Certificate of Liability Insurance - Date, Producer, Coverage and Certificate Holder

Sep 24, 2026

Certificate of Liability Insurance template providing fields to record certificate date, producer/broker contact information, insured party, insurer names and NAIC numbers, and certificate and revision numbers. Includes coverage details for multiple insurance types with policy numbers, effective and expiration dates, limits, and indicators for additional insured, subrogation waiver, and waiver conditions. States that the certificate is informational only and does not amend or alter coverage, and lists cancellation notice terms for the certificate holder. Reference to ACORD form identifiers is included.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Certificate header information

Policy coverage table and limits

Additional insured and operations/locations

Certificate holder and cancellation terms

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CERTIFICATE OF LIABILITY INSURANCE | DATE (MM/DD/YYYY) | | --- | --- | | 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 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) . | | | PRODUCER
SAMPLE BROKER | CONTACT NAME: | | | | --- | --- | --- | --- | | | PHONE
(A/C, No, Ext): | FAX
(A/C, No): | | | | E-MAIL ADDRESS: | | | | | INSURER(S) AFFORDING COVERAGE | | NAIC \# | | | INSURANCE COMPANY NAME
INSURER A : | | | | INSURED
SAMPLE VENDOR | INSURANCE COMPANY NAME
INSURER B : | | | | | INSUARNCE COMPANY NAME
INSURER C : | | | | | INSURER D : | | | | | INSURER E : | | | | | INSURER F : | | | COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: | THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. | | | | | | | | | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | INSR
LTR | TYPE OF INSURANCE | | | | | | | | | | | | | | | ADDL
INSD | SUBR
WVD | POLICY NUMBER | POLICY EFF
(MM/DD/YYYY) | POLICY EXP
(MM/DD/YYYY) | LIMITS | | | | | | A | x | COMMERCIAL GENERAL LIABILITY | | | | | | | | | | | | | | X | | CGL 123456 | 10/01/2020 | 10/1/2021 | EACH OCCURRENCE | | | | $ 1,000,000 | | | | | CLAIMS-MADE | | | | | | X | | | | OCCUR | | | | | | | | DAMAGE TO RENTED PREMISES (Ea occurrence) | | | | $ 1,000,000 | | | | | | | | | | | | | | | | | | | | | | | MED EXP (Any one person) | | | | $ Excluded | | | X | $100,000 SIR | | | | | | | | | | | | | | | | | | | PERSONAL & ADV INJURY | | | | $ 1,000,000 | | | GEN'L AGGREGATE LIMIT APPLIES PER: | | | | | | | | | | | | | | | | | | | | GENERAL AGGREGATE | | | | $ 2,000,000 | | | | POLICY
OTHER: | | | | | PRO
JECT | | | | | | | LOC | | | | | | | PRODUCTS-COMP/OP AGG | | | | $ 1,000,000 | | | | | | | | | | | | | | | | | | | | | | | | | | | $ | | A | AUTOMOBILE LIABILITY | | | | | | | | | | | | | | | | | CAL 987654 | 10/01/2020 | 10/1/2021 | COMBINED SINGLE LIMIT (Ea accident) | | | | $ 1,000,000 | | | | ANY AUTO ALL OWNED
AUTOS
HIRED AUTOS | | | | | | X | | | SCHEDULED AUTOS NON-OWNED AUTOS | | | | | | | | | | BODILY INJURY (Per person) | | | | $ | | | | | | | | | | | | | | | | | | | | | | | BODILY INJURY (Per accident) | | | | $ | | | X | | | | | | | | | | | | | | | | | | | | PROPERTY DAMAGE (Per accident) | | | | $ | | | | | | | | | | | | | | | | | | | | | | | | | | | $ | | | | UMBRELLA LIAB EXCESS LIAB | | | | | | | | | | OCCUR
CLAIMS-MADE | | | | | | | | | EACH OCCURRENCE | | | | $ | | | | | | | | | | | | |

FAQs

What does the certificate of liability insurance state about its legal effect?

It is issued as a matter of information only and does not confer rights or amend, extend, or alter the coverage provided by the policies below. It also does not constitute a contract between the insurer(s), producer, and certificate holder.

Which information must be recorded for the insured and insurers?

The template includes producer/broker contact details, the insured name, insurer(s) affording coverage, insurance company names for each insurer (A-F), and NAIC numbers.

How are policy coverages and limits presented in the certificate?

Coverages are listed in a table by insurance type, with policy numbers, policy effective and expiration dates, and limits such as each occurrence and aggregate. The table also includes indicators for additional insured and subrogation-related fields.

Sep 24, 2026

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