ACORD 25 — Certificate of Liability Insurance

Meridian Insurance

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Header

Date Issued

Customer ID

Revision Number

Producer

Producer / Agency Name

Contact Name

Address Line 1

Address Line 2

City

State

ZIP

Phone (A/C, No, Ext)

Fax (A/C, No)

Insured

Insured Name

Insured Customer Identifier

Address Line 1

Address Line 2

City

State

ZIP

Insurers Affording Coverage

Insurer Name

NAIC #

Commercial General Liability

Include on certificate Claims-Made Occurrence Additional Insured Subrogation Waived

Insurer Letter (A–F)

Policy Number

Other (X)

Effective Date

Expiration Date

Limits

Each Occurrence

Damage to Rented Premises (each occ.)

Med Exp (any one person)

Personal & Advertising Injury

General Aggregate

Products – Comp/Op Aggregate

Aggregate applies per Policy per Project per Location

Automobile Liability

Include on certificate Any Auto Owned Autos Scheduled Autos Hired Autos Non-Owned Autos Additional Insured Subrogation Waived

Insurer Letter (A–F)

Policy Number

Effective Date

Expiration Date

Limits

Combined Single Limit (each accident)

Bodily Injury (per person)

Bodily Injury (per accident)

Property Damage (per accident)

Umbrella / Excess Liability

Include on certificate Umbrella Excess Claims-Made Occurrence Additional Insured Subrogation Waived

Insurer Letter (A–F)

Policy Number

Retention

Effective Date

Expiration Date

Each Occurrence

Aggregate

Workers Compensation & Employers' Liability

Include on certificate Subrogation Waived

Insurer Letter (A–F)

Policy Number

Effective Date

Expiration Date

Any Proprietor / Partner / Executive Officer / Member Excluded?

Limits

E.L. Each Accident

E.L. Disease – Ea Employee

E.L. Disease – Policy Limit

Per Statute (statutory limits) Other

If Excluded — Description of Operations

Other Coverage

Include on certificate Additional Insured Subrogation Waived

Coverage Description

Insurer Letter (A–F)

Policy Number

Limits / Notes

Effective Date

Expiration Date

Description of Operations / Locations / Vehicles

Description (referencing additional remarks if needed)

Certificate Holder

Holder Name

Attention / Contact

Address Line 1

Address Line 2

City

State

ZIP

Authorized Representative

Authorized Representative Name

Signature Date

Notes (Internal Only)

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