Certificates of Insurance
--'
Aon Assn Services, a Division
of Affinity Ins. Services, Inc
1120 20th St NW
Washington, DC 20036
Phone: 800-432-7465 Fax: 202-857-0143
INVOICE#
'"'-- .
184261
Page 1
ACCOUNT NO. OP
SOUHOM3-1001 CB
NonProfit D&O (UWB)
DATE
12/23/08
POLICY #
NOA0303413
Southernmost Homeless
Assistance League, Inc.
P.O. Box 2990
Key West, FL 33045
COMPANY
Twin City Fire Ins. Co.
PRODUCER
Chris Blanchard
EFF[{.TIVE
03/18/09
EXPIRATION
03/18/10
BALANCE DUE ON
03/18/09
,\J\lOllNT PAID
AMO\INT DUE
$ 1,402.79
*** I) LEASE RETURN TOP PORTION WITH REMITTANCE ***
Itm# Trn Date Trn Type Policy #
INVOICE # 184261
455808 12/23/08 REN UBOO NOA0303413
455809 12/23/08 SUR UBDO NOA0303413
455810 I 2/23/08 PFE UBDO NOA0303413
Description
Amount
Policy r~ncwal
$
1,379.0
Stale Surcharges/Fees
$
13.7
Policy Administrative Charge
$
10.0
Invoice Balance:
$
1.402.7
PAYMENT MUST BE RECEIVED BY POLICY INCEPTION DATE OR THE
COVERAGE WILL BE CANCELLED
PLS REMIT PMT TO: Aon Association Services, P.O. Eox 19584A,
Newark, NJ 07195-0584.
.
Additional Entity Endorsement
It is understood and agreed that Item A, ENTITY, of the Declarations has been amended
to include:
Monroe County Board of County Commissioners
The additional premium generated by this action is: $.00
All other terms and conditions remain unchanged. This endorsement is a part of your
policy and it takes effect on the effective date of your policy, unless another effective date
is shown below.
This section is to be completed only when the endorsement is prepared after the policy is effective.
Policy Number: NOA0303413
Effective Date of Endorsement: 3/18/2009
Endorsement's Print Date: 3/18/2009
Entity: Southernmost Homeless
~---_.._-_.._.,-----.:.
2005 Edition
~IONROE COUNTY, FLORIDA
Request For Waiver
of
Insurance Requirements
It is requested that the insurance requirements, as specified in the County's Schedule of Insurance Requirement", be
\vaived or modified on the foJJowing contract.
Con.raclor: ~~.'\~<;.t l:to.~~,I7.~ ~S;~~~1.\('t'~Le~'^-'0
:::::t:::ontractor: 1~~i:~s~C:k;~~~~~(~t~~~ '
---. -~-_. '.,--_., .--. "-~--------------~. ._-
Phone:
~cs- ~._3>~3.-..3k~~
.. ~&l>\'Cl,h"~LQfSQ""'\'r:..t"S.......~cl~~&';'"\
_-foJ~.~u. ~kO_~iL'A&e ~l[.ASce~ Soy
1~o.'v~ \e ~_ c;-{"' . +~~. _s;;~1_ 'i~t~ ~f ~ l~ele~'~'\.t S ~
S\:tl\.Lk~_v~t(--DW'^, ~l();~ \.~~
~e~~ _~ .w~ ~ ;-l.JeWc,k l~e:..Io,ldr\V\,(.~..f~C ('
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r -:\..--.. I .(\ - - -
~~~\.-
APP.. r~'~. d~... '.n . _ ..'. () , Not Approved
.. U\,::..~ . -J~lctoS-
Scope of Work:
Reason for Waiver:
Policies Waiver
will apply to:
Signature of Contractor:
Risk tvlanagemcnt
Date
.G Ch
.~ "--1-\.., ~ t_ __
County Administrator appeal:
Approved:
~ot Approved:
Date:
Board of County Commissioners appeal:
.'\pproved:
:'-1ot Approved: _
\-leeting Dale:
.-\drnini~lration In<;tructinn
.::.rtl96
1(4
,I
.....
