CTR061345 Certificate of Insurance.pdf
PDF 4 MB Posted
- Attached to
- Master Agreement AZ|CTR061345
- Contract number
- CTR061345
- Issued by
- Arizona
About this file
This document is a Certificate of Liability Insurance issued by Marsh USA Inc. for NEC Corporation of America, covering multiple insurance policies with Mitsui Sumitomo Insurance Co. of America and Mitsui Sumitomo Insurance USA, Inc. The certificate is specifically related to work performed for the Arizona Department of Transportation (ADOT) under Solicitation Number ADOT14-060962, and includes various insurance endorsements and coverage types such as Commercial General Liability, Auto Liability, Workers' Compensation, and additional specialized coverages like Technology Errors and Omissions and Network Security/Cyber Liability.
The contract appears to be for a Facial Recognition Software System, with insurance coverage limits ranging from $1,000,000 to $5,000,000 across different policy types. The policy period runs from 04/01/2022 to 04/01/2023, with comprehensive coverage including additional insured status for the State of Arizona, waiver of subrogation, and primary non-contributory insurance provisions. The insurance package includes endorsements for ongoing and completed operations, blanket coverage as required by written contract, and various protective clauses covering potential damages, losses, and liability scenarios across multiple operational contexts.
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Text version
B
212-948-0770
1,000,000
04/01/2023
PKG3101192
X
CHI-009302561-21
1,000,000
5,000,000
WCP9115733 - CA
X
X
22551
5,000,000
N
X
COMP/COLL DED.
04/01/2022
04/01/2023
04/01/2023
Chicago.CertRequest@marsh.com
BVR8304045
A
2,000,000
1,000,000
X
Mitsui Sumitomo Insurance USA, Inc.
1,000,000
X
Professioanl Liability) where required by written contract. Waiver of subrogation is applicable where required by written contract and subject to policy terms and conditions. This insurance is primary and non-
1,000
03/30/2022
04/01/2022
RE: For any and all work performed on or behalf of ADOT and the State of Arizona. Solicitation Number: ADOT14-060962. Description: Facial Recognition Software System.
X
04/01/2022
Phoenix, AZ 85007
State of Arizona - ADOT Procurement
The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees is/are included as additional insured (except workers’ compensation & contributory over any existing insurance and limited to liability arising out of the operations of the named insured subject to policy terms and conditions.
A
CN101822795-Std-Cyber-21-23
10,000
04/01/2023
1,000,000
UMB5000517
A
2,000,000
20362
1,000,000
1,000,000
WCP9115732
540 W. MADISON
MARSH USA INC.
X
CHICAGO, IL 60661
3929 W. John Carpenter Freeway NEC Corporation of America
Irving, TX 75063
X
04/01/2022
1739 West Jackson Street, MD100P
04/01/2022
A
Marsh | U.S. Operations
04/01/2023
866-966-4664
Mitsui Sumitomo Insurance Co. Of America a8812 Accepted
Data Breach Response Limit: $5,000,000; SIR $250,000
Privacy & Cyber Security Limit: $5,000,000; SIR $250,000
Effective Date: 07/31/2021
Carrier: Indian Harbor Insurance Company
Errors & Omissions Technology Limit: $5,000,000; SIR $250,000
Expiration Date: 07/31/2022
Policy Number: MTP9031210 07
Cyber Tech E&O
MARSH USA INC.
3929 W. John Carpenter Freeway NEC Corporation of America
Irving, TX 75063
ADOT SAFETY AND RISK MANAGEMENT 08/11/2020
ADOT CONTRACT INSURANCE CHECKLIST
INSTRUCTIONS/TIPS/INFORMATION FOR THE INSURANCE PROCESS
● Please provide this Checklist and the ADOT contract requirements to your insurance broker or agent as soon as possible
- a checked box indicates required items
● Initial below for each item submitted; print your name and the date at the bottom of the page
● Send this completed checklist, and your Certificate of Insurance with required endorsements, by email to your Procurement Officer
● Your insurance will be reviewed for compliance only when this completed checklist is submitted with attachments
● Failure to follow these steps will cause a delay
☒Certificate of Insurance Applicant Initials___ELR___
* Certificate Holder should read: The State of Arizona or ADOT, 1324 N. 22nd Ave., Phoenix, AZ 85009
☒Additional Insured Endorsement Form for Ongoing Operations Applicant Initials __ELR
☒Additional Insured Endorsement Form for Completed Operations Applicant Initials __ELR
☒Waiver of Subrogation Endorsement Form Applicant Initials __ELR
☒Primary and Noncontributory Endorsement Form Applicant Initials __ELR
☒Additional Insured Endorsement Form Applicant Initials __ELR
☒Waiver of Subrogation Endorsement Form Applicant Initials _ELR
Coverage provided for hazardous materials transportation (if applicable) Applicant Initials ___
☒Waiver of Subrogation Endorsement Form Applicant Initials _ELR
Policy limit meets contract requirements Applicant Initials ___
Includes coverage for pollution losses arising out of completed operations Applicant Initials ___
Additional Insured Endorsement Form Applicant Initials ___
Waiver of Subrogation Endorsement Form Applicant Initials ___
Primary and Noncontributory Endorsement Form Applicant Initials ___
(CONTINUES NEXT PAGE)
CCERTIFICATE OF INSURANCE
COMMERCIAL GENERAL LIABILITY
AUTO LIABILITY
WORKER’S COMPENSATION
PROFESSIONAL LIABILITY
CONTRACTOR’S POLLUTION LIABILITY
DocuSign Envelope ID: 99F8E90C-21FD-4708-9BEB-A89E1AE2FE0D
ADOT SAFETY AND RISK MANAGEMENT 08/11/2020
Policy limit meets contract requirements Applicant Initials ___
☒Technology Errors and omissions Applicant Initials _ELR
☒Network Security (Cyber) and Privacy Liability Applicant Initials __ELR
Media Liability Coverage Applicant Initials ___
☒Commercial Crime Policy or Blanket Fidelity Bond Applicant Initials __ELR
Aviation/Aircraft Liability Applicant Initials ___
Installation Floater Applicant Initials ___
Builder’s Risk Applicant Initials ___
Other __________________________________________________________________ Applicant Initials ___
Vendor / Contractor Representative Signature:___________________________ Date: __________________
PROFESSIONAL ENVIRONMENTAL LIABILITY
OTHER REQUIRED INSURANCE
DocuSign Envelope ID: 99F8E90C-21FD-4708-9BEB-A89E1AE2FE0D
7/29/2022
| CTR061345 Certificate of Insurance |
| Contracts Insurance Requirements Checklist (7.28.22).docx |
| * Certificate Holder should read: The State of Arizona or ADOT, 1324 N. 22nd Ave., Phoenix, AZ 85009 |
File details come from the government source that posted it. Updated .