05/20/2009 Agreement
DANNY L. KOLHAGE
CLERK OF THE CIRCUIT COURT
DA TE:
August 25, 2009
TO:
Dent Pierce, Director
Public Works Division
FROM:
Beth Leto, Assistant Director
Public Works Division
Pamela G. Hanc€!!J15. C.
ATTN:
At the May 20, 2009, Board of County Commissioner's meeting the Board granted
approval to award bid and authorized execution of a Contract for bio-diesel fuel to the lowest
acceptable bidder, Blaylock Oil Company.
Enclosed is a copy of the above-mentioned for your handling. Should you have any
questions please do not hesitate to contact this office.
cc: County Attorney
Finance
File\/'
CONTRACT
BIO-DIESEL FUEL SUPPLIER
THIS AGREEMENT, made and entered into this 20TH day of May, 2009 by and between the
COUNTY OF MONROE, STATE OF FLORIDA, a political subdivision of the State of Florida
hereinafter called "CountY' and BLAYLOCK OIL COMPANY hereinafter called llContractor".
WITNESSETH:
That the parties hereto for the consideration hereinafter named, agree to the following:
1. DESCRIPTION
A. The Contractor shall deliver approximately 200,000 gallons of Bio-Diesel fuel ((B20 thru 899 as
requested), must meet ASTM industry standards) to locations in the Key West, Marathon,
Plantation Key, and Key Largo areas annually as requested by the ordering Monroe County and
School Board departments and on the dates requested by such departments. Fuel shall be
delivered the next day if requested by 4:00pm.
B. The Contractor shall have ability , and may be required to deliver Ultra Low Sulfur Clear Diesel
Fuel, and/or Ultra Low Sulfur Dyed Diesel Fuels on an as needed basis after a hurricane,
natural disaster or other emergencies to locations in the Key West, Marathon, Plantation Key,
and Key Largo areas as requested by the ordering Monroe County and School Board
Departments, and on the dates requested by such departments. Fuel shall be delilvered the
next day if requested by 4:00 PM.
C. Deliveries will be in quantities of less than One Thousand (1000) gallons to Two Thousand Five
Hundred (2,500) gallons (Full Tanks). The Contractor shall have a metered tanker for all
deliveries and shall be required to itemize invoices for each delivery under this provision.
Additionally, the Contractor shall be required to show proof of purchased price per gallon from
Terminal.
D. Upon request by the County, Contractor shall provide documentation supporting most recent
pump meter certification.
E. All deliveries must be witnessed and delivery tickets must be signed and dated by Monroe
County personnel.
F. The Contractor shall have the capability to pump fuel into aboveground tanks through standard
quick detachable couplings.
G. The County reserves the right to purchase from any licensed Contractors as needed in cases
when the Contractor cannot deliver, or in a case of emergency as deemed best for the interests
of the County.
2. TERM OF CONTRACT
A. This contract shall be for a period of One (1) year commencing upon the day in which it has been
executed by both parties.
B. The County shall have the option to renew this agreement after the first year, for bNo (2) additional
one (1) year periods.
3. HOLD HARMLESS
The Contractor covenants and agrees to indemnify and hold harmless Monroe County Board of County
Commissioners from any and all claims for bodily injury (including death), personal injury, and property
damage (including property owned by Monroe County) and any other losses, damages, and expenses
(including attorney's fees) which arise out of, in connection with, or by reason of services provided by the
Contractor or any of its Subcontractor(s) in any tier, occasioned by the negligence or other wrongful act or
omission of the Contractor or its Subcontractor(s) in any tier, their employees, or agents. The extent of liability
is in no way limited to, reduced, or lessened by the insurance requirements contained elsewhere within this
agreement.
4. INSURANCE
Prior to execution of this agreement the Contractor shall furnish the County Certificates of Insurance indicating
the minimum coverage limitations as stated in the General Insurance Requirements for Suppliers of Goods or
Services section of this contract.
5. PAYMENT
A. Price per gallon shall reflect (Contractor Purchase Price) Terminal (RACK) charges.
B. Monroe County may not be charged more than the following prices listed above market (RACK)
price from date ordered.
B20
$ 0.237 Key West
$ 0.237 Sugarloaf
$ 0.237 Marathon
$ 0.237 Plantation Key
$ 0.237 Key Largo
B30
$ 0.237 Key West
$ 0.237 Sugarloaf
$ 0.237 Marathon
$ 0.237 Plantation Key
$ 0.237 Key Largo
B50
$ 0.237 Key West
$ 0.237 Sugarloaf
$ 0.237 Marathon
$ 0.237 Plantation Key
$ 0.237 Key Largo
B70
$ 0.237 Key West
$ 0.237 Sugarloaf
$ 0.237 Marathon
$ 0.237 Plantation Key
$ 0.237 Key Largo
B99
$ 0.237 Key West
$ 0.237 Sugarloaf
$ 0.237 Marathon
$ 0.237 Plantation Key
$ 0.237 Key Largo
Ultra Low Sulfur Clear Diesel Fuel
$ 0.237 Key West
$ 0.237 Sugarloaf
$ 0.237 Marathon
$ 0.237 Plantation Key
$ 0.237 Key Largo
Ultra Low Sulfur Dved Diesel Fuel
$ 0.237 Key West
$ 0.237 Sugarloaf
$ 0.237 Marathon
$ 0.237 Plantation Key
$ 0.237 Key Largo
C. The Contractor shall submit invoice to the County, itemizing the delivery location, the requesting
department, the RACK prices, and all taxes, for each delivery to the locations described herein.
D. Upon receipt of Invoice the County shall have thirty days to render payment to Vendor.
E. Diesel fuels taxes must be itemized on each invoice.
6. INDEPENDENT CONTRACTOR
At all times for all purposes under this agreement the Contractor is an independent Contractor and not an
employee of the Board of County Commissioners for Monroe County. No statement contained in this
agreement shall be construed so as to find the Contractor or any of his/her employees, Sub-contractor(s),
servants, or agents to be employees of the Board of County Commissioners for Monroe County.
7. ASSURANCE AGAINST DISCRIMINATION
Contractor shall not discriminate against any person on the basis of race, creed, color, national origin, sex,
age, or any other characteristic or aspect which is not job related, in its recruiting, hiring, promoting,
terminating, or any other area affecting employment under this agreement or with the provision of services or
goods under this agreement
8. ASSIGNMENT
Contractor shall not assign or subcontract this agreement, except in writing and with the prior written approval
of the Board of County Commissioners for Monroe County, which approval shall be subject to such conditions
and provisions as the County may deem necessary. This agreement shall be incorporated by reference into
any assignment or subcontract and any assignee or subcontractor shall comply with all of the provision of this
agreement. Unless expressly provided for therein, such approval shall in no manner or event be deemed to
impose any obligation upon the County in addition to the total agreed-upon price of the services/goods of the
Contractor.
