Item I2
BOARD OF GOVERNORS
FIRE AND AMBULANCE DISTRICT 1
AGENDA ITEM SUMMARY
Meeting Date: M~l, 2003
Division: County Administrator
Bulk Item: Yes
No X
Department: Fire Rescue
AGENDA ITEM WORDING: Approval of Business Associate Addendum with Advanced Data
Processing, Inc. (ADPI) to ensure that ADPI is carrying out its obligation under the Health Insurance
Portability and Accountability Act (HIPAA) which protects the privacy ofprotecled health insurance
information of patients that are being billed by AD PI for Monroe County.
ITEM BACKGROUND: On April 14, 2003, it became necessary for a Business Associate Addendum
be drawn up in order that the privacy regulations pursuant to Pubtic Law 104-191 of August 21, 1996,
known as the Health Insurance Portability and Accountability Act of 1996, Subtitle F - Administrative
Simplification, Sections 261, et seq., as amended ((HIP AA), ensure the protection of the privacy of any
personally identifiable protected health information (PHI) that is collected, processed or learned as a
result of the Billing Services provided.
PREVIOUS RELEVANT BOCC ACTION: On August 16,2000, Board of Governors approved
contract with Advanced Data Processing for Rescue Ambulance Billing and related professional
services. On June 19,2002, Board of Governors approved Contract Addendum to extend the tenn of
the original Agreement for an additional one (1) year period through August 31, 2003.
CONTRACT/AGREEMENT CHANGES: Additional language as included in the Business
Associate Addendum between Advanced Data Processing, Inc. and Monroe County to ensure that
HIP AA regulations effective April 14, 2003 are canied out.
ST AFF RECOMMENDATIONS: Approval.
TOTAL COST: Nt A
COST TO COUNTY: N/A
BUDGETED: Yes
No
SOURCE OF FUNDS: Nt A
REVENUE PRODUCING: Yes
NoX
AMOUNT PER MONTH_ Year
FIRE CHIEF APPROVAL:
Clark O. Martin, Jr.
~ 0-/'>/"3
~ LU;l'./
James L. Roberts
ACTING COUNTY_ADMlNIS"I'.R81'OR
To Follow K NorR~qt !teu
APPROVED BY: County Atty YES
DIVISION DIRECTOR APPROVAL:
DOCUMENTATION:
DISPOSITION:
Included
AGENDA ITEM # ~ / ~../
Revised 01103
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract #
--
Contract with: Advanced Data Processing, Effective Date: April 14, 2003
Inc. (ADPI)
Expiration Date: August 31, 2003
Contract Purpose/Description: Business Associate Addendum with ADPI to ensure that ADPI
carries out its obligations under the Health Insurance Portability and Accountability Act
(HIP AA) to protect the privacy of any health insurance information of patients being billed by
ADPI for Monroe County.
Contract Manager: Clark o. Martin, Jr.
(Name)
6004
(Ext. )
Fire Rescue
(Department)
for BOCC meeting on May 21 , 2003
Agenda Deadline: May 07,2003
CONTRACT COSTS
Total Dollar Value of Contract: $ N/ A Current Year Portion: $ N/ A
Budgeted? YesO No 0 Account Codes: _-_-_-_ -
Grant: $ __-_-_
County Match: $ _-_-_-_
- - -
----
ADDITIONAL COSTS
Estimated Ongoing Costs: $ N/Nyr For: N/A
(Not included in dollar value above) (eg. maintenance, utilities, janitorial, salaries, etc.)
CONTRACT REVIEW
Changes
Neededri /l~.ewer
Division Director YesO Nol...:] (2...
Risk Management 5"'11 I()~ YesO Nog- ~
O.M.B./Purchasing Sill\) .::3esO NO~~ 0
County Attorney '-/134~3 YesDNo[], ~
Date Out
Date In
S""/~3
51 .,/03
Comments:
OMB Form Revised 9/11/95 Mep #2
-J--
Business Associate Addendum
Advanced Data Processing, Inc. and Second Review, Inc.
(hereinafter collectively referred to as "Business Associates") and Monroe
County hereby amend the Agreement entered into on September 1,2000,
("the Agreement") by adding the following additional language to the
Agreement.
