2-Insurance Certificate.doc
DOC document 94 KB Posted
- Attached to
- Marine Safety Work Boat
- Solicitation number
- ITB-26-00402
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance template issued by Hillsborough County Board of County Commissioners (BOCC) Risk Management Division in Florida for contractors engaged in county work. The certificate serves as proof that insurance policies have been issued to contractors and are currently in force, with provisions requiring 30 days' written notice before any cancellation or reduction in coverage. The document covers multiple insurance types including General Liability, Automobile Liability, Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability. Hillsborough County, identified as a political subdivision of the state of Florida, must be named as an Additional Insured on the General, Auto, and Aircraft Liability Policies. The certificate holder information is directed to Hillsborough County BOCC Risk Management Division at 601 E. Kennedy Boulevard, 26th Floor, Tampa, Florida 33602, with fax number 813-635-8284.
The certificate template requires contractors to specify policy numbers, effective and expiration dates, and coverage limits across all insurance categories, including General Aggregate Limits, Each Occurrence amounts for General Liability, Combined Single Limits for Automobile Liability, and statutory limits for Workers' Compensation. Contractors must indicate whether coverage is provided on a per-policy or per-project basis and whether claims are made on an occurrence or claims-made basis. The template includes checkboxes for optional provisions such as Contractual Liability Coverage inclusion in General and Auto Liability Policies and Separation of Insureds provisions. This insurance certificate requirement is associated with Hillsborough County's Marine Safety Work Boat procurement, which is a one-time purchase of a single vessel with an estimated project value of $400,000.00.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .