09/08/1999 Agreement
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BRANCH OFFICE
3117 OVERSEAS HIGHWAY
MARATIfON, FLORIDA 33050
TEL. (305) 289-6027
FAX (305) 289-1745
CLERK OF THE CIRCUIT COURT
MONROE COUNlY
500 WHITEHEAD STREET
KEY WEST, FLORIDA 33040
TEL. (305) 292-3550
FAX (305) 295-3660
BRANCH OFFICE
88820 OVERSEAS HIGHWAY
PLANTATION KEY, FLORIDA 33070
TEL. (305) 852-7145
FAX (305) 852-7146
H~HQRA~~!!H
FROM:
Leah M. Marquess,
Group Insurance Administrator
Isabel C. DeSantis, Deputy Clerk ~(),/);
November 17, 1999
TO:
DATE:
At the Board of County Commissioners' meeting on September 8,
1999, the Board granted approval and authorized execution of the
Group Insurance Program contract for Third Party Administration
Services between Monroe county and Acordia National effective
October 1, 1999 through September 30, 2000.
Enclosed herewith, please find two (2) duplicate originals of the
subject document for your handling.
Should you have any questions concerning the above, please do not
hesitate to contact this office.
Enclosures
cc: County Attorney
Finance
county Administrator w/o doc.
File
ADMINISTRATIVE SERVICE AGREEMENT
THIS AGREEMENT, made and entered into this JlJ:t.
Ofh-~
by and between Monroe County (hereinafter called "Employer") and ACORDIA
NATIONAL of 602 Virginia Street, East, Charleston, WV 25301, is hereinafter set forth:
WITNESSETH
WHEREAS, Employer has established an employee welfare benefit plan
(hereinafter called "Plan") for the purpose of providing medical, dental, vision, utilization
review, Consolidated Omnibus Budget Reconciliation Act of 1985 ("COBRA"), Health
Insurance Portability and Accountability Act of 1996 ("HIP AA"), and other benefits for
its employees;
WHEREAS, Employer desires to engage the services of Acordia National
as agent for the Employer for the purpose of effecting claim administration under its Plan;
and
NOW, THEREFORE, in consideration of the mutual covenants and
promises hereinafter contained, the parties hereto agree as follows:
1)
2)
The effective date of the Employer's Plan shall be October 1.
The Plan Year shall be from October 1 thru September 30 of each
year.
3)
4)
The Employer's Tax Identification Number is 596000749
For each Plan Year, the Employer shall provide monies sufficient
to pay benefits under the Employer's Plan on a timely basis. "Timely" shall be
defined as within thirty (30) days of Acordia National's notification, oral or
written, that benefit claims have been processed for payment. In the event
Employer shall fail to provide sufficient monies to fund its claims in a timely
manner, a ten percent (10%) surcharge shall be added to the monthly
administrative fee due Acordia National, which surcharge shall become
chargeable beginning on the thirty-first (31st) day after Acordia National's
notification, as described herein. Employer acknowledges and agrees that Acordia
National shall not have any financial duty or responsibility to release claim
payments if Employer has not sufficiently funded the same.
5) Employer acknowledges and agrees that Acordia National
shall not have any financial duty or responsibility to see that the Employer deposit
meets the Employer's Plan requirements; however, Acordia National shall keep
the Employer advised as to the amount of deposit needed to meet said
requirements on a timely basis. Employer further acknowledges and agrees that
Acordia National shall not be deemed a fiduciary for the Plan within the meaning
of the Employee Retirement Income Security Act of 1974 ("ERISA").
Accordingly, the services to be performed by Acordia National hereunder shall be
limited to the ministerial services set forth herein and the performance by Acardia
National shall be subject in all respects to review by Employer within the
framework of Plan provisions as well as policies, interpretations, rules, practices
and procedures established by Employer. Acordia National shall not have any
discretionary authority or control with regard to the management of Plan assets.
To the extent permitted by law, Acordia National shall not incur any liability for
any acts or for failure to act except for its own willful misconduct in administering
the Plan.
2
6) The monthly capitation fee for administrative services will be:
October 1. 1999 October 1. 2000
9.48 PEPM* 9.70 PEPM
1.65 PEPM 1.70 PEPM
0.38 PEPM 0.39 PEPM
PERFORMED BY KPHA
0.36 PEPM 0.37 PEPM
Medical Claims Administration
Dental Claims Administration
Vision Claims Administration
Pre-certification Administration
HIP AA Administration
* Per Employee, Per Month
The above monthly capitation fee for October I, 2000 shall apply to
renewal effective October 1, 2001.
Payment of the fees established above is due from the Employer on or
before the 10th day of each month, beginning on the lOth day of October, 1999.
The fee quoted may be increased by Acordia National upon thirty (30) days prior
written notice to Employer, with any such increase to become effective
automatically following such notice period. Acordia National reserves the right to
initiate price increases without prior written notice on any renewal date of this
Agreement. The cost of any additional services rendered by Acordia National on
behalf of the Employer necessitated by a change in federal or state law will also be
charged to the Employer in addition to the monthly fee.
Acordia National shall provide generic enrollment forms, claim forms and
other administrative and plan forms. In the event Employer desires customized
administrative and plan forms, Acordia National will direct the printing of same,
however, the cost of such printing shall be paid solely by the Employer.
