FY1993 12/09/1992� GOUNTy
c
Jul JAM CUIpfG �OG�
�f
V
OE COUIR�•�
BRANCH OFFICE
3117 OVERSEAS HIGHWAY
MARATHON, FLORIDA 33050
TEL. (305) 289 -6027
30annp 1. Iftorbage
CLERK OF THE CIRCUIT COURT
MONROE COUNTY
500 WHITEHEAD STREET
KEY WEST, FLORIDA 33040
TEL. (305) 292 -3550
BRANCH OFFICE
88820 OVERSEAS HIGHWAY
PLANTATION KEY, FLORIDA 33070
TEL. (305) 852 -7145
M E M R R A R R U M
TO: Division of Management Services c/o
County Administrator
FROM: Isabel C. DeSantis, Deputy Clerk IL'
DATE: May 21, 1993
On December 9, 1992, the Board authorized execution of an
Agreement between Monroe County and the Hospice o the Florida
Keys, Inc. in the amount of $50,000.00.
Attached hereto is a duplicate original of the subject Agreement
which should be returned to Hospice.
cc: County Attorney
Finance
Risk Management w/o document
File
E!t_ED FOR RECORD '
A G R E E M E N T
'93 MAY 21 A 9
THIS AGREEMENT. is made as of the q* day of h — ,
1992, between' -the BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY,
FLORIDA, hereinafter referred to as "Board" and HOSPICE OF THE
FLORIDA KEYS, INC., hereinafter referred to as "Hospice."
WHEREAS, the Board and Hospice desire to enter into an
agreement wherein the Board contracts for services from Hospice
in providing the medical, psychological, physical and social
needs of terminally ill persons and their families and to
mobilize other community resources to meet such needs for the
citizens of Monroe County, Florida, and
WHEREAS, such services have been provided by Hospice in the
past and have been invaluable to the citizens of Monroe County,
and
WHEREAS, such services will promote independence and home
care for terminally ill persons, and
WHEREAS, the Board recognizes the public purpose to be met
by an agreement for services to be rendered in fiscal year
1992 -93; now, therefore,
IN CONSIDERATION of the promises made each to the other, the
Board and Hospice agree as follows:
1. AMOUNT OF AGREEMENT The Board, in consideration of
Hospice satisfactorily performing the duties of the Board as to
rendering services to the citizens of Monroe County, Florida, in
matters of health and education in regard to the care of
terminally ill persons, shall pay to Hospice the sum of Fifty
Thousand Dollars ($50,000) 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. On or before the 15th of each month, Hospice shall
submit to the Board its request for reimbursement. Evidence of
payment shall be in the form of cancelled checks submitted by
Hospice to the Board. After the Clerk of the Board examines and
approves the monthly request for reimbursement, the Board shall
reimburse Hospice. However, the total of said monthly payments
in the aggregate sum shall not exceed the total amount of Fifty
Thousand Dollars ($50,000) during the term of this contract.
4. SCOPE OF SERVICES Hospice, for the consideration
named, covenants and agrees with the Board to substantially and
satisfactorily perform and carry out the duties of the Board in
providing the medical, psychological, physical and social needs
of terminally ill persons and their families and shall mobilize
other community resources to meet such needs for the citizens of
Monroe County, Florida.
5. RECORDS Hospice 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 the 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.
Hospice 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, Hospice shall be billed by the Board
for the amount of the audit exception and Hospice shall promptly
repay any audit exception.
6. INDEMNIFICATION AND HOLD HARMLESS Hospice 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
K
(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 Hospice or any of its agents, employees,
officers, subcontractors, in any tier, occasioned by the
negligence or other wrongful act or omission of Hospice 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 Hospice's failure to purchase or maintain required
insurance, Hospice shall indemnify the Board from any and all
increased expenses resulting from such delay. The first Ten
Dollars ($10.00) of remuneration paid to Hospice 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, Hospice is an independent contractor and not
an employee of the Board. No statement contained in this
agreement shall be construed so as to find Hospice 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, Hospice 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
Hospice.
