06 A to F-Depot Project Manual - Laserfiche WebLink

Home Browse Search

Page 1 of 2 CERTIFICATE OF INSURANCE FOR BUILDING PROJECTS Texas Department of Transportation (TxDOT) pdor to the beginning of work, the Conffactar shall obtain the minimum insurance and endomements specified. O~ly the TxDOT cerlJl~cato of insurance fo~n is accep~ble as proof of insurance for department contracts. A~eets should complete the form providing a{I req~asted infer'maVen then either fax o~ mail this form directly to the address tisted on the beck of this fora1. Cop~es of endorsements listed below are not required as atiachments to this certificate. 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 shall 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: Carrier Phone #: ] Address: City, State, Zip: Type of Insurance Policy Number Effective Date Expiration Date Limits of Liability: I Workers' Compensation Not Less Than; Statutory - Texas Comprehensive General Liability Insurance: Endorsed with TxDOT as Additional Insured and with a Waiver of Subro~ ,ation in favor of TxDOT. Carrier Name: Carrier Phone #: Address: City, State, Zip: Type of Insurance: Policy Number: Effective Date: Expiration Date: Limits of Liability: C~rnprehensive General Not Less Than; Uability Insurance Bodily Injury $ 500,000 each occurrence Property Damage $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, ~tion in ~avor of TxDOT. Carrier Name: Carrier Phone #: Address: City, State, Zip: Type of Insurance: Poticy Number: Effective Date: Expiration Date: Limits of Liability: Comprehensive Automobile Liability Insurance OR Texas Not Less Than: Business Automob{[e Policy $ 250,000 each person Bodily Injury $ 500,000 each occurrence Property Damage $100,000 each occurrence Builder's Risk: Carrier Name: Carrier Phone #: Address: City, State, Zip: Type of Insurance: Policy Number: Effective Date: Exp ration Date: Limits of Liability: 100 % of Contract Amount thsured: StreetJMailing Address: City/State/Zip: Phone Number: Area Code ( THIS IS TO CERTIFY to the Texas Department of Transportation acting on behalf of the State of Texas that the insurance policies named meet all the requirements stipulated and such policies are in full force and effect. If this form is sent by facsimile machine (fax), the sender adopts the document received by TxDOT as a duplicate orfginal and adopts the signature produced by the receiving fax machine as the sender's odginal signature. Authorized Agent name address and zip code Area Code ( ) Authorized Agent's Phone Number Authorized Agent Original Signature Date