07/28/1993 Contract C O N T R A C T
THIS AGREEMENT, made and entered into this 28th day of July,
1993, between Monroe County, Florida (Owner), and EGA, Inc.
(Contractor):
W I T N E S S E S:
That the parties hereto, for the consideration hereinafter set
forth, mutually agree as follows:
I. SCOPE OF THE WORK
- n
The Contractor shall provide janitorial services inclu.ngll
necessary supplies and equipment required in the aperformance-,of
same, for the Marathon Government Center, located€&t' 27 Over-
seas Highway, Marathon, Monroe County, Florida. The Coractor
agrees to, furnish janitorial services in accordance with the
Public Works Manual entitled "Public Works Specification Mairu-
al /Janitorial /Marathon Government Center, attached hereto axed
incorporated as part of this contract document. The manuaif shall
serve as minimum contract standards, and shall be, the b&bis of
inspection and acceptance of all the work. The Contractor shall
insure all exterior doors are locked upon their departure.
II. INDEPENDENT CONTRACTOR
At all times and for all purposes under this agreement the Con-
tractor is an independent contractor and not an employee of the
Board of County Commissioners for Monroe County. No statement
contained in this agreement shall be construed so as to find the
contractor or any of his /her employees, contractors, servants, or
agents to be employees of the Board of County Commissioners for
Monroe County.
III. ASSURANCE AGAINST DISCRIMINATION
The Contractor shall not discriminate against any person on the
basis of race, creed, color, national origin, sex, age, or any
other characteristic or aspect which is not job related, in its
recruiting, hiring, promoting, terminating, or any other area
affecting employment under this agreement or with the provision
of services or goods under this agreement.
IV. ASSIGNMENT
The Contractor shall not assign this agreement, except in writing
and with the prior written approval of the Board of County Commis-
sioners for Monroe County and Contractor, which approval shall be
subject to such conditions and provisions as the Board and Con-
tractor may deem necessary. This agreement shall be incorporated
by reference into any assignment and any assignee shall comply
with all of the provisions of this agreement. Unless expressly
provided for therein, such approval shall in no manner or event
be deemed to impose any obligation upon the Board in addition to
the total agreed -upon price of the services /goods of the contrac-
tor.
V. COMPLIANCE WITH LAW
In providing all services /goods pursuant to this agreement, the
contractor shall abide by all statutes, ordinances, rules and
regulations pertaining to, or regulating the provisions of, such
services, including those now in effect and hereinafter adopted.
Any violation of said statutes, ordinances, rules and regula-
tions shall constitute a material breach of this agreement and
shall entitle the Board to terminate this contract immediately
upon delivery of written notice of termination to the contractor.
VI. INSURANCE
Upon execution of this agreement, the Contractor shall furnish
the Owner Certificates of Insurance indicating the minimum cover-
age limitations as indicated by an "X" on the attached forms
identified as INSCKLST 1 -4, as further detailed on forms WC1,
GL1, VL1, ED1, & GIR 1, each attached hereto and incorpo-
rated as part of this contract document.
VII. HOLD HARMLESS
The Contractor shall defend, indemnify and hold harmless the
County as outlined on the attached form identified as IND1.
VIII. TERM OF CONTRACT
This Contract shall be for a period of one (1) year, commencing
on the day in which it has been executed by both parties. This
Contract term shall be renewable in accordance with Article X.
IX. CANCELLATION
Either of the parties hereto may cancel this agreement with or
without cause by giving the other party sixty (60) days written
notice sent certified mail of its intention to do so.
X. RENEWAL
The Owner shall have the option to renew this agreement after the
first year, and each succeeding year, for two additional one year
periods. The contract amount agreed herein may be adjusted annu-
ally in accordance with the percentage change in the Consumer
Price Index (CPI) for Wage Earners and Clerical Workers in the
Miami, Florida area index, and shall be based upon the annual
average CPI computation from January 1 through December 31 of
the previous year.
2
XI. FUNDING AVAILABILITY
In the event that funds from Facilities Maintenance Contractual
Services are partially reduced or cannot be obtained or cannot be
continued at level sufficient to allow for the purchase of the
services /goods specified herein, this agreement may then be termi-
nated immediately at the option of the Board by written notice of
termination delivered in person or by mail to the contractor.
The Board shall not be obligated to pay for any services provided
by the contractor after the contractor has received written no-
tice of termination.
XII. PROFESSIONAL RESPONSIBILITY
The Contractor warrants that it is authorized by law to engage in
the performance of the activities encompassed by the project
herein described, subject to the terms and conditions set forth
in the Public Works Manual entitled "Public Works Specification
Manual /Janitorial /Marathon Government Center ", which is attached
hereto and incorporated herein as a part of this con-
tract/agreement. The provider shall at all times exercise inde-
pendent, professional judgement and shall assume professional
responsibility for the services to be provided. Continued fund-
ing by the Board is contingent upon retention of appropriate
local, state, and /or federal certification and /or licensure of
contractor.
XIII. NOTICE REQUIREMENT
Any notice required or permitted under this agreement shall be in
writing and hand delivered or mailed, postage prepaid, to the
other party by certified mail, returned receipt "requested, to the
following:
FOR COUNTY FOR CONTRACTOR
Monroe County Public Works EGA, Inc.
5100 College Road P.O. Box 1575
Key West, FL 33040 Marathon, FL 33050
XIV. PAYMENT
The County shall pay to the Contractor for the performance of
said service on a per month in arrears basis on or before the
15th day of the following month in each of twelve (12) months.
The Contractor shall invoice the County monthly for janitorial
services performed under the Specifications contained herein.
The Contract amount shall be as stated by the contractors propos-
al as follows: Twenty -Nine Thousand Eight Hundred Dollars
($29,800.00) per year.
3
In witness whereof, the parties hereto have executed this agree-
ment the day and year first above written,
COUNTY OF MONROE, STATE OF
FLORIDA
By N
ayor /Chairman
Attest: DANNY L. KOLHAGE, Clerk
%lid C. ang,inentza)
Clerk
EGA, INC.
� � � '
By �..�. r/ / alt. _ aEs
Attest:
Xa W e t-trj
WITNESS
/(7
WITNESS
A - - - . 4 • 77C"' f
By
Attorne, 0.::;o
Date
4
' xmc 4ilii
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t?0.130X 1575 MARATHON. FLORIDA 33050
-- 1y3 ys`AS
(o%5 r93 -- 143k y
BID FoR JANITORIAL SERVICE
MARATH O1\l GOVERNMENT GENTEI .
AS PER J013 'DE SCRIPTION 'PAGES a, 3 ILI
ATTACHED HERETO:
4$89, yR.
THIS BID VALID FOR A 'DER10b OF 90 'DAYS
, 1 gJ C Alk_ //fiv
?ALA_ G. MULL E R
?RES.
EGA INC.
SWORN STATEMENT PURSUANT TO SECTION 287.133(3)(a),
FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES
• •
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
•
1. . - This sworn statement is submitted to .
[print name of the public entity) -"c,.
by : ,"l- G - Atu 1 IL7L.
[print individual's name and title]
• for • .. L; . A • �. N C- ' 3 •
[print name of entity submitting sworn statement]
- • whose business address is ,
•
Po /ox ,r7S
p, f a- PI -- F z_ 33dSa -
and (if applicable) its Federal Employer Identification Number (FEIN) is
(If the entity has no FEIN, include the Social Security Number of the individual signing this sworn
statement: .)