9. PROFESSIONAL RESPONSIBILITY AND LICENSING Hospice
shall assure that all professionals have current and appropriate
professional licenses and professional liability insurance
coverage. Funding by the Board is contingent upon retention of
appropriate local, state and /or federal certification and /or
licensure of Hospice's program and staff.
3
10. INSURANCE Hospice shall obtain, prior to the
commencement of work governed by this agreement, at Hospice's own
expense, that insurance specified in the insurance requirements
forms for worker's compensation, general liability, vehicle
liability and professional liability, which forms are attached
hereto and incorporated herein by reference. Hospice will also
insure that all subcontractors, in any tier, have obtained the
insurance as specified in the attached schedules. Hospice will
not be reimbursed for any work commenced prior to coverage with
required insurance. Hospice 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 Hospice to provide satisfactory
evidence of the required insurance, shall not extend deadlines
specified in this agreement. Hospice 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 Hospice's and
subcontractor's insurance shall not be construed as relieving
Hospice or subcontractor from any liability or obligation assumed
under this agreement or imposed by law.
4
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 Hospice 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
Hospice.
13. NON - DISCRIMINATION Hospice 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, Hospice
shall comply with all applicable laws and regulations with regard
to employing the most qualified person(s) for positions under
this agreement. Hospice shall not discriminate against any
person on the basis of race, creed, color, national origin, sex
or sexual orientation, age, physical handicap, financial status
or any other characteristic or aspect in its providing of
services.
14. AUTHORIZED SIGNATORY.
The signatory for Hospice,
below, certifies and warrants that:
61
(a) Hospice's name in this agreement is the full name as
designated in its corporate charter, if a corporation, or the
full name under which Hospice is authorized to do business in the
State of Florida;
(b) He or she is empowered to act and contract for Hospice;
and
(c) This agreement has been approved by the Board of
Directors of Hospice, if Hospice 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 Hospice: Liz Kern, President
Hospice of the Florida Keys, Inc.
724 Truman Avenue
Key West, Florida 33041
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 Hospice 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
R
agreement may be terminated immediately at the option of the
Board by written notice of termination delivered to Hospice. The
Board shall not be obligated to pay for any services or goods
provided by Hospice after Hospice 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 Hospice 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
"
(SEAL)
ATTEST:
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
By
HbGPICE OF THE FLORIDA KEYS,
INC.
By `s -a..� B
S ecretary resident
APPROVED AS TO Fo "I
AW
1;F @AL SUFF(C(r
ttnrney - ;g E-3
Date 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 '
C GENERAL LIABILITY
INSURANCE REQUIREMENTS
, ]'OF
CONTRACT,
BETWEEN
MONROE COUNTY, FLORIDA
Amn
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
• Personal Injury Liability
• E�:panded Definition of Property Damage
• 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
C If split limits are provided, the minimum limits acceptable shall
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
MEDICAL PROFESSIONAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
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
If coverage is provided on a claims made basis, an extended
claims reporting period of four (4) years will be required.
MED2 ' i
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
C
PRO2 ' i
C UNTY o MONROE
KEY WEST FLORIDA 33040
(305) 294 -4641
,
I
M E M O R A N D U M
To: Beth Leto
County Attorney's Office
From: Kay Bahleda
Risk Management
Date: May 14, 1993
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
Subject: Visiting Nurse Assoc dba Hospice
Attached please find the original Certificate of Insurance for
subject funding agreement for the period 3/10/93 through 3/10/94.
I have also enclosed a copy of the letter of acceptance of cover-
age for Worker's Compensation coverage by the Florida Chamber
Fund in the event you do not have it in your file.
These documents constitute insurance sufficiency and the agree-
ment may now be executed.
If you have any questions, please call.
CERTIFICATE- OF INSURANCE R E V I S E D ISSUE DATE (MM /DD /
5 -12 -93 3
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
WILSON, WASHBURN & FORSTER INS. DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
P. 0. BOX 5250 POLICIES BELOW.
HIALEAH, FL. 33014 COMPANIES AFFORDING COVERAGE
COMPANY A
LETTER ST. PAUL FIRE & MARINE INS. CO.
