2-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Attached to
- CDBG-DR Notice of Funding Availability (NOFA) for Small Multifamily Rehabilitation Projects
- Solicitation number
- RFP-26-00365
- 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, for use in connection with contract opportunities. The certificate documents insurance policies required to be maintained by contractors performing work for the county. The document includes provisions for multiple types of insurance coverage including General Liability, Automobile Liability, Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability. The certificate specifies that Hillsborough County's Board of County Commissioners (BOCC) Risk Management Division must be named as an Additional Insured on General, Auto, and Aircraft Liability policies, and requires that all policies include a 30-day written cancellation notice provision to the certificate holder at Hillsborough County's Risk Management office located at 601 E. Kennedy Boulevard, 17th Floor, Tampa, Florida 33602.
The insurance requirements outlined in this template are applicable to the county's CDBG-DR Notice of Funding Availability (NOFA) for Small Multifamily Rehabilitation Projects, which represents a $10,000,000 competitive funding opportunity. Contractors and applicants responding to this solicitation for small multifamily rehabilitation projects addressing unmet recovery needs from Hurricanes Helene and Milton must provide proof of insurance coverage through this certificate format. The template allows for documentation of policy numbers, effective and expiration dates, coverage limits, and specification of whether coverage is provided on a claims-made or occurrence basis, ensuring contractors maintain adequate insurance protection throughout the contract performance period.
View the file
Other files
Show all 17
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .