Item C13Meeting Date:_
May 21,
2014
Division: Employee
Services
Bulk Item: Yes
X
No
Department:--
Employee Benefits
Staff Contact Person/Phone #: Maria Gonzalez Ext. 4448
AGENDA ITEM WORDING: Approval to advertise a solicitation for proposals for a Group Term
Life Insurance and Accidental Death & Dismemberment (AD&D) policy for eligible active employees
and eligible retirees.
ITEM BACKGROUND: Current Group Term Life policy offered to eligible active employees and
eligible retirees:
Basic life: $20,000 (before age of 70).
Benefit reduction schedule: Active employees, ages 70-74: $14,000; age 75 and over $ 10,000;
Retirees - age 70 and over: $10,000.
AD&D $20,000 (Does not apply to Retirees)
Current rates (active employees and retirees): Life rate - $0.57 per $1000; AD&D rate $0.02 per
$ 1,000. Current annualized premium: approximately $223,000.
PREVIOUS RELEVANT BOCC ACTION: Policy originally secured in 2000 with Hartford Life;
RFP's done in 2001, 2007 and 2010. 2010 RFP resulted BOCC approval to continue policy with The
Hartford Life Insurance for two years. June 19, 2013 BOCC approved one additional year, with an
11 % increase in premium due to the County's experience. The current policy is 0through October 1,
214.
Advertising
TOTAL COST:—$800.00 INDIRECT COST: BUDGETED: Yes X No
DIFFERENTIAL OF LOCAL PREFERENCE:
Advertising
COST TO COUNTY:- $800.00 - SOURCE OF FUNDS: Primarily Ad Valorel
�AEJ VENUE PRODUCING: Yes No X AMOUNT PER MONTH— Year
County
APPROVED BY:•Att�* OPMB/Purchasing _ Risk Management
DOCUMENTATION: Included Not Required
1-101SPOSITION: AGENDAITEM#
Revised 7/09
REQUEST FOR PROPOSALS
FOR
GROUP TERM LIFE INSURANC
AND AD&D I
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
W I oll] 0 AA I 10 1 14�
CLERK OF THE CIRCUIT COURT EMPLOYEE SERVICES DIVISION
Amy Heavilin Employee Benefits
-,I 'LIVAMI v
ATTACHMENTS:
A. Group Life Insurance Policies
B. Life Insurance Census
C. Claim Data
D. Questionnaire
E. Pricing •
Attachment B & C to be added after BOCC approval and before advertising
The Proposer f•-• a contractprovide Gr• • Life Insurance and Accidental
Death • • County Employees.r• • Life Insurance only be
provided to Retirees. The initial contract term will be for one (1) year beginning October
1, 2014, or as soon thereafter as is possible and renewable at the County's option for up
to three (3) additional consecutive year terms dependent upon acceptability of cost,
coverage, service,provider staI• and market conditions.
The Basic Life amounts are non — contributory for active employees.
Accidental Death & Dismemberment benefits are included at an amount equal til
- life insurance amount for- employees only.
Under age 70
Age 70 — 74
Age 75 &
Older
Active
$20,000
$14,000
$10,000
• �� It •- -• • • •
wishingRetiree life insurance coverage is bundled with the medical plan. Retirees
to continue their- insurance coverage on •. • - basis
pay a premium of 1,1 per •
- - --
----------------------
Under age 70
Age 75 & Older
•• ---•
Li'/i
1111
1111
with 1 years or • -
of on or
Oct.•
F' retired employee insured on -• - I•- 1 1987 will on October• be
insured for the amountof •I•yee Life Insurance in force on • - •
1987.
Beginning
Period
• - 1�
1' '1 1
1• / /
i* / '1 1
Provide a Supplemental Life Insurance proposal providing a benefit of
either: 1X annual salary up to a maximum of $100,000; or Optional Life
in increments of it i1i up to a Maximum of r! !!.
a. The successful proposer must handle enrollment and participation
on a one on one basis directly with the participating employee. Any
administrative responsibilitiesof the Countybe •
the Proposal.
2. Calendar
RAT;
Activity
May 26, I '
- - Release-
5, 2014Deadline
for Vendor Questions
June 11, i
!'Addendum Release D.
June 25, !
• Opening i' I PM. No .. —swill be accepted
July 18, i14 flates )
1 Selection Committee -. iking Meeting_
August !County:•
.
• • • •' • i' •- • • •- • •• • •
------------
i • - • • • • i • • • • • f .
Monroe County is the southernmost
county United States. It iscomprised of
4 of 43
•. • •• i • i •. • sl'•' • •
To W IT MI
f1l •' / I• • • ♦I • • s • � 'I•• '
County,Monroe County currently offers Basic Life and AD&D coverage to Active Employees of
the • : • all seven Constitutionaloffices.• f' for ' plan extendsto
however,• • to the coverage through a deduction from
their pension
estimatedThe enrollmentbreakout is as follows:
Retirees: add #'s after completion of census
Active Employees: add Ws after completion of census
I I
FLWJ W-Iwl ILIA lam
go
•..�. • . #: :. •. your # • : including
all
f' I• .:• • • •.... • •
♦'
611111111 x�, �srrrt.�rrrsrF,
I Selection• • ' convened to review the Proposalsand recommend which
individual or firm should be selected for the project. The successful Proposer will be select
based on the following criteria. I
--------------------------------------
Cost of services
Fire
Experience and qualifications
20 points -------- -
Amount and breadth of coverage and
exclusions
i
20 points
5 of 43
35161MM
M 0zligel ill wA 219M I Is I I LI-2 I to] I I KIP Mye-Al 9 A I I I
Rol I rZj I I t:
q MI
5 points
ev-lr-- I a
•
i —
--- - ----------------
Total points earned are on a scale of 1 — 100 points
1 = lowest 100 = highest
0 11111 - 1 0 1 . . 0 0 0 6 0 0 0 0 0 0 - . 0 •
There will not be an interview process and Proposers will not be permitted to submit revise,a
proposals after the Bid Opening. Please ensure that you have submitted your best and fin
offer for the Bid Opening. i
5. Requests for Additioon larific- on
Requests for additional ML4tion gr Arificatl'n relating to the specifications
this Request for Proposals shall be submitted in writing directly to: I
1100 Simonton Street, Suite 2-268
Xey West, Florida 33040
Facsimile (305) 292-4452
All requests for additional information must be received no later than 3:00 PM,
June 5, 201 . Any requests received 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
the RFP. All questions must be submitted in writing. Oral requests will not be
answered.
All addenda are a part of the contract documents and each Proposer will be bound by
such addenda, whether or not received by him/her. It is the responsibility of each
Proposer to verify that he/she has received all addenda issued before responses are
opened.
DW0r*TRr-=- &M
VM_
A cover page that states: "Requests for Proposals for Group Term Life Insurance and
AD&D. The cover page should contain Proposers name, address, telephone number,
and the name of the Proposers contact person(s).
B. Tabbed Sections
Tab 1. Executive Summary
The Proposer shall provide a narrative ir s qualities and capabilities thall
f
demonstrates how the firm will work withihXounTtto fulfill the requirements of this
Service.
Tab 2. Experience and QualificationC.
• The Proposer shall be licensed in the State of Florida to provide the requested
insurance.
• The Proposer shall have an A.M. Best rating of A- or higher and a financial size
category of VI or higher.
• If the Proposer is not rated by A.M. Best or the A.M. Best rating is below A -NI,
proposer must submit three (3) years of independent audited financial
statements.
• The Proposer shall provide a minimum of five (5) customer references. At least
two (2) of these references must be from other governmental entities within the
State of Florida. Two (2) of the references must be from former customers.
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.
• The Proposer shall provide copies of all required licensestcertifications and/or
authorizations to conduct business in the state of Florida.
7 of 43
• Please include Section 2: Scope of Services, under this tab.
