Insurance_(2).docx
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- Kittitas County, Washington
About this file
The document is an insurance coverage requirements exhibit from Lewis County, Washington, specifically for a project related to a Juvenile Complex irrigation system design and installation. The exhibit outlines comprehensive insurance requirements for a contractor, detailing mandatory coverage types including General Liability, Automobile Liability, Excess Liability, Worker's Compensation, and Errors & Omissions insurance. The insurance requirements specify specific liability limits for each coverage type, with general and automobile liability set at $1,000,000 per occurrence and $2,000,000 in aggregate, and worker's compensation set at statutory levels with additional employer liability coverage of $1,000,000.
The insurance certificate indicates that Lewis County must be listed as an additional insured, and the insurance provider must deliver a 45-day written notice before policy cancellation. The document is part of a contract requirement for the Juvenile Complex irrigation system project in Chehalis, Washington, and serves as a critical risk management tool to protect the county's interests during the design and installation process. The insurance requirements demonstrate the county's rigorous approach to contractor selection and risk mitigation, ensuring comprehensive coverage across multiple potential liability scenarios for the proposed infrastructure project.
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Text version
EXHIBIT C -- INSURANCE COVERAGE REQUIREMENTS
INDICATES WHAT TYPE OF INSURANCE IS REQUIRED
TYPE OF INSURANCE
LIMITS OF LIABILITY
| Each Occurrence |
| Aggregate |
GENERAL LIABILITY
| Comprehensive Form |
| Bodily Injury |
| $1,000,000 |
| $2,000,000 |
| Premises - Operations |
| Property Damage |
| $1,000,000 |
| $2,000,000 |
Explosion & Collapse Hazard
Underground Hazard
OR
Products/Completed Operations Hazard
| Contractual Insurance |
| Bodily Injury and Property Damage Combined Single Limit |
| $1,000,000 |
| $2,000,000 |
Broad Form Property Damage, Incl. Care, Custody Control
Independent Contractors
| Personal Injury |
| Personal Injury |
| $1,000,000 |
| $2,000,000 |
AUTOMOBILE LIABILITY
| Comprehensive Form |
| Bodily Injury (Each Person) |
| $1,000,000 |
| Owned |
| Bodily Injury (Each Accident) |
| $1,000,000 |
| Hired |
| Property Damage OR |
| $1,000,000 |
| Non-Owned |
| Bodily Injury & Property Damage |
Combined Single Limit $1,000,000
EXCESS LIABILITY (Over and above automobile and general liability
| Umbrella Form |
| Bodily Injury/Property Damage Combined |
| $1,000,000 |
OR
$1,000,000
Excess Liability Gap Layer
| $1,000,000 |
| $1,000,000 |
| WORKER'S COMPENSATION and |
| Statutory |
EMPLOYER LIABILITY
$1,000,000
OTHER
| Builder's All Risk | |
| Amount of Contract Price | |
| $________________ |
| Errors & Omissions (Professional Liability) |
| $1,000,000 $2,000,000 |
| Please indicate: Claims-Made Form:______________, Occurrence Form:____________, |
| Extending Reporting Provisions Avail. ____________ |
The Contractor's insurance company must provide a certificate of insurance on acceptable form showing the above required coverage and modified to conform to the following endorsement. The following endorsement must also be signed by the insurer.
FORM
12.16.03
CS-FACIL
LEWIS COUNTY, WA
CERTIFICATE OF INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
| INSURED (Legal name and business address) |
| CERTIFICATE HOLDER: |
LEWIS COUNTY, WASHINGTON
DEPT. OF CENTRAL SERVICES
CONTRACT NUMBER
| LEWIS COUNTY HISTORICAL COURTHOUSE |
| DATE ISSUED: |
351 N. W. NORTH STREET
CHEHALIS, WASHINGTON 98532
PROJECT DESCRIPTION / LOCATIONS / VEHICLES / RESTRICTIONS / SPECIAL ITEMS:
This is to certify that policies of Insurance listed below have been issued to the Insured named above for the policy period indicated.
CO
LTR
| TYPE OF INSURANCE |
| POLICY NUMBER |
| Date Policy Effective |
(MM/DD/YY)
Date Policy Expires
(MM/DD/YY)
ALL LIMITS IN THOUSANDS
GENERAL LIABILITY
| General Aggregate |
| $ |
Commercial General Liability
| Products Comp/Ops Aggregate |
| $ |
Claims Made
Occurrence
| Personal & Advertising Injury |
| $ |
Owner’s & Contractors Protection
| Each Occurrence |
| $ |
| Fire Damage (Any One Fire) |
| $ |
Deductible $
| Medical Expense (Any One Person) |
| $ |
AUTOMOBILE LIABILITY
| CSL |
| $ |
Any Auto
All Owned Autos
| Bodily Injury (per person) |
| $ |
Scheduled Autos
Hired Autos
| Bodily Injury (per accident) |
| $ |
Non-Owned Autos
Garage Liability
| Property Damage |
| $ |
Deductible $
EXCESS LIABILITY
Each Occurrence
Aggregate
Other Than Umbrella Form
WORKERS COMPENSATION
AND
EMPLOYER’S LIABILITY
STATUTORY
$ (Each Accident)
$ (Disease Policy Limit)
$ (Disease-Each Employee)
OTHER
ADDITIONAL PROVISIONS
LEWIS COUNTY is included as additional insured as related to the above-mentioned project.
Should any of the above described policies be cancelled before the expiration date thereof, the issuing Company must deliver or mail not less than 45 days written notice to the above Certificate Holder, per RCW 48.18.290
| COMPANIES AFFORDING COVERAGE |
| ISSUING COMPANY, AGENT OR REPRESENTATIVE |
| NOTE: | Attach a separate sheet to this certificate giving |
| all the company names and their percentage of coverage, if | clarification is needed, |
NAME:
ADDRESS:
Company Letter Authorized Signature
Title
Signature Date
Signee Name
Telephone No.
A
B
C
D
E image1.png
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