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02/20/2013 AgreementAMY HEA VILIN, CPA CLERK OF THE CIRCUIT COURT DATE: March 21, 2013 TO: Chief James Callahan Emergency Services ATTN.- Holly Pfiester FROM. Pamela G. Hanc c , .C. At the February 20, 2013, Board of County Commissioner's meeting, the Board granted approval and authorized execution of Item C 11 Consultant Contract reviewing the billing and collection on Medicare, Medicaid, and workers' compensation, automobile, commercial and private pay for both air ambulance and ground ambulance transportations to EMS Billing and Consulting, sole proprietorship, Jan Purdin, owner; approval of Business Associate Agreement with EMS Billing and Consulting. On the same meeting date, the Board of Governors granted approval and authorized execution of Item G2 Consultant Contract reviewing the billing and collection on Medicare, Medicaid, and workers' compensation, automobile, commercial and private pay for both air ambulance and ground ambulance transportations to EMS Billing and Consulting, sole proprietorship, Jan Purdin, owner; approval of Business Associate Agreement with EMS Billing and Consulting. Enclosed is an electronic copy of the above -mentioned Agreement between the BOCC, BOG and EMS Billing & Consulting for your handling. Should you have any questions, please do not hesitate to contact this office. cc: County Attorney Finance File CONSULTING AGREEMENT BETWEEN THE BOARD OF COUNTY COMMISSIONERS AND THE BOARD OF GOVERNORS FIRE AND AMBULANCE DISTRICT 1 OF MONROE COUNTY, FLORIDA AND EMS BILLING AND CONSULTING FOR REVIEW AND EVALUATION OF MONROE COUNTY FIRE RESCUE'S EMS GROUND AND AIR RESCUE TRANSPORT BILLING AND COLLECTIONS This agreement (the "Agreement") is made and entered into this 201h day of February, 2013 by and between the BOARD OF COUNTY COMMISSIONERS and the BOARD OF GOVERNORS OF FIRE AND AMBULANCE DISTRICT 1, MONROE COUNTY, a political subdivision of the State of Florida, with principal offices located at 490 63`d Street, Marathon, FL 33050 (the District and Monroe County are hereinafter referred to collectively as the "COUNTY"), and EMS BILLING AND CONSULTING, (hereinafter, "Consultant" or "Business Associate"), as of the latest of the execution dates set forth below in Section VII. WITNESSETH: WHEREAS, the COUNTY intends to enter into an agreement for the provision of consulting services to analyze and recommend changes to ground and air rescue transport billing by the Consultant to the COUNTY; and, WHEREAS, the Consultant represents that it is capable and prepared to provide such Services: NOW THEREFORE, in consideration of the promises contained herein, the parties hereto agree as follows: 1. Term: This agreement commences on February 20, 2013, and terminates on the earlier of (a) the delivery of the deliverables identified in Attachment A to this Agreement or ninety (90) days after execution of the contract, whichever comes first. 2. Scope of Services: Within ninety (90) days following execution of this Agreement, the Consultant shall provide the scope of services described in Attachment A to this Agreement. The results shall be described in a deliverable consisting of a report delivered both in hard copy and electronic form, summarizing the results as to each point. The scope of services may also include the appearance at one Board of County Commissioners/Board of Governors meeting, which may occur no later than sixty (60) days following delivery of the report. 3. Compensation: The Consultant shall receive a total of $6,800 as fixed price, full and final payment for the services described in Attachment A, including all deliverables. There Page 1 of 10 shall be no further costs or expenses allowed, including but not limited to, travel expenses, photocopy costs, facsimile charges, overnight or regular U.S. mail expenses, with the exception that if the attendance of the Consultant is required at a County commission meeting, then pre -approved travel expenses will be reimbursed, subject to rates in Florida statutes and County policy, upon presentation of a request for reimbursement on forms provided by the County. The Consultant shall be paid after delivery of all services identified in Attachment A, including final delivery of the final report described above, and after presentation of a final invoice. All invoices shall be paid in accordance with the Florida Local Government Prompt Payment Act. In the event this Agreement is extended beyond the expiration of the County's fiscal year, this Agreement is subject to appropriation by the COUNTY. 4. Termination: The agreement can be terminated by either party with or without cause with ten (10) days' prior written notice. In the event the termination is without cause, the COUNTY shall be responsible for reimbursement of compensation, on a quantum meruit basis, up to the date of termination, in which case the Consultant will deliver all work product produced to that time. 5. Access to Records and Auditinjz. Consultant understands and agrees that, unless specifically exempted by Florida, Chapter 119, Florida Statutes, generally requires public access to all records and documents. Monroe County shall have access, at all reasonable times, to all books, records, correspondence, instructions, receipts, vouchers and memoranda (excluding computer software) pertaining to work under this Agreement for any purpose, including the purpose of conducting a complete independent fiscal audit. Consultant shall retain all records required to be kept under this Agreement for a minimum of five years, and for at least four years after the termination of this agreement. Consultant shall be responsible for repayment of any and all audit exceptions which are identified by the Auditor General for the State of Florida, the Clerk of Court for Monroe County, the BOCC, or their agents and representatives. 