03/24/1994 Revised Agreementsy �ouwr�� o
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,OE COUNTY. Fy
BRANCH OFFICE
3117 OVERSEAS HIGHWAY
MARATHON, FLORIDA 33050
TEL. (305) 289 -6027
xuannpo[�jage
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
M E M O R A N D U M
TO: Division of Management Services c/o
County Administrator
Attn: Tim Miller, Director C & Information Systems
FROM: Isabel C. DeSantis, Deputy Clerk
DATE: April 6, 1994
At the March 24, 1994 meeting, the Board granted approval and
authorized execution of a revised contract between Monroe County
and Buccaneer Courier and granted the County Administrator
authority to add or delete stops.
Attached hereto for return to "Buccaneer" is a duplicate original
of the subject contract.
Should you have any questions concerning the above, please do not
hesitate to contact me.
cc: County Attorney
Finance
File
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.~I)NTRACT
COURIER SERVICES AGREEMENT
'rHIS AGREEMENT, MADE AND ENTERED INTO THE d ~+~ day of
rrv~ , 1994, by and between BUCCANEER COURIER, whose
principal place of business is at P.O. Box 501439, Marathon, FL,
33050-1439, hereinafter referred to as "Vendor" and MONROE COUNTY BOARD
OF COUNTY COMMISSIONERS, whose address is 5100 College Road, Public
Service Building, Wing IV, Stock Island, Key West, Florida 33040,
hereinafter referred to as "CLIENT".
WHEREAS, VENDOR HAS AN ABILITY TO RENDER COURIER SERVICES, AND THE
CLIENT is desirous of obtaining the services of VENDOR,
NOW, in consideration of the mutual covenants herein contained, and
other good and valuable consideration, the sufficiency of which is
aCknowledged,by both parties, the parties agree as follows:
1.
LOCATIONS TO BE SERVICED (SEE ATTACHED LIST)
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(ALL LOCATIONS ARE IDENTIFIED BY STOP *)
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VENDOR will pick-up and deliver at each locat~bn
and delivery to other locations. ~
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Key West
2.
TIME OF PICK-UP AND DELIVERY (SEE ATTACHED LIST)
Times specified for pick-up and delivery by VENDOR
approximate with the exception of the locations in
and Stock Island which must remain firm.
Pick-up and delivery is required Monday through Friday with
the exception of hOlidays. A list of holidays will be
provided to the VENDOR, and the VENDOR will be notified
should changes to the list occur.
Deliveries to all locations enroute from the Key Largo area west
(south) to Stock Island Public Service Building and inCluding the
Monroe County Courthouse, Key West will be made prior to 8:00AM
daily.
3. MATERIALS TO BE TRANSPORTED
VENDOR will be required to transport inter office envelopes,
mail bags, cash, computer print-outs, copy machine paper and
general office supplies so long as they are boxed, sealed and
weigh no more than 50 pounds per box.
Boxes being used for the transportation of copy machine
paper and general office supplies may be no larger than 18"
-1-
"
,
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wide, 15" deep and 10" 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.
CLIENT 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.
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.
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.
Lock Boxes will be a minimum of 24" wide, 1711 deep and 4811
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
bottom 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 transportation 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 bein9 used for transportation may be no larger than
18" wide, 5" deap and 30" hiqh.
Mail baqs should be made of canvas or an equally durable
material and have a locking mechan1s~.
6. PROVISION OF I~SURANCE BY y~NDOR - INOEMNITY/HOLD HARMLESS
. VENDOR shall procure and maintain during the term of this
agreement the following insurances with limits: Per document~
INSCKLST-l, INSCKLST~2, INSCKLST-3, INSCKLST-4, Wel, GL1,
VL2, MVC, ED1, Indemnification/Hold Harmless attached.
The insurance required shall be primary and any insurance
oarried by CLIENT shall be excess and nonoontributory.
All policies shall be issued by companies authorized to do
business in Florida.
A certificate of Insurance for each policy shall be furnished
to CLIENT'S Office of Risk Management, and shall state that
coveraqe shall not be cancelled, voided, su.pended or reduced
without 30 days prior written notice to CLIENT.
7. PAYMENTS
VENDOR will be paid $136.45 per month for' each location
serviced as per ITEM *1. Locations To Be Serviced and/or any
modifications to said ITEM as per the specific terms and
conditions of this agreement.
8. OTIJM" '-llOVISION~
The term of this agreement shall be for a period of one (1)
year and commence upon execution by the Board of County
commissioners of Monroe County, Florida and VENDOR. This
agreement may be extended for sucoessive one (1) year Terms
thereafter with a limit of (2) two (1) one year terms.
Either party may cancel this 8qreement upon providing no less than
sixty (60) days written notice to the other party prior to tha
effective dat~ of termination, except that VENDOR may not terminatG
the aqreement for the first lS~:days of same.
Any and all delivery items shall be picked up at the
locations specified in ITEM fl. Locations To Be Serviced, or Crt
8Y ~ea.$ftAbie chanqe. in location shall be noticed to the,n
VENDOR by the County Administrator.aft8 dei~ve~'e8 sha!l ~)t~
i*kewiee ~e a..e.
VENDOR shall keep and maintain any And all property pldcea
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,
damaged or lost, and assumes liability for damage or loss
from all causes except war, confiscation, order of any
government 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.
Requests for unscheduled pick-up and delivery at locations
specified in ITEM *1. Locations To Be Serviced, will be the sole
responsibility of the requestor and are not a provision of
this agreement.
Requests 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.
Requests 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 transported
under 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 ar~s~ng
hereunder, 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. ATTORNEY'S FEES
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,
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
paragraph shall be construed to permit any attempted
assignment 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 and 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
terminated immediately at the option of the Board by written notice
of termination delivered in person or by mail to the vendor.
IN WITNESS WHEREOF, the parties have caused this
executed on the day and year written above.
BY:
Agreement to ,be
JilUlttm €81IIier
p. O. Box 1014a9
MIfIIhon, Fl 3ICJ5O
(316) 743-01"
(v.
(Seal)
ATTEST: Danny L. Kolhage, Clerk
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MONROE COUNTY
COURIER SERViCE
LOCATIONS AND ~OUNTY AGENCIES SERVICED
PICK-UP AND DELIVERY LOCATIONS
SERVICE TIMES
COUNTY AGENCIES SERVICED
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lSTOP 1-1
Public Service Building
5100 College Road
Stock Island
Key West, Florida 33040
OUT TO KE~ WEST
11100 AM and 3eOO PM
OUT TO KEYS NORTH
5;00 PM
IN TO STOCK ISLAND
from Keys ~orth
from Key West
County Administrator
Human Resources
Employee Benefits
Community Services Div
Public Works Division
Code Enforcement
Safety Department
Extension Services
PUblic Info. Officer
Airport Finance
Public He.lth Unit
Training Department
Information system.
Risk Management
Off1c& of Mana;. & Budget
Public Facility Maint.
Recycling Department
Bngineer1n; Department
MKG - Construction Man;
Bay.hore Manor . .
Tourist Development Cent.r
Job Training Partnership
Environmental Manag. Div.
Land Autbol'ity
Building D~p.rtment
Purchas1n; Department
So01al Service. Dept/Al1 Agenc;
Veteran Affairs
Grants Management .
before 8:00 AM
2:55 PM
~ t~!e' 2)
.
3706 N. Rooso~elt
Koy wast, 1'1
.t.6ftd. hatl\eri ~y
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-1-
{STOP 3)
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Fira~ State Bank (~p~tail~)
3406 N. Roosevelt Blvd
Key West, Flor' 40
: ~'
,STOP 4l
3583 S. Roosovelt Blvd
Key Wmst, Florida 33040
11:25 AM and 2:35 PM
lS,TOf S}
3491 S. Roosevelt Bvld
Key West, Florida 33040
11130 ~ and 2:30 PM
lSTOP 61
700 Fleming Stroet
Key West, Plori~a 33040
11:45 AM and 2:15 PM
{STOP 7}
310 Fleming Street
Key Welt, Florida 33040
11:55 ~ and 2;05 ~M
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N/ C~
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"~Ou~i~t DCvclopmcnt C5tl~eil
Key West Publio WorKs Garaqe
Faoility Ma1nt - Carpenter Shop'
Key West ROAd Department
Airport Managers Office (KW),
Key' West Library
commia.ioner Harvey
Commissioner FrGeman
County ^ttorney (2nd floor)
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{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
Approx: 5:30 to 6:00 PM
{STOP 10}
Monroe County Regional Service Ctr.
2798 Overseas Highway, MM 47.5 (gulf)
Marathon, Florida 33050
Approx: 7:00 to 7:30 PM
{STOP 11}
Marathon Sheriff's Office
3101 Overseas Highway, MM 48 (ocean)
Marathon, Florida 33050
Approx: 7:15 to 7:45 PM
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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
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{STOP 12}
Marathon Library
3251 Overseas Highway, MM 48 (ocean)
Marathon, Florida 33050
Approx: 7:30 to 7:45 PM
{STOP 13}
Marathon Government Annex
490 63rd Street (ocean)
Marathon, Florida 33050
Approx: 7:45 to 8:00 PM
{STOP I4}
;lMarathon Airport
.~ 9000 Overseas Highway, MM 51.5
Marathon, Florida 33050
Approx: 7:45 to 8:00 PM
{STOP I5}
Marathon Public Works
10600 Aviation Blvd. (gulf)
Marathon, Florida 33050
Approx: 8:00 to 8:15 PM
{STOP 16}
Long Key Land Fill
Volume Reduction Plant *2
MM 68 1/2 u.S. 1 (gulf)
Long Key, Florida 33001
Approx: 9:00 to 9:15 PM
-4-
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
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{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 Key Heights Dr, MM 88-89 (gulf)
Plantation Key, Florida 33070
Approx: 11:30 to 12:00 midnight
{STOP 19}
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}
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Key Largo Volunteer Ambulance Corp.
98600 Overseas Hwy, MM 98.6 (median)
Key Largo, Florida 33037
Approx: 1:30 to 1:45 AM
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Islamorada Library
Public Works
Emergency Management - Radiology
Engineering
Building Dept/Growth 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
/
{STOP 22}
Tradewinds Plaza Key Largo Library
101485 Overseas 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./EnvironmentRI Manag.
Approx: 10:30 to 10:45 PM
{STOP 24}
Cardsound Toll Bridge
County Road 905A
US #A1A
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
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Al',il 22. 1991
1l<1I'rin.inw:
MONROE COUN1Y, fl'LORII>A
INSURANCE CIIF:CKLlST
fl'0 R
VENDOnS SUHMITTING PROPOSALS
FOR'VORK
. .
To assist in the development of your proposal, the insurance coverages 111m ked with an "X" Will
be required in the event an award is made to your firm. Plcase review Ihis fi:mn with your
insurance agent and have him/hcr sign it in thc placc provided. Il is also rcquircd that the b~
sign the form and submit it with each proposal.
.
WORKERS' COMPENSATION
ANI>
E_~ I~LQY EI~LLI[\1J' L[LX
WC'
WC2
WC3
WCUSLH
WCJA
x
Workcrs' Compcnsation
Employers Liahility
Employers Liahility
Employers Liability
US Longshoremen &
Harbor Workers Act
federal Jones Act
Statutory Limits
$ I 00,000/$500,000/$1 00,000
$500,000/$500,000/$500,000
$ I ,000,000/$1 ,000,000/$ I ,OOO~CllOtJ
Same as Employers'
Liability
Same as Employers'
l.iability
Adnlini~1raliye Inslnk.1inn
114709.01
INSCKLST --I
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As a minimum, the required generalliabilily coverages will include:
yENEK~L LIABILITY
· Premises Operations
· Blanket Contractual
· Expanded Definition
of Property Damage
.' ,
Required Limits:
GLJ
x
GL2
GL3
Required Endorsement:
GLXCU
GLLlQ
Products and Completed Operations
Personal Injury
.
.
$100,000 per Person; $300,000 per Occurrence
$50,000 Property Damage
or
$300,000 Combined Single Limit
$250,000 per.Person; $500,000 per Occurrence
$50,OOO-')roperty Damage
or
$500,000 Combined Single Limit
$500,000 per Person; $, ,000,000 per OcculTence
$100,000 Propel1y Damage
or
$1,000,000 Combined Single Limit
Underground, Explosion and Collapse (XCV)
Uquor Liability
All endorsements are required to have the same limits as the basic policy.
^dmini~1",li\'c In~m~1ion
H.t709.01
INSCKLST -'1--
7
"
,
,
AI'ril 22. I'J'J.'
J~ I'rinlin!:
YElIICLE LJAllIL[LY
As a minimum, coverage should extend to liability fi)r:
· Owned; Nonowned; and Ilired Vehicles
Re~tPired Limits:
VLJ
.
VL2
"
VLJ
BR]
MVC
x
PROI
PR02
PR03
POLJ
POL2
POL3
EDJ
E02
GKI
GK2
GKJ
MEOI
MED2
MEDJ
~--
Adhlini!<ltali\'c lrJ.<;(nll1ion
H470'J.OI
$50,000 pcr Person: $100,000 per Occlirrence
$25,000 Propcrty Damage
or
$ 100,000 Combincd Single Limit
$100,000 pCI' Person; $300,000 per Occurrence
$50,000 Propcrly Damage
or
$300,OOQ Gorilbincd Single Limit
$500,000 pcr Person; $1,000,000 per Occurrence
$100,000 Property Damage
or
$ I ,000,000 Combined Single Limit
MISCELLANEOUS COVERAGES
Builders'
Risk
Limits equal to the
completed project.
Motor Truck
Cargo
Limits equal to the maximum
value of anyone shipment.
Professional
Liability
$ 250,000 per Occurrence/$ 500,000 Agg.
$ 500,000 per Occurrence/$I,oOO,OOO Agg.
$ 1,000,000 per Occurrence/$2,000,OOO Agg.
$ 500,000 per Occurrence/$ I ,000,000 Agg.
$1,000,000 per Occurrencc/$2,000,000 Agg.
$5,000,000 per Occurrence/$ I 0,000,000 Agg.
Pollution
Liability
Employee
Dishonesty
$ 10,000
$100,000
$ 300,000 ($ 25,000 per Veh)
$ 500,000 ($/00,000 per Veh)
$ I ,000,000 ($250,000 per Veh)
,$ 500,000/$ 1,000,000 Agg.
$ 1,000,000/$ J,OOO,OOO Agg.
$5,000,000/$10,000,000 Agg.
Garagc
Keepers
Medical
Prorossional
INSCKLST -3
R
.
IF
VLPI
VLP2
VLPJ
BLL
. ,
IIKLI
J IKL2
IIKL3
AIRI
A 11(2
AIRJ
AEOI
AE02
AEOJ
^I"il 22. ""}J
I~ I'rinline
I nsta lIation
Floater
Maximum value of Equipment
Installed
J lazardous
Cargo
Transporter
$ 300,000 (Requires MCS-90)
$ 500,000 {Requires MCS-90}
$1,000,000 (Requires MCS-90)
Bailee Liab.
Maximum Value of Property
Ilangarkeepcrs
Liability
$ 300,000
$ 500,000
$ 1,000,000
$25,000,000
$ 1,000,000
$ 1,000,000
Aircran
Liability
Archih~ct.s Errors
& Omi'ssions
$ 250,000 per Occurrencc/$ 500.000 Agg.
$ 500,000 per Occurrence/$I ,OOO.OOIJ Agg.
$ 1,000,000 per Occurrence/$J,OOO.<X>> Agg.
INSURANCE AGENT'S STATEMENT
I have reviewed the above requirements with the bidder named below. The following dedudiNes
apply to the corresponding policy.
POLICY
OEDUCTmLES
Liability policies are _ Occurrence
Claims Made
Insurance Agency'--
Signature
DIDDERS STATEMENT
.------------
I understand the insurance that will be mandatory ifawarded the contract and will comply in full
with all the requirements. .
^drninimnlivc: In!OlnK1inn
H4709.01
Didder
-.----- Signatlirc--
I NSCK LST -If
9
^,,,iI22. '"1
I~' "rill'inr.
\VOIU((4.:ns' C()l\1rl~NSATI()N
INSUnANCF. nF.QUIRI~MF.N"'S
FOI{
CONTnACI'
. .
UF.T\VEEN
I\lONnOE COUNTY, FLORII>A
ANI>
Prior to the commencemcnt of work governed hy this contract. the Contractor shall ohtain
Workers' Compcnsation Insurance wilh limils su'f1jcicnlto resflond to Florida Statute 4"0.
I n addition, the Contractor shall obtain Employers' Liability Insurance wit h limits of not less tlnm:
$ I 00.000 Dodily Injury by Acci(l~nt
$500,000 Bodily In.;ury by Disease, policy limits
$100,000 Dodily Irtiury 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 10 transact husiness in the
state of Florida and the company or companics must maintain a minimum rating of A- VI, as
assigned by the AM. Dest Company,
If the Contractor has been approved hy the Florida's Department of Labor, as an authorized ~
insurer. the County shall recognize and honor the Contractor's status. The Contractor may be
required to submit a Letter of Authorization isslled by the Department of Labor and a Certiliaar
of Insurance, providing details on the Contractor', Excess Insurance Program.
If the Contractor participates in a self-insurance fimd, a Certificate oflnsurance will be requiIafl..
In addition, the Contractor may be required to submit updated financial statements from the fmdl
upon request from the COllnty,
^dnri"i!>ll1llh'e 1.\'.1ml1i,,"
H470?1
wel
RI
^I',iI22. ".l'J1
'~l"ril~in,:
Gfi:NEnAL LlARlUTY
INSURANCE R~QUII~fi:M(':NTS
FU I~
CONTRACT
. ,
UI~T\VI~fi;N
MONnOfi: COUNTY, FLOrUI>A
AND
Prior to thc commencement ofwC'rk govcrncd by this conlract, thc COfllmctor shall ohtain
Gcneral Liability Insurance. Covcragc shall bc maintaincd I hroughout thc life of the coni met armf
include, as a minimum:
· Premises Operations
· Products and Complete:d Oper..ations
· D1anket Contractual Liability
· Personal Injury Liability
· Expanded Definition of Propcrty Damage
The minimum limits acceptable shall be:
$300,000 Combined Single Limit (CSt)
Ifsplit limits are provided, the minimum limits acceptable shall bc:
$100,000 per Person
$300,000 per Occurrcnce
$ 50,000 Property Damage
An Occurrence Form policy is preferred. Ifcoverage is provided on a Claims Made policy, its
provisions should include covcrage fi)r claims filcd on or allcr thc ellcctivc datc of this conlradl...
In addition. the period for which claims may be reportcd should extend for a minimum oftwcNc
(12) months following the acceptance of work by the County.
The Monroe County Doard ofCollnty Commissioners shall be named as Additional Insured Null
policies issued to satisfy the above requircments.