1. ADPI shall carry out its obligations under this Addendum in
compliance with the privacy regulations pursuant to Public Law
104-191 of August 21, 1996, known as the Health Insurance
Portability and Accountability Act of 1996, Subtitle F -
Administrative Simplification, Sections 261, et seq., as amended
("HIPAA"), to protect the privacy of any personally identifiable
protected health information ("PHI") that is collected, processed or
learned as a result of the Billing Services provided hereunder. In
conformity therewith, Business Associates agree that they will:
a. Not use or further disclose PHI except as permitted under this
Addendum or required by law;
b. Use appropriate safeguards to prevent use or disclosure of PHI
except as permitted by this Addendum;
c. To mitigate, to the extent practicable, any harmful effect that is
known to Business Associates of a use or disclosure of PHI by
Business Associates in violation of this Addendum.
d. Report to Monroe County any use or disclosure of PHI not provided
for by this Addendum of which Business Associates become aware;
e. Ensure that any agents or subcontractors to whom Business
Associates provide PHI, or who have access to PHI, agree to the
same restrictions and conditions that apply to Business Associates
with respect to such PHI;
f. Make PHI available to Monroe County and to the individual who
has a right of access as required under HIPAA within 30 days of
the request by Monroe County regarding the individual;
g. Incorporate any amendments to PHI when notified to do so by
Monroe County;
h. Provide an accounting of all uses or disclosures of PHI made by
Busifless Associates as required under the HIPAA privacy rule
within sixty (60) days;
1. Make their internal practices, books and records relating to the use
and disclosure of PHI available to the Secretary of the Department
of Health and Human Services for purposes of determining
Business Associates' and Monroe County's compliance with HIPAA;
and
J. At the termination of the Agreement, return or destroy all PHI
received from, or created or received by Business Associates on
behalf of Monroe County, and if return is infeasible, the
protections of this Addendum will extend to such PHI.
2. The specific uses and disclosures of PHI that may be made by
Business Associates on behalf of Monroe County include:
a. The preparation of invoices to patients, carriers, insurers and
others responsible for payment or reimbursement of the services
provided by Monroe County to its patients;
b. Preparation of reminder notices and documents pertaining to
collections of overdue accounts;
c. The submission of supporting documentation to carriers, insurers
and other payers to substantiate the health care services provided
by Monroe County to its patients or to appeal denials of payment
for same.
d. Uses required for the proper management of Business Associates
as business associates.
e. Other uses or disclosures of PHI as permitted by the HIPAA privacy
rule.
3. Notwithstanding any other provisions of this Addendum, the
Agreement may be terminated by Monroe County if ADPI has
violated a term or provision of this Addendum pertaining to AD PI's
material obligations under the HIPAA privacy rule, or if ADPI
engages in conduct which would, if committed by Monroe County,
result in a violation of the HIPAA privacy rule by Monroe County.
2
IN WITNESS WHEREOF, each of the undersigned has caused this
AddenduIIYto be duly executed in its name and on its behalf effective as
of April 14, 2003.
Monroe County, Florida
By:
Print Name:
Title:
Date:
Advanced Data Processing, Inc.
By:
Print Name:
Title:
Date:
Second Review, Inc.
By:
Prin t Name:
Title:
Date:
3
--
.-
CONTRACT ADDENDUl\I
for
RESCUE Al\'IBULANCE BILLING
& RELATED PROFESSIONAL SERVICES
TillS CONTRACT ADDENDUM is made and entered into this 19th day of.
June , 2002, between the Board of Governors, Fire and Ambulance
District 1, of Monroe County, Florida, and Advanced Data Processing, Inc.
WHEREAS, on August 16, 2000, the parties entered into an agreement for the
period of September 1, 2000 through August 31, 2002; and
WHEREAS, under the terms and conditions of the agreement, the COUNTY has
the option to renew this agreement for two (2) additional one (1) year terms by giving at
least sixty days notice to CONTRACTOR; and
WHEREAS, the COUNTY desires to renew this agreement for an additional one
(1) year term; now therefore,
IT IS AGREED as follows:
1. The contract between the County of Monroe and Advanced Data Processing, Inc.
shall be extended for the period of September 1, 2002 through August 31, 2003.
In all other respects, the agreement between the parties dated September 1, 2000
remains in full force and effect.
IN WITNESS WHEREOF, the parties have hereunto set their hands and seal, the
day and year first written above.
".--' -....~...
~.~ - -, .,:....:...
;;~~~S~~0\l!
, :'~~-~.:~~~]\.I~n~S.1:'DANNY L.
"~".~.~'_.'-~--:,.:-
By: .
'-- Dep
BOARD OF GOVERNORS OF
FIRE AND AMBULANCE DISTRICT 1
OFMONROECO~FLOIDDA
Mayor! ,. airman
\
'.
By:
~
CONTRACT #
Date:
.,--
CONTRACT BETWEEN
THE COUNTY OF MONROE
AND
ADVANCED DATA PROCESSING. INC.
FOR RESCUE AMBULANCE BILLING & RELATED PROFESSIONAL SERVICES.
-,--
THIS CONTRACT, hereinafter "CONTRACT OR AGREEMENT", made and entered into
this ~day of September, 2000 by and between MONROE COUNTY, a political
subdivision of the State of Florida, with principal offices located at 490 63rd Street,
Marathon, FL 33050, hereinafter referred to as the "COUNTY", and Advanced Data
Processing, Inc., a Florida Corporation with principal offices located at 520 NW 165
Street, Suite 201, Miami, Florida 33169, hereinafter referred to as the
"CONTRACTOR" .
WITNESSETH:
WHEREAS, the parties hereto now wish to enter into an agreement, pursuant to
which the CONTRACTOR will render those professional services in connection with said
project as hereinafter provided;
NOW THEREFORE, the parties hereto agree as fol/ows:
1. DEFINITION OF THE PROJECT. The objective of the project is to utilize the
services of the CONTRACTOR to provide the COUNTY with ambulance billing and
related services.
2. SCOPE OF SERVICES. The CONTRACTOR shall perform and carry out the work
tasks presented in CONTRACTOR'S Scope of Work (Exhibit Al, as summarized herein.
All payments shal/ be paid directly to 'MONROE COUNTY BOARD OF COUNTY
COMMISIONERS' or via "Locked-Box" facility as directed by the COUNTY.
3. TIME OF PERFORMANCE. This Contract shal/ be effective for a two-year period
from September 1, 2000 through August 31, 2002 , under the terms and
conditions contained herein unless otherwise terminated. The COUNTY may, at its
option, renew this agreement for two (2) additional one (1) year terms under the then
in force terms and conditions by giving notice to CONTRACTOR at least sixty (60) days
prior .to expiration of the current term. Monroe County's performance and obligation to
pay under this contract, is contingent upon an annual appropriation by the Board of
County Commission.
4. COMPENSATION AND METHOD OF PAYMENT. The COUNTY reserves the right to
request changes in the services within the general scope of the Contract to be
performed upon mutual agreement by the COUNTY and CONTRACTOR which shall
specify the change ordered and the adjustment of time and compensation required
therefore.
Agreement Page 1 of 6
AmOUlance billing 0. Kelalea ;:)~l v
CONTRACT #
, ~~~-
Date:
Any serv!;:.es added to the scope of this Contract by a change order shall be
executed in camp-Hance with all other applicable conditions of this Contract. No claim
for additional compensation or extension of time shall be recognized unless contained in
the duly executed change order.
The CONTRACTOR shall provide to the COUNTY a monthly invoice representing
fees for the services provided computed as:
Seven percent (7%) of all monies collected by CONTRACTOR, excluding
Medicaid accounts, during the previous month. Pursuant to Florida Statute 409.913(9),
CONTRACTOR will include in the same invoice an amount of $11.40 per Medicaid
account for providing all billing services related to such accounts processed in the
previous month. The COUNTY shall issue a check for the amount invoiced, minus any
disputed amount, within thirty (30) days of receipt and acceptance of the invoice.
The COUNTY shall bear the cost of any and all Lock-box services. All other costs
incurred by CONTRACTOR in the performance of services as specified herein (including,
but not limited to postage, materials, communications and phone costs and, other
operating costs) shall be borne by the CONTRACTOR.
5. REPORTS. The CONTRACTOR shall provide the COUNTY with status reports as set
forth in Exhibit A and other reports as mutually agreed. The CONTRACTOR shall also
provide changes to such reports and ad hoc report requests on a reasonable basis and
as mutually agreed.
6. DATA TO BE FURNISHED BY COUNTY. The COUNTY will make available to the
CONTRACTOR, for use in performance of services under this Contract, all available
reports, studies or any other materials in its possession that may be useful to the
CONTRACTOR. All material furnished by the COUNTY will not be disclosed to any
party without the COUNTY's prior approval.