6. Modification: Additions to, modification to or deletions from the provisions set forth in this agreement shall be effective only in writing and with prior approval of the BOCC. 7. Indemnification and Hold Harmless: The Consultant agrees to indemnify and hold Monroe County BOCC harmless for any and all claims, liability, losses and causes of action which may arise out of its fulfillment of the agreement. It agrees to pay all claims and losses, including related court costs and reasonable attorneys' fees, and shall defend all suits filed due to the negligent acts, errors or omissions of the Consultant employees and/or agents. 8. Insurance. The coverage provided herein shall be provided by an insurer with an A.M. Best Rating of VI or better, that is licensed to business in the State of Florida and that has an agent for service of process within the State of Florida. The coverage shall contain an endorsement providing sixty (60) days notice to the COUNTY prior to any cancellation of said coverage. Said coverage shall be written by an insurer acceptable to the COUNTY and shall be in a form acceptable to the COUNTY. The Consultant shall obtain and maintain the following policies: Page 2 of 10 a) General Liability Insurance Prior to the commencement of work governed by this contract, the Respondent shall obtain General Liability Insurance. Coverage shall be maintained throughout the life of the contract and include, as a minimum: • Premises Operations • Products and Completed Operations • Blanket Contractual Liability • Personal Injury Liability • Expanded Definition of Property Damage The minimum limits acceptable shall be: $500,000 Combined Single Limit (CSL) If split limits are provided, the minimum limits acceptable shall be: $250,000 per Person $500,000 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. b) Professional Liability Insurance Recognizing that the work governed by this contract involves the furnishing of advice or services of a professional nature, the Respondent shall purchase and maintain, throughout the life of the contract, Professional Liability Insurance which will respond to damages resulting from any claim arising out of the performance of professional services or any error or omission of the Respondent arising out of work governed by this contract. The minimum limits of liability shall be: $500,000 per Occurrence / $1,000,000 Aggregate c) Vehicle Liability Insurance Recognizing that the work governed by this contract requires the use of vehicles, the Respondent, prior to the commencement of work, shall obtain Vehicle Liability Insurance. Coverage shall be maintained throughout the life of the contract and include, as a minimum, liability coverage for: • Owned, Non -Owned, and Hired Vehicles Page 3 of 10 The minimum limits acceptable shall be: $300,000 Combined Single Limit (CSL) If split limits are provided, the minimum limits acceptable shall be: $100,000 per Person $300,000 per Occurrence $ 50,000 Property Damage The Monroe County Board of County Commissioners shall be named as Additional Insured on all policies issued to satisfy the above requirements. d) Workers Compensation Insurance Prior to the commencement of work governed by this contract, the Respondent shall obtain Workers' Compensation Insurance with limits sufficient to respond to the applicable state statutes. In addition, the Respondent shall obtain Employers' Liability Insurance with limits of not less than: $500,000 Bodily Injury by Accident $500,000 Bodily Injury by Disease, policy limits $500,000 Bodily Injury by Disease, each employee e) COUNTY shall be named as an additional insured with respect to Consultant's liabilities hereunder in insurance coverages for general liability and vehicle liability. f) Consultant shall require its subconsultants to be adequately insured at least to the limits prescribed above, and to any increased limits of CONSULTANT if so required by COUNTY during the term of this Agreement. COUNTY will not pay for increased limits of insurance for subconsultants. g) Within fifteen (15) days after execution of this Agreement, Consultant shall provide to the COUNTY certificates of insurance or a copy of all insurance policies including those naming the COUNTY as an additional insured. The COUNTY reserves the right to require a certified copy of such policies upon request. The Agreement shall be cancelled and treated as void from its inception if proof of coverage is not provided. 9. Taxes: The County is exempt from federal excise and state sales and use taxes. 10. Independent Contractor: It is the intent of the parties hereto that the Consultant shall be legally considered as an independent contractor and that neither it nor its employees or agents shall, under any circumstance, be considered servants or agents of the County and County shall at no time be legally responsible for any negligence on the part of said successful responder, its employees or agents, resulting in either bodily or personal injury or property damage to any individual, firm, or corporation. Page 4 of 10 11. Disclosure: The Consultant shall be required to list any or all potential conflicts of interest, as defined by Florida Statute 112 and Monroe County Ethics Ordinance. The Consultant shall disclose all actual or proposed conflicts of interest, financial or otherwise, direct or indirect, involving any client's interest which may conflict with the interests of the County. 12. Assi n�: the Consultant shall not assign, transfer, convey, sublet or otherwise dispose of this agreement, or of any or all of its right, title or interest therein, or his or its power to execute such contract to any person, company or corporation without prior written consent of the County. 13. Compliance With Laws: Consultant shall comply with all international, federal, state and local laws and ordinances applicable to the work or payment for work thereof. 14. Force Majeure: The Consultant shall not be liable for delay in performance or failure to perform, in whole or in part, the services due to the occurrence of any contingency beyond its control or the control of any of its subcontractors or suppliers, including but not limited to weather conditions. 15. Governing Law/Venue: This agreement shall be governed and construed by and in accordance with the laws of the State of Florida and constitutes the entire agreement between the County and Consultant. Venue of any court action filed relative to this agreement shall lie in Monroe County, Florida. 16. Antisolicitation: The Consultant warrants that no person has been employed or retained to solicit or secure this contract upon an agreement or understanding for a commission, percentage, brokerage, or contingent fee and that no member of the Monroe County government or the County has any interest, financially or otherwise in the Consultant or its subcontractors. 17. Severability: If any provision of the agreement shall be held by a Court of competent jurisdiction to be invalid or unenforceable, the remainder of this agreement, or the application of such provision other than those as to which it is invalid or unenforceable, shall not be affected thereby; and each provision of the agreement shall be valid and enforceable to the fullest extent permitted by law. 18. Notice: Any notice required or permitted under this agreement shall be in writing and hand -delivered or mailed, postage prepaid by certified mail, return receipt requested, to the other party as follows: For County: Monroe County Fire Rescue Fire Chief 490 63`d Street Ocean, Suite 140 Marathon, FL 33050 (305) 289-6006 For Consultant: EMS Billing and Consulting Attn: Jan Purdin 176 Dove Circle Royal Palm Beach, FL 33411 (561) 714-4211 Page 5 of 10 19. Ethics Clause: The Consultant warrants that it has not employed, retained or otherwise had act on its behalf, any former Monroe County officer or employee in violation of Section 2 or 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 the provision, the County may, at its discretion terminate this agreement without liability and may also, at its discretion, deduct from the agreement or purchase price, or otherwise recover, the full amount of any fee, commission, percentage, gift, or consideration paid to the former or present County officer or employee. 20. Public Entity Crime Statement: A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a response on a contract to provide any goods or services to a public entity, may not submit a response/bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit responses/bids on leases of real property to public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in section 287.017, Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list. 21. General Provisions a) Ownership of files and work product: All files and work product prepared by Consultant or his or her firm at the expense of County (or for which County is otherwise billed) is the property of the County. Without COUNTY's prior written approval, this work product may not be used by Consultant or his or her firm nor disclosed by Consultant or his or her firm to others, except in the normal course of Consultant's representation of COUNTY in this matter. b) Confidential/proprietary information. Consultant understands that in addition to documents which fall under the statutory definition of public records, as part of the review, Consultant may be viewing information and documents that are confidential and proprietary ("Confidential Information") to the third party billing and collection companies under contract to the County. By signing this agreement, Consultant understands and agrees that (i) to protect any and all Confidential Information Consultant receives from unauthorized access, use and disclosure; (ii) not to use the Confidential Information for any purpose other than performing the services for County; (iii) not to record, copy, or reproduce any Confidential Information in any form, except to the extent necessary to perform the services for County; (iv) not to disclose the Confidential Information to, or otherwise permit to access the Confidential Information, any third party, including without limitation Consultant's, except as expressly provided herein or with County's prior written consent; (v) to limit access to and use of the Confidential Information to those of Consultant's employees who have a need to know such information for the purpose of performing the services and have acknowledged, in a writing which will be made available to County upon request, their individual agreement to the terms hereof; and (vi) to take any and all other steps necessary to safeguard Confidential Information against unauthorized access, use, and disclosure to at least the extent Consultant maintains the confidentiality of its most proprietary and confidential information. Consultant further agrees that no amount of money may compensate the third party billing and collection companies for use and disclose Page 6 of 10 of their Confidential Information, and therefore, that the County shall be entitled to seek injunctive relief in order to prevent disclosure of Confidential Information. If, in the event of disclosure, the County is named in a lawsuit by the third party billing and collection companies arising out of Consultant's disclosure, the Consultant agrees to defend and indemnify the County for any losses arising out of Consultant's actions, including but not limited to damages, attorneys' fees, and costs. c) Entire Agreement. The entire agreement between the COUNTY and Consultant with respect to the subject matter hereof is contained in this Agreement. This Agreement supersedes all prior oral and written proposals and communications between the COUNTY and Consultant related to this Agreement. No provision of this Agreement shall be deemed waived, amended or modified by either party unless such waiver, amendment or modification is in writing and signed by the party against whom the waiver, amendment or modification is claimed. This Agreement shall be binding upon and inure to the benefit of the parties hereto, their permitted successors and assigns. d) In the event any administrative proceeding or cause of action is initiated or defended by the COUNTY or Consultant relative to the enforcement or interpretation of this Agreement, the prevailing party shall be entitled to an award of reasonable attorneys' fees and costs. e) Non -Discrimination. Consultant shall not discriminate, in its employment practices and in providing services hereunder, on the basis of race, color, sex, religion, disability, national origin, ancestry, sexual orientation, gender identity or expression, familial