07/15/1992 Contractk
MONROE COUNTY EMERGENCY MEDICAL SEkNtICES
SPECIFICATIONS
for '92 AUG 13 P ? : 1
BIOMEDICAL EQUIPMENT
PROPOSAL/CONTRACT FORM
�.
Mandatory Work and Equipment<_
There shall be one (1) preventive maintenance inspection of each
piece of biomedical equipment of the Monroe County Lower and
Middle Keys Fire and Ambulance District, as identified in
Addendum A, every six (6) months and corrective maintenance on an
as needed basis for the equipment, including all parts and labor,
unless otherwise specifically excluded elsewhere herein.
This quote includes service M-F/8-5 using UPS to ship units in
for repair. Two inspections will be performed on site during the
period. $ 12, 000. 00
Optional Work and Equipment - Price each option separately:
Option No. 1
Option No. 2
Option No. 3
Sign in ink in the space provided below. Unsigned proposals will
be considered incomplete and will be subject to rejection.
IT IS AGREED BY THE UNDERSIGNED VENDOR THAT THE SIGNING AND
DELIVERY OF THIS PROPOSAL REPRESENTS THE VENDOR'S ACCEPTANCE OF
THE TERMS AND CONDITIONS OF THE FOREGOING SPECIFICATIONS AND
PROVISIONS, WHEN EXECUTED BY MONROE COUNTY WILL REPRESENT THE
AGREEMENT BETWEEN THE PARTIES.
COMPANY NAME K- LA AVE
ADDRESS 59(65 - A-7 1�1JcS;MENT �A�lt,
CITY AND STATE 14 S ZIP CODE
TELEPHONE yt7`'1
BY �. DATE
,Authorized Signature) (Date)
CORPORATE SEAL
Attest:
BOARD OF GOVERNORS, LOWER AND MIDDLE KEYS FIRE AND AMBULANCE
DISTRICT
(SEAL)
• .. Attest: Danny L. Kohlage, erk
Chairman
h
Date: 15, 19D, APPROVED A r nRM
By
1
Date - 2= T -
-f ►
MONROE COUNTY EMERGENCY MEDICAL SERVICES
SPECIFICATIONS
for
BIOMEDICAL EQUIPMENT
These specifications are for the sole purpose of requesting price
proposals for providing a total of two (2) maintenance inspections
during the term of this proposal, one (1) every six (6) months, and
corrective maintenance on an as needed basis for biomedical equipment
owned and operated by the Lower and Middle Keys Fire and Ambulance
District, of Monroe County, Florida.
Two (2) categories are specified in this proposal; 1) Mandatory
Work and Equipment; and, (2) Optional Work and Equipment. The vendor
must price and agree to do all work and furnish all equipment listed
under both categories. Monroe County reserves the right to accept or
reject any or all of the work and equipment proposed.
Mandatory Work and Equipment
Preventive Maintenance Inspections
There shall be one (1) preventive maintenance inspection of
each piece of equipment every six (6) months, generally in October
and in April, however, the first preventive maintenance inspection
shall be scheduled within fourteen (14) days of execution, by
Monroe County, of the Proposal/Contract Form. Performance output
and electrical safety inspections shall be performed in accordance
with the standards established by the Joint Commission on the
Accreditation of Hospitals (JCAH) and/or the National Fire
Protection Agency (NFPA).
Each inspection shall include the following:
1. Cleaning the equipment.
2. Calibration: Make required adjustments to bring the equipment
up to the factory specifications. The calibration results of each
piece of equipment shall be recorded and placed in a file that
contains a list of all Monroe County biomedical equipment.
NOTE: The successful vendor must provide Monroe County Emergency
Medical Services with documentation that their test equipment is
calibrated every six (6) months and is traceable to the National
Bureau of Standards (NBS).
3. Mechanical Inspection: Inspect each piece of equipment for
wear, repair as necessary, and record the findings. The inspection
shall include patient cables and lead wires.
4. Leakage Current Measurements shall be recorded and filed.
5. Output Measurements: Defibrillator outputs
6. Lubrication: Each instrument shall be lubricated, as
appropriate, to manufacturer specifications.
7. Scheduling: Mutually agreed upon scheduling of each regular
inspection visit shall be made in advance. inspections shall be
conducted on -site in Monroe County.
8. Documentation: Upon completion of preventive maintenance
inspections, a report outlining the performance of each piece of
equipment will be forwarded to the Monroe County Emergency Medical
Services office within seven (7) calendar days.