9. COMPLIANCE WITH LAW
In providing all services/goods pursuant to this agreement, the Contractor shall abide by all statutes,
ordinances, rules and regulations applicable to this agreement A violation of any of the statutes, ordinances,
rules and regulations applicable to this agreement shall constitute a material breach of this agreement and
shall entitle the County to terminate these Contractor immediately upon delivery of written notice of termination
to the Contractors.
10. NOTICE REQUIREMENT
Any notice required or permitted under this agreement shall be in writing and hand delivered or mailed,
postage prepaid, to the other party by certified mail, returned receipt requested, to the following:
For County:
Monroe County Fleet Management
3583 S. Roosevelt Blvd.
Key West, FL 33040
With a copy to:
Suzanne A. Hutton
Monroe County Attorney
P.O. Box 1026
Key West, FL 33041-1026
For Vendor:
Blaylock Oil Co.
724 S. Flagler Ave.
Homestead, FL 33030
11. FUNDING AVAILABILITY
In the event that funds from Fleet Management Services operating Gasoline and Diesel Accounts are partially
reduced or cannot be obtained or cannot be continued at level sufficient to allow for the purchase of
services/goods specified herein, this agreement may then be terminated immediately at the option of the
county by written notice of termination delivered in person or by mail to the Contractor. The County shall only
be obligated to pay for any goods delivered by the Contractor until the Contractor has received written notice of
termination due to lack of funds.
12. PROFESSIONAL RESPONSIBILITY
The Contractor warrants that it is authorized by law to engage in the performance of the activities
encompassed by the project herein described, subject to the terms and conditions set forth in the Notice of
calling for Bids. The Contractor shall at all times exercise independent, professional judgment and shall
assume professional responsibility for the services to be provided. Continued funding by the County is
contingent upon retention of appropriate local, state, and/or federal certification and/or licensure of Contractor.
13. PUBLIC ENTITY CRIME STATEMENT
A person or affiliate who has been placed on the convicted Contractor list following a conviction for a publiC
entity crime may not submit a bid on a contract to provide any goods or services to a public entity, may not
submit a bid on a contract with a public entity for the construction or repair of a public building or public work,
may not submit bids on leases of real property to publiC entity, and may not be awarded or perform work as a
contractor, supplier, subcontractor, or consultant under a contract with any public entity, and may not transact
business with any public entity in excess of the threshold amount provided in Section 287.017, for CATEGORY
TWO ($3000.00) for a period of 36 months from the date of being placed on the convicted vendor list.
14. TERMINATION
If the Contractor fails to fulfill the terms of this agreement, or attachments, properly or on time, otherwise
violates the provisions of the agreement, the County may terminate the contract by written notice. The notice
shall specify cause. The County shall pay the Contractor the contract price for goods delivered but not paid for
on the date of termination, less any amount of damages caused by the Contractors breach. If those damages
are more than the amount due the Contractor then the Contractor remains liable to the County for the excess
amount.
15. BOOKS. RECORDS. AND DOCUMENTS
Contractor shall maintain all books, records, and documents directly pertinent to performance under this
Agreement in accordance with generally accepted accounting principles consistently applied. Each party to
this Agreement or their authorized representatives shall have reasonable and timely access to such records of
each other party to this Agreement for public records purposes during the term of the Agreement and for four
years following the termination of this Agreement. If an auditor employed by the County or Clerk determines
that monies paid to Contractor pursuant to this Agreement were spent for purposes not authorized by this
Agreement, the Contractor shall repay the monies together with interest calculated pursuant to Sec. 55.03, FS,
running from the date the monies were paid to Contractor.
16. GOVERNING LAW. VENUE. INTERPRETATION
Goveming Law, Venue, Interpretation, Costs, and Fees: This Agreement shall be governed by and construed
in accordance with the laws of the State of Florida applicable to contracts made and to be performed entirely in
the State.
In the event that any cause of action or administrative proceeding is instituted for the
enforcement or interpretation of this Agreement, the County and Contractor agree that venue will lie in the
appropriate court or before the appropriate administrative body in Monroe County, Florida.
The County and Contrador agree that, in the event of confliding interpretations of the terms or
a term of this Agreement by or between any of them the issue shall be submitted to mediation prior to the
institution of any other administrative or legal proceeding.
17. SEVERABILITY
If any term, covenant, condition or provision of this Agreement (or the application thereof to any circumstance
or person) shall be declared invalid or unenforceable to any extent by a court of competent jurisdiction, the
remaining terms, covenants, conditions and provisions of this Agreement, shall not be affected thereby; and
each remaining term, covenant, condition and provision of this Agreement shall be valid and shall be
enforceable to the fullest extent permitted by law unless the enforcement of the remaining terms, covenants,
conditions and provisions of this Agreement would prevent the accomplishment of the original intent of this
Agreement. The County and Contractor agree to reform the Agreement to replace any stricken provision with
a valid provision that comes as close as possible to the intent of the stricken provision.
18. ATTORNEY'S FEES AND COSTS
The County and Contractor agree that in the event any cause of action or administrative proceeding is initiated
or defended by any party relative to the enforcement or interpretation of this Agreement, the prevailing party
shall be entitled to reasonable attorney's fees, court costs, investigative, and out-of-pocket expenses, as an
award against the non-prevailing party, and shall include attorneys fees, courts costs, investigative, and out-of-
pocket expenses in appellate proceedings. Mediation proceedings initiated and conducted pursuant to this
Agreement shall be in accordance with the Florida Rules of Civil Procedure and usual and customary
procedures required by the circuit court of Monroe County.
19. BINDING EFFECT
The terms, covenants, conditions, and provisions of this Agreement shall bind and inure to the benefit of the
County and Contractor and their respective legal representatives, successors, and assigns.
20. AUTHORITY
Each party represents and warrants to the other that the execution, delivery and performance of this
Agreement have been duly authorized by all necessary County and corporate action, as required by law.
21. CLAIMS FOR FEDERAL OR STATE AID
Contractor and County agree that each shall be, and is, empowered to apply for, seek, and obtain federal and
state funds to further the purpose of this Agreement; provided that all applications, requests, grant proposals,
and funding solicitations shall be approved by each party prior to submission.
22. ADJUDICATION OF DISPUTES OR DISAGREEMENTS
County and Contractor agree that all disputes and disagreements shall be attempted to be resolved by meet
and confer sessions between representatives of each of the parties. If no resolution can be agreed upon within
30 days after the first meet and confer session, the issue or issues shall be discussed at a public meeting of
the Board of County Commissioners. If the issue or issues are still not resolved to the satisfaction of the
parties, then any party shall have the right to seek such relief or remedy as may be provided by this Agreement
or by Florida law.
23. COOPERATION
In the event any administrative or legal proceeding is instituted against either party relating to the formation,
execution, performance, or breach of this Agreement, County and Contractor agree to participate, to the extent
required by the other party, in aU proceedings, hearings, processes, meetings, and other activities related to
the substance of this Agreement or provision of the services under this Agreement. County and Contractor
specifically agree that no party to this Agreement shall be required to enter into any arbitration proceedings
related to this Agreement.
