"Certificate of Insurance" - Mississippi

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

Form Details:

  • The latest edition currently provided by the Mississippi Department of Transportation;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Mississippi Department of Transportation.

ADVERTISEMENT
ADVERTISEMENT

Download "Certificate of Insurance" - Mississippi

Download PDF

Fill PDF online

Rate (4.7 / 5) 30 votes
MISSISSIPPI DEPARTMENT OF TRANSPORTATION
CERTIFICATE OF INSURANCE
CONSULTANT SERVICES UNIT
This is to certify that the following described Insurance Policies are in force at this date with limits not less than shown below.
Named Insured:
________________________________
Termini:
___________________
Address:
________________________________
___________________
________________________________
___________________
________________________________
County(ies):
___________________
MDOT Project Number:
________________________________
___________________
Errors and
Comprehensive
Pollution
Workers
Commercial
Omissions
Automobile
Liability
Compensation
General Liability
(Professional
Liability
Insurance
Insurance
Insurance
Liability)
Insurance
Insurance
Company:
Policy Number:
Limits:
Deductibles:
Effective Date:
Expiration Date:
The Insurance coverage recited above shall be maintained in full force and effect by the CONSULTANT during the entire term of the CONTRACT. The
COMMISSION shall be notified of cancellation of any of the required insurance by the CONSULTANT and by the insurance company issuing any such cancellation of
the required policies. Should CONSULTANT cease to carry the errors and/or omissions coverage listed above for any reason, it shall obtain “tail” or extended
reporting period coverage at the same limits for a period of not less than three (3) years subsequent to policy termination or contract termination, whichever is longer.
X
The above policies provide protection as is specified in section ______ of Project Number _______________.
By: ________________________________________
Address: ________________________________________
________________________________________
________________________________________
Sworn to and subscribed before me this
The ______ day of ______________, _________
________________________________________
NOTARY SEAL
Notary Public
NOTICE: THE CONSULTANT MUST RENEW THIS CERTIFICATE ANNUALLY UNTIL THE CONTRACT IS TERMINATED BY THE MISSISSIPPI
DEPARTMENT OF TRANSPORTATION. DO NOT REPLACE THIS FORM WITH A FACSIMILE OR ALTER THIS FORM IN ANY MANNER. IT
WILL NOT BE ACCEPTED BY THE MISSISSIPPI DEPARTMENT OF TRANSPORTATION.
MISSISSIPPI DEPARTMENT OF TRANSPORTATION
CERTIFICATE OF INSURANCE
CONSULTANT SERVICES UNIT
This is to certify that the following described Insurance Policies are in force at this date with limits not less than shown below.
Named Insured:
________________________________
Termini:
___________________
Address:
________________________________
___________________
________________________________
___________________
________________________________
County(ies):
___________________
MDOT Project Number:
________________________________
___________________
Errors and
Comprehensive
Pollution
Workers
Commercial
Omissions
Automobile
Liability
Compensation
General Liability
(Professional
Liability
Insurance
Insurance
Insurance
Liability)
Insurance
Insurance
Company:
Policy Number:
Limits:
Deductibles:
Effective Date:
Expiration Date:
The Insurance coverage recited above shall be maintained in full force and effect by the CONSULTANT during the entire term of the CONTRACT. The
COMMISSION shall be notified of cancellation of any of the required insurance by the CONSULTANT and by the insurance company issuing any such cancellation of
the required policies. Should CONSULTANT cease to carry the errors and/or omissions coverage listed above for any reason, it shall obtain “tail” or extended
reporting period coverage at the same limits for a period of not less than three (3) years subsequent to policy termination or contract termination, whichever is longer.
X
The above policies provide protection as is specified in section ______ of Project Number _______________.
By: ________________________________________
Address: ________________________________________
________________________________________
________________________________________
Sworn to and subscribed before me this
The ______ day of ______________, _________
________________________________________
NOTARY SEAL
Notary Public
NOTICE: THE CONSULTANT MUST RENEW THIS CERTIFICATE ANNUALLY UNTIL THE CONTRACT IS TERMINATED BY THE MISSISSIPPI
DEPARTMENT OF TRANSPORTATION. DO NOT REPLACE THIS FORM WITH A FACSIMILE OR ALTER THIS FORM IN ANY MANNER. IT
WILL NOT BE ACCEPTED BY THE MISSISSIPPI DEPARTMENT OF TRANSPORTATION.