11-TXDOT MULTIPLE USE AGREEMENT - Laserfiche WebLink

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� Texas Department of Transportation (TxDOT) �� CERTIFICATE OF INSURANCE Form 1580-CSS Professional Provlder Insurance (01f12) Page 2 of 2 This cert�cate of insurance is provided for informa6onal purposes only. This ceAificate dces not confer any rights or obligations olher ihan the rights and obiigalions conveyed by the policies referenced on this certificate. The terms oi the referenced policies conUol over the terms of this ceAificate. Prior to the beginning of worlc, the ConVactor shall obtain the minimum insurance and endorsements specified. Only the TxDOT certificate of insurance forrn is acceptable as proof of insurance for department contracts. Agenls should complete the torm providing all requested informaUon then either fax or mail this form directly to the address listed on age two of this form. Copies of endorsements listed below are not required as attachmenls to lhis certficete. . Insured: � : -r e °�r• s StreetlMailing Address: . D. � �,X �03? City: J�o.�� s State: � Zip Code: 'T.S� l Phone Number: �03 -' %a' � 9� �l Vendor EIIV Number (11 digits): �%S',�p0 O 6 3 S�� Workers' Compensation Insurance Coverage: Endorsed with a Waiver of Subrogation in favor of TxDOT. Carrier Name: Carrier Phone Number: Address: City: State: Zip: Type of Insurance Policy Number Effective Date Expiration Date Limits of Liability Workers' Compensation Not Less Than: Statutory - Texas Commercial General Liabilitv Insurance: Carrier Name:% �r; ��..i .� o a. T 14 P Carrier Phone Number: S�- %-a .3 o O Address: . �, Qo � i City: .�ST.'a State: '% Zip:78 / Type of Insurance Policy Number Effective Date Expiration Date Limils of Liability Commercial General Not Less Than: Liability Insurance p_�_ �a �� 3 0- �3 $500,000 each occurrence Bodily Injury S 8 a3 � $100,000 each ocxurrence Property Damage OR $100,000 for aggregate Commercial General OR Liability Insurance $600,000 combined single limit Automobile Liabilitv Insurance: Carrier Name: � as ,.r ;�. � !.0 �-1- /� Carrier Phone Number: J" a�- -- ,Z.3 o O Address: /a p, o �f / City: vs �,��/ State: � Zip: / Type of Insurance Policy Number Effective Date ExpiraGon Date Limits of Liability Business Automobile Policy Not Less Than: 8odily Injury S 8 a 3 ! �,� �-/� q- 3°- � 3 $250,000 each person Property Damage � $500,000 each occurrence $100,000 each occurrence Umbrella Policy (if applicable): Carrier Name: Camer Phone Number: Address: City: State: Zp: Type of Insurance Policy N�mber Effective Date Expiration Date Limits of Liabillty Umbrella Policy Authorized Agent name, address and zip code: THIS IS TO CERTIFY to the Texas Department oi Transportation acfing on behalf of lhe State of Texas ihal lhe insurance policies named are in full force and etfect. !f this /orm is sent by /acsimife machine (fax), the sender adopts the document received by TxDOT as a duplicate original and adopts the signature produced by the receiving fax machine as the sender's original signature. The Texas Department of TranspoAaGon maintains the informalion collected lhrough this form. With few exceplions, you are entitled on request to be i�ormed about the infortnaGon thal we collect about you. Under seclions 555.021 and 553.023 of the Texas Govemment Code, you also are entiUed to receive and review lhe information. Under section 559.004 of the Govemment Code. you a e also enti have us correct infortnation about you that is incorrect. Area Code ( 0-3 ) ,g�`! � / � �� ? S " /.� Authorized Agent's Phone Number Original Signature of Authorized Agent Date