12-G. Insurance Sample and Workers Comp.pdf

INSR ADDL SUBR

LTR INSR WVD

DATE (MM/DD/YYYY)

PRODUCER CONTACT

NAME:

FAXPHONE

(A/C, No):(A/C, No, Ext):

E-MAIL

ADDRESS:

INSURER A :

INSURED INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

POLICY NUMBER

POLICY EFF POLICY EXP

TYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY)

COMMERCIAL GENERAL LIABILITY

AUTOMOBILE LIABILITY

UMBRELLA LIAB

EXCESS LIAB

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

AUTHORIZED REPRESENTATIVE

INSURER(S) AFFORDING COVERAGE NAIC #

Y / N

N / A (Mandatory in NH)

ANY PROPRIETOR/PARTNER/EXECUTIVE

OFFICER/MEMBER EXCLUDED?

EACH OCCURRENCE $

DAMAGE TO RENTED

$PREMISES (Ea occurrence)CLAIMS-MADE OCCUR

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:

PRODUCTS - COMP/OP AGG $

PRO-

OTHER:

LOCJECT

COMBINED SINGLE LIMIT

$(Ea accident)

BODILY INJURY (Per person) $ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS

AUTOS ONLY

HIRED PROPERTY DAMAGE $

AUTOS ONLY (Per accident)

OCCUR EACH OCCURRENCE $

CLAIMS-MADE AGGREGATE $

DED RETENTION $ $

PER OTH-

STATUTE ER

E.L. EACH ACCIDENT $

E.L. DISEASE - EA EMPLOYEE $

If yes, describe under

E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below

POLICY

NON-OWNED

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED

REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.

If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s).

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

CERTIFICATE HOLDER CANCELLATION

© 1988-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03)

ACORDTM CERTIFICATE OF LIABILITY INSURANCE

A X X

A

X X

B

N

1,000,000 1,000,000

01/01/2026

Agency Contact Name 999-999-9999

Agency Contact Email

ABC Insurance Company

DEF Insurance Company

99999 99999

Insurance Agency Company 12345 Street City, State 99999

(999) 999-9999

Insured Name Address City, State 99999

123456567 01/01/2026 01/01/2027 1,000,000

123456567 01/01/2026 01/01/2027 1,000,000 500,000 5,000 1,000,000 1,000,000 1,000,000

123485678 01/01/2026 01/01/2027 X 1,000,000

City of Amarillo Attn: Purchasing Dept.

623 S. Johnson St.

Amarillo, TX 79101

SAMPLE

Lily.Cambric Typewritten text X

Lily.Cambric Typewritten text X

Lily.Cambric Typewritten text Certificate Holder is named as Additional Insured as respects to the Auto & General Liability policies.

Waiver of Subrogation applies in favor of City of Amarillo applies to Workers Compensation policy for all work performed on behalf of the City.

Lily.Cambric Typewritten text Agency Signature

REQUIRED WORKERS’ COMPENSATION

COVERAGE

The law requires that each person working on this site or providing services related to this construction project must be covered by workers’ compensation insurance. This includes persons providing, hauling, or delivering equipment or materials, or providing labor or transportation or other services related to the project, regardless of the identity of their employer or status as an employee.

Call the Division of Workers’ Compensation at 1-800-252-7031 or access the division’s website at www.tdi.texas.gov/wc/indexwc.html to receive information on the legal requirement for coverage, to verify whether your employer has provided the required coverage, or to report an employer’s failure to provide coverage.

Notice 8 (Rev. 12/15) TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION Rule 110.110 http://www.tdi.texas.gov/wc/indexwc.html

TO THE EMPLOYER/CONTRACTOR:

Pursuant to Workers’ Compensation Rule 110.110 (d)(7), a contractor engaged in a building or construction project for a government entity is required to post a notice on each project site informing all persons providing services on the project that they are required to be covered by workers’ compensation insurance. The notice required by this does not satisfy other posting requirements imposed by the Texas Workers’ Compensation Act or other Workers’ Compensation Rules. This notice must:

(1) be posted in English, Spanish and any other language common to the employer’s employee population;

(2) be displayed on each project site;

(3) state how a person may verify current coverage and report failure to provide coverage;

(4) be printed with a title in at least 30-point bold type and text in at least 19-point normal type; and

(5) contain the exact words as prescribed in Rule 110.110 (d)(7).

The notice on the reverse side meets the above requirements. Failure to post the notice as required by this rule is a violation of the Act and Workers’ Compensation Rules. The violator may be subject to administrative penalties.

Notice 8 (Rev. 12/15) TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION Rule 110.110

COBERTURA REQUERIDA DE COMPENSACIÓN

PARA TRABAJADORES

La ley requiere que cada persona que trabaja en este lugar o que proporciona servicios relacionados con este proyecto de construcción debe estar cubierta por un seguro de compensación para trabajadores. Esto incluye a personas que proporcionan, transportan, o entregan equipo o materiales, o que proporcionan mano de obra, transporte u otros servicios relacionados con este proyecto, sin importar la identidad del empleador o el estado como empleado.

Llame a la División de Compensación para Trabajadores (Division of Workers’ Compensation, por su nombre en inglés) al 1-800-252-7031 o visite el sitio Web de la División en www.tdi.texas.gov/wc/indexwc.html para recibir información referente al requisito legal de cobertura, así como para verificar si su empleador ha proporcionado la cobertura requerida, o para reportar a un empleador que no proporciona cobertura.

Notice 8S (Rev. 12/15) TEXAS DEPARTMENT OF INSURANCE, DIVISIONOF WORKERS’ COMPENSATION Rule 110.110 http://www.tdi.texas.gov/wc/indexwc.html

AL EMPLEADOR/CONTRATISTA:

Según lo dispuesto en el Reglamento de Compensación para Trabajadores 110.110 (d)(7), es requerido que un contratista que esté involucrado en el proyecto de construcción de un edificio de entidad gubernamental muestre este aviso en cada lugar donde se lleva a cabo el proyecto para informarles a todas las personas que proporcionan servicios en el proyecto, que es requerido que se les proporcione un seguro de compensación para trabajadores. El aviso presentado aquí no satisface los requisitos para poner a la vista otros avisos que han sido impuestos por la Ley de Compensación para Trabajadores de Texas u otros Reglamentos de Compensación para Trabajadores. Este aviso debe:

(1) ser puesto a la vista en inglés, español y cualquier otro idioma común para la población de los empleados del empleador

(2) ser mostrado en cada sitio del proyecto

(3) indicar cómo una persona puede verificar la cobertura actual y cómo se puede reportar en caso de que no se proporcione una cobertura

(4) ser impreso con un título en letras de por lo menos un tamaño de 30 puntos en letra negrita, y el texto en por lo menos un tamaño de 19 puntos tipo normal; y

(5) contener las palabras exactas tal como se ha señalado en el Reglamento

110.110 (d)(7).

El aviso que se muestra al reverso de esta página cumple con los requisitos señalados en la parte de arriba. El negarse a mostrar o proporcionar esta información, según lo requerido por este reglamento es una violación a la Ley de Compensación para Trabajadores de Texas y a los Reglamentos. El infractor puede estar sujeto a recibir multas administrativas.

Notice 8S (Rev. 12/15) TEXAS DEPARTMENT OF INSURANCE, DIVISIONOF WORKERS’ COMPENSATION Rule 110.110