ACORD ™ CERTIFICATE OF LIABILITY INSURANCE
PRODUCER
Insurance Company Name
Street Address
City, State, Zip Code
Date (MM/DD/YYYY): 03/19/2004
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.
INSURERS AFFORDING COVERAGE
INSURED
Your Company Name
Street Address
City, State, Zip Code
INSURER A: Insurance Company
INSURER B:
INSURER C:
INSURER D:
INSURER E:
COVERAGES
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. AGGREGATE LIMITS
SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POLICY
POLICY
EFFECTIVE
EXPIRATION
POLICY NUMBER
INSR
DATE
DATE
LTR
TYPE OF INSURANCE
(MM/DD/YY)
(MM/DD/YY)
LIMITS
GENERAL LIABILITY
EACH
$
OCCURRENCE
 COMMERCIAL GENERAL LIABILITY
FIRE DAMAGE (Any
$
one fire)
 CLAIMS MADE
MED EXP
$
 OCCUR
(Any one person)
PERSONAL & ADV
$
______________________________
INJURY
______________________________
GENERAL
AGGREGATE
$
GEN’L AGGREGATE LIMIT APPLIES PER:
PRODUCTS –
COMP/OP AGG
$
 POLICY
 PROJECT
 LOC
AUTOMOBILE LIABILITY
 ANY AUTO
 ALL OWNED AUTOS
 SCHEDULED AUTOS
 HIRED AUTOS
 NON – OWNED AUTOS
______________________________
______________________________
GARAGE LIABILITY
 ANY AUTO
______________________________
EXCESS LIABILITY
 OCCUR  CLAIMS MADE
A
 DEDUCTIBLE
 RETENTION
WORKER’S COMPENSATION AND EM
PLOYER’S LIABILITY
COMBINED
SINGLE LIMIT
(Ea accident)
BODILY INJURY
(Per person)
BODILY INJURY
(Per accident)
$
$
$
PROPERTY
DAMAGE
(Per accident)
$
AUTO ONLY – (Ea
Accident)
$
OTHER
THAN
AUTO
ONLY:
EA ACC
AGG
EACH
OCCURRENCE
AGGREGATE
$
$
$
$
$
$
$
X/WC STATUTORY
LIMITS / OTHER
E.L. EACH
ACCIDENT
E.L. DISEASE – EA
EMPLOYEE
E.L. DISEASE –
POLICY LIMIT
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
The University of North Florida Fine Arts Center
CERTIFICATE HOLDER / ADDITIONAL INSURED; INSURER LETTER___
CANCELLATION 10-Day Notice for Non-Payment of Premium
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
The University Of North Florida Board Of Trustees,
THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE
State of Florida, their officers, agents and employees
CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION
4567 St. Johns Bluff Road South
LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
Building 45, Room 2400
AUTHORIZED REPRESENTATIVE
Jacksonville, FL 32224
This excerpt is taken directly from the facility use agreement and should be given to the
insurance company to insure the form is filled out properly.
If you have any questions, please contact the UNF Fine Arts Center Office at 904.620.1895.
13.0 Insurance
CLIENT shall at its own expense obtain and maintain during the term of this Agreement public
liability insurance issued by a company authorized to provide insurance in this State, to cover personal
bodily injury and wrongful death in the amount of $1,000,000, as well as property damage liability
insurance in the amount of $1,000,000, or combined coverage of $2,000,000 aggregate.
The insurance shall cover all of CLIENT’s operations and activities under this Agreement and shall be
effective throughout the effective period of this Agreement, with no exclusions or deductibles. The
Certificate of Insurance must state that thirty (30) days advance written notice will be given to the
Director in the event of cancellation or material change in coverage.
The University Of North Florida Board Of Trustees, State of Florida, their officers, agents and
employees shall be named as additional named insured on each policy by written endorsement.
CLIENT shall provide written evidence that such policies are current and in effect with the signed
copy of the Agreement. Attach as Addendum B