- 2.. I understand that a "public entity crime" as defined in Paragraph 287.133(1Xg), Florida Statutes, means . a
violation of any state or federal law by a person with respect to and directly related to the transaction of business
with any public entity or with an agency or political subdivision of any other state or of the United States, including,
but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or
political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery,
collusion, racketeering, conspiracy, or material misrepresentation.
3. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1Xb), Florida Statutes, means a
finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or
state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result
of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere. •
4. I understand that an "affiliate" as defined in Paragraph 287.133(1Xa), Florida Statutes, means:
1. A predecessor or successor of a person convicted of a public entity crime; or
2. An entity under the control of any natural person who is active in the management of the entity and who has
been convicted of a public entity crim e. The term "affiliate" includes those officers, directors, executives, partners,
shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership
by one person of shares constituting a controlling interest in another person, or pooling of equipment or income
among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that
one person controls another person. A person who knowingly enters into a joint venture with a person who has
been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. '
-. » ,. _ •
5. I understand that a "person" as defined in Paragraph 287.133(1Xe), Florida Statutes, :means any natural person:::
or entity organized under the laws of any state or of the United States with the legal power to enter into a binding ,,
.:... contract and which bids or applies to bid on contracts for the provision of goods or services let by S public entity, '`L
of which otherwise transacts or applies to transact business with a public entity. The term "person" includes those
• officers,` directors, executives, partners, shareholders, employees, members; and agents who are active in •.•' • cnansgeinent of an entity '' :" ;
s I ..f, s . ., J 5
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.... �;..t.+' ., r ... ... �. .. t�bL'n.�^'�.± :..t.. ..r ._. .. » .. ` L
.....n s•+S..;G.: a ✓
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Based on information and belief, the statement I have marked below is true in relation to the entity
w submit • g this sworn statement. [Indicate which statement applies.]
1 _ Neither the entity submitting this sworn statement, nor any of its officers, directors, executives, partners,
shareholders, employees, members, or agents who are active in tbe management of the entity, nor any affiliate of
the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989.
The entity submitting this sworn statement, nor any of its officers, directors, exectutives, partners,
shareholders, employees, members, or agents who are active in the management of the entity, nor an affiliate of
the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989.
• The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners,
shareholders, employees, members, or agents who are active in the management of the entity, or an affiliate of 1
the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there
• has been a subsequent proceeding before a Hearing Officer of the State of Florida, Division of Administrative
Hearings and the Final Order entered by the Hearing Officer determined that it was not in the public interest to
place tbe entity submitting this sworn statement on the convicted vendor list. [attach a copy of the final order] ,
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FORTHE PUBLIC
ENTITY IDENTIFIED ON PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS
FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I ALSO
UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A
CONTRACT INEXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FT.ORTDA STATUTES
FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM.
Ve,-J /
[signature]
Sworn to and subscribed before me this a day of ,19 AN •
•
LG� Personally known G�/G� / ` -4c
OR Produced identification Notary Public - State ofYi�/'�
- ez t Y AN N COLLINS
!�-v �! My Co nt.;t � ki p
(Type of identific on) MY COMMISSION t 208394
• EXPIRES: July 13 1998
(Print - .,...
• commissioned name of notary public)
•
•
Form PUR 7068 (Rev. 06 /11/92) _ -t ,
•
PUBLIC WORKS SPECIFICATION MANUAL
JANITORIAL
MARATHON GOVERNMENT CENTER
TWO DAYS PER WEEK SERVICE /OFFICES
FIVE DAYS PER WEEK /HALLWAYS & RESTROOMS
TABLE OF CONTENTS
TITLE PAGE
A. DESCRIPTION 2
B. WORK HOURS 2
C. GENERAL CLEANING 2
D. RESTROOM SANITATION 2
E. FLOOR TREATMENT 3
F. PERIODIC SERVICES 3
G. COORDINATION OF THE WORK 3
H. PAPER PRODUCTS AND SUPPLIES 4
I. RECYCLING 4
J. INSPECTION OF THE WORK 4
K. INSURANCE /INDEMNIFICATION /HOLD HARMLESS 4
L. PUBLIC ENTITY CRIME AFFIDAVIT 5
M. NON- COLLUSION AFFIDAVIT 5
• t
A. DESCRIPTION
1. The Contractor shall furnish janitorial services, includ-
ing all necessary supplies and equipment required in the
performance of same, for the Marathon Government Center,
located at 2790 Overseas Highway, Marathon, Florida.
B. WORK HOURS
1. The Contractor shall clean all required offices two (2)
nights per week, Tuesday and Friday, each week, and all
required restrooms and public hallways five (5) nights
per week, Monday through Friday. Work shall be per-
formed between the hours of 5:00 p.m. and 7:00 a.m.
C. GENERAL CLEANING
General cleaning shall include the following:
1. All tile floors are to be dust mopped and /or damp mopped
as necessary.
2. All furniture and furnishings dusted and spot cleaned.
3. All walls and woodwork spot cleaned to a height of six
(6) feet monthly.
4. Low ledges, sills, rails, and baseboards dusted and /or
spot cleaned.
5. All ashtrays emptied, damp cleaned, and polished.
6. All cigarette burns cleaned and debris removed.
7. Clean and polish all drinking fountains.
8. All trash receptacles emptied, trash can liners changed.
9. All glass entrance doors shall be washed and polished
inside and outside.
10. All other glass partitions, interior doors, mirrors,
windows, etc., to be washed and polished as needed.
11. Vacuum all upholstered furniture.
12. Carpets in all traffic areas are to be vacuumed each
night, complete area also to be vacuumed each night.
13. All carpeting will be regularly inspected and spot
cleaned.
D. RESTROOM SANITATION
Restroom sanitation shall include the following:
1. All floors swept with a straw broom, loose dirt removed.
2. Wash and disinfect floor and upon completion, floor is
to be mopped to a damp dry condition.
3. Stall partitions damp cleaned.
4. All commodes, urinals, basins and vanities shall be
scoured and disinfected.
5. All urinal traps shall be specially cleaned and disin-
fected.
6. All sanitary napkin receptacles will be cleaned, waste
disposed, and disinfected.
7. All supplies shall be replaced.
8. All mirrors shall be cleaned.
2
8. All slop sink closets to be cleaned completely each
week, and mops, buckets, etc., removed to storerooms
after usage.
9. All other work necessary to maintain a clean and sani-
tary condition in these restrooms shall be accomplished,
whether it is specifically noted in these specifications
or not.
E. FLOOR CLEANING
1. Buildings with floors requiring stripping, refinishing,
and buffing shall receive this treatment on a regularly
scheduled basis, so as never to allow a build -up of old
finish to accrue anywhere on the floors of the complex.
2. Treatment of these floors shall be performed a minimum
of one (1) time per month.
3. All other flooring shall be cleaned as described in
Sections B and E of this specification.
F. PERIODIC SERVICES
The services below shall be included and shall be performed
at the frequency indicated as follows:
1. All door vents cleaned weekly.
2. All high dusting (i.e. pictures, door frames, air vents,
etc., shall be cleaned monthly.
3. All walls dusted monthly
4. All interior windows washed bimonthly.
5. All janitor rooms and closets to be cleaned at all times.
6. Clean /Shampoo all carpeted areas a minimum of once every
six (6) months.
