Exhibit 26 Sample Certificate of Insurance | MAN1425
INSTRUCTIONS TO PRODUCING AGENT: Complete the shaded portions of this certificate and return to the Insured. No condition, term, qualification, limitation, exception, exemption, modification, or proviso shall appear on the certificate. |
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Name, Address and Telephone Number of Producing Agent |
CONTRACT NUMBER: |
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CONTRACT NAME: |
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Name and Address of Insured Contractor |
Certificate Holder (Owner) |
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Type of Insurance (include brief description) |
Policy No. |
Company Affording Coverage |
Policy Period Dates (MM/DD/YY) |
Limits |
Commercial General Liability |
General Aggregate (Per Project) Products-Co./Op Agg Personal & Adv injury Contractual Each Occurrence |
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Commercial Business Automobile Liability Including, but not limited to, owned, hired and non-owned autos |
Combined Single Limit OR Bodily Injury (per person) Property Damage |
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Workers Compensation |
GA Statutory Limits Each Occurrence Disease - Policy Limit Disease Each Employee |
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Commercial Umbrella Liability |
Each Occurrence Aggregate |
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Employers' Liability |
Each Occurrence Disease - Policy Limit Disease Each Employee |
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Additional: |
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Such insurance as is herein certified (i) applies to all insurance issues in connection with the work required by the provisions of the documents forming the contract, (ii) applies whether or not the contract documents between the insured contractor and the Owner have been executed, (iii) is written in accordance with the company’s regular policies and endorsements, subject to the company’s applicable manuals or rules and rates in effect, as modified by this certificate and the insurance article of the contract, (iv) have been issued to the insured named above, and (v) are in force at this time. The Officers, Members, & Employees of the Owner and the State of Georgia are included as additional insureds as their interests may appear. Each Insurer is hereby notified that the statutory requirement that the Attorney General of Georgia shall represent and defend the Indemnities remains in full force and effect and is not waived by issuance of any policy of insurance. Each policy shall contain a provision that coverage afforded under the policies will not be canceled (or not renewed or allowed to lapse for any reason) until at least thirty (30) days after Owner has received notice thereof as evidenced by return receipt of registered letter. All policies must be issued by an insurance company licensed to do business in the State of Georgia, with a minimum AM Best rating of A-, and signed by an authorized agent. |
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Authorized Representative: Date: Type Name: |