Independent Electricity System Operator

Submit By E-mail (pdf with signature) To

Pursuant to Section [No.] of the Contract, the Supplier is hereby submitting this completed Form of Certificate of Liability Insurance to the Buyer.

Capitalized terms not defined herein have the meanings ascribed thereto in the Contract.

Instructions
• This Certificate of Liability Insurance must be completed by the Supplier’s insurance agent or broker and submitted to the Independent Electricity System Operator (“IESO”) prior to commencement of the construction of the Contract Facility. Refer to Section [No.]of the [Contract Type Short Name]Contract dated [Contract Date] (the “Contract”) for a detailed description of insurance requirements, including required coverages.
• Insurer’s standard certificate of insurance is not acceptable in lieu of this Certificate of Liability Insurance.
• It is understood that this Certificate of Liability Insurance is issued as information only. It does not amend, extend or alter coverages afforded by the policies described herein.
• Unless otherwise stated, capitalized terms used in this Certificate of Liability Insurance have the meanings given to them in the Contract.
Identification of Named Insured
Named Insured
as it appears in the Policy / Evidence of Coverage
of Supplier enclosed
Named Insured Address
City
Province
Postal Code
Identification of Contract
Legal Name of Supplier
Name of Contract Facility
Location of Contract Facility (Municipality)
General Liability Insurance
General Liability
Insurer’s Name
General Liability
Insurer’s Policy Number
Policy Term – From / To (Day/Month/Year) / From [Day/Month/Year]
to [Day/Month/Year]
Limit of Liability
(per occurrence)
Aggregate Limit
if Applicable
Deductible or Self-Insured Retention (“SIR”)
umbrella and excess liability Insurance
Umbrella and Excess Liability Insurer (if applicable)
Umbrella and Excess Liability Policy Number
Policy Term – From / To (Day/Month/Year) / From [Day/Month/Year]
to [Day/Month/Year]
Limit of Liability
(per occurrence)
Aggregate Limit
if Applicable
Deductible or SIR
Coverages Provided by Commercial General Liability (“CGL”) and, if applicable,
Umbrella and Excess Policies (Double-click box to check applicable coverages)
Owner’s and Contractor’s Protective Liability / Blasting
Operation of Attached Machinery / Personal Injury Liability
Pile Driving or Caisson Work / Forest Fire-Fighting Expenses
Non-Owned Automobile Liability / Removal or Weakening of Support of Property, Building or Land
Sudden and Accidental Pollution Liability / Products and Completed Operations
Elevator and Hoist Liability / Employees as Additional Insureds
Personal Injury and Advertising Liability / Occurrence Basis Property Damage
Broad Form Property Damage / Contingent Employers Liability
Blanket Contractual / Tenants Legal Liability
Cross Liability / Medical Expense $10,000 Per Person
Intentional Acts for the Protection of Persons or Property / Building Material Replacement Cover
Non-owned Watercraft up to 8 meters
Automobile Liability Insurance
Auto Insurer’s
Name
Auto Insurer’s
Policy Number
Policy Term – From / To (Day/Month/Year) / From [Day/Month/Year]
to [Day/Month/Year]
Limit of Liability
(per occurrence)
Aggregate Limit
if Applicable
Deductible or SIR
WRAP-UP Liability Insurance
Wrap-Up Liability Insurer’s
Name
Wrap-Up Liability Insurer’s
Policy Number
Policy Term – From / To (Day/Month/Year) / From [Day/Month/Year]
to [Day/Month/Year]
Limit of Liability
(per occurrence)
Aggregate Limit
if Applicable
Deductible or SIR
Afforded to all interested parties including Buyer, Supplier, Contractor and Sub-Contractors
Completed Operations Period (Specify)
Certification
The undersigned hereby certifies that:
• Where the Named Insured is not the Supplier, the Supplier is also insured under such policy described in this certificate to the same extent as the Named Insured.
• The policies described herein, subject to their terms, conditions, and exclusions, have been issued to the named insured and are in full force and effect.
• The IESO, the Government of Ontario, the members of the Government of Ontario’s Executive Council and their respective Affiliates, and each of the foregoing Person’s respective directors, officers and employees, shareholders, advisors and agents (including contractors and their employees) are added as additional insureds to each policy described in this Certificate.
• Coverages afforded under policies described herein will not be cancelled or materially changed to restrict coverage unless sixty (60) days prior written notice has been given to the IESO at the address shown on page 1 of this Certificate of Liability Insurance and each of the policies have been endorsed to this effect.
• The undersigned is an authorized representative of each of the insurance companies listed herein, has full knowledge of the facts set forth herein and believes them to be true.
Name of Issuing Agent
or Brokerage
Address of Issuing Agency
or Brokerage
City
Province
Postal Code
Phone Number
Name of AuthorizedRepresentative
Signature of
Authorized Representative
Date of Issue

form of CERTIFICATE OF lIABILITY iNSURANCE

IESOCM-FORM-007(2011-10)Page 1 of 5