FY1993 01/20/1993BRANCH OFFICE
3117 OVERSEAS HIGHWAY
MARATHON, FLORIDA 33050
TEL. (305) 289-6027
TO:
FROM:
DATE:
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OyAO COUN1'�
-Manny I. R10(bage
CLERK OF THE CIRCUIT COURT
MONROE COUNTY
500 WHITEHEAD STREET
KEY WEST, FLORIDA 33040
TEL. (305) 292-3550
M E M O RAN R U M
Division of Management Services c/o
County Administrator
Isabel C. DeSantis,
May 10, 1993
Deputy Clerk Jn • (,• p
BRANCH OFFICE
88820 OVERSEAS HIGHWAY
PLANTATION KEY, FLORIDA 33070
TEL. (305) 852-7145
On January 20, 1993, the Board authorized execution of an
Agreement between Monroe County and the Guidance Clinic of the
Upper Keys, Inc., in the amount of $87,859.00.
Attached hereto is a duplicate original of the subject Agreement,
now fully executed and sealed by all parties, which should be
returned to the Guidance Clinic of the Upper Keys, Inc.
cc: County Attorney
Finance
File
i
L
A G R E E M E N T
THIS AGREEMENT, made this 20th day of January , 1993,
between the Board of County Commissioners of Monroe County,
Florida, ("Board") and the Guidance Clinic of the Upper Keys,
Inc., ("Clinic");
WHEREAS, the Board and the Clinic desire to enter into an
agreement wherein the Board contracts for services from the
Clinic for the rendering of mental health services to the
citizens of the Upper Keys, Monroe County, Florida; and
WHEREAS, the Board is vested and charged with certain duties
and responsibilities relating to the mental health and guidance
of the citizens of Monroe County; and
WHEREAS, such services have been rendered by the Clinic in
the past and have been invaluable to the citizens of the Upper
Keys, Monroe County, Florida; and
WHEREAS, it is proper and fitting to enter into an agreement
for services to be rendered in the forthcoming fiscal year
1992-93; now, therefore,
IN CONSIDERATION of the promises made each to the other, the
Board and the Clinic agree as follows:
1. AMOUNT OF AGREEMENT. The Board, in consideration of
the Clinic substantially and satisfactorily performing and
carrying out the duties and obligations of the Board as to
rendering mental health counsel to the citizens of the Upper
Keys, Monroe County, Florida, shall pay to the Clinic the sum of
Eighty Seven Thousand Eight Hundred and Fifty Nine Dollars
($87,859) for fiscal year 1992-93.
2. TERM. This Agreement shall commence October 1, 1992,
and terminate September 30, 1993, unless earlier terminated
pursuant to other provisions herein.
3. PAYMENT. Payment will be paid monthly as hereinafter
set forth. Certified monthly financial and service load reports
will be made available to the Board to validate the delivery of
services under this contract. The monthly financial report is
due in the office of the Clerk of the Board no later than the
15th day of the following month. After the Clerk of the Board
pre -audits the certified report, the Board will reimburse the
Clinic for its monthly expenses. However, the total of said
monthly payments in the aggregate sum shall not exceed the total
amount of $87,859 during the term of this contract. To preserve
client confidentiality required by law, copies of individual
client bills and records shall not be available to Board for
reimbursement purposes but shall be made available only under
controlled conditions to qualified auditors for audit purposes.
4. SCOPE OF SERVICES. The Clinic, for the consideration
named, covenants and agrees with the Board to substantially and
satisfactorily perform and carry out the duties of the Board in
rendering counsel in the matters of mental health and guidance to
the citizens of the Upper Keys, Monroe County, Florida. The
Clinic shall provide these services in compliance with Florida
Statutes Chapter 394.
5. RECORDS. The Clinic 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.
The Clinic 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 of 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, the Clinic shall be billed by the Board
for the amount of the audit exception and the Clinic shall
promptly repay any audit exception.
