Certificate of Insurance Request
Your firm has contracted with Middlebury to perform services.
Middlebury requires that all contractors, vendors, event sponsors, and caterers (hereinafter
“Contractors”), irrespective of size, volume of work, or length of contract must provide Middlebury with
evidence of insurance coverage. Minimum requirements are evidence of Workers’ Compensation, Auto,
and General Liability insurance.
Failure to provide such evidence will result in delay of authorization to commence work for
Middlebury and withholding of payment for work completed until certificates of insurance are
provided.
Please provide immediately current certificates of insurance, as detailed below to the requesting
department and submit renewed certificates of insurance when applicable.
For questions in regards to specific coverage, contact the Tom Corbin at (802) 443-5504 or at
Corbin@middlebury.edu .
MIDDLEBURY'S MINIMUM INSURANCE REQUIREMENTS
Workers’ Compensation Insurance
Insurance is required to cover all persons working, supervising, or otherwise engaged by Middlebury, the
contractor, or a subcontractor for work performed on premises owned by Middlebury or otherwise
pursuant to a contract with Middlebury..
For Corporations: All officers and employees of corporations must be covered, and the
contractor must provide a Certificate of Insurance verifying that coverage. For corporate officers exempt
by State of Vermont statute or agreement, the contractor must provide an executed copy of Middlebury’s
hold harmless agreement with respect to each exempt officer.
For Sole Proprietors and Owners (if Applicable): Middlebury requires either a Certificate of
Insurance or, if coverage is unavailable in the State of Vermont, a statement to that effect signed by the
firm’s owner as well as an executed copy of Middlebury’s Hold Harmless Agreement.
General Liability Insurance
This coverage must carry limits of not less than $1,000,000 per occurrence.
Auto Liability Insurance:
This coverage must carry limits of not less than $1,000,000 per occurrence.
Property Coverage:
All personal property, including but not limited to machinery, equipment, tools, supplies, and
clothing of the contractor is the responsibility of the contractor and must be insured by the contractor.
Named Insured:
All Certificates should list Middlebury by its full legal name: “The President and Fellows of
Middlebury College”. Middlebury should be a “named additional insured” on the Certificate.
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FROM:
Company Name:
Address:
City:
State:
ZIP:
Tel:
Fax:
Email:
TO:
President & Fellows of Middlebury College
Name of Department:
Address:
City:
State:
ZIP:
Tel:
Fax:
Email:
Re:
Certificate of Insurance – Worker’s Compensation Waiver and Hold Harmless Agreement
I,
of
(name)
(title)
,
(company name)
(hereafter The Company) have knowingly elected not to be covered by workers’ compensation insurance
while in the service of The Company.
The Company and I,
individually, hereby agree, jointly and severally, to defend, indemnify, and
hold harmless Middlebury, its respective affiliates, contractors, officers, directors, trustees, employees,
and agents from and against all claims, liabilities, damages, and expenses, including attorney’s and other
professionals’ fees, arising out of or related to the intentional or negligent acts or omissions of The
Company, its affiliates, contractors, officers, directors, trustees, employees, or agents.
The risk associated with work for and or at Middlebury have been explained to The Company and myself
and I understand the risk I and The Company are assuming.
Signed by its duly
authorized agent:
Date:
Printed Name:
Company Name:
Witness:
Printed Name of Witness:
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