status, or age, and shall abide by all federal and state laws regarding non-discrimination. Upon a determination by a court of competent jurisdiction that such discrimination has occurred, this Agreement automatically terminates without any further action by the COUNTY, effective the date of the court order. Consultant is aware of the provisions of Section 13-101 through 13-106, Monroe County Code, relating to non-discrimination, and agrees to abide by the Code's nondiscrimination requirements. Page 7 of 10 IN WITNESS WHEREOF, the parties have executed this agreement the day and year first above written. (SEAL) ATTEST: AMY HEAVILIN, CLERK By:C 17 Deputy Clerk RESPONDENT: BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY, FLORIDA By: y' Z- 1 Mayor, George Neugent BOARD OF GOVERNORS OF FIRE AND AMBULANCE DISTRICT 1 OF MONROE COUNTY, FL By: By: EMS Billing and Consulting, Sole Proprietorship, Jan Purdin, Owner Date: O/- 9/ - Page 8 of 10 N .� fl LJ .rJ 7 rj l w t-7 •. Q Mayor / Chairman MONROE COUNTY ATTORNEY APPNS,T�F M CY THIA L. HALL ASSISTANT COUNTY ATTORNEY Date 3- (c - �C'I 3 Attachment A SCOPE OF WORK As used herein, the term "contracted independent billing agency" includes both the third party billing company and the collection agency currently under contract with the County. The Consultant will review and make recommendations for improvements as to all of the following: A. Initial Patient Treatment and Information 1. Respondent will review MCFR's records to determine whether sufficient detail has been given in ePCRs (electronic patient care reports) to the independent contracted billing agency to support diagnosis and procedure coding, including insurance and patient demographic information necessary for accurate identification including name, address, social security number, date of birth, and telephone number. The Consultant will make any necessary recommendations for improvement. 2. Respondent will review situations in which immediate medical treatment and patient transport were administered without patient info being collected. In such cases, after transporting said patients, the COUNTY requires the contracted independent billing agency to be solely responsible for retrieving insurance information and any additional patient information which was not identified in the ePCR. The Consultant will make any necessary recommendations for improvement. B. Patient Billing 1. Rates charged by the County are set by resolution, and currently are as follows: Ground Ambulance: $600.00 for Basic Life Support (BLS) $600.00 for Advance Life Support One (ALSI) $800.00 for Advance Life Support Two (ALS2) Plus $12.00 per mile Air Ambulance: $5500.00 for Air Ambulance Transport Fee Plus $80.00 per mile Respondent will make recommendations on modifications to the aforementioned fee for maximization of potential revenues from third -party payers. 2. Respondent will review and validate whether billing agency and collection companies are compliant in sending invoices and other billing notices according to the time frames as agreed to in the contracts with the COUNTY. Respondent will make recommendations on any improvements to billing and initial collection processes. Page 9 of 10 C. Patient Filing 1. Respondent will review contracted independent billing agency utilization of the most up-to-date knowledge and information with regard to coding requirements and standards and proper preparation of electronic and paper insurance filings to ensure compliance with applicable Federal, State and local regulations. D. Specifically relevant to Collections Company 1. Respondent will evaluate independent collection company collection processes and compliance with terms of contract. 2. Respondent will recommend any modifications or improvements to the above processes and contracts to meet best industry standards and revenue collection maximization. A. Respondent will provide any other recommended modifications or improvements relative to billing, collections and revenue maximization. All conclusions, observations and recommendations will be provided to the County in the form of a report no later than ninety (90) days from the date of execution of the agreement between the parties. Page 10 of 10 Attachment B SUBMISSION SOLICITATION RESPONSE FORM BILLING CONSULTANT TO REVIEW AND EVALUATE MONROE COUNTY FIRE RESCUE'S EMS GROUND AND AIR RESCUE TRANSPORT BILLING AND COLLECTIONS Respondent's Name and Mailing Address: E s- A, &� -g /1L_ q" a! -fonscr/�i �a �74, A1lG Ctrc�C 1�6✓nl f a�rr, i3C4cl� , �L 33y// Telephone and Fax Numbers: Email Address � n �Ou r�/i n D �y41�o0 • Comer, Indicate below the compensation you seek for the Scope of Service described in Attachment A. All amounts must be written AND in number format. In case of a conflict between the amount in words and the amount in numbers, the amount in words shall control. I have included: o Submission Response Form o Non Collusion Affidavit o Public Entity Crime Statement 14 o Lobbying and Conflict of Interest Clause Form o Drug Free Workplace Form o Indemnification and Hold Harmless o Local Preference Form (if applicable) (Check mark items above, as a reminder that they are included). d I state that I am authorized to submit this proposal STATE OF COUNTY OF �fI �:� (Si o e ature of Respondent) Olt' �v ��i Date PERSONALLY APPE44ED BEFORE ME, the undersigned authority, --I-,9n1 3, nl who, after first being sworn by me, (name of individual signing) affixed his/her signature in the space provided above on this day of :U . 4 „ 20 / 3 My commission expires: NOTARY PUBLIC CHRISTINE D COOK Notary Public - State of Florida My Comm. Expires Feb 25, 2014 36 Commission # DD 949582 lw.k ,w Attachment C NON- COLLUSION AFFIDAVIT I, Jan per-dln �IW5 �3.!/ins Gno/�OScr /�� of the City of oy� / ,a.�/,,,. 