2-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Attached to
- Uniforms and Protective Clothing
- Solicitation number
- ITQ-27-00013
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance form issued by an insurance producer on behalf of a contractor providing services to Hillsborough County Board of County Commissioners (BOCC) in Florida. The certificate documents the insurance policies currently in force to cover the contractor's operations and liabilities. The certificate confirms that multiple types of insurance coverage have been extended to the insured party, with provisions that no cancellations or coverage reductions will occur without 30 days' written notice to the certificate holder. Hillsborough County has been named as an Additional Insured on the General, Auto, and Aircraft Liability policies, protecting the County against potential claims arising from the contractor's work. The certificate holder is identified as 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 form provides fields for documenting various insurance coverages including General Liability, Automobile Liability, Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability. Specific policy limits and deductible amounts are to be completed by the insurance provider and submitted to the County. The certificate references the provision of contractual liability coverage within the listed General and Auto Liability policies and notes that the General Liability policies include Separation of Insureds provisions to address multiple covered parties under a single policy. This certificate is a standard requirement for contractors engaged by Hillsborough County to ensure adequate protection and risk management.
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| 4-Direct Deposit Authorization Form 5.15.2025.pdf.pdf | ||
| 6-ITQ-27-00013 Uniforms and Protective Clothing.pdf |
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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 .