Exhibit "E-1"
CHANEN CONSTRUCTION COMPANY:
Subcontractor General and Excess Liability Insurance Coverage Supplemental Checklist and Certification
Subcontractor Name: __________________________ Date of ACORD Certificate Issuance: _____________
The ACORD Certificate of Liability Insurance form (25-S), which is completed to attest to the scope of your insurance coverage, only summarizes the various
policies listed as to the limits and coverages provided. It DOES NOT show restrictions, exclusions, or limitations of coverage, which may cause a material
breach under the subcontract agreement. PLEASE HAVE YOU INSURANCE REPRESENTATIVE MARK THIS FORM AS A SUPPLEMENT TO THE Acord
CERTIFICATE AS TO COVERAGE FOR THE EXPOSURE LISTED. COVERAGE IS DEEMED TO BE PROVIDED IF NOT EXCLUDED.
General Liability Insurance
Coverage does include:
YES NO
1.
A Per Project Aggregate
2.
The General Contractor and its Owner/Client as
Additional Insureds as respects the completed operations
hazard (CG 20 10 11/85 edition or equivalent)
3.
Primary & Non-Contributory wording
4.
A Subrogation Waiver
5.
Defense Costs outside of policy limits
6.
Mold
7.
EIFS
8.
Subsidence
9.
Punitive Damages
10.
Water Intrusion
11.
Blanket Contractual Liability
12.
Please specify any other extraordinary exclusions that
have been attached to your general liability policy that
restrict coverage beyond the standard ISO Commercial
General Liability form (CG000110 01).
a.
_________________________
b.
_________________________
c.
_________________________
Umbrella (Excess) Liability Insurance
Coverage does include:
YES NO
Your policy is "Following Form" to the insured General Liability
Policy (meaning no additional exclusions that aren't already on
the CGL policy).
Signature
Date
Insurance Company or Agency Name:
End of Document
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