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Certificates of Insurance ACCOR"® CERTIFICATE OF LIABILITY INSURANCE D06/28/2023D/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MARSH USA LLC. NAME' PHONE FAX 1560 Sawgrass Corporate Pkwy,Suite 300 A/C No Ext: A/C,No): Sunrise,FL 33323 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# CN 1 21229260--GAWUC-23-24 INSURER A:American Casualty Company Of Reading,Pa 20427 INSURED Blue Cross and Blue Shield of Florida, INSURER B:Continental Insurance Company 35289 Inc INSURER C:National Fire Insurance Cc Of Hartford 20478 d/b/a Florida Blue INSURER D:Safety National Casualty Corp. 15105 4800 Deerwood Campus Pkwy Risk Management DC1-7 INSURER E Jacksonville,FL 32246 INSURER F: COVERAGES CERTIFICATE NUMBER: ATL-005207905-18 REVISION NUMBER: 0 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD MM/DD C X COMMERCIAL GENERAL LIABILITY 7014966382 07/01/2023 07/01/2024 EACH OCCURRENCE $ 1,000,000 DAMAG ToTE CLAIMS-MADE � OCCUR PREM SES(a occur ence) $ 100,000 MED EXP(Any one person) $ 15,000 APPROVED BY RISK MANAGEMENT PERSONAL&ADV INJURY $ 1,000,000 ,--„ x "IF �� .',,, GEN'L AGGREGATE PIRMOIT APPLIES PER: BY DATE GENERAL AGGREGATE $ 2,000,000 POLICY JECT � LOC 3 �25�7 PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: WAIVER N/A_YES_ $ C AUTOMOBILE LIABILITY 7014966284 07/01/2023 07/01/2024 COEaMBINED identSINGLELIMIT $ 1,000,000 acc X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident X UMBRELLALIAB X OCCUR 7014967998 07/01/2023 07/01/2024 EACH OCCURRENCE $ 10,000,000 EXCESS LAB CLAIMS-MADE AGGREGATE $ 10,000,000 DED X RETENTION$0 $ A WORKERS COMPENSATION 7014970447 07/01/2023 07/01/2024 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTN ER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICE R/M EMBER EXCLUDED? ❑N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ D Excess Work Comp(FL only) SP4066715 07/01/2023 07/01/2024 Statutory Limits SIR each accident:$750,000 Excess Employers Liability 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) RE:EMPLOYEE BENEFIT PROGRAMS(MEDICAL PLAN ADMINISTRATION)PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA,INC.,(FLORIDA BLUE)TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS,ITS OFFICIALS,EMPLOYEES,AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN CONTRACT WITH THE NAMED INSURED WITH RESPECT TO GENERAL LIABILITY. CERTIFICATE HOLDER CANCELLATION MONROE COUNTY BOARD OF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE COUNTY COMMISSIONERS ATTN:PURCHASING DEPARTMENT THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1100 SIMONTON STREET,RM 1-23 ACCORDANCE WITH THE POLICY PROVISIONS. KEY WEST,FL 33040 AUTHORIZED REPRESENTATIVE ©1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN121229260 LOC#: Lauderdale ACOOR 0 ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED MARSH USA LLC. Blue Cross and Blue Shield of Florida, Inc POLICY NUMBER d/b/a Florida Blue 4800 Deerwood Campus Pkwy Risk Management DC1-7 CARRIER NAIC CODE Jacksonville,FL 32246 EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Crime-Employee Dishonesty: Policy Number:107379777 Carrier:Travelers Casualty and Surety Company of America Effective Date:02/01/2023 Expiration Date:02/01/2024 Limit$20,000,000 Cyber: Policy Number:B0509FINPB2350008 Carrier:Lloyds Effective Date:02/01/2023 Expiration Date:02/01/2024 Limit$10,000,000 SIR Value:$2,500,000 Network&Privacy Liability Limit-$10,000,000 Media Liability Limit-$10,000,000 Managed Care E&0: Policy Number:IH-FFP030C Carrier:Ironshore Specialty Insurance Company Effective Date:02/01/2023 Expiration Date:02/01/2024 Limit$10,000,000 ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD +./ Page 1 of 2 ACORODATE(MM/DDmtYY) C) CERTIFICATE OF LIABILITY INSURANCE 06/21/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND•CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES . BELOW.' 'THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING' INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ' IMPORTANT: If the certificate holder is an ADDITIONAL,INSURED,the pollcy(les)must'have ADDITIONAL INSURED provisions or be endorsed, • If SUBROGATION IS WAIVED, subject to the terms and conditions Of the policy, certain:policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu Of such endorsement(s). PRODUCER CONTACT NAME:- Willis of'Tennessee, Inc. DBA Willis of South Carolina PHONE 1-877-945-7378 FAX 1-888-467-2378 c/o 26 Century, Blvd (A/C.No.EMI: . (A/C.No): A certificates@willis.com P.O. Box 305191 � ADDRESS: Nashville, TN 372305191 USA - INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Valley Forge Insurance Company 20508 INSURED 'INSURER 8: National Fire Insurance Company of Hartfor 20478 Blue Cross and Blue Shield of Florida, Inc d/b/a'Florida Blue 4800 Deerwood Campus Pkwy INSURER C: Continental Insurance Company 35289 Business Risk Solutions DC1-7 INSURER D: American' Casualty Company of Reading Penns 20427 Jacksonville, ,FL 32246 Safety National Casualty'Corporation 15105 INSURER E: INSURER F: ACE American Insurance Company .22667 COVERAGES. CERTIFICATE NUMBER:W11686514 REVISION NUMBER: 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 SUB;IECT'TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN.MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDCSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDD/YYYY)' (MM/DD/YYYY)' ' LIMITS X. COMMERCIAL GENERAL LIABIUTY • EACH OCCURRENCE $ 1,000,000 1-5-(-1 DAMAGE TO RENTED ' CLAIMS-MADE I "-1 OCCUR 'PREMISES�Ea occurrence) $ 1,000,000 • A .MED EXP(Any one person) $ 15,000 Y .6024169600 07/01/2019.07/01/2020 PERSONAL BADVINJURY $ . J.1,,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY I_____I JECT PRO CX1 LOC • 'PRODUCTS'.-COMP/OP AGG "$ 2,000,000 OTHER: $ ' AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT nt $ 1,000,000 1Ea_accide . X ANY AUTO BODILY INJURY(Per person) $ B OWNED SCHEDULED 6024169595 07/01/2019 07/01/2020 BODILY-INJURY $ AUTOS ONLY AUTOS HIRED NON-OWNED • PROPERTY DAMAGE $ ,AUTOS ONLY _ AUTOS ONLY _per acddgnt)__ C X UMBRELLA LIAB X,OCCUR EACH OCCURRENCE $ 10,000,000 ' EXCESSLIAB • CLAIMS-MADE ' 6024169578 07/01/2019 07/01/2020 $ 10,000,000 . DED .X RETENTION$U. . . __AGGREGATE 5 WORKERS COMPENSATION X 'PER I •••OTH- • AND EMPLOYERS'LIABILITY STATUTE ER • D ANYPROPRIETOPJPARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? No N/A 6024169581 07/01/2019 07/01/2020 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ , 1,000,,000 If yes,describe under • -.1,000,000 DESCRIPTIONOFOPERATIONStieloW— ' _. "` - - - -- -E.L.'DISEASE=POLICY'LIMIT. 5 -E Excess Workers Compensation - SP 4060717 07/01/2019,07/01/2020 Statutory Limits '(FL only) Excess Employers Lint$1,000,000 J SIR each accident. $750,.000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) SEE ATTACHED • �A PR \/ fly GEMENT Vet /A CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THEPOLICY PROVISIONS.. ,MONROE COUNTY BOARD OF COUNTY CO1MtISSIONERS AUTHORIZED REPRESENTATIVE ATTN: PURCHASING DEPARTMENT 1100 SIMONTON STREET, RM 1-23 KEY: WEST, RL 33040 //j9/C?7 ©1988-2016 ACORD CORPORATION. All rights reserved, ACORD 25.(2016/03) The ACORD name and Iogo:are:registered marks of ACORD se In: 18140453 BATCH: 1253448 • AGENCY CUSTOMER ID: •• , _ • 'LOC#: AC R® ADDITIONAL REMARKS SCHEDULE' • Page 2 ..of' 2 AGENCY NAMED INSURED - • Willi9 of Tennessee, Inc.. DSA.Willis of South Carolina Blue Cross and Blue Shield of Florida, Inc d/b/a Florida Blue 4800 Deerwood Campus Pkwy - POLICY NUMBER Business Risk Solutions DC1-7 See Page 1 Jacksonville, FL.32296 CARRIER NAIC CODE • See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 • . ADDITIONAL REMARKS- • • THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:. 25 FORMTITLE: Certificate of Liability Insurance RE: EMPLOYEE BENEFIT PROGRAMS '(MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., (FLORIDA BLUE) TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS; ITS OFFICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN CONTRACT WITH THE NAMED INSURED WITH RESPECT TO GENERAL :LIABILITY. • INSURER AFFORDING COVERAGE: ACE American' Insurance Company NAIC##: 22667 POLICY NUMBER: MSP G27114015 006 ' EFF DATE: 02/01/2019 -EXP DATE:. 