13c.i.cl. i f=/nr°,;1•� according to law on my oath, and under penalty of perjury, depose and say that; 1) i am_ J_#2 Pc.r rdr n, �'r113 B, P" -r as,, 1-6 o the respondent making the Solicitation for the project described as follows: Aculdw { 1iC5c4t 's tx5 r gnol �4/r, A4--vcue- 7ranspar 4- f3;//i' anet Co//a�HoMS / 2) The prices in this solicitation have been arrived at independently without collusion, consultation, communication or agreement for the purpose of restricting competition, as to any matter relating to such prices with any other respondent or with any competitor, 3) Unless otherwise required by law, the prices which have been quoted in this solicitation have not been knowingly disclosed by the respondent and will not knowingly 3 be disclosed by the respondent prior to solicitation opening, directly or indirectly, to any other respondent or to any competitor; and 4) No attempt has been made or will be made by the respondent to induce any other person, partnership or corporation to submit, or not to submit, a solicitation for the purpose of restricting competition; and 5) The statements contained in this affidavit are true and correct, and made with full knowledge that Monroe County relies upon the truth of the statements contained in this affidavit in awarding contracts for said project. STATE OF D.e 1%919- T---�/`- (Signature of Respondent) COUNTY OF P�� Date PERSONALLY APPEARED BEFORE ME, the undersigned authority, �f ,J) P Q AJ who, after first being sworn by me, (name of individual signing) affixed his/her signature in the space provided above on this g day of�RTIA , 20 My commission expires: NOTARY PUBLIC OMB - MCP FORM # 1 37 CHRISTINE D COOK Notary Public - State of Florida My Comm. Expires Feb 25, 2014 Commission # DID9gg582 a Attachment D PUBLIC ENTITY CRIME STATEMENT "A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a solicitation on a contract to provide any goods or services to a public entity, may not submit a solicitation on a contract with a public entity for the construction or repair of a public building or public work, may not submit solicitations on leases of real property to public entity, may not be awarded or perform work as a bidder, supplier, subbidder, RESPONDENT or subRespondents under a contract with any public entity, and may not transact business with any public entity in excess of the threshold amount provided in Section 287.017, Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list." By executing this form, I acknowledge that I/my company is in compliance with the above. STATE OF�/J/Z COUNTY OF (Signature of Respondent) l/i-)13 Date PERSONALLY APPEARED BEFORE ME, the undersigned authority, ©GtiZ D i who, after first being swam by me, (name of individual signing) affixed his/her signature in the space provided above on this day of l-7'' 20 J .� My commission expires: NOTARY PUBLIC CHRISTINE D COOK Notary Public - State of I !orida My Comm. Expires Feb 25, 2014 Commission # CD 949582 38 Attachment E DRUG -FREE WORKPLACE FORM The undersigned Respondent in accordance with Florida Statute 287.087 hereby certifies that: !i 5 / , d na Gnd ans4f/11n!6 (Name of Business) 1. Publishes a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2. Informs employees about the dangers of drug abuse in the workplace, the business's policy of maintaining a drug -free workplace, any available drug counseling, rehabilitation, and employee assistance programs, and the penalties that may be imposed ` upon employees for drug abuse violations. 3. Gives each employee engaged in providing the commodities or contractual services that are under solicitation a copy of the statement specified in subsection (1). 0 4. In the statement specified in subsection (1), notifies the employees that, as a condition of working on the commodities or contractual services that are under solicitation, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendre to, any violation of Chapter 893 (Florida Statutes) or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction. 5. Imposes a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community, or any employee who is so convicted. 6. Makes a good faith effort to continue to maintain a drug -free workplace through implementation of this section. As the person authorized to sign the statement, I certify that this firm complies fully with the above requirements. Date OMB - MCP FORM ##5 Signature Sc/c Own et^ 39 Attachment F LOBBYING AND CONFLICT OF INTEREST CLAUSE SWORN STATEMENT UNDER ORDINANCE NO.10-1990 MONROE COUNTY, FLORIDA ETHICS CLAUSE E-M5 11 ili m a e Kol L�ov�sa /f 9 warrants that helit has not employed, retained or otherwise had act on his/its behalf any former County officer or employee in violation 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. (Signature) so% Dwn• Date: /- t -/& STATE OF / X COUNTY OF All?) ti&� PERSONALLY APPEARED BEFORE ME, the undersigned authority, �"� v /\j who, after first being sworn by me, affixed hi signature (name of individual signing) in the space provided above on this O day of 20/-? NOTARY PUBLIC My commission expires: OMB - MCP FORM #4 40 CHRISTINE D C00 Notary public- State of Florida h y Comm. Expires Feb 25, 2014 Commissi on # DD 949582 Attachment G MONROE COUNTY, FLORIDA RISK MANAGEMENT POLICY AND PROCEDURES CONTRACT ADMINISTRATION MANUAL Indemnification and Hold Harmless for Other Respondents and subRespondents The Responder covenants and agrees to indemnify and hold harmless Monroe County Board of County Commissioners AND Board of Governors for District I, its servants, agents and employees 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 consultant's fees) which arise out of, in connection with, or by reason of services provided by the Bidder or any of its subRespondents (s) in any tier, occasioned by the negligence, errors, or other wrongful act or omission of The Responder or its sub -Responder 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 Responder's failure to purchase or maintain the required insurance, the Respondent shall indemnify the County from any and all increased expenses resulting from such delay. The first ten dollars ($10.00) of remuneration paid to the Respondent is for the indemnification provided for above. The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements contained elsewhere within this agreement. Respondent's Signature Solc Ow rn elf - Date 41 (D LU Z 2: LU fu N LU z " LIJ z C� LU 0. 