Laserfiche WebLink
� Texas Department of Transportation (TxDOT) <br />,,,� CERTIFICATE OF INSURANCE <br />Fortn 1560-CSS <br />Professional Provlder Ir4wrence <br />�o,i,z� <br />Page 2 of 2 <br />This cert�cale of insurance is provided for informationai purposes only. This certificale does nol confer any rights or obligations other than the rights and <br />obligations conveyed by the policies reterenced on this cerlificate. The terms oF the referenced policies conUol over the terms oi this ceAificale. <br />Prior to the beginning of work, the Contractor shall obtain lhe minimum insurance and endorsements specfied. Only the TxDOT certHipte of insurance form <br />is acceptable as proof of insurance fo� department contracts. Agents should complete lhe form providing all requested infwmation lhen either fax or mail this <br />form directly to the address listed on age two of Ihis fortn. Copies of endorsements listed below are not required as attachments to ihis certificsle. <br />. <br />Insured: C: T� n f' 4r. S <br />Street/Mailing Address: . O, �X yo3? <br />City: J'�c.� �� State: Zip Code: 'T.S� / <br />Phone Number: 0 3— 7$ if— J� �� Vendor EIN Number (11 digits): 7,S �p0 � 6 3 S' �� <br />Workers' Compensation Insurance Coverage: <br />Endorsed with a Waiver of Subrogation in favor of TxDOT. <br />Carrier Name: Carrier Phone Number: <br />Address: Cily: State: Zip: <br />Type of Insurance Policy Number Effective Date Expiration Date Limits of Liability <br />Workers' Compensation Not Less Than: Statutory - Texas <br />Commercial General Liability Insurance: <br />Carrier Name: %'c �r; �' .� . a. T l¢ P Carrier Phone Number: .?' ,�, — f—a 3 o p <br />Address: .O. Qo ! p City: vS7'.'e� State: %' ZiP:�%8 / <br />Type of Insurance Policy Number Effective Date Expiration Date Limils of Liability <br />Commercial General Not Less Than: <br />Liabiliry Insurance o-1- !oZ q 3 d-�.3 <br />Bodily Injury ,$" 8 a3 1 I" $500,000 each occurrence <br />Property Damage $100,000 each occurrence <br />OR $100,000 for aggregate <br />Commercial General OR <br />Liability Insurance $600,000 combined single limit <br />Automoblle Liability lnsurance: <br />Carrier Name: � 0.S .,r ,'a: � � ., —„� � Carrier Phone Number. S a �. ... � ° � <br />Address:/� p, G, �f / City: v f�,�r/ State: � Zip: j <br />Type of Insurance Policy Number Effective Date Expiralion Date Limits of Liability <br />Business Automobile Policy Not Less Than: <br />Bodily Injury �—� � 3 lQ ��_ I� f— 3Q— ! 3 $zso,000 each person <br />Property Damage $500,000 each occuRence <br />$100,000 each occuRence <br />Umbrella Policy (if applicable): <br />Carrier Name: <br />Address: <br />Tvae of Insurance <br />Umbrella Policy <br />Number I Effective Date <br />Authorized Agent name, address and zip code: <br />Carrier Phone Number. <br />� State: � Zip: <br />Date T Limits of Li� <br />THIS IS TO CERTIFY to the Texas DepaMient oi Transportation acting on behalf of the State of Texas ihal the insurance policies named are in full torce end effecl ll <br />chis /orm is sent by /acsimile machine (faxj, the sender adopts !he document received by TxDOT as a duplicate aigina/ and adopts the signature produced by !he <br />receiving fax machine as the sender'a original si�atwe. <br />The Texas Department of Transportation maintains lhe informalion collecled lhrough this form. Wfth few exceptions, you are en6tled on request to be informed about <br />the infortnaGon lhat we collect about you. Under seclions 655.021 and 553.U23 of the Texas Govemment Code, you also are enGUed to receive and review the <br />information. Under secGon 559.004 of the Govemment Code, you a e also enli have us correct information about you that is incorrect. <br />Area Code ( 03 ) ,S�f —! � 7 � ��-� ,�' � j3 <br />Authorized Agent's Phone Number Original Signature of Authorized Agent <br />Date <br />