2
6. INDEMNIFICATION AND HOLD HARMLESS. The Clinic
covenants and agrees to indemnify and hold harmless Monroe County
Board of County Commissioners from any and all claims for bodily
injury (including death), personal injury, and property damage
(including property owned by Monroe County) and any other losses,
damages, and expenses (including attorney's fees) which arise out
of, in connection with, or by reason of services rendered under
this agreement by the Clinic or any of its agents, employees,
officers, subcontractors, in any tier, occasioned by the
negligence or other wrongful act or omission of the Clinic 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 Clinic's failure to purchase or maintain required
insurance, the Clinic shall indemnify the Board from any and all
increased expenses resulting from such delay. The first Ten
Dollars ($10.00) of remuneration paid to the Clinic 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, the Clinic is an independent contractor and
not an employee of the Board. No statement contained in this
agreement shall be construed so as to find the Clinic 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, the Clinic 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 immediately upon delivery of written
notice of termination to the Clinic.
9. PROFESSIONAL RESPONSIBILITY AND LICENSING. The Clinic
shall assure that all professionals have current and appropriate
3
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
licensure of the Clinic's program and staff.
10. INSURANCE. The Clinic shall obtain, prior to the
commencement of work governed by this agreement, at Clinic's own
expense, that insurance specified in the insurance requirement
forms for worker's compensation, general liability, vehicle
liability and professional liability, which forms are attached
hereto and incorporated herein by reference. The Clinic will
also insure that all subcontractors, in any tier, have obtained
the insurance as specified in the attached schedules. The Clinic
will not be reimbursed for any work commenced prior to coverage
with required insurance. The Clinic 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 Clinic to
provide satisfactory evidence of the required insurance, shall
not extend deadlines specified in this agreement. The Clinic 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.
All 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 the Clinic's and
subcontractor's insurance shall not be construed as relieving the
4
Clinic or subcontractor from any liability or obligation assumed
under this agreement or imposed by law.
Monroe 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.
Any 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. The Clinic 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 the Clinic.
13. NON-DISCRIMINATION. The Clinic 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, the
Clinic shall comply with all applicable laws and regulations with
regard to employing the most qualified person(s) for positions
under this agreement. The Clinic 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.
4
14. AUTHORIZED SIGNATORY. The signatory for the Clinic,
below, certifies and warrants that:
(a) The Clinic's name in this agreement is the full name as
designated in its corporate charter, if a corporation, or the
full name under which the Clinic is authorized to do business in
the State of Florida;
(b) He or she is empowered to act and contract for the
Clinic; and
(c) This agreement has been approved by the Board of
Directors of the Clinic, if the Clinic 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
For Clinic: Richard Matthews
Executive Director
Guidance Clinic of
Upper Keys, Inc.
Post Office Box 363
Tavernier, Florida 33070
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 the Clinic 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.
2
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 the Clinic.
The Board shall not be obligated to pay for any services or goods
provided by the Clinic after the Clinic 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 the Clinic 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) BOARD OF COUNTY COMMISSIONERS
ATTEST: DANNY L. KOLHAGE, CLERK OF MONKA COUNTY, FLORIDA
By ABy.
Deputy ClerR 1. -Xr - 93
VAN IN N NO .� �I �s
riunairman
G'UIDANCE CLINIC OF THE UPPER
KEYS, INC.
t/Board of Director -
I
1 .
APPROVED AS TO F(, r-
AIBtEGAL SUFFICIE
orne 's G'.c
Date 2 Z
7
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Prior to the commencement of work governed by this contract, the
Contractor shall obtain Workers' Compensation Insurance with
limits sufficient to respond to the applicable state's statutes.
In addition, the Contractor shall obtain Employers' Liability
Insurance with limits of not less than:
$200,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, each employee
$500,000 Bodily Injury by Disease, policy limits
Coverage shall be maintained throughout the entire term of the
contract.
C 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. Best Company.
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 addition, the
Contractor will be required to submit updated financial
statements from the fund upon request from the County.