24. NONDISCRIMINATION
County and Contractor agree that there will be no discrimination against any person, and it is expressly
understood that upon a determination by a court of competent jurisdiction that discrimination has occurred, this
Agreement automatically terminates without any further action on the part of any party, effective the date of the
court order. County or Contractor agree to comply with all Federal and Florida statutes, and all local
ordinances, as applicable, relating to nondiscrimination. These include but are not limited to: 1) Title VI of the
Civil Rights Act of 1964 (pt 88-352) which prohibits discrimination on the basis of race, color or national origin;
2) Title IX of the Education Amendment of 1972, as amended (20 USC ss. 1681-1683, and 1685-1686), which
prohibits discrimination on the basis of sex; 3) Section 504 of the Rehabilitation Act of 1973, as amended (20
USC s. 794), which prohibits discrimination on the basis of handicaps; 4) The Age Discrimination Act of 1975,
as amended (42 use ss. 6101-6107) which prohibits discrimination on the basis of age; 5) The Drug Abuse
Office and Treatment Act of 1972 (pt 92-255), as amended, relating to nondiscrimination on the basis of drug
abuse; 6) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of
1970 (Pt91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; 7)
The Public Health Service Act of 1912, ss. 523 and 527 (42 USC ss. 690dd-3 and 290ee-3) , as amended,
relating to confidentiality of alcohol and drug abuse patent records; 8) Title VIII of the Civil Rights Act of 1968
(42 USC s. et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; 9)
The Americans with Disabilities Act of 1990 (42 USC s. 1201 Note), as maybe amended from time to time,
relating to nondiscrimination on the basis of disability; 10) Any other nondiscrimination provisions in any
Federal or state statutes which may apply to the parties to, or the subject matter of, this Agreement.
25. COVENANT OF NO INTEREST
County and Contractor covenant that neither presently has any interest, and shall not acquire any interest,
which would conflict in any manner or degree with its performance under this Agreement, and that only interest
of each is to perform and receive benefits as recited in this Agreement.
26. CODE OF ETHICS
County agrees that officers and employees of the County recognize and will be required to comply with the
standards of conduct for public officers and employees as delineated in Section 112.313, Florida Statutes,
regarding, but not limited to, solicitation or acceptance of gifts; doing business with one's agency; unauthorized
compensation; misuse of public position, conflicting employment or contractual relationship; and disclosure or
use of certain information.
27. NO SOLlCITATIONIPAYMENT
The County and Contractor warrant that, in respect to itself, it has neither employed nor retained any company
or person, other than a bona fide emploYee working solely for it, to solicit or seaJre this Agreement and that it
has not paid or agreed to pay any person, company, corporation, individual, or firm, other than a bona fide
employee working solely for it, any fee, commission, percentage, gift, or other consideration contingent upon or
resulting from the award or making of this Agreement. For the breach or violation of the provision, the
Contractor agrees that the County shall have the right to terminate this Agreement without liability and, at its
discretion, to offset from monies owed, or otherwise recover, the full amount of such fee, commission,
percentage, gift, or consideration.
28. PUBLIC ACCESS
The County and Contractor shall allow and pennit reasonable access to, and inspection of, all documents,
papers, letters or other materials in its possession or under its control subject to the provisions of Chapter 119,
Florida Statutes, and made or received by the County and Contractor in conjunction with this Agreement; and
the County shall have the right to unilaterally cancel this Agreement upon violation of this provision by
Contractor.
29. NON-WAIVER OF IMMUNITIES
Notwithstanding the provisions of Sec. 768.28, Florida Statutes, the participation of the County and the
Contractor in this Agreement and the acquisition of any commercial liability insurance coverage, self-insurance
coverage, or local govemment liability insurance pool coverage shall not be deemed a waiver of immunity to
the extent of liability coverage, nor shall any contract entered into by the County be required to contain any
provision for waiver.
30. PRIVILEGES AND IMMUNITIES
All of the privileges and immunities from liability, exemptions from laws, ordinances, and rules and pensions
and relief, disability, workers' compensation, and other benefits which apply to the activity of officers, agents, or
employees of any public agents or employees of the County,' when performing their respective functions under
this Agreement within the territorial limits of the County shall apply to the same degree and extent to the
performance of such functions and duties of such officers, agents, volunteers, or employees outside the
territorial limits of the County.
31. LEGAL OBLIGATIONS AND RESPONSIBILITIES
Non-Delegation of Constitutional or Statutory Duties. This Agreement is not intended to, nor shall it be
construed as, relieving any participating entity from any obligation or responsibility imposed upon the entity by
law except to the extent of actual and timely performance thereof by any participating entity, in which case the
performance may be offered in satisfaction of the obligation or responsibility. Further, this Agreement is not
intended to, nor shall it be construed as, authorizing the delegation of the constitutional or statutory duties of
the County, except to the extent permitted by the Florida constitution, state statute, and case law.
32. NON-RELIANCE BY NON-PARTIES
No person or entity shall be entitled to rely upon the terms, or any of them, of this Agreement to enforce or
attempt to enforce any third-party daim or entitlement to or benefit of any service or program contemplated
hereunder, and the County and the Contractor agree that neither the County nor the Contractor or any agent,
officer, or employee of either shall have the authority to inform, counsel, or otherwise indicate that any
particular individual or group of individuals, entity or entities, have entitlements or benefits under this
Agreement separate and apart, inferior to, or superior to the community in general or for the purposes
contemplated in this Agreement.
33. ATTESTATIONS
Contractor agrees to execute such documents as the County may reasonably require, to indude a Public Entity
Crime Statement, an Ethics Statement, and a Drug-Free Workplace Statement.
34. NO PERSONAL LIABILITY
No covenant or agreement contained herein shall be deemed to be a covenant or agreement of any member,
officer, agent or employee of Monroe County in his or her individual capacity, and no member, officer, agent or
employee of Monroe County shall be liable personally on this Agreement or be subject to any personal liability
or accountability by reason of the execution of this Agreement.
35. EXECUTION IN COUNTERPARTS
This Agreement may be executed in any number of counterparts, each of which shall be regarded as an
original, all of which taken together shall constitute one and the same instrument and any of the parties hereto
may execute this Agreement by signing any such counterpart.
36. SECTION HEADINGS
Section headings have been inserted in this Agreement as a matter of convenience of reference only, and it is
agreed that such section headings are not a part of this Agreement and will not be used in the interpretation of
any provision of this Agreement.
37. MUTUAL REVIEW
This agreement has been carefully reviewed by CONTRACTOR and the COUNTY, therefore this agreement is
not to be construed against either party on the basis of authorship.