2005 Edition
MONROE COUNTY, FLORIDA
Request 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: ~~t\~t ~~~Jh~<....k~c~~'-'0
k~~~~e~~&~ ~~. ... .
Address of conll1lctor;-1~~3'W,-\s:e ~lUes.. t: +l:L.33~
Contract for:
Phone:
Scope of Work:
Reason for Waiver:
Policies Waiver
will apply to:
Signature of Contractor:
Risk Management
Date
County Administrator appeal:
Date:
_..._.._".,-_._.__._~.~-_.,,_.,,-,,_._.._-----_..,._--,-,-~_.-".~_..-._--,....._~----,..._-~-~.-
.30$ -:...3>9'3 ~ 3~0-__.______,_..___
_~{rH~~~-SU~:Les. _~_~"'ct~
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ho>'V\i..\e~_c>-{'~~_ CL1:....tl~k 6-\: b,""ele~~l ~ _
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Wc~ Co.~~~~It\..~_~a....I,C.-e___ ~c~.<: to ...
u, \ "'-.s~.
~p~~~ -NotApproved .~ '..=-=-
- ~. . a/l:i-~_____
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Approved:
Not Approved: _.__._
Board of County Commissioners appeal:
_..._-,._._--.~-"-,----_..__...,_.._...._-,......_---~-...---
-I
Meeting Date:
Administration Instruction
#4709.6
Approved: ___
Not Approved: ___
--.__....-._-",._~.-
104
It is requested that the insurance requiremenls, as specified in the County's Schedule of Insurance Requirements, be
waived or modified on the following contract
~MUS~ ~~~~
l..~~~~~~.~.~
Address of Contractor; lD--.b.-J.-d.99 (L r~~~~--tel.- ~ 'k>~
-,. .-.....--......___.n.,.__......_... "_.. ..'.._....___
3b5"-3i~-~k-lL__ _
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~::~:~ntraclor: _~.~i;~~~~m=-=
]TIed rL
- ~ral:ai_ ___
-..,.".
Contractor:
Contract for:
Phone:
Scope of Work:
Reason for Waiver:
Risk Management
Date
County Administrator appeal:
Date:
...
2005 Edition
MONROE COUNTY, FLORIDA
Request For Waiver
of
Insurance Requirements
Not Approved
Approved:
Not Approved: ____
-'---""_.n.._ __.__.__
.1
Board of County Commissioners appeal:
-..--..-.......--...---.--..-...--
Meeting Date:
Admin istmtion Instruction
#4709.6
Approved:
Not Approved: _ _ _
~. ..._._..,_._..._~_._"--,-_._------,..._"- -"- --
104
NON-PROFIT SERVICE ORGANIZATION
.
~FORD
lJ ! \i,t t.. ci .- A
. . \.'. ,
CERTIFICATE OF INSURA~E
COVERAGE DECLARATIONS FOR NONPROFIT DIRECTORS' AND OFFICERS. LIASI
NonProfit Directon' and Officers'
Liability Insurance
Policy Number: NOA0303413
Annual Premium: 1~92. 79
.00
A~
1st POLICY YEAR 513.79 Includes FL State Surtharges
2nd POLICY YEAR
3rd POLICY YEAR
Item A. Name of insured ENTITY:
C/O
Street Address
City, State, Zip Code:
Southernmost Homeless
Assistance League, Ioe.
P.O. Box 2990
Key West FL 33045
Item B. POLICY PERIOD:
(12:01 a.m local time at the ENTITY's principal address)
From 3/18/2009 To 3/18/2010
(month, day, year) (mondt day, year)
Item C. Limits of Liability:
(i)
Aggregate each POLICY YEAR:
51,000,000
Item D. Deductible (also known as retention):
(i)
(ii)
EMPLOYMENT PRACTICES CLAIM:
Other than EMPLOYMENT PRACTICES CLAIM:
S2,.~
S1,,~
Each and every CLAIM
Each and every CLAIM
Item E. Prior or Pending Litigation Date: 3/18/2002
(The Prior or Pending Litigation Date excludea cownge for all past and present litigation or lcnovm po1adial claims)
Item F. Retroactive Date: None
(If ro1roactive date is none full prior acts coverage will be provided subject to the Prior or Pending Litigation Date and the Terms and Conditions of tile policy)
Form Numbers of Coverage Parts, Forms and Endorsements that are a part of this policy and that are not listed in the Coverage Parts:
NPOOH022010306_ NPOOH028010306 NPOOB033000803 NPOOB043001203 NPOOR083OOOS04 NPOOB087000S04
NPOOB088000504 NPOOH090000306 NPOOH091000306 NPOOH095000306 NP09B037000803
Program Admini~tor:
Aon A.,sociation Services Mailing Address:
a Division of Affinity Insurance Services, Inc.