7. Sweep all stairs, landings, breezeway area, and brick
area once a week.
8. Pressure clean breezeway twice a month.
9. Pressure clean entrance area and walls once a month.
G. COORDINATION OF THE WORK
1. Contractor shall provide maximum amount of Janitorial
Services with the minimum amount of interference to
building tenants.
2. Coordination of the work with the County area representa-
tive shall be the responsibility of the Contractor. The
Contractor shall perform the work during hours and times
as specified.
3. Keys shall be issued to the Contractor by the area repre-
sentative at the start of the Contract. Written confir-
mation of receipt of keys shall be signed by the Contrac-
tor. The Contractor shall return all keys as issued
upon expiration of the Contract or termination.
4. The Contractor shall be responsible for the cost of
changing locks, etc., for all keyed secured areas for
which the Contractor does not return the keys.
3
H. SUPPLIES
1. The Contractor shall provide all supplies necessary for
the cleaning performance of his work under the con-
tract. All supplies, including but not limited to, hand
soap, sanitary napkins, paper towels, toilet paper, and
trash can liners, shall be supplied by the Contractor.
2. The Contractor shall maintain stock in each facility in
a minimum amount sufficient to last through the next
cleaning day.
I. RECYCLING
1. The Contractor shall be required to participate in the
recycling program on a per office basis. County offices
recycling office paper, aluminum, and newspaper shall
have receptacles indicating specific use. The Contrac-
tor shall be responsible for emptying receptacles to
designated containers.
J. INSPECTION OF THE WORK
1. The tenants of each facility shall be the deemed the
County's representative on a daily basis, and shall
determine if deficiencies exist. Deficiencies shall be
indicated on the attached "Janitorial Contract Deficien-
cy Report
2. Random inspections shall be performed by County Represen-
tatives from the Public Works Division administering the
contracts.
3. Deficiencies shall be corrected within a twenty -four
(24) hour period of notification to the Contractor.
Failure of the Contractor to correct such deficiencies
shall result in prorated deduction from the monthly
invoice.
K. INSURANCE /INDEMNIFICATION /HOLD HARMLESS
1. The Contractor shall defend, indemnify and hold harmless
the County as outlined on the attached form identified
as IND1.
2. The Contractor will be responsible for all necessary
insurance coverage as indicated by an "X" on the at-
tached forms identified as INSCKLST 1 -4, as further
detailed on forms WC1, GL1, VL1, ED1, and GIR1.
2. Certificates of Insurance must be provided to Monroe
County within fifteen days after award of bid. If the
proper insurance forms are not received within the fif-
teen days, bid will be awarded to the next selected
bidder.
4
L. PUBLIC ENTITY CRIME AFFIDAVIT
1. Any person submitting a bid or proposal in response to
this invitation must execute the enclosed Form PUR
7068, SWORN STATEMENT UNDER SECTION 287.133(3) (A),
FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES, including
proper check(s), in the space(s) provided, and enclose
it with his bid or proposal. If you are submitting a
bid or proposal on behalf of dealers or suppliers who
will ship commodities and receive payment from the re-
sulting contract, it is your responsibility to see that
copy(s) of the form are executed by them and are includ-
ed with your bid or proposal. Corrections to the form
will not be allowed after the bid or proposal opening
time and date. Failure to complete this form in every
detail and submit it with your bid or proposal may re-
sult in immediate disqualification of your bid or propos-
al.
M. NON- COLLUSION AFFIDAVIT
1. Any person submitting a bid or proposal in response to
this invitation must execute the enclosed NON- COLLU-
SION AFFIDAVIT. If it is discovered that collusion
exists among the bidders, the bid or proposals of all
participants in such collusion will be rejected, and no
participants in such collusion will be considered in
future proposals for the same work.
5
C MAYO
BOARD OF COUNTY COMMISSIONERS
_1 T.
R, Jack London, District 2
— Mayor Pro TemA Earl Cheal ". - Wilhelmina Harvey, District 1
WEST FLORIDA 33040 l Y . `! �� r � �• Shirley Freeman, District 3
U;
(305) 294 -4641 i � I ' Mary Kay Reich, District 5
Public Works Division
Public Facilities Maint.
5100 College Road
1 01 , 0
Key West, FL 33040
JANITORIAL CONTRACT DEFICIENCY REPORT
Location Date
The following deficiency in Janitorial contractual requirements
are reported as follows:
CONTRACT ITEM # NOTED DEFICIENCY
COMMENTS:
(Signature of Monitor)
Contractor Action Date
Foregoing deficiency has been corrected
(Signature - Contractor Rep)
c.c. Facilities Maintenance Department (after contractor has
corrected deficiency or had sufficient time to do so and
has not taken action)
MONROE COUNTY, FLORIDA
INSURANCE GUIDE
TO
CONTRACT ADMINISTRATION
Indemnification and Hold Harmless
for
Suppliers of Goods and Services
The Vendor covenants and agrees to indemnify and hold harmless Monroe County Board of
County Commissioners from any and all claims for bodily injury (including death), personal injury,
and property damage (including property owned by Monroe County) and any other losses,
damages, and expenses (including attorney's fees) which arise out of in connection with, or by
reason of services provided by The Vendor or any of its subcontractor(s) in any tier, occasioned
by the negligence, errors, or other wrongful act or omission of The Vendor or its subcontractor(s)
in any tier, their employees, or agents.
In the event the completion.of the project (to include the work of others) is delayed or suspended
as a result of the Vendor's failure to purchase or maintain the required insurance, the Vendor shall
indemnify the County from any and all increased expenses resulting from such delay.
The extent of liability is in no way limited to, reduced, or lessened by the insurance
requirements contained elsewhere within this agreement.
•
•
IND1
• April 22, 1993
1st Printing
/ MONROE COUNTY, FLORIDA
F` INSURANCE CHECKLIST
FOR
VENDORS SUBMITTING PROPOSALS
FOR WORK •
•
To assist in the development of your proposal, the insurance coverages marked with an
"X" will be required in the event an award is made to your firm. Please review this form
with your insurance agent and have him sign it in the place provided. It is also required
that the bidder sign the form and submit it with each proposal.
WORKERS' COMPENSATION
AND
EMPLOYERS' LIABILITY
X • Workers' Compensation Statutory Limits
WC1 X Employers Liability $100,000 /$500,000 /$100,000
WC2 Employers Liability $500,000 /$500,000 /$500,000
WC3 Employers Liability $ 1,000,000 /$1,000,000 /$1,000,000
WCUSLH US Longshoremen & Same as Employers'
Harbor Workers Act Liability
WCJA Federal Jones Act Same as Employers'
Liability
WCFELA Federal Employers' Same as Employers'
Liability Act (FELA) Liability -
INSCKLST
1
•
April 22, 1993
1st Printing
GENERAL LIABILITY
As a minimum, the required general liability coverages will include:
o Premises Operations o Products and Completed Operations
o Blanket Contractual o Personal Injury
o Expanded Definition
of Property Damage
1 Required Limits:
GL1 X $100,000 per Person; $300,000 per Occurrence
$50,000 Property Damage; $5,000 Med. Payments
or
$300,000 Combined Single Limit; $5,000 Med. Payments
GL2 $250,000 per Person; $500,000 per Occurrence
$50,000 Property Damage; $5,000 Med. Payments
or
$500,000 Combined Single Limit; $5,000 Med. Payments
GL3 $500,000 per Person; $1,000,000 per Occurrence
$100,000 Property Damage; $5,000 Med. Payments
or
$1,000,000 Combined Single Limit; $5,000 Med. Payments
•
Required Endorsement:
GLXCU Underground, Explosion and Collapse (XCU)
GLLIQ Liquor Liability
All endorsements are required to have the same limits as the basic policy.
a
•
rNSCKLST
2
•
April 22, 1993
1st Printing
VEHICLE LIABILITY
As a minimum, coverage should extend to liability for:
o Owned; Nonowned; and Hired Vehicles
Required Limits:
VL1 $50,000 per Person: $100,000 per Occurrence
$25,000 Property Damage; $5,000 Medical Payments
or
$100,000 Combined Single Limit; $5,000 Medical Payments
VL2 $100,000 per Person; $300,000 per Occurrence
$50,000 Property Damage; $5,000 Medical Payments
or
$300,000 Combined Single Limit; $5,000 Medical Payments
VL3 $500,000 per Person; $1,000,000 per Occurrence
$100,000 Property Damage; $10,000 Medical Payments
or
$1,000,000 Combined Single Limit; $10,000 Medical Payments
•
•
MISCELLANEOUS COVERAGES
BR1 Builders' Limits equal to the
Risk completed project.
MVC Motor Truck Limits equal to the maximum
Cargo value of any one shipment.
PRO1 Professional $ 500,000 per Occurrence/$1,000,000 Agg.
PRO2 Liability $1,000,000 per Occurrence/$2,000,000 Agg.
PRO3 $2,000,000 per Occurrence/$4,000,000 Agg.
POL1 Pollution $ 500,000 per Occurrence
POL2 Liability $1,000,000 per Occurrence
POL3 $2,000,000 per Occurrence
:ED 1 X Employee $ 10 00
., ED2 Dishonesty $100000
•
GK 1 Garage $ 300,000 0,000 ($ 25,000 per Veh)
GK2 Keepers $ 560,000 ($100,000 per Veh) -
GK3 $1,00,000 ($100,000 per Veh)
1NSCKLST
3
` April 22. I993
1st Printing
1
MED1 Medical $ 500,000/$ 1,000,000 Agg.
MED2 Professional $1,000,000 /$ 3,000,000 Agg.
MED3 $5,000,000/$10,000,000 Agg.
IF Installaion Maximum value of Equipment
Floater Installed
VLP1 Hazardous $ 300,000 (Requires_MCS -90)
VLP2 Cargo $ 500,000 (Requires MCS -90)
VLP3 Transporter $1,000,000 (Requires MCS -90)
BLL Bailee Liab. Maximum Value of Property
HKL1 Hangarkeepers $ 300,000
HKL2 Liability $ 500,000
HKL3 • $ 1,000,000
AIR1 Aircraft $25,000,000
AIR2 Liability $ 1,000,000
AIR3 $ 3,000,000
INSURANCE AGENT'S STATEMENT
I have reviewed the above requirements with the bidder named below. The following
deductibles apply to the corresponding policy.
POLICY - DEDUCTIBLES
•
Liability policies are _ Occurrence _ Claims Made
Insurance Agency Signature
BIDDERS STATEMENt
s .;a
I understand the insurance that will be mandatory if awarc.d the contract and will comply
in full with all the requirements. `
f .
to
Bidder I Signature
INSCKLST •
4
April 22, 1993
•
1st Printing
•
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
f MONROE COUNTY, FLORIDA
AND
i
Prior to the commencement of work governed by this contract, the Contractor shall obtain
Workers' Compensation Insurance with limits sufficient to respond to Florida statute 440.
In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not
less than:
$100,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$100,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
r Coverage shall be provided by a company or companies authorized to transact business in
the state of Florida and the company or companies must maintain a minimum rating of A-
VI, as assigned by the A.M. Best Company.
If the Contractor has been approved by the Florida's Department of Labor, as an
authorized self - insurer, the County shall recognize and honor the Contractor's status. The
Contractor may be required to submit a Letter of Authorization issued by the Department
of Labor and a Certificate of Insurance, providing details on the Contractor's Excess
Insurance Program.
If the Contractor participates in a self - insurance fund, a Certificate of Insurance will be
required. In addition, the Contractor may be required to submit updated financial
statements from the fund upon request from the County.
}
We 1
April 22, 1993
1st Printing
VEHICLE LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
{
Recognizing that the work govrned by this contract requires the use of vehicles, the
Contractor, prior to the commencement of work, shall obtain Vehicle Liability Insurance.
Coverage shall be maintained throughout the life of the contract and include, as a
minimum, liability coverage for:
o Owned, Non - Owned, and Hired Vehicles
The minimum limits acceptable shall be:
$100,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$ 50,000 per Person
$100,000 per Occurrence
$ 25,000 Property Damage
•
The Monroe County Board of County Commissioners shall be named as Additional -
Insured on all policies issued to satisfy the above requirements. •
•
•
•
{
VL 1
•
• April 22, 1993
1st Printing
EMPLOYEE DISHONESTY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
The Contractor shall purchase and maintain, throughout the term of the contract, Employee
Dishonesty Insurance which will pay for losses to County property or money caused by the
fraudulent or dishonest acts of the Contractor's employees or its agents, whether acting alone or
in collusion of others.
The minimum limits shall be:
$10,000 per Occurrence
•
ED1
•
April 22, 1993
1st Printing
GENERAL LIABILITY
INSURANCE REQUIREMENTS
E FOR
CONTRACT
E BETWEEN
t MONROE COUNTY, FLORIDA
AND
. Prior to the commencement of work governed by this contract, the contractor shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the
contract and include, as a minimum:
o Premises Operations
o Products and Completed Operations
o Blanket Contractual Liability
o Personal Injury Liability
o Expanded Definition of Property Damage
! The minimum limits acceptable shall be:
$300,000 Combined Single Limit (CSL)
t If split limits are provided, the minimum limits acceptable shall be:
•
$100,000 per Person
$300,000 per Occurrence -
$ 50,000 Property Damage ,
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made
policy, its provisions should include coverage for claims filed on or after the effective date
of this contract. In addition, the period for which claims may be reported should extend
for a minimum of twelve (12) months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional
Insured on all policies issued to satisfy the above requirements.
i
i
i 4
g
i
,
GLI
Ist Printing •
. MONROE COUNTY, FLORIDA
. • INSURANCE GUIDE .
TO
CONTRACT ADMLNISTRATION
General Insurance Requirements
for
Suppliers of Goods or Services
As a pre- requisite of the work governed or the good supplied under this contract
(including the pre - staging of personnel and material), the Vendor shall obtain, at his/her
own expense, insurance as specified in any attached schedules, which are made part of this
contract. The Vendor will ensure that the insurance obtained will extend protection to all
Sub - Contractors engaged by the Vendor. As an alternative the Vendor may require all
Sub - Contractors to obtain insurance consistent with the attached schedules.
The Vendor will not be permitted to commence work governed by this contract (including
pre - staging of personnel and material) until satisfactory evidence of the required insurance
has been furnished to the County as specified below. Delays in the commencement of
work, resulting from the failure of the Vendor to provide satisfactory evidence of the
required insurance, shall not extend deadlines specified in this contract and any penalties
and failure to perform assessments shall be imposed as if the work commenced on the
specified date and time, except for the Vendor's failure to provide satisfactory evidence.