• If your response indicates that you can comply to the Scope of Services but wi
deviations, you must fully explain the deviations in this Tab. I
finTEREEME�m
Attachment E is the official pricing form and is to be provided under this
Tab. No other documents will be utilized for assessing the Cost of this
service. Please provide all of the parameters and contingencies for your
price quote on this form.
The fees 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.
Tab 5. Questionnaire
The Proposer shall include Attachment D — Questionnaire under Tab 5 in
the hard copy Proposal. The Proposer shall also include Attachment D —
Questionnaire, in the electronic version in the original Excel format.
Please note that the Attachment D — Questionnaire is an Excel docume
that is protected and the number of characters in each response is limite
The questions are designed to allow for brief answers and excessi
verbiage will not be an advantage to the Proposer. As shown in t
instructions, if your answer must exceed the space allocated in the Excl
document, you will have the opportunity to include your comple
response under Tab 6.
The successful Proposer will be required to sign a Business Associate
Agreement covering HIPAA and HITECH issues.
The Proposer shall provide copies of all materials that the County will ba
required to sign in order to implement the Life & AD&D Insurance Policy,
including but not limited to: a sample policy for the State of Florida,
application for Insurance, Required Disclosure Forms, Claim Forms, etc.
Proposer shall provide any additional project experience not already
8 of 43
Information '-•-II the spaceD
Questionnaire,be # - •in this section. please include
the complete question andrepeatyour • • -undertab.
scopeIf the Proposer cannot fully provide any of the elements in services, Section 2, or any other elements of this Request for Proposal
these must be spelled out in Tab 6 and labeled "Deviations".
In accordance with Section 2-347(h) of the Monroe County Code, the Proposer mu
provide the following information: i
9 of 43
partner, pdncipal, controlling shareholder or major creditor of the person
entity was an officer, director, general partner, pdncipal, controlling
shareholder or major creditor of any other entity that failed to perform
services or fumish goods similar to those sought in the request for
competitive • i
Proposer shall complete, execute, and attach the forms specified below which are
located in Section Three in this RFP, as well as a copy of a business tax receipt
from • • Office and shall include it in this section,i.e. Tab
Forms:
• SubmissioForm
n Response
• •1• _• and Conflictof -
• Non -Collusion Affidavit
Public• Drug Free Workplace Form
•
• Request forof
Any proposer claimin• . local preference as defined in Monroe County
O• 0• must completef - -nce Form and attach to t
Proposal.
8. COPIES OF " DOCUMEN A TTS
A. Only complete sets of RFP Documents will be issued and shall be us�e
preparing responses.• s•- ! : - •r• •
errorsor - i r • fromof incomplete
B. Complete sets of RFP Documents may be obtained in the manner and at
the locations stated in the Notice of Request for Proposals.
-- • • - r -• - ! • If•- - • •
Interested firms or • • requested to indicate their interest by i • the
following numbers of complete set of responses:
response f •rmat (on either a CD or • •'Ive) compatibliz,
with Microsoft Excel and Word as appropriate (PDF responses will not be
deemed responsive), plus
- three (3) signed originals, (clearly marked as original), plus
- seven (7) complete copies.
• • - - - • - • - 0
• - ' • • • • - • • f
ND&D" marked on the outside. The Proposals must be addressed to Monroe County
Purchasing Department, 1100 Simonton Street, Room 2-213, Key West, FL 33040, an 'I
must be received on or before 3:00 P.M. local time on June 25, 2014. Hand delivered
Proposals may request a receipt. No Proposals will be accepted after 3:00 P.M. Fax
tr e-mailed proposals shall be automatically rejected. It is the sole responsibility of
-ach Proposer to ensure its proposal is received in a timely fashion.
Both the hard copy and electronic Proposal originals will constitute the original
governing documents. In the case of any discrepancy between the original Proposal
and the copies, the original will be the governing document. In the case of any omissior
from one of the original documents, we will consider the information included in the
other original document.
i
A. NON -COLLUSION AFFIDAVIT: Any person submitting a proposal in
response to this invitation must execute the enclosed NON -COLLUSION
AFFIDAVIT. If it is discovered that collusion exists among the Proposers,
the proposals of all participants in such collusion shall be rejected, and no
participants in such collusion will be considered in future proposals for the
same work. -
PUBLIC ENTITY oed CRIMEapersoorFaffinliate who has been placed on the
cnvictvendoo r list fl c) g a c . tio e
for a public entity crimmay
not submit a proposal o ontrac to provide any goods or services to a
public entity, may not submit a proposal on a contract with a public entity
for the construction or repair of a public building or public work, may not
submit Proposals on leases or perform work as a contractor, supplier,
subcontractor, or contractor under a contract with any public entity, and
may not transact business with any public entity in excess of the threshold
amount provided in Section 287.017, Florida Statutes, for CATEGORY
TWO for a period of 36 months from the date of being placed on the
convicted vendor list. Category Two: $25,000.00
C. DRUG -FREE WORKPLACE FORM: Any person submitting a bid or
proposal in response to this invitation must execute the enclosed DRUG -
FREE WORKPLACE FORM and submit it with his/her proposal. Failure 4,
complete this form in every detail and submit it with the bid or proposal
may result in immediate disqualification of the bid or proposal.
D. LOBBYING AND CONFLICT OF INTEREST ETHICS CLAUSE: Any
person submitting a bid or proposal in response to this invitation must
execute the enclosed LOBBYING AND CONFLICT OF INTEREST
CLAUSE and submit it with his/her bid or proposal. Failure to complet
this form in every detail and submit it with the bid or proposal may res
in immediate disqualification of the bid or proposal. I
11 of 43
A. Each Proposer shall carefully examine the RFP and other contract
documents, and inform himself/herself thoroughly regarding any and all
conditions and requirements that may in any manner affect cost,
progress, or performance of the work to be performed under the contract.
Ignorance on the part of the Proposer shall in no way relieve him/her of the
obligations and responsibilities assumed under the contract.
B. Should a Proposer find discrepancies or ambiguities in, or omissions
from, the specifications, or should he be in doubt as to their meaning, he
shall at once notify the County.
The Proposer is required to be familiar with and shall be responsible for complying with
all federal, state, and local laws, ordinances, rules, professional license requirements
and regulations that in any manner affect the work. Knowledge of business tax
requirements for Monroe County and municipalities within Monroe County are the
responsibility of the Proposer.
13. PREPARATION OF RESPONSES
Signature of the Propose
iEMJJ
Written modifications will be accepted from Proposers if addressed to the entity
and address indicated in the Notice of Request for Competitive Solicitation and received
prior to Proposal due date and time. Modifications must be submitted in a sealed
envelope clearly marked on the outside, with the Proposers name and "PROPOSAL
FOR PROVIDING GROUP TERM LIFE INSURANCE AND AD&D." If sent by mail or
by courier, the above -mentioned envelope shall be enclosed in another envelope
addressed to the entity and address stated in the Notice of Request for Proposals.
Faxed or e-mailed modifications shall be automatically rejected.
The Proposer is solely responsible for all costs of preparing and submitting ti
'response, regardless of whether a contract award is made by the County. 0
12 of 43
i M-:4=101=1NA
Responses will be received until the designated time and will be publicly opened.
Proposers' names shall be read aloud at the appointed time and place stated in the
Notice of Request for Competitive Solicitation. Monroe County's representative
authorized to open the responses will decide when the specified time has arrived and
no responses received thereafter will be considered. No responsibility will be attached
to anyone for the premature opening of a response not properly addressed and
identified. Proposers or their authorized agents are invited to be present.
The County reserves the right to reject any and all responses and to waive
Responses that contain modifications that are incomplete, unbalanced, conditional,
obscure, or that contain additions not requested or irregularities of any kind, or that do
not comply in every respect with the Instruction to Proposer, may be rejected at the
option of the County.
A. The County reserves the right: to waive any informality in any response,
reject all proposals, or to re -advertise for all or part of the work contemplated.
0 X-
C. The recommendation of staff shall be presented to the Board of County
Commissioners of Monroe County, Florida, for final selection and award of contract.
