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TADOT Fonn 1560 (Rev 0212001) Previous ede ofthis fonn may not be used. Page 1 of 2 . . Texas Department of Transportation (TxDOT) CERTIFICATE OF INSURANCE Prior to the beginning of work, the Contrador shaD obtain the minimum insurance and endorsements specified. Only the TxDOT certificate of insurance fonn is acceptable as proof of insurance for department contracts. Agents should complete the form providing all requested information then either fax or mail this form directly to the address listed on the back of this form. Copies of endorsemehts listed below are not requirfood as attachments to this certificate. Insured: Main Street Association StreetlMailing Address: P. O. Box 1794 City/StatelZip: La Porte, TX 77572-1794 Phone Number: Area Code~81) 471-5551 Workers' Compensation Insurance Coverage: Endorsed with a Waiver of Subrooation in favor of TxDOT. Carrier Name: Carrier Phone #: Address: City, State, Zip: TVDe of Insurance Policv Number Effective Date Expiration Date Limits of Liabilitv: Workers' Compensalion Not Less Than: Statutory - Texas 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 ubroaation in favor of TxDOT. Carrier Name: Scottsdale Ins. Co. Carrier Phone #: 800-666-0345 ' , Address: % Delta General Agency~ P. O. Box 20~ !CIty, 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 $ 500,000 each occurrence Property Damage $ 100,000 each occurrence OR $ 100,000 for aggregate Commercial General OR Uabilitv Insurance CLS-0783807 10/01/01 10/01/02 $ 600,000 combined single limit Comprehensive Automobile liability Insurance: E d d' h T DOT Add' . II d . h W' f n orse Wit x as Itlona nsure and Wit a alver 0 Subroaation 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 $ 250,000 each person Bodily Injury $ 500.000 each occurrence Property Damage $ 100,000 each occurrence Umbrella Policy (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 ARencv. 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 il)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 meet 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 the signature produced by the receiving fax machine as the sender's original signature. '?l1ZI.A- Signature 9/17/01 Date Area Code (281) 471-2111 Authorized Agent's Pho~e Number