City of Lakewood Insurance Requirements 2024.pdf

REQUIRED INSURANCE DOCUMENTS FOR CONTRACTORS/VENDORS

NOTE: THE FOLLOWING ARE EXAMPLES TO SHARE WITH YOUR INSURANCE CARRIER

Below is a list of sample insurance documents that Contractors/Vendors are required to provide prior to working on City property.

Certificate of Insurance (COI) Certificate Holder (bottom left of COI) to read as follows:

City of Lakewood 480 S. Allison Pkwy Lakewood, CO 80226

COI to list insurance as follows:

a. General Liability

b. Automobile Liability

c. Workers Compensation and Employers Liability

d. Professional Liability (professional services only) (when required) and Cyber

Liability (when required) NOTE: All policies should include an effective date and expiration date. Insurance policies may be with separate insurance companies and therefore a separate COI may be issued.

1. City of Lakewood to be named as an additional insured

2. Required forms:

Additional Insured for Ongoing Operations Endorsement Additional Insured for Completed Operations Endorsement Primary and Non-Contributory Endorsement Waiver of Subrogation Endorsement Schedule of Forms and Endorsements to include policy numbers

1. City of Lakewood to be named as an additional insured

2. Required forms:

Additional Insured Endorsement Primary and Non-Contributory Endorsement Waiver of Subrogation Endorsement Schedule of Forms and Endorsements to include policy numbers

Required documents for Workers’ Compensation and Employers Liability:

Waiver of Subrogation Endorsement to include policy numbers

OR

Notarized Workers’ Compensation Representation form (applicable if sole proprietor or fewer than 10 employees)

GENERAL LIABILITY

AUTO

WORKERS’ COMP

NOTE: Within the Description field please list the following. The City of Lakewood is an Additional Insured for Commercial General and Automobile Liability.

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SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED

REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSR

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS

AUTOSAUTOS

NON-OWNED

HIRED AUTOS

SCHEDULEDALL OWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

ER

OTH-

TORY LIMITS

WC STATU-

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

GENERAL LIABILITY

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY PRO-

JECT LOC

CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

1,000,000.00

2,000,000.00

1,000,000.00

Professional Liability (when required) Cyber Liability (when required)

$1,000,000.00

The City of Lakewood is included as an Additional Insured for General Liability and Automobile Liability.

City of Lakewood 480 South Allison Parkway Lakewood, CO 80226

GENERALLLIABILITY ENDORSEMENTS

POLICY NUMBER:

EFFECTIVE DATE:

ISSUE DATE:

IL T8 01 10 93

LISTING OF FORMS, ENDORSEMENTS AND SCHEDULE NUMBERS

THIS LISTING SHOWS THE NUMBER OF FORMS, SCHEDULES AND ENDORSEMENTS

BY LINE OF BUSINESS.

IL T0 02 11 89 COMMON POLICY DECLARATIONS

IL T8 01 10 93 FORMS, ENDORSEMENTS AND SCHEDULE NUMBERS

IL T0 05 06 10 COMMON POLICY CONDITIONS-WASHINGTON

IL T3 02 07 86 CALCULATION OF PREMIUM-COMPOSITE RATE(S)

IL T8 00 NAMED INSURED ENDORSEMENT

IL T8 03 DESIGNATED ENTITY - NOTICE OF

IL T3 20 05 19 NOTICE - CANC, NONRENEWAL PROVIDED BY US

GENERAL LIABILITY - CONTRACTORS

CG A0 13 11 03 (CGT001) COMMERCIAL GENERAL LIAB COV DEC

CG D4 69 02 19 TOT AGG LIMIT OTHER THAN PROJECTS

CG T0 34 02 19 TABLE OF CONTENTS - COM GEN LIAB COV

CG T1 00 02 19 COMMERCIAL GENERAL LIABILITY COV FORM

CG T8 00 ADDITIONAL INSURED

CG T8 01 ADDITIONAL INSURED

CG T8 02 ADDITIONAL INSURED

CG T8 04 ADDITIONAL INSURED (CONTRACTORS)

CG T8 05 ADDITIONAL INSURED (CONTRACTORS)

