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Page 1 o[ 2 CERTIFIGA TE OF INSURANCE FOR BUILDING PROJECTS ..... Texas Department of Transportation (TxDOT) Pd~ to ~he beginning of wo~, the Contractor shall obtain me minimum insurance and endorsements sp~dfied. Only the TxDOT ced~ficata of insurance form ts acceptable as proof of insurance for depar~nent o:x~b-'acts. Agents should complete the form p~3viding all requested infccma~on then either fax ~- max this form direc~y to the address r~s ted c~ the bad( of ~his form. C<~ies of endcraemenLs ILsted below are not requlmd as attachments to His ce~fic~ta. This Certificate of Insurance neither affirmatively nor negatively amends, extends, or alters the coverage afforded by the above insurance policies issued by the named insurance company. Cancellation of the insurance policies shaZl not be made until THIRTY DAYS AFTER the agent or the insurance company has sent written notice by certified mail to the contractor and the Texas Department of Transportation. Workers' Compensation Insurance Coverage: Endorsed with a Waiver of Subrogation in favor of TxDOT. Carrier Name: C.~n~-'r'~] Tn~urance ~Companies CarrierPhone#:(800) 733-2233 Address: PO ]~O~ 828 City, State, Zip:Van Wert OH 458~1 Type of Insurance Policy Number / Effective Date Expiration Date Limits of Liability: Workers'CompensalJon ?(''7 c)4 ~'c~'~ 400 [[3~/18/00 11/18/01 NotLessThan: Statutoq~-Texas Comprehensive General Liability Insurance: Endorsed with TxDOT as Additional Insured and with a Waiver of Subro~ ~ation in favor of TxDOT. Carrier Name.Centr al Insurance ComDanie s Carrier Phone #1_( 8~00~)_ 733- 2233 Address: P O Box 828 Ctty, State~Zip:Va Weft OR 4589] Type of Insurance: Policy Number: Effective Date: Expiration Date: Limits of Liability: Comprehensive General ~OP7928897 11/15/00 11/15/01 Not Less Than: Liability Insurance Bodily InjuG' $ 500,000 each occurrence Property Damage i $100,000 each occurrence OR $100,000 for aggregate Commercial General OR Liability Insurance $ 600,000 combined single limit Comprehensive Automobile Liability Insurance: Endorsed with TxDOT as Additional Insured and with a Waiver of Subro etlon in ~avor of TxDOT. Carrier Name: Al'[ Am~ric~n Tn~]ll"~nc'p C~m~Ry CarrierPhone#:(R~3c)) 7~q-?~3~ Address: ~ O ~o~ 8~S City, State, Zip:~R~ ~. ~ &~Rq3 T~e of Insurance: Policy Number: Effective Date: Expiration Date: L{mits of Liability: ~mp~ehensive Automobile 9A~7928896 ~[/15/00 1[/[5/01 Uab[li~ Insu~n~ OR Texas Not Less Than: Business Automobile Poli~ $ 250,000 each person B~i[y ~nju~ $ 500,000 ea~ o~u~en~ Prope~ Damage $100,000 ea~ ~en~ Builders Risk: Carrier Name: I Carrier Phone ~: ~ Address: City, State, Zip: T~e of Insurance: Policy Number: Effective Date: Expiration Date: Limits of Liability: 100 % of Contract Amount Builders Risk Insured: Jamar Contrators S[reet/Mailing Address: 2335 Soutfl church CitylS[ate/Zip: Paris, TX '/bGbU Phone Number: /~'ea Code ~) 0 ~ 784--0292 THIS IS TO CERTIFY to the Texas Department of Transportation acting on behalf of the State oi Texas that the insurance policies named meet all the requirements stipulated and such policies are in full force and e[fect. If this form is sent by facsimi;e machine (fax), the sender adopts the document received by TxDOT as a duplicate odginal and adopts the signature produced by the receiving fax machine as lhe sender's original signature. ~.uthorized Agent name address and zip code AuthodzedAgent's Phone Number Authorized Agent~)riginal Signature Date