FY1995 11/23/1994
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mannp 'I.. ltolbagt
BRANCH OFFICE
3117 OVERSEAS HIGHWAY
MARATHON, FLORIDA 33050
TEL. (305) 289-6027
CLERK OF THE CIRCUIT COURT
MONROE COUNTY
500 WHITEHEAD STREET
KEY WEST, FLORIDA 33040
TEL. (305) 292-3550
BRANCH OFFICE
88820 OVERSEAS HIGHWAY
PLANTATION KEY, FLORIDA 33070
TEL. (3051 852-7145
TO:
MEMORANDUM
Peter ~on, Director Q 't1. B
Divisi~;u~~mmunity Servil_
Ruth Ann Jantzen, Deputy Clerk ,tj'.Aj-.
December 13, 1994
FROM:
DATE:
------------------------------------------------------------------------------------------------------------------------
On November 23, 1994, the Board of County Commissioners granted approval
and authorized execution of the following documents:
Contract between Monroe County and the Monroe Association for Retarded
Citizens, in the amount of $30,695.00.
Contract between Monroe County and Helpline, Inc., in the amount of $18,000.00.
Contract between Monroe County and Hospice of the Florida Keys, Inc., in the
amount of $50,000.00.
Contract between Monroe County and Big Pine Key Athletic Association, Inc., in
the amount of $18,000.00.
Contract between Monroe County and Care Center for Mental Health of the
Lower Keys, Inc., in the amount of $214,629.00.
Contract between Monroe County and Heart of the Keys Recreation Association,
Inc., in the amount of $18,000.00.
Contract between Monroe County and the Domestic Abuse Shelter, Inc., in the
amount of $23,010.00.
Contract between Monroe County and Upper Keys Youth Association, Inc., in the
amount of $33,600.00.
Peter Horton
December 13,1994
Page 2
Contract between Monroe County and Wesley House, in the amount of $25,000.00.
Contract between Monroe County and Big Brothers - Big Sisters of Monroe
County, in the amount of $20,000.00.
Contract between Monroe County and Big Brothers. Big Sisters of Monroe
County, in the amount of $20,000.00.
Contract between Monroe County and the American Red Cross of the Upper
Keys, in the amount of $10,000.00.
Contract between Monroe County and the Guidance Clinic of the Middle Keys,
Inc., in the amount of $501,266.00.
Contract between Monroe County and Handicapped Job Placement Council of
the Florida Keys, Inc., in the amount of $12,000.00.
Contract between Monroe County and the Florida Keys Youth Club, in the
amount of $30,000.00.
Contract between Monroe County and Literacy Volunteers of America - Monroe
County, Inc., in the amount of $5,000.00.
Enclosed please find a fully executed copy of each of the above Contracts for
return to the providers.
If you have any questions concerning the above, please do not hesitate to contact
me.
cc: County Attorney
Finance
County Administrator, wlo document
File
AGREEMENT
This Agreement is made and entered into this).? day of JJtv'.
-.,
199..:1:-, between the BOARD OF COUNTY COMMISSIONERi qF M8NRQE
::0,,;2: Cl
COUNTY, FLORIDA, hereinafter referred to as "Board" or "c@.ift;," ~d t~
~::-:~ ". ~ ::
"""x ..' """"
MONROE ASSOCIATION FOR RETARDED CITIZENS, hereinaftesr~ferre~o ~
~, ~ 75
\CI . -
"Provider."
WHEREAS, the Board is authorized by Chapter 70.290, Laws of Florida,
1970, to expend from the Board's general revenue fund such sums as are deemed
necessary and advisable for the care, treatment, and rehabilitation of retarded
citizens, and
WHEREAS, the Provider provides residential care, training, schools,
diagnostic and evaluation services, parent counseling and other programs for
retarded adults of Monroe County, and
WHEREAS, the Board wishes for the Provider to provide such services to
the retarded adults of Monroe County on a free and unrestricted basis as an aid
in the Board's overall mental health program, now, therefore,
IN CONSIDERATION of the mutual promises and covenants contained
herein, it is agreed as follows:
1.
AMOUNT OF AGREEMENT.
