Item S2 �s S.2
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County of Monroe
�y,4 ' �, "tr, BOARD OF COUNTY COMMISSIONERS
County �a� Mayor Heather Carruthers,District 3
�1 `ll Mayor Pro Tem Michelle Coldiron,District 2
The Florida.Keys` )-.���` Craig Cates,District 1
David Rice,District 4
w � Sylvia J.Murphy,District 5
County Commission Meeting
November 17, 2020
Agenda Item Number: S.2
Agenda Item Summary #7487
BULK ITEM: No DEPARTMENT: Emergency Services
TIME APPROXIMATE: STAFF CONTACT: James Callahan (305) 289-6088
1:30 P.M. PUBLIC HEARING
AGENDA ITEM WORDING: A public hearing to consider an application for issuance of a Class
B Certificate of Public Convenience and Necessity (COPCN) to Lyn Tiger LLC, for the operation of
a BLS Transport Service (non-emergency) for all geographical locations in Monroe County Florida,
for the period 11/18/20 through 11/17/22.
ITEM BACKGROUND:
Lyn Tiger LLC has submitted an application to request a new Class B COPCN Certificate for BLS
Transports (non-emergency) for all geographical locations in Monroe County Florida, for the period
11/18/20 through 11/17/22.
Monroe County Code Sections 11-171 et seq., requires the BOCC to hold a public hearing to
consider the application for a new certificate. At the hearing, the Board may receive a report from
the County Administrator or his designee, testimony from the applicant or any other interested party,
and other relevant information. The Board will consider the public's convenience and necessity for
the proposed service and whether the applicant has the ability to provide the necessary service(s).
The Board shall then authorize the issuance of the certificate with such conditions as are in the
public's interest or deny the application, setting forth the reason(s)for denial.
PREVIOUS RELEVANT BOCC ACTION:
N/A
CONTRACT/AGREEMENT CHANGES:
N/A
STAFF RECOMMENDATION: Approval
DOCUMENTATION:
Notice of Public Hearing for Lyn Tiger LLC 11-17-2020
Lyn Tiger LLC - Class B COPCN Notification Letters Signed
Packet Pg. 2674
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Lyn Tiger LLC - Class B COPCN Certificate
Lyn Tiger LLC COPCN Class B Application Received 09.24.20_Redacted
Lyn Tiger LLC - Certificate of Insurance Expires 09-13-2021
FINANCIAL IMPACT:
Effective Date: 11/18/20
Expiration Date: 11/17/22
Total Dollar Value of Contract: N/A
Total Cost to County: N/A
Current Year Portion: N/A
Budgeted: N/A
Source of Funds: N/A
CPI: N/A
Indirect Costs: N/A
Estimated Ongoing Costs Not Included in above dollar amounts: N/A
Revenue Producing: N/A If yes, amount: N/A
Grant: N/A
County Match: N/A
Insurance Required: Yes
Additional Details: N/A
REVIEWED BY:
Pedro Mercado Completed 10/30/2020 5:27 PM
James Callahan Completed 10/31/2020 1:07 PM
Purchasing Completed 11/02/2020 8:10 AM
Budget and Finance Completed 11/02/2020 8:15 AM
Maria Slavik Completed 11/02/2020 10:19 AM
Liz Yongue Completed 11/03/2020 10:01 AM
Board of County Commissioners Pending 11/17/2020 9:00 AM
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NOTICE OF PUBLIC HEARING
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NOTICE IS HEREBY GIVEN TO WHOM IT MAY CONCERN that on Tuesday, November 17, y
2020,at 1:30 P.M.,or as soon thereafter as the item may be heard,the Board of County Commissioners
of Monroe County, Florida,intends to consider the following:
ISSUANCE OF CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY TO LYN
TIGER LLC FOR THE OPERATION OF A BLS NON-EMERGENCY MEDICAL TRANSPORT y
AMBULANCE SERVICE FOR INTER-FACILITY TRANSPORTS WITHIN MONROE A
COUNTY,FOR THE PERIOD NOVEMBER 18,2020 THROUGH NOVEMBER 17,2022. c
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Pursuant to Section 286.0105,Florida Statutes,notice is given that if a person decides to appeal any decision 2
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made by the Board with respect to any matter considered at such hearing or meetings,he will need a record
of the proceedings, and that, for such purpose,he may need to ensure that a verbatim record is made of the
proceedings,which record includes the testimony and evidence upon which the appeal is to be based.
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Pursuant to the Governor's Executive Order No. 20-69, extended by Executive Orders No. 20-112, 20-123,
20-139, 20-150 amended by Executive Orders 20-179 and 20-193, extended by Executive Order 20-246, , 0
Monroe County Emergency Directives 20-06 and 20-10, and the Center for Disease Control ("CDC") U
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social-distancing guidelines established to contain the spread of the COVID-19 virus, the November 17,
2020, Public Hearing will be conducted via Communication Media Technology ("CMT"), using a Zoom
Webinar platform @ httu://www.iiionroecoLinty-fl.(,ov/BoccMeetin(,Novl7. The County will provide s
updates for changing directives for Local Government Public Meetings on the County Website at:
www.MonroeCounty-FL.Gov. Below are the various options available to the public to view the live
meeting and/or to make public comments on certain agenda items during the public portion of the meeting. e-
The Public is strongly encouraged to watch the meeting on Monroe County's MCTV on Comcast Channel N
CD
76, AT&T UVerse Channel 99, or on the County's web portal @
htt ://iiionroecoLintvfl.iqiii2.coiii/Citizens/Default.as x. Simply select the "Watch Live" banner to view
the live meeting with live closed-captioning on an integrated page that includes the agenda and agenda
backup. j
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If a citizen has a Roku device, they can search for and add "MCTV" to their personal lineup. Monroe m
County's "MCTV"is also provided via the Monroe County mobile apps for 10S and Android and through °®
our streaming web portal @ htt s://monroe-fl.vod.castus.ty/vod/?live=chl&nav=live.