Corrective Maintenance
All repairs, modifications and/or calibrations shall be
consistent with the device amendments to the Food, Drug and
Cosmetic Act regulated by the Food and Drug Administration (FDA).
All equipment that is repaired will be calibrated to OEM
performance verification procedures.
1. Service: Repair service shall be available Monday through
Friday, 8:00 AM-5:00 PM, using UPS to ship units in need of repair
to the location identified by the vendor as the repair facility.
The vendor will supply the appropriate shipping containers for each
piece of equipment to be repaired. All transportation/shipping
costs from the repair facility shall be the responsibility of the
vendor.
2. Loaners: Loaner(s) will be provided, on an as needed basis,
if it becomes necessary to remove a defibrillator, monitor, pacer
or blood pressure machine from service. The vendor shall provide a
unit(s), of exactly the same make and model, until the nonoperating
equipment is back in service. All costs associated with providing
a loaner to Monroe County, and its return, shall be the
responsibility of the vendor.
General Conditions
1. Parts: The cost of all parts, components and materials shall
be included as a cost within the Mandatory Work and Equipment
category unless otherwise specifically excluded. All parts shall
be guaranteed to be of new and of current manufacture and of at
least OEM quality, and no part or attachment shall be substituted
or applied contrary to the manufacturer's recommendation and
standard practices. All parts shall be guaranteed for a minimum
Of six (6) months.
Page No. 2
2. Labor: This proposal will include the cost of all labor
associated with the inspection, maintenance and repair of Monroe
County's biomedical equipment. All workmanship shall be equal to
the highest industry standards and performed in a professional
manner so as to insure it is safe and functional. All labor shall
be guaranteed for a minimum of six months.
3. Exclusions: Repair of the following items will not be covered
by this proposal: Blood pressure cuff bladders and tubing, patient
cables, and cases. Inspection of these items shall be included.
Cases may be included if Option No. 3 is exercised.
4. Batteries: This proposal will include the replacement of
certain batteries for the listed life pak monitor/defibrillators,
pacers and automatic blood pressure monitors on an as needed
basis. Batteries are required to be replaced upon expiration of
eighteen (18) months from their date of manufacturer.
Only new batteries, of at least OEM equal quality, will be
used.
5. Insurance: Each vendor must show that they have adequate
Workmen Compensation insurance to include statutory benefits. Each
vendor must also show that they have premises/operations and
products/completed operations insurance in the amount of $1,000,000
per occurrence/$2,000,000 aggregate.
6. Technical Assistance: The successful vendor must provide
technical assistance to Monroe County to establish regulatory
requirements for Monroe County's biomedical equipment.
7. Technician Training: The successful vendor must show, on
demand, the training qualifications of the technicians that will be
working on Monroe County Emergency Medical Service equipment.
8. Technical Data: The successful vendor must show, on demand,
that they have the technical library (current service manuals,
etc.) necessary to support the technician(s) working on the
biomedical equipment.
9. Default Provisions: In case of default, including failure to
respond in a timely manner to a request for service, by the vendor,
Monroe County may procure services from an outside vendor and hold
the vendor responsible for any charges incurred by Monroe County
for the repair of its equipment.
10. Contract Award: Monroe County reserves the right to reject
any or all proposals deemed to be unresponsive and to accept any
proposal which in its best interest best meets the specifications
herein. Monroe County reserves the right, before awarding the
proposal, to require a vendor to submit such evidence
of his qualifications as it may deem necessary. Documentation that
may be required is financial, technical and other qualifications
and abilities of a vendor in making the award in the best interest
of Monroe County. Monroe County shall be the final authority in
the award of the contract. Acceptance of a proposal shall be
Page No. 3
evidenced by execution, by Monroe County, of the Proposal/Contract
Form.
11. Familiarity With Laws: The vendor is presumed to be familiar
with all federal, state and local laws, ordinances, code rules, and
regulations that may in any way affect the work. Ignorance of the
law shall in no way relieve the vendor from responsibility.
12. Licenses: All bidders must have all licenses that are
required by Florida State law and submit copies of them with the
proposal.
13. Quantities: Original price proposals shall be based on those
quantities identified in Schedule A of this specification including
that biomedical equipment for which the Manufacturer's warranty
will expire during the term of this proposal. Manufacturer
warranty expiration dates, when applicable, are listed on Schedule
A.
14. Quantity Increases/Decreases: Monroe County reserves the
right to increase or decrease the equipment listed in Schedule A of
this proposal, during the term of the proposal. Equipment
increases or decreases will be accomplished by contract addendum,
mutually agreed upon and executed by the vendor and Monroe County.
15. Errors or Omissions: The vendor shall take no advantage of
any apparent error or omission which might be discovered in this
specification, but shall forthwith notify the Monroe County EMS
Director at 490 63 St., Suite 140, Marathon, Florida 33050, of
such discovery. The EMS Director will then make such corrections or
interpretations as deemed necessary for reflecting the actual
spirit and intent of the specification.
16. Customer Listing: The vendor must provide Monroe County
Emergency Medical Services a list of Pre -Hospital Emergency Medical
Services for whom the vendor has performed similar or identical
work within the last three years.
17. Initial Term of Proposal: It is the intent of Monroe County
to establish a contract that will commence on execution of the
Proposal/Contract Form, by Monroe County, and expire one year
from that date.
18. Renewal Option: Assuming the availability of budgeted funds,
this proposal may be renewed for an additional one (1) year term if
mutually agreed upon by both parties in writing.
19. Payment: The vendor shall invoice Monroe County in 12 equal
monthly installments, on the first of each month, for the preceding
month. Invoices shall be submitted to the Monroe County EMS
Director, 490 63 St., Suite 140, Marathon, Florida 33050, for
approval and processing.
20. Signature Required: All proposals must be signed with the
firm name and by an officer or employee having the authority to
bind the company or firm by his signature.
Page No. 4
21. Proposal prices shall be valid for at least ninety (90) days
from the closing date for submittal of proposals.
22. Exceptions: Variances or exceptions MUST be noted by number
and explained in full detail on the last page(s) of these
specifications.
23. The vendor agrees to indemnify Monroe County and hold the
COUNTY harmless from and against all claims, damages, losses and
expenses, including reasonable attorneys' fees in any action
arising out of performance of the work herein, including bodily
injury, illness or death, or for property damage including loss of
use, resulting from the vendor's work.
24. This Agreement, its performance and all disputes arising
hereunder, shall be governed by the laws of the State of Florida
and both parties agree that a proper venue for any action shall
be Monroe County.
Optional Work and Equipment
Option No. 1
Paddles, Adult: This proposal will include the cost of
replacing adult defibrillator paddles, on an as needed basis -
Specify unit cost.
Option No. 2
Everything in the proposal will remain the same except there
will be only one (1) preventive inspection. This inspection
shall be within fourteen (14) days of execution of the contract.
Option No. 3
Cases: This proposal shall include the cost of replacing
cases, for the monitors, defibrillators and pacer units, on an as
needed basis - Specify unit cost.
Page No. 5
ADDENDUM A
LOWER & MIDDLE KEYS BIOMEDICAL EQUIPMENT INVENTORY
Description
LP 5 Monitor
LP 5 Monitor
LP 5 Monitor
LP 5 Monitor
LP 5 Monitor
LP 5 Monitor
LP 5 Monitor
LP 5 Monitor
LP 5 Monitor
LP 5 Defibrillator
LP 5 Defibrillator
LP 5 Defibrillator
LP 5 Defibrillator
LP 5 Defibrillator
LP 5 Defibrillator
LP 5 Defibrillator
LS 100
LS 100
LS 100
LS 100
LS 100
LS 100
LS 100
LS 100
LP 5 Charger
LP 5 Charger
LP 5 Charger
LP 5 Charger
Quick Pacer
Quick Pacer
Quick Pacer
Quick Pacer
Quick Pacer
LP 10 With Pacer
LP 10 With Pacer
LP 10 With Pacer
LP 10 With Pacer
LP 10 With Pacer
Battery Support System
Battery Support System
Battery Support System
Battery Support System
Battery Support System
Battery Support System
Serial Number
051754
009935
054370
006561
009936
009444
043653
9937
00057027
028972
032963
007988
019139
008960
022986
030843
000712
000737
004801
004981
004986
004993
004994
004998
009483
020317
010000
9999
001036
001062
001066
001106
001122
007442
00007308
00007300
00007327
004475
009177
014699
00017090
00017116
17021
17028
Page No. 6
SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a),
FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
TIIIS FORM MUST BE SIGNET) AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
1. This sworn statement is submitted to —WAV—
[print name of the public entity]
by 'RkQViA1?b -bAN 1F .) , r
[print individual's name and title]
for
[print name of entity submitting sworn statement]
whose business address is
1�5-1A1 1NVESiM�t�i�Nc,
W c� I P P M BENZ" 'FL O �4
and (if applicable) its Federal Employer Identification Number (FEIN) is
(If the entity has nIN, include the Social Security Number of the Individual signing this
sworn statement:
2. 1 understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a
violation of any state or federal law by a person with respect to and directly related to the transaction of
business with any public entity or with an agency or political subdivision of any other state or of the United
States, including, but not limited to, any bid or contract for goods or services to be provided to any public
entity or an agency or political subdivision of any other state or of the United States and Involving antitrust,
fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.
3. 1 understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes, means
a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any
federal or state trial court of record relating to charges brought by indictment or Information after July 1,
1989, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes, means:
I. A predecessor or successor of a person convicted of a public entity crime; or
2. An entity under the control of any natural person who is active in the management of the entity and
who has been convicted of a public entity crime. The term "affiliate" includes those officers, directors,
executives, partners, shareholders, employees, members, and agents who are active In the management of
an affiliate. The ownership by one person of shares constituting a controlling interest In another person,
or a pooling of equipment or income among persons when not for fair market value under an arm's length
agreement, shall be a prima facie case that one person controls another person. A person who knowingly
enters into a joint venture with a person who has been convicted of a public entity crime in Florida during
the preceding 36 months shall be considered an affiliate.
I understand that a "person" as defined in Paragraph 287.133(l)(e), Florida Statutes, means any natural
person or entity Organized under the laws of any state or of the United States with the legal power to enter
into a binding contract and which bids or applies to bid on contracts for the provision of goods or services
let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The
term "person" includes those officers, directors, executives, partners, shareholders, employees, members, and
agents who are active in management of an entity.
6. Based on information and belief, the statement which I have marked below is true in relation to the ent
submitting this sworn statement. [indicate which statement applies.] ty
Neither the entity submitting this sworn statement, nor any of its officers, directors, executives,
partners, shareholders, employees, members, or agents who are active in the management of the entity, nor
any affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July
1, 1989.
The entity submitting this sworn statement, or one or more of its officers, directors, executives
partners, shareholders, employees, members, or agents who are active in the management of the entity, or
1, affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July
1, 1989.
The entity submitting this sworn statement, or one or more of its officers, directors, executives,
partners, shareholders, employees, members, or agents who are active in the management the entity, or
an affiliate of the entity has been charged with and convicted of a public entity crime subsequent tJuly
1, 1989. However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida,
Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that
it was not in the public interest to place the entity submitting this sworn statement on the convicted vendor
list. [attach a copy of the final order]
I UNDERSTAND TIIAT TIIE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR TIIE
PUBLIC ENTITY IDENTIFIED IN PARAGRAPII 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND
TIIAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR
I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING
INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN YEAR
ON 287.IN 017,
IT IS FILED.
STATUTES FOR CATEGORY 11V0 OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.
7.017, LORIDA
[signature)
Sworn to and subscribed before me this _'l�
C day of 19 C�,
Personally known V
OR Produced identification —
Nota Pu lic - State f % r �
(Type of identt— 'fica(ion)
Form PUR 7068 (Rev. 06/18/92)
My commission expires COry '-r)
(Printed typed or stamped
commissioned name of notary public)
JANET D. SZAKOVITS, NOTARY PUBLIC
STATE OF FLORIDA
MY COMMISSION EXPIRES 9179194
SWORN STATEMENT UNDER ORD I NAME NO. 10-1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE
P'wAvE __warrants that he/it has not employed,
retained or otherwise had act on his/its behalf any former County officer
or employee in voliation 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 fo mer County officer or employee.
(signature)
Date:__7'�
STATE OF TLQQ_A DtA
COUNTY OF __Pat n
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
1C a('CA _iA�Ch'llei(`_1 _ _ who, after first being sworn by me,
►�+��c��ai�cP a3q�� �yC�S51 ��
affixed his/her signature (name of individual signing) in the space
provided above on this cc__day of
19 c�
My commission expires:
NOT RY PUB tIC�
JANET D. SZAKOVITS, NOTARY PUBLIC
STATE OF FLORIDA
MY COMMISSION EXPIRES 9179194
ISSUE DATE (MM/DD/YY)
COMATE `»OF NS RAN- -
� 2
8 5 9
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
Frank J Becker Inc
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
173 Earle Avenue
POLICIES BELOW.
Lynbrook Ny 11563
COMPANIES AFFORDING COVERAGE
Commercial Union
LETTERNYA
INSURED
COMPANY 8
LETTER
R Wave Inc.