7. INDEPENDENT CONTRACTORS. The CONTRACTOR is an independent, contractor
and not an employee or agent of the COUNTY with the following exception:
To the extent necessary to fulfill its billing and collection efforts
under the Agreement, the CONTRACTOR is authorized to sign in an
administrative capacity for the COUNTY the following types of standard
forms and correspondences only: probate filings; letters to patients or
their representatives verifying that an account is paid in full; forms
verifying the tax-exempt status of the COUNTY; and insurance filings
and related forms. The CONTRACTOR has no authority to sign any
document that imposes any liability on the COUNTY.
The CONTRACTOR shall retain full control over the employment, direction,
compensation and discharge of all persons assisting in the performance of service by
CONTRACTOR. The CONTRACTOR shall be fully responsible for all matters relating to
payment of employees, including compliance with Social Security, withholding tax and
all other laws and regulations governing such matters. The CONTRACTOR shall be
Agreement Page 2 of 6
..AmtlulanCe billing 6< Kelaleu .;)<::1 v
CONTRACT # Date:
responsible for i~own acts and those of its agents and employees during the term of
this contract.--
8. INDEMNIFICATION. The CONTRACTOR shall indemnify and hold the COUNTY
harmless from any and all claims, losses and causes of actions which may arise out of
the performance of this Agreement as a result of an act of negligence, of the
CONTRACTOR, its employees. agents, representatives, consultants. or its
SUBCONTRACTORS. The CONTRACTOR shall pay all claims and losses of any nature
whatsoever in connection therewith and shall pay all costs and judgements (including,
but not limited to.. attorneys' fee and expenses and cost of defense provided on bef:1alf
of the COUNTY), that may issue thereon. The above provisions shall survive the
termination of this Agreement and shall pertain to any occurrence during the term of
this Agreement. even though the claim may be made after the termination hereof.
Nothing contained herein is intended nor shall be construed to waive COUNTY's
rights and immunities under the common law or Florida Statutes 768.28, as amended
from time to time.
9. INSURANCE. The CONTRACTOR shall maintain the following insurance coverage:
1) Worker's Compensation Insurance in compliance with Florida Statutes, Chapter
440 and applicable Federal Acts as they may be amended from time to time; and
2) General Liability insurance in an amount no less than $1,000,000 per occurrence.
3) Coverage for business interruption, destruction of data processing equipment and
media, liabilities affecting accounts receivables, contracts and independent
contractors and, valuable documents in an amount no less than $100,000
aggregate;
4) liability coverage for all vehicles whether owned, hired or used in the amount of
$500,000; and
5) Professional liability coverage in the amount of $500,000.
Where applicable all coverage above shall be amended with MONROE COUNTY BOARD
OF COUNTY COMMISSIONERS named as an additional insured. All of the policies of
insurance so required to be purchased and maintained shall contain a provision or
endorsement that the coverage afforded shall not be canceled, materially changed or
renewal refused until at least thirty (30) calendar days written notice has been given to
the COUNTY by certified mail. Prior to commencing work, the CONTRACTOR shall
provide COUNTY with certified copies of all insurance policies providing coverage as
required. Any indemnification provisions in this Agreement are separate and apart and
in no way limited by the insurance amounts stated above.
The liabilities of the CONTRACTOR under this Agreement shall survive and not be
terminated, reduced. or otherwise limited by any expiration or termination of insurance
coverages.
Agreement Page 3 of 6
'.Ambulance Billing & Related :serv
CONTRACT # Date:
10. OWNERStllP OF DOCUMENTS. CONTRACTOR shall be required to work in
harmony with other consultants relative to providing information requested in a timely
manner and in the specified form. The CONTRACTOR agrees that any and all
documents, records, disks, and electronic data produced in the performance of this
Agreement shall be the sole property of the COUNTY, including all rights therein of
whatever kind except as may otherwise be provided hereinafter. Failure to turn over
such documents within seven (7) days of when requested may be cause for the
COUNTY to withhold payments due CONTRACTOR or to enforce this clause by legal
remedies.
11. ATTACHMENTS. The following named attachments are made an integral part of
this Agreement:
A. Proposal presented to Monroe County EMS by Advanced Data Processing dated
July 6, 2000 (Exhibit A attached hereto and made a part hereof) which includes the
Contract with the City of Boca Raton (referenced herein as the "piggyback").
