2-Insurance Certificate.doc
DOC document 94 KB Posted
- Solicitation number
- ITB-26-00390
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance document required by Hillsborough County, a political subdivision of the State of Florida, for contractors performing work on the county's behalf. The certificate serves as proof that the insured contractor maintains active insurance coverage across multiple policy types, including General Liability, Automobile Liability, Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability insurance. The document certifies that all listed policies remain in force and contain endorsements requiring 30 days' written notice to Hillsborough County before any cancellation or material reduction in coverage. The county's Risk Management Division, located at 601 E. Kennedy Boulevard, 26th Floor, Tampa, Florida 33602, must be named as the Certificate Holder and Additional Insured on General, Auto, and Aircraft Liability policies.
The certificate template includes designated fields for insurance carriers to specify policy numbers, effective and expiration dates, and coverage limits across all required insurance types. The contractor must provide detailed limits for each coverage category, including General Aggregate Limits, General Occurrence Limits, Fire Damage, Personal and Advertising Injury, Products-Completed Operations Aggregate, Automobile Liability limits organized by accident type, and Workers' Compensation statutory limits and employer's liability limits by accident and disease categories. A separation of insureds provision is required in General Liability policies, and contractual liability coverage must be included within the listed General and Auto Liability policies. This certificate is associated with the Disposal, Pumping, Cleaning, and Transportation of Leachate contract opportunity valued at $245,350.00 for services at the Northwest County Transfer Station and South County Transfer Station over a three-year period.
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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)
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