^""';ni<lr.live ',....1mdi..n
H47()'J,'
GLI
54
.
^pril 22. I'}'}J
1~II'rinlin&
VEHICLE L.AnILlTY
INSURANCE REQUIRI~MENl'S
FOR
CONTUACl'
. ,
UET\VEEN
1\10NUOE COUNTY, FLOIUI>A
AND
. Recognizing that the work governed by this contract requires the use of vehicles, the Contractm:.
prior to the commencement of work. shall obtain Vehicle Liability Insurance. Coverage shan be
maintained throughout the life of tile contract and include, as a minimum, liability coverage for:
· Owned, Non-Owned, and . fired Vehicles
The minimum limits acceptable shall be:
$300,000 Combined Single Limit (CSL)
· f split limits are providcd, the minimum limits acceptable shall be:
$100,000 per Person
$300,000 per OCCUlTCI1Ce
$ 50,000 Property Damage
The Monroe County Board of COli Illy COl1Jmissioners shall be named as Additional Insured 011.
policies issued to satisfy the above requiremcnts.
'\<.hnini_1II1Ii\'C In"'",<.1ion
VL2
/1,170').1
76
l'
^1"iI22. I')'))
1~II'ri/l'inr:
1\10TORVEIIICLE CAI~G()
INSlJnANCE REQlJIRfi:MF.NTS
FOR
CONTUACT
. ,
UF.T\VEEN
MONHOF. COUNTY, FLOIUI>A
ANI)
Recognizing that the work governed by this conlract involves County property heing transpooted
by the Contractor, and that most liability policies exclude coverage for such items, the COlltratfar
will be required to mainlain Motur Vehicle Cargo Insurance in amounts no less than the
replacement value of the property in the possession of the Contractor.
Maximum Value of tile Coullty's propCrly which is in the possession of the Contractor:
,$ 5) 000 I 0'0_._ .
Must be cOlllplcted hy the Department
NOTE
If a "foree on Board" (PUB) bill of lading is utilized on incoming property, and if the County does
not aSSUllle title until the property is delivered, the Contractor does not have to show evidenceof'
Molar Vehicle Cargo Insurance,
^dRlini.tOl'i\'c Jno;(rudi""
MVC
1I.170?J
fII(
(
April 21. 1'J'JJ
\~II'rilllill':
EMPLOYEE I>ISIIONESTY
INSURANCE REQUIREI\HGNTS
FOR
CONTRACT
BET\VEEN
MONROE COUNTY, FLOI{I()A
AND
The Contractor shall purchase and main lain, throughout lhe term of lhe conlracl, Employee
Dishonesty Insurance which will pay for losses lo Counly properly or money caused by the
fraudulent or dishonest acts oCthe Contractor's employees or its agents, whether acting alone or
in collusion of others.
The minimum Jjmits shall be:
$10,000 per Occurrence
Adnlinistruli\'C'ln'<lmdinn
H47(),).\
EDI
41)
t' '.
'.
,\p,il22. 1<)'))
I~ll'rilllill!:
MONROI~ COUNTY, FLORIDA
INSURANCE GIJlDE
TO
CONTRACT ADMINISTRATION
.'
Illdcmnific;ltiOIl and Hold Hannlcss
for
Supplicr's of Goods ;lIId Scn'i{~cs
The Vendor covenants and agrees to indemnify and hold harmless Monroe County Board of
County Commissioners from any and all claims {()r bodily i(~U1Y (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 providcd by the Vendor or any of its SubconLractor(s) in any tier. occasioned
by the negligence, errors, or other wrongful act or omission of The Vendor or its Subcontractors
in any tier, their ,cmployces. or agents.
In the evcnt the completion of the project (LO include the work of othcrs) is delayed or suspcnded
as a result of the Vendor's failure to purchase or maintain the required insurance, the Vendor shall
indemnify the County from any and all increased expenses rcsulting ft.OIll such delay.
The cxtent ofJiability is in no way limitcd to, reduccd, or lessened by the insurance requirements
contained elsewhere within this agreement.
^dnlinistrnlivc hl\1ruc1ion
1147(),).1
16
.) ,
DRUG-FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida statute
287.087 hereby certifies that:
-.--.----------.-.-...-.kCCJr!?~~-~L~
(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 will be ta]cen 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 (I), 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
occuring in the workplace no later than five (5) days after such
conviction.
S. 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 persoll authorized
this firm complies fully
Date
MCP#5 REV. 6/91
"
",
SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a),
FLORIDA STATUTES. ON PUBLIC ENTITY CIUMES
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR
OTHER OFFICIAL AUT IUZE TO DM ISTER OATHS., This sworn statement is submittal
to
by
(print name of the pub Ie e ty]
~L-7d'7 L:3) ~ (~ 1 ~ ef)
Iprint individual'. name and tille) ~ ~
~(c..~lftt .' ~(fJ./
(print name of entity submitting sworn statement]
for
whose business address is
70 ~y 0/f17
/Jl~4tn /'~ ?3~ ". ~s/?J
and (if applicable) its Fcderal Employer Identification Number (FEIN) is
(If the cntity has no FEIN, include thc Social Security Number of the individual signing this sworn
2~ c.f"- 4>4> - /79/
.
statement:
.)
I understand that a "public entity crime" as defined in Paragraph 287.I33(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 busincss
with any puhlic entity or with an agency or political subdivision of any other state or of the United Statcs,induding,
but not limited to, any bid or contract for goods or services to be provided to any public cntity or an agency or
political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery,
collusion, racketeering, conspiracy, or material misrepresentation.
I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statut~ means a'
finding of guilt or a conviction ofa public entity crime, with or without an adjudication of guilt, in anylederal 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:
1. 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, executives, partners,
shareholders, employees, members, and agents who arc active in the management of an affiliate. The ownership
by one person of shares constituting a controlling interest in another person, or pooling of equipment or income
among persons when not for fair market value under an arm's length agreement, shall he a prima faciec:ase that
one person controls another person. A person who knowingly enters into a joint venture with a person who has
been convictcd of a puhlic entity crime in Florida during the preceding 36 months shall he considered an affiliate.
I understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural person
or entity organized under the laws of any state or of the United States with the legal power to cntcr into a binding
contract and which hids or applies to hid on contracts for the provision of goods or serviccs let hy a public entity,
or which otherwise transacts or applies to transact husiness with a puhlic entity. The term "person" includes those
officers, directors, executives, partncrs, shal'choldcrs, cmployces, mcmhcrs, and agcnts who an~ acth'c in
managemcnt of an entity.1.2.3A.S.
.,
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.)
/
~ither the entity submitting this sworn statement, nor any of its officers, directors, executives,
partners, shareholders, employees, members, or agents who'ar.e active in the management oftbeentity, 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 oCthe entity, nora affiliate
of the entity has been charged with and convicted of a public entity crime subsequent to July I, 1989. _.
- Tl!e entity submitting this sworn statement, or one or more of its officers, directors, executives,
partners, shareholders, employees, members, or agents who are active in the management oftbccntity, or
an affiliate of the entity has been charged with and convicted of a public entity crime subsequCllt to July I,
1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida,
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 ~opy of the final order)
6. I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER
FOR THE PUBLIC ENTITY IDENTIFIED ON PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC
ENTITY ONLY AND, THAT THIS FORM ISVALIDTHROUGH DECEMBER31 OFTHECALENDAR
YEAR IN WHICH IT IS FILED. I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE
PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT EXCESS OF THE RES LD
AMOUNTPROVIDEDINSECTION287.017,FLORIDA TA E FORCA GOR Y
CHANGE IN THE INFORMATION CONTAINED IN TH FO
Sworn to and subscribed before me tbisa~ M- day of ~ ~'tJ
,I9~.
Personally known
OR Produced identification_D ltJ aQI.I.~ 41379 ()
_kOA1/\Oj -
(Type of identification)
Notary Public - State of '4l.J.~
lli~=u~~1~511997
(Printed typed or stamped
commissioned name of notary public)
Form PUR 7068 (Rev. 06/11/92)
MAlIA PIL 110
NOrMY rua.r irATI Of
cot.GftSIOH NO. <:ellIi,.
NY . WAY
,.. 'I" ,
. I,.... ,., .,'
SWORN STATEMENT UNDER ~RDINANCE NO. 10-1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE /I
l19V2L 7tJtN L 2Jr2rl~:warrants that he/it has not eaployed
~ ,
.
retained or otherwise had act on he/its behalf any former County orficer
or employee subject to the prohibition of Section 2 of Ordinance BU.
10-1990 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, in its discretion, deduct from the contract or purchase
price, or otherwise recover, the full amount of any fee, commission,
percentage, gift, or consideration paid to th
employee.
r or
Date:
gnature) .
2-~~yy
STATE OF
~6~
1/7~
COUNTY OF
P~SONALLY ~ARED BEFORE ME, the undersigned authority,
La( Uon-1lrQ te who, after first being swon> by
me,
affixed hislher signature (name of individual signing) in the space
. ~.\ 0,ct
ovided above on thi s dO.
day of
~ODL
, 19~.
NOTARY PUBLIC
My commission expires:
WAlIA OiL 110
NOI'AaY PlJIUc ST41'1. OF
~HO.~
y
~
-
r TO: (~~~ ./
~~l~
SUBJE(:T: l;(j'~ ~
~":'l)jV:
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 -~r -7'Y
...
~
~
,..2 -c,.2?
