Certificates of Insurance DATE(MM/DD/YYYY)
ACORD® CERTIFICATE OF LIABILITY INSURANCE
03/11/2022
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be
endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A
statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT
NAME:
HISCOXInc. PHONE $$$ 202-3007 FAX
520 Madison Avenue -M No Ext: ( ) vc No
32nd Floor
ADDRESS: contact@hiscox.com
New York, New York 10022 INSURER(S)AFFORDING COVERAGE NAIC#
INSURERA: Hiscox Insurance Company Inc 10200
INSURED
INSURER B
LOCI Lehr Inc. INSURER 7
3441 Pittman Road
Dover, FL 33527 INSURER D
INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUBR POLICPOLICY NUMBER MM/DDY EFF MM/pY EXP LIMITS
LTR
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DA
CLAIMS-MADE � OCCUR PREM SESOEa occurrDence $ 100,000
MED EXP(Any one person) $ 5,000
A P100.226.922.4 04/25/2022 04/25/2023 PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000
X POLICY❑ PRO-JECT ❑ LOC PRODUCTS-COMP/OPAGG $ 2,000,000
OTHER: $
AUTOMOBILE LIABILITY COMBINEDSINGLELIMIT $
Ea accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS APer accident
UMBRELLALIAB OCCUR EACH OCCURRENCE $
EXCESS LAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
OFFICE R/M EMBER EXCLUDED? ❑ N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
A Professional Liability P100.226.114.4 04/25/2022 04/25/2023 Each Claim:$1,000,000
Aggregate:$1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
-Required Additional Insured Language for General Liability and Auto Liability Monroe County BOCC.-Workers Compensation: Must provide coverage for the foll
owing State(s): FL APPROVED BY RISK MANAGEMENT
r
DATE 10/11/2022
WAIVER N/A—YES—
CERTIFICATE HOLDER CANCELLATION
Monroe County BOCC
PO Box 100085-FX SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Duluth, GA 30096 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
.,ry SOD wE't��
JIMMY PATRONIS
CHIEF FINANCIAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
** CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW
NON-CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 3/28/2021 EXPIRATION DATE: 3/28/2023
PERSON: LORI L LEHR EMAIL: LORI@LORILEHRINC.COM
FEIN: 811401221
BUSINESS NAME AND ADDRESS:
LORI LEHR, INC.
3441 PITTMAN RD
DOVER, FL 33527
SCOPE OF BUSINESS OR TRADE:
Salespersons or Collectors
Outside
IMPORTANT:Pursuant to subsection 440.05(14),F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under
this section may not recover benefits or compensation under this chapter.Pursuant to subsection 440.05(12),F.S.,Certificates of election to be exempt issued
under subsection(3)shall apply only to the corporate officer named on the notice of election to be exempt and apply only within the scope of the business or
trade listed on the notice of election to be exempt.Pursuant to subsection 440.05(13),F.S.,notices of election to be exempt and certificates of election to be
exempt shall be subject to revocation if,at any time after the filing of the notice or the issuance of the certificate,the person named on the notice or certificate
no longer meets the requirements of this section for issuance of a certificate.The department shall revoke a certificate at any time for failure of the person
named on the certificate to meet the requirements of this section.
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 E01281107 QUESTIONS?(850)413-1609
2018 Edidon
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.
ContractorNendor: Lori Lehr Inc.
Project or Service: .GOm =jt' n _SI. � . ... ..
ContractorNendor
Address&Phone#: 3441 Pittman Rd Dover,FL 33527
i a ort Services
General Scope of Work: Community Ratin�stem��p dces
p Reason for Waiver or Exempt from Worker's Compensation Requirements
Modification:
Policies Waiver or
Modification will apply to: Workers Compensation
m „
Signature of ContractorNendor
Date: Approved .nmm. Not Approved
Risk Management Signature:
Date:
County Administrator appeal:
Approved: Not Approved.
Date:,
Board of County Commissioners appeal:
Approved Not Approved
Meeting Date:
Administrative Instruction 7500.7
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CERTIFICATE OF L1 II INSURANCE
1912021
THIS CERTIFICATE IS ISSUED TT INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE R.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTERTHE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSU R(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IM—PORTANT, E the certificate holder is an ADDITIONAL INSURED,the pollcyp )must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies i an endorsement. A statementon
this certificate does not confer rights to the certificate holder in lieu of such andorsomeniLsh
PRODUCER
kiscox Inc. PHONE )202-3007
0 Madison AvenueFloor oRLcontact@rdscox.com-
New
York NY 1 OM INsu gAFFORDING COVERAGE NAIC#
u A, Hiscox Insurance Company Inc 10200
INSURED INSU
Lod Lehr I
1 Pbroan Road tNSURERC,
Dover,FL 33527 INSURERD,
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE.POLICY RI
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENTTO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE PCLICIS DESCRIBED HEPEIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH I.ICIES.LIMITS SHOWN Y HAVE BEEN REDUCEDBY PAID CLAIMS.
POLICY EFF P
LTR E OF I?$DCE GYNU ER
COMMERCIAL GENERAL
EACH
s
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CLANS-MADE R PREMISES
Approved RiskManagement PE S YINJURY $
N TS S
IGE
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AUTOMOBILE LIABILITY 6-29-2021 COMBINED SINGLE U1MrF S
11---
ANY AUTO ILYJURY( ) II
OWNED SCHEDULED SOCILY LNJURY ) S
AUTOS Y AUTOS
HIRED NOR-OWNED ER S
AUTOS Y AUT ONLY r
s
UMBRELLA UIAB
OCOUR EACH OCCURRENCE S
EXCESS LIM E AGGREGATE S
DEDj_jRETENTIONS s
iaKERS COMPENSATION PER
AND EMPLOYERS,LIABILITY YIN STATUTE Ow'*
ANTICMEWEWMCERWAR7NEOMED?ECUTIYE N/A Et.EACH ACCIDENT $
DFFIClbRISAEMaERElfCLUDED'S
( cry in I" EL.DISEASE-EA EMPLOYEE $
11
D M,d asc d
ON OF OPERATIONS belew E.L.DISEASE-POLICY Ll S
A Professional Liability N U 1A1 EO-21 0412512021 04r2mW Ifech Claim: 1,000,01110
greg : $1.000,000
MWRWnDNOFOPERATONSILOCATWNSIVEHICLES (ACORD 1Dt,Ad, ks$dWuV@6 maybraftchadgmunaa
CERTIFICATE HOLDER CANCELLATION
MonroeCourdy SOCC
1100 Shordon Steel SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Key t FL 33040 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED I
ACCORDANCE WI :THE POLICY PROVMIONS.
AUTHORIZEDPEPRESENI'AThM
1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(201 3) The ACORD name and logo ard registered s of ACORD
ACIOR0� CERTIFICATE OF LIABILITYINSURANCE
ibo�- [ 0411912021
THIS CERTIFICATE IS ISSUED MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE I
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. I CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSU R(S), AUTHORtZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT. If the Certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed,
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the cortificate holder In lieu of such endorsomen s.
PRODUCER NTa T
s I PHONE (688)2024007
SM Madison Awwue E4LAILConta his x. m
Floor
New,York NY 10 wsu s aF INoCOVERAGE KIM U
INSURER A: HIswx Insurance Company Inc 10200
MURED INSu a:
Lori Lehr int
1 Pitiman Roadc°
Dover, 7 INSURER D:
MURER E.
INSURER F:
COVERAGES CERTIFICATE NUMBER.: REVISION NUMBER:
THIS IS TO C TIFY T THE POLICIES OF INSURANCE LISM BELOW RAVE BEEN ISSUED TO THE INSURED FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR,CONDITION OF ANY CONTRACT OR OTHER DOCUMENT 1 P T TO WHICH THIS
CERTIFICATE Y 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 REDUCEDPAID CLAIMS.
LTR cESEOFiNsu POLICY P r v
TY
MM
X C c o
EACH u ENCE $
1t,®000000,,0000
00 IYARIMCLAIMS-MADE R s 100A00
MED Aano 3 C000
imrr P • UDC-414123 GL-21 0412 021 0412 0 a INJURY S
GENZTELAPIAJE
GENERAL AGGREGATE $2,000,000
XPRO-
POLICYOJECT ElLOC PRODUCTS MPIOP AGG $Sff CAm.
