2-Insurance Certificate.doc
DOC document 94 KB Posted
- Attached to
- Truncated Domes and Detectable Warning Devices State and local contract opportunity
- Solicitation number
- ITB-26-00340
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance form issued to Hillsborough County, a political subdivision of the state of Florida, for a contract involving the furnishing, removal, and installation of detectable warning devices and truncated domes at various locations throughout the county. The certificate serves as proof that the contractor maintains active insurance policies covering general liability, automobile liability, workers' compensation, and employer's liability. The form indicates that Hillsborough County, through its Board of County Commissioners Risk Management Division located at 601 E. Kennedy Boulevard, 26th Floor, Tampa, Florida 33602, has been named as an additional insured on the general, auto, and aircraft liability policies. The certificate requires 30 days' written notice prior to any cancellation or modification of the listed coverage.
The certificate template includes provisions for multiple types of insurance coverage with specific limits to be completed by the contractor's insurer, including general aggregate limits, fire damage coverage, automobile liability for any autos or scheduled vehicles, excess liability coverage, and workers' compensation statutory limits. The contractor is required to maintain contractual liability coverage within the listed general and auto liability policies and must include a separation of insureds provision in the general liability policies. The certificate holder contact information identifies Hillsborough County Risk Management Division with a fax number of 813-635-8284, indicating this document is a standard requirement for contractors bidding on or executing this three-year detectable warning device project with an estimated value of $284,125.00.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| 1-Drug Free Workplace Form.doc | DOC document | |
| 4-Direct Deposit Authorization Form 5.15.2025.pdf.pdf | ||
| 6-ITB-26-00340 Truncated Domes and Detectable Warning Devices.pdf | ||
| 5-ITB-26-00340 Insurance Requirements.pdf | ||
| 3-Substitute W9 Form.pdf.pdf |
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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, 26th FL
Tampa, FL 33602 Authorized Representative:
Signature _____________________________________
ICM – 015 (09/10)
File details come from the government source that posted it. Updated .