DATE
BY_ ~ J-1:,..L?Z~
; T\~;?;(~J;~
' ,~~-' ':_'); "i~1M
.;:;! ~
t.J
fl" [. ') 1 1994
COUNTY ATTY
BY
RMCC-847-3
PRINTED IN U.S.A.
.\l'ril 22. 1993
I stPrinting
MONROE COUNTY, FLORIDA
RC1lucst For Waivcr
of
Insurance Requircments
It is requested that the insurance requirements, as specified in the County's Schedule of Insurance
Requirements, be waived or modified on the following contract.
Contractor:
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
Scope of Work:
Deliver & Pick-up inter-department correspondence
Reason for Waiver:
Waive Motor Vehicle Cargo Insurance
Minimal County property transported per Information
Signature of Contractor:
a~~~~
Approved
x
Not Approved
Risk Management
0r::Ju~
;;J-. .~. ~/, q Y
Date
County Administrator appeal:
Approved:
Not Approved:
Date:
Board of County Commissioners appeal:
Approved:
Not Approved:
Meeting Date:
WAIVER
A~ BY RISI< MANA(;EMENl
(QrxfY . ~
BY 1;~]:1,(1 (Ii APPLICATION FOR
DATE ~ F LOR IDA
/ EHective Date:
WAIVER: N/A i~S~i WORKERS COMPENSATION INSURANCE
/:t V~l'I. -.1'-' n ~~.'-C'.~ This application must be typed or printed and fll6d, In duplicate with:
'!U ~....vf Florida North-NCCI-Florida-North, P.O. Box 74604, Chicago, IL 60675-4604 e 407-997-4633
I . Florida South-NCCI-Florida-South, P.O. Box 74629, Chicago, IL 60675-4629
Important: Instructions for completing this application can be found In the Florida Workers Compensation Insurance Plan-Information and
Procedures-Handbook. This handbook I. available from NCCI-Order Processing. 750 Park of Commerce Drive, Boca Raton, FL 33487.
PI&ase answer all qu&stions end requ&sl&d information thoroughly. Omissions may result in delay of coverag&,
The undersign&d &mployer h&r&by applies for work&rs compensation Insurance in Florida and expressly represents that such insurance is sought in good faith.
This'application does not provide coverage.
For Division Use Only
I. GENERAL INFORMATION
Previously Faxed
1, NAME OF EMPLOYER
t3 UCCllJ'1[[V tOUr! [y
2.fEO eRAl.EM Pl.OYEFt, ,,',',"'.... 'PH, 'ONE
I D ENTIFICATION.NUMI3ER
REQUESTEO
EFFECTIVE DATE
ESTIUATED
.REVENUE
3 - I ~ qif
'75/000.
5 treet
3. MAILING ADDRESS
OE R- 330
7.
8.
If yes, explain:
9
1 Q. Has there been a name change or
If yes, give previous name and date
'dation, merger or other Own,fH~b!A change durin~ast three years? 0 Yes r.;:rffo.
change and contact the NCCI-A~h\I{;'Oivision ab6tlt~A 11:
11. Are there operations in states other than Florida? 0 Yes ~. If yes, you must list those states and give length of time in business
by S1ate:
12. Are you requeS1ing covBmge for any of th(;:::~ ~;tates? 0 Yes ~ If yes, you must list those states:
Please note: Coverage in additional states is subject to Field Office and carrier review and approval. Coverage may not be available in
some states.
II. AGENCY A~RODUCER
Agency Name ~)( )+hc~' n nlCS+
Address J I eLf 77()rnc~f1 JJ/I.E: nu r
Fax No, ,-305- ;;;;C,tj-S(()7'f
/n 5 {)("r.( n (] f Phone No. 305" dC((,;- ,<:;0,:) d
) K~J{ tDE7-t- Pi -~?J()'f()
ARP.Fl ,
At~oiii.~--.C.ERnFICA T
4_. 4 ~ '
PRODUCER
.INSU
I F RMATI N
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
-~---
COMPANIES AFFORDING COVERAGE
SGtit r,erruit()St, L ;'i:i\...Lr'.::u:{~'~,+)
.ll C,:,lTrUltld.f.1 !\\/p-,nU(:;
i',(,',Z
I\.;:,t, "i. ?3C'n -0323
COMPANY
A
\h)\//~
Cd::,-;,t:a
'C~)rnr-i{.tl-l
I
. -- h~~"~~~r j;~~~~'T :~:: BY '0~~nMm I
I""'"'.''''''' "1'30c(; OOM~'" DAlE ()--~"' jet 'I ;;. " ~ I
i ce=~ CE~~IF~ ~~:T T~~-~~~~~I~~~~~NS~~~N~: ~~S;E~ B~L:~ ~AVE BEEN ISSU::~~~E I:R:~~A~~~:B;vWOJ ~HE POLICY PEit;1- i
I INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS .
I CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO I POlICY EFFECTIVE I POLICY EXPIRATION
L TRI TYPE OF INSURANCE POLICY NUMBER DATE (MMlDDIYY) I DATE (MMlDDIYY)
-1GENaw. uABiiITv
p iXl COMMERCIAL GENERAL LIABILITY
\ iu. T CLAIMS MADE OCCUR Pi nck~r 1* ~1-10217c:".'.
I OWNER'S & CONT PROT
LIMITS
PRODUCTS-COMP/OP AGG
$ 1 i 000 ,000.
$l,OOO,OOC.
$1,000,000.
$1,000,000.
GENERAL AGGREGATE
02/1 8/c/*
(l7/1F/Q<:
PERSONAL & ADV INJURY
EACH OCCURRENCE
FIRE DAMAGE (Anyone fire) $
MED EXP (Anyone person) $
50,OOC.
, ()C:O "
AUTOII08IlE LIABIlITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
COMBINED SINGLE LIMIT $
BODILY INJURY
(Per person)
$
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE $
GARAGE LIABIlITY
ANY AUTO
AUTO ONLY - EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EACH OCCURRENCE $
AGGREGATE $
$
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
THE PROPRIETOR!
PARTNERSlEXECUTIVE
. OFFICERS ARE:
: O'l'HER
INCL
EXCL
~{~eived
Risk l\1g$t. & Loss Control
DATE ~ -,2y- /'7
1NI11AL ---;t;;% o.c
STATUTORY LIMITS
EACH ACCIDENT $
DISEASE - POLICY LIMIT $
DISEASE - EACH EMPLOYEE $
liEshAIPTfON Of' OIfERA1lONSi[ocA't'iONSNEHiCLeS!SPECiAI iTEMS
***Monroe County Named Additional Insured******
CERTtFlCATEHOt..Of:R
CAtCEl.LATfON
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIRCATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALl IMPOSE NO OBlIGATION OR lIABILITY
KIND UPON THE COMPANY, ~ A~ OR REPRESENTATIVES. !
- ,.. T'j- \-/ -/~, ~"'~~~~/'~~::-
Cc. \}J4.~",-
I
,
I
I AeoRD-~ (3193)
"{"1 () n r OE~? (' {J U ~:-l t }"
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Xey
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330/1(\
SOUTHERNMOST INSURANCE TEL No.305-294-5574
Feb 28,94 :4:(5 No.OJ3 P.02/02
.....DATE'iMM'OOlYyl
021z2/94
Southerrm:>st Insurance Agency
1104 1'ruman Avenue
P.O. Box 323
Key West. J?l 3304'-01n
ONLY AND CONFERS NO RIGHTS UPON THE CERnt:ICATE
HOLDER. 11-IIS CERTtFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVEMAoe Af'FORDED BY THE POLlCII:S BELOW.
COMPANIES AFFORDING COVERAGE
~.
lsuocaneer . Couuier
P.O.'Box 501439
Marathon I FL 33050
COW'Atff
A NOVA casualty COlopany
COMPANY
8
OCMPAHY
C
COMPANY
D
co
LTR
~. ~'f'\'t ."....' ",;r7~':~~_~~\ab'f./'
, r.' ',.' , . j' ;~~~"~~i.~r.i,~~;:~.~~.1~_~"
THIS IS 'TO CERTIFY THAT THE POU F INSURANCE L1StEO eEL.OW HAVE BEEN ISSUED TO TI-\f INSURED NAMI;OABOVE FOR THE POI.ICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TEAM OR l'.nt.lnl11ON OF ANV CONTRACTOR OrHEFl DOCUMENT WITII RI:8PEOT to WHICH THIS
CERTIFICATE MAY BE ISSUEO OR NAY PERTAIN, THE INSURANCE ~FORDED BY tHE POLICIES DESCRIBED HEREIN IS SUBJECT TO AlL THE TEAMS,
EXCLUSIONS ~ND CONDITIONS ~ SUCH POUCtES. UMITSSHOWNM.\Y HAVE BEEN REDUCa> BY PAID CLAIMS.
-..t. .- '1- "~VEFl'lC'l1Y; ~EXPIRA~
TYJII! r IMSURAIICe ,-/ POUCV..-.. DAT1! I*OOi'tYI DATI (lIIIWON'rJ
4)EN&Mi. ~IY I
,
COUMCRClAL GENERAl,. L.tA8IUTY
ClAl~ MADE ~ OOCUfl ninder #: M40Z 1 7~5
OWNER'S' CONT PAO'r
LlllIIT'I
02/18/94
02/18/95
GENERAl. AGGREGATE
PROOUCT~PIQP AIJtJ
PfFlSONALl40V lHJUAY
~'. ."..- .
EACH OCCURRENCe
1-;'IREOAMAG~ ~.0I'tt")
.-eD ElC~~ one PMGn)
AUTOIIOIILE UUII.ITV
~ AUtO'
All OWNEO AUTOS
SCHEO!.UP AUTOS
HIRED AtJTOS
NON-OWNfb AlJT05
C0W5NEO SINGI.E LIMIT .
IlOO11. Y INJURY
(Per pnon)
.
IlOOIlY INJURY
(PerllllllCllllt)
.
GAMoE LWM./TY
Ni't AUTO
I
I"
I
,
PROf'EATV DAMAGe
.
I
ec.:wved I
t. & Loss Con 01
AUTO ONL V - EA ACCIDENT .
OTHIiA THAN Al1TD DNL y, ~ '. ,
~CH ACCIDENT .
AM""U,TE ,
EACH OOOJRRliNCE .
.. .------. .
AnfIRI'OAn;
,.. .-.-------- '.'.'-
-
STATUTORv U&.lITS
EACH AC(:It)iNT .
..
1)1SliA8E r>CILlCV \.lIMT .
t)ISeASe - EAcPl EMPLOYEE .
I .~~~'
-,
:.~"
EXCelS UAIlL/TY
~lLA FOAM
OTH~ llWI ~aReUA fOAN
WOIIlU5CClMfllu1lOll ~
IMftLOYUllJ' UMlUTf
TfiE PAOfIA~ORI
PAATIoII!AM!lCECVTI'/l;
OFFICERS ARE:
,
INOlI
exCL
--r'~--' .
!
I
I
'~lh.M11GHM.OCA~ClAl:"'"
,.
~OL1)~VJ: ,~~,(;,,;:r.:"'lm'I~I,;...~t"''''~ . . i ,,!~ ,\
..' -" ',,'.. . :"'" . "-'... .: .....-'.. ~'",'. :.~.~:;~~ ~:'''';~ :,~,:,~,~~~.'''::,..;..s.~'..,...:~;.i,.~~",.J.~~..-';' ., .
T>WL-
***Nonroe Count~'Named Additional Insured******
.t. no ..",r. 'I~. '~\"'~"'~''II:., !.
j
MnnTO& County RiSk Managomen~
5100 College Road
Key West~ FL 33040
TO' "
. 1/~/t(JR to-t<<rf A-
,(~ ~La4~jL~if;;~
J2~ /1~~.~ A.'Cf . t7'
~~ pi
td/R~ ~~ L)
~C' a~ .
~~ /5eu~.-L ~/t
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(J~4-e'/ cUi. r 0/ fZ... JU T!- ~
~~~ ~ ~!:Z2~ $ :/V/f- 4~~
~ ./iht.r db ~ -:>(J c:R~ ~d ~~ -
fh/(.. ~ ~J /ochj'. {/ {l~ - ~. ~ .
~ ~ cI~/~ nu4f t/ie ~<Y-/ ~ J-Q;::;u/J C~.
, ~. ~~~tf. cALl ~d y~ ~~ f'~>>c.k~
At, ,~)1~.c~. 0 &~ ~ ~.R.. ,;~ art;; ",b?e. d~
l1,<1 /;,,:~, -- a/ln.,;;; / u~~ 0 ~~~4
I.
THE JOHNSONS INSURANCE AGENCY
POST OFFICE BOX 2346
MARATHON SHORES, FLORIDA 33052
Phone 305 - 289-0213
:2- --22--1y
. :\:F~qRtbJ(~U:rQ~bj)r~Ii>il'i'TlJNDEklVR.i:rING
. _... -\."..~ -. :, -.. . . - " ~. SER~Errsy:l;TATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY
~ APPLICATION APPLIES TO: BUSINESS AUTe.TRUCKERS POLICY
Producer's Name _
'UJ4--JItM'~11.
ASSOCIATION
" :.-.... '.
srrep,x
o Pa(ltlership
. 0 Corporation. 0 Other
List the state where each vehicle is registered
Vehicle 1. (f'. ) Vehicle 2. (
.CLASSES
FACTORS
Vehicle 3. (
UENHOLDER
2. Applicant (As shown on motor vehicle registration)
,C/lRtTO 'IT)!'~'
City . Cqunty ..:
m /ff1.frTH1J AI fI1J!I J PrE
Business of applicant (describe use of vehi e)
CO U~/lFl2 SBeLllcc
Employer's Name IAddress
3. DESCRIPTION AND USE:
Vah.
No.
v... Trede Name, Body Type Trudl. DJft1) TrLdl'T,aiet. ~oI1JM PuIchaud "Gtou Vehicle .CSU) , "(RDus)
8 Tructl..Tracklr. T'....SemI.T,.IIer.Bus. ..P&8P1u1IBu1 I W' hi GJ ~'''''um l.cal
.........~~.?~:.~~.~.=.:::.~~.............................................. Ceo.m.a.l CooI_ Tr:.~W) ~~u_ Ino.mociolo -..y
b.. h' . .',' Mol'(r. ......, .....~.,., ~Dilt
........~?..'.':.~.!~~.~~~~~~~.~..~~~~..~y.~~.................... ....-........... ............................... o;;;.i~;;;;;;.~................ .:~~~... .~~i. .s;;;.;w........... .....................
RlIIftg RlIIftg (Cho.... & Body IncL Weighl (GCW) _ InduaOy _ory
C Garaging Location (Cooplata Address) T....""Y CIou.l_ = = Of -g;: Tr_ =- CIou
.~..I.~f~~.F~~LI!!..~~...P.'9:..~P... c.. I qqf 1/D1, It/. ~~
b5Nb/V 7)010 $ IV U)OOO '3 r1f ............................... .................. ................... .................... ...............~". ..................... .L................
NAME ,ADDRESS
AND ZIP CODE
1
2
Ibo.
........................................................................................................
.................................................................................... ..................
Ibo.
~
3
.....................................................................
t 1":."
. .
.............................'...l..:~.....~............................
4. RADIUS OF OPERATIONS ROUTES - Fixed and Occasional (both outgoing and relurn). Give'Complete information.
Principal Cities Entered
Commodities Carried
5. COVERAG~S:'
Equal limits Of liability Must Be Purchased For All Vehicles
, , ,i.-
BOOI L Y INJURY. LIABIU~ ...,. ....:.:.1 :.:.k.~...... .... ......... ........ ........... .................. ......... ......................
'"
.PROPERTY DAMAGE LI-\BILITY ..... ......... ..... .............. .................................,~.................................
COMBINED S.INGLE UYl'fS OF L1~BIUTY ...;..............;...;..;.................i..i~.,.....:...i....,...................
.'PERSONAL INJURY PRciTECTION ...........................,....,...:,.... ............:....,....':",..............................
: )i:l No OOO....!uc. iible or.. '.' ." . . ' . '." >.,"".' " "
. Deductib~eofp' $2~0,'cO $500 0 $1,000 0 $2,000' .
Applicable to: 0 Named Insured or
'" o. ".n 'Name 'Insy,red, ~ -o~R8,nde~I.~!l.sident Relatives
OPTIONS TO ELIMINATE PIPBENEFITS.i=OR:
o Work Loss 0 Named Insured or
,.. 0 Nam~ Insured & Dependent Resident Relatives
..P Military Benefits (Nam~ Insured & DependenfRel\id~l'lr~l!latives)
MEDICAL PAYMENTS'[j $500 0 $1.000 wi2,ooo ....~:::.:...::::...:...............................:::.......
COLU,SION (Maximum $40.000. M.S.R.P.) Oeductibleof ,0 $250 '0 $500 0 $1 ,000 ......
COMPREHENSIVE (Maximum $40,000 - M.S.R.P.)' Deductible of 0$250 0 $50d 0 ${OOO
UNINSURED MOTORIST.. (Stack~) 0 Non-Stacked ..............................................................
:=.;~:xi~~~.:~~~.::::::::::':::::::~::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
FINANCIAL RESPONSIBILITY FILING CHARGE ($15 lor each filing; .................,.........................
Estimated pre.mium. ~
Limits
Vehicle - No.1
Premiums
Vehicle. No.2
Vehicle - No.3
Limits
Premiums
Limits
Premiums
SAME AS
VEH.l
SAME AS
VEH.l
SAME AS
VEH.l
SAME AS
VEH..l
~..,...." '~.,r
. ..:/
I'PA~PLAN; 1
o ANNUAL . _ .
o SERVICING CARRIER INSTALLMENT PLAN
o PREMIUM FINANCED (Attached Legible Premium F;inance Contract)
'. Amount submitted with application $
6. OPERATOR INFORMATION: Names of all Operators.
Name Birth Date
Name
Birth Date Driver's License No. & Stale
2.
3: C.:7.' '
4.
7. HIRED CAR C'!VERAGE:
J
Types Hired
Principal Garaging or Locations Where Automobiles Will Be Used
'. Estin;latilQArinual
. eost of Hire
Rates Per $100
B.I.
P.O.
'FAJUA.2.:rr (EDITION 4.93)
8. ACCIDENTS: Has applicant. or named insured and any other person who usua~y operates the motor''Vehide(s) been involved, either as owner'or operator; in ,ANY motor vehide'
accident dl.ting the three year period immediately preceding the effective date of this application? I'1SI Yes If "Yes", complete the following.
Date of Accident Place olAced. Degree of Accd. Exception
r State Negligence Code
Name of Operator
%
C/tP- t
%
EXCEPTIONS: See Manual Rule 23.B.1. for list of nonchargeable accidents and indicate a~ident exception code if applicable.
. ".' .' . ~~, " " -", " -.. - " " " "_ r-
9. CO~V1.CTIO~S: (~OTO~ VEHICLE) Has'the apPlicant, or namea insure({a,,(fahyothetp9~son who usually operates the motor vehicle(s), been Convicted or Forfeited Bail at
anytime during the immediatel~ preceding thirty-six monlhs?!'O' Yes 11 "'fes7,corripletethlflollowing (if necessary, use Re~arkssection). NOTE: A paid ticket or fine is an admission
of guilt and therefore CClnstitutes a conviction.
Name of Operator
'" Nature of Violation
Place of Yiolation
City
State
CIIt2Fc €SS WII/.
.ff P1GYaS.
FL
,I; .
10. FINANCIAL RESPONSIBILITY: ~';,~ "' \
Is applicant Of otherellglble operator required to file evidence of financial responsibility? 0 Yes Type of Filing:
Name . 0 Owner'1I (~lIow for operation of owned Vehicles)
Case or File Number Social Security No. 0 .Operat6r'i"io allow for operation of non-owned vehicles)
State Where Filing Required _ . 0 Both :,'_
FILINGS: Is. filing required to comply with 0 I.C.C. 0 S.tate D. Local ordiljance. (Attach Copy) File'or Docket No.
If block(s) checked list state(s)' and cities requiring filings and limits 6f liability required by lavi"
NOTE: An Insured's request for cancellation may be delayed if a financial responsibility filing or certificate of insurance has been filed to enable the Servicing Carrier to comply with any!
advance notice of cancellation requirements.
- 11. EMPLOYERS NON-OWNERSHIP LIABILITY: More than. 50% of employees regularly use owned vehicle in applicants business? t 0 Yes
I! Yes, do more than 50% make regular and frequent deliveries? 0 Yes 0 No Total number of employees on payroll
12. PUBLIC AUTO: Use of Vehicle Mfg. Specified Seating Capacity
Territory(s) in which or through which vehicle is operated
13. INSURANCE REC~RD;Mr~J 0' A IlIll"r'lJ~
Name ollatest carner '1", 'IV W' vC
No
14A. FLORIDA UNINSURED MOTORIST COVERAGE" SELECTION/REJECTION FORM
YOU ARE EtECTING NOT TO PURCHASE CERTAIN ALUABLE COVERAGE WHICH PROTECTS YOU
AND YOUR FAMILY OR YOU ARE PURCHASING UNINSURED MOTORIST LIMITS LESS THAN YOUR
BODILY INJURY LIABILITY LIMITS WHEN YOU SIGN THis FORM."PLEASE READCAREFULLV~
Uninsured MotoristCoverage provides for payment of certain benefits fordamages caused by C?Wners orop,erators of uninsu(lld motorvehides because of bodily injuryor death resulting
therefrom. Such benefits may include payments for certain medical expenses, lost wages, anil pain and suffering, sU,bject to limitations and conditions contained in the policy. For the
purpose of this coverage an uninsured motor vehicle may indude a motor vehicle as to which the bqdlly injury liabilitY. limits are less than your damages.
Flori~dl requires that motor vehicle liability policies include Uninsured Motorist coverage III limits equal to the Bodily Injury Liability limits in your policy unless you selE>Ct a lower
limit ct Uninsured Motorist Coverage entirely. Please indicate your selection or rejection below.
a. hereby reject Uninsured Motorist Coverage . . .
b. I ereby select Uninsured Motorist limits of $ _. - / . . which are lower than my Bodily Injury liability limits. "
. c. 0 I hereby elect Uninsured Motorist limits equal to my njury Liability . I 0 ,bold print.
I understand and agree that this selection or rejection appl' to Iicy ins ur n or replacements of such policy which are issued at the same
Bodily Injury ~i~bility Ii~its. If I decide to change myse. on or cti ;'1 t the Company know in Wri~:;If _ iijJ'
",' X-{. Date ,..... D /Y
Termination Date
FAJUA-UM, (4-93)
j';'.'i.....:.:.
149.
, ELECTION OF NON-STACKEDCOVERAGE
,,(Do not {X)mpleteif you have rejected,Uninsured Motorist) ~,
You have the option to purchase, at a reduced rate, non-stacked (limited) type of Uninsured Motorist coverage. Under this form if injury occurs in a vehicle owned or leased by you or
any family member who resides with you, this policy will apply only to the extent of coverage (if any) which applies to that vehicle in'this policy. If an injury occurs while occupying
someone else's vehicle, or you are struck as a pedestrian, you are entitled to select the highest limits of uninsured motorist coverage available on anyone vehicle for which you
are named insured, insured family member, or inllured resident of the named insured's household. This policy Will not apply if you select the coverage available under any other
policy issued to you or the policy of any other family member who resides with you.
I! you do not elect to purchase the non-stacked form, your policy limit(s) for each motor vehicle are added together (stacked) for all covered injuries. Thus, your policy limits would
automatically change during the policy term if you increase or decrease the number of autos covered under the policy.
o I hereby elect the non-stacked form of UnInsured MotorIst Coverage.
I understand and agree that selection of any of the above options applies to my liability insurance policy and future renewals or replacements of such policy which are issued atthe same
Bodily Injury Liability limits, If I decide to select another option at some future time, I must let the Company know in writing. .
X Date
Applicant's Signature
',~ " ,." . "-. ' '., .. \. ~ ,,("
15. ELECTION-. OF PERS.ONAL INJURY PROTECTION At,tD PROPERTY DAMAGE LIABILITY COVERAGE ONLY:
I elect to purchase PerSonal Injuly' Protection Coverage and Property Damage Liability Coverage only and reject Automobile Bodily Injury Coverage and Uninsured Motorist Coverage
available to,1I)8 /hrough ,the Florida Automobile Joint Underwriting Association.
",'\' 11\ . ":,,, ." . ", 'X
.. . i \ Applfcant's Signature \ ~~ "'-
FAIR CREDIT REPORTING ACT NOTICE: In addition toroutine verification of information pertinent to the insurance applied for, if the application is by an individu8J for insurar1ce
primarily for personal or family purposes, the FAJUA may.have an investigative ,consumer report'..rnade .inclUding information bearing on character, general reputation, personal
characteristics or mode of living and, upon the individual's wrinen request, will disclose in writing the nature and scope of the investigation requested, if such report is prOOJred.
BINDER PROVISION: The company agrees to hold bound the limits ,and coverage'speCified in this anachedapplication of the insured named herein, such application being completed, duly
executed and accepted by the Producer, subject to the following conditions. . . '
1. This binder is in effect for a period not to exceed 30 days frorrithe effective dalastated herein. This blndei' will terminate immediately upon: (a) The issuance of the policy applied for,
or (b) The issuance of any policy affording siniilar insurance, or (c) 30 days from the effec:tivedate stated herein, . ... '.' 'c"'. ,o"'"
2. A pro rata premium charge will be made for this binder if the policy, when and as.issued. isnotaccepted by.the jnsured~,. <0"".. ' ,"" ':~::.:,'.~:',:':~..,.....~,,".,
3, The insurance bound hereunder shall be subject to all the terms and conditions of policy form F:AJlJA-22 (QUSINESS AUTOORTRUCKER POliCY) or policy form FAJUA.11 (PERSONAL
AUTO POliCY), if applicable, to be issued. '. "".. .
4. This binder shall not exceed Bodily Injury Limits of $1001300 and Property Damage Liability L its of $50,000 or Combined Single Limits of Liability of $300,000. (Note: Higher limits may
be requested and retroactively approved to the effective date of the binder.) . . .
. fi Qll~. .l!itAM This application is mined purs 4nt
Effective '_ LL.Z-1/P . ..:0 PM .
. nth Year .l4ci r X
Date
Date :; -/6 -9,/ ,-,
. . ature~ ~f.. Producer's No. ~, \,.,
t AP'Ptlc NT'S STATEM NT,. ' ,'. '~\', ._, "
I declare to the best of my knowledge and belief that all statements contained in this application are true and thatthe~ statements are offered as an IndUCement to the Company to issue the
policy lor, w~ictl t '":1 8JtRlyin.a,..1 understand that my: .agent;s ~t.au~qri~~.!O ~leplQo~H:inancial Res~nsibiftty or:<:;ertifi~te'l? Of'f~sura. nce on my behalf 10 any third party. How
are you paying premiums? 0 Cash 0 Check suppOrted by.sHffJCjlint fundsm an actiWllccount m.adepayable to the ServIClngCarner:.~
THIS APPLICATION AND THE 'ESTIMATED PREMIUM ARE SUBJECT TO THE APPROVAL OF THE SERVICING CARRIER IN. AC;CORDANCE WITH,RATES, RULES
AND FORMS F1t,:EDWlTI:l AND APPROVED BY THE FLORIDA INSURANCEDEPA.RTM,ENT. .. .- '.. '. .,.... ....... \:' . '\.' '\"'.<:: ....... ........ ... ............
. '.' ; , '.' \. . . .'. .",'" " ..... ,"', -.' '.', \., ", . \ \ ,",
TH~SINSUR'ANCE 'IS BEING AFFORDEO THROUGH THE 'FLORIDA AUTOMOBILEJOINTUNOERWRITING
ASSOCIAtiON. AND': NOT THROUGH; THE\RRfV ]:'E',. MAR KET. PLEASE,BE"~DVISED'.t.H-A1;.'C6VERAGE
WITH A 'PRIVATE'INSURER MA'{'BEAVAI L FROM OTH T AT A LOWER COST. AGENT
AND:,CO~PANV'lJSTINGS ARE A V.AllAB I l[ GES;\'
X-
, 'I AppliCant's SignatUre
1qh1
.
........
Huo3
Vehicle Damaged' IF .YES. EXPLAIN
DYes 'X1 No IN REMARKS SECTION
;~ Does.vehiclE! h,,!ve dam;lged glass? 0 Yes:.lf .ves., explain in RElmarks Section
Is vehicle customized? 0 Yes: II.Yes., explain in Remarks Section
LIENHOLDER (If physical damage is requested) APPRdVt\'}!V RISK 'MAYM:o~nrr
, ~. :,;;
(City, State, Zip Code)
o
. ':-:::;\
\:~"1'~\
Year
I
Ma.ke
VEHICLE. 2
Model Name & Body Style
Length 01 Motor Home
Vehicle Identilication Number
Length 01 Motor Home
Cost New
Vehicle Damaged
o .Yes 0 No
IF .YES. EXPlAIN
IN REMARKS SECTION
Does vehicle have damaged glass? 0 Yes; If "Ves., l1xplain in Remarks Section
Is vehicle customized? 0 Yes: II .Yes., explain in Remarks Section
LIENHOLDER (II physicai damage is requested) I Leased 0 Yes
"
5;"C,9YE,R,~~,E~;~.~"" ,gq~lliiL,iri)ilSPt~i~!(ty'~iJ~IBe PWch~sed ForA!lYi!~I~~s~,:::,,:, \, "
Cycle WI.
Street
Cjty
B'f
Street
City
Stale
Zip
)' ',.
Premiums
, ' BODILY INJURY LIABILITY ",,,....,,,,. "",,,,...,,,,,,,.,,,,.,,,,,,,,,,,,,,,,,,,,,:.1.;::.......:.;,,.,..,,,,;,;;,,.;;.i.,.,,,;....'..,,,,;..,,,,..;,,.. ,;'
~. . ~. .0.-'.-..,,;.......... ..'.....,. .""." """"", "",-,..,,.;., ~ ~ "'~' ..._.....~. .~_...w~, ,~,.....,.~.. u_+
PRqP.ERTY DAMAGE L1ABI L1TY ..... ". ",,"" "",," ...". ". """... ."""...... "..".."." """"'" ...."...,..".... ".....", .""".. ".
PERSONAL INJURY PROTECTION ...,. ...... ......"..... .............,...... .....', "...,..., .....,... ....". ....".,... .:;."... ..,,,..,,, ". ."."
XN~.DedUCti9Ie or Deductible 01 0 $250 O$~O O.}1,00Q-.:g~~;OOO:,'" :.:J:.\ \~.;~.
I Applicable to: 0 Named Insured or O'Name Insured &,~pendent R~~e~I.~~lalives. . .,:. .' ',.
OPTIONS TO ELIMINATE PIP BENEFITS FOR: .~, ".' \." \
O~~ ~~~~q~~~dlnS~red or.,(ONlI(Tled Insured & Dependent Resident Relatives
DMihtaq Be.nefits(Narned Insured & Dependent Resident Relatives)
MEOICALf:lAYMENT~',O $500'.0 $1,000 ')l$2,000 .""""""".".."......".......,,......................................
, COLLISION (Maximium$40,OQC. M.S,R.P.) Deductible 01 0 $250 0 $500 0 $1,000 ....."...."....."....
c"_'i""" '.'. ."c',(('.:.'. ':,.;'"..'.'-'" ':". .....'..,.. '," " : "', .',' ,"
COMflREHE.N~IVF(Maxim.ium $40,OQQ - t"t,s.fl,P.')i Ded~c!ibleol 0$250. 0 $500 0 $l;OQQ ,.,........
r~ "",,1 "'. J ~~. ..0<; ','. ~ ' ".'''\', ,,' ..__~" ~ )',., .. I; _ "' J.. _ .' '. ','.', >" .,~. ~,.,' . . "',' ,
UNINS~REp"MOTORIST (Stacked) .. 0, Non-Slack~ ..:......................................................;~...,:.c.......;....;.,..
f.f~.tt'" l'.....,;.... ; '.... . . ~ > ,"
I=INAt-lCIAL RESPONSIBILITY FILING CHARGE ($15 lor each filing) ...,.......;.........,.................:........,..........,..
i h.\'!. j '., U,) ,i. ,. .' '.' '. .. '.' '. Eatlmatedpremium$
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~~~~g~~~GCARRIER I'!~~~~~~~~~:)p~~ \.j':,C
: ClFREMIUM FINANCED '(AttaC?9dLegible Pre'!1ium Finance Contract)
SAME AS
. .-YEH..1
10,000
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SAME AS
'- VEtI. 1
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~'premjum' $
~ premium all vehicles $
Amount submitted with apPII!l8.I~ ~
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6. QP.ERATOR INFORMATION:
.- 'Applicant and Other Drivers
:~~~~:'$i!It1Dati .~'l,6NS
1 2 MoJDaylYr.M-F "
"MIS - Marital Status; S.Sing!e, M.Married, W.Widowed, D.Divorced, SP-Separated
, . "'.'. . .. .
\. Children's Birth D~fell [I'1Hbusehoj~(.MoiDay'!v(.,1j ':l;'
13 Years and over. >"Male
"Driver's'Ucense No: and State .
O<:cupation'- .
APPLICANT
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Female
OFiIVER..S L!.9~NSg:. Has !hejr1s~!.e~(l!) ~nqll!!YQne whQ Ull.llallyolXlrat!lS the automobile been licElosQd lorat least three years in the U,S., District 01 Columbia.or Canad~?
O'N~' ,If "No", give date olissuance original license
OJPf,li~~J;lI'jAI~!NG;~~) ~:v~ry d~~;.~li!libi~!fBr.~rive;~ai(\i~9f'~cjjl:qu~ii.Il<l'L.,d;.yes~'..~ II .Yllll;,S~bmitsch~1 certificate " "1
. -E!.MATURE OPERATOR MOTOR-VEHICLE.ACCIDENT PREVENTION.600RSE DISCOUNT>....g. Yes" ,-""It 'Yes",' submit Course Completion Certificate....
;:.b!.~~Ti;r6ckE3AAKING.~YSTEM DISf()(JNT . .,..' "i'c 2""'; ,:
. 0 AIRBAG.pl~C9~,~T~, \!': \:. .;'f.. \t" (:.~
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7. ACCIDENt~: Has applicant, or named insured and any other perso~\vvh(> uJillally oPerates the "'itor vehide(s) been involved, either as owner ()( operator, in ANY motor vehide
accid!'nt ~uring the three year period immediately preceding the efl.~Ate of this application? r 0 Yes If "Yes., complete the following.
Date of Accident Place of Aced. Degree of Aced. Exception
MolDaylY State Negligence Code
e
Name of Operator
EXCEPTIONS: See Manual Rule 23.B.1. for list of nonchargeable accidents and indicate accident exception code if applicable.
8. CONVICTIONS: (MOTOR VEHICLE) Has the applicant, or named insured and any other person who usually operates the motor vehicle(s), been Convicted or Forfeited Bail at
anytime during the immediately preceding thirty-six months? 0 Yes I! "Yes., complete the following (if necessary, use Remarks section). NOTE: A paid ticket or fine is an admission
of guilt and therefore constitutes a conviction.
Name of Operator
Date of
Violation
MolOaylYr
Did Violation Arise
As A Result of Accd.
(Yes ()( No)
Place of Violation
Nature of Violation
State
C /tf2- I."'T-D Iv "?;)t2I/I/-E
W1l
c5
C/J72 Et. ~S I;;(2; 1I)J/.
-'9. FINANCIAL RESPONSIBILITY:, . ...' .' ..' , ,
'.s applicaiit ()( other e1lgible'operator required to' fi1&evld~nce of fiMncial "tes'Pt>ri*ibilitj?
Name
Case ()( File Number Social Security No.
State Where Filing Required
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Yes'"
"TypeofFilirig: ",'-"), ,','" \''-,''\
o Owner's (to allow f()( operation o;'owned vehides)
o Operator's (to allow for operation of non.owned vehicles)
o Both
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10. NAMED NON-OWNER: Complete below if this application is for non-owner policy.
(a) Does the applicant own an automobile? 0 Yes
(b) Vehicle will be operated in applicant's occupation ()( business? 0 Yes
o No (c) Is vehide owned by a member of the household? 0 Yes 0 No
pOliCYN77 rJ Qf7~~h Termination Dat;'lg- f,
1UNSURANCE RECORD:
Nameoflatestcarrier Nlf1jo.~ t()Jr:>~
12A. FLORIDA UNINSURED MOTORIST COVERAGE. SELECTION/REJECTION FORM . , ,..
YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE WHICH PROTECTS YOU
AND YOUR FAMILY OR YOU ARE PURCHASING UNINSURED MOTORIST LIMITS LESS THAN YOUR
BODILY INJURY LIABILITY LIMITS WHEN.YOU SIGN THIS FORM. PLEASE READ CAREFULLY.
Uninsured MotoristCoverage provides for payment of certain benefits for damages caused by owners or operators of uninsured motor vehides because of bodily injury or death resulting
therefrom. Such benefits may indude payments for certain medical expenses, lost wages, and pain and suffering, subject to limitations ard conditions contained in the policy. For the
purpose of this coverage an uninsured motor \1i/:1icle may indude a motor vehicle as to which the bodily injury liability limits are less than your damages.
Florida law requires that motor vehicle liability po~cies indude Uninsured Motorist coverage at limits equal to the Bodily Injury Liability limits in your policy unless you select a lower
li~()( ect Uninsured Motorist Coverage entirely. Please indicate your selection or rejection below.
. I hereby reject Uninsured Motorist Coverage
b. I hereby select Uninsured Motorist limits of $ I which are lower than my Bodily Injury Liability limits.
. c, 0 I hereby elect Uninsured Motorist limits equal to odi ,. .. If " nore bold print.
I understand and agree that this selection or rejection a ies to ~r~~ls.or replacements of such policy which are issued at the same
Bodily Injury Liability limits. I! I decide to change my;l tion or ~ I ~ the Company k~:in '~~6 "''1''
FAJUA-UM (4-93)
Applicant's Signature
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12B.
ELECTION OF NON-STACKED COVERAGE
(Do not complete if you have rejected Uninsured Mot()(ist)
You have the option to purchase, at a reduced rate, non-stacked (limited) type of Uninsured Motorist coverage, Under this form if injury occurs in a vehicle owned or leased by you ()(
any family member who resides with you, this policy will apply only to the extent of coverage (if any) which applies to that vehicle inthis policy. I! an injury occurs while occupying
someone else's vehicle, or you are struck as a pedestrian, you are entitled to select the highest limits of uninsured motorist'coverage available on anyone vehicle for which you
are named insured, insured family member, or insured resident of the named insured's household. This policy will not apply if you select the coverage available under any other
policy issued to you ()( the policy of any other family member who resides with you.
I! you do not elect to purchase the non-stacked form, your policy limit(s) for each motor vehicle are added together (stacked) for all covered injuries. Thus, your policy limits would
automatically change during the ponty term if you increase or decrease the number of autos covered under the policy.
o I her.by .Iect the non.stacked form of Uninsured Motorist COv....g..
I understand and agree that selection of any of the above options applies to my liability insurance policy and future renewals or replacements of such policy which are issued at the same
Bodily Injury Liability limits. I! I decide to select another option at some future time, I must let the Company know in writing.
X ~
Applicant's Signature
13. ELECTION OF PERSONAL INJURY PROTECTION AND PROPERTY DAMAGE LIABILITY COVERAGE ONLY:
I elect to purchase Personal Injury Protection Coverage and Property Damage Liability Coverage only and reject Automobile Bodily Injury Coverage and Uninsured Motorist Coverage
available to me through the Florida Automobile Joint Underwriting Association,
X ~
Applicant's Signature
FAIR CREDIT REPORTING ACT NOTICE: In addition to routine verification of information pertinent to the insurance applied for, if the application is by an individual for insurance
primarily f()( personal ()( family purposes, !he FAJUA may have an investigative consumer report made including information bearing on character, general reputation, personal
characteristics or mode of living and, upon the lndividual's written request, will disclose in writing the nature and scope of the investigation requested, if such report is procured.
BINDER PROVISION: The ~pany agr~s to hold bound-.rhe limits and coverage specified in this attached application of the insured named herein, such application being completed, duly
execUte4, anQ aCtepled\by'~ P,totlucer, '$lJbj~ct.l9'ihe-following conditions,
1, This bh\de'r is irieffett foi'a ~riodnotto excoed30'days from the effective date stated herein. This binder will terminate immediately upon: (a) The issuance of the policy applied for,
or (b) The issuance of any poIi~ affording sjmilar insurance, or (c) 30 days from the effective date stated herein.
~. A. pio ~ta premium\d:targa,wihbe ~ade,for ttlis~binder if the-policy, when and as issued, is not accepted by the insured.
3, Ilie-insurance bound hereunder shall be subjecl to allthe'terms and conditions of policy form FAJUA-11 (pERSONAL AUTO POLICY) or policy form FAJUA-22 (BUSINESS AUTO), if
applicable, to be issued.
4. This binder shall not exceed Bodily Injury limits of $1001300 and Property age liability L' it of $50,000 ()( Combined Single limits of liability of $300,000. (Note: Higher limits may
be r~uest~ \I~ retrotlctively~pprO~~~effecti~~T~f~e o~ r. ons of Section 626.752 Florida Statutes,
Effectiv&5ri:..I9tl, -(9-t)/O:>M' -' / //
Month Day Year Hour , ~, I , ' Q'!te ,Il-,(G ~c.r
roducer's Signature
, ',' " ,,', <.;. " ' , 4PPLICANJ.'S STATEM~NT " " , ',,' , , ,',
I declare to llie 'besi of my knowledge and belief that all statements contained in this application are true ilrid that these statements are offered as an indut:emerllto the'Cort'1pany to issue the
policy f()( w~ic, h, I arry apPIy,in.a.,I u,nderstand, th, a,t mY"agen,t',is not aU,.~oriZ,',ed,to,~I,e' pro,of, of Finan,cial Re,spo,nsibility ()( C, ertifi~tes of I~sur~ce o~ m, y b,ehal,f to an,y third party, How
are you paYing premlu~s?- W \-C,~h ,'~Q~~ SU~r'llKiby,lI1!ff~Ie.r:1l,funds,ln-an-8ctlvQ_~made payable10 the ServiCing Carner. '" ", '-/ " ;. ,:::"\.:'.,
THIS APPLlCATlON'ANbtHE'ESTtMAtED'PfIEMIU,MARE'S"t/BJECT TO THE APPROVAL OF THE SERVICING CARRIER IN ACCORDANCE WITH RATES, RULES
AND FORMS FILED WITH AND APPROVED BYTHE ~U>RIDA INSUR~N~EDEPARTMENT. " " .,' '__
THISjNSUR~NCE"S BeiNG AFFORDED tHRQUGH THE FLORIDA AUTOMoBid:JQINTUNDERWRITING
ASSOCIATION .AND NQT, THROUQH,-':HE., RRIV.MARKET. PLEASE. ADVISED THAT COVERAGE
WITH'APRIVAT.EJNSURER MAY 'B'EAtt'AttA . .hM 'OTH . -AT A LOWER' COST~ AC;ENT
AND COMPANY L1STINGS,AREA,V AILABL L Y.
",.:',' "-" "': "';""-'" ,- ...'X...... ,
",<J~/h- 91
Date (7"
1111111 ,
4111WI
DISHONESTY BOND APPLICATION
Secupty .
~iates, Inc. 411t
:::1/111111:::11111111
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1) APPLICANT'S FUU:. NAME (Exactly as it should appear on the bond):
2) ADDRESS:
It! /kJ;Y S'o/t!3'1 1lf/iJf/l'T1/p)J ~ ?3D5D -/13'7 3t)~- ~j'-M)3
. Number. Street, City. State, Zip Phone Number
3) TYPE OF BUSINESS: C-O{A(<.I ~l~ f)6<.\.Jl~e
4) CLASSIFICATION OF BUSINESS: (Classifications A, B and C all contain a CONVICTION CLAUSE)
( ) A. Professional and business offices such as accountants, architects, physicians and dentists. insurance
agents. attorneys. realtors, service and social organizations. (Maximum coverage SlO.C(XlOO)
( ) B. Businesses with more exposure such as cafes, gas stations, retail stores, businesses with salespeople who
make collections and other businesses where cash 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 convicted in court before coverage will apply.)
~c. B' . ,'; iding service outside the business location such as in customers' homes. customers' offices,
delivery services, tc. (Janitorial Services)
CO VICTION CLAUSE. (In order to protect you and your employees against unjustified
allegations of dishonesty. the employee must be convicted in court before coverage will apply.)
5) HAVE YOU SUSTAINED A}JY EMPLOYEE DISHONESTY LOSSES IN THE LAST 6 YEARS?
( ) YES N NO
If yes. please provide in writing all the details pertaining to the loss.
7) EXACT NUMBER OF OWNERS: /
NAMES: C/1/2.L-70N '];)t2-/t/CE
6) HAS ANY INSURER DECLINED TO ISSUE. CANCELLED OR REFUSED TO RENEW ANY EMPLOYEE DISHONESTY
COVERAGE DURING }H9PAST 6 YEARS?
( ) YES (/<j. NO M'rQ(WFfl RY RISK M"N~r,FMFNT
"' () ~1~~
[}flTE . I
wr,I~.EfR N/A~~W~'O
i=' OL C, b l-
v
If yes, please provide in writing all the details.
ARE OWNERS TO BE COVERED?
~ YES
( ) NO
J
8) EXACT NUMBER OF EMPLOYEES AND/OR INDIVIDUALS:
NAMES:
t:A1J+ J 1) yiA- r{ - ft{li -n e LP It T E It ,'] !tFR ,.Iv T /
{:;'m /J l. D~ FE "{::rI J /:2 / A./4 ~/ El7 ..e..
.x <::; . ;5 D eft- /Jjo7i~ e oP C/f?1/CBL/977 ())) ,/11/111 L/ff'S G&- ?
f"""':-- ,
INDIVIDUALS ARE: (~EMPLOYEES
or
( ) INDEPENDENT CONTRACTORS ( see note below)
NOTE: WE Will NEED THE FOllOWING INFORMATION REGARDING INDEPENDENT CONTRACTORS:
1) Sample copy of the Application required to be completed by Independent Contractor when being hired.
2) Written explanation detailing the controls and supervisIon Implemented over the Independent Contractors.
SUBMIlTED BY:
00
A/@2
o ~3~?-2~
~I)pture
RESS & TELEPHONE:a{)f/tJS6N.s )1J5tI~lIIt~ II1t:NG'j '3o~ -J),?f9... 0 ')../3
fie) %tlA$~6
M fffJ{o SjftJ~ F~ )~OS~
10131 S.W. 40th STREET. MIAMI, FLA. 33165-3947. (305) 552-5414
DATE:
~-/b-r1
AGENT I S NAME,
soot ;#206
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