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For Joint Agency Agreements) Capital Contract Metropolitan Transportation Authority Operating Contract All Other Agreements CERTIFICATE OF INSURANCE (For Joint Agency Agreements) AGREEMENT or CONTRACT NAME/DESCRIPTION: AGREEMENT or CONTRACT #: Producer: DATE RECEIVED: REFERENCE #: CERTIFICATE ISSUANCE DATE: ADDRESS: PHONE #: CO COMPANIES AFFORDING COVERAGE INSURED: LTR ADDRESS: A NAIC # B NAIC # PHONE #: C NAIC # D NAIC # CERTIFICATE Metropolitan Transportation Authority HOLDER: Attention: Risk & Insurance Management E NAIC # ADDRESS: 2 Broadway, 21st 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 EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY 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 $ AUTOMOBILE LIABILITY (Ea accident) 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 OTHER THAN EA ACC Hired Autos Only $ 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 MTA Joint Agency (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. Metropolitan Transportation Authority (MTA), and its subsidiaries and affiliates Metropolitan Transportation Authority (MTA), and its subsidiaries and And the respective affiliates and subsidiaries existing currently or in the future affiliates of 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. Metro-North Commuter Railroad Company (MNR) Metropolitan Transportation Authority (MTA), and its subsidiaries and Metro-North Commuter Railroad Company (MNR) affiliates Metropolitan Transportation Authority (MTA), and its subsidiaries and Connecticut Department of Transportation affiliates The State of Connecticut Connecticut Department of Transportation Jones Lang LaSalle Americas, Inc. The State of Connecticut Midtown Trackage Ventures LLC Jones Lang LaSalle Americas, Inc. Midtown TDR Ventures LLC Midtown Trackage Ventures LLC Argent Ventures LLC Midtown TDR Ventures LLC And the respective affiliates and subsidiaries existing currently or in the future Argent Ventures LLC of 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. New York City Transit Authority (NYCT) Manhattan and Bronx Surface Transit Operating Authority (MaBSTOA) New York City Transit Authority (NYCT) Staten Island Rapid Transit Operating Authority (SIRTOA) Manhattan and Bronx Surface Transit Operating Authority (MaBSTOA) MTA Capital Construction Co. (MTACC) Staten Island Rapid Transit Operating Authority (SIRTOA) MTA Bus Company (MTA Bus) MTA Capital Construction Co. (MTACC) Metropolitan Transportation Authority (MTA), and its subsidiaries MTA Bus Company (MTA Bus) and affiliates Metropolitan Transportation Authority (MTA), and its subsidiaries The City of New York (as owner) and affiliates And the respective affiliates and subsidiaries existing currently or in the future The City of New York (as owner) of 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. Triborough Bridge & Tunnel Authority (TBTA) Metropolitan Transportation Authority (MTA), and its subsidiaries and Triborough Bridge & Tunnel Authority (TBTA) affiliates Metropolitan Transportation Authority (MTA), and its subsidiaries and The State of New York. 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 of and successors to each Indemnified Party listed herein. Other: Other: Long Island Rail Road (LIRR) Metropolitan Transportation Authority (MTA), and its subsidiaries and Long Island Rail Road (LIRR) affiliates Metropolitan Transportation Authority (MTA), and its subsidiaries and New York & Atlantic Railway Company, when applicable affiliates Anacostia Rail Holdings New York & Atlantic Railway Company, when applicable And the respective affiliates and subsidiaries existing currently or in the future Anacostia Rail Holdings of and successors to each Indemnified Party listed herein. And the respective affiliates and subsidiaries existing currently or in the future National Railroad Passenger Corp. (Amtrak) of and successors to each Indemnified Party listed herein. NJ Transit Corporation National Railroad Passenger Corp. (Amtrak) NJ Transit Rail Operations, Inc. NJ Transit Corporation Consolidated Rail Corporation NJ Transit Rail Operations, Inc. CSX Transportation Inc. Consolidated Rail Corporation Triborough Bridge & Tunnel Authority (B&T) CSX Transportation Inc. The Port Authority of NY and NJ Triborough Bridge & Tunnel Authority (B&T) The Port Authority of NY and NJ MTA Bus Company (MTA Bus) Metropolitan Transportation Authority (MTA), and its subsidiaries and MTA Bus Company (MTA Bus) affiliates Metropolitan Transportation Authority (MTA), and its subsidiaries and The State of New York affiliates The City of New York The State of New York PBS Capital LLC The City of New York MIU Realty, LLC PBS Capital LLC JLK Capital, LLC MIU Realty, LLC Green Bus Holding Corp. JLK Capital, LLC Jamaica Bus Holding Corp. Green Bus Holding Corp. Triboro Coach Holding Corp. Jamaica Bus Holding Corp. New York Bus Services Triboro Coach Holding Corp. And its affiliates and the respective affiliates and subsidiaries existing New York Bus Services currently or in the future of and successors to each Indemnified Party listed And its affiliates and the respective affiliates and subsidiaries existing herein. currently or in the future of and successors to each Indemnified Party listed herein. Additional Indemnitees Required for work at 2 Broadway: United States Trust Company of New York as Trustee under the 2 Broadway Additional Indemnitees Required for work at 2 Broadway: 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 and successors to each Indemnified Party listed herein. Other: Other: 11/27/2017 CERTIFICATE OF INSURANCE MTA Joint Agency (Continued) Page 3 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 ______________ 11/27/2017 .
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