12/09/1998 Agreement
nlannp 'I.. ltolbage
BRANCH OFFICE
3111 OVERSEAS IDGHWAY
MARA mON, FLORIDA 330SO
TEL. (305) 289-6021
FAX (305) 289-1145
CLERK OF THE CIRCUIT COURT
MONROE COUNTY
SOO WHITEHEAD STREET
KEY WEST, FLORIDA 33040
TEL. (305) 292-3550
FAX (305) 295-3660
BRANCH OFFICE
88820 OVERSEAS HIGHWAY
PLANTA nON KEY, FLORIDA 33010
TEL. (305) 852-1145
FAX (305) 852-1146
MEMORANDUM
TO: Dent Pierce
Director of Public Works
Ruth Ann Jantzen, Deputy Clerk A?/Jj.
FROM:
DATE:
December 30, 1998
-------------------------------------------------------------------------------------------------------------------------
On December 9,1998, the Board of County Commi40.~ioners granted approval and
authorized execution 0.... Lease Apllll e.t between Monroe County and th~
~-.Outnadt C.utlon,to provide office space for the non-profit organization, in the
amount of $100 per month for utilities consumption.
Enclosed please fmd a fully executed duplicate original of the Lease Agreement
for return to the Florida Keys Outreach Coalition.
If you have any questions concerning the above, please do not hesitate to
contact this office.
Enclosure
cc: County Attorney
Fmance
County Administrator, wlo document
Fde
AGREEMENT
-
THIS AGREEMENT, made this 9th <;Jay of December, 1998, by and between the Soard of
County Commissioners of Monroe County, Florida (hereinafter referred to as SOCC) and Florida
Keys Outreach Coalition, Inc. (hereinafter referred to as The Coalition), a not-for-profit corporation
incorporated in the State of Florida.
WHEREAS, the SOCC has approved for the Administrator to make limited, temporary office
space available to nonprofit organizations serving the County community on the condition that the
organizations are responsible for their own cleaning, telephone and similar costs and provipe a
reasonable payment to the County for the cost of electricity; and \D i ."
3:. 0 co -
Co') "". I
WHEREAS, the Coalition provides information, referral services, and if~mfior~e
homeless in Monroe County; ~~:< ~ -rt
cyr- 0 <:)
WHEREAS, the sacc has determined that it is in the best interests of ~~~ C;QL.Int~o
enter into this agreement; ~C")r- :x rT\
_ -{ :r: C5 ("')
..,.,.):> .. 0
NOW, THEREFORE, for and in consideration of the mutual covenants con~ne~hetln, ~
parties agree as follows: .
1, Contract Term and Sum, This agreement is for the period commencing December 15,
1998, and through December 14, 1999, unless earlier terrliinated pursuant to paragraphs 6 or 23
below. Upon providing written notice to the Coalition at least sixty days prior to the expiration date,
SOCC may exercise an option to extend this agreement for two (2) additional years under the same
terms and conditions. The Coalition hereby agrees to pay the BOCC the sum of $100,00 per month
for the utility consumption and upkeep costs,
2. Scope of Services. The Coalition shall provide the program development, and
sponsorship necessary to accomplish within Monroe County the goals and purposes set forth by the
Coalition. The Coalition shall install its own telephones, supply its own office furniture and
equipment, and provide for its own janitorial service.
3. BOCC Responsibility, The BOCC shall direct its Administrator, Department Heads,
County Attorney and staff to provide certain facilities and support to the Coalition as can be provided
without requiring an increase in personnel or any purchase or lease of real property, The BOCC
shall provide to the Coalition, within the aforementioned limitation, as well as all rules applicable to
County, the following:
a) One existing trailer, in as is condition, located on the property of the Public
Service Building, 5100 College Road, Stock Island, Key West, Florida,
4. Records - Access and Audits. The Coalition shall maintain adequate and complete
records for a period of four years after completion of any event or program. The SOCC shall have
access to the books, records, and documents of the Coalition, The access to and inspection of such
books, records and documents by the BOCC shall occur at any reasonable time.
5. Relationship of Parties. The Coalition is, and shall be, in the performance of all
works, services and activities under this Agreement, an independent contractor and not an
employee, agent or servant of the BOCC. The Coalition shall exercise control, direction, and
supervision over the means, manner personnel and volunteers through which it performs the work.
