3-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Solicitation number
- RPS-26-00137
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance form issued for Hillsborough County, a political subdivision of the State of Florida, related to a Miscellaneous Architectural/Engineering Services contract. The certificate template is designed to document insurance coverage requirements for contractors performing design and construction services on County projects, which may include architectural, civil, landscaping, structural, mechanical, plumbing, and electrical work. The contract opportunity offers a four-year term with a maximum total fee not to exceed $3,000,000.00 for selected qualified firms providing basic A/E services or specialized services.
The Certificate of Liability Insurance requires the contractor to maintain General Liability, Automobile Liability, Workers' Compensation and Employer's Liability coverage, with Hillsborough County named as an Additional Insured on the listed General, Auto, and Aircraft Liability policies. The certificate must include 30-day written notice of cancellation or change provisions to the certificate holder. The document specifies that coverage must include Commercial General Liability with either Claims Made or Occur basis, with specified policy limits for General Aggregate, Fire Damage, Personal & Advertising Injury, and Products-Completed Operations Aggregate. Additional requirements include Contractual Liability Coverage in the General and Auto Liability policies and a Separation of Insureds provision in the General Liability policies. The certificate should be submitted to the Hillsborough County BOCC Risk Management Division at 601 E. Kennedy Boulevard, 17th Floor, Tampa, Florida 33602, Fax 813-635-8284.
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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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