COMPANY `.
LETTER
173 Newtown Road
Plainview NY 11803
COMPANY
D
LETTER
COMPANY E
LETTER
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 TYPE OF INSURANCE POLICY NUMBER
LTR
POLICY EFFECTIVE POLICY EXPIRATION LIMITS
DATE (MM/DD/YY) DATE (MM/DD/YY)
GENERAL LIABILITY
GENERAL AGGREGATE s3,000,000
A X COMMERCIAL GENERAL LIABILITY
PRODUCTS-COMP/OP AGG. $
CLAIMS MADE X OCCUR. CJR131586
8 / 1 / 92 8 / 1 / 93 PERSONAL & ADV. INJURY $ 1 ) 000 , 000
OWNER'S & CONTRACTOR'S PROT.
EACH OCCURRENCE $ 1 , 000 , 000
FIRE DAMAGE (Any one fire) $ 50,000
MED. EXPENSE (Any one person) $ 5,000
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 $
AND
DISEASE —POLICY LIMIT $
EMPLOYERS' LIABILITY
DISEASE —EACH EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
CIEN'T941CATE HOAR
CANCELLATION
County of MOnroe
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
490 63rd Street
EXPI ATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
Ocean Suite 170
MAIL�O DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
Marathon FLA 33050
LEFT, BUT FAILURE T MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY K U ON THf COMPANY, ITS AG NTS OR EPRESENTATIVES.
AUTHORIZED REP NT E
ACORD 25-5 M
CORPORATION" 1990
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TO V1i_A'!E 5 DAYS WkI'1'TEN I40'1'ICE 01- SUCH CANCELLATION
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AUI,IiF:SSED Slihl,i, Bi-, :,lff'I''li'IEIJT COMPLIANCE WI7111 `I'Itl j 1'R()VIS:IgN. THE STAT INSURANCE
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?��85 iNS72UMphit NiFC;-PROF-ScltiNt Nt)0 �, � -
ABOVE 2AT!S APE SUBJtCt t6 °.()% DISCOUNT A
TirjS IS NOT A GILL. THE 0001t WMNt 0' 1. 404,94 OkEVIOUS0
BILIEO 15 CONTINUED IN 909E6t ObA fN3 11NNAL i
EFFECTIVE JULY 1, 101, NEW Atilt) AMWAL P668191 W!LL INCLUDE
AN EXPENSE CONSTANT OP WO ktdAODt tgj OP:'AAlmlom 9tit .
EFFECTIVE JULY 1, 1991 , Ik YbUR PbLf6v Mom
A CUAPOPAIION, THEN THE WNIMOM WW0 hI. WL''000
AN EXECUTIVE OOFICER WILL Ht: t4tt, 'tHE MAkYMUWwMLY
PAVRJ:�I L FOR AN EXECU't1Vt: OroictR wftt op t glo,.
,
METROPOLITAN PROPERTY AND CASUALTY INSURANCE COMPANY
AUTOMOBILE INSURANCE DECLARATIONS p cTi
S 3
'OUCY NUMBER:
'Ol_!CY EFFECTIVE OATS: 05 28.- 92
t.RANSA<;l;lf�tyTYP�: 'POLICYi CHANCiE 01
:v E.4PIRATION DATE. 11.�28-9 TfZAN5AETION
A3. 1 01 AM Ei FEPTIVF, 48-92.
r;M��aINSURED: - BILL INSURED
R-WAVE, INC. /\
R I CHARD D AN I ER I 3965 INVESTMENT LANE
SIKFE _IiA7 (/
180 FOREST AVE 11WEST PALM BEACH,, FL 3.3404 �v
MASSAPEQUA NY 758 g
4.Q1•42-3660
777-7-7
1 �U - Co
, ,4 VEHICLE D> SCRIPTIUN - -- -
t! EAR MAKE M IC R (BdDY:TYPE V..HfCE 10 IUM�E 4
UEEP HE K ST �IAG 1J J L 1LL 1 41000 $5 SUM .t_E_R�aRY
_ g CHEVROLET RVETT CON IGIYY318OK5105539 A281000 19 06
COVERAGE C1$Gp1PTIQN$ :; APPLICABLIE LIMITS SE M: T [�w ie !16 l . CGICu,llur
`' KSONAL INJURY PROTECTION:
r1'; ATORY (BASIC) PIP
,�TIONAL PIP
LOSS - 3 YEAR LIMIT
5It_ITY:
_.--) j LY INJURY
PROPERTY DAMAGE
SURED/UNDER INSURED
J RISTS:
E_DILY INJURY
'H .)ICAL DAMAGE:
-UAL CASH VALUE LESS
�DUCTIBLES FOR LOSS BY:
COLLISION
COMPREHENSIVE
TOWING AND LABOR
`;nNAL COVERAGES:
LASS DEDUCTIBLE BUYBACK
NO DEDUCTIBLE ` "
$ 50,000 PER PERSON 67 67
$ 50,000 PER PERSON
$ 2,000
$ 100,000 PER PERSON/
$ 300,000 PER OCCURRENCE 131 131
$ 50,000 PER OCCURRENCE 64 64
$ 100,000 PER PERSON/
$ 300,000 PER ACCIDENT 45 45
DEDUCTIBLES:
VEH 2 VEH 3
$ 500 $ 500 1238
82
LIMIT $50 PER DISABLEMENT ?8
}+! SEMI-ANNUAL PREMIUM: $1,308.00 VEHICLE TOTALS:
�R SEMI-ANNUAL PREMIUM: $1,697.00
4:'i IN PREMIUM FROM 05-28-92 THROUGH 11-28-92: $ 389-
DECLARATIONS DOES NOT SUPERSEDE ANY CANCELLATION NOTICES.
:ADDITIONAL INFORMATION ON THE FOLLOWING DECLARATIONS PAGES)
=`•`S AND ENDORSEMENTS: MPL 7066-031 P877A NY#3A P659 P670 P845
EPRESENTATIVE IS: PICKETT LINDA J
f_-RVTCE, CALL 800-422-4272 OR WRITE T0; METROPOLITAN
SUBURBAN BR N Y
''3. ,JTICA- NEW YORK 13503; FOR CLAIMSIM D RECTir"
INCL
518 790
P906 C102
516-293-8050
R07--803-a
R IVAVE INC. TEL No . 516 593 F5630
--Tun 17,92 10
53 P .03/ 03
INVESTMENT LANE
S-ZH4 fA
'cty3
EVEST PALMi BEACH, FL 33404 THE STATE INSURANCE
FUND
407-842-3660 199 Church Strool. New YOrk,N.Y
10007
Cg16) 942-6802
C t lypc
;roLD 40
Yximd C'va'od
if
[:�NFORMAT�10NOo
PAGE (REV)
000
2/05/92 TO
02/05/93*
R7-nRESENTATIVE:123190 zNSURED:
897 516-1
F-RANK J BECKER INC R-WAVE INC
887 Ste~i
173 EARLE AVE 173 NEWTOWN ROAC-
Oago
_YNBROCK NY 11563 PLAINVIE'W
NY 11403
801 Naa-Uur
L642 580
' E,R100 OF COV&RAGL BEGINS AND EN07 AT TWEI,VE AND ONE MINUTE O'CLOCK A,M, EA.STER14 STANC)ARD TIME
!7PR Or BUSINESS: CORPORATION
DEPOSIT PREMIUM BILL A#fl INFORMATION PAGE (REVISED/
MANUAL RATE PREMIUM . . . . . . . . . . . . . . .
1,197.4b
2. EXPENSE CONSTANT . . . . . . . . . . . . . . . .
140.09
3. TOTAL RATING BOARD PREMIUM . • . . , .
. 1,337.40
a. STATE FUND DISCOUNT - 307 OF ITEM 1. . .
. 359,22CR
5, ESTIMATED ANNUAL STATE FUND PREMIUM. . . . . . .
, 078.18
6. DEPOSIT PREMIUM REQUIRED - 1QQ%; OF ITEM 5,
578.18
7. LESS DEPOSIT FOR TMIS PERIOD PREVIOUSLY BILLED
1,691,13CR
8. NET STATE FUND PREMIUM FOR THIS PERI00
712 9SCR
9. BALANCE AS OF 2/18/92 LAST BILL # L620 687.
. 3.026.71
10. ACCOUNT BALANCE PRIOR TO THIS SILL . , . , , , ,
. .
3,026.'1
11. AMOUNT DUE STATE FUND, ,
, , , , , , , , , , , ,
, , , , , , •
$2,313.76
-!-:S •GIVES CREDIT FOR PREVIOUS DEPOSIT BILL, NUMBER L620687,
SUBJECT TO ANNUAL PAYROLL REPORT BY ASSURED, OR AUDIT, AS 0FTEPMjNE0
BV STATE
; L n,