01/19/1994 AgreementGpUNTj.
UJ �Jy CuiO`�ap
y
04,0E COUNTV
BRANCH OFFICE
3117 OVERSEAS HIGHWAY
MARATHON, FLORIDA 33050
TEL. (305) 289 -6027
Mannp IL. Rolbage
CLERK OF THE CIRCUIT COURT
MONROE COUNTY
500 WHITEHEAD STREET
KEY WEST, FLORIDA 33040
TEL. (305) 292 -3550
BRANCH OFFICE
88820 OVERSEAS HIGHWAY
PLANTATION KEY, FLORIDA 33070
TEL. (305) 852 -7145
MEMORANDUM
TO: Division of Management Services
C/O The County Administrator
Attention: Tim Miller, Director
Information Systems
FROM: Ruth Ann Jantzen
Deputy Clerk
DATE: April 8, 1994
On January 19, 1994 the Board of County Commissioners granted approval and
authorized execution of a Contract Agreement between Monroe County and Buccaneer
Courier.
Inasmuch as Buccaneer Courier has received their copy of this contract today,
this is for your information only.
Should you have any questions concerning the above, please do not hesitate to
contact this office.
cc: County Attorney
Finance - Hand delivered contract
File
-"[-
,,8"[ u-eq~ .l:ao.l:-el ou aq l\.-ew sa11ddns a;)1110 l-e.l:auao pu-e .l:ad-ed
aU1q;)-ew l\.do;) 10 u01~-e~.l:~dsu-e.l:~ aq~ .l:01 pasn oU1aq saxog
oxoq .l:ad spunod OS u-eq~ a.l:OW ou q01aM
pu-e pa"[-eas 'paxoq a.l:-e l\.aq~ s-e ouol os sa11ddns a01110 l-e.l:auao
pu-e .l:ad-ed aU1qo-ew l\.doo 's~nO~~U1.l:d .l:a~ndwoo 'qs-eo 'SO-eq l1-ew
'sadolaAua a01110 .l:a~u1 ~.l:odsu-e.l:~ o~ pa.l:1noa.l: aq 111M HOaNaA
aa~HOds~H~ ag O~ S~~IHa~~W O€
0l\.11-eP
~OO:8 o~ .l:01.l:d ap-ew aq 111M ~saM l\.a~ 'asnoq~.l:noJ l\.~unoJ ao.l:UOW
aq~ oU1pnlou1 pu-e OU1Pl1ng a01A.l:as 011qnd pu-elS1 ~oo~S o~ (q~nos)
~saM -ea.l:-e 06.l:-e~ l\.a~ aq~ WO.l:1 a~no.l:ua su01~-eoOl ll-e o~ sa1.l:aA11aa
O.l:n;)oo ~s11 aq~ o~ saou-eqo Plnoqs
pa111~ou aq 111M HOaNaA aq~ pu-e 'HOaNaA aq~ o~ pap1AO.l:d
aq 111M sl\.-ep110q 10 ~s11 ~ osl\.-eP110q 10 U01~daoxa aq~
q~1"'6l\.'EP1.l:d<qonO.l:q~ l\.'EPUOW pa.l:1noa.l: s1 l\..l:aA11ap pu-e dn-~01d
"::, R
N
""~saMLl\.a~
::0 a.l:'E
I
:::J:;:
Cl.
~n ~~d
OW.l:11 u1'Ewa.l: ~snw q01qM PU'E1S1 ~oo~S pu-e
u1:--=sU01~'EOOl aq~ 10 u01~daoxa aq~ q~1M a~-ew1xo.l:dd-e
~NaA l\.q l\..l:aA11ap PU'E dn-~01d .l:01 pa1110ads saw1~
:. ~
.. 0 su01~ 'EOOl .l:aq~o o~ l\..l:aA 11 ap PU'E
~~01~'E;)01 qo-ea ~'E .l:aA11ap pu-e dn-~01d 111M HOaNaA
:z
C1
z{~SI~ aaHJ~~~ aas) ^HaAI~aa a~ dn-~Jld dO aWI~
Oz
'<;t
P'
JI:
(* dO~S Xg aaldI~NaaI aH~ SNOI~~JO~ ~~~)
(~SI~ aaHJ~~~~ aaS) aaJIAHaS ag O~ SNOI~~JO~ 01
III
:sMoll01 s-e aa.l:o'E sa1~.l:'Ed aq~ 'sa1~.l:'Ed q~oq l\.q paopalMOu~o'E
s1 q01qM 10 l\.oua1;)1jjns aq~ 'u01~'E.l:aP1suoo alq'En1-eA pu-e pooo .l:aq~o
PU'E 'pau1-e~uo;) u1a.l:aq S~U'EUaAOO l'En~nw aq~ jO u01~-e.l:aP1suoo u1 'MON
'~OaNaA 10 Sa01A.l:aS aq~ OU1U1'E~qo 10 sno.l:1sap s1 ~NaI~J
aH~ aN'i 'SaJIA~aS ~aI~nOJ HaaNa~ O~ UI~Ig'ci N'i S~H ~oaNaA 's~aHaHM
OIl~NaI~JII s-e o~ pa.l:.l:aja.l: .l:a~j-eu1a.l:aq
'otO€€ -ep1.l:01d '~saM l\.a~ 'PU'E1SI ~oo~S 'AI oU1M 'OU1Pl1ng a01A.l:as
011qnd 'p-eo~ aoa110J 001S s1 ssa.l:pp-e asoqM 'SHaNOISSIWWOJ UNnOJ dO
CIIDlOg UNflOJ am:!:NOW pu-e ".l:opuaAII s-e o~ pa.l:.l:aja.l: .l:a~j-eu1a.l:aq '6€tl-0S0n:
'~a 'uoq~-e.l:'EW '6(tl0~ xog oood ~-e s1 ssau1snq jO ao-eld l-ed10U1.l:d
asoqM '~aTH.nOJ HaaN'iJJna uaaM-=laq pUB l\.q I t661 ' A..umub'l'
10 AEP ~461 aHili O~NI aa~a~Na aN'i aa~w '~Nawaa~D~ SlH~
~NawaaHD~ saJh^HaS ~al~no~
J..~ 'ii:I.l.N., 0...
,
'Hide, l5H deep and lOll high.
All items being transported must be properly sealed and have
the delivery location and the physical address of the
delivery location clearly marked on the exterior of the
item. Items should indicate the sender and the person to
whom the item is being transported.
4. PROVISION OF LOCK BOXES
':'
Lock boxes for the purpose of temporarily storing items until
such time as they are picked up by VENDOR, will be installed at
each location. EXCEPTIONS: STOP #2 thru STOP #8 will not need a
lock box as they are serviced during normal office hours.
-J '-~ \~. ; .,
.f L '~. ;,...
~ ..!.....: '! ~ - ,
CLI~~T will be responsible for the purchase of Lock Boxes to
be installed at each location serviced, and such purchase(s)
will be made in accordance with Monroe County Purchasing
policies and Procedures.
...' .:-J
VENDOR will be responsible for the installation of Lock Boxes in
accordance with specification provided, herein. Lock Boxes for each
stop will be installed at a location designated by client.
:~
"
Lock Boxes will be constructed of materials suited for
, extended exposure to the elements, whether they be located
under cover or in an outside area.
~:_!_ ~_ ,,_i..~ .
J?;,',':.....,.,.-....
~.._~.:..,
5"'
.,.- - ...-....'... .__.._.,.....-~.
'...:.: .
............. . .
;-...'-
~~p'-~
...,:...- . -~~ ! '-
.-..i i.
Lock Boxes will have a keyed locking device, and a sufficient
number of keys will be provided to CLIENT for disbursement to
each Department and/or Agency having authorized access.
) '.~ -'~""
Lod~ Boxes will be a minimum of 24" wide, 17" deep and 48H
:l'... '~;" ,high. Vendor will in every case be responsible for the
provision of Lock Boxes suited to the average daily volume of
materials being transported to each location.
Lock Boxes will be constructed in such a way that all
materials stored therein will be a minimum of 6" above the
bot1:om of the Lock Box.
Lock Boxes will be constructed in such a way that the door
(s) will seal so as to provide maximum protection against
leakage, and all hinges will be attached to the inside of the
box.
VENDOR will install each Lock Box in such a way that it is.
securely fastened to the surface upon which it is placed.
5. PROVISION OF MAIL BAGS
Mail bags are to be used as the ~ransportation media of
choice, and are to be provided by CLIENT at the expense of
each Department and/or Agency as specified in ITEM #1,
-2-
Locations To Be Serviced.
Mail bags being used for transportation may be no larger than
18" wide, 5" deep and 30" high.
Mail bags should be made of canvas or an equally durable
material and have a locking mechanism.
6. PROVISION OF INSURANCE BY VENDOR - INDEMNITY/HOLD HARMLESS
VENDOR shall procure and maintain during the term of this
agreement the !ollowing insurances with limits: Per documents
INSCKLST-1, INSCKLST-2, INSCKLST-3, INSCKLST-4, WC1, GL1,
VL2, MYC, ED1, Indemnification/Hold Harmless attached.
The insurance required shall be primary and any insurance
carried by CLIENT shall be excess and noncontributory.
All policies shall be issued by companies authorized to do
busi.ness in Florida.
~M.._;"',.."'~
A CE~rtificate of Insurance for each policy shall be furnished
to CLIENT'S Office of Risk Management, and shall stp-.te that
. .#
covE~rage shall not be cancelled, vOl.ded, suspended o~ reduced
without 30 days prior written notice to CLIENT.
~_h'
7.
PAYl~ENTS
VEm)OR will be paid $162.10 per month for each location
serviced as per ITEM #1. Locations To Be Serviced and/or any
modifications to said ITEM as per the specific terms and
conditions of this agreement.
8. OTH:E:R PROVISIONS
The term of this agreement shall be for a period of one (1)
year and commence upon execution by the Board of County
Commissioners of Monroe County, Florida and VENDOR. This
agreement may be extended for successive one (1) year Terms
thereafter with a limit of (2) two (1) one year terms.
Either party may cancel this agreement upon providing no less than
sixty (60) days written notice to the other party prior to the
effective date of termination, except that VENDOR may not terminate
the agreement for the first 180 days of same.
Any and all delivery items shall be picked up at the
locations specified in ITEM ~1. i:ocations To Be Serviced , or
by reasonable change noticed to the VENDOR and deliveries
shall likewise be made.
VENDOR shall keep and maintain any and all property placed
in its possession with proper care so that it shall not be
-3-
damaged or lost, and assumes liability for damage or loss
from all causes except war, confiscation, order of any
'Jovernment or public authority, discoloration or
deterioration from natural or inherent causes, or from like
reasons.
The property transported by VENDOR, is and will remain, and
at all times shall be deemed to be the sole and exclusive
property of client and vendor has no right of property
therein. The property shall not be transported or delivered
to an other person, corporation, or other entity without
prior written consent or instruction of CLIENT.
Regue:sts for unscheduled pick-Up and delivery at locations
speci.fied in ITEM *1. Locations To Be Serviced, will be the sole
respcmsibility of the requestor and are not a provision of
this agreement.
RequE~sts for pick-Up and delivery by departments and/or
agencies other than those specified in ITEM *1. Locations To
Be Serviced, will be the sole responsibility of the requestor
and are not to be construed as a part of this agreement.
Requl:sts for pick-Up and delivery of items not included in
ITEM #3. Materials To Be Transported, or which do not meet
specifications provided therein, shall not be tradsp6rted
unde:r the terms and conditions of this agreement. .
9 ~ ENTIRE AGREEMENT
CLIENT and VENDOR understand and agree that this Agreement
supersedes and cancels any and all prior and existing
agreements, understandings, representations or statements,
oral or in writing between the parties with respect to the
subject matter of this Agreement.
10. PARTIAL INVALIDITY
If any terms or provisions of this Agreement shall be found
to be illegal or unenforceable, then notwithstanding such
illegality or ineffaceability, this Agreement shall remain in
full force and effect and such term or provision shall be
deemed to be deleted.
11. CHOICE OF LAW
This Agreement, its performance and all disputes arising
herl:under, shall be governed by the laws of the State of
Florida and both parties agree that proper venue for any
action shall be Monroe County.
12. AT'rORNEY' S FEES
-4-
The prevailing party in any action brought to enforce the
provisions of this Agreement shall be entitled to an award
of all costs, including reasonable attorney's fees.
13. SUCCESSORS AND ASSIGNS
This Agreement shall insure to the benefit of and be-binding
upon the respective successors, heirs and assigns, if -any, of
the parties, except that nothing contained in this
para<;;rraph shall be construed to permit any attempted
assi<;;rnment which would be void or unauthorized pursuant to
any other provision of this Agreement. No assignment of this
agreement shall become effective until agreed to in writing by
both parties.
14. COMPLIANCE WITH LAW
In providing all services/goods pursuant to this agreement, the
vendor shall abide by all statutes, ordinances, rules and
regulartions pertaining to, or regulating the provisions of, such
services; including those now in effect and hereinafter adopted.
Any violation of said statutes, ordinances, rules ~~d regulations
shall constitute a material breach of this agreement~and shall
entitle the Board to terminate this contract immediately upon
delivery of written notice of termination to the vendor.
15. FUNDING AVAILABILITY
In the event that funds from INFORMATION SYSTEMS contractual
services are partially reduced or cannot be obtained or cannot be
continued at a level suffiecient to allow for the purchase of the
services/goods specified herein, this agreement may then be
terrrlinated immediately at the option of the Board by written notice
of t.ermination delivered in person or by mail to the vendor.
IN WITNESS WHEREOF, the parties have caused this Agreement to be
executed on the day and year written above.
BY:
Danny L. Kolhage, Clerk
~~~
r.,
-5-
"t
MONROE COUNTY
COURIER SERVICE
LOCATIONS AND COUNTY AGENCIES SERVICED
PICK-UP AND DELIVERY LOCATIONS
COUNTY AGENCIES SERVICED
SERVICE TIMES
{STOP 1}
before B:OO AM
2:55 PM
County Administrator
Human Resources
Employee Benefits
Community Services Div
Public Works Division
Code.Enforcement
Safety Department
Extension Services
Public Info. Officer
Airport Finance
Public Health Unit
Training Department
Information sysfems
Risk Management ~
Office of Manag. & Budget
Public Facility Maint. .
Recycling Department
Engineering Department
MKG - Construction Mang
Bayshore Manor
Tourist Development Center
Job Training Partnership
Environmental Manag. Div.
Land Authority
Building Department
Purchasing Department
Social Services Dept/All Agencies
Veteran Affairs
Public Service Building
5100 College Road
Stock Island
Key West, Florida 33040
OUT TO KEY WEST
11 : 0 0 ~[ and 3: 00 PM
OUT TO KEYS NORTH
5:00 PM
""-~'.~''''' -
IN TO S~~OCK ISLAND
from Keys North
from Key West
{STOP 2}
Perry's Plaza
3706 N. Roosevelt Blvd, suite I
Key West, Florida 33040
Land Authority
11:10 ~M and 2:50 PM
-1-
{STOP 3}
First State Bank (upstairs)
3406 N. Roosevelt Blvd, suite 201
Key West, Florida 33040
11:15 AM and 2:45 PM
{STOP4}
3581 S. Roosevelt Blvd
Key West, Florida 33040
11 : 25 AMl and 2: 35 PM
{STOP 5 )~
.o;...~....a:
.~...
3491 s. Roosevelt Bvld
Key West, Florida 33040
~-"..,-p
11 : 30 Nil and 2: 30 PM
.{STOP 61.
700 Fleming Street
Key West, Florida 33040
11:45 AM and 2:15 PM
{STOP 7}
310 Fleming Street
Key West, Florida 33040
11:55 1~ and 2:05 PM
Tourist Development Council
Key West Public Works Garage
Facility Maint - Carpenter Shop
Key West Road Department
Airport Managers Office (KW)
:'
"
Key West Library
Commissioner Harvey
commissioner Freeman
County Attorney (2nd floor)
-2-
{STOP 8}
Monroe County Courthouse
500 Whitehead Street
Key West, Florida 33040
12:00 noon and 2:00 PM
Court Administrator
County Clerk
Tax Collector
Sheriff's Office-
Property Appraiser
Clerk of Courts
Finance Department
Payroll Department
Supervisor of Elections
State Attorney
{STOP 9}- thru {stop 23} delivery and pick-up from locked outside box
or container
Alamo Building, suite B
MM 19 1/2 u.s. 1 (ocean)
Sugar loaf Key, Florida 33042
....:J>'!.;oo...
Approx: 5:30 to 6:00 PM
{STOP lcU.
Monroe County Regional Service Ctr.
2798 OVE~rseas Highway, MM 47.5 (gulf)
MarathoIl, Florida 33050
Approx: 7:00 to 7:30 PM
{STOP ll}
Marathon Sheriff's Office
3101 Overseas Highway, MM 48 (ocean)
Marathon, Florida 33050
Approx: 7:15 to 7:45 PM
Mayor Jack London
:,
,
Growth Management/Suite 400
Planning Dept/Suite 410
Building Dept/Suite 300
Marine Resources
Environmental Res/Suite 430
Accounting/Suite 440
Property Appr/Suite 310
Code Enforcement/Suite 330
Communications/Suite 320
Public Works Building Supv.
Sheriff's Department
Courthouse
Tax Collector
County Clerk
-3-
{STOP 12}
Marathon Library
3251 Overseas Highway, MM 48 (ocean)
Marathon, Florida 33050
Approx: 7:30 to 7:45 PM
{STOP 13l
Marathon Government Annex
490 63rd Street (ocean)
Marathon, Florida 33050
Approx: 7:45 to 8:00 PM
{STOP 14:}
Marathon Airport
9000 Ove~rseas Highway, MM 51.5
Marathon, Florida 33050
Approx: 7:45 to 8:00 PM
{STOP l~U
Marathon Public Works
10600 ~viation Blvd. (gulf)
Marathon, Florida 33050
Approx: 8:00 to 8:15 PM
{STOP 16}
Long Key Land Fill
volwne Reduction Plant ~2
MM 68 1/2 u.S. 1 (gulf)
Long Key, Florida 33001
Approx: 9:00 to 9:15 PM
Marathon Library
Mayor Pro Tern Earl Cheal
Fire Marshall
Emergency Medical Services
Veteran Affairs
social Services
Public Safety
Translator
Supervisor of Elections
",
,
Airport Manager's Office
Marathon Public Works
Communications - Shop
Marathon Animal Control
Marathon Recycling Operations
Marathon Road Department
Marathon Engineering
M.S.D./Environmental Manag
-4-
{STOP 17}
Islamorada Library
MM 81.5 (gulf)
Islamorada, Florida 33036
Approx: 9:30 to 9:45 PM
{STOP 18}
Plantation Key Public Works
186_KeyHeights Dr, MM 88-89 (gulf)
Plantatio~ Key, Florida 33070
Approx: 11:30 to 12:00 midnight
{STOP 19}
'.:".{I"
Ellis Building
88800 OVerseas Hwy, MM 88-89 (gulf)
Plantation Key, Florida 33070
Approx: 12:15 to 12:30 AM
{STOP 20}
Plantation Government Center
88820 Overseas Hwy, MM 88-89 (gulf)
Plantation Key, Florida 33070
Approx: 12:45 to 1:00 AM
{STOP 21}
Key Largo Volunteer Ambulance Corp.
98600 Overseas Hwy, MM 98.6 (median)
Key Largo, Florida 33037
Approx: 1:30 to 1:45 AM
Islamorada Library
.
Public Works
Emergency Managementu- Radiology
Engineering
:,
"
Building Dept/G~owth Management
Tax Collector
Property Appraiser
social Services
Veteran Affairs
Supervisor of Elections
Code Enforcement
County Clerk
State Attorney
Commissioner Reich
Emergency Medical Services
Key Largo Volunteer Ambulance
Upper Keys Trauma Center
-5-
{STOP 22}
Tradewinds Plaza Key Largo Library
101485 Ove~rseas Hwy, MM 101. 485 (ocean)
Key Largo, Florida 33037
Approx: 2:00 to 2:15 AM
{STOP 23}
Key Largo Landfill
Volume Reduction Plant *1
State Rd. 905 (gulf)
Key Largo, Florida 33070
M.S.D./Environmental Manag.
Cardsound Toll Bridge
Approx: 110:30 to 10:45 PM
.....," {STOP 24}
:'
It
Cardsound Toll Bridge
County Road 905A
US iA1A
Cardsound Toll Bridge
Approx: 2:45 to 3:00 AM
{STOP 25 }.
cudjoe Key Landfill
MM 21.5 Blimp Road
cudjoe Key, FL 33042
Approx. 6:00 to 6:30 PM
-6-
; =~:R~. \ ~ ~
. ;/$~~,J1i ~'l ~_i':illi'JI i
L~fi & ~ Mil ~~ '.
_~~ ~ iilR 0,.' ;~ l~o ,)
~ft}~~~;~-h - p,,~ ,~.1)~]~rl-- -j!
~.~~~~~...,wA::>-' iWJ. j',;L D 1;,
~~..'" 'll r ~ >-- ',,~ '- .,,;; ."
~,. ~~l :: '14 ,,:~J..i. J. ......r~
t' \ e ;. f ::: < .1"""' I" · )
" :; · _-0.. .,.., - . ·
'i, · ~i'l~ 'k\A~oo~n~ ,)~T.ii?
I-A ....IS II n'~ (..~--
_ "Q' ~_ '"1--'l .".. <"""'"
... ,; ",_ ~ l"b~' r~"
00 ,J .--: ~;:;"'1"' -I
~ i _IF --'~ ;'~ L ~ <\-lli~
'" I" I.'" ..=3. --- .~ · ':
I '@!13JII: J.-: ~!: \ .. r.. 2 '(I hf'>-' ·
,~ g; >.. i'ir ~~ ~~. ,,~I [.--If
~ _ _ _ I. _I < , /" ol .. ~"X F- ~ ] II ,,!
o :--Inn *' ~,~ A:?=!' ~\u:t · j c.J
; : I ),~ ,;.. - ~~xr~~~ ~~ ~ ,..";1 it! : ~
,0 ",,' _ _, .. · t-<
j-~ ~ '" ....",'-- -1 . . ' ". 1. · -'~
f ::,~ ftf'~f+!O-- - ~-~,r~' " ~~~,. : . .
, ,~; "'~: ,~'-- _ 1.1'" \ ",,,,v -
1 \, ~~)''"'l~''~o ~ ~i~..' l -,l'U - ----, - ',---- .--
, ,,:,' <> ,.....,,,,,' ~.' .J>\'~' " ~
~ ,r:J-: ~ ~ ~.,,, :.4.... '!"'~~fI'\' ~~? \ ~I ~
, ~". .. . " VI" t1~' 2
: a::': 7J"'~ ~ l' . ~":'.r WI A '\ ~ n-
o a', ;~'f' I -: :';'0/\" -< "- '" do: 1.1
! ' ',:/ 'V/ 1"'- ~ ' " ,~ ~;',," ( 1\
, ' ~ , ..... r ~ .~,-~
./ : __', :1 !Ii d "H'l. " ~l
....u _ ; --:-_____~>- 00 '::lI!:I--':' i . ~~ ~ ~ J
~ ' ~ _~ ~~_:~_] _ i _!~ ~. ",",;0 1
~ j ~ . I~ _i~lI!i~<c' ,,--
___n-- ~ -\ Ii Jt1 i J.. "'~ "' ~
__ ---c:r'- ~~1jl- 11r ~ ~ n
= ;-.=- _ _ ~"i Ui~1"''' \'\ .'"
7rTI~ -- __ _. - __ r.:,! · IF; /1iJli'" ;. ...'{o; W" - I
~~~~ _ __ - . ~1~ - ~~ .~,~. *:
b ~D ~rli~ II ~~. i#~~~~ L'~~~ ~I ~c..~.'~ ~~ J -,
_.__ . :I ~~...:..' E:z5~ ...~ ~\?'" of"
_ _ _____ _ ff'},,,,~'2'9~lj '~ · - ......
.. 'j : tJ it ,141'::1 ~,.,..."'" (I~ o' · -u h ... . -
." ./ ..' n..'" il 1. .::- ;fi"'1~, -A~ ~t. ~a ~~ t._ e H I'
~ gl o!l~' ii . :"j' ):~ - _-1:1. Il.
~l"'" ~..l r~. \-:~.' .'~~: \ "':1 0
. <. !l .,," . ,- <-
.~ P- ~ ~:.<;" " .. "" ., or .. rTT --' Ul
~. _.: gAj~:~~~''3!l/.-~'-ll ~ ~ 7- - - I
~ "I!'I,.U.J!,"1 · la' -----.,
j up I l! ~. ~J "J.i
~,t l 1..... -41l1ci f
~ re ~ r~~,.,..35 1
": ! ~& l ,,!~" ~
"1 '.' :
::>.
(/
+'
c..
v'"
~
o
o
.....
~
~
-~
."
-,
~"'!'.~;...~
,~......'"
~
~
~
~
-I
~ i
~~
('II
IH
o
rl
(I)
0\
l1:S
Pi
-I
to
c..
o
E-t
en
-
M
N
0- N
rz:l
8 0 ~
- ~ +J 0
~ (J)
N N
M rz:l
8 Q)
c.a H tn
~ tU
r-l ~
0 Ii M ~ 10 .
rl rl rl rl CIa
(J) >-
Ct: Pot p.. ~ ~ p.. UI~ I
0 0 0 0 0 ~"-5; i
0 8 E-I 8 8 E1 ~J'''l
tJ) . cr. (J) cr. tr.
t- , rl =~Si
-
c( N g-
P-; &&.
0 0
Eol
0 ~ (J)
...I 01 -
nI -
D. CI
~ r-1 en
c( C ~
%"l p;
~ 'Ql. C llc
f-t 0
(J) E-l
cr.
tn
>-
w
~ .....
-
10
N ,...
""'
P-r j:.;
0
E-t ~
(J)
CIl
.......
1,;1 I'ri,.inc
l\10NnOE COUN1Y, FLORIDA
INSlJRANCfi: CHECKLIST
Fon
VENDons Sunl\'lrn'ING 1')torOSALS
Fon 'YORK
. .
To assist in the development of your proposal, the insurance coverages 111m ked with an .X...l1
be required in the event an award is made to your firm. Pleasc review this form with your
insurance agent and have him/her sign it in thc place provided. IL is also rcquired that the billib
sign the form and submit it with each proposal.
WORKERS' COMPENSATION
ANI>
J;Jv1I)LOYEl~.s' ~l^nILlT'(
WCI
WC2
WC3
WCUSLI I
WCJA
x
Workers' Compensation
Employers Liahility
Employers Liahility
Employers Liability
US Longshoremen &
Ilarbor Workers Act
Fe:Jcral Jones Act
Statutory Limits
SI 00,000/$500,000/$100,000
S500, 000/$500, 000/$500,000
$1,OOO,OOO/SI,OOO,OOO/SI,OOO..Ol!lO
Same as Employers' K
Liability .
Same as Employers'
I.iability
Adnlini.1ralivc 1/I~nl<.1i"n
""709.01
I NSCK LST .- I
(.
-
..... \~:~.1iL ~' ..
-;...~, ~ -, - .
. \..
~s.:;~~. .:...~
I.,' .'.""""t,
QENEI~L LIAUlLlIj:.
As a minimum. the required general liability coverages will include:
. .
.
Premises Operations
mankct Contractual
Expanded Definition
of Property Damage
Products i1nd Completed Operations
Personal Injury
.
.
.
.
GLI
Required Limits:
)<.
$100,000 per Pcrson~ $300,000 per Occurrence
$50,000 Property Damage
or
$300,000 Combined Single Limit
$250,000 per.Person~ $500,000 per Occurrence
$50,000 Property Damage .
or
$500,000 Combined Single Limit
$500,000 per Person~ $1,000,000 per OcculTence:
$100,000 Property Damage :(
or .
$1.000.000 Combined Single Limit
GL2
~\x,...;.., G L3
',.~1'.~,.. .
.....;........
~..-
\1IlJ.,.~.:.,~
, .
.......,..;.;.. .
~..'!ttl~~...-~"'* ..
f " ~.
---.,.... .. '*.. ...--.
.
Required Endorsement:
GLXCU
GLLlQ
Underground, Explosion and Collapse (XCV)
Liquor Liability
All endorsements are required to have the same limits as the basic policy.
Mmini"",li\"C~ Imtmc1ion
'.1709.0 I
INSCK LST - ~
7
1<1 1""~II'f;
YEII[~LE LJ^BU)J.~.X
As a minimum, coverage should extend to liability fi}r:
. Owned; Nonowned; and Ilired Vehicles
Re~H'ired Limits:
VLI
.
VL2
VL3
. -.~_.'
......
~'~.. \'
._,t'
".'.,,,,-:-:,,,,,,". oJ.
.,~'1..~',,-
DRl
MVC
-'.".....,-~-- PROI
PR02
PR03
POLl
POL2
POL3
EDI
ED2
GKI
GK2
GK3
MEDI
MED2
MEDJ
~
x
--L__
I1-17O?O I
Adn.ini!dnlh'e Irl.'llnrction
-
$50,000 per Person: SIOO,OOO per Occurrence
S25,000 Property Damage
or
SIOO,ooO Combined Single U!llit
$100,000 per I)el'son; $300,000 per Occurrence
$50,000 Property Damage
or
$300,000 COIhbincd Single Limit
S500,OOO per Person; $1,000,000 per Occurrence
$100,000 Property Damage
or
$1,000,000 Combined Single Unlit
:l
,
MISCELLANEOUS COVERAGES
Duilders'
Risk
Limits equal to the
completed project.
Motor Truck
Cargo
Limits equal to the maximum
valuc of anyone shipment.
ProCessional
Liability
$ 250,000 per Occurrencel$ 500,000 Agg.
$ 500,000 pcr Oceurrencel$I,OOO,OOO Agg.
$1,000,000 per Occurrcnce/$2,000,OOO Agg.
$ 500,000 per Occurrcnccl$I,OOO,OOO Agg.
$1,000,000 per Occun'cnccl$2,OOO,OOO Agg.
$5,000,000 per Occurrcnce/$ J 0,000,000 Agg.
Pollutioll
Liability
Employee
Dishoncsty
$ 10,000
$100,000
$ 300,000 ($ 25,000 pcr Veh)
$ 500,000 ($ J no,ooo per Veh)
$1,000,000 ($250,000 per Veh)
$ ?OO,OOO/S 1,000,000 Agg.
$1,000,000/$ 3,000,000 Agg.
S5,OOO,OOO/$IO,O()(),OOO Agg.
Garage
Keepers
Medical
Pro Cossional
INSCKLST - 3
R
t."....
'~~.':-j..;.
~..~ '
.\~:.~. .
~~-r'
.nl,.~:~
-..-.
-e--"
~..~'
.....~c.-...
-...
If-
I nstallalion
floaler
VLPI
VLP2
VLP3
DLL
II a7.ardous
Cargo
Transporter
Dailee Linb.
. .
IIKLJ
'11KL2
IIKL3
AIRI
AIR2
AIRJ
Ilangarkeepcrs
Liability
Aircran
Liability
,'.
AEOI
AE02
AE03
Architects Errors
& Omissions
Il<Il'ril~ir'l:
Maximum valuc or Equipment
Installed
$ 300,000 (Requires MCS-90)
$ 500,000 (Requires MCS-90)
$1,000,000 (Requires MCS-~O)
Maximum Value or Property
$ .300,000
$ 500.000
$ 1,000.000
$25,000,000
$ 1.000.000
$ J .000.000
$ 250.000 per Occurrcncel$ 500.000 Agg.
$ 500,000 per Occurrcncel$I.OOO.OOO Agg.
$ 1.000.000 per Occurrcncel$3,OOO.OOO Agg.
INSURANCE AGENT'S STATEMENT
"
'I have revie:wed the above rcquiremcnts with the bidder named below. The folluwin"'g dcdudilJles
apply to the:: corresponding policy. .
POLlCY
". .1
DEDUCTII3LES
Liability pollicies are _ Occurrence _ Claims Madc
Insurance Agency
.1)1DD~BS STA TE.MliNT
. Signature
I understand the insurance that will he mandatory if awarded the contract and will comply in full
with all the requirements. .
Bidder
----- Signahi;C--
Acfmini~nlive "",,",..1i..n
'''709.01
INSCKLST - Jf
I}
--
WOIU(li:US' COMI'I':NSATION
INSUUANCF. nF.QlJlRI~MF.NTS
fOR
CONTUAcr
nF.T\VEF.N
1\10NUOE COUNTY, FLORIUA
ANI)
. ,
Prior to the commencemcnt of work governed hy thi~ contract, the Contractor sharI ohtain
Workers' Compensation Insurance with limits sul1icicnt to rcspond to Florida Statute 4-10.
In addition, the Contractor sharI obtain Emflloyer~' Liability In~ura.ncc with limit~ of not less tInm:
$100,000 Bodily Injury by Accident
$500,000 Bodily In.jury by Disease, policy limits
$100,000 nodily Injury by Disease, each employee
Coverage shall be-maintained throughout the entire term of the contract.
:.'
Coverage shall be provided by a company ur companics authorizcd to transact .husirress in the
statc of FloJrida and the company or companics must maintain a minimum rating of A-VI. as
assigned by the AM. Dest Company. .
I f the Contractor has been npproved by thc Florida's Department of Labor, as an authorized ....
insurer, thc County shall rccogni7.e and honor thc Contrnctor's status. Thc Contractor may be
rcquired to submit a Letter of Authori7.ation issucd by the Department of Labor and a Certili~
of I nsuranCl:=. providing details on the Contractor'.. Excess Insurance Program.
If the Contractor participates in a self-insurance timd, a Certificate of Insurance will be rcquiml..
In addition, the Contractor may be required to submit updated financial statements from the r.
upon request from the County.
^d,"ini'l1ralh.e 1rl\1In'l1i"n
11470?1
wel
IH
GI~NEnAL LIABILITY
INSUltANCF. Itr:QUIIH~MI':NTS
Fon
CONTRACT
HI~TWIUt;N
MONitOR COUNTY, FLO(tIl)A
. ANI>
. ,
I'rior to the commencemcnt ofw0.rk governed hy this contract, the Conlmctor shnll ohlnin
General Linbillity Insurance. Coverage shall be mnintained throughout the lile of the contract nrwH
include, as a minimum:
. Pr,emises Operations
. Products and Completed Opcrations
. Blanket Contractual Liability
. Personal Injury Liability
. E~:panded Definition of Property Damage
The minimum limits. acceptable shall be:
:1
$300,000 Combined Single Limit (CSt)
"
Ifsplit limits are provided, the minimum limits acceptable shall be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
An Occurrence Form policy is preferred. Ifcoverage is provided Oil a Claims Made policy, its
provisions should include cover-age (br claims filed on or allcr thc eflcctive date of this contr-ad..
