Standard Consultant Certificate of Insurance

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Standard Consultant Certificate of Insurance Powered By Docstoc
					                                                                  Certificate of Insurance
                                                        City Road and Right-of-Way Use Permit Form

This certifies that policies of insurance as described below have been issued to the Insured named below and are in full force and effect at this time. It
is understood and agreed that thirty (30) days' written notice of cancellation or reduction in applicable limit of insurance of any of the policies listed
below, with the exception of ICBC, will be given to the holder of this certificate.

NOTE:       INSURANCE COMPANIES MUST BE LICENSED TO OPERATE IN CANADA.

This Certificate is issued to:       The City of Surrey, 14245 - 56 Avenue, Surrey, B.C. V3X 3A2

Insured:        Name:
                Address:

Broker:         Name:                                                                   Agent’s Name:
                Address:                                                                      Phone:

Location, Project No. and nature of contract, permit, lease, license or operation to which this Certificate applies:




                                                                                                   Policy Term
Type of Insurance                                       Company and Policy Number                  yyyy/mm/dd            Limits of Liability/Amount
Section 1                                                                                                        Bodily Injury, Death & Property Damage
                                                                                             From:               $                    Per Occurrence
Commercial General Liability                                                                 To:                 $                    General Aggregate
                                                                                                                 $                    Products & Completed
__________ ___________                              ____________________                     ___________                              Operations Aggregate
                                                                                             From:
   Umbrella Liability                                                                        To:
_____________________                               _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _   ___________         $                  Umbrella Limit

      Excess Liability                                                                       From:
                                                                                             To:                 $                  Excess Limit
                                                                                                                 $                  Deductible
                                                                                                                        MINIMUM $3,000,000
Section 2                                                                                    From:               Bodily Injury & Property Damage
Automobile Liability (owned or leased                                                                            $                   Limit
vehicles)                                                                                    To:                        MINIMUM $2,000,000
Section 3                                                                                    From:
Other:                                                                                                           $                   Limit
                                                                                             To:                 $                   Deductible

                             Particulars of General Liability Insurance (Sections 1): X indicates that the coverage is included.
   City of Surrey as Additional Insured                          Broad Form Property Damage                   Broad Form Tenants Legal Liability
   Premises & Operations                                         Incidental Medical Malpractice               Advertising Liability
   Broad Form Products & Completed Operations                 Broad Form Loss of Use                         Host Liquor Liability
   Owners & Contractors Protective                            Personal Injury                                Intentional Injury
                                                                  Use of explosives for blasting               Volunteers as Additional Insureds
   Blanket Contractual
                                                                                                               Members as Additional Insureds
   Cross Liability/Severability of Interests                     Vibration from pile driving or caisson
                                                                  work                                         Injury to Participants (sporting events)
   Employees Additional Insureds
                                                                  Removal or weakening of support of           Aviation Liability
   Non-Owned Automobile                                          property, building or land whether the       Non-owned aircraft liability
   Attached Machinery                                            support is natural or otherwise              Watercraft liability
   Occurrence Property Damage                                    Work below ground level over 3 meters        Non-owned watercraft liability
   Contingent Employer’s                                         (XCU extension)
   Broad Form Loss of Use

It is understood and agreed any deductible or reimbursement clause contained in the policy shall be the sole responsibility of the Named Insured.


                  (Authorized to Sign on Behalf of Insured)                                                          Date Signed



    (Authorized to Sign on Behalf of Insurers) and Brokers Stamp                                                     Date Signed



Jan 1, 2008
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