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APPENDIX B #05-45C
Certificate of Insurance
This is to certify that the insured, named below is insured as described below.
***This form must be completed and signed by your insurer or insurance broker.***
Note: 1. Proof of liability insurance will be accepted on this form only (with no amendments).
2. If a facsimile has been transmitted, the original certificate must follow.
3. Insurance company must be licensed to operate in Canada.
Name of Insured Telephone No. (including area code) Fax No.
Insured’s Address (Street Name, City, Province and Postal Code)
Type of
Insurance
Insurance Company
(full legal name)
Policy Number Effective Date
Year Month Day
Expiry Date
Year Month Day
Limits of Liability (Bodily
injury & Property Damage -
inclusive)
Commercial
General Liability
$
Umbrella Excess
$
Other
(Explain)
$
Commercial General Liability: Occurrence Basis, Including Personal Injury, Property Damage, Broad Form Property Damage,
Contractual Liability, Non-Owned Automobile Liability, Owner's and Contractor's Protective Coverage,
Products - Completed Operations, Contingent Employers Liability, Cross Liability Clause and Severability
of Interest Clause.
Tenant's Legal Liability:
G No or G Yes . . . (Limit) $___________________
Motor Vehicle
Liability
$
Umbrella Excess
$
Other (Explain)
$
Motor Vehicle Liability - must cover all vehicle owned, or operated by, or behalf of the insured.
This is to certify that the Policies of Insurance as described above have been issued by the undersigned to the Insured named
above and are in force at this time.
If cancelled or changed in any manner, that would affect the Thames Valley District School Board as outlined in coverage
specified herein for any reason, so as to affect this certificate, thirty (30) days prior written notice by registered mail or facsimile
transmission will be given by the insurer(s) to:
Thames Valley District School Board
Attention: Purchasing Department
1250 Dundas Street
London, Ontario
N5W 5P2
Fax: (519) 452-2399
This certificate is executed and issued to the aforesaid Thames Valley District School Board, the day and date herein written below.
Name of Insurance Company or Broker (completing form) Telephone Number with area code
Address Fax Number with area code
Name of Authorized Representative (Please print)
Signature of Authorized Representative Date (Year, Month, day)