09/18/2002 Agreement
Cleltl 01 De
Circul coun
Danny L. Kolhage
Office (305) 292-3550 Fax (305) 295-3663
Memnrandum
To:
James L. Roberts,
County Administrator
Attn:
Maria Z. Fernandez,
Croup Insurance Administrator
From:
Isabel C. DeSantis,. L
Deputy Clerk ;.pr
Date:
Tuesday, November 19, 2002
At the BOCC meeting on September 18, 2002, the BOCC granted approval and
authorized execution of the following:
Employer-Provider Network and Utilization Review and Case Management
Services Agreement between Monroe County and Keys Physician Hospital Alliance
(KPHA) for the employer-provider network and utilization review and case management
services effective 10/1/02 through 9/30/03.
Attached hereto is a fully executed copy of the above document for your
handling. Should you have any questions concerning the above, please do not hesitate
to contact this office.
cc: County Attorney
Finance
File /'
pt:~ ,:'_l;'l'-' , "
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EMPLOYER-PROVIDER NETWORK
AND
UTILIZATION REVIEW AND CASE MANAGEMENT SERVICES
AGREEMENT
THIS AGREEMENT is entered into as of this first day of OCTOBER 2002 by and
between Keys Physician-Hospital Alliance ("KPHA") and the County of Monroe
("County"), hereon referred to as "Employer".
RECITALS
WHEREAS, the KPHA has established a network of participating health care
providers, which providers, pursuant to the terms and conditions of provider agreements
with KPHA, have agreed to deliver medical services in a cost effective manner to persons
covered under the health benefit plans and policies of Employer.
WHEREAS, KPHA has agreed to provide utilization review and case management
services to Employer and personnel, dependents, Cobra beneficiaries and eligible retirees
covered under the health benefit plans and policies of Employer.
WHEREAS, Employer administers the health care benefrt plans and has the express
authority, by signing this Agreement, to bind the Employer to all of the terms and conditions
ofthis Agreement.
WHEREAS, Employer desires and agrees to offer KPHA Provider Network to
persons covered under the Employers health benefits plans;
Now, THEREFORE, the parties agree as follows:
1. RECITALS. The foregoing recitals are hereby incorporated by reference and
made a substantive part hereof.
2. LIST OF PARTICIPATING PROVIDERS. KPHA shall provide Employer
with a list of Participating Providers, to include hospitals, physicians, dentists, pharmacies,
and other ancillary health services, and shall provide Employer with periodic updates of the
Network roster of Participating Providers from time to time. Such updates will be at least
semi-annually and in such a printed format as distributable to persons covered under the
Employers health benefits plans.
Page 1
OUT-OF COUNTY PROVIDERS. KPHA agrees to negotiate and contract with
"Dimension Network" in Dade, Broward and Palm Beach Counties for discounted fee
arrangements with physicians, hospitals, and other ancillary health services as needed for the
benefit of the Employer. If the "Dimension Network" is not utilized, or becomes unacceptable to
the Employer, KPHA will propose other alternative arrangements for such out of county
services.
3. UTILIZATION MANAGEMENT AND OUALITY ASSURANCE. KPHA shall
provide for Employer Utilization Review services to include
. Review of inpatient admissions and of continued hospital stay
. Discharge planning
. Data collection and reporting
. Review of supportive or treatment services
. Review of office visits, ambulatory surgery and diagnostic or other outpatient
services
. Review of billing practices and appropriateness of charges of network providers
. Large Case Management services .
The monthly capitation fee for such services will be $1.35 per employee per month. This fee will
be payable by the County to KPHA by the 20th of each month beginning on the 20th day of
October, 2002. The number of enrollees will be detennined on the 1 st business day of each
month.
KPHA shall provide for Large Case Management services for a fee of$55.00 per hour on an as-
needed basis. Large Case Management services may be pre-approved by the County on a case by
case basis and billings for such fees incurred shall be provided monthly with details of all
charges.
Utilization Review and Large Case Management services will be performed according to pre-set
protocols developed in conjunction with the claims administrators (Acordia National's) standards
and will be documented in the claims administrators' computer system.
4. WELLNESS PROGRAMS AND OTHER EDUCATIONAL SERVICES. KPHA
shall design and implement with the coordination of Employer's staff, the Worksite Wellness
Program and other similar services to the Employer and Covered Persons to promote healthy
lifestyles and preventative health care. The Worksite Wellness Program will include, at no
additional charge to Employer or Covered Persons, a heahh risk assessment for each employee
and may include, for a charge by a Participating Provider, Health Physical Packages. Health Fair
coordination and implementation or other services as negotiated and deemed to promote heahhy
lifestyles and preventative health care may also be included in this service.
Page 2
5. PARTICIPATING PROVIDER COMPENSATION. Employer shall compensate
Participating Providers for covered services minus any plan participant responsibilities.
Employer has the responsibility for implementation of the applicable claims payment submitted
by Participating Providers for services rendered or for any billing or other function related to the
health care services provided by Participating Providers to Covered Persons. All claims for
covered services, whether payable by the Employer or a Covered Person will receive a discount
off of provider billed charges as specified in Attachment A. This discount will be rescinded if
an appropriately documented and non-contested claim is not paid to the Participating Provider
within thirty (30) days of being received by the claims administrator (Acordia National).
NON-APPROPRIATIONS CLAUSE. Monroe County's performance and obligation
to pay under this contract is contingent upon an annual appropriation by the BOCC. Monroe
County may not deny payment for valid and accurate claims properly submitted and rendered
during the plan year.
PROVIDER REIMBURSEMENT TERMS. KPHA shall use best efforts to ensure that
the Participating Provider's physician Usual Customary and Reasonable (VCR) charges will not
change during the term of one year. Thereafter, KPHA agrees to provide a ninety (90) day
notification in the event of a charge increase. Physician UCR charges will be based upon "the
Medicode database." The above agreed upon discount will be applied to the billed charge, not to
exceed the UCR charge for a service.
KPHA further agrees that no other self-insured employer contracting with KPHA will be
provided with better overall terms than what is being here agreed. If however, better terms are
provided to another self-insured employer contracting with KPHA, such terms will also be
extended to the Employer.
6. COVERED PERSON IDENTIFICATION. Employer shall supply Covered Persons
with identification cards or other means of identification which clearly identifies KPHA, reflects
the Covered Person's coverage under the applicable Employers heahh benefit plan, and reflects
the Covered Person's eligibility to receive services from Participating Providers in accordance
with the terms of this Agreement. Employer shall also provide such other services as may be
required in order for Participating Providers promptly to verify the status of individuals as
Covered Persons, the terms of the Covered Person's health care benefits, including but not
limited to the applicable terms of coverage, deductible status and co-insurance.
7. NETWORK EXCLUSIVITY. During the course of the agreement Employer agrees not
to participate or enter agreements to utilize other provider networks other than that agreed upon
with KPHA and the Employer. Employer during the term of this Agreement shall not seek to
negotiate with individual network members for care or services outside of contractual provisions
without prior notification to KPHA.
Page 3
8. BOOKS AND RECORDS. KPHA shall make available to claims administrator
(Acordia National) all records and other data relating to both the network and utilization review
and case management services for the purpose of periodic audits of KPHA's services.
Information/data will be maintained, as required, to assure confidentiality and compliance with
all applicable regulations.
9. RESPONSmILITY FOR HEALTH CARE SERVICES. Employer agrees that KPHA
shall not have any responsibility or liability for any act, omission, or decision related to medical
services rendered by Participating Providers to a Covered Person.
10. TERM. This Agreement shall continue in effect for one (1) year from the date first
above written. Thereafter, the Agreement shall renew for two (2) consecutive one (1) year terms.
KPHA agrees to provide the Employer with at least ninety (90) days written notice of the intent
to terminate, non-renew, or amend this Agreement. The Employer agrees to provide KPHA with
at least ninety (90) days written notice of the intent to terminate or non-renew this agreement.
Any modification of the terms of this agreement may occur upon the mutual' agreement of the
parties.
BREACH AND CURE. Notwithstanding the foregoing, this Agreement may be
terminated by either party upon a material breach ofthis Agreement by the other party, providing
that the breaching party does not cure the breach within thirty (30) days following receipt of a
written notice from the non-breaching party specifying the nature of the breach and requesting
that it be cured.
11. GENERAL PROVISIONS.
A. THIRD PARTIES: The terms and provisions of this Agreement are for the
benefit of the parties hereto and are not intended to provide any other person with any right or
cause of action on account thereof.
B. NOTICES: Any notice required to be given pursuant to the terms and provisions
thereof shall be in writing and shall be hand-delivered, with return receipt thereof, or sent by
certified or registered mail, return receipt requested and first-class postage prepaid to the
addresses as follows:
Employer:
County of Monroe
Manager- Employee Benefits
Public Service Building
5100 College Road, Stock Island
Key West, FI 33040
Page 4
KPHA:
Keys Physician-Hospital Alliance
c/o Lower Florida Keys Physician Hospital Organizatio~ Inc.
