Certificates of Insurance
ACORo'M CERTIFICATE OF LIABILITY INSURANCE
DATE (MMlDD1YY)
QUINTANA & ASSOC INC
1704 N ROOSEVELT BLVD
KEY WEST FL
33040
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
PRODUCER
OVERSEAS JANITORIAL SERVICES
3312 NORTHSIDE DR APT 515
KEY WEST, FL 33040
INSURER A.
INSURER B:
INSURER C.
INSURER D:
INSURER E.
INSURED
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO \/\/HICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POliCIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I~f: TYPE OF INSURANCE POLICY NUMBER PJ>1-~~~ri~8~~ Pg~lfl(~~~t~N LIMITS
GENERAL LIABILITY
-
X COMMERCIAL GENERAL LIABILITY
I CLAIMS MADE I)(l OCCUR
_1--_1 ~
-
-
GEN'L AGGREGATE LIMIT APPLIES PER
I POLICY n ~:g: n LOC
AUTOMOBILE LIABILITY
-
CLS0532755
EACH OCCURRENCE $ 300,000
6/09/1998 6/09/1999 $ 50,000
FIRE DAMAGE (Anyone fire)
MED EXP (Anyone person) .$
PERSONAL & ADV INJURY $ 300 000
GENERAL AGGREGATE $ 300,000
PRODUCTS - COM PlOP AGG $ 300,000
HIRED AUTOS
0' 'frr rtOl~ ~
, .
DATE~:t~lq'i
- !
WA IVER: I~,::, _ :::::::. YES
COMBINED SINGLE LIMIT
(Ea accident)
ANY AUTO
-
.-.--.---
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per person)
-
-
NON-OWNED AUTOS
BODILY INJURY
(Per accident)
-
-
-
PROPERTY DAMAGE
(Per accident)
GARAGE LIABILITY
=l ANY AUTO
EXCESS LIABILITY
=:=J OCCUR D CLAIMS MADE
'I DEDUCTIBLE
I RETENTION $
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN
AUTO ONLY
EA ACC $
AGG $
EACH OCCURRENCE
AGGREGATE
IT~n~~I~sl IUER'
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYE $
E.L. DISEASE - POLICY LIMIT $
I OTHER
i
DESCRIPTION OF OPERATIONSlLOCATIONS1VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER I XI ADDITIONAL INSURED; INSURER LETTER;
CANCELLATION
MONROE COUNTY BOARD OF COMM.
5100 COLLEGE RD ROOM 203
KEY WEST, FL 33040
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL---1Q.. DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSrNO OBLIGATION OR LIABILITY OF .l"'""'\IND UPON THE INSURER, ITS AGENTS OR
REP~SetHATIVES../"'"'l c.. }
~V~ O(CU/~{l J
/ @ ACORD CORPORATION 1988
I
ACORD 25-S (7197)
1996 Edition
MONROE COUNTY, FLORIDA
Req:aes"i For Waiver
of
Insurance Requirements
It is requested that the insurance requirements, as specified in the County's Schedule of Insurance Requirements, be
waived or modified on the following contract.
. Contractor:
Oversen~ .lnn; rnr; "" 1 .C::orui CQS
Address of Contractor:
Janitorinl SP~?~ - Key W~st Intgrnational-A~
3312 Northside Dr. Apt 515
Key West/ FL 33040
Contract for:
Phone:
(305) 294-4384
Scope of Work:
Janitorial
Reason for Waiver:
Workers Cornoensation - Rxompr
Policies Waiver
will apply to:
Signature of Contractor.
---
Date
pproved -rc Not Approved
~fft~
Risk Management
County Administrator appeal:
Approved:
Not Approved:
Date:
Board of County Commissioners appeal:
Approved:
Not Approved:
Meeting Date:
Administration Instruction
#4709,2
103
@ TheOhi~ Casualty GroupOfl1l5urancecompanies
: .
BUSINESS S~RVfCES
BONO I
APPLlCA:1'10N I
AGENCY MA'l'SOll-CRARr.TOk S1lRE!LGRO!JI'lOCATION 6291 BlRD->J-"!IAH1J.:I.-:l3155 '
NAME OF APPLfCANr Qverseas 0"'C2f}}'f-Qr,I' <1l~<\er ~l~C~._._.____
ADDRESS 33/02.. (\Jo,~cb 1\4,. ,. ar-ts }5:) K~ WR.~-t. fL 33c1-ro
(STR~eT &. NUMBER I (CtTY, I ~- { ,. (5li\ I/: 1 (ZIP)
~TYPE OF BUSINESS. 3' Q n ( +-0,-;0-1 5~ r vt c e~_____~h'__
.WHAT COMPANY WRITES APPLICANT'S L1ABILrTY INSURANCE? ~~Ct I L
AMOUNT OF COVERAGE: $5,OoO;qO ~_ $10,000.00 _.__ $2~,OCO.OO
EFFECTIVE DATE ~01 I - q~_, NUMBER OF EMPLOYEES _I~~__
NUMBER OF OWNE ( (C ERAGE ON OWNERS IS PRovrD~l5 ~AlJmMAT'CA,LLY
I A PROPRIETORSHIP OR PARTNr::RSHlf'l
HAVE THER~'I;N ANY OISHONESrY LOSSES IN THE PAST SIX (6) YEA.RS?