Citizens can listen to audio-only from their phone by dialing (646) 518-9805 or(669) 900-6833 and,when 0
prompted, enter the Webinar ID# 929 7515 9065 followed by the #key.
The public can comment during the live Public Hearing either by phoning in or by connecting to the
live Zoom webinar link using the following instructions: 2
a) To comment on an item by phone: Dial (646) 518-9805 or (669) 900-6833 and, when CL
prompted, enter the Webinar ID# 929 7515 9065 followed by the #key, then *9 to "Raise your hand"to 0
be recognized by the Zoom webinar host.
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b) To comment on an item using the live Zoom webinar link: Open this live Zoom webinar
link @ htt ://www.iiionroecoLinty-f1.�ov/BoccMeetin(,Nov17 (that also appears in both the published
Agenda and Agenda Packet). When prompted, enter your email address and name to join the webinar. E
Packet Pg. 2676
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When the Mayor calls for speakers on the item(s) on which you wish to comment, or when the Board is
nearing your item(s)as the meeting progresses, select the "Raised Hand"feature that appears at the bottom CL
of the Zoom webinar screen, to be recognized by the Zoom webinar host. U
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The Zoom Webinar monitor will request the agenda item 4 on which you wish to comment and will enable W
your participation when the Mayor calls for public speakers on your item. To report problems with the U
broadcast,please call: (305) 872-8831. 0
A person may submit written or other physical evidence on a particular agenda item for consideration at
the BOCC meeting to: Lindsey Ballard, via email to: ballard-lindsey ttiizonroecounty-fl.;�ov, or by mail
to: County Administrator's Office, 1100 Simonton Street, Suite 205, Key West, FL 33040. The 0
documents must be received by 3:00 P.M. on Monday, November 16, 2020, and must include the r_
submitter's name, address,phone number,email address, and the agenda item number to which the
documents refer.
ADA Assistance: If you are a person with a disability who needs special accommodation in order to
participate in this meeting,please contact the County Administrator's Office,by phoning(305)292-4441,
between the hours of 8:30 a.m. —5:00 p.m., no later than five (5) calendar days prior to the scheduled
meeting; if you are hearing or voice-impaired, call '711': Live Closed Captioning is available at our U
web portal @ for meetings of the Monroe County 0
Board of County Commissioners.
DATED at Key West,Florida, this 30th day of October, 2020.
(SEAL) KEVIN MADOK, Clerk of the Court and ex ofcio
Clerk of the Board of County Commissioners of
Monroe County, Florida
N
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Publication Dates:
Key West Citizen: Wed., 11/04/2020
Keys Weekly: Thur., 11/05/2020
News Barometer: Fri., 11/06/2020
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Packet Pg. 2677
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i BOARD OF COUNTY COMMISSIONERS
County of MonroeMa%oa I leather Carruthers, 111Astrict 3
Th
$' Florida s Maw nt r Pro l e Michelle C'oldiron, District 2
C'rtigCates District t ca
David Rice. Dkirict=l
S Ivia.l. NIUrrph\. District 5
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October 28, 2020
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Michael Arguelles
American Ambulance Service(Ijalck)
6605 NW 74th Ave �
Miami, Fl, 331 6
This shall serve as notice that, in accordance with Monroe County Code Sections I 1-171 et seg., a Public Hearing
of the Monroe County Board of County Commissioners will be held on Tuesdal,November 17,2020 at 1.30 pm
t the Harvey Government Center, 1200 Truman Avenue,Key West,Monroe County,Florida,to consider an
application from Lyn Tiger LLC for issuance of a Certificate of Public Convenience and Necessity( `C PC N),Class
B, BLS service in all geographical locations in Monroe County, Florida.
At the hearing,the Board may receive the report of the County Administrator, testimony frorn the applicant or any
other interested party and any other relevant information. The Board will consider the public's convenience and W
the necessity for the service in the zone or area requested and whether the applicant has the ability to provide the
necessary service. The Board will consider recommendations from municipalities within the applicant's requested
service zone or area. The Beard shall then authorize the issuance of the certificate with such conditions as are in the public's interest or deny the application, setting forth the reasons for denial.
If you have any questions, or rewire additional information, please contact my office.
Sincerely,
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Raman Castesi
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County Administrator
Packet Pg. 2678
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r BOARD CAE COUNTY COMMISSIONERS
County of MonroeAt%or I leeadi r Carruthers, Disiricl 3
The � ?rida Keys Mail of Prof tirt Mich tlt.C'c�lclir«t�, District
fr. Ct ttg C aTes, District I
1 David Rice. District 4
Sy le itt J Murphv,District 5
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October 28, 2020
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Debbie Islaiser, Office Manager
IslatmoradaVillage of Islands
00 Oversea Highway 1 st Floor �
Islalmorada, Ff., 33036
This shall serve as notice that, in accordance with Monroe County Code Sections 11-171 et Sect„ a Public Hearing
of the, Monroe County Hoard Of County Commissioners will be held tin Tues v,Nove ber 17,2020 at 1 c U Pm 0
at the Harvey Government Center, 1200 Truman an Avenue,Key West,Monroe County,Florida,to consider an
application from Lvn Tigrcr LLC for issuance of a Certificate of Public Convenience and Necessity(COPCN).Class
B, BLS service in all geographical locations in Monroe County, Florida.
At the hearing, the Board may receive the report of the County .Administrator,testimony from the applicant or any
other interested party and any other relevant information, The Board will consider the public's convenience and
the necessity for the service in the zone or area requested and whether the applicant has the ability to provide the �
necessary service. The Board will consider recommendations from municipalities within the applicant's requested
service zone or area. The Board shall then authorize the issuance ofthe certificate with such conditions as are in
the public's interest or deny the application, setting forth the reasons for denial.
If you have any questions, or require additional information, please contact my office.
Sincerely,
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Rornan C astesi
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County Administrator
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Packet Pg. 2679
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a' r a BOARD OF COUNTY COMMISSIONERS
k-lounty of MonroeMayor I leather Carruthas. Disirict 3
Maw<or P o-tern Michelle Coldimri. District
The Florida Keys � as
+ � 1 Craig C'~rtc� District 1 y
D aN id Rice. District,t
`4.. SGlei<t.l, Nlurlah , t)iwtriGr
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October 28, 2020
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Betsy Elkoury, Office Manager
Key largo Volunteer Ambulance
9 600 O/S l%i hway �
Key Largo, FL 33037
This shall serve as notice that, in accordance with Monroe County Code Sections 1 1-171 et seq., a Public Iiearint
of the Monroe County Board of County Commissioners will be held on Tuesday,November 17, 020 at 1:30 rim
t the Harvey Government Center, 1200 TrumanAvenue,Key West,Monroe County,Florida,to consider an
application from Lyn Tiger LL;C for issuance of a Certificate of Public Convenience and Necessity(COPCN),Class
B, BLS service in all geographical locations in Monroe County, Florida.
t the hearing, the Board may receive the report of the County administrator, testimony from the applicant or any
other interested party and any other relevant information. The Board will consider the public's convenience and W
the necessity for the service in the zone or area requested and whether the applicant has the ability to provide the �
necessary service. The Board will consider recommendations from municipalities within the applicant's requested
service zone or area, `the Board shall there authorize the issuance of the certificate with such conditions as are in °—
the public's interest or deny the application, setting forth the reasons for denial.
If you have any questions,or require additional information, please contact my office.
Sincerely„
Doman Gastesi U
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County administrator
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Packet Pg. 2680
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u BOARD OF COUNT" COMMISSIONERS
k1ounty of Monroe % r I leather Carruthers, District 3
FloridaThe S
M year Pro]em Michelle('okhrcm, District
6 Craig C'titcs, District 1 �
David Rice District l �
S�Iviii J. Murphy' District 5 �
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October 28, 2020
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Anna Hendricks, Administrative officer
0
Marathon Fire Rescue
00 Overseas Highway �
Marathon, FL 33050
This shall serve as notice that, in accordance with Monroe County Code Sections I I.171 et seg., a Public Hearing
of the Monroe County Board of County Commissioners will he held on Tuesday,November 17,2 2t1 ALjj36_
at the Harvey Government Center, 1200 Truman Avenue,Key West,Monroe County,Florida,to consider an
application from Lyn Tiger LLC for issuance of a Certificate of Public Convenience and Necessity(COPCN),Class
13, BLS service in all geographical locations in Monroe County, Florida.
At the hearing, the Board may receive the report of the County Administrator, testimony from the applicant or any
other interested party and any other relevant inforrnation. The Board will consider the public's convenience and W
the necessity for the service in the zone or area requested and whether the applicant has the ability to provide the
necessary service. The., Board will consider recommendations from municipalities within the applicant's requested
service :zone or area. The Board shall then authorize the issuance of the certificate with such conditions as are in the public's interest or deny the application. setting;forth the reasons foi-denial.
Ifyou have any questions, or° require additional information, please contact my office.
Sincerely,
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Roman Ciastesi U
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County Administrator
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Packet Pg. 2681
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�� BOARD OF COUNTYCOMMISSIONERS
klouuty of MonroeWvor I leather Carruthers. District 3
The Florida �, Mayor Pro I °irt Michelle Crrldiron, District 2
r Craig Cates, District I
David Dice. Disirict-3
titI�is.J 111r >h}', Distiict5
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October 28, 2020
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Caitlin C3ourassa
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Monroe County Fire Rescue
490 63rd St. Ocean �
Marathon, FL 33050
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This shall serve as notice that, in accordance with Monroe County Cade Sections 11-171 et seq., a Public Hearing
of the Monroe County Board of County Commissioners will be held on TuesdayNovember 17,2020 at 1:30 pm 0
at the Harvey(Government Center, 1200 Truman Avenue,Key Feat,Monroe County,Florida to consider an
application from Lyn Tiger LLC for issuance of Certificate of Public Convenience and Necessity(COPCN),Class
B, BLS service in all geographical locations in Monroe County, Florida.
At the hearing,the Board may receive the report of the County Administrator, testimony front the applicant or any
other interested party and any other relevant information. The Board will consider the public's convenience and W
the necessity for the service in the zone or area requested and whether the applicant has the ability to provide the
necessary service. The Board will consider recommendations from municipalities within the applicant's requested
service zone or area. The Board shall then authorise the issuance of the certificate with such conditions as are in the public's interest or deny the application, setting forth the reasons for denial.
If you have any questions, or require additional information, please contact my office.
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Sincerely,
Roman Gastesi U
CL
County Administrator
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Packet Pg. 2682
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t�= BOARD OF COUNTY COMMISSIONERS
County of MonroeMayor I Juither C arrUthers,District 3
The Florida Keys � N-b%err Pro Teat Michelle.C'olcliron, Disirict 2
� C'raig, Cates, District l
d
., David Rice. District 4 �
Sykia.1. Murph%, District 5 �
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October 28, 2020
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Alissa Garcia, CF0
National Health Transport
2290 NW I Idth Avenue �
Sweetwater, FL 33172
This shall serve as notice that, in accordance with Monroe County Code Sections I I-171 et seq., a Public Flearin
of the Monroe County Board of County Commissioners will he held can Tuesday,I ovemb 11.7,2020 at 1.30 nm
at the Harvey Government Center, 1200 Truman avenue,Key West,Monroe County,Florida,to consider an
application from Lyn Tiger LLC for issuance of Certificate of Public Convenience and Necessity(COPCN),Class
B, BLS service in all geographical locations in Monroe County-, Florida. �
At the hearing, the Board may receive the report of the County Administrator, testimony froth the applicant or any,
other interested party and any other relevant information, The Board will consider the public's convenience and CL
_
the necessity for the service in the zone or area requested and whether the applicant has the ability to provide the
necessary service. The Board will consider recommendations from municipalities within the applicant's requested
service zone or area, The Beard shall then authorize the issuance of the certificate with such conditions as are in the public's interest or deny the application, setting forth the reasons for denial.
