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Page 2 of 2 Texas Department of Transportation BUILDING CERTIFICATE NOTES TO AGENTS: Agents must provide all requested information then either fax or mail this form directly to the address listed below. Pre-printed limits are the minimum required, if higher limits are provided by the policy, strike-through or cross-out the pre-printed limit and enter the higher limit amount. To avoid work suspension, an updated insurance form must reach the address listed below one business day prior to the expiration date. Insurance must be in force in order to perform any work. Binder numbers are not acceptable for policy numbers. This BUILDING certificate of insurance is job specific, coverage on this form will need to remain in effect through out the duration of the job until project is completed. The TxDOT certificate of insurance form is the only acceptable proof of insurance for department contracts. List the contractor's legal company name, including the DBA (doing business as) name as the insured or list both the contractor and staff leasing service as insured when a staff leasing service is providing insurance. Over-stamping and/or over-typing entries on the certificate of insurance are not acceptable if such entries change the provisions of the certificate in any manner. This form may be reproduced. The SIGNATURE of the agent is required. Stamped/typed/printed signatures are not acceptable. CERTIFICATE OF INSURANCE REQUIREMENTS: WORKERS~ COMPENSATION INSURANCE: The contractor is required to have Workers' Compensation Insurance if the contractor has any employees including relatives. The word STATUTORY, under limits of liability, means that the insurer would pay benefits allowed under the Texas Workers' Compensation Law. GROUP HEALTH or ACCIDENT INSURANCE is not an acceptable substitute for Workers' Compensation. COMPREHENSIVE GENERAL LIABILITY INSURANCE or COMMERCIAL GENERAL LIABILITY INSURANCE: If coverages are specified separately, they must be at least these amounts: Bodily Injury $500,000 each occurrence Property Damage $100,000 each occurrence $100,000 for aggregate MANUFACTURERS' or CONTRACTOR LIABILITY INSURANCE is not an acceptable substitute for Comprehensive General Liability Insurance or Commercial General Liability Insurance. COMPREHENSIVE AUTOMOBILE LIABILITY INSURANCE or TEXAS BUSINESS AUTOMOBILE POLICY: The coverage amount for a Texas Business Automobile Policy or Comprehensive Automobile Liability may be shown as a minimum of $600,000 Combined Single Limit by a typed or pdnted entry and deletion of the specific amounts listed for Bodily Injury and Property Damage. BASIC AUTOMOBILE LIABILITY INSURANCE is not an acceptable substitute for Comprehensive Automobile Liability Insurance or Texas Business Automobile Policy. MAIL ALL CERTIFICATES TO: Texas Department of Transportation CST - Contract Processing Unit 200 E. Riverside Drive Austin TX 78704 (512) 4t 6-2429 iV), (512) 416-2536 iF)