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- Form Instructions
- Certificate of Insurance

Texas Department of Transportation

Form Instructions
Certificate of Insurance

Instructions

BEFORE YOU SUBMIT THIS FORM, MAKE SURE:

You have the most current 1560-CS TxDOT form. Go to the following TxDOT Internet site: https://www.txdot.gov/business/peps/additional-requirements-contracting-peps/insurance-requirements.html then look for the Form 1560-CS.
You have entered the 11-digit Vendor Identification Number, which includes your nine-digit FEIN (Federal Employer Identification Number).
You have entered each authorized agent's complete address, telephone number, policy expiration dates, sign and date.
If more than one agent covers different types of insurance (one writes Workers' Compensation, but another writes Auto), both have issued the certificate in its entirety.
You have provided all requested information on the forms, which may be faxed but must be followed up with the originally signed forms to the address listed below.
The form is being submitted in connection with a professional services contract.
For construction and maintenance contracts, go to the following TxDOT Internet site: https://www.txdot.gov/business/road-bridge-maintenance/contract-letting/contractor-insurance-requirements.html then look for the Form 1560.

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

To avoid work suspension, an updated insurance form must reach the address listed below one business day prior to the expiration date. List the contractor's legal company name, including the DBA (doing business as) name as the insured. If a staff leasing service company is providing insurance, the staff leasing company name is shown first as the named insured and then in parenthesis identify the contractor/client company (i.e. XYZ Staff 4 U, Inc.-staff leasing service company (ABC Engineering, Inc.)). Show contact information (i.e. address, phone number, and etc.) for the insured/staff leasing service company in the appropriate spaces. Show the contact information (i.e. address, phone number, and etc.) for the contractor/client company in the appropriate spaces. The certificate of insurance, once on file with the department, is adequate for subsequent department contracts provided adequate coverage is still in effect. Do not refer to specific projects or contracts on this form. Over-stamping or over-typing entries on the certificate of insurance are not acceptable if they change the provisions of the certificate in any manner. Stamped, typed, or printed signatures are not acceptable. Pre-printed limits are the minimum required; if higher limits are provided by the policy, enter the higher limit amount and strike through or cross out the pre-printed limit. Binder numbers are not acceptable for policy numbers.

WORKERS' COMPENSATION INSURANCE:

The contractor is required to have Workers' Compensation Insurance if the contractor has any employees, including relatives. The word STATUTORY, under limits of liability, means that the insurer would pay benefits allowed under the Texas Workers' Compensation Law. GROUP HEALTH or ACCIDENT INSURANCE is not an acceptable substitute for Workers' Compensation.

COMMERCIAL GENERAL LIABILITY INSURANCE:

If coverages are specified separately, they must be at least these amounts:

Bodily Injury $500,000 each occurrence

Property Damage

$100,000 each occurrence

$100,000 for aggregate

MANUFACTURERS' or CONTRACTOR LIABILITY INSURANCE is not an acceptable substitute for Comprehensive General Liability Insurance or Commercial General Liability Insurance.

BUSINESS AUTOMOBILE POLICY:

The coverage amount for a Business Automobile Policy may be shown as a minimum of $600,000 Combined Single Limit by a typed or printed entry and deletion of the specific amounts listed for Bodily Injury and Property Damage. Personal Automobile Liability Insurance is not an acceptable substitute for a Business Automobile Policy.

MAIL CERTIFICATES TO:

Texas Department of Transportation

Contract Services Office

125 E. 11th St.

Austin, TX 78701-2483

512-416-4620 (V) 512-416-4621 (F)

CERTIFICATE OF INSURANCE

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.

Prior to the beginning of work, the Contractor shall obtain the minimum insurance and endorsements specified. Only the TxDOT certificate of insurance form is acceptable as proof of insurance for department contracts. Agents should complete the form providing all requested information then either fax or mail this form directly to the address listed on page one of this form. Copies of endorsements listed below are not required as attachments to this certificate.

Insured

Street/Mailing Address

City

State

Zip Code

Phone Number

Vendor ID Number (11 digits)

Contractor/Client (if applicable)

Street/Mailing Address

City

State

Zip Code

Phone Number

Vendor ID Number (11 digits)

Workers' Compensation Insurance Coverage:

Endorsed with a Waiver of Subrogation in favor of TxDOT.

Carrier Name

Carrier Phone Number

Address

City

State

Zip Code

Type of Insurance	Policy Number	Effective Date	Expiration Date	Limits of Liability
Workers' Compensation				Not Less Than: Statutory - Texas

Commercial General Liability Insurance:

Carrier Name

Carrier Phone Number

Address

City

State

Zip Code

Type of Insurance	Policy Number	Effective Date	Expiration Date	Limits of Liability
Commercial General Liability Insurance Bodily Injury Property Damage OR Commercial General Liability Insurance				Not Less Than: $500,000 each occurrence $100,000 each occurrence $100,000 for aggregate OR $600,000 combined single limit

Automobile Liability Insurance:

Carrier Name

Carrier Phone Number

Address

City

State

Zip Code

Type of Insurance	Policy Number	Effective Date	Expiration Date	Limits of Liability
Business Automobile Policy Bodily Injury Property Damage				Not Less Than: $250,000 each person $500,000 each occurrence $100,000 each occurrence

Authorized Agent's Email

Authorized Agent name, address and zip code

THIS IS TO CERTIFY to the Texas Department of Transportation acting on behalf of the State of Texas that the insurance policies named are in full force and effect. If this form is sent by facsimile machine (fax), the sender adopts the document received by TxDOT as a duplicate original and adopts the signature produced by the receiving fax machine as the sender's original signature.

The Texas Department of Transportation maintains the information collected through this form. With few exceptions, you are entitled on request to be informed about the information that we collect about you. Under sections 555.021 and 553.023 of the Texas Government Code, you also are entitled to receive and review the information. Under section 559.004 of the Government Code, you are also entitled to have us correct information about you that is incorrect.

Authorized Agent's Phone Number

Original Signature of Authorized Agent

Date