2-Insurance Certificate.doc
DOC document 94 KB Posted
- Attached to
- Gambusia Holbrooki Mosquito Fish
- Solicitation number
- ITB-26-00227
- 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, specifically designed for contractors providing services to the county. The certificate establishes insurance requirements and coverage verification for vendors working with Hillsborough County Board of County Commissioners. The document serves as formal certification that required insurance policies are in force and will maintain coverage through the contract period, with a mandatory 30-day written notice requirement before any cancellation or material reduction in coverage. The certificate holder is identified as Hillsborough County - BOCC Risk Management Division, located at 601 E. Kennedy Boulevard, 26th Floor, Tampa, Florida 33602, with contact fax number 813-635-8284.
The certificate template requires contractors to obtain multiple types of insurance coverage including General Liability, Automobile Liability, Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability insurance. The form mandates that Hillsborough County be named as an Additional Insured on General, Auto, and Aircraft Liability policies. Contractors must provide specific coverage limits across multiple categories, including General Aggregate limits, Each Occurrence limits, Fire Damage coverage, and Products-Completed Operations Aggregate coverage. The template accommodates various policy structures including Claims Made and Occurrence basis options, allowing flexibility in how contractors structure their insurance programs while maintaining minimum protection standards required by the county for all contract work.
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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 .