Certificate of Insurance Companies Affording Coverage:
Broker Name:
Date Insured:
Address:
Name of Insured:
Address: 		Company A
Company B
Company C
Company D
Coverages: This is to certify that policies of Insurance listed below have been issued to the Insured named above for the policy period indicated. Nothing herein shall be held to waive, alter, or extend any of the limits, conditions, agreement or exclusions of the policy to which the certificate applies.
CO LTR
Type of Insurance Liabilities:
Policy Number
Policy EFF. Date
Policy EXP. Date
 All Limits in Thousands Deductible
General
Comprehensive Form
Broad Form Extension Included
Commercial Form
Claims Made Occurence
Severability of Interest Clause
Cross Liability
General Aggregate:
$
Products/Completed Operations Aggregate:
 $
Personal & Advertising Injury:
 $
Each Occurrence:
 $
Fire Damage (Any One Fire):
 $
Medical Expense( Any One Person):
 $
  Auto
Any Auto (Code 1)
All Owned Autos (Code 2)
Scheduled Autos (Code 7)
Hired Autos (Code 8)
Non-Owned Autos(Code 9)
Other
CSL
$
Bodily Injury (Per Person)
$
Bodily Injury (Per Accident)
$
Property Damage
$
   
  Excess
Umbrella Form Other
Claims Made Occurence

Each Occurence

Aggregate
  Professional
Claims Made Occurence
Each Occurence
Aggregate
Workers Compensation and Employer's Liability As required by Federal and California Law

 
Special Provisions in relation to a General Liability policy, not a Worker's Compensation policy:
1) The Regents of the University of California, its officers, agents, and employees are included as additional insureds but only in connection with the agreement between the University's college Work-Study Program and: 2) This Insurance shall be primary insurance as respects The Regents of the University of California, its officers, agents, and employees. Any Insurance or self-insurance maintained by The Regents of the University of California shall be excess of and non-contributory with this insurance.
3) The provision under paragraphs (1&2) of this section, "Special Provisions", shall apply to claims, costs, inuries or damages but only in proportion to and to the extent such claims, costs, injuries or damages are caused by or result from the negligent acts or omissions of the named insured.
4) Should any of the insurance programs described herein be materially modified or cancelled before the expiration date thereof, the issuing company will mail thirty (30) days written notice to the Certificate holder below.
Certificate Holder:
The Regents of the University of California, et. al. College Work-Study Program,212 Sproul Hall
Berkeley, CA 94720-1962		 The undersigned certifies that he/she is authorized to sign this Certificate and that the special provision described herein have been made a part of the policy(ies) shown above. Authorized Representative:
_____________________________________________________