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CERTIFICATE OF INSURANCE - SUPPORT SERVICES DIVISION

1560-RFC.pdf

Step 1 of 8

Primary Information

Agents should complete the form providing all requested information then return to the TxDOT office awarding this contract. Copies of endorsements listed below are not required as attachments to this certificate.

This certificate is issued as a matter of information only and confers no rights upon the certificate holder. 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 policies referenced in this certificate control over the terms of the certificate.

PROJECT ID:

City

County

Description of Project

CONTRACT AMOUNT $

INSURED / CONTRACTOR’S NAME (to include DBA /Ltd.,/Inc, etc. and/or Staff Leasing Company for WC only)

Street / Mailing Address

City / State / Zip

Area Code

Phone

Area Code

FAX

Step 2 of 8

Worker's Compensation Insurance Coverage: Endorsed with a Waiver of Subrogation in favor of TxDOT

Carrier Name:

Area Code/Phone Number

Address

City / State / Zip

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

Step 3 of 8

Commercial General Liability Insurance: Endorsed with TxDOT as Additional Insured and with a Waiver of Subrogation in Favor of TxDOT.

Carrier Name:

Area Code/Phone Number

Address

City / State / Zip

Type of Insurance	Policy Number	Effective Date	Expiration Date	Limits of Liability
Commercial General Liability Insurance				Not Less Than:$600,000 combined single limit

Step 4 of 8

Business Automobile Policy: Endorsed with TxDOT as Additional Insured and with a Waiver of Subrogation in Favor of TxDOT.

Carrier Name:

Area Code/Phone Number

Address

City / State / Zip

Type of Insurance	Policy Number	Effective Date	Expiration Date	Limits of Liability
Business Automobile Policy				Not Less Than:$600,000 combined single limit

Step 5 of 8

Builder's Risk Insurance: With TxDOT named under the Loss Payable clause

Builders risk coverage is required at 100% for all contracts $100,000.00 and more.

Carrier Name:

Area Code/Phone Number

Address

City / State / Zip

Type of Insurance	Policy Number	Effective Date	Expiration Date	Limits of Liability
Builder’s Risk Insurance				100% of contract Amount

Should any of the above described policies be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions.

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.

Step 6 of 8

Authorized Agent Info

Authorized Agent’s Company Name:

Dated

Address

City

State

Zip

Area Code

Phone

Area Code

FAX

Print Agent’s Name

Authorized Agent’s Original Signature

A Rubber Stamp Signature is not acceptable

Step 7 of 8

NOTES OF AGENTS:

Agents must provide all requested information then either fax or mail this form directly to the TxDOT office requesting this insurance coverage for this contract. Address should be provided by the insured party/your customer.

Pre-printed limits are the minimum required, if higher limits are provided by the policy, strike-through or cross-out the pre-printed limit and enter the higher limit amount.

To avoid work suspension, an updated insurance form must reach the address listed below one business day prior to the expiration date. Insurance must be in force in order to perform any work.

Binder numbers are not acceptable for policy numbers.

This BUILDING certificate of insurance is job specific, coverage on this form will need to remain in effect through out the duration of the job until project is completed.

The TxDOT certificate of insurance form is the only acceptable proof of insurance for department contracts.

List the contractor’s legal company name, including the DBA (doing business as) as the insured. If a staff leasing service is providing insurance to the contractor/client company, list the staff leasing service as the insured and show the contractor/client company in parenthesis.

Over-stamping and/or over-typing entries on the certificate of insurance are not acceptable if such entries change the provisions of the certificate in any manner.

This form may be reproduced.

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

DO NOT COMPLETE THIS FORM UNLESS THE BUILDERS RISK POLICY NAMES TxDOT UNDER THE LOSS PAYABLE CLAUSE.

The SIGNATURE of the agent is required.

Step 8 of 8

CERTIFICATE OF INSURANCE REQUIREMENTS:

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:

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

BUSINESS AUTOMOBILE POLICY:

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

Bodily Injury

$250,000 each person
$500,000 each occurrence

Property Damage

$100,000 each occurrence

PRIVATE AUTOMOBILE LIABILITY INSURANCE is not an acceptable substitute for a Business Automobile Policy.

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 552.021 and 552.023 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.

BUILDER'S RISK POLICY ‐ required on all SSD projects

RETURN THIS FORM TO THE TxDOT OFFICE AWARDING THIS CONTRACT

Form 1560-SSD (Rev. 07/25)