COMPAN
INSURED Y B
LETTER
VISITING NURSE ASSOC. COMPANY Re
OF THE FLORIDA KEYS LETTER C Risk Mgmt & Loss Control
P. 0. BOX 6 5 5 8
COMPANY D DATE--
KEY WEST, FL. 33041 LETTER �
COMPANY J LETTER E v
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 POLICY EFFECTIVE POLICY EXPIRATION LIMITS
LTR DATE (MM /DD /YY) DATE (MM /DD /YY)
GENERAL LIABILITY
GENERAL AGGREGATE
$ 2,0 00,
00 0 .
A X COMMERCIAL GENERAL LIABILITY
PRODUCTS- COMP /OP AGG.
$ 2,00 0 ,
00 0.
CLAIMS MADE X OCCUR. FK- 0 6 8 0 16 17
3 -10 -93 3 -10 -94 PERSONAL & ADV. INJURY
$ 1,
000, 000.
OWNER'S & CONTRACTOR'S PROT.
EACH OCCURRENCE
$ 1,000,
00 0.
FIRE DAMAGE (Any one fire)
$1
000
MED. EXPENSE (Any one person) $r
n n n
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
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION
AND
EMPLOYERS' LIABILITY
OTHER
f PROFESSIONAL FK- 06801617 3 -10 -93 3 -10 -94 $1, 000,OOO.EACH PERSON
$3,000,000.TOTAL LIMIT
CLAIMS MADE POLICY RETRO DATE 3 -10 -88
DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES /SPECIAL ITEMS CERTIFICATE HOLDER NAMED AS ADDITIONAL INSURED.
NAMED INSURED: HOSPICE OF THE FLORIDA KEYS, INC., HOSPICE OF THE FLORIDA KEYS,
INC. DBA VISITING NURSE ASSOCIATION OF THE FLORIDA KEYS
CERTIFICATE HOLDER
MONROE COUNTY BOARD OF COUNTY
COMMISSION, WING II, #207
P.S.B. 5100, COLLEGE ROAD
KEY WEST, FL. 33040
EACH OCCURRENCE $
AGGREGATE $
STATUTORY LIMITS
EACH ACCIDENT
$
DISEASE — POLICY LIMIT
$
DISEASE —EACH EMPLOYEE
$
CAN[C]ELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL 45_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED _ P�SENTATIVE W j;, WILSON
,r
/. If 'L.._ I
Actin® 25-S Choi
TME F Rr.A
CHAMBER
FUND
A Workers' Compensation Commercial Insurance Fund
Serving Florida Chamber of Commerce Members
BOARD OF
TRUSTEES
Chairman
Wade L. Hopping
Hopping. Boyd,
Green i1 Sams. P.A.
Tallahassee. FL
Vice Chairman
Wmiter L. Revell
H. J. Ross Associates. Inc.
Coral Gables. FL
Treasurer
George E. Greene 111
Florida Power Corp.
St. Petersburg, FL
Secretary
Malcolm S. Scott
U.S. Agri Chemicals Corp.
Fort Meade. FL
Trustee
W. E. "Duke" Adamson
Rich United Corp.
Sanlord, FL
Trustee
F. E. Booker
F. E. Booker Company
Pensacola. FL
Trustee
Stephen J. Cline
Southern Gultslreant Corp
Coral Gables. Fl
Trustee
H. Michael Dye
Post, Buckley,
Schuh 6 Jernigan
M-ami, FL
ADMINISTRATOR
William D. Grillin
June 26, 1992
TO: Mr. Russ Morris
Department of Labor and Employment Security
Bureau of Workers' Compensation Compliance
2728 Centerview Dr., Suite 100 Forest Building
Tallahassee, FL 32399 -0661
This is to certify that The Florida Chamber Fund hereby assumes the workers' compensation for:
Hospice of the Florida Keys, Inc. dba Visiting Nurse Associates of the Florida Keys
724 Truman Ave
Key West, FL 33040
Covered by policy number 08257 effective July 1, 1992
yf BY L " d Title Administrator
William D. Griffin -tc
The Florida Chamber Fund
If —
cc: Hospice of the Florida Keys, Inc. dba Visiting Nurse Associates of the Florida Keys
Wilson & Washburn Insurance Agents
(813) 951 -2022 • FAX (800) 226-FUND
Mailing A.:�ress P.O. Box 1598. Sarasnta, Florida 34230 -1598
1680 Fruitville Road. Sarasr 1 orida 34236
z� IIi
a W11S'WUM INSUVANCE _-"ENM
BOX 5250
- �1I,FAfi, FL .33R1.4
r I I '.. �., "(' rl ;r� `.
