Item F06
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: November 15. 2006
Division: Employee Services
Bulk Item: Yes --X- No
Department: Employee ServiceslRiskManagement
Staff Contact Person: Maria L. Slavik
AGENDA ITEM WORDING: Approval to accept renewal with Interisk Corporation to provide Risk
Management, Employee Benefits and Workers Compensation consulting services.
ITEM BACKGROUND: Interisk Corporation is the County's "insurance" consultant, who prepare
RFP's for all insurance policies and Third Party Administrators contractors for Worker's Compensation,
HealtWLife Insurance, and PropertylLiabilitylRisk Management Programs.
PREVIOUS REVELANT BOCC ACfION: On September 24, 2004, the County entered into the
existing consulting agreement which became effective October 1, 2004. The original agreement with this
vendor began in 1998.
CONTRACT/AGREEMENT CHANGES: Renewal dates of October 1,2006 - September 30,2007.
This is the second renewal of the contract.
STAFF RECOMMENDATIONS: Approval.
TOTAL COST: $120.001hour BUDGETED: Yes -X. No
COST TO COUN1Y: $120.00/hour SOURCE OF FUNDS: AD VALORUM
REVENUE PRODUCING: Yes No -X AMOUNT PER MONTH_ Year
APPROVED BY: County Atty _ OMBlPurchasing _ Risk Management ~
DOCUMENTA TION:
Included ~
To Follow
Not Required _
DISPOSmON:
AGENDA ITEM #
Revised 2/27/01
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MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract with: Interisk Corporation Contract #_
Effective Date: October 1,2006
Expiration Date: September 30, 2007
Contract Purpose/Description:
Extend existing insurance consulting agreement with Interisk Corporation. Change of
renewal dates for one year term. Consultant prepares RFP's for insurance policies,
Third Party Administrator contracts, and reviews, analyzes and evaluates matters as
directed by the County.
Contract Manager: Maria Slavik 3178 Employee ServicesIRisk Mgmt
CN:ame) (Ext. ) (Department/Stop #)
for BOCC meeting on Nov. \5,2006 Agenda Deadline: Oct. 31, 2006
CONTRACT COSTS
Total Dollar Value of Contract: $ 120.00 hour Current Year Portion: $
Budgeted? Yesrg] No 0 Account Codes: 501-07501-530-310-_
Grant: $ n/a 502-08001-530-310-_
County Match: $ n/a 503-08501-530-310-_
- - -
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ADDITIONAL COSTS
Estimated Ongoing Costs: $_/yr For:
(Not included in dollar value above) (eg. maintenance, utilities, janitorial, salaries, etc.)
CONTRACT REVIEW
Date Out
Division Director
County Attorney Ib~)6 Y esD No~'
Comments:
Office of the Employee Services Division Director
The Historic Gato Cigar Factory
1100 Simonton Street, Suite 268
Key West, FL 33040
(305) 292-4458 - Phone
(305) 292-4564 - Fax
/-...... ,.....-.....,..
,
BOARD OF COUNTY COMMISSIONERS
Mayor Charles "Sonny" McCoy, District 3
Mayor Pro Tern Dixie M. Spehar, District 1
George Neugent, District 2
Mario Di Gennaro, District 4
Glenn Patton, District 5
O~~y ~o~~~E
(305) 294-4641
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~etY
TO:
Board of County Commissioners
FROM:
Teresa E. Aguiar,
Employee Services Director
DATE:
October 16,2006
SUBJ:
Extension of contract - Interisk consulting
This item requests approval of an extension to the existing contract between the County and Interisk
Corporation. The extension is to the existing Contract which covers the period of October 1,2005
through September 30,2007. This contract was originally approved by the BOCC in September, 2004.
This is the second renewal of the contract.
The original agreement with this vendor began in 1998. It is staffs recommendation to approve the
renewal and continue to do business with Interisk Corporation for the remainder of the term.
EXIENSION OF INSURANCE CONSULTING AGREEMENT
This renewal agreement is made on this _ day of November, 2006, by and between Momoe County,
a political subdivision of the State of Florida, the County, and Interisk Corporation, the Consultant
Whereas, on September 21,2005, the parties entered into an agreement whereby the Consultant was to
provide various insurance related consulting services; and
Whereas, the agreement bad an initial one-year term with a provision for two one-year extensions; and
Whereas, the parties desire to extend the agreement for another one-year term;
NOW, THEREFORE, in consideration of the mutual covenants contained in this extension, the parties
agree:
1) The parties' September 21, 2004 consulting agreement, a copy of which is attached and incorporated
into this extension as Exhibit ~ is hereby extended for another one-year term commencing September 30,
2006.
2) In all other respects, the parties' September 21,2004, consulting agreement remains in full force and
effect.
IN WITNESS WHEREOF, the parties have set their hands and seal on the day and year last written
below.
(SEAL)
ATTEST: DANNY L. KOLHAGE, ClERK
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
By:
By:
Deputy Clerk
Mayor/Chainnan
Date:
WITNESS:
INTERISK CORPORATION
By:
President
Date:
MONROE COUNTY ATT
PROVED AS TO
NATILEENE W. CASSEL
ASSISTANT COUNTY ATTORNEY
Date If) ~ :.2 <-{- /)~
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CONTRACT
THIS CONTRACT, entered this ~y of ~tv\~2004, by and Between the
Board of County Commissioners of Monroe County (COUNTY). Florida, and Interisk Corporation
(CONTRACTOR).
WHEREAS, County has a fiscal responsibility to limit risk or liability to the County; and
WHEREAS, the County provides certain insurance benefits to employees; and
WHEREAS, it has been detennined that it is in the best interest of the County to contract with a
consultant to assist with such services, NOW THEREFORE
IN CONSIDERA nON OF the mutual promises contained herein, the parties agree as follows:
I. TERM OF AGREEMENT:
This agreement shall be for a twelve (12) month period beginning, If) / I ~ 2004 and
ending at 12:00 midnight on !1.I'E 0 . 2005. The tenn of this agreement shall be renewable
in accordance with Section IV.
II. PAYMENT:
The total compensation to be paid to the Contractor in consideration of its services under this
Agreement shall be $ J ~ ,,~ per hour. The County shall pay the Contractor on a per
month in arrears basis. Billing shall be directed to the appropriate sections marked Risk
Management, Workers' Compensation or Group Insurance. The Contractor shall provide a monthly
invoice on or about the 1 st day of each month to the Division of Management Services, and payment
shall be made on or about the I st day of the following month, after receipt of a proper invoice by
the County Finance Department, in compliance with the Florida Prompt Payment Act. In the event
that funds are partially reduced or cannot be obtained or continued at a level sufficient to allow for
the purchase of the services contemplated, then the contract may be tenninated immediately at the
option of the County upon written notice of tennination being de~ivered in person or by mail to the
Contractor. The County will not be obligated to pay for any services provided by the Contractor
after the Contractor has received written notice of immediate tennination.
III. SCOPE OF SERVICES:
The Contractor shall provide consulting services on an as needed basis, which shall include
but not be limited to:
8. Review Risk Management/Employee Benefits (Group Insurance and Workers
Compensation) procedures.
b. Review Pricing of insurance and other outside services.
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c. Prepare insurance specifications for property, casualty, and employee benefits and
Workers' Compensation insurance coverages
d. Review coverages under present insurance contracts and make recommendation for
coverage improvements.
e. Communicate with agents and brokers during the bidding process.
f. Analyze insurance proposals.
g. Review present method of funding insured and non-insured risks.
h. Analyze and evaluate Monroe County's performance with respect to its self-insured
programs.
i. Assist in the development of insurance and other sections of vendor contracts to ensure the
interests of Monroe County are adequately protected.
j. Analyze and evaluate Monroe County's Risk Management and Employee Benefit
programs and make recommendations based on their performance and current industry
practices.
k. Perform other Risk Management and Employee Benefits matters as directed by the
County .
IV. RENEWAL:
The County shall have the option to renew this agreement after the first year, for three (3) additional
one-year periods. The contract amount agreed to herein may be adjusted annually in accordance
with the percentage change in the Consumer Price Index (CPI) for all urban consumers (CPI-U) for
the most recent 12 months available.
v. CONTRACTOR'S LICENSE: The Contractor shall secure, maintain and pay all applicable
fees for any permits and licenses necessary to provide services under this agreement. By signature
hereon, the Contractor warrants that it is authorized by law to engage in the performance of the
activities herein described, subject to the terms and conditions set forth in these contract documents.
