Attachment_5_-_Insurance_Requirements.pdf

ENCROACHMENT PERMIT INSURANCE CHECKLIST

Permit Application Applicant Initials____

Questionnaire required If Special Event Applicant Initials____

*Please note: Insurance is required from the contractor performing the actual services

CERTIFICATE OF INSURANCE

Certificate of Insurance Applicant Initials____

*Certificate Holder should read: The State of Arizona or ADOT, 1324 N. 22nd Ave., Phoenix, AZ 85009 (Permit Office address is acceptable)

COMMERCIAL GENERAL LIABILITY

Additional Insured Endorsement Form for Ongoing Operations Applicant Initials____

Additional Insured Endorsement Form for Completed Operations (Construction Only) Applicant Initials____

Waiver of Subrogation Endorsement Form Applicant Initials____

Primary and Non-Contributory Endorsement Form Applicant Initials____

AUTO LIABILITY

Additional Insured Endorsement Form Applicant Initials____

WORKER’S COMPENSATION

*ANY OF THE ABOVE ITEMS NOT RECEIVED MAY DELAY

APPROVAL OF INSURANCE CERTIFICATE

Applicant Signature: Date:

Permit Tech Signature: Date:

ADOT SAFETY AND RISK MANAGEMENT 072015

TYPE OF INSURANCE COVERAGE AND

ENDORSEMENTS OR LANGUAGE

REQUIRED IN THE CERTIFICATE OF

INSURANCE

ENCROACHMENT

PERMIT MINIMUM

LIMITS OF INSURANCE

FILM PERMIT /

SPECIAL EVENTS

MINIMUM LIMITS

OF INSURANCE

PARADES ONLY

MINIMUM LIMITS

OF INSURANCE

Commercial Liability (per occurance) 1,000,000 5,000,000 1,000,000 General Aggregate 2,000,000 5,000,000 2,000,000 Bodily Injury / Property Damage 1,000,000 1,000,000 1,000,000 Products Completed Only for Construction and Some Installation 1,000,000 1,000,000 1,000,000 Persons / Advanced Injury 1,000,000 1,000,000 1,000,000 XCU (Explosion, Collapse and Underground Damage) 1,000,000 1,000,000 1,000,000 Fire Legal 50,000 50,000

Business Auto - Any Auto 1,000,000 1,000,000 Dependent on Activity

Questionaire Response

Worker's Compensation / Employers Liability 1,000,000 1,000,000

Dependent on Activity Questionaire Response

Commercial / General Liability YES YES YES Auto Liability (all) YES YES YES

Commercial / General Liability YES YES YES Worker's Compensation YES YES YES Auto Liability (all) YES YES YES Primary Endorsement Required YES YES YES

Additional Insured Requirements (ADOT Required to be Named as an Additional Insured):

Waiver of Subrogation Required (Policies Provided to ADOT are Required to Contain a Waiver of Subrogation Endorsement in Favor of ADOT):

To the fullest extent permitted by law, Contractor shall defend, indemnify, save and hold harmless the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees (hereinafter referred to as “Indemnitee”) from and against any and all claims, actions, liabilities, damages, losses, or expenses (including court costs, attorneys’ fees, and costs of claim processing, investigation and litigation) (hereinafter referred to as “Claims”) for bodily injury or personal injury (including death), or loss or damage to tangible or intangible property caused, or alleged to be caused, in whole or in part, by the negligent or willful acts or omissions of Contractor or any of its owners, officers, directors, agents, employees or subcontractors. This indemnity includes any claim or amount arising out of, or recovered under, the Workers’ Compensation Law or arising out of the failure of such Contractor to conform to any federal, state, or local law, statute, ordinance, rule, regulation, or court decree. It is the specific intention of the parties that the Indemnitee shall, in all instances, except for Claims arising solely from the negligent or willful acts or omissions of the Indemnitee, be indemnified by Contractor from and against any and all claims. It is agreed that Contractor will be responsible for primary loss investigation, defense, and judgment costs where this indemnification is applicable. In consideration of the award of this contract, the Contractor agrees to waive all rights of subrogation against the State of Arizona, its officers, officials, agents, and employees for losses arising from the work performed by the Contractor for the State of Arizona.

This indemnity shall not apply if the contractor or sub-contractor(s) is/are an agency, board, commission or university of the State of Arizona.

ENCROACHMENT PERMIT INSURANCE MATRIX

ADOT SAFETY AND RISK MANAGEMENT / SPS REVISED 012016

Requirements Regarding Coverage:

1) Insurance is to be placed with duly licensed or approved non-admitted insurer in the state of Arizona with an "A.M. Best" rating of not less than A- VII. The State of Arizona in no way warrants that the above required minimum insurer rating is sufficient to protect the permittee or contractor from potential insurer solvency. Self-insurance will be evaluated by ADOT Risk Management and will be approved on a case by case basis. A letter of Self-insurance will be required.

2) ADOT reserves the right to require an increase or allow a decrease in insurance limits or coverage based on the risks and financial exposure arising out of the event or activity proposed in the permit application or contract.

3) Any excess insurance policies provided to meet the minimum limits shall be "following form" coverage.

4) XCU (Explosion, Collapse and Underground Damage: this term is used in Business Liability Insurance to indicate that certain types of construction work involve these hazards. This covereage will be required based on activity to be performed.

5) Auto Liability is combined single limit (CSL) coverage required if the permit applicant or contractor will own, lease hire or borrow a vehicle. An EXCEPTION applies if volunteers drive personally owned vehicles (which must by law be insured).

6) Worker's Compensation coverage is required for special events if any paid members of the insured's organization will be acting in the course or scope of employment for the purposes of the event. If the event is staffed only by volunteer, this coverage will be waived.

7) Policy provided by the Contractor performing the work shall be endorsed, as required by this written agreement, to include the state of Arizona, and it's departments, agencies, boards, commisions, universities officers, officials, agents and employees as addtional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor.

8) Policy provided by the Contractor performing the work shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the state of Arizona, and it's departments, agencies, boards, commisions, universities officers, officials, agents and employees for losses arising the activities performed by or on behalf of the Contractor.

9) The Contractor performing the work shall provide policies that stipulate the insurance afforded the Contractor are the primary and that any insurance carried by the department, its agents, officials, employees or the State of Arizona shall be excess and not contributory insurance, as provided by A.R.S. § 41-621 (E).

CERTIFICATE HOLDER

© 1988-2010 ACORD CORPORATION. All rights reserved.

ACORD 25 (2010/05)

AUTHORIZED REPRESENTATIVE

CANCELLATION

DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE

LOCJECT

PRO-POLICY

GEN'L AGGREGATE LIMIT APPLIES PER:

OCCURCLAIMS-MADE

COMMERCIAL GENERAL LIABILITY

GENERAL LIABILITY

PREMISES (Ea occurrence) $

DAMAGE TO RENTED

EACH OCCURRENCE $

MED EXP (Any one person) $

PERSONAL & ADV INJURY $

GENERAL AGGREGATE $

PRODUCTS - COMP/OP AGG $

$RETENTIONDED

CLAIMS-MADE

OCCUR

AGGREGATE $

EACH OCCURRENCE $UMBRELLA LIAB

EXCESS LIAB

INSR

LTR TYPE OF INSURANCE POLICY NUMBER

POLICY EFF

(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY) LIMITS

WC STATU-

TORY LIMITS

OTH-

ER

E.L. EACH ACCIDENT

E.L. DISEASE - EA EMPLOYEE

E.L. DISEASE - POLICY LIMIT

ANY PROPRIETOR/PARTNER/EXECUTIVE

If yes, describe under DESCRIPTION OF OPERATIONS below

(Mandatory in NH)

OFFICER/MEMBER EXCLUDED?

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY Y / N

AUTOMOBILE LIABILITY

ANY AUTO

ALL OWNED SCHEDULED

HIRED AUTOS NON-OWNED

AUTOS AUTOS

AUTOS

COMBINED SINGLE LIMIT

BODILY INJURY (Per person)

BODILY INJURY (Per accident)

PROPERTY DAMAGE $

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.

INSR

ADDL

WVD

SUBR

N / A

(Ea accident)

(Per accident)

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 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 rights to the certificate holder in lieu of such endorsement(s).

The ACORD name and logo are registered marks of ACORD

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:

PHONE

(A/C, No, Ext):

PRODUCER

ADDRESS:

E-MAIL

FAX

(A/C, No):

CONTACT

NAME:

NAIC #

INSURER A :

INSURER B :

INSURER C :

INSURER D :

INSURER E :

INSURER F :

INSURER(S) AFFORDING COVERAGE

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

A X

AUTO PHYSICAL

DAMAGE

Insurance Agency 123 Sample Street Phoenix, AZ 12345

50,000

1,000,000

123456

02/07/2015

X

X

01/12/2015

2,000,000

02/07/2015

Insurance Agent

Y 1,000,000

The State Of Arizona Arizona Department of Transportation Arizona Department of Public Safety 1324 N. 22nd Ave MD 128A Phoenix, AZ 85009

01/12/2015

01/12/2015 agent@insuranceco.com

Policy #XXXXX

Encroachment Owner 123 Sample Drive Phoenix, AZ 12354

A

01/12/2015 1,000,000

500,000

A

500,000

02/07/2015

Signature of Representative

( 123)555-1234

1,000,000

1,000,000

Sample Company

(May have multiple companies listed)

Y

Y Y

X A

INSURED

Y Y

Policy #XXXXX

Policy #XXXXX

N

This is an optional coverage and may not be shown; if shown, policy #, wavier and addl insured must be marked.

optional amounts

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)

State of Arizona, ADOT and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees shall be named as additional insureds with respect to liability arising out of activities performed by or on behalf of the permittee or contractor. Waiver of Subrogation applies.

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