I n addition, the period for which claims may be reported should extend for a minimum of twen.e
(12) months rollowing the acceptance of work by the County.
The Monroe County Doard ofCounly Commissioners shall be named as Additionallnsuled OIUJl
policies issucd to satisfy the above requircments.
\
^clmini<lI.livc 1.....1nl<1;,,,,
/I.nO?1
<ILl
5.1
'~II'ri,.i..C
VEHICLE LlAnlLlTY
INSlJltANCF. nEQUIRI~MF.NTS
FOI{
CONTUACT
. ,
HF.T\VEEN
1\10NnOE COUNTY, FLOlunA
ANn
. Recognizing that the work governed by this contrRct re<luires the use of vehicles, the Contradrn;.
plior to the commencement of work. shall ohtain Vehicle Liability Insurance. Coverage shall be
maintained throughout the life of the contract and include, ItS a minimum, liability coverage for:
. Owned, Non-Owned, and Ilired Vehicles
The minimum limits acceptable shall be:
......,
$300,000 Comhined Single Limit (CSL)
Ifsplit limits ~lre provided, the minimum limits acceptable shall be:
$100,000 per Person
$300.000 per Occurrence
$ 50,000 Property Damage
:t
,
~'''';,;:.Il.+t'...
The Monroe County Board ofCounly Commissioners shall be named as Additional Insured 0..
policies issued to satisfy thc abovc rC<luircmcnts.
,\,h..j..j,1,..livc '..<In...1....n
VL2
11-1711') I
7(,
I"' l'ril~in,:
1\10TOR VI~IIICLJi: CA nGO
INSllRANCE REQllIRJi:MF.NTS
FOR
CONTltACT
. .
IH~TW Ji:EN
MONROE COUNTY, FLOIUDA
ANI)
Recognizing that the work governed by this l:nnlract involves County property being transponecJ
by the Contractor. and tlmt most linhilily policic5 cxcludc covcragc for l'uch ilct1l!'l. the Contr-.1or
will be reqllin~d to mainlnin Molor Vehicle Cargo Insurance inamollnls no less than the
replacement value of the property in the possession ofLhe Contracllir:
Maximum Value of the County's property which is in the possession ofthe Contractor:
. $ 5) 000_,0-0_.
Must be completcd by thc Department
:.f
if
............~_.or_
NOTE
If a "free on Board" (fOD) bill of!nding is utilized on incoming property. amI iflhe County does
not assume little until the property i5 delivered, the Contractor docs not have 10 show evidence 01"
Motor Vehicle Cargo Insurance.
^dmini<lnlti\"C h'<U'K1i,,,,
MVC
lI.nO?1
(,I(
EI\I rLOYI~E DISHONESTY
INSlIRANCli: RICQlIIIU:MrCNTS
FOR
CONTRACT
B E'I'W l~r~N
MONROE COUNTY, FLORIDA
ANI)
The Contractor shall purchase and maintain, throughout the tcnn of the contract, Employec
Dishonesty Insurance which will pay for losses to Counly property or mOllcy caused by thc
fraudulent or dishonest acts oCthe Contractor's employees or its agents, whether acting alonc or
in collusion of others.
. The minimum limits shall be:
$10,000 per Occurrcnce
^clnlini~Ii\'(' 'n""1<.1i"n
1147Cl?1
EDI
.-
:l
'"
49
J\]ONROI~ COUNTY, FLOl{II>A
INSURANCE GlJIDfi:
TO
CONTRACT ADMINISTRATION
IIH.Icmnific~llion and Hold lIanlllcss
rOI"
SlIpplicl'S or Goods mid Scn,kcs
The Vendor covenants and agrees to indemnify and hold harmless Monroe County 13o(\rd of
Counly Commissioners from any and all claims (()r bodily injury (including death), personal injury,
and prop(~rty 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 Vendor or any ofilS SubconLfactor(s) in any tier, occasioned
by the negligence, errors, or other wrongful act or omission of The Vendor or its Subcontractors
in any tielr, their employees, or agents.
In the event the completion of the project (to include the work or others) is delayed or suspended
as a result ofthe Vendor's failure to purchase or maintain the required insurance, the Vendor shall
indemnifY the County from any and (\11 increased expenses resulting c.'om such :delay.
: (
The extent ofliability is in no way limited to, reduced, or lessened by the insurance requirements
contained elsewhere within this agreement.
^d",ini~trDli"c Illstollc1ion
f1.17(J').1
1(,
.-,'
BID SHEErII #2
~ .
FOR
"MONROE COUNTY COURIER SERVICE"
rAve k4:KJ~f/.jJ 51;i, ,/c;/O
I
(Amount in writing)
f;' ~d- /1)
($ Amount in numbers)
a!1d /6/100 Per Month, Per Stop
Per Month, Per Stop
ALTERNATE LOCATION -.k (dn~;"Iu~~/ ~ -lc/J-Iit~
I, '~ - , I/fSS"t. - I ~~ klf ~ A~'
O~t lJu'11l"./I~I'c/ );,.r Cuo and /ZJ /100 Per Month, Per St~~0
(Amount in writi g)
F / b;2. I tJ Per Mon~h,:' Per stD!>>
. ! ~mount in numbers) :;t:F tf./P>B>e eq'/I be- ~~ /t> 1"'1 ;hl/ ~
Gra\ ~ 1:>~~~ r AJJ-u le~.Cf) ~ rnl>7)~ -It> nk .6/q1' ~~ /i11e~;Yc t:~ir.
;J } B~DDE.R . ~
'1.) l.tC-e.., 'f)A)Eei~ CJ--4 tf\_Jf, ~..-I
(Name/Company)
.-.-::>
I~' O. $oK- 5LJ / L/3c;
(Address)
111/12/1 fArm ;::-L 53e;~.:.. 11"27
J
By: &/2i.>7cJAJ L. 7)124
/;J (r;Jam,e & >>ue)
u4cdZ ~
ee7 /:2,(97)
,
(Date)
PURCHASn~G DEPARTMENT
5100 COLLEGE ROAD
PUBLIC SERVICE BUILDING, CROSS WING, ROOM #002
KEY WEST, FL 33040 '
PHONE: (30S) 292-4464
FAX: (305) 292-4515
\..
~uttanttt (:outlrt
P. O. Box 501439
Marathon, FL 33050
(305) 743-0183
tlfJt mOE CDur lTY couru ER SErN I CE B I [)
October 12~ 1993
Ref:
Insurance Agent's statement
Due to the e::pense of placing ,the insut-anCI:-? policies required by
Monroe County for this birl~ Buccaneer Courier' will wait until an
award is made to it before going to this expense.
If Buccane!;'r' Cour'ier is a\.-J.=\r-c1ed thE' c()ntr'.=\c:t.~ l-Je will of:'c;,our'se
provide the proofs of insurance~ certificates, stateme~ts~ etc.,
in order to fully comply with the requirements of the County for
this Contract.
P/:-L
4#~'
Cdr 1 ton L. Dt- ake
Owner
jSu(canetr <<:outitt
P. O. Box 501439
Marathon, FL 33050
(305) 743-0183
MONROE COUNTY COURIER SERVICE BID
October 12~ 1993
Ref:
\.tlorkers' Compensat.ion / Employers' Liability Insur"ance.
Buccaneer Courier requests a Waiver of this insurance requirement
of the above ref en?ncF~d Eli d. \.tIe make thi s r-equest for" sever"al
rea~ons:
l'~~
It is our understandi ng t.hat \.tJ. C. i nsuy" ance is NOT requi red by
the State of Florida unless firms have four (4) or more "
employel?s. Buccaneer" Courier is a SOlE! pr"op"l~ietorship being
operated only by myself and my wife (part-time) at this point
in t.ime. \,ole hAve NO Ft'lPL.OYEES. Our plans for e::pansion and
growth were to solicit Independent Contractors as additional
personnel were needed. Your requirement goes beyond,State
requirements~ and is in contradiction to the state ru~es.
(f
Accordi ng t.o my i nSLlr"anCe agent ~ t.he y"ates used for" W. C.
policies in t.he courier business are extremely high "due to
hi gh~lay e}:posur"e. As you \::no\.'1 ~ pr"emi urns for" thi s insurance are
based an annual payroll t.otals. If we were to use employees~
~.oJe ~lOuld be r"equj-Y"erl t.o pay pr"emiums for" ?"\L.L employees~ even if
they did not perform any work under the Courier Contract to be
a~larded .
t-
.4..
r"'"
Si nce the ant i c i pated E~i'lr"ni ngs of (-\LL pE'r"sonnel must be used in
our attempt to calculate W.C. premiums~ and since (other than
because of the requirements of the Bid) we would not be
incurring any of this expense~ we must include this ~xpense in
our bi d. We f eel that t.hi s r"epr"E.sents a cost 1 y and
unne~cessary expense to Buccane~r Courier and to the TAXPAYERS
of Monroe County~ who ultimately fund the contract.
We are offering two (2) different quotations for this Bid: one
includinq \.t1.C. insur"ance~ and one conditional upon this ~Jaiver
Request being granted. It is our sincere hope that you will
agree t.hat this provision should be Waiver"ed. Buccaneer Courier
would very much like to provide courier service to the County~
but. !!Ie str'ongly feel thi'lt. t.his insurance requirement. leads to
much hi gher cost than necessar-y.
Thank you ver-y much f or" your' consi dE?r' at i on of thi s y"equest.
Resp lull y ~ I;{!-<.'
./-~/\ // "
d~ 6'&t') \ e: { h(
Carlton L.~ake ~
Owner .
<) .
DRUG-FREE WORKPLACE FORM
The undersigned vendor in accordance Witll Florida statute
287.087 hereby certifies that:
_.__._._..-kc~#.e~JR~(6_ _
(Name of Business)
1. Publish 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 wi 11 be talten against employees for
violations of such prohibition.
2. Inform 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. Give 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 tllat, 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
occuring in the workplace no later than five (5) days after such
conviction.
5. Impose a sanction on, or require the satisfactory
participation in a drug abuse assistance or rehabilitation
program if such is available in the employee's community, or apy
employee who is so convicted.
6. Make a good faith effort to continue to maintain a
drug-free workplace through implementation of this section.
As the person authorized
this firm complies fully
to sign the statement, I cert. y hat
with the?? regui rement ~A
~~,;'ture ~
..-? ~ 4~
Date 7.L..r--Y,;
MCP#5 REV. 6/91
".
SWORN STATEMENT PURSUANT TO SECfION 287.133(3)(a),
FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
by
THIS I~ORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR
OTHER OFFICIAL AUTHORIZED TO ADMINISTER OATHS., This sworn statement is submitted
to r(i:/n~~ d71 /~~+--..
[print name of the public entity]
C'k.vUJI'<J L '2:>~.f' J ~("A.
r -.........
Iprint lndlviduar. name and Uu r
[y J/~fTtv1RtrL OOcU feU
[print name of entity submillingsworn statement]
for
whose business address is
PC). Bo~ ~r1lysr;
P?/M,I)W/th\ /1- ~?~rt"-/~T1
,
and (if ;Ipplicahle) its Federal Employer Identification Number (FEIN) is
(If the entity has no FEIN, include the Social Security Number of the individual signing this sworn
statement: ZZ</,-{;{P /l7 /
.)
