2-Insurance Certificate.doc
DOC document 94 KB Posted
- Attached to
- Portable Toilet Rentals and Maintenance Services
- Solicitation number
- ITB-26-00150
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance form for Hillsborough County, a political subdivision of the state of Florida, related to the Portable Toilet Rentals and Maintenance Services contract opportunity. The certificate template outlines required insurance coverage types and limits that must be maintained by contractors bidding on or performing work for Hillsborough County. The document specifies that Hillsborough County – BOCC Risk Management Division (located at 601 E. Kennedy Blvd, 26th Floor, Tampa, FL 33602) must be named as the certificate holder and additional insured on applicable policies. The template accommodates multiple insurance types including General Liability, Automobile Liability, Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability coverage. All listed policies must include 30-day notice provisions before cancellation or material changes in coverage.
The certificate form requires contractors to specify policy numbers, effective dates, expiration dates, and coverage limits for each insurance type selected. Contractors must indicate whether General Liability coverage is provided on a claims-made or occurrence basis and specify aggregate limits on a per-policy or per-project basis. The form allows contractors to document scheduled or non-owned auto coverage as applicable to their operations. Additionally, contractors may need to provide evidence that contractual liability coverage is included in their General and Auto Liability policies and that a Separation of Insureds provision is included in their General Liability policies. This insurance documentation is a standard requirement for the two-year portable toilet rental and maintenance services contract with an estimated value of $246,994.50.
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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 .