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liability insurance_Sample of Certificate of Insurance - CERTIFICATE OF LIABILITY

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					                                                                                                                                                                              DATE (MM/DD/YY)

                                                            CERTIFICATE OF LIABILITY INSURANCE                                                                                07/23/09
                                                                                                                                                                                                  INSURERS: names of
 PRODUCER: Insurance              PRODUCER                                        Phone No. 212-488-0200      THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
 Agent/Broker who issues          «Broker Name»                                   Fax No.   212-488-0220      ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
                                                                                                              HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
                                                                                                                                                                                                  insurance companies
                                  «Address 1»
 certificate                      «City», «State», «Zip»                                                      ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.                                  providing coverage to
                                                                                                            INSURERS AFFORDING COVERAGE                                           NAIC #          the insured
                                  INSURED
                                                                                                            INSURER A:             Insurance Carrier Name
                                  «Insured Name»
 NAME OF INSURED:                 «Address_1»
                                  «City», «State» «Zip»
                                                                                                            INSURER B:             Insurance Carrier Name                                         POLICY EFECTIVE
 Must be legal name of
                                                                                                            INSURER C:             Insurance Carrier Name
                                                                                                                                                                                                  DATE: must be prior
                                                                                                            INSURER D:             Insurance Carrier Name
 the contracting company                                                                                                                                                                          or coincidental with
                                                                                                            INSURER E:
                                  COVERAGES                                                                                                                                                       effective date of
                                   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                                   contract
                                   MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
                                   POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
                                  INSR ADD’L
                                   LTR INSRD        TYPE OF INSURANCE                   POLICY NUMBER
                                                                                                            POLICY
                                                                                                           EFFECTIVE
                                                                                                                                POLICY
                                                                                                                              EXPIRATION                             LIMITS                          POLICY
                                  A            GENERAL LIABILITY
                                                 COMMERCIAL GENERAL LIABILITY
                                                                                                                                              EACH OCCURRENCE
                                                                                                                                              DAMAGES TO RENTED
                                                                                                                                                                              $
                                                                                                                                                                                                     EXPIRATION
                                                                                                                                              PREMISES (Ea Occurrence)        $
TYPES OF INSURANCE:                              CLAIMS MADE              OCCUR
                                                                                                                                              MED EXP (Any one person)        $
                                                                                                                                                                                                     DATE: If
                                                 PRODUCTS LIABILITY
                                                                                                                                              PERSONAL & ADV INJURY           $                      occurrence form
Must include types of insurance                                                                                                               GENERAL AGGREGATE               $
                                                                                                                                                                                                     must be on or after
                                               GEN’L AGGREGATE LIMIT APPLIES PER
                                                                                                                                              PRODUCTS - COMP/OP AGG          $
required by contract                             POLICY
                                                               PRO-
                                                               JECT          LOC                                                              PRODUCTS - COMP/OP EA OCC $                            termination of
                                  B            AUTOMOBILE LIABILITY                                                                           COMBINED SINGLE LIMIT
                                                                                                                                              (Ea accident)
                                                                                                                                                                              $                      contract
                                                 ANY AUTO
                                                 ALL OWNED AUTOS                                                                              BODILY INJURY
                                                                                                                                              (Per person)
                                                                                                                                                                              $
                                                 SCHEDULED AUTOS
                                                 HIRED AUTOS                                                                                  BODILY INJURY
                                                                                                                                              (Per accident)
                                                                                                                                                                              $                     LIMITS OF
                                                 NON-OWNED AUTOS
                                                                                                                                              PROPERTY DAMAGE
                                                                                                                                                                              $
                                                                                                                                                                                                    INSURANCE: Must
                                                                                                                                              (Per accident)
                                                                                                                                                                                                    be the same or
                                               GARAGE LIABILITY                                                                               AUTO ONLY - EA ACCIDENT         $
                                                                                                                                                                                                    greater than required
  This box may include the                       ANY AUTO                                                                                     OTHER THAN
                                                                                                                                              AUTO ONLY:
                                                                                                                                                                   EACH ACC $

                                                                                                                                                                      AGG                           by contract
  following:                      C            EXCESS/UMBRELLA LIABILITY                                                                      EACH OCCURRENCE                 $
                                                 OCCUR             CLAIMS MADE                                                                AGGREGATE                       $
  - endorsements                                 DEDUCTIBLE
                                                 RETENTION            $

  - named additional insured:     D     WORKER’S COMPENSATION AND
                                                                                                                                                   WC STATU-
                                                                                                                                                  TORY LIMITS
                                                                                                                                                                      OTH-
                                                                                                                                                                       ER
                                        EMPLOYERS’ LIABILITY
  Arkema Inc. must be named             Y/N
                                                                                                                                              E.L. EACH ACCIDENT              $
                                        ANY PROPRIETOR/PARTNER/EXECUTIVE                                                                                                      $
  additional insured                    OFFICER/MEMBER EXCLUDED?
                                                                                                                                              E.L. DISEASE - EA EMPLOYEE

                                        If yes, describe under
                                        SPECIAL PROVISIONS below                                                                              E.L. DISEASE - POLICY LIMIT     $
  - exclusions                          OTHER

                                  DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
  - etc …                                                                                                                                                                                           NOTICE OF
                                                                                                                                                                                                    CANCELLATION:
                                                                                                                                                                                                    Most commonly 30
  CERTIFICATE HOLDER:
                                                                                                                                                                                                    days
  Must be Arkema Inc.             CERTIFICATE HOLDER                                                          CANCELLATION
                                                                                                               SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION

  Attn: Purchasing Department     «Certificate Holder Name»
                                                                                                               DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL       30    DAYS WRITTEN
                                                                                                               NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
                                  «Contact»                                                                    IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
  2000 Market Street              «Address_1»                                                                  REPRESENTATIVES.
                                  «Address_2»                                                                  AUTHORIZED REPRESENTATIVE                                          «TypeCode»        AUTHORIZED
                                  «City», «State» «Zip»
  Philadelphia, PA 19103                                                                                                                                                                            REP: Must be signed