1st Amendment 04/17/2019 Sc��c uRTJ\11
`'tee:.-7 ,N•#, Kevin Madok, CPA
ogi
71,1
•P- Clerk of the Circuit Court&Comptroller—Monroe County, Florida
DATE: February 25, 2020
TO: Bryan Cook, Director
Employee Services
ATTN: Mark Gongre
1
FROM: Pamela G. Hanco 1.C.
SUBJECT: April 17,2019 BOCC Meeting
Attached is an electronic copy of the following item, that was just received by this office for
execution, for your handling:
C35 1"Amendment with Employer's Mutual, Inc.,Third Party Administrator for
Worker's Compensation, to update the name of the Corporation.
Should you have any questions, please feel free to contact me at (305) 292-3550.
cc: County Attorney
Finance
File
KEY WEST MARATHON PLANTATION KEY PK/ROTH BUILDING
500 Whitehead Street 3117 Overseas Highway 88820 Overseas Highway 50 High Point Road
Key West,Florida 33040 Marathon,Florida 33050 Plantation Key,Florida 33070 Plantation Key,Florida 33070
305-294-4641 305-289-6027 305-852-7145 305-852-7145
FIRST AMENDMENT TO
CONTRACT FOR WORKERS COMPENSATION THIRD PARTY
CLAIMS ADMINISTRATION SERVICES
BY AND BETWEEN MONROE COUNTY,FLORIDA,AND
EMPLOYER'S MUTUAL,INC.D/B/A ASCENSION BENEFITS&
INSURANCE SOLUTIONS
THIS First Amendment ("First Amendment") is made to be effective the 1 nth day of'
2019 ("Effective Date"), by and between Relation Insurance Services of Florida, Inc.
("Relation"), formerly known as Employers Mutual, Inc. d/b/a Ascension Benefits & Insurance
Solutions,and Monroe County,Florida("County").
WHEREAS, on September 21, 2016,Monroe County,Florida entered into a Contract for
Workers Compensation Third Party Claims Administration Services with Employers Mutual,
Inc., a Florida for-profit corporation doing business as Ascension Benefits & Insurance
Solutions;and
WHEREAS,the Contract remains in effect until September 20,2019, with the possible of
automatic renewals until September 20,2021; and
WHEREAS, on October 12, 2017, Employers Mutual, Inc. filed an amendment to its
Articles of Incorporation with the Florida Secretary of State, amending the name of the
corporation to Relation Insurance Services of Florida, Inc, with no change to the federal
employer's identification number;and
WHEREAS, on December 5, 2017, Employers Mutual, Inc. cancelled its registration of
the fictitious business name "Ascension Benefits & Insurance Solutions" with the Florida
Secretary of State; and
WHEREAS, the parties now desire to amend the Contract to reflect the correct current
name of the vendor.
NOW, THEREFORE, in consideration of the mutual covenants and conditions set forth
below,Assignor and Assignee agree as follows:
1. The name of the Contractor is changed in the Contract from Employers Mutual,
Inc, d/b/a Ascension Benefits & Insurance Solutions to Relation Insurance Services of Florida,
Inc.,wherever it appears in the Contract.
2. In all other respects the terms and conditions of the Contract remain in full force
and effect.
3. This First Amendment may be executed in multiple counterparts, each of which
shall be deemed an original and which together shall constitute one and the same instrument. In
accordance with Monroe County Ordinance No. 005-2018, this document may be signed using
1
I
•
an electronic or digital signature.
4. Each signatory to this Amendment represents that he possesses the requisite
corporate authority to bind his respective entity.
IN WITNESS WHEREOF, each party has caused this First Amendment to be duly
executed and effective as of the date above written.
Witness: Relation Insurance Services of Florida,Inc.
