Certificate of Insurance
..---. -- T
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDNY)
TM 01/31/2003
PRODUCER (305)2;'4-2542 FAX (305)296-7985 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
The Porter Allen Company ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
513 South~rd Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Key West, Fl 33040
INSURERS AFFORDING COVERAGE
INSURED OLD FIRE HOUSE PRESERVATION, INC. INSURER A: GRESHAM & ASSOCIATES
P. O. BOX 5563 INSURER B:
KEY WEST, FL 33045 INSURER c:
INSURER D:
I INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE POLICY NUMBER P~A'{~~~~~R~~!' PRi!fJ,~~~!gN LIMITS
LTR
~NERAL LIABILITY LS 8051877 SCOTTSDALE 10/16/2002 10/16/2003 EACH OCCURRENCE $ 1 MILLION
X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anyone fire) $ 100,000
l CLAIMS MADE m OCCUR MED EXP (Anyone person) $ 5,000
A PERSONAL & ADV INJURY $ 1 MILLION
-
GENERAL AGGREGATE $ 1 MILLION
I--
GEN'L AGGREGATE LIMIT APnS PER: PRODUCTS - COMP/OP AGG $ 1 MILLION
~ n PRO-
POLICY JECT LOC
~TOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
-
ALL OWNED AUTOS BODILY INJURY
'-- $
SCHEDULED AUTOS (Per person)
I--
HIRED AUTOS BODILY INJURY
- $
NON-OWNED AUTOS (Per accident)
-
- PROPERTY DAMAGE $
(Per accident)
RAGE LIABILITY AUTO ONLY- EA ACCIDENT $
ANY AUTO OTHER THAN EA ACe $
AUTO ONLY: AGG $
EXCESS LIABILITY EACH OCCURRENCE $
=:J OCCUR 0 CLAIMS MADE AGGREGATE $
~TrIv~~;r RISKtl NAGEMENT $
R DEDUCTIBLE BY l.. ()d 11/ ~ $
RETENTION $ 0" , " -IT .. $
WORKERS COMPENSATION AND DATE rx I IflU ) I ~qSTATU- I rom-
TORY LIMITS ER
EMPLOYERS' LIABILITY N/A.:f- EL. EACH ACCIDENT $
WAIVER "'ES EL. DISEASE - EA EMPLOYEE $
E L. DISEASE - POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESlEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
If
CERTIFICATE HOLDER ~ADDITIONAL INSURED; INSURER LETTER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
E~UTION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
MONROE COUNTY - BOARD OF COUNTY COMMISSIONERS ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
AND TOURIST DEVELOPMENT COUNCIL BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
1100 SIMONTON STREET OF AN~ND UPON nf,e COMPANY-ITS AGENTS OR REPRESENTATIVES.
KEY WEST, FL 33040 AUT: ~PRE~~A!l~1tr
.... /~/L- t: .... . "1::/1/'-
Eli a et Fr ema 89742
ACORD 25-5 (7/97) @ACORD CORPORATION 1988
1996 Edition
MONROE COUNTY, FLORIDA
Request For Waiver
of
Insurance Requirements
It is requested that the insurance requirements, as specified in the County's Schedule ofInsurance Requirements,
be waived or modified on the following contract.
Contractor: Alex Veqa
Contract for: Old Fire House Preservation Inc.
Address of Contractor: 1543 4th Street
Key West, Fl. 33040
Phone: Hm-(305) 296-4010 Wk- (305) 292-8179
Scope of Work: Old Fire House Preservation is committed
to the restoration of No. 3 Fire Station.
.". - - -
Reason for Waiver: Old Fire House Preservation Inc. ts'a,non:
profit organization with a volunteer (see attached)
Policies Waiver Workers Compensation insurance
will apply to:
Signature of Contractor:
Risk Management
Date
County Administrator appeal:
Approved: Not Approved:
Date:
Board of County Commissioners appeal:
Approved: Not Approved:
Meeting Date:
Administration Instruction
#4709.3 102
Attached Waiver sheet for Workers Compensation insurance 2/5/03
and Empl.oyer's Liability insurance.
Reason for Waiver - board that operates in an advisory capacity only,
------------------ there are no employee's. We do recognize that
insurance will be required for all contractors and
sub contractors. We also accept responsibility for
ensuring that all contractors and sub contractors
meet all of the insurance requirements specified in
the contract.
1996 Edition
.
MONROE COUNTY, FLORIDA
Request For Waiver
of
Insurance Requirements
It is requested that the insurance requirements, as specified in the County's Schedule ofInsurance Requirements,
be waived or modified on the following contract.
Contractor: Alex Vega
Contract for: Old Fire House Preservation Inc.
Address of Contractor: 1543 4th Street
Key West, Fl. 33040
Phone: Hm-(305) 296-4010 Wk-(305) 292-8179
Scope of Work: Old Fire House Preservation is committed
to the restoration of old No. 3 Fire Station.
See attached sheet
Reason for Waiver: Old Fire House does not own any vehicles
that Would be used for the construction. See attached
Policies Waiver Comprehensive Auto Liability Insurance
will apply to:
Signature of Contractor: (~ (Lr-
Risk Management Approved X p Approved
i1/~
Date :2 /~/{)3
County Administrator appeal:
Approved: Not Approved:
Date:
Board of County Commissioners appeal:
Approved: Not Approved:
Meeting Date:
Administration Instruction
#4709.3 102
2/5/03
Attached Waiver Sheet For Auto Liability Insurance
~~~E!:_~~_~~~~.: Old Fire House Preservation Inc.
is a volunteer board that operates
in an advisory capacity only, there
are no employee's.
Reason for Waiver: Old Fire House Preservation does
-----------------
recognize that insurance will be
required for all contractors and
Sub contractors. We accept responsibilty
for ensuring that all contractors and
sub contractors meet all of the insurance
requirements specified in the contract.