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CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
Month/Date/Year
PRODUCER
Insurnce Agent/Broker Name
Insurnce Agent/Broker Street Address or P.O. Box
Insurnce Agent/Broker City, State & Zip Code
Contact & Phone Number
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
NAIC #
INSURED
Client Name
Street Address or P.O. Box
City, State & Zip Code
INSURER A: Name of Insurance Company
INSURER B: Name of Insurance Company (if applicable)
INSURER C: Name of Insurance Company (if applicable)
INSURER D: Name of Insurance Company (if applicable)
INSURER E:
COVERAGES
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MM/DD/YY)
POLICY EXPIRATION
DATE (MM/DD/YY)
LIMITS
A
GENERAL LIABILITY
COMMERICAL GENERAL LIABILITY
CLAIMS MADE OCCUR
GEN’L AGGREGATE LIMIT APPLIES PER:
POLICY PROJECT LOC
Enter Policy #
Enter Effective
Date
Enter Expiration
Date
EACH OCCURENCE
$1,000,000.00
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
GENERAL AGGREGATE
$
PRODUCTS - COMP/OP AGG
$
$
B
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
Enter Policy #
Enter Effective
Date
Enter Expiration
Date
COMBINED SINGLE LIMIT
(Each Occurrence)
$1,000,000
BODILY INJURY
(Per person)
$
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
GARAGE LIABILITY
ANY AUTO
Enter Policy # (if
required)
Enter Effective
Date
Enter Expiration
Date
AUTO ONLY - EA ACCIDENT
$
OTHER THAN
AUTO ONLY:
EA ACC
$
AGG
$
C
EXCESS/UMBRELLA LIABILITY
OCCUR CLAIMS MADE
DEDUCTIBLE
RETENTION $
Enter Policy # (if
required)
Enter Effective
Date
Enter Expiration
Date
EACH OCCURRENCE
$2,000,000
AGGREGATE
$
$
$
$
D
WORKERS COMPENSATION AND
EMPLOYERS’ LIABILITY
ANY PROPRIETOR/PARTNER/EXECU-
TIVE OFFICER/MEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
Enter Policy #
Enter Effective
Date
Enter Expiration
Date
WC STATU-
TORY LIMITS
OTH-
ER
E.L. EACH ACCIDENT
$1,000,000
E.L. DISEASE - EA EMPLOYEE
$
E.L. DISEASE - POLICY LIMIT
$
OTHER
CERTIFICATE HOLDER
CANCELLATION
MGM Resorts Corporation
Attn.: Risk Management
3730 Las Vegas Blvd., So.
Las Vegas, NV 89109
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO
MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2001/08) © ACORD CORPORATION 1988
INSR
LTR
ADD’L
INSRD

X

27X3457801

9/16/2016

9/16/2017

$40,000.00

IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this
certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an
endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such
endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contact between the issuing
insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively
amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2001/08)