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Item C9BOARD OF COUNTY COMMISSIONERS AGENDA ITEM SUMMARY Meeting Date: May 21, 2014 Division: Employee Services Bulk Item: Yes X No Department: Risk Management Staff Contact Person: Maria L. Slavik x3178 AGENDA ITEM WORDING: Approval to advertise a solicitation for Proposals for General Liability and Excess Workers' Compensation Insurance. ITEM BACKGROUND: The General Liability, Vehicle Liability and Public Officials/Employee Practices Liability provides insurance coverage for sums which the County may become legally obligated to pay as a result of bodily injury, property damage, or personal injury arising out of its operations. The Excess Workers' Compensation policy provides statutory benefits in excess of the County's self - insured retention. The Excess Workers' Compensation policy also provides Employers Liability coverage with limits of $1,000,000 for claims that have the appearance of a workers' compensation claim but fall outside of the purviews of Florida Statute 440. PREVIOUS REVELANT BOCC ACTION: The General Liability policy was previously bid in 2011 and a recommendation was made to the BOCC to accept the proposal with FMIT. The last renewal with FMIT was approved by the BOCC on September 17, 2013. The Excess Workers' Compensation Policy was previously bid in 2009 and a recommendation was made to the BOCC to accept the proposal with Star Insurance Company of Brown & Brown Insurance. In 2013, we were notified that Star Insurance Company would be withdrawing from the governmental insurance market. Brown and Brown then sought quotes from other carriers and the County ultimately recommended Preferred Governmental Insurance Trust (PGIT) to the BOCC on September 17, 2013 at an increase of approximately 45%. CONTRACT/AGREEMENT CHANGES: It is being recommended that we bid both of these policies as a bundled package in anticipation in receiving a better premium from carriers. The renewal effective date will be October 1, 2014. STAFF RECOMMENDATIONS: Approval to advertise Advert TOTAL COST: $800 INDIRECT COST: - BUDGETED: Yes X No IJIMIDW111114040 I I I ultimalpC101 Advert COST TO COUNTY: $100 SOURCE OF FUNDS:--hternal Service Fund Primarily Ad Valorem REVENUE PRODUCING: 1 i PER MONTH APPROVED BY: County A R sTng Risk Management tty-LY0 WOCUMENTATION: Included )L Not Required ' 1 i V REQUEST FOR PROPOSi,;!,,'.,'!` FOR LIABILITY (GENERAL LIABILITY, VEHICLE LIABILITY/PHYSICAL DAMAGE, PUBLIC OFFICIA AND EMPLOYMENT PRACTICES) AND EXCESS WORKERS'COMPENSATION INSURANCEI BOARD OF COUNTY COMMISSIONERS Mayor, Sylvia J. Murphy, District 5 Mayor Pro Tern, Danny L. Kolhage, District 1 George Neugent, District 2 Heather Carruthers, District 3 David Rice, District 4 KO I I M A ow .U0j11[;11W9T0--i - CLERK OF THE CIRCUIT COURT EMPLOYEE SERVICES DIVISION Amy Heavilin I of 107 SECTION No. DESCRIPTI -0 ---- N-- PAGE NUMBER(S) Instructions to Proposers •Sample Aqreement Scope of Services Cou= Forms Proposal Forms Underwriting Information Will be added before advertising: ➢ The County's projected payroll for 2014115 by Workers' Compensation classification > The County's most recent Experience Modification Worksheet v Number of County employees and volunteers 2 of 107 The County is seeking proposals for insurance coverages in accordance with the specifications outlined this Request for Proposals. The County will accept proposals both from brokers/agents and direct fron carriers. The County anticipates that this contract will be awarded for an effective date of October 1, 2014. The initial policy term will be for 1 year and the County may elect to renew for up to three (3) additional consecutive 1 year terms, dependent upon acceptability of cost, coverage, service, provider stability and market conditions. > Excess Workers' Compensation > Commercial General Liability > Business Automobile Liability > Automobile Physical Damage (scheduled vehicle > Public Officials Liability > Employment Practices Liability The County prefers that all of the requested coverages be provided by one insurer but will retain the right to purchase the coverages from different agents and insurers. Proposers are required to indicate if the coverages can be purchased separately and are required to provide the pricing for separate coverages as well as pricing for a "Package" program that includes all of the requested coverages under one master insurance policy. The County also desires to evaluate the cost benefits of having the requested coverages provided on a "Net of Commission" basis and paying the selected agent(s) an annual fee for administering the program. Agents are requested to provide proposals based both on a Commission and a Net of Commission basis. Proposers will be required to submit their proposals on the proposal forms included within this RFP. T proposal forms are structured to allow the Proposer to provide the cost of individual coverages and the cost of the coverages combined. In addition, the proposal forms will permit the Proposer to provide a response based on a "Fee" and a "Commission" basis. RFP on Demand Star On or about 5/26/14 Requests for Additional Information ' Issuing of Addendum Responding to Requests for Additional Information U TTIrs I .ire 3:00pm � 8/5/14 o• o: Evaluatin ofPrposals 14 through 8/15/14 - Selection Committee Meeting ..... --------- Week of 8/1/14 SWATT 9 9 =9 Ion NNTMON * 1 17/14 and 9/18/14 Program Implementation S1171FIEm- There will be no market assignments for this RFP. Proposers are free to approach any insurer they believe have the ability and desire to provide the coverages the County is requesting. 1[07FI-In! itell o1472(g1wj I VA#j1 I a f 116-21111 LOVOU I M I I IJ301011 I I IVA KV] I I I 0101',Qv-14 a I a elffole 1 0 4 of 107 Type SIR Excess_ 1 • Brown/ • Workers'• to Empl..• .' /1 111' �� .• Compensation • /Million • • •. Municipal • •; League / Insurance i� of to $200,000 LiabilityGeneral Trust Cities 10/1/14 Business Florida Municipal Florida League i 10/1/13 Automobile Insurance of to Liability Trust Cities 10/1/14 Automobile • •. • tLeaguei • •. 1 Physical insurance of to Damage Trust Cities ------------------ 1 /' . f • Florida Florida1Incl. in Municipal.• Insurance • /1 /'1/' Commercial iGeneral • • Trust Cit es / Liability A SelectionCommittee will • - convened to review the Proposals w • recommend which individual or be selected for the project. The successfulProposer will ••• - be selected based on - following Cost of services 35 points Experience and qualifications of proposing is points agent Terms and conditions of coverages being 33 points proposed Financial stability of insurers being proposed 11 points Compliance with the Bid Specifications 4 points Recommendations from government clients 4 points Location of firm (local preference if 5 points applicable: up to 5 additional points) Total points earned are on a scale of 1 — 100 points '11 = highest Selection•'' be analyzing Proposals and provide recommendations to the County Administr of 1' who will ultimately make a recommendation to the Board of County Commissioners regarding which Propli should be hired. W. MM 1111176 1=1 - TSMITINF-Mt SEEM 0 Workers' Compensation Questions: Maria Gonzalez, Sr. Benefits Administrator 1100 Simonton Street, Suite 2-268 Key West, Florida 33040 Facsimile (305) 292-4564 Email: gonzalez-Maria @Mon roecounty- Fl. Gov General Liability Questions: Maria Slavik, Risk Administrator 1100 Simonton Street, Suite 2-268 Key West, FL 33040 Facsimile (305) 292-4564 Email: Slavik-Maria @Mon roecounly-Fl. Gov. A copy of any Requests for Additional Information should also be sent to Interisk Corporation at the 'following address: Sid Webber Interisk Corporation 1111 N. Westshore Blvd. Suite 208 Tampa, FL 33607 Facsimile (813) 287-1040 Email: Sid.Wcbber@1nterisk.net The County will honor email Requests for Additional Information. All requests for additional information must be received no later than 3:00 PM, July 3, 2014.1Any requests receive( after that date and time will not be answered. All questions received prior to the deadline will be answered to the best of the County's ability and will be distributed to all interested Proposers in the form of an Addendum to this RFP. All Addendums, will be posted on Demand Star on or about July 8, 2014. All questions must be submitted in writing. Oral requests will not be answered. IPF:11 111:11nii1r;II; I whether or • ' • by of eachProposer •:verify received all addenda issued before responses are opened. While the County will complete applications for the selected agents and insurers if required, the County will not # •applications• Additional • t The Proposal submitted in response to this Request for Proposals (RFP) shall be printed on 8-1/2" x 11 " white paper and •! • be and concise, .•'•'• and provide • ! requested Statements submitted withoutrequired information will notbe considered. Responses a be organized as indicated below. The Proposer should not withhold any information from the written response in anticipation of presenting the information orally or in a demonstration, since oral presentation., or demonstrations may not be solicited. Each Proposer must submit adequate documentation to certify th( Pp compliance • !requirements.•!1 should focus specificallyon information requested. County If the i purchase the coverageson of • • basis and pays a separate contract included in this RFP (Section Two). to the agent, the successful agent will be required to execute a contract with the County similar to the draf 1:11112 ME i cover page"Requests Insurance." The cover page should contain Proposer's name, address, telephone number, and the name of the Proposer's contact person(s). Tab 1. Executive Summary The Proposer shall provide a narrative of the firm's qualities and capabilities that demonstrate -- how the firm will work with the County to provide services associated with the coverages provided Regardless if the coverages are provided on a commission basis or a fee basis, the selecte( agent will be expected to provide the services outlined in the section below labeled "Tab 3 Scopi of Services". • All agents shall be licensed in the State of Florida in accordance with Florida Statutes Ch. 626. Proposer shalprovide minimumof At • of includereferences must be from other governmental entities within the State of Florida. References ma, former• _ no longer 7 of 107 Each reference at a minimum shall include: • Name and full address of the client; • Name, address, title, and telephone number of the client contact, • Identification of coverage provided; and • The length of time the policy was in place. Provide an overview of how the agent markets their client's coverages. For example, is the agen responsible for all marketing activities, does the agent work for an agency that has a dedicatec marketing department or does the agent primarily use the services of a wholesale broker? Copies of the insurance licenses for all agents that will be part of the County's service team mus be provided. • Provide information to show that all insurers have an A.M. Best rating of A- or higher and a financia size of VI or higher, or provide an explanation for the deviation. • Provide information to show that all insurers are licensed by the Florida Department of InsurancE for all coverages provided. • If the Insurer is not rated by A.M. Best or the A.M. Best rating is below A -NI, the proposal mus include a minimum of three (3) years of independent audited financial statements. In this tab, for each type of coverage covered by your proposal, attach a completed Proposa Form (attached at the end of this RFP). All pricing for I! coverages must be shown on the Proposal Form, and must include all fees and assessments that may be imposed including those imposed by the State of Florida. The County will consider purchasing the coverages on a "Net of Commission" basis and compensate the selected agent(s) on a "Fee" basis. Regardless of whether the coverages are provided on a Commission or Fee basis, all remuneration received by the selected agent shall be all- inclusive. No additional costs or fees will be paid, including but not limited to travel costs, per diems, telephone charges, facsimile charges, and postage charges. Responses such as "See Policy Form" or "Per Policy"will not be viewed as an acceptable response.. -7X,oliiT:73rtlr- = , =-t Proposer shall provide any additional project experience not already described in other tab" that will give an indication of the Proposers overall abilities to service the County for th( coverages awarded to the Proposer. Information that exceeded the space allotment in the Proposal Forms or the Co Questionnaire, may be included in this section. If needed, please include the compleft question and repeat your entire response under this tab. If the Proposer cannot fully comply with any of the terms contained in the draft contract, shown h Section Two, all deviations to the terms must be spelled out in this section, i.e. Tab 5. If the Propose cannot fully provide any of the elements in scope of services, these also should be spelled out in Tal In accordance with Section 2-347(h) of the Monroe County Code, the Proposer must provid( the following • • Proposer • • and attach the formsspecified below which are locatedSection Three in this RFP, as well as a copy of a business tax receipt from the Tax Collector's Office and shal' include it in this section, i.e. Tab 8: Submission•... 9 of 107 Certificates of Insurance are not received within the fifteen (15) day period, the contract may be awarded to the next selected Proposer. Policies shall be written by companies licensed to do business in the State of Florida and having an agent for service of process in the State of Florida. All insurance companies shal have an A.M. Best rating of A- or better. The required insurance shall be maintained at all times while Proposer is providing service to County. Minimum acceptable limits Compensation Liability Bodily Injury by - dent Bodily Injury by policy Bodilyby each employee General Liability, including Premises Operation ''•a • • • - -• •I•- • ContractualBlanket .• Personal.• Statutory Limits mom ` 11'1 111 • •. • •- -MRIIIN•I •• • • ! . • •!' V • • 11i i1i •- '. 1i'i 111 ' •• '•. CountyThe Proposer to whom a contract is awarded shall defend, indemnify and hold harmless t outlined •- • The Proposer covenants and agrees to indemnify, hold harmless and defend Monroe County, commissioners, officers,• # -es, agents andservants fromandall claimsfor bodily including death, personal injury, and property damage, including damage to property owned by Monroz- County, and any other losses, damages, and expenses of any kind, including attorney's fees, court costs and expenses, which arise out of, in connection with, or by reason of services provided by the Proposer or any of its Subcontractor(s), occasioned by the negligence, errors, or other wrongful act or omission of the Proposer, its Subcontractor(s), their officers, employees, servants or agents. 13 of 107 In the event that the service is delayed or suspended as a result of the Propose rNendo r's failure to purchase or maintain the required insurance, the ProposerNendor 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 Proposer is consideration for the indemnification provided for above. The extent of liability is in no way limited to, reduced, or lessened bi the insurance requirements contained elsewhere within this agreement. 0 W If the Proposer cannot fully comply with any of the terms contained in the draft contract, shown in Section Two, all deviations to the terms must be spelled out in Tab 3, Other Information. 