38. INDEMNIFICATION/HOLD HARMLESS
Notwithstanding any minimum insurance requirements prescribed elsewhere in this agreement, Lessee shall
defend, indemnify and hold the COUNTY and the COUNTY's elected and appointed officers and employees
harmless from and against (i) any daims, adions or causes of action, (ii) any litigation, administrative
proceedings, appellate proceedings, or other proceedings relating to any type of injury (induding death), loss,
damage, fine, penalty or business interruption, and (iii) any costs or expenses (induding, without limitation,
costs of remediation and costs of additional security measures that the Federal Aviation Administration, the
Transportation Security Administration or any other governmental agency requires by reason of, or in
connection with a violation of any federal law or regulation, attorneys' fees and costs, court costs, fines and
penalties) that may be asserted against, initiated with respect to, or sustained by, any indemnified party by
reason of, or in connedion with, (A) any activity of Lessee or any of its employees, agents, contradors or other
invitees on the Airport during the term of this AGREEMENT, (B) the negligence or willful misconduct of Lessee
or any of its employees, agents, contractors or other invitees, or (C) Lessee's default in respect of any of the
obligations that it undertakes under the terms of this lease, except to the extent the daims, actions, causes of
action, litigation, proceedings, costs or expenses arise from the intentional or sole negligent ads or omissions
of the COUNTY or any of its employees, agents, contractors or invitees (other than CONTRACTOR). Insofar
as the claims, actions, causes of action, litigation, proceedings, costs or expenses relate to events or
circumstances that occur during the term of this lease, this sadion will survive the expiration of the term of this
lease or any earlier termination of this lease.
In witness whered,:d._:~.have executed this agreement the day and year first above written,
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(Seal):, . ,,: \,:" , ' BOARD OF COUNTY COMMISSIONERS
Attest DANNY LKOU-fAGEitLSRK MONROE COUNTY, FLORIDA
By.G-.f~ ~~~4 )f)~,~
Clerk Mayor/Chairman
BY
(Corporate Seal)
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RISK MANAGEMENT
POLICY AND PROCEDURES
CONTRACT ADMINISTRATION
MANUAL
General Insurance Requirements
for
Other Contractors and Subcontractors
As a pre-requisite of the work governed, or the goods supplied under this contract (including the pre-staging of
personnel and material), the Contractor shall obtain, at his/her own expense, insurance as specified in any
attached schedules, which are made part of this contract. The Contractor will ensure that the insurance obtained
will extend protection to all Subcontractors engaged by the Contractor. As an alternative, the Contractor may
require all Subcontractors to obtain insurance consistent with the attached schedules.
The Contractor will not be permitted to commence work governed by this contract (including pre-staging of
personnel and material) until satisfactory evidence of the required insurance has been furnished to the County as
specified below. Delays in the commencement of work, resulting from the failure of the Contractor to provide
satisfactory evidence of the required insurance, shall not extend deadlines specified in this contract and any
penalties and failure to perform assessments shall be imposed as if the work commenced on the specified date
and time, except for the Contractor's failure to provide satisfactory evidence.
The Contractor shall maintain the required insurance throughout the entire term of this contract and any
extensions specified in the attached schedules. Failure to comply with this provision may result in the
immediate suspension of all work until the required insurance has been reinstated or replaced. Delays in the
completion of work resulting from the failure of the Contractor to maintain the required insurance shall not
extend deadlines specified in this contract and any penalties and failure to perform assessments shall be
~mposed as if the work had not been suspended, except for the Contractor's failure to maintain the required
Insurance.
The Contractor shall provide, to the County, as satisfactory evidence of the required insurance, either:
· Certificate of Insurance
or
· A Certified copy of the actual insurance policy.
The County, at its sole option, has the right to request a certified copy of any or all insurance policies required
by this contract.
All insurance policies must specify that they are not subject to cancellation, non-renewal, material change, or
~eduction in coverage unless a minimum of thirty (30) days prior notification is given to the County by the
Insurer.
The acceptance and/or approval of the Contractor's insurance shall not be construed as relieving the Contractor
from any liability or obligation assumed under this contract or imposed by law.
The Monroe County Board of County Commissioners, its employees and officials will be included as
"Additional Insured" on all policies, except for Workers' Compensation.
Any deviations from these General Insurance Requirements must be requested in writing on the County
prepared form entitled "Request for Waiver of Insurance Requirements" and approved by Monroe County
Risk Management.
GENERAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT BIO-DIESEL FUEL SUPPLIER
BElWEEN
MONROE COUNTY, FLORIDA
AND
BLAYLOCK OIL COMPANY
Prior to the commencement of work governed by this contract, the Contractor shall obtain General Liability
Insurance. Coverage shall be maintained throughout the life of the contract and include, as a minimum:
· Premises Operations
· Products and Completed Operations
· Blanket Contractual Liability
· Personal Injury Liability
· Expanded Definition of Property Damage
The minimum limits acceptable shall be:
$1,000,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$ 500,000 per Person
$ 1,000,000 per Occurrence
$ 100,000 Property Damage
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its provisions
should include coverage for claims filed on or after the effective date of this contract. In addition, the period for
which claims may be reported should extend for a minimum of twelve (12) months following the acceptance of
work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on all policies
issued to satisfy the above requirements.
GL3
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
CONTRACT BIO-DIESEL FUEL SUPPLIER
BETWEEN
MONROE COUNTY, FLORIDA
AND
BLAYLOCK OIL COMPANY
Prior to the commencement of work governed by this contract, the Contractor shall obtain Workers'
Compensation Insurance with limits sufficient to respond to the applicable state statutes.
In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less than:
$500,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$500,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business in the state of Florida.
If the Contractor has been approved by the Florida's Department of Labor, as an authorized self-insurer, the
County shall recognize and honor the Contractor's status. The Contractor may be required to submit a Letter of
Authorization issued by the Department of Labor and a Certificate of Insurance, providing details on the
Contractor's Excess Insurance Program.
If the Contractor participates in a self-insurance fund, a Certificate of Insurance will be required. In addition,
the Contractor may be required to submit updated financial statements from the fund upon request from the
County.
WC2
VEmCLE LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT BIO-DIESEL FUEL SUPPLIER
BETWEEN
MONROE COUNTY, FLORIDA
AND
BLAYLOCK OIL COMPANY
Recognizing that the work governed by this contract requires the use of vehicles, the Contractor, prior to the
commencement of work, shall obtain Vehicle Liability Insurance. Coverage shall be maintained throughout the
life of the contract and include, as a minimum, liability coverage for:
· Owned, Non-Owned, and Hired Vehicles
The minimum limits acceptable shall be:
$1,000,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$ 500,000 per Person
$1,000,000 per Occurrence
$ 100,000 Property Damage
The Monroe County Board of County Commissioners shall be named as Additional Insured on all policies
issued to satisfy the above requirements.
VL3
HAZARDOUS CARGO TRANSPORTERS LIABILIlY
INSURANCE REQUIREMENTS
FOR
CONTRACT BI()..DIESEL FUEL SUPPLIER
BETWEEN
MONROE COUNTY, FLORIDA
AND
BLAYLOCK OIL COMPANY
Prior to the commencement of work governed by this contract, the Contractor shall purchase Pollution Liability
Insurance which extends to the hauling of toxic and hazardous material by motorized vehicles. In compliance
with the Motor Carrier Act, the policy should be endorsed with an MCS-90 Endorsement, demonstrating
financial responsibility for spills and clean-up. Any pollution exclusion limiting coverage under this policy
shall be removed.