�'I:'11 'l: t`1 T': `I ", .•I..rll • �'!/`,I'? (llyt' .
:OD■ " (1
'NUB -CODl lit
(Iy.•:1iF,�'1;) ssttlJ:l L %'gal (l;tivh
COMPANY t ± 6/8/92
FWRIDA Cfi11rg3 UNDaRYYRITen '
�P'PUCAIITNAM� ffOS)?j� ----- •••- _ �� ---- - _ _ 1 .' ,
�' �4II; Fi4iZI DA KEYS
bV - -- - - -
I106PI
7IIC-F10RIDA KEYS ..'' INC �DBA' • INC. & i
OF 7i E FWIULIA KEY .. _ _ VISITING NmsB ASSp�
MAIL1Nt) ADORCN (In�l�d -
trtp IIIP Colo) . II I
P.O. BOX 6558
rno iy K ey
we�jt 'F 1 -1 33041 t a '
' INDWIOl1A� iTT
(� pp� + +� PORATION TT"
8 =J_��2 __ I '„ OAANERSHIP�• L
FRDEML ZMPLOYCR 1. NUM •USCNAPIER'igt• CORP. l% !
159 - 2386289 � ' ' I „ ,
,NGIweT� oTMW ial Rif — wiii i:o.
X_ 1_ t
YN
X No
90001 U.S. 41•, Tavernier
6799 Ov erseas f
'ROPOSED
F. DAtd ( �kW .•.= :.i.+Ly
DD"Y),
_
7/1/92
)IVIDCTID Phil iii GROUP
F1 33070
5• , I'ra'� F'1 33050
PIKTP08ED IXPjDATI (M,l T P; xxjj**-� l / Y "TING DATI •.ii i>7 'r 93 IPATING
ADDITIONAL COMPANY Ai1D •TAT! INFORMATION • PAR1 1
PART 1 (Stala�) 7/1 _ NON- PARTICIPAIING
�AAp�OYCR'S LIABILITY
� U UU EACH ACCIDENT
Florida( S00,060. _ DI
9 EABE- POLICY LIMIT
LUU / OU1).—DISEASE•EACH EMPLOYEE
Z Am. x
1 tIF CLASS CODE COI.IPANY
USE CATEOORIES, DUTIES, CLASSIFICATIONS
NO. OP
EM-
- --
- - -- PLO EES
8 810 C.I_L f ti Clu, OF'F'ICE
'LC3YEES
8833 - --
ff06PI'i'11L:PI�fJF'FSSICNI�L, EM
PUBLI 11r•:11M11 NURS
4PECIF -Y A00111014AL COVEFIAOES/ENDOR9EMENTB All ax
l pwwam axplalned
y -
prt j': n
pn�Ei �L
D
RlTRO PLAN 3 I:
OtNER COYEFTAOCi -
(ExPlaln below)
-I U S.L. a m.
VOLUNTARY COMPEN911
DEDUCTIBL! ' --
CoikiU ;&- i Liiiii - . .. - .
ACTUAL
"FMUN-
MOIR
ERA IION PAST
RFMUNF-IIATION
■
M PO" •I'1 1!�
BOUND (aM da• INor a taoh oom '• 1 r' I Nn.
BILUN0 PLAN ' ' •'
P/►TMENt
- l o l l NEXT
_..PO11CY PtcR10p - -
RATE
-
+' i ' • r : '
- - -- — - -
AGENCY BILL
ANNUAL
,r AUDIT RECORD '
-._
_...........
..