- YES 1_ NO. IF YES, SUBMIT DETAILS AND COI)Bm!~~.:~T1QN l4.I~~J_.UN.9m
SEPARATE tOVER.
,
.
.' .~ .
. .
!
----.----. ..1---.___ _.'_'___
BOND COVERAGE APPLIES ONLY IF l:MPI.OYEE IS CONVICTED
COVERAGE f'~OVIDED FOR ~UT NOA LIMITED m:
~flORIAL HI=R~ . SECURITY GUARD INfERIOR DECOFl/\TOR
PEST CONIROL _, CARPET CLEANING LOCKSMITHS
MAID SERVICE . APPLIANCE REPAIR MF.SSENGER SEF:VICE
HOME PHOlOGFtAPHER FOOD CATERING OTHER CONTRACTURS
RATES
EMPLOYEES
(Includes $250.00 Deductlblel
~5,OOd.oo ~,OOfAOQ -
~25,(ld9.:00
""-
:;: ACORD
, TM
33045
"""""""""""""""""""",,":::::'::::'::::::::::::::::;'::::';;"::;i:':';i:::':::::::::::::::::::'::":'::::::"::"":::':':':::::::::::::,"""""""""""{",}"",:""""""""",,,,:,:""""""""",:,:,;::::1',:11111,1:,1:111:1111,1,11:,11111111111:111:,1111111:11:111'1:1:11,::111:1.11111111.11:::IIII:;?~7~~DIVY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANY :tntegon Nat10nal
A
PRODUCER
The Fullers,
PO B.ox 5282
Key W"e st, Fl.
Inc.
INSURED
Kateh1s D1on1s1os
3312 Norths1de Dr. 1515
Key West, Fl. 33040
I COM~ANY
I COMPANY
! C
COMPANY
o
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
co I
LTR i
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MM/DDIVY) DATE (MM/DDIVY)
LIMITS
GENERAL LIABILITY
COMPREHENSIVE FORM
PREMISES/OPERATIONS I
UNDERGROUND I
EXPLOSION & COLLAPSE HAZARD
H PRODUCTS/COMPLETED OPER I
, ! CONTRACTUAL !
, INDEPENDENT CONTRACTORS !
I BROAD FORM PROPERTY DAMAGE I'
PERSONAL INJURY
AUTOMOBILE LIABILITY
I ANY AUTO
I ALL OWNED AUTOS (Private Pass)
ALL OWNED AUTOS
(Other than Private Passenger)
HIRED AUTOS
I NON-OWNED AUTOS
i GARAGE LIABILITY
i scheduled aut s CFL 6766909 01
BODILY INJURY OCC :$
BODILY INJURY AGG $
PROPERTY DAMAGE OCC , $
PROPERTY DAMAGE AGG I $
BI & PD COMBINED OCC '$
BI & PD COMBINED AGG $
PERSONAL INJURY AGG $
~
4/30/98 4/30/99
$ 10,000
BODILY INJURY $ 20,000
(Per accident)
PROPERTY DAMAGE $ 10,000
BODILY INJURY &
PROPERTY DAMAGE $
COMBINED
EACH OCCURRENCE
AGGREGATE
\W, 'IIFR:
:\> .: ./ yr('
I,,' ,..tC-- '_oj
ii,
~.
" --
EXCESS LIABILITY
I UMBRELLA FORM
i OTHER THAN UMBRELLA FORM
I WORKERS COMPENSATION AND
I EMPLOYERS' LIABILITY
THE PROPRIETOR/
PARTNERS/EXECUTIVE
OFFICERS ARE:
OTHER
INCL
EXCL
$
EL DISEASE - POLICY LIMIT $
EL DISEASE - EA EMPLOYEE $
DESCRIPTION OF OPERATIONSlLOCATIONSlVEHICLESlSPECIAL ITEMS
commercial auto policy on janitorial service
:i:r;~mll*.ii"g,g~li:i:H;:lji:i:::i:i:l::::i:i!H::i::i:lJii:iiii:I:H!:::::iiiiiim::::I:H:m:::H:iiiI:i:1Hii::i::i:l::i:::i::!::i!HII:i:j::::i:lni:i!i!i:i:i:i:iIIiifi:i:~j".J.I_!j::i:::::::i:li:i!i:::::iI:::li:i:i:i!::i:::::::::i:i::!i:i!:i::i::i:i::i:iIii:iiiii::::::iiii:i:iiiijiI:i:::::l::iili:H:ii:!I:ji::i:!i!i!:i:ji:::H:i:jiI:::::::::::n::i:i:i!i:i:::i:ii:i::::ii::i:iii:i!i:j
ltLonroe County BOCC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
5100 College Rd. EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
Key,} West, Fl. 33040 ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY IND UPON MPANY, ITS AGENTS OR REPRESENTATIVES,
AUTHORIZ EPRESENT
l:Diillll:;"':UIIII:I:i::i:i:::i:i:lt::::::i:tii:iliiil::::i:::illml::H::ml::i:i::;]l::i:i:i:il::;:i:J:J::::t::Il:::::::::::]::::]:::]:il:::li:i::::::;::i:::::::::::::]:::::::::]::::::::::::::::::i::IIiiii:t::::,,{::::?,.':,,:,J1:::i:::t":::;;i::::}:,j::i:Itiii:i::I:I:::n:iiw::::::::i:::::::iii:i::tmr:!i!';:;:;;::':':':':;"::,::'::::::':':':"':""":'}Bllm'.!::illi::
The Fullers Insurance
3600 North Roosevelt Blvd.
Key West, FI. 33040
Phone (305) 294-6677 Fax (305) 292-4641
Date: 2/4/99
To: Monroe County
Regarding: Kathesis Dionisios
This is to certify that Integon will not add a governmental entity as additional insured.