The Vendor shall maintain the required insurance throughout the entire term of this
contract and any extensions specified in the attached schedules. Failure to comply with
this provision may result in the immediate suspension of all work until the required
insurance has been reinstated or replaced. Delays in the completion of work resulting
from the failure of the Vendor to maintain the required insurance shall not extend
deadlines specified in this contract and any penalties and failure to perform assessments
shall be imposed as if the work had not been suspended, except for the Vendor's failure to
maintain the required insurance.
The Vendor shall provide, to the County, as satisfactory evidence of the required
insurance, either:
• Certificate of Insurance
or
• A Certified copy of the actual insurance policy.
The County, at its sole option, has the right to request a certified copy of any or all
insurance policies required by this contract.
All insurance policies must specify that they are not subject to cancellation, non - renewal,
material change, or reduction in coverage unless a minimum of thirty (30) days prior
notification is given to the County by the insurer.
The acceptance and/or approval of the Vendor's insurance shall not be construed as
relieving the Vendor from any liability or obligation assumed under this contract or
imposed by-law. - --
The Monroe County Board of County Commissioners, its employees and officials will be
included as "Additional Insureds" on all policies, except for Workers' Compensation.
Any deviations from these General Insurance Requirements must be requested in writing
on the County prepared form entitled "Request for Waiver of Insurance Requirements"
and approved by Monroe County's Risk Manager.
GIR1
BURNS & WILCOX, LTD. C E R T I F I C A T E OF I N S U R A N C E ISSUE DATE : 04/12/93
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
JOHNSONS INSURANCE AGENCY NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,
P.O. BOX 2346 EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
MARATHON SHORES, FL 33052 APPROVED BY RISK MANAGEMENT
COMPANIES AFFORDING COVERAGE
COMPANY LETTER A SCOTTSDALE INSURANCE COMPANYB 11JJ
�j
INSURED COMPANY LETTER B �j�l
E.G.A. Inc COMPANY LETTER C DATE
PO Box 1575 COMPANY LETTER D y
Marathon Fl 33050 COMPANY LETTER E WAIVER: N /A,X yEs
COVERAGES
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED, NOT WITHSTANDING 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.
LTR TYPE OF INSURANCE POLICY NUMBER EFF. DATE EXP. DATE LIMITS
GENERAL LIABILITY GENERAL AGGREGATE $ 300 000
A [X] COMMERCIAL GENERAL LIABILITY Binder #93137 PRODUCTS - COMP /0P AGG. $ 300 1 190
[ ] CLAIMS MADE [X] OCCURRENCE 7/28/93 - 7/28/94 PERSONAL & ADV. INJURY $ 300 COO
[ ] OWNER'S & CONTRACTOR'S PROT. EACH OCCURRENCE $ 300 b G
[ ] FIRE DAMAGE $ 50 (b0
[ ] MED. EXPENSE $ excluded
AUTOMOBILE LIABILITY
[ ] ANY AUTO COMBINED SINGLE LIMIT $ 0
[ ] ALL OWNED AUTOS
[ ] SCHEDULED AUTOS BODILY INJURY (PER PERSON) $ 0
[ ] HIRED AUTOS
I ] NON -OWNED AUTOS BODILY INJURY (PER ACCIDENT)$ 0
[ ] GARAGE LIABILITY
[ ] PROPERTY DAMAGE $ 0
EXCESS LIABILITY EACH OCCURRENCE $ 0
([ ] UMBRELLA FORM AGGREGATE $ 0
I[ ] OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION [ ] STATUTORY LIMITS
AND ! EACH ACCIDENT $ 0
EMPLOYER'S LIABILITY I I DISEASE - POLICY LIMIT $ 0
I I I DISEASE -EACH EMPLOYEE $ 0
OTHER
DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES /SPECIAL ITEMS
Janitorial Service Certificate holder is additional insured
CERTIFICATE HOLDER CANCELLATION
Monroe County Board of Count SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
Commissioners THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
5100 College Rd. J CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE
Stock Island Fl 33040 J NO OBLIGATION OR LIABILTIY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
LO
AUTHORIZED REPRESENTAT?v"
FLORIDA JOINT UNDERWRITING ASSOCIATION
SERVICED BY: State Farm Mutual Automobile Insurance Company
• APPLICATION APPLIES TO: BUSINESS AUTO - TRUCKERS POLICY 4 0 61 6
1.A encyName Producer's Tax er Producer's Social Secur N nber
3x44 4 /6 s//n-eeS ../30.5-7.__ Tele hone umber Producer's C9d Producer Name
O c 1 Z&Q — o 2 / 7y /644,/,9-7,/ ./.1-4.49,9622
2. Apples s owmotor vehicle registration) Mailiny�lAddress /5 Address No.
City County State In City Zip C de Telephone (Incl. Area Code)
PM 40i 14 ( : moo. 3 i r "„ '.,, 1 13n.C sk -9P#
Bus iine ss of applicant (describe use ofvehicle) Self ❑Yes Federal Employers Tax I.D. Number (TIN)
Employed �: No
■/ �/VrTOR //9 c— J/. / //� ��
l_c,� Li Individual I 1 Partnership
74 COME Nry O ),4)&1) iv� Corporation ❑Other
/ L� //1/�y / Employers Name Address
3. DESCRIPTION AND USE: • CLASSES FACTORS LIENHOLDER
Vox. l Ma. b0. TW• • irW. •Yi,* „u,✓r, W,. NM MgrW WO, [ax ,r, En . S,. h.n.n
...• CwwW 6•r NU w M, , {C C •C .t. W. W W" !WWI =Z.'''. ,
a , a . e h .wa NAME, ADDRESS
Vehi- b Vehicle Indentification Number (VIN) 0 Cow.. ?a,,..c.mo Ia.. r,.o •...... AND ZIP CODE
cle �w
Rating w "' faw ti.w p .. ial o• . Wm.&IGC I - F.b h
s
No. C Garaging Location (Complete Address) , u,rxmv Cwr Co* c..
ao ((1.N..1 l/ /CLe;
f
1 b
/045/e/e: 1 . ,
2 b 00/V,eo6 Cp /.. / . !
. .. X./T/2. .J. .. d er.
c CerM44 / 5s% oNC—X $, 5 T? Co CC. / 7e-x- � j . -4/9-. t- //
a /<...........1..: s'T , �L, 3 JS /5 ' C,2 if / • er N � r A%7�
3 b r CQ.n� fl:. -T 77 /F /}�/7i' 2) / `S �.... .1TllOi✓6G
c //1/S11/ fl7Tftcflt=7) P )4J/N 0 0 ,-- � T
4. RADIUS OF OPERATIONS
ROUTES -Fixed and Occasional (both outgoing and return). Give complete information.
Veh. From(Terminal) To(Terminal) Miles Number of PrincipalCities Entered Commodities Carried
No. Trips Mo.
1
2
3
4
5. COVERAGES: Equal Limits Of Liability Must Be Purchased For All Vehicles Vehicle - No. 1 Vehicle - No. 2 Vehicle - No. 3
Limits Premiums Limits Premiums Limits Premiums
BODILY INJURY LIABILITY ...4. �� SAME AS SAME AS
�,' VEH. 1 VEH. 1
PROPERTY DAMAGE UABIU
COMBINED SINGLE LIMITS OF LIABILITY
PERSONAL INJURY PROTECTION
❑ No Deductible or MOVED t • RISK MAP / GEMENT
Deductible of 5250 ❑ 5500 ❑ 51,000 ❑ 52,000 -
Applicableto: ❑ Named Insured BY -
❑ Named Insured & Dependent Resident Relatives e 7 �
AE ) _
OPTIONS TO ELIMINATE PIP BENEFITS FOR: DA E
❑ Work Loss ❑ Named Insured •
❑ Named Insured & Dependent Resident Relatives WA VER N A .
❑ Military Benefits (Named Insured & Dependent Resident Relatives) SAME AS SAME AS
VEH.1 VEH.►
MEDICAL PAYMENTS
COMPREHENSIVE INCLUDING COLLISION (Maximum $35,000)
Deductible of ❑ $1000 5250 or ❑ $500 SAME AS SAME AS
UNINSURED MOTORISTS VEH. 1 VEH. 1
EMPLOYERS NON - OWNERSHIP LIABILITY SAME AS c 9
HIRED CAR COVERAGE ABOVE -30
FINANCIAL RESPONSIBILITY FILING CHARGE - ->
PAY PLAN Estimated premium $ $ $
• NNUAL Estimated premium all vehicles $
❑ SERVICING CARRIER INSTALLMENT PLAN
❑ PREMIUM FINANCED (Attach Legible Premium Finance Contract) Amount submitted with application $ sg
5A. INSURANCE RECORD: `
Name oflatestcarrier NONE fi 3 Policy No. Termination Date
6. OPERATOR INFORMATION: Names of all Operators.
O ���� Name Birth Date Driver's Licens No. & State Name Birth Date Driver's License & State
1. z. 6.
3. 7.
4. 8.
•
7. ACCIDENTS: Has the applicant, or named insured and any other person who usually operates the motor vehrclels), been involved, either as owner or operator, in ANY motor
• vehicle accident. during the three year period, immediately preceding the effective date of this application? 7 7 Ves If "Yes" complete the following.
Name of Operator Date of Accident Place of Accd. Degree of Accident Applicant Insured's Insurer had a loss under another insurance policy' -
Mo. /Day/Yr. State Negligence Exception Code Yes: No: Remarks
/ %
q
•
EXCEPTION: See Manual Rule 23 for list of noncharable accidents and indicate accident exception code if applicable.
8. CONVICTIONS: (MOTOR VEHICLE) Has the applicant or name insured and any other person who usually operates the motor vehicle(s), been convicted or forfeited bail at any
time during the immediatley preceding thirt•six months? L7 Yes: If yes. complete the following lif necessary, use Remarks section/. NOTE: A paid ticket or fine is an admission
of guilt and therefore constitutes a conviction.
- Date of Did Conviction Arise Place of Violation
Name of Operator Violation As a Result of Acc. Nature of Violation -
Mo. /Day/Yr. (Yes or No) Town State -
/ /
9. PUBLIC AUTO: Use of Vehicle Mfg. Specified Seating Capacity
Territory(s) in which or through which vehicle is customarily operated
10. HIRED CAR COVERAGE:
Types Hired Principal Garaging or Locations Where Automobiles Will Be Used
Estimated Annual ' Rates Per $100
T
YP P g g Cost of Hire
B.I. I P.D.
11. EMPLOYERS NON - OWNERSHIP LIABILITY: More than 50% of employees regularly use owned vehicle in applicants business? LI Yes)<No ..
11 yes, do more than 50% make regular and frequent deliveries? :_j, Yes ❑ No peg/ 2,&72 k CQ,e p Qpr r s
12e. FINANCIAL RESPONSIBILITY
Is applicant or other eligible operator required to file evidence of financial responsibility? ( I Yes Type of filing.
•
Name: I I Owner's Ito allow for operation of owned vehicles) •
Case or File Number Social Security No. I I Operator's (to allow for operation of non -owned vehicles)
State Where Filing Required I I Both
b. FILINGS: Is filing required to comply with I I I.C.C. I I State LI Local ordinance (Attach Copy) File or Docket No. •
If block(s) checked list states) and cities requiring filings and limits of liability required by law
o
NOTE: An insured's request for cancellation may be delayed if a financial responsibility filing or certificate of insurance has been filed to enable the Servicing Carrier to
i
comply with any advance notice of cancellation requirements. � 13.FLORIDA UNINSURED MOTORIST COVERAGE - SELECTION /REJECTION FORM
YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE WHICH PROTECTS YOU
AND YOUR FAMILY OR YOU ARE PURCHASING UNINSURED MOTORIST LIMITS LESS THAN YOUR
BODILY INJURY LIABILITY LIMITS WHEN YOU SIGN THIS FORM. PLEASE READ CAREFULLY.
Uninsured Motorist Coverage provides for payment of certain benefits for damages caused by owners or operators of uninsured motor vehicles because of bodily injury or
death resulting therefrom. Such benefits may include payments for certain medical expenses, lost wages, and pain and suffering, subject to limitations and conditions contained
in the policy. For the purpose of this coverage an uninsured motor vehicle may include a motor vehicle as to which the bodily injury liability limits are less than your damages.
Florida law requires that motor vehicle liability policies include Uninsured Motorist Coverage at limits equal to the Bodily Injury Liability limits in your policy unless you select
a lower limit or reject Uninsured Motorise Coverage entirely. Please indicate your selection or rejection below.
a. ❑ I hereby reject Uninsured Motorise Coverage.
b. ❑ I hereby select Uninsured Motorist limits ofS / which are lower than my Bodily Injury Liability limits.
I understand and agree that this selection or rejection applies to my policy of liability insurance and future renewals or replacements of such policy which are issued at the
same Bodily Injury Liability limits. 11 I decide to change my selection or rejection of Uninsured Motorist Coverage, I must let the Company know in writing.
X Date
■ Applicant's Signature •
14.ELECTION OF PERSONAL INJURY PROTECTION AND PROPERTY DAMAGE LIABILITY COVERAGE ONLY:
I -elect to purchase Personal Injury Protection Coverage and Property Damage Liability Coverage only and reject Automobile Bodily Injury Coverage and Uninsured Motorists
•
Coverage available to me through the Florida Joint Underwriting Association.
o X Date
Applicant's Signature
•
FAIR CREDIT REPORTING ACT NOTICE: In addition to routine verification of information pertinent to the insurance applied for, if the application is by an individual for
insurance primarily for personal or family purposes, the FJUA may have an investigative consumer report made including information bearing on character, general reputation, _
personal characteristics or mode of living and, upon the individual's written request, will disclose in writing the nature and scope of the investigation requested, it such report is
procured.
BINDER PROVISION: The company agrees to hold bound the limits and coverages specified in this attached application of the insured named herein. such application being
completed. duly executed and accepted by the Producer. subject to the following conditions.
1. This binder is in effect for a period not :o exceed 30 days from the effective date stated herein. This binder will terminate immediately upon: (a) The issuance of the policy
applied for, or (b) The issue, of any policy affording similar insurance, or (c) 30 days from the effective date stated herein.
2. A pro rate premium charge will be made for this binder if the policy, when and as issued, is not accepted by the insured.