159 East County Line Rd
Hatboro, P A 19040
1-800-432-7465
Aon Association Services
a Division of Affinity Insurance Services, Inc.
1120 20th Street, N.W.
W~ D.C 20036
Special Program:
Tbe United Way of America Endorsed D&O Program
Insurance Provided by:
Twin City Fire Insurance Co
Hartford Plaza
Hartford, Connecticut 06115
A Member of THE HARTFORD
NonProfit Directors and Officers Liability Policy (Ed.6-99)
Form No. NP 00 B03! 00 0803
.
_ Ell*" Ea......t
It is lDlderstoocllDd qreed that Item A, ENTITY, of the -. has been amended
to include:
---C__-"efc..tJ~
tile .......... ....... ......... .., ... ....... 5.00
All other terms IDd conclitionl n:main Il~ TIIia eacIonem.at is a part of your
policy and it ... effect on the etrectWe date of your policy, unless another eIfective date
is shown below.
ThilIeCtion is to be cxmpleted only.... the IIICIorIerI8It is pftl)llleCl after the policy is etfectiw.
PoJic;y Number: NOA03lMU
Etfective Date ofEDdonement: 3I11J211t
Endonemears Print Date: 3/1.,..,
Entity: s.tMt~ ....11_
2{)O~ EdttlOn
~IONROE COUNTY. FLORIDA
Request For Waiver
of
Illsurace Requirements
It IS n.~ that rhe IlliU1a111:e mtWmaen&s. .. specifac:d ia me cOUDtYs Schedule of 11lIU1'8nCe R4.'q1Iir<<:ment5.. be
\\ar.'td nr modified Oft the follO\\o1D8 c:oalraCt. ~
t'on1nCI0r. So~~~t. Y.c~e~~~,,~\tt~e_J..t?~~
l'onnc;t for; \e..~, -kc ':;\b:c.e ~~ \ ~_ ~c.40 .~~ .
.\ddres.o;orConll1lC(Dr; lo_~~ -~.9CW T"~\ lDe~\- ~ r L 3.~~.s
----- - ~ - .--....-. -- ....-... ...... ....-. -- .-.......... - - ......... --
Phone:
~s:: ~q,3 --3 ~.k'kL _ _._ _ _ __ ._ __ _
- Coot&.~~~of ~l,u.es-~_ ~-!'"cL~\
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l.1&..W..e. .J ~.Q.\oJ:..\ ~_ l6~~ ~ _ _
- - ~~ ~~ ~ .- = = ~ ~ - - -
J\p~~ ~ ~,.- . n NoI Approved -
. - \l ,-=-~ -2>-.,lt-o~
-- Z, -1- I:j-(;I:l_ - _
Scope of Work;
RftbOIl for Waiver:
PobCles W."w
wilt appl) to:
SiInalun: of Contractor:
Ri-;k MIIDapIDCfIT
Date
County ."'dmin1~tCK 8pp\:aJ:
Appro\ \o-d.
~uI r\ppro\"ed: _ __ _
I)a Ie"
Board oj' CnUDty (....'mml~6Ct.,~" rJppec1J:
\rPro~<<L
~(\t . \ppn."rcd. _ _ _
\1~ln!! {)atc:
. \drnlnlstrtltl,'n 'n"IFdl:UllO
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I Ct4
20DS EelulOIl
MONROE COUNTY. FLORIDA
Request For Waiver
of
la.8raaee Req........1I
It is ~ lbal die iDIurIace n:qairemenca, IS spedrJCd iD tile CGmtys Schedule of_uraace R.equiremen~ be
watved ar modified 011 the foIlowina contract.
