10-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Solicitation number
- IFB-26-00363
- Issued by
- Hillsborough County, Florida
About this file
This Certificate of Liability Insurance is related to a roadway resurfacing, repair, and preservation contract with Hillsborough County Engineering and Operations in Florida for Districts 3 and 4. The certificate template outlines the required insurance coverages that contractors must maintain throughout the project duration, including general liability, automobile liability, garage liability, excess liability, and workers' compensation and employer's liability insurance. The certificate holder is identified as Hillsborough County Board of County Commissioners (BOCC) Risk Management Division, located at 601 E. Kennedy Boulevard, 17th Floor, Tampa, Florida 33602, and contractors must provide 30 days' written notice prior to any cancellation or material change to the coverage. Additionally, Hillsborough County must be named as an additional insured on all general, auto, and aircraft liability policies maintained by the contractor.
The certificate template requires contractors to complete specified policy details including policy numbers, effective and expiration dates, and coverage limits across multiple insurance categories. Contractors must confirm contractual liability coverage is included in their general and auto liability policies and verify that their policies contain a separation of insureds provision. This insurance requirement applies to the $16,000,000 estimated roadway resurfacing and preservation project, which involves milling, resurfacing, preservation treatments, and full depth reclamation throughout the county. The contract includes a 5% Small Business Enterprise (SBE) subcontractor participation goal that must be met by the awarded contractor.
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Text version
CERTIFICATE OF LIABILITY INSURANCE
Date:
Producer, Address, Telephone No.
Insurers Affording Coverage
Insurer A:
Insurer B:
Insured, Address
Insurer C:
Insurer D:
Insurer E:
This is to certify that the insurance policies listed below have been issued to the insured and are in force at this time. It is further certified that these policies have been endorsed to provide that they will not be cancelled or changed so as to reduce the described coverages until 30 days after written notice of such cancellation or change has been delivered to the certificate holder at the address shown below.
Insr
Ltr
| Type of Insurance |
| Policy Number |
| Policy Effective Date |
| Policy Expiration Date |
| Limits |
| General Liability |
FORMCHECKBOX
Commercial General Liability
FORMCHECKBOX
Claims Made FORMCHECKBOX Occur
FORMCHECKBOX
FORMCHECKBOX
General Aggregate Limit Applies per:
FORMCHECKBOX
Policy FORMCHECKBOX Project FORMCHECKBOX Loc
| Each Occurrence |
| $ |
| Fire Damage |
| $ |
| Personal & Advertising Injury |
| $ |
| General Aggregate |
| $ |
| Products – Completed Operations Aggregate |
| $ |
| Automobile Liability |
FORMCHECKBOX
Any Auto
FORMCHECKBOX
All Owned Autos
FORMCHECKBOX
Scheduled Autos
FORMCHECKBOX
Hired Autos
FORMCHECKBOX
Non-Owned Autos
FORMCHECKBOX
FORMCHECKBOX
| Combined Single Limit (Each Accident) |
| $ |
Bodily Injury
(Per Person)
Bodily Injury
(Each Accident)
Property Damage
(Per Accident)
| Garage Liability |
FORMCHECKBOX
Any Auto
FORMCHECKBOX
| Auto Only – Ea Acc |
| $ |
Other than Ea Acc Auto Only:
Aggregate
| Excess Liability |
FORMCHECKBOX
Occur FORMCHECKBOX Claims Made
FORMCHECKBOX
Deductible
FORMCHECKBOX
Retention $
| Each Occurrence |
| $ |
| Aggregate |
| $ |
| Workers’ Compensation and |
Employer’s Liability
| FORMCHECKBOX |
WC Statu- FORMCHECKBOX Oth-tory Limits er
| E. L. Each Accident |
| $ |
| E. L. Disease – Ea Emp |
| $ |
| E. L. Disease – Pol Limit |
| $ |
| Other |
| $ |
FORMCHECKBOX
Contractual Liability Coverage is Included in listed General and Auto Liability Policies.
FORMCHECKBOX
“Hillsborough County, a political subdivision of the state of Florida” has been named as an Additional Insured on the listed General, Auto and Aircraft Liability Policies.
FORMCHECKBOX
Listed General Liability Policies include a Separation of Insureds (severability of interests) provision.
FORMCHECKBOX
Other Provisions/Limitations/Conditions:
Certificate Holder: Fax No. 813-635-8284 Hillsborough County - BOCC
Risk Management Division
601 E. Kennedy Blvd, 17th FL
Tampa, FL 33602 Authorized Representative:
Signature _____________________________________
ICM – 015 (09/10)
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