DIRECT BILL /
SEMI- ANNUALr
OT ER: x AT EXPIMT)ON
I Irtl MONTI'
rt!" 1
3.30
••a .;.''J i;i ., {�;�.c.+i
QUAFIT TILY
°- -- ----- -- (.1 '• bAwIll-)UtNIJAL I1 I OTHEq
-
% DOWN:
BtrMl. My. County. BtW, 21p Cad,
QUARTERLY . i
1
_ No
724 7Y1II1k7I1 Avenue.../
K Wes t F
r«
L
33040
X_ 1_ t
YN
X No
90001 U.S. 41•, Tavernier
6799 Ov erseas f
'ROPOSED
F. DAtd ( �kW .•.= :.i.+Ly
DD"Y),
_
7/1/92
)IVIDCTID Phil iii GROUP
F1 33070
5• , I'ra'� F'1 33050
PIKTP08ED IXPjDATI (M,l T P; xxjj**-� l / Y "TING DATI •.ii i>7 'r 93 IPATING
ADDITIONAL COMPANY Ai1D •TAT! INFORMATION • PAR1 1
PART 1 (Stala�) 7/1 _ NON- PARTICIPAIING
�AAp�OYCR'S LIABILITY
� U UU EACH ACCIDENT
Florida( S00,060. _ DI
9 EABE- POLICY LIMIT
LUU / OU1).—DISEASE•EACH EMPLOYEE
Z Am. x
1 tIF CLASS CODE COI.IPANY
USE CATEOORIES, DUTIES, CLASSIFICATIONS
NO. OP
EM-
- --
- - -- PLO EES
8 810 C.I_L f ti Clu, OF'F'ICE
'LC3YEES
8833 - --
ff06PI'i'11L:PI�fJF'FSSICNI�L, EM
PUBLI 11r•:11M11 NURS
4PECIF -Y A00111014AL COVEFIAOES/ENDOR9EMENTB All ax
l pwwam axplalned
y -
prt j': n
pn�Ei �L
D
RlTRO PLAN 3 I:
OtNER COYEFTAOCi -
(ExPlaln below)
-I U S.L. a m.
VOLUNTARY COMPEN911
DEDUCTIBL! ' --
CoikiU ;&- i Liiiii - . .. - .
ACTUAL
"FMUN-
"�•I:I1�7Gt1'11�j+��
E;iIIMAIED
ERA IION PAST
RFMUNF-IIATION
-- _- 1Z- M4NTr •_ (
- l o l l NEXT
_..PO11CY PtcR10p - -
RATE
-
ESTIM,;
ANNUAL F
- - -- — - -
293,500.
.72
-._
_...........
..
2 , 1 1.1
84,000.
3.30
427,000 1U.021
I
TO TAL - - -- _ L — - - - - --
_ 847 , fT'
EXPERIENCE MODIFICATION
MODIFIED PREMIUM
PREMIUM DISCOUNT 2 > 4 2 (
EXPENSE CONSTANT ` 4 07
s38,48a
' TOTAL ESTIMATE[)
PREMIUM
I ANNUAL + � 3
tl111r1,1 1 '•II1 •I I MINIMUM �- - 38, '
• .,:... .. ,::: :. ::.
,;! -:. :> '' ISSUEUATF,(MM/DD/YY) _.
Alrlllal• CERTIFICATE OF INSURANCE
12 / 2 9 / 9 2
PRODUCER
THIS CERTIFICATTi IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
W ILSON & WASHBURN INS.
NO RIGHT'S UPON T'HE CER'1711CAIT. HOLDER, PHIS CE It'll 11CATL DOM NOT AMEND,
EXTEND OR AL"1'1?R'i'HE COVERAGE AFFORDED BY THE POLICIES BELOW.
7 050 N . W . 77TH COURT
COMPANIES AFFORDING COVERAGE
IAMI, FL
COMPANY
LEITER AST PAUL FIRE & MARINE INS CO
3 3166
P5) 591 -8110
SRmroDE
COMPANY
LIATER B
INSUwn
COMPANY ecelvc
LEI _ ER C R1,1: MgmI.. Loss Control
ISITING NURSE ASSOC.