The minimum limits acceptable shall be:
$1,000,000 per Occurrence
VLP3
, ..
NON-COLLUSION AFFIDAVIT
I, l.".1ll\n.uloc LL ofthecityof~\Me~~.o A-
my oath, ~ penalty of perjury, depose and say that: t
according to law on
1. lam L.\-\-. (b\~lo~\L >> Qen
of the firm of -----Bl~ Lo",l(. 0'. L e.ol/lAftA.'^7
making the Bid for the services/work/project described in the Request for Bids for:
SlD- p~rD- cto- ~'15 -100Q / p\lR/ {J \I (l5,o1)~lL(.1 F\ic.l) and that I
executed the said Bid with full authority to 00 so:
2. The prices in this bid/Bid have been arrived at independently without collusion, consultation,
communication or agreement for the purpose of restricting competition, as to any matter relating to
such prices with any other bidder or with any competitor.
3. Unless otherwise required by law, the prices and percentage of return which have been quoted in
this bid/Bid have not been knowingly disclosed by the responder and will not knowingly be
disclosed by the responder prior to bid/Bid opening, directly or indirectly, to any other
bidder/responder or to any competitor.
4. No attempt has been made or will be made by the bidder/responder to induce any other person,
partnership or corporation to submit, or not to submit, a bid/Bid for the purpose of restricting
competition.
5. The statements contained in this affidavit are true and correct, and made with full knowledge that
Monroe County relies upon the truth of the statements contained in this affidavit in awarding
contracts f t r:' service ork.
tl.. M(&.v~ I,. 20d ~
(Date)
STATE OF:
I=" t()\I',J~
D~J.<-
COUNTY OF:
PERSONALLY APPEARED BEFORE ME, the undersigned authority, L.l-\. fb\~ loc.{L. who, after
first being sworn by me, (name of individual signing) affixed his/her signature in the space provided above on
this ~ day of -.-M ~ 20a.
NOTARY PUBIJC-8TATE OF FLORIDA
i"...~ Juan Sanchez
Commission # DD679118
. IlpJrea: lULY IJ,2011
II ID 'tIDu ATl.NmeIMlftmfOea, DIC.
Vo.-v" So..~
~\Jl, \3, 'tOl \
DRUG-FREE WORKPLACE FORM
ned Contractor/biqderlresponder in accordance with Florida Statute 287.087 hereby certifies that:
lC. tL
1. Publishes a statement notifying employees that the unlawful manufacture, distribution, dispensing,
possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will
be taken against employees for violations of such prohibition.
2. Informs employees about the dangers of drug abuse in the workplace, the business's policy of maintaining
a drug-free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and
the penalties that may be imposed upon employees for drug abuse violations.
3. Gives each employee engaged in providing the commodities or contractual services that are under bid a
copy of the statement specified in subsection (1).
4. In the statement specified in subsection (1), notify the employees that, as a condition of working on the
commodities or contractual services that are under bid, the employee will abide by the terms of the statement
and will notify the employer of any conviction of, or plea of guilty or nolo contendere to, any violation of Chapter
893 (Florida Statutes) or of any controlled substance law of the United States or any state, for a violation
occurring in the workplace no later than five (5) days after such conviction.
5. Imposes a sanction on, or requires the satisfactory participation in a drug abuse assistance or rehabilitation
program if such is available in the employee's community, or any employee who is so convicted.
6. Make a good faith effort to continue to maintain a drug-free workplace through implementation of this
section.
statement, I certify that this firm complies fully with the above
~ \/ J 260'1
Date
STATE OF:
.J=\OV\ JtA.
'])et-<'1z-
COUNTY OF:
PERSONALLY APPEARED BEFORE ME, the undersigned authority, l-.~.g \~ \oe-l'- who, after
first being sworn by me, (name of individual signing) affixed his/her signature in the space provided above on
this \ l-h. day of M (~.......,k
~1OMIr , ,lUlU, C.aTA1'I 0 , lLOlun.a
~ .Juan SancIJei"~
~#DDc5~18
" 1IIIr___=-~~
- Jv~ S
My Commission Expires: ~\a ~ I ~. ~o l ,
LOBBYING AND CONFLICT OF INTEREST CLAUSE
SWORN STATEMENT UNDER ORDINANCE NO. 010-1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE
CEO -
warrants that he/it has not employed, retained or otherwise had act on his/its behalf any former County officer or
employee in violation of Section 2 of Ordinance No. 010-1990 or any County officer or employee in violation of Section 3
of Ordinance No. 010-1990. For breach or violation of this provision the County may, in its discretion, terminate this
Agreement without liability and may also, in its discretion, deduct from the Agreement or purchase price, or otherwise
recover, the full amount of any fee, commission, percentage, gift, or consideration paid to the former County officer or
employee" .
~~
' ' "
,,~ .. /;- .. . . 'Bt Code..
(Signature) . ~
Mcw~ \L, ~D01
Date:
STATE OF:
~~\ J.".....
V~
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on
~t,t..-..
l VJ "1...-t? l) ~
,
(date) by
L. (-\. Q, \ M.4 l\) c.-lL-..
\'
(name of affiant). ~/She is personally
known to me or has produced
-
~/A
as
identification. (type of identification)
NOTARY PUBUC-BTA1'E OF FLORIDA
<i"'~ Juan Sanchez
COmml....'DD6m18 '
~ EIp/ra: JULY 13, 20111
~1HIU A'IUHIIC B<lmmo co., INC.
"'-
My commission expires: .:rv L, 11, tOl \
CERTIFICATE OF INSURANCE
lNSUREO
145--098-0
BLAYLOCK OIL CO
724 S FLAGLER AVE
HOMESTEAD FL 33030
DESCRIPTION OF OPERATIONSlLOCATIONSNEHICLESlSPECIAllTEMS
CERTIFICATEHOLDER IS AN ADDITIONAL INSURED FOR
GENERAL LIABILITY.
CERTIFICA TEHOLDER IS AN ADDITIONAL INSURED SUBJECT TO THE
CONDITIONS OF THE ADDITIONAL INSURED BY CONTRACT ENDORSEMENT
FOR BUSINESS AUTO LIABILITY.
AUTO LIABILITY POLICY CONTAINS ENDORSEMENT MCS-90
POLLUTION UABILJTY COVERAGE PROVIDED ON THE BUSINESS AUTO
SUBJECT TO THE CA-F-85 ENDORSEMENT. THIS ENDORSEMENT DOES
PROVIDED COLLISION, UPSET AND OVERTURN COVERAGE SUBJECT TO
THE CONDITIONS OF THE POLICY.
