2-Insurance Certificate.doc
DOC document 94 KB Posted
- Attached to
- Sand Delivered for Sandbag Operations State and local contract opportunity
- Solicitation number
- ITB-26-00073
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance form for Hillsborough County Board of County Commissioners in Florida related to a sand delivery contract for sandbag operations. The certificate template provides a standardized format for contractors to document their insurance coverage requirements, including general liability, automobile liability, garage liability, excess liability, and workers' compensation and employer's liability insurance. The form requires contractors to specify policy numbers, effective dates, expiration dates, and coverage limits for each insurance category, with checkboxes indicating whether coverage applies on a per-policy or per-project basis. Hillsborough County, identified as a political subdivision of the State of Florida, must be named as an Additional Insured on the listed General, Auto, and Aircraft Liability Policies. The certificate holder is listed as Hillsborough County – BOCC Risk Management Division, located at 601 E. Kennedy Boulevard, 26th Floor, Tampa, Florida 33602, with fax number 813-635-8284.
The insurance certificate requires that all policies include a 30-day written notice clause before any cancellation or reduction of coverage becomes effective, ensuring continuous protection for the county. Contractors must provide evidence that contractual liability coverage is included in their general and auto liability policies and that their general liability policies contain a Separation of Insureds (severability of interests) provision. This insurance documentation is required as a condition of participation in the three-year sand delivery contract with an estimated project value of $617,490.00.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| 5-ITB-26-00073 Insurance Requirements Attachment.pdf | ||
| 1-Drug Free Workplace Form.doc | DOC document | |
| 4-Direct Deposit Authorization Form 5.15.2025.pdf.pdf | ||
| 3-Substitute W9 Form.pdf.pdf | ||
| 6-ITB-26-00073 Sand Delivered for Sandbag Operations.pdf |
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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 .