14 of 107 ♦ f 1011175=1111U31=1I•- ♦ • COUNTY CONTRACT FOR OF f - THIS AGREEMENT is made and entered into this _day of , by MONROE COUNTY ("COUNTY"), a political subdivision of the State of Florida, whose address is 1100 Simonton Street, Key West, Florida 33040 and ("CONTRACTOR"), whose address is CONTRACTOR shall• • perform •'carryout professional and proper duties agreement.described in the Scope of Services — Exhibit A — which is attached hereto and made a part of this described, subjecttothe terms andconditions• _Agreement• • cuments. The CONTRACTOR shall at all times exercise independent, professional judgment and shall assume professional responsibility for the services to be provided. Contractor shall provide services using the following standards, as a minimum requirement: A. The CONTRACTOR , require under the Agreement resulting from this RFP process. B. The personnel shall not be employees of or have any contractual relationship with th County other than this document. To the extent that Contractor uses subcontractors o independent contractors, this Agreement specifically requires that subcontractors an independent contractors shall not be an employee of or have any contractual relationshi with County. C. All personnel engaged in performing services under this Agreement shall be fully qualified, and, if required, to be authorized or permitted under State and local law t perform 2.1 The County will provide such data as is required by the Contractor and is mutually agreed upon. 2.2 The County will make payments as outlined in Section 4 of this Agreement. 3.1 Except as noted below, this Agreement shall begin on the 1 st day of October, 2014 and will conclude on the 30th day of September 2015 This Agreement shall continue for one year. The initial term may then be renewed at the option of • for • to one year terms. 15 of 107 respective•under Agreement • of • • to th same degree •extent totheperformance ofsuch functionsand duties of officers, , volunteers, or employees outside the territorial limits of the COUNTY. Non -Delegation of • • or Duties.• - not •-• to, nor shall it • construed as, relieving any participating entity from any obligation or responsibility imposed upon th entity by law except to the extent of actual and timely performance thereof by any participating entity, i which case the performance may be offered in satisfactionof - obligation or •• • or statutory duties of the COUNTY, except to the extent permitted by the Florida constitution, state statutE Agreement is not intended to, nor shall it be construed as, authorizing the delegation of the constitutionc, case law. No person or entity shall be entitled to rely upon the terms, or of of Agreement to enforce CONTRACTORattempt to enforce any third -party claim or entitlement to or benefit of any service or program contemplated hereunder, and the COUNTY and the CONTRACTOR agree that neither the COUNTY nor the or agent, officer, or •I• of -authority• inform,counsel or otherwise indicate that any particular individual or group of individuals, entity or entities, have entitlements or benefits under this Agreement separate and apart, inferior to, or superior to the communit� in generalor • the purposes in this Agreement. CONTRACTOR agrees to execute such documents as the COUNTY may reasonably require, includinc but • being limited to, a Public • a i • WorkplaceLobbying . • Conflict of • Non -Collusion A• - This Agreement may be executed in any numberof • •. of be -• e *1riginal,of ••'ther shall constitute one •' the same instrument and any of hereto may execute this Agreement by signing any such counterpart. 21 of 107 A -IF V-TeRR =*F 10111MUMIFUNWIMOM T-TOUNIVIRM9 RUMLOR 11141:1 &*1410111FRI14surol Loq ) I :: ;�1111111�11l ii�ll 111pip111111111111111 , ''I 11111111i (Note: amounts of coverage are subject to change in final contract) The Contractor shall be required to maintain the following types and amounts of insurance coverage as indicated below. Certificates of Insurance must be provided to Monroe County within fifteen (15) days after award of contract, with Monroe County BOCC listed as additional insured as indicated. If the proper insurance forms are not received within the fifteen (15) day period, the contract may be terminated without any financial obligations being imposed on the County. Policies shall be written by companies licensed to do business in the State of Florida and having an agent for service of process in the State of Florida. All insurance companies shall have an A.M. Best rating of A- or better. The required insurance shall be maintained at all times while Contractor is providing service to County. r M-1 Minimum acceptable limits 11'orkers' Compensation Employers' Liability Insurance Bodily Injury by Accident Bodily Injury by Disease, policy limits Bodily Injury by Disease, each employee General Liability, including Premises Operation Prttycts ant GirmAW61 #Atrat4ins Blanket Contractual Liability Personal Injury Liability Minimum acceptable limits Statutory Limits I '1W111r11T10-LQ11 9 23 of 107 the CONTRACTOR or b andunnecessarydelay' • bythe willful nonperformanceof CONTRACTOR and shall be solely responsible and answerable for any and all accidents or injuries t persons or property arising out of its performance of this contract. The amount and type of insuranc coverage requirements set forth hereunder shall in no way be construed as limiting the scope of indemni set forth in this paragraph. Further the CONTRACTOR agrees to defend and pay all legal costs aftendan toacts attributableo the sole• •' of At all times and for all purposes hereunder, the CONTRACTOR is an independent contractor and not a employee of the Board of County Commissioners. No statement contained in this agreement shall b construed so as to find the CONTRACTOR or of employees, rs, servants or to be employees of the Board of County Commissioners for Monroe County. As an independen contractor the CONTRACTOR shall provide independent, professional judgment and comply with a I federal, state, and local statutes, ordinances, rules and regulations applicable to the services to b provided. The CONTRACTOR shall be responsible for the completeness and accuracy of its work, plan, supportin data, and other documents prepared or compiled under its obligation for this project, and shall correct I its expense all significanterrors or omissions therein which may be disclosed. - cost of - wor necessary to correct those errors attributable to the CONTRACTOR and any damage incurred by th COUNTY as a result of additional costs caused by such errors shall be chargeable to the CONTRACTOR This provision shall not apply to any maps, official records, contracts, or other data that may be providec by •' or other public or • • agencies. The CONTRACTOR agrees that no charges or claims for damages shall be made by it for any delays o hindrances attributable to the COUNTY during the progress of any portion of the services specified in thi contract. Such delays or hindrances, if any, shall be compensated for by the COUNTY by an extension o time for a reasonable period for the CONTRACTOR to complete the work schedule. Such an agreemen shall be made between the parties. IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed on the Vay of 2014. (SEAL) • • • Co11•-_ a by Mayor/Chairman (Name of Contractor) by Title: 24 of 107 Regardless if the coverages .', Commission basis, thil- selected agent will be expectedthe minimum services identified below. accomplishell inclusive and the Proposer shall include in Tab 3 any and all services which are necessary 1 3 order to .Proposalsi which is incorporated herein purposeThe of the Agreementpurchase the following coverages: > Excess •'Compensation > Commercial General Liability Business! ••'Liability > Automobile Physical Damage (scheduled vehicles) > Public Officials Liability • For of • •`s after year 1, agents must meet with the County Countyconsultant prior to any marketing activities to discuss the results of the current program and the marketing approach the agent will take in developing proposals for all renewals being administered by the agent. Such meetings should take place no later than 4 months prior to the expiration of the coverages being administered by the agent. • For renewal of coverages after year 1, agents will be expected to research all available markets and submit the County's account to all insurers that have the capability and desire to provide the County with renewal options for the coverages being serviced by the agent. • Negotiate with the insurers and arrange for all endorsements that may be necessary throughout thE • Arrange/issue Certificates of Insurance as required. • Keep the County advised of the current state of the insurance market throughout the year. • Present all renewal proposals in a timely fashion as dictated by the County • Assist the County.• Assist the County with any other insurance/risk management issues that may be required. • Make presentation to County staff and/or the Board of County Commissioners as requested by the • i • coverages as directed by • proposing agent does notbinding a complete description of the binding requirements must be provided. • Provide a complete and full explanation of all deviations from the requested coverages. Responses such as "Per Policy Terms" or "Refer to Policy" will not be acceptable. • Fully cooperate with the County's independent insurance consultant. 25 of 107 26 of 107 # 9�9 - 0 1 419-4-49 NQQ El acknowledge receipt of Addenda No.(s) I have Included: • Response Form 0 • Lobbying and Conflict of Interest Clause 0 • Non -Collusion Affidavit 0 • Drug Free Workplace Form 13 • Public Entity Crime Statement 0 • Copy of business tax receipt from the r_1 Tax Collectors office • Local Preference Form (if applicable) 11 1:1 have included a current copy of the following professional licenses and business tax receipts: ljj-11*4-i4�11 !j APPLICANT ORGANIZATION: (Registered business name must appear exactly as it appears on www.sunbiz.org). from Sunbiz, and a copy of the most recent annual report flied with the Florida Department of State, Division of Corporations. LMMM�� Fax: Signed: Witness: (Print Name) (Title) STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me on "71717, =-1 Date (date) by (name of aff iant). He/She is personally known to me or has produce, (type of identification) as identification. NOTARY PUBLIC My Commission Expires: 27 of 107 ETHICS CLAUSE 11 ... warrants that he/it has not employed, retained or otherwise had act on his/her behalf any forme County off icer or employee in violation of Section 2 of Ordinance No. 010-1990 or any County off icer o employee in violation of Section 3 of Ordinance No. 010-1990. For breach or violation of this provision thi County may, in its discretion, terminate this Agreement without liability and may also, in 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 County officer or employee." (Signature) Subscribed and sworn to (or affirmed) before me on identification (type of identification) as NOTARY PUBLIC My Commission Expires: 28 of 107 NON -COLLUSION AFFI of of 2,nd under penalty of perjury, depose and say that RME of the firm of the bidder making the Proposal for the project described in the Request for Proposals for • that I executed the said proposal authorityfull • • • • 2. The prices in this bid 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 bidder or with any competitor; 3. Unless otherwise required by law, the prices which have been quoted in this bid have not been knowingly disclosed by the bidder and will not knowingly be disclosed by the bidder prio to bid opening, directly or indirectly, to any other bidder or to any competitor; and 4. No attempt has been made or will be made by the bidder to induce any other person, partnership or corporation to submit, or not to submit, a bid for the purpose of restricti competition; 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. (Signature) C_70Iil��lil0 Subscribed and sworn to (or affirmed) before me on (date) by (name of affiant). He/She is personally known to me or ha (type of identification) as identification. 29 of 107 DRUG -FREE • FORM (Name of Business) 1 . Publishes a statement notifying employees that the unlawful manufacture, distribution, dispensing possession, or use • a controlled substance is prohibited in the workplace and specifying thl • that will • taken .•. employees for violations of such prohibition. 2. Informs employees about the dangers of drug abuse in the workplace, the business' policy c • a drug -free workplace, any available drug counseling, rehabilitation, and employei assistance programs, and the penalties that may be imposed upon employees for drug abusl violations. 3. Gives each employee engaged in providing the commodes or contractual services that are unde bid a copy • the statement speced in • (1). 4. In the statement specified in subsection (1), notifies the employees that, as a condition of workin( • the commodities • • services that are under !• the •• will abide by the term',, • the statement and will notify the employer • any conviction of, • plea • guilty or • contendere to, any violation of Chapter 893 (Florida Statutes) or of any controlled substance law o the United States or any state, for a violation occurring in the workplace no later than five (5) day., after such conviction. 5. Imposes a sanction on, or require the satisfactory participation in a drug abuse assistance o rehabtation program if such is available in the employee's community, or any employee who convicted. 6. Makes a good faith effort to continue to maintain a drug -free workplace through implementation o this • As the person authorized to sign the statement, I certify that this firm complies fully with the above •' STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me on —(date) by (name of affiant). He/She is personally known to me or has produced as identification. NOTARY PUBLIC My Commission Expires: (type of identification) 0 "A person or affiliate who has been placed on the convicted vendor list following a conviction for publii entity crime may not submit a bid on a contract to provide any goods or services to a public entity, may no submit a bid on a contract with a public entity for the construction or repair of a public building or publi4 work, may not submit bids on leases of real property to public entity, may not be awarded or perform worl as a contractor, supplier, subcontractor, or CONTRACTOR under a contract with any public entity, an( may not transact business with any public entity in excess of the threshold amount provided in Sectior 287.017, Florida Statutes, for CATEGORY TWO for a period of 36 months from the date of being place( on the convicted vendor list." I have read the above and state that neither (Proposer's name) nor ani Affiliate has been placed on the convicted vendor list within the last 36 months. A X91 a -11 " "0 BE= name of aff iant). He/She is personally known to me or has (type of identification) as identification. NOTARY PUBLIC My Commission Expires: 31 of 107 A. Vendors claiming a local preference according to Monroe County Ordinance 023-2009 must complete this form. Name of Bidder/Responder Date: 1. Does the vendor have a valid receipt for the business tax paid to the Monroe County Tax Collector dated at least one year prior to th4 notice or request for bid or proposal? (Please furnish copy. ) 2. Does the vendor have a physical business address located within Monroe County from which the vendor operates or performs business of a day to day basis that is a substantial component of the goods or services being offered to Monroe County? List Address: Telephone Number:. B. Does the vendor/prime contractor intend to subcontract 50% or more of the goods, services or construction to local businesses meeting the criteria above as to licensing and location? If yes, please provide: 1. Copy of Receipt of the business tax paid to the Monroe County Tax Collector by the subcontractor dated at least one year prior to the notice or request for bid or proposal. 