CERTIFICATE HOLDER
MONROE COUNTY BOARD OF
COUNTY COMMISSIONERS
1100 SIMONTON ST ROOM 1-213
KEY WEST FL 33040
38
JUN-I9-20G9 FRI 11:48 AM Federaled CPU
,.--. - .
FAX NO. 5074558806
P. 03
Fe~Irated Int(3rnal Copy - fonts and fonnat n'aay vary from original
POLICY NUMBER: 9323565
COM M!!RCIAL GENERAL UABILlTY
CG 20 10 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of AddItional Person(s)
Or Organizations Locatlon(s) Of Covered Operations
MONROE: COUNTY BOARD OF COUNTY COMMISSIONERS BLAYLOCK OIL CO DELIVERS FUEL TO MONROE
1100 SIMONTON STREET ROOM 2-213 COUNTY aOARD OF COUNTY COMMISSIONERS.
KEY WEST FL 33040
.__..--
Information reauired to comolete this Scf1edule. if not shown above. will be shown in the Declarations.
A. Section II - Who Is An Insured is amended to
Include as an additional insured the person(s) or
organization(s) shown In the Schedule, but only
with respect to liabilily for "bodily injury";
"property damage" or "personal and advertising
injury" caused. in whole or In part, by:
1. Your acts or omissions; or
2. The acts or omissions of those acting on
your behalf;
in the performance of your ongoing operations
for the additional insured(s) at the locatlon(s)
designated above.
BLAYLOCK OIL co
724 S FLAGLER AVE
HOMESTEAD FL 33030
B. With respect to the insurance afforded to these
additional Insureds, the following additional
exclusions apply:
This insurance does not apply to "bodily injury"
or "property damage" occurring after:
1. All work, including materials, parts or
equipment furnished In connection with such
work, on the project (other than service,
maintenance or repairs) to be performed by
or on behalf of the additional insured(s) at
the location of the covered operations has
been completed; or
2. That portion of "your work" out of whIch the
injury or damage arises has been put to its
intended use by any person or organization
other than another contractor or
subcontractor engaged in performing
operations for a principal as a part of the
same project.
r.-r:: ?n 1 n...fi7 n.il
@ ISO Properties, Inc., 2004 Page 1 of 1
EnHr'Y Nllmhpr" Q:1':1FiF\Fi Tr;;:aru::;::u~linfl r:{fQpH..A n.:llt~- n'la_ ':II L .,nno
JUN-19-2009 FRI 11:48 AM FederaLed CPU
FAX NO. 5074558806
P. 04
Feirraled Internal Copy - fonts and fOrll1at nlay vary from original
POLICY NUMBER: 9323565
COMMERCIAL GENERAL LIABILITY
CG 20 10 07 04
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED.. OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Person(s)
Or Organizations Locatlon(s) Of Covered Operations
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS FOR THE DELIVERY AND UNLOADING OF
1100 SIMONTON STREET ROOM 2-213 PETROLEUM PRODUCTS SOLD BY THE NAMED
KEY WEST FL 33040 INSURED
Information reqUired to complete this Schedule. if not shown above. will be shown in the Declarations.
A. SectJon II - Who Is An Insured is amended to
include as an additional insured the person(s) or
organization(s) shown in the Schedule. but only
with respect to liability for "bodily injury",
"property damage" or "personal and advertising
fnjury" caused, In whole or In part, by:
1. Your acts or omIssIons; or
2. The acts or omissions of those acting on
your behalf;
in the performance of your ongoing operations
for the additional Insured(s) at the locatlon(s)
desIgnated above.
BLA YLOeK OIL co
724 S FLAGLER AVE
HOMESTEAD FL 33030
B. with respect to the insurance afforded to these
additional insureds, the following additional
exclusions apply:
This insuranoo does not apply to "bodily injury"
or "property damage" occurring after:
1. All work, including materials, parts or
equipment furnished in connection with such
work, on the project (other Ulan servioo,
maintenance or repairs) to be performed by
or on behalf of the additional insured(s) at
the location of the covered operations has
been completed: or
2. That portion of "your work" out of which the
fnjury or damage arises has been put to its
intended use by any person or organization
other than another contractor or
subcontractor engaged in performing
operations for a principal as a part of the
same project.
........cG_.20.'fO 07 M
@ ISO Properties, Inc., 2004
Pnlirv Nl,mht:lr O'l?'lC:;:~Jr;:
Tra....~.......,..I.I,.,..... [:!"__..:.~_ I""'\._"_~ ^_ _ ~ _^_.....
Page 1 of 1
JUN-19-2009 FRI 11:46 AM Federaled CPU
FAX NO. 5074558806
P. 05
Fe~xrated Internal Copy - fonts and forrnat may vary from original
THIS ENDORSEMENT CHANGES THe POLICY. PLEASE READ IT CARErULL Y.
ADDITIONAL INSURED BY CONTRACT ENDORSEMENT
This end~rserTlent modifies insurance provided under the following:
BUSINESS AUTO COVERAGE PART
with respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless
modified by the endorsement.
A. WHO IS AN INSURED for" bodily injury" and II property damageh liability Is amended to Include:
Any person or organization other than a joint venture. for which you have agreed by written contract to
procure bodily injury or property damage "auto" Jlabllity Insurance arising out of operation of a covered
tlauto" with your permission. However, this additional insurance does not apply to:
(1) The owner or anyone else from whom you hire or borrow a covered "auto". This exception does
not apply if the covered "auto" is a "trailer" connected to a covered "auto" you own.
(2) Your "employee" if the covered "auto" is owned by that "employee" or a member of his or her
household.
(3) Someone using a covered "auto" while he or she is working in a business of selling, servicing.
repaIring. parking or storing "autos" unless that business is yours.
(4) Anyone other than your "employees''. partners (if you are a partnership). members (if you are a
limited liability company)! or a lessee or borrower or any of their "employees". while rroving
property to or from a oovered "auto".
(5) A partner (if you are a partnership), or a member (if you are a limited liability company) for a
. covered flauto" owned by him or her or a member of his or her household.
B. The r.overage extended to any additional insured by this endorsement is limited to. and subject to all terms.
conditions, and exclusions of the Coverage Part to which this endorsement is attached.
In addition, coverage shall not exceed the terms and conditIons that are required by the terms of the written
agreement to add any insured, or to procure insuran('~.
C. The .limits of insurance applicable to such insurance shaff be the lesser of the limits required by the
agreement between the parties, or the limits provided by this policy.
D. Additional exclusions. The insurance afforded to any p&rson or .organization as an .insUred under this
endorsement does nof apply:
1. To "loss" which occurs prior 10 the date of your contraot with such person or organiz~tion;
2. To "loss" arising out of the sole negligence of any person or organi7--atlon that would not be an insured
except fo.' this endorsement. u
3. To "Ioss" for any leased or rented auto" when the lessor or his or her 8gent takes possession of the
leased or rented II auto" or the polley period ends. whichever occurs first.
Incrudes copyrighted material of Insurance Services Office. Inc. with Its permissIon.
