1st Renewal 09/11/2024 GVS COURTq°
o: A Kevin Madok, CPA
-
�o ........ � Clerk of the Circuit Court& Comptroller Monroe County, Florida
�z cooN
DATE: September 18, 2024
TO: Mark Gongre, Senior Safety and Security Administrator
Employee Services
Kelly Cummings, Executive Administrator
Employee Services
FROM: Liz Yongue, Deputy Clerk
SUBJECT: September 11, 2024 BOCC Meeting
The following item has been executed and added to the record:
C15 1st Renewal with Relation Insurance Services of Florida, Inc., for Workers'
Compensation third-parry claims administration (TPA), per renewal clause in current contract.
All other terms and provisions of the Contract not modified by this renewal, or any other
amendments or addenda, shall remain unchanged.
Should you have any questions please feel free to contact me at(305) 292-3550.
cc: County Attorney
Finance
File
KEY WEST MARATHON PLANTATION KEY
500 Whitehead Street 3117 Overseas Highway 88770 Overseas Highway
Key West, Florida 33040 Marathon, Florida 33050 Plantation Key, Florida 33070
FIRST RENEWAL TO .
MONROE COUNTY CONTRACT FOR WORKER'S COMPENSATION THIRD PARTY CLAIMS
AD
MINISTRATION INISTRATION SERVICES •
• This First Renewal(this"Renewal"), is entered into by and between Relation Insurance •
Services of Florida, Inc ("Relation"), and Monroe County Board of.County Commissioners
("County").
• BACKGROUND
Relation and the County are parties to a Contract for Worker's Compensation Third
Party. Claims Administration Services (the"Contract") dated September 21, 2021, under
which Relation provides Worker's Compensation Administration Services to the County;
• and
The parties desire to renew the contract in accordance with Section 3.1 of the
• Contract; and • • •
• Pursuant to the terms of Section 3.1 the Contract shall be renewed for one year.from. •
•the date of the expiration of the initial term.(September 21, 2024).
The Effective Date of this Renewal shall be September 22, 2024. •
All other terms and provisions of the Contract not modified.by this renewal, or any
other amendments or addenda, shall remain unchanged. •
IN WITNESS WHEREOF, Relation and the County have executed this Renewal as of
the effective date above.
For Relation:
- Monroe County Board of Commissioners
..
DocuSigned by:
By: B
Timothy . a Mayor/Chairman C.:.;T? 1--
f—r1
•
Title:CEO ,....,,.,
• Date Date: • �- �r. •�-� : :
✓i✓' ..,cis hCr`/`r 1y"'r° 'N'°c. 4/
r, fAtte`st Kevin Madok, Clerk
Approved as to form and legal sufficiency: / 7;:�4 , r � :A%j�.��,,� i J ;f y. �j''Y'of�' i�i'i.. -
S rc�J' j�A T•�`� [ tkl� {�
Monroe County Attorney's Officer �s`. :� v �
Digitally signecopy3
Date: Anjelica Harden= � B/• y _ , p
Anjelica.Harden�I� na1 � �y �y�,
°Y-
lvanoski Date:2024.08.1 ,"E> ,.:L � X �As D puty Clerk
August 15, 2024 11:33:58-04'00' ' .&
DATE(MMIDD/YYYY)
A�" CERTIFICATE OF LIABILITY INSURANCE
08/20/2024
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
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).
PRODUCER CONTACT Miriam Fox
NAME:
Relation Insurance Services dba Pan American Insurance Services pAH/CNN. Ext: (925)407-0417 a/c,No): (925)322-6655
2300 Contra Costa Blvd.Suite 525 E-MAIL miriam.fox@relationinsurance.com
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
Pleasant Hill CA 94523 INSURERA: Valley Forge Insurance Company 20508
INSURED INSURER B: American Casualty Co.of Reading PA 20427
AQ Sunshine Parent,LLC and its subsidiaries INSURER C: Allied World Surplus Lines Ins 24319
Relation Insurance Inc.,Relation Insurance Services,Inc. INSURER D:
2300 Contra Costa Blvd.Suite 525 INSURER E
Pleasant Hill CA 94523 INSURER F:
COVERAGES CERTIFICATE NUMBER: 24/25 GL BA WC REVISION NUMBER:
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE 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.
INSR TYPE OF INSURANCEAUULbUBK POLICY EFF POLICY EXP
LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE FX OCCUR PREM SDAMAGES Ea oNcurDreme $ 100'000
MED EXP(Any one person) $ 5,000
A Y 7014962316 06/18/2024 06/18/2025 PERSONAL&ADV INJURY $ 1,000,000
GEN'LAGGREGATE LIMITAPPLIES PER: APPROVED BY RISK MANAGEMENT GENERAL AGGREGATE $ 2,000,000
X PRO-
POLICY ❑ ar
JECT r, PRODUCTS-COMP/OP AGG $ 2,000,000
❑ LOC
OTHER:
DATE A���7n74 � $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
WAIVER N/A YES Ea accident
ANYAUTO BODILY INJURY(Per person) $
B OWNED SCHEDULED 7014962333 06/18/2024 06/18/2025 BODILY INJURY(Pe r accide nt) $
AUTOS ONLY AUTOS
X HIRED �/ NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY X AUTOS ONLY Per accident
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LAB CLAIMS-MADE AGGREGATE $
DED I I RETENTION $ $
WORKERS COMPENSATION X1 STER ATUTE EORH
AND EMPLOYERS'LIABI LI TY Y/N 1'000'000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
B OFFICER/MEMBER EXCLUDED? ❑ N/A 714962347/714962364 06/18/2024 06/18/2025
(Mandatory in NH) DISEASE-EA EMPLOYEE $ 1,000,000
E.L.
If yes,describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
P
Errors and Omissions er Claim $5,000,000
C 0313-9753 08/30/2024 06/30/2025 Aggregate $5,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Insured:Relation Insurance Services of Florida,Inc.
Monroe County,Florida,has been included as additional insured with respect to General Liability&Auto Liability when required by written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Monroe County,Florida ACCORDANCE WITH THE POLICY PROVISIONS.
1100 Simonton Street
AUTHORIZED REPRESENTATIVE
Key West FL 33040
I
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ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD