Xerox Scanner manual Appendix B, Year Month Day

	Page 20
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 Company		Policy Number	Effective Date	Expiry Date	Limits of Liability (Bodily
Insurance	(full legal name)			Year Month Day	Year Month Day	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)