Contractor Forms - GL - CJ's Install Solutions

Contractor Forms - GL

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. 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).
Insurance Company Info
The following pertains to your insurance company's information:
Producer*
Insurance Company Name
Address*
Insurance Company Address

Street Address Address Line 2 City ST ZIP / Postal Code
Contact Name

Insurance Company Contact Name
Phone*
Fax
Email
Insurer(s) Affording Coverage*

List Name and NAIC# for each Insurer
Your Company Info
The next questions are about your company (the insured).
Your Name*
First Last
Your Email*
Insured Company Name*
Enter your company name here
Address*
Your company's address

Street Address Address Line 2 City ST ZIP Code
Coverage and Limits
This section is about your policy coverage and limits.
Commercial General Liability
Choose one:
- Claims Made
- Occur
Gen'l Aggregate Limit Applies Per:
Choose one:
- Policy
- Project
- LOC
- Other
If other, please explain:
Addl Insd
- Yes
- No
Policy Number
Policy Eff:
MM slash DD slash YYYY
Policy Exp:
MM slash DD slash YYYY
Limits
Enter your policy limit amounts below:
Each Occurance:
Damage to Rented Premises (Ea occurrence)
Med Exp (Any one person)
Personal and Adv Injury
Aggregate
Products Comp/Op AGG
Description of Operations / Locations / Vehicles:
Certificate Holder & Signature
Name*
Address*
Street Address Address Line 2 City ST ZIP Code

19103

Contractor Forms - GL

Insurance Company Info

Your Company Info

Coverage and Limits

Limits

Certificate Holder & Signature

About CJ’s Install Solutions

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