FY1994 10/20/1993/�our�► C6
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BRANCH OFFICE
3117 OVERSEAS HIGHWAY
MARATHON, FLORIDA 33050
TEL. (305) 289 -6027
Mattnp I. A01b
CLERK OF THE CIRCUIT COURT
MONROE COUNTY
500 WHITEHEAD STREET
KEY WEST, FLORIDA 33040
TEL. (305) 292 -3550
MEM ORAND
BRANCH OFFICE
88820 OVERSEAS HIGHWAY
PLANTATION KEY, FLORIDA 33070
TEL. (305) 852 -7145
TO: Division of Management Services
c/o County Administrator
FROM: Isabel C. DeSantis, Deputy Clerk
DATE: November 24, 1993
On October 20, 1993, the Board authorized execution of a Funding
Agreement between Monroe County and the Big Pine Key Athletic
Association, in the amount of $18,000.00; and Hospice of the
Florida Keys, Inc., in the amount of $48,000.00, to provide
assistance to Monroe County.
Enclosed are duplicate originals of the subject Agreements
executed and sealed by all parties which should be returned to
the providers.
cc: County Attorney
Finance
File
A G R E E M E N T
THIS AGREEMENT is made as of the 20th day of OctoberZj
1993, between the BOARD OF COUNTY COMMISSIONERS OF MONROE C4UNTY -
FLORIDA, hereinafter referred to as "Board" and HOSPICE fF' THE
FLORIDA KEYS, INC., hereinafter referred to as "Hospice."
WHEREAS, the Board and Hospice desire to enter in :�o
agreement wherein the Board contracts for services from Hb`Spic1'
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
1993 -94; 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 Forty
Eight Thousand Dollars ($48,000) for fiscal year 1993 -94.
2. TERM This Agreement shall commence October 1, 1993,
and terminate September 30, 1994, 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
t '
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 Forty
Eight Thousand Dollars ($48,000) 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.
G. 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
2
(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 schedules
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 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 thirty (30) 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 insurance shall not
be construed as relieving Hospice from any liability or
obligation assumed under this agreement or imposed by law.
Monroe County, Monroe County Board of County Commissioners,
its employees and officials shall be included as "additional
insureds" on all policies, except for worker's compensation.
Any deviations from these general insurance requirements
must be requested in writing on the County - prepared form entitled
Cl
"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:
(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;
5
(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.
131.9 William Street
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
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.
2
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
B C.
Deputy Clekk
BOARD OF COUNTY COMMISSIONERS
OF MONR.QR COUNTY, FLORIDA
77 A -
By,
yor /unairman
(SEAL)
ATTEST:
r�
HOSPICE OF THE FLORIDA KEYS,
INC.
By B /<
Secretary rest ent
i
April 22.199-3
Ist Printing
WORICERS' COMPENSATION
INSURANCE REQUIREMENTS
F011
CO N TRA C1'
BETWEEN
MONROE COUNTY, FLORIDA
AND
HOSPICE OF THE
FLORIDA 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 Florida Statute 440.
In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less than:
$100,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$100,000 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. T11e 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 request from the County.
Administralin lrninxikm WC 1 1
94749.1 8
April 22. 1973
Ist 1'riiding
GENERAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CON`T'RACT
BETWEEN
MONROE COUN'T'Y, FLORIDA
AND
HOS OF THE FLO RIDA KEYS, INC.
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:
• Premises Operations
• Products and Completed Operations
• Blanket Contractual Liability
• Personal Injury Liability
• Expanded Definition 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 Donn policy is preferred. If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or aller the elFcctive date of (his contract.
In addition, the period for which claims may be reported should extend 1br a mininwm 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.
Adminidralive Iminidiom GL3
1/4719.1
56
K�
VEHICLE LIABILITY
INSURANCE REQUIREMENTS
FOR
CON'I'RACT
BU!"WEEN
MONROE COUNT - Y, FLORIDA
AND
HOSPICE OF THE
FLORIDA KEYS, INC.
April 22. 1993
Isl PriiNiiq;
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 life of the contract and include, as a minimum, liability coverage for:
• Owned, Non - Owned, and I fired Vehicles
The minimum limits acceptable shall be:
$100,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$ 50,000 per Person
$100,000 per Occurrence
$ 25,000 Property Damage
The Monroe County Board of County Commissioners shall be named as Additional Insured on all
policies issued to satisfy the above requirements.
AJminktralivc ImAniclion V L 1
Nd709.1 75
MEDICAL PROFESSIONAL LIA1311,1'1'Y
INSURANCE REQUIREMEN'I'S
FOR
CON'1'RAC7'
13F;1IVII;EN
MONIZOE COUNTY, FLORIDA
AND
HOSPICE OF THE
FLORIDA KEYS. INC.
