Subcontractor Insurance Compliance Statement

Introduction
The purpose of this document is to confirm that the insurance requirements contained in our
Subcontract Agreement with your company are met for our mutual protection. Certificate of .
Insurance forms typically used by the insurance industry are inadequate, given the number of
restrictive endorsements currently used by the insurance industry and not notated on the
certiFicates. This document supplements the Certificate of Insurance and needs to be
completed by your insurance agent. Return this completed form along with your
initial Certificate of Insurance. We will only require this document once per poli,ty year.

Does your Commercial General Liability policy contain any of the following restrictive
end o rs e m ents?

• Residential or multi-family exclusion Yes- No-

• Subsidence or earth movement exclusion Yes_,_ No-

• Exterior insulation and finish system (EIFS) exclusion Yes- No-

• Mold or indoor air quality exclusion Yes- No-

• Damage to your work performed by subcontractor exclusion Yes

- No-

Does your policy contain an exclusion For explosion, collapse,

or underground hazards? Yes- No_

: Does your General Lia~iJjty policy include the following?

Contractual coverage provided to include the tort liability

assumed in the hold-harmless agreement Yes_ No_
Additional insured status to include' completed operations Yes_' _ No_

Name of Subcontractor

____ ~ Project-----------------------

Reviewed by:

Name Oate. _

Agency ~ Phone _