FY1993..07/07/1993 Agreement
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BRANCH OFFICE
3117 OVERSEAS HIGHWAY
MARATHON, FLORIDA 33050
TEL. (305) 289-6027
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 County Administrator
Attention: Melonie Bryan, Budget Director
FROM:
Ruth Ann Jantzen fitlfl
Deputy Clerk ~ -
DATE:
September 14, 1993
On July 7, 1993 the Board of County Commissioners approved execution of a
Funding Agreement with the Big Pine Athletic Association in the amount of $14,000.00.
Enclosed for return to the Big Pine Athletic Association is a fully executed
duplicate original of the subject contract.
For your information, also enclosed is a ~ of the Management Agreement with
the Big Pine Key Athletic Association to operate and supervise the Big Pine Key Youth
Center. The duplicate original of this Agreement is being sent to Public Works for
forwarding to the Big Pine Athletic Association.
If you have any questions on the above, please contact me.
cc: County Attorney
Finance
County Administrator, w/o document
Risk Management
Public Works
File
..
FUNDING AGREEMENT
This Agreement is made as of the ( day of ~,~ '
1993, between the BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY,
FLORIDA, (hereinafter "Board") and BIG PINE KEY ATHLETIC
ASSOCIATION, (hereinafter "BPKAA").
WHEREAS, BPKAA is a not-for-profit corporation established
for the provision of activities for the wholesome development of
youths' personal, social, physical, emotional and spiritual
growth; and
WHEREAS, BPKAA provides such activities in a wholesome,
alcohol-free and drug-free environment for young people of Monroe
County; and
WHEREAS, it is a legitimate public purpose to provide
facilities and services for recreational use and social functions
of the community in a wholesome environment free from drugs and
alcohol; now, therefore,
IN CONSIDERATION of such services rendered, ~PKAA ~d the
'Il
Board agree as follows: 55-~~' V? -~
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1. Al-I0UNT OF AGREEMENT. The Board, in cons"ideraHonrof
--.l
BPKAA substantially and satisfactorily performini:~.:.and ~rryipg
out the duties and obligations of the Board ~s to ;,j>rov:L"'de
facilities and services for recreational use for-' youn~ peo'tile
living in Monroe County, Florida, shall pay to BPKAA the sum of
Fourteen Thousand Dollars ($14,000) for fiscal year 1992-93.
2. ~. This Agreement shall commence June 15, 1993, and
terminate September 30, 1993, unless earlier 'terminated pursuant
to other provisions herein.
3. PAYMENT. Payment will be paid monthly as hereinafter
set forth. On or before the 15th of each month, BPKAA shall
submit to the Board its request for reimbursement. Evidence of
payment shall be in the form of cancelled checks submitted by
BPKAA t() the Board. After the Clerk of the Board examines and
approves the monthly request for reimbursement, the Board shall
reimburse BPKAA. However, the total of said monthly payments in
the aggregate sum shall not exceed the total amount of Fourteen
Thousand Dollars ($14,000) during the term of this agreement.
4. SCOPE OF SERVICES. BPKAA, for the consideration named,
covenants and agrees with the Board to substantially and
satisfactorily perform and carry out the duties of the Board in
providing activities in a wholesome environment free from drugs
and alcohol to young persons living in Monroe County, Florida.
5. RECORDS. BPKAA shall maintain appropriate records to
insure a proper accounting of all funds and expenditures, and
shall provide a clear financial audit trail to allow for full
accountability of funds received from said Board. Access to
these records shall be provided during weekdays, 8 a.m. to 5
p.m., upon request of the Board, the State of Florida, or
authorized agents and representatives of the Board or State.
BPl,AA shall be responsible for repayment of any and all
audit exceptions which are identified by the Auditor General of
the State of Florida, the Clerk of Court for Monroe County, an
independent auditor, or their agents and representatives. In the
event c)f an audit exception, the current fiscal year contract
amount or subsequent fiscal year contract amounts shall be offset
by the amount of the audit exception. In the event this
agreement is not renewed or continued in subsequent years through
new or amended contracts, BPKAA shall be billed by the Board for
the amo'unt of the audit exception and BPKAA shall promptly repay
any audit exception.
