INSURANCE REQUIREMENTS AND MINIMUM LIMITS

INSURANCE REQUIREMENTS AND MINIMUM LIMITS – PUPS Permits

Private use of public spaces (excluding street performers) requires that a Certificate of Insurance be

provided showing Commercial General Liability insurance that includes the City of Raleigh as additional

insured with limits determined by the City’s Risk Management Division. The permit applicant(s) shall

purchase and maintain this insurance, providing coverage for the permit with an insurance company

authorized to do business in the State of North Carolina.

The Certificate of Insurance showing current Commercial General Liability insurance must list the City of

Raleigh as an additional insured by the specific additional insured endorsement CG 20 12 07 98. The

insurance must protect the City of Raleigh, its officers, officials, employees and agents from any and all

claims for damages to property and/or bodily injury which may result from or in connection with any of

the operations carried on by the private use. The City’s Risk Management Division must receive a copy

of all certificates of insurance for all coverages before a permit will be issued.

Commercial General Liability

Per Occurrence: $1,000,000

Personal & Advertising Injury $1,000,000

Products/Completed Ops. $1,000,000

General Aggregate $2,000,000

Additional Insured Status

The permit applicant(s) agrees to list the City of Raleigh as additional insured by specific additional

insured endorsement CG 20 12 07 98 to the Commercial General Liability. Certificate of Insurance

should state, in the “Description of Operation” section: The City of Raleigh, its officers, employees and

agents are listed as an additional insured by the CG 20 12 07 98 endorsement OR the actual completed

CG 20 12 07 98 endorsement must be provided with the Certificate of Insurance.

Certificate of Insurance

The permit applicant(s) agrees to provide the City of Raleigh a Certificate of Insurance evidencing

current Commercial General Liability limits and CG 20 12 07 98 endorsement required herein are

maintained and in full force and effect.

The Certificate Holder address should read: City of Raleigh, PO Box 590, Raleigh, NC 27602-0590

DATE (MM/DD/YYYY)

CERTIFICATE OF LIABILITY INSURANCE

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS

CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES

BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED

REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to

the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the

certificate holder in lieu of such endorsement(s).

CONTACT

NAME:

FAX

PHONE

(A/C, No):

(A/C, No, Ext):

E-MAIL

ADDRESS:

INSURER(S) AFFORDING COVERAGE NAIC #

INSURER A :

INSURED

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD

INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS

CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,

EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

ADDL SUBR

INSR POLICY EFF POLICY EXP

TYPE OF INSURANCE LIMITS

POLICY NUMBER

LTR (MM/DD/YYYY)

(MM/DD/YYYY)

INSR WVD

GENERAL LIABILITY

EACH OCCURRENCE $

DAMAGE TO RENTED

PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE

OCCUR MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $

PRO-

POLICY LOC

JECT

COMBINED SINGLE LIMIT

AUTOMOBILE LIABILITY - check all that apply

(Ea accident) $

BODILY INJURY (Per person) $

ANY AUTO

ALL OWNED SCHEDULED

BODILY INJURY (Per accident) $

AUTOS AUTOS

NON-OWNED

PROPERTY DAMAGE

HIRED AUTOS

(Per accident)

AUTOS

UMBRELLA LIAB

EACH OCCURRENCE $

OCCUR

EXCESS LIAB

CLAIMS-MADE AGGREGATE $

DED RETENTION $

WC STATU- OTH-

WORKERS COMPENSATION

TORY LIMITS ER

AND EMPLOYERS' LIABILITY

Y / N

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. EACH ACCIDENT $

N / A

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMIT $

DESCRIPTION OF OPERATIONS below

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

The ACORD name and logo are registered marks of ACORDACORD 25 (2010/05)

AUTHORIZED REPRESENTATIVE

HOPSC-2 OP ID: AT

08/12/2014

PRODUCER

1,000,000

50,000

5,000

1,000,000

2,000,000

included/amount

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

City of Raleigh

P.O. Box 590

Raleigh, NC 27602

Company Name

Company Street Address or P.O. Box

Company City, State & Zip Code

Insurance Agent/Broker Name

Insurance A

gent/Broker Street Address or P.O. Box

Insurance Agent/Broker City, State & Zip Code

Contact & Phone Number

Name of Insurance Company

Enter NAIC#

Name of Insurance Company (if applicable)

Enter NAIC#

Name

Phone Number

Email Address

Enter Policy #

Effective

Date

Expiration

Date

Liquor Liability

This must read:

The City of Raleigh, its officers, employees, and agents are listed as additional insured on the specific endorsement CG 20 12 07 98.

Signature of authorized representative

COLOR KEY - COI example form

Yellow: required limits for all permit applicants

G15

ADDITIONAL INSURANCE GUIDELINES AND DEFINITIONS

Defined terms correspond to specific sections of the Certificate of Insurance (COI). Questions? Contact

Kathy Cox with the City of Raleigh Risk Management Division, 919-996-4956

Producer: This information will be the contact information for the insurance broker or carrier. Please

ensure the contact name and phone number is included in case contact is needed to clarify or ask

questions concerning the COI.

Insured: This information will be the name and contact information of the named insured on the

insurance policies. This should match the exact name of the permit applicant requesting the Private Use

of Public Spaces Permit.

Insurer(s) Affording Coverage: This section will list the names of the insurance companies providing

insurance coverage to the insured. The NAIC # is a number assigned to each individual underwriting

company by the National Association of Insurance Commissioners.

Coverages: All COIs should have the minimum insurance requirements for the Commercial General

Liability insurance.

- Insured Letter

- Type of Insurance

- Policy Effective Date

- Policy Expiration Date

- Policy Number

- Additional Insured

- Limits

Policy coverage must remain in force during the permit period.

Only Risk Management is allowed to lower the limits or waive insurance requirements.

Description of Operations/Locations

- A description of the purpose of the request for use of public space should be listed in the

description of operations for identification purposes.

- The City of Raleigh should be listed as an additional insured by the endorsement CG 20 12 07

98 for Commercial General Liability.

Certificate Holder: Per standard COR contract, the Certificate Holder address should read as follows:

- City of Raleigh

PO Box 590

Raleigh, NC 27602-0590