Connetot: ~~~t ~~~~e_l.e~~
COJIhcIfor: _~~~~~,~_~~~~_ .
AddftssofCOIlIractor: -fo ~~ ~~'T lllcesS---tL ~
Phoae:
Seope oCWOIt:
Reasoa for WaiwI':
Pohcies Wliwr
~u IPPly \0:
Sip8IDre of Colltr8ctor: _
RUk MIII8pIbcDt
Date
Couaty Adm..~ appeal:
Date:
--- ..........-.-.. ---.-. ..----..----...-------. ---.-...-------..- ......--. ~ - - .............. ~
~os- -~3 ::..a~" __ __ _
- CoolclL,.-.ah~J!&LIA~~l"'~ ~_~Al:\
-=for ~~ Lt~\...O t(O,^&e ~~(..~~
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- - ----- .......-...... ----- - ...-.-.-. ---.-
~--------_._-
Approved _ NotApproved ___
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......... ~ .--.-. ---- ~ ..-...-
Approved: _. __
Not Appmved: __
..,. -----...-.""- -............--. "'~ .........-- ...---. ~... ---...... --. ---- --
Board of COUDIy Conuniuioaels appeal:
ApproW!d: ___e
Mccbftg Date:
Adminftntloa (o5truuion
#4 '09.6
Nnt Approved; _. _ _
......-...---- -.. -- ......
104
If IS n.~ed lllat the J1tIurauce requiremerds~ as speculed in the COUIlly's Schedule of IDIIlI1l1lCe RcquU'CmeDts.. be
"..,'Cd rw modified 011 the follow... contracL
~--L~L~~~~
l~~_~~_ ~~_e.~__
-~~()rConuactol-. to l ~a.e." 1.1_ -LI h -"......
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-- ~ ~ ~ ~ -.-...-.- ~ ------ -.--. -.- ~ - ----. - -....-.. - -
1h~-n~--1aJ,faL~ __ _ _._ _ _ _ _ _
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~:n~ ~ $.~ .J1tJt.&_ - ~ ·
~~~~' -~
JjJ~
- '=t-a1:.di - -_
ConU1lCIOF:
Coalracl for:
Phone:
Scope ot"Wodt.
R~ Cor ".aj,ocr.
Risk Maaapmmt
Date
200~ EditIOn
I\tONROE COVNTV~ FLORIDA
Request For Waiver
of
luuraee RequlremClltl
Not Approved
COUD1y Admim"'FalOr appeal:
Approved: _ _
Nut Appro\": _ _ _
I).I~'
~~"""""--------------"""""''--''-~-........-----
80mf orCount~ Comnuuioners appeal:
Not Approved. _ ___ _
Meeting l>ate:
Adminifinltion 'nstnMion
.., 1119 6
AppI'Q\.ed:
---.. ----- ..............................-.- -----. ---.. - ------ ~ -
lo.J
2005 Edition
MONROE COUNTY, FLORIDA
Request For Waiver
of
Insurance Requirements
Pbone:
It is requested that the insurance requirements, as specified in the County's Schedule of Insurance Requirements, be
waived or modified on the folJowing contract.
~~~,,-~~t- ~~~sJkst~~ ~~
-~ Q~~/~{;~~l1ti~~~M.r-
Address of ConlIactor: -W ~\l, J...9~ 0 ~ .____
-~~i . f L 3 "304-\('
- bO~ O~'1~ . ~L
~ \o~se~t~&~ {/"er~ C~~"VV\ .
Contractor:
Contract for:
---.._.--~---
Scope of Work:
~----"'.""~..-..",-,...~...
Reason for Waiver:
Less ~ 3 etts.o~~~
2_~~~ ~~_______
_H~~
Policies Waiver
will apply to:
Signature of Contractor:
..-----------...-.........--.-.........~~........---
ot Approved
Risk Management
Date
-...~..._'~.._-----~---------------.----
Date:
County Administrator appeal:
JdZ~
Not Approved:
.,
Board of County Commissioners appeal:
Approved:
Meeting Date:
--
Administration Instruction
#4709.6
104
~~ -A~ _ . _..
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