Military Bus Agreement

CERTIFICATE OF INSURANCE
This is to certify that:
_____________________________________________________________ (hereinafter called
the Insurer) of (Name of Insurer)
__________________________________________ has issued to __________________________________
(Address of Insurer)
(Name of Bus Carrier)
(hereinafter called the Named Insured) of ____________________________________________ an insurance
(Address of Bus Carrier)
policy No. _____________________________ with respect to the Public Liability of the said
carrier for bodily
injury effective from _________________________ to _________________________. The
limits of liability under the said policy are not less than the following, with respect to:
(a) Vehicle with seating capacity of 16 passengers or more ... $5,000,000.00
(b) Vehicle with seating capacity of 15 passengers or less ... $1,500,000.00
The terms and conditions of the policy apply within the following geographical limits (if any):
This policy complies with Department of Transportation requirements set forth in 49 C.F.R. 387
and with Interstate Commerce Commission requirements set forth in 49 C.F.R. 1043. If the
insurer changes or cancels the policy, insurer agrees to notify the Military Surface Deployment
and Distribution Command, ATTN: SDPP-IP, 200 Stovall Street, Alexandria, VA 22332-5000.
(Name of Insurer)
Date ____________ 20 ______
_______________________________________________
(Name and Address of Broker - if applicable)
________________________ personally appeared before me this ____________ day (Typed
Name of Above Signatory) of _____________________ and swore that he has personal
knowledge that the insurance is in effect and is in (Month and Year) accordance with the terms
specified hereon, and that he is authorized to sign the above certificate.
Subscribed and sworn to before me this _________ day of _____________________
(Month and Year) SEAL ________________________________________
________________________________________
NOTE: All signatures must be handwritten. Rubber stamp impressions are not acceptable.
ATTACHMENT 3