Certificate of Liability Insurance Example

This document is a sample Certificate of Liability Insurance. It includes standard certificate elements with fillable areas such as producer information, insured information, coverage tables, policy details, and instructional boxes.

The top portion contains the document title “Certificate of Liability Insurance,” the date “04/06/05,” and a disclaimer stating "THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW."

Producer information appears at the top left, listing “I Sell Insurance Company,” its address, and phone number as an example. The insured section lists “I Manage Boats, Inc.” along with its mailing address. Several insurance companies (A, B, C, D) are identified on the top right section.

The main body of the certificate contains a coverage table with columns labeled as TYPE OF INSURANCE, POLICY NUMBER, POLICY EFFECTIVE DATE, and LIMITS. Categories under "Types of Insurance", include General Liability, Automobile Liability, GARAGE LIABILITY, EXCESS LIABILITY, WORKERS’ COMPENSATIONS and OTHER: WATERCRAFT LIABILITY, OWNED, NON-OWNED AND HIRED. Each row includes policy numbers, effective and expiration dates, and coverage limits (for example, $1,000,000 per occurrence for general liability).

 

Yellow Boxed Instructional Callouts:
Several instructions are displayed in yellow boxes that sit outside the form fields. These boxed callouts include:
• “Commercial General Liability may ONLY be written by a United States company.”
• “Certificate MUST contain a policy number. Binders are NOT acceptable.”
• “Comprehensive General Liability minimum is per occurrence.”
• “Certificate must show the following as the additionally insured: United States of America, Department of the Interior, National Park Service, 1 Baxter Way Suite 180 Westlake Village, CA 91362.”
• “Certificate MUST show the exact description of the services authorized under the permit.”
• “Certificate MUST contain a 30‑day cancellation clause, and MUST be signed by an insurance company representative.”

These boxed notes function as instructional requirements and are visually separated from the form entries.

Yellow-Highlighted Areas Within the Form:
Additional content is highlighted in yellow directly on the certificate itself. These highlights appear:
• Over certain fillable areas, serving as example text or emphasis for required fields
• Along specific coverage lines to draw attention to key instructions
• Near the cancellation clause area, marking portions that need special attention

These highlights are overlays applied onto the form fields themselves to visually indicate important areas or example entries.

The Descriptions of Operations section shows an example that a "certificate holder is listed as an additional insured for water transportation and towing services, and includes an office location in Madison, WI."

The Certificate Holder block identifies: “United States of America / Department of the Interior / National Park Service,” with an address in Westlake Village, CA.

On the bottom right of the document a cancellation clause states the insurer will “endeavor to mail 30‑days written notice,” although failure to do so does not impose liability on the insurer. An authorized representative signature line appears beneath this section.

Overall, this document is a non‑fillable sample meant to demonstrate the typical structure and informational components of a Certificate of Liability Insurance. It is not intended to function as an active or valid insurance certificate.

For any questions reagarding this example, contact the Office of Special Park Uses at [e-mail] or 805-370-2308.