ACCEPTED SIR GL 01.30.25-01.30.26.pdf
PDF 322 KB Posted
- Attached to
- Master Agreement AZ|CTR069671
- Contract number
- CTR069671
- Issued by
- Arizona
About this file
This document is a Self-Insured Retention (SIR) Practices letter from Nutrien Ag Solutions, Inc. to the Arizona Department of Transportation (ADOT) in Phoenix, Arizona. The letter outlines the company's self-insurance practices for general liability, auto liability, and workers' compensation, which have been approved by the Motor Vehicle Division (MVD) and Arizona Industrial Commission, respectively.
The document specifies that Nutrien Ag Solutions, Inc. self-insures up to $2 Million on a per occurrence basis for risks associated with permitted and non-public use of ADOT's right-of-way. The company agrees to maintain adequate retained earnings to meet these self-insuring obligations and will provide annual reports upon request. The letter also confirms that ADOT will have additional insured status for vehicle and general liability, with coverages limited to the amounts specified in the ADOT Permit Insurance Matrix. The company's self-insurance is primary and will assume responsibility for any losses or risks related to work performed within the ADOT right-of-way.
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Text version
Date: ___________________________
The State of Arizona Arizona Department of Transportation 1324 N. 22nd Avenue, MD 128A Phoenix, AZ 85009
RE: General Liability, Auto Liability, and Workers' Compensation Self-Insured Retention (SIR) Practices for ___________________________________________
__________________________________, hereinafter referred to as "The Company", is a business with operations in Arizona. Based on its financial condition, The Company utilizes an SIR mechanism as an equivalent to third-party provided insurance for portions of its aggregate general liability risk. Auto liability self-insurance has been approved by MVD via self-insurance application process, and an official MVD issued self-insurance certificate is attached. Workers' compensation self-insurance coverage has been approved according to all applicable statutory requirements and can be verified through the Arizona Industrial Commission.
Under the SIR, The Company self-insures for these risks at the level and dollar amounts, up to $___ Million, on a per occurrence basis, as specified under the Agreement between The Company and ADOT for permitted and non-public use of the State of Arizona's and/or ADOT's right-of-way.
The Company maintains adequate levels of retained earnings or revenue to meet these self-insuring obligations. Copies of the Annual Report are available and electronic copies will be provided upon request.
The Company agrees to waive its rights of recovery in subrogation as to ADOT, its officials and employees for all claims, damages, losses, liabilities, or expenses relating to, arising from, or resulting from work performed by or on behalf of The Company within the ADOT right-of-way.
ADOT shall have additional insured status with respect to The Company's self-insured vehicle liability and general liability insurance to the scope and extent of ISO Form CG20101185; and with all stated coverages limited to the amounts specified in the ADOT Permit Insurance Matrix.
________________________'s self-insurance shall be primary and any insurance maintained by ADOT shall not contribute to, or be excess of, ________________________’s self-insurance.
As part of the SIR, The Company assumes responsibility to respond to any loss or risk relating to, arising from, or resulting from work performed by or on behalf of The Company within the ADOT right-of-way, to the extent that standard insurer policies would respond to an insurable loss.
Sincerely, jebryant Sticky Note ...in conjunction with third-party insurance jebryant Cross-Out jebryant Cross-Out jebryant Cross-Out mavandee Typewritten text Nutrien Ag Solutions, Inc.
mavandee Typewritten text Nutrien Ag Solutions, Inc.
mavandee Typewritten text Nutrien Ag Solutions, Inc.
mavandee Typewritten text Nutrien Ag Solutions, Inc.
mavandee Typewritten text mavandee Typewritten text Tim Smith Sr. Director Nutrien Ag Solutions, Inc.
mavandee Typewritten text 1/30/2025
Timothy Smith
Cindy Lewis GL Only
| ADOT Self-Insured Retention Letter Template.pdf (p.1) |
| Untitled.pdf (p.2-13) |
| ARIZONA DEPARTMENT OF TRANSPORTATION.pdf (p.1-2) |
| Endorsement - 2024-2025 - Auto - CA04441013 Waiver of Sub.pdf (p.3) |
| Endorsement - 2024-2025 - Auto - CA04491116 PNC.pdf (p.4) |
| Endorsement - 2024-2025 - Auto - XIC 411 1013 AI Automatic.pdf (p.5) |
| AUTOMATIC ADDITIONAL INSURED |
| Business Auto Coverage Form |
| Endorsement - 2024-2025 - GL - ADDITIONAL INSURED - DESIGNATED.pdf (p.6) |
| CG 20 26 12 19 -blanket |
| Endorsement - 2024-2025 - GL - Primary Insurance.pdf (p.10) |
| Endorsement - 2024-2025 - GL - WAIVER OF SUBROGATION.pdf (p.11) |
| CG 24 04 12 19 -blanket |
Endorsement - 2024-2025 - WC - Waiver of Subrogation .pdf (p.12)
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