Instructions for Completing the ACORD Certificate of Liability Insurance
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“Date (MM/DD/YYYY)” – This is the date the Certificate is generated;
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“Producer” – Insert the complete name and address of the insurance agency or broker issuing this
certificate; in the adjacent cell (located just to the right of the “Producer” cell) include “Contact
Person”’s name, office phone, fax number, and email address.
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“Insured” – Enter the complete legal name and address of the Consulting Firm, the Contractor’s
Company, or the Supplier’s Company (include any “DBA” used);
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“Insurer(s) Affording Coverage” – Insurer “A” through “E” – enter the insurance carrier’s complete
Operating Company name or NAIC (National Association of Insurance Commissioners) ID number (5
digit). Note that if the name of the Insurer cannot be located in the A.M. Best Directory, then the
NAIC number will be required.
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“Certificate Number” or “Revision Number” – These two data fields, if utilized by the insurance agency
or insurance broker, could be used as a quick reference number; SAWS does not require this to be
used.
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“Coverages” – “Insurer” Letter (“INSR/LTR”) column – place the corresponding letter of the insurance
carrier affording coverage by each respective type of insurance coverage;
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Type of Insurance – “General Liability”
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“Commercial General Liability” – place an “X” in the space provided;
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“Occur” (Occurrence based form) – place an “X” in the space provided;
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“Gen’l Aggregate Limit Applies Per” – For Construction Contracts, place an “X” in the box right in
from of the word “Project”; or For all Other Contracts, place an “X” in the box right in front of either
the word “Policy” or “Loc” (Location).
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“Addl Insr” and “Subr Wvd” columns – an “X” indicates whether this line of insurance coverage is
endorsed with both the Additional Insured and the Waiver of Subrogation. Each item is inserted
into the “Description of Operations” section, following specific wording.
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Enter complete “Policy Number,” “Policy Effective Date” (MM/DD/YYYY), and “Policy Expiration
Date” (MM/DD/YYYY).
Type of Insurance – “Automobile Liability”
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Place an “X” in the box in front of each appropriate auto category for which coverage applies.
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“Addl Insr” and “Subr Wvd” columns – an “X” indicates whether this line of insurance coverage is
endorsed with both the Additional Insured and the Waiver of Subrogation. Each item is inserted
into the “Description of Operations” section, following specific wording.
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Enter complete “Policy Number,” “Policy Effective Date” (MM/DD/YYYY), and “Policy Expiration
Date” (MM/DD/YYYY).
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If the Contractor’s Pollution Liability policy is required and the policy is not endorsed to provide
transportation coverage beyond the boundaries of the job site, the Automobile Liability policy
must have the CA9948 endorsement: “Contractor’s Commercial/Business Automobile Liability
insurance coverage is endorsed with the CA9948 endorsement to provide transportation
coverage beyond the boundaries of the job site.” The policy must also be endorsed with the
MCS90 endorsement when hazardous materials are being transported.
Type of Insurance – “Excess/Umbrella Liability” (where applicable)
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“Coverage form used” – place an “X” in the appropriate box that identifies the coverage form
under which this Policy is written: “Umbrella Liab” or “Excess Liab”; and
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“Occurrence” or “Claims-made basis” – an “X” is required in the box right in front of the word
“Occur.”
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“Addl Insr” and “Subr Wvd” columns – an “X” indicates whether this line of insurance coverage is
endorsed with both the Additional Insured and the Waiver of Subrogation. Each item is inserted
into the “Description of Operations” section, following specific wording.
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Enter complete “Policy Number,” “Policy Effective Date” (MM/DD/YYYY), and “Policy Expiration
Date” (MM/DD/YYYY).
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The above limits may vary depending on the degree of and potential for greater liability exposure.
Type of Insurance – “Workers’ Compensation and Employer’s Liability”
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Answer the Question, “Any Proprietor/Partner/Executive Officer/Member Excluded?” If yes,
describe under the “Special Provisions” section.
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Contractors who are sole proprietors or are excluded from coverage shall provide proof of health
and disability insurance.
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“Addl Insr” and “Subr Wvd” columns – an “X” indicates whether this line of insurance coverage is
endorsed with both the Additional Insured and the Waiver of Subrogation. With this line of
coverage, “N/A” is already placed in the “Additional Insured” column on the form. The Waiver of
Subrogation only is inserted into the “Description of Operations” section, following specific
wording.
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Enter complete “Policy Number,” “Policy Effective Date” (MM/DD/YYYY), and “Policy Expiration
Date” (MM/DD/YYYY).