7D- X _j z < < ce u 0 <too U-) > 0 CC (D Z CO uj -� cl� (D Z M LLJ < m Ln ZA C� IL Z _j Z uj u 0 u 0 0 0 < < Z— (n a. >- F..2 0 LL 0 V) uj —o F- U N Z� V) Z NZ 0 a 0 7:5 -U z o 0 z uj v. (D (1) F- �� LU Z W 0 cx 0 U U u N ID I N 5 0 s >. LLI M o D(4 0) Ln of to C U a) CD 0 x m m m #A I(U A u) IA IA 4) 0 aU. _j ui c c W vi v) (L) aO 0 LL *r 0 uj ca LU = :3 =3 to ca ca 0 th Z M c r*4 U) UJ 06 cm C) 0i w 4) jm LU U) z 74 UJ UO C) Z V) N 0 CL z 0 LL C%j Lu c ca m 0 xu u c 0 Inc. LU LU z j< U LU 4; 0 z ce .0 :3 V) ui ce z n 0C Lu Q z =) > CL CL 0 4- t 0 Ol 0- Z%D0 0 LL- 0 u LU <r, .0 �(v 0 ui fu O H x EN E I < z E'O m 0 0 r-i M LU F- < 0 v) v) z < C u uj U.)�­ (U c: " 0) a) c: 0 r� N in UJ Lu < ca 3: of E < 0 u < x LU > V) LU VAN N N A KIM- 2012 / 2013 MONROE COUNTY BUSINESS TAX RECEIPT EXPIRES SEPTEMBER 30t 2013 Business Name: EMS BILLING AND CONSULTING Owner Name: JAN L PURDIN Mailing Address: 176 DOVE CIRCLE ROYAL PALM BEACH, FL 33411 RECEIPT* 47161-109724 Business Location: 490 63RD ST OCEAN MARATHON, FL 33050 Business Phone: S61-714-4211 Business Type: MISCELLANEOUS SERVICE (MEDICAL BILLING/CONSULTING) Rooms Seats Employees Machines Stalls 1 For Vending Business Only Numhwr of Marki—.- Tax Amount Transfer Fee Sub -Total Penalty venuaiy iypn: Prior Years Collection Cost Total Paid 22.00 0.00 22.001 0.00 1 0.00 1 0.00 1 22.00 Paid 125-12-00001977 01/02/2013 22.00 THIS RECEIPT MUST BE POSTED CONSPICUOUSLY IN YOUR PLACE OF BUSINESS THIS BECOMES A TAX RECEIPT Danise D. Henriquez, CFC, Tax Collector THIS IS ONLY A TAX. WHEN VALIDATED PO Box 1129, Key West, FL 33041 YOU MUST MEET ALL COUNTY AND/OR MUNICIPALITY PLANNING AND ZONING REQUIREMENTS. MONROE COUNTY BUSINESS TAX RECEIPT P.O. Box 1129, Key West, FL 33041-1129 EXPIRES SEPTEMBER 30, 2013 Business Name: EMS BILLING AND CONSULTING RECEIPT* 47161-109724 176 Business Location: 490 63RD ST OCEAN Owner Name: L IN MARATHON, FL 33050 Mailing Address: 76 DOVVEE CIRCLE Business Phone: 561-714-4211 ROYAL PALM BEACH, FL 33411 Business Type: MISCELLANEOUS SERVICE (MEDICAL BILLING/CONSULTING) Rooms Seats Employees Machines Stalls 1 For Vending Busines Number of Machines: Tax Amount Transfer Fee Sub -Total Penalty 22.00 0.00 22.001 0.00 Paid 125-12-00001977 01/02/2013 22.00 Vending Type; Prior Years Collection Cost jTotal Paid 0.00 0.0 22.00 r Village of Royal Palm Beach ROYALAL PALM BEACH raun. Business Tax Receipt 1050 Royal Palm Beach Blvd. Royal Palm Beach, FL 33411 Tel: (561)790-5178 Fax: (561)790-5129 EMS BILLING & CONSULTING 176 DOVE CIR ROYAL PALM BEACH FL 33411 Business Tax Receipt #: 13 - 0 0 016 8 3 9 Dear Business Owner: This is your new Business Tax Receipt. Please keep the upper portion for your records and detach the bottom of this form. Verify the information and display it conspicuously at your place of business, open to the view of the public. This Business Tax Receipt is in addition to and not in lieu of any other license or tax required by law or municipal ordinance and is subject to regulations of zoning, health, and any other lawful authority. Business Tax Receipts may be transferred to a new owner when evidence of a sale is provided; the original Business Tax Receipt is surrendered and a transfer fee is paid. Business Tax Receipts may be transferred to a new location when proof of zoning approval is provided; the original Business Tax Receipt is surrendered and a transfer fee is paid. Business name changes require a new Business Tax Receipt. This Business Tax Receipt expires on September 30, 2013. Renewal notices are mailed at the beginning of August. If you do not receive the notice by the end of August, please let us know. We hope you have a successful year. **** DFTACH AND DISPLAY BO"ITOM PORTION **** VILLAGE OF ROYAL PALM BEACH Rom,,, 1050 ROYAL PALM BEACH BOULEVARD 13 - 0 0 016 8 3 9 ROYAL PALM BEACH, FL 33411 DATE: 12/21/12 LOCAL BUSINESS TAX RECEIPT EXPIRES: SEPTEMBER - 30 - 2013 EMS BILLING & CONSULTING 176 DOVE CIR ROYAL PALM BEACH FL 33411 DISPLAY IN PLACE OF BUSINESS NON -TRANSFERABLE DESCRIPTION BUSINESS OFFICE/HOME OCCUP T • $100.00 LOCATION: 176 DOVE CIR r'1 n N r: LI . G n N ry <:i tv CONSTITUTIONAL TAX. Cot.LECTOR P.O. Box 3353, West Palm Beach, FL 33402-3353 "LOCATED AT" emiraq Pwtrn rararh ct>wnry www.taxcollectorpbc.com Tel: (561) 355-2272 176 DOVE CIR ROYAL PALM BEACH, FL 33411 TYPE OF BUSINESS OWNER CERTIFICATION # RECEIPT #/DATE PAID AMT PAID BILL # 54 1219 BILLING COMPANY PURDIN JAN L iiz 1oos1 a 840113578 This document is valid only when receipted by the Tax Collector's Office. EMS BILLING AND CONSULTING EMS BILLING AND CONSULTING 176 DOVE CIR ROYAL PALM BEACH, FL 33411 STATE OF FLORIDA PALM BEACH COUNTY 2012/2013 LOCAL BUSINESS TAX RECEIPT LBTR Number: 201257636 EXPIRES: SEPTEMBER 30.2013 This receipt does not constitute a franchise, agreement, permission of authority to perform the services or operate the business described herein when a franchise, agreement or other county commission, state or federal permission of authority is required by county, state of federal law. Attachment H (1 of 4) INSURANCE REQUIREMENTS FOR CONTRACT BILLING CONSULTANT TO REVIEW AND EVALUATE MONROE COUNTY FIRE RESCUE'S (MCFR) EMS GROUND AND AIR RESCUE TRANSPORT BILLING AND COLLECTIONS BETWEEN MONROE COUNTY, FLORIDA "LIED EMS BILLING AND CONSULTING Prior to the commencement of work governed by this contract, EMS BILLING AND CONSULTING shall obtain General Liability Insurance. Coverage shall be maintained throughout the life of the contract and include, as a minimum: • Premises Operations • Products and Completed Operations • Blanket Contractual Liability • Personal Injury Liability • Expanded Definition of Property Damage The minimum limits acceptable shall be: $500,000 Combined Single Limit (CSL) If split limits are provided, the minimum limits acceptable shall be: $250,000 per Person $500,000 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. Page 1 of 5 Attachment H (2 of 4) PROFESSIONAL LIABILITY INSURANCE REQUIREMENTS FOR CONTRACT BILLING CONSULTANT TO REVIEW AND EVALUATE MONROE COUNTY FIRE RESCUE'S EMS GROUND AND AIR RESCUE TRANSPORT BILLING AND COLLECTIONS BETWEEN MONROE COUNTY, FLORIDA AND EMS BILLING AND CONSULTING Recognizing that the work governed by this contract involves the furnishing of advice or services of a professional nature, EMS BILLING AND CONSULTING