CERTIFICATE OF INSURANCE REQUIREMENTS
Certificates of Insurance covering General and Automobile Liability, Worker’s Compensation
and Garage and Garage Keepers Liability are required to be furnished by the awarded bidder for
Bid 1727. To comply with the requirements issued by the Risk Manager, Office of City
Attorney, an Affidavit of No Interest form must accompany each Insurance Certificate submitted
by the insurance company. The Affidavit states that no city official or employee has or will
receive anything of value in connection with your insurance carrier furnishing the requested
The Affidavit(s) must be notarized, referenced and signed by the same Agent or Surplus Lines
Intermediary who signed the insurance certificate.
The corresponding City bid, contract and/or purchase order number is referenced in the upper
right hand corner of the Affidavit.
The completed and original Affidavit of No Interest form(s) should be submitted to:
City of Milwaukee-Procurement Services
Attn: Janine Wilant-Bid 1727
200 E. Wells Street, Room 601
Milwaukee, WI 53202
If additional copies of the Affidavit form are needed, copies may be made of the following
AFFIDAVIT OF NO INTEREST
AFFIDAVIT MUST ACCOMPANY EACH CERTIFICATE OF INSURANCE
ISSUED, INCLUDING NEW AND RENEWALS
_______________________________________, being first duly sworn, on oath deposes and
(Insurance Agent that signed insurance certificate submitted)1
says that he/she is the agent of the
____________________________________________, insurer, on the attached certificate issued
(Insurance Company(s) Named on Insurance Certificate that apply
-under Insurers Affording Coverage)
(Name of Insured/Contractor listed on insurance certificate)
Affiant further deposes and says that no officer, official or employee of the City of Milwaukee
has any interest, directly or indirectly, or is receiving any premium, commission, fee or other
thing of value in connection with the furnishing of said insurance certificate.
Subscribed and sworn to/before me this ___________ day of ___________________________,
________________________________________________, Notary Public
My Commission expires: _______________________________________.
NOTE: THIS “AFFIDAVIT OF NO INTEREST” MUST BE COMPLETED
SIGNED BY THE PERSON WHO EXECUTED THE CERTIFICATE OF
SUBMITTED WITH YOUR CERTIFICATE OF INSURANCE.
The name of the insurance agent signing this affidavit –not the name of the insurance company. The same agent
whose name/signature is on the insurance certificate must complete this affidavit.