DATE (MM/DD/YY) FACSIMILE OF CERTIFICATE Shaded Areas Denote TDOT

date (mm/dd/yy) facsimile of certificate shaded areas denote tdot concerns certificate of liability insurance exampl

DATE (MM/DD/YY)

FACSIMILE OF
CERTIFICATE
Shaded areas denote TDOT concerns

CERTIFICATE OF LIABILITY INSURANCE
EXAMPLE
COMPANY
A
COMPANY
B
COMPANY
C
COMPANY
D
A
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT
AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE

PRODUCER
(insurance company's name, address, phone and e-mail address)
NOTE: This certificate should be mailed directly by your insurance
company.
(as applicable)

INSURED
(consulting firm's name and address)

COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE
BEEN ISSED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR
OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN
IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MM/DD/YY)
POLICY EXPIRATION
DATE (MM/DD/YY)
LIMITS

GENERAL LIABILITY

AUTOMOBILE LIABILITY

GARAGE LIABILITY

EXCESS LIABILITY

WORKERS COMPENSATION AND EMPLOYERS' LIABILITY

OTHER
Professional liability
for omissions and errors
(policy number)
(date)
(date)
Each Claim: (dollar amount)
Annual Aggregate: (dollar amount)

DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS

Agreement (TDOT agreement number)
TDOT project manager (manager’s name)
NOTE: If there is no claim limit, state this fact explicitly.
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
______ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL INPOSE NO OBLIGATION OF
LIABIOLITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE

CERTIFICATE HOLDER
Tennessee Department of Transportation
Suite 1300, James K. Polk Building
Nashville, TN 37243-0348


(signature)
ATT: Jeff Jones, Civil Engineering Director, Design Division