20- SAMPLE INS CERT.pdf
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- Solicitation number
- S-KS0510-00017594
- Issued by
- Oregon
About this file
This is a sample insurance certificate template for a railroad contractor project. The certificate outlines the required insurance coverage and policy details that contractors must maintain when performing work for railroad clients. The template specifies three primary insurance policies: General Liability with limits of $2,000,000 per occurrence and $6,000,000 aggregate, Pollution Liability with $1,000,000 limits, and an additional $1,000,000 policy. The certificate holder is identified as the railroad's Real Estate Department, located at 13901 Sutton Park Drive South, Suite 270, Jacksonville, Florida 32218. The template requires that the insured name, railroad name, agreement number, city, county, and state all match the corresponding written contract documentation.
The certificate mandates that all policies provide additional insured status to the certificate holder and any other parties specified in the written contract. A blanket automatic waiver of subrogation endorsement must be included in all policies. The General Liability policy must include CG2417 endorsement or its equivalent to remove exclusions for work within 50 feet of the railroad, with railroad name and agreement number matching the written contract. For gas pipeline projects, the limits increase to $5,000,000 per occurrence and $10,000,000 aggregate for General Liability and $5,000,000 per occurrence for Pollution Liability. An umbrella policy may be utilized to meet General Liability requirements provided it follows the form of the underlying coverage. All policies must list effective dates, expiration dates, insurer NAIC numbers, and authorized representative contact information.
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✪ ✫ ✬ ✭ ✮ ✯ ✮ ✰ ✱✪ ✫ ✬ ✭ ✮ ✯ ✮ ✯ ✱✪ ✫ ✬ ✭ ✮ ✯ ✮ ✲ ✱✪ ✫ ✬ ✭ ✮ ✯ ✮ ✳ ✱✪ ✫ ✬ ✭ ✮ ✯ ✮ ✴ ✱✪ ✫ ✬ ✭ ✮ ✯ ✮ ✵ ✱ ✗ ✣ ✖ ★ ✶✫ ✵ ✷ ✯ ✱✳ ✸ ✫ ✹ ✵ ✳ ✹ ✺ ✵ ✻ ✳ ✼ ✫ ✽ ✾ ✱✰ ✵ ✿✯ ❀ ✷ ✵ ✪ ❁✵ ✲ ✲ ✮ ✯ ✬ ✬ ✱❂ ✮ ✸ ✲ ✭ ✳ ✯ ✮ ✺ ✵ ✻ ✳ ✼ ✫ ✽ ✼ ✯ ❃ ❄ ✾ ✱❂ ❅ ✸ ✫ ✯✪ ✫ ✬ ✭ ✮ ✯ ✲ ❆ ❇ ❈ ❉ ❊ ❉ ❋ ● ● ❍ ■ ❏ ❇ ❆ ❑▲ ❇ ❆ ▼ ❉ ◆ ❉ ▲ ❖ ▼ ❇ ● ❍ ■ ❏ ❇ ❆ ❑▲ ❋ ❈ ❇ ❆ ❖ P ❇ ❊
◗ ❘ ❙ ❚ ❯ ❱ ❲ ❳ ❱ ❨ ◗ ❩ ❬ ❭ ❪ ❫ ❪ ❴ ❬ ❵ ❩ ❵ ❫ ❛ ❬ ❪ ❭ ❜ ❝ ❞ ❪ ❴ ❵ ❡ ❛ ❢ ❲ ❣ ❣ ◗ ❱ ◗ ❚ ❳ ❲ ❤ ◗ ❳ ✐ ❥ ❯ ❦ ❣ ❧ ❬ ❭ ❪ ♠ ❜ ❝ ❵ ❫ ♥ ♦ ❵ ❪ ❡ ♣ q r ❡ ❬ ❭ ❛ s ❪ ❲ ❣ ❣ ◗ ❱ ◗ ❚ ❳ ❲ ❤ ◗ ❳ ✐ ❥ ❯ ❦ ❣ ♠ ❴ ❜ s ❵ ❡ ❵ ❜ ❢ ❡ ❜ ❴ t ❪ ❪ ❢ ❞ ❜ ❴ ❡ ❪ ❞ ✉◗ ❩ ✐ ❥ ✈ ❯ ❚ ✇ ❲ ❱ ◗ ❚ ❳ ◗ ✐ ① ❲ ◗ ② ❦ ❣ ❧ ❡ r t ③ ❪ ❫ ❬ ❬ ❜ ❬ ❭ ❪ ❬ ❪ ❴ q ❡ ❛ ❢ ❞ ❫ ❜ ❢ ❞ ❵ ❬ ❵ ❜ ❢ ❡ ❜ ❩ ❬ ❭ ❪ ♠ ❜ ❝ ❵ ❫ ♥ ❧ ❫ ❪ ❴ ❬ ❛ ❵ ❢ ♠ ❜ ❝ ❵ ❫ ❵ ❪ ❡ q ❛ ♥ ❴ ❪ ④ r ❵ ❴ ❪ ❛ ❢ ❪ ❢ ❞ ❜ ❴ ❡ ❪ q ❪ ❢ ❬ ✉ ❲ ❡ ❬ ❛ ❬ ❪ q ❪ ❢ ❬ ❜ ❢❬ ❭ ❵ ❡ ❫ ❪ ❴ ❬ ❵ ❩ ❵ ❫ ❛ ❬ ❪ ❞ ❜ ❪ ❡ ❢ ❜ ❬ ❫ ❜ ❢ ❩ ❪ ❴ ❴ ❵ ⑤ ❭ ❬ ❡ ❬ ❜ ❬ ❭ ❪ ❫ ❪ ❴ ❬ ❵ ❩ ❵ ❫ ❛ ❬ ❪ ❭ ❜ ❝ ❞ ❪ ❴ ❵ ❢ ❝ ❵ ❪ r ❜ ❩ ❡ r ❫ ❭ ❪ ❢ ❞ ❜ ❴ ❡ ❪ q ❪ ❢ ❬ ♦ ❡ ♣ ✉❱ ⑥ ◗ ✐ ⑦ ❦ ❯ ❱ ◗ ⑧ ◗ ⑦ ❲ ❱ ❦ ◗ ✐ ◗ ✐ ✐ ❥ ❦ ❣ ❲ ✐ ❲ ❘ ❲ ❱ ❱ ❦ ❯ ❚ ⑧ ◗ ❳ ⑧ ❚ ❯ ❘ ❲ ❱ ◗ ❚ ❳ ❚ ❳ ❤ ⑨ ❲ ❳ ❣ ⑦ ❚ ❳ ⑧ ❦ ❯ ✐ ❳ ❚ ❯ ◗ ✇ ⑥ ❱ ✐ ❥ ❙ ❚ ❳ ❱ ⑥ ❦ ⑦ ❦ ❯ ❱ ◗ ⑧ ◗ ⑦ ❲ ❱ ❦ ⑥ ❚ ❤ ❣ ❦ ❯ ✉ ❱ ⑥ ◗ ✐⑦ ❦ ❯ ❱ ◗ ⑧ ◗ ⑦ ❲ ❱ ❦ ❣ ❚ ❦ ✐ ❳ ❚ ❱ ❲ ⑧ ⑧ ◗ ❯ ❘ ❲ ❱ ◗ ② ❦ ❤ ⑨ ❚ ❯ ❳ ❦ ✇ ❲ ❱ ◗ ② ❦ ❤ ⑨ ❲ ❘ ❦ ❳ ❣ ❧ ❦ ⑩ ❱ ❦ ❳ ❣ ❚ ❯ ❲ ❤ ❱ ❦ ❯ ❱ ⑥ ❦ ⑦ ❚ ② ❦ ❯ ❲ ✇ ❦ ❲ ⑧ ⑧ ❚ ❯ ❣ ❦ ❣ ✈ ⑨ ❱ ⑥ ❦ ❙ ❚ ❤ ◗ ⑦ ◗ ❦ ✐✈ ❦ ❤ ❚ ① ✉ ❱ ⑥ ◗ ✐ ⑦ ❦ ❯ ❱ ◗ ⑧ ◗ ⑦ ❲ ❱ ❦ ❚ ⑧ ◗ ❳ ✐ ❥ ❯ ❲ ❳ ⑦ ❦ ❣ ❚ ❦ ✐ ❳ ❚ ❱ ⑦ ❚ ❳ ✐ ❱ ◗ ❱ ❥ ❱ ❦ ❲ ⑦ ❚ ❳ ❱ ❯ ❲ ⑦ ❱ ✈ ❦ ❱ ① ❦ ❦ ❳ ❱ ⑥ ❦ ◗ ✐ ✐ ❥ ◗ ❳ ✇ ◗ ❳ ✐ ❥ ❯ ❦ ❯ ♦ ✐ ♣ ❧ ❲ ❥ ❱ ⑥ ❚ ❯ ◗ ❶ ❦ ❣❯ ❦ ❙ ❯ ❦ ✐ ❦ ❳ ❱ ❲ ❱ ◗ ② ❦ ❚ ❯ ❙ ❯ ❚ ❣ ❥ ⑦ ❦ ❯ ❧ ❲ ❳ ❣ ❱ ⑥ ❦ ⑦ ❦ ❯ ❱ ◗ ⑧ ◗ ⑦ ❲ ❱ ❦ ⑥ ❚ ❤ ❣ ❦ ❯ ✉
❷ ❸ ❹ ❺ ❻ ❼ ❽ ❾ ❿ ➀ ➁ ➂ ➂ ➃ ➄ ❿ ➅ ➆ ➇❽ ❺ ➁ ➁ ➂ ➂ ➃ ➄ ❿ ➅ ➆ ➇ ➈➈ ✗ ➉ ✣
➊ ➋ ➌ ➍➎ ➏ ➐➑ ➐ ➐ ➒➓ ➔ ➊ ➐→ ➣ ↔ ↕ ↔ ↕ → ➙ ➛ ➜ ➝ → ↔ ➞ ➟ → ➣ ➠ → → ➣ ➜ ➡ ➙ ➢ ↔ ➛ ↔ ➜ ↕ ➙ ➞ ↔ ➤ ↕ ➥ ➝ ➠ ➤ ➛ ➜ ➢ ↔ ↕ → ➜ ➦ ➧ ➜ ➢ ➙ ➨ ➣ ➠ ➩ ➜ ➧ ➜ ➜ ➤ ↔ ↕ ↕ ➥ ➜ ➦ → ➙ → ➣ ➜ ↔ ➤ ↕ ➥ ➝ ➜ ➦ ➤ ➠ ➫ ➜ ➦ ➠ ➧ ➙ ➩ ➜ ➞ ➙ ➝ → ➣ ➜ ➡ ➙ ➢ ↔ ➛ ➟ ➡ ➜ ➝ ↔ ➙ ➦↔ ➤ ➦ ↔ ➛ ➠ → ➜ ➦ ➭ ➤ ➙ → ➨ ↔ → ➣ ↕ → ➠ ➤ ➦ ↔ ➤ ➯ ➠ ➤ ➟ ➝ ➜ ➲ ➥ ↔ ➝ ➜ ➫ ➜ ➤ → ➳ → ➜ ➝ ➫ ➙ ➝ ➛ ➙ ➤ ➦ ↔ → ↔ ➙ ➤ ➙ ➞ ➠ ➤ ➟ ➛ ➙ ➤ → ➝ ➠ ➛ → ➙ ➝ ➙ → ➣ ➜ ➝ ➦ ➙ ➛ ➥ ➫ ➜ ➤ → ➨ ↔ → ➣ ➝ ➜ ↕ ➡ ➜ ➛ → → ➙ ➨ ➣ ↔ ➛ ➣ → ➣ ↔ ↕➛ ➜ ➝ → ↔ ➞ ↔ ➛ ➠ → ➜ ➫ ➠ ➟ ➧ ➜ ↔ ↕ ↕ ➥ ➜ ➦ ➙ ➝ ➫ ➠ ➟ ➡ ➜ ➝ → ➠ ↔ ➤ ➳ → ➣ ➜ ↔ ➤ ↕ ➥ ➝ ➠ ➤ ➛ ➜ ➠ ➞ ➞ ➙ ➝ ➦ ➜ ➦ ➧ ➟ → ➣ ➜ ➡ ➙ ➢ ↔ ➛ ↔ ➜ ↕ ➦ ➜ ↕ ➛ ➝ ↔ ➧ ➜ ➦ ➣ ➜ ➝ ➜ ↔ ➤ ↔ ↕ ↕ ➥ ➧ ➵ ➜ ➛ → → ➙ ➠ ➢ ➢ → ➣ ➜ → ➜ ➝ ➫ ↕ ➳➜ ➸ ➛ ➢ ➥ ↕ ↔ ➙ ➤ ↕ ➠ ➤ ➦ ➛ ➙ ➤ ➦ ↔ → ↔ ➙ ➤ ↕ ➙ ➞ ↕ ➥ ➛ ➣ ➡ ➙ ➢ ↔ ➛ ↔ ➜ ↕ ➭ ➢ ↔ ➫ ↔ → ↕ ↕ ➣ ➙ ➨ ➤ ➫ ➠ ➟ ➣ ➠ ➩ ➜ ➧ ➜ ➜ ➤ ➝ ➜ ➦ ➥ ➛ ➜ ➦ ➧ ➟ ➡ ➠ ↔ ➦ ➛ ➢ ➠ ↔ ➫ ↕ ➭ ➈➈➈➈❾ ❻ ❷ ❾ ❺ ❻ ❸ ➺ ➻ ➼ ➽ ➼ ➾ ❺➚ ❷ ➻ ➪ ➶ ➺ ➪ ➹ ➘ ➴ ❻ ➺ ❽ ❾ ❿ ➀ ➁ ➂ ➂ ➃ ➄ ❿ ➅ ➆ ➇➚ ❷ ➻ ➪ ➶ ➺ ➪ ➹ ➘ ➴ ❻ ➺ ❽ ❾ ❿ ➀ ➷ ❿ ➀ ➬ ➮ ➅ ➇➱ ❷ ➽ ➚ ➪ ➹ ❺ ➻ ✃ ➪ ➹ ➾ ➶ ❺ ➶ ➪ ➽ ➪ ❸➼ ➴ ❸ ❷ ✃ ❷ ➹ ➶ ➺➼ ➴ ❸ ❷ ✃➼ ➴ ❸ ❷ ✃ ❷ ➹ ➶ ➺ ➹ ❷ ➹ ❐ ❷ ❒ ➹ ❺ ➻✃ ➱ ❹ ❺ ➻ ➴ ➶ ❺ ➻❷ ❒ ➹ ❺ ➻➼ ➹ ➺ ➼ ➴ ❸ ❷✵ ✭ ✹ ✸ ✷ ✸ ✴ ✪ ❁ ✯ ❁ ✪ ✵ ✴ ✪ ❁ ✪ ✹ ❮
❰ ➉ ✗Ï ✸ ✮ Ð ✯ ✮ ✬ ✳ ✸ ✷ ❂ ✯ ✫ ✬ ✵ ✹ ✪ ✸ ✫✵ ✫ ✲ ✯ ✷ ❂ ❁ ✸ ❮ ✯ ✮ ✬ Ñ ❁ ✪ ✵ ✴ ✪ ❁ ✪ ✹ ❮Ò Ó Ó Ô Õ Ö × Ø Ù Ö Ù Ú Ö × Ö Û Õ Ü Ý Þ Ö Þ ß✜ à á â ã á ä å æ ç è â ✗ é ✢➻ ❺ ✃ ➱ ❻ ➪ ❾ ❸ ➪ ❷ ➹ ❷ ê ❷ ❾ ❺ ❻ ➼ ❸ ➪ ❷ ➹ ✃ ë ❿ ì ➮ í➪ î ï ❿ ➬ ð ➄ ❿ ➬ ➂ ➀ ➃ ë ❿ ñ ➅ ➄ ❿ ➀ò ó ô õ × Ò õ × Ô Ö ö Ò × Ø õ ò × ö ó Ö × Ø Ö Û Ö Õ Ý ö Ô ÷ Ö ➈➈➈❺ ø ➶ ø ➻ ➪ ✃ ❺ ➼ ✃ ❺ ❐ ❾ ❷ ➶ ➪ ➱ ➺ ➶ ➪ ➽ ➪ ❸❺ ø ➶ ø ➻ ➪ ✃ ❺ ➼ ✃ ❺ ❐ ❺ ➼ ❺ ➽ ❾ ➶ ❷ ➺ ❺ ❺❺ ø ➶ ø ❺ ➼ ➱ ❹ ➼ ➱ ➱ ➪ ➻ ❺ ➹ ❸ ❺ ❻❷ ❸ ❹ ❐✃ ❸ ➼ ❸ ➴ ❸ ❺❾ ❺ ❻
❁ ✪ ✷ ✪ ✹ ✬✺ ✷ ✷ ✻ ✲ ✲ ✻ ❮ ❮ ❮ ❮ ✾❂ ✸ ❁ ✪ ✳ ❮ ✯ ✿ ❂✺ ✷ ✷ ✻ ✲ ✲ ✻ ❮ ❮ ❮ ❮ ✾❂ ✸ ❁ ✪ ✳ ❮ ✯ ✰ ✰❂ ✸ ❁ ✪ ✳ ❮ ✫ ✭ ✷ ✴ ✯ ✮✹ ❮ ❂ ✯ ✸ ✰ ✪ ✫ ✬ ✭ ✮ ✵ ✫ ✳ ✯➒ ù ➍➓ ➔ ➊ ➍
✲ ✯ ✬ ✳ ✮ ✪ ❂ ✹ ✪ ✸ ✫ ✸ ✰ ✸ ❂ ✯ ✮ ✵ ✹ ✪ ✸ ✫ ✬ ✻ ❁ ✸ ✳ ✵ ✹ ✪ ✸ ✫ ✬ ✻ ú ✯ ❅ ✪ ✳ ❁ ✯ ✬ ✺ ✵ ✳ ✸ ✮ ✲ û ü û ✼ ✵ ý ý þ ❄ þ ✽ ÿ � ✁ ✮ ✂ ✄ � ☎ ✆ ✝ ✬ ✞ ✟ ✂ ý ✠ ✁ ✂ ✼ ✄ � ✡ ☛ ✂ � ❄ ❄ � ✞ ✟ ✂ ý þ ☞ ✄ ✽ ☎ ✂ ✝ ✌ � ✞ ✂ þ ✝ ☎ ✂ ✍ ✠ þ ☎ ✂ ý ✾ ✯ ✿ ✳ ✯ ✬ ✬ ❁ ✪ ✵ ✴✭ ✷ ✴ ✮ ✯ ❁ ❁ ✵ ❁ ✪ ✵ ✴ ➈❺ ➼ ➱ ❹ ❷ ➱ ➱ ➴ ❻ ❻ ❺ ➹ ➱ ❺ ➈➼ ➾ ➾ ❻ ❺ ➾ ➼ ❸ ❺ ➈❷ ➱ ➱ ➴ ❻➱ ➶ ➼ ➪ ➽ ✃ ❐ ➽ ➼ ➻ ❺➻ ❺ ➻ ❻ ❺ ❸ ❺ ➹ ❸ ➪ ❷ ➹ ➈
