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Triborough Bridge and Tunnel Authority Certificate of Insurance

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Triborough Bridge and Tunnel Authority Certificate of Insurance Capital Contract Triborough Bridge & Tunnel Authority Operating Contract Entry Permits CERTIFICATE OF INSURANCE 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 Triborough Bridge & Tunnel Authority/MTA HOLDER: Attention: 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 $ Hired Autos Only OTHER THAN Non-Owned Autos Only AUTO 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) 11/27/2017 CERTIFICATE OF INSURANCE TBTA (Continued) Page 2 LIABILITY COVERAGES: PROPERTY COVERAGES: Check all that apply ADDITIONAL INSUREDS Check all that apply Coverage: Commercial Liability, Garage Liability, Excess/Umbrella Liability ADDITIONAL NAMED INSUREDS/LOSS PAYEE Property, Builder’s Risk, etc. For All TBTA Agreements: Triborough Bridge & Tunnel Authority (TBTA) For All TBTA Agreements: Metropolitan Transportation Authority (MTA), and its subsidiaries and affiliates Triborough Bridge & Tunnel Authority (TBTA) The State of New York Metropolitan Transportation Authority (MTA), and its subsidiaries and affiliates And the respective affiliates and subsidiaries existing currently or in the future The State of New York of and successors to each Indemnified Party listed herein. And the respective affiliates and subsidiaries existing currently or in the future LAZ Parking New York/New Jersey LLC of and successors to each Indemnified Party listed herein. Consultant (or Design Firm) LAZ Parking New York/New Jersey LLC Consultant (or Design Firm) Additional Indemnitees Required on TBTA Agreements for work at 2 Broadway: New York City Transit (NYCT) Additional Indemnitees Required on TBTA Agreements for work at 2 Broadway: Metro North Commuter Railroad Company (MNR) New York City Transit (NYCT) Long Island Railroad (LIRR) Metro North Commuter Railroad Company (MNR) The State of New York Long Island Railroad (LIRR) MTA Bus Company (MTABus) The State of New York United States Trust Company of New York as Trustee under the 2 Broadway MTA Bus Company (MTABus) Ground Lease Trust United States Trust Company of New York as Trustee under the 2 Broadway Two Broadway LLC Ground Lease Trust ZAR Realty Two Broadway LLC CBRE, INC. (or current property manager under contract at the time of ZAR Realty Certificate Insurance) CBRE, INC. (or current property manager under contract at the time of And the respective affiliates and subsidiaries existing currently or in the future of Certificate Insurance) and successors to each Indemnified Party listed herein And the respective affiliates and subsidiaries existing currently or in the future of LAZ Parking New York/New Jersey LLC and successors to each Indemnified Party listed herein Consultant (or Design Firm) LAZ Parking New York/New Jersey LLC Consultant (or Design Firm) 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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