Form 03-0001-R1 - Certificate Of Insurance Form - California Insurance Department Page 2

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CERTIFICATE OF INSURANCE

This is to Certify to: San Francisco Bay Area Rapid Transit District (BART) Insured:___________________________

Insurance Department

___________________________

300 Lakeside Drive, LKS-22

________________________

Oakland, CA 94612

The following described policy(ies) has been issued to the Insured stated above. BART’s Agreement No.: _____________________________

Description and Location of Project: ________________________________________________________________________________________

G. PROPERTY DAMAGE

I. PROFESSIONAL LIABILITY/ERRORS &

Required: Yes _________ No ____________

OMMISSION INSURANCE

$ ______________ Each Occurrence Limit

Required: Yes _________ No ____________

$ ______________ Annual Aggregate Limit

______ Occurrence Form ______ Claims Made

Insurance Co: _______________________________

________________ Retroactive Date (if applicable)

Policy Number: _____________________________

$ ______________ Each Occurrence Limit

AM Best Rating: ____________________________

$ ______________ Annual Aggregate Limit

Policy Term: ______________ to ______________

Retro Exclusion Date: ________________________

Extended Reporting: ________________________

Insurance Co: _______________________________

Property Damage Insurance to cover all forms of physical loss or damage to

Policy Number: _____________________________

District property while in transit from or to District facilities, or otherwise in the

AM Best Rating: ____________________________

care, custody and control of Contractor. The form of coverage shall be replacement

Policy Term: ______________ to ______________

cost.

__________________________________________________________________

_______________________________________________

J. RAILROAD PROTECTIVE COVERAGE

Required: Yes _________ No ____________

H. BUILDERS RISK/INSTALLATION FLOATER

$ ______________ Each Occurrence Limit

Required: Yes _________ No ____________

$ ______________ Annual Aggregate Limit

$ ______________ Each Occurrence Limit

Insurance Co: _______________________________

$ ______________ Annual Aggregate Limit

Policy Number: _____________________________

Insurance Co: _______________________________

AM Best Rating: ____________________________

Policy Number: _____________________________

Policy Term: ______________ to ______________

AM Best Rating: ____________________________

Policy Term: ______________ to ______________

For bodily injury (including death), property damage and

physical damage to railroad property applicable to all

Builders’ Risk Insurance provided on an “All-Risk” basis excluding Earthquake for

operations of Grantee and its contractors or subcontractors

the full replacement cost of materials, supplies, all property to be incorporated into

within 50 feet vertically or horizontally of BART’s

the finished work, and completed work in an amount not less than the full

trackway, The named insured shall be the San Francisco

completed value of the covered structure or the replacement value of alterations or

Bay Area Rapid Transit District. Prior to commencing work

additions. BART shall be named as a loss payee and losses will be payable to both

or entering onto BART property, Grantee shall file the

Contractor and BART, as their interests may appear.

original copy of the policy with the BART Insurance Dept.

Policy is to be kept in effect until the entire project is

completed.

No policy will be cancelled, non-renewed, or materially changed without providing thirty (30) days prior written notice to the District at the

above address. The Contractor shall annually submit to the District’s Insurance Department, or its authorized agent, certifications

confirming that the insurance required has been renewed and continues in place.

It is hereby certified that the above policy(ies) provide liability insurance as required by the Agreement dated __________________ between BART

and the insured designated above.

This certificate is a matter of information. This certificate is not an insurance policy and does not amend, extend or alter the coverage afforded by the

policy(ies) listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate

of insurance may be issued or may pertain, the insurance afforded by the policy(ies) described herein is subject to all terms, exclusions and

conditions of such policies.

Date: _____________________

Signed: _____________________________________________________________________

Authorized Representative of Insurance Carriers

Firm: ______________________________________________________________________

Address: ___________________________________________________________________

Phone: __________________________ Fax: __________________________

E-Mail: ___________________________________

Print Form

Form No. 03-0001-R2 (Rev. 12/21/10-Insurance)