3-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Solicitation number
- RPS-26-00366
- 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, through its Board of County Commissioners (BOCC) Risk Management Division. The certificate serves as documentation of insurance coverage for contractors and vendors engaged with the county. The document outlines required insurance policies and coverage types, including General Liability, Automobile Liability, Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability. The certificate specifies that all policies must include 30-day written notice provisions prior to cancellation or material changes in coverage. Hillsborough County must be named as an Additional Insured on General, Auto, and Aircraft Liability Policies. The certificate holder is addressed to Hillsborough County BOCC Risk Management Division, located at 601 E. Kennedy Boulevard, 17th Floor, Tampa, Florida 33602, with fax notification capability at 813-635-8284.
The certificate template requires contractors to specify policy numbers, effective dates, expiration dates, and coverage limits across all insurance categories. General Liability coverage must include per-occurrence limits, general aggregate limits, fire damage limits, personal and advertising injury limits, and products-completed operations aggregate limits. Automobile Liability requirements address any autos, owned autos, scheduled autos, hired autos, and non-owned autos with combined single limits or individual bodily injury and property damage limits. Workers' Compensation coverage must meet statutory limits with employer's liability components for each accident, disease per employee, and disease policy limits. The certificate confirms that contractual liability coverage is included in the listed General and Auto Liability Policies and that the listed General Liability Policies include separation of insureds provisions for protection of multiple parties.
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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 .