By:
Print an-e: S Poa Edward Nathan Page,President
Date: 3/ //9
,Attest:lcK vin Madok,CPA,Clerk Monroe County, Florida
fol1 n w 4
♦ '\,/0- 77, t
4r��r ' /r� r'�i.aF
V�,t � y', By: •
I,N),e `'` Deputy Clerk Sylvia J. Murphy,Mayor
•oL` -fi��� �
Date: artAX ,7 19
APPROVAL AS TO FORM
MONROE COUNTY ATTORNEY'S OFFICE:
Digitally signed by Cynthia L Hall
DN:cn=Cynthia L Hall,o=Monroe
t. IlOsteCountyMCC,ou,email=hall-
Cynthia@monroecounty-fl.gov,
- �+ c=US
1-1-I _ Date:2019.04.02 08:43:44-04'00'
.^% acC - r
Ln
CD c `.C�
Jc�t O
T
2
AC a® CERTIFICATE OF LIABILITY INSURANCE DATEIMM/DONYYY)
02/20/2020
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on
this certificate does not confer rights to the certificate holder In lieu of such endorsement(s).
PRODUCER CONTACT Miriam Fox
NAME:
RISI,dba Pan American Insurance Services PHONr o,E■tl: 925-407.0417 I( ,No): 925.322.6655
1277 Treat Boulevard ADDRESS: miriam.fox@relationinsurance_com
Ste 400 INSURER(S)AFFORDING COVERAGE HAIL
Walnut Creek CA 94597 INSURER A: Travelers Prop CBS CO of America 25674
INSURED INSURER a: Travelers Ind Co of Connecticut 25682
Relation Insurance Inc. INSURER c: Capitol Specialty Insurance Corp
Relation Insurance Services of Florida,Inc. INSURERD:
700 SE Central Parkway INSURERS:
Stuart FL 34994 INSURERF:
COVERAGES CERTIFICATE NUMBER: 19/20 GL BA WC REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR TYPE OF INSURANCE A SO wvo POLICY NUMBER I°OUCY EFF POLICYMD YV LIMITS
(MM(DOf YYYYI IMMrODlYYYYI
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
InD
CLAIMS-MADE IX OCCURPREMISES(EaE TO�occurrence) S 1,000,000
MED EXP y one parson) $ 5,000
(An
A Y 6308F426365TIL19 06/18/2019 06/18/2020 PERSONALS ADVINJURY $ 1.000,000
GEM.AGGREGATE LIMITAPPLIES PER: GEHERALAGGREGATE S 2.000.000
X POLICY❑TA: El LOC PRODUCTS-COMP/OP AGG S 2.0D0.000
OTHER $
AUTOMOBILE LIAMM' COMBINED SINGLE LIMIT $ 1,000,000
_ F( Li accident)
ANY AUTO BODILY INJURY(Per person) $
g — OWNED SCHEDULED Y BA-1N27929A-19-14-G 06/18/2019 06/18/2020 BODILY INJURY(Per ecddenl) S
AUTOS ONLY L_ AUTOS
HIRED NON.OWNED PROPERTY DAMAGE S
X AUTOS ONLY X AUTOS ONLY (Par accident)
S
UMBRELLA LIAO OCCUR EACH OCCURRENCE S
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DED RETENTION $
WORKERS COMPENSATION >([PERTUTE ER I H-
AND EMPLOYERS'UABILRY ���Ii STA OT
ANY PROPRIETOR/PARTNER/EXECUTIVE Y 1 N EL EACH ACCIDENT S 1.000,000
A OFFICERIMEMBEREXCLUDED7 ❑ N/A UB-6K678843-19-14-G 06/18/2019 06/18/2020
(LUndetorylnNH) EL DISEASE-EA EMPLOYEE S 1.000.0D0
It yes,describe under 1000,000
DESCRIPTION OF OPERATIONS helms ES.DISEASE-POLICY LIMIT S
ERRORS&OMISSIONS Per Claim $10,000,000
C 1A2017112403 04/30/2019 04130/2020 Aggregate $10,000,000
DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES(ACORD let,Additonal Remarks Schedule,may be attached If mere space Is required)
Monroe County BOCC has been Included as Additional Insured,on the General Liabiltly and Auto Liability when required by written contract.
A $Y ISKtvgGEMENT
•
WAIVER WA YFR„._
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Monroe County BOCC ACCORDANCE WITH THE POLICY PROVISIONS.
1100 Simonton Street
Suite 2-266 AUTHORIZED REPRESENTATIVE 24,,/„.„,„.
/�Key West FL 33040 _/, /��a►
I
(D1968-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD