EXHIBIT C - Insurance Carriers or Agents Acknowledgment Form.docx

EXHIBIT C

Insurance Carrier or Agent's Acknowledgement

Project Description: Contract No._______ – ________________________________________________________________

Your Insurance Carrier or Agent must complete the Form below. You must complete the Bidder's Acknowledgment. This Form shall be returned with the Bid submission.

Insurance Agent:

NAME OF FIRM

Address:

Email:

Fax No.: Phone No.:

Please review the SCWA insurance requirements contained in this Contract which are listed in the Instructions to Bidders. Confirm that you have read these specific requirements (pay particular attention to required limits) and that you are complying with them by placing a check in the appropriate box.

1. Automobile Liability

1. Material is Delivered by common carrier

1. General Liability

1. Excess Liability

1. Vendor’s Endorsement

1. Worker’s Compensation

1. Owners and Contractors Protection Liability (OCP)

1. Professional Liability Insurance

1. Builders Risk or Installation Coverage Floater

1. Crime

We have reviewed the insurance requirements set forth in the above proposed contract and are capable of providing such insurance to our insured in accordance with such requirements in the event the contract is awarded to our insured and provided our insured pays the appropriate premium.

Dated: Sign:

Authorized Insurance Agent or Representative

Print Name:

BIDDER'S ACKNOWLEDGMENT

The Bidder herein acknowledges that he/she has reviewed the insurance requirements within this Contract and has considered the costs, if any, of procuring the required insurance and will be able to supply the insurance required as per the Contract, if awarded to the Bidder, at no additional cost to the SCWA.

Sign:

Officer of Company Print Name

(Failure To Have This Form Properly Filled Out and Signed by The Insurance Agent as Well as The Bidder May Result in Your Bid Being Considered Non-Responsive.)

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