Proof of such licenses and approvals shall be submitted to the County upon request The Contractor
has, and shall maintain throughout the term of this contract, appropriate licenses and approvals
required to conduct its business, and that it will at all times conduct its business activities in a
reputable manner.
VI. INDEPENDENT CONTRACTOR
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1 At all times and for all purposes, the Contractor, its agents and employees are strictly considered to
2 be independent contractors in their perfonnance of the work contemplated hereunder. As such, the
3 Contractor, its agents and employees shall not be entitled to any of the benefits, rights or privileges
4 of County employees. The provider shall at all times exercise independent, professional judgment
5 and shall assume professional responsibility for the services to be provided.
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7 VII. STAFFING
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9 Since this contract is a service agreement, staffing is of paramount importance. Contractor shall
10 provide at its own expense all necessary personnel to provide the services under this contract. The
11 personnel shall not be employees of or have any contractual relationship with the County. All
12 personnel engaged in performing services under this contract shall be fully qualified, and, if
13 required, to be authorized or permitted under State and loca1law to perform such services.
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15 VIII. HOLD HARMLESS/INSURANCE REQUIREMENTS:
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17 The Contractor covenants and agrees to indemnify and hold harmless Monroe County Board of
18 County Commissioners and the County Court of Monroe County from any and all claims for bodily
19 injury (including death), personal injury, and property damage (including property owned by
20 Momoe County) and any other losses, damages, and expenses (including attorney's fees) which
21 arise out of, in connection with, or by reason of services provided by the Contractor or any of its
22 Subcontractor(s) in any tier, occasioned by the negligence, erro~ or other wrongful act of omission
23 of the Contractor or its Subcontractors in any tier, their employees, or agents.
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2S The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements
26 contained within this agreement.
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28 Prior to execution of this agreement, the contractor shall furnish the Owner Certificates of Insurance
29 indicating the minimwn coverage limitations as indicated below, each attached hereto and
30 incorporated as part of this contract docwnent, and all other requirements found to be in the best
31 interest of Monroe County as may be imposed by the Monroe County Risk Management
32 Department. The Contractor shall obtain and throughout the entirety of the agreement maintain the
33 following insurance:
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3S A. Workers' Compensation Insurance Requirements - Prior to the commencement of work
36 governed by this contract, the Contractor shall obtain Workers' Compensation Insurance with
37 limits sufficient to respond to Florida Statute 440.
38 In addition, the Contractor shall obtain Employers Liability Insurance with limits of not less
39 than:
40 $ I 00,000 Bodily Injury by accident
41 $500,000 Bodily injury by Disease, policy limits
42 $ J 00,000 Bodily Injury by Disease, each employee
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44 Coverage shall be maintained throughout the entire term of the contract.
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2 Coverage shall be provided by a company or companies authorized to transact business in the
3 S tate of Florida.
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5 If the Contractor has been approved by the Florida's Department of Labor, as an authorized self-
6 insurer, the County shall recognize and honor the Contractor's status. The Contractor may be
7 required to submit a Letter of Authorization issued by the Department of Labor and a Certificate
8 of Insurance, providing details on the Contractor's Excess Insurance Program.
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10 If the Contractor participates in a self-insurance fund, a Certificate of Insurance will be required.
11 In addition, the Contractor may be require to submit updated financial statements from the fund
12 upon request from the County.
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14 B. Vehicle Liability Insurance Requirements - Recognizing that the work governed by this
15 contract requires the use of vehicles, the Contractor, prior to the commencement of work, shall
16 obtain Vehicle Liability Insurance. Coverage shall be maintained throughout the life of the
17 contract and include, as a minimum, liability coverage for:
18 Owned, Non-Owned, and Hired Vehicles
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20 The minimum limits acceptable shall be: $100,000 Combined Single Limit (CSL)
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22 If split limits are provided, the minimum limits acceptable shall be:
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24 $ 50,000 per Person
25 $100,000 per occurrence
26 $ 25,000 Property Damage
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28 The Monroe County Board of County Commissioners shall be named as Additional insured on
29 all policies issued to satisfy the above requirements.
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31 C. Professional Liability Insurance Requirements - Recognizing that the work governed by this
32 contract involves the furnishing of advise or services of a professional nature, the Contractor
33 shall purchase and maintain, throughout the life of the contract, Professional Liability Insurance
34 which will respond to damages resulting from any claim' arising out of the performance of
35 professional services or any error or omission of the Contractor arising out of work governed by
36 this contract.
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38 The minimum limits of liability shall be: $250,000 per Occurrence/$500,000 Aggregate
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40 D. General Liability Insurance Requirements - Prior to the commencement of work governed by
41 this contract, the Contractor shall obtain General Liability Insurance. Coverage shall be
42 maintained throughout the life of the contract and include, as a minimum:
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44 . Premises Operations
45 . Products and Completed Operations
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I . Blanket Contractual Liability
2 . Personal Injury Liability
3 · Expanded Definition of Property Damage
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5 The minimum limits acceptable shall be: $300,000 Combined Single Limit (CSL)
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7 If split limits are provided, the minimum limits acceptable shall be:
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9 $100,000 per Person
10 $300,000 per Occurrence
11 $ 50,000 Property Damage
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J3 An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its
J4 provisions should include coverage for claims filed on or after the effective date of this contract.
15 In addition, the period for which claims may be reported should extend for a minimum of twelve
16 (12) months following the acceptance of work by the County.
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18 The Monroe County Board of County Commissioners shall be named as Additional Insured on
19 all policies issued to satisfy the above requirements.
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21 IX. NON-DISCRIMINATION:
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23 County and Contractor agree that there wiU be no discrimination against any person, and it is
24 expressly understood that upon a determination by a court of competent jurisdiction that
25 discrimination has occurred, this Agreement automatically terminates without any .further action on
26 the part of any party, effective the date of the court order. County or Contractor agree to comply
27 with all Federal and Florida Statutes, and all local ordinances, as applicable, relating to
28 nondiscrimination. These include but are not limited to: 1) Title VI of the Civil Rights Act of i964
29 (PL 88-352) which prohibits discrimination on the basis of race, color or national origin; 2) Title IX
30 oftbe Education Amendment of 1972, as amended (20 USC 58. 1681-1683, and 1685-1686), which
31 prohibit discrimination on the basis of sex; 3) Section 504 of the Rehabilitation Act of 1973, as
32 amended (20 use s. 794) which prohibits discrimination on th~ basis of handicaps; 4) The Age
33 Discrimination Act of 1975, as amended (42 USC ss. 6101 - 6107) which prohibits discrimination
34 on the basis of age; 5) The Drug Abuse Office and Treatment Act of 1972 (PL 92-255), as
35 amended, relating to nondiscrimination on the basis of drug abuse: 6) The Comprehensive Alcohol
36 Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970(PL 91-616), as
37 amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; 7) The Public
38 Health Service Act of 1912 SS, 523 and 527 (42 USC 55. 690dd-3 and 290ee-3), as amended,
39 relating to confidentiality of alcohol and drug abuse patent records; 8) Title VIII of the Civil Rights
40 Act of 1968 (42 use s. et seq.) as amended, relating to nondiscrimination in the sale, rental or
41 financing of housing; 9) The Americans with Disabilities Act of 1990 (42 USCs. 1201 Note), as
42 may be amended from time to time, relating to nondiscrimination on the basis of disability; 10)
43 Monroe County Code Ch. 13, Art. VI, prohibiting discrimination on the basis of race, color, sex,
44 religion, disability, national origin, ancestry, sexual orientation, gender identity or expression,
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familial status or age; and II) any other nondiscrimination provisions in any Federal or state
statutes which may apply to the parties to, or the subject matter of this Agreement.
X. INSPECTION OF BOOKS AND F ACILITIES/ AUDIT/ACCOUNTING:
The Contractor shall maintain the financial records in accordance with generally accepted
accounting principles, and allow the County to inspect its books and records at any reasonable time.
Contractor shall retain all records pertaining to this agreement for a period of four years after term
expIres.
XI. PUBLIC RECORDS
The Contractor shall comply with the Public Records laws of the State of Florida, subject to any
provisions providing exemption from disclosure.
XII. BREACH OF TERMS BY CONTRACTOR
The passing, approval, and/or acceptance by the Owner of any defect in the services furnished by
the Contractor, shall not operate as a waiver by the County of strict compliance with the terms of
this Contract, and specifications covering the services. County may immediately terminate the
Agreement due to any violations by Contractor of criminal statutes governing consulting services.
Any other Contractor breach of this agreement shall be governed by the article below on
termination for cause.