1`1.5 113 NFL% F-2111111i"
The Proposer shall be responsible for all necessary insurance coverage as
indicated below. Certcates of Insurance must be provided to Monroe County within
fifteen ,� 1 5�, darAs after award of
insured as indicated. If the proper insurance forms are not received within the fifteen
(15) I
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 havi
an agent for service of process in the State of Florida. Companies shall have an A M ,
Best rating of VI or better. The required insurance shall be maintained at all times,whi
Proposer is providing service to County.
13 of 43
Employers' Liability Insurance
Bodily Injury by Accident
Bodily Injury by Disease, policy limits
Bodilv Iniury by Disease- eanW
General Liability, including
Premises Operation
Products and Completed Operations
s.';Ianket Contractual Liability
I-lersonal Injury Liability
Fxpanded Definon of Property Damage
Statutory Limits
. lot to
Oil:
off off
If split limits are provided, the minimum limits acceptable shall
$500,000 per person
$1,000,000 per occurrence
,-IPA $100,000 property damage
4000,000 per Occurrence
$2,000,000 Aggregate
policy. Monroe County shall be named as an Addonal Insured on the General Liability
The Proposer to whom a contract is awarded shall defend, indemnify and hold
harmless the County as outlined below.
The Proposer covenants and agrees to indemnify, hold harmless and defend
Monroe County, its commissioners, officers, employees, agents and servants from any
and all claims for bodily injury, including death, personal injury, and property damage,
including damage to property owned by Monroe 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.
In the event that the service is delayed or suspended as a result of the
Proposer/Vendor's failure to purchase or maintain the required insurance, the Vendor
14 of 43
shall indemnify the County from any and all increased expenses resulting from such
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 n(f
way limited to, reduced, or lessened by the insurance requirements contained
elsewhere within this agreement.
The County intends to make an award to the Proposer that has complied with the
terms, conditions and requirements of the RFP. Any agreement resulting from this RFP
must be approved by the Monroe County Attorney, must be governed by the laws of the
State of Florida, and must have venue established in the State of Florida. The
2greement approved by the Monroe County Attorney will be submitted to the Monroe
County Board of County Commissioners for final approval.
•' •
•
Deliverables: ,! • provide a policy
Yes, Can Comply but
Yes
No
with Specified
Service
Can
Cannot
Deviations (please
Comply
Comply
detail deviations
below
Waive Actively at Work
requirements for the initial
enrollment.
The County will provide a
list of covered individuals at
implementation and the
insurer will accept these as
FT
covered individuals.
Provide a toll free
telephone number and
sufficient staffing to handle
inquiries directly from staff
and plan members.
Provide prompt
reimbursement of claims.
Provide estimated renewal
rates 180 days in advance
of renewal.
Provide firm renewal rates
45 days in advance of
renewal.
All charges for any service
or optional service must be
clearly outlined in the
pricing Attachment.
No party to this Agreement
shall be required to enter
into any arbitration
proceedings related to the
-Agreement.
Comply with the Florida
Local Government Prompt
Payment Act, Section
218.70, Florida Statutes.
The Provider shall submit to
the County an invoice with
supporting documentation in
a form acceptable to the
Clerk. Following receipt of
the invoice, the County will
have 45 days to pay the
invoice without interruption
of service.
The CONTRACTOR may
terminate this Agreement
with ninety (90) days' notice
to the COUNTY.
The COUNTY may terminate
this Agreement with or
without cause upon thirty
(30) days' notice to the
CONTRACTOR. COUNTY
shall pay CONTRACTOR for
work performed through the
date of termination.
Disclose any commissions
and/or service fees that are
included in your rate
quotation, including the
amount of the commissions
and/or service fees, to whom
they may be paid and your
reason(s) for including them.
Provide firm rates for the
effective date of the policy
based on the information
provided in the RFP.
Pursuant to Florida Statute
§119.0701, Contractor and its
subcontractors shall comply
with all public records laws of
the State of Florida, specifically
to:
(a) Keep and maintain
public records that ordinarily
and necessarily would -
17 of 43
required by Monroe County
in the performance of this
Agreement.
(b) Provide the public
with access to public records on
the same terms and conditions
that Monroe County would
provide the records and at a
cost that does not exceed the
cost provided in Florida
Statutes, Chapter 119 or as
otherwise provided by law.
(c) Ensure that public
records that are exempt or
confidential and exempt from
public records disclosure
requirements are not disclosed
except as authorized by law.
(d) Meet all requirements
for retaining public records
and transfer, at no cost, to
Monroe County all public
records in possession of the
contractor upon termination
of this Agreement and =;
destroy any duplicate public IA
=
records that are exempt or E
confidential and exempt from
public records disclosure
requirements. All records
stored electronically must be
provided to Monroe County
in a format that is compatible
with the information
technology systems of
Monroe County.
The CONTRACTOR does
hereby consent and agree to
indemnify and hold harmless
the COUNTY, its Mayor, the
Board of County
Commissioners, appointed
Boards and Commissions,
Officers, and the Employees,
and any other agents,
individually and collectively,
from all fines, suits, claims,
demands, actions, costs,
obligations, attorney's fees, or
liability of any kind arising out of
the sole negligent actions of the
18 of 43
CONTRACTOR or substantial
and unnecessary delay caused
by the willful nonperformance of
the CONTRACTOR and shall
be solely responsible and
answerable for any and all
accidents or injuries to persons
or property arising out of its
performance of this contract.
The amount and type of
insurance coverage
requirements set forth
hereunder shall in no way be
construed as limiting the scope
of indemnity set forth in this
paragraph. Further the
CONTRACTOR agrees to
defend and pay all legal costs
attendant to acts attributable to
the sole negligent act of the
CONTRACTOR.
19 of 43
•N THREE: COUNTY FORMS.
MS
page intentionally left blank,
20 of 43
I have Included:
• Response Form ❑
• Lobbying and Conflict of Interest Clause ❑
• Non -Collusion Affidavit ❑
• Drug Free Workplace Form ❑
• Public Entity Crime Statement ❑
• Copy of business tax receipt from the ❑
Tax Collector's office
• Local Preference Form (if applicable) ❑
❑ I have included a current copy of the following professional licenses and business tax receipts:
(soleIf the applicant is not an individual supply
APPLICANT ORGANIZATION:
(Registered business name must appe e'tactly as
Telephone:
Fax: Date
Witness:
(Print Name)
(Title)
STATE OF:
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on
(date) by
to me or has produced
identification.
My Commission Expires:
(name of affiant). He/She is personally known
(type of identification) as
21 of 43
SWORN STATEMENT UNDER ORDINANCE NO. 010-1990
MONROE COUNTY, FLORIDA
"...warrants that he/it has not employed, retained or otherwise had act on his/her behalf
any
former r officer or employee • a of Sectionof Ordinance • 1 1'
1990 or any County officer or employee in violation of Section 3 of Ordinance No. 010-
1990. For breach or violation of this provision the 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
•I+
STATE OF:
(type of identification) as identification
(Signature)
+
(name of affiant). He/She is
22 of 43
NON-001L1LLISQN=,F,1,,FFID"IT
mm--,
1, of the city of
law on my oath, and under penalty of pedury, depose and say that
M • •' Me
1 1 am of the firm
of the bidder
making the Proposal for the project described in the Request for Proposal
for and that I executed
the said proposal with full authority to do so;
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
with any competitor;
3. Unless otherwise required by law, the prices which have been quoted in thi
bid have not been knowingly disclosed by the bidder and will not knowingl
be disclosed by the bidder prior 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
the purpose of restricting competition;
5. The statements co I rf" his affil avit are true and correct, and made
with full knowledg t at - " oe Co4' relies upon the truth of the
statements contai t s ffidavi rin awarding contracts for said project]
B��
Date:
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 (type of identification)
as identification.
NOTARY PUBLIC
My Commission Expires:
23 of 43
DRUG -FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies
that:
(Name of Business)
1 . Publishes a statement notifying employees that the unlawful manufacture,
distribution, dispensing, possession, or use of a controlled substance is
prohibited in the workplace and specifying the actions that will be taken agains)l
employees for violations of such prohibition.
