Sample_Insurance_Template.pdf
PDF 896 KB Posted
- Solicitation number
- 0000037829
- Issued by
- Fresno County, Kings County, Madera County, Merced County, Monterey County, San Benito County, Santa Clara County, Santa Cruz County, Fresno City, Kingsburg City, Monterey Park City, Madera City, Madera Acres CDP, Madera Ranchos CDP, Corte Madera Town, Merced City, University of California-Merced CDP, Monterey City, Kings Beach CDP, Santa Clara City, Santa Cruz City, Monterey Park Tract CDP, California
About this file
This is a Certificate of Insurance template issued by the State of California Department of Veterans Affairs for Solicitation Number 26HS0006, related to Fire Protection System Services at the California Central Coast Veterans Cemetery. The solicitation is restricted to certified Small Business and Micro Business firms only. The project involves fire protection systems services, specifically sprinklers and hydrants, with detailed requirements outlined in the Scope of Work (Exhibit A). A mandatory walkthrough is required for all interested bidders, and all questions must be submitted via email according to the timeline specified in the Solicitation for Quote (SFQ) Letter.
The certificate of insurance template requires contractors to maintain multiple types of coverage, including general liability with stated limits for general aggregate, commercial general liability products, and per-occurrence claims; automobile liability covering any auto, hired autos, and non-owned autos with combined single limits and bodily injury/property damage coverage; and workers' compensation with statutory limits. The State of California, its officers, agents, employees, and servants must be named as additional insureds with respect to work performed for the state. Insurance carriers must provide 30 days' written notice of cancellation to the State of California at the specified address in Sacramento, California.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 26HS0006_-_CCC.pdf | ||
| 26HS0006_-_Quote_Rate_Sheet.xlsx | XLSX spreadsheet | |
| 26HS0006_-_Exhibits_A-D.pdf | ||
| 26HS0006_-_STD_204.pdf | ||
| 26HS0006_-_STD_205.pdf | ||
| 26HS0006_-_Bidder_Declaration.pdf | ||
| 26HS0006_-_CUF_Form.pdf | ||
| 26HS0006_-_DVBE_Declarations.pdf | ||
| 26HS0006_-_Sample_STD_213.pdf | ||
| 26HS0006_-_Darfur.pdf | ||
| DVBEProgramRequirements_-_Contracts_-_Revision_Date_012022.pdf | ||
| 26HS0006_-_SFQ_(SB)_Letter.pdf |
Show all 12
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Text version
State of California Solicitation Number: 26HS0006 Department of Veterans Affairs
CERTIFICATES OF INSURANCE
DATE (MM/DD/YY) / /
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
NO RIGHT UPON THE CERTIFICATE HOLDER. THIS COVERAGE DOES NOT AMEND,
EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANY
A
INSURED COMPANY
B
COMPANY
C
COMPANY
D
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDIDTION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE POLlCY NUMBER
POLICY
EFFECTIVE
DATE
(MM/DD/YY)
POLICY
EXPIRATION
DATE
(MM/DD/YY)
LIMITS
GENERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS - COMP/OP AGG $
CLAIMS
MADE
OCCUR PERSONAL & ADV INJURY $
OWNER AND CONTRACTOR’S PROT EACH OCCURRENCE $
FIRE DAMAGE (Any one fire) $
MED EXP (Any one person) $
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO
ALL OWNED AUTOS BODILY INJURY (Per person) $
SCHEDULED AUTOS
HIRED AUTOS BODILY INJURY (Per accident) $
NON-OWNED AUTOS
PROPERTY DAMAGE $
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EXCESS LIABILITY
EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
WORKERS COMPENSATION AND
EMPLOYERS’ LIABILITY
STATUTORY LIMITS
THE PROPRIETOR/ EACH ACCIDENT $
PARTNERS/ EXECUTIVE
OFFICERS ARE:
INCL DISEASE - POLICY LIMIT $
EXCL DISEASE - EACH EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
The State of California, its officers, agents, employees and servants are hereby named as additional insured but only with respect to work performed for the State of California.
CERTIFICATE HOLDER
ATTENTION:
BID NO.
STATE OF CALIFORNIA
P.O. Box 4038 Sacramento, CA 95812-4038
CANCELLATION
SHOULD ANY OF THE ABOVE-DESCRIBED POLICIES BE CANCELED BEFORE THE EXPIRATION DATE
THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE
NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR
RESPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
I hereby certify under penalty of perjury that the foregoing is true and correct.
X
SAMPLE
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