COI Insurance Waiver-WC 2018 Cdinon
MONROE COUNTY, FLORIDA
REQUEST FOR WAIVER OF INSURANCE REQUIREMENTS
It is requested that the insurance requirements, as specified in the County's Schedule of insurance
Requirements, be waived or modified on the following contract.
Contractor /Vendor: 2 4Q � � '0Qa SPS q ‘CSLS o Key UJFY "AK-
Project or Service: Anf tTD &_____S2 S
ContractoriVendor
Address & Phone 17 — 50 f (_L Ale,
( s_4 4/ 33 605) Aci LI - L 783
General Scope of Work: n k‘40(2-, D(L\ R J�cV ic.Q.5
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Reason for Waiver or
Modification:
Policies Waiver or
Modification will apply to: __ t
Signature of Contractor /Vendor: ,...c.3 e„...... -_
Date: �/ y . . proved t ..../ Not Approved
Risk Management Signature: i , 1 - Ail
Date:
_County Administrator appeal:
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