8-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Solicitation number
- IFB-26-00265
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance form required by Hillsborough County Board of County Commissioners for the Northwest Transfer Station Community Collection Center Floor Upgrades project in Florida. The certificate template establishes the insurance requirements that contractors must maintain throughout the contract period, with Hillsborough County named as the Certificate Holder at 601 E. Kennedy Blvd, 17th Floor, Tampa, FL 33602. The form documents multiple types of required coverage including General Liability, Automobile Liability, Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability insurance. All policies must include contractual liability coverage and name "Hillsborough County, a political subdivision of the state of Florida" as an Additional Insured on the General, Auto, and Aircraft Liability policies. Crucially, all insurance policies must be endorsed to provide that they will not be cancelled or reduced without 30 days' written notice to the certificate holder, and General Liability policies must include a Separation of Insureds provision.
The certificate serves as proof that the contractor's insurance policies are in force at the time of submission and establishes the minimum coverage limits required for the $2.24 million concrete floor upgrade project. Contractors must complete this form with their insurance provider's information, including policy numbers, effective and expiration dates, and specific coverage limits for each insurance type. The form requires an authorized representative's signature and serves as a binding commitment that the contractor will maintain continuous coverage meeting Hillsborough County's requirements throughout the project duration, with any changes to coverage subject to the mandatory 30-day cancellation notice provision.
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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 .