FY1995 11/23/1994BRANCH OFFICE
3117 OVERSEAS HIGHWAY
MARATHON, FLORIDA 33050
TEL. (305) 289-6027
GOUNTy
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�E COUN.1.4. F�
;Dannp 1. Rotbage
CLERK OF THE CIRCUIT COURT
MONROE COUNTY
500 WHITEHEAD STREET
KEY WEST, FLORIDA 33040
TEL. (305) 292-3550
MEMORANDUM
TO: Eva Limbert
Office of Management & Budget
FROM: Ruth Ann Jantzen, Deputy Clerk�� .
DATE: January 30, 1995
BRANCH OFFICE
88820 OVERSEAS HIGHWAY
PLANTATION KEY, FLORIDA 33070
TEL. (305) 852-7145
On November 23, 1994, the Board of County Commissioners granted approval
and authorized execution of a Contract between Monroe County and the Guidance
Clinic of the Upper Keys, Inc., in the amount of $87,859.00.
Enclosed please find a fully executed duplicate original of the above contract for
return to your provider.
If you have any questions regarding the above, please do not hesitate to contact
me.
cc: County Attorney
Finance
County Administrator, w/o document
File
f .
AGREEMENT
This Agreement is made and entered into this oar- day of Vermb ef-
1994, between the BOARD OF COUNTY COMMISSIONERS OF MONROE
COUNTY, FLORIDA, hereinafter referred to as "Board" or "County," and the
GUIDANCE CLINIC OF THE UPPER KEYS, INC., hereinafter referred to as
"Provider."
WHEREAS, the Board and the Provider desire to enter into an agreement
wherein the Board contracts for services from the Provider 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 Provider in the past
and have been invaluable to the citizens of the Upper Keys, and
WHEREAS, it is proper and fitting to enter into an agreement for services to
be rendered in the forthcoming fiscal year 1994-95, now, therefore,
IN CONSIDERATION of the mutual promises and covenants contained
herein, it is agreed as follows: i Nnv �08NG14
1. AMOUNT OF AGREEMENT. The Board, in consideration of the
Provider substantially and satisfactorily performilff'Or Al 9&4Cng%Ut the duties
and obligations of the Board, as to rendering ifthit il� h"Jtg ll tinsel to the
citizens of the Upper Keys, Monroe County, Florida, shall pay to the Provider the
sum of Eighty -Seven Thousand Eight Hundred Fifty -Nine Dollars ($87,859.00) for
fiscal year 1994-95.
2. TERM. This Agreement shall commence on October 1, 1994,
and terminate September 30, 1995, 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 shall reimburse the Provider for its monthly expenses.
However, the total of said monthly payments in the aggregate sum shall not
exceed the total amount of $87,859.00 during the term of this agreement. To
preserve client confidentiality required by law, copies of individual client bills and
records shall not be available to the Board for reimbursement purposes but shall
be made available only under controlled conditions to qualified auditors for audit
purposes.
4. SCOPE OF SERVICES. The Provider, 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 matter of mental
health and guidance to the citizens of the Upper Keys, Monroe County, Florida.
rA
The Provider shall provide these services in compliance with Florida Statutes
Chapter 394.
5. RECORDS. The Provider 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 Provider 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 Provider
shall be billed by the Board for the amount of the audit exception and the
Provider shall promptly repay any audit exception.
6. INDEMNIFICATION AND HOLD HARMLESS. The Provider
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)
C
which arise out of, in connection with, or by reason of services provided by the
Provider occasioned by the negligence, errors, or other wrongful act or omission
of the Provider's employees, agents or volunteers. The extent of liability is in no
way limited to, reduced, or lessened by the insurance requirements contained
elsewhere within this agreement.
7. INDEPENDENT CONTRACTOR. At all and for all purposes
hereunder, the Provider 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 Provider 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 Provider shall abide by all statutes, ordinances, rules and
regulations pertaining to or regulating the provision 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 Provider.
9. PROFESSIONAL RESPONSIBILITY AND LICENSING. The
Provider shall assure that all professionals have current and appropriate
professional licenses and professional liability insurance coverage. Funding by
4
the Board is contingent upon retention of appropriate local, state and/or federal
certification and/or licensure of the Provider's program and staff.
