2-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Attached to
- Cold Weather Shelter Partnerships
- Solicitation number
- RFQ-26-00101
- Issued by
- Hillsborough County, Florida
About this file
This Certificate of Liability Insurance is required by Hillsborough County, a political subdivision of the State of Florida, as part of the Cold Weather Shelter Partnerships contract opportunity. The certificate serves as documentation that an applicant organization maintains active insurance coverage across multiple liability categories, including general liability, automobile liability, workers' compensation, and employer's liability insurance. The certificate holder must name Hillsborough County—specifically the BOCC Risk Management Division located at 601 E. Kennedy Boulevard, 17th Floor, Tampa, Florida 33602—as an additional insured on all general, auto, and aircraft liability policies. All listed insurance policies must include endorsements ensuring that coverage will not be cancelled or reduced without providing 30 days' written notice to the county.
The insurance requirements mandate that applicant organizations demonstrate comprehensive coverage across multiple insurance types with specified limits, though specific dollar amounts are not pre-filled in this template document. The certificate must confirm that general liability policies include a separation of insureds (severability of interests) provision and that contractual liability coverage is included in the listed general and auto liability policies. This insurance requirement is essential for organizations seeking to partner with Hillsborough County to provide cold weather shelter services with a project budget of $175,000 during the 2026 cold weather season. Applicants must be registered 501(c)(3) organizations, faith-based organizations, shelters, or community service providers in good standing with the State of Florida, with facilities capable of providing shelter for a minimum of 15 nights throughout the cold weather season.
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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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