2-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Solicitation number
- RFP-26-00262
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance form issued for Hillsborough County, a political subdivision of the state of Florida, specifically for the Water Resources Department's Customer Billing, Payment, and Engagement Solution contract. The certificate documents insurance policies in force for the contractor and certifies that coverage will not be cancelled or materially reduced without 30 days' written notice to Hillsborough County's Risk Management Division. The form establishes that Hillsborough County has been named as an additional insured on the contractor's general, auto, and aircraft liability policies, and confirms that contractual liability coverage is included in the listed policies. The certificate requires detailed information regarding policy types, numbers, effective and expiration dates, and specified coverage limits across multiple insurance categories.
The insurance requirements outlined in this certificate include General Liability coverage with specified aggregate and per-occurrence limits, Automobile Liability coverage for any or scheduled autos, Workers' Compensation and Employer's Liability coverage, Excess Liability coverage, and Garage Liability coverage as applicable. The form mandates that the contractor maintain continuous insurance coverage throughout the five-year contract period valued at $26,314,792.80 for the electronic payment receipt system project. Certificate holder information directs all communications to Hillsborough County—BOCC Risk Management Division at 601 E. Kennedy Boulevard, 17th Floor, Tampa, Florida 33602, with a fax number of 813-635-8284. This certificate serves as proof of the contractor's compliance with the County's mandatory insurance requirements prior to contract execution and during performance.
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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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