I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes. means a
violation of any state or federal law by a person with respect to and directly related to the transaction of business
with any puhlic entity or with an agency or political subdivision of any other state or ofthe United States. including,
but not limited to, any bid or contract for goods or services to he provided to any public entity or an agency or
political subdivision of any other state or of the United States and involving antitrust, fraud, th~ bribery,
collusion, racketeering, conspiracy, or material misrepresentation.
I underslland that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statuta-, means a'
finding of guill or a conviction of a public entity crime, with or without an adjudication of guill, in any federal or
state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result
of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.
I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes, means:
I. A predecessor or successor of a person convicted of a public entity crime; or
2. An entity under the control of any natural person who is active in the management of the entity and who has
been convicted of a public entity crime. The term "affiliate" includes those officers, directors, executivcs.partners,
shareholders, employees, members, and agents who are active in the management of an affiliate. TheowDership
by one p,,'rson of shares constituting a controlling intercst in another person, or pooling of cquipment or income
among p<~rsons when not for fair market valuc under an arm's length a~reement, shall he a prima facie case that
one person controls another person. A person who knowingly enters into a joint venture with a person who has
been convicted of a public entity crime in Florida during the prccedin~ 36 months shall bc considered an affiliate.
I underst:lIId that a "person" as defined in Paragraph 287.133(J)(e), Florida Statutes, means any natural person
or entity or~anized under thc laws of any statc or of the United States with the le~al power to enter into a binding
contractlllnd which hids or applies to hid on contracts for the provision of goods or services let by a public entity,
or which clllherwise transacts or applies to transact business with a public entity. The term "person" includes those
officers, directors, executh'es, partners, shar'cholders, employees, memhers, and agents who are acth'e in
management of an entity. 1.2.3.4.5.
"\ '. "
. . 1.1 ,. ..
Based on information and belief, the statement which I have marked below is true in relation to the entity
submitting this sworn statement. (Indicate which statement applies.)
~either 'he entity suhmitting this swnrn "alemen~ nor any or i's om.ers, dir..'ors, ""..nlives,
partners, shareholders, employees, members, or agents who'ar.e active in the management of the entity, nor
any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July
1, 1989.
-- The entity submitting this sworn statement, nor any of its officers, directors, executives, partners,
shareholders, employees, members, or agents who are active in the management of the entity, nor:maffiliate
of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. ..
-- T~e entity submitting this sworn statement, or one or more of its officers, directors, executives,
p:artners, shareholders, employees, members, or agents who are active in the management oftbecutity, or
an affiliate of the entity has been charged with and convicted of a public entity crime subsequcut to July 1,
1~189. However, there has been a subsequent proceeding before a Hearing Officer of the State ofFJorida,
Division of Administrative Hearings. and the Final Order entered by the Hearing Officer determined that
it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor
list. (Attach a c'opy of the final order)
6. I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACfING OFFICER
FOR THE PUBLIC ENTITY IDENTIFIED ON PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC
ENTITY ONLY AND, THATTHIS FORM IS VALID THROUGH DECEMBER3! OFTHECALENDAR
YJ~AR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE
PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACf IN EXCESS OF THE THRESHOLD
Al'110UNTPROVIDEDINSECfION287.017,FLORIDA T T E ORCATEGORY1WOO ANY
CHANGE IN THE INFORMATION CONTAINED IN THIS F
Sworn 10 and suhscribed bernre me 'hiJd rtL day or ~.P .Qnll\J~,
tl'~.
Pel'sonally known
O't PJ~duee~~den'ifi.a'ion O~aO) t ;ij 737 q ()
-~"- WAtQg.
(Type of identification)
Notary Public - State of \tl~1,.
i$:onrnt1~ 1~7
(Printed typed or stamped
commissioned name of notary public)
Form rUR 7068 (Rev. 06/11/92)
," 'I" ..
. .
~\J. ...' ",'
SWORN STATEMENT UNDER 6RDINANCE NO. 10-1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE
[~L-RJtV L~ ~109/~
~ ,
warrants that he/it has not eaployed
.
retain~:!d or otherwi se had act on he/its behalf any former County of"ficer
or employee subject to the prohibition of Section 2 of Ordinance Bo.
lO-1990 or any County officer or employee in violation of Section 3 of
..
Ordinance No. 10-1990. For breach or violation of this provision 'the
County may, in its discretion, terminate this contract without liability
and may also, 1n its discretion, deduct from the contract or purchase
price, or otherwise recover, the full amount of any fee, commission,
emploYE!e.
r or
percentage, gift, or consideration paid to t
Date:
(signature) .
Z-22-f~
STATE OF
t7&~(;/11
1~,(t;L
COUNTY OF
lfRSONA,LLY APPEARED BEFORE
lar I tOn Dr Q Ke
affixeqQ/her
,----'
ME, the undersigned authority,
signature (name
G;Bnc:l
~d above, on this
, .~. 19qq
'OolaMQO(h
NOTARY PUBLIC
My commission expires:
M'An4 DCi,L ilO
NOTARY.!"'JMJc STAtlOP
COMMISSION NO. ~
MY COJllf~~N P..!....~ Y 15.19'R
--- ~--.
t- 'TO: ~ ~~ ./
~ ~~7<>
SUBJECT: L;tf",,:~ ~
FROM:
MONROE COUNTY
RISK MANAGEMENT & LOSS CONTROL
Wing II, Room 207, P.S B.
STOCK ISLAND, KEY WEST, FLORIDA 33040
(305) 292-4454 Fax (305) 292-4401
DATE c::l -~ -7'Y
_~ yLe;,4~-p ~_
~~ ~
12 ., fl - ~ ~k
.~.. .~...I....~ ~~/a-~
..~~~.~ - ~ ~
.._~~. . . ....-: . v.. ~ ~~
-'
,..2 -pL~
DATE
BY ~ ~ ~P'::... 4C.
~C..!;.,~~~a~'1~. ~n ~
~; ::~~ ~w.;n> ~ ~ L~ r
;,t- ~ J .
MM~ 1 1994
COUNTY ATTY
BY
RMCC.847.3
PRINTED IN U.S.A.
-" .
.\[1rtl 22. 19,).~
I sll'rillllllg
MONROE COUNTY. FLORIDA
RCllllcst For Waivcr
of
Insul'ancc RC(IUircmcn~s
It is requested that the insurance requirements, as specified in the County's Schedule of Insurance
Rcquircmcnts, be waived or modified on thc following contract.
Contractor:
Buccaneer Courier
Contract for:
Courier Service
Address of Contractor:
P.O, Box 501439
Marathon, FL 33050-1439
Phone:
305) 743-0183 or 800) 221-0526
Scop<: of Work:
Deliver & Pick-up inter-department correspondence
Rcason for Waivcr:
Waive Motor Vehicle Cargo Insurance
Minimal County property transported per Information
Signature of Contractor:
ad~vZ~
A pprovcd
x
Not Approvcd
Risk Managcmcnt
0~~/uy
? -2- J/' /[ f
Datc
County Administrator appeal:
Approved:
Not Approved:
Datc:
., .
Board of County Commissioncrs appcal:
Approvcd:
Not Approvcd:
Mccting Date:
WAIVER
A~ BY RISt( M~N~GtMENT
6- ,?\t)l, .
lOJ , ~"'~
av ---'\0 ,~): '~1(1 c{' APPLICATION FOR
DATE ~ F LOR IDA
/ EHectille Date:
wAlvrR: N/~ '~S ,. WORKERS COMPENSATION INSURANCE
ft' .', i~~ J... ~,(L.~'}'-' This application must be typed or printed and nJed, In duplicate with:
V C~V Florida North-NCCI-Florida-North, P.O. Box 74604, Chicago, IL 60675-4604 e 407-11117-4633
I . Florida South-NCCI-Florlda-South, P.O. Box 74629, Chicago, IL 60675.4629
Important: Instructi"ns for completing this application can be found In the Florida Worker. Compensation Insurance Plan-Information and
Proceduru-Handbook. Thia handbook I. available from NCCI-Order Procu.lng e 750 Park of Commerce Drille, Boca Raton, FL 33487.
Please answer all qUllStions and requested information thoroughly. Omissions may result in delay of coverage.
The undersigned employer hereby applies for worker. compensation Insurance in Florida and exprusly represents that such insurance is aought in good faith.
This'application do.. not provide coverage.
f'or Oilli.ion Use Only
I. GENERAL INFORMATION
Previously Faxed'i .
,.. NAME OF EMPLOYER
DUCCCLnEfv COUrl Er
2.FEOERALEMPI.OYEFt< ..
10 ENTI F1CATIc>t-iNPMi3f;J{PHONE
. . REQUESTED
EFFECTIVE DATE
RISK 10 NO.
..ESTIMATED
REVENUE
3 - 1- qt..f-
6. PAYROLL OFFICE ADDRESS
7.
8.
9.
DYes 1d1\lO.
11. Are there operations in states other than Florida? 0 Yes
by S1ate:
o. If yes, you must liS1 those S1ates and give length of time In business
12. Are you requeS1ing cov,wlge for any of th(;::? ~.;tates? 0 Yes ~ If yes, you must liS1 those S1ates:
4'.
Please note: Coverage in additional S1ates is subject to Field Office and carrier review and approval. Coverage may not be available in
some S1ates.
II. AGENCY A~;~ODUCER Fax No. ~S. :d'1<j -b1D7 'f
Agency Name )., ;+hEt, n tncs+ /tJ5{)(-r.i n (1 f Phone No. 305 - ,;)9/1/- ,,')O$.;J
Address //tL{-7(vrr,lcJZ ;J[;t:n~f- / -K~A{ tDf'5f- rr/ .S?Jn'f6
ARP.FI ,
. ~TJ:.:.na;;~IUCI.gAUl""'E-'
A.~...III.. - . . ~~...... "".."_...fi'''''_......''''',;;.,_,~.. .. -
'~'PROoUC~'R .- '!\'"' ;~'. ...,.. ~""~~-"'. ;"'~~""'''''.,'''_....."'''','''~'''."-.".''''''.,..::;..~%..,-,,.,.,,._.. 'r"""'''''w..,..>.~
\:~'I ~~'i )'~~,~ I
Southernmost Insurancp Agency
11 04'I'rumiill Avenue
P.O. Box 323
Key K~st, FI 33041-0323
ONL Y 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
Buccaneer Couaier
P.O. Box 501439
~~rathon, FL 33050
COMPANY
A NOVA Casualty Company
COMPANY APf'RO\IEO BY 1Sf( MANAGnitNT
B
COMPANY BY
C
THIS IS TO CERTIFY THAT THE POlICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED OR THE ICY PE 100
INDICATED, NOlWlTHSTANDING 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 TYPE fFlIBJRANClE POUCY_ I'CIUCY EFFK1M l'OLICy EllPlRATION LMfS
LTR DATE IIMOOIYY) DATE (IMa)IYY)
r'
---. LIMI!"" GENERAL AGGREGATE
COMMERCIAL GENERAL UA8UTY PAOOUCTs.coMPlOP AGG
~ MADE [J~ OCCUR Binder # M4021755 02/18/94 02/18/95 PERSONAL & ADV INJURY
OWNER'S a CONT PROT EACH OCCURRENCE
FIRE DAMAGE (Any one fire)
lotED EXP (Any one per8Ol'I)
~ UMa.ITY
'. COMBINED SlNGI..E lIMIT $
NlV AUTO
ALL OWNED AUTOS BOOIL Y INJURY
(Per per8Ol'I) $
SCHEDULED AUTOS
HIRED AUTOS BOOIL Y INJURY
(Per~ $
NON-<JWNED AUTOS
PROPERTY DAMAGE $
8MMIIE IJMLITY AUTO ON.. Y - EA ACCIDENT $
NlV AUTO OTHER THAN AUTO ON.. Y:
EACH ACCIDENT $
AGGREGATE $
EXCU8 lJMIIJTY EACH OCCURRENCE $
UMBREu.A FOAM AGGREGATE $
OTHER THAN lJMBRELU. FOAM $
WOMIII8 OOIlPEl...TION A_ STATUTORY LIMITS
EIIPt.OYERI' IJMLITY EACH ACCIDENT 1$
THE PflOPRIETORI INCl DISEASE - POLICY LIMIT $
PARTNERSlEXECUTIVE 01
OFFICERS ARE: EXCL DISEASE - EACH EMPLOYEE $
DA11i:
INnlAL
'OF UPt:JtA1~
***Ronroe County Named Additional Insured******
., .
Monroe County RiSk Management
5100 College Road
Key West, FL 33040
EXPIRATION DATE TltEAEOF, THE IS8UING COIoW'NlV WIlL ENDEAVOR TO UIL
3 C DAYS WRITTBI NOTICE TO THE CERTlFlCATE HOL.DER NMIED TO THE LEFT,
.,.. ,M.URE TO UIL SUCH NOTICE SHALL ~ NO O8I.JGATION OR lJMIIJTY
iKJND UPON THE COIoW'AII'f,
i
l
.. "--"~"'-"-'--' -------_._._---_..~~""''''''-~. .
'. Af~ftlll..
f ~ "'.' "
"/tOOUCfR
'DATEj!.lM'OOlVVj
02/22/94
SOUthenllOOl5t Insurance ~ency
1104 1J'I;'\.IIIan AVl!!nuQ
P.O. 'B(~ 323
Key Wel:t. fl 3304' -O'?~
ONLY AND CQHFI!RS NO RIGHTS UPON THE CERnFICATE
HOLDER. THIS CERTIFICA T! DOES NOT AMEND, EXTEND OR
AL.TER THI!: COYEMAGI!: A'P'OIIDED !ty THE POUClJ:8 BELOW.
COMPANI!S AFFORDING COVERAGE
COMP~
A NOVA casualty ~~ny
"
lJuexaneer . CouIlier
P.O.'Box 501439
Marathon,FL 33050
OOUftANY
I
OOMPAHY
C
... .
COMI'ANY
D
. "-:.l4THIS' IS '1'0 CER~FY MA'rtHE POUCI o~ INSURANCl!lIS'rE~ eEL-OW HAVE BEEN ISSUED TO T~ ;N~~~t~~ci~~"
INDICATEO. NOTWITHSTANDING ANY REQUIREMENT. TERM OR MNnmON OF ~v CONTRAcTDR OTl-lliiR DOCUMENT WITlI Rl:8PE!CT 'l'O WHICH THIS
CERTlfttCATE tAAY BE ISSUED OR MAY PERTo\lN, THE INSURANCE AFFORDED BY tHE POLlOIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
I:XClUSlONS ~D (X>NDITIONS OF SUCH POUCI!S. UUITSSHOWNWAYHAVEBI!I!N REDUOeD BY PAID CLAIMS.
" "'1 .. -poucy IPfIC11YI! flOUCY 1lCPIIlA~
TYJlII r MuIWlCE '_I I"OUCY ..-,. DAR C*DDItYt DAft CWM)(WIJ
OM&ML~I' I
COUMIiROlAL l1/!HI!lW. t.lA8ILlTY
VlAl~ MADE ~ OCCUR ninder # M40Z17~5
OWNER'S, COHT ''AO'r
00
LTR
I.IITt
A
02/18/94
02/18/95
O!NI!IW. AGGREGATE
PROOLJC1S-OOuM;lP MO
I'E"SONAL a ADV IHJUftY
I!ACH QCWAAfjtj()f
j -'IRE 0Ni0IM1! ~._ .,)
, MiD ilCP I~ D/llI pQIn)
.
MIfOIIOMI ~
ANY AUtO '
ALL OWNEO AUT08
llClE)~ AlITOl!I
HlMO Al./T08
NON~I> AUTOli
COM8NED 'INGLi LMIT
.
BCOII.V INJUAV
c.... pnoa)
.
1OOl.Y lIUJRf
(Ptr~
.
PROI'&1m' ONolAQi
.
-T-
.
AUrO ONLY - EA AOCIDENI' .
OTHiA THM Al1TO 011. y.
UI~ ACClOENT .
~4T1i .
.
ace. UAIIUTY
~LLAI'OlW
OTHalllWIUMiACUA FOAU
WCJM-. CC"'lIAllI* ~
llil'Lo,..... ~,
==-- Ri
I
,
I
.~thll'U~~J....
iACHOOOJ~
AMIWlATIi
,
.
~tiivtd I
t. &; Loss Con' 01
STATlITC*VLltolITC '
I!ACH 1lCQDit(f .
O~ l'OLlCV lJIMT .
l)ISfASI! - IACi'I EMPLOV!E .
~I:'~. ~ v~ ~
, )-
awtcf.u. ....
---L------.- .
--TJWL-
-IrrlrHonroe count!!. Named Additi.onal Insured**irUtlt
Mnnr09 Coun~y RiSk Hanagom.n~
5100 College Road
K.y West; FL :U040
'..:
eo""'"
. .-" -. '('" ..,.
: .
".: .....: l"- I~, .~ \, .. '-v'
THE JOHNsONs INSURANCE AGENCY
POST OFFICE BOX 2348
MARATHON SHORES, FLORIDA 33062
Phone 306 - 289-0213
.
t
l
I
I
I
2-,-Z 2-,-1Y
_.d .
5.COVERAG~: . Eq~LimiIl0l~~7~Be~~""'F"AN.~eIVdea.,.: " ('tImIIo
==~~~:=::;::s~s~;::'
PERSONAL INJURY PRCrric;r1ON ..............._.__...............~.....,..f1:..~1't'..""._..C'".y~..........
'. ~NQPJ.i~;;;: . '. " "" .; (, ,'H I :/'f'~~" f' :~'~', .'.,.' ".
DeduCli~OI ('h2S(Y~cr $500 CI'I ,0000D U,llQO" \! ~:' ~ d~ .... !", !,
ApPli~ jg;'b'~ inoUr.. ..; ::~~':'.':- '.:~" ~..2'~~~;::.~..
,.. "~."o'rwne.~...~~~IRet...... ___ \ '';\.
. OPTiONS.1o ElUNATE IlIP BENEFITSJ'.oR;. .. "'~" ._..._.,_
o Work L... 0 Named ""IX.. Dr ,
.. _..".':, . 0 ~ ~IXed . Doponclanl Reoiden1 AoI........ _,..._ . '___...
'. O"'jlltatyBel1lfill~~~lUred.O~'Rn.ld!Ji~1) n,,;;:, . ""-0,_
MEDICAL PAYIIEHTS'[;} 1500-; 0 ,I.OOCI'VR.OOO .;;.=.;-;;=;.:..:,:;;...;:;~~~~::::-:::::.;.:.; ..
COL~ (Maximum ..0.000.. ....S.R.P;) ..~ of II:] t2S0'''OIlOO-' lU",-..,".~
COIlI.PREHENSlVE (MaximUm'I,4O.000 : M.S, R.P.l',~iblf tit O~:,~ ~ '~'''':&o
UNINSURED MOTORIST, (Slacked) 0 N<>n-StacI<ed .........................................,.....................
~:~.colGl~.r.'~ j,:-':::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
FINANCIAL RESPONSIBILITY FlUNG CHARGE (115 for each filingj.,..:.......:.,:....:.,...,...............,. '.
'. ---- ........a!.1ll
I.Ali~.9ll:'P,f,1v . .
~tfl!lWl,>,,^JJ;g!l~
S?oN$[~3tf(;
i~~~""02/'3
2, Applica", IAa shown 0' mOlor IIeIlicle reglatralion)
~tr()AJ,~~~ '.
City AI' . j ~nty
~,"-f'
uvSlness 1)( appllCMll (de.scrn.IW use 0 Vi .)
COUf<I8c ~1.4.cc
0,;~,F.q::;U~IDA AU:rQMO)jI"'U:.J.bINTPNP)3RWRITING ASSqC;!ATIO~
,-----..........".... .. ~DBY:STATEFARMMl1TUAl~INSURANCECOMPANY. .
APPUCATION APPUES TO: ~TRUCKERS POUCy
Prod"""'a Heme. r
Ul4.-j~:~
S_ <'Zip'Code
Employer'$ N~/Addr"lI-
3. DESCRIPTION AND USE:
Vall,
No.
~
Y_,Tr...N_....rr,.-T......O"'~,..'_=.,uM ~ ....~
;~:~~~~~~'::==:::=::..~:~:=~=. ..~::.:r~.".;; ~~L.:.~;' ~=
CGar.gL_(~_.... ':::. ~~::~:=S..., ....Ere
~.l~.,,~1&Jj..i!.~~,p.~.:'- C- 1m .. 1'1,/ t . '. /,~
.to1J!{}j~,~!p.~9QQ..'3..~ ..:...,.~...__.. ............... .................. .................. ..................................... .......... .
VIhltAe 3. (
UENHOlDER
NAME. ADDRESS
AND ZIP CODE
................................................~............m...
........-...........................................................
2
...H......................_.............H..............."H........_
.....................................................................
................,............-......-........-..................
3
........_.............,~....................~~_...................
..-...........;....~....~..,......~..............~.".........
CoIM1oditift Carried
Vehicle . No. 2
llmtts Premiums
V4Ihlcte . No. 3
Umits Premiums
SAME AS
VEH.l
SAME AS
VJH.1.
IJ' ',. ,_,
,..;
,
{
"-~
I ";',4 ;PLAN;i;l:':-';':~':'''''
o ANNUAL " '"r.. .
o SERVICING CARRIERIHsTALLMENT PlAN' -'J " .
o PREMIUM FINANCED (Allached Legibie PrBf!/ilm 1'1...... ContracQ.
\ "'t~;""'_
..........f. $
~ P'8mlum alt vehides S
" Amount aubmlllod with appI\callon .
l :~..;..
Name
Birlll Dele Drivtt's Licon.. No. . Stale
2.
,'''';
I. HIRED CAR C~E!lAGE:-.,..
Type. Hired
'. lE.~Mn\lOl
PrinciPal Garaging Dr LOCaIiona Whor.AulDmObil.i WI Be U... ': .,.'.;' Colli of Hir.
Ral.. Per'IOO
B.I,
P.D,
'\.JUA-I.2T (EDmQN ....,._' ."__
8. ACCIOENTSo Has applicant. or named insured and anyOltler porIOn wrc usuaCYopo<Blu1he lTIOtlIrWhide(s) been In_. .ilher as owner'or operator. in.AN'! motor vehid."
accident during 1I1e ttv.. y.ar period immediat.1y preceding 1I1e .tfocliv. d... ofll1is applicalion? ;'151 !V.. If "Y.... com~te 111. foIlowlng. ._
Dart 01 Aa:ldenl P\aco oI,Accd. llogroo 01
. " Neglig.nce
.,:. ..
Aced. Excop~on
" Cod.
Cjtfl. /,1-0 N j)/li
Nam. of Oper~tori' .
'"
I I '"
EXc:"PTIONS:SooMantJalRUI.23.1I.1.tornslofnonclwJo~accI<!OnIa""l?~~.~~W~' __ _: .'. .. ... ...
9. COI!'i1cTIONS, t!iOTOI\ VEHlCILE) Hos iho APPIfcant, .. namH r1iurod ~~ ~~. wrc uaually _.... 1I1e malDr _(.). boon Conviclod or Forloitod Bail at
arIy1lmodurhgN lrirIlodl.toI>;pr''''''ding.1hirly-'bl monlhai/o'V" ')..,III'..~W.~ (If nocosaary. us. R.~.oclion). NOTE: A peld ticltot or fine is an admlsai.on
of guilt and Iherefore ~Stitutel. con'klion. . , ",' \ 11', 't ("'i",' : f .." , . ,:"J,
~ 01 Operator .- =-:'rr'~ ..f::. r=.~ =., '--"--NIIDIIlIIVloIa*ln"~'''' ,_ PI... of YIoIallon
. .,1\ ~r, ,.".(Y..orNo) . State
(n~eroN'~f!.{
eMF" E!S WIll
L
la.FIHANClAL RISPONSIBIUTY: 0 VM :~'-.rc..-0I' ...IF'~: \ '.
II ....01_ eRglblo_... requlrod ID IIlo 0'tIcIIiilIl oIlliIllnci.I rospanat>Nlly? ".. ......
Nama J~.,q ClWnoI'l ~..1Or oporoIIon 01 oWnO'h.lildos) '. ..
Coso or File Number ~_ SocIal Soourtly No. , ."O,~jlD _Ioropotalion of non-ownod _)"
SIaIo Whore FlInt RequIred , 'l:.<-.O .... ~....._ I .. .
FlLlNOS:I.ftIlngroqUi..dIDCOI1lIllywith OI.C.C. OS..... q. Local ""l1Qanoa. (Attaell Copy) FilftrOodlo. No. .'~" i.
If block(.) chockod lot slalo(') .nd _ requiring flings and rmi.. 6ft_i1r NquIrod I:ir l..we. . . I . '.' : ,
NOTE:An lnand'. _. for co_don may be -Y!d If allnanclal',,1pOl1tIlllIIIty 'ling or ~ 01 imuranoo hosboon tIlod 10 ._ 1I1e Servldng Carrier 10 comply will1 any I
advonca notIico of _aIion r .....,.."... ", I
. ".~~::~YE":'~='::'B~~:'1d~?of~"OO~yuao==ofn.=~~tl DV~ No
lZ. PUBLIC AlITO: Usa of Vehido MIg. SpodlIod Sodng <:..,..;ty
Toni1ory(.) In _ or thtough whleIl..1'Oc1e is opot.tod . ,
13.INSUAANCERECORD;Mr__rD.d,,'-.c . ~7~1 ---/1 t7,L.L:.
Namooll.,.stcarrior ff" IV IIVIV~ ,," Polley No.. ,. tV ~() O....~
,\ "
T.rmlnalion Oal
-I;'y
14A. FLORIDA UNINSURED MOTC'RIST COVERAGE. SELECTION/REJECTION FORII
YOU ARE ElECTIN(; NOT TO PUttCHASE CERTAIN ALUABLE COVERAGE WHICH PROTECTS YOU
AND YOUR F7AMIL Y OR YOU ARE PURCHASING UN Sv'8EO ~O;rORI$T LIMITS LESS THAN YOUR
B02~~~~:is~~~.::~~~~!!~~.~~~:~~e.~~~~~~~,,!~!t;:n~~':~;~~o~:~~r.'U"ing
1I1erafrom. SUch bonoftto may indude payments for certain modicaI."""n.... loa.wagos. inil pain ,tht~. . I. 1Lll>IeCs11l11mI'-lions .... condItlona contained In 1I1e polley. For tho I
_eo 01 11110 _ago.n un,n.ured motor ..hiclo may Indude. tnOfor_ .. ID..... 11\0 ~~ iWit.lr\lIta ....,...lhan your damage..
Florida~requirOO lt1at motor 'lOhiclo liabiily poIioi.. include Unlnaurod MoIDri at 00_. II. 1ImIIi.. ... ID lI1.llocII'>' lijury LIabli1r Ilmi..'n your policy unle.. you ..leet . lower
limit ct Uninsured Motor~lt Cover. entirefy. PI....Indk::lt. your a&ection Or' rt;tdIon betoIt: .. I ,. -.J ' ~J,'
a. herebyreiectUni""~redMDtori'ICoverage ~;' ,.,',,' ',l'>.~. "~-l! ~ .;n' ' "F 3
b. I rat>y_Unin.urodMlllOrillimilsof.._._.. :._,,'..... ...1-.____.-..__... ..--. ...._...._than my Bodily In/ury lllbllly.ml...-.
. e. 0 I hor.1:ir .lect UninaL"ed MlIlOriat Umlts equallD m~ ury llablll . J :.II bold pmL
I und.rstand and agr.. 1110' this aolection or r.joctlon . 10 ney In or ropiacomonta Ol.ucI1 policy which are i.aued 0.111. 18m.
Bod~,lnjurY~!~!ly.'~m)~HldocidolD~~::' or ."___..,lhoCompony=lnWri~";"/6_ ,,1/
FAJUA.UM.,(4..e3) " . ~ w: h'lj;r.Hl~"':~.tln". r: I"'.,;'~ I C; rj-'ij:L'::,':lf~r: t
14B. ,_ . '" .,..c. .ILI " HOH..sT~ ".
. '.., . - -(DonoIClOmploloI'~_~MlIlOrIII).-...._._..""" '_"'''''' _'_'__...w..,_...._
Vou ha..1I1e option 10 purchoao. .t.reduced r.to. non.._ (lmilod)ly"eof Urinaurod MlIIDrilI.OOIIO_: Under;,;.'form Itlnju,y occuroln._ owned orloosod I:ir you or I
any family member who ra_ will1 you. lI1it policy will apply only ID tho .>IIon1 of 00Y<<ag0 ~I "1_ appII.. 10 11101 IIOhiclo In,lI1i. poIiey. If an Injury occur. while oa:upylng ,
someone elM" whickt. or you "'41 ,truck as . pede.trian, you ar. enrided 10 -*:t the I16gheIt IimIta 01 unlnaured motDriat coverage ....ilable on any one vehicle for which you
are named inaurod. insured larniy membor. or in-"red r.oIdon, of 1110 named in.urod'. _. ThIo poIlcy wi. nOt _Iy K you eolecl1l1e coverago .vallable under any other
policy i.aued ID you or 1I1e poicy 01 any olher lamiy mambor who rHidOs will1 you. ; .
If you do nol oIoct II> purehoaa 1I1e non-.lad<ed Iorm. your policy .mit(s) Ior..eIl motor _... edded IDgOIher (.tacIlod) lor all co_lnjuri... Thu.. your policy limits would
auloma~calfy cI1ango during 111. pc~icy IIrm If you _. or dacr_1I1e .....bor of.UIOIlXlvolod under lho policy.
o 1 haroby _, tho non_eked ""'" of UnIneuNd aloe""'" eov...... . ,
t undofatand .nd agrM thal_., 01 any 011l1e oboYo opdono appIloa 10 myllobili1\' lnauronoo poicy ....1Ulu............ or ropIacomon.. of.ucI1 poley which ar.,.1lled allho aarn.
Bodily Injury liability limits. If t decide 10 _ anolher opllon at....... futuro...... I muot IoIlho Company "'- in wri1Ing. .
X I' :DaIo
'" -, '" '\" ." ""'. AppIlcant'. ~ I . .1
15. ELlCTIOII'OF PEIl$OHAL IN.IU!'V PROTEC'TION ,..PROPERTY DAMAGE L1AB'UTY COVIAAOI ONLV: . . _ ";
I oIoet ID p(Jrchoao "-'ionaIlnjury P_n eo-. .... PIOf*1Y Doinago UabIIlIy Cow_ only .... raJoct AUIDmObilo Bodily Injury Cowrag. .nd Uninsured MlIlOrist Co_ag.
.vaiI~ )001'1" ~'1'"th '!'~ ~~. AutornobIIo Joi(1I \Jrldo-'dng Aosoctalion... ,
'\":\'\' ,d';:" \' .,.'.. 'X ".. ' """',
. ..". . ""'" ~SlgnaIuto~';, '," \ ;::'. Date
',; '-I.' ~ '1 \' -: \ .:., \ ',,; '\' ~ <!
FAIR CREDIT REPOATlHO ACT HClTlCI;: In oddition 1O.nlutln.......1Ion oI.lnforma~on ~1D"'tnauronceoPpuodlor. if 111. applk:alion is by an individual for insurance.
primarily lor potSOna/ or fomIly purp_. 1I1e FAJUA may...... an invoalioalNLconaumar ~'.'1ncklcIng inl~ be.ring on character. gon.r.1 rapuI.1Ion. potIOnal
chor_1iCI or modo of living ..... .'pon lho indlvicalol'. wrltIan roquoal. wII....lnwrillng Iho na-n .... of ....ImoooolIg.tion roquo_. " ouch reportla proc;u~. . :
BINDER PROVISION: Tho """-'Y'W- ID hold bound Iho 1mIta..... ~llod in II1Ia ______oIthoin.urod named heroin. auch appllcalion balnQ Complated. duly
.xoculodandaccoplOdl:ir'" PIOduolr. aubjoctlO 1I1e -~~""""i ' '." . '-1.' v . "~" ,_ . . i
,. This binder '" In .- lor . porlod '1lOl1D .- 30 oIays fIlillI'M'iIIIoclI.. __ horaIn. l;IQ' ~ .....tno.. i_1y upon: (.) Tho it.uanco 01 Iho po.ey applied lor,'
or(b)ThoI.._olanypollcy.!Iordlng.ln\lIarlnauronoo.orle)!6days'""".....oIIocll..4...._~,.._...'1 .,. . ,,',.. r'll'" .
~: i:7lg~i5'=-;,~~~:~m:~':~~~:~-':~~ORTRUCl<ERP<iK:VjorPOI~iO';"i:~i;11PERSW:i'
.. Thi. binder - not.lICOod 80dIIylnjury Urnlts of $100I30O and Property Dart"Oo UablIIY ..Of-.060Ol'CorlIblnod Single Urnlto 01 Uabi&ly 01 S3OO,ooo. (Note: H1ghorlimits may
bo roquoa1od .nd r.troo<:~vely 0""'0_ ID \f1e .Hoctivo date of Iho _ ~ , . .
~ fi 9t,/~"". M ThIoopplcatlon ... ...00.So. ."""". 82a.1jlZ..f.Ior1..da.S .talut...
Elloctivogr;;;;-' '~~ 'OPlil , '~ -S::>-... " .~. . .'.
. - -.... ,I '. X .. '... ~..".,". :::..~. ;'l ';'Jr... ~9' / \ \
~.. ~ /t7 .., ,~: \
, '.' r.. Pr _"""*-'. No.' , .
~ ,," 'j \ ,\' '\ t".," A Ssy; ,",:?.\~"'i (n _.~;,)\":." ,",. ...\".... ':"._~
I docIaro 10 1I1e boll of my knowloclg. and bohf that .n sl8lan*lI. contained in II1IUpplica1lon art.. and ~ 'latoments. are oNorad u an indu<l8monllO 1I1e Corripany to issus tho
policy ~ - \"" _pIylnll,,! undl......nd lI1at "'l':.n'''Iil.t.~*,lQ ~,.~iiliili:la! AoIP.iinailli~ly lll:~~. ,,!'In...rance on my behalf to any II1Ird party. How
are you p:aylno plolnlurnt? '[J Caeh 0 Chock auppt\nlljl bt~.'1WlId.'1l\.. 8clW-=um,... 'jltyoble 10 tho SoIvictnlICahter..~
THIS APPLICATlON"AND THE 'ESTIIIATED PREIIIUM ARE SUBJECT TO THE APPROYA1'OF"TliE SERVIC1NO CARRIER IN. ACCORDANCE WITH RATES. RULES
ANDFO~:':1~WT'\'H~NOAPP1:tOVEDIYTHEFLOIlI)l~NCE~~~:-;:-...._... '.' .'~"':~ '.\~< ....'\:.S... . .... ... '..
THISINSURANCE.'.IS.' I:JEING AFFOFiDED'THA(jUGH tH~ 'FLO. RIDA AUTOM9BIL~ JOINT I,INDE~WRITING
ASSOCIAllON AND, NOT THROI,J$1'1l JtiJ: "~RI'l iE\M~RKE't. PLEASE, BE -ADVISE[)'THAT,:COVERAGE
WITH A PRIVATE INSURER MAYBE AVAI ROM OTH AT A LOWER COST. AGENT
ANDCOMP'~YllSTIING~ ARE AVAil'AB Ilr GES: 'o,.
. --
5"'~V'!~~~jE~~\.'~,:~'~~'~rii!.'~~'!W! ~ I ~~p:~..i~.....e.. Il-
. . BOOIL Y INJURY UAIIUTY ..................................................:l:.~~;:~..:~:...;,.:.~~~.~.:;.1:~.~~~~;::8
..,......... ".~. ......_,..._.,-.~...__.__..--,......,.__..,..,....... -...-..--.'-"...-....--... ;-
, i ::~~:=~~:~. ::::::::::::::::::::::.:::::::::::::::::::::::::::::::::::::::::::::::::~::::5~::~::::::::::::::::::::::
· ~.~CIlPlU'OoduCliblotJlI 0&250 ..0$$00 Qi1'~'~i '. ~\:.~. ,'4.;'-. "!
. fA;~IO~ONomodlnllftdOf O_lnaurod&.~~twaMi-:' \,,\,,,.
, OPTIQNSiO ElIMftolATE PIP 1JENEmil FoR: "..<;'''''''9~:'i~' .' .' ',"
O~ ~~q_~~; lna';'..l or.;Q"j.."..r...urod & ~~ Re.ldent RelaIive. ''-J .
. QlAiHlI()' Benellll1Named InlUrod & Dependent Re.idClntJlCllalive",... " .
MEDlC"'L.I'AY!lJ.Hrt:~,b .soo'. .0'1.000 'Sl~.ooo ...;,............._~...::.:..~._............,.....................
COL,us.!9.!lJ~.~~~t!!<lll }".i;.MJ~ ~~~ q.~;:'O ~~.. q",,\lCl!!~'A~;"....m;:';:,
~~'~~Y~i~'I' ~'!ll:trtf:!l~lj ~~t\t~, c;:! f5f!j(.jp,'!~r:"i::"J'
, ~nffl'~~~~W"IS~ jStack!d): ;.o,~~,;;..t"f"":":':';'r'7'?h.:t:"r'jt'~~'ff:~'l'hf~t. ;
, ~~efflLJ~~~IBILITYF!LIltCl~R~E !$15.fo<.~~';';"'f.;.~:t:l:t"':"1'7i"i.:.~t':i"'."f')': . .
tl~l'i.A"CJ..__':"':~_.. .__~P:..~ _'''C~..::.:2~::::::' ___. :=:-s ~_"_s
~....'" - \f\\~\i,)'" I;(,\\J:)E., . ,;... -'~~.~ \.. ~. \. Q[i;;;"... Amountoubmlt1..._~.!
.....",.,$ElMCING.CARRlER INSTAUMENTPlAN V\ ~\-\A:'~ ~. \\::,
.'ct,rAElMUMFINANCEQJAaaa.rflI'l~flilWiOf'~ ::;-------.-.-- "1-'--' .._ .
, d "'.(Ii ~ ....'.'; '~"!:": 'lI"_' ,\:', -: F'~ ie;- ",\it. \1'1-':. Iflt,";'<" ,,>
s. QP.iRATOA INFOAIllAT1ON:"".'; ,,' ';, 'MIS- MIriIaI S1aIuI: s.SlngIe. U-IMrried, W-Wldowed, [).~cod, SP.Separated
~, ,
~'''~f>Io:WSlalli- .. - "Ocaopallon-
'. . ';:. \~".
Length 0/ MoIor Homo
VIIllde Oem..., ,
o .V.. 0 No 'j.
Does VlIhi<lVle...dMIIoed gIua? 0 V..: " "tH', lljlilin in RemaItoa Section
,,- Qll1Dmlzod? 0 YH: N -V.... .xplein In Rem_ SeClion
LIENHOlDER IN phyllicel clemege" reque.ted) / L..sed 0 YH
~,I:!j'Cl~
ClIr
SIaIa
Zip
CydCl WI.
SAME AS
. -WIt. 1
\'"
_AS
\~;1
.' . 0f1lc0 UN
."'" "APPLICANT
t'
Chil9ren'.QiI'fb.~J.irrHi!lis
13 Year. and 0lIl,.
.:"....J.._.. .~ '. ", ,J \ '.
./
DR1VEIl.~ ~NSJ;~ [I)a_ir!sY!!2(l1l1lJ!l"'.Yil!i,~ ~~~.II\t' ~Ia 0-.... iliff! Mllhrt.eYM!J ill... U.S" DilfJiClof cioIlHIllliACir Canlde?
o 'Net" N "No";^gIW.... OrIalUMi:. ortGinoIl"",-
O.h '., ~V '~;~':i~,_lf' .M"":'" ,I] (It.i\-i'_, Ll""'J...-;.!'.LL1Ae'___.J ...\1jo<{. .........~.v' ~Ij' i".'t)lWI~ i!l ,~f!!Cttt,f_""" r',UJ 1::6.... ~. ,"0_ .
'. l>P~IV.tJ:l.'T,7'~1m"~li"I".~~ifI".~!Ilr;n-_""",'~"A :JI,.JY~,,,,, ",.II'1t<HIi.~_bla. 'C ".
-8.MA-TUAEOPEAATOAMOTOA\lEH~~&oOISOGUNJ~"-. "~_CoUIMCompIetion___,. ''''.'
, f O'Aiirl-'t'bCK'IlIi'AKINdSYSTEMOiSC<iJNr ;, ...~', '''''' ""!""\> _ "_O.,..,ev, ~, ""''''.lJll!!:,.
. o AiRaAG I'll~'~~,,\ "".l\~',\i...~: "'.--:_.m: ..- '--,,: " ~;. \:?,,~ \~~_)...
- .~\,-T~:V'.J >, Vl'.. _ , ,. . ~. ",.. ,\\, . \,' (
"o~ertfrR~~~-..:-...- ....~._---.i\?i~~~ ,,~'''-;,;'.'\f'~; ~:~:~;"~\'~'..':.' \\~~c~.:
.. . ',. -~. n -~~--~__ . ... .. ", r.f \t:~. ,,,~"._' '. '.,."\j'.' ','
'.j~:l.'.j '-.. r.)'_-",,-,.b"~, j rPt:); _ , ,
- _ _'_" _ ."__J~_e,;,;,;,-~~~..'1 j .,:",;'_~J~> -: ~ I
.~.~ F~;~~'''';-;~: :. ~-::,~,",~'~:~:~~:':'~';L~"~~,,;~;;: ~~~:~:';C;~,~ :x,:~~ ;.;'~_....__. ..
~; ,
~
~,:
0::-===-
~'
CIllO ~laIII, Inc. 41 .
:l!!!iii :::IIIIIIWt::lllm I
DISHONESTY BOND APPUCATION
1) APPLICANT'S FUU:. NAME (Exactly os it should appear on the bond):
cA-'</..roAJ 'J)Mf'E ~i9- /?1/(1)JA/~
( ) Corporation ( ) Partnership
cou~
Ie Proprietor
2) ADDRtSS:
1c:J hoJ: UJ/tf3<J /JIliIf/J'Th'tJAJ R--- '53D f;"D -/f'Sl 3t)~- ~3-D4'3'
Number'"1ii-eet, ~ate. Zip Phone NlDnber
3) TYPE OF BUSINESS: to !At<., €P-, ~g< \) Ie, ~
4) CLASSIFICATION OF BUSINESS: (Classifications A, B am C all contain a CONVICTION CLAUSE)
( ) A. Professional and business offices such os accountants. architects, physicians and dentists, Insurance
agents, attorneys, realtOlS, service and social organlzotlons. (Maxtmum coverage $10.~.OO)
) B. Businesses with more exposure such as cafes, gos stations. retail stores, businesses with salespeople who
make collections and other buslnesses where cosh Is handled by numerous employees.
CONTAINS CONVICTION CLAUSE. (In order to protect you and your employees against unjustified
allegations of dishonesty. the employee must be convtcted In court before coverage will apply.)
ekc. . - ,- ~'ng service outsJde the business location such as In customers' homes. customers' offices,
ellvery services. tc. (Janitorial Services)
CO 1- ICTION CLAUSE. (In order to protect you and your employees against unjustified
allegations of dishonesty, the employee must be convtcted In court before coverage will apply.)
5) HAVE YOU SUSTAINED APJY EMPLOYEE DISHONESTY LOSSES IN THE LAST 6 YEARS?
( ) YES C><l NO
If yes. please provide In writing 011 the details pertaining to the loss.
7) EXACT NUMBER OF OWNERS: I
NAMES: C/J'~~ 70,v "])/2/tKE
6) HAS ANY INSURER DECLINED TO ISSUE. CANCEllED OR REFUSED TO RENEW ANY EMPLOYEE DISHONESTY
COVERAGE DURING JH~AST 6 YEARS?
( ) YES ~ NO ~~P!lovfO RY RISK MAN~GEMFNT
RY ()tHlA.~~
d/" \~/4~
DAlE -- I
'1IA1JR: N/A~~0:;::"
T(fL e ~,'v~ t-
If yes. please prOvilje In writing all the detaRs.
ARE OWNERS TO BE COVERED? ~ YES
( ) NO
J
i '
8) EXACT NUMBER OF EMPLOYEES AND/OR INDMDUAlS:
NAMES: /4tf}'t 1 ~'fA-1f - 1tN-n (, Pit T€ If,,, IIE72..'ll/r I
f'JT/;Fl2 t?m", l ~li"F' '7::H 0:2 nt/..!/. vEJlt.ll!...
l2en~jcS: xs . jo ~~'Y~nt::Ef of 41#~77tJAJ ,/JVI1I1../tf'SLF-?
~ (lAV'.:\LI oJ;: I"'~"""_ C.~I~ At"-s:r:- '
"'TI se reverse sld81f~ry)
INDIVIDUALS ARE: (~EMPLOYEES or () INDEPENDENT CONTRACTORS (see note below)
NOTE: WE WILL NEED THE FOLLOWING INFORMATION REGAROINQ INDEPENDENT CONTRACTORS:
I) Sample copy or the Appllcat10n requlrea to ~ Compte," by "lMplrldlrit CilCllJ"....1<.,lIlIflen blIIng hlr~.
2) Written explanation d<ttallng the controlt and IlIP8MIIon Irr1plerrlel Met ~ lie Inclepet IClent ConIractOll.
Please note Independent Contractors are covered anlywhen they are regular Independent Contractors of the
Applicant and not IAIorldng for other similar businesses. A RIder must be attached to the Bond In order to provide
coverage on the~ Ilje nd ent Contr . (PREMIUM MAY VAIN WHEN INDEPENDENT CONTRACTORS ARE COVERED.)
9) AMOUNT OF~. VE G
~/q' . ~
SUBMITTEDBY:~ ~3l??-Z DATE: (J..-/b-rolf
AGOO'S NAME, ~ESS & TFUPfU:m:~HfBN~ IAJStJ4ttNtE fI19.Jl>j '3o~ -cJ.~ _ 0 ') 13
~:I~~~ FL- 3'305;;>"
10131 S.w. 40th STREET . MIAMI. FLA. 33165-3947. (305)552-5414
sbal#2Q6