Community Impact & Enhancement Department

Upload the Certificate(s) of Insurance at the end of this document.  

The Community Impact & Enhancement Grants Management Division has the following insurance requirements for our contractors:

1. Comprehensive Public Liability: No less than $1,000,000 for injuries including accidental death to any person, per accident, and $2,000,000 in the aggregate for the policy term.
2. Workers Compensation and Employee Liability: Not less than $100,000 per person for employer’s liability.
3. Auto Insurance: For injuries or damages caused by the Contractor’s vehicle on the job site, a minimum combined single liability of $500,000. 

Upload copies of your certificate(s) of insurance below and any certifications you might have.

The undersigned contractor certifies that all information given herein is correct and further agrees:

1. That all insurance requirements and proper licenses will be maintained as required by the City;
2. That the work will be performed in accordance with all codes, standards, zoning regulations, and specifications, subject to a clear final inspection by the Community Impact & Enhancement Department;
3. That if the work is found to be unsatisfactory by the inspector or if contract relations between the contractor and homeowner are found to be unsatisfactory, the contractor’s name may be removed from the approved list; and
4. That I/We will abide by the U.S. Department of Housing and Urban Development (HUD) regulations pertaining to equal employment opportunity, and all other applicable federal and state regulations.
5. That the City of Bloomington is hereby authorized to verify the company’s credit status and any information contained in this application. 
6. That I/We will maintain comprehensive liability insurance, worker's compensation and employee liability, and auto insurance.

AUTHORIZATION TO RELEASE INFORMATION

Program Administrator (Sponsor) Name: Community Impact & Enhancement Department, City of Bloomington, Illinois

Program Administrator (Sponsor) Address:115 E. Washington St., PO Box 3157, Bloomington, IL 61702-3157

I hereby authorize the City of BloomingtonCommunity Impact & Enhancement Department to verify my bank accounts employment records, outstanding debts, and supplier statements, to order consumer credit reports, and to make other inquiries pertaining to my qualifications to be on the Economic and Community Development Department’s Approved Contractor list. The Sponsor may make copies of this letter for distribution to any party with which I have a financial or credit relationship and such party may rely on such copy as if the same were an original.

PRIVACY ACT NOTICE: All the information collected by the Sponsor or its assignees shall be used in determining whether I qualify to be on the Community Impact & Enhancement Department Grants Management Division’s “Approved Contractor’s List.” Such information will not be disclosed outside of the Sponsor except as required and permitted by law. 

Thank you for applying. A member of the staff will contact you if any additional information is needed.