"Certificate of Insurance for Railroad Protective Liability Coverage" - Mississippi

Certificate of Insurance for Railroad Protective Liability Coverage is a legal document that was released by the Mississippi Department of Transportation - a government authority operating within Mississippi.

Form Details:

  • Released on June 1, 2017;
  • The latest edition currently provided by the Mississippi Department of Transportation;
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MISSISSSIPPI DEPARTMENT OF TRANSPORTATION
Cert. of Ins. (Part A)
CERTIFICATE OF INSURANCE
Rev. 06-2017
FOR RAILROAD PROTECTIVE LIABILITY COVERAGE
This is to certify that the following described Liability Insurance Policy is in force at this date with limits not
less than shown below.
Name and address of Insured
Railroad Company:
Railroad Protective Liability
Company:
Policy No.:
MDOT Minimum
Without Passenger Trains $2,000,000 occ. / $6,000,000 agg. OR
Limits:
With Passenger Trains $5,000,000 occ. / $10,000,000 agg.
Railroad Specific
Limits:
Effective Date:
Expiration Date:
MISSISSIPPI DEPARTMENT OF TRANSPORTATION CONTRACT NUMBER(S)
County (ies)
In the event of cancellation of said policies or failure on the part of the company to renew at expiration date, the company agrees to give the Railroad
Company listed and the Mississippi Department of Transportation, Jackson, Mississippi, not less than thirty days written notice sent by certified mail stating
when cancellation or expiration date shall be effective, unless such cancellation is due to non-payment of premium in which case notice will be sent at least
ten (10) days prior to cancellation.
The above policies provide protection as is specified in Special Provision Number 907-107.14.2.2--Railroad Protective (2004 Standard Specifications)
or sub-section 107.14.2.2 –Railroad Protective (2017 Standard Specifications), however they are limited to policy terms, limits, exclusions and declarations.
By:
Signature
Agent’s Typed Name
MS Insurance ID Number
Address:
Sworn to and subscribed before me this
The
day of
,
Notary Public
NOTICE:
THE CONTRACTOR MUST RENEW THIS CERTIFICATE UNTIL THE CONTRACT IS ACCEPTED BY THE
MISSISSIPPI DEPARTMENT OF TRANSPORTATION.
If you alter this form in any manner, it will not be accepted by the Mississippi Department of Transportation.
ONLY ORIGINAL SIGNATURES WILL BE ACCEPTED.
MISSISSSIPPI DEPARTMENT OF TRANSPORTATION
Cert. of Ins. (Part A)
CERTIFICATE OF INSURANCE
Rev. 06-2017
FOR RAILROAD PROTECTIVE LIABILITY COVERAGE
This is to certify that the following described Liability Insurance Policy is in force at this date with limits not
less than shown below.
Name and address of Insured
Railroad Company:
Railroad Protective Liability
Company:
Policy No.:
MDOT Minimum
Without Passenger Trains $2,000,000 occ. / $6,000,000 agg. OR
Limits:
With Passenger Trains $5,000,000 occ. / $10,000,000 agg.
Railroad Specific
Limits:
Effective Date:
Expiration Date:
MISSISSIPPI DEPARTMENT OF TRANSPORTATION CONTRACT NUMBER(S)
County (ies)
In the event of cancellation of said policies or failure on the part of the company to renew at expiration date, the company agrees to give the Railroad
Company listed and the Mississippi Department of Transportation, Jackson, Mississippi, not less than thirty days written notice sent by certified mail stating
when cancellation or expiration date shall be effective, unless such cancellation is due to non-payment of premium in which case notice will be sent at least
ten (10) days prior to cancellation.
The above policies provide protection as is specified in Special Provision Number 907-107.14.2.2--Railroad Protective (2004 Standard Specifications)
or sub-section 107.14.2.2 –Railroad Protective (2017 Standard Specifications), however they are limited to policy terms, limits, exclusions and declarations.
By:
Signature
Agent’s Typed Name
MS Insurance ID Number
Address:
Sworn to and subscribed before me this
The
day of
,
Notary Public
NOTICE:
THE CONTRACTOR MUST RENEW THIS CERTIFICATE UNTIL THE CONTRACT IS ACCEPTED BY THE
MISSISSIPPI DEPARTMENT OF TRANSPORTATION.
If you alter this form in any manner, it will not be accepted by the Mississippi Department of Transportation.
ONLY ORIGINAL SIGNATURES WILL BE ACCEPTED.
MISSISSSIPPI DEPARTMENT OF TRANSPORTATION
Cert. of Ins. (Part B)
CERTIFICATE OF INSURANCE
Rev. 06-2017
FOR CONTRACTOR’S LIABILITY - RAILROAD
This is to certify that the following described Liability Insurance Policies are in force at this date with limits
not less than shown below.
Name and address of Insured
Contractor:
Contractors Liability
Automobile
Workers’
Excess/Umbrella
incl. XCU,
Liability
Liability
Compensation and
Subcontractors,
Employers’
Contractual
Railroad
Liability
Company:
Policy No.:
MDOT Minimum
Statutory:
$1,000,000 occ.
$1,000,000 csl
$5,000,000 occ.
Limits:
$100,000 accident
$2,000,000 agg.
$5,000,000 agg.
$100,000 employee
$500,000 P. L.
Railroad Specific
Limits:
Effective Date:
Expiration Date:
MISSISSIPPI DEPARTMENT OF TRANSPORTATION CONTRACT NUMBER(S)
County (ies)
In the event of cancellation of said policies or failure on the part of the company to renew at expiration date, the company agrees to give the Mississippi
Department of Transportation, Jackson, Mississippi, not less than thirty days written notice sent by certified mail stating when cancellation or expiration
date shall be effective, unless such cancellation is due to non-payment of premium in which case notice will be sent at least ten (10) days prior to cancellation.
The above policies provide protection as is specified in Special Provision Number 907-107.14.2.2--Railroad Protective (2004 Standard Specifications)
or sub-section 107.14.2.2 –Railroad Protective (2017 Standard Specifications), however they are limited to policy terms, limits, exclusions and declarations.
By:
Signature
Agent’s Typed Name
MS Insurance ID Number
Address:
Sworn to and subscribed before me this
The
day of
,
Notary Public
NOTICE:
THE CONTRACTOR MUST RENEW THIS CERTIFICATE UNTIL THE CONTRACT IS ACCEPTED BY THE MISSISSIPPI
DEPARTMENT OF TRANSPORTATION.
If you alter this form in any manner, it will not be accepted by the Mississippi Department of Transportation.
ONLY ORIGINAL SIGNATURES WILL BE ACCEPTED.
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