6. INDEMNIFICATION AND HOLD HARMLESS. BPKAA covenants and
agrees to indemnify and hold harmless Monroe County Board of
County Commissioners from any and all claims for bodily injury
(including death), personal 1nJury, 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 o~ services rendered under
this agreement by BPKAA or any of its agents, employees,
officers, subcontractors, in any tier, occasioned by the
negligerlce or other wrongful act or omission of BPKAA or its
subcontractors in any tier, their employees or agents. In
the event the completion of services is delayed or suspended as a
result of BPKAA's failure to purchase or maintain required
insurance, BPKAA shall indemnify the Board from any and all
increased expenses resul ting from such delay. The first Ten
Dollars ($10.00) of remuneration paid to BPKAA is for the
indemnification provided above. The extent of liability is in no
way limited to, reduced, or lessened by the insurance require-
ments contained elsewhere within this agreement.
7. INDEPENDENT CONTRACTOR. At all times and for all
purposes hereunder, BPKAA is an independent contractor and not.an
employee of the Board. No statement contained in this agreement
shall be construed so as to find BPKAA or any of its employees,
contractors, servants or agents to be employees of the Board.
8. COMPLIANCE WITH LAW. In providing all services
pursuant to this agreement, BPKAA shall abide by all statutes,
ordinances, rules and regulations pertaining to or regulating the
provisions of, such services, including those now in effect and
hereinafter adopted. Any violation of said statutes, ordinances,
rules or regulations shall constitute a material breach of this
agreement and shall entitle the Board to terminate this contract
immedia.tely upon delivery of written notice of termination to
BPKAA.
9. PROFESSIONAL RESPONSIBILITY AND LICENSING. BPKAA shall
assure that all professionals have current and appropriate
professional licenses and professional liability insurance
coverage. Funding by the Board is contingent upon retention of
appropriate local, state and/or federal certification and/or
licensu,re of BPKAA' s program and staff.
10. INSURANCE. BPKAA shall obtain, prior to the commence-
ment of' work governed by this agreement, at BPKAA' s own expense,
that insurance specified in the insurance requirements forms for
worker's compensation, general liability, vehicle liability and
professional liability, which forms are attached hereto and
incorporated herein by reference. BPKAA will also insure that
all subcontractors, in any tier, have obtained the insurance as
specified in the attached schedules. BPKAA will not be
reimbursed for any work commenced prior to coverage with required
insurance. BPKAA will not be reimbursed for any services
governed by this contract until satisfactory evidence of the
required insurance has been furnished to the Board via either
Monroe County's certificate of insurance or a certified copy of
the actual insurance policy. Delays in the commencement of work,
resulting from the failure of BPKAA to provide satisfactory
evidence of the required insurance, shall not extend deadlines
specified in this agreement. BPKAA and any subcontractors shall
maintain the required insurance throughout the entire term of
this agreement. Failure to comply with this provision may result
in the ~immediate termination of reimbursement.
The Board, at its sole option, has the right to request a
certified copy of any or all insurance policies required by this
agreement. If a certificate of insurance is provided, the
County-prepared form must be used. "Accord Forms" are not
acceptable.
Al:l insurance policies' must specify that they are not
subject to cancellation, non-renewal, material change, or
reduction in coverage unless a minimum of forty-five (45) days
prior notification is given to the Board by the insurer. The
standard language of "endeavor to provide notification" is
insufficient. The acceptance and/or approval of BPKAA's and
subcont1:"actor's insurance shall not be construed as relieving
BPKAA or subcontractor from any liability or obligation assumed
under this agreement or imposed by law.
MOtlrOe County, Monroe County Board of County Commissioners,
its employees and officials shall be included as "additional
insureds" on all policies, except for worker's compensation.
