Certificate of Insurance Requests
Requester's information:
Requester's Name (First & Last)
Email
Requester's Phone Number
Request for Railroad Liability Policy
Please note - it is uncommon to request for a Railroad Liability Policy. Only select "yes" if
project will be located above, below or adjacent to a railroad
.
Request for Railroad Liability Policy too?
Yes
Railroad Liability Policy Details
Insured Name (Railroad)
Insured Address
Effective Date
Expiration Date
Entity(ies) performing the work
Please select...
InfraServices Group Resources LLC
InfraServices Group Wireless LLC
Recovery Logistics LLC
Hold down CTRL key for multiple selection
Contract Number or Nake
Does your work include any bridge work?
Yes
No
Does the project involve overhead lines and/or wireworks?
Yes
No
Does the project involve underground lines/wire and/or underground pipe work?
Yes
No
Does the project involve any work within 50 feet of the railroad right of way?
Yes
No
Is a slow order in place for the duration of the project?
Yes
No
Will the railroad add flagmen or supervisors to the project?
Yes
No
Will other railroad employees (other than flagmen/supervisors) be assigned to the project
Yes
No
Description of work to be performed:
Project Location (be as detailed as possible - mile marker, cross roads, etc.)
State where project is located
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
In which city is the project located?
The work is: (Select all that apply)
Please select...
Adjacent to the tracks
Over the tracks
Under the tracks
at right angles to the track
parallel to the tracks
Hold down CTRL key for multiple selection
The project involves: (Select all that apply)
Please select...
Use of explosive or fireworks
Underground construction such as subways or mines (does not apply to underground pipes)
Work in existing refineries, chemical plants, mills or grain elevators
Hazardous chemicals
Underwater
Actual construction
Hold down CTRL key for multiple selection
Total Contract Price
# of trains per day
Contract Price within 50ft of the Railroad Right of Way
Requested Limit
Division of Company
Please select...
Infraservices Group LLC
Infraservices Group Wireless LLC
QualTek Fulfillment LLC
QualTek LLC
QualTek Recovery Logistics LLC
QualTek USA, LLC
QualTek Wireless LLC
QualTek Wireline LLC
Recovery Logistics LLC
Recovery Logistics, LLC
Site Safe, LLC
Vertical Limit Construction, LLC
This is the division that will appear on the COI.
Scope of work being performed
Certificate Holder Information:
Certificate Holder Name
As needed on COI. This is who is requested, not QualTek, Empire, Velocitel or NX. Fill in information, please do not say refer to attached.
Certificate Holder Address
As needed on COI. This is for the certificate holder, NOT your address. Must be a full address with Street, City, State and Zip Code.
Additionally Insured
If needed, list name and any other required specifications. Fill in information, please do not say refer to attached. This should NOT be a division of QualTek.
Other requirements:
Please list and describe additional items needed. Examples: endorsements, specifications in the description of operations, etc. Fill in information, please do NOT say refer to or see attached.
Is this certificate holder based out of New York State?
Yes
No
New York Entities Only
Is a New York State DB-120.1 Certificate of NYS Disability Benefits Insurance required
Yes
No
Is a New York State C-105.2 Certificate of Workers' Compensation Insurance required
Yes
No
Attach a copy of their sample COI
QualTek Renewables LLC
Primary and Non Contributory
Waiver of Subrogation
Contact Information