2-BID 26-09 Insurance Checklist.pdf

County expects to pay a fair and reasonable price not-to-exceed those quoted in this Bid for all products in the event of a disaster, emergency, or hurricane. Vendor/Contractor shall furnish a 24-hour phone number in the event of such an emergency on the Vendor Acknowledgement Form.

8) Non-Governmental Entity Human Trafficking Affidavit (§787.06(13), Fla. Stat.): The undersigned, as an officer or representative of the Vendor hereby attest, declare, and affirm that it does not use coercion for labor or services as defined in Section 787.06, Florida Statutes, effective July 1, 2024. Under penalties of perjury, Vendor declares that it has read the foregoing Vendor Acknowledgement Form and that the facts stated in it are true.

9) Acknowledgement of Addenda: Vendor hereby agrees that all addenda associated with this Solicitation Response has been acknowledged and understood that by virtue of submitting this Vendor Acknowledgement Form the Vendor has no further questions regarding the solicitation.

Vendor Acknowledgement Form BID TITLE: Furnish and Delivery of Lubricants BID NO.: 26-09/HV

Solid Waste Authority of Palm Beach County 7501 N. Jog Road, West Palm Beach FL, 33412

Purchasing Department Purchasing Agent: Heiley Vivas

Telephone – 561-640-4000

Vendor Name: Fed. ID No. or TIN:

Respondent’s Name/ Signature:

Respondent’s Title: 24-hour Emergency Telephone Number:

Mailing Address:

Street:

Toll Free Telephone Number: E-Mail Address:

City: State: ZIP: Office Number: ( )

Is Vendor a Certified Small Business Yes / No Enterprise?

Certified or Cashier's Check is attached, when required, in the amount of $

Title Description: Furnish/Delivery of Lubricants Prepared: 2026 04 16 SWA Bid/Agreement No.: 26-09/HV

SWA Level 7 Risk Profile 7501 N. Jog Rd, West Palm Beach, FL 33412 REV 2026 04 16

Solid Waste Authority of Palm Beach County

INSURANCE REQUIREMENTS CHECKLIST

TYPE OF COVERAGE MINIMUM COVERAGE LIMITS

Must be Included if marked

“X”

Comprehensive Commercial General Liability

Bodily Injury & Property Damage $1,000,000. Per Occurrence $2,000,000. General Aggregate or CSL $1,000,000. Products – Comp/Op Aggregate

(Please note special instructions →) Silica product exclusion must be eliminated if cement/concrete materials are used during construction. Before accessing the SWA property or commencing activities under this agreement, the insured must provide the SWA with an acceptable certificate of insurance, including an Additional Insured, and Waiver of Subrogation endorsement. Minimum insurance coverage and limits marked on this list are required and must be no more restrictive than most recent ISO forms. A certificate must include the current date and list the SWA as a Certificate Holder. The prime firm is responsible, insurance requirements extend to employees and subcontractors. Endorsements must be listed by form name and number, or copies provided. The SWA may request copies of policy documents.

X Occurrence Form X Premises Operations X Delete XCU Exclusion X Products-Completed Operations X Contractual Liability X Independent Contractors X Personal Injury Blasting Demolition

Watercraft – by exception for non-owned or Hull/ P&I (if used in the project)

Pollution extension, CPL, or separate EIL

Automobile Liability Bodily Injury & Property Damage

$1,000,000. Combined Single Limit (Ea. accident) $ 10,000. Personal Injury Protection (PIP)

X Any Auto Covered or Scheduled X Non-owned/Hired (if no owned vehicles)

X Workers’ Compensation

Employer’s Liability If required, F.S. Chapter 440/Federal Gov’t.

Statutory Limits $100,000. Occurrence $500,000. Aggregate $100,000. Disease

Umbrella/Excess Liability

$ Occurrence

Professional Liability/Errors and Omissions

$__________. Each Loss

X

Pollution Liability or Environmental Impairment Liability (EIL), Contractor Pollution Liability (CPL)

$1,000,000. BI & PD Aggregate or CSL

Cyber Liability

$__________. Each Incident/Claim

Builder’s Risk

100% of Value Property Under Construction

The SWA of Palm Beach County, its Officers, Employees, and Agents must be named Additional Insured except for Workers’ Compensation and Employer’s Liability, Professional Liability, and Inland Marine.

Vendor must use the following ISO form(s), or others approved by the SWA Risk Management: Additional Insured Endorsement Form(s) CG2010, and CG2026. Must use ISO Waiver of Subrogation Endorsement CG2404 except for Workers’ Compensation Professional Liability and Inland Marine. Include the SWA Agreement Title, Number, and specific project description on the certificate.