2-Insurance Certificate.doc
DOC document 94 KB Posted
- Solicitation number
- ITB-27-00005
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance template issued by Hillsborough County, a political subdivision of the state of Florida, for use in contractor compliance with county contracting requirements. The certificate serves as proof that an insured contractor maintains active insurance policies meeting specified coverage requirements. The document establishes that insurance policies issued to the contractor will not be cancelled or reduced without providing 30 days' written notice to Hillsborough County's Risk Management Division, located at 601 E. Kennedy Boulevard, 26th Floor, Tampa, Florida 33602. The certificate holder requirement mandates that Hillsborough County be named as an Additional Insured on all listed General, Auto, and Aircraft Liability policies.
The certificate template requires contractors to document multiple types of insurance coverage, including General Liability, Automobile Liability, Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability insurance, with specified policy limits and effective/expiration dates to be completed by the contractor's insurance provider. Contractors must indicate coverage types through checkboxes and provide corresponding policy numbers, effective dates, expiration dates, and liability limits for each coverage category. The template addresses the Lift Station Landscaping Maintenance Services contract, a five-year SBE Set-Aside valued at $503,750.00, requiring experienced contractors to provide landscaping maintenance services including mowing, weed eating, and edging at county pump station facilities and various other sites throughout Hillsborough County, Florida.
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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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