2-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Attached to
- Uniforms for Hillsborough County Sunshine Line
- Solicitation number
- ITQ-26-00124
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance form for Hillsborough County, Florida, Board of County Commissioners (BOCC), specifically related to the Uniforms for Hillsborough County Sunshine Line procurement opportunity. The certificate serves as proof that an insured contractor has obtained the required insurance coverage and will maintain such coverage throughout the contract term. The form outlines multiple types of insurance coverage that must be provided, including General Liability, Automobile Liability, Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability. Hillsborough County, identified as a political subdivision of the State of Florida, must be named as an Additional Insured on the General, Auto, and Aircraft Liability policies. The certificate holder is the Hillsborough County BOCC Risk Management Division located at 601 E. Kennedy Boulevard, 17th Floor, Tampa, Florida 33602, with a fax number of 813-635-8284. The insurance policies must include an endorsement providing 30 days' written notice to the certificate holder before any cancellation or reduction in coverage.
The certificate requires that all insurance policies remain in force at the time of execution and throughout the contract performance period. Specific dollar limits and coverage types must be indicated and completed by the insurance producer, including General Aggregate limits, Each Occurrence limits, and other applicable coverage thresholds. The form includes checkboxes for various coverage options such as Claims Made versus Occurrence basis, different automobile classifications, and statutory workers' compensation limits. All listed General Liability policies must include a Separation of Insureds provision ensuring severability of interests among multiple parties. This insurance requirement applies to the estimated $30,862.00 uniform supply contract with a two-year term.
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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, 17th FL
Tampa, FL 33602 Authorized Representative:
Signature _____________________________________
ICM – 015 (09/10)
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