2-Insurance Coverage Declaration.pdf
PDF 67 KB Posted
- Solicitation number
- 804951-1
- Issued by
- Johnson County, Kentucky
About this file
This document is an Insurance Coverage Declaration form that outlines mandatory insurance requirements for a contractor proposing to work with a county government. The form specifies three primary types of insurance coverage that must be provided: 1) Commercial General Liability insurance with a $2,000,000 aggregate and $1,000,000 per occurrence limit, 2) Comprehensive Automobile and Water Vehicle Liability covering automotive equipment with a $1,000,000 combined single limit, and 3) Worker's Compensation insurance with employer's liability coverage of $1,000,000 per occurrence.
The document requires contractors to complete the insurance declaration table by listing their insurance carriers, types of coverage, coverage limits, and expiration dates. Failure to attach the required insurance policies and complete the form may result in proposal rejection. Additionally, the Worker's Compensation policy must include a provision that prevents cancellation without 30 days prior written notice to the county. Firms with owner/operators who have filed for worker's compensation exemption must provide a signed copy of their exemption notice, which must meet the applicable Worker's Compensation law requirements.
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Text version
INSURANCE COVERAGE DECLARATION
Contractor shall complete the form below and attach the following insurance policies (including all endorsements) to this proposal. Failure to do so, may result in a rejected Proposal.
1. Commercial General Liability – in the amount of two million dollars ($2,000,000.00) aggregate/one million dollars ($1,000,000.00) per occurrence. The General Aggregate limit shall either apply separately to the resulting Contractor or shall be at least twice the required occurrence limit.
2. Comprehensive Automobile and Water Vehicle Liability – covering any automotive equipment to be used in performance of the service, with a minimum limit in the amount of One Million Dollars ($1,000,000.00) per occurrence combined single limit / any auto.
Physical Damage Insurance covering owned or rented machinery, tools, equipment, office trailers, and vehicles.
3. Worker’s Compensation – Proposer shall provide a policy with employer’s liability coverage with limits of not less than One Million Dollars ($1,000,000.00) per occurrence for each accident or illness. The Worker’s Compensation policy shall state that it cannot be cancelled or materially changed without first giving thirty (30) days prior notice thereof in writing to the County. Firms that have owner/operators that have filed a “Notice of Election to be Exempt” shall supply a signed copy of said notice. Any such exemption shall meet the requirements that qualify for an exemption under the applicable Worker’s Compensation law.
Insurance Carrier Type of Coverage Limit ($) Expiration Date
General Liability
Commercial Auto
Worker’s Compensation
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File details come from the government source that posted it. Updated .