2-Insurance Certificate.doc
DOC document 94 KB Posted
- Solicitation number
- ITB-26-00355
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance document issued for Hillsborough County, a political subdivision of the State of Florida, related to the Railroad Crossing Dynamic Envelope Installation and Maintenance contract. The certificate serves as verification that required insurance policies are in force and will remain active for the duration of the contract work. Hillsborough County Board of County Commissioners (BOCC) Risk Management Division is named as the certificate holder at 601 E. Kennedy Boulevard, 26th Floor, Tampa, Florida 33602, with fax contact at 813-635-8284. The document outlines the framework for multiple types of insurance coverage that contractors must maintain throughout the three-year contract period for maintaining and installing railroad crossing dynamic envelopes at various locations throughout the county.
The certificate template specifies requirements for General Liability (including Commercial General Liability with Claims Made or Occur basis options), Automobile Liability (covering any owned, scheduled, hired, or non-owned autos), Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability coverage. Hillsborough County must be named as an Additional Insured on the listed General, Auto, and Aircraft Liability Policies, with a requirement that insurance policies include a 30-day cancellation notice provision to the certificate holder. The document requires contractors to maintain Contractual Liability Coverage within their General and Auto Liability Policies and includes Separation of Insureds provisions. All specific coverage limits, deductibles, and retention amounts are to be completed by the producer based on the contract requirements established by Hillsborough County.
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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 .