EXHIBIT F - CERTIFICATE OF INSURANCE.pdf
PDF 76 KB Posted
- Attached to
- 1411-26-R-RFQF-00001
- Solicitation number
- 3140004602
- Issued by
- Simpson County, Mississippi
About this file
This is a Certificate of Insurance document required for a Mississippi Community Development Block Grant Disaster Recovery (CDBG-DR) residential reconstruction and rehabilitation project. The certificate establishes mandatory insurance coverage requirements that contractors must maintain throughout project execution, with all policies issued by companies licensed in Mississippi and countersigned by Mississippi-licensed agents.
Contractors must provide comprehensive insurance coverage including Commercial General Liability with a $1,000,000 general aggregate and $500,000 per occurrence limit; Owners/Contractors Protective Liability with matching aggregate and per occurrence limits; Automobile Liability with a $500,000 combined single limit or alternatively $250,000 bodily injury per person, $500,000 per accident, and $100,000 property damage; Excess Liability/Umbrella coverage of $1,000,000 aggregate and per occurrence for projects exceeding $500,000; Workers' Compensation with Employers' Liability limits of $100,000 per accident, $500,000 disease policy limit, and $100,000 disease per employee; and Property Insurance (Builders' Risk or Installation Floater) equal to the value of work, except when the project involves demolition only. All policies must include an endorsement requiring the insurance company to provide thirty days written notice to the project owner prior to cancellation or non-renewal.
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Text version
CERTIFICATE OF INSURANCE
This certificate of insurance neither affirmatively nor negatively amends, extends, or alters the coverage afforded by the policies below.
INSURED: (Contractor’s Name & Address)
COMPANIES PROVIDING COVERAGE w/ MID Lic or NAIC #
A #
B #
PROJECT: (Number, Name & Location) C #
D #
E #
OWNER: Owner F #
G #
Companies above must be approved by the MS Ins Dept at https://www.mid.ms.gov (or most up-to-date link) per Code & WComp at http://www.mwcc.ms.gov/ (MID mod’d 041615)
Type Insurance Co Policy Number Policy Period Coverage and Minimum Amount
General Liability
Commercial General Liability
General Aggregate
$ 1,000,000
Products Comp/Ops (Aggregate
$ 1,000.000
Personal Injury (Per Occurrence)
$ 500,000
BI & PD (Per Occurrence)
$ 1,000,000
Fire Damage (Per Fire)
$ 50,000
Medical Expense (Per Person)
$ 5,000
Owners/Contractors Protective Liability
General Aggregate $ 1,000,000 Per Occurrence $ 500,000
Automobile Liability
Bodily Injury/Property Damage Combined Single Limit (Per Occurrence)
$ 500,000
OR
Bodily Injury (Per Person)
Bodily Injury (Per Accident)
Property Damage (Per Occurrence)
$ 250,000
$ 500,000
$ 100,000
* Excess Liability (Umbrella on projects over $500,000)
Aggregate $ 1,000,000 Per Occurrence $ 1,000,000
Workers’ Compensation (As required by Statute)
Employers’ Liability
Accident (Per Occurrence) $ 100,000
Disease-Policy Limit $ 500,000
Disease-Per Employee $ 100,000 Property Insurance (not required when project is demolition ONLY – required for ALL other projects including paving)
Builders’ Risk
OR
Installation Floater
Must be equal to Value of Work
Other
Certification: I certify that these policies (subject to their terms, conditions and exclusions) have been (1) issued to the Insured for the coverages and at least the amounts as indicated by companies licensed in Mississippi; (2) countersigned by a Mississippi Licensed Agent; and (3) endorsed to require the company to give thirty (30) days written notice to the Owner prior to cancellation or non-renewal of above.
Producing Agent: (Name, Address and Telephone)
(Signature) MID Lic # or countersign below
(Name and Title of Authorized Representative) (typed) Agent must be approved by the MS Ins Dept or countersign https://www.mid.ms.gov
Check if Mississippi Licensed Agent OR Countersign by Mississippi Licensed Agent MID Lic #
File details come from the government source that posted it. Updated .