2. Informs employees about the dangers of drug abuse in the workplace, the
business' policy of maintaining a drug -free workplace, any available drug
counseling, rehabilitation, and employee assistance programs, and the penalties
that may be imposed upon employees for drug abuse violations.
3. Gives each employee engaged in providing the commodities or contractual
services that are under bid a copy of the statement specified in subsection (1).
4. In the statement specified in subsection (1), notifies the employees that, as a
condition of working on the commodities or contractual services that are under
bid, the employee will abide by the terms of the statement and will notify the
employer of any conviction of, or plea of guilty or nolo contendere to, any
violation of Chapter 893 (Florida Statutes) or of any controlled substance law of
the United States or any Wam, for a lation c urring in the workplace no later
Tc
than five (5) days after su h nvictl
5. Imposes a sanction on, ��quire Aeatisfa ory participation in a drug abuse
assistance or rehabilitation program if such is available in the employee's
community, or any employee who is so convicted.
1,,. Makes a good faith effort to continue to maintain a drug -free workplace through
implementation of this section.
As the person authorized to sign the statement, I certify that this firm complies fully with
the above requirements.
EZ=
V0
STATE OF:
COUNTY OF:
Subscribed and sworn to (or affirmed) before me on
7-Em
(name of afflant). He/She is personally known to me or has
(type of identification) as identification.
ROTARY PUBLIC
My Commission Expires: __
24 of 43
I have
• the above and state that neither(Proposers
nor any Affiliate has been placed on the convicted vendor
•
months.
(Signature)
Date:
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
(type of identification) as identification.
NOTARY PUBLIC
My Commission Expires:
25 of 43
MONROE COUNTY,FLORIDA
RISK MANAGEMENT
POLICY AND PROCEDURES
CONTRACTr •
Indemnification andHold Harmless
j
The Contractor covenants and agrees to indemnify and hold harmless Monroe County
Board of County Commissioners from any and all claims for bodily injury (including
death), personal injury, and property damage (including property owned by Monroe
County) and any other losses, damages, and expenses (including attorney's fees) which
arise out of, in connection with, or by reason of services provided by the Contractor or
any of its Subcontractor(s) in any tier, occasioned by negligence, errors, or other
wrongful act of omissionof the Contractoror •' • -
rs in any tier, their
employees, or agents.
In the event the completion of the project • include the work of others)delayed or
suspended as a result of the Contractor's failure to purchase or maintain the required
insurance, the Contractor • - County• • all increased
expenses resulting from such delay.
The first ten dollars ($10.0 Jof I
0) ,I-emuneratir",— paid to the Contractor is for the
The extent of . •ility is in no way limited to, reduced, or lessened by - insurance
requirements contained elsewhere within this agreement.
26 of 43
0 1I;J*M,•
AND
Prior to the commencement of work governed by this contract, the Contractor shall
obtain Workers' Compensation Insurance with limits sufficient to respond to the
applicable state statutes.
In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not
less than:
$1,000,000 Bodily Injury by Accident
$1,000,000 Bodily Injury by Disease, policy limits
$1,000,000 Bodily Injury by Disease, each employe.-,
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact
business in the state of Florida.
If the Contractor has been apo )ed by4 i Florid3's Department of Labor, as an
authorized self -insurer, the County shall recognize and honor the Contractor's status.
The Contractor may be required to submit a Letter of Authorization issued by the
Department of Labor and a Certificate of Insurance, providing details on the
Contractor's, Excess Insurance Program.
If the Contractor participates in a self-insurance fund, a Certificate of Insurance will be
required. In addition, the Contractor may be required to submit updated financial
statements from the fund upon request from the County.
27 of 43
GENERAL LIABILITY
Prior to the commencement of work governed by this contract, the Contractor shall
obtain General Liability Insurance. Coverage shall be maintained throughout the life of
the contract and include, as a minimum:
• Premises Operations
• Products and Completed Operations
• Blanket Contractual Liability
• Personal Injury Liability
• Expanded Definition of Property Damage
The minimum limits acceptable shall be:
If split limits are provided, the minimurl- its ac*Wable shall be:
$500,000 per Person
$1,000,000 per Occurrence
$100,000 Property Damage
An Occurrence Form policy is preferred. If coverage is provided on a Claims Mad(. -
policy, its provisions should include coverage for claims filed on or after the effectivs
1ate of this contract. In addition, the period for which claims may be reported should
axtend for a minimum of twelve (12) months following the acceptance of work by the
County.
The Monroe County Board of County Commissioners shall be named as Additiona.
Insured on all liability policies issued to satisfy the above requirements.
28 of 43
Recognizing that the work governed by this contract involves the furnishing of advice or
services of a professional nature, the Contractor, shall purchase and maintain,
throughout the life of the contract, Professional Liability Insurance which will respond to
damages resulting from any claim arising out of the performance of professional
services or any error or omission of the Contractor arising out of work governed by this
contract.
24 of 43
There will be times when it will be necessary, or in the best interest of the County, to
deviate from the standard insurance requirements specified within this manual.
Recognizing this potential and acting on the advice of the County Attorney, the Board of
County Commissioners has granted authorization to Risk Management to waive and
modify • provisions.
Specifically excluded from this authorization is the right to waive:
beingThe County as as an r'•itional Insured — If a letter from
Insurance • •. •- presented, • that they are unable
unwilling to name the County as an Additional Insured, Risk Management has
not been granted the authority to waive this provision.
The Indemnification
Waiving of insurance provisionsQ01d exc A the'lunty tn economic loss. For this
reason, every attempti tc.•- • •• •. • insurance requirements.
If a waiver or a modification is desired, a Request forof Insurance
Requirement form should be completed and submitted for consideration with the
proposal.
After consideration by Risk Management and if approved, the form will be returned, to
the County Attorney who will submit the Waiver with the other contract documents for
execution by the Clerk of the Courts.
Should Risk Managementdeny this Waiver Request, the other party may file an appea.'
with the County Administratoror the Board of Countyi • • retains
final decision -making •
30 of 43
Request For Waiver
of
Insurance Requirements
It is requested that the insurance requirements, as specified in the County's Schedule
Insurance Requirements, be waived or modified on the following contract: i
Contractor:
Contract for:
Address of Contractor:
Phone:
Scope of Work:
Reason for Waiver:
Policies Waiver
will apply to:
Signature of Contractor:
Approved Not Approved
Risk Management:
Date:
County Administrator appeal:
Approved Not Approved
Date:
Board of County Commissioners appeal:
Approved Not Approved
Meeting Date:
1:j ZIC09.11 4
SIGNATURE
31 of 43
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 the 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 on 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 Cquigyfrom whig the subcontractor operates:
Tel. Number
Print Name:
Signature and Title of Authorized Signatory for
Bidder/Responder
STATE OF:
reTelifin-IRV073
Subscribed and sworn to (or affirmed) before me on
(date) by (name of affiant). He/She is personally known to me or has
produced
identification.
(type of identification) as
NOTARY PUBLIC
My Commission Expires:
32 of 43
MONROE COUNTY BOARD
Life and Acold i ental Death and Dismemberment
The following provisions are applicable to residents of Florida.
THE BENEFITS OF • - • •' r • - • •1nzVr• -
• • - • - ■
Group Life Insurance (Benefits
CERTIFICATE OF INSURANCE ..................... PAGE
SCHEDULE OF INSURANCE 2
Who is eligible for coverage? ................................................................................................................................ 3
When wilt You become eligible? (Eligibility Waiting Period) ........................... . ............. 3
What is Evidence of Good Health?.. 3
When will Evidence of Good Health be required? . ............................... 3
...........
re .....................................
What Life benefits aavailable to You? ......................... ..............,.. 3
What Life Benefits are available to Retirees? . ............' 3
What AD&D Benefits are available to You?....................................................................................................... 4
What reductions in Your coverage will occur due to Your age............................................................'............"" 4
ELIGIBILITY AND ENROLLMENT.. u age?............................................................................. 4
Must You contribute toward the cost of coverage?............................................................................. ......... 5
How do You request coverage for Yourself? , ........°°°.° 5
When does coverage start? 5
What is the Deferred Effective Date.provision for Rettireireess??...........................................
°°......°...................................•..............................,....................... 5
What is the Deferred Effective Date provision for employees? ......................... ....... "`.."•""""°""` 5
Whenare changes effective? ............................. ..............
BENEFITS......... ....................................... 6
LifeInsurance Benefit..................................................°..................,....................,............................................. 6
Accelerated Death Benefit .............. "'""' ................................ 6
Accidental Death and Dismemberment (AD&D) Benefit ............... ....
,........
.......................... ........................ 6
TERMINATION.................................•.............................................. 7
Whendoes Your coverage terminate?........................................•..°°°....... ................ °°............................................ 9
Under what conditions can Your insurance be continued under the continuation provisions? ................ CONVERSION PRIVILEGE.,......... 9
GENERAL PROVISIONS....................'............,..................................................................,...............,.........,....... 1 I
DEFINITIONS ...... ................ ..........• 12
STAILTORY" PROVISIONS.....................................................................................,.................,......................... 13
15
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY
Hartford, Connecticut
(Herein called Hartford Life)
CERTIFICATE OF INSURANCE
under Master Group Insurance .Policy GVL-016007
Effective August 1,1989
Issued by
Hartford Life
TRUSTEE OF
THE PUBLIC EMPLOYERS INDUSTRY GROUP VOLUNTARY LIFE AND DISABILITY INSURANCE
TRUST
(Herein called the Policyholder)
This is to certify that We have issued and delivered the above named Group Insurance Policy (Policy) to The
Policyholder. The Policy provides group insurance benefits to the Participant Employer's employees who:
• are eligible for the insurance;
become insured; and
continue to be insured,
according to the terms of the Policy.
The terms of the Policy which affect an employee's insurance are contained in the following pages. This Certificate
Of Insurance and the following pages will become Your Booklet -certificate. This Booklet -certificate is a part of the
Policy. 'This Booklet -certificate replaces any other which We may have issued to the Participant Employer to give to
You under the Policy specified herein.
C.
09
Richard G. Costello, Secretary John C. Walters, President
GBD-1100 As (303613) GL 1.6 (FNC) 2
St,me of the terns used within this Booklet -certificate are capitalized and have special meanings. Please refer to the
definitions at the end of this Booklet -certificate when reading about Your benefits.
SCHEDULE OF INSURANCE
Final interpretation of all provisions and coverages will be governed by the Group Insurance Policy on file with
Hartford Life at its home office.
The Participant Employer: MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
Account Number: 303613
Policy Effective Date: October 1, 1999
Anniversary Date: October I of each year, beginning in 2011.
Who is eligible for coverage?
Eligible Class(es): All Active Full-time Employees who are U.S. citizens or U.S.
residents, excluding temporary and seasonal employees
When will You become eligible? (Eligibility Waiting Period)
If You are working for the Employer prior to the Policy Effective Date and were covered under the Prior Plan, You
are eligible for coverage on the later of the Policy Effective Date or the date You enter an eligible class.
If You start working for the Employer after the Policy Effective Date, You will be eligible for coverage on the date on
which You complete a waiting period of 60 days of continuous service.
Retirees are eligible for coverage on the later of
1. the date on which the individual meets the definition of a Retiree; or
2. the Policy Effective Date.
What is Evidence of Good Health?
Evidence of Good Health is information about a person's health from which We can determine if coverage or
increases in coverage will be effective. Information may include questionnaires, physical exams, or written
documentation as required by Us,
Inquiries as to the status of Your submission of Evidence of Good Health should be addressed to Your Employer
and/or Benefit Administrator, We, Your Employer and/or Benefit Administrator will notify You of approvals. We
will notifv You, in writing, of any disapprovals.
When will Evidence of Good Health be required?
Evidence of Good Health is required if You elect no coverage when eligible to do so and later opt for coverage for any
Amount of Life Insurance for Yourself.
Evidence of Good Health must be provided at Your own expense.
If. Evidence of Good Health is not approved in the situation(s) described above, no coverage will become effective.
AMOUNT OF LIFE INSURANCE
Employee and Retiree Only
What Life benefits are available to You?
Amount of Life Insurance:
An amount equal to $20,000.
What Life benefits are available to Retirees?
Amount of Life Insurance:
Employees with 10 or more years of service, who retired on or after October 1, 1987 have an amount of Life
Insurance equal to $20,000, which is reduced to $10,000 at age 70,
Employees who retired, and elected Life Insurance benefits, prior to October 1, 1987 have an amount of Life
Insurance equal to the amount of Employee Life Insurance in force on September 1, 1987.
Employees who retired, and did not elect Life Insurance benefits, prior to October 1, 1987 have an amount of Life
Insurance equal to lesser of,
I - 50% of the amount of Life Insurance in force on the day before the date of retirement; or
2. $5,000.
Are there other limitations which apply to Amounts of Life Insurance for Employees and Retirees?
Your Amount of Life Insurance will be reduced by any life benefit!
1, paid to You under an accelerated death benefit in the Prior Plan; and
2. in force for You under any disability extension provision of the Prior Plan.
If You convert, does It affect the Amount of Life Insurance benefit payable?
The Amount of Life Insurance under the Policy will be reduced by the amount of the individual life insurance issued
in accordance with the Conversion Privilege for reasons other than reductions in coverage.
ACCIDENTAL DEATH, DISMEMBERMENT
AND LOSS OF SIGHT BENEFIT (AD&D)
Employee Only
NOTE: NOT APPLICABLE TO RETIREES,
What AD&D Benefits are available to You?
Principal Sum:
An amount which equals the Amount of Life Insurance in force for You.
The Principal Sum will not exceed the Amount of Life Insurance for which You are insured
REDUCED AMOUNTS OF INSURANCE
What reductions in Your coverage will occur due to Your age?
NOTE: NOT APPLICABLE TO RETIREES.
Your Amount of Life Insurance and Principal Sum will decrease by 33% on the Anniversary Date which occurs on or
next follows the date You attain age 70 and by 50% when You attain age 75. The reduction will apply to the Amount
of Life Insurance and Principal Sum in force immediately Prior to that Anniversary Date.
Additionally, if.
I - You become insured under the Policy; or
2. Your coverage increases,
on or after the date You attain age 70, We reduce the amount of coverage for which You would otherwise be eligible
in the same manner.
Reduced amounts of Life Insurance and Principal Sum will be rounded to the next higher multiple of $1000, if not
already such a multiple.
ELIGIBILITY AND ENROLLMENT
Must You contribute toward the cost of coverage?
With respect to active Employee Life Insurance and AD&D coverage, You do not contribute toward the cost,
With respect to Retiree Life Insurance coverage, you may have to contribute towards the cost.
How do You request coverage for Yourself!
if You are not required to contribute toward the cost of coverage, You are not required to request coverage.
Enrollment will be automatic. However, You will be required to complete a beneficiary election form.
When does coverage start?
If You are not required to contribute toward the cost of coverage, You will become insured on the date You become
eligible for coverage.
All effective dates of coverage are subject to the Deferred Effective Date provision.
What is the Deferred Effective Date provision for Retirees?
If Retiree is confined at home, in a hospital or elsewhere because of a physical or mental condition on the date an
increase in coverage or a new benefit added to the Policy would otherwise have become effective, the effective date of
any increase or additional benefit will be deferred until the Retiree is discharged from the hospital or no longer
confined and has engaged in substantially all the normal activities of a healthy person of the same age for a period of
at least 15 days in a raw.
"Confined elsewhere" means the individual is unable to perform, unaided, the normal functions of daily living, or
leave home or other place of residence without assistance.
What is the Deferred Effective Date provision for employees?
If You are absent from work due to a physical or mental condition on the date Your insurance, an increase in coverage
or a new benefit added to the Policy would otherwise have become effective, the effective date of Your insurance, any
increase in insurance or the additional benefit will be deferred until the date You return to wont as an Active Full-time
Employee.
Are there exceptions to the Deferred Effective Date provision?
NOTE: NOT APPLICABLE TO RETIREES
If You were insured under the Prior Plan on the day before the Policy Effective Date and You would be eligible for
coverage on the Policy Effective Date except that You are not able to meet the requirements of the Deferred Effective
Date provision. then:
1. the Deferred Effective Date provision will not apply to the original effective date of coverage; and
2. the coverage amount shown in the Schedule of Insurance will not apply to You.
Instead, You will be considered to be insured and Your coverage amount will be the lesser of:
the Amount of Life Insurance and Principal Sum under the Prior Plan; or
^. the Amount of Life Insurance and Principal Sum shown in the Schedule of Insurance,
reduced by;
1. any coverage amount in force or otherwise payable due to any disability benefit extension under the Prior Plan; or
2. any coverage amount that would have been in force due to any disability benefit extension under the Prior Plan
had timely election for the disability provision been made.
You will remain insured under this provision until the first to occur of -
I. the date You return to work as an Active Full-time Employee;
2, the date Your insurance terminates for a reason stated under the Termination provision;
3. the last day of a period of 12 consecutive months which begins on the Policy Effective Date; or
4. the last day You would have been covered under the Prior Plan, had the Prior Plan not terminated.
When are changes effective?
The provisions, terms and conditions of the Schedule of Insurance or this Booklet -certificate may be modified,
amended or changed at any time; consent from any covered individual is not required.
If there is any type of change in Your class, the Schedule of Insurance or the Booklet -certificate which:
1. decreases an amount of coverage or deletes, limits or restricts the availability of a benefit or provision, then that
decrease, deletion, limitation or restriction will be effective on the date the change in class, the Schedule of
Insurance or the Booklet -certificate is effective;
2. increases an amount of coverage or adds, improves or increases availability of a benefit or provision, then that
increase, addition or improvement will be effective on the date the change in class, the Schedule of insurance or
the Booklet -certificate is effective, subject to application of the Deferred Effective Date provision and Our
approval where Evidence of Good Health is required.
BENEFITS
Life Insurance Benefit
To whom and how are benefits paid?
A completed claim form, a certified copy of the death certificate and Your enrollment form must be sent to the
Employer or Us. When the required claim papers are received and approved by Us, the Amount of Life Insurance will
be paid.
Your death benefit will be paid in a lump sum to the beneficiary(ies) designated by You in writing and on file with the
Employer.
Unless You have requested something different, payment will be made as follows:
I . if more than one beneficiary is named, each will be paid an equal share.
2. if any named beneficiary dies before You, His share will be divided equally among the named surviving
beneficiaries.
If no beneficiary is named, or if no named beneficiary survives You, We may, at Our option, pay:
1. up to 5500 of Your life insurance to any party that We deem is entitled because of their payment of burial
expenses. We will be released from further liability for any amount so paid; and/or
2. the executors or administrators of Your estate; or
3. Your surviving relatives in the following order:
a) all to Your surviving spouse; or
b) if Your spouse does not survive You, in equal shares to Your surviving children; or
c) if no child survives You, in equal shares to Your surviving parents.
If a minor does not have a legal guardian, We may, until such a guardian is appointed, pay the person We deem to be
caring for and supporting him. Such payment will be in monthly installments of not more than $200.
If a death benefit payable meets Our guidelines, then the benefit is payable into a checking account. Your beneficiary
owns the checking account. A lump sum payment may be elected by writing a check for the full amount in the
checking account.
Accelerated Death Benefit
What is the benefit?
If You are diagnosed as being Terminally III and proof of such diagnosis is provided by an attending physician
licensed to practice in the United States, and You are:
I. less than age 60; and
2, insured for at least $10,000,
then You may request that a portion of Your Amount of Life Insurance be paid to You prior to death.
The request cannot exceed 80% of the in force Amount of Life Insurance, and is subject to a minimum of $3,000 and
a maximum of $500,000. You may exercise this option only once per person.
For example, if You have an Amount of Life Insurance equal to $20,000 and You are Terminally Ill, You can request
any portion of the life insurance between $3,000 to $16,000 to be paid to You now instead of to Your beneficiary at
Your death. However, if You decide to request only $3,000 now, You cannot request the additional $13,000 in the
future.
What does Terminal Illness/Terminally III mean?
Terminally III or Terminal Illness means that an individual has a life expectancy of 12 months or less.
RECEIPT OF ANY BENEFITS IN ACCORDANCE WITH THIS PROVISION WILL REDUCE LIFE
INSURANCE BENEFITS PAYABLE UPON DEATH.
What if an individual is no longer Terminally in?
If diagnosed as no longer Terminally 111, coverage may or may not remain in force. Coverage which remains in force
will be reduced by any amount of Accelerated Death Benefits received and premium is due for this reduced amount.
If coverage does not remain in force, then the reduced amount of coverage may be converted.
What limitations apply to this benefit?
The Accelerated Death Benefit provision will be subject to all applicable terms and conditions of the Policy.
No Accelerated Death Benefit will be paid if You are required by law to accelerate benefits to meet the claims of
creditors, or if a government agency requires You to apply for benefits to qualify for a government benefit or
entitlement.
What if You made an assignment under this plan?
If You have executed an assignment of rights and interest with respect to Your Amount of Life Insurance, in order to
pay benefits to You under this provision, We must receive a release from the individual to whom the assignment was
made before any benefits are payable.
Accidental Death and Dismemberment (AD&D) Benefit
Employee Only
NOTE: NOT APPLICABLE TO RETIREES.
What conditions are necessary for benefits to become payable?
We will pay a benefit if You suffer an accidental injury while insured and:
1. a Loss results directly from such injury, independent of all other causes; and
2. such Loss occurs within 90 days after the date of the accident causing the injury.
When should We be notified of a claim?
A claimant must give Us, or Our appropriate representative, written notice of a claim within 20 days after the loss
happens or starts. If notice cannot be given within that time, it must be given as soon as possible after that.
Such notice must include:
L the claimant's name and address; and
2. the Policy or account number.
Are special forms required to file a claim?
Within 15 days of receiving a notice of claim, We or Our appropriate representative will send forms to the claimant
for providing proof of loss. If the forms are not provided within 15 days, the claimant may submit any other written
proof which fully describes the nature and extent of claim.
When must Proof of Loss be given?
Satisfactory written proof of loss must be sent to Cis or Our appropriate representative, within 90 days after the date of
such loss. However, all claims must be submitted to Us within 90 days of the date any individual's insurance
terminates.
If proof is not given by the time it is due, it will not affect the claim if
-
I , it was not possible to give proof within the required time; and
2, proof is given as soon as possible, but no later than a year after it is due unless the claimant is not legally
competent.
When and to whom will Your claim be paid?
Benefits for Loss of life will be paid in accordance with Your life insurance beneficiary designation. Unless otherwise
specified, benefits for all other Losses are payable to You.
Benefits for all other Losses will be paid as soon as due written proof is received. Benefits for all other Losses will be
paid not more than 60 days after written proof is received.
Any payments, other than for Loss of life, which are owing at Your death may be paid to Your estate. If any payment
is owed to:
1. Your estate;
2. a person who is a minor; or
3. a person who is not legally competent,
then We may pay up to $1,000 to Your relative who is entitled to it in Our opinion. Any such payment shall fulfill
Our responsibility for the amount paid.
What types of injuries are excluded from coverage?
