2-Insurance Certificate.doc
DOC document 94 KB Posted
- Solicitation number
- ITB-26-00147
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance template for Hillsborough County Board of County Commissioners (BOCC) Risk Management Division in Tampa, Florida, related to the Fuel Site Maintenance, Repair, & Parts Supply Services contract opportunity. The certificate documents insurance policies issued to contractors and certifies that coverage remains in force with 30 days' written notice required before any cancellation or material changes. The template accommodates multiple insurance types including General Liability (with claims-made or occurrence basis options), Automobile Liability (covering any auto, owned, scheduled, hired, or non-owned vehicles), Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability coverage. The certificate requires Hillsborough County to be named as an Additional Insured on the General, Auto, and Aircraft Liability Policies, with specific line items for policy limits across all coverage types, including General Aggregate Limits, Each Occurrence limits, Bodily Injury, Property Damage, and Disease coverage thresholds.
The certificate form requires detailed information from the Producer including policy numbers, effective and expiration dates, and specific limits for each coverage type, though actual dollar amounts and coverage selections are not populated in this template. The certificate holder is identified as Hillsborough County – BOCC Risk Management Division at 601 E. Kennedy Boulevard, 26th Floor, Tampa, FL 33602, with a fax number of 813-635-8284. The form includes optional provisions allowing contractors to confirm that contractual liability coverage is included in listed policies and that General Liability policies include severability of interests provisions. An authorized representative signature is required to validate the certificate.
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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 .