Item C23
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: December 16.2009
Division: Emergency Services
Bulk Item: Yes X
No
Department: Fire Rescue
Staff Contact PersonlPhone #: Darice I 6004
AGENDA ITEM WORDING: Approval of a Renewal Agreement by and between the Board of
County Commissioners of Monroe County, Florida and Emergency Medical Sciences Academy, Inc.
(EMS Academy) to provide an emergency medical services (EMS) training environment.
ITEM BACKGROUND: In September of 2006 the Board of County Commissioners approved an
Affiliation Agreement with EMS Academy which would provide a resource for a comprehensive
learning experience for the EMS Academy students, within a clinical field setting, for completion of
the students' program criteria (EMT-Basic and Paramedic). The Affiliation Agreement included an
option to extend the Agreement for an additional one (1) year period on a yearly basis. Fire Rescue is
requesting approval to exercise this option.
PREVIOUS RELEVANT BOCC ACTION: On September 20, 2006 the Board approved the
Affiliation Agreement with EMS Academy for the provision of an EMS training environment for the
period September 20,2006 through December 31,2007. _
On December 19,2007 and January 28,2009 the Board approved Renewal Agreements for the years
2008 and 2009.
CONTRACT/AGREEMENT CHANGES: The Renewal Agreement will be for the period January
1,2010 through December 31,2010. All other terms of the original Affiliation Agreement of
September 20, 2006 remain in full force and effect.
STAFF RECOMMENDATIONS: Staff recommends approval of the Renewal Agreement between
EMS Academy and the Monroe County Board of County Commissioners so that Academy students
can have the training environment they require to complete EMS courses. These EMS courses are also
available for locals who are interested in pursuing further courses in the Emergency Medical Services
field.
TOTAL COST:N/A INDIRECT COST:
BUDGETED: Yes No
DIFFERENTIAL OF LOCAL PREFERE!iCE: NI A
COST TO COUNTY:N/A
SOURCE OF FUNDS:
REVENUE PRODUCING: Yes No X AMOUNT PER MONTH _ Year
APPROVED BY: County Atty!:!..l- OMB/Purchasing _ Risk Management ~
DOCUMENTATION: Included X Not Required_
DISPOSITION:
AGENDA ITEM #
Revised 7/09
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CONTRACT SUMMARY
Contract with: Emergency Medical Sciences Contract #_
Academy, Inc. (EMS Academy) Effective Date: January 1,2010
Expiration Date: December 31, 2010
Contract Purpose/Description:
To provide an EMS training environment for students of EMS Academy within a clinical field setting
with Monroe County Fire Rescue.
Contract Manager: Darice Hayes 6004 Fire Rescue 1 Stop #14
(Name) (Ext. ) (Department/Stop #)
for BOCC meeting on Dec. 16,2009 Agenda Deadline: Dec. 1, 2009
CONTRACT COSTS
Total Dollar Value of Contract: $
Budgeted? YesD No 0
Grant: $
County Match: $
N/A
Account Codes:
Current Year Portion: $
- - - -
------
- - ~ ~
--...............--
-
- - - -
-----
- - - -
~----
Estimated Ongoing Costs: $_/yr
(Not included in dollar value above)
ADDITIONAL COSTS
For:
(eg. maintenance, utilities, janitorial, salaries, etc.)
CONTRACT REVIEW
Date In
Division Director I ;). ~ 1 - 0 '1
R~aua~~;.... 'I ~- 30 - ~ '1 y"O No!1l .
O.M.B.!Pdtch~mg l{ V; \~ YesD NofJl
CountyAttom~~ \\\ ~. ~~ YesDNo~ _ ~ t .tf-rJJ
i. ,. I. .. -
Comments: ',r ",' ,\ " ',Ii '" M
\t~o--D1' ~ rpCtu~<~ .
Changes
Neede!.;..
YesO No[::1
Date Out
}01-/-0;
OMB Form Revised 2/27/01 MCP #2
RENEWAL AGREEMENT
This RENEWAL AGREEMENT dated the day of , 2009, by
and between the Board of County Commissioners of Monroe County, Florida, hereinafter referred to as
"AMBULANCE SERVICE" and EMERGENCY MEDICAL SCIENCES ACADEMY, INC., hereinafter
referred to as the "AGENCY".
WITNESSETH
WHEREAS, the parties hereto did enter into an agreement dated September 20, 2006 to provide a
comprehensive learning experience for participants form the AGENCY, within a clinical setting; and
WHEREAS, said agreement provided an option for an additional (1) year period extension if elected by
both parties; and
WHEREAS, both the AGENCY and the AMBULANCE SERVICE have elected to exercise said option;
now therefore
IN CONSIDERATION of the mutual convenants and obligations contained herein, the parties agree as
follows:
-
1. The parties elect to renew the contract for an additional year pursuant to paragraph III.C of the
agreement entered September 20, 2006.
2. The effective date of this amendment is January 1,2010 and shall extend through December
31,2010, under the same terms and conditions of the contract dated September 20,2006.
3. All other terms and conditions ofthe contract dated September 20,2006 shall remain in full
force and effect.
(SEAL)
Attest: DANNY L. KOLHAGE, CLERK
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
By:
Deputy Clerk
By:
Mayor/Chairman
EMERGENCY MEDICAL SCIENCES
ACADEMY, INC,
(CORPORATE SEAL)
Attest:
By:
By:
Title:
Title:
MONROE COUNTY ATTORNEY
PROVED AS 0 F.ORM:
.
RENEWAL AGREEMENT
This RENEWAL AGREEMENT dated the day of , 2009, by
and between the Board of County Commissioners of Monroe County, Florida, hereinafter referred to as
"AMBULANCE SERVICE" and EMERGENCY MEDICAL SCIENCES ACADEMY, INC., hereinafter
referred to as the "AGENCY".
WITNESSETH
WHEREAS, the parties hereto did enter into an agreement dated September 20,2006 to provide a
comprehensive learning experience for participants fonn the AGENCY, within a clinical setting; and
WHEREAS, said agreement provided an option for an additional (1) year period extension if elected by
both parties; and
WHEREAS, both the AGENCY and the AMBULANCE SERVICE have elected to exercise said option;
now therefore
IN CONSIDERATION of the mutual convenants and obligations contained herein, the parties agree as
follows:
1. The parties elect to renew the contract for lfn additional year pursuant to paragraph III. C of the
agreement entered September 20,2006.
2. The effective date of this amendment is January 1, 2010 and shall extend through December
31,2010, under the same tenns and conditions of the contract dated September 20,2006.
3. All other terms and conditions of the contract dated September 20,2006 shall remain in full
force and effect.
(SEAL)
Attest: DANNY L. KOLHAGE, CLERK
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
By:
Deputy Clerk
By:
Mayor/Chainnan
EMERGENCY MEDICAL SCIENCES
ACADEMY, INC,
(CORPORATE SEAL)
Attest: ~ / ~
By: I J'~
Title: Ck/~r', / (;.j?";;1;jr.
By:
;e~-zt~&-
f}es; d-eni-
Title:
CERTIFICA
Cert ID 22776
ACOR~..
ITV INSURANCE
DATE IMM/OD/YYYY)
10/27/2009
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.
PROOUCER
SEITLIN
6700 N. ANDREWS
FORT LAUDERDALE
(954) 938 - 8788
AVENUE, STE #300
FL 33309
(954)
NOV 1 'f' 1009
INSURED
Emergency Medical Sciences Academy, Inc.
SURERS AFFORDING COVERAGE
NAIC#
2000 WEST COMMERCIAL BLVD., STE #200
FORT LAUDERDALE FL 33309
PHILADELPHIA INDEMNITY INS. CO
INSURER B: GENERAL STAR INDEMNITY CO.
INSURER C: TECHNOLOGY INSURANCE COMPANY
INSURER D: AMERICAN CASUALTY CO/READING
INSURER E:
18058
37362
43276
20427
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I~: OO'L POLICY EFFECTIVE Pg~!f1 EXPIRATION
'''''Rn POLICY NUMBER LIMITS
~NERAL LIABILITY EACH OCCURRENCE S 1 000 000
A JL =rMERCIAL GENERAL LIABILITY PltPK480580 10/7/2009 10/7 /2010 ~~~~lSis lEa occurencel S 100,000
- CLAIMS MADE ~ OCCUR MED EXP (Anyone person} S 5,000
- PERSONAL & ADV INJURY S 1,000,000
GENERAL AGGREGATE S 2,000,000
~'L AGGREGATE LIMIT APPLIES PER: PRODUCTS. COM PlOP AGG S 2,000,000
POLICY n P,~T I;l'LOC
~TOMOBILE LIABILITY COMBINED SINGLE LIMIT S
A JL ANY AUTO PltPK480580 10/7/2009 10/7 /2010 (Ea accident} 1,000,000
ALL OWNED AUTOS -
- BODILY INJURY S
SCHEDULED AUTOS )r (Per person)
-
JL HIRED AUTOS 19 BODILY INJURY
S
JL NON.QWNEO AUTOS _(OJ' (Per accident)
. _ ..' !) J PROPERTY DAMAGE S
i.. ~ I", 7I:r- (Per accident)
==rAGE LIABILITY ~ \-- 0 1..--' L/ AUTO ONLY. EA ACCIDENT $
" ']
ANY AUTO ly OTHER THAN EA ACC $
,,",':, , " AUTO ONLY: AGG S
~ESSJUMBRELLA LIABILITY EACH OCCURRENCE S 10,000,000
B X OCCUR D CLAIMS MADE IUG395725E 10/7/2009 10/7/2010 AGGREGATE S 10,000,000
S
8 DEDUCTIBLE S
X RETENTION S ~O, 0 DO S
C WORKERS CDMPENSATION AND TWC3209719 9/21/2009 10/7/2010 X IT~~$'T~JN;, I 10J~-
EMPLOYERS' LIABILITY 500,000
MlY PROPRIETORlPARTNER/EXECUnVE E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDEO? EL OISEASE . EA EMPLOYEE S 500,000
If yes. describe under 500,000
SPECIAL PROVISIONS below EL DISEASE. POLlCY LIMIT S
D OTHER STUDENT MEDICAL PROF 0127294541 10/7/2009 10/7/2010 $1,000,000 EACH OCCURANCE
$5,000,000 AGGREGATE
OCCURRENCE FORM
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
*10 DAYS NOTICE OF CANCELLATION IN THE EVENT OF NON-PAYMENT OF PREMIUM. CERTIFICATE HOLDER AS
DESIGNATED ORGANIZATION IS AN ADDITIONAL INSURED AS RESPECTS GENERAL LIABILITY SUBJECT TO THE TERMS,
CONDITIONS AND EXCLUSIONS OF THE POLICY.
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENOEAVOR TO MAIL ~ DAYS WRITTEN
MONROE COUNTY BOCC
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
490 63 STREET IMPOSE NO OBLIGATION OR L1ABILlTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
SUITE #140 REPRESENTATIVES.
Marathon FL 33050 AUTHORIZED REPRESENTATIVE ~y-tZ. aJ2
I
ACORD 25 (2001/08)
@ ACORD CORPORATION 1988
Page 1 of 1
10/27/2009
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement{s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
-
ACORD 25 (2001/08)
Page 2. of 1
RENEWAL AGREEMENT
(,-'!fL
This RENEWAL AGREEMENT dated the dQ ~ day of 2009, by
and between the Board of County Commissioners of Monroe Co , Florid ereinafter referred to as
"AMBULANCE SERVICE" and EMERGENCY MEDICAL SCIENCES ACADEMY, INC., hereinafter
referred to as the "'AGENCY". ,
WITNESSETH
WHEREAS, the parties hereto did enter into an agreement dated September 20, 2006 to provide a
comprehensive learning experience for participants fonn the AGENCY, within a clinical setting; and
WHEREAS, said agreement provided an option for an additional (1) year period extension if elected by
both pmties; and
WHEREAS, both the AGENCY and the AMBULANCE SERVICE have elected to exercise said option;
now therefore
IN" CONSIDERATION of the mutual convenants and obligations contained herein, the parties agree as
follows:
-
1. The parties elect to renew the contract for an' additional year pursuant to paragraph III.C of the
agreement entered September 20, 2006.
2. The effective date of this amendment is January 1,2009 and shall extend through December
31, 2009, under the same terms and conditions of the contract dated September 20, 2006.
,,;~~~~:@S01!Jer,!enns and conditions of the contract dated September 20, 2006 shall remain in full
,f,,~~'~;.:::r(f~~:ffect.
/P,.,;/ C~-' 23 ..... ~t.\"
!/~?' ~f\'2. g="
;/r::,'!=f1tfl1, ..: ' '''1\
;"l ,~~~ ~ ( ---:iJd"';"~~' :~' :
.""'.'F.'e~'! ." ,. ~.J
:;e~';:.f~ 1. or ~''-:' . ~ /
"~\::~,: _ :;,~::: \:;~' ../?' , L. KOLHAGE) CLERK
'\";t~ _ I. /!
B;U~~
Deputy Cler1< .
BOARD OF COUNTY COMMISSIONERS
OF M<?pROE COUNTY, FLORIDA
By:~"...4!", n~,~
Mayor/Chairman
(CORPORATE SEAL)
Attest:~" ~
By: t.../'?"".Ph . d~ l.
, ,
EMERGENCY :MEDICAL SCIENCES
ACADEMY, INC,
By:
?~A~
//..es/c1 tf#J+
Title:Cw! t'?'F ~1/44I'tci. 't'/ _ (7Pi=u _~/r!-.
Title:
ACORDm CERTIFICA
PRODUCER
SEJ:TLIN
6700 N. ANDREWS AVENUE, STE #300
FORT LAUDERDALE UL 33309
(954) 938-B788 (954) 93B-~){~
DATE {MMIODIYYYY)
10/13 200S
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
LV AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BV THE POLICIES BELOW.
INSUREO
Emergenoy Medioal Soiences Aoademy. Inc.
INSURERS AFFORDING COVERAGE
INSURER A: PBILADELPBJ:A INDEMNITY INS. CO
INSURER e: GENERAL STAR INDEMNITY CO.
INSURER C: nCHNOLOGY INSlJIUNCE COMPANY
INSURER 0: CHICAGO INSURANCE COMPANY
INSURER E:
2000 WEST COMMERCIAL BLVD., 5TE #200
FORT LAUDERDALE I!'L 33309
NAIC#
18058
37362
43276
112266
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR 00' POLICY NUMBER POLICY EFFECTive PRi!f.! EXPIRATION LIMITS
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES aE CANCELLED BEFORE THE El<PIRATlON
MONROE COUNTY .!Ioee OATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO !MIL 2L OAYS WRITTEN
NOTICE TO THE CeRTIFICATE HOLDER HAMEO TO THE LEFT. BUT FAILURE TO 00 SO SHo\LL
490 63 ST1l;EE'l' IMPOSE NO OBLIOA TION OR LIABiliTY OF ANY KIND UPON THE lNSURER, ITS AGENTS OR
SUITE #14 () REPRESENTATIVES.
Marathon l'L 33050 AUTHORIZED REPRESENTO\T1VE ~7ti' a It:.
I 1-".._ """-,,
A
~NERAL LIABILITY
L ~MERCIAL GENERAL LIABILITY
_ --.J CLAIMS MADE W OCCUR
10/7 12009
EACH OCCURRENCE S
I ~~EMI"ES rEa ~~.;'nce\ S
MED EXP (Anyone palOon) S
PERSONALS ADV INJURY S
GEt-IERALAGGREGATE S
PROOUCTS . COMPlOP AGG $
PBPK353270
10/7/2008
A
~LAGGR~L1MIT AP~S PER:
I POLICY I I ~~P.T I X I LOC
~TOMOBIU;: LIAellITV
~ ANY AUTO
_ Al.l OWNEO AUTOS
_ SCHEDULED AUTOS
.1f.. HIRED AUTOS
.1f.. NON.owNED AUTOS
;'~f\I~ '1;,(7"(;.;~c.t:) ,";'" " ,
;':,:,.~..l\ff. ~ "P";;~.;>!1""""'" <,
Li;: ~ ,H_...,.,1:.Z\.{...Q.~__.___
!A~;. ~..,....r'. i\Ub .. ,....:.
OTHER THAN
AUTO ON!. Y:
l'HPK353270
10/7/2009
COMBtNeOSINGlE LIMIT
{Ea acochlnll
111/7/2008
eOlIlLY lNJURY
(Pa, J>ef$OO)
eOOILY INJURY
(per acddlt/11l
PROPERTY DAMAGE
(l>eracQ"'=nl)
~A.GE !.lABILITY
I ANY AUTO
AUTO OtolL Y - EA ACCIDENT S
EA ACC S
AGG S
S
S
S
13
~!;SSlUMBRELI.A UABILlTY
.JU OCCUR 0 CLAIMS MADE
I DEDUCTIBLe
-;1 RETENTION S 10.oaa
WORI';ERS COMPENSATION At-ID
EMPLOYERS' LIABILITY
my PROPRIETORlf>ARTNERlEXECUTlVE
OFFICERlMEMBER EXCLUDED?
~~~~1~~~JJls16NS below
OTHER STODBNT MlIDICAL PROP
10/7/2009
EACH OCCURRENOE
IUG395725D
111/1120118
10/1/2009
AGGREGATE
C
9/21/2009
X I WCSTATU. I jOlt
E.t. EACH ACCIDEtIlT S
E.L. DISEASE. Ell EM~LOYEe S
e.L. DISEASE . POLICY LIMIT S
$1,0110,000 EACH OCCORANCE
$3,1100,000 AGGREGA~E
TWC3180507
9/21/2008
:0
AHC-1219125
10/7/2008
DESCRIPTION OF OPERATIONS I LOCATIONS IveHICLES I EXCLUSIONS ADDED BY ENOoRSEMEtIlT' SPECIAL PROVISIONS
*10 DAYS NOTICE OF CANCELLlI.TION IN THE EVENT OF NON-PAYMENT OF PREMIUM. CERTIFICATE: HOLDER AS
DESIGNATED ORGANIZATION IS AN ADDITIONAL INSUR!:D AS RESPEC~S GENERAL LIlIBILITY SUBJECT TO THE TERMS,
CONDITIONS AND EXCLUSIONS OF THB POLICY,
CERTIFICATE HOLDER
GANCELLA TION
ACORD 25 (2001/08)
. ^^^ ^^^
100,000
5,000
1,000,000
2,000.1100
2,1100,1100
S '
1,0110,0110
S
S
10,000,000
10,000,000
S
$
500, ODD
SOO,OOO
500,000
page 1 of 1
@ ACORD CORPORATION 1988
lG/l3/20GS
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the polfcy{les) must be endorsed. A statement
on this certificate does not confer rights to Ihe certificate holder in lieu of such endorsemenl(s).
If SUBROGATION IS WAIVED, sUbject 10 the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights 10 Ihe certificate
holder in lieu of such endorsemenl(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not consUlute a contract between
the issuing insurer(s}, authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
.
ACORD 25 (2001/08)
E'age 2 of 1
RENEWAL AGREEMENT
JC7tU _ tl F
TIus RENEW p~ AGREEMBNT dated the <' day of. lU~./l-. ,2007, by -,.
and betvveen the Board of County Commissioners of Monroe County, Florida, hereinafter referred to as
"AMBULAl'<ICE SERVICE".and EMERGENCY MEDICAL SCIENCES ACADEMY. INC.. hereinafter
refelTed to as the "AGENCY".
WITNESSETH
WHEREAS, the parties hereto did enter into all agreement dated September 20, 2006 to provide a
comprehensive learning experience for participants from the AGENCY. within a clinical setting; and
WHEREAS, said agreement provided an option for an additional (1) year period extension if elected by
both patties; and
WHEREAS, both the AGENCY and the AMBULANCE SERVICE have elected to exercise said option;
now therefore
IN CONSIDERATION of the mutual convellants and obligations contained herein, the parties agree as .
follows:
-
1. The parties elect to renew the contract for an additional year pursuant to paragraph III. C. of the
agreement entered September 20, 2006.
2. The effective date of this amendment is January 1, 2008 and shall extend through December
31, 2008, under the same terms and conditions of the contract dated September 20, 2006.
~ ;~Ih~~. . terms and conditions of the contract dated September 20, 2006 shall remain in full
,~;o ~ ~ .t:J:'.
~~ *hect.
18 23 &,c;t\
-If
:l
.~ ;~
, L. KOLHAGE, CLERK
~
.'
(CORPORATE SEAL)
Attesl~\a ~ ~. _\. . TIt .'
By: ~ ~t<J..C..Ol~
Title: S (U tt- No.1 S~ {\/1 Le.S
ELIZABETH fACOEELU
Nola~ Public - Stale of Florida
CommissIon expires May 25, 20'10
Commission iJ- DD 513509
nded by NaUonal Notary Asan.
BOARD OF CO~Y COMl\tIISSIONERS
OF MONROE C TY, FLORIDA
By. k
Mayor/Chainn
EMERGENCY MEDICAL SCIENCES
ACADEMY, INC,
BY~
Title: -rj\..~DIACC(CA.....
MONROE COUNTY ATTORNEY
~~t~M
ASSISTANT COUI\lTY ATTORNEY
Dot8._._LJ$,.:...~r;":..J..tJ tJ =1---_
+' " .~
r- ;J;11r;/~5!ii6~"~;r~li::;r.;~;'1?ljl;-;lll(i'O" ~A'cU"r.;; ~-:-)')I(f; I[ n ;';;;H-!L~ fil-;; nli~n~llJ'~';{;-I~,Il(,"',.\r;;; ~~ I ~--;;;,~;;;;;;;;;--
" ,p<.,: 'W In,l',,,\,,, \.,,,,'> b!f '''" u U It ~ d'!J'~<!. l~;"'~, J lh,1J6&~tr"J>U u (f liU'i'JQ) ruM! f\'1I>L:>~ 2.0'/<1.&/2007
rn~-'-'---~-"""""-"~'''__'h'___~___~ Ct:l'iTtFiCATE!: IS ~iSSUeD I~$ A WIAFr'iE~ ~l~ 1l~f.onliMYiOf;j- -:-
2t;:<;;;>r.:ITi -:: ONLY"AND CONFERS NO 1~IGMI$ UPON Tl-2E GEt~Trr:ICATE .
E:7UO tl. mmmms Z>.vtwr~, S'!'13 0;;;0/1 HOLE'lEl't il-f=S CERTlr-ecATE DOES NOT AllJlENO~ l:)(TEND OR
VORi' Ll'llJtlGR!).;u,lil IT!> 3330f> ALTeR iHe COVE-MGE AFFOROf::D BY TliG P~l C!l:S am..oIDL-
I~S~} ~3~~S7SG (95~) ~Se-SEGG
mSUlUm
Em5:1:gGln<:llr HC!d;l.<;lill Soiontlc[iI ll.on.:16my, !tlc.
INSURERS AFFORDING COVERAGE
IN'sURERA: Pl'l1L1lDlml?H:rA Ilmmm!T1C nrs. C!O
mSlfRER6: GmlmAAL BXi\n. INDI,:WU:TY CO.
ttlSUReRC: i,J;13m'l'lI' mr.eU1lL .l?.tl1n niB. co.
JNGURERO:
INSUIlER E:
3000 ~mS51 crolmiilRC!J:l'.L BIWi:l., am i'l200
It'oa.'l:' LAtIDlmDllJ',3 l1L 33309
.:.a....- I
. COVERAGES
NAIC ~~
113058
37362
23035
I HE POliCIES OF INSURANCE LISTeD BELOW I-lAVE BEEN ISSUED TO THE INSURED NAMED ABOve FOR THE PO'-lCY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TaRM OR CONDITION OF ANY CONTRACT OR OTH5R OOCUMENr Wrrt-J RESPECT TO WI-IICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFOROEO BYTHe POUCIlES DESCRIBeD HEREIN IS SUBJECT TO AL!. nil:: TERMS, exCLUSIONS AND CONDfTlONS OF SUCli
PO!.IOIES. AGGREGATE LIMITS SHOWN MAY HAve SEEN REDUCED BY [:lAID CLAIMS.
JlJsn "'D . ..';,,~ _ POUCVlmfllElER PJlMli';~ POL cv ~v.prR~T1DIf
-
COMllJt.leOSfNGI.EUMn' S
(Ell ~eddanl) 1,1l1l0.000
BOO/LV II'IJUilY S
(Petpllllian)
BOo/lYlNJURV 1;
(Pernodd.nt)
~ROP.ERTYDAMAGE S
PIIt .cddanl)
AUTO ON!..Y -EAACCIOalr S
01HE~Afol !!Alice s
AUTO ~ AGG S
SHOULD ANY OF UlEIIElOVEOESOBfel!O POUCliS ill; CANCEllED BEI'OJlElHE EllPlRATlOW
IlO1iP,oIl COom:~ I10CC DATE TIlERUOF. THE ISSUING lIlSURltR W1~1. ENDEAVOR TO r~All ...AQ.... l}AVS WflmEll
tlO'l1Ce TO lHil:IJERTlPlCA'fl;f!OI..OEit ~nEIl TO tilE l.Ef1'.IlUI'Fllf~URE TO CO SO SHALL
~90 <i3 S'J:REBT U~POSE 110 OBLIl3ATlOll OR lWllLIlY OF ANY IUtlO UPON THt! IIlS\lIlE:l'l, liS AOlmTS OR
StlX'J:l!: 1/1\';0 llEPIl.ESarrAllVEi.B.
UC3;athon I'L 33050 AUlllOlUZSO REPRliSllllTA11'Ie .' ;.~l:
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PROOUCTS -CQMP/O? AGO S
A
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10/7/2009
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~'OCCUR 0 ClAIMS MADE
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10/7/2007 10/1/2008
eACH OCCURRENCE
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DESCIIIl''II011 OP OpltilATlOllflf1.QMTlONG lVEHlOU!s I EllCWSIOIIS AODED av ENDOrlser.u;r1T Il1Pl!OUII. PROVlS!OllS
~.
Cl!:P.~r9XCA'rE S'OUlIUl AS DIISIGN1I'mD OrtQl\.NIZA'l'l(lN J:S my AtIDI\IlJ;ONllL mstmlm as ll!ilSPBCTS G~11mllL IiIABIr.:r:'l'l{
stm.:mC'l' !CO !l)Em !CJ::RllS, Cml'f)r.t'I01itB miD m;cr.USJ;ONS Oli' :rim POLICY.
ceRTIFICATE NOLDER
CANCELLATION
ACORD 2a (200'l/fJaI
$
~ oon.onn
100 000
!i.000
1,000.000
&,000,000
2,000 000
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500.000
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If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorssd. A statement
on this cettii'lcate does nol confer rigllts to the csrlificelte holder in lieu of such endorsemsnt(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain pollcies may
rGqulre an endorsement. A statement on this certificate does not confer rights to the cerllfieats ..
holder In Ifeu of such endorsement{s).
DISCLAiMER
Tile Certificate of Insurance on the reverse side of this fonn does not constitute a contract between
the issuIng Insurer(s), authorized representaUve or producer. and the certificate holder, nor does It
afllnnatrvely or negaUvely amend, extend or aileI' the coverage afforded by the policies listed thereon.
-
ACORD 25 (2001/03)
, .,
.AJFlfi'KILRp1. 'Flf (1) Ii )~ G1RUEjEIV[JEr'~1f
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li.
JtD A]R']['J[lClIIf' A 1r~J<G AGJENCmS
~
This AGREEMENT between EMERGENCY MEDICAL SCIENCES ACADEMY~
TI-.rC., hereinafter refened to as the AGENCY, and the BOARD OF COUNTY
COMMISSIONERS OF MONROE COill\ITY, FLORID~ hereinafter refell'ed to as
the AMB~N~ERVICE is entered into this dtJtf::t.-day of .
. ~ ~ 92006.
1f1[. PlI:.JmIDOSE OF AGlRlEJEMJEN'f
It is mutually agreed that the pUlpose of this AGREEMENT is to provide a
comprehensive leaming el~perience for participants from the AGENCY, within a
clinical setting, in accordauce with provisions ofilie guidelines set forth in this
AGREEMENT.
JIll. GENERAL PROVISIONS OF AGREEI\1DEN1I'
-
A. Both parties agree that there will be no distinction in employment or
placement because of race, sex, color) creed, age, national origin, religion,
malital status, disability or handicap and adhere to the pl'Ovisions of
Federal and State laws regarding discrimination.
B. The AMBULANCE SERVICE will provide, to the Participant, at the
Participant's expense, emergency care for injuries or acute illness while on
duty at the AMBULANCE SERVICE in accordance with the provisions of
this agreement.
. ;
c. The telm of this AGREEMENT shall be from the date of the
AGREEMENT, and shall remain in full force and effect until December
31, 2007. Either party may elect annually to extend this AGREEMENT
for an additional one (1) year pe1iod upon providing at least thirty (30)
days prior written notice of intent to extend. Either party hereto may
terminate this AGREEMEt.1T by giving at least thirty (30) day written
notice to the other party.
NOTICE: Where notice is required under this AGREEMENT to be given to either
party, the notice shall be mailed to:
For AGENCY:
Prank Galgano, Program. Director
EMS Academy) Inc.
600 N. PUle Island Rd., Suite 320
Plantation, FL 33324
For AMBULANCE SERVICE:
Clark o. Martin, Jr., Fire ChieflDiv. Director
Monroe County Fire Rescue
490 63 rd Street, Suite 140
Marathon, FL 33050
1
lI'F, SJF1E(CmFl[{'~ IRUESW(DI\TSlI]EKlnr-!rrTIlE~) ow 1f'1f:rrm; A<GJENtCY
.-:.
-;-
A, AGENCY shall designate a person or persons to coordinate and act as a
liaisoll willi the appropriate AMBULA1\fCE SERVICE personnel. ,-
ID. AGENCY shall provide the AMBULANCE SERVICE with a list of
participants in the lem11ing experience at least ten (I 0) days before each
program is to start
<C. AGENCY shall instu'e that participants have the necessary didactic
prerequisites to maximize the learning expedence at the AMBULANCE
SERVICE.
1IIl. AGENCY shall insure that the participants comply with the provisions of
Section VI.
E. AGENCY does undertake and agree that it will indemnify and hold
harmless the AMBULANCE SERVICE and its officers, 4irectors~
employees, and agents, and reasonable attorney's fees on account thereof,
that may be sustained or incurred by reason of any and all claims,
demands~ suits~ actions, judgments, and executions for damages of any and
every kind and by whomever and whenever made or obtained~ allegedly
caused by, alising out o~ or relating in any lllanner to the activity of any
participant or participants supplied by the AGENCY pursuant to this
AGREEMENT.
-
,
,<
][f. AGENCY shall procure.and maintain, dUling the term of this
AGREEMENT and any renewal, liability insurance to cover any and all
liability (including professional liability) for claims, damages, or injuries
to persons or property of whatsoever kind of nature arising out of the
activities of the participants carried out under this AGREEMENT. Such
insurance shall be on an occurrence basis in amounts no less than
$1,000,000/ $3,000,000 for personal injuries and $50,000 for property
damage; and the AMBULANCE SERVICE shall be an additional named
insured ~der such general and professional liability policy or policies.
AGENCY shall submit certificates of insw:allce to the AMBULANCE
SERVICE evidencing such insw'ance at the time of the execution of this
AGREEMENT, and as requested by the AMBULANCE SERVICE.
AGENCY agrees that the AI\ffiULANCE SERVICE will receive no less
than thirty (30) days written notice prior to cancellation, modification, or
non-renewal of any of the insurance coverage's described herein,
Participants who do not have patient contact (non-allied health
participants) will not be required to be covered by professional liability
insurance.
2
-\}
, -
giP"ITi:(~]f1F.f[(~ 1FUE@,jp'([(lI<.Tf3mlff,lIILIf1I'nm:;~~ O]F 1I'IHilE AJ\1.0Bf[]l,A\l""tICfE
8JEIrtVlIC~
";"
It shall be the responsibility ofthe Afv1BlTLANCE SERVICE to:
.'
h. Provide an appl'Opliate orie-iltatiOl1 of participants in connection with its
facilities and its policies and procedures.
IF.B. Provide opportunities for a leaming experience with appropliate
supmvisioll.
C. Retain ultimate responsibility for patient care even if that care is given by
a participating shldent.
ID. Designate a preceptor (or coordinator) from its staff to act as the liaison
with the AGENCY in this AGREEMENT, as appropriate to the leol1llng
objectives.
'0/']1. SJPllEClfJF]IC USPONSmillLJI'lrlIlES OF 1fJHUE P AR'I['1[CKJP> ANT
-
It shall be the responsibility of the Participant{s) assigned through this AGREEMENT
to:
A. Comply with the policies and procedures of the AMBULANCE SERVICE.
B. Provide the necessmy and appropriate unifOl'm while on duty in the
AMBULANCE SERVICE.
C. Obtain prior vvritten approval of both parties to this AGREEMENT before
publishing any material related to the learning experience provided under
the terms of the AGREEMENT.
11), Sign a "Hold Harmless Agreement" with the AMBULANCE SERVICE
'prior to commencing his/her experience within the AMBULANCE
SERVICE of which is attached to this AGREEMENT as Exhibit A.
.
,
,
E. At all times, must weal' the appropliate badge on every clinical rotation,
and comply in all respects with the student requirements set forth in the
requirement sheets.
Vll. REQUEST FOR WITlIIDRA W AL OF PARTICIPANT
The AMBULANCE SERVICE shall reserve the right to deny any Participant from
access to its facilities whose conduct or work with patients or personnel is not in
accordance with the policies and procedm'es of the AMBULANCE SERVICE or is
detrimental to patients or others.
"
;J
\:/TIH[, I~lI((r'1D'KJFn(CA~ JI'I[r[)f:;J (I]lff!' -,6~{G1f.~JE1E1WJEI'Tlr'
Moditication ofUrli AGREElV1ENT may be made by mutual conSGni: of both parties,
in writing, and attached to tins AGREEMENT and shall include the d;lte and the
sigllattu\~s of parnes agreeing to the modification, .'
~. COpmSOFAGREE~NT
Copies of this signed AGREEMENT shall be placed 011 file and be available at the
corporate office of the AGENCY and in the offices of the AMBULANCE SERVICE.
IN WITNESS WHEREOF the parties hereto have caused this AGREEMENT to be
executed in their respective corporate names and their corporate seals to be affixed by
duly authorized officers, all on the day and year first set forth above.
,;.:(SEA~)
,fAttest; l?,~y L. Kolhage, Clerk
:,,' ~ i._. . -.\ / ',. cl .
h.: . I . I
... ~~'~':~ ~.
Board of Colmty Commissioners
of Monroe County, Florida
(\\\
Mayoi' / Cl~ir1\lan
J .,
Emergency Medical Sciences Academy, Inc.
~~
~i~J
Franlc Galgan . . Director
4
.,.
-
1::, HH.l'~
1ErMl1lEfg<<~fE~~c;V ~1E[iJnCfi~l $CnlEfi~]eJE~ ~(C~~u'j)IEIMiJY
IKJOllfj1 ~~~M[LfE~S ~~G!RlElEMn:u~1r AfftJIjQJ 1R1E1L1EA$1E
I, , am presently enrolled as an Emergency
Medical Technician or Emergency Medical Technician Paramedic student at Emergency
Medical Sciences (EMS) Academy. My course of instruction at this school requires me
to train, study, and receive instruction at EMS Academ~{ and/or Monroe County Fire
Rescue (County).
In consideration for the County providing me this opportunity to acquire training,and
instruction, I, tl16 undersigned, agree tn indemnify, protect, and hold harmless the
County and its officers, directors, employees, agents and assignees from any liability
judgments, claims, costs. damages or injury arising out of or in connection with any and
all acts of negligent conduct on my part, however caused, during any instructional or
training activity. I agree that I will defend at my own expense, any and all actions,
lawsuits Ol" proceedings which may be bro'ught against the County in connection with
the above and shall satisfy, pay and discharge any and all judgments that may be
entered against the County in any such claims, lawsuits, or proceedings.
I understand that, generally, while I am engaged in the activities of and related to this
course of instruction and training, I am not considered an employee of the County and
therefore, I am not eligible for any benefits available to County's employees, nor to
Worl<srs Compensation coverage pursuant to Florida Statute Chapter 440 (1989-90 or
its successor amendments/statutes).
I understand that there are inherent risks in training with County, including but not
limited to, my own injury, exposure to blood-borne illnesses. and e)cposure to
contagious diseases and contraction of such diseases. Participation in this training can
result in severe injury and even death. I release County from any and all liability from
any consequences arising out of my training with County.
Date of Instructional Activities:
<
;
to
Date
Date
Signature:
Date:
Witness:
Date:
..,.
-
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SlIITE '1(1'1 ~
Pe,mbrolt0 pjnGZ Ft.. 3302B U\lSURERS Al>FOROING COVERAGe NP.JC t!
ltlSURt!O ~rJlERGEtK-;V P.J1!:OIC.l\L S(,:IE~lces A(:{l!lE~JlY INt; IlfJSUREF1 a, SCcmSIJALE INSUP.ANCE CO -'
6011 NORm PINE ISLAt~!:rFl:Ot\O iF 320 INSURER B:
PLANTATION, f.1. 3332:~ INSURER C: I -
INSURER c: T
INSURlOR E: J !
CO"ERAG~S
THE POLICIES OF INSURANCE LISTED BeLOW HAVE seEN ISSUED TO THE INSURED NAMED ABove FOR THE POLIcy PERIOD INDICA1ED. NOlWlTrlSTANOING
ANY REQUIREMENT. 1ERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT Willi RESPECT TO WHICH nns CERTIFICATE MAY ElE ISSUED OR
MAY PERTAIN, lHE INSURANce AFFORDED BY TliE POLICIES OESCRlEl"'D HEREJN IS SUf3JECT TO ALL TliE TERMS, E)(CLUSIONS AND CONDITIONS OF SUCH
POLICIES, AGGREGATE LIMITS SHOWN MAY I'lAVE BEEN REDUCED BY PArD CLAIMS.
D'l ~ POLlC'; Nu~'er;;R POUCY r:~r-BCTlVe Pouay I nON
A
J{
(li:Ni:RAL UAeILlTY
" COMMERCIAL GENERAL UAEIUJ'Y ClS124fJ3all
Cl.AlMS MADE [[] OCCUR
04111/2006
04(11/2007
UMlTB
200001111
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s 2,000,0011
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COMBINED SINGLE LIMIT
(Ea. QQc/dan!l
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[Parp.mm)
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(parllccid.ol)
GAWUlE lIAeIUTV
ANY AUTO
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(F'ernccklanl)
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ellCEElllJUMElREllA UAI'IILlTY
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EMPLOYERS' UAaIUrv
ANY PRClPRleTOR/PARTNeRII::XECUTIVE
OI'FlCERlMEMBr:R seCLUDED?
If aucr1be ~ndlll
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leeCRIPTlO~1 OF OPEF'.ATlons Il.OCAll0US IVEHICLalt I!l(CLUSICNS ALlDt!C BV ENDOlllIEMENT/SPt!CIAl.PROllleIOlllS
~ERnFICATE HOLDER IS I.lST!:D AS ADDITIONAL INSURr:O
:ERTIFICATE HOLDER
MONROE COUNTY BOec
490 63 STREET SUITE 140
CANCELlAnON
SHOULD MJV OFTHEABOVE OESeRlSleD POLfCIESBEOANCElJ..lOD ElEFORE:THe eJ[PIRATlOrl
PATE mr:REOF. THE ISSUING I!lSURER WILL IillDEAVOR TO MAlL ~ DAVS WRlITEtl
NOTICE TO THE CliRllFlOATE HOLDER NAMED TO TIlE LEFT, eUT FAILURE TO DO SO SHALl.
III'POSE NO OBLIGATION OR LfAeIUTV 01' AllY IUND UPON 1llt! mSURE:R, ITS Aot!UTa OR
REPRE!t!NTATIIIES.
AlITHORl,MD aePRear:NTATIVE <:~RC>
eJ ACORD CORPOF'.ATiON 'i9138
MAMTNON, FL 33050
::ORO 25 (2011'lIu(j)
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If the cerUfrDElte holder is an ADD1T10rlJAL INSURED, the poUcY{ies} must be endorsed, A statement
on this carlmests does not confer rights to the certlfiCElte holder In lieu of such endorsement(s).
If SUBROGAT10hl IS WAIVED, sUbJsct to the terms and conditions of the polley, certain policies may
require an endorsement. A statement 011 tllis certmca~e dOGS not confer l'lghts to the cartiftcate
holder In lieu of such endorsement(s).
D9$Cl!..A8MER.
The Cermlcate of Insurance on the reverse srde of this form does not constitute El contract between
the Issuing Insurer{s), authorized reprassntaUvs or produDer, and ihe certificate holdsI'. nor does It
ElffhmaUvely or nsgl:ltlvely amend, 6ldend or alter the coverage afforded by the policies listed theraon.
.'
:OR!:! 25 (200'1108)
or,
11
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,sum: '10'; . -
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IrJBURl!1:l !:PJlGRe!:~3CV MElmCAL scmmc!:s ACMemy ING INSURER A: taIJANSTD~j INS CO 0" J
600 t~Or.,/1 !"INE ISltlNi:fROM INSUREI': B:
StlliE 320 INSUREr;, c:
PLANTATION f-L 33324- INSURER D:
INSlIRER E:
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" "" 'P'e,.s j
COVERAGES
THE POLICIes OF INSURANCE LISTED EJELOW HAve BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TI-/E POLICY PERIOD INDICATED. NOlWlTHSTANDING
ANY REQUIReMENT, tERM OR CONDI110N OF AtN CONTRACT OR OTHER DOCUMENT WITH RESF'ECT TO WHICH n~IS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. 1HE INSURANCIO AFFORDED ElY TI-IE POLICIES DESCRIBED HEREIN IS SUSJECT TO ALL THE TERMS. IOXCLUSIONS AND CONDITIONS OF SUCN
.....!~ES. AGGREGAlE LIMITS SHOWN MAY I-IAVE BEEN REDUCED BY PAID CLAIMS,
~ ~ TV<>,,~;: ~ r:>OLtCV tJUlYElEP. PDLlOV EFI'Eci'iVE PclUOV Ellr:>IRATitlN LIMITS
~-N8R/U, LlABfUiY EACH OCCURRENCE $ 1,000 nOD
A J( I-- ~IMERClAI.. EENERALLlABllJTY SMfl3'i393 1111112D05 11/'l1J21106 DAMAGE TO ~E___ 5
'-- ---I Cl.AJMS MADE 0 OCCUR I ..,,=,:, EX!' (Anll Ona nemonl ~
,t PROFESSIONAL UAB PERBONAL l\ ADV INJURV "
GENERALAGGREGAlE S a.DOO 000
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~'l.AGGR~ UMITAP~$PER:
i-- _ I POLICY t . J ~.fI.P.;: I I LOC
.!illTOMOeILE LlABIUTV
_ ANY AUTO
1_ AU.OWNEoAUTOS
_ SCHEOULEO AlITOS
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_ NON-oWNr:OAUTOS
~tJRA!lE LIAElIUl'V
_I ANY AUTO
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--1 OCCUR 0 CI.AlMS MAcr:
RDEDUCTlBLC
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WOP.KelW COl\IPE!lI8ATION Al'dD
EMPLOYER9'LIAllIUTY
ANY PROPRilmJRipARTNERlEXECUTIVE
Df'FICERlMEMBER EXCLUDED?
! U~~f!.~'S'!b8JI~~s k.I.,,,
OiliER
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Jf HI. Lur...... 'i ,.. P_;..,. '-of
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WJ\lVGR rlfA ..'t.. '.. ,. . J-..
COMBINED SINGLE LIMIT I-
(En llccldanl) $
BODILY INJURY S
(PIlr pamn)
BDDlL V INJURY $
(Par llGCldenl)
PRDPERTV D.MIAGE S
(por ncelOOnl)
v
-
OTHER THAN
AUTO ONLY:
EACH OCCURRE"'ce
.~ TE
AUTO ONl.Y-EAACClDENT S
EAACC S
AGO S
s
s
Is
:$
S
-r we STATO-. I IOJL'"
E,L EACH ACCloe.rr I .
E.L D1SF:"SE - EA ElAPLOV!:I! 5
!;,L. O""'.ARE - POLl~ LIMIT I s
.t,t
15SCRIPilOl4 or- O?tl:RA11011~ I LOCATlOUS I \Il!HICLES I EllCLUSIOlls ADDeo BV ENDORBEiMENT I ElPECIAL PRO\II8rO~4S
:ERTIFICATE HOLDER
:;OP.O 25 (j!O01/88)
.!IU.._ r:l [.
CANCELLATION
SHOULD AHV OFTHEASOllE D5GCRIElED POUclE8 E1ECANCELLeOElEFORE nil' EXPIRATION
DATE THEREOF, THE ISSlJllJG INSURER WILL ENDEAlIOR TO MAIL .1L DAVS IfIIflITTEN
Nones TO TH5 CI:RTlFlCATE HOLDER NAMED TO THE LEFi. aUT FAILURE TO DO SO SHALL
IMPOse NO OIilUGAT/OI1 on UAelLlTV OF AtIV laND UPOU THe INSURER, ITEll'.Gema OR
RBPRE8ENTA'I1IIl!B.
AllTIiDRIZEO RePRESEI.JTATlVe <Me:-
@ACORD COFl.tl10RA'i'KlN 'lNlS
MONROE COUNTY soce
49063 STREET sUITe 140
rJ/ARA1HON, FI. 3305D
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p
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If tha certlflcete holder is an AODlTIONAL INSURED, the pollcY(ies) must be endorsed. A staten1Emt
on this certifrcate dOEls no! confer rights to the carUfica!e holder in lieu of such endorsen1el1t{s).
If SUBROGATION IS WAIVED, subject to the tarms and conditions of the policy, celtsln policies may
require an endorsement. A statement on this certificata does not confer rights to the certificate
holdElr in lieu of such endorseme3l1t(s}.
DiSCLAlIMlSR
The Certificate of Insurance on the reverse side of this form does not constitute l?l contract between
the issuing lnsurar{s), authorized representaUve or producer, and the certificate holder, nor does it
affirmatively or negatively amend, axtenc.l or altar the coverage afforded by the policies listed thereon.
~OP.:D 25 (28lJ'U6e)