The Board, in consideration of the
Provider substantially and satisfactorily performing and carrying out the duties of
the Board as to rendering services in matters of care, treatment and rehabilitation
of retarded adults in Monroe County, shall pay to the Provider the sum of Thirty
Thousand Six Hundred Ninety-Five Dollars ($30,695.00) for payment of personnel
and operating expenses for fiscal year 1994-95.
2. TERM. This Agreement shall commence on October 1, 1994,
and terminate September 30, 1995, unless earlier terminated pursuant to other
provisions herein.
3. PAYMENT. Payment will be paid periodically, but no more
frequently than monthly as hereinafter set forth. Reimbursement requests will be
submitted to the Board via the Clerk's Finance Office. The County shall only
reimburse, subject to the funded amounts below, those reimbursable expenses
which are reviewed and approved as complying with Florida Statutes 112.061 and
Attachment A - Expense Reimbursement Requirements. Evidence of payment by
the Provider shall be in the form of a letter, summarizing the expenses, with
supporting documentation attached. The letter should contain a certification
statement as well as a notary stamp and signature. An example of a
reimbursement request cover letter is included as Attachment B.
After the Clerk of the Board examines and approves the request for
reimbursement, the Board shall reimburse the Provider. However, the total of
said reimbursement expense payments in the aggregate sum shall not exceed the
total amount of $30,695.00 during the term of this agreement.
4. SCOPE OF SERVICES. The Provider, for the consideration named,
covenants and agrees with the Board to substantially and satisfactorily perform
and carry out the duties of the Board in providing services in the area of:
(a) Residential care
2
(b) Diagnostic and evaluation services
(c) Sheltered workshop
(d) Case work service
(e) Training schools
(f) Other related services
for retarded citizens of Monroe County, as far as practical with the funds to be
provided by the Board.
5. STANDARD OF CARE. The services provided shall meet the
standards of the State Department of Health & Rehabilitative Services, Division of
Developmental Service.
6. RECORDS. The Provider shall maintain appropriate records to
insure a proper accounting of all funds and expenditures, and shall provide a
clear financial audit trail to allow for full accountability of funds received from
said Board. Access to these records shall be provided during weekdays, 8 a.m.
to 5 p.m., upon request of the Board, the State of Florida, or authorized agents
and representatives of the Board or State.
The Provider shall be responsible for repayment of any and all audit
exceptions which are identified by the Auditor General of the State of Florida, the
Clerk of Court for Monroe County, an independent auditor, or their agents and
representatives. In the event of an audit exception, the current fiscal year
contract amount or subsequent fiscal year contract amounts shall be offset by
the amount of the audit exception. In the event this agreement is not renewed or
continued in subsequent years through new or amended contracts, the Provider
3
shall be billed by the Board for the amount of the audit exception and the
Provider shall promptly repay any audit exception.
7.
INDEMNIFICATION AND HOLD HARMLESS.
The
Provider
covenants and agrees to indemnify and hold harmless Monroe County Board of
County Commissioners from any and all claims for bodily injury (including death),
personal injury, and property damage (including property owned by Monroe
County) and any other losses, damages, and expenses (including attorney's fees)
which arise out of, in connection with, or by reason of services provided by the
Provider occasioned by the negligence, errors, or other wrongful act or omission
of the Provider's employees, agents, or volunteers.
8.
INDEPENDENT CONTRACTOR.
At all times and for all
purposes hereunder, the Provider is an independent contractor and not an
employee of the Board. No statement contained in this agreement shall be
construed so as to find the Provider or any of its employees, contractors,
servants or agents to be employees of the Board.
9. COMPLIANCE WITH LAW. In providing all services pursuant to
this agreement, the Provider shall abide by all statutes, ordinances, rules and
regulations pertaining to or regulating the provision 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 terminate this contract immediately upon
delivery of written notice of termination to the Provider.
4
10. PROFESSIONAL RESPONSIBILITY AND LICENSING. The
Provider shall assure that all professionals have current and appropriate
professional licenses and professional liability insurance coverage. Funding by
the Board is contingent upon retention of appropriate local, state and/or federal
certification and/or licensure of the Provider's program and staff.
11. MODIFICATIONS AND AMENDMENTS.
Any and all modifi-
cations of the services and/or reimbursement of services shall be amended by an
agreement amendment, which must be approved in writing by the Board.
12. NO ASSIGNMENT. The Provider shall not assign this
agreement except in writing and with the prior written approval of the Board,
which approval shall be subject to such conditions and provisions as the Board
may deem necessary. This agreement shall be incorporated by reference into
any assignment and any assignee shall comply with all of the provisions herein.
Unless expressly provided for therein, such approval shall in no manner or event
be deemed to impose any obligation upon the Board in addition to the total
agreed upon reimbursement amount for the services of the Provider.
13. NON-DISCRIMINATION. The Provider shall not discriminate against
any person on the basis race, creed, color, national origin, sex or sexual
orientation, age, physical handicap, or any other characteristic or aspect which is
not job-related in its recruiting, hiring, promoting, terminating or any other area
affecting employment under this agreement. At all times, the Provider shall
comply with all applicable laws and regulations with regard to employing the
5
most qualified person(s) for positions under this agreement. The Provider shall
not discriminate against any person on the basis of race, creed, color, national
origin, sex or sexual orientation, age, physical handicap, financial status or any
characteristic or aspect in its providing of services.
14. AUTHORIZED SIGNATURES. The signatory for the Provider below,
certifies and warrants that:
(a) The Provider's name in this agreement is the full name as designated
in its corporate charter, if a corporation, or the full name under which the
Provider is authorized to do business in the State of Florida.
(b) He or she is empowered to act and contract for the Provider; and
(c) This agreement has been approved by the Board of Directors of the
Provider if the Provider is a corporation.
15. NOTICE.
Any notice required or permitted under this agreement
shall be in writing and hand-delivered or mailed, postage pre-paid, by certified
mail, return receipt requested, to the other party as follows:
For Board:
Louis LaTorre
Monroe County Social Services Director
Public Service Building
5100 College Road
Key West, Florida 33040
and
Monroe County Attorney
310 Fleming Street, upstairs
Key West, Florida 33040
For Provider:
M.A.R.C.
Post Office Box 428
Key West, Florida 33041
6
16. CONSENT TO JURISDICTION. This agreement shall be construed by
and governed under the laws of the State of Florida and venue for any action
arising under this agreement shall be in Monroe County, Florida.
17. NON-WAIVER. Any waiver of any breach of covenants herein
contained to be kept and performed by the Provider shall not be deemed or
considered as a continuing waiver and shall not operate to bar or prevent the
Board from declaring a forfeiture for any succeeding breach, either of the same
conditions or covenants or otherwise.
18. AVAILABILITY OF FUNDS.
If funds cannot be obtained or cannot
be continued at a level sufficient to allow for continued reimbursement of
expenditures for services specified herein, this agreement may be terminated
immediately at the option of the Board by written notice of termination delivered
to the Provider. The Board shall not be obligated to pay for any services or
goods provided by the Provider after the Provider has received written notice of
termination, unless otherwise required by law.
19. PURCHASE OF PROPERTY. All property, whether real or
personal, purchased with funds provided under this agreement, shall become the
property of Monroe County and shall be accounted for pursuant to statutory
requirements.
20. ENTIRE AGREEMENT. This agreement constitutes the entire
agreement of the parties hereto with respect to the subject matter hereof and
7
supersedes any and all prior agreements with respect to such subject matter
between the Provider and the Board.
IN WITNESS WHEREOF, the parties hereto have caused these presents to
be executed as of the day and year first written above.
(SEAL)
ATTEST:DANNYL.KOLHAGE,CLERK
By:.~~~~J
Dep Cle
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY, FLORIDA
ByS[.1I; d:1P~h
Mdyor/Chairman '--
q~,c"1J
Witness
MONROE ASSOCIATION OF
RETARDED CITIZENS
(FederallD No. S9-//J3/5/fc:::' )
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~.. Witness
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Dannp I. Itolbagt
BRANCH OFFICE
3117 OVERSEAS HIGHWAY
MARATHON, FLORIDA 33050
TEL. (305) 289-6027
CLERK OF THE CIRCUIT COURT
MONROE COUNTY
500 WHITEHEAD STREET
KEY WEST, FLORIDA 33040
TEL. (305) 292-3550
BRANCH OFFICE
88820 OVERSEAS HIGHWAY
PLANTATION KEY, FLORIDA 33070
TEL. (305) 852-7145
Dear Human Service Organizations,
In an effort to streamline the expense reimbursement process,
please note the change of address for submitting your requests.
Effective with your fiscal year 1995 contracts (October 1, 1994
thru September 30, 1995), all reimbursement requests should be
mailed to:
Clerk of the
500 Whitehead
Key West, FL
Court
Street
33040
Attn: Finance Department
You will
document
prepared
required
also find several attachments to the contract.
ti tIed "Expense Reimbursement Requirements."
in an attempt to eliminate any confusion
supporting documentation.
One is a
This was
regarding
A "prototype cover sheet" has been provided in an effort to assist
you in packaging your request, as well as to facilitate the review
process in our office. Please let me know if you want blank copies
of the cover sheet for your reimbursement requests.
Please contact me at 292-3528 with any questions or comments
regarding this change.
Sincerely,
~1Jrfk
Stephanie Griffiths
Chief Accountant
ATTACHMENT A
Expense Reimbursement Requirements
This document is intended to provide "basic" guidelines to Human
service organizations, county travellers, and contractual parties
who have reimbursable expenses associated with Monroe County
business. These guidelines, as they relate to travel, are
interpreted from Florida statute 112.061, which is attached for
reference.
A cover letter summarizing the major line items on the reimbursable
expense request should also contain a certified statement such as:
I certify that the attached expenses are accurate and in
agreement with the records of this organization. Furthermore,
these expenses are in compliance with this organization's
contract with the Monroe County Board of County Commissioners.
Invoices should be billed to the contracting agency. Third party
payments will not be considered for reimbursement. Remember, the
expense should be paid prior to requesting a reimbursement.
Only current charges will be considered, no previous balances.
Reimbursement requests will be monitored in accordance with the
level of detail in the contract. This document should not be
considered all-inclusive. The Clerk's Finance Department reserves
the right to review reimbursement requests on an individual basis.
Any questions regarding these guidelines should be directed to
stephanie Griffiths at 305-292-3528.
Payroll:
A certified statement verifying the accuracy and authenticity of
the payroll expenses.
If a Payroll Journal is provided, it should include:
Payroll Journal dates
employee name, salary, or hourly rate
hours worked during the payroll journal dates
withholdings where appropriate
check number and check amount
If a Payroll Journal is not provided the following must be listed:
check number, date, payee, check amount
support for applicable payroll taxes
Original vendor invoices must be submitted
Compensation and liability insurance coverage.
for Worker's
1',"1 I
:d '
Telephone expenses:! : . I
A user log of pertinent information must be remitted: the ~arty
called, the caller, the telephone number, the date, and the purpose
of the call must be identified.
Telefax, fax, eto.:
A fax log is required. The log must define the sender, the
intended recipient, the date, the number called, and the reason for
sending the fax.
supplies, servioes, eto.:
For supplies or services ordered the county requires the original
vendor invoice.
Rents, leases, eto.:
A copy of the rental agreement or lease is required. Deposits and
advance payments will not be allowable expenses.
postage, overnight deliveries, oourier, eto.:
A log of all postage expenses as it relates to the County contract
is required for reimbursement. For overnight or express
deliveries, the original vendor invoice must be included.
Reproduotions, oopies, eto.:
A log of copy expenses as it relates to the County contract is
required for reimbursement. The log must define the date, number
of copies made, source document, purpose, and recipient. A
reasonable fee for copy expenses will be allowable. For vendor
services, the original vendor invoice is required and a sample of
the finished product.
Travel expenses: please refer to Florida statute 112.061.
Travel expenses must be submitted on a state of Florida Vouoher for
Reimbursement of Travel Expenses. Credit card statements are not
acceptable documentation for reimbursement.
Airfare reimbursement requires
portion of the airline ticket.
to facilitate the audit trail.
the original passenger receipt
A travel itinerary is appreciated
Auto rental reimbursement requires the original vendor invoice.
Fuel purchases should be documented with original paid receipts.
Original taxi receipts should be provided. However, reas~~a~l.
fares will be reimbursed without receipts. Taxis are' r.ot
reimbursed if taken to arrive at a departure point: for examp~.,
taking a taxi from one's residence to the airport for a business
trip is not reimbursable.
original toll receipts should be provided.
tolls will be reimbursed without receipts.
However, reasonable
Parking is
destination.
considered a reimbursable travel expense at
Airport parking during a business trip is not.
the
LOdging reimbursement requires a detail listing of charges. The
original lOdging invoice must be submitted. The County will only
reimburse the actual room and related bed tax. Room service,
movies, and personal telephone calls (see previous guidelines) are
not allowable expenses. Per diem lodging expenses may apply.
Again, refer to Florida statute 112.061.
Meal reimbursement is breakfast at $3.00, lunch at $6.00, and
dinner at $12.00. Meal guidelines are that travel must begin prior
to 6 am for breakfast reimbursement, before noon and end after 2pm
for lunch reimbursement, and before 6pm and end after 8 pm for
dinner reimbursement.
Mileage reimbursement is calculated at 20 cents per mile for
personal auto mileage while on county business. Effective October
1, 1994, mileage will be reimbursed at 25 cents per mile. An
odometer reading must be included on the state travel voucher for
vicinity travel. A mileage map is attached for reference to
allowable miles from various Florida destinations.
Mileage is
departure:
a business
not allowed from a residence or office to a point of
for example, driving from one's home to the airport for
trip is not a reimbursable expense.
Data processing, PC time, etc.:
The original vendor invoice is required for reimbursement.
Intercompany allocations are not considered reimbursable
expenditures unless appropriate payroll journals for the charging
department (see Payroll above) are attached and certified.
The fOllowing expenses are not allowable for reimbursement:
penalties and fines
non-sufficient check charges
fundraising
contributions
capital outlay expenditures (unless specifically included in
the contract)
depreciation expenses (unless specifically included in the
contract)
SGRIFFITHS
WP51\PROCEDUR\EXP_REIM
ATTACHME~T B
HUMAN SERVICE ORGANIZATION LETTERHEAD
Monroe County Board of County Commissioners
Finance Department
500 Whitehead Street
Key West, Florida 33040
November 4, 1994
The following is a summary of the expenses for
Orqanization name) for the time period of
(Human Service
to
Check # pavee Reason Amount
101 A Company rent $xxxx.xx
102 B Company utilities $xxxx.xx
103 o Company phones $xxxx.xx
104 Person A payroll $xxxx.xx
105 Person B payroll $xxxx.xx
(A) Total $xxxx.xx
(B) Total prior payments $xxxx.xx
(C) Total requested and paid (A + B) $xxxx.xx
(D) Total contract amount $xxxx.xx
Balance of contract (0 - C) $xxxx.xx
I certify that the above checks have been submitted to the vendors
as noted and that the expenses are accurate and in agreement with
the records of this organization. Furthermore, these expenses are
in compliance with this organization's contract with the Monroe
County Board of County Commissioners and will not be submitted for
reimbursement to any other funding source.
Executive Director
Attachments (supporting documentation)
Sworn and subscribed before me this ____ day of
199_
I
Notary Public
Notary Stamp
MILEAGE CIIAIlT
KEY WFST TO:
Bay Point 15
Big Coppitt 10
Big Pine 31
Big Torch Key 29
Clearwater Beach 399
Coco Beach 350
Conch Key 55
Cudjoe Key 22
Dania 180
Daytona Beach 416
Duck Key 62
Fl. Lauderdale 183
Fl. Myers 275
Gainesville 476
Grassy Key 56
Hollywood 175
Homestead 127
Islamorada 83
Jacksonville 50S
Key Colony Beach 53
Key Largo 101
Lakeland 365
Layton 70
Little Torcb Key 28
Long Key 70
Lower Matecumbe Key 75
Maratbon 48
Maratbon Sbores 53
Marco Island 221
Miami 155
Miami Beacb 170
Middle Torcb Key 26
Naples 236
Ocean Reef 118
Opa Locka 180
Orlando 378
Palm Beach 223
Palm Beacb Gardens 238
Panama City 702
Plantation Key 87
Ramrod Key 27
Rock Harbor 100
Stock Island OS
Sugarloaf Key 17
Summerland Key 24
W. Summerland Key 31
Sunshine Key 39
Tallahassee 606
Tampa 391
Tavernier 92
Vacation Village 84
MAllAmON TO:
Big Pine Key 17
Conch Key 12
Islamorada 35
Key Largo 50
Long Key 22
Miami 110
Plantation Key 39
Summerland Key 24
Sunshine Key 09
Tavernier 45
BOOT KEY TO: IlWG KEY TO:
Long Key 20 Boot Key 20
Middle Torch 22 Cudjoe Key 47
BOMRIITF..AD TO: Homestead 61
Islamorada 16
Key West 127
Marathon 22
Plantation 42
Miami 109
Tavernier 35
Middle Torch 43
KEY LAllGO TO:
Plantation Key 20
Big Pine Key 70
MIAMI TO:
Homestead 27
Islamorada 72
Islamorada 36
Key Largo 54
Long Key 40
Marathon 110
Marathon SO
PLANTATION TO:
Miami 57
Big Pine 56
Ocean Reef 17
Duck Key 26
Plantation 14
Homestead 42
Key LaI'lO 14
Key West 87
Layton 17
Marathon 3'
Miami 67
Sumbine Key 41
Ac:nmt.
