LIABILITY INSURANCE REQUIREMENTS Excerpt from Sammamish Plateau Water and Sewer District Developer Extension Agreement (most current edition) WS-12 LIABILITY INSURANCE The Developer shall procure commercial general liability, automobile liability, excess/umbrella liability, and workers compensation insurance on an occurrence basis against liability to the developer, the District, the District Engineer and the District employees for negligent injury to person or property related in any way to the performance of this Agreement and/or resulting from performance, supervision, or inspection of the work. The District shall be named as an additional insured/certificate holder under such policy. Proof of the existence of such insurance shall be provided to the District by original certificate of insurance and endorsements in the form attached hereto. The minimum limits of coverage shall be as follows: 1. Commercial General Liability $2,000,000 each occurrence Bodily Injury and Property Damage $2,000,000 General Aggregate Employees and Volunteers as Additional Insured for both on-going and completed operations Premises and operations Broad form property damage including underground, explosion and collapse hazards (XCU) Products completed operations (through guaranty period) Blanket contractual Subcontractors Personal Injury with employee exclusion deleted Employers liability (Stop gap) 2. Automobile Liability $2,000,000 per accident Bodily Injury and Property Liability covering: o Any owned automobile o Hired automobiles o Non-owned automobile 3. Umbrella Liability $2,000,000 per occurrence $2,000,000 aggregate 4. Workers Compensation and Employers Liability $2,000,000 per occurrence $2,000,000 aggregate
SAMPLE CERTIFICATE OF LIABILITY (SEE CONTRACT FOR EXACT LIMITS)
SAMPLE ENDORSEMENT OF ADDITIONAL INSURED (1985 Form covering both on-going and completed operations)
SAMPLE ALTERNATIVE ENDORSEMENT OF ADDITIONAL INSURED (Alternative Forms to cover on-going and completed operations Both of the following are required in place of CG 20 10 11 85)
SAMPLE ENDORSEMENT OF AGGREGATE LIMITS
SAMPLE QUESTIONNAIRE NOTE: THIS QUESTIONNAIRE MUST BE COMPLETED AND ATTACHED TO CERTIFICATE OF INSURANCE AND POLICY ENDORSEMENT. Insurance Coverage Questionnaire For Big Toys Construction, Inc. (Name of Insured) Project Number 93-0011 Project Owner Big Mountain Water and Sewer District Are the following coverages &/or conditions in effect? Yes The Policy form is ISO Commercial General Liability form CG 00 01 of CG 00 02 (circle one). If No, attach a copy of the X policy with required coverages clearly identified. Products and Completed operations coverage Personal Injury Liability Coverage. (with employee exclusion deleted) X X No Broad Form Property Damage with X, C, U Hazards included Blanket Contractual Liability coverage applying to this contract Employers Liability - Stop Gap X X x Deductibles or SIRs: GL $500 AL None Excess $10,000 Insurer Best Rating GL A-XI AL A-XV Excess A-XV This Questionnaire is issued as a matter of information. This questionnaire is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies indicated on the attached Certificate of Insurance. ADF Insurance Agency Agency/Broker 1234 5 th Street, Any Place, WA Address Jane Doolittle Completed by (type) Completed by (Signature) Sal Smith (206) 555-1234 Name of Person to contact Telephone Number
NOTE: THIS QUESTIONNAIRE MUST BE COMPLETED AND ATTACHED TO CERTIFICATE OF INSURANCE AND POLICY ENDORSEMENT. Insurance Coverage Questionnaire For Project Number Project Owner (Name of Insured) Are the following coverages &/or conditions in effect? Yes The Policy form is ISO Commercial General Liability form CG 00 01 of CG 00 02 (circle one). If No, attach a copy of the policy with required coverages clearly identified. Products and Completed operations coverage Personal Injury Liability Coverage. (with employee exclusion deleted) No Broad Form Property Damage with X, C, U Hazards included Blanket Contractual Liability coverage applying to this contract Employers Liability - Stop Gap Deductibles or SIRs: GL AL Excess Insurer Best Rating GL AL Excess This Questionnaire is issued as a matter of information. This questionnaire is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies indicated on the attached Certificate of Insurance. Agency/Broker Completed by (type) Address Completed by (Signature) Name of Person to contact Telephone Number