CA-F-127 (03-03) Policy Number: 9323565 Transaction Effective Date:03-31-2009
JUN-19-2009 FRI 11:46 AM FederaLed CPU
FAX NO. 5074558806
P. 08
Fe(~~o~t&~'nternal Copy - fonts and fannat may vary from original
fORM MCS 90
OMB NO. 212S-D074
ENDORSEMENT FOR
MOTOR CARRIER POLICIES OF INSURANCE FOR PUBLIC LIABILfTY
UNDER SECTIONS 29 AND 30 OF THJE MOTOR CAR.RIER ACT OF 1980 .
DEFINITIONS AS USED IN THIS eNDORSEMENT
ACCIDENT includes continuous or repeated exposure to conditions which results in bodily injury, property
damage, or environmental damage which the Insured neither expecled nor intended.
MOTOR VEHICLE means a land vehicle, machine, truck, tractor, trailer, or semitrailer propelled or drawn by
mechanical power and used on a highway for transporting property, or any combination thereof.
BODILY INJURY means Injury to the body, sickness, or disease to any person, including death resulting from any
of thesa.
ENVIRONMENTAL RESTORA nON means restitution for the loss. damage or destruction of natural resources
arising out of the accidental discharge, dispersal, release or escape into or upon the land, atmosphere,
watercourse, or body of waler, of any commodity transported by a motor carrier. This shall include the cost of
removal and the cost of necessary measures taken to minimize or mitigate damage to human health, the natural
environment, fish, shellfish and wildlife.
PROPgRTY DAMAGE means damage to or loss of use of tangible property.
PUBLIC LIABILITY means liability for bodily injury, property damage, and environmental restoration.
The insurance policy to which this endorsement is attached provides automobile liablUty insurance and is
amended to assure compliance by the insured, within the limits stated herein, as a motor carrier of property. with
Seotions 29 and. 30 of the Motor Carrier Act of 1980 and the rules and regulations of the Federal Highway
Administration (FHWA) and the Interstate Commerce Commission (ICe).
In consideration of the premium stated in the policy to which this endorsement is attached, the insurer (the
company) agrees to pay, within the limits of liability described herein. any final judgment recovered against the
insured for public liability resulting from negligence in the operation, maintenance or use of motor vehicles
subject to the financial responsibility requirements of Section 29 and 30 of the Motor Carrier Act of 19BO
regardless of whether or not each motor vehicle is specifically described In the policy and whether or not such
negligence occurs on any route or In any territory authorized to be served by the insured or elsewhere. Such
insurance as is afforded for public liability does not apply to injury or to death of the insured's employees while
engaged in the course of their employment, or property transported by the insured, designated as cargo.
It Is understood and agreed that no condition, provision, stipulation, or limitation contained In the policy, this
endorsement, or any other endorsement thereon. or violation thereof, shall relieve the company from liability or
from the payment of any final judgment, within the limits of liability herein described, irrespective of the financial
condition, insolvency or bankruptcy of the insured. However. all terms, conditions, and limitations In the policy to
whIch the endorsement is attached shall remain in full force and effect as binding between the insured and the
company. The insured agrees to reimburse the company for any payment made by the company on account of
any accident. claim. or suit Involving a breach or the terms of the policy, and for any payment that the company
would not have been obligated to make under the provisions of the policy except for the agreement contained In
this endorsement.
It is further understood and agreed that, upon failure of the company to pay any final judgment recovered against
the insured as provided herein, the judgment creditor may maintain an action in any court of competent
jurisdiction against the company to compel such payment.
The limits of the company's liability for the amounts prescribed in this endorsement apply separately to each
accident and any payment under the policy because of any ona accident shall not operate to reduce the liability of
the company for the payment of final judgments resulting from any other accident.
The policy to which this endorsement is attaohed provides primary or excess insurance, as indicated by "X", for
the limits shown:
o This insurance is primary and the company shall not be liable for amounts In excess cf $, ,000.000
for each accident.
o This insurance is excess and the company shall not be liable for amounts in excess of $
each accident in excess of the underlying limit of $ for each accident.
for
MCS.90 (01-96)
Policy Number: 9323565
Page 1 of 2
TranSAction Effective Date: 12-31.2008
_ .__ JUN-l9-2o.~~ FRLJ 1: 47.ilM Federaled CPU
FAX NO, 5074558806
p, 07
Fe9~6~t~lnternal Copy - fonts and fOrlllat n,ay vary frorn original
Whenever required by the FHWA or the Ice the company agrees to furnish the FHWA or the Ice a duplicate of
said policy and all Its endorsements. The company also agrees. upon telephone request by an authorized
representative of the FHWA or the tCc, to verify thaL the policy is in force as of a particular date. The telephone
number to call Is: C(07) 455~5200
Cancellation of this endors~ment may be effected by the company or the Insured by giving (1) thirty-five (35) days
notice in writing to the other party (said 35 days notice to commence from the date the notice is mailed, proof of
mailing shall be sufficient proof of notice). and (2) if the insured is subject to the ICC's jurisdiction, by providing
thirty (30) days notice to the Ice (said 30 days notice to commence from the date notice is received by the Ice at
its office In Washington, D.C.).
Issued to:
BLAYLOCK OIL CO
PO BOX 310
HOMESTEAD FL 33090
Dated at Owatoonar MN 5fiOfiO on -1.0::02-'008
Amending Policy No. 9323&65
(Month, Day, Year)
Effective Date
1 7-31-200B
Countersigned by
~~~~
Vice President
Authorized Company Representative
Name of Insurance Company I=l=flf!D.4.n:n MUTUAt If\lSURANC-= r.nUPANV
The Motor Carrier Act of 1980 requires limits of financial responsibility according to type of carriage and
commodity transported by the motor carrier.
It is MOTOR CARRIER.S obligation to obtain the required limits of financial responsibility.
THE SCHEDULE OF LIMITS SHOWN BELOW DOES NOT PROVIDE COVERAGE.
The limits shown in this schedule are for information purposes only.
SCHeDULE OF LIMITS
Public L1abllltv
Type of Can1~e 1 Commoc:Utv Tranaoortod Minimum Insurance
(1) For-hire Property (Non-hazardoUs) $ 750,000
(in interstate or foreign
commerce ) ---
(2) For-hire and Private Hazardous substances as defined in 49 CFR 171.8, $5.000.000
(in interstate, foreign or transported In car~o tanks, portable tanks,
intrastate commerce) or hopper-type ve icles with capacities In excess
of 3.500 water gallons; or in bulk Divisions 1.1..
