2-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Solicitation number
- RFP-26-00372
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance issued for a Community Development Block Grant (CDBG) Multi-Family Acquisition Rehabilitation project with Hillsborough County Board of County Commissioners in Florida. The certificate documents insurance coverage requirements for contractors and service providers working on the project, which has an estimated value of $3,800,000.00. The certificate confirms that insurance policies have been issued to the insured and are currently in force, with provisions requiring 30 days' written notice prior to any cancellation or reduction in coverage. Hillsborough County, as a political subdivision of the state of Florida, has been named as an additional insured on the listed General, Auto, and Aircraft Liability Policies, with the certificate holder identified as the Hillsborough County BOCC Risk Management Division located at 601 E. Kennedy Boulevard, 17th Floor, Tampa, Florida 33602.
The certificate outlines comprehensive insurance coverage requirements including General Liability, Automobile Liability, Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability coverage. Specific policy limits, deductibles, and coverage types must be completed and verified by an authorized representative signature. The document requires contractors to maintain contractual liability coverage as included in their General and Auto Liability policies and mandates a Separation of Insureds provision in their General Liability policies. This insurance requirement ensures adequate protection for all parties involved in the multi-family acquisition rehabilitation project, which includes both rental housing and homeownership housing conversion components.
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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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