Certificate_of_Insurance_Sample.pdf
PDF 200 KB Posted
- Attached to
- SWW Fairgrounds Friendlyville Improvements
- Solicitation number
- 31-2607b
- Issued by
- Kittitas County, Washington
About this file
This is a Certificate of Insurance Sample document issued by Lewis County, Washington, Department of Central Services for the SWW Fairgrounds Friendlyville Improvements project located at 1909 S Gold Street, Centralia, Washington. The document establishes mandatory insurance coverage requirements that contractors must maintain throughout the contract period. A mandatory pre-bid walk is scheduled for June 15, 2026 at 1:00 p.m., with sealed bids due June 30, 2026 at 2:00 p.m. at the Historical Courthouse, 351 N.W. North Street, Chehalis, Washington. Bids will be opened publicly on June 30, 2026. Each bid must include 5% bid security and a signed non-collusion affidavit submitted electronically through the procurement portal.
The insurance requirements include General Liability with limits of $1,000,000 per occurrence and $1,000,000 aggregate for bodily injury and property damage; Automobile Liability with limits of $500,000 for bodily injury per person and per accident, and $500,000 for property damage; Excess Liability (Umbrella or Gap Layer form) with $1,000,000 combined limits; Workers Compensation and Employer Liability with statutory limits and $1,000,000 employer liability; and Builder's All Risk insurance in the amount of the contract price. Errors and Omissions (Professional Liability) coverage of $500,000 is required, with the option for Claims-Made Form or Occurrence Form with Extending Reporting Provisions available. Contractors must provide the certificate of insurance on the Lewis County form, and Lewis County must be included as an additional insured. The insurer must provide 45 days written notice of any policy cancellation. Contact Matt Patana, Specialist, at (360) 219-5134 or matt.patana@lewiscountywa.gov for additional information.
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Text version
EXHIBIT 1 -- INSURANCE COVERAGE REQUIREMENTS
INDICATES WHAT TYPE OF INSURANCE IS REQUIRED
TYPE OF INSURANCE
LIMITS OF LIABILITY
Each Occurrence
Aggregate
GENERAL LIABILITY
Comprehensive Form Bodily Injury $1,000,000 $1,000,000
Premises - Operations Property Damage $1,000,000 $1,000,000
Explosion & Collapse Hazard
Underground Hazard
OR
Products/Completed Operations Hazard
Contractual Insurance Bodily Injury and Property Damage Combined Single Limit
$1,000,000 $1,000,000
Broad Form Property Damage, Incl. Care, Custody Control
Independent Contractors
Personal Injury Personal Injury $1,000,000 $1,000,000
AUTOMOBILE LIABILITY
Comprehensive Form Bodily Injury (Each Person) $500,000
Owned Bodily Injury (Each Accident) $500,000
Hired Property Damage OR $500,000
Non-Owned Bodily Injury & Property Damage Combined Single Limit
$500,000
EXCESS LIABILITY (Over and above automobile and general liability
Umbrella Form Bodily Injury/Property Damage Combined
$1,000,000
OR
$1,000,000
Excess Liability Gap Layer $500,000 $500,000
WORKER'S COMPENSATION and Statutory
EMPLOYER LIABILITY $1,000,000
OTHER
Builder's All Risk Amount of Contract Price $________________
Errors & Omissions (Professional Liability) $500,000
Please indicate: Claims-Made Form:______________, Occurrence Form:____________, Extending Reporting Provisions Avail. ____________
The Contractor's insurance company must provide a certificate of insurance on the Lewis County form showing the above required coverage and modified to conform to the following endorsement. The following endorsement must also be signed by the insurer.
Authorized Signature
Titl
FORM
12.16.03
CS-FACIL
LEWIS COUNTY, WA
CERTIFICATE OF INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY.
THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURED (Legal name and business address) CERTIFICATE HOLDER:
LEWIS COUNTY, WASHINGTON
DEPT. OF CENTRAL SERVICES
CONTRACT
NUMBER
LEWIS COUNTY HISTORICAL COURTHOUSE DATE ISSUED:
351 N. W. NORTH STREET
CHEHALIS, WASHINGTON 98532
PROJECT DESCRIPTION / LOCATIONS / VEHICLES / RESTRICTIONS / SPECIAL ITEMS:
This is to certify that policies of Insurance listed below have been issued to the Insured named above for the policy period indicated.
CO
LTR
TYPE OF INSURANCE POLICY NUMBER Date Policy Effective
(MM/DD/YY)
Date Policy Expires
(MM/DD/YY)
ALL LIMITS IN THOUSANDS
GENERAL LIABILITY General Aggregate $
Commercial General Liability Products Comp/Ops Aggregate $ Claims Made Occurrence Personal & Advertising Injury $ Owner’s & Contractors Protection Each Occurrence $ Fire Damage (Any One Fire) $ Deductible $ Medical Expense (Any One Person) $
AUTOMOBILE LIABILITY
CSL $
Any Auto All Owned Autos Bodily Injury
(per person) $ Scheduled Autos Hired Autos Bodily Injury
(per accident) $ Non-Owned Autos Garage Liability Property
Damage $ Deductible $ EXCESS LIABILITY Each Occurrence
Aggregate
Other Than Umbrella Form
WORKERS
COMPENSATION
AND
EMPLOYER’S LIABILITY
STATUTORY
$ (Each Accident) $ (Disease Policy Limit) $ (Disease-Each Employee)
OTHER
ADDITIONAL PROVISIONS
LEWIS COUNTY is included as additional insured as related to the above-mentioned project.
Should any of the above described policies be cancelled before the expiration date thereof, the issuing Company must deliver or mail not less than 45 days written notice to the above Certificate Holder, per RCW 48.18.290
COMPANIES AFFORDING COVERAGE ISSUING COMPANY, AGENT OR REPRESENTATIVE
NOTE: Attach a separate sheet to this certificate giving all the company names and their percentage of coverage, if clarification is needed, NAME:
ADDRESS:
C om pa ny
L et te r
A
B
C
D
E
File details come from the government source that posted it. Updated .