3. The insurance bound hereunder shall be subject to all the terms and conditions of policy form FJUA•22 or FJUA -22T (BUSINESS AUTO OR TRUCKERS POUCY) to be issued. -
4. This binder shall not exceed Bodily Injury Limits of 5100 /300 and Property Damage Liability Limits of 550.000 or Combined Single Limits of Liability of 5300,000. (Note: Higher
limits may be requested and retroactivity approved to the effective date of the binder.)
r. C- / �a PM / 17 AM This ajar i• yy 1 is Submitted . ant t� • provisions of Section 626.752 Florida Statutes.
Effective Z l. .' � `//
Munch Day ' Vear Hour 6 ' � •� n
_ /r,' .. , / / 9 6 Date L - Y3
•
Produ, . 'Signature / Producer's No.
APPLICANT'S STATEMENT
I declare to the best of my knowledge and belief that all statements contained in this application are true and that these statements are offered as an inducement
to the Company to issue the policy for which I am applying. I understand that my agent is not authorized to file proof of Financial Responsibility or Certificates of
Insurance on my behalf to any third party. How are you paying premiums? ❑ Cash ❑ Check supported by sufficient funds in an active account made payable to
the Servicing Carrier.
THIS APPLICATION AND THE ESTIMATED PREMIUM ARE SUBJECT TO THE APPROVAL OF THE SERVICING CARRIER IN ACCORDANCE WITH RATES, RULES AND •
FORMS FILED WITH AND APPROVED BY THE FLORIDA INSURANCE DEPARTMENT.
THIS INSURANCE IS BEING AFFORDED THROUGH THE FLORIDA JOINT UNDERWRITING
ASSOCIATION AND NOT THROUGH THE PRIVATE MARKET. PLEASE BE ADVISED THAT COVERAGE
WITH A PRIVATE INSURER MAY BE AVAILABLE FROM ANOTHER AGENT AT A LOWER COST.
AGENT AND COMPANY LISTINGS ARE tVAILLE N / THE L CA YELLOW PAGES.
7 '5 9
•
Applicaraignature
REMARKS:
•
n. .nrn r 11,1nn11 n n.... non
•
{ap ration }R - special
foribusiness services bond employee dishonesty
iv;toLa Surety Corporation
, ,, :: ;. protection
NAME OF INSURED
E. G. A. inc G
BUSINESS ADDRESS for orc-
PO Box 1575, Marathon Fl 33050 '�'
TOTAL NUMBER TYPE OF BUSINESS business � el '
OF EMPLOYEES �l
-.•
• i
2 Janitorial service
,.� Have you sustained any employee dishonesty losses in professions
4 the last 6 years? gl No
V
❑ Yes- give date(s), amount(s), employee's name(s) V
and actions(s) taken.
, )�: ;
/
�\
,
Has any insurer declined to issue, cancelled or refused �_�
to renew any employee dishonesty insurance during 'R��
the past 6 years? , �(
N o — Walk � VR
Yes- explain 1% ��lT� "`�,• ,� 11. t7i �
CI _ i
n C .- /AA-NV.A\___.) 7 - - 9 5 / ;:- ' ' .
gnature of Apphcant Date t
Coverage is not effective until application is accepted by the company. --------------- -- - ` + i
BYO
your Ai Ty =h agent is
on
.ruspg ;mss�/ yo l;.merspremises
fole49--hvAismseE"S '-L 330.sa
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` - Lawyers 'urety Corporation E
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Dallas, Texas
ORSC 21107 (9 -87) ALL STATES EXCEPT N C e
i
APPROVED BY •ISK MANAGEMNT
BY �.
DATE ` I
WAIVER N/A _ YES
4
S
t
i
,
L 1 UNITED BUSINESSES SELF INSURERS FUND
L il : WORKERS COMPENSATION PRONTO PRICING
FAX TO: 407- 774 -2527 ATTN: Pronto Pricing Underwriter PHONE: 800- 669 -0228 • 407 -788 -1200
i
Applicant's Name, Physical Address and Zip Code Producer's Name and Address Agent No. 1 3 4.
�
t . ZrI
r ., i e��"' p
- 5 -3 t.e 1 S o•x -b its D `EI Val - D.0 .-to q E.lt o,rta ° �/Ur'�
MUIt /
TIt,0.ta &-vn r(- 33o6U Fax No: 3 5_79y. 6s8L Phone No: 3oS -743 6 9f
Detailed Description of Operations �J�
�Q/d. <�@'Lc.as/ / 7t a (... nr
Years in Business Years exp. in this work Anniversary Rating Date 0 ,6 Commercial % Residential Coverage E8. Date
_ a Ito O 4 51 4 -t'
General Underwriting Information — Please Provide Details for All "Yes" Responses
Mee No Yes No
1. Does applicant own, operate or lease aircraft/watercraft? y 17. Does all or part of applicant's business Include dealing with,
2. Any exposure to flammables, explosives, caustics, fumes? _✓ using, maintaining, or providing the following types of activities? /
3. Any exposure to radioactive materiels? V a. Using or being exposed to asbestos? v
4. Any work performed underground or above 8 feet? --,/ — b. Operation of ambulance or emergency vehicle?
5. Any work performed on barges, vessels, docks ? - L c. Armed guards?
8. Is applicant engaged in any other type of business?
_ -- -V— d. Bars and taverns? N./ 7, Are sub - contractors used? e. Crane rental? ,/ 8. Any work sublet without certificates of insurance? _� f. Crop dusters? 1
9. Is a formal safety program in operation? - g. Hazardous waste? �!
10. Any group transportation provided? - -�j h. Home health care? ✓/
11. Any part time or seasonal employees ✓/ i. Any travel/work performed out of the State of Florida? N./
' 12. Is there any volunteer or donated labor? Z I. Governmental activities? ✓
13. Are pre - existing injuries documented? \ ' k. Services provided 24 hours per day? \//
14. Are athletic teams sponsored? - -- -✓ I. Leased employees? —
15. Are pre - employment physicals required ? -- -V m.Pest control? �/
16. Any coverage declined /canceled /non- renewed (last 3 years)? _— __NZ n. Professional sports teams? v
Comments _ - -__. _—
Prior Premium and Loss History
Polley Prlor No. of No. of Paid Open Total
Year Carder/Polley No. Exp. Mod Premium _ Claims Open Claims Clelms Resents, Incurred
1 /L o _) 9L ,/ OZ ' -. — -
Premium Calculation to be Provided by Agent Number Premium Basis Rates per Estimated
Hazard Code of Estimated Total $100 of Annual
Group Number Classification of Operations Employees Annual Remun. Annual Remun. Premium
9 .-�r�K- -z -� - / ,26, 0- >0 c i. 92 -2 S76
... t; 1 : ' . MANAGEM'NT
BY ad a
()ATE
WAIVER: NIA Y
FOR S.I.F. USE ONLY — This account Is hereby: 'TOTAL MANUAL PREMIUM
❑ Approved ❑ Declined for reason shown: INCREASED EMPLOYER'S LIABILITY
0 Does not meet underwriting guidelines
❑ Referred for EXPERIENCE MODIFICATION
❑
Special Acceptance Needs 2-3 years prior w/c experience
❑ Prior loss history TOTAL STANDARD PREMIUM
❑ Classification
❑ Other
Policy No.
I DEPOSIT % DUE: I
Dues Paid Remarks
FEIN No.
•
Ck. No. __ — _
Amt. Pd. _ _.. __ FUBSIF Underwriter
SM 0137
t,uuNTY OCCUPATIONAL LICENSE ii 99 _i
MONROE COUNT S TE LORIDA-
104286 THIS LICENSE EXPIRES s.p
.... •r Q
33 , 193 COST AND TAX 413"----541111
man
or EMPLOYEES 5 PENALTY '
07
$,ldpj,OYgE$ 2 TRANSFER FEE 0
STATE CERTIFICATEIlt7191t3ER
MKS HARRY TOTAL DUE
TO
F. Itb1IGHT CPC 0 9• m
TAX COLLECTOR 2 94 -8403 •E.G.1 Ilk:. °
P.O. Oet 1129 jaul S. Hiller
o
KEY WEST, FL. 330 40 —I129 P .O. BOX 1575 �
PLEASE SEE BACK OF FORM
ACCT f 38051 MARATHON, lL. 33050 j 4 "
MOBILE C k m
LL LEAbiI SERVICE"
LOC: MOB /LE 1 ROE CO
E *�� *NpJKNIQHT4�t* tTAi1'Y
?.0O CA O /22/93 238001111t000000>It018694
lit
THIS FORM BECOMES A RECEIPT ONLY WHEN VALIDATED BY RECEIPTING
MACHINE SHOWING TRANSACTION NUMBER DATE, AND AMOUNT PAID 1 \hw`V'
C
V �
t
TEMPORARY RECEIPT -
MONROE COUNTY TAX COLLECTOR'S OFFICE N? 17040
DATE July 20, 1993
RECEIVED FROM: E.G.A. Inc.
P.O. BOX 1575
MARATHON, FL. 33050
VEHICLE: AMOUNT
CERT. TITLE LICENSE TAG
AUTO WT ORIGINAL TITLE CERT.
19 TAG NO TITLE CERT. TRANSFER
� � � � kY " MAKE -TYPE TAG TRANSFER
ID. NO DUPLICATE TAG
•9c A5‘-.> MODEL CYL DUPLICATE CERTIFICATE OF TITLE
DISABLED PERSONS PARKING PERMIT
9 Ji!' PENALTY
\` ' �,, LIEN
`, G( SALES TAX
J- BOAT: xxxxx xx
I ,' ' �� FL* 19 / BOAT REGISTRATION
V � ORIGINAL TITLE APPLICATION
TITLE TRANSFER
TRANSFER OF REGISTRATION
LIEN
SALES TAX
SERVICE CHG.
HUNTING FISHING: x x x x x x x
LICENSE* 19 / HUNTING & FISHING LICENSE
SERIES* PERMIT*
DOG: xxxxx xx
19 / DOG LICENSE*
OCCUPATIONAL: x x x x x x x
ACCT.* 31051 19 / OCCUPATIONAL LICENSE 9 00
TRANSFER FEE
TAXES: xxxxx xx
❑ REAL ESTATE 19 / PAYMENT:
❑ TANGIBLE ❑ CURRENT
❑ WASTE ❑ DELINQUENT
TOTAL 1 9 100 1 F
Occ Rec # 104286
''7
HARRY F. KNIGHT TAX COLLECTOR L I Irin (c6)\---CLERK
(SIGNED)
WHITE CUSTOMER YELLOW: ACCOUNTING PINK CLERK
• s
i ?
s SWORN STATEMENT UNDER ORDINANCE NO. 10 -1990
MONROE COUNTY, FLORIDA
ETHIC // S ,/ CLAUSE
(J rT 1AdC— warrants that ire /it has not employed,
retained or otherwise had act on behalf any former County officer
or employee subject to the prohibition of Section 2 of Ordinance No.
10 -1990 or any County officer or employee in violation of Section 3 of
Ordinance No. 10 -1990. For breach or violation of this provision the
County may, in its discretion, terminate this contract without liability
and may also, in its discretion, deduct from the contract or purchase
price, or: otherwise recover, the full amount of any fee, commission,
percentage, gift, or consideration paid to the former County officer or
employee.
(sign :ture)
Date: G 3
/
STATE OF CLOT /
COUNTY OF rhaA -
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
who, after first being sworn by me,
affixed hi her signatu '(name of individual signing) in the space
provided above on this ,33 day of
PvOi v s T , 19 9
NOTARY PUBLIC
My commission expires:
' Ci' vdvii .rtl:.w F:.:'+.A';':11Ae31u n::x2
'd.'6.. 4., MARY ANN COLLINS
41.
A. . MY COMMISSION 0 OC 208394
�. a ;' EXPIRES: July 13, 1996
pF P� Bonded Thru Notary Public Underwriters
i
BURNS & WILCOX, LTD. C E R T I F I C A T E OF I N S U R A N C E ISSUE DATE : 04/12/93
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
JOHNSONS INSURANCE AGENCY NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,
P.O. BOX 2346 EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
MARATHON SHORES, FL 33052 AMI NlOIII MANAAEIIIENT
COMPANIES AFFORDING COVERAGE III , ,' Jj �1 r
COMPANY LETTER A SCOTTSDALE INSURANCE COMPANY BY a ✓C/ C�+'�
INSURED COMPANY LETTER B CI ' ,
A1E 6 / 3 Q �/I
E.G.A. Inc. COMPANY LETTER C Q 1 ��
COMPANY LETTER 0 ,
P.O. Box 1575 COMPANY LETTER E WAIVER NIA �.. —
Marathon, Fl. 33050
COVERAGES
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED, NOT WITHSTANDING 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.
LTR TYPE OF INSURANCE POLICY NUMBER EFF. DATE EXP. DATE LIMITS
GENERAL LIABILITY GENERAL AGGREGATE $ 300,000
A [X] COMMERCIAL GENERAL LIABILITY CLS086198 7/28/93 7/28/94 PRODUCTS - COMP /OP AGG. $ 300,00CD
( ] CLAIMS MADE [X] OCCURRENCE PERSONAL & ADV. INJURY $ 300,001
[ ] OWNER'S & CONTRACTOR'S PROT. EACH OCCURRENCE $ 300,01
( ] FIRE DAMAGE $
50,00
[ ] MED. EXPENSE $
excluded
AUTOMOBILE LIABILITY
[ ] ANY AUTO COMBINED SINGLE LIMIT $ 0
[ ] ALL OWNED AUTOS
[ ] SCHEDULED AUTOS BODILY INJURY (PER PERSON) $ 0 E
[ ] HIRED AUTOS
( ] NON -OWNED AUTOS BODILY INJURY (PER ACCIDENT)$ 0
[ ] GARAGE LIABILITY
[ ] PROPERTY DAMAGE $ 0
!EXCESS LIABILITY I EACH OCCURRENCE $ 0
I[ ] UMBRELLA FORM I I AGGREGATE $ 0
I( ] OTHER THAN UMBRELLA FORM
(WORKER'S COMPENSATION I Received [ ] STATUTORY LIMITS
AND I Risk Mgmt. & L iss Control EACH ACCIDENT $ 0
(EMPLOYER'S LIABILITY I DISEASE - POLICY LIMIT $ 0
I I DATE / — / 2 '2ff I DISEASE -EACH EMPLOYEE $ 0
INTTrrAL 2' -
(OTHER I
I I I
DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES /SPECIAL ITEMS Monroe County Board of County Commissioners
janitorial as additional insured
mac;
CERTIFICATE HOLDER I CANCELLATION
Monroe County Risk Management I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE
5100 college Road I THEREOF THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE
Key West, Fl. 33040 I CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE
I NO OBLIGATION OR LIABILTIY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE