ESBD_415083_1746037489453_04. Certificate of Insurance Form 1950.pdf

CERTIFICATE OF INSURANCE INSTRUCTIONS

BEFORE YOU SUBMIT THIS FORM, PLEASE ENSURE THE FOLLOWING:

You have the most current 1950 insurance form. You can go to the following TxDOT Internet site to download this form:

https://www.txdot.gov/content/gov-txdot-forms-adaptive/us/en/formsportal/htmlformsportal.html

You have entered the 9-digit Federal Employee Identification Number (EIN).

You have entered each authorized agent's complete address, telephone number, policy number with expiration dates, sign and date.

You have provided all requested information on the signed form, which may be emailed to the address below.

You are submitting the insurance form in connection with a purchase of services Purchase Order (PO).

Note: Each insurer must submit a separate form if more than one agent covers different types of insurance (one writes Workers' Compensation, but another writes Auto).

To avoid work suspension, an updated insurance form must be emailed to PRO_Insurance@txdot.gov one business day prior to the expiration date.

The named insured on the certificate and the name of the vendor, as it appears on the Purchase Order with TxDOT, must be the same. (Note: In a case where the Purchase Order is in the name of a party such as "John Jones dba Jones Construction Company," the named insured on the Certificate of Insurance may be "Jones Construction Company" and vice versa. The abbreviations of "Co." for "Company" and "Inc." for "Incorporated" are acceptable.). Liability limits listed are the minimum required; if higher limits are provided by the policy, enter the higher limits amount manually.

Binder numbers are not acceptable for policy numbers. Accord insurance forms are not acceptable.

Over-stamping and /or typed entries made on the certificate of insurance by the agency /insuring company are unacceptable if such entries change the provisions of the certificate in any manner.

Workers' Compensation: Amounts of coverage are minimums and notice provisions are statutory (Texas Labor Code Chapter 406 and Title 28 Texas Administrative Code Chapter 110).

The word STATUTORY, under limits of liability for Workers' Compensation, means that the benefits allowed under the Texas Workers' Compensation Law will be paid by the insurer.

Commercial General Liability Insurance includes: Not less than $600,000 each occurrence

MANUFACTURERS' AND CONTRACTORS' LIABILITY insurance is not an acceptable substitute for COMMERCIAL GENERAL LIABILITY insurance.

Commercial Automobile Insurance: The coverage amount may be shown as a minimum:

$600,000 combined single limit, or Bodily Injury $250,000 each person $500,000 each occurrence Property Damage $100,000 each occurrence

PERSONAL AUTOMOBILE LIABILITY Insurance is not an acceptable substitute for COMMERICAL AUTOMOBILE insurance.

The signature of the agent shall be original in ink. Stamped / typed / printed signatures are unacceptable.

This form may be reproduced.

The certificate of insurance, once on file with TxDOT, is good for subsequent purchase orders provided adequate coverage is still in effect. With an original on file, other TxDOT offices will accept copies.

EMAIL CERTIFICATES TO:

PRO_Insurance@TxDOT.gov

Form 1950 (Rev. 5/24) Instructions

Form 1950 (Rev. 5/24)

Previous versions of this form may not be used.

CERTIFICATE OF INSURANCE FOR SERVICES

Prior to the beginning of work, the vendor shall obtain the minimum insurance and endorsements specified. Agents must complete the form providing all requested information and submit by fax, U.S. mail or e-mail as requested by TxDOT. Copies of endorsements listed below are not required as attachments to this certificate. Only certificates of insurance published by TxDOT are acceptable as proof of insurance. Commercial carriers' certificates are unacceptable.

This certificate of insurance is provided for informational purposes only. This certificate does not confer any rights or obligations other than the rights and obligations conveyed by the policies referenced on this certificate. The terms of the referenced policies control over the terms of this certificate.

P.O. No.

Insured:

Street/Mailing Address:

City: Zip Code:

Phone Number:

State:

Federal EIN Number (9 digits):

Name: Email:Telephone:

Vendor Point of Contact (Employee Contact for the Insured Party, Not the Insurance Agent):

Workers' Compensation Insurance Coverage:

Endorsed with a Waiver of Subrogation in favor of TxDOT.

Address:

Carrier Phone Number:Carrier Name:

City: State: Zip:

Type of Insurance Policy Number Effective Date Expiration Date Enter Limits of Liability

Workers' Compensation

DO NOT COMPLETE THIS FORM UNLESS WORKERS' COMPENSATION IS ENDORSED WITH A WAIVER OF SUBROGATION IN FAVOR OF TxDOT.

Commercial General Liability Insurance:

Endorsed with TxDOT as Additional Insured and with a Waiver of Subrogation in favor of TxDOT.

Address:

Carrier Phone Number:Carrier Name:

City: State: Zip:

Type of Insurance Policy Number Effective Date Expiration Date Enter Limits of Liability

Commercial General Liability including:

Bodily Injury

Property Damage DO NOT COMPLETE THIS FORM UNLESS OTHER INSURANCE COVERAGE (i.e. GARAGE KEEPERS INSURANCE, OR OTHER) INCLUDES ADDITIONAL INSURED AND WAIVER OF SUBROGATION ENDORSMENTS IN FAVOR OF TxDOT.

Commercial Automobile Insurance:

Endorsed with TxDOT as Additional Insured and with a Waiver of Subrogation in favor of TxDOT.

Address:

Carrier Phone Number:Carrier Name:

City: State: Zip:

Type of Insurance Policy Number Effective Date Expiration Date Enter Limits of Liability

Commercial Automobile Bodily Injury Property Damage

DO NOT COMPLETE THIS FORM UNLESS COMMERCIAL AUTOMOBILE LIABILITY INSURANCE INCLUDES ADDITIONAL INSURED AND WAIVER OF SUBROGATION ENDORSMENTS IN FAVOR OF TxDOT.

Form 1950 (Rev. 5/24)

Other Insurance Coverage: i.e. Garage keepers insurance, or other.

Endorsed with TxDOT as Additional Insured and with a Waiver of Subrogation in favor of TxDOT.

Carrier Name: Carrier Phone Number:

Address: City: State: Zip:

Type of Insurance Policy Number Effective Date Expiration Date Enter Limits of Liability

DO NOT COMPLETE THIS FORM UNLESS OTHER INSURANCE COVERAGE (i.e. GARAGE KEEPERS INSURANCE, OR OTHER) INCLUDES ADDITIONAL INSURED AND WAIVER OF SUBROGATION ENDORSMENTS IN FAVOR OF TxDOT.

AGENT CERTIFICATION

THIS IS TO CERTIFY to TxDOT, acting on behalf of the State of Texas, that the insurance policies above are in full force and effect.

Authorized Agent's Phone Number

Area Code ( )

Name of Insurance Company:

Company Address:

Zip:State:City:

Original Signature of Authorized Agent

Date

Name of Authorized Agent:

Agent's Address:

Zip:State:City: