C 218 Form PDF Details

In the complex world of contract management and insurance within the State of New York, the C 218 form serves a critical function, ensuring that contractors working with the New York State Department of Transportation (NYSDOT) meet essential insurance requirements. This comprehensive Certificate of Insurance, last updated on February 9, 2010, is a requisite document designed to provide NYSDOT with proof that a contractor has procured the necessary insurance coverages for their project. It encompasses a wide array of insurance types, including Workers’ Compensation, Commercial General Liability, and Professional Liability, among others, detailing policy numbers, effective and expiration dates, limits of liability, and specifics regarding deductibles or self-insured retentions (SIR). Additionally, it outlines the procedures for policy changes, cancellations, and notifications, thus ensuring that all party obligations under New York State law and contractual agreements are transparent and enforceable. Notably, the form requires notarization and mandates that policy coverage stated therein must align with the actual coverage, with any discrepancies being subject to legal penalties under Section 2110 of the New York State Insurance Law. By providing a standardized approach to certify insurance coverage, the C 218 form facilitates smoother project executions and contributes to the overall integrity and reliability of contractual engagements in the state's transportation sector.

QuestionAnswer
Form NameC 218 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesNew_York, False, hr218 c form ny, Notarization

Form Preview Example

C 218 fillable form (02/09/10)

 

CERTIFICATE OF INSURANCE

 

Send Both Certificates to

 

New York State Department of Transportation

 

Office of Contract Management

 

Office of Contract Management

 

 

 

 

50 Wolf Road, 1st Floor

 

 

 

 

Albany, New York 12232

 

 

 

Name & Address of Insured Contractor:

Additional Insured: (under items b, c, d & h)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Description of Work:

Contract #:

The subscribing insurance company, authorized to do business in the State of New York, certifies that insurance of the kinds and types and for limits of liability herein stated, covering the work described in the underlying contract herein identified, has been procured by and furnished on behalf of the insured and is in full force and effect for the period listed below.

Kind of Insurance

Policy Number

Effective Date

Expiration Date

Limits of Liability (in thousands)

 

Insurer

 

 

Per Occurrence

Aggregate

(a)Workers’ Compensation and

 

 

 

 

 

Disability.

 

 

 

Statutory

Statutory

Attach C-105.2 (workers’ comp.),

 

 

 

 

 

and DB-120.1 (disability)

 

 

 

 

 

(b) Commercial General Liability.

 

 

 

 

 

Additional Insured

Endorsement:

 

 

 

 

Endorsement (identify ISO

 

 

 

 

 

form or attach copy of

 

 

 

 

 

endorsement).

 

 

 

 

 

Completed Operations

Endorsement:

 

 

 

 

(If provided under

 

 

 

 

 

endorsement, identify ISO form

 

 

 

 

 

or attach copy).

 

 

 

 

 

Insured-administered

 

 

 

Deductible/SIR

Deductible/SIR

deductible or Self-Insured

 

 

 

 

 

Retention (SIR)*

 

 

 

 

 

(state amount of SIR)

 

 

 

 

 

(c) Commercial Auto Liability

 

 

 

 

 

Insurance.

 

 

 

 

 

Insured-administered

 

 

 

Deductible/SIR

Deductible/SIR

deductible or SIR*

 

 

 

 

 

(state amount of SIR)

 

 

 

 

 

(d) Umbrella or Excess Liability

 

 

 

 

 

Insurance.

 

 

 

 

 

(e) Special Protective and Highway

 

 

 

 

 

Liability.

 

 

 

 

 

(f) Railroad Protective Liability

 

 

 

 

 

Insurance.

 

 

 

 

 

(g) Professional Liability

 

 

 

 

 

Insured-administered

 

 

 

Deductible/SIR

Deductible/SIR

deductible or SIR*

 

 

 

 

 

(state amount of SIR)

 

 

 

 

 

(h) Builders’ Risks

 

 

 

 

 

Insured-administered

 

 

 

Deductible/SIR

Deductible/SIR

deductible or SIR*

 

 

 

 

 

(state amount of SIR)

 

 

 

 

 

(i) Other (describe)

 

 

 

 

 

* NYSDOT requires disclosure of deductibles and retention levels that are not pursuant to policy provisions, not bonded or otherwise collateralized.

This is to certify that

2

(hereinafter called Company) of

has issued to of

a policy or policies of insurance effective from the dates listed on the front of this certificate at 12:01 A.M. standard time at the address of the insured stated in said policy or policies and continuing until cancelled as provided herein to provide liability insurance covering the obligations imposed upon such contractor by the provisions of the laws of the State of New York, regulations promulgated therewith and the terms and provisions of Contract

D .

Such insurance as is herein certified (1) applies to all operations of said insured in connection with the work required by the provisions of the documents forming the contract, (2) applies on the effective date stated above, whether or not the contract documents between the insured contractor and the New York State Department of Transportation have been executed, and (3) is written in accordance with the company’s regular policies and endorsements, subject to the company’s applicable manuals or rules and rates, in effect, and the insurance provisions of the contract.

This Certificate is furnished in accordance with the specifications of the New York State Department of Transportation applicable to NYSDOT’s contract with the Named Insured and covering the operations therein described.

These certificates described herein may not be cancelled without cancellation of a policy to which it is attached. Such cancellation may be issued by the company or the insured giving thirty (30) days’ notice in writing is actually received in the Main Office of New York State DOT, Director of Contract Management & Audit, 50 Wolf Road, 1st Floor, Albany, New York 12232. No policy referred to herein shall be changed, cancelled or coverage terminated for any reason including expiration of the policy or nonpayment of premiums until thirty (30) days written notice has been received by the Director. Such notice shall be mailed via certified mail or registered mail.

Policy coverage MUST agree with coverage stated on this Certificate. False statements of coverage are punishable under Section 2110 of the New York State Insurance Law.

Notarization

Sworn before me this _______

day of _____________, 20___.

Notary Public (attach stamp)

By: _______________________________________________

(Signature of Authorized Representative)

RUBBER STAMP NOT ACCEPTABLE

Dated: ________________________

Agency Name and Address:

Dated: _______________________

Telephone Number: ________________________________________

C218 (12/29/09)

REVERSE

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Writing part 1 in New_York

2. Once your current task is complete, take the next step – fill out all of these fields - Additional Insured Endorsement, Insurance, Insuredadministered deductible or, d Umbrella or Excess Liability, Insurance, e Special Protective and Highway, Liability, f Railroad Protective Liability, Insurance, g Professional Liability, Insuredadministered deductible or, h Builders Risks, Insuredadministered deductible or, DeductibleSIR, and DeductibleSIR with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Completing section 2 in New_York

3. Completing This is to certify that, Such insurance as is herein, This Certificate is furnished in, applicable to NYSDOTs contract, These certificates described, Policy coverage MUST agree with, and Section of the New York State is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Guidelines on how to fill in New_York stage 3

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The best ways to complete New_York part 4

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