1.2, and 1.3 materials. Division 2.3, Hazard Zone
A, or Division 6.1, Packing Group I, Hazard Zone
A materIal; in bulk Division 2.1 or 2.2; or
highway route controlled quantities of a Class
7 material. as defined in 49 CFR 173.403
(3) For-hire and Private Oil listed in 49 CFR 172.101; hazardous waste, $1 ,ooo~ono
(in interstate or foreign hazardous materials and hazardous substances
commerce; in any quantity) defined in 49 CFR 171.8 and listed in 49 CFR
or (in intrastate commerce: 172.101. but not mentioned in (2) or (4)
in buJk onlv)
(4) For-hire and Private Any quantity of Division 1.1, 1.2, or 1.3 material; $5.000,000 --
(in interstate or foreign any quantity of a DivIsion 2.3, Hazard Zone A, or
commerce) Oivis,on 6.1, Packing Group I, Hazard ZOne A matef-
ialj or highway route controlled quantities of a
Class 7 material as defined in 49 CFR 173.403
NOTE .
1. The type of carriage listed under numbers (1), (2) and (3) apply to vehicles with a gross vehicle weight rating
of 10,000 pounds or more. The type of r.arrlage listed under (4) applies to vehioles with a gross vehicle weight
rating of less than 10,000 pounds.
MCS-90 (01-96)
Policy Number: 9323566
Page 2 of 2
Transaction Effective Date: 12~31-200B
Workers Compensation and Employers Liability
Insurance Policy
.
ZURICH
NORTHERN INSURANCE COMPANY OF NEW YORK
Information Page
NCCICompanyNo.: 1376S
ACCOUNTNUMBFll: M018452S.61-OOI..oooo1
Branch I Policy Number I Producer Code I Previous Policy Number. I
17 OMAHA OFFICE we 0290159500 IS900764 NEW I
Servicing Address 13810 PNB PARXW A Y P.O.BOX 542003 OMAHA NE 68154
.-
ITEM 1. Name Insured and Mailing Address
BLA YLOCK OIL COMPANY T.R. Jones & Company
P. Q. BOX 310
HOMESTEAD FL 33090 P.O. Box 1505
Homestead, FL 33030
1hi.s Infonnation Page, with policy provisions and endorsements. jf any. completes this policy.
Insured is: CORPORATION
Risk I.D. No: 09452732S I F.E.I.N.: 591208100 I
Other Workplaces Not Shown Above: SEE SCHEDULE Of INSUREDS AND LOCA '00.""5
ITEM 2. Policy Period: From: 0410 112008 To: ow 112009 12:01 a.m. Standard Time at the Insured's Mailing Address
ITEM 3.
A. Workers Compensation Insurance: Pan One of the policy applies to the Workers Compensation Law of the states listed here
FL
B. Employers Liability Insurance: Part Two of tbe policy applies to work in each state listed in Item 3A. 1he limits of our
liability under Part Two are:
Bodily Injury by Accident S I, (0). (XI) Each Accident
Bodily Injury by Disease S 1.(11).(0) Policy Limit
Bodily Injury by Disease S I, (0). (XX) Each Employee
C. Other States Insurance:. Part Three of the policy applies to the states, if any, listed here:
ALL STATES EXCEPTND, OH, WA, WV, WY ANOmOSELISTEDIN3A.
D. This policy includes these endorsements and schedules: SEE FORMS AND ENDORSEMENTS APPUCABLE UST
ITEM 4.
The premium for this policy wi)) be determined by our manuals of rules, classifications. rates and rating plans. All infonnation
required on the following Classification Scbedule (s) is subject to verification and change by audit.
SKE CLASSIFICATION SCIIEDULE
Total Estimated Standard Premium S 25.499.00 If indicated below, adjustments of premium &ball be made:
Premiwn Discount S ],402.00- [!]
Expense Constant $ 200.00 AnnualJy
Premium for Endorsements $ 286.00 D Semi-Annually
Taxes and Surcharges $ 8 Quarterly
Total Estimated Annual Premium $ 24., S83~OO Montbly
Minimum Premium S 796.00
Deposit Premium $ 24.583.00
.
"'i"" AI\. "1\ n 1 n I~'" I\ft n~'\.
AGENT COPY Countersigned By Authorized Representative
COJ)vri~hl. 1987 National Couac:il 00 CompcnsatioD Insurance
Issue Date: 03/3012008
Workers Compensation and Employers Liability
Insurance Policy
NORTHERN INSURANCE COMPANY OF NEW YORK
Schedule of Insureds and Locations
.
ZURICH
Branch I Pollcy Number Prodllcer Code
OMAHA OFFICE we 0290 I S9S 00 I S9007M
SCHEDULE OF INSUREDS AND LOCATIONS
BLAYUXX OIL aJU)ANY 724 S l'lKLHR AVE
F.E.I.N.': 59-1208100 ~iHItD FL, 33030
33 S W 4 STREET
fDFSfF.AD FL. 33030
Issue Date: 031300008
we 99 00 02 (Ed. ]0-99)
PAGE I OF I
INSURED COPY
Workers Compensation and Employers Liability
Insurance Policy
NORTHERN INSURANCE COMPANY OF NEW YORK
Classification Schedule
.
ZURICH
Branch I Policy Number I Producer Code
OMAHA OFFICE we 0290159500 15900764
ITEM 4. CLASSIFICATION OF OPERATIONS
Premium Basis Rates
Entry in this item. except as specifically provided elsewhere Total Estimated Estimated
in this policy. does not modify any of the other provisions of Code Annual Per $100 of Annual
LOC. this policy. No. Remuneration Remuneration Premium
BLAYUlX OIL mtl'AW
H..DRI Th\
001 724 S Fl..atJLER AVE
IDO:!SJF.AD F4 33030
GASOLINE (R OIL IEALER & DRIVERS 83~ 310,<XXl 1.940 24,614
SALESPERnts Cll Ul.LF.CIDRS - WrSllE 8742 532,CXXl .640 3,405
W!1UCAL <FFlffi HMPWYEES ~ g810 111,900 .370 414
002 33 S W 4 SI'REET
IDtIESI'EAD 101" 33030
GNlLI NE (Jl 01 L DHAlliR & IlU \elS 8350 1P ANY 7.940 0
SALESPER."mS OK ~ - WrSlDE 8742 WANT .640 0
a..ERIC\L (Jt}'ICE EMPLOYEES 1<< 8810 IP ANY .310 0
p,6CJ.{I{
PlU'J4IUM ~ l:cREASlID LIMITS PART no 9812 .0140 398
rnRTIFIED SAFE'!" amDlT 9165 .020- 577-
lXUJ FREE ~ CREDIT 9841 .050- 1.413 -
1UrAL PREMIUM SUBJECT 11> EXPERIFla OIFICATla; 26.841
PRalIUM OlFIED 'm Rf'.FLlO' EXPHRIFlCB MJD (F 9898 .950 1.342-
IDrAL ESfIMATED N4NlIAL S'l'ANIWID PREMIUM 25,499
PRallUM Dl~ 0063 .055- 1.402-
EXPENSE awsl'AYl' rnAK<E ~ 200
FORE.I~ 'lHUD) s.'1I 9740 953,900 .030 286
'IurAL ESfJMATFD ANNUAL PREMIUM 24. 583
Issue Date: 0313012008
we 99 00 05 (Ed. 10-99)
PAGE 1 OF I
INSURED COPY