April 22. 1993
I.t Prin ing
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.
'fhe 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.
Adminktrntivc InAnx1ion ICI ED2 1
114709.1 66
OF INSURAN ISSUE DATE (MM /DD /YY)
10/26/93
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
[ POLICIES
P.O. BOX 5250
BELOW.
H IALEAH , FL 33014
COMPANIES AFFORDING COVERAGE
COMPANY A
LETTER
ST. PAUL FIRE & MARINE INS. CO.
INSURED
COMPANY
LETTER B U�t��w
HOSPICE OF THE FLORIDA KEYS, INC. be
COMPANY
C
HOSPICE OF THE FLORIDA KEYS, INC
LETTER
DBA VISITING NURSE ASSOCIATION OF
COMPANY DAIS
D
THE FLORIDA KEYS
LETTER
P.O. BOX 6558
COMPANY E
KEY WEST, EL 33041
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 $ 2,000,000.
XX COMMERCIAL GENERAL LIABILITY
PRODUCTS- COMP /OP AGG. $
2,000,000.
A CLAIMS MADE OCCUR.
I %% FK 06801617
PERSONAL & ADV. INJURY $
.3/10/93 3/10/94 1.,000,000...
OWNER'S & CONTRACTOR'S PROT.
EACH OCCURRENCE $ 1,000,000.
I
FIRE DAMAGE (Any one fire) $ 1,000,000.
F
MED. EXPENSE (Any one person) $
AUTOMOBILE LIABILITY
3
COMBINED SINGLE $
i ANY AUTO
LIMIT
i ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS
Received (Per person)
HIRED AUTOS Risk MRm & I ors (OI1iL0l BODILY INJURY
NON -OWNED AUTOS i 1
�' (Per accident) $
DATE
GARAGE LIABILITY
INITIAL
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
$1,000 EACH PERSON LMT.
A PROFESSIONAL FK 06801617
3/10/93 3/10/94 $ 3,000,000. TOTAL LIMIT
LIAB.
E CLAIMS MADE POLICY RETRO DATE 3/10/RR
DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES /SPECIAL ITEMS
t ADDED AS ADDITIONAL INSURED ONLY AS RESPECTS TO GRANT GIVEN TO INSURED.
CERTIFICATE HOLDER
CANCELLATION
U
MONROE CO NTY BOARD OF COUNTY
F COUNTY
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
ON O WING II,
DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
P.S.B. 5100, COLLEGE ROAD
MAIL —14— DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
KEY WEST, FL 33040
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZ&P REPRESENTATIVE
ACOi#I< 2Sfi41j7f98a, ..;.
,. , ®�kFRt CO[I;PQIiAT�1N i�90
- - - - - - - - - - I ------ ----
••
ACORD,
-' -
ISSU DATE (MM/DDryy)
•
11/10/93
,}.
'�• }If,��
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PRODUCER
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Wilson & Washburn Ins.
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 5250
COMPANIES AFFORDING COVERAGE
Hialeah Lakes Station
Hialeah, FL 33014
COMPANY LETTER A BANKERS INSURANCE CO - FAJUA
INSURED
COMPANY LETTER B
AROMP fW RISK MA"ARFMFK
COMPANY LETTER C
Hospice of the Florida Keys
A a
Inc. dba Visiting Nurses Assoc.
COMPANY LETTER D
P.O. Box 6558
IN IF
COMPANY LETTER E
Key West, FL 33041
WANM #/A YES
....................... x ..... .
: { .::;:.:n }. ................. igg- K
0 WIN"
-51) 1841% W 1-111
. ...........
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.
,
�
::+¢?r, )i;}}}.ti i .}4 :{+
" \�v\ . .. }•: 4'? ik :•: ' Q:•:: v . ................ .............................
GENERAL LIABILITY
General Aggregate
Commercial General
Products-Comp/Op Agg.
Liability
Personal & Adv. Injury
Claims Made Occur.
Each Occurrence
Owner's &
Fire Damage (Any one fire)
Contractor's Prot.