WC2 i
GENERAL LIABILITY
INSURANCE REQUIREMENTS
Fop
CONTRACT.,
BETWEEN
MONROE COUNTY, FLORIDA
AND
Prior to the -commencement of work governed by this contract, the
Contractor shall obtain General Liability Insurance. Coverage
shall be maintained throughout the life of the contract and
include, as a minimum:
o Premises Operations
o Products and Completed operations
o Blanket Contractual Liability
o Personal Injury Liability
o E-cpanded Definition of Property Damage
o Medical Payments
The minimum limits acceptable shall be:
$500,000 Combined Single Limit (CSL)
$ 5,000 Medical Payments
If split limits are provided, the minimum limits acceptable shall
be!
$250,000 per Person
$500,000 per Occurrence
$ 50,000 Property Damage
$ 5,000 Medical Payments
An Occurrence Form policy is preferred. If coverage is provided
on a Claims Made policy, its provisions should include coverage
for claims filed on or after the effective date of this contract.'
In addition, the period for which claims may be reported should
extend for a minimum of twelve (12) months following the
acceptance of work by the County.
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.
GL2 ;
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 of the contract and
include, as a minimum, liability coverage for:
o Owned, Non -Owned, and Hired Vehicles
o Medical Payments
The minimum limits acceptable shall be:
$300,000 Combined Single Limit (CSL)
$ 5,000 Medical Payments
r If split limits are provided, the minimum limits acceptable shall
t be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 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 issued to
satisfy the above requirements.
VL2 i
C
C
PROFESSIONAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Recognizing that the work governed by this contract involves the
furnishing of advice or services of a professional nature, the
contractor shall purchase and maintain, throughout the life of
the contract, Professional Liability Insurance which will respond
to damages resulting from any claim arising out of the
performance of professional services or any error or omission of
the contractor arising out of work governed by this contract.
The minimum limits of liability shall be:
$500,000 per Occurrence
PRO2 ' i
C
UNTY 10NROE
KEY WESTLORIDA 33040
(305)294-4641
M E M O R A N D U M
To: Beth Leto
County Attorney's Office
From: Kay Bahleda
Risk Management
-0
Date: May 6, 1993
BOARD OF COUNTY COMMISSIONERS
MAYOR, Jack London, District 2
Mayor Pro Tern, A Earl Cheal, District 4
Wilhelmina Harvey, District 1
Shirley Freeman, District 3
Mary Kay Reich, District 5
Subject: Re: Guidance Clinic of the Upper Keys
Enclosed please find the approved, original Certificate of Insur-
ance for General Liability and Auto Liability for subject funding
agreement.
This certificate constitutes insurance sufficiency for contract
requirements and agreement may now be executed.
If you have any questions, please call.
M
C
UNTY joNROE
KEY WESTLORIDA 33040
(305)294-4641
Monroe County Risk Management
Wing II, Room 207 P.S.B.
5100 College Road
Key West, FL 33040
April 27, 1993
Ms. Linda Holmes
The Johnsons Insurance Agency
P.O. Box 2346
Marathon Shores, FL 33052
BOARD OF COUNTY COMMISSIONERS
MAYOR, Jack London, District 2
Mayor Pro Tem, A Earl Cheal, District 4
Wilhelmina Harvey, District 1
Shirley Freeman, District 3
Mary Kay Reich, District 5
Re: Guidance Clinic of the Upper Keys Certificate of Insurance
Policy # 1MP300470687
Dear Ms. Holmes:
Attached please find the original Certificate of Insurance for-
warded to the Risk Management office by your organization. Note
that there is a hand written X in the Hired autos section of the
certificate. If this change was made by you, please initial by
the X and return it to my office. If not, please call me to
discuss this situation.
Thank you for your cooperation.
Sincerely,
Kay Bahleda
Risk Management
LEJIGUID/txtbahl
RECEIVED AFP 3 b L99j
3
iG E F R —IF I F= I E Pi -T E C3 F= I r%J E3 U FR ocF% (-- E
Issue dates 4/22/93
Producers ; This certificate is issued as a matter of information only and confers
no rights upon the certificate holder. This certificate does not amo*d,
extend or altar the coverage afforded by the policies below.
