3-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Attached to
- Miscellaneous Subsurface Investigation & Testing
- Solicitation number
- RPS-26-00367
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance form associated with Hillsborough County's Capital Programs Department subsurface investigation and testing services contract valued at approximately $6,000,000. The certificate establishes insurance requirements for contractors providing geotechnical services, construction materials testing, roofing and waterproofing assessments, materials engineering, and asbestos-related services throughout Florida. The document serves as proof that insurance policies have been issued and are currently in force, with the requirement that Hillsborough County, as a political subdivision of the State of Florida, be named as an Additional Insured on all General, Auto, and Aircraft Liability Policies. The certificate includes 30-day written notice provisions for any cancellation or reduction in coverage, ensuring continuous protection for the county throughout the contract term.
The certificate specifies multiple insurance coverage types including General Liability (with options for Claims Made or Occur basis), Automobile Liability (covering any auto, owned autos, scheduled autos, hired autos, or non-owned autos), Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability insurance. The form is configured as a template with blank fields for the producer, insurers, policy numbers, effective dates, expiration dates, and specific coverage limits to be completed. The certificate holder is identified as the Hillsborough County Board of County Commissioners (BOCC) Risk Management Division located at 601 E. Kennedy Boulevard, 17th Floor, Tampa, Florida 33602, with fax notification at 813-635-8284. The document requires certification that General Liability policies include a Separation of Insureds provision and that Contractual Liability Coverage is included in listed policies.
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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 .