10. INSURANCE. As a pre -requisite of the services supplied under
this contract, the Provider shall obtain, at its own expense, insurance as
specified in any attached schedules, which are made part of this agreement.
The Provider shall maintain the required insurance throughout the entire
term of this agreement. Failure to comply with this provision may result in
immediate suspension of all work until the required insurance has been
reinstated or replaced.
The Provider shall provide, to the County, as satisfactory evidence of the
required insurance, either:
Certificate of insurance
or
A certified copy of the actual insurance policy.
The Board, at its sole option, has the right to request a certified copy of
any or all insurance policies required by this agreement.
All insurance policies must specify that they are not subject to
cancellation, non -renewal, material change, or reduction in coverage unless a
minimum of thirty (30) days prior notification is given to the Board by the insurer.
5
J
The acceptance and/or approval of the Provider's insurance shall not be
construed as relieving the Provider from any liability or obligation assumed under
this agreement or imposed by law.
The 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 Risk
Management.
11. MODIFICATIONS AND AMENDMENTS. Any and all modifi-
cations 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 Provider 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
G
be deemed to impose any obligation upon the Board in addition to the total
agreed upon reimbursement amount for the services of the Provider.
13. NON-DISCRIMINATION. The Provider shall not discriminate against
any person on the basis 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 Provider shall
comply with all applicable laws and regulations with regard to employing the
most qualified person(s) for positions under this agreement. The Provider 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
characteristic or aspect in its providing of services.
14. AUTHORIZED SIGNATURES. The signatory for the Provider below,
certifies and warrants that:
(a) The Provider'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
Provider is authorized to do business in the State of Florida.
(b) He or she is empowered to act and contract for the Provider; and
(c) This agreement has been approved by the Board of Directors of the
Provider if the Provider is a corporation.
7
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 Street, upstairs
Key West, Florida 33040
For Provider: Richard Matthews
Executive Director
Guidance Clinic of the
Upper Keys, Inc.
P. O. 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 Provider 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 the Provider. The Board shall not be obligated to pay for any services or
8
goods provided by the Provider after the Provider 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 Provider 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
Witness
' �"neis-
b/CONS/guidanc3.doc
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
By: OL , - - z&,��
Pew—
MayVltfiairman
GUIDANCE CLINIC OF THE UPPER
KEYS, INC. C
(Federal ID
By
Director
B%4: fj:�J,
President
A!'P—vrin AS TO r(`!7.
BRANCH OFFICE
3117 OVERSEAS HIGHWAY
MARATHON, FLORIDA 33050
TEL. (305) 289-6027
Syr.ouNrr0cG J� JJM CU%04,` 9
i
oi9�E . COUNT'•R�(�
xuacnnp �L.orfjage
CLERK OF THE CIRCUIT COURT
MONROE COUNTY
500 WHITEHEAD STREET
KEY WEST, FLORIDA 33040
TEL. (305) 292-3550
Dear Human Service Organizations,
BRANCH OFFICE
88820 OVERSEAS HIGHWAY
PLANTATION KEY, FLORIDA 33070
TEL. (305) 852-7145
In an effort to streamline the expense reimbursement process,
please note the change of address for submitting your requests.
Effective with your fiscal year 1995 contracts (October 1, 1994
thru September 30, 1995), all reimbursement requests should be
mailed to:
Clerk of the Court
500 Whitehead Street
Key West, FL 33040
Attn: Finance Department
You will also find several attachments to the contract. One is a
document titled "Expense Reimbursement Requirements." This was
prepared in an attempt to eliminate any confusion regarding
required supporting documentation.
A "prototype cover sheet" has been provided in an effort to assist
you in packaging your request, as well as to facilitate the review
process in our office. Please let me know if you want blank copies
of the cover sheet for your reimbursement requests.
Please contact me at 292-3528 with any questions or comments
regarding this change.
Sincerely,
al"4
Stephanie Griffiths
Chief Accountant
ATTACHMENT A 11
Expense Reimbursement Requirements
This document is intended to provide "basic" guidelines to Human
Service Organizations, county travellers, and contractual parties
who have reimbursable expenses associated with Monroe County
business. These guidelines, as they relate to travel, are
interpreted from Florida Statute 112.061, which is attached for
reference.
A cover letter summarizing the major line items on the reimbursable
expense request should also contain a certified statement such as:
I certify that the attached expenses are accurate and in
agreement with the records of this organization. Furthermore,
these expenses are in compliance with this organization's
contract with the Monroe County Board of County Commissioners.
Invoices should be billed to the contracting agency. Third party
payments will not be considered for reimbursement. Remember, the
expense should be paid prior to requesting a reimbursement.
Only current charges will be considered, no previous balances.
Reimbursement requests will be monitored in accordance with the
level of detail in the contract. This document should not be
considered all-inclusive. The Clerk's Finance Department reserves
the right to review reimbursement requests on an individual basis.
Any questions regarding these guidelines should be directed to
Stephanie Griffiths at 305-292-3528.
Payroll:
A certified statement verifying the accuracy and authenticity of
the payroll expenses.
If a Payroll Journal is provided, it should include:
Payroll Journal dates
employee name, salary, or hourly rate
hours worked during the payroll journal dates
withholdings where appropriate
check number and check amount
If a Payroll Journal is not provided the following must be listed:
check number, date, payee, check amount
support for applicable payroll taxes
Original vendor invoices must be submitted for Worker's
Compensation and liability insurance coverage.
;F,
1
Telephone expenses:
A user log of pertinent information must be remitted: the party
called, the caller, the telephone number, the date, and the purpose
of the call must be identified.
Telefax, fax, etc.:
A fax log is required. The log must define the sender, the
intended recipient, the date, the number called, and the reason for
sending the fax.
Supplies, services, etc.:
For supplies or services ordered the County requires the original
vendor invoice.
Rents, leases, etc.:
A copy of the rental agreement or lease is required. Deposits and
advance payments will not be allowable expenses.
Postage, overnight deliveries, courier, etc.:
A log of all postage expenses as it relates to the County contract
is required for reimbursement. For overnight or express
deliveries, the original vendor invoice must be included.
Reproductions, copies, etc.:
A log of copy expenses as it relates to the County contract is
required for reimbursement. The log must define the date, number
of copies made, source document, purpose, and recipient. A
reasonable fee for copy expenses will be allowable. For vendor
services, the original vendor invoice is required and a sample of
the finished product.
Travel expenses: please refer to Florida Statute 112.061.
Travel expenses must be submitted on a State of Florida Voucher for
Reimbursement of Travel Expenses. Credit card statements are not
acceptable documentation for reimbursement.
Airfare reimbursement requires
portion of the airline ticket.
to facilitate the audit trail.
the original passenger receipt
A travel itinerary is appreciated
Auto rental reimbursement requires the original vendor invoice.
Fuel purchases should be documented with original paid receipts.
Original taxi receipts should be provided. However, reasonable
fares will be reimbursed without receipts. Taxis are not
reimbursed if taken to arrive at a departure point: for example,
taking a taxi from one's residence to the airport for a business
trip is not reimbursable.
i
Original toll receipts should be provided. However, reasonable
tolls will be reimbursed without receipts.
Parking is considered a reimbursable travel expense at the
destination. Airport parking during a business trip is not.
Lodging reimbursement requires a detail listing of charges. The
original lodging invoice must be submitted. The County will only
reimburse the actual room and related bed tax. Room service,
movies, and personal telephone calls (see previous guidelines) are
not allowable expenses. Per diem lodging expenses may apply.
Again, refer to Florida Statute 112.061.
Meal reimbursement is breakfast at $3.00, lunch at $6.00, and
dinner at $12.00. Meal guidelines are that travel must begin prior
to 6 am for breakfast reimbursement, before noon and end after 2pm
for lunch reimbursement, and before 6pm and end after 8 pm for
dinner reimbursement.
Mileage reimbursement is calculated at 20 cents per mile for
personal auto mileage while on county business. Effective October
1, 1994, mileage will be reimbursed at 25 cents per mile. An
odometer reading must be included on the state travel voucher for
vicinity travel. A mileage map is attached for reference to
allowable miles from various Florida destinations.
Mileage is not allowed from a residence or office to a point of
departure: for example, driving from one's home to the airport for
a business trip is not a reimbursable expense.
Data processing, PC time, etc.:
The original vendor invoice is required for reimbursement.
Intercompany allocations are not considered reimbursable
expenditures unless appropriate payroll journals for the charging
department (see Payroll above) are attached and certified.
The following expenses are not allowable for reimbursement:
penalties and fines
non -sufficient check charges
fundraising
contributions
capital outlay expenditures (unless specifically included in
the contract)
depreciation expenses (unless specifically included in the
contract)
SGR IFFITHS
WP51\PROCEDUR\EXP REIM
U
I It••
ATTACHMENT B
HUMAN SERVICE ORGANIZATION LETTERHEAD
Monroe County Board of County Commissioners
Finance Department
500 Whitehead Street
Key West, Florida 33040
November 4, 1994
The following is a summary of the expenses for (Human Service
Organization name) for the time period of to :
Check # Payee
Reason Amount
101
A Company
rent
$xxxx.xx
102
B Company
utilities
$xxxx.xx
103
D Company
phones
$xxxx.xx
104
Person A
payroll
$xxxx.xx
105
Person B
payroll
$xxxx.xx
(A)
Total
x
(B)
Total prior payments
$xxxx.xx
(C)
Total requested and paid
(A + B)
$xxxx.xx
(D)
Total contract amount
$xxxx.xx
Balance of contract (D -
C)
,$K xx
I certify that the above checks have been submitted to the vendors
as noted and that the expenses are accurate and in agreement with
the records of this organization. Furthermore, these expenses are
in compliance with this organization's contract with the Monroe
County Board of County Commissioners and will not be submitted for
reimbursement to any other funding source.
Executive Director
Attachments (supporting documentation)
Sworn and subscribed before me this
Notary Public
day of 199_.
Notary Stamp
MILEAGE CHART
KEY WEST TO:
Bay Point
15
Big Coppitt
10
Big Pine
31
Big Torch Key
29
Clearwater Beach
399
Coco Beach
350
Conch Key
55
Cudjoe Key
22
Dania
180
Daytona Beach
416
Duck Key
62
Ft. Lauderdale
183
Ft. Myers
275
Gainesville
476
Grassy Key
56
Hollywood
175
Homestead
127
Islamorada
83
Jacksonville
505
Key Colony Beach
53
Key Largo
101
Lakeland
365
Layton
70
Little Torch Key
28
Long Key
70
Lower Matecumbe Key
75
Marathon
48
Marathon Shores
53
Marco Island
221
Miami
155
Miami Beach
170
Middle Torch Key
26
Naples
236
Ocean Reef
118
Opa Locka
180
Orlando
378
Palm Beach
223
Palm Beach Gardens
238
Panama City
702
Plantation Key
87
Ramrod Key
27
Rock Harbor
100
Stock Island
05
Sugarloaf Key
17
Summerland Key
24
W. Summerland Key
31
Sunshine Key
39
Tallahassee
606
Tampa
391
Tavernier
92
Vacation Village
84
MA,RA IHON TO:
Big Pine Key
17
Conch Key
12
Islamorada
35
Key Largo
50
Long Key
22
Miami
110
Plantation Key
39
Summerland Key
24
Sunshine Key
09
Tavernier
45
BOOT KEY TO:
Long Key 20
Middle Torch 22
HOMESTEAD TO:
Key West
127
Plantation
42
Tavernier
35
KEY LARGO
TO:
Big Pine Key
70
Homestead
27
Islamorada
36
Long Key
40
Marathon
50
Miami
57
Ocean Reef
17
Plantation
14
LONG KEY
TO:
Boot Key
20
Cudjoe Key
47
Homestead
61
Islamorada
16
Marathon
22
Miami
109
Middle Torch
43
Plantation Key
AHAM1
20
TO:
Islamorada
72
Key Largo
54
Marathon
110
PLANTATION
Big Pine
TO:
56
Duck Key
26
Homestead
42
Key Largo
14
Key West
87
Layton
17
Marathon
39
Miami
67
Sunshine Key
48
• �. Alxil 22. I'M
1A Priitiisg
GENERAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT MENTAL HEALTH CLINICS
BII,"1VEf EN
MONROE COUNTY, FLORIDA
AND
GUIDANCE CLINIC OF THE UPPER KEYS, INC.