shall purchase and maintain, throughout the life of the contract, Professional Liability Insurance which will respond to damages resulting from any claim arising out of the performance of professional services or any error or omission of EMS BILLING AND CONSULTING arising out of work governed by this contract. The minimum limits of liability shall be: $500,000 per Occurrence/$1,000,000 Aggregate Page 2 of 5 Attachment H (3 of 4) VEHICLE LIABILITY INSURANCE REQUIREMENTS FOR CONTRACT BILLING CONSULTANT TO REVIEW AND EVALUATE MONROE COUNTY FIRE RESCUE'S EMS GROUND AND AIR RESCUE TRANSPORT BILLING AND COLLECTIONS BETWEEN MONROE COUNTY, FLORIDA AND EMS BILLING AND CONSULTING Recognizing that the work governed by this contract requires the use of vehicles, EMS BILLING AND CONSULTING, prior to the commencement of work, shall obtain Vehicle Liability Insurance. Coverage shall be maintained throughout the life of the contract and include, as a minimum, liability coverage for: • Owned, Non -Owned, and Hired Vehicles The minimum limits acceptable shall be: $300,000 Combined Single Limit (CSL) If split limits are provided, the minimum limits acceptable shall be: $100,000 per Person $300,000 per Occurrence $ 50,000 Property Damage The Monroe County Board of County Commissioners shall be named as Additional Insured on all policies issued to satisfy the above requirements. Page 3 of 5 Attachment H (4 of 4) WORKERS' COMPENSATION INSURANCE REQUIREMENTS FOR CONTRACT BILLING CONSULTANT TO REVIEW AND EVALUATE MONROE COUNTY FIRE RESCUE'S EMS GROUND AND AIR RESCUE TRANSPORT BILLING AND COLLECTIONS BETWEEN MONROE COUNTY, FLORIDA AND EMS BILLING AND CONSULTING Prior to the commencement of work governed by this contract, EMS BILLING AND CONSULTING shall obtain Workers' Compensation Insurance with limits sufficient to respond to the applicable state statutes. In addition, EMS BILLING AND CONSULTING shall obtain Employers' Liability Insurance with limits of not less than: $500,000 Bodily Injury by Accident $500,000 Bodily Injury by Disease, policy limits $500,000 Bodily Injury by Disease, each employee Coverage shall be maintained throughout the entire term of the contract. Coverage shall be provided by a company or companies authorized to transact business in the state of Florida. If EMS BILLING AND CONSULTING has been approved by the Florida's Department of Labor, as an authorized self -insurer, the County shall recognize and honor EMS BILLING AND CONSULTING status. The Respondent may be required to submit a Letter of Authorization issued by the Department of Labor and a Certificate of Insurance, providing details on EMS BILLING AND CONSULTING'S Excess Insurance Program. If EMS BILLING AND CONSULTING participates in a self-insurance fund, a Certificate of Insurance will be required. In addition, EMS BILLING AND CONSULTING may be required to submit updated financial statements from the fund upon request from the County. Page 4 of 5 Attachment H (4 of 4) MONROE COUNTY, FLORIDA Request for Waiver of Insurance Requirements It is requested that the insurance requirements, as specified in the County's Schedule of Insurance Requirements, be waived or modified on the following contract. Respondent: EMS BILLING AND CONSULTING Contract for: BILLING CONSULTANT Address of Respondent: EMS BILLING AND CONSULTING ATTN: JAN PURDIN 176 DOVE CIRCLE ROYAL PALM BEACH, FL 33411 Phone: (561) 7144211 Scope of Work: REVIEW AND EVALUATE MONROECOUNTY FIRE RESCUE'S EMS GROUND AND AIR RESCUE TRANSPORT BILLING AND COLLECTIONS Reason for Waiver: SOLE PROPRIETORSHIP WITH NO EMPLOYEE OTHER THAN THE OWNER Policies Waiver will apply to: WORKERS' COMPENSATION INSURANCE REQUIREMENTS FOR CONTRACT Signature of Respondent: Risk Management Date County Administrator appeal: Approved: Date Board of County Commissioners appeal: Approved: Not Approved: Not Approved: BOCC Meeting Date: FEBRUARY 20, 2013 Page 5 of 5 i 490 83rd Street Ooeen Stills 140 ACCORDANCE WITH TN! P CY PROVISIONS. — __ . �..� • •• Marathon. Fl 33050 AUM01020 MAae MIM11 wrnon ea reruwr� �Lq &,.Q, - w Zaoo-cv,u AVVw Vuwvw►TIOM All rights f6sanrod. The ACORD name and logo are registered marks of ACORD AMOROSO NPRISMAVA 01988.2010 ACORD CORPORATION -Au The ACORD name and logo are registered marks of ACORD Pdtolary Recipients libe I PM4 Ageot, M A4 OPP, Degism - Wp-. ProgesM P.R Bet M739 ONdW4 ON 44101 140t1a9s,2m Certificate of Insurance bttps://www.con mr.isl.progressive ccmf?Jo>11 uMey-A2CFEW-.. AVOgAMW * Peet amber. G095100 Progtm" 14mbts ear " NA Sh 3. 2013 Pays 1 of 1 60*10 now idoiidhAred.....................................1r1tVP(>ifg INWO .......................... ....... awm ...........P60Gµ MOMOE ODUNNIOCC EMS 8411NGAND CONSLLi1NG liCIAL..............._.........»....». POem 94739 490 63RD Sr OMAN AIDE 140 176 DONE CIRCLE QEVELAND. OH 44101 MARATHON. R 33050 ROYAL PALM WC. FL 33411 This document catifies that insurance polides identified below have been issued by the designated insurer tools insured named above for ltte partoM) indicated. This Cudmte is tzued far i* ma t ptrrposses a 4. btcortters nod" upon the otrdame holder and does not dtang% Sher, Rmdl y, or extend the coverages afforded by the poldes fisted below. The coverages afforded by the poides listed below are subject to all the tams, exclusions, dn>etadora, ends iner9% and carlr8tians d these polder. Polley EfEet ie�tiacx Mil 3, 2G13 ....... .» ��polcyEitplratluri Date Men.3. 2014......I........................................ . raonMa�eowe (� wmft eod�y In !!1!Rrcparyr Da!ne9.................................. ............ 30Q i Comb i>ed 5ui la Limrt................._....................................... Porsonil Injury Ffob m 10.000 w%}0 Dad �llamad t b RalativQ..»......................».......-. Description of LoadonNehkles4eciai items ScheMed autos oaiy 2008 TOYOTA COROLLA am 1NMPJ2Eii9A137 """'""""" • • ........» • . ». tardSa tonumbw 06213AO9863 Rem be advised that addlttond inamedeand Iosepgyeeewill be notified in the vmd of a retd4elm oanodlatton. �4, Q-qjv� rMsu mron loft 3/3/2013 7.03 PM CERTIFICATE OF LIABILITY INSURANCE I °A 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 pollcyges) must be endorsed. If SUBROGATION 1S WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certiNcate does not confer rights to the certificate holder In Ileu of such endorsements . PRODUCER Hiscox Inc. 520 Madison Avenue. 