120 Adelaide Street West
Suite 1600
Toronto, Ontario M5H 1T1
T 416-967-7474
F 416-967-1947
www.ieso.ca
FORM OF CERTIFICATE OF LIABILITY INSURANCE
contract.management@ieso.ca
IESOCM-FORM-007(2011-10)
SUBMIT BY E-MAIL (PDF WITH SIGNATURE) TO
contract.management@ieso.ca
Pursuant to Section [No.] of the Contract, the Supplier is hereby submitting this completed Form of Certificate of Liability Insurance to the Buyer.
Capitalized terms not defined herein have the meanings ascribed thereto in the Contract.
Instructions
• This Certificate of Liability Insurance must be completed by the Supplier’s insurance agent or broker and submitted to the
Independent Electricity System Operator (“IESO”) prior to commencement of the construction of the Contract Facility.
Refer to Section [No.] of the [Contract Type Short Name] Contract dated [Contract Date] (the “Contract”) for a detailed
description of insurance requirements, including required coverages.
• Insurer’s standard certificate of insurance is not acceptable in lieu of this Certificate of Liability Insurance.
• It is understood that this Certificate of Liability Insurance is issued as information only. It does not amend, extend or alter
coverages afforded by the policies described herein.
• Unless otherwise stated, capitalized terms used in this Certificate of Liability Insurance have the meanings given to them in the
Contract.
IDENTIFICATION OF NAMED INSURED
Named Insured
as it appears in the Policy
Evidence of Coverage
of Supplier enclosed
Named Insured Address
City
Province
Postal Code
IDENTIFICATION OF CONTRACT
Legal Name of Supplier
Name of Contract Facility
Location of Contract
Facility (Municipality)
GENERAL LIABILITY INSURANCE
General Liability
Insurer’s Name
General Liability
Insurer’s Policy Number
Policy Term – From / To
(Day/Month/Year)
From
to
[Day/Month/Year]
[Day/Month/Year]
Limit of Liability
(per occurrence)
Aggregate Limit
if Applicable
Deductible or Self-Insured
Retention (“SIR”)
FORM OF CERTIFICATE OF LIABILITY INSURANCE
IESOCM-FORM-007(2011-10)
Page 1 of 3
Independent Electricity System Operator
UMBRELLA AND EXCESS LIABILITY INSURANCE
Umbrella and Excess Liability
Insurer (if applicable)
Umbrella and Excess
Liability Policy Number
Policy Term – From / To
(Day/Month/Year)
From
to
[Day/Month/Year]
[Day/Month/Year]
Limit of Liability
(per occurrence)
Aggregate Limit
if Applicable
Deductible or SIR
COVERAGES PROVIDED BY COMMERCIAL GENERAL LIABILITY (“CGL”) AND, IF APPLICABLE,
UMBRELLA AND EXCESS POLICIES (Double-click box to check applicable coverages)
Owner’s and Contractor’s Protective Liability
Blasting
Operation of Attached Machinery
Personal Injury Liability
Pile Driving or Caisson Work
Forest Fire-Fighting Expenses
Non-Owned Automobile Liability
Removal or Weakening of Support of Property, Building or Land
Sudden and Accidental Pollution Liability
Products and Completed Operations
Elevator and Hoist Liability
Employees as Additional Insureds
Personal Injury and Advertising Liability
Occurrence Basis Property Damage
Broad Form Property Damage
Contingent Employers Liability
Blanket Contractual
Tenants Legal Liability
Cross Liability
Medical Expense $10,000 Per Person
Intentional Acts for the Protection of Persons or Property
Building Material Replacement Cover
Non-owned Watercraft up to 8 meters
AUTOMOBILE LIABILITY INSURANCE
Auto Insurer’s
Name
Auto Insurer’s
Policy Number
Policy Term – From / To
(Day/Month/Year)
From
to
[Day/Month/Year]
[Day/Month/Year]
Limit of Liability
(per occurrence)
Aggregate Limit
if Applicable
Deductible or SIR
FORM OF CERTIFICATE OF LIABILITY INSURANCE
IESOCM-FORM-007(2011-10)
Page 2 of 3
Independent Electricity System Operator
WRAP-UP LIABILITY INSURANCE
Wrap-Up Liability Insurer’s
Name
Wrap-Up Liability Insurer’s
Policy Number
Policy Term – From / To
(Day/Month/Year)
From
to
[Day/Month/Year]
[Day/Month/Year]
Limit of Liability
(per occurrence)
Aggregate Limit
if Applicable
Deductible or SIR
Afforded to all interested
parties including Buyer,
Supplier, Contractor and
Sub-Contractors
Completed Operations
Period (Specify)
Certification
The undersigned hereby certifies that:
• Where the Named Insured is not the Supplier, the Supplier is also insured under such policy described in this certificate to the
same extent as the Named Insured.
• The policies described herein, subject to their terms, conditions, and exclusions, have been issued to the named insured and
are in full force and effect.
• The IESO, the Government of Ontario, the members of the Government of Ontario’s Executive Council and their respective
Affiliates, and each of the foregoing Person’s respective directors, officers and employees, shareholders, advisors and agents
(including contractors and their employees) are added as additional insureds to each policy described in this Certificate.
• Coverages afforded under policies described herein will not be cancelled or materially changed to restrict coverage unless
sixty (60) days prior written notice has been given to the IESO at the address shown on page 1 of this Certificate of Liability
Insurance and each of the policies have been endorsed to this effect.
• The undersigned is an authorized representative of each of the insurance companies listed herein, has full knowledge of the
facts set forth herein and believes them to be true.
Name of Issuing Agent
or Brokerage
Address of Issuing Agency
or Brokerage
City
Province
Postal Code
Phone Number
Name of Authorized Representative
Signature of
Authorized Representative
Date of Issue
FORM OF CERTIFICATE OF LIABILITY INSURANCE
IESOCM-FORM-007(2011-10)
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