CG D3 25 01 04 ADDITIONAL INSURED - MORTGAGEE,ASSIGNEE

CG D3 61 03 05 ADD'L INSURED-OWNERS,LESSEES,CONTRACTORS

CG D3 73 11 05 ADD'L INSURED,OWNERS,LESSEES,CONTRACTORS

CG D4 11 04 08 ADDL INSD-DESIG PERSON OR ORGANIZATION

CG D4 26 02 19 OTHER INS-DESIG ADDL INS-PRIMARY

CG D6 61 10 12 ADDL INSD-ENG/ARCH/SURVEY NOT ENGAGED

CG 20 10 10 01 ADDL INSD-OWNER/LESSEE/CONTRACTOR B

CG 20 37 07 04 ADD INSURED-OWNRS,LESSEES,CONT COMPL OPS

GN 01 13 11 03 EMPLOYERS OVERHEAD LIABILITY

CG D2 03 12 97 AMEND-NON CUMULATION OF EACH OCC

CG D2 46 04 19 BLANKET AI-W/COMP OPS IF REQ BY CONTRACT

CG D2 47 04 19 SCHED AI W/COMP OPS IF REQ BY CONTRACT

CG D3 16 02 19 XTEND ENDORSEMENT FOR CONTRACTORS

CG D3 31 08 13 EXCL-ALL PROJECTS SUBJECT TO WRAP-UP

CG D8 23 02 19 ELECTRONIC DATA LIABILITY COVERAGE

CG D8 84 04 20 PRIMARY/NONCONTRIB-OTHER INS-ADDL INSD

CG T8 03 EXCLUSION - ALL HAZARDS

CG D2 93 11 03 EXCL-CONSTRUCT MANAGE ERRORS & OMISSIONS

CG D3 22 01 04 EXCLUSION-SUITS BY ONE NAMED INSURED

CG D5 46 10 11 EXCL - ARCHITECT/ENG/SURVEY PROF SERV

CG D6 18 10 11 EXCL-VIOLATION OF CONSUMER FIN PROT LAWS

CG D0 76 06 93 EXCLUSION-LEAD

CG D1 42 02 19 EXCLUSION-DISCRIMINATION

CG D2 40 09 15 EXCLUSION -SILICA OR SILICA-RELATED DUST

CG T3 20 02 19 EXCL-ALL POLLUTION INJURY OR DAMAGE

CG T5 69 02 19 EXCL ALL POLL INJURY/DAMAGE HOST FIRE EX

PAGE: 1 OF 2

GENERAL LIABILITY SCHEDULE OF FORMS AND ENDORSEMENTS

INCLUDE

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COMMERCIAL GENERAL LIABILITY

CG 2010 0413

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED - OWNERS, LESSEES OR

CONTRACTORS - SCHEDULED PERSON OR

ORGANIZATION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations

City of Lakewood All locations, as required by written contract

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by:

1. Your acts or omissions; or

2. The acts or omissions of those acting on your behalf;

in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above.

However:

1. The insurance afforded to such additional insured only applies to the extent permitted by law; and

2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply:

This insurance does not apply to "bodily injury" or "property damage" occurring after:

1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s) at the location of the covered operations has been completed; or

2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project.

CG 2010 0413 © Insurance Services Office, Inc., 2012 Page 1 of 2

GENERAL LIABILITY ENDORSEMENT_ ONGOING OPERATIONS

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C. With respect to the insurance afforded to these additional insureds, the following is added to Section Ill - Limits Of Insurance:

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable Limits of Insurance shown in the Declarations;

whichever is less.

This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.

Page 2 of2 © Insurance Services Office, Inc., 2012 CG 2010 0413

CG 20 37 12 19

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED - OWNERS, LESSEES OR

CONTRACTORS - COMPLETED OPERATIONS

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

SCHEDULE

Name Of Additional Insured Person(s) Or Organization(s) Location And Description Of Completed Operations

All locations, as required per written contract

City of Lakewood

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location designated and described in the Schedule of this endorsement performed for that additional insured and included in the "products-completed operations hazard".

However:

1. The insurance afforded to such additional insured only applies to the extent permitted by law; and

2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.