Mod. Expense (Am we person)
AUTOMOBILE LIABILITY
Combined Single Limit
Any Auto
Bodily Injury (Per person)
$100,000
All Owned Autos
Bodily Injury (Per accident)
$300,000
Scheduled Autos
Property Damage
$50,000
A
(X) Hired Autos
FJC3636982003
5/16/93
5/16/94
Non-Owned Autos
Garage Liability
(X) Employer's Non-
Ownership
EXCESS LIABILITY
Each Occurrence
Umbrella Form
Received
Aggregate
Other Than Umbrella
Risk
Mgmt. & Loss ('Ontrol
Form
COMPENSATION
DATE Z
Statutory Limits
Each Accident
AND
TMTIAL
OZI
Disease-Policy Limit
EMPLOYERS' LIABILITY
Disease-Each Employee
OTHER
DESCRIPTION OF OPERATIONS /LOCATIONS/VEHICLES/SPECIAL ITEMS
Add'I Insured: Monroe County Board of County Commission
---------------- ---------- ---
Should any of the above described policies be cancelled before the
expiration date thereof, the issuing company will endeavor to mail 10 days
Monroe County Board of County Commission
written notice to the certificate holder named to the left, but failure to mail
Commission Wing 2, #207
such notice shall impose bligation or liability of any kind upon the
A 0
P.S.B. 5100 College Road
compan age or representatives.
Key West, FI 33040
J w lz ;&&W
g - X
IRK. ............... W.*A
. 11 1 1 111 7111111
X
mon., ot .. �
m v-
. ........
Original Printing Issued May 1 1988 Standard
INFORMATION PAGE
RISK ID 097191808 FEIN 59- 2386289
Insurer: Commerce Mutual Insurance Company,
an assessable mutual
P 0';,L I C Y N 0.
0825
NCCI Carrier Code No. 25836
1. The Insured: Hospice of the Florida Keys, Inc. & Hospica Inc. dba
Visiting Nurses Assoc. of the Florida Keys
724 Truman Ave., Key West, FL 33040
_Individual _Partners
Mailing Address: same
%Corporation DATE _ Z '
Other workplaces not shown above:
90001 U.S. #1, Tavernier, FL 33070 WAIVER: N /A_. __YES
6799 Overseas Highway #5, Marathon, FL 33050
2. The policy period is from July 1, 1993 to July 1, 1994 at the insured's mailing
address. The Anniversary Rating Date is July 1 .
3. A. Workers' Compensation Insurance: Part One of the policy applies to the Workers'
Compensation Law of the states listed here: FLORIDA
B. Employers Liability Insurance: Part Two of the policy applies to work in each
state listed in Item 3.A. The limits of our liability under Part Two are:
Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any,
listed here: NONE.
D. This policy includes these endorsements and schedules: none
4. The premium for this policy
will be determined by
our Manuals of Rules,
Classifications,
Rates and Rating Plans. All information required
below is subject to
verification and
change by audit.
Classifications Code
Premium Basis
Rate Per
Estimated Annual
No.
Total Estimated
$100 of
Premium
Annual Remuneration
Remuneration
SEE ATTACHED
Total Estimated Annual Premium $
Minimum Premium $650.00
Countersigned by:
WilsC
aee June 2, 1993
Copyright 1987 National Council on Compensation Insurance
Commerce Mutual Insurance Company
Premium Summary
RISCORP of Florida
Guarantee Cost Plan
Member Services Quotation
08257 -000
Name : HOSPICE OF THE FL KEYES INC
: VISITING NURSE ASSOC OF THE FL KEYS
Address : 724 TRUMAN AVE 305 - 294 -8812
City : KEY WEST FL 33040
Contact : GEORGE SAUNDERS
Agency : WILSON, WASHBURN & FORSTER INSURANCE
Phone : 305/591 -8110
Report Date 06/01/93
Policy Begin 07/01/93
Policy End 07/01/94
Anv.Rate Date 07/01/93
00336 -000
Guarantee Cost Plan Premium Calculation
1. Manual - Rating Year 1993 ... ............................... 73,840
2. Increased Employers Liability Coverage .
3. Other Additions .... ............................... 73,840
4. Experience Modification ............................... - 10,338
07/01/93- 07/01/94 0.86
5. Estimated Modified Premium .......................... 63,502
6. Drug -Free Program Credit ................ - 0
7. FCCPAP ............. ...............................
8. Premium Deviation ...................... 0.00t - 0
9. Stock Carrier's Discount ............... 6,377
10. Airplane Seats .........................
11. Estimated Direct Premium ............................ 57,125
12. Expense Constant ... ............................... + 140
Estimated Total Premium ............................. 57,265
Employer's Liability Limits: Accident Disease (policy) Disease (employee)
100,000 500,000 100,000
----- ---- -------- - - - - -- Individual Classifications ----------------- - - - - --
Class Estimated Estimated Employees
Codes Description Payroll Rate Manual Full Part
8810 CLERICAL OFFICE EMPL
232,194 0.74
1,718
14
0
8833 HOSPITAL: PROFESSION
33,099 3.76
1,245
4
0
8835 PUBLIC HEALTH NURSIN
-------------------------------------------------------------------------------
604,749 11.72
70,877
31
0
Totals....
870,042
73,840
49
0
Premium Subject To Audit