OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137) IMPORTANT - If CLAIMS MADE is checked in the COVERAGE / LIMITS section below, this is an application for a claims-made policy. Read all provisions of the policy carefully. Attach to ACORD 125
F.Additional insured will receive advance notice if insurer cancels (GL policy) Yes No and no other option is available with this insurer E.According to the terms of this GL policy, the additional insured has primary and noncontributory coverage #: Title: CG 20 26 CG 20 32 CG 20 33 CG 20 37 CG 20 38 Other: CG 20 10 additional insured location: building: loss payee vehicle: boat: mortgagee scheduled item number: lienholder other employee as lessor item description: interest rank: name and address reference #: certificate required interest in item number additional insured location: building: loss payee vehicle: boat: mortgagee scheduled item number (Form – ACORD 25 [Version: 2016/03]) 1. statement noting this endorsement shall be placed either in the blank area just below the this line of coverage “N/A” is already placed in the Additional Insured column on the form. The use of the Waiver of Subrogation column alone does not meet SAWS Insurance ACORD 25 - Additional Insured and Waiver of Subrogation Indicators - Part 14 How to Complete a Certificate of Liability Insurance About a third of the way from the left hand side of the COVERAGE section, next to the TYPES OF INSURANCE are two columns labeled ADDL INSD and SUBR WVD. Request to use older ACORD forms. Under ACORD’s licensing agreement, the prior editions of superseded forms can be used for one year from the time the new forms are introduced. For example, the latest ACORD 25 is dated September 2009. The prior edition was January 2009. Therefore, under ACORD's licensing agreement, the January 2009 form can ACORD 25 (2009/09) AUTHORIZED REPRESENTATIVE CANCELLATION CERTIFICATE OF LIABILITY INSURANCE DATE (Attach ACORD 101, Additional Remarks Schedule, if more space is required) INSR LTR TYPE OF INSURANCE POLICY NUMBER If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to Home Contact Us Below you'll find all of the ACORD forms we offer. Sign up for a FREE trial of our Fillable ACORD forms system. Our program allows you to fill out ACORD forms on screen and save the data anywhere anytime 24/7.
ACORD 25 (2014/01) AUTHORIZED REPRESENTATIVE CANCELLATION CERTIFICATE OF LIABILITY INSURANCE DATE (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSR If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to Use this step-by-step guideline to complete the Acord 25 Form 2014-2018 swiftly and with perfect precision. How to complete the Acord 25 Form 2014-2018 online: To start the document, utilize the Fill & Sign Online button or tick the preview image of the blank. The advanced tools of the editor will lead you through the editable PDF template. ADDITIONAL INSURED – DESIGNATED PERSON OR ORGANIZATION WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or rented to you. Title: CG2026N5.PDF Author: Unknown permission to use their forms and information. April 2013 The beginning of the Certificate of Liability ACORD # 25 states. 10/28/2013 3 In the ACORD instructions for compilation of ACORD 25: What is a certificate of insurance? policy if YOU are added to MY policy as an additional insured ACORD 25 (2014/01) AUTHORIZED REPRESENTATIVE CANCELLATION CERTIFICATE OF LIABILITY INSURANCE DATE (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSR If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to F.Additional insured will receive advance notice if insurer cancels (GL policy) Yes No and no other option is available with this insurer E.According to the terms of this GL policy, the additional insured has primary and noncontributory coverage #: Title: CG 20 26 CG 20 32 CG 20 33 CG 20 37 CG 20 38 Other: CG 20 10
A. Section II – Who Is An Insured is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured. B. With respect to the insurance afforded to these additional insureds, the following exclusion is added: 2. Exclusions does any named insured sell to other named insureds? 1. any medical facilities provided or medical professionals 12. any structural alterations contemplated? additional interest/certificate recipient acord 45 attached for additional names general information acord 126 (2004/03) attach to applicant information section. date (mm/dd/yyyy OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137) IMPORTANT - If CLAIMS MADE is checked in the COVERAGE / LIMITS section below, this is an application for a claims-made policy. Read all provisions of the policy carefully. Attach to ACORD 125 ACORD 25 (2014/01) AUTHORIZED REPRESENTATIVE CANCELLATION CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with From the WCIRB's California Workers' Compensation Insurance Forms Manual - 1999. 5. S A M P Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II – Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only
ADDITIONAL INTEREST (Not all fields apply to all scenarios - provide only the necessary data) POLICY NUMBER EFFECTIVE DATENAMED INSURED(S) AGENCY CARRIER NAIC CODE The topic of additional insured status is a difficult one at best. Many misconceptions result when adding contracting parties to one an-other’s insurance policies as additional insureds. There is also the tug-of-war between insurers and indemnitors that want to limit the scope of additional insured coverage under their policies and the in- effective date: named insured policy number carrier naic code agency loc #: agency customer id: additional remarks schedule page of additional remarks form number: form title: ACORD 855 NY, New York Construction Certificate of Liability Insurance Addendum, may be used to supplement ACORD 25, Certificate of Liability Insurance, in the state of New York, to provide more information about the policy's coverage when required by the certificate holder. ACORD 25 (2014/01) AUTHORIZED REPRESENTATIVE CANCELLATION CERTIFICATE OF LIABILITY INSURANCE DATE (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSR If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to Use this step-by-step guideline to complete the Acord 25 Form 2014-2018 swiftly and with perfect precision. How to complete the Acord 25 Form 2014-2018 online: To start the document, utilize the Fill & Sign Online button or tick the preview image of the blank. The advanced tools of the editor will lead you through the editable PDF template.
Insured Policy Number Insurer Intermediary ADDITIONAL REMARKS SCHEDULE Page of ADDITIONAL REMARKS Form Number: Form Title: This Additional Remarks form is a schedule to ACORD form, Title: ACORD 3101 (2012/02) Author: ACORD Corporation Created Date:
