*** SAMPLE DOCUMENT - FICTIONAL - NOT A REAL POLICY ***

CERTIFICATE OF INSURANCE

Insurer:             Insurance company X (sample)
Policy No.:          SAMPLE-POL-001
Insured:             Rental company (sample)

Insured equipment:   Electric scissor lift, model SAMPLE-10E,
                     serial No. SAMPLE-0042

Cover:               machinery breakdown and third-party liability
Period of insurance: 01.01.2026 - 31.12.2026

Date of issue:       02.01.2026

For the insurer: (signature)                   SAMPLE