No benefit will be paid for a Loss caused or contributed to by:
I. sickness;
2. disease;
3. any medical treatment for items (1) or (2),
4, any infection, except a pus -forming infection of an accidental cut or wound;
5. war or any act of war, whether war is declared or not;
6. any injury received while in any armed service of a country which is at war or engaged in armed conflict;
7, any intentionally self-inflicted injury, suicide, or suicide attempt, whether sane or insane;
8. taking drugs, sedatives, narcotics, barbiturates, amphetamines or hallucinogens unless prescribed for or
administered by a licensed physician; or
9. the injured person's intoxication.
Intoxication means that blood alcohol content or the results of other means of testing blood alcohol level, meet or
exceed the legal presumption of intoxication under the law of the state where the accident took place.
What is the benefit payable?
The benefit payable for any Loss is that which is shown opposite the Loss in the following schedule. The Principal
Sum is shown in the Schedule of Insurance. No benefit is payable for any Loss which is not shown in the schedule
below.
DESCRIPTION OF LOSS
Loss of life
Loss of a hand
Loss of a foot
Loss of an eye
More than one of the above
resulting from one accident
RENEFIT
Principal Sum
One-half the Principal Sum
One-half the Principal Sum
One-half the Principal Sum
Principal Sum or the sum of
the Benefits payable for each
Loss, whichever is lesser.
Loss means the following:
1. Loss of a hand or foot means that it is completely cut off at or above the wrist or ankle joint.
2. Loss of an eye means that sight in the eye is completely lost and cannot be recovered or restored.
TERMINATION
Employee and Retiree Coverage
When does Your coverage terminate?
Unless continued in accordance with the Exceptions to Termination section, Your insurance will terminate on the first
to occur of
I . the date the Policy terminates;
2. the last day of the period for which You made any required premium contribution, if You fail to make any
further required contribution;
3. the date You are no longer in a class eligible for coverage;
4. the date Your Employer terminates Your employment;
5. the date You arc absent from work as an Active Full-time Employee; or
6. the date on which Your Employer ceases to be a Participant Employer.
EXCEPTIONS TO TERMINATION
Vnder what conditions can Your insurance be continued under the continuation provisions?
If You are absent from work as an Active Full-time Employee, Your insurance may be continued up to the maximum
period of time stated. In each instance, such continuation shall be at the Employer's option, but must be according to a
plan which applies to all employees in the same way. Continued coverage:
1. is subject to any reductions in the Policy;
2. is subject to payment of premium by the Employer; and
3. terminates when the Policy terminates or Your Employer ceases to be a Participant Employer,
If You are on a documented leave of absence, other than Family or Medical Leave, all of Your coverages, upon
approval by the Employer, may be continued for 6 consecutive month(s) following the month in which the leave of
absence commenced.
If You are granted a leave of absence according to the Family and Medical Leave Act of 1993, all of Your coverages
may be continued for up to 12 weeks, or 26 weeks if You qualify for Family Military Leave, or longer if required by
state law, following the date Your insurance would have terminated, subject to the following:
l . the leave authorization must be in writing;
2. the required premium for You must be paid;
3. Your benefit level will be that which was in effect on the day before said leave started, subject to any reductions
included in the Policy;
4. the amount of Earnings upon which Your benefit may be based, will be that which was in effect on the day
before said leave started; and
5. continued coverage will cease immediately if one of the following events should occur:
a) the leave terminates prior to the agreed upon date;
b) the Policy terminates or Your Employer ceases to be a Participant Employer;
c) You or the Policyholder fail to pay premium when due; or
d) the Policy no longer insures Your class.
In all other respects, the terms of Your insurance remain unchanged.
Family Military Leave of Absence: If Your spouse or child enters active full-time military service outside of the
continental United States, Hawaii, Puerto Rico or Alaska, and You:
1) have been employed with the same employer for at least two years; and
2) have completed 1,250 hours of service during a 12 month period immediately prior to the
date Military Leave of Absence would begin; and
3) have exhausted all the other time made available to you by Your Employer except sick time
and short term disability;
Then Your coverage may be continued for up to 30 days. If the leave ends prior to the agreed upon date, this
continuation will cease immediately.
To elect a Family Military Leave of Absence, You must notify Your Employer at least 14 days prior to the date the
leave would begin if the leave would consist of five or more consecutive work days. For a leave of less than five
days, the Employee should give notice as soon as reasonable possible.
If You are absent from work due to sickness or injury, all of Your coverages may be continued until the last day of a
period of 12 month(s) which begins on the date You were first absent from work as an Active Full-time Employee. If
You feel that Your condition may continue for an extended period of time, You should request that Your Employer
file a waiver of premium claim.
What Is Waiver of Premium?
Waiver of premium is a provision which allows for continued employee life insurance, without payment of premium,
while You are Disabled. This provision does not apply to Retirees.
To what coverages does the Waiver of Premium apply?
These provisions apply only to Your Life insurance.
Waiver of Premium does not apply to any AD&D Insurance.
Wbat conditions must be satisfied before You qualify for Waiver of Premium?
1. You must be less than age 60, insured and Disabled; and
2. acceptable proof of Your condition must be famished to Us within one year of Your last day of work as an
Active Full-time Employee.
What does Disabled mean?
Disabled means that You have a condition that prevents You from doing any work for which You are or could become
qualified by education, training or experience and it is expected that this condition will last for at least six consecutive
months from Your last day of work as an Active Full-time Employee; or You have been diagnosed with a life
expectancy of 12 months or less.
When will We waive premium?
We will waive premium after proof that You are Disabled is provided by an attending physician licensed to practice in
the United States and We approve the proof. You will be notified by Us of the date We will begin to waive premium.
Continued coverage will be subject to any age reductions provided by any part of the Policy.
What if You die before You qualify for Waiver of Premium?
IF
1. You should die within one year of Your last day of work as an Active Full-time Employee but prior to qualifying
for waiver of premium; and
2. You were Disabled,
We will pay the Amount of Life Insurance which is in force for You.
Can We have You examined for proof that You continue to be Disabled?
During the first two years following the date You qualify as Disabled, We may have You examined at reasonable
intervals. 'Thereafter, We will only require an annual examination to confirm that You continue to be Disabled. If
You fail to submit any required proof or refuse to be examined as required by Us, then Your coverage will terminate.
What If You are no longer Disabled?
If, for any reason, You are no longer Disabled, Your premium will no longer be waived. On that date, You may or
may not return to work.
If You return to work in an Eligible Class, then all of Your coverages will be reinstated subject to the terms of the
Policy in effect on the reinstatement date.
If You do not return to work within an Eligible Class, and You are not eligible for any other group life insurance, then
You are entitled to the Conversion Privilege. You may convert the Amount of Life Insurance that is in force for You
on the date it is determined that You are no longer Disabled
On the date waiver of premium terminates, if You do not return to work, You will be entitled to convert Your
coverage. You may convert no more than Your Amount of Life insurance that is in force on the date waiver of
premium terminates.
What if the Policy terminates before You qualii� for waiver of premium?
If the policy terminates or an Employer ceases be a Participant Employer, before You qualify for waiver of premium,
You may be eligible to convert. Additionally, You may later be approved for waiver of premium.
What if the Policy terminates after You qualify for waiver of premium?
termination of the Policy, or an Employer ceasing to be a Participant Employer, will not. affect Your coverage under
the terms of this provision.
CONVERSION PRIVILEGE
The following does not apply to any AD&D Benefits.
When can an individual convert?
If insurance, or any portion thereof terminates, then any individual covered under the Policy may convert his life
insurance to a conversion policy without providing Evidence of Good Health.
If the qualifying event is policy termination, termination of coverage for a class, or Your Employer is no longer a
Participant Employer then the individual must have been insured for at least s years under the Policy in order to be
eligible for this conversion privilege.
What is the conversion policy?
The conversion policy will:
be on one of the life insurance policy forms, except term insurance, then customarily issued by Us for conversion
purposes;
contain no disability, supplementary or AD&D benefits; and
be effective on the 32nd day after group life insurance terminates.
How much can be converted?