If you have any questions, or require additional information, please contact my office.
Sincerely,
Roman Gastesi U
County Administrator CL
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Packet Pg. 2683
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t'9 BOARD OF COUNTY COMMISSIONERS
k1ounty of Monroe ` Ma\or Ileather Carruthers, District 3
The
�7r� Keys May err P u l e,rrr Michelle C oldiron,{district
Craig Cates, District I �
David Rice, District 4 (n
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Sylvia J.Murpfi%,District 5 U
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October 28, 2020 y
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Ronnie Fell
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Ocean Reef Volunteer Fire Dept., Inc. dlbfa Ocean Reef Public Safety
110 Anchor Dr. �
Key Largo, FL 33037 0.
This shall serve as notice that, in accordance with Monroe County Code Sections 11-171 et seq., a. Public:. Hearing
of the Monroe County Board of County Commissioners will be held on Tuesday November 17 2020 at 1: 0 Pm 0
at the Harvey Government Center, 1200 Truman Avenue,Key West,Munroe County,Florida,to consider an CD
application from Lyn Tiger LLC for issuance of a Certificate of Public Convenience and Necessity(COPCN),Mass
B. BLS :service in all geographical locations in Monroe County, Florida.. �
At the hearing,the Board may receive the report of the County Administrator, testimony from the applicant or any
other interested party and any other relevant information. The Board will consider the public's convenience and. W
the necessity for the service in the zone or area requested and whether the applicant has the ability to provide the
necessary service. The Board will consider recommendations from municipalities within the applicant's requested
service zone or area. The Board shall then authorize the issuance of the certificate with such conditions as are in the public's interest or deny the application, setting forth the reasons for denial.
If you have any questions, or require additional information, please contact my office.
Sincerely,
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Roman Gastesi U
CL
County Administrator
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Packet Pg. 2684
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d" BOARD OF COUNTY COMMISSIONERS
%-Iounty of Monroe Mayor Heather CarrUthers, District 3
Th
( i 'w S flay or Pro l em ;�tididle Colclirott, District 2
Craig Cates Distrtcl I
� q : y
[ Da%,icl Rice,District 4
5y it ia,l. %Iurph%, District 5
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October 28, 2020
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Frank Ramos, President
Healthcare Ride -transportation Inc d/b/a1 Healthcare Ride,
175 Fontainbleau Blve ST 2D2
Miami, FL 33172
This shall serve as notice that, in accordance with Monroe County Code Sections 11-171 et se ., a Public Hearing
of the Monroe County Board of County Commissioners will be held on Tuesday,November 17 2020 at 1» din
at the Harvey Government Center, 1200 Truman Avenue, Key West,Monroe County,Florida,to consider an
application from Lyn Tiger LLC for issuance of a Certificate of Public Convenience and Necessity(COPC'1s1),Class
B, BLS service in all geographical locations in Monroe County, Florida.
At the hearing,the Board may receive the report of the County Administrator-, testimony from the applicant or any
other interested party and any other relevant information. The Board will consider the }public's convenience and CL
the necessity for the service in the zone or area requested and whether the applicant has the ability to provide the
necessary service. The Board will consider recommendations from municipalities within the applicant's requested
service zone or area. `the Board shall then authorize the issuance of the; certificate with such conditions as are; in the public's interest or deny the application, setting forth the reasons for denial.
If you have any questions, or require additional information, please contact► y office.
Sincerely,
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Rogan Gastesi U
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County Administrator
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Packet Pg. 2685
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BOARD OF COUNTY COMMISSIONERS
k1ounty of Monroe Mayor Hearher Carruthers,I?istrict 3
The Florida Keys � � Ma\or Pro ern 1Y1rchelle Coldirm, District 2 �
Craig Cates. District I �
DaN id Rice District 4 �
Sylvia J. Murphy.. District 5 �
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October 28, 2020
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Eddy Bonilla
c
Florida Keys Ambulance Service
PC) Box 1259
Tavernier, FL 33070
This shall serve as notice that, in accordance with Monroe County Code Sections 11-171 et seq., a Public 1iearing
of the Monroe County Board of County Commissioners will be held on Tuesday,November 17,2020 at1 0 pm 0
at the Harvey Government Center, 1200 Truman Avenue,Key Nest,Monroe County,Florida,to consider an CD
application from Lyn Tiger LLC for issuance of Certificate Of Public Convenience and Necessity(COPCN),Class
, BLS service in all geographical locations in Monroe County; Florida. �
At the hearing,the Board may receive the report of the County Administrator, testimony from the applicant or any
ether interested party and any other relevant information, The Board will consider the public's convenience and _
the necessity for the service in the zone or area requested and whether the applicant has the ability to provide the
necessary service. The Board will consider recommendations from municipalities within the applicant's requested
service zone or area. The Board shall then authorize the issuance of the certificate with such conditions as are in the public's interest or deny the application, setting forth the reasons for denial,
lfyou have any questions, or require additional information, please contact nay office.
Sincerely,
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Roman Gastesi U
CL
County Administrator
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Packet Pg. 2686
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rye BOAR OF COUNTY COMMISSIONERS
County of MonroeMayor l leather Ca
rruthers, District 3
The
t rld t Maw Pro lCrra MichelleColdiron. District
C_ratg Cates, District
cn
David Rice. District 4 (n
4yl iat.l. Murp1n. District:
0
October 28, 2020
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Steve Portnon
Rapid Response Ambulance
8350 W SR 84
Davie, Ft.,33324
m
This shall serve as notice that, in accordance with Monroe County Cade Sections I I-171 et seq., a Public Hearing
of the Monroe County Board of County Commissioners will be held on Tuesday,November 17,2020 at 1 0 rs
at the Harvey Government Center, 1,200 Truman Avenue,Key'Nest,Monro,e County,Florida,to consider an
application from Lyn Tiger LLC for issuance of a Certificate of Public Convenience and Necessity(COPCN),Class
H, BLS service in all geographical locations in Monroe County, Florida.