P.O. Box 9107
Key West, Florida 33041-9107
Attn.: Ronald Bierma~ Secretary
C. ASSIGNMENT: This Agreement may not be assigned, subcontracted,
delegated, transferred by either party without the express written consent of the other party, and
any attempted assignment, subcontract, delegation or transfer shall be void.
D. INDEPENDENT CONTRACTORS: None of the provisions ofthis Agreement
are intended to create, nor shall be deemed to, or construed to create any relationship between
KPHA and Employer other than that of independent entities contracting with each other
hereunder solely for the purposes of effecting the provisions of this Agreement. Neither of the
parties hereto, nor any of their respective officers, directors, or employees shall be construed to
be the agent, employee, or representative of the other.
E. GOVERNING LAW: This Agreement shall be governed in all respects by the
laws of the State of Florida without regard to Florida's choice of law statutes or decisions. Any
action by any party, whether at law or in equity, relating to this Agreement shall be commenced
and maintained, and venue shall be proper, only in Monroe County, Florida.
F. ORDINANCE 10-1990: KPHA warrants that it has not employed, retained or
otherwise had acted on his behalf any former County officer subject to the prohibition in Sec. 2
of Ordinance no. 10-1990 or any County officer or employee in violation of sec. 3 of Ordinance
10-1990, and that no employee or officer of the County had any interest, financially or otherwise,
in KPHA except for such interest, permissible by law and fully disclosed by affidavit attached
hereto. For breach or violation of this paragraph, the County may, in its discretio~ terminate this
agreement without liability and may also, in its discretio~ deduct from the contract or purchase
price, or otherwise recover, the full amount of any fee, commission, percentage, gift or
consideration paid to the former County officer or employee.
G. CONFLICT OF INTEREST: KPHA assures the County that to the best of its
knowledge information and belief, the signing of this agreement does not create conflict of
interest.
Page 5
H. OWNERSHIP OF INFORMATION: All Utilization Review and Case
Management documents which are prepared in the performance of this agreement are to be, and
shall remain, the property of the County and shall be transferred to the County or to a
replacement Utilization Review/Case Management service provider upon request and no later
than thirty (30) days after termination of this agreement. Any patient identifying information
shall not be disclosed without written consent ofthe patient.
I. INSURANCE REOUIREMENTS: KPHA is required to maintain the types of
insurance identified in Attachment B.
J. SEVERABILITY: If any provision of this Agreement is held to be illegal,
invalid, or unenforceable, under present or future laws effective during the term hereof, such
provision shall be fully severable. In such event, this Agreement shall be construed and enforced
as if the illegal invalid or unenforceable provision had never been a part hereof, and the
remaining provisions shall remain in full force and effect unaffected by such severance- provided
that if the illegaL invalid or unenforceable provision is material to the overall purpose and
oper~t~on of this Agreement, then this Agreement shall terminate upon the ~everance of such
prOVISIon.
K. COUNTERPARTS: This Agreement and any amendment hereto may be
executed in multiple originals, all counterparts together constituting one and the same
instrument.
L. ENTIRE AGREEMENT: This Agreement, along with its exhibits, contains all
the terms and conditions agreed upon by the parties hereto regarding the subject matter of this
Agreement and supersedes any prior Agreements, promises, negotiations, or representations
either oral or written, relating to the subject matter of this Agreement.
M. HOLD HARMLESS: KPHA shall indemnify and hold the County harmless
from and against any and all losses, penalties, damages, professional fees, including attorney fees
and all costs of litigation and/or judgment arising out of any willful misconduct or negligent act,
error or omission of KPHA incidental to the performance of this agreement or work performed
thereunder. This indemnity shall extend to amounts the County becomes legally obligated to pay
and shall be limited by any sovereign immunity limit applicable to the underlying claim plus
costs of litigation.
In witness wherof, the Employer and KPHA have caused this Agreement to be executed by their
respective corporate officers, effective as of the ftrst day of October 2002.
Page 6
By: cf,(ules 'Jont1yf'lJ1c{':)"
Its: /tIl oyer/ Chit i rman 9--/ a--(J~
Keys Physician-Hospital i\l1i~
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DEPUTY CLERK
Employer:
Board of Co
of Monroe
Commissioners
_ Florida
Page 7
Attachment A
Reimbursement Schedule
KPHA Members
850/0 of billed charges with the cap of the 90tll percentile of the Medicode
Fee Schedule.
In County Providers (IPN)
85% of blUed charges with the cap of the 90tll percentile of the Medicode
Fee Schedule.
Out-of-County Providers (IPN) 70% of blUed charges with the cap of the 90tll percentile of the Medicode
Fee Schedule.
Dimension Providers
Dimension Network Fee Schedule
Fisherman's Hospital
75% of billed charges.
Lower Keys Medical Center
75% of billed charges.
A list of specific providers and discount percentages will be provided to Acordia National by KPHA for
implementation.
//-(/~
Date
Stephen Krathen, D.O.
KPHA President
ql$/~
Date
1996 Edition
RISK MANAGEMENT
POLICY AND PROCEDURES
CONTRACT ADMINISTRATION
MANUAL
General Insurance Requirements
for
Other Contractors and Subcontractors
As a pre-requisite of the work governed, or the goods supplied under this contract (including the
pre-staging of personnel and material), the Contractor shall obtain, at his/her own expense,
insurance as specified in any attached schedules, which are made part of this contract The
Contractor will ensure that the insurance obtained will extend protection to all Subcontractors
engaged by the Contractor. As an alternative, the Contractor may require all Subcontractors to
obtain insurance consistent with the attached schedules.
The Contractor will not be permitted to commence work governed by this contract (including
pre-staging of personnel and material) until satisfactory evidence of the required insurance has
been furnished to the County as specified below. Delays in the commencement of work,
resulting from the failure of the Contractor to provide satisfactory evidence of the required
insurance, shall not extend deadlines specified in this contract and any penalties and failure to
perform assessments shall be imposed as if the work commenced on the specified date and time,
except for the Contractor's failure to provide satisfactory evidence.
The Contractor shall maintain the required insurance throughout the entire term of this contract
and any extensions specified in the attached schedules. Failure to comply with this provision
may result in the immediate suspension of all work until the required insurance has been
reinstated or replaced. Delays in the completion of work resulting from the failure of the
Contractor to maintain the required insurance shall not extend deadlines specified in this contract
and any penalties and failure to perform assessments shall be imposed as if the work had not
been suspended, except for the Contractor's failure to maintain the required insurance.
The Contractor shall provide, to the County, as satisfactory evidence of the required insurance,
either:
. Certificate of Insurance
or
. A Certified copy of the actual insurance policy.
The County, at its sole option, has the right to request a certified copy of any or all insurance
policies required by this contract.
All insurance policies must specify that they are not subject to cancellation, non-renewal,
material change, or reduction in coverage unless a minimum of thirty (30) days prior notification
is given to the County by the insurer.
The acceptance andlor approval of the Contractor's insurance shall not be construed as relieving
the Contractor from any liability or obligation assumed under this contract or imposed by law.
Administration Instruction
#4709.3
14
1996 Edition
The Monroe County Board of County Commissioners, its employees and officials will be
included as "Additional Insured" on all policies, except for Workers' Compensation.
Any deviations from these General Insurance Requirements must be requested in writing on the
County prepared form entitled "Request for Waiver of Insurance Requirements" and
approved by Monroe County Risk Management.
Administration Instruction
#4709.3
15
1996 Edition
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Kevs Physician-Hospital Alliance
Prior to the commencement of work governed by this contract, the Contractor shall obtain
Workers' Compensation Insurance with limits sufficient to respond to Florida Statute 440.
In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less
than:
$100,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$100,000 Bodily Injury by Disease, each employee
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 approved by the Florida's Department of Labor, as an authorized self-
insurer, the County shall recognize and honor the Contractors 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.
wet
Administration Instruction
#4709.3
88
PROFESSIONAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Kevs Physician-Hospital Alliance
1996 Edition
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.
The minimum limits of liability shall be:
$500,000 per Occurrence/$l,OOO,OOO Aggregate
PR02
Administration Instruction
#4709.3
I
78
1996 Edition
VEHICLE LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Kevs Physician-Hospital Alliance
Recognizing that the work governed by this contract requires the use ofvehic1es, the Contractor,
prior to the commencement of work, shall obtain Vehicle Liability Insurance. Coverage shall be
maintained throughout the life of the contract and include, as a minimum, liability coverage for:
. Owned, Non-Owned, and Hired Vehicles
The minimum limits acceptable shall be:
$300,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
VL2
Administration Instruction
#4709.3
82
1996 Edition
EMPLOYEE DISHONESTY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Kevs Phvsician-Hosoital Alliance
The Contractor shall purchase and maintain, throughout the tenn of the contract, Employee
Dishonesty Insurance which will pay for losses to County property or money caused by the
fraudulent or dishonest acts of the Contractor's employees or its agents, whether acting alone or
in collusion of others.
The minimum limits shall be:
$10,000 per Occurrence
EDl
Administration Instruction
#4709.3
4S
1996 Edition
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
Kevs Physician-Hospital Alliance
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:
$500,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$250,000 per Person
$500,000 per Occurrence
$ 50,000 Property Damage
An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective date of this contract.
