"Certificate of Insurance - Building Construction Contract Coverage" - Mississippi

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

Form Details:

  • Released on May 1, 2016;
  • The latest edition currently provided by the Mississippi Department of Transportation;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

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INSURANCE BUILDING CONSTRUCTION CONTRACT COVERAGE
MISSISSIPPI DEPARTMENT OF TRANSPORTATION
Cert. of Ins.
Buildings
CERTIFICATE OF INSURANCE
Rev. 05-2016
BUILDING CONSTRUCTION CONTRACT COVERAGE
This is to certify that the following described Insurance Policies are in force at
INSURED
this date with limits not less than shown below.
The below policies provide protection as is specified in AIA section 11.1.5,
however they are limited to policy terms, limits, exclusions and declarations.
CONTRACT NUMBER(S)
POLICY
POLICY
TYPE OF INSURANCE
POLICY NUMBER
EFFECTIVE DATE
EXPIRATION DATE
COVERAGE AND MINIMUM AMOUNT
(MM/DD/YY)
(MM/DD/YY)
General Aggregate
$ 1,000,000 Aggregate
GENERAL LIABILITY
Products & Completed
$ 1,000,000 Aggregate
Commercial General Liability
Operations
(Including XCU)
Personal & Advertising
$ 500,000 Per
Injury
Occurence
Bodily Injury & Property
$ 500,000 Per
Damage
Occurence
Fire Damage Liability
$ 50,000 Per Fire
Medical Expense
$ 5,000 Per Person
Bodily Injury & Property
OWNERS & CONTRACTORS
$ 1,000,000 Aggregate
Damage
PROTECTIVE LIABILITY
Bodily Injury & Property
$ 500,000 Per
Damage
Occurence
AUTOMOBILE LIABILITY
(Owned, Non-owned & Hired Vehicle)
Bodily Injury & Property
$ 500,000 Per
Damage
Contractor Insurance Option Number 1:
Occurence
(Combined Single Limit)
Bodily Injury
$ 250,000 Per Person
Contractor Insurance Option Number 2:
Bodily Injury
$ 500,000 Per Accident
$ 100,000 Per
Property Damage
Occurence
Bodily Injury & Property
EXCESS LIABILITY
Damage
$ 1,000,000 Aggregate
(Umbrella on projects over $ 500,000)
(Combined Single Limit)
$ 100,000 Per
WORKERS COMPENSATION
Accident
Occurence
(As Required by Statute)
EMPLOYERS’ LIABILITY
Disease
$ 500,000 Policy Limit
Disease
$ 100,000 Per Employee
Builders Risk
Equal to Value of Work
PROPERTY INSURANCE
Or
Installation Floater
Equal to Value of Work
OTHER
AGENT (PRINTED NAME & SIGNATURE)
AGENT ADDRESS
Authorized Agent Printed Name
Authorized Agent Signature
MISSISSIPPI INSURANCE ID NUMBER
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 registered mail stating when cancellation or expiration
date shall be effective, unless such cancellation is due to non-payment of premium in which case ten (10) days notice prior to cancellation will be sent.
NOTICE: THE CONTRACTOR MUST RENEW THIS CERTIFICATE UNTIL THE CONTRACT IS ACCEPTED BY THE MISSISSIPPI DEPARTMENT OF
TRANSPORTATION.
INSURANCE BUILDING CONSTRUCTION CONTRACT COVERAGE
MISSISSIPPI DEPARTMENT OF TRANSPORTATION
Cert. of Ins.
Buildings
CERTIFICATE OF INSURANCE
Rev. 05-2016
BUILDING CONSTRUCTION CONTRACT COVERAGE
This is to certify that the following described Insurance Policies are in force at
INSURED
this date with limits not less than shown below.
The below policies provide protection as is specified in AIA section 11.1.5,
however they are limited to policy terms, limits, exclusions and declarations.
CONTRACT NUMBER(S)
POLICY
POLICY
TYPE OF INSURANCE
POLICY NUMBER
EFFECTIVE DATE
EXPIRATION DATE
COVERAGE AND MINIMUM AMOUNT
(MM/DD/YY)
(MM/DD/YY)
General Aggregate
$ 1,000,000 Aggregate
GENERAL LIABILITY
Products & Completed
$ 1,000,000 Aggregate
Commercial General Liability
Operations
(Including XCU)
Personal & Advertising
$ 500,000 Per
Injury
Occurence
Bodily Injury & Property
$ 500,000 Per
Damage
Occurence
Fire Damage Liability
$ 50,000 Per Fire
Medical Expense
$ 5,000 Per Person
Bodily Injury & Property
OWNERS & CONTRACTORS
$ 1,000,000 Aggregate
Damage
PROTECTIVE LIABILITY
Bodily Injury & Property
$ 500,000 Per
Damage
Occurence
AUTOMOBILE LIABILITY
(Owned, Non-owned & Hired Vehicle)
Bodily Injury & Property
$ 500,000 Per
Damage
Contractor Insurance Option Number 1:
Occurence
(Combined Single Limit)
Bodily Injury
$ 250,000 Per Person
Contractor Insurance Option Number 2:
Bodily Injury
$ 500,000 Per Accident
$ 100,000 Per
Property Damage
Occurence
Bodily Injury & Property
EXCESS LIABILITY
Damage
$ 1,000,000 Aggregate
(Umbrella on projects over $ 500,000)
(Combined Single Limit)
$ 100,000 Per
WORKERS COMPENSATION
Accident
Occurence
(As Required by Statute)
EMPLOYERS’ LIABILITY
Disease
$ 500,000 Policy Limit
Disease
$ 100,000 Per Employee
Builders Risk
Equal to Value of Work
PROPERTY INSURANCE
Or
Installation Floater
Equal to Value of Work
OTHER
AGENT (PRINTED NAME & SIGNATURE)
AGENT ADDRESS
Authorized Agent Printed Name
Authorized Agent Signature
MISSISSIPPI INSURANCE ID NUMBER
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 registered mail stating when cancellation or expiration
date shall be effective, unless such cancellation is due to non-payment of premium in which case ten (10) days notice prior to cancellation will be sent.
NOTICE: THE CONTRACTOR MUST RENEW THIS CERTIFICATE UNTIL THE CONTRACT IS ACCEPTED BY THE MISSISSIPPI DEPARTMENT OF
TRANSPORTATION.