If the qualifying event is policy termination, termination of coverage for a class, or Your Employer is no longer a
Participant Employer then the amount which may be converted is limited to the lesser of:
1. the amount of group coverage in force prior to the qualifying event, reduced by the amount of any other group
coverage for which the individual becomes covered within 31 days of termination of group coverage; or
2. $2,000.
If conversion is due to retirement or any other qualifying event, the full amount of coverage lost may be converted
How does an individual convert coverage?
To convert life insurance, the individual must, within 31 days of the date group coverage terminates, make written
application to Us and pay the premium required for his age and class of risk.
What if death occurs during the conversion election period?
If the individual should die within the 31 day conversion election period, We will, upon receipt of acceptable proof of
His death, pay the Amount of Life Insurance He was entitled to convert.
GENERAL PROVISIONS
When can this plan be contested?
Except for non-payment of premium, the Policy cannot be contested after two years from the Policy Effective Date.
No statement relating to insurability will be used to contest the insurance for which the statement was made after the
insurance has been in force for two years during the individual's lifetime. In order to be used, the statement must be in
writing and signed by the affected individual.
Who interprets policy terms and conditions?
We have full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and
Provisions of the Policy.
Ire there any rights of assignment?
Except for the dismemberment benefits under the AD&D Benefit, You have the right to absolutely assign all of Your
rights and interest under the Policy including, but not limited to, the following:
I. the right to make any contributions required to keep the insurance in force;
2. the privilege of converting; and
3. the right to name and change a beneficiary.
No absolute assignment of rights and interest shall be binding on Us until and unless:
1. the original of the form documenting the absolute assignment; or
2. a true copy of it,
is received and acknowledged by Us at our home office.
We have no responsibility:
I. for the validity or effect of any assignment; or
2. to provide any assignee with notices which We maybe obligated to provide to You.
Flow do You designate or change Your beneficiary?
You may designate or change a beneficiary by doing so in writing on a form satisfactory to Us and filing the form
with the Employer. Only satisfactory forms sent to the Employer prior to Your death will be accepted.
Designations will become effective as of the date You signed and dated the form, even if You have since died. We
will not be liable for any amounts paid before receiving notice of a beneficiary change from the Employer.
In no event may a beneficiary be changed by a Power of Attorney.
Can We have a claimant examined or request an autopsy?
We reserve the right to have a claimant examined and to have an autopsy performed, if not forbidden by law. Any
such examinations will be as reasonably required by Us and at Our expense.
What notification will You receive if Your claim Is denied?
If a claim for benefits is wholly or partly denied, the claimant will be furnished with written notification of the
decision. This written decision will:
1, give the specific reason(s) for the denial;
2. make specific reference to the provisions upon which the denial is based; and
3. provide an explanation of the review procedure.
What recourse do You have if Your claim is denied?
On any denied claim, the claimant or His representative may appeal to Us for a full and fair review.
The claimant may:
1, request a review upon written application within 60 days of receipt of claim denial;
2. review pertinent documents; and
3. submit issues and comments in writing.
A request for an appeal will not be denied if not submitted within 60 days if it is not reasonably possible to make such
request within 60 days. in this case, the request must be submitted as soon as reasonably possible thereafter,
A decision will be made by Us no more than 60 days after the receipt of the request, except in special circumstances
(such as the need to hold a hearing), but in no event more than 120 days after the request for review is received.
When can legal action be taken?
Legal action cannot be taken against Us:
1. sooner than 60 days after proof of loss has been furnished; or
2. 3 or more years after the time proof of loss is required to be furnished according to the terms of the Policy.
How does this plan affect Workers' Compensation coverage?
The Policy does not replace Workers' Compensation or affect any requirement for Workers' Compensation coverage.
Physician -patient Relationship
You may choose any licensed physician, We shall not in any way disturb the physician -patient relationship.
DEFINITIONS
Active Full-time Employee — An employee who works for the Employer on a regular basis in the usual course of the
Employer's business. An employee must work at least the number of hours in the Employer's normal work week. This
must be at least 25 hours. You will be considered actively at work with Your Employer on a day which is one of
Your Employer's scheduled work days if You are performing, in the usual way, all of the regular duties of Your job
on a fill( -time basis on that day. You will also be considered actively at work on a paid vacation day or a day which
is not one of Your Employer's scheduled work days only if You were actively at work on the preceding scheduled
work day -
Anniversary Date — The date occurring in each calendar year which is an anniversary of the Policy Effective Date,
]Employer -- The Participant Employer named in the Schedule of Insurance,
HetHis — He or she. His or her.
Participant Employer — An Employer who agrees to participate in the Trust, pays the required contribution for His
employees and is a Participant in accordance with the provisions of the Policy.
Policy Effective Date —The effective date of the Participant Employer's plan of insurance shown in the Schedule of
Insurance.
Prior Plan — A plan of group term life insurance sponsored by the Employer which was in force on the day before the
Policy Effective Date.
Retiree — A former Active Full-time Employee of the Employer who:
• has completed at least 10 years of active Full-time service with the Employer; and
• is participating in an Employer -sponsored plan.
Or
• has completed a total of 10 years of active full-time service with Florida Government Agencies; and
• is eligible for immediate benefits under the Florida State .Retirement System.
Trust — The Public Employers Industry Group Voluntary Life and Disability Insurance Trust.
We/Us/Our —The Hartford Life and Accident Insurance Company.
You/Your — The employee to whom this Booklet -certificate is issued.
STATUTORY PROVISIONS
LIFE
The following provision is applicable to residents of Florida and is included to bring Your Booklet -certificate into
conformity with Florida state law.
Conversion Privilege
The amount of $2,000 appearing in the Life Conversion Privilege is amended to read $10,000.
The Plan Described in this Booklet
is Insured by the
Hartford Life and Accident Insurance Company
Hartford, Connecticut
Member of The Hartford Insurance Group
account.1. Provide the name, address and telephone number of the office that wil se i
this • provide the name -
person who will have _
responsibility.•
3. Provide the location f•' be paid.
4. What are your •• of Loss requirements?Please be specific
timing and maximum allowable timeframe
• •
life claims, from the receipt of properly completed claim
the claim payment? For 5. What is the proposed claim office's current turnaround time (in business days) fc
• .
;
plan.6. Are all or any of the coverages quoted portable? Yes No _ if yes, what ar
the costs associated with portability and for what period of time?
7. Currently, MCBCC employees have the option to convert coverage Describ
the conversion Policies available for each class of participant. In'clude aril,
restrictions contained in those policies.
8. Describe all costs associated with conversion from each plan to an individua
9. Do the life rates assume waiver of • No yes, is there _
ny
cost associated with waiverof premium?
l Fully describe any costs• -• with the Continued Life Insurance
Total during
Disability provisions of - in force Life Insurance certificate.
11. Describe in detail,• definition of disability
duringInsurance Total Disability provisionsof •
rce Life Insurance
12. Describe the enrollment assistance that you will provide to MCBCC during Open
Enrollment. Include samples of materials that would be included in the enrollment
package.
13. Are you capable of enrolling employeesdirectly •. your
Enrollment and providing reports to the Benefits Department? Is there a fee for
Open
this service?
14, What are the guaranteed issue amounts for the supplemental options?
15. Describe the options available to MCBCC to provide Certificates of Coverage U
plan participants. Are you willing to mail certificates directly to employee' ---
residences at no additional charge? Yes — No
16. Will you provide an accelerated death benefit? Yes No Indicate
conditions under which such benefits would be paid. SpE�c�i the percentage of
benefits withheld if an accelerated benefit is sought. Describe completely how
this benefit works.
17. Describe fully any exclusions or limitations to the coverages you are proposing.
Specifically address:
- suicide
- piloting an airplane
- skydiving or recreational diving
- felony
driving while under the influence (DUI)
18. Describe any additional benefits available (without additional cost), such as seal
belt riders, etc.
19. Fully describe all benefits that are being provided under the AD&D policy.
k" 0 - List the AD&D exclusions as well as whether there are any time limitations.
21. Describe a claimant's payment options, and any services available to the
beneficiaries.
ATTACHMENT E -
PRICING