COMPANY
DATE
F THE FLORIDA KEYS
P. O. BOX 6558
LIFTE D
COMPANY INI"i'IAt. u ) ma c
E
KEY WEST, FL 33041
L ITEl
COVERAGES
THIS IS To CERTIFY THAT THE P011CIES OF INSURANCE LISTED BEIDW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
REOUIRIiMEN'r, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMIiN'1' WITH RPSPIiC'T TO WHICH THIS
INDICATED NO'I WIT7iS'I'ANDING ANY
MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DFSCRIBEU HEREIN IS SUBJECT" I'O ALL THE TERMS, ��GJ
ciijrh11CA'I
EXCLUSIONS AND CONDITIONS OF SUCH POIICIFS. LIMITS SHOWN MAY HAVE IlliliN RI DUCFD BY PAID CLAIMS.
CO.
TYPR OF INSURANCE
POLICY NUMIIFR
IOLICV EFFHCPIVF.
DAI (MM /DD/YY)
IOLICY EXPIRATION
DATE (MM /DD(YY)
LIMnS
IXR
GENERAL LIAJIILrIT
GENERA. AGGREGATE
s
PRODUCrS( OMP/OPS AGG.
s
COMMERCIAL GENERAL IRABILrrY
F K06801617
3/10/92
3 / 10 / 9 3
PERSONAL & ADV. INJURY
S •
CLAIMS MADE ® OCCUR.
IsACI I OCCURRENCE
f
OWNER'S &CONTRACTOR'S PROT.
FIREDAMAGE(A.r...e.q
$
ME). E(PENSE (A.r
s
AUPOM011II.E LIAIIILrrY
COM11INEDStNGLE
LIMir
s
ANY AUrO
BODILY INJURY
(Per per. )
s
100, 000.
ALL OWNED AUrOS
SCI BTULFD AUrOS
11MM AUros
JC3535982002
5/16/92
5/16/93
ROILY INJURY
s
Qbr —kini)
300, 000.
NON-OWN M- AUTOS
PROPERTY DAMAGE
f 50,000.
GARAGE LASILMY
T 7.'?="r� I' p "'�.
11 i_
6'XCPS.S LIAistuiv
GACIIOCCURRENCE
s
AGGREGATE
s
OTIIERTI IAN UMBRER.AFORM
ry
ql � L
)Q93
bTATUTORY LIMMS
WORKERS COMPE?,9An0N
AND
( \}\ j 7 _
! /� UINTY
V
A� p V
EACI I ACCID04T
$
DtSEASGPOLICI' IRMrr
$
F111PLOYERS' LIABILrrY
�v `
DISEASE- EACIIIN- PLOYEE
f
01'I1ER
ROFESSIONAL
F K06801617
3/10/92
3/10/93
$1,000,000. EACH PERS
IABILITY
$3,000,000. TOTAL LIM
LAIMS MADE POL.
RETRO DATE 3/10/88
-F lonsnocnTlors/ vrancl�snR� tilxlcnor.�srEcw.nr:Ms CERTIFICATE HOLDER N AMED
Dr�culPnonOF01
NAMED INSURED: HOSPICE OF THE FLORIDA KEYS, INC.. HOSPICE Or THE FLORIDA KEYS, INC. pBA/
VISITING NURSE ASSOCIATION OF THE FLORIDA KEYS. 1 )f��
CEwrmCATE'.IIOLnrR C AN CrLr,AT10N
SIIOULD ANY OF 7NE ABOVE DESCRIBED POUCIFS BE CA NCE U-E D BEFORE THE
ONROE COUNTY BOARD OP COUNTY EXPIRATION DATE: '111IIREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
OMMI S SIGN, WING 1 MAI13 0 DAYS WRITTEN NOTICE To THE CERTIFICATE HOLDER NAMED To T
. S . B . 5100, COLLEGE RD LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
iQ�viP I AGENTS OR REPRIZS TATIVFS.
K EY WEST, FL 33040 IIABI UTY OF ANY KIND UPON 7 ^�" 4N
�vr
WA�,HK ' EM .
ACOKD`25 :i (7190) _.: AC RI) CORPORATION >1990 >