An)T deviations from these general insurance requirements
must be requested in writing on the County-prepared form entitled
"Request for Waiver or Modification of. Insurance Requirements"
and approved by Monroe County's Risk Manager.
11.. MODIFICATIONS AND AMENDMENTS. Any and all modifica-
tions of the services and/or reimbursement of services shall be
amended by an agreement amendment, which must be approved in
writing by the Board.
12. NO ASSIGNMENT. BPKAA shall not assign this agreement
except in writing and with the prior written approval of the
Board, which approval shall be subject to such conditions and
provisions as the Board may deem necessary. This agreement shall
be incorporated by reference into any assignment and any assignee
shall comply with all of the provisions herein. Unless expressly
provided for therein, such approval shall in no manner or event
be deemed to impose any obligation upon the Board in addition to
the total agreed upon reimbursement amount. for the services of
BPKAA.
13. NON-DISCRIMINATION. BPKAA shall not discriminate
against any person on the basis of race, creed, color, national
origin, sex or sexual orientation, age, physical handicap, or any
other characteristic or aspect which is not job-related in its
recruiting, hiring, promoting, terminating or any other area
affecting employment under this agreement. At all times, BPKAA
shall comply with all applicable laws and regulations with regard
to employing the most qualified person(s) for positions under
this ag,reement. BPKAA shall not discriminate against any person
on the basis of race, creed, color, national origin, sex or
sexual orientation, age, physical handicap, financial status or
any other characteristic or aspect in its providing of services.
14. AUTHORIZED SIGNATORY. The signatory for BPKAA, below,
certifies and warrants that:
(a) BPKAA' s name in this agreement is the full name as
designated in its corporate charter, if a corporation, or the
full name under which BPKAA is authorized to do business in the
State of Florida;
(b) He or she is empowered to act and contract for BPKAA;
and
(c) This agreement has been approved by the Board of
Directors of BPKAA, if BPKAA is a corporation.
15. NOTICE. Any notice required or permitted under this
agreement shall be in writing and hand-delivered or mailed,
postage pre-paid, by certified mail, return receipt requested, to
the other party as follows:
For Board:
Monroe County Attorney
310 Fleming St., Rm. 29
Key West, Florida 33040
, ~. ~
e,J1-. J~5 (Name)
(Title)
et1c Association
Big
Florida 33043
For BPKAA:
16. CONSENT TO JURISDICTION. This agreement shall be
construed by and governed under the laws of the State of Florida
and venue for any action arising under this agreement shall be in
Monroe County, Florida.
17 . NON-WAIVER. Any waiver of any breach of covenants
herein contained to be kept and performed by BPKAA shall not be
deemed or considered as a continuing waiver and shall not operate
to bar or prevent the Board from declaring a forfeiture for any
succeeding breach, either of the same conditions or covenants or
otherwise.
18. AVAILABILITY OF FUNDS. If funds cannot be obtained or
cannot be continued at a level sufficient to allow for continued
reimbursement of expenditures for services specified herein, this
agreement may be terminated immediately at the option of the
Board by written notice of termination delivered to BPKAA. The
Board shall not be obligated to pay for any services or goods
provided by BPKAA after BPKAA has received written notice of
termination, unless otherwise required by law.
19. PURCHASE OF PROPERTY. All property, whether real or
personal, purchased with funds provided under this agreement,
shall become the property of Monroe County and shall be accounted
for pursuant to statutory requirements.
20. ENTIRE AGREEMENT. This agreement constitutes the
entire agreement of the parties hereto with respect to the
subject matter hereof and supersedes any and all prior agreements
with respect to such subject matter between BPKAA and the Board.
IN WITNESS WHEREOF, the parties hereto have caused these
presents to be executed as of the day and year first written
above.
