CERTIFICATES OF INSURANCE
Instructions to New York City Agencies, Departments, and Offices
All certificates of insurance (except certificates of insurance solely evidencing Workers’
Compensation Insurance, Employer’s Liability Insurance, and/or Disability Benefits Insurance)
must be accompanied by one of the following:
(1) the Certification by Insurance Broker or Agent on the following page setting forth the
required information and signatures;
-- OR --
(2) copies of all policies as certified by an authorized representative of the issuing insurance
carrier that are referenced in such certificate of insurance. If any policy is not available at
the time of submission, certified binders may be submitted until such time as the policy is
available, at which time a certified copy of the policy shall be submitted.
CITY OF NEW YORK
CERTIFICATION BY INSURANCE BROKER OR AGENT
The undersigned insurance broker or agent represents to the City of New York that the attached
Certificate of Insurance is accurate in all material respects.
_____________________________________________________
[Name of broker or agent (typewritten)]
_____________________________________________________
[Address of broker or agent (typewritten)]
_____________________________________________________
[Email address of broker or agent (typewritten)]
_____________________________________________________
[Phone number/Fax number of broker or agent (typewritten)]
_____________________________________________________
[Signature of authorized official, broker, or agent]
_____________________________________________________
[Name and title of authorized official, broker, or agent (typewritten)]
State of ……………………….)
) ss.:
County of …………………….)
Sworn to before me this _____ day of ___________ 20___
_______________________________________________________
NOTARY PUBLIC FOR THE STATE OF ____________________