2. Subcontractor Address within Monroe County from which the subcontractor operates: Tel. Number Print Name: Signature and Title of Authorized Signatory for Bidder/Responder STATE OF: F01411INS-W60 Subscribed and sworn to (or affirmed) before me on (date) by (name of aff iant). He/She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC My Commission Expires: 33 of 107 • TOINCLUDE Coverage is requested on an Occurrence Basis to pay for liability arising out of all operations of th County and include: I 1`- Premises and Operations Products Completed Operations 1`- Employee Benefits Program Administration Liability > Blanket Contractual Liability > Personal Injury Liability > Discrimination and Civil Rights Liability > Independent Contractors > Broad Form Property Damage > Medical Attendants'/Medical Director Malpractice 1-97=17r;rTal 7KW If a separate Excess or Umbrella policy is utilized to achieve the desired limits, its terms and conditions must be no more restrictive than the underlying primary policy. Alternative Limits and Deductible options will be evaluated based on cost and the adequacy of protectio that is being offered to the County. I 34 of 107 e"t MTme'7 t.t7rMM Number of Employees County Payroll Budget 74,809 547 'Incl. temp. and pari time) The County's most current audited financial statements and budget is available on the County's website E www.monroecountv-fi.aov. The County's Risk Administer in cooperation with the County's legal staff administers all claims that fall within its self insured retention. Retaining this practice will be a critical factor in the evaluation of the proposals received. Detailed Loss Runs for the past 5 years are included as an attachment to this RFP. 35 of 107 VEHICLE LIABILITY AND PmysiLMD&I Coverage should be equal to, or broader than, the current Business Automobile policy filed by thE Insurance Services Office (ISO). Coverage should include: Symbol 1 —Uninsured Motorists Willbe-relected NBebo nefits Syml 5 (will be included within 7o-Fault retention) n N insL O-F, Physical Damage Scheduled vehicles (basically those with an original cost in excess of $25,000) Deductible/SIR $5,000,000 Combined Single $200,000 Limit ------------- - No -Fault Included within Retention Benefits -------------------- ----- ---- - Physical $1,000 for both Actual Cash Value Damage ! Comprehensive and Collision Alternative Limits and Retention options will be evaluated based on cost and the adequacy of protectio that is being offered to the County. I A current vehicle schedule is included as an attachment to this RFP. Physical Damage coverage i requested only for those vehicles that reflect an original cost on the schedule. Fire Rescue an Emergency Medical vehicles are separately insured for Physical Damage and are not included as part o this RFP. )I NOTE: Named Insured must be extended to include the various Leasing companies with whom Monro County contracts with. If the lease requires "Split Limits", the policy must be endorsed to satisfy the leas requirements. I The County's Risk Administer in cooperation with the County's legal staff administers all claims that fall within its self insured retention. Retaining this practice will be a critical factor in the evaluation of the proposals received. r-• F I q tll� W III IN I I 37 of 107 PUBLIC OFFICIALS LIABILITY AND EMPL0YMEt-LE2JCMCff&LbMUJL-j,, The form should provide coverage for actual or alleged wrongful acts of public officials, includin negligence, errors and omissions, breaches of duty, misfeasance, malfeasance and nonfeasance, an, include members of the Monroe County Board of County Commissioners, and all elected or appointei officers including employees, volunteers and any individual or organization required by statUtE agreement, contract or lease or other circumstances including all existing boards, committees and thei members and all newly created boards, committees and their members during the term of the policy. Coverage must also include as insureds, the constitutional officers of: WTA 2 FM ro - S_11j!Lq0&MW*] OR RN TO! Himi kyj _. , . 0 Coverage should include violation of civil rights, sexual harassment, claims seeking non -monetary relief claims involving dismissal or demotion, failure to hire or promote; other employment related claims anc intentional acts. The County's current Public Officials Liability program includes Employment Practices Liability insurance A separate policy will be considered and acceptable to the extent the desired coverages are provided. Coverage should include indemnification of individuals included above and expenses to the exten- permitted by law. If a Claims Made form is to be utilized, a pre -agreed Extended Reporting Endorsement is requested at a pre -determined premium. Mir=; Alternative Limits and Deductible options will be evaluated based on cost and the adequacy of protecti that is being offered to the County. I • • •- • • Umdnlff�flt rim: ••_ no• •• • • - iunty's Risk Administer in cooperation•legal administers within its self insured retention. Retaining this practice will be a critical factor in the evaluation of the proposals '•' 39 of 107 The form should provide standard workers compensation coverages that complies with Florida Statute Ch. 440. While the County currently purchases Excess coverage, the cost effectiveness of converting th program to a "Large Deductible" or other more traditional insurance will also be considered. Propose rl are encouraged to submit alternative structures to the County's current program. ',T,Vhile the County's current program does not contain an "Aggregate Stop Loss", such a feature would b viewed as a favorable enhancement. I • 1- *♦ M 11 0 RI-10116yu NFI-14111 REH 9�� -'§ 1/1 1A6111f If specific limits are proposed for Workers' Compensation, they should be clearly stated within thz -troposal r- I'MMM rorammi The County currently contracts with Ascension Benefits & Insurance Solutions located in Stuart, Florid as their Third Party Claims Administrator (TPA). The County desires to retain Ascension as their TPA. Al proposals must clearly indicate that Ascension is acceptable to the insurer submitting the proposal Proposals that do not indicate Ascension is an acceptable TPA or state that Ascension is unacceptable t the insurer will be eliminated from further consideration. I y I I A. Projected payrolls by Workers' Compensation classification codes B. Copy of the County's Drug Free Work Place policy statement Narrative descriptions of losses for past 5 years with Incurreds in excess of $50,000 D. Current Valued Loss Runs E. Additional Underwriting Information To assist interested proposers in their initial evaluation efforts the following table displays the historica experience of the County's program valued as of March 31, 2014. 1 40 of 107 0 11 C Y Year---' No. of Paid to Da --- t --- e-I-Open Reserves Total I Claims IncurredP �r• r Medical Only � r rA lot Medical Only MOTION •• Medical Only Medical V#1 Ki E, Medical In • •. - • • • classificationThe County desires that the successful Proposer fully understands its operations and that the curren codes • • accepted • : the full policy • • any subsequent payroll audits. County thoroughly reviewed each employee function, resulted in the current : •. . schedule. Proposers invited to pre -inspect •. : operations prior to providing • proposal •: to . • r a. or the classification to avoid potential conflict in payroll allocation upon audit. 41 of 107 n The County currently utilizes Ascension Benefits & Insurance Solutions to administer all claims that fall within its self insured retention. Retaining Ascension as the County's TPA will be a critical factor in the • • the proposals received. The County's current financial statements can be obtained from its web -site at: http://www.monroecounty-fl.00v/ArchiveCenterNiewFile/Item/1613 42 of 107 a►- ♦rr - a a • a 43 of 107 MOT Proposal Forms must be completed and submitted with each proposal. All respondents must complet( this general proposal form in addition to a separate proposal for each coverage proposed. Additiona information can be attached to the forms. Public Official Liability and Employment Practices Liability Excess Workers' Compensation TIVATITATIM "IMT, a Fee basis? ME= Yes No 44 of 107 Is Agent/Broker licensed in the State of Florida for the type of coverage proposed? Yes No Are coverages different from requested program? Yes — No If so, state differences Effective date(s) of coverage(s)? Describe payment plan, including down payment terms, interest or service charges. Proposal valid until (date)? Rate Change/Policy Modification wording included as requested? Yes No Termination Notice wording included as requested? Yes - No I If not, state wording :01 Yes No 45 of 107 reportsClaim • be provided -• -d If not, state details. Will the County retain the right to investigate and adjust their Liability claims within its self -insured retention? Yes No WIII the County be able to retain Ascension Benefits & Insurance Solutions as their Workers' Compensation Third Part Claims Administer? Yes No Will Insurers adjust claims exceeding the County's retention? Yes No WIII the County retain the right to select defense counsel? Yes No Provide details on specialized loss control services to be provided. m■� The Proposer stated below is the authorized agent of the company or companies proposed, and i., authorized to bind coverages upon acceptance by Monroe County, Florida. Deviations from the requeste( program have been stated. Coverage will be issued as proposed. The insurer agrees to deliver C' policy(ies) to the insured within forty-five (45) days after inception of coverages. It is agreed that polic) premiums will be payable upon receipt by insured of complete policy conforming with the accepte(' proposal. *7 0 TOM M. I 47 of 107 Ly, Company Underwriting office used Address • FORMS GENERAL LIABILITY Telephone number Current A.M. Best Co. rating? Is policy form and all endorsements included for review? Yes No Are the following coverages included? Premises and Operations Yes No Independent Contractors Yes No Products/Completed Operations Yes No Blanket Contractual Yes No (all related contracts included?) Yes No (any reporting requirements?) Yes No Personal Injury Liability Yes No Employee Benefits Liability Yes No Medical Attendants'/Medical Director Malpractice Yes No Discrimination and Civil Rights Liability Yes No Broad Form Property Damage Yes No Are all Coverages provided on an Occurrence Basis?Yes No If not, which Coverages are provided on a Claims Made Basis? Please provide the proposed Retroactive Date for all coverages provided on a Claims Made Basis. Are defense costs included in the aggregate limit of liability? Yes No Isrequested Named Insured wording used? Yes No If not, stated wording to be used Deductible ---------------------- Annual Premium/Fee Insurers Option All Taxes, Fees and Assessments Proposed Agent Annual Fee if Coverages are Proposed on a "Net of Commission" Basis 5U,he above premium subject to audit? Yes If so, on what terms? ProposerThe • below is the authorized agent of • • or • 'a proposed, •' is authorized to bind coverages upon acceptance by Monroe County. Deviations from the requested program have been stated. Coverage will be issued as proposed. The insurer agrees to deliver a policy(ies) to the insured within forty-five (45) days after inception of coverages. It is agreed that policy premiums will be payable upon receipt by insured of complete policy conforming with the accepted • op 7M 50 of 107 n TIT REQUEST FOR PROPOSALS PROPOSAL FORMS VEHICLE LIABILITY AND Pyysic,4L D4v4GE I Company Underwriting office used Address Telephone number Current A.M. Best Co. rating? Is policy form and all endorsements included for review? Which coverage symbols are proposed for: Liability? No -Fault Benefits? Physical Damage? Are defense costs included in the aggregate limit of liability? Yes No 51 of 107 LiMITS/ PREMIUMS Deductible Annual Premium Requested Coverage W I nsurers Option All Taxes, Fees and Assessments moo. WN 1111amia-ZiUMMOVIUVIO I Mill lVeductible Premium The Proposer stated below is the authorized agent of the company or companies proposed, and i authorized to bind coverages upon acceptance by Monroe County. Deviations from the requestel program have been stated. Coverage will be issued as proposed. The insurer agrees to deliver policy(ies) to the insured within forty-five (45) days after inception of coverages. It is agreed that polic premiums will be payable upon receipt by insured of complete policy conforming with the accepte: proposal. Signature of Authorized Representative Date Wmm 23• = REQUEST FOR PROPOSALS PROPOSAL FORMS PUBLIC OFFICIALS LIABILITY AND -6.MPLOYMENT PRACTICES LiABILI-4 c 111,� L c I roploymenr t-racticeS Liability proposals are offered, pleas -a complete separate forms for each coverage. Company Underwriting office used Address Telephone number Current A.M. Best Co. rating? Is policy form and all endorsements included for review? Does coverage extend to: Board of County Commissioners? Elected Officials? Appointed Officers? Employees? Volunteers? 9M Yes Yes Yes No No 53 of 107 MM What retrospective date is being offered? If so, provide details and cost Are defense costs included in the aggregate limit of liability? Yes No Is requested Named Insured wording used? Yes No If not, stated wording to be used LiMITS/PREMIUMS Deductible Annual Premium M -MI MRMONT#= All Taxes, Fees and Assessments Proposed Agent Annual Fee if Coverages are Proposed on a "Net of Commission" Basis 54 of 107 The Proposer stated below is the authorized agent of the company or companies proposed, and 1; authorized to bind coverages upon acceptance by Monroe County. Deviations from the requestel program have been stated. Coverage will be issued as proposed. The insurer agrees to deliver - policy(ies) to the insured within forty-five (45) days after inception of coverages. It is agreed that polic, premiums will be payable upon receipt by insured of complete policy conforming with the accepte(' proposal. I 55 of 107 Telephone Number Current A. M. Best Co. rating Does the County • • it • Is requested policy formproposed? If not, • Is a VoluntaryCompensation Endorsement included? Is an All States • •rsement included What experience • • i used developing this • •p Does insurer agree to the current classificationschedule? Is Excess Insurance Proposed? If •specify• Is a Large Deductible Program Proposed? If • specifythe deductible. �s an Alternative Program Proposed? If • provide detailsof the program. Yes Yes No No Yes Yes No No Yes Yes No No Yes No Yes No 56 of 107 UMEWEENZO D• proposing insurer view Employers Mutual Inc. (EMI) as an acceptable TPA ? Yes LIMITS/PREMIUMS 0 Retention Annual Premium $500,000 Employers • $1,000,000 Proposed Agent Annual Fee if Coverages are Proposed on a "Net of Commission" Basis M U The Proposer stated below is the authorized agent of the company or companies proposed, and ic authorized to bind coverages upon acceptance by Monroe County. Deviations from the requestec program have been stated. Coverage will be issued as proposed. The insurer agrees to deliver E policy(ies) to the insured within forty-five (45) days after inception of coverages. It is agreed that policl premiums will be payable upon receipt by insured of complete policy conforming to the accepted proposal, Signature of Authorized Representative Date 57 of 107 Irl DEVELOPMENT OF PROPOSALS [This page intentionally left blank, with forms to follow.] 58 of 107 59 of 107 T, s- - •r • • 60 of 107 VEHICLE SCHEDULE AS 1! P .