THE J01#W S INS AGCV
PD BOX 2346 ; COMPANIES AFFDAVZMO COVERA&E
MARATHON %0RESFL 33052 -- -- ---- —
Cod*# Sub -coder ; Co Ltr As U S F & 6 COMPANIES
Insureds Ca Ltr Br U S F & 6 COMPANIES '\
Co Ltr Co
GUIDANCE CLINIC--U K-------------- dn�--
P 0 BOX 30 ; Co Ltr as
TAVERNIER FL 33070 -------------- --
Co Ltr Es �.
V
RE's:„eu,, e
COVERAGES ''►R'`��isk Mgmt, & Loss Control
This is to certify that policies of insurance listed below have beep issued to the Insured eased D oDi TUP'�lhr�ra od
Indicated, notwithstanding may requirement, tore or condition o1 any contract or other document w��rp*ct to which this
certificate way be Issued or may pertain, the insurance afforded by the policies described heroin is subJ*c
exclusions, and conditions of such policies. Limits shown way have been reduced by paid claims.
Co
�
t
t Policy
�
; Policy
;
Ltr; Type of Insurance
; Policy number
;effective date
;expiration date;
Limits
A :GENERAL LIABILITY
1MP30047%87
1 7/01/92
�— 7/01/93
— :general aggregates
1'
1 000 000
:[X] Commercial general liability
;
:
I
:Products-comp/opt aggrag#;g
1'0001000
Claims and& [X] Occur
:
:
:
:Parsonal/advartiving inJs;f
1I
Owner's 6 contractor's prot
:
;Each occurrences
;t
1,0001000
;Fire damages
—
+B
:Medical expenses
;AUTOMOBILE LIABILITY
1 IPP300470687
D�f
1 7/01/92
1 — 7/01/93
;Combined Single-----_:0
Any auto
:Limits
lg
1 � 000
All owned autos
:
:
:
:Bodily inJury
;
/ 1
Scheduled autos'
;
;
;
:(ier person)#
;t
Hired mules /
;
;
;
;Bodily inJury
;
[X] Mon-ownod autos
11fP*r accident)#
Garage liability
;
i
--
::Property damages
�t
'EXCESS LIABILITY
�_�--M---
w---_�'
-- —
i£aeh Occurrence
�f
;I Umbrella fora
1,Aggragato
�f
Other than umbrella form
MORKER'S COMPENSATION
�— :Statutory Limits
i
EMPLOYERS' LIABILITY
:
:!Disease -policy limit)
;t
:!Disease-oach omploy*e)
;•
;OTHER
Description of operations/locations/vehicles/rostrictions/spoclal items#
MENTAL HEALTH CENTER
CERTIFICATE HOLDER
UME COUNTY (ADD'L. INSURED)
ROOM #207
5100 COLLEGE ROAD
KEY HEST FL 33M
CANCELLATION
Should may of the above described policies be cancelled before the
expiration date thoroof, the issuing company will **deeper to
mail 45 days written notice to the certificate holder *awed to the
loft, but failure to mail such notice shall impose no obligation or
liability of any kind upon the company, its agents or roprosontativos.
LII AURAE HOLME /�
4/G9
� ISSUE DATE (MM/DD/YY)
Alr Ilsl� SATE � 4/93
03/i
PRODUCER CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
FTHIS
ONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
(�UOi5OES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
BROWN & BROWN, INC./FCCMH BOOK
P.O. DRAWER 1712 COMPANIES AFFORDING COVERAGE
DAYTONA BEACH FL 32115 Governmental Frisk Insurance Trust
COMPANY
A
�,4'
LETTER
y
COMPANY B_
INSURED LETTER
0027i) _Received 04n
COMPA
GUIDANCE CLINIC OF THE UPPER KEYS ETTERNYCRisk Mg nt. & Loss Control
P.O. BOX 363
DATE
TAVERNEER FL 33070 ETT RNY D
WF7TAL a
e _
COMPANY
E
LETTER `
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.
COTYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION' LIMITS
LTR DATE (MM/DD/YY) DATE (MM/DD/YY)
GENERAL LIABILITY GENERAL AGGREGATE $
COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP/OP AGG. $
CLAIMS MADE OCCUR. PERSONAL & ADV. INJURY $
OWNER'S & CONTRACTOR'S PROT. EACH OCCURRENCE $
FIRE DAMAGE (Any one fire) $
MED. EXPENSE (Any one person) $
AUTOMOBILE LIABILITY COMBINED SINGLE
ANY AUTO LIMIT $
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS
BODILY INJURY $
NON -OWNED AUTOS (Per accident)
GARAGE LIABILITY
PROPERTY DAMAGE $
EXCESS LIABILITY EACH OCCURRENCE $
UMBRELLA FORM AGGREGATE $
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION STATUTORY LIMITS_
EACH ACCIDENT $ 100 k
A AND 00270 07/01/92 07/01/93 DISEASE —POLICY LIMIT $ 500
EMPLOYERS' LIABILITY
10-0
DISEASE —EACH EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPI4 ON DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MONROE COUNTY RISK MGMT MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
5100 COLLEGE RD LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
KEY WEST FL 33040 LIABILIRESENTATIVE
A T RIZ
�1 1
Account Number. 1: 1_ G-UlD 3631
Date: ; �+ '�'/r�3 Initials: DC'
CERTIFICATE OF INSURANCE
Amer, i cai-i Home Ass>ur•ati7c:e Compat-iy
c/o: American Professional Agency, Inc.
95 Broadway, Amityville, NY 11701
This is to certify that the insurance policies specified below have been issued by the company indicated
above to the Insured named herein and that, subjectto their provisions and conditions, such policies afford the
coverages indicated insofar as such coverages apply to the occupation or business of the Named Insured(s) as
stated.
THIS CERTIFICATE OF INSURANCE NEITHER AFFIRMATIVELY NOR NEGATIVELY AMENDS, EXTENDS OR
ALTERS THE COVERAGE(S) AFFORDED BY THE POLICY(IES) LISTED ON THIS CERTIFICATE.
Name and Address of Insured:
GUIDANCE CLINIC: CIF THE
UPPER KEYS, INC.
P.O. PDX 363
TAVERNIER, FI_ 33070
Occupation or Business: SOCIAL SERVICE AGENCY
Location of Operations:
(if different than address listed above)
A M TM onal f2fame" insure'�"s:
BLANKET COVERAGE
Receive
Risk Mgmt. & Loss Control
DATE Y-/••� - % 3
INITIAL •.
1 1�
Type of Work Covered: PROF'. MENTAL HEALTH C:OUN 7ELINC
Policy
Effective
Expiration
Limits of
Coverages
Number
Date
Date
Liability
PROFESSIONAL./
i , 0001000
S<,
,,
NOTICE OF CANCELLATION WILL ONLY BE GIVEN TO THE FIRST NAMED INSURED ON THIS POLICY AND
HE OR SHE SHALL ACT ON BEHALF OF ALL INSUREDS WITH RESPECT TO GIVING OR RECEIVING NOTICE
OF CANCELLATION.
Claim History:
Comments:
This Certificate Issued to:
Name:
GUIDANCE CLINIC OF THE
Address: UPPER KEYS, INC.
PAO. DOX 363
TAVERNIER, F'L. 33070
GEN 152
i•1/1c/�.'' SCCIAL S�_,-1JIC: AGL%CY PPP-)Fz- SSION AL LIAisILITY POLICY
DECLARATIONS
POLICY NO: SSA— 69 C 4 71 3 ACCOUNT NO: F L—G U I 0 3 6 3-1
ITEM 1. NAME AND ADDRESS OF INSURED: A60I69W ANAWr14561W61X X
BLANKET COVERAGE
6UICANLE CLINIC OF 1HE
UPPER KEYS. INC.