(SEAL)
ATTEST: DANNY L. KOLHAGE, CLERK
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
BY~~~J
uty er
By
!'nOSO
BIG PINE KEY AHTLETIC
ASSOCIATION
L/'",
By 1:*
Name f . -. ~ o~~
Title rp~~~ t'-
Cy
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GENERAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Prior to the commencement of work governed by this contract, the
Contractor ahall obtain General Liability Insurance. coverage
ahall be ..intained throughout the life ot the contract and
include, as a .ini.um:
o Premises Operations
o Products and completed operations
o Blanket Contractual Liability
o Personal Injury Liability
o Expanded Definition of Property Damage
o Medical Payments
The minimum limits acceptable shall be:
(
$300,000 Combined Single Limit (CSL)
$ 5,000 Medical Payments
If split limits are provided, the minimum limits acceptable shall
be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 Property Daaage
$ 5,000 Medical Payments
An Occurrence Form policy is preferred. If coverage is provided
on a Clai.. Made policy, it. proviaiona should include coverage
for claims filed on or after the effective date of this contract.:
In addition, the period for which claims may be reported should
extend for a minimum of twelve (12) months following the
acceptance of work by the County.
Monroe County and Monroe County's Board of County commissioners
shall be named as Additional Insureds on all policies issued to
satisfy the above requirements.
GLl . I
(
VEHICLE LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Prior to the commencement of work governed by this contract, the
Contractor shall obtain Vehicle Liability Insurance. coverage
shall be maintained throughout the life ot the contract and
include, as a minimu., liability coverage for:
o Owned, Non-Owned, and Hired Vehicles
o Medical Payments
The minimum limits acceptable shall be:
(
$100,000 Combined single Limit (CSL)
$ 5,000 Medical Payments
If split limits are provided, the minimum limits acceptable shall
be:
$ 50,000 per Person
$100,000 per Occurrence
$ 25,000 Property Damage
$ 5,000 Medical Payments
Monroe County and Monroe County's Board of County Commissioners
shall be named as Additional Insureds on all policies is.ued to
satisfy the above requirements.
VLl . I
(
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
I. }fOP
CONTRACT!
BETWEEN
MONROE COUNTY, FLORIDA
~ND
pr.ior to the commencement of work governed by this contract, the
contractor shall obtain workers' compensation Insurance with
limits sufficient to respond to the applicable state's statutes.
In addition, the contractor shall obtain Employers' Liability
Insurance with limits of not less than:
$100,000 Bodily Injury by Accident
$200,000 Bodily Injury by Disease, each employee
$200,000 Bodily Injury by Disease, policy limits
coverage shall be maintained throughout the entire term of the
contract.
(
coverage shall be provided by a company or companies authorized
to transact business in the state of Florida and the company or
companies must maintain a minimum rating of A-VI, as assigned by
the A.M. Be5t com~any.
If the Contractor has been approved by the Florida's Department
of Labor, as an authorized self-insurer, the County shall
recognize and honor the contractor's status. The contractor
shall be required to submit a Letter of Authorization issued by
the Department of Labor and a Certificate of Insurance, providing
details on the Contractor's Excess Insurance Program.
If the Contractor participates in a self-insurance fund, a
Certificate of Insurance will be required. .In addi ticn I the
contractor will be required to submit updated financial
statements from the fund upon request from the County.
wel' .
SWORN STATEMENT UtIDER ORDINANCE NO. 10-1990
~
1
MONROE COUNTY; FLORIDA
ETHICS CLAUSE
~;tf(fJ;\e...- A4't Je~'c AsS't)Cl4(~ ~M,arrants that he/it has not employed,
T I
retained or otherwise had act on his/its behalf any former County officer
or employee in violation of Section 2 of Ordinance No. 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 the former County officer or employee.
~ b ~ (j~a,j-,-t
(si~ture) / @JAIl-
Date: 1/7)13
STATE OF ~o~,ck.
COUNTY OF lYlonf"o e....
me
Subscribed and sworn to (or affirmed) before
on /5 4t( kt J) I 7 7 )
j( ;~ ; /71 :];;~~3
(date) by
(name of affiant).
He/She is personally known to me or has produced
;J{~'/l.S'o'v'A/IY /5/\jO(\'~ 1u I1lk as identification.
(type of identification)
~,\~1\Y PiJ,~
..v,.~v..i"
* ji~ * JAMES L WYATT JR
· · My ComrtU.ion CC287812
1J~ · ElcpIr.. May 18.1001
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~ UJictif-
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110TARY PUBLI C
f1CPtt4 REV. 2/92
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SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a),
FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
TillS FORI\1 MIJST BE SIGNED AND SWORN TO IN TIlE PRESENCE OF A NOTARY PUBLIC OR OTHER
OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
1. Thissworn statement issuhmiffed to~-oI1"~ (~..Gt14 (ju..b (/~ GOOf)::..>
~ name of the public entity)
. ~
by ~,~ G. J <>"'e5 \ crf;',d~ 8iJPIt
~ ,
(print indh'idual', name and title)
for (ti'~J:'e Ai1de:t, 'c A<;.s"Cq'4'~
(print nllme of entity !tuhmitting Jworn statement)
whose bU5ine55 address is
~~89
~;, (B~e. f<~J
I.F~
,
3~a l.f3
and (if applicable) its Federal Employer Identification Number (FEIN) is S-'j 22SS-7~ 0
(If the entity hils no FEIN, include the Social Security Number of the individual signing this sworn
stAtement:
.)
2. I understand th.t R "public entity crime" AS defined in ParAgraph 287.133(I)(g), Florida Statutes. means a
violation of any state or federalla" by a person with respect to and directly related to the transaction of business
with any public entity or with an Agency or politic a' subdivision of any other st.te or of the United States, incllldinR,
but not limited to, any bid or contract for goods or services to be provided to any public entity or an Agency or
politic.1 subdivision ~f any other stAte or of the United ~f.tes sand involving antitrust, fraul, theft, bribery,
collusion, racketeerint, conspiracy, or material misrepresentation.
J. I understand that"convicted" or "conviction" as defined in Paragr.ph 287.J33(I)(b), Florida Statutes, means.
finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or
sf.te trial court of record relAting to charges brouRht by indictment or Information after July I, 1989, as . result
of a jury verdict, nonjury trial, or entry of. pleA of guilty or nolo ~ontendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133(I)(a), Florida Statutes, means:
1. A predecessor or successor of I person convicted of I public entity crime; or
2. An entity under the (ontrol of any natural person who is adive in the management of the entity and who has
been (onvided of a publk entity (rime. The term "affiliate" indudes those offi(er5, diredor5, elKutives, partners,
shareholders, employees, members, and agents who are adive in the management of an affiliate. The ownership
by one person of shares (onstituting a (ontrolling interest in another person, or pooling of equipment or in(ome
Among persons when not for fair market value under an arm's length agreement, sha" be. prima r.cle case that
one person controls another person. A person who knowingly enters into 8 Joint venture with. person who has
been (onvided of a publi( entity (rime in Florida during the prKeding 36 months shan be (onddered an amliate.
s. I understand that a "person" as defined in Paragraph 287.t33(t)(e), Florida Statuta, means Iny natural person
or entity organized under the laws of any state or of the United States with the legal power to enter into a binding
(ontnd and whi(h bids or applies to hid on (ontrads for the provision of goods or servi(es let by a publi( entity,
or which otherwise transacts or applies to tnnsad business with a publi( entity. The term "person" indudes those
offi(ers, dirKtors, ellKutives, partners, shareh..lders, employees, members, and agents who are adive in
mAnAgement or an entity.
. 6. 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.) "1
- Neither the entity submitting this ltworn statement, nor any of its officers, directors, executives, partners,
shareholders, employees, members, or agents who are 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 I, 1989.
- The entity submitting thilt sworn lttatement, nor any of itlt officers, directors, exectutives, partners,
shareholders, employees, memben, or agentlt who are adive in the management oCthe entity, nor an affiliate of
the entity halt been charged with and convicted of a public entity crime subsequent to July I, 1989.
