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Standard Certificate of Insurance

*** This form must be completed and signed by your insurer or insurance broker. ***

Notes:

  1. Proof of insurance will be accepted on this form only (with no amendments).
  2. Insurance company must be licensed to operate in Canada.

This is to certify that the Insured, named below is insured as described below.

Section 1 - Primary

Comprehensive General Liability (Occurrence Basis)

Policy dates

Limits of Liability/Amounts

Body Injury and Property Damage

Section 2

Automobile Liability

Policy dates

Limits of Liability/Amounts

Body Injury and Property Damage

Section 3

Excess/Umbrella

Policy dates

Limits of Liability/Amounts

Section 4

Additional Insureds as required by contract:

  1. The Corporation of the City of Kitchener
  2. Other: Regional Municipality of Waterloo

PROVISIONS / AMENDMENTS / ENDORSEMENTS

  1. Comprehensive General Liability Insurance (and Excess, if any) is extended to include the following coverage: Cross Liability and Severability of Interest Clause, Premises and Operations Liability, Blanket Contractual Liability, Products / Completed Operations, Personal Injury, and Non- Owned Automobile Liability.
  2. With respect to the Comprehensive General Liability Insurance (and Excess, if any), THE CORPORATION OF THE CITY OF KITCHENER, its officers and/or officials, employees and volunteers (and “other” entities as outlined in Section 4 above) have been added as Additional Insureds but only with respect to liability arising out of the operations of the Named Insured.
  3. The Comprehensive General Liability Insurance (and Excess, if any) Policy(ies) identified above shall protect each Insured in the same manner and to the same extent as though a separate policy has been issued to each, but shall not increase the Limits of Liability as identified about beyond the amount or amounts for which the company would be liable if there had been only one Insured. Any failure to comply with any provision of the insurance policy by the Named Insured shall not affect coverage provided to The Corporation of the City of Kitchener.
  4. The policy(ies) identified above shall apply as primary insurance and not excess to any other insurance available to THE CORPORATION OF THE CITY OF KITCHENER.
  5. If cancelled or changed to reduce the coverage as outlined on this Certificate, during the period of coverage as stated herein, thirty (30) days (ten (10) days if cancellation is due to non-payment of premium) prior written notice by registered mail will be given by the Insurer(s) to:

THE CORPORATION OF THE CITY OF KITCHENER
ATTENTION: RISK MANAGER
200 KING ST. W., BOX 1118
KITCHENER, ON N2G 4G7
Fax: (519) 741-2960

This certificate is executed and issued to the aforesaid Corporation of the City of Kitchener, the day and date herein written below.

Authorized representative or official

I understand that checking this box constitutes a legal signature, and also understand that by checking this box, I confirm that the information contained on this form (both default wording in the form and that entered by myself) are true and accurate.