8-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Attached to
- Southshore Sportsplex - Phase 2
- Solicitation number
- IFB-26-00279
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance template issued for the Hillsborough County Parks and Recreation Department's Southshore Sportsplex - Phase 2 construction project located at 6110 Waterset Boulevard, Apollo Beach, Florida. The certificate establishes insurance requirements for contractors working on this project and designates Hillsborough County, a political subdivision of the state of Florida, as an additional insured on the general, auto, and aircraft liability policies. The certificate holder is the Hillsborough County - BOCC Risk Management Division located at 601 E. Kennedy Boulevard, 17th Floor, Tampa, Florida 33602, with contact information via fax at 813-635-8284. The document includes provisions for multiple types of insurance coverage including Commercial General Liability, Automobile Liability, Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability, with fields to document policy numbers, effective dates, expiration dates, and coverage limits for each category.
The certificate requires contractors to maintain specified insurance policies with 30-day cancellation notice provisions to protect the County's interests. The underlying construction contract for Phase 2 of the Southshore Sports Complex carries an estimated base bid value of $12,650,011.00 with additional alternate bid items totaling $2,769,574.00. The solicitation includes an 8% Small Business Enterprise (SBE) participation goal for subcontractor involvement, and contractors must submit questions and requests for interpretation within 14 calendar days after solicitation issuance, site visit, or pre-bid conference, whichever occurs later, as specified in the Contract Terms and Conditions Document.
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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 .