P.I✓. UX 353
TAVERAIER• FL 33070
TYPE OF ORG.: CORPORATION
ITEM 2. ADDITIONAL INSUREDS:
ITEM 3. POLICY PERIOD: FROM: 1t'/01/ )1 TO: 10/01/93
12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE WSURED AS STATED HEREIN:
ITEM 4. LIMITS OF LIABILITY: $ 1.000900°7 EACH CLAIM
S 19 0 0 0► 0 00 ASIMEGATE
ITEM 3. PREMIUM SCHEDULE:
CLASSIFICATION
NUMBER
RATE
ANNUAL PREMIUM
i
;
t
I
I
i
19650.09
TOTAL PREMIUM:
COUNTERSIGNED BY: GEORGE B. MCNEIL
AUTHORIZED REPRESENTATIVE
_,P-A is 16111 FOOM 4:"414 7—V5 F",r 4f+i65 11_ 37
ISK ID
INFORMATION PAGE
FEIN 59-1462836
nsurer: Governmental Risk Insurance Trust P 0 L I C Y N 0.
00270
The Insured: Guidance Clinic of the Upper Keys XX Corporation (Non -Profit)
MAiling Address: P.O. Box 363 Municipality
Tavernier, FL 33070
Physical Address:
92140 U.S. Highway
Tavernier, FL 33070
Sublocations: 90290 Overseas Highway, Suite 101, Tavernier, FL 33070
The policy period is from July 1. 1992 to July 1, 1993
and the anniversary rating date is July 1 at the insured's mailing address.
A. Workers' Compensation Insurance: Part One of the policy applies to the Workers'
Compensation Law of the states listed here: FLORIDA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state
listed in Item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident $100,000 each accident
Bodily Injury by Disease $M,000 policy limit
Bodily Injury by Disease $100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed
here: NONE.
D. This policy includes these endorsements and schedules: WC 09 04.02. VC 89 06 00 A
The p:reniwi for this policy will be determined by our manuals of Rules, Classifications,
Rates and Rating plans. All information required below is subject to verification and
chin by-' audi t .
lassifications Code Premium Basis Rate Per Estimated Annual
No. Total Estimated $100 of Premium
Annual Remuneration Remuneration
SEE ATTACHED
inimum Premium $174.00
Total Estimated Annual Premium $
Countersigned by:
Expense Constant $
& Brown, Inc.
July 28, 1992
)0/001 GRIT (10/90)
COMM'ERCIAL GENERAL LIABILITY COVERAGE PART - DECLARATIONS USFU®
Policy No. 1MP 300470687 00 INSURANCE
LIMITS OF INSURANCE:
$ ,000 000 General Aggregate Limit (Other than Products -Completed Operations)
$ 1 00�u Products -Completed Operations Aggregate Limit
$ 1.00 .000 Personal and Advertising Injury Limit
$ 1.000.000 Each Occurrence Limit
$ UUU Fire Damage Limit (Any One Fire)
$ ��O Medical Expense Limit (Any One Person)
FORM OF BUSINESS:
Individual Partnership Joint Venture M Corporation
Other
LOCATION OF ALL PREMISES YOU OWN, RENT OR OCCUPY:
Same as shown in Item 1 of the Common Policy Declarations.
❑ X See below.
PREMIUM SCHEDULE: See Supplemental Schedule.
Premium
Classifications Code No. Bases")
Rates Advance Premiums
Praa./ Prod./ Prom./ Prod./
ops. (2) Cowp,ope. (3) oP02) Cmnp.ops.(3)
2140 OVERSEAS HMY SUITE 85
AVERNIER, FL 33070
HEALTH CARE FACILIRIES-CLICS, DISPENSARI 44439
A/1,000
267.530
2".00
ES OR INFIRMARIES TREATING OUTPATIENTS 0
HLY NO REGULAR BED AND BOARD FACILITIES
OTHER THAN NOT -FOR -PROFIT
INCLUDING PRODUCTS MO/OR COMPLETED
OPERATIONS
0290 OVERSEAS MY SUITE 101
AVERNIER, FL 33070
HEALTH CARE FACILITIES-CLICS, DISPENSARI "439
A/600
267.530
161.00
ES OR INFIRMARIES TREATING OUTPATIENTS 0
NLY NO REDR.AR BED AND BOARD FACILITIES
OTHER THAN NOT -FOR -PROFIT
INCLUDING PRODUCTS AND/OR COMPLETED
OPERATIONS
TOTAL ADVANCE PREMIUM FOR THIS COVERAGE PART:
AUDIT PERIOD: RAnnually Semi -Annually
FORMS AND ENDORSEMENTS APPLICABLE TO THIS COVERAGE PART:
COIL 151 07 90
CG 00 01 11 88
RETROACTIVE DATE:
CG 22 44 11 85
CL/CG 21 02 07 89
$ 429.00$
11 Quarterly Monthly
CG 22 52 11 85
(Coverages A. and B. provide claims -made coverage when form CG 00 02 applies.
