Fillable TXDOT Form 1560 (City of El Paso)

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TXDOT Form 1560 (City of El Paso)

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U.S.A. forms for City of El Paso

BROWSE CITY OF EL PASO (TX) FORMS

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CERTIFICATE OF INSURANCE
Agents should complete the form providing all requested information then either fax or mail this form directly to the address listed on page two of this form. 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.
WORKERS' COMPENSATION INSURANCE COVERAGE:
Endorsed with a Waiver of Subrogation in favor of TxDOT.
COMMERCIAL GENERAL LIABILITY INSURANCE:
BUSINESS AUTOMOBILE POLICY:
UMBRELLA POLICY (if applicable):
Agency Name
Address
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.
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 §§552.021 and 552.023 of the Texas Government Code, you also are entitled to receive
and review the information. Under §559.004 of the Government Code, you are also entitled to have us correct information about you that is incorrect.
Fax completed form to: 512/416-2536
Form 1560
(Rev. 01/12)
Previous editions of this form may not be used.
Page 1 of 2
Phone Number:
City/State/Zip:
Street/Mailing Address:
Insured:
Address:
Carrier Name:
City, State, Zip:
Carrier Phone #:
Workers' Compensation
Type of Insurance
Policy Number
Effective Date
Expiration Date
Limits of Liability:
Not Less Than: Statutory - Texas
Carrier Name:
Address:
Type of Insurance:
Commercial General
Liability Insurance
Not Less Than:
$ 600,000 each occurrence
Policy Number:
Effective Date:
Expiration Date:
City, State, Zip:
Carrier Phone #:
Limits of Liability:
Carrier Name:
Address:
Type of Insurance:
Business Automobile Policy
Bodily Injury
Property Damage
Not Less Than:
$ 600,000 combined single limit
Policy Number:
Effective Date:
Expiration Date:
City, State, Zip:
Carrier Phone #:
Limits of Liability:
Carrier Name:
Address:
Type of Insurance:
Umbrella Policy
Policy Number:
Effective Date:
Expiration Date:
Limits of Liability:
City, State, Zip:
Carrier Phone #:
Authorized Agent's Phone Number
Authorized Agent Original Signature
Date
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
NOTES TO AGENTS:
Agents must provide all requested information then either fax or mail this form directly to the address listed below.
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.
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.
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/contracts on this form.
List the contractor's legal company name, including the DBA (doing business as) name 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.
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) name as the insured or list both the
contractor and staff leasing service as insured when a staff leasing service is providing insurance.
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.
The SIGNATURE of the agent is required.
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:
If coverages are specified separately, they must be at least these amounts:
Bodily Injury
$500,000 each occurrence
$100,000 each occurrence
$100,000 for aggregate
Property Damage
MANUFACTURERS' or CONTRACTOR LIABILITY INSURANCE is not an acceptable substitute for Comprehensive
General Liability Insurance or Commercial General Liability Insurance.
BUSINESS AUTOMOBILE POLICY:
PRIVATE AUTOMOBILE LIABILITY INSURANCE is not an acceptable substitute for a Business Automobile Policy.
MAIL ALL CERTIFICATES TO:
Texas Department of Transportation
CST Contract Processing Unit (RA/200 1st Fl.)
125 E. 11th Street
Austin, TX 78701-2483
512/416-2540 (Voice), 512/416-2536 (Fax)
Form 1560
(Rev. 01/12)
Page 2 of 2
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TXDOT Form 1560 (City of El Paso)

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Completed 12 February 2021

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