Prior to the commencement of work governed by this contract, the Contractor shall obtain
General -iability insurance. Coverage shall be maintained throughout the lit( of the contract and
include, as a minimum:
• Premises Operations
• Products and Completed Operations
• Blanket Contractual Liability
• Personal Iniury Liability
• Expanded Dcrinition of Property Damage
The minimum limits acceptable shall be:
$1,000,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$ 500,000 per Person
$ 1,000,000 per Occurrence
$ 100,000 Property Damage
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 alicr the effective (late 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.
The Monroe County Board of County Commissioners shall be named as Additional Insured on all
policies issued to satisfy the above requirements.
Adenini: h slivc hrAnwik)n GL3 r
04709.1 56
April 22, 1993
1 %I I`riN ie1l;
VEHICLE LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT MENTAL HEALTH CLINICS
1;ETWEEN
MONROE COUNTY, FLORIDA
AND
GUIDANCE CLINIC OF THE UPPER KEYS,•INC
Recognizing that the work governed by this contract requires the use of vehicles, the Contractor,
prior to the commencement of work, shall obtain Vehicle Liability Insurance. Coverage shall be
maintained throughout the litc of the contract and include, as a minimum, liability coverage for:
• Owncd, Non-Owncd, and llired Vehicles
The minimum limits acceptable shall be:
$1,000,000 Combined Single Limit (CSL) +
If split limits arc provided, the minimum limits acceptable shall be:
$ 500,000 per Person
$1,000,000 per Occurrence
$ 100,000 Property Damage
The Monroe County Board of County Commissioners shall be named as Additional Insured on all
policies issued to satisfy the above requirements.
AJminiaralivc livAnklion VL3 1
114709.1 77
y Apra 22. 17v.1
v Ixl IYirinq;
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
CONTRACT MENTAL HEALTH CLINICS
BETWEEN
MONROE COUNTY, FLORIDA
AND
GUIDANCE CLINIC OF THE UPPER KEYS, INC.
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 statutes.
In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less than:
$1,000,000 Bodily Injury by Accident
$1,000,000 Bodily Injury by Disease, policy limits
$1,000,000 Bodily Injury 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 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. Tile Contractor may 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 may be required to submit updated financial statements from the fund
upon.rcggcst from the County.
Adminisinlivc Immnw1ion WC3
April 22. 1',-)3
Iu 1'rinling
MEDICAL PROFESSIONAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT MENTAL HEALTH CLINICS
BETWEEN
MONROH; COUNTY, FLOItIDA
AND
GUIDANCE CLINIC OF THE UPPER KEYS, INC.
Recognizing that the work governed by this contract involves the providing of professional
medical treatment, the Contractor shall purchase and maintain, throughout the life of the contract,
Professional Liability Insurance which will respond to the rendering of, or failure to render
medical professional services under this contract.
The minimum limits of liability shall be:
$1,000,000 per Occurrence/$3,000,000 Aggregate
If coverage is provided on a claims made basis, an extended claims reporting period of four (4)
years will be required.
AJministralive Irninjction M ED2
11,1709.1 66
BOARD OF COUNTY COMMISSIONERS
OUNTYof MONROE
KEY WEST FLORIDA 33040
(305) 294-4641
MEMORANDUM
To: Eva Limbert
OMB
From: Kay Miller
Risk Management
Date: January 24, 1995
MAYOR, Jack London, Distict 2
Mayor Pro Tem, A Earl Cheal, District 4
Wilhelmina Harvey, Dictrict 1
Shirley Freeman, District 3
Mary Kay Reich, District 5
Subject: Guidance Clinic of the Upper Keys
Attached are approved insurance certificates and Request for
Waiver of Insurance Requirements form for subject funding agree-
ment.
These forms constitute insurance sufficiency.
this agreement for execution as soon as possible.
If you have any questions, please call.
