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.. TADOT Form 1560 (Rev 0212001) Previous e_ of this form may not be used. Page 1 of 2 . Texas Department of Transportation (TxDOT) CERTIFICATE OF INSURANCE Prior to the beginning of work, the Contrador shall obtain the minimum insurance and endorsements specified. Only the TxOOT certificate of insurance fOITn is aa:eptable as proof of insurance for department contracts. Agents should complete the form providing all requested infolTnation then either fax or mail this form directJy to the address listed on the back of this form. Copies of endorsements listed below are not requimd as attachments to this certificate. Insured: Main Street Association StreeUMailing Address: P. O. Box 1794 City/StatelZip: La Porte, TX 77572-1794 Phone Number: Area Code~81) 471-5551 Workers' Compensation Insurance Coverage: e Endorsed with a Waiver of Subroaation in favor of TxDOT. Carrier Name: Carrier Phone #: Address: City, State, Zip: TVnA of Insurance Policy Number Effective Date EXDiratlon Date I Limits of Liabilltv: Workers' Compensation i Not Less Than: Statutory - Texas I Comprehensive General Liability Insurance: E d d' h T DOT Add" . II d d . h W' f S n orse Wit x as Itlona nsure an Wit a alver 0 ubrooation in favor of TxDOT. r.lmier Name: Scottsdale Ins. Co. Carrier Phorle #: 800-666-0345 . .. Address: % Delta General Agency~ P. O. Box 20/ .l:lty, State, Zip: Houston, TX 77252 Type of Insurance: Polley Number: Effective Date: Expiration Date: Limits of Liability: . Comprehensive General Not Less Than: Liability Insurance Bodily Injury S 500,000 each occurrence Property Damage S 100,000 each occurrence OR S 100,000 for aggregate Commercial General OR Liability Insurance CLS-078380'7 10/01/01 10/01/02 S 600,000 combined single limit Comprehensive Automobile Liability Insurance: E d d 'th T DOT Add' . II d d . h W' f S b n orse WI x as Ibona nsure an Wit a alver 0 u rOQation in favor ofTxDOT. Carrier Name: Carrier Phone #: Address: City, State, Zip: Type of Insurance: Policy Number: . Effective Date: Expiration Date: Limits of Liability: Comprehensive Automobile Liability Insurance OR Texas Not Less Than: Business Automobile Policy S 250,000 each person Bodily Injury S 500,000 each occurrence Property Damage $ 100,000 each occurrence Umbrella Policv (if applicable\: Carrier Name: Carrier Phone #: Address: City, State, Zip: Type of Insurance: Policy Number: Effective Date: Expiration Date: Limits of Liability: Umbrella Policy Authorized Agent name address and zip code Bavshore Insurance Agencv. Inc., P. O. Box 1459, La Porte, TX 77572-1459 This Certificate of Insurance neither affinnatively nor negatively amends, extends, or alters the coverage afforded by the above i~surance policies issued by the named insurance company. Cancellation of the insurance policies shall not be made until THIRTY DAYS AFTER the-agent or the insurance company has sent written notice by certified mail to the contractor and the Texas Department of Transportation. THIS IS TO CERTIFY to the Texas Department of Transportation acting on behalf of the State of Texas that the insurance policies named meel all the requirements stipulated and such pOlicies 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 lhe signature produced by the receiving fax machine as the sender's original signature. 7lI2lA- Signature 9/17/01 Date Area Code (281) 471-2111 Authorized Agent's Pho~e Number