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“WC” (Worker’s Compensation) – enter an “X” in the box right in front of the words “WC Statutory
Limits.” In California, Worker’s Compensation is required by law for any company which has
employees. Umbrella Insurance cannot serve as a substitute for it.
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“E.L.” (Employer’s Liability) – see limits above.
Type of Insurance – Other
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The row of blank cells located immediately below the “Worker’s Compensation and Employer
Liability” row is typically used for such lines of coverage as “Professional Liability” (Engineers,
Architects), “Contractor’s Pollution Liability,” “Commercial Crime,” and/or “Builder’s Risk” lines of
insurance coverage.
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“Addl Insr” and “Subr Wvd” columns – an “X” indicates whether this line of insurance coverage is
endorsed with both the Additional Insured and the Waiver of Subrogation. Since the lines of
insurance listed in the above are not required to be endorsed, do not place anything in either of
the “Addl Insr” or “Subr Wvd” columns.
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Enter complete “Policy Number,” “Policy Effective Date” (MM/DD/YYYY), and “Policy Expiration
Date” (MM/DD/YYYY).
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The minimum limits (the per occurrence/claims reported limit as well as the policy aggregate limit)
for whichever “Type of Insurance” coverage you are declaring in this “Other” space must match
with or exceed limits stated in the Insurance Specifications/Requirements.
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If the line of insurance coverage is for either “Professional Liability” or “Contractor’s Pollution
Liability,” identify in the “Description of Operations” section whether the lines of coverage are
“Claims-made form” or “Occurrence Basis.” If the Claims-made basis includes a “Retro-Active
date,” the project’s start date or earlier must be included in “Description of Operations.” If the
Occurrence basis is declared, no further info is required. If the Contractor’s Pollution Liability is
included and has an endorsement, the “Description of Operations” must include “Contractor’s
Pollution Liability insurance coverage is endorsed to provide transportation coverage beyond the
boundaries of the job site.” It there is no endorsement, the wording in “Description of Operations”
must include the CA9948 wording above (as well as the MCS90 endorsement).
“Description of Operations/Locations/Vehicles”
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Enter in this space the SAWS’ Job, Contract and/or Project number such as 09-1111 or P-09011-MR;
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The Project or Contract name may be included but is not required.
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Where applicable or as needed, enter “Description of Locations, Vehicles” and/or “Exclusions
Added By Endorsement.”
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“Special Provisions” include the wording for the “Additional Insured” and “Waiver of Subrogation
Endorsements,” declaring the type of policy coverage and other misc. info which may be required.
The “30-Day Notice of Cancelation” must also be included in this section.
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“Special Endorsements” should be worded as listed below.
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“Certificate Holder” should include the name and address below, in addition to the contract/bid/project
number. It should include the following language: “Legal Counsel, Cal Poly Corporation, 1 Grand
Avenue, Building 15, San Luis Obispo, CA, 93407-0707.”
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“Authorized Representative” must include the agency’s authorized person’s (wet or stamped)
signature, agent’s (wet or stamped) signature, or agent’s typed in name.
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“Endorsements” shall contain language to the effect as follows:
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The “Additional Insured” Endorsement must list, “Cal Poly Corporation, State of California,
Trustees of the California State University, California Polytechnic State University, their officers,
directors, employees, representatives, volunteers, and agents for ongoing and completed
operations and products by or on behalf of the Contractor and providing coverage for bodily
injury, personal injury, property damage and contractual liability.”
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The “Waiver of Subrogation” Endorsement must list, “Waiver of transfer of rights of recovery in
favor of Cal Poly Corporation, State of California, Trustees of the California State University,
California Polytechnic State University, their officers, directors, employees, representatives,
volunteers, and agents.”
Policy Documentation shall contain language to the effect as follows:
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For General and Auto Liability: “This policy shall be primary for claims related to the work as
respects Cal Poly Corporation, State of California, Trustees of the California State University,
California Polytechnic State University, their officers, directors, employees, representatives,
volunteers, and agents.”
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For General and Auto Liability: “Insurance or Self-Insurance maintained by Cal Poly Corporation,
State of California, Trustees of the California State University, California Polytechnic State
University, their officers, directors, employees, representatives, volunteers, and agents shall be
excess of the Contractor’s insurance and shall not contribute with Contractor’s insurance.”
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The “30-day Notice of Cancellation” should list, “Each of the above described policies is so
endorsed requiring Cal Poly Corporation, State of California, Trustees of the California State
University, California Polytechnic State University, their officers, directors, employees,
representatives, volunteers, and agents to be provided thirty (30) calendar days advance written
notice of any suspension, cancellation, or non-renewal, and not less than ten (10) calendar days
advance written notice for nonpayment of premium.”