02/01/2020 • TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: .Managed Care Professional Liab Per Claim $15,0D0,000 Aggregate $15,000,000 SIR: $5,000,000 • • • • ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 18140453 BATCH: 1253448' CERTr W11686514 Page 1 of 1 1 ® A�� o CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 06/29/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Willis of Tennessee, Inc. DBA Willis of South Carolina C/o 26 Century BlvdIN P.O. Box 305191 PHONE 1-877-945-7378 FAX 1-888-467-2378 A/C No E-MAIL certificates@willis.com ADDRESS: INSURE S AFFORDING COVERAGE NAIC# Nashville, TN 372305191 USA INSURER A: National Fire Insurance Company of Hartford 20478 INSURED Blue Cross and Blue Shield of Florida, Inc d/b/a Florida Blue 4800 Deerwood Campus Pkwy INSURERS: Continental Insurance Company 35289 INSURERC: ACE American Insurance Company 22667 INSURER D : Business Risk Solutions DC1-7 INSURER E Jacksonville, FL 32246 INSURER F : COVERAGES CERTIFICATE NUMBER: W2837470 REVISION NUMBER: 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. INSR LTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM/DDPOLICY /YYYY MM DD/YYYY LIMITS X COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE F x] OCCUR PREMISES EaENTEoccu ence $ 1,000,000 MED EXP (Any one person) $ 15,000 A Y N 6024169600 07/01/2017 07/01/2018 PERSONAL & ADV INJURY $ 1,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO JECT [ X] LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COEa accidentMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ X ANY AUTO A OWNED SCHEDULED AUTOS ONLY AUTOS Y N 6024169595 07/01/2017 07/01/2018 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY B )( UMBRELLALIAB X OCCUR EXCESS LIAR CLAIMS -MADE N N 6024169578 07/O1/2017 07/01/2018 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 DED I X I RETENTION $ 0 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STAPERT ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED) ❑ N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ C Managed Care Professional Liabil N N MSP G27114015 004 02/01/2017 02/01/2018 Per Claim 15,000,000 Aggregate 15,000,000 SIR: 5,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space is required) RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., (FLORIDA BLUE) TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS; ITS OFFICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN CONTRACT WITH THE NAMED INSURED WITH RESPECT TO GENERAL LIABILITY. RI Iv6 AGEMENT 9✓:f '� cL WAI N/A ' CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS AUTHORIZED REPRESENTATIVE ATTN: PURCHASING DEPARTMENT 1100 SIMONTON STREET, RM 1-23-' KEY WEST, FL 33040 A ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 14738695 BATCH: 365213 Page 1 of 1 DATE (MM/DDNYYY) CERTIFICATE OF LIABILITY INSURANCE 01/30/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terns and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate hoffiCEJUM of such endorsement(s). PRODUCER CONTACT NAME: Willis of Tennessee, Inc. DBA Willis of South Carolina PHONE 1-877-945-7378 FAX 1-888-467-2378 c/o 26 Century Blvd FEB 12 2013 E MC4No Ex!): AIC No P.O. Box 305191 ADDRESS: certificates@willis.com Nashville, TN 372305191 USA MONROE COUNTY ATTOR 1IPV INSURERS AFFORDING COVERAGE NAIC # National F' I Co H tf 20478 INSURED Blue Cross and Blue Shield of Florida, Inc d/b/a Florida Blue 4800 Deerwood Campus Pkwy Business Risk Solutions DCS-7 Jacksonville, FL 32246 INSURERA: ire Insurance ompany o ar or INSURERS: Continental Insurance Company 35289 INSURERC: American Casualty Company of Reading, PA 20427 nacnocc n . ACE American Insurance Company 22667 F: COVERAGES CERTIFICATE NUMBER: W5179528 REVISION NUMBER: 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. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICYNUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS X COMMERCIALGENERALLIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE I —XI OCCUR DAMAGEINE. ENTED PREMISES Ea occuRence $ 1,000,000 MED EXP (Any one person) $ 15,000 A PERSONAL &ADV INJURY $ 1,000,000 Y 6024169600 07/01/2017 07/01/2018 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO- 7 LOC POLICY ❑ JE PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY (CEO,SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ X ANY AUTO A AWNED SCHEDULED AUTOS ONLY AUTOS 6024169595 07/01/2017 07/01/2018 BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTYDAMAGE Per accident $ B X UMBRELLA LIAB M OCCUR EACH OCCURRENCE $ 10, 000, 000 AGGREGATE $ 10,000,000 EXCESS LIAB CLAIMS -MADE 6024169578 07/01/2017 07/01/2018 DED X RETENTION $ 0 $ C — WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBEREXCLUDED7 No (Mandatory -in -NH)--- - - - -- -- N/A ---- 6024169581 -- - 07/Ol/2017 --- - --- 07/Ol/2018 --- -- X PERRH EEO E.L. EACH ACCIDENT $ 1,000,000 -E:L-DISEASE--EA-EMPLOYEE-$-----1.�0000.OQ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $ 1,000,000 D Managed Care Professional Liab MSP G27114015 005 02/01/2018 02/01/2019 Per Claim 15,000,000 Aggregate 15,000,000 SIR: 5,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., (FLORIDA BLUE) TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS; ITS QU RED ITTEN CONTRACT WITH THE OFFICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED W:-APP NAMED INSURED WITH RESPECT TO GENERAL LIABILITY. V t AGEMENF BY WAIVER /A4 Y_S.� CC� CERTIFICATE HOLDER CANCELLATION1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MONROE COUNTY BOARD OF COUNTY COMNIISSIONERS AUTHORIZED REPRESENTATIVE ATTN: PURCHASING DEPARTMENT 1100 SIMONTON STREET, RM 1-23 KEY WEST, FL 33040 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 2V2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 15592799 BATc6: 588360 Gr✓ K Page 1 of 1 ACoO �® �V�R CERTIFICATE OF LIABILITY INSURANCE DATE 29/2I017 06/29/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Willis of Tennessee, Inc. DBA Willis of South Carolina c/o 26 Century Blvd P.O. Box 305191 CONTACT NAME: PHONE 1-877-945-7378 FAX 1-888-467-2378 AIC No Ext : AIC No): E-MAIL ADDRESS: certificates@willis.com INSURER(S) AFFORDING COVERAGE NAIC# Nashville, TN 372305191 USA INSURERA: National Fire Insurance Company of Hartford 20478 INSURED Blue Cross and Blue Shield of Florida, Inc d/b/a Florida Blue INSURER B : Continental Insurance Company 35289 INSURERC: American Casualty Company of Reading, PA 20427 4800 Deerwood Campus Pkwy INSURER D : ACE American Insurance Company 22667 Business Risk Solutions DCS-7 INSURER E Jacksonville, FL 32246 INSURER F : COVERAGES CERTIFICATE NUMBER: W2837469 REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE F04 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. INSR LTR TYPE OF INSURANCE ADDL SUBRi POLICYNUMBER POLICY EFF MM/DDIYYYY POLICY EXP MMOILQ YYY LIMITS X COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE OCCUR DAMAGETO S(RENTED PREMISES Ea occurrence) $ 1,000,000 MED EXP (Any one person) $ 15,000 A Y N 6024169600 07/01/2017 07/01/2018 PERSONAL & ADV INJURY $ 1,000,000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 GEN'L POLICY JECT PRO [ X1 LOC PRODUCTS - COMP/OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ X ANY AUTO A OWNED SCHEDULED AUTOS ONLY AUTOS N N 6024169595 07/01/2017 07/01/2018 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY L $ B X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 EXCESS LIAB CLAIMS -MADE N N 6024169578 07/01/2017 07/01/2018 DIED I X I RETENTION $ 0 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN N ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? No (Mandatory in NH) NIA N 6024169581 07/01/2017 07/01/2018 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 D Managed Care Professional Liabil N N MSP G27114015 004 02/01/2017 02/01/2018 Per Claim 15,000,000 Aggregate 15,000,000 SIR: 5,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., (FLORIDA BLUE) TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS; ITS OFFICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED WHEREZAD WR N ONTRACT WITH THE NAMED INSURED WITH RESPECT TO GENERAL LIABILITY. g A GEMENT orsIV`y�� WAI !A S _ CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS AUTHORIZED REPRESENTATIVE ATTN: PURCHASING DEPARTMENT 1100 SIMONTON STREET, RM 1-23C= KEY WEST, FL 33040 C-C,�-- ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 14738695 BATCH: 365213 Page 1 of 2 A� Q ® DATE (MWDDNYYY) CERTIFICATE OF LIABILITY INSURANCE 06/22/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Willis of Tennessee, Inc. DBA Willis of South Carolina PHONE 1- 877 - 945 -7378 FAX 1- 888- 467 -2378 c/o 26 Century Blvd (A/C. No. ExO: (A/C, No): E -MAIL P.O. Box 305191 ADDRESS: certificateB@willis.com Nashville, TN 372305191 USA INSURER(S) AFFORDING COVERAGE NAIC INSURER A: Valley Forge Insurance Company 20508 INSURED INSURER B: National Fire Insurance Company of Hartfor 20478 Blue Cross and Blue Shield of Florida, Inc d /b /a Florida Blue 4800 Deerwood Campus Pkwy INSURER C: Continental Insurance Company 35289 Business Risk Solutions DC1 - INSURER D: American Casualty Company of Reading Penns 20427 Jacksonville, FL 32246 Safet National Casualt Co ration 15105 INSURER E : y y rpo INSURER F: ACE American Insurance Company 22667 , COVERAGES CERTIFICATE NUMBER: W6575321 REVISION NUMBER: 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. NSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO CLAIMS -MADE OCCUR PREMISES (Ea RENTED $ 1,000,000 A MED EXP (Any one person) $ 15,000 Y 6024169600 07/01/2018 07/01/2019 PERSONAL &ADVINJURY _ $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO JECT X LOC PRODUCTS - COMP /OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) X ANY AUTO BODILY INJURY (Per person) $ B OWNED — SCHEDULED 6 024169595 07/01/2018 07/01/2019 BODILY INJURY $ AUTOS ONLY AUTOS _ HIRED — NON -OWNED PROPERTY DAMAGE $ AUTOS ONLY _ AUTOS ONLY (Per accident) $ C X UMBRELLA LIAB X OCCUR _EACH OCCURRENCE $ 10, 000, 000 EXCESSLIAB CLAIMS - MADE 6024169578 07/01/2018 07/01/2019 AGGREGATE $ 10,000,000 DED X RETENTION $ 0 $ WORKERS COMPENSATION X AND EMPLOYERS' LIABILITY STATUTE ER Y/N D ANYPROPRIETOR/PARTNER/EXECUTIVE E.L EACH ACCIDENT $ 1,000,000 OFFICER /MEMBEREXCLUDED? N/A 6024169581 07/01/2018 07/01/2019 1,000,000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under 1, 000, 000 DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ E Excess Workers Compensation - SP 4057047 07/01/2018 07/01/2019 Statutory Limits (FL only) Excess Employers