- The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
shareholders, employees, memben, or agents who are active in the management of the entity, or an affiliate of
the entity has been charged with and convicted or. public entity crimesubsequent to July 1, 1989 . However, there
has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative
Hearings .rod 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 copy of the final order)
I UNDERSTAND TIIA TTHE SUBMISSION OFTHIS FORM TOTHE CONTRACTING OFFICER FOR mE PUBLIC
ENTITY IDENTIFJEDON PARAGRAPH I (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONL V AND, mA TTIIIS
FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR VEAR IN WHICH IT IS FILED. I ALSO
UNDERSTAND mAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A
CONTRACT IN EXCESS OF TIlE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORlDAST A TIITES
FOR CATEGORY TWO OF ANV CHANGE IN THE INFORMATION CONTAINED IN mIS FORM.
t&- b~
~gn.turej
CYh-'--5,jJ
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Sworn to and subscribed before me this /~/7,
dRY of
4u {ruJ I
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,
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Personally known I'D 1l<JL
OR Produced identificRtion
Notary Public - State or
(Type of identificRtion)
My Commission expires
(Printed typed or stamped
commissioned name of notary public)
~,\~RY PUI.
. ~ ~(/c-t
M. JAMESLWVATTJR
: · My Convni..ion CC287612
fit. Expir.. May 18, 1 G97
~JJ ~~ ·
~ OF fLt\~~
Form PUR 7068 (Rev. 06/11/92)
At~.4tillt~
CERTIFICATE OF INSURANCE
ISSUE DATE (MM/DD/YY)
8/11/93
THIS CERTIFICATE IS ISSUED--ASAMATTER"O-FINFORMA TION ONLY AN~D ._-
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
PRODUCER
Regan Insurance Agency, Inc.
90144 Overseas Highway
Tavernier, Fl 33070
f~i'i~~NY A
Nautilus Ins. Co.
l/'
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~. . l'-/ //), .l(?//-'
~VYi.. . .....l....'."/./C
. i (,~ 'r:,: q' / 11 ctl
COMPANIES AFFORDING COVERAGE
INSURED
f~T~~~NY B
Big Pine Athletic Association
PO Box 89
Big Pine Key, Fl 33043
f~T~~~NY C
f~T~~~NY D
I ~~~~NY E ~ l ~ (( l .i~'
! COVERAGES......;... .z...;;.' u u
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAiMS.
ICO
iLTR
I
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MM/DDIYY) DATE (MM/DD/YY)
LIMITS
GENERAL LIABILITY
iA
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE X OCCUR.
OWNER'S & CONTRACTOR'S PROTo
NS 020187
6/29/93
6/29/94
GENERAL AGGREGATE $ 1 ,000,000
PRODUCTS-COMP/OP AGG. $ 1 ,000 ,000
PERSONAL & ADV. INJURY $ excluded
EACH OCCURRENCE $ 1,000, 000
FIRE DAMAGE (Anyone fire) $ excluded
MED. EXPENSE (Anyone person) $ ex.clude.d____
COMBINED SINGLE
LIMIT
$
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
GARAGE LIABILITY
I<ecelveo
lusk Mgmt. & Loss Control
DATE -_L: /4..-2:g
INrfIAL __ ~ olC--
BODIL Y INJURY $
(Per person)
BODIL Y INJURY $
(Per accident)
PROPERTY DAMAGE $
EACH OCCURRENCE $
AGGREGATE $
STATUTORY LIMITS
EACH ACCIDENT $
DISEASE-POLICY LIMIT $
DISEASE-EACH EMPLOYEE $
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION
AND
EMPLOYERS' LIABILITY
1-.--
OTHER
DESCRIPTION OF OPERA TIONS/LOCA TIONS/VEHICLES/SPECIAL ITEMS
Athletic Association
I Watson Field, Blue Heron Park & facilities at Sugarloaf Club, St. Peter's Catholic Church
, and Sunshine Key Camping Resort
f CERTIFICATE HOLDER
CANCELLA TION
Monroe County Board of County
Commissioners, Additional Insured
At t : Risk Management
5825 Jr. College Rd
Key West, Fl 33040
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL --1.0- DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTlce..-sHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIN U N THE COMP '~'(ITS AGENTS OR REPRESENTATIVES.
