EAMPLE CERTIFICATE OF LIABILITY INSURANCE EXAMPLE OF CERTIFICATE Shaded areas denote TDOT concerns DATE (MM/DD/YY)

COMPANY A COMPANY B COMPANY C COMPANY D A COMPANIES AFFORDING COVERAGE 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.

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.

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

GENERAL LIABILITY

AUTOMOBILE LIABILITY

GARAGE LIABILITY

EXCESS LIABILITY

WORKERS COMPENSATION AND EMPLOYERS' LIABILITY

OTHER

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

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 37243-1402

ATTN: Jennifer Lloyd, Civil Engineering Director, Roadway Design Division (signature)