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<br />EXflIBU A <br /> <br />RFP or Contract # <br /> <br />TxDOT Form No. 1560 (Rev. 1291) Previaus cditions ofdtis form may noc bo used. <br /> <br />NOTE: Copia oflbc CDdonemcnb listed below are <br />DOt required u anachmcnu to this <br />certificate. <br /> <br />TEXAS <br />DEPARTMENT OF TRANSPORTATION <br />CERTIFICATE OF INSURANCE <br /> <br />~ <br /> <br />The named coalractOl sbaIlllOC commcaco work until he/she has obWaed the miDilDun insurance specified Sa Section D. below, aDd obtained the foUowial <br />endorsements: the Texu Dcpartmcal OrTraJIlIportadoD U 14 AddltloDlI hasurcd for covcnges] and 4, and. Waiver of Subroaadoa Us favor arlhc same <br />depllltmeDl uncIu coverqes 2, ,3 and 4. Ooly certi1kaccs ofinsunnce publisbed by this deputmeat are acceptable u proof orlnsuraace. Commercial canien' <br />certiru:atc=sare UDaeeeptable. <br /> <br />SECTION I IDENTIFICATION DATA <br /> <br />..1 Insured Coottactor's Name <br /> <br />1.2 SttcetIMaUing Address <br /> <br />1.3Ciry <br /> <br />Il.4StlIC <br /> <br />II.SZiP <br /> <br />t.6 PhoDe Number <br /> <br />Area Code ( <br /> <br />SECTION II TYPE OF INSURANCE <br />Type Policy <br />N,"""", <br /> <br />Effective <br />Dale: <br /> <br />ExpiratiOD <br />Date: <br /> <br />LimiuofLiability <br />Not Less Tbau: <br /> <br />2. WORKERS' COMPENSATION <br />2.1 <br /> <br />2J <br /> <br />SlalutoryTcxas <br /> <br />2.2 <br /> <br />Endoned with a Waiver oC SubrocadoD in favor ollhe Texas Department ofTnuuportatiOD. <br />3. COMMERCIAL GENERAL LlABlUTY <br /> <br />$600,000 combiDcd siDgle limir <br />each occurrence and io the <br />.......~ <br />Endorsed with the Texas Department ofTransponatioD 1.1 an AdditlOlUlllasured and endorsed with a Waiver of SubrOlattoa ia favor oftbe Texas Department of <br />Transportation. <br /> <br />Bodily lDjurylPropmy <br />Damage <br /> <br />3.1 <br /> <br />3.2 <br /> <br />3" <br /> <br />4. TEXAS BUSINESS AUTOMOBILE POLICY <br /> <br />A. Bodily Injury <br /> <br />4.2 <br /> <br />4J <br /> <br />5250,000 ea. Person <br />5500,000 ea. Occ:urreacc <br /> <br />4.1 <br /> <br />B. Property Damage <br /> <br />4.4 <br /> <br />4.' <br /> <br />4.6 <br /> <br />5100,000 ea. oec:wrcnce <br /> <br />Endorsed with the Texas Depanment afTransportatiaa as an Addltlanallasured and endarsed with a Waiver of SubrOlattoa in favor oftbe Texas Departmenl af <br />Transportalion. <br /> <br />5. UMBRELLA POLICY (It Applicable) <br />'.1 <br /> <br />SECfION III CERTIFICATION <br /> <br />'.2 <br /> <br />,,, <br /> <br />s <br /> <br />This Certificale oClDsuraacc neitbcr affarmadvcly or aeptivcly ameads, extends, ar allm the COVCtl.JC afforded by tbe above insurance policies issucd by the <br />insurance company named belaw. <br /> <br />CanceUatioa oCme insurance policies shall 0.01 be made until THIRTY DAYS AFTER the undcrsiplcd agent ar hislbcr COmpaDy bu seal written notices bycertificd <br />mail 10 me contractor and me Texas Department afTramportation. . . <br /> <br />THIS IS TO CERTIFY to me Texas Deparurnt alTransportation. acting an behalf aCthe State OlTClW, dw the insW"a.ll.cc policics above meet aU the requirements <br />stipulatcd above and such policies are in full force and effect. <br /> <br />6.1 Name ollDsurance COD1JI.DY 7.1 NameaCAutborized Apt <br />6.2 Company Addreu 7.2 Ageat's Address <br />6.3 City 6.4Scate 6.5 Zip 7.3 City 17.4S~~ 7.SZip <br />7.6 Autharized Agent's Phone No.. Original Signanarc of Autharized Aaeat <br />Area Code { , <br /> Dale <br /> <br />Page 1 of 1 <br />