Sincerely,
Norman Fuller
~~:~L ~
@ The Ohio Casualty Group of Insurance Companies
BUSINESS SERVICES BOND BOND NO. 3-5))-714
In consideration of an agreed premium, The Ohio Casualty Insurance Company, a corporatio.n organized u[lder the laws of
the State of Ohio., (hereinafter called "Surety"), hereby~ees to indemnify OVerseas Janitorial ~r'ITl.ces
of 3312 tbrthslde DR. Apt. 515. Kev West, FL '=3 , (hereinafter called 'Obligee"),
against direct loss of money or other property, from the premises of any and all subscribers (hereinafter called "Subscriber")
to its services, and belonging to the Subscriber, or in which the Subscriber has a pecuniary interest or for which the Sub-
scriber is legally liable, which the Subscriber shall sustain as the result of any fraudulent or dishonest act, as hereinafter de-
fined, of an Employee or Employees of the Obligee acting alone or in collusion with others, and for which the Obligee is liable,
if in excess of $250, to an amount not exceeding in the aggregate Ten 'Ih:usarxi
Dollars ($ 10,CXXl.OO ) for that amount in excess of the deductible,
THE FOREGOING AGREEMENT IS SUBJECT TO THE FOllOWING CONDITIONS AND LIMITATIONS:
TERM OF BOND:
Section 1. The term of this bond begins at 12:01 A. M. Standard Time on the 1st day of ~r , 19 ~
at the address of the Obligee above given, and ends at 12:01 A.M. Standard Time on the effective date of the cancellation
of this bond in its entirety.
DISCOVERY PERIOD:
Section 2. Loss is covered under this bond only (a) if sustained through any act or acts committed by an Employee of Obli-
gee while this bond is in force to such Employee, and (b) if discovered within no more than 180 days after the expiration or
sooner cancellation of this bond in its entirety as provided in Section 10, or from its cancellation or termination in its entirety
in any other manner, whichever shall first happen.
DEFINITION OF EMPLOYEE:
Section 3. The word Employee or Employees, as used in this bond, shall be deemed to mean, respectively, one or more of
the natural persons (except directors or trustees of the Obligee, if a corporation, who are not also officers or employees thereof
in some other capacity) while in the regular service of the Obligee in the ordinary course of the Obligee's business during
the term of this bond, and whom the Obligee compensates by salary, or wages and has the right to govern and direct in the
performance of such service, and who are engaged in such service within any State of the United States of America, or within
the District of Columbia, Puerto Rico, the Virgin Islands, or elsewhere for a limited period, but not to mean brokers, factors,
commission merchants, consignees, contractors, or other agents or representatives of the same general character.
If the Obligee is a sole proprietorship or partnership, the proprietor or partners shall be considered to be Employees for the
purposes of this bond.
FRAUDULENT OR DISHONEST ACT:
Section 4. A fraudulent or dishonest act of any Employee or Obligee shall mean a fraudulent or dishonest act causing loss
during the time the Employee is engaged in services on the premises of the Subscriber, and which is punishable under the
Criminal Code in the jurisdiction within which act occurred, for which said Employee is tried and convicted by a court of proper
jurisdiction.
MERGER OR CONSOLIDATION:
Section 5. If any natural persons shall be taken into the regular service of the Obligee through merger or consolidation with
some other concern, the Obligee shall give the Surety written notice thereof and shall pay an additional premium on any
increase in the number of Employees covered under this bond as a result of such merger or consolidation computed pro rata
from the date of such merger or consolidation to the end of the current premium period.
NON-ACCUMULATION OF LIABILITY:
Section 6. Regardless of the number of years this bond shall continue in force and the number of premiums which shall be
payable or paid, the liability of the Surety under this bond shall not be cumulative in amounts from year to year or from peri-
od to period.
LIMIT OF LIABILITY UNDER THIS BOND AND PRIOR INSURANCE:
Section 7. With respect to loss or losses caused by an Employee or which are chargable to such Employee as provided in
Section 4 and which occur partly under this bond and partly under other bonds or policies issued by the Surety to the Obli-
gee or to any predecessor in interest of the Obligee and terminated or cancelled or allowed to expire and in which the period
for discovery has not expired at the time any such loss or losses thereunder are discovered, the total liability of the Surety
under this bond and under such other bonds or policies shall not exceed, in the aggregate, the amount carried under this
bond and such loss or losses or the amount available to the Obligee under such other bonds or policies, as limited by the
terms and conditions thereof, for any such loss or losses, if the latter amount be the larger.
S-4960
OCO.605
SALVAGE:
Section 8. If the Obligee shall sustain any loss or losses covered f:>y this bond which exceed the amount of coverage provid-
ed by this bond, the Obligee shall be entitled to all recoveries, except from suretyship, insurance, reinsurance security and
indemnity taken by or for the benefit of the Surety, by whomsoever made, on account of such loss or losses under this bond
until fully reimbursed, less the actual cost of effecting the same, and less the amount of the deductible carried on the Em-
ployee causing such loss or losses; and any remainder shall be applied to the reimbursement of the Surety.
CANCELLATION AS TO ANY EMPLOYEE:
Section 9. This bond shall be deemed cancelled as to any Employee: (a) immediately upon discovery by the Obligee, or by
any partner or officer thereof not in collusion with such Employee, of any fraudulent or dishonest act on the part of such
Employee; or (b) at 12:01 A.M., Standard Time, upon the effective date specified in a written notice served upon the Insured
or sent by mail. Such date, if the notice be served, shall be not less than ten days after such service, or, if sent by mail, not
less than fifteen days after the date of mailing. The mailing by Surety of notice, as aforesaid, to the Obligee at its principal
office shall be sufficient proof of notice.
CANCELLATION AS TO BOND IN ITS ENTIRETY:
Section 10. This bond shall be deemed cancelled in its entirety at 12:01 A. M. Standard Time, upon the effective date speci-
fied in a written notice by the Obligee upon the Surety or by the Surety upon the Obligee, or sent by mail. Such date, if the
notice be served by the Surety, shall be not less than ten days after such service, or if sent by the Surety by mail, not less
than fifteen days after the date of mailing. The mailing by the Surety of notice, as aforesaid, to the Obligee at its principal
office shall be sufficient proof of notice. The Surety shall refund to the Obligee the unearned premium computed pro rata
if this bond be cancelled at the instance of the Surety, or at short rates if cancelled or reduced at the instance of the Obligee.
PRIOR FRAUD, DISHONESTY OR CANCELLATION:
Section 11. No Employee, to the best of the knowledge of the Obligee, or of any partner or officer thereof not in collusion
with such Employee, has committed any fraudulent or dishonest act in the service of the Obligee or otherwise. If prior to
the issuance of this bond, any fidelity insurance in favor of the Obligee or any predecessor in interest of the Obligee and covering
one or more of the Obligee's employees shall have been cancelled as to any of such employees by reason of (a) the discovery
of any fraudulent or dishonest act on the part of such employees, or (b) the giving of written notice of cancellation by the
insurer issuing said fidelity insurance, whether the Surety or not, and if such employees shall not have been reinstated under
the coverage of said fidelity insurance, or superseding fidelity insurance, the Surety shall not be liable under this bond on
account of such employees unless the Surety shall agree in writing to include such employees within the coverage of this bond.
LOSS - NOTICE - PROOF - LEGAL PROCEEDINGS:
Section 12. At the earliest practical moment, after discovery of any potential fraudulent or dishonest act on the part of any
Employee by the Obligee, or by any partner or officer thereof not in collusion with such Employee, the Obligee shall give the
Surety written notice thereof and within 90 days after the criminal conviction of any employee covered under this bond, shall
file with the Surety affirmative proof of loss, including a certified copy of the final disposition of the criminal action, and shall
upon request of the Surety render every assistance, not pecuniary, to facilitate the investigation and adjustment of any loss.
No suit to recover on account of loss under this bond shall be brought before the expiration of two months from the filing
of proof as aforesaid on account of such loss, nor after the expiration of fifteen months from the discovery as aforesaid of
the fraudulent or dishonest act causing such loss. If any limitation in this bond for giving notice, filing claim or bringing suit
is prohibited or made void by any law controlling the construction of this bond, such limitation shall be deemed to be amended
so as to be equal to the mimimum period of limitation permitted by such law,
EXCLUSIONS:
Section 13. This bond does not apply:
(a) to the defense of any legal proceeding brought against the Obligee or Subscriber, or to fees, costs or expenses incurred
or paid by the Obligee or Subscriber in prosecuting or defending any legal proceeding whether or not such proceeding results
or would result in a loss to the Obligee or Subscriber covered by this Bond.
(b) to potential income including but not limited to interest and dividends, not realized by the Obligee or Subscriber because
of a loss covered under this Bond.
(c) to damages of any type for which the Obligee or Subscriber is legally liable, except direct compensatory damages arising
from a loss covered under this Bond.
(d) to costs, fees and other expenses incurred by the Obligee or Subscriber in establishing the existence of, or amount of,
loss covered under this Bond.
SIGNED, SEALED AND DATED
f1::n::rrh:>r 8, 1998
The Ohio Casualty Insurance Company
.di
Attorney~in-fact
l))nra M. Keefer
1-800-927-6446
770 SDuth Dixie Highway. Suite 101
Coral Gables. Rorida 33146
Phone: (305) 662-3852
Fax: (305) 661-9948
http://www.mcsurety.com
ED
Matson-Charlton Surety Group
December 15, 1998
OVERSEAS JANITORIAL SERVI
3312 NORTHSIDE DR. APT 51
KEY WEST, FL 33040
Re: OVERSEAS JANITORIAL SERVI Pol# 3-500-714
Dear Sir/Madam;
We are pleased to enclose the above captioned
Janitorial Service Bond.
Please review the Bond carefully and if you have any
questions or feel that any changes should be made, do
not hesitate to contact our office.
Thank you.
Sincerely,
1
~Cial Surety
Jane Sullivan
Department
MEMBER
--
NATlONALAISOCIATIONOf
SUlUT\" aDtlD 'aoDloICIllIS
. ,
,
~
r
CONSTRUCTION INDUSTRY STATa uSl ONl.Y
CERTIFICATE OF ELECTION TO BE EXEMPT FROM
THE FLORIDA WORKERS' COMPENSATION LAW . DATI
~
PQSTUAIIK DATE
i"r
MAIL TO: D...."....... .f L._ . t......",,- .~
.......... W.e. c-...-
ltea om.. ... 7_
T..I....._, '" 323'''7100
T...~,: (1041 4"'Z~
TIri.lIO_.... lie - ..... -.-...-
._01"-_" &1...., - - --.
......... or _ o/IIUI........., ....-.
~IA'E TYPE 011 ""I NT:
JEE REVERSE SIDE: OF THIS FORM FOR ELlGI81LITY REOUIR~ENTS AHD RENEWAL INFORMATION.
..e: V-fQ1ULS..\ l0') J<. k tAT t: lj \ ') ~ / /3J A 0 vf:; j{ )'cA ')
(L.a;.. au..".a Nam. or SOl. ?rcp"el::nnJP. Penn.... 01 CorporallonllOiSlA II PI'CBI."
) ~ ~v; ( (; )
:oo.I.lUta of :\uam.. or Traaa:-.-::I A IV' ('7 0 ~ IfA L
-~~-- ( 3o~1 'L94-~3jJ4--
wc-\( FL. '3'30 q-o 069 4-A'51'10 C 305) /_C; l{-O~ 4-tJ,
(Sial.' (Zip' IFee- emplOY" la.,lIhcallon Numoert (Talepnon. -,
~&JZI/I (GSa
at. {j 5_ .___-,--
\a~.._ A~::~":. ,. ~~I!!I"~~
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(M....1I1.. Aaar...'
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Pur...."t to Rul. 3aF.'s.OOlll", .. of 12:01 ..m. 30 day. followin, tII. ...1. of tII. m.iIIn, of till. form. you .re h..aby MllfIecf tII.t tII. followin, Sol. Propri.tor.
p.nn.r or Corpor.t. O"lc.r 0' the .bo....n.med lIullin... d_. .lect to II. ...mpt from tII. provision. of th. Florida W..It.... eo"'p.n..1ioft Law. I
und.r_nd Itl.t'. ..I. propri.lor. ind.p.nd.nt oonv.ctor. p.nn.r. or officer 0' . corpor.tlon who .I_ta ..."'pllon from thl. ch.p,.r IIy fllIn, ·
e.rtiflcala of .Ieclion under So 440.05 may nOf r__ Hn.fllm.. eomp.nution ..naar thl.o".pt.... llurtl'lfi "neI.,.tand ltI.t th.,. i. · limit of thr.a p~rtn.r.
Of' 11\._ cor...r.,. offlo.rL I c.rtify tII.t any a",p1OY_ of ttltl bu.n... n.med aM". i. co_ad by --.... o_....._II_ln_r.-
REQUIREMENT: LIST CERTIFIED OR REGISTERED LICbSU HELD PURSUAHT TO CHAPTER.... F.B. OR LOCAL OCCUPATIONAL. LICENSES.
~~ ~ -r 'I ~::;..::-~Q..L((112\ T'IOr. .~ <.( NTY ~~ ~ ~D '- &'7~ 6 "L
IMPOR':' Atn: A NON.REF'<.lNDA8U TWENTY FIVE DOLLAAS (125.00l inai_v" ...III..u- flllneJ..I. raq. ".._t to CMptw 440.0.' F.'\
and RuM 311f...DD'(... and I. pay.bIe Oftly by .......... cIlMk _ _.Y or"... to W.e. .-...IftI........ Tru. IfIlM. If..... to ........ ... .l1li accurataly
."d ,.tally _III.ta thl. IcImI will r._1t I" return o' tile raqueat ..... _- a d.lay 1ft ........tIOn.
AFFIDAVIT OF INDEPENDENT C:ONTRACTOR STATUS:
I. 0 I 0 Nt \ l{) \ K._.J.cA T .(~~ - und'" _th. do d...._ .. foIlowC
1. I m.intain . _per.,. 11001."... with my -" __ "_Ily. lfUclt, OCIvipm..." ma,.rial.. - llimllar ..........II_a;
:z. 1 holcl or ...... .IIp1ied f_ . .....,.1 ."'ptayar ..........tIeft number,
3. I perform or .,r.. to p.rtor", ...eoiflo ........ -" tor .....Iflo amounta of _y and eOfttrOt tile mean. of perfCIImin, 1tI. _vie.. or _rlt;
4. I incur tII. prineipel ..p.n... r.I.1ad to th. aervice.. _rlt tl1.t I p.rform or .,r_ to perform;
5. I a'" r.aponllilll. lor tha ..tiat.ctory ~tion .. _rlt CJr _viea. ltIall parform or a,r_ to perte.rm .nd could II. l1eld 1I.1l1a I~,r · lailur. 10 eo,,,pl.,.
I. I rec.i_ compen..lioft f_ __ _ __._. ,...n-=:: ;. ~ :: :~""""'.;')ia" or 0" a o.r job .. co",p..llv..bld usi.4nd not on 'tny othor 1I.1Iia;
7. I m.y ro.liz.. pro'it or ...".. .1o_1ft _...Hfion With pertormin, _rlt or _vic.a;
a. 111.... continuin, or recvrrint .........1IaIMII..... ....llI.tiona; and
t. Th. succooo or '.ilur. of my 1Iu....... d......... on tII. ral.tionaltip oIIlUIli"... r.oolpt. to .apandlluNL
,,;0; WVI'Il~" "'f'~ _"'_.
SOCIal S ac:u"1V Numt:lar'
Siona:'3.
(Onl,}' 0.". ;;o~n.lUr. P.. FermI
. . . . tit ~~~,.. ..... .... .. .. .
P~s:oon'ocAlAJf~..ecr:~3P ~ ~ ~'~::/.<J-,q~cc~p~O~FF1ce;:v;rr..=
SWOi'lN TO ANO suesC;:;ISE::l 3:",C;:;e" ME" THIS .It-1L-r;jA.Y.C.....~W...fJ.== ~ J -~S: - . /' ICA.
~onaIlY ~e.:n ~d"'II. " """ " OFFlCW, NOTARY SEAL
. ".. . "." ~. RCPEyrr c.-fuL{
_ ... .. If ~,. . f.;,~ ,.., ..~.
;ort:IdUcad ..la.,lI..caaon if.-qTARY PlmUC ~~iAT:tl OF Fl.ORIDA NCllAIV lie. Sial. Aonae
. . .(:C)~~t<n:~~',~.~_'/) I'J:J. CC(:,4'1471 My Ccmm.saon &pltea:
Typo Of la....lIhcsuon i';,Y COMr.;lS~;':':'d f..XP.III1AY l~.'iJOl
.
- .
........
-
$25.00 F'UHQ FEE REOUIRED WITH FORM
'-'"5 FOfIIM BCM._It"..- !,2;:31 :
~
I
IREQUIREMENTS FOR COMPLETING THIS FORM I
(1) THIS FORM SHOULD eE COMPLETED ONLY BY AN EMPLOYER OPERATING WITHIN FLORIDA.
(2) THE CONTRACTORS BELOW ARE REQUIRED TO FURNISH THE LICENSE NUMBER AND TYPE OF ANY
CERTIFIED OR REGISTERED UCENSES ISSUED BY THE DEPARTMENT OF'PROFESSIONAL REGULATION.
(A) GENERAL CONTRACTOR(F) ELECTRICAL CONTRACTOR
(B) COMMERCIAL CONTRACTOR (G) HEATING-A/C CONTRACTOR
(C) RESIDENTIAL CONTRACTOR (H) SWIMMING POOL CONTRACTOR
(D) ROOFING CONTRACTOR (I) SHEET METAL CONTRACTOR
':.1 (E) PLUMBING CONTRACTOR
I LRENEWAL ~NFORM.A.TION
!EFFECTIVE JANUARY 1, 1994, THE CERTIFICATE OF" ELECTION IS VALID UNTIL THE SOLE
PROPRIETOR. PARTNER, OR CORPORATE OFFICER REVOKES SUCH ELECTION.
THIS FORM SHOULD BE SUBMITTED TIMELY ALLOWING IT TO' REACH THE DIVISION AT
LEAST 31 DAYS PRIOR TO THE DATE THE EMPLOYER WOULD LIKE FOR IT TO BE
EFFECTIVE. A $25.00 NON-REFUNDABLE FILING FEE IS REQUIRED.
ANY FORM RECEIVED INCOMPLeTE OR INCORRECT W~LL BE RETURNED
UNPROCESSED. THE EFFECTIVE DATE OF ANY RETURNED FORM WILL BE 30 DAYS AFTER
THE POSTMARK OF THE CORRECTED FORM.
IWORKERS' COMPENSATION INSURANCE INFORMATION
NAME OF W.C. CARRIER
CARRIER ADDRESS:
CITY: STATE; & ZIP
IPO C --...-....-..-.... ,,~.
Ll Y NUMBER: :r..:;\.I I. v t:. 1.1.'-\ i~. . _ .
-'. , . _ ~.! "_ ~- _.-;.A-ro -..,...__._ --. .-L. ~ ~ ~- ._-~~_._.~~
PURSUANT TO SECTION 440.05(3), F.S. PLEASE LIST THE NAME, SOCIAL SECURITY
NUMBER OR FEDERALIDENTIFICATION NUMBER OF EACH SOLE PROPRIETORSHIP,
PARTNERSHIP, OR CORPORATION THAT YOU WILL BE EMPLOYED BY:
FEIN OR
NAME: SS# :
FEIN OR
..... .... ... ....
NAME: SS#: : : : : ::: :
.
FEIN OR :.~.. ..... :
. .
. ...
NAME:
SS# :
.-.
.. .
. .
- .
. .
- -
.. .
- -
. ....
. ... .
. ....
. .
LES FORM BCM-204(1 2/93)
. . ..... ... . ....
... .... . .
.... ..... ....
- .. . ....
. .. .... .. .
.... ..... ew. . .. ....
-
AC!JRQ.
>.'_~_-_',''''''',.,'',';-:-c._'''''''.'".'.~_- .... :.'.-"'.,'~"yA: _~; ,-,. "'.~,''''-._':<:~,'''''''''':,:,,".''''''_'':'':__':U,'''''''''.''''';-;-' "__.","""",~'~'''''''''''''~,,:''' ~"_,'."":':--=' ~_.~"_,'" .~.
.........c.e.RTI..r=I.CA.,...E.....O.r=......l..l.lII'.llm1J......,._J'_.~N~._.............................................................................................. .DATE (MM/DDNY)
....y ... ......'O';T~ISCE-RTI~;CATEISPISSUEOAS A MATTER OF U:~9IJ,(TION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
_.__._-.-_..~._..
PRODUCER
ISLAND INSURANCE AGENCY,INC.
3229 FLAGLER AVE #112
KEY WEST,FL. 33040
I~-;~~;~~~--- --
. A
!KATEHIS DIONISIOS
['OVERSEAS JANTImIAL
P.O. BOX 5190
KEY WEST,FL. 33040
COMPANY
B
INTEOON NATIOOAL INS CO.
INSURED
SERVICE"
COMPANY
C
~.,. ~~ --
I
I
I AUTOMOBILE LIABILITY
1___-----,
I
I
ICFL-3315939-OO
7/01/99
7/01/00
___J ANY AUTO
Ii ~~ ALL OWNED AUTOS
A SCHEDULED AUTOS
I H HIRED AUTOS
A P NON-OWNED AUTOS
I
V
L' ;
I GARAGE LIABILITY
1--1
L-J ANY AUTO
I i
~_n~ _u_
. I
~E~CESS LIABILITY
I ___I UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
&u&m6RQ
THE PROPRIETOR!
PARTNERs/EXECUTIVE
OFFICERS ARE:
OTHER .
INCL!
i EXCLi
DESCRIPTION OF OPERATlONSlLOCATlONSlVEHICLEs/SPECIAL ITEMS
GENERAl AGGREGATE
PRODUCTS-COMProPAGG
PERSONAL & ADV INJURY
EACH OCCURRENCE
: FIRE DAMAGE (Anyone fire)
MEO EXP (Anyone pel'lOn)
COMBINED SINGLE LIMIT
BOOIL Y INJURY
(Perpel'llOl1)
BODILY INJURY
(Per accident)
PROPERTY DAMAGE
$
$
$
$
--.--.-----.-----.
$
$
I
: $
--- ---~._-
$ 25,000
1$ 50,000
1-
1$ 25,000
I AUTO ONLY- EA ACCIDENT I
OTHER THAN AUTO ONLY:
EACH ACCIDENT I $
1- ----.--.-...---.
AGGREGATE $
EACH OCCURRENCE I $
----r---------~-----
AGGREGATE I $
-,----
I $
$
$
EL DISEASE - EA EMPLOYEE $
JANITORIAL SERVICE.
1991 CHEVY S-10:VIN 1GCCS14Z9M8300245
, 1977 Gl>1CVAN VIN:TGL2584513991
f'C$Ai"iFiCpitiJ5HQ1;iiPlltW.r:'.... ....'...... ......:."';.,.:..;..,:.:~,::....'<..;1::'E~~JfBjj.19N{:)':'.'?I::::}:%g':'},:t;:,{t"t::}:Tt?.............. ......... ...... ..
I MOJ:\IROE COUNTY BOARD OF COUNTY COMMISIONERS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
51.00 COLLEGE RD EXPIRATION DATE T~EREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
KEY WEST, FL. 33040 _ S WR_ITTEN NO E TO THE CERTiFICA~E HOLDER NAMED TO THE LEFT,
BUT FAI RE TO MAIL SUCH NOTICE SHALL IMPOSE. NO OBLIGATION OR LIABILITY
OF ANY
AUTHO~IZED RE
1978 FORD VAN:VIN E04HBEC0898
I
!
I .'
l ,
,,~~..:~~l.,'...t:;it~i!@%:::
'"' "H _" "", ....
'.... :.:::::: :::::::::::::;:~~~r(:i:i:~~~:~~~:~:~:~:j:~:~:;:~:~:~:~:?~t::.:.:.' .... . .
....':>:~::,.8
ACORQ.
. ..... _... _ _...._. "........ _,.,,_,_ .__ ...d'....._ ,',.. _"
.",.................te...m...... m. .......1::..........1....1'>-........... }A:.. ....~.... ..........1.. ....................."..... ... <.....I!.......i..< .... A.................m............I......I. ............. i'r... .. ... ".................1.*.. .....1. ..0.. ... ......)Ift A I"'. :..-"..... .............:1.............
