4-Risk Forms.pdf
PDF 3 MB Posted
- Attached to
- PCI Pentest Services State and local contract opportunity
- Solicitation number
- DFW11992
- Issued by
- Dallas County, Texas
About this file
This file contains two insurance-related forms required for Dallas Fort Worth International Airport Board solicitations. The first form is an Insurance Affidavit that must be completed by both the bidder/proposer and their insurance provider, confirming that the contractor will comply with all insurance provisions specified in the solicitation requirements and that insurance coverage can be obtained without affecting the offered prices. The second form is a Workers Compensation Hold Harmless and Indemnification Agreement designed for sole proprietors who qualify for exemption from workers compensation insurance requirements under applicable law.
The Workers Compensation Hold Harmless Agreement serves as an alternative to traditional workers compensation insurance for qualifying sole proprietors, requiring the contractor to release and indemnify the Airport and the Cities of Dallas and Fort Worth from claims related to injury, death, disease, or employer liability arising from contract work performance, except in cases of Airport's sole negligence. The sole proprietor must certify their legal exemption status, confirm they are the firm's only proprietor, and provide proof of personal medical insurance coverage as the only person performing work under the contract. Both forms include spaces for required signatures, dates, and identifying information but do not specify contract amounts, funding sources, or other financial terms.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| 10-Special Provisions.pdf | ||
| 2-Endorsement Form.pdf | ||
| 1-Business Disclosure Form.dotx.pdf | ||
| 8-FCPA Disclosure Statement.pdf | ||
| 3-General Terms and Conditions.pdf | ||
| 5-Workforce Composition Form.xls | XLS spreadsheet | |
| 6-Bid Instructions and Requirements.pdf | ||
| 7-Specifications - Scope of Works.pdf | ||
| 9-Insurance Contract Provisions EXHIBIT A - Request Number REQ00004079.pdf |
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Text version
INSURANCE AFFIDAVIT
Dallas Fort Worth International Airport Board Solicitation No. _____________
NAME OF BIDDER:
To be completed by the Bidder/Proposer:
I confirm that, if awarded the Contract, I will comply with all of the Insurance Provisions, as stated in the Insurance Requirements of Solicitation No. ___________, and said insurance shall be provided without change to the prices offered.
Name of Proposer:
Authorized Agent (please print):
Authorized Agent’s Signature:
Date:
To be completed by Bidder/Proposer’s insurance provider:
I confirm that, if awarded the Contract, the Bidding Firm stated above either has insurance coverage or can obtain coverage in compliance with the requirements of DFW International Airport Board
Solicitation No. __________. I further confirm that this Insurance Agency can comply with the insurance provisions as stated in the Insurance Requirements.
Insurance Agency:
Insurance Agent’s Name (please print):
Insurance Agent’s Signature:
Date:
WORKERS COMPENSATION HOLD HARMLESS
AND INDEMNIFICATION AGREEMENT
For and in consideration of the sums paid to Contractor by Airport under Contract No.
(the “Contract”) and Airport’s agreement to allow Contractor to provide this Hold Harmless and
Indemnification Agreement in lieu of workers compensation insurance, Contractor, for himself and as sole proprietor of Contractor, hereby agrees to release the Airport, the Cities of Dallas and Fort Worth, and their respective officers, agents and employees from, and to indemnify each of them against any and all claims and causes of action for injury, death, disease, or employer liability arising from or in connection with my performance of the Contract Work, save and except such personal injury, death, disease or employer liability as are caused by the sole negligence of the Airport.
I further certify that my firm qualifies for exemption from workers compensation insurance requirements under the law; that I am the firm’s sole proprietor; and that I will provide proof of medical insurance for myself, the only person from my firm that will be performing work under this contract.
NAME OF FIRM:
NAME OF SOLE PROPRIETOR:
SIGNATURE OF SOLE PROPRIETOR:
DATE:
| Workers Compensation Hold Harmless and Indemnification Agreement.pdf |
| 6 UWORKERS COMPENSATION HOLD HARMLESS AND INDEMNIFICATION AGREEMENT |
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File details come from the government source that posted it. Updated .