B. With respect to the insurance afforded to these additional insureds, the following is added to Section Ill - Limits Of Insurance:

If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance:

1. Required by the contract or agreement; or

2. Available under the applicable Limits of

Insurance shown in the Declarations;

whichever is less.

This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.

CG 20 37 12 19 © Insurance Services Office, Inc., 2012 Page 1 of 1

GENERAL LIABILITY ENDORSEMENT_COMPLETED OPERATIONS

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CG 20 01 04 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 20 01 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1

PRIMARY AND NONCONTRIBUTORY –

OTHER INSURANCE CONDITION

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART

The following is added to the Other Insurance Condition and supersedes any provision to the contrary:

Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that:

(1) The additional insured is a Named Insured under such other insurance; and

(2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured.

GENERAL LIABILITY_ PRIMARY AND NON-CONTRIBUTORY ENDORSEMENT

CG 24 04 10 93

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992 Page 1 of 1

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

SCHEDULE

Name of Person or Organization:

(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.)

The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV – COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following:

We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard".

This waiver applies only to the person or organization shown in the Schedule above.

GENERAL LIABILITY_WAIVER OF SUBROGATION ENDORSEMENT

City of Lakewood

AUTOMOBILE LIABLITY ENDORSEMENTS

POLICY NUMBER: INCLUDE

EFFECTIVE DATE:

ISSUE DATE:

LISTING OF FORMS, ENDORSEMENTS AND SCHEDULE NUMBERS

THIS LISTING SHOWS THE NUMBER OF FORMS, SCHEDULES AND ENDORSEMENTS

BY LINE OF BUSINESS

IL TO 02 11 89

IL TS 01 01 01

IL TO 01 01 07

IL T3 02 07 86

IL TS 25

COMMERCIAL AUTO

CA TO 01 02 15

CA TO 03 02 15

CA TO 30 02 16

CA TO 31 02 15

CA 00 01 10 13

CA 01 59 05 17

CA 20 55 10 13

CA 21 62 11 18

CA 22 44 11 16

CA 31 06 07 19

CA 99 03 10 13

CA T4 52 02 16

CA T4 59 02 15

CA T4 74 02 16

CA T3 40 02 15

CA T3 53 02 15

CA TS 01 10 20

INTERLINE ENDORSEMENTS

IL T4 27 06 19

IL TS 00 10 20

IL T4 12 03 15

IL 00 21 09 08

IL 02 66 09 08

IL TS 01 01 01

COMMON POLICY DECLARATIONS

FORMS ENDORSEMENTS AND SCHEDULE NUMBERS

COMMON POLICY CONDITIONS

CALCULATION OF PREMIUM - COMPOSITE RATES

CALCULATION OF PREMIUM - COMPOSITE RATES

BA- COVERAGE PART DECS (ITEMS 1 & 2)

BUS AUTO COV PART DECLARATIONS-4&5

BUSINESS AUTO/MC COV PART-UM SUPPL SCHD

TABLE OF CONTENTS-BUSINESS AUTO COV FORM

BUSINESS AUTO COVERAGE FORM

UTAH CHANGES

FELLOW EMPLOYEE COVERAGE

UTAH UNINSURED MOTORISTS COVERAGE

UTAH PERSONAL INJURY PROTECTION

UTAH UNDERINSURED MOTORISTS COVERAGE

AUTO MEDICAL PAYMENTS COVERAGE

SHORT TERM HIRED AUTO - ADDITIONAL INSURED AND LOSS

PAYEE

AMENDMENT OF EMPLOYEE DEFINITION

BLANKET ADDITIONAL INSURED - PRIMARY AND

NON-CONTRIBUTORY WITH OTHER INSURANCE

BLANKET WAIVER OF SUBROGATION

BUSINESS AUTO EXTENSION ENDORSEMENT

NAMED INSURED

ADDITIONAL BENEFITS

GENERAL PURPOSE ENDORSEMENT

AMNDT COMMON POLICY COND-PROHIBITED COVG

NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT (BROAD

FORM)

UTAH CHANGES - CANCELLATION AND NONRENEWAL

PAGE: 1 OF 1

AUTO SCHEDULE OF FORMS AND ENDORSEMENTS

COMMERCIAL AUTO

CA20481013

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

DESIGNATED INSURED FOR

COVERED AUTOS LIABILITY COVERAGE

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSI NESS AUTO COVERAGE FORM

MOTOR CARRI ER COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement.

This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form.

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Named Insured:

Endorsement Effective Date:

Name Of Person( s) Or Organization( s):

City of Lakewood

SCHEDULE

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A 1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form.

CA20481013 © Insurance Services Office, Inc., 2011

Insured Full Copy

AUTOMOBILE LIABILITY_ADDITIONAL INSURED ENDORSEMENT

CA 04 49 11 16

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CA 04 49 11 16 © Insurance Services Office, Inc., 2016 Page 1 of 1

PRIMARY AND NONCONTRIBUTORY –

OTHER INSURANCE CONDITION

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.

A. The following is added to the Other Insurance Condition in the Business Auto Coverage Form and the Other Insurance – Primary And Excess Insurance Provisions in the Motor Carrier Coverage Form and supersedes any provision to the contrary:

This Coverage Form's Covered Autos Liability Coverage is primary to and will not seek contribution from any other insurance available to an "insured" under your policy provided that:

1. Such "insured" is a Named Insured under such other insurance; and

2. You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to such "insured".

B. The following is added to the Other Insurance Condition in the Auto Dealers Coverage Form and supersedes any provision to the contrary:

This Coverage Form's Covered Autos Liability Coverage and General Liability Coverages are primary to and will not seek contribution from any other insurance available to an "insured" under your policy provided that:

1. Such "insured" is a Named Insured under such other insurance; and

2. You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to such "insured".

AUTOMOBILE LIABILITY_ PRIMARY AND NON-CONTRIBUTORY ENDORSEMENT

CA 04 44 10 13

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

WAIVER OF TRANSFER OF RIGHTS OF RECOVERY

AGAINST OTHERS TO US (WAIVER OF SUBROGATION)

This endorsement modifies insurance provided under the following:

AUTO DEALERS COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

MOTOR CARRIER COVERAGE FORM

With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement.

This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below.

Named Insured:

Endorsement Effective Date:

SCHEDULE

Name(s) Of Person(s) Or Organization(s):

Information required to complete this Schedule, if not shown above, will be shown in the Declarations.

The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident" or the "loss" under a contract with that person or organization.

CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Page 1 of 1

City of Lakewood

AUTOMOBILE LIABILITY_WAIVER OF SUBROGATION ENDORSEMENT

WORKERS' COMPENSATION ENDORSEMENT

WC124 (4-84) Page 1 of 1 WC 00 03 13 Copyright 1983 National Council on Compensation Insurance, Inc. Uniform FormsTM

WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13

(Ed. 04-84)

WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT

We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.)

This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.

Schedule

City of Lakewood

This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.

(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)

Endorsement Effective Policy No. Endorsement No.

Insured Premium $

Insurance Company Countersigned by

INCLUDE

WORKERS' COMPENSATION_WAIVER OF SUBROGATION ENDORSEMENT

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City of Lakewood Property & Purchasing Services 480 South Allison Parkway Lakewood Colorado 80226-3127 303-987-7670

303-987-7678 FAX

WORKERS’ COMPENSATION REPRESENTATION

I/we, the undersigned, doing business as ____________________________________ (Business name)

(the “Business”), do hereby state that the Business has no employees subject to the Workers’ Compensation Act of the State of Colorado. Every person, other than a bone fide subcontractor of the Business, who may perform any work or services on behalf of the Business in fulfillment of the contract, agreement or purchase order to which this form is attached must sign below.

Signature Date

Sworn before me this _________ day of ________________________, 20__.

By _____________________________________________________________

Notary Public _______________________________

My commission expires: _________________________ Seal

Signature Date

Sworn before me this _________ day of ________________________ 20__.

By _____________________________________________________________

Notary Public _______________________________

My commission expires: _________________________ Seal

REQUIRED IF SOLE PROPRIETOR OR FEWER THAN 10 EMPLOYEESEES

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