10-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Attached to
- Countywide Fire Hydrant Replacement - WORCS-5
- Solicitation number
- IFB-26-00348
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance template associated with Hillsborough County's Countywide Fire Hydrant Replacement project (WORCS-5) in Florida. The certificate serves as documentation that an insured contractor maintains active insurance policies covering general liability, automobile liability, garage liability, excess liability, and workers' compensation with employer's liability coverage. The template requires completion with specific policy numbers, effective dates, expiration dates, and coverage limits across multiple insurance categories. Hillsborough County, through its Board of County Commissioners Risk Management Division located at 601 E. Kennedy Boulevard, 17th Floor, Tampa, Florida 33602, must be named as an additional insured on the general, auto, and aircraft liability policies. All listed policies must include 30-day written notice requirements prior to cancellation or material changes to coverage.
The certificate template mandates that contractors maintain contractual liability coverage within their general and auto liability policies and include separation of insureds provisions in general liability policies. The insurance requirements establish minimum protections for the county during the fire hydrant replacement project, which involves replacement of hydrants, hydrant assemblies, and valves on existing water mains throughout the county with an estimated project value of $1,900,000. No specific dollar amounts for insurance limits are pre-filled in the template, indicating that required coverage amounts must be specified in the project's bid documents or contract specifications. The certificate holder information block designates the Risk Management Division as the primary contact with a fax number of 813-635-8284 for certificate delivery and verification purposes.
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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)
File details come from the government source that posted it. Updated .