XIII. TERMINATION WITHOUT CAUSE:
The County may terminate this agreement without cause by providing the Contractor with written
notice oftennination at least sixty (60) days prior to the effective date of termination.
XIV. TERMINATION WITH CAUSE:
The County may terminate this agreement for cause if the Contractor shall default 10 the
perfonnance of any of its obligations under this agreement.
xv. ASSIGNMENT:
The Contractor shall not assign or subcontract its obligations under this agreement, except in
writing and with the prior written approval of the Board of County Commissioners of Monroe
County and Contractor, which approval shall be subject to such conditions and provisions as the
Board may deem necessary and pursuant to the recommendation of the County Court
Administrative Judge. This paragraph shall be incorporated by reference into any assignment or
subcontract and any assignee or subcontractor shall comply with all of the provisions of this
agreement. Unless expressly provided for therein, such approval shall in no manner or event be
deemed to impose any additional obligation upon the board.
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XXVI. COMPLIANCE WITH LAW
In providing all services/goods pursuant to this agreement, the Contractor shall abide by all statutes,
ordinances, rules and regulations pertaining to, or regulating the provisions of, such services,
including those now in effect and hereinafter adopted. Any violation of said statutes, ordinances,
rules and regulations shall constitute a material breach of this agreement and shall entitle the Board
to tenninate this contract immediately upon delivery of written notice of termination to the
contractor. The contractor shall possess proper licenses to perform work in accordance with these
specifications throughout the term of this contract.
XVII. DISCLOSURE AND CONFLICT OF INTEREST
A. The Contractor represents that it, its directors, principles and employees, presently have no
interest and shall acquire no interest, either direct or indirect, which would conflict in any
manner with the perfonnance of services required by this contract, as provided in Sect.
112.311, et. seq., Florida Statutes.
B. Upon execution of this contract, and thereafter as changes may require, the Contractor shall
notify the County of any financial interest it may have in any and all programs in Monroe
County which the Contractor Sponsors, endorses, recommends, supervises, or requires for
counseling, assistance, evaluation, or treatment. This provision shall apply whether or not
such program is required by statute, as a condition of probation, or is provided on a
voluntary basis.
XVIII. FINANCIAL RESPONSIBILITY
The Contractor shall not pledge the County's credit or make it a guarantor of payment or surety
for any contract, debt, obligation, judgment, lien, or any form of indebtedness. The Contractor
further warrants and represents that it has no obligation or indebtedness that would impair its
ability to fulfill the terms of this contract.
XIX. NOTICE REQUIREMENT
Any notice required or permitted under this agreement shall be in writing and hand delivered or
mailed, postage prepaid, to the other party by certified mail, returned receipt requested, to the
following:
FOR MONROE COUNTY:
County Administrator and
1100 Simonton Street
Key West, Fl. 33040
County Attorney and
PO Box 1026
Key West, Fl. 33041-1026
Director Management Services
1100 Simonton Street
Key West, FL 33040
FOR CONTRACTOR:
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XX. TAXES
The County is exempt from payment of Florida State Sales and Use taxes. The Contractor shall
not be exempted by virtue of the County's exemption from paying sales tax to its suppliers for
materials used to fulfill its obligations under this contract, nor is the Contractor authorized to
use the County's Tax Exemption Number in securing such materials. The Contractor shall be
responsible for any and all taxes, or payments of withholding, related to services rendered under
this agreement.
XXI. GOVERNING LAWS
This Agreement is governed by the laws of the State of Florida. Venue for any litigation arising
under this Agreement must be in Monroe County, Florida. In the event of any litigation, the
prevailing party is entitled to attorney's fees and costs. The parties waive their rights to trial by
Jury.
XXII. 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 goods or services to a public
entity, may not submit a bid on a contract with a public entity for construction or repair of a public
building or public 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 amount provided in Section 287.017, F.S. for CATEGORY TWO for a period of 36
months from the date of being placed on the convicted vendor list. (CATEGORY TWO:
$25,000.00).
XXIII. AUTHORIZED SIGNATORY:
The signatory for the Contractor, below, certifies and warrants that:
(a) The Contractor's name in this agreement is its full name as designated in its corporate
charter.
(b) He or she is empowered to act and contract for Contractor.
(c) This agreement has been approved by the Contractor's Board of Directors.
Further, Contractor shall, upon execution of this agreement, provide proof of incorporation and a
list of its Board of Directors.
XXIV. ENTIRE AGREEMENT:
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9 . (SEAL)\\..~..
10 '. Attest: DANNY L. KOLHAGE, CLERK
:~ B~~~C.. ~~~-W
13 . -,."'....,., Deputy Clerk
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This agreement constitutes the entire agreement between the County and the Contractor for the
services contemplated herein. Any amendments or revisions to this agreement must be in writing
and be executed in the same manner as this agreement.
IN _WJlNESS WHEREOF the parties hereto have executed this Agreement on the day and
d~e: fusi~Wdtim.above in four (4) counterparts, each of which shall, without proof or accounting for
~ oilier c6uritetp$ts, be deemed an original contract.
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
By: ~~
MAYOR PRO-TEM
(SEAL)
Attest:
INTERISK CORPORA nON
By:
Title:
By: ~LJ.I
Title: f'll74 ,'Ju. 1-
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NON-COLLUSION AFFIDAVIT
according to law
of the firm of '"E fe.r,'.sl<. Co,..i r-.~ o~
e project described in the Notice for Calling for Bids for:
f- .
, the bidder
2. I executed the said proposal with full authority to do so.
3. The prices in this bid have been arrived at independently without collusion, consultation,
communication or agreement for the purpose of restricting competition, as to any matter relating to such
prices with any other bidder or with any competitor.
4. 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.
5. No attempt has been made or will be made b the bidder to induce any other person, partnership or
corporation to submit, or not to submit, a bid for the purpose of restricting competition.
6. The statements contained in this affidavit are true and correct, and made with full knowledge that
Monroe County relies upon the truth of the statements contained in this affidavit in awarding contracts
for said P'f!~
t~ ~'/~
(Signature of Bidder)
Aru" f '1- ~ 201l 'f
(Date
STATE OF: 30("~
COUNTY OF:JJ) 0 (HOo€
PERSONALL Y APPEARED BEFORE ME, the undersigned ~uthority, ~ who,
providing proof of identity, or (J()being personally known to me, and having been firs1
sworn by me, affixe<lhislher signature in the space provided above on this ~ day of !ivy ~
200~
~cJ~
NOTARY PUBLIC
My Commission Expires:
Marlo L Slavik
ti-J'<i]'- 1_":5
SV,'.:X {fiR{; H,'t/' AiN ,.>Sj/.t.~F.1HC.
SWORN STATEMENT UNDER ORDINANCE NO. 10-1990
MONROE COUNTY, FLORIDA
ETHICS CLAUSE
Mer/SK (? ~C) r~~ warrants that he/it has not employed, retained or otherwis(
had act on his/its behalf 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 3 of Ordinance No. 10-1990. For bread
or violation of this provision the County may, in its discretion, terminate this contract without liability ane
may also, in its discretion, deduct from the contract or purchase price, or otherwise recover, the full amoun
of any fee, commission, percentage, gift, or consid~r.ation' aid to the former County officer or employee.
{Signature)
A.'f.d- 2- 'I, ).-0 ~ cJ
(Date) ,
STATE OF -BO(" clq
COUNTY OF j]) '() n ( De
PERSONALL Y APPEARED BEFORE ME, the undersigned authority,
~QtL~ ~vl.:m: who, after first being sworn by me, affixed his/her signature (name of
individual signing) in the space provided above on pus ~daY of , 20 Q!L.
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NOTARY PUBLIC
Marta l SlavlIc
My commission expires: MVcOMMlSS\ONI 00121839 EXPIRfS
OMB - MCP FORM #4
DRUG-FREE WORKPLACE FORM
The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies that:
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(Name of Business)
1. Publishes 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. Informs 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 employee assistance
programs, and the penalties that may be imposed upon employees for drug abuse violations.
3. Gives 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 (I), notifies the employees that, as a 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 of guilty or nolo contendere to, any
violation of Chapter 893 (Florida Statutes) or of any controlled substance law of the United States or an)
state, for a violation occurring in the workplace no later than five (5) days after such conviction.
5. Imposes a sanction on, or require the satisfactory participation in a drug abuse assistance 0]
rehabilitation program if such is available in the employee's community, or any employee who is s(
convicted.
6. Makes a good faith effort to continue to maintain a drug-free workplace through implementation of thi
section.
As the pe~son . zed to sign the statement, I certify that this firm complies fully with the abov
requireme ~ / /
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Bidder's Signature / Date