Although this Agreement is a cooperative agreement, similar in many respects (but not all) to a
, partnership, the Coalition shall have no authority whatsoever to act on behalf and/or as agent for the
BaCC in any promise, agreement or representation other than specifically provided for in this
Agreement. The BaCC shall at no time be jegally responsible for any negligence on the part of the
Coalition, its employees, agents or volunteers resulting in either bodily or personal injury or property
damage to any individual, property or corporation.
6. Modification. Additions to, modification to, or deletions from the provIsion of this
contract may be made only in writing and executed by the BaCC, No modification shall become
effective without written approval of both parties.
7, Breach and Penalties, The parties agree to full performance of the covenants
contained in this contract. Both parties reserve the right, at the discretion of each, to terminate the
services in this contract for any misfeasance, malfeasance or nonperformance of the contract terms
or negligent performance of the contract terms by the other party, Any waiver of any breach of
covenants herein contained shall not be deemed to be a continuing waiver and shall not operate to
bar either party from declaring a forfeiture for any succeeding breach either of the same conditions
or covenants or otherwise.
8. Insurance Requirements. The Coalition shall carry, during the term of this agreement,
public liability insurance, including bodily injury and property loss damage to cover all claims,
demands or actions by any person or entity in any way arising from the operation of the Agreement.
Such liability insurance shall meet the requirements of the Insurance Requirement Attachments
hereto. Monroe County shall be named as an additional"ihsured under the insurance policy and
such insurance shall be primary and non-contributing with any insurance carried by the BaCC. The
Coalition shall furnish the County with a certificate evidencing the insurance required by this
paragraph at the time of executing this Agreement.
9, Indemnification and Hold Harmless. The Coalition shall indemnify and hold harmless
the BaCC, their departments, agencies, officials, employees, agents, servants and contractors
against any claims, liabilities and expenses (including reasonable attorney's fees) arising as a result
of any direct and/or indirect action of the Coalition, its employees, agents, servants, volunteers
and/or contractors in the performance of the terms of this agreement or otherwise related to activity
conducted in the furtherance of this agreement except to the extent that, in the case of any act of
negligence, the Coalition reasonably relied upon material or services supplied by the BaCC or any
employee of the BaCC. The Coalition shall immediately give notice to the BaCC of any suit, claim
or action made against it that is related to any activity under this Agreement and will cooperate with
the BaCC in the investigation arising as a result of any suit, claim or action related to this
Agreement.
10. Permits. The Coalition shall secure all required permits and/or licenses necessary to
carry out any of the services rendered under this Agreement.
11. Laws and ReQulations,
a) This Agreement shall be construed by and governed under the laws of the State of
Florida unless in an area of law pre-empted by federal law. The Coalition agrees for venue of any
dispute to lie in Monroe County, Florida.
b) The Coalition shall comply with all laws, including but not limited to those listed in
Exhibit C.
2
c) The Coalition shall comply with all federal, state and local laws and ordinances
. applicable to the work or payment for work thereof, and shall not discriminate on the grounds of
race, color, religion, sex, age or national origin in the performance of work under this Agreement.
d) Any violation of said statutes, ordinances, rules, regulations and executive orders
shall constitute a material breach of this Agreement and shall entitle the sacc to terminate this
Agreement immediately upon delivery of written notice to the Coalition.
12. Taxes. The SOCC is exempt from Federal, Excise and State of Florida Sales Tax,
13. Finance CharQes. The sacc will not be responsible for any finance charges,
14. Severability, If any provision of this contract shall be held by a court of competent
jurisdiction to be invalid or unenforceable, the remainder of this contract, or the application of such
provision other than those as to which it is invalid or unenforceable, shall not be affected thereby;
and each provision of this contract shall be valid and enforceable to the fullest extent permitted by
law,
15, Force Maieure, The Coalition shall not be liable for delay in performance or failure to
perform in whole or in part, the services due to the occurrence of any contingency beyond its control
or the control of any of its sub-contractors or suppliers, including labor dispute, strike, labor shortage,
war or act of war, whether an actual declaration thereof is made or not, insurrection, sabotage, riot or
civil commotion, act of public enemy, epidemic, quarantine restriction, accident, fire, explosion,
storm, flood, drought or other act of God, act of any governmental authority, jurisdictional action, or
insufficient supply of fuel, electricity, or materials or supplies, or technical failure where the Coalition
has exercised reasonable care in the prevention thereof, and any such delay or failure shall not
constitute a breach of the Agreement. The Coalition shall notify the sacc of any delay or failure to
perform within five (5) days of such action, Upon demand of the sacc, the Coalition must furnish
evidence of the causes of such delay or failure.
