9-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Solicitation number
- IFB-26-00362
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance form associated with a roadway resurfacing project managed by Hillsborough County Engineering and Operations in Florida. The document outlines the insurance requirements and coverage specifications that contractors must maintain throughout the contract term. The certificate serves as proof that the contractor has obtained appropriate insurance policies and agrees to maintain those policies without cancellation or material reduction for a minimum of 30 days following written notice to the county. Hillsborough County's BOCC Risk Management Division, located at 601 E. Kennedy Boulevard, 17th Floor, Tampa, FL 33602, is designated as the certificate holder and additional insured on applicable policies. The form requires documentation of multiple insurance types, including general liability, automobile liability, garage liability, excess liability, and workers' compensation and employer's liability coverage, with specific limits and conditions to be completed by the contractor's insurance provider.
The certificate requires contractors to name "Hillsborough County, a political subdivision of the state of Florida" as an additional insured on all listed general, auto, and aircraft liability policies. The insurance documentation must confirm that contractual liability coverage is included in the general and auto liability policies and verify that the general liability policies include a separation of insureds provision. This insurance requirement applies to the roadway resurfacing repair and preservation project estimated at $16,000,000.00 covering District 1 and 2 throughout Hillsborough County, which may involve milling, resurfacing, preservation treatments, and Full Depth Reclamation methods. The solicitation includes a 5% Small Business Enterprise (SBE) subcontractor participation goal.
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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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