3-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Solicitation number
- RPS-26-00269
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance template issued to Hillsborough County, a political subdivision of the State of Florida, by its Risk Management Division. The document establishes insurance coverage requirements for contractors providing professional traffic engineering services to the County's Engineering and Operations Department. The certificate holder is identified as Hillsborough County – BOCC Risk Management Division, located at 601 E. Kennedy Blvd, 17th FL, Tampa, FL 33602, with fax number 813-635-8284. The template allows for specification of multiple insurance carriers and coverage types, including general liability, commercial general liability (both claims-made and occurrence-basis options), automobile liability, garage liability, excess liability, and workers' compensation with employer's liability coverage.
The certificate mandates that Hillsborough County be named as an Additional Insured on all listed General, Auto, and Aircraft Liability Policies, with written notice requirements stipulating that coverage cannot be cancelled or materially reduced without providing 30 days' advance written notice to the certificate holder. Contractors must document specific policy limits across various coverage categories, including General Aggregate Limits, Each Occurrence limits, Fire Damage, Personal & Advertising Injury, Products – Completed Operations Aggregate, Automobile Liability limits, and Workers' Compensation statutory limits. The document includes provisions for Contractual Liability Coverage to be incorporated within listed General and Auto Liability Policies and specifies that General Liability Policies must include Separation of Insureds (severability of interests) provisions, ensuring individual coverage protection for multiple insureds under the same policy.
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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 .