The Certificate of Liability Insurance (Sample) is an insurance certificate form published by the Montana Department of Labor and Industry, Business Standards Division (Licensing Boards). It lists the general liability, automobile liability, umbrella or excess liability, and workers compensation and employers' liability policies issued to an insured, with policy numbers, policy periods and limits. A note on the form says that naming the Board of Private Security as certificate holder is optional. On FillingPDF you can fill out the form online and download or print the completed PDF; the original PDF is published by the Montana agency.
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What is Certificate of Liability Insurance (Sample) – Montana?
The Certificate of Liability Insurance (Sample) is a certificate form, published by the Montana Department of Labor and Industry's Business Standards Division (Licensing Boards), that summarizes the insurance policies issued to an insured and lists the insurers, policy numbers, policy periods and limits for each type of coverage.
The heading of the form states what it is not. The certificate is issued as a matter of information only and confers no rights upon the certificate holder. It does not affirmatively or negatively amend, extend or alter the coverage afforded by the policies, and it does not constitute a contract between the issuing insurer(s), the authorized representative or producer, and the certificate holder. The insurance is subject to all terms, exclusions and conditions of the policies, and the limits shown may have been reduced by paid claims.
The form is laid out in blocks:
- the certificate date, the producer and its contact details, and the insured;
- insurers A to F affording coverage, with their NAIC numbers;
- the COVERAGES section, with a certificate number and a revision number;
- rows for general liability, automobile liability, umbrella or excess liability, and workers compensation and employers' liability;
- the description of operations, locations and vehicles;
- the certificate holder and cancellation block, and the authorized representative.
The title marks the document as a sample. A note in the certificate holder box says that naming the Board of Private Security as a certificate holder is optional, and that if you do, a renewal copy of your certificate is automatically sent to the board.
Who needs to file Certificate of Liability Insurance (Sample) – Montana?
The form is laid out for an insurance producer or authorized representative to complete for an insured: it has a producer block with contact details, an insured block, insurer lines A to F, and an AUTHORIZED REPRESENTATIVE block at the bottom. Anyone who has to show proof of liability, automobile, umbrella or excess, or workers compensation coverage can use the layout to present it.
The certificate holder is the person or organization that receives the certificate. The form says the certificate gives that holder no rights. If the holder is an additional insured, the policy or policies must be endorsed. If subrogation is waived, certain policies may require an endorsement. A statement on the certificate does not take the place of those endorsements.
The note in the certificate holder box addresses insureds who deal with the Board of Private Security: naming the board as certificate holder is optional. The form sets no other eligibility rule and lists no exclusions.
When to file Certificate of Liability Insurance (Sample) – Montana
The form prints no filing deadline. It is completed whenever a certificate is issued, and it is dated by the entry in the DATE (MM/DD/YYYY) box. Each coverage row shows its own policy effective date and policy expiration date, also in MM/DD/YYYY format.
If you choose to name the Board of Private Security as certificate holder, which the form calls optional, a renewal copy of your certificate is automatically sent to the board. The cancellation block adds that, if any of the described policies is cancelled before its expiration date, notice will be delivered in accordance with the policy provisions.
Documents you need
- ACORD 101, Additional Remarks Schedule: attach it only if more space is required for the description of operations, locations and vehicles.
- Policy endorsement: the form says the policy or policies must be endorsed if the certificate holder is an additional insured, and certain policies may require an endorsement if subrogation is waived.
How to fill out Certificate of Liability Insurance (Sample) – Montana
Enter the certificate date
In the DATE (MM/DD/YYYY) box at the top, enter the date the certificate is issued in month/day/year format.
Complete the producer block
Under PRODUCER, enter the producer's name and address, and in the contact area the contact name and e-mail address.
Identify the insured
In the INSURED block, enter the name and address of the party to whom the listed policies were issued.
List the insurers and NAIC numbers
Under INSURER(S) AFFORDING COVERAGE, enter each insurer on lines INSURER A through INSURER F, with its NAIC number. Use the matching letter in the INSR LTR column of each policy row.
Add certificate and revision numbers
In the COVERAGES line, enter the certificate number and the revision number.
Complete general liability
Mark commercial general liability, and claims-made or occurrence, and the option for how the general aggregate limit applies. Enter each occurrence, premises, medical expense, personal and advertising injury, general aggregate, and products-completed operations aggregate limits.
Complete automobile liability
Mark the autos covered: any auto, all owned, scheduled, hired or non-owned autos. Enter the combined single limit, bodily injury per person and per accident, and property damage per accident.
Complete umbrella or excess liability
Mark umbrella or excess liability and occurrence or claims-made. Enter the each occurrence and aggregate limits and the deductible or retention.
Complete workers compensation
Answer the question on whether any proprietor, partner, executive officer or member is excluded, or enter N/A. Enter the E.L. each accident, E.L. disease per employee and E.L. disease policy limit.
Enter policy numbers and dates
For each coverage row, enter the policy number and the policy effective and expiration dates in MM/DD/YYYY format.
Describe operations and add the holder
Write the description of operations, locations and vehicles, attaching ACORD 101 if more space is required. Enter the certificate holder, optionally the Board of Private Security.
Review, sign and download the PDF
Check the dates, limits and insurer letters, and complete the authorized representative block. Download or print the completed PDF from FillingPDF.
How to submit Certificate of Liability Insurance (Sample) – Montana
The form names no mailing address, portal or e-mail of its own. The only routing it prints is the certificate holder box, so deliver the completed certificate to the party that asked for it.
- Certificate holder: enter the name and address of the person or organization that will receive the certificate in the CERTIFICATE HOLDER box.
- Board of Private Security (optional): if you name the board as certificate holder, a renewal copy of your certificate is automatically sent to the board.
- Agency forms page: the Business Standards Division publishes the Board of Private Security forms at https://boards.bsd.dli.mt.gov/private-security/forms. Confirm any other delivery requirement with the party requesting the certificate or with the board.
FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Treating the certificate as granting rights to the holder; the form says it is issued as information only and confers no rights upon the certificate holder.
- Relying on a statement on the certificate instead of a policy endorsement when the holder is an additional insured or subrogation is waived.
- Writing the certificate date or the policy effective and expiration dates in another format instead of MM/DD/YYYY.
- Squeezing a long description into the box instead of attaching ACORD 101, Additional Remarks Schedule, when more space is required.
- Treating the limits as untouched, when the form states that limits shown may have been reduced by paid claims.
- Assuming the Board of Private Security must be named as certificate holder; the form calls this optional.
Frequently asked questions
What is the Certificate of Liability Insurance (Sample)?
It is a certificate form published by the Montana Department of Labor and Industry's Business Standards Division. It summarizes an insured's policies, with insurers, policy numbers, policy periods and limits for general liability, automobile, umbrella or excess, and workers compensation coverage.
Does the certificate give the certificate holder any rights?
No. The form states that it is issued as a matter of information only and confers no rights upon the certificate holder. It also does not amend, extend or alter the coverage of the policies and is not a contract between the insurer, the producer and the holder.
Do I have to name the Board of Private Security as certificate holder?
No. A note in the certificate holder box says naming the Board of Private Security is optional. If you do name it, a renewal copy of your certificate is automatically sent to the board.
What if the certificate holder must be an additional insured?
The policy or policies must be endorsed. The form warns that a statement on the certificate does not confer rights in place of an endorsement, and that certain policies may require an endorsement when subrogation is waived.
What if the description of operations needs more space?
The form says to attach ACORD 101, Additional Remarks Schedule, if more space is required for the description of operations, locations and vehicles. Do not shrink or cut the description to fit.
What date format does the form use?
The form prints MM/DD/YYYY for the certificate date and for each policy effective and expiration date. Enter month, day and four-digit year, such as 01/31/2026.
Can I fill out this certificate online on FillingPDF?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not issue, file or deliver the certificate; delivery follows the holder's or the Board's requirements.
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