Please forward
UPA
E OF INSURANCE: GUIDA-1
PRODUCER
The Johnsons Insurance Agency
89015 Overseas Highway
Tavernier FL 3307D
CSR SC 12 30 94
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
305-852-9247 COMPANY
------------------------------------------------------------ A US F &G ENT
INSURED--------------AP_P_BOYEO.BY RISK_MAN QGEM
----____________--______-
COMPANY
B
------------------------- (f----------------------------------------
COMPANY DATE
Fhe Guidance Clinic* C
POBox 363 ----------------------------------- -------------------------------
Tavernier FL 33070 COMPANY tiVA'�'ER: N/A 'fES
D
> COVERAGES <_____________________________________----------- ____________________________________________________________________
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.
---------------------------------------------------------------------------------------------------------------------------------
LTRI TYPE OF INSURANCE POLICY NUMBER IDATEOLICY (MM/DDFF IDATE(MM/DD/YY)IPOLICY EXP LIMITS
AI
AI
-------------------------------
GENERAL LIABILITY
IX ] COMMERCIAL GEN LIABILITY
[ ] CLAIMS MADE [XI OCC.
[ ] OWNERS'S & CONTRACTOR'S
PROTECTIVE
-------------------------------
AUTOMOBILE LIABILITY
[ ] ANY AUTO
[ ] ALL OWNED AUTOS
[ ] SCHEDULED AUTOS
[ ] HIRED AUTOS
IX I NON -OWNED AUTOS
[ J
-------------------------------
GARAGE LIABILITY
[ ] ANY AUTO
-------------------------------
EXCESS LIABILITY
[ ] UMBRELLA FORM
[ I OTHER THAN UMBRELLA FORM
-------------------------------
WORKERS COMP. AND EMP. LIAB.
THE PROPRIETOR/PARTNERS/
EXECUTIVE OFFICERS ARE:
[ ] INCL. [ ] EXCL.
OTHER
1MP300470687
1MP300470687
07/01/94
07/01/95
----------------------------
07/01/94 07/01/95
--------------------
GENERAL AGGREGATE
PROD-COMP/OP AGG.
PERS. & ADV. INJURY
EACH OCCURRENCE
FIRE DAMAGE
(ANY ONE FIRE)
MED. EXPENSE
(ANY ONE PERSON)
-------------------
COMB. SINGLE LIMIT
BODILY INJURY
(PER PERSON)
BODILY INJURY
(PER ACCIDENT)
PROPERTY DAMAGE
AUTO ONLY (EA ACC)
OTHER / AUTO ONLY:
EACH ACCIDENT
AGGREGATE
EACH OCCURRENCE
AGGREGATE
--------------
L, 000, 00(
L, 000, 00(
L, 000, 00(
L, 000, 00(
i0, 000
),000
--------------
L, 000, 00(
------------------- --------------
]STATUTORY LIMITS
EACH ACCIDENT
DISEASE-POL. LIMIT
DI$EA E-EACH EMP.
"Za
--- - ----------------------------
t �)SS ContTot
CRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS----------------------------------------
----------------------- --
Ltal Health Clinic
'E: Ce >'ficate Holder is listed on the policy as Additional Insured.
7
> CERTIFICATE H LDER
MONCO-3
Monroe County Risk Management
Keyy Bahleda
51D0 College Road
Key West FL 33040
ACORD 25-S (3/93)
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
10 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 iC..O�MiP.A-NYi--
TS --G- --T-S-- 0 -R-E-S-E-,NTATIVES.
-------------------------- ------
I
AUTHORIZED REPRESENTAT
The Johnsons Insurance Aar cv /
• Acreount Number: F'L GUID 3631.
Date:12/0*7 /94 Initials: DC
CERTIFICATE OF INSURANCE
Amer i cari Hcmie Assui--aiice C.cmip arty
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, subject to 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 OF THE
UFT'ER KEYS, INC.
T'AVERNIER ! Fi_ '33070
APPROVED BY RISK MANAGEMENT
BY
DATE /' - a y '�
WA'VFR: N/A - YFS ✓
Occupation or Business: ;30CIAL. SE'RVIC:E: AGENCY R--ccived.
1bsk N."gent. & Lass Confro,
Location of Operations: DATE ._.__Z.2-
(if different than address listed above) HIPTIAL
Type of Work Covered: PROF'. MENTAL HEALTH COUNSELING
Policy
Effective
Expiration
Limits of
Coverages
Number
Date
Date
Liability
F'r-WF E SSICINAI_/
I., 000 , 000
13z
,
/ 5
70
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:
Address: COUNTY OF- MONROE
OFFICE OF MANAGEMENT &
BUDGET, AT'T'N : EVA 1_.IMI: EI-"-:T'
5100 COLLE:GE,' ROAD
KEY wEsT, FL 33040
GEN 152
DATE (MM/DD/YY)F
�
A114MUP. � � ■ "URAN . ,,.;.-..... {35� 1 �.IUGxI - d
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
0002 5 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
FT)E.' f% I3F?(:)Wlkl„ :I:('i(:;.,/i C:t':lYll I S:ti(: 0I< ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
F•' .. 0 ,. XJF AwI:::I:,: :I. 1.2 COMPANIES AFFORDING COVERAGE
DAYIONA BE'ACH FL. 3) 2 11.5 COMPANY Governmental Risk: Insurance Tr+LtSt
A APPROVED BY RISK MANAGEMENT
INSURED 00270
( J 1 DA7 ICE' Cl_. I hI I C OF 7i-II : (.)F'E'E R I<1EYS
COMPANY
B BY
F' .. O .. F 0X 363
COMPANY DATE /-.2
F'I.-. .:i.:i' } 70
C
COMPANY WAIVER: N/A YES
D
COVERAGES
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.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MM/DD/YY)
POLICY EXPIRATION
DATE (MM/DD/YY)
LIMITS
GENERAL
LIABILITY
GENERAL AGGREGATE
$
PRODUCTS-COMP/OP AGG
$
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE OCCUR
PERSONAL & ADV INJURY
$
EACH OCCURRENCE
$
OWNER'S & CONT PROT
FIRE DAMAGE (Any one fire)
$
MED EXP (Any one person)
$
AUTOMOBILE
LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
$
BODILY INJURY
(Per person)
$
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY
(Per accident)
$
HIRED AUTOS
NON -OWNED AUTOS
PROPERTY DAMAGE
$
I
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT
$
OTHER THAN AUTO ONLY:
ANY AUTO
EACH ACCIDENT
$
AGGREGATE
$
EXCESS LIABILITY
EACH OCCURRENCE
$
AGGREGATE
$
UMBRELLA FORM
$
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
STATUTORY LIMITS
EMPLOYERS' LIABILITY
EACH ACCIDENT
$
p-
THE PROPRIETOR/ INCL
PARTNERS/EXECUTIVE
00270
07/01 /9
07/01 /9 `'
DISEASE -POLICY LIMIT
$ -w -
DISEASE - EACH EMPLOYEE
$ 100
OFFICERS ARE: EXCL
OTHER
i
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/SPECIAL ITEMS
F1CAiE's HCLR
CANCELLATION,
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,
(.' 7tM.'I T l' OF, I'i(.)I,IFt 0I::.
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF' lyl(.311 T 8z. Z (•JI)(: F:
OF ANY jqND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
i;i:l•(}{,) i-1101-,-I...I.(:)1. I':x)
AUTHORIZ RESENT ATIVE
l e ACORD CORPORATION 1003
9 . .I
101 00 100 00:00
ItmAmlias R 1914993
005 P03
MYiq ♦a. I %"-.
it r(wift
M ONROV, C OUl ry. Fl OMOA
ltequest For Waiver
,of
luzurancc Requimuntx
it is Rcquc#ktt 111M IN- ia+eurnlu c CAtarm,1Qi118, as SpWnud ill die Ckxltity15 $C1tocllrtt; OC hownitxX
Rogtarcwoms, bo wsivod a "irmd wl 11w rQ119willg 0111FOvt,
Cuutrid Aw
blcAddress of Coauadlm:
CT
Scope of work:
Rems for Waiver.
d
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BMW of County Cou lissivacra avml:
wmiss Dino•
tu%V *Ai,s1mw km
04709.1
WAIVER
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1
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