>2014 Vehicle Serial City # Model Make Cost Description Comp Coll New 1 2702 00-898 1995 FORD 13,001.00 F150 PICKUP 1000 1000 2 7689 03-709 1995 FORD 13,001.00 F150 PICKUP 1000 1000 3 8822 03-737 1986 FORD 9,500.00 DUMP TRUCK 1000 1000 4 0557 10-063 1995 FORD 13,001.00 F150 PICKUP 1000 1000 5 2219 20-435 1990 CHEVROLET 15,913.00 CREW CAB 1000 1000 6 2610 05-093 1986 FORD 9,439.00 VAN 1000 1000 7 4420 05-12-3 1989 FORD 0.00 4-DR n/a n/a 8 7077 02-479 1987 GMC 0.00 PICKUP n/a n/a 9 1555 03-825 1992 CHEVROLET 0.00 PICKUP n/a n/a 10 0251 40-363 1994 FORD 52,950.00 DUMP TRUCK 1000 1000 11 2954 40-364 1994 FORD 0.00 PICKUP n/a n/a 12 0215 40-413 1995 FORD 37,000.00 DUMP TRUCK 1000 1000 13 3720 40-251 1990 CHEVROLET 0.00 PICKUP n/a n/a 14 4092 41-391 1994 FORD 41,419.00 DUMP TRUCK 1000 1000 15 4147 40-320 1991 FORD 0.00 STAKE BODY n/a n/a 16 7685 40-396 1995 FORD 0.00 F150 PICKUP n/a n/a 17 6863 44-030 1983 FORD 0.00 OIL TRUCK n/a n/a 18 6673 40-417 1981 FORD 0.00 PICKUP n/a n/a 19 8474 07-075 1994 FORD 36,000.00 ELDORADO BUS 1000 1000 20 3006 06-003 1989 FORD 0.00 10 PASSENGER VAN n/a n/a 21 8475 07-076 1994 FORD 36,000.00 ELDORADO BUS 1000 1000 22 2024 07-066 1992 FORD 38,000.00 12 PASSENGER VAN 1000 1000 23 8385 07-081 1994 FORD 38,000.00 ELDORADO BUS 1000 1000 24 7373 07-068 1992 FORD 38,000.00 12 PASSENGER VAN 1000 1000 25 8384 07-082 1994 FORD 36,000.00 ELDORADO BUS 1000 1000 26 7664 17-004 1994 FORD 38,500.00 12 PASSENGER VAN 1000 1000 27 3005 06-002 1989 FORD 0.00 10 PASSENGER VAN n/a n/a 28 1194 07-094 1996 FORD 41,000.00 ELDORADO BUS 1000 1000 29 0873 13-039 1992 FORD 0.00 NAVISTAR AMBULANCE n/a n/a 30 7462 13-036 1992 FORD 0.00 AMBULANCE n/a n/a 31 3472 602-15 1993 FORD 0.00 AMBULANCE n/a n/a 32 8400 13-037 1991 FORD 0.00 AMBULANCE n/a n/a 33 1819 19-061 1994 FORD 0.00 AMBULANCE n/a n/a 34 1163 12-036 1989 FORD 0.00 AMBULANCE n/a n/a 35 8040 16-080 1997 FORD 0.00 SUPER DUTY AMBULANCE n/a n/a 36 3413 39-195 1990 E-ONE 0.00 PUMPER n/a n/a 37 2127 39-281 1994 SOUTHERN 0.00 FIRE TRUCK n/a n/a 61 Of 107 gi i WTURI SCHEDULEVEHICLE AS 1 . , Vehicle Serial City # Model Make Cost Description Comp Coll New 38 7111 31-070 1986 CHEVROLET 0.00 PUMPER n/a n/a 39 6578 31-017 1981 SLSBRY 0.00 TK/PUMPER n/a n/a 40 8070 32-216 1989 SIMON-DUPLEX 0.00 PUMPER n/a n/a 41 6579 32-042 1981 SLSBRY 0.00 TK/PUMPER n/a n/a 42 6580 34-061 1981 SLSBRY 0.00 TK/PUMPER n/a n/a 43 5763 40-177 1992 FORD 0.00 RESCUE n/a n/a 44 3415 40-166 1990 E-ONE 0.00 PUMPER n/a n/a 45 6561 37-361 1992 SLSBRY 0.00 HOSE REEL n/a n/a 46 5676 37-300 1988 SPARTAN 0.00 RES. PUMPER n/a n/a 47 3212 08-223 1975 CHEVROLET 0.00 RESCUE TRUCK n/a n/a 48 7849 01-297 1997 CHEVROLET 0.00 S-10 TRUCK n/a n/a 49 9874 00-128 1985 FORD 0.00 PICKUP n/a n/a 50 6442 03-480 1988 CHEVROLET 0.00 VAN n/a n/a 51 6154 03-657 1993 FORD 0.00 F150 PICKUP n/a n/a 52 6155 10-053 1993 FORD 0.00 F150 PICKUP n/a n/a 53 1133 03-800 1988 CHEVROLET 0.00 PICKUP n/a n/a 54 3435 14-014 1988 GMC 0.00 VAN n/a n/a 55 2051 05-041 1990 FORD 0.00 AEROSTAR VAN n/a n/a 56 1653 05-064 1990 FORD 0.00 AEROSTAR VAN n/a n/a 57 7680 02-441 1987 DODGE 0.00 VAN n/a n/a 58 7499 00-070 1992 FORD 0.00 TAURUS n/a n/a 59 3127 01-462 1991 FORD 0.00 TEMPO n/a n/a 60 6916 05-021 1988 DODGE 0.00 ARIES n/a n/a 61 4103 40-507 1990 NISSAN 0.00 PICKUP n/a n/a 62 0337 05-072 1992 DODGE 0.00 DYNASTY n/a n/a 63 8255 05-074 1993 DODGE 0.00 DYNASTY n/a n/a 64 0772 00-031 1987 TOYOTA 0.00 PICKUP n/a n/a 65 1596 03-694 1994 DODGE 0.00 B150 VAN n/a n/a 66 1594 03-696 1994 DODGE 0.00 B150 VAN n/a n/a 67 2958 20-434 1994 FORD 0.00 PICKUP n/a n/a 68 2959 40-366 1994 FORD 0.00 PICKUP n/a n/a 69 7690 01-170 1995 FORD 0.00 F150 PICKUP n/a n/a 70 4163 00-151 1995 FORD 0.00 8 PASSENGER VAN n/a n/a 71 0031 01-177 1995 FORD 0.00 E150 VAN n/a n/a 72 0032 03-174 1995 FORD 0.00 E150 VAN n/a n/a 73 7687 10-061 1995 FORD 0.00 F150 TRUCK n/a n/a VEHICLE SCHEDULE AS OF Vehicle Serial City # Model Make Cost Description Comp Coll New 74 0400 01-497 1995 FORD 0.00 TAURUS n/a n/a 75 2953 03-682 1994 TBD 0.00 PICKUP n/a n/a 76 6222 01-055 1988 CHEVROLET 0.00 PICKUP n/a n/a 77 8273 01-184 1989 FORD 0.00 E350 VAN n/a n/a 78 6007 01-169 1991 FORD 0.00 F150 PICKUP n/a n/a 79 0509 01-188 1989 FORD 0.00 4 DOOR n/a n/a 80 0495 01-190 1989 FORD 0.00 4 DOOR n/a n/a 81 0498 01-191 1989 FORD 0.00 4 DOOR n/a n/a 82 1113 01-192 1990 CHEVROLET 0.00 4 DOOR n/a n/a 83 1328 01-193 1990 CHEVROLET 0.00 4 DOOR n/a n/a 84 1591 01-194 1990 CHEVROLET 0.00 4 DOOR n/a n/a 85 0491 01-196 1989 FORD 0.00 4 DOOR n/a n/a 86 0595 01-200 1997 FORD 46,000.00 DUMP TRUCK 1000 1000 87 6471 01-225 1986 CHEVROLET 0.00 VAN n/a n/a 88 3615 01-219 1997 CHEVROLET 0.00 3500 CREW CAB PICKUP n/a n/a 89 8527 01-223 1988 CHEVROLET 0.00 CAPRICE n/a n/a 90 0566 01-212 1997 FORD 0.00 CROWN VICTORIA n/a n/a 91 0565 01-211 1997 FORD 0.00 CROWN VICTORIA n/a n/a 92 0675 00-098 1997 CHEVROLET 0.00 1500 PICKUP n/a n/a 93 4020 025638 1997 CHEVROLET 0.00 PICKUP n/a n/a 94 5109 03-860 1998 DODGE 0.00 3500 CREW CAB n/a n/a 95 7559 05-131 1990 FORD 0.00 AMBULANCE n/a n/a 96 0506 01-240 1989 FORD 0.00 CROWN VICTORIA n/a n/a 97 0493 01-242 1989 FORD 0.00 CROWN VICTORIA n/a n/a 98 2001 01-243 1990 CHEVROLET 0.00 CAPRICE n/a n/a 99 1361 01-245 1990 CHEVROLET 0.00 CAPRICE n/a n/a 100 2118 09-023 1998 CHEVROLET 0.00 ASTRO CARGO VAN n/a n/a 101 1019 417-14 1998 JEEP 0.00 CHEROKEE n/a n/a 102 4372 03-858 1998 DODGE 0.00 RAM PICKUP n/a n/a 103 5659 05-109 1998 FORD 0.00 TAURUS n/a n/a 104 5814 07-012 1998 FORD 0.00 TAURUS n/a n/a 105 8484 01-224 1991 FORD 0.00 ESCORT n/a n/a 106 4370 02-393 1998 DODGE 0.00 RAM PICKUP n/a n/a 107 5377 05-107 1998 FORD 0.00 TAURUS n/a n/a 108 7767 40-477 1998 CHEVROLET 23,707.00 PLATFORM TRUCK n/a n/a 109 8907 40-478 1998 CHEVROLET 23,707.00 PLATFORM TRUCK n/a n/a 110 9432 40-481 1998 CHEVROLET 24,203.00 CHS-CAB TRUCK n/a n/a VEHICLEI AS OF . , 219 2014 Vehicle Serial City # Model Make Cost Description Comp Coll 111 0324 40-482 1998 GMC New 23,091.00 STAKE BODY TRUCK n/a n/a 112 4369 02-392 1998 DODGE 0.00 RAM PICKUP n/a n/a 113 8337 1989 CHEVROLET 0.00 CORSICA n/a n/a 114 1406 1989 CHEVROLET 0.00 CORSICA n/a n/a 115 1084 1988 GMC 0.00 VAN n/a n/a 116 4602 1984 TOYOTA 0.00 VAN n/a n/a 117 8420 1992 FORD 0.00 TAURUS n/a n/a 118 6472 1995 FORD 0.00 TYPE n/a n/a 119 5641 1994 FORD 0.00 TYPE AMBULANCE n/a n/a 120 6031 1988 CHEVROLET 0.00 VAN n/a n/a 121 5050 1990 FORD 0.00 RANGER n/a n/a 122 4763 1987 CHEVROLET 0.00 PICKUP n/a n/a 123 4236 1989 CHEVROLET 0.00 CELEBRITY n/a n/a 124 9738 1981 T-G OSHKOSH 0.00 FIRE TRUCK n/a n/a 125 7375 180706 1992 FORD 38,000.00 12 PASSENGER VAN 1000 1000 126 9845 901162 1992 DODGE 0.00 CARAVAN n/a n/a 127 0358 3-001 1981 SLSBRY 0.00 FIRETRUCK n/a n/a 128 4431 1-313 1998 OSHKOSH 311,780.00 FIRE TRUCK 1000 1000 129 5629 6-192 1992 FORD 0.00 AMBULANCE n/a n/a 130 5642 906-3 1994 FORD 0.00 AMBULANCE n/a n/a 131 6262 0-059 1982 FORD 38,000.00 DUMP TRUCK 1000 1000 132 963D 40-322 1981 ELGIN 0.00 STREET SWEEPER n/a n/a 133 4443 40-110 1984 FORD 0.00 TRUCK n/a n/a 134 2777 40-384 1995 FORD 53,225.00 DUMP TRUCK 1000 1000 135 1633 00-035 1989 CHEVROLET 0.00 DUMP TRUCK n/a n/a 136 0825 3-516 1989 CHEVROLET 0.00 DUMP TRUCK n/a n/a 137 0048 0-026 1988 CHEVROLET 0.00 PICKUP n/a n/a 138 4802 3-689 1987 CHEVROLET 0.00 TRUCK n/a n/a 139 3227 0-647 1985 CHEVROLET 0.00 TRUCK n/a n/a 140 6445 0-564 1984 CHEVROLET 34,000.00 TRUCK 1000 1000 141 1652 1-078 1991 FORD 0.00 HERO VAN n/a n/a 142 1967 0-252 1990 CHEVROLET 0.00 TRUCK n/a n/a 143 2108 0-255 1990 CHEVROLET 0.00 TRUCK n/a n/a 144 3718 0-253 1990 CHEVROLET 0.00 PICKUP n/a n/a 145 9649 0-339 1992 CHEVROLET 0.00 PICKUP n/a n/a 146 1656 4-005 1983 FORD 0.00 OIL TRUCK n/a n/a 64 of 107 ! # #,u SCHEDULEVEHICLE AS OF APR 2014 Vehicle Serial City # Model Make Cost Description Comp Coll New 147 2960 0-368 1994 FORD 0.00 PICKUP n/a n/a 148 0965 0-447 1997 CHEVROLET 0.00 1500 TRUCK n/a n/a 149 9781 7-002 1993 CARGO 0.00 VAN n/a n/a 150 4285 3-486 1986 FORD 0.00 PICKUP n/a n/a 151 4726 0-038 1989 CHEVROLET 0.00 S10 PICKUP n/a n/a 152 1632 0-039 1989 CHEVROLET 0.00 S10 PICKUP n/a n/a 153 1989 -093 1992 CHEVROLET 0.00 PICKUP n/a n/a 154 0451 0-95 1992 CHEVROLET 0.00 PICKUP n/a n/a 155 8478 0-428 1992 CHEVROLET 0.00 PICKUP n/a n/a 156 7110 1-444 1990 PLYMOUTH 0.00 VOYAGER VAN n/a n/a 157 2182 5-041 1989 CHEVROLET 0.00 PICKUP n/a n/a 158 4827 5-053 1990 NISSAN 0.00 PICKUP n/a n/a 159 3256 3-679 1989 CHEVROLET 0.00 PICKUP n/a n/a 160 2950 0-055 1994 FORD 0.00 PICKUP n/a n/a 161 6156 20-432 1993 FORD 0.00 TRUCK n/a n/a 162 3559 1-165 1984 GMC 0.00 STEP VAN n/a n/a 163 0033 3-175 1995 FORD 0.00 E150 VAN n/a n/a 164 8644 5-024 1982 FORD 0.00 TRUCK n/a n/a 165 9839 1-115 1985 DODGE 0.00 PICKUP n/a n/a 166 5708 1-183 1990 FORD 0.00 E350 VAN n/a n/a 167 3550 1-220 1997 CHEVROLET 0.00 3500 CREW CAB PICKUP n/a n/a 168 4162 2-467 1992 CHEVROLET 0.00 CARGO VAN n/a n/a 169 7004 LEASED 1997 CHEVROLET 0.00 ASTRO VAN n/a n/a 170 7460 LEASED 1997 GMC 0.00 SONOMA TRUCK n/a n/a 171 3009 6-006 1989 FORD 24,800.00 VAN n/a n/a 172 6916 7-069 1993 FORD 38,000.00 12 PASSENGER VAN 1000 1000 173 3964 -111 1998 ELDORADO 44,302.00 NATIONAL BUS 1000 1000 174 1439 11-031 1993 CHEVROLET 0.00 CORSICA n/a n/a 175 7594 0-905 1994 FORD 0.00 TEMPO n/a n/a 176 9366 0-912 1994 CHEVROLET 0.00 CORSICA n/a n/a 177 4751 0-862 1991 FORD 0.00 ESCORT n/a n/a 178 5014 -090 1992 FORD 0.00 TEMPO n/a n/a 179 5812 -171 1998 FORD 0.00 TAURUS n/a n/a 180 0338 5-073 1992 DODGE 0.00 DYNASTY n/a n/a 181 8673 15-054 1992 FORD 0.00 TAURUS n/a n/a 182 8254 15-067 1993 DODGE 0.00 DYNASTY n/a n/a 183 4861 5-108 1998 FORD 0.00 TAURUS n/a n/a 65 of 107 VEHICLE SCHEDULE AS 1 1 1 R> 2014 Vehicle Serial City # Model Make Cost Description Comp Coll New 184 9439 7-087 1991 FORD 0.00 TEMPO n/a n/a 185 0662 1-180 1985 CHEVROLET 0.00 CELEBRITY n/a n/a 186 9411 3-690 1985 CHEVROLET 0.00 CAVALIER n/a n/a 187 6721 1-538 1993 FORD 0.00 TAURUS n/a n/a 188 7742 1-230 1990 FORD 0.00 TAURUS n/a n/a 189 4467 1-199 1988 FORD 0.00 CROWN VICTORIA n/a n/a 190 0559 1-254 1990 JEEP 0.00 EAGLE n/a n/a 191 1776 1-244 1990 CHEVROLET 0.00 CAPRICE n/a n/a 192 9643 1-247 1989 PONTIAC 0.00 4 DOOR n/a n/a 193 0988 1-253 1989 CHEVROLET 0.00 CORSICA n/a n/a 194 2053 1-261 1990 CHEVROLET 0.00 CAPRICE n/a n/a 195 2380 1-262 1990 CHEVROLET 0.00 CAPRICE n/a n/a 196 8516 1-263 1991 CHEVROLET 0.00 CAPRICE n/a n/a 197 8650 1-264 1991 CHEVROLET 0.00 CAPRICE n/a n/a 198 9606 1-266 1992 FORD 0.00 CROWN VICTORIA n/a n/a 199 8657 LEASED 1997 CHEVROLET 0.00 LUMINA n/a n/a 200 5943 LEASED 1998 CHEVROLET 0.00 LUMINA n/a n/a 201 3754 LEASED 1996 FORD 0.00 TAURUS n/a n/a 202 9319 LEASED 1996 FORD 0.00 TAURUS n/a n/a 203 1126 LEASED 1998 MERCURY 0.00 SABLE n/a n/a 204 2687 3-852 1998 FORD 24,800.00 E150 CARGO VAN 1000 1000 205 1027 3-1058 2001 DSE 0.00 8 PASSENGER GOLFCART n/a n/a 206 0581 3-1707 2005 FORD 0.00 F150 n/a n/a 207 0576 0-1706 2005 FORD 0.00 F150 n/a n/a 208 0575 0-1703 2005 FORD 0.00 F150 n/a n/a 209 0580 3-1699 2005 FORD 0.00 F150 n/a n/a 210 0579 3-1698 2005 FORD 0.00 F150 n/a n/a 211 8799 3-1701 2005 FORD 0.00 E250 VAN n/a n/a 212 1133 3-1700 2005 FORD 0.00 E250 VAN n/a n/a 213 8436 0-1704 2005 FORD 0.00 E250 VAN n/a n/a 214 8437 3-1697 2005 FORD 0.00 E250 VAN n/a n/a 215 0578 0-1702 2005 FORD 0.00 F150 n/a n/a 216 0652 0-1695 2005 FORD 0.00 FREESTAR WAGON n/a n/a 217 0577 32-097 2005 FORD 0.00 F150 n/a n/a 218 4354 00-967 2004 CHEVROLET 0.00 VENTURA n/a n/a 219 6983 0-3197 2005 FORD 0.00 F150 PICKUP n/a n/a 220 1830 00-940 2003 CHEVROLET 0.00 S10 n/a n/a VEHICLE •r r AS OF Ar t 2014 Vehicle Serial City # Model Make Cost Description Comp Coll New 221 5532 0-4510 2005 FORD 0.00 EXPLORER n/a n/a 222 5531 0-4511 2005 FORD 0.00 EXPLORER n/a n/a 223 6022 0-4896 2005 FORD 0.00 F150 PICKUP n/a n/a 224 6019 1-4895 2005 FORD 0.00 F150 PICKUP n/a n/a 225 6023 1-4925 2005 FORD 0.00 F150 PICKUP n/a n/a 226 6020 2-4926 2005 FORD 0.00 F150 PICKUP n/a n/a 227 6021 2-4927 2005 FORD 0.00 F150 PICKUP n/a n/a 228 6329 44889 2005 FORD 0.00 F150 PICKUP n/a n/a 229 9153 0-4973 2006 FORD 0.00 ECONOLINE n/a n/a 230 3968 70-222 2004 FORD 0.00 F800 CLAM TRUCK n/a n/a 231 1150 405130 2006 MACK 58,942.00 ROAD TRACTOR 1000 1000 232 1149 405129 2006 MACK 58,942.00 ROAD TRACTOR 1000 1000 233 1148 405128 2006 MACK 58,942.00 ROAD TRACTOR 1000 1000 234 7958 005141 2006 FORD 12,838.00 E250 1000 n/a 235 3632 405176 2006 MACK 58,643.00 DUMP TRUCK 1000 1000 236 3631 405175 2006 MACK 58,643.00 DUMP TRUCK 1000 1000 237 3630 405174 2006 MACK 58,643.00 DUMP TRUCK 1000 1000 238 3629 405173 2006 MACK 92,794.00 DUMP TRUCK 1000 1000 239 7871 055142 2006 FORD 0.00 E250 n/a n/a 240 3938 77KW90 2006 FORD 55,690.00 TURTLE TOP PASS BUS 1000 1000 241 3061 405195 2006 INTERNATIONAL 240,763.00 VACTOR TRUCK 1000 1000 242 2683 405363 2006 FORD 14,663.00 F150 PICKUP 1000 n/a 243 2689 405362 2006 FORD 14,663.00 F150 PICKUP 1000 n/a 244 2681 405361 2006 FORD 14,663.00 F150 PICKUP 1000 n/a 245 2690 035360 2006 FORD 14,663.00 F150 PICKUP 1000 n/a 246 2684 205365 2006 FORD 14,663.00 F150 PICKUP 1000 n/a 247 2682 205369 2006 FORD 14,663.00 F150 PICKUP 1000 n/a 248 2687 705368 2006 FORD 14,663.00 F150 1000 n/a 249 2686 705367 2006 FORD 14,663.00 F150 PICKUP 1000 n/a 250 TBD 2005 FORD 40,769.00 F550 CREW CAB DUMP 1000 n/a 251 TBD 2005 FORD 39,099.00 F550 CREW CAB DUMP 1000 n/a 252 5747 2006 FORD 15,125.00 E150 8 PASSENGER VAN 1000 n/a 253 7020 2006 FORD 12,185.00 FOCUS 1000 n/a 254 1489 2006 FORD 15,113.00 E250 CARGO VAN 1000 n/a 255 1488 2006 FORD 13,643.00 E250 CARGO VAN 1000 n/a 256 6011 2006 FORD 11,378.00 F150 PICKUP 1000 n/a 67 of 107 i i W i #T-M VEHICLE SCHEDULE AS OF 1 1 R f.... Vehicle Serial City # Model Make Cost Description Comp Coll New 257 6014 2006 FORD 11,378.00 F150 PICKUP 1000 n/a 258 6015 2006 FORD 11,378.00 F150 PICKUP 1000 n/a 259 6012 2006 FORD 11,378.00 F150 PICKUP 1000 n/a 260 6010 2006 FORD 11,378.00 F150 PICKUP 1000 n/a 261 6005 2006 FORD 10,843.00 F150 PICKUP n/a n/a 262 6008 2006 FORD 21,686.00 F150 PICKUP 1000 n/a 263 6006 2006 FORD 10,843.00 F150 PICKUP 1000 n/a 264 TBD 2006 FORD 11,078.00 F150 PICKUP 1000 n/a 265 TBD 2006 FORD 11,378.00 F150 PICKUP 1000 n/a 266 TBD 2006 FORD 11,378.00 F150 PICKUP 1000 n/a 267 TBD 2006 FORD 10,843.00 F150 PICKUP 1000 n/a 268 2685 2006 FORD 11,378.00 F150 PICKUP n/a n/a 269 TBD 2006 FORD 39,879.00 F550 CREW CAB DUMP 1000 n/a 270 TBD 2006 FORD 11,078.00 F150 PICKUP 1000 n/a 271 TBD 2006 FORD 11,378.00 F150 PICKUP 1000 n/a 272 TBD 2006 FORD 17,260.00 F150 4X4 PICKUP 1000 n/a 273 TBD 2006 FORD 18,593.00 EXPLORER 1000 n/a 274 2813 005420 2006 FORD 29,224.00 EXPEDITION 1000 n/a 275 2812 165421 2006 FORD 29,224.00 EXPEDITION 1000 n/a 276 6063 2006 FORD 14,868.00 F150 PICKUP 1000 n/a 277 2688 2006 FORD 11,378.00 F150 PICKUP n/a n/a 278 6064 2006 FORD 14,868.00 F150 PICKUP 1000 n/a 279 1955 2006 CHEVROLET 16,970.00 UPLANDER VAN n/a n/a 280 2011 2006 FORD 12,185.00 FOCUS n/a n/a 281 6273 2006 FORD 38,879.00 E550 DUMP TRUCK 1000 n/a 282 6066 055474 2006 FORD 14,868.00 F150 PICKUP n/a n/a 283 6065 055472 2006 FORD 14,868.00 F150 PICKUP n/a n/a 284 6009 055473 2006 FORD 14,868.00 F150 PICKUP n/a n/a 285 4789 025476 2006 FORD 14,868.00 F150 PICKUP n/a n/a 286 4790 025475 2006 FORD 14,868.00 F150 PICKUP n/a n/a 287 9335 005523 2006 FORD 11,078.00 F150 PICKUP 1000 n/a 288 9333 005524 2006 FORD 11,078.00 F150 PICKUP 1000 n/a 289 9334 1-5534 2006 FORD 17,260.00 F-150 PICKUP 1000 n/a 290 0262 3-5535 2006 FORD 0.00 F-250 PICKUP n/a n/a 291 7572 015576 2006 FORD 0.00 EXPLORER n/a n/a 292 9208 005515 2006 FORD 0.00 EXPLORER n/a n/a 293 7305 035599 2006 FORD 24,076.00 F-250 1000 n/a VEHICLE SCHEDULE AS 1 Vehicle Serial City # Model Make Cost Description Comp Coll New 294 9097 015633 2006 FORD 17,260.00 F-150 n/a n/a 295 8965 005637 2007 FORD 0.00 TAURUS n/a n/a 296 9500 025638 2006 FORD 0.00 E-150 n/a n/a 297 7571 005639 2006 FORD 24,252.00 EXPLORER 1000 n/a 298 9806 005656 2007 FORD 0.00 TAURUS n/a n/a 299 1052 195655 2006 FORD 0.00 EXPLORER n/a n/a 300 5335 005684 2007 FORD 0.00 TAURUS n/a n/a 301 4408 705131 2007 FORD 0.00 F350 PICKUP n/a n/a 302 6031 205799 2007 FORD 0.00 F550 PICKUP n/a n/a 303 6030 405800 2007 FORD 0.00 F550 PICKUP n/a n/a 304 1614 68MK70 2006 FORD 0.00 E150 VAN n/a n/a 305 0143 005458 2006 GMC 0.00 CANYON PICKUP n/a n/a 306 6820 705811 2007 STERLING 89,943.00 CLAM TRUCK 1000 1000 307 2686 705368 2006 FORD 0.00 PICKUP n/a n/a 308 9527 005852 2006 CHEVROLET 0.00 IMPALA n/a n/a 309 8056 035616 2006 WILDWOOD 10,800.00 TRAVEL TRAILER n/a n/a 310 8030 035017 2006 WILDWOOD 10,800.00 TRAVEL TRAILER n/a n/a 311 7961 035618 2006 WILDWOOD 10,800.00 TRAVEL TRAILER n/a n/a 312 8167 035619 2006 WILDWOOD 10,800.00 TRAVEL TRAILER n/a n/a 313 7963 035620 2006 WILDWOOD 10,800.00 TRAVEL TRAILER n/a n/a 314 1843 005624 2005 MALLARD 22,600.00 TRAVEL TRAILER n/a n/a 315 1846 005625 2005 MALLARD 22,600.00 TRAVEL TRAILER n/a n/a 316 2439 005088 2005 CARGO 0.00 TRAILER n/a n/a 317 8110 015861 2007 CHEVROLET 0.00 MALIBU n/a n/a 318 4658 005865 2007 CHEVROLET 0.00 MALIBU n/a n/a 319 2081 055864 2007 CHEVROLET 0.00 MALIBU n/a n/a 320 1310 055863 2007 CHEVROLET 0.00 MALIBU n/a n/a 321 9505 055862 2007 CHEVROLET 0.00 MALIBU n/a n/a 322 9612 205871 2007 FORD 0.00 F-150 PICKUP n/a n/a 323 7800 205870 2007 FORD 0.00 F-150 PICKUP n/a n/a 324 7799 405869 2007 FORD 0.00 F-150 PICKUP n/a n/a 325 7798 035867 2007 FORD 0.00 F-150 PICKUP n/a n/a 326 7797 035866 2007 FORD 0.00 F-150 PICKUP n/a n/a 327 7808 015874 2007 FORD 0.00 F-150 PICKUP n/a n/a 328 7807 015873 2007 FORD 0.00 F-150 PICKUP n/a n/a 329 9613 025877 2007 FORD 0.00 F-150 PICKUP n/a n/a 330 7805 015868 2007 FORD 0.00 F-150 PICKUP n/a n/a II i i ' !1 VEHICLEN AS OF i / 1. 