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Metro-North Railroad Certificate of Insurance

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Metro-North Railroad Certificate of Insurance Capital Contract Metro-North Railroad Operating Contract CERTIFICATE OF INSURANCE Entry Permits AGREEMENT or CONTRACT NAME/DESCRIPTION: AGREEMENT or CONTRACT #: INSURANCE PRODUCER: CERTIFICATE ISSUANCE DATE: DATE RECEIVED: REFERENCE #: ADDRESS: PHONE #: CO COMPANIES AFFORDING COVERAGE INSURED: LTR ADDRESS: A NAIC # B NAIC # PHONE #: C NAIC # D NAIC # CERTIFICATE Metro-North Railroad/MTA HOLDER: Attn: Risk & Insurance Management E NAIC # st ADDRESS: 2 Broadway, 21 Floor F NAIC # New York, NY 10004 G NAIC # PHONE#: (646) 252-1428 CO POLICY EFFECTIVE EXPIRATION TYPE OF INSURANCE LIMITS LTR NUMBER DATE DATE COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGES TO RENTED Occurrence $ SIR/Deductible $ PREMISES (Ea occurrence) PERSONAL & ADV INJURY $ GEN’L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ Policy Project Loc PRODUCTS – COMP/OP AGG $ Other: SIR/Deductible $ $ COMBINED SINGLE LIMIT $ (Ea accident) AUTOMOBILE LIABILITY Any Auto BODILY INJURY (Per person) $ Owned Autos Only Scheduled Autos BODILY INJURY (Per accident) $ Hired Autos Only Non-Owned PROPERTY DAMAGE $ Autos Only (Per accident) UMBRELLA LIAB Occurrence EACH OCCURRENCE $ Excess Liab Claims Made DED Retention $ AGGREGATE $ WORKER’S COMPENSATION STATUTORY LIMITS AND EMPLOYER’S LIABILITY USLH Jones Act “Other States” Coverage EMPLOYER’S LIABILITY $ GARAGE LIABILITY AUTO ONLY EACH ACCIDENT $ Any Auto Owned Autos Only EA ACC $ OTHER THAN Hired Autos Only AUTO ONLY Non-Owned Autos Only AGG $ PROFESSIONAL LIABILITY Includes incidental Pollution Liability $ Deductible $ OTHER: $ OTHER: $ OTHER: $ EVIDENCE OF RAILROAD PROTECTIVE LIABILITY AND/OR BUILDER'S RISK INSURANCE, WHEN APPLICABLE, REQUIRES SUBMISSION OF THE ORIGINAL POLICY. THE ORIGINAL BINDER(S) WILL BE ACCEPTED, PENDING ISSUANCE OF THE ORIGINAL POLICY(S). Revised 11/27/2017 CERTIFICATE OF INSURANCE MNR (Continued) Page 2 LIABILITY COVERAGES: PROPERTY COVERAGES: Check all that apply ADDITIONAL INSUREDS Check all that apply Coverage: General Liability, Garage Liability, Excess/Umbrella Liability ADDITIONAL NAMED INSUREDS/LOSS PAYEE Property, Builder’s Risk, etc. For All MNR Agreements: Metro-North Commuter Railroad Company For All MNR Agreements: Metropolitan Transportation Authority (MTA), and its subsidiaries and affiliates Metro-North Commuter Railroad Company And the respective affiliates and subsidiaries existing currently or in the future of Metropolitan Transportation Authority (MTA), and its subsidiaries and affiliates and successors to each Indemnified Party listed herein. And the respective affiliates and subsidiaries existing currently or in the future of and successors to each Indemnified Party listed herein. Additional Indemnitees Required on MNR Agreements, depending on Location of Work: Additional Indemnitees Required on MNR Agreements, depending on Location Connecticut Department of Transportation (CDOT) of Work: The State of Connecticut Connecticut Department of Transportation (CDOT) Midtown Trackage Ventures LLC The State of Connecticut Midtown TDR Ventures LLC Midtown Trackage Ventures LLC National Railroad Passenger Corp. (Amtrak) Midtown TDR Ventures LLC NJ Transit Rail Operations Inc. National Railroad Passenger Corp. (Amtrak) New Jersey Transit Corporation NJ Transit Rail Operations Inc. CSX Transportation Inc. & New York Central Lines LLC New Jersey Transit Corporation Delaware & Hudson Railway Company, Inc. CSX Transportation Inc. & New York Central Lines LLC Norfolk Southern Railway Company & Pennsylvania Lines LLC Delaware & Hudson Railway Company, Inc. Housatonic Railroad Company Norfolk Southern Railway Company & Pennsylvania Lines LLC Providence & Worcester Railroad Company Housatonic Railroad Company Danbury Terminal Railroad Co. Providence & Worcester Railroad Company Maybrook Railroad Company Danbury Terminal Railroad Co. Argent Ventures LLC Maybrook Railroad Company Jones Lang LaSalle Americas, Inc./LPI Argent Ventures LLC CBRE, INC. (or current property manager under contract at the time of Jones Lang LaSalle Americas, Inc./LPI Certificate Insurance) (341-347 Madison, 420 Lex & NWP) CBRE, INC. (or current property manager under contract at the time of Certificate Insurance) (341-347, 420 Lex & NWP ) Other: Other: CERTIFICATION BY INSURANCE BROKER OR AGENT The undersigned insurance broker or agent represents that the Certificate of Insurance is accurate in all material respects. [Name of broker or agent (typewritten)] [Address of broker or agent (typewritten)] [Email address of broker or agent (typewritten)] [Phone number/Fax number of broker or agent (typewritten)] [Signature of authorized official, broker or agent] [Name and title of authorized official, broker, or agent (typewritten)] State of…………..……………) ) s.s.: County of…………..…………) Sworn to before me this ____ day of ___________ 20___ ____________________________________________________ NOTARY PUBLIC FOR THE STATE OF ______________ Revised 11/27/2017 .
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