Ana
.
o: THEM $
AUTOMOBILEEa� NED SINGLE
ANYAUTO BODILY INJURY(P ) S
OWNEAUTOS ONLY AUTOS
SOMULED BODILY INJURY( )
HIIRED L! N ONEDD PR__6PERTY DAMAGE
t
LY
UMBRELLALIAH OCCUR _g8SHOCCURREN CE S
EXCESS LIM CL0UMS-MAn91 AGGREGATE i
DED RETENTIONS S
WORKERS COMPENSATION TIE ER
AND 8° LRY YIN
ORIET PARTN CYE =1N f a EL H I 5
OF FAEXCLUDED7 Li(Malwa"In ) E.L DkIltEASE-FA EMPLOYEE b
K SCRIPTION OF OPERATIONS bakw E.L.DISEASE-POLICY u $
DESCRUITION OF OPERATIONSt LOCAMNS IVEHICLES JACORD 101.AddIdonal e6 may be afteah6d If mom opus la roqutradl)
CERTIFICATE HOLDER CANCELLATION
Monme County BOCC
1106 slmmftn Sbw SHOULD ANY OF THE ABOVE DESCRIBED OLICIE E CANCELLED BEFORE
Key West L 33040 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED I
ACCORDANCEWITH THE POLICY PROVISIONS.
AUl}IO 6NTA
1988-201 S ACORD CORPORATION. All rights reserved.
(2161 ) The ACORD name and logo am_registered marks of ACORD
C)PRbP CERTIFICATE OF LIABILITY INSURANCE
DATE IMIIDDIYYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER I ... N A
Hiscox Inc.
520 Madison Avenue
32nd Floor
New York. NY 10022
INSURED
Lori Lehr
3441 Pittman Road
F:
202-3007
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
10200
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.
LTR
TYPE OF INSURANCEINS
POLICY NUMBER
POLICY EFF
POLICY E%P LIMITS
x
COMMERCIAL GENERAL LIABILITY
CLAIMS -MADE OCCUR
EACH OCCURRENCE
_PREMISES (Ea ooccum nca
15 2.000,000
1 5 100.000
5 5.000
MED EXP (Any one person)
A
Y
Y
UDC-1538299-CGL-16
02/0212016
02/0212017 PERSONAL & ADV INJURY_ _
S 2.000,000
_
GENL AGGREGATE LIMIT APPLIES PER;
GENERAL AGGREGATE
5 2,000.000
I I R C] JECT El LOC
O
PRODUCTS
S SIT Gen. Agg.
AUTOMOBILELIABILIY
COEa soddeMBINEDraSING L
S
BODILY INJURY (Per person)
S
ANY AUTO
;AALL UTOS OWNED �.. .-� ODLILED
_'. HIRED AUTOS E Auros
BODILY INJURY (Per aeddem)
S
� E�eRDAMAGE
5
is
I I
' UMBRELLALIAB :OCCUR
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EXCESSL'MWS•
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�
�
� AGGREGATE -
I S
I5 —
(B�
DEi 0 ITI RETENTION S
wORKERSCOMPEHSATN711
AND EMPLOYERS' LIABILITY Y l N
ANYPROPRIETORIPARTNERIEXECUTIVE
OFFICERMEMBEREXCLUDED?
NIA
i
I
PER ! OTH-
ITATV - t IR
E L EACH ACCIDENT
S _.. -----.
(Mandalay in UN)
<
E.L. DISEASE . EA EMPLOYEE
S
N yes describe under
DESCRIPTION OF OPERATIONS below
( I
E L DISEASE -POLICY LIMIT
_
5
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{
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD Ill, Additional Remarks Schedule, may be attached If mom span le squired)
Monroe County BOCC is listed as additional insured
R �r
OEA
w
CERTIFICATE HOLDER CANCELLATION
Monroe County SOCC
1100 Simonton Street
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Key West FL
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHOR02O REPRESENTATIVE
01908-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
ATTACHMENT D
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.
Contractor. Lori Lehr
Contract for. Lori Lehr, Inc
Address of Contractor. 3441 Pittman Road
Dover, Florida 33527
Phone: 727-235-3875
Scope of Work: Post Hurricane Irma Damage Assessment
within Unincorporated Monroe County
Reason for Waiver: Vehicle is not used for business
purposes in Monroe County.
Policies Waiver Lori Lehr Contract for Post Hurricane
will apply to: Irma Damage Assessment Contract Ammendment
Signature of Contractor.
Approved.
Risk Management
Date `
County Administrator appeal:
Not Approved
Approved: Not Approved:
Date:
Board of County Commissioners appeal:
Approved:
Meeting Date.
Administration Instruction
Not Approved:
104