4 Vehicle Serial City # Model Make Cost Description Comp Coll New 331 7806 055872 2007 FORD 0.00 F-150 PICKUP n/a n/a 332 7804 035876 2007 FORD 0.00 F-150 PICKUP n/a n/a 333 7803 405884 2007 FORD 0.00 F-150 PICKUP n/a n/a 334 7802 005883 2007 FORD 0.00 F-150 PICKUP n/a n/a 335 3955 5MK110 2007 GM 60,583.00 TURTLE TOP 11 PASS 1000 1000 336 7920 005910 2007 DODGE 0.00 CARAVAN n/a n/a 337 7921 005909 2007 DODGE 0.00 CARAVAN n/a n/a 338 5505 035916 2007 CHEVROLET 0.00 MALIBU n/a n/a 339 3538 015921 2007 FORD 0.00 EXPLORER n/a n/a 340 8242 035922 2008 FORD 0.00 F350 PICKUP n/a n/a 341 6338 095920 2007 FORD 0.00 FOCUS n/a n/a 342 9700 005924 2007 FORD 0.00 F150 PICKUP n/a n/a 343 2586 5970 2007 HALLMARD 229,863.00 FIRE APPARTOS 1000 1000 344 0606 6037 2007 CHEVROLET 0.00 COBALT n/a n/a 345 2668 6082 2007 GM 74,988.00 17 PASS BUS 1000 1000 346 2713 6036 2007 CHEVROLET 0.00 COBALT n/a n/a 347 1217 6079 2007 CHEVROLET 0.00 COBALT n/a n/a 348 3397 706054 2007 STERLING 115,841.00 ROLL OFF 1000 1000 349 0413 6073 2008 FORD 0.00 FOCUS n/a n/a 350 0414 6074 2008 FORD 0.00 FOCUS n/a n/a 351 0412 6075 2008 FORD 0.00 FOCUS n/a n/a 352 4864 400001 1999 OLDSMOBILE 0.00 INTRIGUE n/a n/a 353 2073 5806 2007 STERLING 0.00 AMBULANCE n/a n/a 354 2511 5098 2006 STERLING 0.00 AMBULANCE n/a n/a 355 3365 416208 2001 FORD 0.00 AMBULANCE n/a n/a 356 6187 405951 2007 FORD 0.00 F150 PICKUP n/a n/a 357 6989 976059 1990 MACK 0.00 DUMP TRUCK n/a n/a 358 1158 976059 1997 FORD 0.00 CLAM TRUCK n/a n/a 359 2813 005420 2006 FORD 0.00 EXPEDITION n/a n/a 360 9493 5502 2006 FORD 0.00 CROWN VICTORIA n/a n/a 361 0515 6253 2007 FORD 139,165.00 COMMAND UNIT 1000 1000 362 7545 006262 2008 FORD 0.00 RANGER n/a n/a 363 7546 006263 2008 FORD 0.00 RANGER n/a n/a 364 7887 6276 2007 PIERCE 374,864.00 PUMPER 1000 1000 365 7888 6277 2007 PIERCE 374,864.00 PUMPER 1000 1000 366 7621 6412 2008 NISSAN 0.00 VERSA n/a n/a 367 5420 6413 2008 NISSAN 0.00 VERSA n/a n/a 70 of 107 MIM SCHEDULEVEHICLE AS OF t r R 2014 Vehicle Serial City # Model Make Cost Description Comp Coll New 368 7950 6427 2008 FORD 0.00 EXPLORER n/a n/a 369 4587 6426 2008 FORD 0.00 ESCAPE n/a n/a 370 7505 6425 2008 FORD 0.00 ESCAPE n/a n/a 371 2235 6472 2008 NISSAN 0.00 VERSA n/a n/a 372 4962 6393 2007 FORD 0.00 CROWN VICTORIA n/a n/a 373 4983 6358 2007 FORD 0.00 CROWN VICTORIA n/a n/a 374 3042 6477 2008 FORD 0.00 ESCAPE n/a n/a 375 9118 6478 2008 FORD 0.00 RANGER n/a n/a 376 2517 6550 2008 FORD 0.00 FOCUS n/a n/a 377 6953 6395 2008 FORD 0.00 FOCUS n/a n/a 378 9321 6554 2008 TOYOTA 0.00 VAN n/a n/a 379 2517 6550 2008 FORD 0.00 FOCUS n/a n/a 380 9118 6426 2008 FORD 0.00 ESCAPE n/a n/a 381 3042 6425 2008 FORD 0.00 RANGER n/a n/a 382 7294 011841 2001 CHEVROLET 0.00 MALIBU n/a n/a 383 4756 011004 2002 DODGE 0.00 1500 PICKUP n/a n/a 384 4750 901532 2002 DODGE 0.00 1500 PICKUP n/a n/a 385 6538 031026 2003 FORD 0.00 F150 PICKUP n/a n/a 386 8242 035922 2008 FORD 0.00 F350 PICKUP n/a n/a 387 4755 940574 2002 DODGE 0.00 1500 PICKUP n/a n/a 388 8475 006293 2008 STERLING 133,558.00 BUCKET TRUCK 1000 1000 389 7249 1998 FORD 57,000.00 AEROTECH BUS 1000 1000 390 0377 6711 2009 NISSAN 0.00 SENTRA n/a n/a 391 7950 006427 2008 FORD 0.00 ESCAPE n/a n/a 392 3042 006477 200B FORD 0.00 ESCAPE n/a n/a 393 2517 006478 2008 FORD 0.00 FOCUS n/a n/a 394 0440 903821 1997 PACE AMERICAN 0.00 TRAILER n/a n/a 395 6189 405952 2007 FORD 0.00 CREW CAB n/a n/a 396 4762 001009 2002 DODGE 0.00 1500 PICKUP n/a n/a 397 0436 903003 2001 CHEVROLET 0.00 SILVERADO n/a n/a 398 0370 6728 2009 FORD 0.00 ESCAPE n/a n/a 399 4155 6729 2009 FORD 0.00 ESCAPE n/a n/a 400 9148 076761 2009 CHEVROLET 77,000.00 BUS 1000 1000 401 4735 410093 2003 FORD 0.00 F-150 n/a n/a 402 8467 6507 2008 NAVISTAR 179,298.00 AMBULANCE 1000 1000 403 7572 5576 2006 FORD 0.00 EXPLORER n/a n/a 404 8767 6798 2009 CHEVROLET 0.00 IMPALA n/a n/a 71 of 107 VEHICLE.l M AS OF APREL 21, 2014 Vehicle Serial City # Model Make Cost Description Comp Coll New 405 3131 6813 2009 FORD 0.00 E450 AMB n/a n/a 406 1211 6817 2010 FORD 0.00 FUSION n/a n/a 407 4654 6819 2010 FORD 0.00 F550 n/a n/a 408 9707 6816 2010 FREIGHTLINER 0.00 COM. TANKER n/a n/a 409 6745 200853 2002 FORD 0.00 RANGER n/a n/a 410 3426 6844 2010 NISSAN 0.00 VERSA n/a n/a 411 0438 6845 2009 FORD 118,995.00 AMBULANCE 1000 1000 412 1717 241115 2001 FORD 150,191.00 F-550 1000 1000 413 1905 6939 2010 HME 319,665.00 INTRUDER II 1000 1000 414 4478 6965 2010 NISSAN 0.00 SENTRA n/a n/a 415 5878 092070 2011 FORD 0.00 F350 n/a n/a 416 5877 090370 2011 FORD 0.00 F350 n/a n/a 417 7133 141470 2011 CHEVROLET 0.00 SILVERADO 2500 n/a n/a 418 3743 2001 GMC 24,800.00 SAVANA CARGO VAN 1000 1000 419 8320 100270 2011 FORD 22,415.00 F150 1000 1000 420 1690 320070 2011 FORD 22,415.00 F150 1000 1000 421 8755 100170 2011 FORD 0.00 FUSION n/a n/a 422 1949 044070 2011 FORD 58,685.00 F750 1000 1000 423 6528 094070 2011 FORD 28,740.00 F350 1000 1000 424 0346 094070 2011 FORD 28,740.00 F350 1000 1000 425 6344 097070 2011 FORD 0.00 ESCAPE n/a n/a 426 6345 097070 2011 FORD 0.00 ESCAPE n/a n/a 427 0402 01-088 1995 FORD 0.00 TAURUS n/a n/a 428 8333 140171 2011 FORD 0.00 F150 n/a n/a 429 6222 040071 2011 NISSAN 0.00 VERSA n/a n/a 430 7726 040071 2011 NISSAN 0.00 VERSA n/a n/a 431 4735 7126 2011 CHERVOLET 0.00 SILVERADO n/a n/a 432 0637 7148 2008 CHEVROLET 0.00 IMPALA n/a n/a 433 7592 100272 2012 FORD 0.00 FUSION HYBRID n/a n/a 434 7595 500072 2012 FORD 0.00 FUSION HYBRID n/a n/a 435 7593 300072 2012 FORD 0.00 FUSION HYBRID n/a n/a 436 7594 330072 2012 FORD 0.00 FUSION HYBRID n/a n/a 437 8265 0-7258 2012 FORD 33,240.00 F350 1000 1000 438 8491 07259 2012 FORD 29,555.00 F350 1000 1000 439 3264 7283 2012 FORD 0.00 EXPLORER WAGON n/a n/a 440 3263 7284 2012 FORD 0.00 EXPLORER WAGON n/a n/a 441 9988 7323 2012 CHEVROLET 0.00 SILVERADO n/a n/a 72 of 107 l ' I 1 1 ' 11 VEHICLEi ! AS F ApRm 219 2014 Vehicle Serial City # Model Make Cost Description New 442 7596 007333 2012 FORD 0.00 FUSION HYBRID 443 7602 007334 2012 FORD 0.00 FUSION HYBRID 444 0569 7338 2012 GMC 0.00 SIERRA 445 1125 7352 2013 FORD 0.00 TAURUS 446 1124 7353 2013 FORD 0.00 TAURUS 447 9980 007390 2012 NISSAN 0.00 VERSA 448 2984 053681 2000 CHEVROLET 0.00 IMPALA 449 5173 001560 1998 DODGE 0.00 MINI VAN 450 6142 007423 2013 FORD 0.00 TRANSIT 451 6144 007424 2013 FORD 0.00 TRANSIT 452 6143 007422 2013 FORD 0.00 TRANSIT 453 6141 007479 2013 FORD 0.00 ESCAPE 454 8493 7529 2013 CHEVROLET 0.00 SILVERADO 455 5896 7489 2013 FORD 0.00 F150 456 5897 7490 2013 FORD 0.00 F150 457 5898 7491 2013 FORD 0.00 F150 458 5899 7492 2013 FORD 0.00 F150 459 5900 7483 2013 FORD 0.00 F150 460 5901 7494 2013 FORD 0.00 F150 461 5902 7495 2013 FORD 0.00 F150 462 5903 7496 2013 FORD 0.00 F150 463 5904 7497 2013 FORD 0.00 F150 464 5905 7498 2013 FORD 0.00 F150 Comp Coil n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a 73 of 107 74 of 107 MONROE COUNTYFLORIDA VALUEDCURRENTLY 1',1 ! V!!, ! • VALUED AS OF ) 4 Claim Type Date of Injury Outstanding Reserve Sum Paid Sum Incurred Sum Claim Status Short Description of Accident M 10/8/2009 $0.00 $2 498.55 $2 498.55 C Mouth/Lip Left Upper): Claimant was putting toget M 10/1212009 $0.00 $489.04 $429.04 C Eye (Right): Eye Irritation and swelling from unkn M 10/14/2009 $0.00 $10.00 $10.00 C Lun s: Durina annual physical claimant tested posi M 10/15/2009 $0.00 $81.50 $81.50 C Eye (Left): Claimant went to pick up garba-ge and h M 10/1612009 $0.00 $1 763.22 $1 763.22 C Le RI ht : While doing an Inspection on Cook's I M 10/16/2009 $0.00 $275.19 $275.19 C Arm Left forearm): Claimant was clearin a site t M 10/20/2009 $0.00 $10.00 $10.00 C Lun s: Duringclaimants annual physical his TB tea BLT 10/21/2009 $15 458.91 $25 755.81 $41 214.72 O Shoulder (Right): Claimant was movin boxes from t M 10/2212009 $0.00 $116.50 $116.50 C Thumb (Left): Claimant was closing a folding table M 10/23/2009 $0.00 $10.00 $10.00 C Back (Lower): While claimant was waking and gettin M 10/26/2009 $0.00 $1 348.20 $1,348.20 C HI (Right), Knee (Right), Butt RI ht : Durino DT M 10/28/2009 $0.00 $87.00 $87.00 C Foot (Left): Claimant was Pryinq boards off of pla M 11/1/2009 $0.00 $361.42 $361.42 C Ankle Left Back (L2n!)-Body (Lon!)-Bodymusclespain: A V M 11/6/2009 $0.00 $5 629.34 $5 629.34 C Shoulder (Right): During defensive tactics doing d M 11/8/2009 $0.00 $423.50 $423.50 C Wris4 Inside Right): An Inmate was choking anothe M 11/9/2009 $0.00 $3 992.23 $3 992.23 C Shoulder Left Blade . During defensive tactics cl BLT 11/9/2009 $0.00 $24,112.41 $24,112.41 C Knee (Right): Claimant pulled tire off of truck an M 11/13/2009 $0.00 $402.42 $402.42 C ..Eye (Left): Claimant was weedeating and something M 11/1312009 $0.00 $3 327.02 $3 327.02 C Mouth/Bod(Exposure): While claimant was ivin C M 11/14/2009 $0.00 $8 618.87 0,618.87 C Knee RI ht Back Left Side): Claimant was sitti M 11/19/2009 $0.00 $572.76 $572.76 C Nose Eye Brow: Claimant walked Into a ole in unl M 11/20/2009 $0.00 $4 837.97 $4 837.97 C Right elbow was Inured when he was walkin down h M 11/28/2009 1 $0.00 $791.28 $791.28 C Arm (Right Inner Forearm): Claimant received minor M 12/2/2009 $0.00 $4 381.72 $4 381.72 C Chest/Heart: While at work the claimant experlence M 12/8/2009 $0.00 $5 141.27 $5 141.27 C Back: Claimant was walking on sidewalk and stepped M 12115/2009 $0.00 $36 714.48 $36 714.48 C Passed out when exercising after running and was w M 12115/2009 $0.00 $0.00 $0.00 C I Heartal stations and tl htness In the chest. M 12/30/2009 $0.00 $3 342.73 $3 342.73 C Hand Left Hip QeftNeck: Claimant was welkin M 12/30/2009 $0.00 $531.00 $531.00 C Hand RI ht Arm (Right), Ex osure : Claimant we BLT 1/4/2010 $0.00 $303 166.78 $303 166.78 C Neck Back: The claimants patrol vehicle was struc BLT 1/13/2010 $0.00 $2 461.04 $2 461.04 C Groin Left Side): Claimant removed a file cabinet M 1/14/2010 $0.00 $3 021.37 $3 021.37 C Heart: Claimant became III at work while on duty a M 1/15/2010 $0.00 $50.78 $50.78 C Ankle (Left): While trimming tree limbs from right M 1/18/2010 $0.00 $1,373.16 $1,373.16 C Back (Lower): Claimant had just opened the da room 75 of 107 -MONROE COUNTY1 ' D CURRENTLY VALUED 1' 1 I' O, 1 VALUED AS OF MARCH 319 2014 Claim Type Date of Injury Outstanding Reserve Sum Paid Sum Incurred Sum Claim Status Short Description of Accident M 2/9/2010 $0.00 $621.73 $621.73 C Heart: Claimant was assigned to Ocean Reef area an M 2/10/2010 $0.00 $7 515.07 $7 515.07 C Back Lower RI ht Leo (Right): While running dow M 2/16/2010 $0.00 $327.36 $327.36 C Ankle (Right): Claimant twisted her right ankle on M 2116/2010 $0.00 $10.00 $10.00 C _IzLe RI ht Lower): Clalmant is a volunteer deliver M 2/18/2010 C Back (Lower): Claimant was weed eg1M and his bac M 34/2010 $0.00 $931.04 $931.04 C Foot RI ht : After runnlnq to helD an officer tha BLT 3/11/2010 $0.00 $33 770.88 $33 770.88 C Knee (Left): Clalmant slipped Setting out of en in M 3/16/2010 $2 846.42 $7 163.58 $10 010.00 O Ears LT&R : Due to an on golng Increase In hear) LT T23/2010 $0.00 $4 656.85 $4 656.85 C Ankle/Foot RI ht : Clalmant stopped on a rock wit M 3/24/2010 $0.00 $437.00 $437.00 C Fin er (Right Hand Index): While the claimant was BLT 4/1/2010 $65 163.86 $272 836.14 $338 000.00 OL Ankle R : Clalmant in ured his ankle while gettin M 4/5/2010 $0.00 $205.35 $205.35 C Cheek Left Side): An Inmate scratched the clalman M 4/6/2010 $0.00 $616.76 $616.78 C Back (Lower): Claimant hurt his back while lifting M 4/6/2010 $0.00 $1 887.99 $1 887.99 C Heart Blood Pressure): Clalmant became dizzy, swe M 4/7/2010 $0.00 $1 976.98 $1 976.98 C Arm/Wdst RI ht : The claimant was bitten by inse BLT 4/9/2010 $0.00 $260 818.52 $260 818.52 C Shoulder RI ht Abdomen: The toll booth was unla M 4/11/2010 $0.00 $503.00 $503.00 C Arm (Right, Lower), Wrist RI ht : While assistin BLT 4/12/2010 $0.00 $8 593.84 $8 593.84 C Hand/Wrist (Left): Claimant tripped and fell on hl M 4/14/2010 $0.00 $3 493.35 $3 493.35 C Knee (Left): Clalmant sllpped on floor covered wit M 4/16/2010 $0.00 $375.37 $375.37 C Arm Right), Neck Back (Lower): Claimant was a pa M 4/18/2010 $0.00 $143.00 $143.00 C Knee (Right), Elbow (Left): Claimant was attem tin M 4/21/2010 $0.00 $75.50 $75.50 C Wrist (Right): Claimant has an Insect orspider bi M 4/23/2010 $0.00 $4.969.58 $4.969.58 C Chest/Ribs: Claimant was in ured whlle affecting a BLT 4/24/2010 $0.00 $18 916.69 $18 916.69 C Abdomen (Lower): Claimant was liftlnq batteries an BLT 5/3/2010 $0.00 $32 681.74 $32 681.74 C Arm Ri ht : The claimant strained his ri ht arm w M 5/6/2010 $0.00 $320.50 $320.50 C RI ht ringfinger was Injured after closingate w BLT 5/11/2010 $0.00 $4 746.96 $4 746.98 C Laceration to forehead after control of golf cart M 5/14/2010 $0.00 $1 510.80 $1 510.80 C Arm Left Lower: Claimant was feeding a sloth and M 5/19/2010 $0.00 $101.50 $101.50 C Knee (Right), Back: Clalmant was in line of traffl M 5/19/2010 $0.00 $686.41 $686.41 C Ankle Left : The claimant stepped off the bottom M 5/25/2010 $0.00 $616.33 $616.33 C Throat Face Arms (Exposure): Air freshener was s LT 5/25/2010 $0.00 $4 261.76 $4 261.76 C Knee (Left): The claimant twisted his knee while r M 5l27/2010 $0.00 $3 566.00 $3 568.00 C Fin er: fLnft Pink - While in a foot chase after 76 of 107 MONROE COUNTY FLORIDA CURRENTLY VALUED VALUED AS '.1 31�2014 Outstanding Claim Date of Reserve Claim T e In ury Sum Paid Sum Incurred Sum Status Short Description of Accident M 5/30/2010 $0.00 $2 261.43 $2 261.43 C Head (Right Side): As claimant stood up he turned M 6/3/2010 $0.00 $742.42 $742.42 C Back lower : Claimant was advancing a hose line w M 6/3/2010 $0.00 $143.00 $143.00 C E e left n4 : Claimaof II uld cleaner in here e M 6/7/2010 $0.00 $192.00 $192.00 C Knee (left): Claimant slipped on wet floor and fel BLT 6/8/2010 $0.00 $51 266.47 $51 266.47 C Back/Shouders: Claimant leaned over in her chair a M 6/10/2010 $0.00 $1 350.50 $1 350.50 C Thumb (left): Claimant was collecting razors from BLT 6/14/2010 $0.00 $4 369.75 $4 369.75 C Ankle (right): Claimant was stepping off the fire M 6/14/2010 $0.00 $1 711.30 $1 711.30 C Claiman4 was weak and dl from hea4 exhaustion M 6/17/2010 $0.00 $10.00 $10.00 C Chest/Heart: Claimant experienced chest pain and r LT 6/22/2010 $102 795.36 $48 437.39 $151 232.75 O MVA- Claimant lost control of her vehicle hitting M 6/202010 $0.00 $214.50 $214.50 C Eve R : Claimant was restraining an Inmate and sh M 7/1/2010 $0.00 $1 926.47 $1 928.47 C Back/Neck/Foot R : Claimant was holding a resides M 7/4/2010 $0.00 $4 245.69 $4 245.69 C Back: Claimant was In ursult of a suspect on foot M 7/16/2010 $0.00 $0.00 $0.00 C Ankle R : Claimant was vmrklnq in the field and s M 7/20/2010 $0.00 $9 879.94 $9 879.94 C Arm R : Claimant was snaking a pipe and he pulled M 7/21/2010 $0.00 $4 685.02 $4 685.02 C Back: Claimant was coming down a ladder and he tvW M 7/2312010 $0.00 $186.45 $t86.45 C E e L : Claimant was romovIng calling the and so M 7/24/2010 $0.00 $3 916.67 $3 916.67 C Chest: Claimant ex edenced chest pain and shortne M 7/28/2010 $0.00 $232.50 $232.50 C ACCIDENT DESCRIPTION: Claimant sliced finger on to M 7/28/2010 $0.00 $101.50 $101.50 C Middle Finger R : Claimant cut her finger moving M 8/6/2010 $0.00 $1 095.59 $1 095.59 C Shoulder R : Claimant pulled shoulder out of plac M 8/25/2010 $0.00 $1 118.13 $1 118.13 C Back (Lower : The IW was doing DDCE and the chair M 8/27/2010 $0.00 $6 665.72 $6 665.72 C Thumb R : Claimant was moving bags with dog feces M 9/1/2010 $0.00 $1 891.32 $1 891.32 C Index Finger L : Claimant was cuffing sheeting W BLT 9/1/2010 $0.00 $60146.32 $60146.32 C Shoulder R : Claimant leaned back In his chair an M 9/1/2010 $0.00 1 $1 053.85 $i 053.85 C Thumb R : The IW was bitten by a dog on his ri h BLT 9/3/2010 $0.00 $43 364.33 $43 364.33 C Shoulder R : Claimants shoulder hurts from vacuum M 9/3/2010 $0.00 $1 617.74 $1 617.74 C Back/Buttocks: Claimant slipped and fell down some M 9/3/2010 $0.00 $1 745.81 $1 745.81 C Ankle L : Claimant got out of the engine cabin an M 9/14/2010 $0.00 $201.73 $201.73 C Hand R : Claimant was removing crime scene tape f BLT 9/20/2010 $0.00 $15 842.41 $15 842.41 C Finger(FIT Hand Trigger): The IW's right hand trig M 10/1/2010 $0.00 $997.13 $997.13 C Knee R : The IW was ern n oil Into tank and w M 10/4/2010 $0.00 $75.50 $75.50 C Finger LT Middle): The IW caught his finger In th M 10/6/2010 $0.00 $2 201.10 $2 201.10 C Chest/Ribca e: The IW was participating in a defen M 10/14/2010 $0.00 $1,701.28 $1 701.28 1 C I Fin er LT Index): The I W was opening a door and 77 of 107 MONROE COUNTY1 ' I'1 VALUEDCURRENTLY Claim T e Date of Injury Outstanding Reserve Sum Paid Sum Incurred Sum Claim Status Short Description of Accident M 10/25/2010 $0.00 $106.50 $106.50 C Face: The IW was stuck In an elevator for an hour M 1 10/28/2010 $0.00 $449.79 $449.79 C Ankle (LT): The IW twisted her left ankle between M 10/29/2010 $0.00 $1 199.80 $1 199.80 C Back (Upper/Middle): The W got out of his car and M 11/212010 $0.00 $390.50 $390.50 C Hand L : Exposure. DuOng a search warrant the I M 11/4/2010 $0.00 $842.90 $842.90 C Le LT Lower): The IW tied up a rebar and a tie w M 11/5/2010 $0.00 $473.95 $473.95 C Knee L Ankle R : The IW fell on the concrete LT 12/7/2010 $0.00 $13 620.50 $13 620.50 C Wrist (LT): While the IW was performing exercixe I BLT 12110/2010 $0.00 $60 176.01 $60 176.01 C Hand(LT),Wrist (LT): The IW went to sit down In M 12/10/2010 $0.00 $2 024.40 $2 024.40 C Nose Cheek (LT): While unhooking the la a 5' suc LT 12/15/2010 $0.00 $9 925.76 $9 925.76 C Left ankle was In ured while doing PT he stepped b LT 12/17/2010 $0.00 $9 145.38 $9 145.38 C Left ankle In ured while walking down steps his a BLT 12120/2010 $0.00 $1 256.56 $1 256.56 C Rib/Chest RT Side): While pulling a canine out of M 12/26/2010 $0.00 $2 658.78 $2 658.78 C Elbow L Ankle (RI): The IW was walking from ar BLT 12/30/2010 $0.00 $10 743.10 $10 743.10 C Ankle R : The IW slipped on wet floor in the sta M 12/31/2010 $0.00 $7 640.18 $7 640.18 C Head: Upon entering a cell in unit alpha to retch M 1/1/2011 $0.00 $1 046.61 $1 046.61 C HanclANdst R : Due to Re etitive typing pain in LT 1/17/2011 $0.00 $32 540.81 $32 540.81 C Ankle R : The IW twisted his right ankle dude M 1/19/2011 $0.00 $1 430.23 $1 430.23 C Back (Lower : The IW twisted his back while steppi M 1/19/2011 $0.00 $299.50 $299.50 C Fin er(FIT Index): The IW was pufflngjaLm from dl M 1/19/2011 $0.00 $10.00 $10.00 C Ears Sinuses Throat Lungs: The IT In dispatch s BLT 1/21/2011 $0.00 $30 168.05 $30 168.05 C Knee L : The IW felt severe pain in his left kne M 1/2212011 $0.00 $1 569.28 $1 569.28 C Hand R Exposure: The IW pIcked up an unldentif M 1/25/2011 $0.00 $0.00 $0.00 C Heart: At the Ws annual phusIcal exam on January M 1/30/2011 $0.00 $647.50 $647.50 C Arm R : While stoppIng a fight the IW got blood LT 1/31/2011 $0.00 $16 798.49 $18 798.49 C Bo (Heart): The IW felt faint and weak hot and M 2/5/2011 $0.00 $10.00 $10.00 C Head Throat: The IW has health Issues due to poor BLT 2/7/2011 $152.63 $49 078.00 $49 230.63 R Shoulder L : The IW was liftin the 5' hard suct M 2/15/2011 $0.00 $3 714.08 $3 714.08 C Blood Exposure: The IW was assistin with a combat M 2/15/2011 $0.00 $207.50 $207.50 C Lungs (Exposure): Possible TB exposure annual phy LT 3/2/2011 $0.00 $9 599A9 $9 599.09 C Shoulder L : The IW Injured his shoulder from ge LT 3/16/2011 $0.00 $20 098.50 $20 098.50 C Arm JET Upper): Duringturbo draft o s the IW was M 3/21/2011 $0.00 $447.70 $447.70 C Hand L Arm (LT): The IW In ured his left hand LT 3/24/2011 $0.00 $152 457.67 $152 457.67 C Head LT Side Shoulder L Rib Cage L : Whll M 3/24/2011 $0.00 $1 319.88 $1 319.88 C Heart/Cardlac: An abnormal baseline was discovered M 3/28/2011 $0.00 $202.50 $202.50 C Lungs: The IW tested positive for TB he comes Int FLORIDAMONROE COUNTY CURRENTLY VALUED IJEA Claim Type Date of Injury Outstanding Reserve Sum Paid Sum incurred Sum Claim Status Short Description of Accident M 4/212011 $0.00 $852.94 $852.94 C Le RT Lower): A dog ran out of a fenced yard wit M 4/4/2011 $0.00 $1 407.39 $1 407.39 C Wrist (0, Face: While the IW was drIvInq the cou M 4/4/2011 $0.00 $10.00 $10.00 C Left buftock/thl h - MRSA/Abscess. Unclean small e M 4/7/2011 $0.00 $88.50 $88.50 C Eye (M: While the IW was cuffing grass something BLT 4/7/2011 $0.00 $3 790.28 $3 790.28 C Back (Lower): While the 1W was pressure washing he M 411412011 $0.00 $0.00 $0.00 C Back lower LouL : the IW replaced his duty r M 4/15/2011 $0.00 $2 030.24 $2 030.24 C Knee L : The clmnt was learning a new ground fig M 4/19/2011 $0.00 $564.16 $564.16 C Finger RT Middle): The IW cut his rl ht middle 11 M 4/20/2011 $0.00 $363.50 $363.50 C Back (Lower): During a search warrant the IW sli pp BLT 4/25/2011 $7 882.98 $17 117.02 $25 000.00 R Back (Lower): The IW ulled a muscle in his lower M 5/5/2011 $0.00 $85.50 $85.50 C Groin L : While the IW was testing LDH (large di BLT 5/11/2011 $21606.97 $61812.53 $83419.50 OL Hands Arms Left Side Knees: While directina tra LT 5/13/2011 $0.00 $21 886.41 $21 886.41 C Knees Hands Back Ribs: A subject resisted arres M 6/15/2011 $0.00 $2 518.90 $2 518.90 C Knee L : While the IW was pulling a chair Into t M 6/2/2011 $0.00 $6 059.78 $8 059.78 " C Back Shoulder blade RT Upper): the IW was doing M 612/2011 $0.00 $3 335.84 $3 335.84 C Back Lower. U r Neck: as the IW entered the k LT 6/312011 $0.00 $12 381.82 $12 381.82 C General: the IW got heat exhaustion while playing M 6/6/2011 C ACCIDENT DESCRIPTION: Ankle (Right). IW was res M 6/15/2011 $0.00 $6 778.23 $6 778.23 C Low Blood Sugar: the IW felt like he couldn't catc M 6/15/2011 $0.00 $4 302.81 $4 302.81 C Elbows Hands: Not an accident-Shootinpain radia M 6/16/2011 $0.00 $8 542.57 $8 542.57 C Ankle R : during a take -down of a defensive tact M 6/22/2011 C Chest: the IW was driving south US1. As he was drl M 6/23/2011 $0.00 $1 319.50 $1 319.50 C Tooth front upper): while qrabblnulllngthe SC M 6/27/2011 $0.00 $2 482.52 $2 482.52 C Thumb Wrist R : while t!yIng to control subject M 7/2/2011 $0.00 $156.93 $156.93 C Knee R : while the IW was opening the door Insid M 7/3/2011 $0.00 $1 754.73 $1 754.73 C Forearm (LT): patient was combative -diabetic. the M 7/5/2011 $0.00 $268.50 $268.50 C Shoulder (LT): the IW was removing an old faucet o M 7/6/2011 $0.00 $397.44 $397.44 C Eve (LT): while leaf blowing with safety glasses o LT 7/8/2011 $0.00 $11 886.99 $19 886.99 C Shoulder (LT): during defensive tactics training, M 7/15/2011 $0.00 $13 243.49 $13 243.49 C Groin Muscle: the IW felt stab of pain In groin mo M 7/27/2011 $0.00 $2 246.41 $2 246.41 C ACCIDENT DESCRIPTION: Head. IW struck boat T-To M 7/27/2011 $0.00 $2 566.58 $2 566.58 C ACCIDENT DESCRIPTION: Ankle/Foot (Right). While BLT 7/28/2011 $0.00 $9 434.35 $9 434.35 C ACCIDENT DESCRIPTION: Back (Lower). While perform M 7/31/2011 $0.00 $171.00 $171.00 C ACCIDENT DESCRIPTION: Lun s/Airbome. IW was sup M 8/12/2011 $0.00 $1 325.73 $1 325.73 C Arm LT&RT Lower),Ex osure Knee R : While taki 79 of 107 MONROE COUNTY1'I'i VALUEDCURRENTLY WORKERS' 1> c VALUED AS OF MARCH 31, 2014 Claim Type Date of In u Outstanding Reserve Sum Paid Sum Incurred Sum Claim Status Short Description of Accident M 8/17/2011 $0.00 $897.90 $897.90 C Knee (Ln Ankle (Lp, Fln er LT Dinky): The clmnt BLT 8/20/2011 $0.00 $13 381.95 $13 381.95 C Shoulder (LT): The clmnt Inured her left rotator M 8/25/2011 $0.00 $925.21 $925.21 C Back (Lower): During weight Ming physlcal train M 8/26/2011 $0.00 $286.00 $286.00 C Lungs: TB test read Positive during annual physics M 8/26/2011 $0.00 $286.00 $286.00 C Internal Lungs: positive PPD resulting from ossib LT 8/27/2011 $8 005.83 $75 154.28 $83160,11 O Arm L : During a training evolution the clmnt fe M 9/9/2011 $0.00 $3 027.35 $3 027.35 C Eye L Hand (LT): while sitting In a briefing m M 9/14/2011 $0.00 $672.18 $672.18 C Back lower : The IW was IIftlnq a box onto a cart M 9/22/2011 $0.00 $3 679.45 $3 679.45 C -Lungs Smoke inhalaflon : The clmnt was entedn a M 9/26/2011 $0.00 $505.17 $505.17 C -Finger RT middle : just found homemade tattoo nee M 10/4/2011 $0.00 $178.00 $178.00 C Exposure, face eve and mouth: While gIvIng out me M 10/1112011 $0.00 $702.12 $702.12 C Back: The clmnt tripped and fell on the rug by the 10/14/2011 $0.00 $4 601.68 $4 601.66 C Back(Spine): The cimnt was liftinga hydraulic s M EMLT 10/21/2011 $0.00 $7 493.39 $7 493.39 C Back (lower): lookin for a file In boxes the IW M 10/28/2011 $0.00 $0.00 $0.00 C Neck: while workln on the night of 10/28/11 the 11/1/2011 $0.00 $4 427.20 $4 427.20 C Knees: the IW twisted both knees when weeding on s BLT 11/1/2011 $948.75 $29 993.75 $30 942.50 O Shoulder Arm (upper), Elbow Forearm L : the IW M 11/6/2011 $0.00 $0.00 $0.00 C Legs (upper, buttock area): multiple abscesses on M 11/13/2011 $0.00 $768.46 $768.46 C Knee L : the IW responded to a domestic dlsturba LT 11/1412011 $79 900.58 $152 709.42 $232 610.00 O Head Neck Chest Shoulder R Arm R : the IW M 11/16/2011 $0.00 1221.97 $221.97 C Ankle (R]): the IW went to County Yard to have a v M 11/21/2011 $0.00 $154.32 $154.32 C Arm L : by tree wasp stung the Ws left arm. M 11/29/2011 $0.00 $990.82 $990.82 C Calf R : the IW was attempting to make contact w LT 12/4/2011 $9 510.46 $50 499.54 $60 010.00 O Back (lower): the IW was takina the stretcher out M 12/4/2011 $0.00 $1 281.78 $1 281.78 C Expos reArm R : the IW arrived on scene and we LT 12/5/2011 $6 269.77 $3fi 977.64 $43 247.41 R Knee R : the IW was vacuuming and right knee gav LT 12/5/2011 $0.00 $8 731.04 $6 731.04 C Hand (Rn, Ankle (LT): the IW fell while cllmbin M 1211412011 $0.00 $2 045.11 $2 045.11 C the IW tripped and fell on the hall wa . M 12/16/2011 $0.00 $1 283.20 $1 283.20 C While securina sub ect In handcuffs subject sudde M 12/2212011 $0.00 $6 761.18 $8 761.16 C Back (lower): after weedIng, the IW stepped up ova LT 12/30/2011 $0.00 $5 566.92 $5 566.92 C Foot/Ankle R : on police motorcycle from station M 1/3/2012 $0.00 $10.00 $10.00 C Lun s: Test positive for TB/Annual Physical. M 1 1/5/2012 $0.00 $1 526.23 $1 526.23 C Face Chin Neck: open wound on chin due to scratc LT 1 1/15/2012 $879.25 $30 250.75 $31 130.00 R -Finger RT middle): while on a watch order in an BLT 1 1/1912012 $0.00 $61 919.01 $fii 919.01 C Shoulder (LT): while striking in with sled a hamm f • 1 MONROE COUNTYFLORIDA VALUEDCURRENTLY 1 Claim Type Date of Injury Outstanding Reserve Sum Paid Sum Incurred Sum Claim Status Short Description of Accident M 1/24/2012 $0.00 $325.48 $325.48 C Back: the IW was under porch at lighthouse running M 1/25/2012 $0.00 $262.00 $262.00 C Hand R Eyebrow R : Inmate became aggressive BLT 1/27/2012 $0.00 $63 833.16 $63 833.16 C Shoulder (LT): closing large door over head on the M 1/31/2012 $0.00 $222.06 $222.06 C Eve (LT): the IW waschipping up brush and somethl M 2/10/2012 $0.00 $866.50 $866.50 C Feet Arms E e L : while round fighting. the m M 2/19/2012 $0.00 $3 422.22 $3 422.22 C Neck: the IW stopped for a red Il ht and the next M 2/21/2012 $0.00 $5 671.69 $5 671.69 C Back: pulling out coconut tree with backhoe the t M 2/29/2012 $0.00 $325.99 $325.99 C Wrist L : the IW was weed wacking and rock hit I M M 3/5/2012 3/10/2012 $0.00 $0.00 $1 215.49 $1 893.14 $1 215.49 $1 893.14 C C Eye R : while op,2ratlngbuzz bar, debris blew in Ex sure: an Inmate was sent to hospital. While th M 3/14/2012 $0.00 $889.00 $889.00 C Arms: while attempting to Place Inmate IM In restr M 3/14/2012 $0.00 $199.41 $199.41 C _Eye Aplacing Inmate Eaves In restraint chair M 3/15/2012 $0.00 $0.00 $0.00 C Forearm: during simulation training, the IW receiv M 3/19/2012 $0.00 $2 598.79 $2 598.79 C Toes L : opened door and bottom of door hit the M 4/1/2012 C Knee L : reinfury of left knee. the IW stood sud M 4/4/2012 $0.00 $1 841.12 $1 841.12 C Back: the IW strained back when makin a residents BLT 4/9/2012 $0.00 $53 582.66 $53 582.68 C Shoulder (AT): Ilftln ark bench the Ws should M 4/11/2012 $0.00 $432.74 $432.74 C Back lower): wheeling patient on stretcher, the u M M 4/19/2012 4/20/2012 $0.00 $0.00 $273.00 $737.36 $273.00 $737.36 C C Side (FM: the IW went to answer phone on the left Back (lower): the IW was painting toll booth plaza BLT M 4/22/2012 4/25/2012 $0.00 $0.00 $9 035.47 $1 628.67 $9 035.47 $1 628.67 C C Back (lower): removing weeds by hand and shovel t Wrist L : the IW started to exhibit symptoms of M 5/1/2012 $0.00 $349.81 $349.81 C Back: changina vacuum bag, the IW leaned back and M 5/1/2012 $0.00 $0.00 $0.00 C Heel R : the IW stopped off tanker 9 and bruised M 5/1/2012 $0.00 $399.00 $399.00 C Foot L : outside barrier door at the Marathon Go M 5/6/2012 $0.00 $1 285.73 $1 285.73 C Arm Finger R7 : the IW.suspects Possible cause a M 5/8/2012 $0.00 $941.64 $941.64 C Heel R : the IW did not see a small section of I M M 5/11/2012 5/11/2012 $0.00 $0.00 $999.90 $1 129.94 $999.90 $1 129.94 C C Wrist R : the cleat of the Ws right bike shoe Arm LT u er : the IW took wrong stop of claim t LT 5/12/2012 $0.00 $5 717.05 $5 717.05 C Ankle R : while conducting a security round the BLT 5/26/2012 $0.00 $9 416.43 $9 416.43 C Wrist HI L : after washing N911 FK the IW was BLT 5/26/2012 $0.00 $9 014.19 $9 014.19 C Inured back while working a detail at Higgs beac BLT 5/26/2012 $0.00 $6 792.03 $6 792.03 C Fingers, Knee Shoulder R : trying to oat out of M 1 6/2/2012 $0.00 $10.00 $10.00 C Forearm (FM: working unit B-1 the IW had travele M 1 6/4/2012 $0.00 $1 249.40 $1 249.40 C Thumb Hand Arm )LT): suspect possible cause as w 81 of 107 MONROE COUNTYFLORIDA CURRENTLY jT COMTENSATIOg Loll Julia's 1 1 E,> Claim Type Date of In u Outstanding Reserve Sum Paid Sum Incurred Sum Claim Status Short Description of Accident LT 6/11/2012 $0.00 $13 674.15 $13 674.15 C Testicle: while moving patient on stretcher over I M 6/15/2012 $0.00 $88.13 $88.13 C Shin R : during group ride the IW's front tire M 6/19/2012 $0.00 $217.17 $217.17 C Shoulder L : the IW was movino ballot boxes arou M 8l20/2012 $0.00 $0.00 $0.00 C Heart: hi h stress environment caused heart d sfun M 7/2/2012 $0.00 $354.70 $354.70 C Face: while Performing duties on card sound ROW t M 7/3/2012 $0.00 $218.01 $218.01 C Tallbone Back (Lower): The IW fell backwards afte BLT 7/11/2012 $15 847.11 $38 772.67 $52 619.78 O Shoulder (LT): the IW inured her left shoulder wh M 7/13/2012 $0.00 $10.00 $10.00 C Exposure: the IW has been exp2sed to all shower or LT 7/16/2012 $0.00 $8 486.22 $8 486.22 C Foot (LT): the NU stopped up on a step and felt a LT 7/19/2012 $0.00 $14 489.88 $14 489.88 C Deputy Valdes was handling a residential alarm cal M 7/19/2012 $0.00 $189.11 $189.11 C Le (LT): the IW woke up 7/19/12 In room 205 of th M 7/20/2012 $0.00 $492.08 $492.08 C Thumb L : cutting grass and wasp stung the IW. LT 7/25/2012 $0.00 $52 682.74 $52 682.74 C Shoulder R : when en terin fire truck on an ewer M 7/25/2012 $0.00 $181.50 $181.50 C Fin er LT Index): removing dog from rear assen M 7/30/2012 $0.00 $2 477.50 $2 477.50 C Exposure: the IW felt bad and was vomiting. He bel M 8/1/2012 $0.00 $895.46 $895.46 C Knees Ankle L : the IW stepped in pot hole and M 8/2/2012 $0.00 $1 221.33 $1 221.33 C Forearm R : during altercation with detainee he BLT 8/3/2012 $5 593.15 $39 138.15 $44 731.30 R Knees Elbow (FIT): the IW fell down three stairs t M 8/5/2012 $0.00 $9 637.40 $9 637.40 C Back: while lifting weights, the IW re -aggravated M 8/7/2012 $0.00 $2 681.55 $2 681.55 C Forearm: dog bit the Ws arm during K-9 demonstra M 8/8/2012 $0.00 $321.08 $321.08 C Knees Shin L Ankle (AT): the IW tripped and f M 8/8/2012 $0.00 $10.00 $10.00 C Exposure: positive reading for TB. M 8/18/2012 $0.00 $1 411.75 $1 411.75 C Hand R : while doing a perimeter check of the fa M 8/19/2012 $0.00 $1 753.67 $1 753.67 C Arm (AT): asslstIn2 rescue moving patient, the IW M 8/20/2012 $0.00 $3 039.17 $3 039.17 C Back: the IW was traveling southbound on US1 when M 8/24/2012 $0.00 $1 992.75 $1 992.75 C Trauma: emotional trauma as a result of traffic cr M 9/2/2012 $0.00 $1 953.14 $1 953.14 C Ankle (LT): walking slowly, surface changed. M 9I7/2012 $0.00 $1 875.90 $1 875.90 C Ex osure: afternDtIno to control a combative orlson M 9/22/2012 $0.00 $1 168.31 $1 168.31 C Wrist R : while attempting to place subject undo LT 9/29/2012 $43 207.01 $49 802.99 $93 010.00 O Knee R : while doing PT on duty, the IW was erf M 10/11/2012 $0.00 $1 543.50 $1 543.50 C Foot R : the IW was participating In defensive t LT 10/18/2012 $0.00 $69 431.23 $69 431.23 C Breathing: after the redman drill in DT class the BLT 10/18/2012 $0.00 $43 802.41 $43 802.41 C Shoulder (LT)-. the IW felt someone on her back and BLT 10/29/2012 $0.00 $54 441.36 $54 441.36 C Shoulder R : cutting trees and or loading Into LT 11/5/2012 $4 612.91 $52 423.35 $57 036.28 0 Knee Foot R : climbin down from was the IW fe 82 of 107 MONROE COUNTYFLORIDA VALUEDCURRENTLY WORKERS'1 E i I MR WWI Claim Date of Outstanding Incurred Claim T e In u Reserve Sum Paid Sum Sum Status Short Description of Accident M 11/5/2012 $0.00 $9 206.78 $9 206.78 C Shoulder R Back: the IW went to sit on the cha BLT 11f7/2012 $882.63 $7 137.38 $8 020.01 R Elbow Knee Hip jBp. up on escorting arrestee to M 11/12/2012 $0.00 $438.51 $438.51 C Ankle R : advancing hose line on fire scene foo M 11/12/2012 $0.00 $0.00 $0.00 C Chest: Annual physical TB p2sitive. Elbow R : while handling rescue equipment on a c M 11/13/2012 $0.00 $186.26 $186.26 C M 11/13/2012 $0.00 $84.00 $84.00 C Le R : the IW step2ed Into weeds and cut lower M 11/13/2012 $0.00 $205.40 $205.40 C Eye L : moving manikin off table computer cable M 11/14/2012 $0.00 $428.00 $428.00 C Finger R : takIniLdown scaffolding,the IW recel M 11/1612012 $0.00 $390.50 $390.50 C Wdst L : the IW lifted leaf blower and twisted M 1 11/19/2012 $1 695.95 $30 414.05 $32 010.00 O Due to a recent change in positions In November. T M 11/28/2012 $0.00 $2 904.04 $2 904.04 C Shoulder (AT): lifting scanner lid when paper lams M 12/3/2012 $0.00 $514.42 $514.42 C Back lower : while raising stretcher, Vol FF Tlm LT 12/11/2012 $0.00 $3 451.87 $3 451.87 C Shoulder (LT): while lifting a battery backup unit M 12111/2012 $0.00 $237.50 $237.50 C Foot L : the IW ste2ped on board with nail and M 1/6/2013 $0.00 $1 999.52 $1 999.52 C -Exposure: upon Intake butler the IW was spit In f M 1/6/2013 $0.00 $2 735.76 $2 735.76 ure: upon Intake butler, the IW was spit on. M 116/2013 $0.00 $291.84 $291.84[qc HI R Hands: the IW went to et the ri M 1f7/2013 $1 955.00 $13 055.00 $15 010.00 TKnees, Shoulder R :while movin chairs to set uM 1/9/2013 $0.00 $98.13 $98.13 ure: subject was convulsing and foaming at th M 1/9/2013 $0.00 $98.13 $98.13 C Exposure* the IVV was exposed to patient Infected w M 1/9/2013 $0.00 $88.13 $88.13 C -Exposure bacterial meningitis): subject was convu M 1/11/2013 $0.00 $1 798.34 $1 798.34 C Bice L: plcklng up the recycle cans to ut Int M 1/12/2013 $0.00 $651.60 $651.60 C Blood Exposure: a male fell during road race whil BLT 1/1312013 $12 913.15 $49 096.85 $62 010.00 O Le LT Elbow R : while working a traffic cras M 1/15/2013 $0.00 $2 158.95 $2 158.95 C Ankle R : Inlury occurred while exiting a wooded M 1/18/2013 C Lungs: annual physical - positive PPD reading. M 1/21/2013 $0.00 $0.00 $0.00 C Metal Stress: due to harrassment from union presid M 1/2212013 $0.00 $490.64 $490.64 C Eye R : while building cabinets for the new juve M 1/30/2013 $0.00 $4 738.16 $4 738.16 C Head Neck Back: the IW was driving southbound on M 1/30/2013 $0.00 $9 114.32 $9114.32 C Head Neck Back HI Le Foot R : the IW was M 1/31/2013 $0.00 $401.08 $401.08 C Eye R : walking through the bushes branch hit t M 2/4/2013 $350.31 $309.69 $660.00 R Foot RT : the IW noticed aln in right foot while M 2111/2013 $0.00 $474.90 $474.90 C Foot RT : the IW stepped on rusty nail while ciea BLT 2/19/2013 $0.00 $4 501.60 $4 501.60 C Finger R : while feeding and petting a lemur thr LT 2/21/2013 $0.00 $22 861.22 $22 861.22 C Groin R : while takinga patient down stairs th M 2/22/2013 $0.00 $2 799.95 $2 799.95 C Head Neck, Back, Shoulder (RT): while exitinn Taw MONROE COUNTY FLORIDA CURRENTLY VALUED Claim Type Date of Injury Outstanding Reserve Sum Paid Sum Incurred Sum Claim Status Short Description of Accident M 2/25/2013 $0.00 $161.00 $161.00 C Forearm Finger (Q, Thumb R : the IW was bitte M 2/28/2013 $0.00 $10.00 $10.00 C Hear: while standing Inspection, had clutched ches M 2/28/2013 $0.00 $868.00 $868.00 C Eye )LT): while teaching a class the IW was poked BLT 3/5/2013 $27 369.65 $30 640.35 $58 010.00 O Arm R : while attempting to place a sub ect Into M 3/14/2013 $0.00 $0.00 $0.00 C Blood: while participating in first aid refresher M 3116/2013 $0.00 $2 553.38 $2 553.36 C While struggling to arrest a sub ect he was resist M 3/27/2013 $0.00 $997.74 $997.74 C Head: the IW was In continuous stop and go traffic M 3130/2013 $0.00 $7 208.94 $7 208.94 C Ex sure: effecting an arrest of stabbing suspect, LT 4/6/2013 $0.00 $21 464.62 $21464.62 C Head Face Elbows Hands Knee (RD, Neck Back F M 4/6/2013 $0.00 $2 082.54 $2 082.54 C Lungs: while directing traffic the IW inhaled smo BLT 4/6/2013 $4 199.06 $7 800.94 $12 000.00 O Back lower : shoveling debris during fire Invests M 4/6/2013 $0.00 $1 547.09 $1 647.09 C Eyes: up2n arrival the wind shlfted and filled pa M 4/9/2013 $0.00 $401.50 $401.50 C Exposure: whilespeaking to a victim who has a tra M 4/11/2013 $533.50 $2 476.50 $3 010.00 O Fin er L : upon removin the prong from the defe BLT 4/11/2013 $23 493.27 $41 506.73 $65 000.00 O Shoulder L : the IW was opening the hood of the M 4/12/2013 $0.00 $1 552.26 $1 552.26 C Foot R : the IW slipped on wet floor. Right foot M 411712013 $0.00 $1 793.35 $1 793.35 C -Exposure: trustee was cleaning out the refri erato LT 4/28/2013 $10 910.51 $36 630.69 $47 641.20 OL Heart: Irregular heartbeat. The IW was transported M 5/1/2013 $0.00 $90.75 $90.75 C Forearm L : Insect bite on left forearm which be M 5/10/2013 $0.00 $7 020.38 $7 020.38 C Face Arm L : MVA the IW hit another cal from b BLT 5/10/2013 $67 333.18 $107 686.82 $175 000.00 OL Back (lower): after cutting down trees and loading M 5/21/2013 $0.00 $6 282.37 $6 282.37 C Heart: rapid heartbeat and blurred vision. M 5/24/2013 $0.00 $0.00 $0.00 C Heart: the IW was helping someone at the boat dock M 5/29/2013 $0.00 $88.13 $88.13 C Knee Hand R Back: the IW S1113ped and fell at M 6/21/2013 $0.00 $1 222.75 $1 222.75 C Finger (LT): while making a repair to the emer enc M 6124/2013 $0.00 $2 272.77 $2 272.77 C -Exposure: the IW was not feeling good. Not sure I M 7/4/2013 $0.00 $1 067.95 $1 067.95 C Ankle R : the IW was returning back to his vehic M 7/7/2013 $318.92 $881.08 $1 200.00 O Finger (LT): the IW responded to a back up call W M 7/9/2013 $0.00 $666.00 $666.00 C Eve R : the IW was getting odor ban out of the o M 7/9/2013 $0.00 $0.00 $0.00 C Dehydration: during obstacle course the IW starts M 7/9/2013 $0.00 $155.50 $155.50 C Back: while lifting the stretcher and Patient Into M 7/10/2013 $0.00 $0.00 $0.00 C Lungs: annual physical - PPD positive. M 7/21/2013 $10 024.36 $24 975.64 $35 000.00 OL Heart: after turbo draft training,they returned t M 7/25/2013 $0.00 $2 003.87 $2 003.87 C _L29 L Hips, Forearm R : the IW walked into r LT 7/26/2013 $0.00 $28 776.41 $28 776.41 C Knee Leg,Foot R : while conducting a welfare c M 7/30/2013 $0.00 $0.00 C Heart: the IW qot from his desk to his oatrol car. 84 of 107 MON ,r , COUNTY FLORIDA VALUEDCURRENTLY VALUED AS OF 4 Claim Type Date of Injury Outstanding Reserve Sum Paid Sum Incurred Sum Claim Status Short Description of Accident M 8/1/2013 $0.00 $3 400.37 $3 400.37 C Head: the IW was entering library from back door I M 8/2/2013 $0.00 $613.50 $613.50 C Leg (1-11 trimming trees on road the IW got pols LT 8/9/2013 $3 072.50 $51 327.50 $54 400.00 O Arm Shoulder Knee L Nose: attempted to walk M 8/11/2013 $0.00 $0.00 $0.00 C the IW was at the airport performing airport dutle M 8/21/2013 $0.00 $301.00 $301.00 C Exposure: Inmates it saliva on left arm while be[ M 8/21/2013 $0.00 $0.00 $0.00 C Annual Physical. Positive PPD M 9/3/2013 $0.00 $0.00 $0.00 C Ankle Knee HI R Elbows Neck: the IW took e M 9/6/2013 $0.00 $0.00 $0.00 C Sinus: Wake up eve morning coming off shift at s M 9/9/2013 $0.00 $0.00 $0.00 C Lungs: congestion and coughingu reen flem after BLT 9/11/2013 $1 606.20 $16 893.80 $18 500.00 O Hand Finger R : while moving rubber molding for M 9/1212013 $0.00 $3 725.66 $3 725.66 C Knee (Q, Head: the IW tripped and fell when gain M 9/18/2013 $0.00 $201.77 $201.77 C Shoulder (M: loading tree limbs to dump truck t M 9/24/2013 $74.98 $425.02 $500.00 O Knee R : when the IW got out of truck he missed M 10/10/2013 $0.00 $0.00 $0.00 C HI L : while returning back to Dorm Echo the I M 10/17/2013 $0.00 $0.00 $0.00 C Exposure: the IW has been exposed to mold before m M 10/18/2013 $0.00 $0.00 $0.00 C Lungs: annual physical. Positive PPD TB. M 10/25/2013 $0.00 $349.68 $349.68 C Forearm Hand Elbow (LTI., practice of bent wrist M 10/29/2013 $0.00 $502.51 $502.51 C Elbow R : R elbow area hurts from chipping trees LT 11/1/2013 $7 742.50 $1 257.50 $9 000.00 O Groin: lifting and moving boxes In an enclosed tra LT 11/4/2013 $201.63 $23 466.89 $23 668.52 0 Knee L :the IW fell off vessel ladder, approx 3 M 11/7/2013 $2 809.98 $7 190.02 $10 000.00 O HIp (Q, Head: while stepping down to exit AU18 M 11/9/2013 $0.00 $140.00 $140.00 C Heat: doing strenuous exercise caused heat exhaus M 11/12/2013 $0.00 $4 590.82 $4 590.82 C Head: the IW was not drinking enough water before M 11/12/2013 $340.64 $159.36 $500.00 O Exposure: transporting a 80 year old patient via t M 11/14/2013 $1 112.83 $1 887.17 $3 000.00 O Hand R : during defensive tactics while working LT 11/16/2013 $28 734.76 $40 265.24 $69 000.00 O 1 Arm (LT): while hel In a sub act up from the grou M 11/19/2013 $500.00 $0.00 $500.00 O Exposure, Check Eye L : while attempting to sec M 11/20/2013 $0.00 $1 707.37 $1 707.37 C Wrist Rpulling tubes out of shoot tube the I M 11/25/2013 $809.33 $2 190.67 $3 000.00 O Finger L : while counting razors one of the cov M 11/25/2013 $0.00 $238.94 $238.94 C Shoulder Hand LT Arms Elbows: the IW was ddv M 11/25/2013 $0.00 $0.00 $0.00 C Annual Physical. Possitive PPD TB. LT 11/27/2013 $5 087.04 $9 912.96 $15 000.00 O Le (LT): the IW was checking the area of an occu BLT 11/29/2013 $4 682.40 $631.82 $5 314.22 O Knee L : the IW slipped In mud while conducting M 12/2/2013 $0.00 $898.50 $898.50 C Eve R : while the IW was hand pulling plants,a M 12/3/2013 $0.00 $208.32 $208.32 C Arm (LT): while working at the Marsh House unloads M 12/11/2013 $0.00 $205.18 $205.18 C Foot L : unattached metal key board tray arm fel MONROE COUNTY FLORIDA CURRENTLY VALUED WORKERS' COMPENSATION • VALUED As OF MARCH 319 2014 i.. • MONROE+ COUNTY BOARDOF COUNTY COMAnSIONERS WC _ C12imC with Tntal TnamrvaA ;a Ti --- nF Ocn "an Date of .�.,.,'...,.. Settlement Amount InjuryAccident Description Diagnosis Current Medical Status Litigated After several surgeries, hardware removal, Ankle (R): Claimant injured his infection and MRSA the treating doctors are 4/1/2010 ankle while getting on and off Avulsion fracture considering amputation to alleviate his pain but Yes NA the mower. would like to try a spinal cord stimulator prior to this drastic measure. The claim is closed. Neck, Back: The claimants JCC signed order on 10/26/12. 1/4/2010 patrol vehicle was struck Cervical Fusion Subrogation was closed — no Yes $130,000.00 broadside by another truck recovery. rl'• Treated with Dr. Vanni and was placed at NMI 24% PIR on 03/01/12 after his 04/18/11 cervical fusion. Shoulder (Right), Abdomen: The toll booth was unlatched by Right rotator cuff tear, The claim is closed. 4/9/2010 coworker, the claimant leaned cervical spinal stenosis, and JCC signed order on 12120/11. against the door causing it to right carpal tunnel Treated with Dr. Evans and was placed at MINI Yes $110,850.00 open and he lost his balance syndrome. with a I I% PIR on 07/28/11. striking his shoulder Head, Neck, Chest, Shoulder JCC signed order on 04/02/14. 11/14/2011 (IT), Arm (RT): the IW slipped Shoulder fracture with neck Treated with Dr. Klodniak for his right shoulder on the staircase and fell and back sprain/strain which surgery was completed on 11/14/11. He p No $75,000.00 approximately 5-6 steps. also treated with Dr. Schecther for his spine and Back (lower): after cutting down Dr. Demeo for ain management and injections. trees and loading them into 5/10/2013 chipper on Friday, the IW's back TLIF L4-SI A fusion to the lumbar spine was completed on was very sore. Injuries 01/16/14. Yes NA progressively worsened resulting in a trip to the ER on 5/13113. Head (LT Side), Shoulder (LT), Rib Cage (LT): While pulling Treated with Dr. Perry. Surgery was completed down mulch in back of the truck on 05/16/11 and on 01/16/12. He then referred 3/24/2011 sort wouldn't overflow so then Kidney pain Left shoulder the employee for a second opinion due to the IW turned to get out he slipped on mulch and fell out of surgery. continued pain complaints. He saw Dr. Badia No NA the back of truck and landed on who operated on 08/07/12. He was eventually his left side MI placed at M6% PIR on 11/28/12. 1 MONROE COUNTY BOARD OF COUNTY COMMISIONERS WC Claims with Total Incurred in Excess of $50,000 Date of Nury Accident Description Diagnosis Current Medical Status Litigated Settlement Amount MVA- Claimant lost control of 6/22/2010 her vehicle hitting a tractor trailer Deceased. Dependent is receiving death benefits. that was sitting on the side of the Dew. We have a P party leis as the dependents father Yes NA road resulting in her death litigated the claim but it has remained inactive. Placed at NM 6% on 03/15/13 by Dr. Knee (RT): while doing PT on Left knee ligament Wilkerson after left knee ligament 9/29/2012 duty, the IW was performing reconstruction ACL tear and reconstruction. 03/15/13 is the last date he was No squats when knee buckled. q shoulder pain. seen. If the employee does not seek treatment NA his SOL will run on 09/29/14. The file is re -open to pay a bill that was recently received. Hands, Arms, Left Side, Knees: Recently set up with new doctors in north While directing traffic at the Cervical injury, Thoracic Florida. Dr. Stevensen for her cervical condition 5/11/2011 school crossing at Woods spine denied, Bilateral elbow and Dr. Powell for her elbow injuries. She Avenue and US1 the IW was injury w/ possible CTS recently obtained council upon the request from Yes NA struck by a vehicle Dr. Powell for possible CTS surgery if deemed related to the in'u . Arm (LT): During a training The employee underwent surgery with Dr. 8/27/2011 evolution the clmnt fell and hurt TFCC left tear sprain carpal Collins on 03/15/12. Used his one-time change his left arm joint with tendinitis. and was set up with Dr. Badia. He later moved No NA and was set up with Dr. Aired for follow up care. The employee treated with Dr. Beyslow a Breathing: after the redman drill nephrologist. He was placed at h MI 0% on 10/18/2012 in DT class, the IW could not Acute kidney injury. 03/14/13 and asked to follow up with in a year. He control his breathing and his was seen on 03/27/14 and everything was No NA pulse rate was extremely high. with in normal limits. He no longer has to follow up for his work injury. We will be proceeding Arm (LT): while helping a subject with a denial of further treatment. 