Annual Backflow Tester Information and Certificate of Insurance

All persons performing backflow preventer tests in the City of Lincoln who wish to be on the Lincoln Water System list of approved backflow contractors must submit documentation annually. Please see the List of Requirements tab for details on insurance criteria.

Submit the form below, or download the PDF form(, 0B) and return it along with Annual Certificate of Insurance Documentation to Lincoln Water System, Backflow Prevention Office, 2021 N 27th Street, Lincoln, NE 68503 | Email: backflow@lincoln.ne.gov | Fax: 402-441-8003.

Form & Insurance Requirements  Download PDF (, 0B)

Approved Tester Insurance and Grade VI Requirements

All persons performing backflow preventer tests in the City of Lincoln who wish to be on the Lincoln Water System list of approved Backflow Contractors must meet the following criteria:

1. Annually provide a Certificate of Insurance that has City of Lincoln and/or Lincoln Water Systems as an additional insured under the General Liability Coverage. (This should be indicated on the Certificate of Liability Insurance under the Description of Operations/Locations/Vehicles/Exclusions Added by Endorsement/Special Provisions.)
   1. 4.7 Certification and Registration of Technicians
      1. 4.7.1 Persons performing inspections, tests and repairs of backflow prevention assembly(s), and persons conducting surveys and investigations of property or properties served by the Lincoln Water System for the purpose of backflow prevention compliance, shall be Registered Grade 6 Water Operators as defined by LMC Title 17. The Lincoln Water System will maintain a current list of registered Grade 6 Water Operators.
      2. 4.7.2 Registered Grade 6 Water Operators must always maintain public liability insurance coverage for all claims arising out of all work in the City of Lincoln. Such insurance shall be commercial or comprehensive general liability policy, or an acceptable substitute as permitted by the City Attorney. The minimum combined single limit of $500,000.00 aggregate for any one occurrence on any job for which a permit is required under this code, provided the City of Lincoln shall be named an additional insured thereunder. The coverages required herein shall be subject to review and approval by the City Attorney for conformance with the provisions of this section.
2. Annually provide a copy of CG 20 12 11 85 the Additional Insured-State or Political Subdivisions-Permits with the policy number on the endorsement, listing Lincoln Water System 2021 N 27th Street Lincoln NE 68503. Any endorsement referencing a written contract will be returned as the insured is NOT contracting with the City of Lincoln or Lincoln Water System to do work.
3. The certificate of insurance must include verification that the general liability policy includes 30 days written notice of cancellation. In the event the certificate of insurance form does not provide a field to include this information, it can be identified in the Description of Operations section; by attaching a copy of the language in the policy; or providing a copy of the cancellation endorsement.
4. The certificate must list the policy number for the general liability coverage and be signed by an authorized agent.

Please attach a copy of your current certificate of insurance or proof of self-insurance in the online form; mail a copy to Lincoln Water System C/O Backflow Specialist at 2021 North 27th Street, Lincoln NE 68503; fax to 402-441-8003; or email backflow@lincoln.ne.gov.

Example Certificate of Insurance and Additional Endorsement  Download PDF (, 0B)

If you have any questions, please contact the Lincoln Water System Backflow Office at 402-441-5912 or email backflow@lincoln.ne.gov.