At the hearing, the Board may receive the report of`the County' Administrator, testimony froth the applicant or any
ether interested party and any other relevant information. The Board will consider the public's convenience and
the necessity for the service in the zone or area requested and whether the applicant has the ability to provide the W
necessary service. The Board will consider recommendations from municipalities within the applicant's requester)
service zone or area, The Board shall then authorize the issuance of the certificate with such conditions as are in
the public's interest or deny the application, setting forth the reasons for denial. )
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If you have any questions, or requite additional information, please contact nay office.
Sincerely,
nce papyy n�.cera -]y,/, W
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Roman C astest.
County Administrator U
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Packet Pg. 2687
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BOARD CAE COUNTY COMMISSIONERS
S
%.ounty of Monroe lwta%or I leather Carruthers District 3
The Florida Keys k Ma4or t'ro t enr Michelle C'oldiron, Disirict 2
Craig Cates, District I
..e:,.� I7a4 id ice, Dkiric:t,t..
4VM1 I. ML11-PhN, District
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October 28, 2020
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Charlie Mayrnon, 'Vice President
MCT Express, Inc.
2766 NW 62nd Street �
Miami® FL,331 47 0.
This shall serve as notice that, in accordance with Monroe County Code Sections I I-1.71 et seq., a Public Hearing
of"the Monroe County Board of County Commissioners will be held on Tuesday,November 17,2020 at 1t30 pm
at the Harvey Government Center, 1200 Truman Avenue,ley West,Monroe County, Florida,to consider an
application from Lyn Tiger L,LC for issuance of a Certificate of Public Convenience and Necessity(COPCN),Class
B, BLS service in all geographical locations in Monroe County, Florida,
At the hearing., the Board may receive the report of the County Administrator, testimony from the applicant or any 2
other interested party and any other relevant information. The Board will consider the public's convenience and
the necessity for the service in the zone or area requested and whether the applicant has the ability to provide the W
necessary service, The Board will consider recommendations from municipalities within the applicant's requested
service zone or area, The Board shall then authorize the issuance of the certificate with such conditions as are in
the public's interest or deny the application., setting Forth the reasons for denial. —
If you have any questions,or require additional information, please contact my office.
Sincerely,
1
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Doman Gastesi
County Administrator U
CL
Packet Pg. 2688
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BOARD OF COUNTY COMMISSIONER$
k-lounty of Monroe Mawr Ikatther Carruthers, District
The Florida IKeys
Msa%or Pro Tenn Micheile Coldiron. District M
Craig Cates, Distrio I Ch
r ft David Ricc, District 4
S)Iw a,I. Murphy, District
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October 28, 2020 �
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Robert Ortega, President
Ride Mobile Transportation
1513 SE 20" PL �
Homestead, FL 33035
This shall serve as notice that, in accordance with Monroe County Code Sections 11-171 et seq., a Public Hearing
of the Monroe County Board of County Commissioners will be held on Tuesday,November 17,2020 at 1:30 pm U
at the Harvey Government+Center, 1200 Truman Avenue,Key West,Monroe County,Florida,to consider an
application from Lyn Tiger LLC for issuance of Certificate of Public Convenience and Necessity(C OPC ),Class
B, BLS service in all geographical locations in Monroe County, Florida.
t the hearing, the Board may receive the report of the County Administrator, testimony from the applicant or any 2
other interested party and any other relevant information, The Board will consider the public's convenience and
the necessity for the service in the zone or area requested and whether the applicant has the ability to provide the
necessary service. The Board will consider recommendations fi-one municipalities within the applicant's requested �
service zone or area. The Board shall then authorize the issuance of the certificate with such conditions as are in
the public's interest or deny the application, setting forth the reasons for denial.
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If you have any questions, or require additional information, please contact my office.
Sincerely,
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Roman Gastes
County Administrator U
CL
Packet Pg. 2689
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d" BOARD OF COUNTY COMMISSIONERS
k1ounty of Monroe Maa%or I leather(" anthers, District 3
e Florida c` Keys M�a}or Pro I em M ichella.�Coldircn, District t 2
Craig Cates. DkIrict l Ch
David Rice. District 4
Sylvia J.MtarphN, 1 isO—ic:t 5
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October 28, 2020
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Nirlenis f scalon.a Hernandez, Owner
Lyn Tiger L LC;
146 Peary CT Unit B �
Key West, FL 33040
m
This shalt serve as notice that, in accordance with Monroe County Code Sections 1 1-171 et seq,, a public hearing
of the Monroe County Board ofC aunty Commissioners will be held can 'T`uesd y� urerr� e� �7,20 0 a �; 0 � c
at the Harvey Government Center, 1200'Truman Avenue,key West,Monroe County,Florida,to consider an
application from. Lyn Tiger LLC for issuance of Certificate of Public Convenience and Necessity(COPCN),Class
, BLS service in all geographical locations in Monroe County, Florida.
At the hearing, the Board may receive the report of the County Administrator, testimony from the applicant or any 2
other interested party and any other relevant information. The Board will consider the public's convenience and
the necessity for the service in the zone or area requested and whether the applicant has the ability to provide the
necessary service. The Board will consider recommendations from municipalities within the applicant's requested �
service zone or area. The Board shall then authorize the issuance of the certificate with such conditions as are in
the public's interest or deny the application. setting forth the reasons for denial.
a�
If you have any questions.,or require additional information, please contact my office.
Sincerely,
0
Roman Gastesi
County Administrator
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Packet Pg. 2690
County of Monroe Mai or I ieather Carruthers, Dis,1 rct
The Florida eye nrir I1rfa I er�r 'tchctic Coldir�rri. District
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DaN id Rice, I?imn t,l �
ti 1%ia J1 `urph%. rD7 trio 5
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October 28, `020 c
k6r 0i FaWkP be 2..
EMS Chief c
City of Key West Fire Dept �
1600 N. Roosevelt Blvd.
Key West, Ff.., 304
a
This shall verve as notice that, in accordance with Monroe Cotuttwv Code Sections 1 1-171 et seq., a Public Flearing U
of the Monroe County Board of County Commissioners will be held can Tuesdal,November 17*2020 at 1. 0 Plte
at the Harvey Government Center, 1200 Truman Avenue, Key Nest,Monroe County,Florida,to consider an
application front Lyn'ri er LLC for issuance of a Certificate of`Public Convenience and Necessity(COPC'N),C lass �
13, BLS service in all geographical locations in Monroe County, Florida.
t the hearing, the Board may receive the report of the County Administrator, testimony from the applicant or any
other interested part and any other relevant infor-nation. The Board will consider the: public's convenience and
the necessity for the service in the zone or area requester and whether the applicant has the ability to provide the �
necessary service. The Board will consider recornniendat:ions from municipalities within the applicant's requested
service zone:or area. The Board shall then authorize the issuance of'tire certificate with such conditions as are in
the public's interest or deny the application, setting forth the reasons for denial.
If you have any yucstions, or require additional inforsrsation, please: contact stay office,
Sincerely,
c
Roman Gastesi U
CL
County administrator
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County of Monroe �; BOARD OF COUNTY CO'VIMISSCO]VERS -
Mayor Sylvia J.Murphy,District 5
Ma) Pro Tern Danny L.Kolhage,District 1
s The Florida Keys - Michelle Coldiron,District 2
Heather Carruthers,District 3
David Rice.District 4
0
Division of Emergency Services
Fire Rescue Department
490 6311 Street,Ocean
Marathon,FL 33050
Phone: 305-289-6004
Fax: 305-289-6336 u
0
ClassCOPCN ec Lit
Please Attach all of the following documents when submitting your application:
,s 2
I/ The name, business mailing address, and telephone number of the service.
The name, age, address and telephone number of each owner of the nonemergency medical W
transportation service,or, if the service is a corporation,the directors of the corporation and of each
stockholder of the corporation,or, if the service is a volunteer organization,the names of its officers.
The date of incorporation or formation of the business association.
The year, model,type, department of health vehicle permit number, mileage, passenger capacity,and
state vehicle license number of every vehicle that will be used for patient transport.
ry
The location of the place from which the applicant will operate, and the geographic areas to be served
ry
by the applicant.
I/ A description of the applicant's communication system, if any, including its assigned frequencies,
mobiles and portables,and a copy of each FCC license issued for those frequencies.
The names and addresses of three U.S. citizens who will act as references for the applicant.
A schedule of rates which the applicant will charge during the certificate period.
Verification of adequate insurance coverage during the certificate period.
An affidavit,signed by the applicant or an authorized representative thereof, stating that all information 9
provided in the application,to the best of the applicant's knowledge, is true and correct. 0.
A statement indicating the method of screening that will be used to assure that all calls responded to 0.
require only transportation as may be provided by a nonemergency medical transportation service and ca
vehicle. v'
Such other pertinent information as the administrator may request.
An initial nonrefundable application fee of 50.00/$25.00 for Renewal
❑ An audit to be provided to the county administrator by an independent certified public accountant of CL
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the accounts and records of the service involved,said audit to be done annually to coincide with the end
of the business year of the service. U
Packet Pg. 2693
t
APPLIC AT ION FOR CEKI'IFICATE OF PIT LIC CONVENIENCE AND NECESSIT ► CN
CLASS NON-EMERGENCY MEDICAL IC'AL TRANSPORTATION SE `IC
(PRINT TYPE)
A
INITIAL APPLICATION-$50A0 Ej RENEWAL WAL APPLICATION-525.0
IF RENENNI)AL,PLEASE LISTNUMBER OF PREVIOUS CERTIFICATE:#
1. NAME F°SERVLC' . LYN TIGER LL
BUSINESS MAILING ADDRESS 146 P APB° CT UNIT BN KEY WEST FL 33040
BUSINESS PHONE,NUMBER 7864540578 EMERGENCY Y P14ONE NUMBER 3053022688
0
2. TYPE OF OWN ERSHIP(i.e.,Sole Proprietor,Partnership,Corporation,etc.) ,TI I _. ._
0
ATE OF INCORPORATION OR FORMATION OF THE BUSINESS ASSOCIATION 7/16/201
® LIST ALL OFFICERS,RS,DIRECTORS,AND SHAREHOLDERS(Use separate sheet if necvssar )s �
2
N.A 'I �146
ADDRESS .� 11_. TELEPHONE- ____- I0SITIC?N II'I'LF
Irle I c I r� I er 146 Peery l� ►t 78646406 6 Owner .�
Fe Est ! 040
ry
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. DESCRIBE THE GFrOGRA HIC"AICEA(S)'I AT YOUR SERVICE DESIRES TO SERVE(Use separate sheet if
necessary)-
Inter-facility Transports Only within Monroe County, No 911 - Response Work
ALL GEOGRAPHICAL LOCATIONS IN MONROECOUNTY FLORIDA
U
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5. LIST THE ADDRESS AND/OR DESCRIBE THE; LOCATION OF YOUR BASE STATION AND ALL SUB-
STATIONS(Use separate sheet if necessary): �
SSE STATION 146 PEARY CT KEY WEST FI 33040
SUB-STATION
Page I of
Packet Pg. 2694
. DESCRIBE YOUR C°ONI L"NIC;ATI N SYSTEM( It ch copy of all FCC licenses):
FREQUENCIES CALL NI;,MBEIRS� #CIF`.YIC)IIILES� #OF F`CTI2'T"ABLES _: c
CELL PHONE
3053022688 m� 2 '
. LIST THE NAMES AND ADDRESSES RESSES OF'THREE( )U.S.CITIZENS EtNS O WILL ACT AS I LFE ENf_ES FOR
YOUR SERVICE.
E.