"I:;:n-:::I< :r~.:"Mt:I:}""'<::::w:r:>::':L. ",:g: :;~ . >1>:-1<>:,: .:I:.:a":~Fl~:.:":~~.,...:.
. _.~..~.~_.....~............ .._.-. ,-----_.~- ..----
I THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION i
I ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE I
I HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR I
I___~~"LER THE COVERAGE AFFORDED BY THE POLICIES BELOW._~
COMPANIES AFF()ROING COVERAGE 1
CFI'fr:D !
COMP~ I.,..... ,..l i
r .._~- , ;
l J~~~ \
AiRPORTS
Dt1'~fflY")
PRODUCER
ISLAND INSURANCE AGENCY,
3229 FLAGLER AVE #112
KEY WEST,FL. 33040
INC.
COMPANY
A
CENTURY SUR
INSURED
COMPANY
B
DIONISIOS KATEHIS dba
"OVERSEAS JANITORIAL SERVICE"
P.O. BOX 5190
KEY WEST,FL. 33045
COMPANY
C
~l
CQveaAoe$ ... . .. i
THIS is TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD I'
iNDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WiTH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, I
EXCLUSiONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
J
COMPANY
o
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MMlDDIVY) DATE (MM/DDIVY)
LIMITS
GENERAL LIABILITY
xx: COMMERCIAL GENERAL LIABILITY
99-o15(BINDER #)
6/2/999
6/2/00
GENERAL AGGREGATE ,$210001000
PRODUCTS - COMP/OP AGG $ lrOOGTOOQ.-
PERSONAL & ADV INJURY . $ llOOO~
EACH OCCURRENCE $ 1,000 , 000
FIRE DAMAGE (Anyone fire) . $. 50;000. I
MED EXP (Anyone person) $ 5 ,000
-------.--.-1
COMBINED SINGLE LIMIT $
CLAIMS MADE
OCCUR
OWNER'S & CONTRACTOR'S PROT
A
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON.OWNED AUTOS
BODILY INJURY
(Per accident)
$
W.4IVER:
,.. """""-:Yt'S
ill." . . -C- ~,
~'~
., "~
CC.
BODILY INJURY
(Per person)
$
~.y
GARAGE LIABILITY
ANY AUTO
PROPERTY DAMAGE
~--(n$TOONLY-EAACCIDENT $
OTHER THAN AUTO ONLY:
$
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
EACH ACCIDENT . $
AGGREGATE $
EACH OCCURRENCE $
AGGREGATE $
$
WC STATU-
TORY LIMITS
EL EACH ACCIDENT
OTH.
.ER
THE PROPRIETOR!
PARTNERS/EXECUTIVE
OFFICERS ARE:
OTHER
INCL
EXCL
$
$
EL DISEASE - EA EMPLOYEE $
EL DISEASE. POLICY LIMIT
DESCRIPTION OF OPERATIONSlLOCATIONSlVEHICLESlSPECIAL ITEMS
CERTIFICATE HOLDER IS ADDITIONAL INSURED
MONROE COUNTY BOARD OF COUNTY COMMISIONERS
5100 COLLEGE RD RM 203
KEY WEST,FL. 33040
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRAT
10
AGENTS OR REPRESENTATIVES.
..-.-.---.-.'.....-.-..........................................-..............-...............
..............COlbt;~RA11dtI19a8
ACORD~ CERTIFICATE OF LIABILITY INSl.JRANC~wl~l I DATE (MM/DDIVY)
01/06/00
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Key West Insurance, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P. O. Box 5487 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Key West FL 33045-5487 INSURERS AFFORDING COVERAGE
Phone: 305-294-1096 Fax: 305-294-8016
INSURED INSURER A: Bankers Insurance Group
INSURER B:
Overseas Janitorial Services INSURER C:
Dionisios Katehis dba
3312 Northside Drive #515 INSURER D:
Key West FL 33040 INSURER E:
I
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR TYPE OF INSURANCE POLICY NUMBER DA~b MMIDDIVY LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE D OCCUR
LOC
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
GARAGE LIABILITY
ANY AUTO
EXCESS LIABILITY
OCCUR D CLAIMS MADE
DEDUCTIBLE
RETENTION $
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
OTHER
A Employee Dishnsty
01/06/00
01/06/01
BINDER
DESCRIPTION OF OPERATIONSlLOCATIONSlVEHICLESlEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER
CANCELLATION
N ADDITIONAL INSURED; INSURER LETTER:
EACH OCCURRENCE $
FIRE DAMAGE (Anyone fire) $
MED EXP (Anyone person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
COMBINED SINGLE LIMIT
(Ea accident)
BODILY INJURY
(Per person)
$
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
AUTO ONLY - EA ACCIDENT $
OTHER THAN
AUTO ONLY:
EA ACC $
AGG $
$
$
$
$
$
EACH OCCURRENCE
AGGREGATE
$
E.L. DISEASE - EA EMPLOYE $
EL DISEASE - POLICY LIMIT $
10,000
MONROEC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR BILITY OF ANY KIND UP THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
Monroe County Building Dept
5100 College Road
Key West FL 33040
Bar
ACORD 25-5 (7/97)