Use this form when reviewing a contractor's ACORD 25 Certificate of Liability Insurance.
Form Version 1.0
Esper EHS · esper-ehs.com
Section 1 — Named Insured Verification
Done
Check
Result / Notes
☐
Named insured on the certificate matches the legal entity in the contract.
Name on COI: ________________________________Name in contract: ________________________________
☐
Named insured is a legal entity (Inc., LLC, LP) rather than a trade name or individual DBA.
Policies written to a trade name or DBA may not cover the contracting entity as a separate legal entity.
Section 2 — General Liability
Done
Check
Result / Notes
☐
Per-occurrence limit meets or exceeds contract minimum.
Shown on COI: $_____________
☐
General aggregate limit meets or exceeds contract minimum.
Shown on COI: $_____________
☐
Policy type is Occurrence (preferred) or Claims-Made.
If Claims-Made: confirm retro date and tail coverage plan.
☐
GL policy is not expired. Expiration date covers the full work period.
GL expiration date shown: _____________
Section 3 — Workers' Compensation
☐
Workers' compensation is in place and covers the state(s) where contractor employees will work.
States shown on COI: _____________________________________________Note: Texas does not mandate workers' comp for most private employers. For TX-based contractors, confirm coverage status separately.
☐
Workers' comp policy is not expired.
WC expiration date shown: _____________
☐
Employers' liability limits are adequate.
BI by accident (each): $_____________ BI by disease (policy): $_____________ BI by disease (each employee): $_____________
Auto liability coverage is in place (if contractor vehicles will be on-site).
Coverage type (any auto / hired / non-owned): _____________ Limit: $_____________
Section 5 — Additional Insured Endorsements
The ACORD 25 checkbox alone does not confirm that an endorsement exists. Request the actual endorsement pages from the contractor's broker and verify below.
☐
ISO CG 20 10 endorsement (ongoing operations) obtained and reviewed.
Endorsement references policy number: _____________ Endorsement date: _____________
☐
ISO CG 20 37 endorsement (completed operations) obtained and reviewed.
Endorsement references policy number: _____________ Endorsement date: _____________
☐
Endorsement policy numbers match the policy numbers on the ACORD 25 certificate.
☐
Primary and non-contributory language included (if required by contract).
☐
Waiver of subrogation included (if required by contract).