2-Insurance Certificate.doc
DOC document 94 KB Posted
- Attached to
- Rental of Traffic Control Devices
- Solicitation number
- ITB-27-00002
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance form associated with the Hillsborough County Board of County Commissioners' competitive sealed bid solicitation for the rental of traffic control devices. The certificate template outlines the required insurance coverage that bidders and contractors must maintain throughout the contract period. Hillsborough County, identified as a political subdivision of the state of Florida, must be named as an Additional Insured on all General, Auto, and Aircraft Liability Policies. The certificate requires documentation of multiple insurance types including Commercial General Liability, Automobile Liability, Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability coverage, with specific limits to be completed by the insured party based on contract requirements.
The certificate establishes that all listed insurance policies must include endorsements providing 30 days' written notice to the certificate holder prior to cancellation or reduction of coverage. The certificate holder is identified as Hillsborough County - BOCC Risk Management Division, located at 601 E. Kennedy Blvd, 26th Floor, Tampa, FL 33602, with fax contact at 813-635-8284. Contractors must confirm that Contractual Liability Coverage is included in their General and Auto Liability Policies and that listed General Liability Policies contain a Separation of Insureds provision. This insurance requirement applies to the three-year traffic control device rental contract with an estimated value of $688,970.00.
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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 .