~ .
@ACORD CORPORATION 1990
i
!
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!
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L~~_RD 25-8 (7/90)
AUTHORIZED REPREse
.\pnl 22. 19<).~
1st llrlnting
MONI{OE COlJN'f\', FLO({IDA
n.equcst For Waivcr
of
Insurance Rcqu~rcnlcnts
Il is requested that the insurance requireIllents. as specified in the ('oullty's Schedule of Insurance
Requirelllents. be \vaived or 11l0dified on the follo\ving contract.
Conlraclor: ~ ~;,e A1{,kt,c ASS(\(fj~
COnlf<lcl for: Nl1dl~'\1 of kl(led,~~] 6'kJ(-~h,. <; c.t* CJ/lte ~ef~ <lIrk
Address of Contractor: (p(YAA
Phone:
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Scope of Work:
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Reason for Waiver:
.~~-e~d-t-~ -Ga.-. ~ ~ ~.
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Signature of Contractor:
!~~
Approved / ~ Nol Approved
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Risk Man3gelllent
Date
('ounty Adrui nislrator appeal:
Approved:
Not Approved:
Date:
Board of ('oullty ('onllllissiollcrs appeal:
Approved:
Nol Approved: __
Meeting Date:
\VAIVER
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A,_t~lllte
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ISSUE DATE (MM/DD/YY)
Ray Hampson & Assoc.
P. O. Box 1617
Big Pi n e Key, Fl. 3 3 0 4 3
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 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
PRODUCER
f~T~~~NY A
INSURED
f~T~~~NY B
f
/MyJ
Up'~
C'
C
Lumbermans Mutual
Big Pine Athletic Assoc.
P. O. Box 89
Big Pine Key, Fl. 33043
J n c .
f~T~~~NY C
f~T~~~NY D
f~rr~~NY E
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
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.
ICT~
!
!
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MM/DD/YY) DATE (MM/DD/YY)
LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
GENERAL AGGREGATE $
PRODUCTS.COMP/OP AGG. $
PERSONAL & ADV. INJURY $
EACH OCCURRENCE $
FIRE DAMAGE (Anyone fire) $
MED. EXPENSE (Anyone person) $
CLAIMS MADE OCCUR.
OWNER'S & CONTRACTOR'S PROTo
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON.OWNED AUTOS
GARAGE LIABILITY
I{ecerr~
Risk Mgm~ &~~'Ol
DATE --~~ ~-..-
INITIAL ~ O/~_
COMBINED SINGLE $
LIMIT
BODIL Y INJURY $
(Per person)
BODIL Y INJURY $
(Per accident)
PROPERTY DAMAGE $
EACH OCCURRENCE $
AGGREGATE $
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
I
1'-'"
j
IA
l
i
i
I
J
I
Binder #
091564493239003861
8/24/93
8/24/94
STATUTORY LIMITS
EACH ACCIDENT
DISEASE-POLICY LIMIT
DISEASE-EACH EMPLOYEE
$ 1 00
$ 500
$ 1 00
WORKER'S COMPENSATION
AND
EMPLOYERS' LIABILITY
OTHER
I
I
i
!
I DESCRIPTION OF OPERA TIONS/LOCA TIONS/VEH ICLES/SPECIAL ITEMS
!
I
I Athletic Association
I CERTIFICATE HOLDER
CANCILL.AT.ON
Monroe County, Risk Management
Attn: Donna Perez
5100 College Rd., Wing 2, Rm. 207
Key West, Florida 33040
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL"~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
I
\ ACORD 25-S (7/90)
AUTHORIZED REPRESENT A TIVE j
l...._ .
Tim Hampsoo// )
~
/ il / c
'._ R""''''~O:/,0 " /
/ @ACORD CORPORATION 1990