CERTIFICATE OF INSURANCE JMW
00435 .
ISSUE DATE (MMJDDIYY)
INSURANCE INC.
9108
FL 33041-9108
09/19/94
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,
COMPANIES AFFORDING COVERAGE
COMPANY A REGIS/PROGRAM UNDERWRITERS
lmER
INSURED
COMPANY
LEITER
B PROGRESSIVE
n
ONROE ASSN. FOR
ETARTED CITIZENS, INC.
.0. BOX 428
EY WEST, FL 33041-0428
COMPANY C
LETTER
COMPANY 0
lETTER
COMPANY E
LETTER
""~
YES_
THIS IS TO CEATIFYTHAT THE POllCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED NOTWITHSTANDING ANY REaUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICAtE MAY BE ISSUED OR MAY PERTAI"!. THE'iNSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREiN is SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POU.....IES.
o
TR
:').1\',.';"
POLICY EFFECTIVE POLICY EXPIRATION
LIMITS
ATE (MMfOOIYY) DAn:: (MMIDDIYY)
07/21/94 07/21/95 BOOILYINJU""OCC. .
BODILY INJURY AGG.
PROPERTY DAMAGE ace. .
PROPERTY DAMAGE AGG. .
61 & PO COMBINED OCC. . 1 000
BI & PD COMBINED AGG. . 1 000
PERSONAl lNJURY AGG, .
07/21/94 07/21/95BOOILYINJu""
(Per person) .
BODILY INJURY
'.;1!' (Per accident) .
PROPERTY DAMAGE
.
BODilY INJURY &
tJ PROPERTY DAMAGE
COMBINED . 300 00
EACH OCCURRENCE .
AGGRI::GATE .
STATUTORY LIMITS
EACH ACCIDENT .
DISEASE-POlICY LIMIT .
DISEASE EACH EMPLOYEE .
TYPE OF INSURANCE
POUCY NUMBER
RM1l3188
COMPREHENSIVE FORM
PREMJSES/OPEAAi)ONS
UNDERGROUND
EXPLOSION & COLLAPSE HAZARD
PRODUCTS!COMPlETEO OPER.
CONTRACTUAL
INDEPENDENT CONTRACTORS
BROAD FORM PROP DAMAGE
PERSONAL INJURY
AUTOMOBILE LIABILITY
ANY AUTO
AlL O!NNED AUTOS (Priv. Pass.)
All OWNED AUTOS (~I~~~::~
HIRED AUTOS
NON-OWNED AUTOS
GARAGE UMIUTY
CA088563030
<" (~ :'
jh1['Ui\i,
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FOAM
WORKeR'S COMPENSATION
AND
EMPLOYERS' LIABILITY
OTHER
DESCRIPTION OF OPERATIONSlLOCATIONSNEHIClES/SPECIAlITEMS
ERTIFICATE HOLDER IS ADDITIONAL INSURED
MONROE COUNTY BOARD OF
COUNTY COMMISSIONERS
5100 COLLEGE ROAD
KEY WEST FL 33040
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCElLED BEFORE THE
EXPIRATION DATE THEREOF. THE ISSUING COMPANY WILL ENDEAVOR TO
MA1L...l.O...... DAYS WRITTEN NOTICE TO THE CERTIFICATE. HOLDER NAMED TO THE
LEFT. BUT FAILURE TO MAil SUCH NOrlCE SHALL IMPOSE NO OBLIGATION OR
liABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
c<:.! r/.
0"'<5 I .,.........