In addition, the period for which claims may be reported should extend 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 Additional Insured on
all policies issued to satisfy the above requirements.
GL2
Administration Instruction
#4709.3
55
PUBLIC ENTITY CRIME STATEMENT
"A person or affiliate who has been placed on the convicted vendor list
following a conviction for public entity crime may not submit a bid on a
contract to provide any goods or services to a public entity, may not submit
a bid on a contract with a public entity for the construction or repair of a
public building or publ ic work, may not submit bids on leases of real
property to public entity, may not be awarded or perform work as a
contractor, supplier, subcontractor, or consultant under a contract with any
public entity, and may not transact business with any public entity in excess
of the threshold amOUllt provided in Section 287.017, fOl.CATEGORY
TWO for a period of 3 6 months from the date of being placed on the
convicted vendor list. II
j"
ATTACHMENT B
DRUG-FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida Statue 287.087 hereby certifies that:
KEYS PHYSICIAN-HOSPITAL ALLIANCE
(Name of Business)
1. Publish 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 against employees for violations of such prohibition.
2. Inform employees about the dangers of drug abuse in the workplace, the business's policy of
maintaining a drug-free workplace, any available drug counseling, rehabilitation, and
employees assistance programs, and the penalties that may be imposed upon employees for
drug abuse violations.
3. Give 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), notify the employees that, as 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
guilty or nolo contender to, any violation of Chapter 893 (Florida Statues) or of any
controlled substance law of the United States or any state, for a violation occurring in the
workplace no later that five (5) days after such conviction.
5. Impose a sanction on, or require the satisfactory 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.
6. Make 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 form complies fully with the
above requirements.
~')
Bidder's Signature
1j'3kt
Date I
ATTACHMENT C
NON-COLLUSION AFFIDAVIT
I, KEYS PHYSTCTAN-ijOSPTTAT, AT.T.T ANr.F.
of the city
of KEYS PHYSICIAN HOSPITAL ALLIANCE according to law on my oath, and under
penalty of perjury. depose and say that;
1) I amKEYS PHYSICIAN-HOSPITAL AU.T ANr.F.
Proposal for the project described as follows:
. the bidder making the
~
2) The prices in this bid have been arrived at independently without col!usion,
consultation, communication or agreement for the purpose of restricting competition, cis
to any matter relating to such prices with any other bidder or with any comp.etitor;
3) Unless otherwise required by law, the prices which have been quoted in this bid
have not been knowingly disclosed by the bidder and will not knowingly 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 th~ bidder to induce any other
persQn, partnership or corporation to submit, or not to submit, a bid for the purpose of
restricting competition;
r
,.
5) The statements contained in this affidavit are'true and correct, and made with
, full knowledge that Monroe County relies upon the ..Of th'e\tatements contained in
this affidavit in awarding contracts for said proj 1. ') .
. C{;~/
STATE OF FLORIDA
COUNTY OF MONROE
(Signature of Bidder)
94Yk;
/ /
DATE
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
/3
,p ~/ltJ1.
My commi~s)jnJ e/Pires:
rfi;CJJ;c3
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OMB - MCP FORM #1
ATIACHMENT 0
SWORN ST^TETv1ENT UNDER ORDINANCE NO, 10-1990
MONROE COUNTY. FLORIDA
ETHICS CLAUSE
KEYS PHYSICIAN-HOSPITAL ALLIANCE
warrants that he/it has not employed. retained
or otherwise had act on his/its b~half any former County officer or employee in violation of
Section 2 of Ordinance no. 10-1990 or any County officer or employee in violation of
Section J of Ordinance No.' I (l-1990. For breach or violation of this provision the County
may. in its discretion. tcrmin:lte this contract without liability and may also, in its discretion.
deduct from the contract or purchase prkc. or otherwise recover, the full amount of any fcc,
eonun ission, percentage, gin. or eonsidemtion paid to ~jer or employee.
(signature)
Date: ?/l.:>101
/ I
STATEOF FLORIDA
COUNTY O'F MONROE
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
S&')i2i1 ~.I;i,,/'1 who, after first being sworn by me, affixed hislher
(name of individual signing) in the space provided above on this /3 day of
My c()llll11issio'J:e~p)res:
~/(J'll}3
. ...tlY PI./. OfFICIAL MJiM V SEAl.. -,
0....- ~~ OlGA RUIZ
~ ~ COlAMISSIOO NUMBER
< CC842135
~ ~ MY COt.IMISOON EXPIRES
OF f\.O JUNE 1 2003
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