EXAMPLE

DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
Insurance carrier's name PHONE
(A/C, No, Ext):
FAX
(A/C, No):
Address E-MAIL
ADDRESS:
City, State and Zip INSURER(S) AFFORDING COVERAGE NAIC #

INSURER A :
INSURED INSURER B :

Facility Legal Business or DBA Name INSURER C :

Facility or Agency Address INSURER D :

City, State and Zip INSURER E :

INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
DAMAGE TO RENTED
COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $

CLAIMS-MADE OCCUR MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $

PRO- $
POLICY JECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(Ea accident) $
ANY AUTO BODILY INJURY (Per person) $
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS (Per accident)
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $

DED RETENTION $ $
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS' LIABILITY TORY LIMITS ER
Y/N
500,000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? Y N/A 030510.207 04/20/2023 04/19/2024
E.L. EACH ACCIDENT $
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 500,000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000
Coverage dates should be current
and not expired. It should cover at least
part of the renewal period.
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

Note: If the actual facility address is not listed above in the Insured box, it will need to be listed in this section,
or on the "Addtional Named Insured" page.

CERTIFICATE HOLDER CANCELLATION

Minnesota Department of Health SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Health Regulation Division THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

P.O. Box 64900

ACCORDANCE WITH THE POLICY PROVISIONS.

St. Paul, MN 55164-0900 AUTHORIZED REPRESENTATIVE

(MDH must be listed as the Certificate Holder) Must be signed by the insurance carrier.
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