CTR066856 ADOT Contract Insurance Checklist.pdf
PDF 459 KB Posted
- Attached to
- Master Agreement AZ|CTR066856
- Contract number
- CTR066856
- Issued by
- Arizona
About this file
This document is an Arizona Department of Transportation (ADOT) State and Risk Management Contract Insurance Checklist, revised in August 2021, outlining comprehensive insurance requirements for vendors or contractors doing business with ADOT. The document is specifically designed to guide applicants through the process of submitting appropriate insurance documentation, with a focus on ensuring proper coverage and endorsements for various types of liability.
The checklist details required insurance types including Commercial General Liability, Auto Liability, Worker's Compensation, Professional Liability, Contractor's Pollution Liability, and other miscellaneous insurance categories such as Technology Errors and Omissions. While no specific contract details, goods, or services are outlined in this document, it mandates specific endorsements like Additional Insured status, Waiver of Subrogation, and Primary and Noncontributory coverage. The document emphasizes that failure to follow the specified steps will cause delays in the procurement process, and all documentation must be submitted to the ADOT Procurement Officer for review. The form was signed by a vendor/contractor representative on 09/19/2023, indicating it is part of an active procurement or contract process.
View the file
Other files
Show all 14
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
ADOT STATE AND RIKS MANAGEMENT (Rev. 08/2021)
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 require items
• Initial below each item submitted; print your name and 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
Certificate of Insurance
Applicant Initials
*Certificate Holder should read: The State of Arizona or ADOT, 1324 N. 22nd Ave., Phoenix AZ 85009
COMMERCIAL GENERAL LIABILITY
☒ Additional Insured Endorsement Form for Ongoing Operations Applicant Initials ☒ Additional Insured Endorsement Form for Completed Operations Applicant Initials ☒ Waiver of Subrogation Endorsement Form Applicant Initials ☒ Primary and Noncontributory Endorsement Form Applicant Initials
AUTO LIABILITY
☒ Additional Insured Endorsement Form Applicant Initials
☒ Coverage provided for hazardous material transportation (if applicable) Applicant Initials
WORKER’S COMPENSTATION
PROFESSIONAL LIABILITY
☐ Policy limit meets contract requirements Applicant Initials
CONTRACTOR’S POLLUTION LIABILITY
☐ 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
PROFESSIONAL ENVIRONMENTAL LIABILITY
☐ Policy limit meets contract requirements Applicant Initials
OTHER REQUIRED INSURANCE
☒ Technology Errors and Omissions Applicant Initials ☐ Network Security (Cyber) and Privacy Liability Applicant Initials ☐ Media Liability Coverage
Applicant Initials
(CONTINUES NEXT PAGE)
RC
RC
RC
RC
RC
RC
RC
RC
RC
RC
ADOT STATE AND RIKS MANAGEMENT (Rev. 08/2021)
☐ Commercial Crime Policy or Blanket Fidelity Bond Applicant Initials ☐ Aviation/Aircraft Liability Applicant Initials ☐ Installation Floater Applicant Initials ☐ Builder’s Risk Applicant Initials ☐ Other: Applicant Initials
Vendor/Contractor Representative Signature: Date: 09/19/2023
File details come from the government source that posted it. Updated .