New Jersey Department of Transportation 
Insurance Certificate

This certifies that for the policies indicated below have been issued to the insured for the subject Contract for the policy period indicated, that the policies comply with the requirements of Section 107.11.02 and Section 152 of the New Jersey Department of Transportation Standard Specifications for Road and Bridge Construction as amended by the Special Provisions, and that all information contained herein is true and accurate.
CONTRACTOR:	     	
PROJECT NAME :	     	
LOCATION:	     	
DP FILE NO:	     	

A   COMPREHENSIVE GENERAL LIABILITY INSURANCE 	

Company Providing Coverage:	
     	
	
       ENDORSEMENTS       
 PERSONAL INJURY
 CONTRACTUAL LIABILITY 
 PREMISES & OPERATIONS
 PRODUCTS & COMPLETED OPERATIONS
 INDEPENDENT CONTRACTORS
 WAIVER OF SUBROGATION 
 SEVERABILITY OF INTEREST/SEPARATION OF INSURED
  PER PROJECT AGGREGATE
  EXPLOSIONS
 DAMAGE TO UNDERGROUND UTILITIES
 COLLAPSE OF  FOUNDATIONS	

Policy Number:	
     	

Effective Date:	
     	

Expiration Date:	
     	

Limit of Liability: $	
     	
per occurrence Combined Single Limit (B.I & P.D.)	

Deductible: $	
     	

	

This policy names the State, its officers, employees and agents	

As additional insured  Yes    No	

	
B   COMPREHENSIVE AUTOMOBILE LIABILITY INSURANCE

Company Providing Coverage:	
     	
	
     ENDORSEMENTS  
 WAIVER OF SUBROGATION 
 SEVERABILITY OF INTEREST/SEPARATION OF INSURED

Policy Number:	
     	

Effective Date:	
     	

Expiration Date:	
     	

Limit of Liability: $	
     	
per occurrence Combined Single Limit (B.I. & P.D.)	

Type of Coverage:  ALL OWNED AUTOS    NON-OWNED AUTOS    HIRED AUTOS	

	
C   OWNER’S AND CONTRACTOR’S PROTECTIVE LIABILITY INSURANCE

Company Providing Coverage:	
     	
	
     ENDORSEMENTS  
 SEVERABILITY OF INTEREST/SEPARATION OF INSURED
 PER PROJECT AGGREGATE	

Policy Number:	
     	

Effective Date:	
     	

Expiration Date:	
     	

Limit of Liability: $	
     	
per occurrence Combined Single Limit (B.I. & P.D.)	

This policy names the State, its officers, employees and agents	

As additional insured  Yes    No	

	
D   WORKERS’ COMPENSATION AND EMPLOYER’S LIABILITY INSURANCE

Company providing Coverage:	
     	
	
ENDORSEMENTS  
US LONGSHORE & HARBOR WORKERS COVERAGE
AND JONES ACT:      Yes       No	

Policy Number:	
     	

Effective Date:	
     	

Expiration Date:	
     	

Limit of Liability: $	
     	
Each accident	

       $	
     	
Disease, each employee	

$	
     	
Disease, policy limit	

	

New Jersey Department of Transportation 
Insurance Certificate
CONTRACTOR:	     	
PROJECT NAME:		

E   EXCESS LIABILITY INSURANCE

Company Providing Coverage:	
     	
	
Policy takes effect if the primary policy is impaired or exhausted and has 	

the same terms and conditions as the primary underlying coverage for the 	

Policy Number: 	
     	
	
following:	

	
	
     A  COMPREHENSIVE GENERAL LIABILITY	

Effective Date:	
     	
	
     B  COMPREHENSIVE AUTOMOBILE LIABILITY	

	

Expiration Date: 	
     	

	

Limit of Liability: $	
     	
per occurrence	

	
F   MARINE  LIABILITY INSURANCE   (required only if construction operations require marine operations)

Company Providing Coverage:	
     	
	
     ENDORSEMENTS  
 PERSONAL INJURY
 CONTRACTUAL LIABILITY 
 WAIVER OF SUBROGATION 
 PER PROJECT AGGREGATE	

	

Policy Number:	
     	

Effective Date:	
     	

Expiration Date:	
     	

Limit of Liability: $	
     	
per occurrence	

This policy names the State, its officers, employees and agents	

as additional insured:  Yes     No	

	
G     RAILROAD PROTECTIVE LIABILITY INSURANCE   (if required by Special Provisions)

Company Providing Coverage:	
     	
	
     ENDORSEMENTS  

 SEVERABILITY OF INTEREST/SEPARATION OF INSURED
 PER PROJECT AGGREGATE	

	

Policy Number:	
     	

Effective Date:	
     	

Expiration Date:	
     	

Limit of Liability: $	
     	
per occurrence, $	
     	
annual aggregate	

H   POLLUTION LIABILITY INSURANCE
									     ENDORSEMENTS
Company Providing Coverage:	
     	
	
 BODILY INJURY AND PROPERTY DAMAGE
 NATURAL RESOURCES DAMAGE
 ENVIRONMENTAL CLEAN UP INCLUDING RESTORATION
 LEGAL DEFENSE
 TRANSPORTATION OF WASTE FROM THE PROJECT LIMITS
 DISPOSAL LIABILITY
 WAIVER OF SUBROGATION
 SEVERABILITY OF INTEREST/SEPARATION OF INSURED
 PER PROJECT AGGREGATE

The policy does not contain exclusions or limitations for:
 LIABILITIES ASSUMED
 LEAD, SILICA, ASBESTOS
 UNDERGROUND STORAGE TANKS
 INSURED VS. INSURED EXCLUSION THAT RESTRICTS
      COVERAGE TO THE STATE 

	

Policy Number:	
     	

Effective Date:	
     	

Expiration Date:	
     	

Limit of Liability: $	
     	
per occurrence	

                               $	
     	
aggregate	

Policy is written on the following basis:	

        Occurrence form, and completed operations coverage to be provided for no less than	

             2 years after Acceptance	

        Claims made, and Extended Reporting Provision coverage to be maintained for no	

             less than 2 years after Acceptance	

This policy names the State, its officers, employees and agents	

As additional insured:    Yes     No	

		

Certificate Holder

New Jersey Department of Transportation 
Regional Construction Engineer
Address:	
     	

     	

	I certify that I am an authorized representative for each of the above indicated insurance
Companies, and that all policies have been endorsed to require written notice of cancellation or non-renewal to the named Certificate Holder, 30 days prior to cancellation or expiration of the policy.	
	Company:	     			     		
	Address:	     			                          Signature	
		     		Name:	     		
	Phone: