ACORD 25 (2016/03), Certificate of Liability Insurance Completed Form Examples and Samples
Explore comprehensive examples and samples of the ACORD 25 (2016/03) Certificate of Liability Insurance form. See how to correctly fill out a COI for various industries, including details on general liability, auto, workers' compensation, additional insureds, and waivers of subrogation. Perfect for understanding and verifying proof of insurance.
ACORD 25 Example – Construction Contractor
How this form was filled:
A detailed example of an ACORD 25 form filled out for a construction company providing proof of insurance to a property management company. This sample includes General Liability, Auto, Umbrella, and Workers' Compensation coverages, along with specific endorsements like Additional Insured and Waiver of Subrogation in the 'Description of Operations' section.
Information used to fill out the document:
- Producer: Evergreen Insurance Agency, Denver, CO
- Insured: Summit Construction Inc., Boulder, CO
- Certificate Holder: Keystone Property Management, Aspen, CO
- General Liability Insurer: Apex National Insurance Co. (NAIC #12345)
- General Liability Policy #: CGL-987654321
- General Liability Limits: $1M Each Occurrence / $2M General Aggregate
- Auto Liability Insurer: Bedrock Casualty Co. (NAIC #23456)
- Auto Liability Policy #: AUT-112233445
- Auto Liability Limit: $1M Combined Single Limit
- Umbrella Liability Insurer: Granite State Assurance (NAIC #34567)
- Umbrella Liability Limits: $5M Each Occurrence / $5M Aggregate
- Workers Comp Insurer: Mountain Peak Indemnity (NAIC #45678)
- Workers Comp Limits: Statutory Limits / $1M E.L. Each Accident
- Policy Effective Date: 01/01/2026
- Policy Expiration Date: 01/01/2027
- Date Issued: 05/20/2026
- Description of Operations: Details project #2026-A15, names Keystone Property Management as Additional Insured for GL, and includes a Waiver of Subrogation for GL and WC.
What this filled form sample shows:
- Correctly lists multiple insurers for different coverage types (GL, Auto, Umbrella, WC) with their corresponding NAIC codes.
- Details specific liability limits for each policy.
- The 'Description of Operations' section clearly defines the scope of work, project number, and location.
- Specifies Additional Insured status for the certificate holder on the General Liability policy.
- Includes a Waiver of Subrogation clause in favor of the certificate holder for both General Liability and Workers Compensation.
- Indicates that the General Aggregate Limit applies per project, a common requirement in construction contracts.
Form specifications and details:
| Form Name: | ACORD 25, Certificate of Liability Insurance |
| Form Edition: | 2016/03 |
| Use Case: | Construction contractor providing proof of insurance to a client (property manager) for a specific project. |
Created: February 03, 2026 06:12 AM