➈❾ ❻ ❷ ➻ ➴ ➱ ❸ ✃ ❐ ➱ ❷ ➽ ❾ ✎ ❷ ❾ ➼ ➾ ➾ ➈➾ ❺ ➹ ❺ ❻ ➼ ➶ ➼ ➾ ➾ ❻ ❺ ➾ ➼ ❸ ❺ ➈❾ ❺ ❻ ✃ ❷ ➹ ➼ ➶ ✏ ➼ ➻ ✑ ➪ ➹ ➘ ➴ ❻ ➺ ➈➽ ❺ ➻ ❺ ✒ ❾ ❽ ➼ ➅ ï ➮ ➅ ❿ ➷ ❿ ➀ ➬ ➮ ➅ ➇ ➈❺ ➼ ➱ ❹ ❷ ➱ ➱ ➴ ❻ ❻ ❺ ➹ ➱ ❺➻ ➼ ➽ ➼ ➾ ❺ ❸ ❷ ❻ ❺ ➹ ❸ ❺ ➻ ➈❾ ❻ ❺ ➽ ➪ ✃ ❺ ✃ ❽ ❺ ➁ ➮ ➂ ➂ ñ ➀ ➀ ❿ ➅ ➂ ❿ ➇★ ✥ à à ✛ ✚ ★ ✖ ✣ ✓ ✧ ✛ ✗ ✛ ✚ ✣ ✓ ✓ ✖ ✣ ✔ ✖ ✓ ✖ ✕ ❰➱ ➶ ➼ ➪ ➽ ✃ ❐ ➽ ➼ ➻ ❺ ❷ ➱ ➱ ➴ ❻➾ ❺ ➹ ✖ ➶ ➼ ➾ ➾ ❻ ❺ ➾ ➼ ❸ ❺ ➶ ➪ ➽ ➪ ❸ ➼ ❾ ❾ ➶ ➪ ❺ ✃ ❾ ❺ ❻ ❼❾ ❷ ➶ ➪ ➱ ➺ ❾ ❻ ❷ ❐➘ ❺ ➱ ❸ ➶ ❷ ➱
▲ ❖ ● ▲ ❇ ✗ ✗ ❖ ▼ ❉ ❋ ●✵ ✭ ✹ ❅ ✸ ✮ ✪ ✘ ✯ ✲ ✮ ✯ ❂ ✮ ✯ ✬ ✯ ✫ ✹ ✵ ✹ ✪ ú ✯❖ ▲ ❋ ❆ ✙ ✚ ✛ ✜ ✚ ✢ ✣ ✤ ✥ ✢ ✦ ✧ ★ ✣ ✩ ✪ ✪ ✫ ✚ ✢ ✣ ✛ ❖ ▲ ❋ ❆ ✙ ▲ ❋ ❆ ✬ ❋ ❆ ❖ ▼ ❉ ❋ ● ✭ ❖ ✮ ✮ ✯ ✰ ✱ ✲ ✳ ✴ ✯ ✵ ✴ ✵ ✯ ✶ ✵ ✷ ✭
❹ ➪ ❻ ❺ ➻➼ ➴ ❸ ❷ ✃ ❷ ➹ ➶ ➺
Insert Date Prepared
Insurer Name No.1 NAIC#
Producer's Name
Producers Address
Insured Name
Insured Address ***Insured Name should match written contract**** x
X X
X X
X
A
A
B
Insert Policy #
Insert Policy #
Insert Policy #
2,000,000
6,000,000
1,000,000
1,000,000 x
***Railroad Name should match written contract***
Umbrella Policy may be used to meet CGL requirements. If used, policy must "follow form"
Insurance Agent Name Telephone #
Insurance Agent's Email Address Fax #
Insert Date Policy becomes effective
Insert Date Policy Expires
Insurer Name No.2 NAIC#
Insert Date Policy becomes effective
Insert Date Policy becomes effective
Insert Date Policy Expires
Insert Date Policy Expires
Insert Authorized Representative Name blewis Text Box (Railroad Name) Its Indemnitees and Shareholders Attn: Real Eastate Department 13901 Sutton Park Drive South Suite 270 Jacksonville Fl, 32218 blewis Text Box •The policies shown provides additional insured status to the certificate holder and any other party(ies) specified in or required by written contract between the named insured and the certificate holder. All policies include a blanket automatic waiver of subrogation endorsement that provides this feature in favor of the certificate holder and any other party(ies) specified in or required by written contract between the named insured and the certificate holder.
•The General Liability certificate is also required to show proof of CG2417 or its equivalent – Contractual Liability Railroads (removes any exclusion for work within 50’ of the CGL Policy). If your policy does not carry this exclusion please note this under Description of Operations on the certificate.
blewis Text Box blewis Text Box If this is a Gas Pipeline the limits will be $5M Each Occurrence and $10M Aggregate blewis Text Box A Gas Pipeline will require $5M each occurrence Pollution Liability
General Liability Policy Number
Railroad Name Agreement Number
City, County, State
***Railroad Name, Agreement Number, City, County and State should match written contract***
***Policy Number referenced should match insurance certificate provided to Railroad****
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