Certificate of Insurance

To be completed by the Insurer

Contract

Description and Location of Work:

Contract No.:

Project No.:

Insurer

Name:

Address (No., Street):

City:

Province:

Postal Code:

Broker

Name:

Address (No., Street):

City:

Province:

Postal Code:

Insured

Name of Contractor:

Address (No., Street):

City:

Province:

Postal Code:

Additional Insured

Her Majesty the Queen in right of Canada as represented by the Minister of Public Works and Government Services.

This insurer certifies that the following policies of insurance are at present in force covering all operations of the Insured, in connection with the contract made between the named insured and Her Majesty the Queen in right of Canada, represented by the Minister of Public Works and Government Services.

Policy

Type	Number	Inception Date	Expiry Date	Limit of Liability
Commercial General Liability
Builder's Risk "All Risks"
Installation Floater "All Risks"
Other (List)

Each of these policies includes the coverages and provisions as specified in Insurance Terms and each policy has been endorsed to cover Her Majesty as an Additional Insured. The Insurer agrees to notify Her Majesty and the Named insured in writing thirty (30) days prior to any material change in, or cancellation of any policy or coverage.

Name of Insurer's Officer or Authorized Employee:

Telephone Number:

Signature:

Date (Y M D):