Liak $1,000,000 I SIR each accident $750,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Re ks Schedule' ' ay be attached if more space is required) AB B RISK yat SEE ATTACHED 9Y �� }L DATE_ 7 – / WAIVER N /A CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS ATTN: PURCHASING DEPARTMENT AUTHORIZED REPRESENTATIVE 1100 SIMONTON STREET, RM 1 -2 ~ KEY WEST, FL 33040 • I- I nl a rk _, 1 7 ' © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD SR ID: 16349852 BATCH: 760695 AGENCY CUSTOMER ID: LOC #: AWR o ® ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Willis of Tennessee, Inc. DBA Willis of South Carolina Blue Cross and Blue Shield of Florida, Inc d /b /a Florida Slue 4800 Deerwood Campus Pkwy POLICY NUMBER Business Risk Solutions DC1 -7 See Page 1 Jacksonville, FL 32246 CARRIER NAIC CODE See Page 1 See Page 1 EFFECTIVE DATE: See Page 1 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., (FLORIDA BLUE) TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS; ITS OFFICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN CONTRACT WITH THE NAMED INSURED WITH RESPECT TO GENERAL LIABILITY. INSURER AFFORDING COVERAGE: ACE American Insurance Company NAIC #: 22667 POLICY NUMBER: MSP G27114015 005 EFF DATE: 02/01/2018 EXP DATE: 02/01/2019 TYPE OF INSURANCE: LIMIT DESCRIPTION: LIMIT AMOUNT: Managed Care Professional Liab Per Claim 15,000,000 Aggregate 15,000,000 SIR: 5,000,000 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 16349852 BATCH: 7 60695 CERT: W6575321 Page 1 of 2 BATE(MM/OD/YYYY) ,�c® 'n° CERTIFICATE OF LIABILITY INSURANCE �- O1/29/201'9 THIS CERTIFIC• ATE'IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO.RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,-EXTEND OR ALTER THE COVERAGE AFFORDED BY THE'POLICIES BELOW. THIS'CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE.A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED. REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE,HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(Ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the.policy,certain policies may require an endorsement. A statement on this certificate dges not confer rights to the certificate holder In lieu of,such endorsement(s). PRODUCER CONTACT _NAME: • _ ' Willis of Tennessee, Inc. DBA Willis of South Carolina c/o 26 Century. Blvd PHONE 1-877-945-7378 FAX, 1-888-467-2378 (A/C.No.Ext):• {AIC,No): E-MAIL certificates @willis.com P.O. Box 305191 ADDRESS: Nashville, TN 372305191 USA _ INSURER(S)AFFORDING_COVERAGE NAIL#' INSURER A: Valley Forge' Insurance Company 20508- INSURED INSURER B: National Fire Insurance Company of Hartfor 20478 Blue Cross and Blue Shield of Florida, Inc d/b/a Florida'Blue '-" - 4800 Deerwood Campus Pkwy INSURERC: Continental Insurance Company 35289 Business Risk Solutions DC1-7 INSURERD: American Casualty Company of Reading, Penne '20427 Jacksonville, FL 32246 Safety National Casualty .Corporation 15105' INSURER E: , .... INSURERFi ACE ,American Insurance Company 22667 COVERAGES CERTIFICATE.NUMBER:W9995893 . REVISION NUMBER: . 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 SUCK POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED-BY.PAID CLAIMS. INSR TYPE OF INSURANCE- ADDLTSUB 1 4 ��'P'OLICY EFF ' POLICY EXP7 -- LIMITS' INSD I 4WD I POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) X COMMERCIAL GENERAL LIABILITY • EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED CLAIMS-MADE'I X I OCCUR • . PREMISES(Ea occurren�e)� $ 1,000,000 A - _�_ • MED'EXP(Any oneREeon) $ 15,000 Y 6024169600 07/01/2018 07/01/2019 PERSONAL&ADVINJURY $ 1,000,000 GEN'L AGGREGATE.LIMIT APPLIES PER: ' GENERAL AGGREGATE $ 2,000,000 POLICY 1.PRO LX I LOG PRODUCTS-COMP/OP AGG $ 2,000,000 JECT OTHER: $ AUTOMOBILELIABILITY COMBINED SINGLE LIMIT $ 1,-000,-000 _(_a accident) X ANY AUTO •BODILY INJURY.(Per person) $ B OWNED SCHEDULED ' 6024169595 07/01/2018 07/01/2019 r BODILY INJURY(Per accident) $ ' AUTOS ONLY AUTOS HIRED NON'-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY jeer accidgne_____ ,_. $ C X. UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 • EXCESSLIAB CLAIMS-MADE 6024169578 07/01/2018 07/01/2019 AGGREGATE_ $ .10,000,000 __ DED 'X 'RETENTION$0 - $ . WORKERS COMPENSATION' x'I PERTUTE I II l ERH AND EMPLOYERS'LIABILITY Y,/,N D ANYPROPRIETOR/PARTNER/EXECUTIVE • E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBEREXCLUDED? No' NIA 6024169581 07/01/2018 07/01/2019— (Mandatory In NH) ' E.L.DISEASE-EA EMPLOYEE $ 1,000,000 II yes.describe under 1,000,000 DESCRIPTION OF'OPERATIONS below E.L.DISEASE-POLICY LIMIT •$ ---E--Excess-Workers-Compensation ------- ---- - 'SP 4057047.- -- - --07/01/2018:-07/01/2019-Statutory-Limits----- -- ---- '- ---- _ (FL only) Excess Employers Liab$1,000,000 SIR each accident • $750,000 .• DESCRIPTION'OF OPERATIONS(LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached If morespace Is required) SEE ATTACHED APPROV• I wit BY .•-• -: EMENT DA- l�la:ti . WAIVE / E .�- CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. • MONROE COUNTY BOARD.OF COUNTY COMMISSIONERS ATTN: PURCHASING DEPARTMENT AUTHORIZEUREPRESENTATIVE r1100 SIMONTON STREET, RM 1-23 r '�iffl4� c'-�KEY WEST, FL 33040 • ©1988-2016'ACORD CORPORATION.'All rights reserved. ACORD 25(2016/03) The-ACORD name and logo are registered marks of ACORD' .911 ID: 17457957 BATCH: 1046211 2 of 2 1202 'AGENCY CUSTOMER ID: . .. . .. LOC#: • ACORO • ADDITIONAL REMARKS SCHEDULE • Page 2 . Of ' 2 AGENCY NAMED INSURED. --WilliB Blue'Cross.and Blue Shield of Florida, Inc d/b/a Florida Blue 'of Tennessee, Inc, BSA Willis of South Carolina - 4800 Deerwood Campus.Pkwy POLICY NUMBER Business Risk Solutions DC1-7 See Page 1 Jacksonville, FL 32246 • CARRIER NAIC.CODE ' ' See Page 1 See Page 1 EFFECTIVE DATE:See page .1 ADDITIONAL REMARKS' THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM.TITLE:.Certificate of Liability Insurance RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL.PLAN ADMINISTRATION).PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., (FLORIDA BLUE) TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS; ITS OFFICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN CONTRACT WITH THE NAMED INSURED WITH RESPECT TO GENERAL LIABILITY. . • INSURER AFFORDING COVERAGE: ACE American Insurance Company.. NAIC#: 22667 POLICY NUMBER: MSP G27114015 006 ' EFF' DATE: 02/01/2019 'EXP DATE: 02/01/2020 • TYPE' OF INSURANCE: LIMIT DESCRIPTION: . LIMIT AMOUNT: Managed Care Professional Liab Per Claim $15,000,000 Aggregate $15,000,000 SIR: $5,000,000 • • • • • • • ACORD 101 (2008/01) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 17457957 BATCH: 1046211 CERT: W9995893 �'-■41 SLUECRO -05 SEQUEIRARR '4 EZV CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YVYY) 1/26/2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS • CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Willis Towers Watson Certificate Center NAME: Willis of Tennessee, Inc. DBA Willis of South Carolina PHONE FAX c/o 26 Century Blvd (ac, No, Ext): (877) 945 -7378 I (A/C, N (888) 467 -2378 P.O. Box 305191 Wass, ESS: certificates@willis.com Nashville, TN 37230 -5191 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: National Fire Insurance Company of Hartford 20478 INSURED INSURER B : Continental Casualty Company 20443 Blue Cross and Blue Shield of Florida, Inc. d/b /a Florida Blue INSURER C : American Casualty Company of Reading, PA 20427 4800 Deerwood Campus Pkwy i Business Risk Solutions DC1 -7 INSURER D : ACE American Insurance Company 22667 Jacksonville, FL 32246 INSURER E : -- — — — -- INSURER F : - - -- COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP W LTR INSD VD (MMIDDIYYYY) IMM/DDIYYYY) LIMITS A X COMMERCIAL GENERAL UABILITY 1 EACH OCCURRENCE 3 CLAIMS -MADE X OCCUR X 6024169600 06/01/2016 06/01/2017 PREMISES Ea E occu ante) $ 1,000,000 MED EXP (Any one person) $ 15,000 PERSONAL & ADV INJURY 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JECaT X LOC PRODUCTS- COMP /OPAGG $ 2,000,000 OTHER: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 X ANY AUTO _ 6024169595 06/01/2016 06/01/2017 BODILY INJURY (Per person) $ OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED NON -OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) $ - _$ S X UMBRELLA t lAB X OCCUR F 10,000,000 EACH OCCURRENCE EXCESS LAB CLAIMS -MADE 6024169578 06/01/2016 06/01/2017 AGGREGATE 0 .___$ 10,000,000 DED I X RETENTION j $ C AND EMPL COMPENSATION YRS' IABLITY Y / N X STATUTE ER 60241 - 69581 06/01 /2016 06/01/2017 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE N N / A E.L. EACH ACCIDENT $ EXCLUDED? OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 D Managed Care E &O MSP G27114015 004 02/01/2017 02/01/2018 See Attached , DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached N more space is required`- RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., (FLORIDA BLUE) TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COMMISSION RS; ITS OFFICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN C T - • CT E NAMED IN URED WITH RESPECT TO GENERAL LIABILITY. � �/ B PR /E[) \ AGEM ' /,1 tkit is . Li W WAIV R N/A Y _ a 1 . 9 CERTIFICATE HOLDER CANCELLATION 10# SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS AUTHORIZED REPRESENTATIVE ATTN: PURCHASING DEPARTMENT _ . - _ - _ - - - - 1100 SIMONTON STREET, RM 1 -23 i1it,`1 KEY WEST. FL 33040 ACORD 25 (2019 03) © 1988-2015 ACORD CORPORATION. All rights reserved. c c : The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGE SCHEDULE COVERAGE LIMITS Managed Care Professional Liability POLICY TYPE: Managed Care E&O $15,000,000 Per Claim CARRIER: ACE American Insurance Company $15,000,000 Aggregate POLICY TERM: 02/01/2017 - 02/01/2018 $5,000,000 SIR POLICY NUMBER: MSP G27114015 004 .acoR CERTIFICATE OF LIABILITY IN DATE(MM/DD/YYYY) INSURANCE RA N C E 03/23/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED PRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. Al"ORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT MARSH USA, INC. NAME: TWO ALLIANCE CENTER PHONE FAX 3560 LENOX ROAD, SUITE 2400 (A/C. No Fry -- _ A/C Noy. _— E-MAIL ----------- ATLANTA, GA 30326 ADDRESS', - Attn: ealthcare.AccounlsCSS@maish.com/FAX:212-948-1307 - — -- — - ------- __ __ INSURERS) AFFORDING COVERAGE ---------- _ NAICN INSURED Great Northern Insurance Company ---- BLUE CROSS AND BLUE SHIELD OF INSURER A_ P y 20303 ----------------------------------------------------- FLORIDA, INC. Federal Insurance Com an — INSURER B : P Y 20281 4800 DEERWOOD CAMPUS PKWY -- ----- -- -- - - -- -- ---- - Darwin Select Insurance Com an — - - JACKSONVILLE, FL 32246-8273 INSURER c_-- P y 24319 INSURER 0 :----------------------- ------ - INSURER E : ---------------------------------------- -- - - INSURER F COVERAGES CERTIFICATE NUMBER: ATL-002598058-01 REVISION NUMBER: 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. INSR AD L SUBR LTR TYPE OF INSURANCEAD NUMBER POLICY EFF POLICY EXP GENERAL LIABILITY --- ----- MM/DD/YYYY MM/DD/YYYY LIMITS _ A X EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY 3591-74-91 06/01/2010 06/01/2011 DA A T RENT D -- PREMISES Ea occurrence $ 1,000,000 CLAIMS -MADE L__XJ OCCUR MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: _ X PRO- PRODUCTS - COMP/OP AGG $ 2,000.000 POLICY LOC $ AUTOMOBILE LIABILITY B COMBINED SINGLE LIMIT X ANY AUTO 7355-74-73 06/01/2010 06/01/2011 (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY (Per person) $ SCHEDULED AUTOS LOLL DIED. $500 BODILY INJURY (Per accident) $ COMP DIED $500 X HIRED AUTOS PROPERTY DAMAGE (Per accident) $ X NON -OWNED AUTOS X UMBRELLA LIAB X $ B OCCUR EACH OCCURRENCE $ 10,000,000 EXCESS LIAB CLAIMS -MADE 7985-60.84 0610112010 06/01l2011 DEDUCTIBLE - AGGREGATE $ 10,000,000 RETENTION $ _ WORKERS COMPENSATION $ _ AND EMPLOYERS' LIABILITY WC STATU- OTH- --' ANY PROPRIETOR/PARTNER/EXEC:UTIVE Y / N Y OFFICER/MEMBER EXCLUDED? N / A E.L. EACH ACCIDENT $ (Mandatory in NH) If yes, describe under E.L. DISEASE - EA EMPLOYE $ DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ C Managed Care 0303-0411 02/0112011 02/01/2012 Per Claim Professional Liability SIR: $5M $20,000,000 Aggregate $20,000,000 DESCRIPTION OF OPERATIONS / LOCAT*NS / VEHICLES (AHach ACORD 101, Additional Remarks Schedule, if more space Is required) RE: RFA (MEDICAL PLAN ADMINISTRATION PROPOSAL) AND BLUE CROSS & BLUE SHIELD OF FL, INC. THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS IS AN ADDITIONAL INSURED FOR GENERAL LIABILITY PER TERMS OF WRITTEN CONTRACT WITH NAMED INSURED, CERTIFICATE HOLDER CANCELLATION MONROE COUNTY BOARD OF COUNT( OMMISSIONERS STN: PURCHASING DEPARTMENT 00 SIMONTON STREET, RM 1-23 KEY WEST, FL 33040 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Donna Clampitt © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD dh CERTIFICATE OF LIABILITY INSURANCE D0TE(MM/2D/YYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MARSH USA, INC. CONTACT NAME: TWO ALLIANCE CENTER 3560 LENOX ROAD, SUITE 2400 ATLANTA, GA 30326 PHONE FAI( x A/C No E-MAIL ADDRESS: Attn: Healthcare.AccountsCSS@marsh.com/FAX: 212-948-1307 INSURERS AFFORDING COVERAGE NAIC # INSURER A: Great Northern Insurance Company 20303 INSURED BLUE CROSS AND BLUE SHIELD OF INSURER B: Federal Insurance Company 20281 FLORIDA, INC. 4800 DEERWOOD CAMPUS PKWY INSURER c : Darwin Select Insurance Company 24319 INSURER D : JACKSONVILLE, FL 32246-8273 INSURER E : INSURER F : --- --- •--•-•—-wcavw�rva RCY WIVry rvUMtSCK: 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. INSR ADDL UBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS-MADElxl OCCUR 3591-74-91 ? Y. 06/01/2011 06/01/2012 EACH OCCURRENCE $ 1,000,000 X DAMAGE TO RENTED PREMISES Ea occurrence $ 1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 A GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO- LOC C �� v \y/ 1 �C PRODUCTS -COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS X NON -OWNED AUTOS [ , I ��- 7355-74-73 �� I (� COLL DED. $500 COMP DED $500 06I01/2011 06/01/2012 COMBINED SINGLE LIMIT Ea accident) 1,000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ $ B X UMBRELLA LIAB ExcEss LIAB X OCCUR CLAIMS -MADE 7985-60 84 06/01/2011 06/01/2012 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 WORKERS COMPENSATION DED RETENTION $DRY AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? El (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WC STATU- OTH- $ E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ C Managed Care 0303-0411 02/01/2012 02/01/2013 Per Claim $20,000,000 Professional Liaiblity SIR: $5M Aggregate $20,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) RE: RFA (MEDICAL PLAN ADMINISTRATION PROPOSAL) AND BLUE CROSS & BLUE SHIELD OF FL, INC. HE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS IS INCLUDED AS AN ADDITIONAL INSURED FOR GENERAL LIABILITY WHERE REQUIRED BY WRITTEN CONTRACT WITH NAMED INSURED. f CDTICII-ATC UA1 nCn _ MONROE COUNTY BOARD OF COUNTY COMMISSIONERS ATTN: PURCHASING DEPARTMENT 1100 SIMONTON STREET, RM 1-23 KEY WEST, FL 33040 f CG. L SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. ManashiMukherjee _-TAAXNAOCIV--� IJAIAA4.11 . ACORD 25 (2010/05) W IVCO-,ZUTU AtrUKU UURPURATION. All rights reserved. The ACORD name and logo are registered marks of ACORD i 1 AR" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) o5/3uzo1 z THIS CERTIFICATE IS ISSUED AS A MATTER O T7^ti ^tll v er`n NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR 4EGATIV {ND OR TER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE OES NOI CONTRA BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CE ITIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDI IONAL INSURED, the policy(ies) mus be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain po icies may,"ire as erW�ement. A tatement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MARSH USA, INC. TWO ALLIANCE CENTER 3560 LENOX ROAD, SUITE 2400 MONROE co RISK MANAO CONTACT NAME_ Y �— FAx A/C No 1�IR;Mo. ATLANTA, GA 30326 Attn: Healthcare.AccountsCSS@marsh.comlFAX: 212-948-1307 INSURERS AFFORDING COVERAGE NAIC # INSURER A: Great Northern Insurance Company 20303 INSURED BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. INSURER B : Federal Insurance Company 20281 INSURER C : Darwin Select Insurance Company 24319 INSURER D : 4800 DEERWOOD CAMPUS PKWY JACKSONVILLE, FL 32246-8273 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: ATL-002900651-06 REVISION NUMBER: 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. INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY MWDD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY 3591-74-91 06/01/2012 06/01/2013 DAMAGE TO RENTED PREMISES Ea occurrence 1,000,000 $ MED EXP (Any one person) $ 10,000 CLAIMS -MADE I OCCUR Ap A PERSONAL & ADV INJURY $ 1,000,000 D GENERAL AGGREGATE $ 2,000,000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 $ X POLICYIR� �LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 BODILY INJURY (Per person) $ B X ANY AUTO 7355-74-73 06/01/2012 06101/2013 BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS X X NON -OWNED HIRED AUTOS AUTOS COLL DED. $500 TYDAMAGE PROPERTY accident) $ $ COMP DED $500 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 B EXCESS LIAR CLAIMS -MADE 7985-60-84 06101/2012 06/01/2013 DED RETENTION $ WORKERS COMPENSATION WC STATU-TS1 OTH- ER AND EMPLOYERS' LIABILITY Yf N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in NH) N/A E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT 1 $ If yes, describe under DESCRIPTION OF OPERATIONS below C Managed Care 0303-0411 02101/2012 02/01/2013 Per Claim $20,000,000 Professional Liaiblity SIR: $5M Aggregate $20,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) RE: RFA (MEDICAL PLAN ADMINISTRATION PROPOSAL) AND BLUE CROSS & BLUE SHIELD OF FL, INC. THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS IS INCLUDED AS AN ADDITIONAL INSURED FOR GENERAL LIABILITY WHERE REQUIRED BY WRITTEN CONTRACT WITH NAMED INSURED. CERTIFICATE HOLDER CANCELLATION MONROE COUNTY BOARD OF COUNTY COMMISSIONERS ATTN: PURCHASING DEPARTMENT 1100 SIMONTON STREET, RM 1-23 KEY WEST, FL 33040 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee— NA_,-tz-n� © 1988-2010 ACOHU CUHNUHA I ION. All ngnts reserves. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ®,a► CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 0210112013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES EEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIF ATE HOOR IMPORTANT: If the certificate holder is an ADDITION L INSURED, the policy(ies) must be dorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policie may require an endorsement. A state ant on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER MARSH USA, INC. TWO ALLIANCE CENTER FEB Cf NT NAM PHONE aC No): E-MAIL 3560 LENOX ROAD, SUITE 2400 ATLANTA, GA 30326 PAONR Attn: Heafthcare.AccountsCSSomarsh.com/FAX: 212-948-1307 RISK MA4AGEMW INSU ER S AFFORDING COVERAGE NAIC s INSURER A: UlFeat NORMIT11 Insurance Company 20303 INSURED BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC. INSURER B : Federal Insurance Company 20281 INSURER C : Darwin Select Insurance Company 24319 INSURER D : 4800 DEERWOOD CAMPUS PKWY JACKSONVILLE, FL 32246.8273 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: ATL-002900651-09 REVISION NUMBER: 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. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE M OCCUR 3591-74-91 0610112012 0610112013 DAMAGE T R NTED PREMISES Eaoccurrence) $ 1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 Comb. Total Agg $ 20,000,000 POLICY PRO X LOC AUTOMOBILE LIABILITY COJFCT MBINED SINGLE LIMIT Ea accident 1,000,000 BODILY INJURY (Per person) $ A X ANY AUTO 7355-74-73 06/01/2012 06/01/2013 BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS PROPERTY DAMAGE Per accident $ X X NON -OWNED HIRED AUTOS AUTOS COLL DED. $500 $ COMP DIED $500 X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 B EXCESS LIAB CLAIMS -MADE 7985-60-84 06/01/2012 06/01/2013 DIED RETENTION $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNERIEXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED' ❑ N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ If yes describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT I $ C Managed Care 1 02/01/2013 02/01/2014 Per Claim $20,000,000 Professional Liaibliry TS'IR Aggregate $20,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) RE: RFA (MEDICAL PLAN ADMINISTRATION PROPOSAL) AND BLUE CROSS & BLUE SHIELD OF FL, INC. THE MONROE COUNTY BOARD OF COUNTY COMMISSIONERS IS INCLUDED AS AN ADDITIONAL INSURED FOR GENERAL LIABILITY WHERE REQUIRED BY WRITTEN CONTRACT WITH NAMED INSURED. AP G MEN BY(��1ki an u: file WAI '�fMI4U 6 lfa:�11R1•fc\I�a•1�I�Ja: •f_Vl•1��r►y�ll• MONROE COUNTY BOARD OF COUNTY COMMISSIONERS ATTN: PURCHASING DEPARTMENT 1100 SIMONTON STREET, RM 1-23 KEY WEST, FL 33040 G C. J� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjee _J%taur+c" 01988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD ACOREI CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) `� 06/03/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MARSH USA, INC. TWO ALLIANCE CENTER 3560 LENOX ROAD, SUITE 2400 ATLANTA, GA 30326 CONTACT NAME: PHONE FAX A C N Q. Ex A/C No): E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC # Attn: Healthcare.A000untsCSS@marsh.com/FAX: 212-948-1307 INSURER A: American Zurich Insurance Company 40142 INSURED BLUE CROSS AND BLUE SHIELD OF INSURER B : American Guarantee & Liability Ins Co 26247 Darwin Select Insurance Company INSURER C : CP Y 24319 FLORIDA, INC. 4800 DEERWOOD CAMPUS PKWY JACKSONVILLE, FL 32246-6273 INSURER D INSURER E : INSURER F : COVERAGES CERTIFICATE NUIMIBER- ATI-no9wwri-1n GevletnW uuuaooc. 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. INSR LTR TYPE OF INSURANCE ADDL SUER WVDPOLICY NUMBER MMIDDY/YYYY) (MMIDDNYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY GLA 5574621-00 06101/2013 06/0112014 DAMA E TO RENTED PREMISES Ea occurrence $ 1,000,000 —XI MED EXP (Any one person) $ 10,000 CLAIMS -MADE I OCCUR PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY 7 PRO X LOC Comb. PolicyTotal A gg $ 10,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 A X ANY AUTO GLA 5574621-00 06/0112013 06/01/2014 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON -OWNED AUTOS COLL DED. $1,000 PROPERTY DAMAGE Per accident $ COMP DED $1,000 $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 B EXCESS LIAR CLAIMS -MADE AUC 6542352-04 06/01/2013 06/01/2014 AGGREGATE $ 5,000,000 DIED 11 1 RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N I TEEL E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below C Managed Care 0303-0411 02/01/2013 02/01/2014 Per Claim $20,000,000 Professional Liaiblity SIR: $51M Aggregate $20,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., (FLORIDA BLUE) AND ITS SUBSIDIARY OPERATIONS TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS; ITS OFFICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN CONTRACT WITH THE NAMED INSURED WITH RESPECT TO GENERAL LIABILIj%P1�.EO MAN EM ENT ��A Or'g: (,,44 WAIVER /A _ LC :-ri I e �•/� t� i Q. �. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS ATTN:PURCHASING DEPARTMENT 1100 SIMONTON STREET, RM 1-23 KEY WEST, FL 33040 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE of Marsh USA Inc. Manashi Mukherjeeauaol.: ACORD 25 (2 O/05) v 1aus-ZU1U ACURD GORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BLUECRO-05 WILLIAMSSA Ate-= o° �►�oT�c��+nTG n� i MRII IW INSURANCE DATE(MMID2/20/2014`14 ) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: ff the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain polici s Way require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).R000 yea CONTACT PRODUCER NAME: Willis of Tennessee, Inc. DBA Willis of South C��iaQ 3 PHONE g77 945-7378 FAX No : (888) 467-2378 A/C No Ext : ( ) C/o 26 Century Blvd E-MAIL P.O. Box 305191 ADDRESS: Nashville, TN 37230-5191 Finance DePL INSURERS AFFORDING COVERAGE NAIC # INSURER A: American Zurich Insurance Company 40142 INSURED r can Guarantee and Liability Insurance Comp 26247 Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue American Insurance Company 22667 Business Risk Solutions, DC1-7 4800 Deerwood Campus Pkwy DC1-7 Jacksonville, FL 32246 REVISION NUMBER: COVERAGES t.r_m i trwm i w- r.v�.�u"�. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PE 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 E BY PAID POLICY AIMS ILTR LIMITS TYPE OF INSURANCE 7xD POLICY NUMBER MMIDD MMIDD 1,000,000 EACH OCCURRENCE $GENERAL LABILITY1,000,000 GLA 5574621-00 611/2013 61112014 PREMISES Ea occurrence $A X COMMERCIAL GENERAL LIABILITY 10,000 MED EXP (Any one person) $ —1 CLAIMS -MADE Al OCCUR GEML AGGREGATE LIMIT APPLIES PER: POLICY I I PRO X LOC AUTOMOBILE LIABILITY A X ANY AUTO ALLOWNED SCHEDULED AUTOS HAUTOS AUTOS NON -OWNED HIRED AUTOS H UMBRELLA LIAB X OCCUR B EXCESS LIAB CLAIMS WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N 1 A OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If ves. describe under C JErrors 8: Omissions 5574621-00 G27114015 001 611 /2013 1 61112014 6/1 /2013 1 611 /2014 211/2014 I 2/1 /2015 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,00 PRODUCTS - COMP/OP AGG $ 2,000,00 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ V TY DAMAGE $ CIDENTColl Ded. $ CCURRENCE $ AGGREGATE $ E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ See Attached 1 1 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) THIS CERTIFICATE VOIDS AND REPLACES THE PREVIOUSLY ISSUED CERTIFICATE DATED 214/2014. RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., (FLORIDA BLUE) AND ITS SUBSIDIARY OPERATIONS TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS; ITS OFFICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN CONTRACT WITH THE NAMED INSURED WITH RESPECT TO GENERAL LIABILITY. APPR &EMENT Iva % Iv�IC CERTIFICATE HOLDER CANCELLATION - SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS AUTHORIZED REPRESENTATIVE ATTN: PURCHASING DEPARTMENT —; 1100 SIMONTON STREET, RM 1-23 C�91lic KEY WEST FL 33040 ©1988-2010 ACORD CORPORATION. All rights reserved. ArnRn 25120101051 The ACORD name and logo are registered marks of ACORD BLUE RO-05 SMITHGA ,a►C CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 1 /23/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED HOLDER. THIS BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING IN URER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does IS WAIVED, subject to not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Willis of Tennessee, Inc. DBA Willis of South Carolina c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 37230-5191 ONTACTNAME: certificates@willis.com CONTACT-NAME: PHONE Ex877 945-7378 A/c t `() j XC. No): 888 467-2378 IL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC X INSURER A: Zurich American Insurance Coml iany 16535 INSURED Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue Business Risk Solutions, DC1-7 4800 Deerwood Campus Pkwy INSURER B: American Zurich Insurance Coml iany40142 INSURER C : American Guarantee and Liability Insu nce Company 26247 INSURER D:ACE American Insurance Compa iy22667 INSURER E: DC1-7 Jacksonville, FL 32246 INSURER F ^+ M 101/-ATG uluaoco. RFViC1AN MIIM FR- THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SU FOR THE POLICY PERIOD RESPECT TO WHICH THIS BJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000. CLAIMS -MADE OCCUR X GLA5574621-01 06/01/2014 06/01/2015 DAMAGE TO RENTE PREMISES(Ea oocu 3 ence $ 1,000,00 MED EXP (Any one rson) $ 10100 PERSONAL & ADV IIN JURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGRE TE $ 2,000,00 PRODUCTS - COMP PAGG $ 2,000,00 POLICY ❑ PRO LOC JECT S OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE Ea accident IMIT $ 1,000,00 BODILY INJURY (Pe person) $ B X ANY AUTO GLA5574621-01 06/01/2014 06/01/2015 BODILY INJURY (Per accident) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE$ 10,000,00 PCLAIMS-MADE AGGREGATE $ 10,000,00 C EXCESS LIAB AUC 6542352-05 06/01/2014 06/01/2015 DED I X I RETENTION $ 0 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE STATUTE ERH E.L. EACH ACCIDENT$ E.L. DISEASE - EA EMPLOYEE $ OFFICERIMEMBER EXCLUDED? ❑ (Mandatory in NH) N / A E.L. DISEASE - POLI Y LIMIT $ If yes, describe under DESCRIPTION OF OPERATIONS below D Errors & Omissions MSP G27114015 002 02/01/2015 02/01/2016 See Attached DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space Is required) RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA, BLUE) AND ITS SUBSIDIARY OPERATIONS TO MONROE COUNTY BOARD OF COUNTY COMMISSIJitRO COMMISSIONERS; ITS OFFICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONWE UI CONTRACT WITH THE NAMED INSURED WITH RESPECT TO GENERAL LIABILITY. AG By INC., (FLORIDA ARD OF COUNTY ED BY E ENT1I I IAI nCf1 ! AmJr l 1 AT1"w I 1V VIM 1 H VV SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS AUTHORIZED REPRESENTATIVE ATTN: PURCHASING DEPARTMENT SIMONTON STREET, RM 1-23 1100 KEY WEST FL 33040 W 7VOO-ZU14 AL UKU t+VKI'VKAI I m. Au ngnrs reserveu. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGE SCHEDULE COVERAGE LIMITS Managed Care Professional Liability POLICY TYPE: Managed Care E&O CARRIER: ACE American Insurance Company $15,000,000 Per Claim POLICY TERM: 02/0112015- 02/01/2016 $15,000,000 Aggregate POLICY NUMBER: MSP G27114015 002 $ 5,000,000 SIR BLUECRO-05 WRIGHTDU DATE (MM/DD/YYYY) ORD°i CERTIFICATE OF LIABILITY INSURANCE 1 5120/2015_ --T THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). r �uTe�T PRODUCER Willis of Tennessee, Inc. DBA Willis of South Carolina c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 37230-5191 INSURED Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue Business Risk Solutions, DC1-7 4800 Deerwood Campus Pkwy DC1-7 Jacksonville, FL 32246 PHONEo Extl• () 877 945-7378 iac No): (888) 467-2378 IAIC N certificatesOmillis.Com A: American Guarantee and Liability Insurance B:ACE American Insurance Company C: D: E: F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: AVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THIS INDICATED. CERTIFICATE EXCLUSIONS LTR A IS TO CERTIFY THAT THE POLICIES NOTWITHSTANDING ANY REQUIREMENT, MAY BE ISSUED OR MAY AND CONDITIONS OF SUCH POLICIES. TYPE OF INSURANCE X COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR OF PERTAIN, INSD X INSURANCE LIMITS NND LISTED BELOW H TERM OR CONDITION OF ANY THE INSURANCE AFFORDED BY SHOWN MAY HAVE BEEN REDUCED POLICY NUMBER GLA 5574621-02 CONTRACTOR THE POLICIES POLICY E FY PAID MM/DD/YYYY 06/01/2015 OTHER DESCRIBED POCLAIMS. L CY EXP MM/DD/YYYY 06/01/2016 DOCUMENT WITH RESPECT HEREIN IS SUBJECT TO LIMITS OCCURRENCE TO WHICH THIS ALL THE TERMS, $ 1,000,00 ISES Ea occurrence $ 1,000,000 EXP (Any one person) $ 10,000 ONAL & ADV INJURY $ 1,000,00 !GENERALAGGREGATE $ 2,000,00GEN'L AGGREGATE LIMIT APPLIES PER: JECOT a LOC - COMP/OP AGG 2,000,00DUCTS $POLICY❑ $OTHER: A LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS GLA 5574621-02 06/01/2015 06/01/2016 BINED SINGLE LIMIT ccident BODILY INJURY (Per person) $ 1,000,00AUTOMOBILE $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ A X UMBRELLA LIAB X OCCUR EXCESS LIAB CLAIMS -MADE / A UC 6542362-06 06/01/2015 06/01/2016 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 PER OTH- STATUTE ER DED X RETENTION $ 0 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNEWEXECUTIVE ElN OFFICER/MEMBER EXCLUDED? E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT See Attached $ B (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Errors & Omissions MSP G27114015 002 02/0112015 02/01/2016 —A. ha attached N more space is required) DESCRIPTION OF 6ERATIOW / LOCATIOW VEHICLES (AUUKU 1U1, F FLORIDA, 1114k;., (I"LUMIUM RE: EMPLOYE ENE�{{T PROG (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE SHIELD O BLUE) TO MO E COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUN MMISSIONERS; ITS OFFICIALS; EMPLOYEES; D VC&1JNTEEj1§*RE INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED Y4R�VNkTRACT WITH THE NAMEDINSUREDWITH RESPE C O � ERAL� �LITY. AP E MENJ'J�Q`�' 4. I ''�`CD Zi WAIV R N/A S_ � �u l a ISHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS AUTHORIZED REPRESENTATIVE ATTN: PURCHASING DEPARTMENT --! 1100 SIMONTON STREET, RM 1-23 ' ©1988-2014 ACORD CORPORATION. All ngnis reserveu. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD A ADDITIONAL COVERAGE SCHEDULE COVERAGE LIMITS Managed Care Professional Liability POLICY TYPE: Managed Care E&O CARRIER: ACE American Insurance Company $15,000,000 Per Claim POLICY TERM: 0210112015- 02/01/2016 $15,000,000 Aggregate POLICY NUMBER: MSP G27114015 002 $ 5,000,000 SIR .0 •� Er-. Cl)Uj —� CT+ J 00 C?CJ O Uj C3 � tsa W "1 Z L^ C? BLUECRO-05 SMITHGA ACORO CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 1 1/27/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Willis of Tennessee, Inc. DBA Willis of South Carolina c/o 26 Century Blvd P.O. Box 305191 CONTACT NAME: Willis Towers Watson Certificate Center PHONE g77 945-7378 FA� No): (888) 467-2378 A/c Et : ( ) E-MAIL ADDRESS- certificates@willis.com INSURER(S) AFFORDING COVERAGE NAIL # Nashville, TN 37230-5191 INSURER A: American Guarantee and Liability Insurance Company 26247 INSURED INSURER B:ACE American Insurance Company 22667 INSURERC: Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue INSURERD: 4800 Deerwood Campus Pkwy Business Risk Solutions DC1-7 Jacksonville, FL 32246 INSURER E : INSURER F : IS THE POLICIES, OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD THISI TO CERTIFY THAT 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE RENT PREMISES Eaoccurrence $ 1,000,000 CLAIMS -MADE a OCCUR X GLA 5574621-02 06/01/2015 06/01/2016 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY ❑ PRO � LOC JECT OTHER: COMBINED SINGLE LIMIT Ea accident) $ 1,000,000 AUTOMOBILE LIABILITY BODILY INJURY (Per person) $ A X GLA5574621-02 O6/01/2015 06/01/2016 ANY AUTO ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED Per accident PROPERTY DAMAGE $ HIRED AUTOS AUTOS $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 A EXCESS LIAB CLAIMS -MADE UC 6642352-06 06/01/2015 06/01/2016 AGGREGATE $ 10,000,000 DED X RETENTION $ 0 PER OTH- $ WORKERS COMPENSATION STATUTE I I ER E.L. EACH ACCIDENT $ AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) E.L. DISEASE - POLICY LIMIT 1 $ If yes: descnhe under DESCRIPTION OF OPERATIONS below B Managed Care E&O MSP G27114016 003 02/01/2016 02/01/2017 See Attached DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 'RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., (FLORIDA BLUE) TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS; ITS OFFICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN CON RACT WI H THE NAMED INSURED WITH RESPECT TO GENERAL LIABILITY. _t�r'PRO ED GOENT Y UmL WAIV N A YES_{ �e 1, �Af"O,t 30�NUW .Ml les-� ' CERTIFICATE �� 910Z SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 7 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. tryr�� n�, l�� MONROE COUNTY BOARD OF' CIUIYT T i gim 6 JIURS AUTHORIZED REPRESENTATIVE ATTN:PURCHASING DEPARTMENT 1 1100 SIMONTON STREET, RM 1-23 w TIA�1 w 11 .-6 ....-A ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGE SCHEDULE COVERAGE LIMITS Managed Care Professional Liability POLICY TYPE: Managed Care E&O CARRIER: ACE American Insurance Company $15,000,000 Per Claim POLICY TERM: 02/01/2016- 02/01/2017 $15,000,000 Aggregate POLICY NUMBER: MSP G27114015 003 $ 5,000,000 SIR BLUECRO-05 SMITHGA CERTIFICATE OF LIABILITY INSURANCE DATE6/812 DIYYYY) /8/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Willis of Tennessee, Inc. DBA Willis of South Carolina c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 37230-5191 CONTACT NAME: Willis Towers Watson Certificate Center PHONE ($77) 945-7378 A/� No): (888) 467-2378 Ext E-IMCAIL ADDRESS: certificates@willis-com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: National Fire Insurance Company of Hartford 20478 INSURED Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue INSURER B : Continental Casualty Company 20443 INSURER C : ACE American Insurance Company 22667 INSURER D : 4800 Deerwood Campus Pkwy Business Risk Solutions DC1-7 Jacksonville, FL 32246 INSURER E : INSURER F CERTIFICATE NUMBER: REVISION NUMBER: 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. INTRR TYPE OF INSURANCE p INSD WVD POLICY NUMBER POLICY EFF MM/DDfYYYY POLICY EXP MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE LX] OCCUR X 6024169600 06/01/2016 07/01/2017 PREMISES Ea occurrence $ 1,000,000 MED EXP (Any one person) $ 15,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ElPRO-� LOC JECT GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP/OP AGG $ 2,000,000 OTHER: AUTOMOBILE LIABILITY COMBINED (Ea acccidentSINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ A X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS 6024169595 06/01/2016 07/01/2017 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 6024169578 06/01/2016 07/01/2017 EACH OCCURRME �.� �",000,000 AGGREGATE $ ,000,000 DIED X RETENTION $ 0 WORKERS COMPENSATION t PER A STATUTE J• TH- $ I E.L. EACH ACCID f (* $ C AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Managed Care E&O N / A MSP G27114015 003 02/01/2016 02/0112017 E.L. DISEASE - FA E REbYE $ --'� E.L. DISEASE - POLJ Y LIMIT $ ,. See Attached O DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE S IELD OF A, INC., (FLORIDA BLUE) TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COM SI E TS FICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN CON AC NAMED INSURED WITH RESPECT TO GENERAL LIABILITY. '0 V K M GEMENT a WAIV N _ZIA,- CERTIFICATE HULDEK MONROE COUNTY BOARD OF COUNTY COMMISSIONERS ATTN: PURCHASING DEPARTMENT 1100 SIMONTON STREET, RM 1-23 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE %1 7 V 1VOIS-LU14 Alit/ KU I+VKrVKA 1 IV 17. P%II IIij I RJ 10*01 VOU- ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD wo ADDITIONAL COVERAGE SCHEDULE COVERAGE LIMITS Managed Care Professional Liability POLICY TYPE: Managed Care E&O CARRIER: ACE American Insurance Company $15,000,000 Per Claim POLICY TERM: 02/01/2016- 02/01/2017 $15,000,000 Aggregate POLICY NUMBER: MSP G27114015 003 $ 5,000,000 SIR BLUECRO-05 SMITHGA A4.� R CERTIFICATE OF LIABILITY INSURANCE E FDAT/YYYY) 1 /23/2023/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED RESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. PORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Willis of Tennessee, Inc. DBA Willis of South Carolina c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 37230-5191 CONTACT NAME: certificates@willis.com PHONE o E:t : (877) 945-7378 (FAX No ; (888) 467-2378 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC N INSURER A: Zurich American Insurance Company 16535 INSURED INSURERB:American Zurich Insurance Compan 40142 Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue Business Risk Solutions, DC1-7 INSURER C : American Guarantee and Liability Insurance Company 26247 INSURER D:ACE American Insurance Company 22667 4800 Deerwood Campus Pkwy DC1-7 Jacksonville, FL 32246 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. IEXP LTR TYPE OF INSURANCE POLICY NUMBER MM DDY/YYYY MM DDEFFY/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS MADE OCCUR X GLA5574621-01 06/01/2014 06/01/2015 DAMAGE TO RFNTEIY- PREMISES Ea occurrence $ 1,000,00 MED EXP (Any one person) $ 10,00 PERSONAL & ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRO JECT LOC GENERAL AGGREGATE $ 2,000,00 2,000,00POLICY❑ $ OTHER: aUTOMOBILE LIABILITY COMBINED SINGLE LIMIT accient Ea d $ 1,000,00 X ANY AUTO GLA5574621-01 06/01/2014 06/01/2015 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ S X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,00 AGGREGATE $ 10,000,00 C EXCESS LIAB CLAIMS -MADE AUC 6542352-05 06/01/2014 06/01/2015 DED I X I RETENTION $ 0 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N / A PER OTH- STATUTE I IER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ D Errors & Omissions MSP G27114015 002 02/01/2015 02/01/2016 See Attached DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., (FLORIDA BLUE) AND ITS SUBSIDIARY OPERATIONS TO MONROE COUNTY BOARD OF COUNTY CO ISSIONERS. ONRO BOARD OF COUNTY W E UIRED BYTE,N „ COMMISSIONERS; ITS OFFICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS DITION4BY CONTRACT WITH THE NAMED INSURED WITH RESPECT TO GENERAL LIABILITY. AGR C�U /A CERTIFICATE HOLDER CANCELLATION NLU4 I a/' DW i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS AUTHORIZED REPRESENTATIVE ATTN: PURCHASING DEPARTMENT 1100 SIMONTON STREET, RM 1-23 KEY WEST FL 33040 ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGE SCHEDULE COVERAGE LIMITS Managed Care Professional Liability POLICY TYPE: Managed Care E&O CARRIER: ACE American Insurance Company $15,000,000 Per Claim POLICY TERM: 02/01/2015- 02/01/2016 $15,000,000 Aggregate POLICY NUMBER: MSP G27114015 002 $ 5,000,000 SIR BLUECRO-05 WRIGHTDU CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD� 1 5/20/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES SLOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED PRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. PORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Willis of Tennessee, Inc. DBA Willis of South Carolina c/o 26 Century Blvd P.O. BoX, TN 37 Nashville, TN 37230-5191 CONTACT NAME: PHONE g77 945-7378 A/C No Et: ( ) FA/C No : (888) 467-2378 ADDRIESS: certificates willis.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: American Guarantee and Liability Insurance Company 26247 INSURED Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue INSURER B:ACE American Insurance Company 22667 INSURERC: Business Risk Solutions, DC1-7 4800 Deerwood Campus Pkwy DC1-7 INSURER D : INSURER E : Jacksonville, FL 32246 INSURER F : COVERAGES CERTIFICATE NIIMRPM: . ------ rNG V 1JIV11 11 VIYIOCrt. 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. INSR TYPE OF INSURANCE L INSD WVD POLICY NUMBER POLICY EFF /Y MM/DDYYY POLICY EXP MM/DD/YYYY LIMITS A A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE FXIOCCUR X GLA 5574621-02 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 1,000,000 06/01/2015 06/01/2016 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO -rj(] GENERAL AGGREGATE $ 2,000,00 PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY JECT LOC OTHER: Alex AUTOMOBILE — LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,000 ANY AUTO GLA 5574621-02 06/01/2015 06/01/2016 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS HIRED AUTOS NON -OWNED OS PROPERTY DAMAGE $ Per accident UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 10,000,000 4DED AGGREGATE $ 10,000,000 AEXCESS LIAB CLAIMS -MADE UC 6542352-06 06/01/2015 06/01/2016 X RETENTION $ 0 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY Y / N STATUTE ER E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? ❑ N / A (Mandatory in NH) It yes, describe under E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS below B Errors & Omissions MSP G27114015 002 02/01/2015 02/01/2016 See Attached DESCRIPTION OF 6MRATOO / LOCATIOW VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: EMPLOYE ENE�{T PROGR (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., (FLORIDA BLUE) TO MO E C NTY BOAbtD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUN MMISSIONERS; ITS OFFICIALS; EMPLOYEES; D VC=NTEER$,*RE INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED Y R N C TRACT WITH THENAMED INSURED WITH RESPE O O ERALct �LITY. APP F A IA MENI' WAIV R N/A p S _ c�• MONROE COUNTY BOARD OF COUNTY COMMISSIONERS ATTN: PURCHASING DEPARTMENT 1100 SIMONTON STREET, RM 1-23 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE V 1UUIS-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD w ADDITIONAL COVERAGE SCHEDULE COVERAGE LIMITS Managed Care Professional Liability POLICY TYPE: Managed Care E&0 CARRIER: ACE American Insurance Company $15,000,000 Per Claim POLICY TERM: 02/01/2015- 02/01/2016 $15,000,000 Aggregate POLICY NUMBER: MSP G27114015 002 $ 5,000,000 SIR W J r = 00 U O U- W x BLUECRO-05 SMITHGA AC. "PC" `.� CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDNYYY) 1/27/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES FLOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED RESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. PORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Willis of Tennessee, Inc. DBA Willis of South Carolina c/o 26 Century Blvd P.O. Box Nashville,, TN TN 37 37230-5191 CONTACT NAME: Willis Towers Watson Certificate Center PHOPAX ac NE No Ext : (877) 945-7378 A/C,No): (888) 467-2378 ADDE-MRESS: certificates@willis.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: American Guarantee and Liability Insurance Company 26247 INSURED INSURER B:ACE American Insurance Company 22667 Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue 4800 Deerwood Campus Pkwy Business Risk Solutions DC1-7 INSURER C : INSURER D : INSURER E : Jacksonville, FL 32246 INSURER F : CUVERA1Jrb CERTIFICATE NUMBER: REVISION NUMBER• 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. INSR LTR TYPE OF INSURANCE AUX INSD WVD POLICY NUMBER POLICY EFF MMlDD/YYW POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS -MADE � OCCUR X GLA 5574621-02 06/01/2015 06/01/2016 hNILD PREMISES Ea occurrence $ 1,000,00 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,00 GENT AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑ JECOT- � LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,00 X BODILY INJURY (Per person) $ ANY AUTO GLA 5574621-02 06/01/2015 06/01/2016 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 A EXCESS LIAB CLAIMS -MADE AUC 6542352-06 06/01/2015 06/01/2016 DIED I X I RETENTION $ 0 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS! LIABILITY Y / N STATUTE ER E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPERATIONS below B Managed Care E&O MSP G27114015 003 02/01/2016 02/01/2017 See Attached DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., (FLORIDA BLUE) TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS; ITS OFFICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN CON RACT WI H HE NAMED, INSURED WITH RESPECT TO GENERAL LIABILITY. �awille t D t YPI20 GEMENi"i' AINfl0i 3UJNGW WAIV N A YES_ CERTiFiCAT E MULUEK CANCELLATION U • 6 -C Wd _ 833 n SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 7 'O� DATE THEREOF, NOTICE WILL BE D NERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MONROE COUNTY BOARD`60 0 4WJNI4 34dRS ATTN: PURCHASING DEPARTMENT 1100 SIMONTON STREET, RM 1-23 AUTHORIZED REPRESENTATIVE i KEY WEST FL 33040 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGE SCHEDULE D COVERAGE LIMITS Managed Care Professional Liability POLICY TYPE: Managed Care E&O CARRIER: ACE American Insurance Company $15,000,000 Per Claim POLICY TERM: 02/01/2016- 02/01/2017 $15,000,000 Aggregate POLICY NUMBER: MSP G27114015 003 $ 5,000,000 SIR BLUECRO-05 SMITHGA W-PS4E CERTIFICATE OF LIABILITY INSURANCE DATED/vYYY) s/8/2 is/2o1s THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT- If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Willis of Tennessee, Inc. DBA Willis of South Carolina c/o 26 Century Blvd P.O. Box, TN 37 Nashville, TN 37230-5191 CONTACT NAME: Willis Towers Watson Certificate Center PHONE FAX A/C No Ext : (877) 945-7378 A/c, No , (888) 457-2378 E-MAIL certificates@willis.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: National Fire Insurance Company of Hartford 20478 INSURED INSURER B : Continental Casualty Company 20443 Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue 4800 Deerwood Campus Pkwy Business Risk Solutions DC1-7 INSURER C : ACE American Insurance Company 22667 INSURER D : INSURER E : Jacksonville, FL 32246 INSURER F tuver.Aut, CERTIFICATE NUMRFR- 0Cv1e1nu euleanre. 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. INSIR TR TYPE OF INSURANCE ADM NSD SUN WVD POLICY NUMBER MMID Y� MMIDDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE a OCCUR X 6024169600 06/01/2016 07/01/2017 PREMISES Ea occurrence $ 1,000,000 MED EXP (Any one person) $ 15,000 PERSONAL & ADV INJURY $ 1,000,000 AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 GENT PRO - POLICY LOC JECT PRODUCTS - COMP/OP AGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident)$ 1,000,000 A X BODILY INJURY (Per person) $ ANY AUTO 6024169595 06/01/2016 07/01/2017 ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident —� X UMBRELLA LIAB X OCCUR EACH OCCURRENME SIL.— M'000,000 B EXCESS LIAB CLAIMS -MADE 6024169578 06/01/2016 07/01/2017 AGGREGATE - $ ,000,000 DED X RETENTION $ 0 T $ I WORKERS COMPENSATION TH- UJ AND EMPLOYERS' LIABILITY YIN STATUTE O C E.L. EACH ACCID Yr $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under N / A E.L. DISEASE - EA E IQM1OYE $ '-3 _ E.L. DISEASE - POLI Y LIMIT $ `7D DESCRIPTION OF OPERATIONS below C Managed Care E&O MSP G27114015 003 02/01/2016 02I01/2017 See Attached DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE S IELD OF A, INC., (FLORIDA BLUE) TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COM SSI E TS FICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN CON AC NAMED INSURED WITH RESPECT TO GENERAL LIABILITY. -'I V K M GEMENT%yQ WAN N MONROE COUNTY BOARD OF COUNTY COMMISSIONERS ATTN:PURCHASING DEPARTMENT 1100 SIMONTON STREET, RM 1-23 V CLLN 1 IUIY SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE a tJ 1 WOU-2U14 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGE SCHEDULE COVERAGE LIMITS Managed Care Professional Liability POLICY TYPE: Managed Care E80 CARRIER: ACE American Insurance Company $15,000,000 Per Claim POLICY TERM: 02/01/2016- 02/01/2017 $15,000,000 Aggregate POLICY NUMBER: MSP G27114015 003 $ 5,000,000 SIR BLUECRO-05 SEQUEIRARR CERTIFICATE OF LIABILITY INSURANCE DATE(MI� v2s/201YY2o17 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE -AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Willis Towers Watson Certificate Center Willis of Tennessee, Inc. DBA Willis of South Carolina 26 Centu9Blvd P.O. Box 30571Ei PHONE FAX, -2378c/o , Et: (877) 945-7378 (A/CNo :(888) 467 AD"DF . certificates@willis.com Nashville, TN 37230-5191 INSURERS AFFORDING COVERAGE NAIC # INSURER A: National Fire Insurance Company of Hartford 20478 INSURED Blue Cross and Blue Shield of Florida, Inc. d/b/a Florida Blue 4800 Deerwood Campus Pkwy Business Risk Solutions DC1-7 INSURER B : Continental Casualty Company 20443 INSURER C: American Casualty Company of Reading, PA 20427 INSURER D : ACE American Insurance Company 22667 INSURER E : Jacksonville, FL 32246 INSURER F : --- -- -------------— — -- COVERAGES CERTIFICATE NAIMRFR- RFVICInkl I611100RGR• THIS 1S 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. INSR AJ1ILM TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF D POLICY EXP MM D LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR X 6024169600 06/01/2016 06/01/2017 EACH OCCURRENCE 1,000,000 DAMAGE TEMISESO RENTED $ 1,000,000 MED EXP (Any onePerron) 15,000 PERSONAL & ADV INJURY 1,000,000 1.1- AGGREGATE LIMIT APPLIES PER: POLICY D JE° LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG 2,000,000 OTHER: A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) 11000,000 $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS 6024169595 06/01/2016 06/01/2017 X BODILY INJURY Perperson) $ BODILY INJURY Per accident $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY B X UMBRELLA LIAB X OCCUR EACH OCCURRENCE 10,000,000 AGGREGATE 10,000,000 EXCESS LIAS CLAIMS -MADE 6024169578 06/01/2016 06/01/2017 DED I X I RETENTION $ O C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N EXCLUDED? N❑ FI In NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 6024169581 O6/01/2016 06/01/2017 �( PER OTH- E.L. EACH ACCIDENT 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE -POLICY LIMIT 1,000,000 $ D Managed Care E&O MSP G27114015 004 02/01/2017 02/01/2018 See Attached DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space Is required' - RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE SHIELD OF FLORIDA, INC., (FLORIDA BLUE) TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COMMISSION RS; ITS OFFICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL INSURED WHERE REQUIRED BY WRITTEN C T CT E NAMED IN URED WITH RESPECT TO GENERAL LIABILITY. �Q AP If iED AGEMEM"7 av WAN R N/A YES_ i lL;8:[U16 rl q [7 MONROE COUNTY BOARD OF COUNTY COMMISSIONERS ATTN:PURCHASING DEPARTMENT 1100 SIMONTON STREET, RNA 1-23 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE At.UKU ZD (ZU9gTJUS) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGE SCHEDULE COVERAGE LIMITS Managed Care Professional Liability POLICY TYPE: Managed Care E80 $15,000,000 Per Claim CARRIER: ACE American Insurance Company- $15,000,000 Aggregate POLICY TERM: 02/01/2017 - 02/01/2018 $5,000,000 SIR POLICY NUMBER: MSP G27114015 004 BLUECRO-05 LANEDE �— A� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 5/28/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Willis of Tennessee, Inc. DBA Willis of South Carolina C/o 26 CenturyBlvdE-MAIL P.O. Box 305191 Nashville, TN 37230-5191 CONTACT NAME: -2378 PHONE g77 945-7378 FAX No), (888) 467AA ( ) E-MIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Zurich American Insurance Company 16535 INSURED Blue Cross and Blue Shield of Florida, Inc. d/bla Florida Blue Business Risk Solutions, DC1-7 4800 Deerwood Campus Pkwy INSURER B: American Zurich Insurance Company 40142 INSURERC: American Guarantee and Liability Insurance Company 26247 INSURER D:ACE American Insurance Company 22667 DC1-7 Jacksonville, FL 32246 INSURER E : INSURER F : 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. INSR A TYPE OF INSURANCE X COMMERCIAL GENERAL LIABILITY CLAIMS�v1ADE OCCUR ADDL X UBR POLICY NUMBER GLA5574621-01 POLICY EFF MM/DD/YYYY 6/1/2014 POLICY EXP MM/DDNYYY 6l1/2015 LIMITS EACH OCCURRENCE ET R NTED PREMISES Ea occurrence PREMDAMAISES MED EXP (Any one person) A2,000,00 PERSONAL & ADV INJURY GENERAL AGGREGATE GEN'L AGGREGATE LIMIT APPLIES PER: �� POLICY PRO FX] LOC JECT PRODUCTS $ 2,000,00 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ 1,000,00 BODILY INJURY (Per person) $ B X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS GLA5574621-01 6/1/2014 6/1/2015 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ Comp/Coll Ded: $ 1,00 C X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE AUC 6542352-05 6/1/2014 6/1/2015 EACH OCCURRENCE $ 5,000,00 AGGREGATE $ 5,000,00 PER OTH- STATUTE ER DED RETENTION $ WORKERS COMPENSATION E.L. EACH ACCIDENT $ AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE Y / N E.L. DISEASE - EA EMPLOYEE $ OFFICER/MEMBER EXCLUDED? ❑ (Mandatory in BE N / A If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ D Mgd Care Prof Liab MSP G27114015 001 2/1/2014 2/1/2015 See Attached DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) BLUE SHIELD OF FLORIDA, INC., (FLORIDA RE: EMPLOYEE BENEFIT PROGRAMS (MEDICAL PLAN ADMINISTRATION) PROVIDED BY BLUE CROSS AND BLUE) AND ITS SUBSIDIARY OPERATIONS TO MONROE COUNTY BOARD OF COUNTY COMMISSIONERS. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS; ITS OFFICIALS; EMPLOYEES; AND VOLUNTEERS ARE INCLUDED AS ADDITIONAL IbISUR WHERE REQUIRED BY WRITTEN CONTRACT WITH THE NAMED INSURED WITH RESPECT TO GENERAL LIABILITY. BYPROV D AN ENr o/g#AMU VA:r DA L WAIV y ,,� I N0'r1 V 1 '1�iNi►O� 34�t.K-, (� . GERTIFIGA It MULLJtF( ELLED wa 9- I THE SHOULD EXPIRATIONDATEDABTEV THEREOF, NOTICES BE WILLBEDELIVERED BEFORE IN ACCORDANCE WITH THE POLICY PROVISIONS. R'99rCOU 4 C3 03113 MONROE COUNTY BOA OMMISSIONERS AUTHORIZED REPRESENTATIVE ATTN: PURCHASING DEPARTMENT �- 1100 SIMONTON STREET, RM 1-23 ta111'1 ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD �nnnilo wTlAwl All ...-k4- wece..inil ADDITIONAL COVERAGE SCHEDULE COVERAGE LIMITS POLICY TYPE: Managed Care E&O $15,000,000 Per Claim CARRIER: ACE American Insurance Company $15,000,000 Aggregate POLICY TERM: 2/1/2014 to 2/1/2015 $ 5,000,000 SIR POLICY NUMBER: MSP G27114015 001