Certificates of Insurance THIS CERTIFICATE IS ISSUED AS A MA'TI'ER OF INFORMATION
PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
REGAN INSURANCE AGCY HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTEI~ THE COVERAGE AFFORDED BY THE POLICIES BELOW.
90144 OVERSEAS HWY ' COMPANIES AFFORDING COVERAGE
TAVERNI ER FL 33070 COMPANY
A THE HARTFORD
INSURED COMPANY
MICHAEL D HUNTER MD PA S
COMPANY
BOX 522380 C
MARATHON SHORES FL 33052 COMPANY
D
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. EMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POUCY EFFECTIVE POUCY EXPIRATION
CO TYPE OF INSURANCE POLICY NUMBER UMITS
LTR DATE (MM/DD/YY) DATE (MM/DD/YY)
~ GE.~.~UAB,Lrr* 21SBABK3240 8/01/02 8/01/03 G£NERALAGGREGATE $1, 000, 000
X COMMERCiaL GENERAL L~S~UTY PRODUCTS' COMP/OP AGG $1, 000, 000
I CLAIMS MADE ~] OCCUR PERSONAL & ADV INJURY $ 500, 000
DWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE $ 500 ~ 000
FIRE DAMAGE (Any one fire) $ 300 t 000
MED EXP (Any one person) $ 10 t 0 0 0
AUTOMOBILE LJABlUTY
COMBINED SINGLE LIMIT $
ANY AUTO
ALL OWNED AUTOS A i MAE ENT (Per person) $
SCHEDULED AUTOS E~ ~, ~
HIRED AUTOS ~)t BODILY INJURY
NON.OWNED AUTOS DATE__ -- . ' ~' (Per accident) $
WAIVER N/A yE ., PROPERW D~AGE $
GARAGE MABILYrY AUTO ONLY- EA ACCIDENT $
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT
AGGREGATE $
EXCESS UABILI~ EACH OCCURRENCE $
UMBREU.~ FORM AGGREGATE $
OTHER THAN UMBRELLA FORM $
WC STATU- 1%T~'i-
WORKERS COMPENSATION AND TORY l M TS
EMPLOYERS' U~IUTY E, EACH ACC~D~rr $
THE PROPRIETOR/ ~ INCL EL DISEASE-POLICY LIMIT
PARTNERS/EXECUTIVE
OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE $
OTHER
DESCRIPTION OF OPERATIONS/t. OCATIONS/VEHICLES/SPECIAL ITEMS
USUAL TO INSURED'S OPERATIONS
CERTIFICATE HOLDER IS SHOWN AS AN ADDITIONAL INSURED DUE TO CONTRACT
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE
MONROE COUNTY BOARD OF COME EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
ATT MARIA SLAVIK RISK MANAG' 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
1 1 0 0 S IMONTON STREET BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBUGATION OR UABILITY
KEY WEST FL 33040 OF ANY KIND UP. II, THE COMPANY,~) AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRF..~N'I~'IIVE ~ .~
"~ '~" ~'~'~' ~'"~ BM ..~ ..................................
Ro er
POLICY NUMBER
HR3t 8227888
CINCINNATI INSURANCE ~og~NIES
THE CINCINNATI INSURANCE
AUTOMOBILE PAYOR - INSURED
C}{ANGE EFFECTIVE POLICY EXPIRATION
07-15-02 06-13-03
ISSUED TO:
MICHAEL & MARY HUNTER
1640 LAKE SHORE DRIVE
SARASOTA FL 34231-3406
It is agreed the policy is amended as follows:
ADD ADDITIONAL INSURED TO TOYOTA TACOMA
AME~IDATORY E~-DORSEMENTS: CPAl184 (11/01) HOA9000 (01/01) CPA0406 (11/01)
CPA1350 (11/01) AP404FL(11/93) CPA1092 (05/88) CPA1094 (11/01)
CPA1249(07/93) CPA1376 (07/01) IP412 (12/92) MI-1659(05/01)
MI1533 (03/99) *CPA1002 (11/01) FA4000T(06/01)
Municipal Code 000999
ADDITIONAL INSURED Car 2
MONROE COUNTY BOARD OF COUNTY
COMMISSIONERS
1100 SIMONTON STREET
KEY WEST, FL 33040
WAIVER N!A .~.YES -
This is a true copy of the original document.
Sworn before me
Notary Publ
this ~9__~__~day~ ,2002.
My Commi ssion ~-x~i res:
~.~3~- Linda K Cummings
,~My Commission CC851270
t,~w~e,'~ Exl3tres July 1, 2003
Nothing herein contained shall vary, alter, waive, or extend any of the
terms, representations, conditions, or agreements of this policy other
than as above stated.
09-054 Atlas Mortgage & Insurance,~/
07-18-02 FLVER071502 BY:
PAGE 1 ORIGINAL
#01
PL-1050 (1/96)
Insurance Solutions for Healthcare Providers
MEMORANDUM OFINSURANCE
MONROE COUNTY OFFICE OF RISK MANAGEMENT NAMED INSURED:
A-I-FN: MARIA SLAVIC MICHAEL DAVID HUNTER, M.D.
1100 SIMONTON STREET P.O. BOX 522380
KEY WEST, FL 33040 MARATHON SHORES, FL 33052
This
nam(
mem(
~urance Company, Inc. has issued to the
to all the terms of such policy. This
ds, extends or alters the coverage of such
claim
CLAIMS REPORTING
PERIOD
Clas~
Date
FPIC-9(1/86) 259/3 FL-P80054
1000 Riverside Avenue, Suite 800 · Jacksonville, Florida 32204 * (904) 354-5910 * 1-800-741-3742 * Fax (904) 358-6728
EO. Box 44033 · Jacksonville, Florida 32231-4033 * Internet Address: http://www, medmal.com
07/25/02 14:17 FAX 941 361 6914 DIST 12 ~[ED EXA~iINER
Jul 25 02 ll:37a Claud~.a
Jul-Zi-O2
941 -951 -281'7
T-181 P.002/005
~002
p.1
FPIC
Imurgnce ~olutk~ ~c He, Ir. bourn Provider.~
TO WHOM IT MAY CONCERN:
MEMORANDUM OF fl~IglJRANC£
NAMED INSURED:
MICHAEL DAVID HUNTER, M.D.
P.O. Box 59.~80
MAR,~r'rK)N SHORES, FL 33052
Thfs i~ ~ adv~e you that the First Ft~lona# I~,Ura't~ ~y, I~. has ~ to ~e
me~~ ne~er ~at~ or ~t~Y a~nds, ~s or a~m ~ e~e of s~h
! NUMBER INSU~CE LIMrr~ P~RIOD __
Li,M)lllty 1,500.000 aggregate To: 0810'1/2003
Rdatroactlve Date: 08/011200:2
Class S2 - FORENSIC MEDICINE
APP~V~ ~ANAGEMENT ~
WAIVER N/A ~YE$
Date Issued-' 07/2S/2002
FPIC-g(1/~O) ESg/'3 I~L-PSO064
44033 '~ J0tksonvitle, ~.ohc~, 3ZZ31-403J ,, fnrbyiz[ Addrg~l; ht~T)://www, meGimal.com
MONROE COUNTY, FLORIDA
Request For Waiver
of
Insurance Requirements
It is requested that the insurance requirements, as specified in the County's Schedule of Insurance Requirements,
be waived or modified on the following contract.
Contractor:
Contract for:
Ad.ess of Contractor:
Phone:
Scope of Work:
Reason for Waiver:
Policies Waiver
will apply to:
Signature of COntractor:
Risk Management
Date
County Administrator appeal:
Approved:
Not Approved
Not Approved:
Date:
Board of County Commissioners appeal:
Approved:
Not Approved:
Meeting Date:
Administration Instruction
#4709.3
102
NOTICE OF ELECTION TO BE EXEMPT
Please refer to the written instructions prepared by the
Division of Workers' Compensation before completing this form.
By filing this application, you elect to be exempt from the provisions of Chapter 440,
Florida Statutes and waive any right you may have to workers' compensation benefits in
the State of Florida should you become injured on the job. Any person who knowingly and
with intent to injure, defraud~ or deceive the Division or any employer~ employeq or
insurance company or purposes progran~ f'des a Notice of Election to be Exempt containing
any false or misleading information is guilty of a felony of the third degree. Certain
documentation is required by law to be attached to this application-refer to the instruction
sheet for more details.
Effective/Issue Date:
Expiration Date:
Control Number:
Postmark Date:
Received Date:
I am applying for exemption as a (check only one box in this section):
CONSTRUCTION INDUSTRY ( $ 50.00 FEE REQUIRED)
[] Sole Proprietor [] Partner [] Corporate Officer (your corp. title: ) -OR-
NON-CONSTRUCTION INDUS~T/~Y ( NO FEE REQUIRED)
L_~ Corporate officer (your corp. title: ~)l'~,Ig; ~ ~'~ )
CORPORATE OFFICERS AND PARTNERS: List the registration number of your business on file with the Division of Corporations,
Department of State's Office (121~ OTE: your parmers.hip may not have one, but all corporations must have one. If your partnership doesn't
have one, state '~N/A"): ~ O ~ O O O ~ ~ O '-/~" ~
THIS EXEMPTION APPLICATION APPLIES ONLY TO THE PERSON SIGNING THE APPLICATION
AND ONLY FOR THE BUSINESS ENTITY LISTED IN THE FOLLOWING SECTION
Business Name:
Business Mailing Address:
County: [ Phone No.:
Trade Name; d/b/a; or a/k/a:
City: ! State: [ Zip:
Nature of Business: [ FEIN:
Unemployment Corrq~nsation ] Date Business Established: No. of Employees:
Are you required to be registered or certified pursuant tg Chapter 489, F. S.? [-']No I_~'Yes: list all certified or registered
licenses issued to you pursuant to Chapter 489, Florida Statues I~ t~ ~ e.'e ~ tn~ ~ ~'t)O ~M,
Are you or a qualifier for your business required by the county or the municipality in which your busi~ss n~ting address is
located to have an occupational hcense for the business which ~s the subject of this apphcataon. [ ~ rio [~Yes:
YOU MUST ATYACH A COPY OF A CURRENT OCCUPATIONAL LICENSE
Are you emptied by any sole proprietorship, partnership, corporation or business entity other than the business to which this application
applies? [~NO [] YES list the name of all other businesses in which you are employed:
Has the above-referenced business entity..~bee~l~,in operation long enough to have filed with or be required to file by the IRS,
an annual Federal Income Tax Return? L~ No [] Yes, You must attach tax records. See instruction sheet for details.
AFFIDAVIT OF APPLICANT: I hereby certify that the information contained herein is true and correct to the best of my
knowledge and belief; that this election does not exceed exemption limits for corporate officers or partners as provided in ~440.02
Florida Statutes; and that I will secure the payment of workers' compensation benefits, pursuant to Chapter 440, Florida Statutes,
for any employee I now have or may hereinafter acquire, for which my business is required by Florida law to secure such benefits.
I.,2
~~~. APPLYING ~OR EXE/~M~rION SOCIAL._~/SECURITYI' / NO.eoOA mO.DATE oFdaYBIRTH yr.
APPLICANT'S SIGNATURE J/.. ~-n~ DATE SIGNED
NOTARY STATE OF FLORIDA, COUNTY OF__
Personally Known V ~. ~r,oduced Id~,~, .___~..Ty? _of_identification Producedu ~,~'~[~_~ lanaa ~< Cummings
NOTARY SIGNATURE ~'~~ /[ · LA,&.,~~ My Commission Expires
?~My COmm~s3ion CCaS127n
LES FORM BCM-2~em-~ed February 2000 0
(SEE REVERSE FOI~¢A~~.~L~II~ORMATION)
~.i~% Lin(i;~ p Gummings
~.~.My Corr~r,~i.~....ion CC851270
'~'~W~l~r~y Expires July 1, 2003
:: A'CoRo. ::i I:DENCE::OF::PROPERT¥ INSU NCE
:...~ ..... :.:.:.:.: ........ ::::::::::::::::::::::::::::::::::::::: ........ ............:...........~................................ ............. ....................................................... 07/15/02
THIS IS EVIDENCE THAT INSURANCE AS IDENTIFIED BELOW HAS BEEN ISSUED, IS IN FORCE, AND CONVEYS ALL THE
RIGHTS AND PRIVILEGES AFFORDED UNDER THE POLICY.
PRODUCER liP,,~.cO.N~o~'~, e~): 9 41 - 3 6 6 - 8 4 2 ~/9 41 - 9 51 - 7 5 5 ', COMPANY
Atlas Insurance Agency
2063 Main Street Cincinnati Insurance Company
P.O. Box 3498 P.O. Box 145496
Sarasota FL 34230-3498 Cincinnati OH 45250-5496
Robert W Brown, CIC
CODE: I SUB CODE:
AGENCY
CUSTOMER ID #: a~[~l'~I 1
INSURED LOAN NUMBER ] POUCY NUMBER
Michael D HunterI HR48227888
1640 Lake Shore Dr 06/13/02 06/13/03 TERMINATEO IF CHECKED
Saraso ta FL 3 4 2 31 - 3 4 0 6 THIS REPLACES PRIOR EVIDENCE DATED:
I
LOCATIONIDESCRIPTION
001
1640 Lake shore Drive
Sarasota FL 34231-3406
COVERAGE/PERILS/FORMS AMOUNT OF INSURANCE DEDUCTIBLE
~Auto coverage per co forms
bodily injury/Liability 100/300
comp ded 500
other than comp ded 500
Property damage 50000
WAIVER N/A ..~/YES -
R~EMA.' R~K~.:(I~.C'I~ ~h~
Premium $ 1155
THE POLICY IS SUBJECT TO THE PREMIUMS, FORMS, AND RULES IN EFFECT FOR EACH POLICY PERIOD. SHOULD THE
POLICY BE TERMINATED, THE COMPANY WILL GIVE THE ADDITIONAL INTEREST IDENTIFIED BELOW l0 DAYS
WRITTEN NOTICE, AND WILL SEND NOTIFICATION OF ANY CHANGES TO THE POLICY THAT WOULD AFFECT THAT
INTEREST, IN ACCORDANCE WITH THE POLICY PROVISIONS OR AS REQUIRED BY LAW.
NAME AND ADDRESS MORTGAGEE ~ ADDITIONAL INSURED
I I
LOSS PAYEE
1100 Simonton Street AUT~REB~d~Ti~a/.
~C~3111 i i i.!1! i i i ~i:!:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:i:
POLICY NUMBER
HRA 8227888
CINCINNATI INSURANCE
THE CINCINNATI INSURANCE
AUTOMOBILE
CHANGE EFFECTIVE
07-15-02
ISSUED TO:
MICHAEL & MARY HUNTER
1640 LAKE SHORE DRIVE
SARASOTA
FL 34231-3406
PAYOR - INSURED
POLICY EXPIRATION
06-13-03
It is agreed the policy is amended as follows:
ADD ADDITIONAL INSURED TO TOYOTA TACOMA
AMENDATORY ENDORSEMENTS: CPAl184 (11/01) HOA9000 (01/01) CPA0406 (11/01)
CPA1350 (11/01) AP404FL (11/93) CPA1092 (05/88) CPA1094 (11/01)
CPA1249 (07/93) CPA1376 (07/01) IP412 (12/92) MI-1659 (05/01)
MI1533 (03/99) *CPA1002(ll/01) FA4000T(06/01)
Municipal Code 000999
ADDITIONAL INSURED Car 2
MONROE COUNTY BOARD OF COUNTY
COMMISSIONERS
1100 SIMONTON STREET
KEY WEST, FL 33040
Nothing herein contained shall vary, alter, waive, or extend any of the
terms, representations, conditions, or agreements of this policy other
than as above stated.
09-054 Atlas Mortgage & Insurance,
07-18-02 FLVER071502 BY:
PAGE 1
MEMORANDUM
#01
PL-1050 (1/96)
First Professionals Insurance Company
TO:
TO WHOM IT MAY CONCERN:
MEMORANDUM OFINSURANCE
NAMED INSURED:
MICHAEL DAVID HUNTER, M.D.
P.O. BOX 522380
MARATHON SHORES, FL 33052
This is to advise you that the First Professionals Insurance Company, Inc. has issued to the
named insured the policy enumerated below, subject to all the terms of such policy. This
memorandum neither affirmatively or negatively amends, extends or alters the coverage of such
policy.
POLICY TYPE OF CLAIMS REPORTING
NUMBER INSURANCE LIMITS PERIOD
57588 Professional 500,000 each claim From: 08/01/2004
Liability 1,500,000 aggregate To: 08/01/2005
Retroactive Date: 08/01/2002
Class 17- FORENSIC MEDICINE
Date Issued: 10/07/2004
'
BY
DATE ]
r ~YES
WAIVER
Authorized Representative
FPIC-9(1/86) 259/3 FL-P80054
1000 Riverside Avenue, Suite 800 · Jacksonville, Florida 32204 ° (904) 354-5910 ° 1-800-741-3742 ° Fax (904) 358-6728
P.O. Box 44033 ° Jacksonville, Florida 32231-4033 · Internet Address: http://www, medmal.com
First Professionals Insurance Company
TO:
TO WHOM IT MAY CONCERN:
MEMORANDUM OFINSURANCE
NAMED INSURED:
MICHAEL DAVID HUNTER, M.D.
27223 OVERSEAS HIGHWAY
RAMROD KEY, FL 33042
This is to advise you that the First Professionals Insurance Company, Inc. has issued to the
named insured the policy enumerated below, subject to all the terms of such policy. This
memorandum neither affirmatively or negatively amends, extends or alters the coverage of such
policy.
POLICY TYPE OF CLAIMS REPORTING
NUMBER INSURANCE LIMITS PERIOD
57588 Professional 500,000 each claim From: 08/01/2005
Liability 1,500,000 aggregate To: 08/01/2006
Retroactive Date: 08/01/2002
Class 17 - FORENSIC MEDICINE
Date Issued: 07/28/2005
Authorized Representative
FPIC-9(1/86) /
259/3
DATE ......'"
/--~ ~__YES -
WA \ ~-
lO00 Riverside Avenue, Suite 800 · Jacksonville, Florida 32204 · (904) 354-5910 · 1-800-741-3742 ° Fax (904) 358-6728
P.O. Box 44033 · Jacksonville, Florida 32231-403 ~ ° Internet Address: http://www, medmal.com
,
F 81'" INSURED COPY
rl~...@
.~----
r~--
I
i
~:;\icr~
I, ~ " : \ ._ 1 '
.'-- ~ ..-._~.,._-~
First Professionals Insurance Company
AUG 2 1
j,.. .-.-. --:-,::::-~-~--:;--..
':/('iI,:r,;)I: G,.U!!T,
~:<:l', ~',i:"'I:,'\C::~,~[l\'T
~~.._..--_.-
\
I
,
MEMORANDUM OF INSURANCE
TO:
TO WHOM IT MAY CONCERN:
NAMED INSURED:
MICHAEL DAVID HUNTER, M.D.
27223 OVERSEAS HIGHWAY
RAMROD KEY, FL 33042
This is to advise you that the First Professionals Insurance Company, Inc. has issued to the
named insured the policy enumerated below, subject to all the terms of such policy. This
memorandum neither affirmatively or negatively amends, extends or aiters the coverage of such
policy.
POLICY
NUMBER
57588
TYPE OF
INSURANCE
Professional
Liability
LIMITS
500,000 each claim
1,500,000 aggregate
CLAIMS REPORTING
PERIOD
08/01/2006
08/01/2007
From:
To:
Retroactive Date: 08/01/2002
Class 17 - FORENSIC MEDICINE
Date Issued: 07/24/2006
C-c. :h"" ~ .. c ~
~~p,~ .! ,,I ~.;;I 4~
O/'F' ___=.CtiS=~. Vice President of Underwriting
W~I~"'~ "I '1- v"_..__ _ ~
c5L?i - .-I II
Cl..\\~
Stac~ D~'{cl-ute.
FPIC-9(1/86)
259/3
FL-P80054
1000 Riverside Avenue, Suite 800. Jacksonville, Florida 32204. (904) 354-5910.1-800-741-3742. Fax (904) 358-6728
P.O. Box 44033 . Jacksonville, Florida 32231-4033 . Internet Address: http://www.medmal.com