9-Insurance Certificate.doc.doc
DOC document 94 KB Posted
- Solicitation number
- IFB-26-00354
- Issued by
- Hillsborough County, Florida
About this file
This is a Certificate of Liability Insurance document issued for Hillsborough County, Florida, specifically related to the Bearss Avenue at Florida Avenue Intersection Improvements project managed by the Hillsborough County Engineering and Operations Department. The certificate outlines the insurance coverage requirements and policies that must be maintained by the contracted vendor throughout the project execution. The document specifies that Hillsborough County, a political subdivision of the state of Florida, must be named as an Additional Insured on all General, Auto, and Aircraft Liability policies. The certificate confirms that all listed insurance policies remain in force and establishes a 30-day cancellation notification requirement to the certificate holder at the Hillsborough County BOCC Risk Management Division, 601 E. Kennedy Blvd, 17th Floor, Tampa, Florida 33602, with fax number 813-635-8284.
The insurance certificate is a standard template document (ICM-015, revised 09/10) that requires the vendor to provide multiple types of coverage including Commercial General Liability, Automobile Liability, Garage Liability, Excess Liability, and Workers' Compensation and Employer's Liability insurance. Specific coverage limits, policy numbers, effective and expiration dates, and claim-made versus occurrence basis options are to be completed by the insurance producer. The document includes checkboxes for various coverage options such as any auto, all owned autos, scheduled autos, hired autos, and non-owned autos for automobile liability coverage. The certificate also allows for notation of contractual liability coverage inclusion and separation of insureds provisions within the General Liability 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 .