B. Public Entity Crime Statement and Sworn Ethics Clause
Where terms, conditions or scope of services stated in either this Agreement or the
above attachments conflict, this Agreement and any superceding Amendments thereof
shall prevail.
12. TERMINATION for CAUSE. During the time of this agreement the COUNTY may
terminate this Agreement after first giving to CONTRACTOR notice of default and
opportunity to cure the default within thirty (30) days after receipt of such notice. In
the event the acts constituting default are a violation of law, CONTRACTOR shall be
subject to immediate termination of contract. Notwithstanding the provisions above,
the COUNTY shall not have any right to cancel this contract without cause.
Upon termination, the CONTRACTOR shall submit an invoice(s) to the COUNTY in an
amount(s) that representing fees for services actually performed or obligations incurred
to the date of effective termination for which the CONTRACTOR has not been
previously compensated. Upon payment of all sums found due, the COUNTY shall be
under no further obligation to the CONTRACTOR, financial or otherwise.
13. UNCONTROLLABLE FORCES. Neither the COUNTY nor CONTRACTOR shall be
considered to be in default of this Agreement if delays in or failure of performance shall
be due to Uncontrollable Forces, the effect of which, by the exercise of reasonable
diligence, the non-performing party could not avoid. The term "Uncontrollable Forces"
shall mean any event which results in the prevention or delay of performance by a party
of its obligations under this Agreement and which is beyond the reasonable control of
the non-performing party. It includes, but is not limited to fire, flood. earthquakes,
storms, lightning, epidemic, war, riot, civil disturbance, sabotage, and governmental
actions.
Neither party shall, however, be excused from performance if non-performance is due
to forces that are preventable, removable, or remediable nor which the non-performing
party could have, with the exercise of reasonable diligence. prevented, prevented.
Agreement Page 4 of 6
"Ambulance Billing & Related Serv
CUNTRACT #
. -::3- .....
Date:
removed, or rem~jed with reasonable dispatch. The non-performing party shall, within
a reasonable timeof being prevented or delayed from performance by an uncontrollable
force, give written notice to the other party describing the circumstances and
uncontrollable forces preventing continued performance of the obligations of this
Agreement.
14. JURISDICTION, VENUE and CHOICE OF LAW. All questions pertaining to the
validity and interpretations of this Contract shall be determined in accordance with the
laws of the State of Florida. Any legal action by either party against the other
concerning this agreement shall be filed in Monroe County, Florida, which shall be
deemed proper jurisdiction and venue for the action.
15. PIGGYBACK. It is hereby a precondition of any part of this Agreement that the
Most Favorable Terms of CONTRACTOR's Agreement with the City of Boca Raton
(dated March 17, 1999) shall be extended to the COUNTY including any modifications,
amendments or exclusions for the term of referenced agreement. Effectively, this
allows the COUNTY to piggyback the agreement with the City of Boca Raton.
16. ASSIGNMENT OF CONTRACT. The CONTRACTOR shall not sell, transfer, assign
or otherwise dispose of this Contract or any part thereof or work provided therein, or of
its right, title or interest therein, unless otherwise provided in the contract, without
express prior consent by the COUNTY.
17. NOTICES. Delivered or mailed to such party at their respective addresses as
follows:
To the COUNTY:
Monroe County EMS
490 Sixty-Third Street
Marathon, FL 33050
Attn: Teresa Gorentz, Director
To the CONTRACTOR:
Paul Franzelas
Vice President
Advanced Data Processing, Inc.
520 NW 165 Street Road, Suite 201
Miami, Florida 33169
18. REPESENTATION AND WARRANTY. CONTRACTOR represents that they have
experience and agrees to follow all Federal, State and Local Laws including, but not
limited to, Public Records Laws and those laws and statutes applicable to
discrimination.
Agreement Page 5 of 6
Ke::;t;U~ MIIIUUldll~l::: Clllllll~ U I
CONTRACT #
lo........... ....,...... ...---
Date:
19. ENTIRE CONTRACT. This Contract contains the entire agreement between the
-.--
parties. The..GONTRACTOR represents that in entering into this Contract it has not
relied on any previous oral and/or implied representations, inducements or
understandings of any kind or nature.
IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed on
the day and year first above written:
SEAL
By:
MQNROE COUNTY
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11: - ~.___....~----
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Yvonne Harper:'"' Chairperson
Lower and Middle Keys Fire
and Ambulance District
Board of Governors
Attest:~b.Q~~/D,C.
Danny Kolhage. erk of the Court
~;"llD-OO
Advanc
By:
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Agreement Page 6 of 6
A
I. CORD".. CERTIFICATE OF LIABILITY INSURANCE I u",", I C \11011'_11 UU/T Y Y YJ
04/14/03
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
!iamilton Dorsey Alston Company ONL Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
4401 Northside Pkwy Suite 400 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Atlanta, GA 30327-3078
770 850-0050 .r-
.r- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: FCCllnsurance Company
Advanced Data Processing, Inc. INSURER B: Illinois Union Insurance Company
520 NW 165th Street Road INSURER C:
Suite 201 INSURER D:
Miami, FL 33169-6303 INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD iNDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN is SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
N::>K ~~~[ TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE Pg~fJ 1~J,~t,~lgN LIMITS
LTR DATE (MMIDDIYYI
A G[NERAL :""JADIL:iY CPPOCG1 SS5 1 on 0/02 10/10/0::1 E;CH CCCURRENCE s1 000,000
II CO~IMEF,CIAL GENERAL LIABILITY ~~~'t~~I9E~Eo~~~r~ence \ S50 000
I CLAiMS MADE ~ OCCUR MED EXP (Anyone person) s5 000
~ PERSONAL & ADV INJURY s1 000,000
GENERAL AGGREGATE s1,OOO 000
GEN.L AGGREGA TE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG 51 000,000
I nPRO. n
POLICY JECT LOC
A AUTOMOBILE LIABILITY CAOO02425 10/10/02 10/10/03 COMBINED SINGLE LIMIT
- 51,000,000
ANY AUTO (Ea accident)
I-
ALL OWNED AUTOS BODIL Y INJURY
r--- 5
SCHEDULED AUTOS (Per person)
I-
~ HIRED AUTOS BODILY INJURY
5
X NON.OWNED AUTOS (Per accident)
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.!... Hired Car PO $100 Compo PROPERTY DAMAGE
Deductibles: $250 Collision (Per accident) 5
GARAGE LIABILITY AUTO ONLY. E.A. ACCiDENT 5
=j ANY AUTO OTHER THAN EA ACC 5
AUTO ONLY: AGG 5
A 0ESS/UMBRELLA LIABILITY UMBOOO01097 10/10/02 10/10/03 EACH OCCURRENCE 52 000 000
X OCCUR 0 CLAIMS MADE AGGREGATE 52,000 000
5
R DEDUCTIBLE 5
RETENTION 5 $10,000 5
A WORKERS COMPENSATION AND 001 WCC2A51763 1 O/~ 0/02 10/10/03 ! wc STATU-, I IOJ~'
rRY: iMrrs
EMPLOYERS' LIABILITY 5500,000
ANY PROPRIETOR/PARTNER/EXECUTIVE EL. EACH ACCIDENT
OFFICER/MEMBER EXCLUDED? E.L. DISEASE. EA EMPLOYEE 5500,000
If yes. descnbe under 5500,000
SPECIAL PROVISIONS below E.L. DISEASE. POLICY LIMIT
B OTHER Errors & BM120003667 10/10/02 10/10/03 $2,000,000 Occ/Agg
Omissions $25,000 Retention
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DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLEAI:F1S~~j'r;fE~' .. ,.r!:CIAL PROVISIONS Rf"-C~IV
' , I I 'l I " \..t-'I) II I (.,,;1 , C .::: EC
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BY ~) I L-F ~ ~.-C ~ '0C , r~ n (\ I.~
DATe: .. f ~ i /1'11""
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'NAIVER N/A~YES ...., ',I,
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CERTIFICATE HOLDER
CANCELLA TION
. - ,"l '.:: ,-J _ _ -=
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-
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE fHE EXPIRATION
Monroe County BOCC DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL -31L. DAYS WRITTEN
Attn: Darice;Room 268 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
1100 Simonton St. . Room 268 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Key West, FL 33040 REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
~ ~
ACORD 25 (2001/08) 1 of 2
#S159805/M152419
CMW
@ ACORD CORPORATION 1988