11/16/2013 up from the ground, the IW felt a Treated with Dr. Badia surgery was completed sharp and immediate pain in his Distal bicep tear on 12/12/13. He was placed at NM 0% on No NA left upper arm. 03/17/14. Shoulder (LT): the was opening the hood off the clam t Treating with Dr. Badia. Employee initially truck and felt pain in his left Shoulder pain, rotator cuff wanted to treat conservatively with PT and 4/11/2013 shoulder. The shoulder had tear — traumatic w/ Labral injections. He was placed at NM 3% on been tickling him for a while, but tear. 07/03/13. With his continued pain surgery was No NA when he opened the hood, the completed on 02/18/14. He was last seen on pain intensified. 03/31/14 and was released to limited duty work MONROE COUNTY BOARD OF COUNTY COMMISIONERS WC Vinimc with Tntal „r Oen nnn Date Ly✓vyvvv Nury Accident Description Diag nosis gnosis Current Medical Status Litigated Settlement Amount 1/27/2012 Shoulder (LT): closing large door Left rotator cuff and labral File is closed. over head on the fire prop. tear. Dr. Evans performed surgery on 06/19/12 and No NA laced the em to ee at NH 0% on 11/16/12. M Leg (LT), Elbow (RT): while working a traffic crash, the IW slipped in the rocks on the Full thickness tear of the Treating with Dr. Gilbert who performed right 1/13/2013 embankment, causing her to right extensor tendon. elbow sure on 05/31/13 and was eventually surgery y scrape left leg, landing on arms Lateral epicondylitis and placed at MMI 1 % on 11/21/13. She was last No NA and on her previous injured right radial tunnel syndrome. treated on 02/27/14. elbow. Shoulder (LT): while striking pin File is closed. 1/19/2012 with sledge hammer, the IW felt Left shoulder artropathy, Treated with Dr. Evans, surgery was performed something tear or move in left rotator cuff tear. on 04/10/12. The employee was placed at NMI No NA shoulder. 3% on 08/17/12. Hand (LT), Wrist (LT): The IW File is closed. 12/10/2010 went to sit down in a chair when the chair moved and she fell on Tear in the left shoulder. JCC signed order on 02/07/12. Yes $25,000.00 her left hand and left wrist Treated with Dr. Harrell. Surgery performed on 02/17/11. Placed at MNII 6% on 05/17/11. Shoulder (R): Claimant leaned File is closed. 9/1/2010 back in his chair and fell to the Right shoulder labrum tear. Treated with Dr. Evans. Surgery was completed No NA floor on O1/25/11. Placed at NMI 3% on 05/18/11. Back (lower): the was taking the stretcher out off the truck. Lumbago Displacement of The employee treats with Dr. Schecther. He was 12/4/2011 After the stretcher was set, he the lumbar intervertebral placed at MMI 6% on 02/17/12. He was last seen made a wrong gesture and had disc w/o myelopathy and on 03/26/14 for an acute exacerbation of his now No NA real bad back pain. sciatica. chronic lumbar condition. Arm (RT): while attempting to place a subject into handcuffs, 3/5/2013 there was a struggle between Rupture of the right rotator Surgery performed on 03/21/13 by Dr. Harrell. the IW and the subject, resulting cuff. Placed at MMI 7% on 03/26/14. I13's are being No NA in right arm being forcefully paid• ulled backward and forward. MONROE COUNTY BOARD OF COUNTY COMMISIONERS WC Claims with Total Incurred in Excess of $50,000 hdurDate y Accident Description Diagnosis g Current Medical Status Litigated Settlement Amount Initially treated at KW Urgent Care for right foot contusion with edema. Was placed at NMI 0% on 11/14/12.Went back to the Urgent Care about 2 months later and was referred to podiatry due Knee, Foot (RT): climbing down to continued complaints. Treating with Dr. 11/5/2012 from was, the IW fell backward large pipe and hit chest. on to PP Plantar faciitis. Torregorsa who diagnosed him with Plantar faciitis. He related this to the original injury. No NA Injured right knee and foot. Surgery was completed on 05/28/13. He was placed at NMI 1 % on 11/07/13. At a post op follow up it was noted he developed a bone spur and would need additional surgery. There is no urgency for the surgery. Employee was last seen on 04/17/14. Shoulder (RT): cutting trees and File is closed. 10/29/2012 or loading into pick up for Right shoulder pain with Treated with Dr. Badia, surgery completed on disposal. rotator cuff tear. 12/04/12. Placed at MMI 3% on 03/11/13.1B's No NA wereaid. Arm, Shoulder, Knee (LT), Nose: attempted to walk under folding Treated with Dr. Reilly. Surgery was performed 8/9/2013 ladder located in a hallway. The Left humerus fracture and on 08/26/13. Placed at NMI 12% on 01/02/14 IW lost his footing and stumbled about 6 feet, falling onto the left knee contusion. with Permanent restrictions. He has since retired NO NA carpet. from the County. Shoulder (RT): lifting park File is closed. 4/9/2012 bench, the Ws shoulder Right rotator cuff tear. Treated with Dr. Perry. Surgery was performed popped. on 07/09/12. Placed at M4% on 02/07/13. MI No NA IB'said. Shoulder (RT): when entering fire truck on an emergency call, File is closed. 7/25/2012 the IW twisted and felt a pop in shoulder, with pain and cannot Right rotator cuff tear. Treated with Dr. Peary. Surgery performed on No NA raise arm above shoulder. 01/07/13. NM 2% on 07/12/13. IB's paid. Shoulder (LT): the IW injured her left shoulder while lifting and Treated with Dr. Loeffler. Surgery was 7/11/2012 moving mail totes filled with absentee ballots that they were Left shoulder biceps tear performed on O1/29/13. Placed at NM 3% on No NA delivering to the post office for 06/26/13. Last treated on 12/02/13 and was told processing. to follow up yearly. MONROE COUNTY BOARD OF COUNTY COMWSIONERS WV Vla;vne xwv**16 9P-#-] Ir- —ed'Lnft'ftnn Date of UK W.YV,%PVV Settlement Amount Nury Accident Description Diagnosis Current Medical Status Litigated 6/8/2010 Back/Shouders: Claimant leaned over in her chair and the chair Cervical exacerbation and thoracic back pain, and File closed. Treated with Dr. Guttentag and was placed at Inclusive settlement tipped over shoulder pain. NM or PIR for his shoulder. Placed at NOG Yes with another claim 0% for his cervical by Dr. Shields. for $87,238.00 92 of 107 MONROE COUN GENERAL LIABI CLAIMS CLAIM # EVENT DATE CLAIMANT TYPE EXPENSES PAYMENTS RESERVES STATUS DESCRIPTION 201000GL 8/14/09 VENTURA BI 516.50 2,000.00 0 EQUIPMENT FELL ON PATIENT 200101GL 06/10/09 ALONSO BI 1,000.00 O INJURED WHEN FELL IN HOLE LOCATED AT 587 BONITO AVE. 201002GL 04/08/08 ESTATE OF CARLOS HUMBERTO CIFUENTES SAENZ BI FBO RESPONSIBLE 0.00 0 RAMP COLLAPSE AT KW IA 201003GL 5/15/09 STEFANELLI gl — 0.00 --T-- C CLAIMANT 201004GL 10/13/09 SANTIAGO BI 5,543.73 2,000.00 0 CLAIMANT CLAIMS HE FELL AS A RESULT OF NEGLIGENTL Y MAINTAINED HOLE IN THE GROUND. 201005GL 12/18/09 MOORE 3,487.90 0 EEOC CLAIM 201006GL 3/6107 MAY 3,592.72 0.00 0 CIVIL RIGHTS CLAIM 93 of 107 MONROE COUNTY GENERAL LIABILITY CLAIMS CLAIM # EVENT DATE CLAIMANT TYPE EXPENSES PAYMENTS RESERVES STATUS DESCRIPTION OPERATOR GOT CLOSE 201007GL December MERRITT PD 600.00 C TO FENCE AND DAMAGED FENCE O INVERSE CONDEMNATI 201008GL 12/07/09 HOUSE 29,904.93 ON O INVERSE CONDEMNATI 201009GL 01/13/04 KEEGAN 6,294.17 ON 201010GL 06/07/08 ESTATE OF CHARLES EUGENE BECKER BI 1,410.34 3,®®O.00 ® WRONGFUL DEATH CONSERVATI 201011GL 06/18/10 HAUK PD 500.00 0 ON LAND TREE FELL ON NEIGHBOR'S FENCE O INVERSE CONDEMNATI 201012GL 04/15/10 HANDTE 3,051.98 ON CLAIMANT 201013GL 5/2/1/10 SCHREIBER PD 8,750.00 C CLAIMS DRIVER CLOSED THE DOOR ON RIGHT ARM 94 of 107 MONROE COUNTY GENERAL LIABILITY CLAIMS CLAIM # EVENT DATE CLAIMANT TYPE EXPENSES PAYMENTS RESERVES STATUS DESCRIPTION 201014GL 09/01/08 ECHOLS 109,547.65 2,478.66 C INVERSE CONDEMNATI ON 201015GL 12/01/09 MOORE 152,627.76 51,303.12 C DISCRIMINATI ON CLAIMANT CLAIMS BOAT 201016GL 07/19/09 REAGAN PD 295.25 2,000.00 O WAS H DAMAGEEADIBY STRIKING CHANNEL MARKER RESIDENT 201017GL 08/05/10 TURNER BI 0.00 C FELL IN HER ROOM BAYSHORE MANOR. LIMB FELL 201018GL 07/28/10 HANE PD 88.88 C OVER WATER LINE WHILE CREW WAS CUTTING TREES 773.97 SUBRO C VANDALISM AT STATION WHERE HE 201100GL 10/28/10 LEONARD PD WORKS M• -Of GENERAL LIABILITY CLAIMS n:NmTff--!;j vUNTY CLAIM # EVENT DATE CLAIMANT TYPE EXPENSES PAYMENTS RESERVES STATUS DESCRIPTION HIT IN MOUTH 201101GL 12/14/10 NAVARRETTE BI 500.00 O BY ROCK THROWN BY MOWER 201102GL 12/16/10 PEREZ 3,412.05 2,052.78 O EEOC 201103GL 4/8/2008 WHITE gI O RAMP COLLAPSE AT KW IA 201104GL 2/19/2011 PORQUETT 13,972.41 O EEOC SUSTAINED 201105GL 8/10/2009 WALTER FKAA JUR. C INJURIES ON THE RAISED MANHOLES 201106GL 5/31/2011 ANTHONY PD 2,618.00 C CTY VEHICLE DAMAGED CARPORT ALLEGES THAT SHE 201107GL 07/27/11 CHAVERS gI 1,000.00 O FELL MAIN TERMINAL ENTRANCE MARTHON AIRPORT 96 of 107 MONROE COUNTY GENERAL LIABILITY CLAIMS I V. I � I � I �Ff �j All. CLAIM # EVENT DATE CLAIMANT TYPE EXPENSES PAYMENTS RESERVES STATUS DESCRIPTION CTY TRUCK/BOOM STUCK DOWN 201108GL 08/02/11 WILEY PD 2,017.81 C ELECTRICAL LINE DAMAGED WEATHER HEAD CLAIMAINT ALLEGES 201109GL 07/26/11 WILSON BI 500.00 0 INJURIES SUBSTAINED DUE TO NEGLIGENCE. CLAIMANT ALLEGES HE 201110GL 11/19/07 TOLIEN BI 500.00 0 WAS INJURED WHEN BIKE COLLIED WITH A SIGN CTY 201111GL 08/25/11 O'BRIEN PD 435.00 C EMPLOYEE DAMAGED FENCE AND BENT 1 POLE ALLEDGED 201112GL 03/17/04 SUNSET MARINA RESIIDENTS PD 5,000.00 O DEPRIVATION OF PROCEDURA L DUE 97 of 107 MO -OE GENERAL LIABILITY CLAIMS CLAIM # EVENT DATE CLAIMANT TYPE EXPENSES PAYMENTS RESERVES STATUS DESCRIPTION 201113GL 08/10/11 THE MORGANTI GROUP, INC pp 3,000.00 O ALLEGED BREACH OF CONTRACT 201114GL 07/21/11 ROCK HARBORMARINA INC PD 2,000.00 O 201200GL 08/02/11 KEYS ENERGY PD 19,135.37 C COUNTY EMPLOYEE DAMAGED POLES AND KNOCKED DOWN LINES 201201GL 10/31/2011 FKEC pp :: 1,000.00 O LOWBOY DAMAGED POLE 201202GL 11/28/09 MICHAEL L. JENNINGS AS PERSONAL REP OF CHRISTOPHER LEE JENNINGS BI - 50,000.00 - O TORT 201203GL 11/28/09 ROBERT T. CARROLL, PERSONAL REP OF DEBORAH L. MAGNUM BI 50,000.00 O TORT 201204GL 01/30/12 BARTELMO PD 150.00 C CTY EMPLOYEE CAUGHT FENCE WITH MOWER DECK 201205GL 10/21/11 NORBER BI C TRIP AND FALL FBO- KW IA • 1' MO' -OE GENERAL LIABILITY CLAIMS • a Ii 1. CLAIM # EVENT DATE CLAIMANT TYPE EXPENSES 201206GL 01/03/12 GARCIA 1,301.00 201207GL 04/02/12 BUXTON BI 201208GL 5/3/2012 COX PD 131.55 201209GL 5/25/2012 MARTINEZ PD 201210GL 8/2/2011 GAGLIARDI PD 6,181.96 201211GL 7/11/2012 CARSON PD 516.00 of FALL ON ESCALATOR METER c• COUNTYN OVER BY WHILE MONROE COUNTY GENERAL LIABILITY CLAIMS CLAIM # EVENT DATE CLAIMANT TYPE EXPENSES PAYMENTS RESERVES STATUS DESCRIPTION 201212GL 03/24/04 GUTIERREZ PD 2,489.50 O INVERSE CONDEMNATI ON 201213GL 07/20/12 DEBRECKI PD O BREACH OF CONTRACT 201214GL 06/18/12 NEWTON PD O INVERSE CONDEMNATI ON 201215GL 06/04/12 AT&T PD 2,339.18 1,482 07 C CTY EMP. CUT TELEPHONE LINE WHILE CUTTING BRANCES 201216GL 09/07/12 PADRON PD 1,482.07 C CONTRACTO R KNOCKED DOWN THE POWER LINE 201217GL 07/19/12 PORQUETT 2,323.51 O EEOC 201218GL 07/26/12 WEBSTER PD 41.00 C CLOTHING DAMAGED MONROE COUNTY GENERAL LIABILITY CLAIMS I VkNmime, , CLAIM # EVENT DATE CLAIMANT TYPE EXPENSES PAYMENTS RESERVES STATUS DESCRIPTION LARGE 201219GL 08/27/12 NASET PD 4,550.84 C BUTTONWOO D TREE ON COUNTY R.O.W. BROKE OFF 1,000.00 O ALLEGED BUS 201220GL 06/29/10 SCHEHR pp INCIDENT CLAIMANT 201221GL 08/24/12 OTTO PD 200.00 O CLAIMS THAT CREW RUINED HER TREE AFTER TRIMMING. RESIDENT 201300GL 10112/12 SANDBUSEN pp 500.00 O CLAIMS THE VIBRATION FROM EQUIPMENT 201301GL 4/1/2012 ROMERA 24,689.34 ® DISCRIMINATI ON O INVERSE CONDEMNATI 201302GL TBD NEWTON/REYNOLDS PD 2,672.31 ON SLIP AND 201303GL 11/25/12 STEFANI BI 2,000.00 O FALL AT KEY WEST INTERNATION AL AIRPORT MONROE COUNTY GENERAL LIABILITY CLAIMS • , CLAIM # EVENT DATE CLAIMANT TYPE EXPENSES PAYMENTS RESERVES STATUS DESCRIPTION 201304GL 02/03/13 PENA BI 0 O SLIP & FALL- CTY EMPLOYEE 201305GL 03/07/13 CODY PD 36.54 C HIT TRASH CAN WITH BACKTIRE WHILE TRIMMING BRUSH O INVERSE INVERSE 201306GL 07/04/05 MITCHELL PD 19,583.78 ON C PRIVATE VEH DAMAGE EMPLOYEES 201307GL 04/12/13 GOODRICH PD 106.99 SHOES FIRE RESCUE BACKEDINTO 201308GL 5/1712013 Ep PD 250.00 O WOODEN POLE OF LEASED PROPETY TO COUNTY 201309GL TBD VENTURE OUT V. FKAA PD 1,545.65 0 WASTE WATER 500.00 0 DAMAGE TO HOME OWNERS 201310GL 6/21/2013 PD PHONE LINE 102 of 107 CLAIM # `"G"' DATE 201311GL 6/24/2013 201312GL 1 07/01/13 201313GL 1 07/23/13 201314GL 1 7/26/2013 201315GL 1 8/9/2013 201316GL 1 7/24/2012 ELLIS FLORIDA KEYS ELECTRIC -,-T*T*Jq.rcTjwA MONROE COUNTY GENERAL LIABILITY CLAIMS TYPE J EXPENSE` PD PD BI PD PD 2,111.15 1 PAYMENTS RESSERVE STATUS DESCRIPTION CUT FOOT/DAMAGE 1,500.00 0 D TOENAIL WHILE ENTERING COURTHOUSE 2 PHONE LINE 500.00 0 PULLED DOWN BY BUZZ BAR RESIDENT 1,000.00 0 PUSHED BY ANOTHER RESIDENT CTY WORKER 500.00 0 HIT POWER LINES WITH BUZZ BAR CHIPPER RAN OVER C MANOLE AND BROKE COVER STATE EMPLOYEE 2,000.00 O INVOLVED IN CTY VEHICLE ACCIDENT MONROE COUNTY GENERAL LIABILITY CLAIMS CLAIM # EVENT DATE CLAIMANT TYPE EXPENSES PAYMENTS RESERVES STATUS DESCRIPTION 201317GL 09/30/13 MARTINEZ BI 300.00 O CLAIMANT FELL OFF BIKE ON SHOULDER CLAIMANT 201400GL 09/02/13 ZIEGLER gl 1,678.99 C FELL ON STEPS AT HIGGS BEACH CTY 201401GL 1/30/2014 CONDELLA pp 100.00 O EMPLOYEE KNOCKED OVER MAILBOX. 201402GL 01/14/12 RODRIGUEZ BI 1,000.00 O CLAIMANT FELL ON UNEVEN SURFACE FIRE RESCUE 201403GL 03/22/14 KAPLITZ PD 1,000.00 O BACKED INTO ELECTRICAL WEATHERHE AD BELONGS TO THE C TRIP & FALL AT HARVEY 201404GL 11/20/13 NAGER P® FDOT SIDEWALK 104 ®f 107 MONROE COUNTY GENERAL LIABILI CLAIMS CLAIM # EVENT DATE CLAIMANT TYPE EXPENSES 201405GL __7 02/24/14 PEREZ-CRUZ BI 201406GL 02/26/14 EMMEL BI 105 of 107 SHERIFF COLLIDED 1,000.00 O WITH MOTORCYCLE ON CR905 MONROE COUNTY VEHICLE LIABILITY CLAIMS VALUED AS OF 4/25114 CLAIM # EVENT DEPT CLAIMANT TYPE EXPENSES PAYMENT RESERVE STATUS DESCRIPTION DATE 0201100AL 2/27/10 PROPERTY APPRAISER National Car Rental PD 684.76 C STRUCK BY CTY VEHICLE 0201101AL 12/01/10 DEGNAN PD 792.28 C CTY VEHICLE BACKED INTO PRIVATE VEHICLE 0201102AL 11/29/10 WRIGHT PD 1,030.93 C PRIVATE VEHICLE STRUCK BY CTY VEHICLE 0201103AL 02/02/11 PUBLIC WORKS NEVERS PD 1,474.80 C BRANCH FELL ON VEHICLE 0201104AL 02/02/11 PUBLIC WORKS TUCKER PD C BRANCH FELL ON VEHICLE 0201105AL 1128111 FAC BETZ PD 887.60 C EMPLOYEE HIT OFFICIER'S TRUCK WITH WOOD 0201006AL 2126/11 FIRE RES JACKSON PD 1,357.23 C CUPPED THE FRONT BUMPER OF ANOTHER RECRUITS VEHICLE. 0201107AL 4/14/11 ROADS ORTUETA PD 973.20 C PIECE OF BURSH HIT THE WINDOW OF A VEHICLE. 0201108AL 8/2/11 FLEET GARCIA PD 4,326.43 C FUEL TRAILER BROKE LOOSE AND IMPACTED PARKED VEH. 0201109AL 8/29/11 ROADS TEJEDA PD 1,526.25 C PALM PHROM FELL ON VEHICLE 0201110AL 8/13/11 TECH SRVS BUDGET RENT A CAR PD 441.30 C RENTAL CAR WAS KEYED 0201200AL 10/25/11 FIRE RES ECHEVARRIA PD 1,231.20 C ENGINE 8 TURNED SHARPLY AND HIT PICK UP TRUCK 0201201AL 02/16/12 TRANSP. KRUMEL PD 500.00 O CTY VEHICLE HIT PRIVATE VEHICLE 0201202AL 02/21/12 TRANS ADVANTAGE RENT A CAR PD 243.32 C CTY VEHICLE STRUCK RENTAL CAR 0201203AL 05/03/12 HEALTH DEFT THRIFTY CAR RENTAL PD 754.55 C CTY VEHICLE STRUCK RENTALCAR 0201204AL 05/14/12 ROADS MENDEZ PD 676.39 C MOWER SHOT ROCKS AND BROKE WINDSHIELD -DENTS & SCRATCHES 0201205AL 9/20/12 KW LIB FIORE PD DENIED C BACKED VEHICLE INTO TREE LIMB 106 of 107 r -O JECOUNTY ITY VEHICLE UABIL CLAIMS 0201206AL 5/25/2012 FIRE RESCUE MARTINEZ P® CLAIMANT WILL REPAIR C R11S MIRROR TAPPED A DIRECT TV VAN 0201300AL 1/3/13 TRANS HASKINS PLUMBING PD 45.00 150.00 O COUNTY VEHICLE DROVE TO CLOSE BROKE MIRROR 0201301AL 02106/13 FIRE RES SHIPP PD 200.00 O ENGINE 22 GRAZED REAR CORNER OF PRIVATE VEH AIRPORT GATE CLOSED ON RENTAL VEHICLE 0201302AL 01/28/13 MARA AIRPORT NATIONAL CAR RENTAL PD 435.49 C 0201303AL 01/18/13 ROADS ROLEWICZ PD 1,230.38 C O C C HIT EXPOSED REBAR ON PALM DRIVE. DAMAGED TIRES AND RIMS COUNTY BUS AND PRIVATE VEHICLE STRUCK MIRROR TO MIRROR FIRE TRUCK BUMPED INTO FRONT END OF TRUCK CREW WAS WEEDEATING AND ROCK HIT CAR 0201304AL 06/13113 TRANS BALLARD Pp 500.00 0201305AL 6/20/13 MCFR KAUTZ PD 749.25 0201306AL 8/20/2013 PW MCGILVRA PD 420.83 0201400AL 12/2/13 FAC ZUCKER PD 1805.80 C HIT BY COUNTY VEHICLE WHILE BACKING 0201401AL 01/08/14 ROADS REDLAND COMPANY PD 1,649.47 C O COUNTY CHIPPER WAS BACKING UP AND STRUCK DUMP TRUCK BUS DRIVER BACKED INTO CAR 0201402AL 03/06/14 TRANSPORTATION BUTT PD 1,000.00 107 of 107