ACORD 25 (2016/03), Certificate of Liability Insurance Completed Form Examples and Samples
Explore detailed examples and samples of the ACORD 25 (2016/03) Certificate of Liability Insurance. See how a completed, filled form looks for various business scenarios, helping you understand the key sections and requirements.
ACORD 25 Example – General Contractor for Commercial Project
How this form was filled:
This is an example of a completed ACORD 25 form for a general contractor, 'Summit Construction Inc.', providing proof of insurance to their client, 'Oakridge Properties LLC'. It details coverages like General Liability, Auto, Umbrella, and Workers' Compensation, with specific limits and policy periods. The 'Description of Operations' section is crucial, naming the client as an Additional Insured for the specific project.
Information used to fill out the document:
- Date of Issue: 10/26/2026
- Producer: Reliable Insurance Brokers, 789 Insurance Plaza, Suite 100, Capital City, USA 54321
- Insured: Summit Construction Inc., 123 Builder's Way, Anytown, USA 12345
- Insurer A (General Liability): Sturdy Insurance Co.
- Insurer B (Automobile Liability): AutoGuard National
- Insurer C (Umbrella/Excess): Global Indemnity Group
- Insurer D (Workers Comp): Workforce Mutual
- Commercial General Liability Policy #: CGL987654321
- General Liability Policy Period: 01/01/2026 to 01/01/2027
- General Liability Limits (Each Occurrence): $2,000,000
- General Liability Limits (Damage to Rented Premises): $300,000
- General Liability Limits (Med Exp): $10,000
- General Liability Limits (Personal & Adv Injury): $2,000,000
- General Liability Limits (General Aggregate): $4,000,000
- General Liability Limits (Products - Comp/Op Agg): $4,000,000
- General Aggregate Applies Per: Project
- Automobile Liability Policy #: ALN555444333
- Automobile Liability Policy Period: 01/01/2026 to 01/01/2027
- Automobile Liability Coverage: Any Auto
- Automobile Liability Limit (Combined Single Limit): $1,000,000
- Umbrella Liability Policy #: UMB2026-001
- Umbrella Liability Policy Period: 01/01/2026 to 01/01/2027
- Umbrella Liability Limit (Each Occurrence): $5,000,000
- Umbrella Liability Limit (Aggregate): $5,000,000
- Workers Compensation Policy #: WC1122334455
- Workers Compensation Policy Period: 01/01/2026 to 01/01/2027
- Workers Compensation Limits: Statutory Limits
- Employers' Liability Limit (E.L. Each Accident): $1,000,000
- Employers' Liability Limit (E.L. Disease - EA Employee): $1,000,000
- Employers' Liability Limit (E.L. Disease - Policy Limit): $1,000,000
- Description of Operations: RE: Project #2026-101, Oakridge Commercial Center at 456 Business Park Dr, Anytown, USA. Certificate Holder is included as Additional Insured with respect to General Liability where required by written contract. A Waiver of Subrogation applies in favor of the Certificate Holder with respect to General Liability and Workers Compensation.
- Certificate Holder: Oakridge Properties LLC, 456 Business Park Dr, Anytown, USA 12345
- Cancellation Notice: Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions.
- Authorized Representative: Signature of Jane Smith (Reliable Insurance Brokers)
What this filled form sample shows:
- Clear identification of the Insured (contractor) and Certificate Holder (client).
- Comprehensive coverage limits for General Liability, Auto, Umbrella, and Workers' Compensation.
- Specific project information and critical endorsements, like Additional Insured and Waiver of Subrogation, listed in the Description of Operations.
- Accurate listing of all Insurers, policy numbers, and current policy effective/expiration dates.
- Specification that the General Aggregate limit applies per Project, a common requirement for construction jobs.
Form specifications and details:
| Form Name: | ACORD 25, Certificate of Liability Insurance |
| Form Edition: | 2016/03 |
| Use Case: | General contractor providing proof of insurance to a commercial client for a specific construction project. |
Created: February 03, 2026 07:40 PM
