9-PA1858 Risk Forms.pdf
PDF 3 MB Posted
- Attached to
- Pension Fund Consulting Services
- Solicitation number
- PA1858
- Issued by
- Dallas County, Texas
About this file
The document contains two administrative forms from the Dallas Fort Worth International Airport Board: an Insurance Affidavit and a Workers Compensation Hold Harmless and Indemnification Agreement. The Insurance Affidavit requires bidders to confirm their ability to comply with the airport's insurance provisions for a specific solicitation, with spaces for both the bidder and their insurance provider to complete and sign.
The Workers Compensation Hold Harmless and Indemnification Agreement is specifically designed for sole proprietors seeking exemption from standard workers compensation insurance requirements. The document requires the sole proprietor to release the airport and associated cities from liability for workplace injuries, with the exception of incidents caused solely by the airport's negligence. The sole proprietor must also certify their firm's exemption status and provide proof of personal medical insurance for themselves as the only worker performing contract duties.
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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:
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File details come from the government source that posted it. Updated .