NAME _. s....n . _ _......A..,....._.. ADDRESS
BRIAN MADIA 5436 5th AVEWEST FLORIDA 33040
SONJALOPEZ 140 SUNSETLNTAVERN!TAVERNIER FL 33070
THOMAS CASTANEDA
.__ 151 74th ST OCEAN MARATHON
. ATTACH A SCHEDULE OF RATES WHICH H OU SERVICE WILL CHARGE DURING THE COPCN PERIOD. �
. PROVIDE VERIFICATION OF ADEQUATE INSIIIRANC E COVERAGE DURING THE C OPC'N PERIOD. CL
10. ATTACH A STATEMENT INDICATING THENIETHOD OF SCREENING THAT WILL BE USED TO ASSURE �
THAT ALL CALLS RESPONDED TO REQUIRE ONLY TRANSPORTATION AS MAY BE PROVIDED BY A
NON-EMERGENCY MEDICAL T'IR.ANSPC R"FATI N SERVICE AND YF IIIC 1,E. �
11. ATTACH A CHECK KO MONEY ORDER IN THE APPROPRIATE AMOUNT,MADE PAYABLE T THE �
MON OE COUNTY BOARD OF C OUNTY C OMMISSIONE:IRS. ry
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12. XUTACII A COPY OF AUDIT REPORT AS REQUIRED BY THE ATCTNIRCIE COUNTY NON-EMERGENCY
MEDICAL SERVICES I<:S ORDINANCES. �
I,THE UNDERSIGNED REPRESENTATIVE OF THE ABOVE NAMED SERVICE,E, CI HEREBY ATTEST MY SERVICE
NIEE TS ALL OF THE REQUIREMENTS FOR OPERATION OF ANON-IJM ERG ENC"Y IEDIC:AL TRANSPORTATION
SERVICE IN MONROE COUNTYAND THE STATE OF FLORIDA. I FURTHER ATTEST T AT ALL THE
INFORMATION CONTAINED IN THIS APPLICATION,I`D THE BEST OF MY KNOWLEDGE,IS TRUE AN
CJ
Nidenis Escalona Hernandez
IGNA I`I IRE OF A' ]odda'
�l"[iC()t IZE IIG�"P F SENTATI "
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Credentialling Criteria and Standards
Initials y
eSr Date Title Standard
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Complaint Tracking,Reporting The organization must have and maintain a system to
Rcsoluti an(not required to track,report and document resolution of complaints
submit at this time) iae nricied inter il' roc ess.
Debarment Novider must not be on any applicable state or
federal d.elnamient list.http://w-ww.oig.hhs.gov/
e organization must have the ability to maintain -�
Driver Logs driver bags for all services arovi ed..
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e€argavirzation must have and maintain a driver
training program that addresses utilization of safety
Driver Training restraints,non-smoking,safe driving,defensive driving
d patient assistance.
Drivers "riarairaa.l eorganization must have and provide evidence f
Background Checks a recent Driver DMV t-listory and National
Criminal BackgTound check as required �
Employee Substance
e organization must have and maintain current copies
of e np➢oyee substance set een as required by the
Screening State. i
Incident Reporting
e orgaani,?ation gust have and maintain a method f ry
reporting incidents inclusive ofaccident reporting.
e organizAtion must have and provide evidence of �
Insurance
adequate insurance as required the Provider Network
Agreement.ACORD foi nriat with AccessWare.as �
additional certificate holder,
e organization must have and provide copies of al c
LLicensure and Compliance current licenses rewired by state or federal laws. �
e organization must have and maintain written
Policies and procedures(not policies and procedures in compliance with the Policies
required to submit at this timed and procedures in the Network Provider Manual y
r,eider later ira races.
elnicle t ainten cc The organization must have a documented vehicle
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cleaning and preventive maintenance program.
After review and Inspection of all applicable documents and records,I attest that �V�n�i� t !➢
has met the above credenlialin requirements. Attached are copies oft the required documents.
idenis Escalona Hernandez 120/2 2
Client a e Date
Page 6o
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SCHEDULE OF RATES
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MILE :AMBULATORY TRAMNSPORT
LOADED
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Packet Pg. 2698
AC40RV CERTIFICATE OF LIABILITY INSURANCE
08120/2020
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 BOLDER. y
IMPORTANT; If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed. y
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
UCER A : Raul aul Sardine CIC
,. . _—_—
Sardy's Group Corporation PHONE lv (305)48 -011 v _ _.. � �1 (305)485-063
..__�_.._
10126 W.Fle E-MAIL
ler St. REss; rauljr,@sardysinsurance.com 2
Miami FL 33174 INSURERA; SCOTTSDALE INSURANCE CO. 41297
INSURED) INSURERS. CONTINENTAL DIVIDE INSURANCE COMPANY 35939
Lyn Tiger,LiC ANItg
146 Peary Ct INSURER 0
Unit S INSURER E _I_ _. ........._.— O
__ --_—..... _. ___ ..._
Key West FI_ 33040 INSURER y O
COVERAGES CERTIFICATE NUMBER: REVISION NU SER:
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 VAHICH THIS �
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED WHEREIN IS SUBJECT TO ALL THE TERMS, �
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
AND __ — '� Y OF S1 . — P1C PiOL.cEC_.Ys ESP
TYPE OF INSURANCE � IMR Y r-..-.._.____.—_._...._....., LIMITS
._.._.___..-----..._..�....._..._..._ _,
POLICY
COMMERCIAL GENERAL LIABILITY ; ( ^�EACH OCCURRENCE is 300,000
- DAMAUE ENTIS
CLAIMS-MADE OCCUR IC
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4EDi- (Any ..,�
one son) i g
A 6 . - .. _ y j 1 CPS329 79 t 09117)2019 0911712Q2Q�PERSONAL&ADV INJURY �$ 00,g00
G GENERAL. , Is 300000 cuG€d`LtarB KF £ PR
IxaIJCY __1 JECT 1. J Lam° PROD care s A $_300„000
OTHER. _
AUTOMOBILE LIABILITY I COMBINED SINGLE U IT 5 300,000
!ANY AUTO ^ + I BODILY INJURY(Per n)
'OWNED
(y_ SCHFDUL ED I 05APM021726-01 09/1312019 0911312020 I'BODILY INJURY(€sr d E3 AUTOS
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I� HIRED i 1 NOW -EC ' ( � ; � ��IxQNERT"YC2A�9ACE Q
AUTOS ONLY _.. AUTOS ONLY j F
I $
ELLA
U_.T L.I_A._S �OCC.... !.._i. ......U..R ( .EACH OCCURRENCE
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CESSLIAR CAhSMAbE G_RE ATE .—._._.. _S
I.Eo 3__W..._....._....._._ ......._.__..._....__.�._'RE1 ENT ION 5 � ! I i$
WORKERS COMPENSATION 1 P€R C3'rH-EMPLOYERS' 'T—
aAND LIABILITY T'8N pylA� ^ � �........._SIAI UTE...L .... €R_.. ......� ..__._ ......-
1ANY€�R,OPRIETOR(PARTNNERtEXECUTIVE C L,EAC ht A Cfb€NT 13
�OFFICERIMEMBER EXCLUDED? � ? � --__ .. .�. ... .—._„_ - -_... _.. .__
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(Mandatory in NFdI C E LI DISEASE-.. EhAryL€.AYF_ $ ,Cb
If yes, scr'a urxPo€ I i I i .._u..... ... _._. ........ �_......_... �. .-...._....._....._.. _
DESCRIPTION OF OPERATIONS mflo t � ? 'E.L.DISEASE-POLICY LIMIT j$ �.