32nd Floor York, NY 10022 PHONE (888) 202-3007 VAX 'mA . contactus@hiscoxuea.com ADDRNew N AFFORDINO COVERAGE NAK: s INSURER A • Hlscox Insurance Company, Inc. 10200 INSURED EMS Billing & Consulting 175 Dove Circle West Palm Beach, FL 33411 INSURERS. NSVRMC, NaURSR D INSURER E N F: ,+nSleo Al2=Q C-wRTIFIr^ATF NIIMAR 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 REOUIREMENT, 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. LTRINSR 7YPBOFNsuRAHCE Po NUMBER POLICY ow Lserrs A GRNWALLIABILITY x COMMERCULGENERAL LIASILRY CWMS-MADE a OC" Y N UDC-1329369-CGL-13 02/2012013 0=012014 EACH OCCURRENCE S 1,000,000 DAMAGE TO B:RTE�Cal $ 100,000 MEDS(P en. S 5,000 PERsowu.aADvI"RY s 1,000,000 GENERAL AGGREGATE i 2,000,000 (3ENT. AGGREGATEIJWTAPPLIES PER, X1 POLICY MO Loa PRODUCTS .COMPIOPAGO S S/TGenAgg. i LIABILITY BILITY ANY AUTO AOWNED SACHEDULED AUTOIIPR HIRED AUTOS A QED OOMSNEDSMLELIwr i BODILY INJURY IPw p=w) $ BODILY INJURY jPw sod" i D f i UNBRELLALIA9 EXCESS LIAR OCCUR I CLAIMSMADE EACHOCCURRENCE i AGGREGATE D RETENTIONS S WORKERS COMPENSATION AND EMPLOYFM LIABILITY AW PROPRIETORWARTNER/EXECUnYE Y❑ i ow EXCLUDED? I deeabs under 0 ON OF OPERATIONS bm. N ! A S LATU- 1 _ EL EACH ACCIDENT i EL DISEASE - EA EMPLOYE i EL DISEASE - POLICY LIMIT S A Professional Liabflty Y1329389-EO F[UDC- 13 02/20/2013 02/20/2014 Each Claim: $1,000,000 Aggregate: $1,000,000 DESCRWnON OF OPBRATI N S !LOCATIONS I VEHICLES (Attach ACORD rot. Admsonal Ramada If more ewce Is reswnd) Certificate Holder to Additional Insured on both the General Llablity policy and the Professional Liability policy. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Monroe County Board of County Commissioners THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 490 63rd Street Ocean Suite 140 ACCORDANCE WITH THE P7r PROVISIONS. Marathon, FL 33050 AUTHORIiEb REPRESENTATIVE ( k) AOO C k ACORD 25 (2010105) a 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACURU Av vA CERTIFICATE 4F LIABILITY INSURANCE 1 °"2`2' 02i1812013 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 pollay(ies) must be endorsed. tf SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain poiicles may require an endorsement. A statement on this certificate does not confer rights to the eernficate holder In lieu of such endorsemen e . PRODUCER HI°cox Inc. 520 Madison Avenue, 32nd Floor New York, NY 10022 °ibli. (888) 202-3007 f ADDRESS . contactusodscoxusa.com INSUIUMMAIFFORDINGCOVERAOS NAIL I 94SUPJMA: Hlscox insurance Company, Inc. 10200 INSURED EMS Baling B Consutting 175 Dave Circle West Palm Beach, FL 33411 INSURER B INOURERC; (NaVRER D: wsuRER E : Ft rnvctaencc CORTIOICATO NI1MriCR• 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. TYPE OFINSURANCa PouCYMARIER Lem rA GENARAL LJABIITY X COMMERCIAL GENERA. LIABILITY CLAIMS MADE a OCCUR Y N UDC-1329369-CGL-13 02/2012013 02/2012014 EACH OCCURRENCE i 1,000,000 DAMAGE TO RENTED u $ 100,000 MID EXP an i 6,000 PERSONAL &ADVINJURY S 1,000+000 GENERAL AGGREGATE i 2,000,000 Gen. AGGREGATE LIMIT APPLIES PER: X POLICY LOC PRODUCTS - COMPIOP AGO i SR Gan.Agg. i AUTOMOaII.E UABUTY ANYAUTO ALL OWNED CHH�EDULED NON -OWNED HIRED AUTOS AUTOS -00MI NI BODILYINJURY (Per pemaN i SWILYINJURY (Paaccbeno i —P $ i UMBRELLALIAD LIAR OCCUR CLAIMS•MADE �� EACH OCCURRENCE IIIEXCESS AGGREGATE D® I I RETENTION WORNEReCOMPENSATION AND EMPLOYERS' LIABILITY YiN ANY PROPRIETORIPARTNERIEXECUTNE ❑ OFFICERRAEMBER MCCLUDW7 (Mutd•IayinNM If dualW taldr D PTION OF OPERATIONS below NIA YVC OTtI- EL EACH ACCIDENT i E.LDISEASE- EAEMPLOYE i EL. DISEASE- POUCY LIMB 13 A Professional Liability Y N UDC-1329369-EO-13 02/2012013 02120/2014 Each gate:Claim1, 00,0000 Aggregate: 1i 1,DDD,DDD bMCRWnON OF CPERATUM I LOCATIONS 1 VMCLES (Attach ACORD 101, Addhimal Remalu ache t", I mom %pace Is nqulnd) Certillosta Holder Is Additional Insured on both the General Liability policy and the Professional Liability, policy. Monroe County Board of County Commissioners 490 63rd Street Ocean Suite 140 Marathon, FL 33050 ( IU A-A-Ick-- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE P01a1CY PROVISIONS. AUTHORREDREPRESENTATIVE ( i (C 1988.2010 All rights reserved. The ACORD name and logo are registered marks of ACORD Prinou Recipients Ww bsumd, Agent, LK AL OPF. Degisme - bUp... bitps-.//www.comn=ial.progesdve.cojW?Jou=W%ey=A2CFE9F..- PMPS*e P.O. Ba 94739 OweaK ON 44101 14K"S-IM Certificate of Insurance Policy amber. 02095M-0 Un*AWam by: Progm,ve Egret 10 cavary humb 3. 2013 Page I Of 1 Cudftft Nddw I ,, - Apat .................. M� ................. .. ixk . owfa .................... .......................... m1m.15 ................. .. MONROE COUNTY BOCC EMS BUING AND CONSULTING PO BOX 94739 490 63RD Sr OCEAN 2ATE 140 176 DOVE CIRCLE CLEVELAND. ON44101 MARATHON, Fl. 33050 ROYAL PALM BEAC. Fl. 33411 TWsdocument certifies that insurance polidesiderdied below have been issued by the designated insurer tothe insured named above for the period(s) Indicated. This Caftate is issued for information purposes only. it (aft no rights upon the, certificate holder and does W change, alter, mortify, or extend the coverages afforded by the poldes listed bekw. The coverages afforded by the policies listed below are subject to all the terms, exclusions, lirritations, endorsements, and cDnftcns of these policies. Polka i*6iti.**Miii,,i6iiiliiiiration ,Date: "Mar 'i"iii4**"*, . .......................................... W y I nju I yfropety Damage 5300 Carbuied Single Omit . ............... . . ....... Persona! Injury Prooeclion ........... ............................................................................. ................ S10.ODOw/$O Ded -Named lrdd& Relative Dozalption of Loation/Vehildo/Speetal litans SchGMedautos only ........... ... ... .............................. I ...... I .......... Cerfiftnts number 06213AO9863 Rom be advised that additional insuredeand loss paMewlll benctified In the &Ant of a mid-term cancellation. fan 5U 11100 I Of 1 3/3/2013 7:03 PM