2-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Solicitation number
- RFP-26-00156
- Issued by
- Hillsborough County, Madeira Beach City, Florida
About this file
This is a Certificate of Liability Insurance template issued by Hillsborough County Board of County Commissioners (BOCC) Risk Management Division in Florida for a membrane-based landfill leachate treatment services contract. The certificate serves as proof that a contractor has obtained and maintains required insurance coverage for the Southeast County Landfill leachate treatment project located at 15960 County Road 672, Lithia, FL. The project is valued at $26,600,000.00, and the certificate holder must provide proof of active insurance policies with coverage effective through the contract term. Questions and requests for interpretation regarding the contract must be submitted no later than 14 calendar days after the solicitation issuance, site visit, or pre-bid conference, whichever occurs latest.
The certificate requires contractors to obtain General Liability, Automobile Liability, Workers' Compensation and Employer's Liability insurance, with Hillsborough County named as an Additional Insured on all applicable policies. All insurance policies must include endorsements prohibiting cancellation or reduction of coverage without providing 30 days' written notice to the certificate holder. Specific coverage limits, deductibles, and aggregate amounts must be completed by the contractor's insurance provider. The certificate must be signed by an authorized representative of the insured party and submitted to Hillsborough County BOCC Risk Management Division at 601 E. Kennedy Boulevard, 17th Floor, Tampa, FL 33602, with notification via fax at 813-635-8284.
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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)
File details come from the government source that posted it. Updated .