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DESCPJP77ON OF OPERATIONS d LOCATIONS 1 VEHICLES(AC 101,Additional Renraft Scbaduis,may be attacked N mom space la acquired) t8
Certificated bolder is listed as additional Insured tJ
2015 Nissan ALTIMA Vin#d 1 N4AL33AP0FN40727 stag Value$6,000 z
2019 TOYOTA SIE A VwW 5TDY23DC2.KS973542 Stated Value$30,000
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CERTIFICATE BOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE P
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
A Ss2 C'e ACCORDANCE WITH E POLICY PROVISIONS,
6200 SOUTH SYRACUSE WAY AUTHORIZED RERRESENTAT1vE
200
GREENWOOD VILLAGE CO 80111
01988-201S ACORD CORPORATION. All rights reserved.
O (2016103) The C name and logo are registered marks of ACORD
Packet Pg. 2699
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146 PEARY CT KEY WEST FL 33040
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APPLICATION
SCREENING METHOD 0
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We require rs notive to schedulenon-emergency
transportation through a MedicateAgency
We also offer the same day transportation.
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Sincerely
N
09/21/2020
Nirlenis Escalona Hernandez
Owner
Lyn Tiger Ilc
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`~ BOARD OF COUNTY COMMISSIONERS a)
q_�ounty of MonroeMayor Heather Carruthers,District 3 w
Mayor Pro Tem Michelle Coldiron,District 2
eFloridas y
Craig Cates,District 1 y
David Rice,District 4
Sylvia J.Murphy,District 5
onroe County Fire Rescue
490 631 Street Ocean �
Marathon,FL 330504'�"0�"w a)
Phone(305)289-6088
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MEMORANDUM c
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Nicole
Caitlin r ss
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SUBJECT: Check for Deposit
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09/25/2020ry
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Attached please find Check_ dated /1 /22 , in the amount of$50.00, to be deposited in the
General Fund. This check has been issued for the application of a Class B Certificate of Public
Convenience and Necessity for Lyn Tiger LLC.
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Thank you,
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Caitlin C�P
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DATE(( S.2.e'
,acoizo® CERTIFICATE OF LIABILITY INSURANCE
09/15/2020
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TH
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIE
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZE
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. y
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorse y
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement c
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
CONTACT 0
PRODUCER NAME: Raul Sardina CIC
Sardy's Group Corporation PA/ic°N No,
Ext: (305)485-0116 FAX No): (305)485-0633
10126 W. Flagler St. ADDRESS: rauljr@sardysinsurance.com
INSURER(S)AFFORDING COVERAGE NAIC# (n
Miami FL 33174 INSURERA: SCOTTSDALE INSURANCE CO. 41297 -
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INSURED INSURER B: CONTINENTAL DIVIDE INSURANCE COMPANY 35939
Lyn Tiger, Llc INSURER : 0
146 Peary Ct INSURER D: (B
Unit B INSURER E 7
Key West FL 33040 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIC
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TH °N
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICY NUMBER MM/DD MM/DD/YYYY O
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 300,000
DAMAGE TO RENTED
CLAIMS-MADE OCCUR PREMISES Ea occurrence $ 5,000
MED EXP(Any one person) $
A y CPS3296799 09/17/2020 09/17/2021 PERSONAL&ADV INJURY $ 300,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 300,000 U
PRO-
X POLICY JECT LOC PRODUCTS-COMP/OP AGG $ 300,000
OTHER: $ `IL
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 300 000 r
Ea accident
ANY AUTO BODILY INJURY(Per person) $ CD
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B OWNED �/ SCHEDULED AUTOS ONLY AUTOS
05APM021726-02 09/13/2020 09/13/2021 BODILY INJURY(Per accident) $
/�
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
$ N
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $ LLJ
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY STATUTE ER
Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ cu
OFRCER/MEMBER EXCLUDED? N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
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DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Certificated Holder is listed as additional Insured
2015 Nissan ALTIMA Vin#1 N4AL33APOFN40727 stated Value$6,000
2019 TOYOTA SIENA Vin#5TDYZ3DC2KS973542 Stated Value$30,000 CJ
P
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOF
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 0)
ACCORDANCE WITH THE POLICY PROVISIONS.
Access2care
O
6200 SOUTH SYRACUSE WAY AUTHORIZED REPRESENTATIVE
200 - -
GREENWOOD VILLAGE CO 80111
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
Packet Pg. 2704