILITY THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR Broad Form Property Damage. CERTIFICATE OF LIABILITY INSURANCE (Sample) Date (MM/DD/YYYY) A statement does not confer rights to the certificate holder in lieu of such endorsement(s). (PLEASE ATTACH COPY OF ADDITIONAL INSURED FORM. CERTIFICATE OF LIABILITY INSURANCE. LOC COMMERCIAL GENERAL LIABILITY THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED CERTIFICATE OF LIABILITY INSURANCE. DATE (MM/DD/YYYY). THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY. AND CONFERS NO SAMPLE CERTIFICATE OF LIABILITY INSURANCE - *= REQUIRED FIELDS. DATE (MM/DD/YY). PRODUCER – Name and address of insurance producer. Phone number is also AGGREGATE. $ N/A. OTHER THAN UMBRELLA FORM. $.
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