16. AssiQnment. The Coalition shall not assign, transfer, sublease, pledge, hypothecate,
surrender, or otherwise encumber or dispose of this contract or any estate created by this contract or
any interest in any portion of the same, or permit any other person or persons, company or
corporation to perform services under this contract without first obtaining the written consent of the
sacc, In the event of such consent, this agreement shall be binding upon the Coalition's
successors and assigns,
17, Disclosure, The Coalition shall be required to list any or all potential conflicts of
interest, as defined by Florida Statutes Chapter 112, Part III and the Monroe County Ethics
Ordinance, The Coalition shall disclose to the sacc all actual or proposed conflicts of interest,
financial or otherwise, direct or indirect, involving any client's interest which may constitute a conflict
under said laws.
18. Additional Conditions, The Coalition agrees to accept additional conditions governing
the use of funds or performance of work as may be required by federal, state or local statute,
ordinance or regulation or by other policy adopted by the SOCC. Such additional conditions shall
not become effective until the Coalition has been notified in writing and no such additional conditions
shall be imposed retroactively.
19. Independent Professional Judqment The Coalition shall at all times exercise
independent professional judgment and shall assume full responsibility for the service to be provided
and work to be completed,
3
20. Care of Property. The Coalition shall be responsible to the BOCC for the safekeeping
and proper use of tbe property entrusted to the Coalition's care, and to process all documents
necessary to continue, without interruptions, any maintenance or service contracts relating to such
equipment for its service life. The Coalition shall provide services Monday through Friday, 8:00 a,m,
_ 5:00 p,m., and shall ensure that their patrons do not loiter or congregate on the Public Service
Building property.
21. Ethics Clause, The Coalition warrants that it has not employed, retained or otherwise
had act on its behalf any former County officer or employee subject to the prohibition of Section 2 of
Ordinance No. 010-1990 or any BOCC officer or employee in violation of Section 3 of Ordinance No,
010-1990, For breach or violation of this provision, the County may, in its discretion, terminate this
contract without liability and may also, in its discretion, 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 the Coalition or BOCC officer or employee,
22, Notice, Any notice required or permitted under this Agreement shall be in writing and
hand-delivered or mailed, postage prepaid, by certified mail, return receipt requested, to the other
party as follows:
To the Coalition:
Pat Valerga
P,O. Box 4767
Key West, FL 33040
To County
Monroe County Facilities Maintenance
3583 S, Roosevelt Boulevard
Key West, FL 33040
23. Termination, Termination of this Agreement shall occur at the natural ending date, or
earlier should either party determine that there has occurred any material breach of any covenants
herein contained, or either party otherwise deems it in their best interest to terminate, Termination
may be with or without cause, and shall require written notice to be given to the other party as
follows:
a) In the event either party terminates for breach of contract, termination shall be
effective at such time as the terminating party shall declare in its act to terminate for cause, with a
minimum of fourteen days notice in writing required prior to effective termination,
b) In the event either party terminates without cause, the termination shall not
take effect until at least sixty days subsequent to written notice to the other party, and the effective
date of termination shall be specified in said notice,
24. Full AQreement. This Agreement constitutes the entire and full understanding
between the parties hereto and neither party shall be bound by any representations, statements,
promises or agreements not expressly set forth herein and in duly executed amendments under
paragraph 6 hereof.
4
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
By V'ir~'
By
~k/~~~
Mayor/Chairma
(SEAL)
Attest:
FLORIDA KEYS OUTREACH COALITION, INC,
Title
CBy ~~
Title ~€~\ ~~
By
APPROVED AS TO FOR
AND LE AL SUFFIC
5
1996 Edition
MONROE COUNTY, FLORIDA
RISK MANAGEMENT
POLICY AND PROCEDURES
CONTRACT ADMINISTRATION
MANUAL
General Insurance Requirements
for
Organizations/Individuals
Leasing County-Owned
Property
Prior to the Organization or Individual taking possession ofthe property owned by the County,
or commencing its concessionaire operations, the Organization/Individual shall obtain, at his/her
own expense, insurance as specified in the attached schedules, which are made part of this
lease/rental agreement.
The Organization/Individual will not be permitted to occupy or use the property until satisfactory
evidence of the required insurance has been furnished to the County as specified below.
The Organization/Individual shall maintain the required insurance throughout the entire term of
this lease/rental agreement and any extensions specified in the attached schedules. Failure to
comply with this provision may result in the immediate termination of the lease/rental agreement
and the return of all property owned by the County.
The Organization/Individual 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 and/or approval of the Organization/Individual's insurance shall not be construed
as relieving the Organization/Individual from any liability or obligation assumed under this
contract or imposed by law.
The Monroe County Board of County Commissioners, will be included as "Additional Insured"
on all policies. They will also be named as "Loss Payee" with respect to Fire Legal Exposure.
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
#4709.2
28
1996 Edition
ALL RISK PROPERTY
INSURANCE REQUIREMENTS
FOR
LEASES/RENT ALS OF
COUNTY -OWNED"PROPERTY
BETWEEN
MONROE COUNTY, FLORIDA
AND
Prior to the Organization/Individual taking possession of the property governed by this
lease/rental agreement, the Organization/Individual shall obtain All Risk Property Insurance (to
include the perils of Flood and Wind) with limits no less than the Replacement Cost Value of the
property leased or rented. Coverage shall be maintained throughout the life of the LeaseIRental
Agreement and include, as a minimum, liability coverage for:
Fire
Sprinkler Leakage
Windstorm
Civil Commotion
Lightning
Sinkhole Collapse
Smoke
Aircraft and Vehicle Damage
Vandalism
Falling Objects
Explosion
Flood
The Monroe County Board of County Commissioners shall be named as Additional Insured and
Loss Payee on all policies issued to satisfy the above requirements.
Administration Instruction
#4709.2
29
1996 Edition
GENERAL LIABILITY
INSURANCE REQUIREMENTS
FOR
LEASE/RENT AL OF PROPERTY
OWNED BY THE COUNTY
BETWEEN
MONROE COUNTY, FLORIDA
AND
Prior to the Organization/Individual taking possession of the property governed by this
lease/rental agreement, the Organization/Individual 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
. Fire Legal Liability (with limits equal to the fair market value of the leased property.)
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
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 termination ofthe LeaseIRental Agreement.
The Monroe County Board of County Commissioners shall be named as Additional Insured on
all policies issued to satisfy the above requirements.
Administration Instruction
#4709,2
30
1996 Edition
WORKERS' COMPENSATION
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
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 Contractor's 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.
Ifthe Contractor participates in a self-insurance fund, a Certificate ofInsurance will be required.
In addition, the Contractor may be required to submit updated financial statements from the fund
upon request from the County.
wel
Administration Instruction
#4709.2
88
ACORDTM
CERTIFICATE OFLIABILIT'l INSl.JRAN~E
",. .,.~"" .,' ......, .,., '" ,. ,.. ." '." ,...,.,.. . . . ,12/1Q/98
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
_____.~__.___._+______.____H. __._.__ .___ _____.________.__.____.___._
COMPANIES AFFORDING COVERAGE
DATE (MMlDDIYY)
PRODUCER
ISLAND INSURANCE AGENCY, INC.
3229 FLAGLER AVE #112
KEY WEST,FL. 33040
COMPANY
C
BURLINGTON INSURANCE ~d
(1 kVi1 ~'.. 0) I c/ l q (
V~\ \~rr
COMPANY
A
i
! INSURED
!
,
!
,
FLORIDA KEYS OUTREACH
P.O. BOX 4767
KEY WEST,FL.33040
COALITION,INC.
COMPANY
B
i
r"'~="""'"'''' '
iCOVSSRAGES
i THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
, INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
COMPANY
D
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MM/DOIYY) DATE (MMlDDIYY)
LIMITS
GENERAL LIABILITY
XX COMMERCIAL GENERAL LIABILITY
B0165G413370
9/25/98
9/25/99
GENERAL AGGREGATE
PRODUCTS, COMP/OP AGG
PERSONAL & ADV INJURY
EACH OCCURRENCE
FIRE DAMAGE (Anyone fire)
MED EXP (Anyone person)
$1,000,000
$1/00/0000
$1,000,000
$1,000,000
$
$
I
i
\
I
I
I
,
I
50,000 i
EX{::frOOEI) I
I
I
I
;
,
CLAIMS MADE
OCCUR
A
OWNER'S & CONTRACTOR'S PROT
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON,OWNED AUTOS
COMBINED SINGLE LIMIT
$
BODILY INJURY
(Per person)
$
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE $
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
AUTO ONLY, EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EACH OCCURRENCE $
AGGREGATE $
$
GARAGE LIABILITY
ANY AUTO
WCSTI\TlJ- '
TORY LIMITS
EL EACH ACCIDENT
OTH,
ER
HI
I
;
I
I
I
, ,,..'OJ
THE PROPRIETOR/
PARTNERS/EXECUTIVE
OFFICERS ARE
OTHER
INCL
EL DISEASE, POLICY LIMIT
$
$
EL DISEASE, EA EMPLOYEE $
EXCL
i
I
I
I
IDE-SCRIPTION OF OPERATIONslLOCATIONSNEHICLES/SPECIAL ITEMS------..'.---- -- -.. -------------------'
I NON-PROFIT ORGANIZATION. OFFICE LOCATION: 5100 COLLEGE RD(REAR)
KEY WEST, FL. 33040
I CERTIFICATE HOLDER IS ADDITIONAL INSURED.
F(;~~c;.A.~~()~Q~>'.."'".'...\....'<...........<?\\\?>~~1.;oqflJ'
I ~O~~~ :'ARD OF COUNTY cOMMISSIONERS"
KEY WEST,FL. 33040
,"_c_"_ .'~ ~':~:"":~:",~~~.r_:'7""'~''7'~.-',-:--.~c~_' 'T_'''':_.~ ',..r-:"~.,...."c."',""""""'~
. ..... - .""...." ,,--,,-",,"" ....- "". -".-
I
.. .._,_J
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SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
I
I
L A~~,!~ 25-~!~f!i)
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
~D
AGENTS OR REPRESENTATIVES.
@ ACORD CORPORAnON 1988 ,
.
PRODUCER
DavisBaldwin, Inc.
P.O. Box 25277
Tampa, Florida 33622
DATE
12/15/98
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND
ALTER THE COVERAGE AFFORDED BY THE POL CIES
COMPANIES AFFORDING COVERAGE
813-287 -1936
COMPANY
A Hartford Casualty Insurance
INSURED
ADP TotalSource III, Inc,
5800 Windward Parkway
Alpharetta, GA 30005
COMPANY
B
COMPANY
C
INDICATED, NOlWlTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO
LTR
TYPE OF INSURANCE
GENERAL LIABILITY
COMMERCIAL GENERAL L1ABILI
CLAIMS MADE D OCCUR
OWNER'S & CONTRACTOR'S PRO
POLICY NUMBER
POLICY EFFECTlV POLICY EXPIRATlO
DATE (MM/DDIYY) DATE (MM/DDIYY)
LIMITS
O"'E-
GENERAL AGGREGATE $
PRODUCTS, COMP/OP AG $
PERSONAL & ADV INJURY $
EACH OCCURRENCE $
FIRE DAMAGE (Anyone fire $
MED EXP (Anyone person) $
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON,OWNED AUTOS
'vy
COMBINED SINGLE LIMIT $
BODILY INJURY $
(Per person)
W~\lJt,t
Fp<?'~l}c~i~~~yrY $
PROPERTY DAMAGE $
A
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION AND
EMPLOYERS' LIABILITY
21WNJ73500
04/01/1998
04/01/1999
AUTO ONLY, EA ACCIDENT $
OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EACH OCCURRENCE $
AGGREGATE $
$
X TORY LIMITS
EL EACH ACCIDENT $
EL DISEASE, POLICY LIMIT $
EL DISEASE, EA EMPLOYE $
1,000,000
1,000,000
1,000,000
THE PROPRIETOR!
PARTNERS/EXECUTIVE
OFFICERS ARE:
D INCL
D EXCL
OTHER
,
DESCRIPTION OF OPERA TIONS/LOCA TIONSNEHICLES/SPECIAL ITEMS
For those employees leased to FLORIDA KEYS OUTREACH DBA COALITION INC.
FROM ADP TotalSource III, Inc.
BROAD FORM ALL STATES COVERAGE ENDORSEMENT INCLUDED.
MONROE COUNTY - RISK MANAGEMENT
ATTN: DONNA PEREZ
5100 COLLEGE ROAD
KEY WEST, FLORIDA 33040
OATE
MONROE COUNTY, FLORIDA
Request For Waiver
of
Insurance Requirements
It is requested that the insunmcc requirements. as specified in the County's Schedule of Insurance
Requirements. be waived or modified on the following contract.
Contractor:
Contract for:
Address of Contractor:
Phone:
Scope of Work:
Reason for Waiver:
Policies Waiver
will apply to:
Signature of Contractor:
Risk Management
Date
County Administrator appeal:
Date:
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Approved /- Not Approved
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.
Approved:
Not Approved:
Board of County Commissioners appeal:
Meeting Date:
c\ r-'" ,
I'
Approved:
Not Approved:
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