Coverage does not apply to "bodily injury" or "property damage" that occurred, or to a "personal injury" or
"advertising injury" offenses committed, before this date.)
(1) See Description of Tw"w Used se P►smium Down.
C L/ I L 151 07 90 2) P.of iCo Jopo.: c PremieeProductca6apr.r.d op.rnt.n.
07/28/92 33,,277 4707/28/92
' BUSINESS AUTO COVERAGE PART - DECLARATIONS (PART 1) USF&OC
Policy No. 1MP 300470687 00 INSURANCE
ITEM ONE. FORM OF BUSINESS:
Individual ElPartnership Joint Venture [_x] Corporation
Other
ITEM TWO. SCHEDULE OF COVERAGES AND COVERED AUTOS:
This Coverage Part provides only those coverages where a charge is shown in the premium column below.
Each of these coverages will apply only to those "autos" shown as covered "autos." "Autos" are shown as
covered "autos" for a particular coverage by the entry of one or more of the symbols from the COVERED
AUTO Section of the Business Auto Coverage Form next to the name of the coverage.
COVERED
LIMIT
COVERAGES
AUTOS
THE MOST WE WILL PAY FOR ANY ONE
PREMIUM
ACCIDENT OR LOSS
Liability
8 9
$ 1,000,000
$ 110.00
Personal Injury Protection (P.I.P.)
Separately Stated In Each P.I.P. Endorsement Minus
(or equivalent No -Fault coverage)
S Deductible.
$
Added Personal Injury Protection
(or equivalent Added No -Fault
Separately Stated In Each Added P.I.P. Endorsement.
coverage)
$
Property Protection Insurance
Separately Stated In The P.P.I. Endorsement Minus
(Michigan Only)
$ Deductible for Each 'Accident.'
$
'Auto" Medical Payments
$
S
Uninsured Motorists
$
=
Underinsured Motorists
(when not included in Uninsured
Motorists coverage)
$
$
Actual Cash Value Or Cost Of Repair, Whichever is Less Minus
Physical Damage
3 Deductible For Each Covered "Auto," But
Comprehensive Coverage
No Deductible Applies To 'Loss' Caused By Fire Or Lightning.
See ITEM FOUR for hired or borrowed "autos."
t
Physical Damage
Actual Cash Value Or Cost Of Repair, Whichever Is Less Minus
'Auto" "Loss"
Specified Causes
$25 Deductible For Each Covered For Caused
Of Loss Coverage
By Mischief or
Vandalism. See ITEM FOUR for hired or borrowed 'autos.'
t
Physical Damage
Actual Cash Value Or Cost Of Repair, Whichever Is Less Minus
'Auto.'
Collision Coverage
$ Deductible For Each Covered
"autos."
See ITEM FOUR for hired or borrowed
f
Physical Damage Towing and
S For Each Disablement Of A Private
Labor (not available in California)
Passenger 'Auto.'
$
Premium For Endorsements:
$
TOTAL ESTIMATED PREMIUM FOR THIS COVERAGE PART:
$ 110.00
FORMS AND ENDORSEMENTS APPLICABLE TO THIS COVERAGE PART:
CA 00 01 06 92 CA 01 28 10 91 CA 02 67 09 91 CL/IL 741 04 91M
ITEM THREE. SCHEDULE OF COVERED AUTOS YOU OWN: SEE VEHICLE SCHEDULE.
CVIL 741 04 91M (Part 1)
331,277 69
(ISO CA00021290)