3
7) Acordia National shall provide the following services in connection with
the administration of Employer's Planes):
a) Provide assistance to enroll all eligible Employees
(as defined in the Employer's Plan) in Employer's Plan, as agreed
with Employer;
Design and obtain other coordinating or
supplemental types of insurance coverage, where necessary, as
requested by Employer in writing;
Assist and advise employer in revising Plan
Document. Provide prototype Plan Documents and Identification
Cards (ID Cards) for the Employer. Arrange for printing and
preparation of such documents. The cost of the printing will be the
responsibility of the Employer;
d) Conduct informational programs for all eligible
Employees to fully explain the benefits available under the
Employer's Plan, as requested by Employer;
b)
c)
e) Respond to telephone and mail inquiries from Plan
participants regarding benefits available to them and their
dependents;
f)
Provide information concerning Plan benefits and
participants, based upon information provided by Employer;
Review and analyze all claims and determine
whether the charges of health care providers submitted are within
g)
4
j)
h)
reasonable payment guidelines and/or are related to diagnostic
related groups, preferred provider organization agreements or other
industry standards;
Correspond with claimants, as necessary, to process
claims and to ascertain whether other coverage exists which might
pay the claim in whole or part;
Receive, review, and administer all claims for
benefits under the Employer's Plan, including the evaluation of
claims made; standard evaluation of the eligibility status of all
claimants, coordination of and at least annual auditing of the
utilization Review and Case Management function, provide the
County with results of Utilization Review audit, appropriate
Coordination of Benefits evaluation of all claims, supply data to
Health Recoveries, Inc. necessary for subrogation and other
functions usual to the efficient and cost effective administration of
i)
claims;
k)
Aid the employer in developing an efficient claims
control program;
Provide information, on request, for the completion
by the Employer of all necessary IRS and ERISA filings;
Provide Employer with a monthly report of claims
1)
paid;
5
Do all things necessary to properly effect the
responsibilities of a claims administrator under the Employer's
Plan, provided that all such actions/non-actions not otherwise
required by this Agreement shall first be approved by Employer.
Provide assistance and resources to Monroe County
in identifying, analyzing and maintaining the Employer's Plan in
accordance with state and federal laws, industry standards,
regulations and changes that affect the Plan;
0) Report all potential excess claims to the excess
m)
n)
insurer, and provide Employer with monthly updates;
p) Make documents available to the Employer and/or
their Consultants for periodic audit of files for accuracy and
efficiency of Acordia National's claims administration, and;
q)
r)
s)
Process, authorize, and issue payment of all
complete and eligible claims within twenty (20) days of receipt;
Provide the County with adequate training and
make available access to its on-line computerized claim system.
Acordia agrees that this contract is not assignable by
Acordia without prior written permission from Monroe County.
8) Acordia National shall provide COBRA administration services, if desired by
Employer (check one blank below). It is agreed and understood that COBRA
administration services are provided for medical and dental plans only and are not
provided for 125 Reimbursement Account Plans.
6
Applicable
Non-applicable
x
In the event Employer desires Acordia National to provide COBRA
administration services, Acordia National agrees to:
a)
Provide initial notification of continuation of
coverage option to all employees;
Provide notification, enrollment information and
enrollment forms to all qualified beneficiaries within 14 days of
notification by Employer of a qualifying event;
Provide monthly billing and collection services for
all qualified beneficiaries who elect to continue coverage under the
program and supply monthly reports of premiums collected by
Employer;
b)
c)
d)
Track participating beneficiaries and notify them of
their right to convert if a conversion option is available under
Employer's Plan;
Process all claims for continuing beneficiaries under
a segregated category and report, through regular monthly
reporting series, claims experience of continuing beneficiaries
(COBRA claims will be aggregated during the normal check
processing cycle but reported separately at month's end);
e)
7
On an annual basis, at the beginning of Employer's
Plan Year, provide rates to be charged continuing participants for
coverage in the new Plan Year;
g) Provide prototype language to be included in the
f)
Plan document to ensure compliance with COBRA legislation;
h) Provide prototype language for inclusion in
Employer's Summary Plan Description and coordinate, at
Employer's option, the printing of new plan booklets at employer's
expense; and
Mail all correspondence to Plan participants or
qualified beneficiaries directly to the last known address of the
employee and/or dependent by first class mail.
In consideration for receipt ofthese services from Acordia National, Employer
agrees to:
i)
a)
Notify Acordia National within thirty (30) days of
qualifying events for which the Employer has knowledge.
Qualifying events include:
termination of employment or any reason short of gross
misconduct; and employee's reduction of work hours, the
Employer's filing for reorganization under Chapter XI of the
Bankruptcy Code; an employee's divorce or legal separation; death
of an employee; an employee's child ceasing to be a dependent;
and a beneficiary's entitlement to Medicare. If the Employer is not
8
notified and does not have knowledge of a qualifying event, the
employee has sixty (60) days from the qualifying event in which to
notify Acardia National of the same to be eligible or the
continuation of coverage option; and
Notify Acordia National of any address changes or
other pertinent information regarding employee participation in the
Employer's Planes) to allow Acordia National to properly fulfill the
requirements of COBRA legislation.
It is acknowledged by employer that future legislation related to continuation of benefit
coverage or other matters not currently required by COBRA legislation and COBRA
b)
regulations on the date ofthis Agreement may necessitate an adjustment in the fee for
COBRA administration.
9) In the event Employer does not desire COBRA administration services by
Acordia National, but instead the development of COBRA rates applicable to its Plan,
Acordia National shall provide the same upon terms, and for a fee, to be agreed upon
between Employer an Acordia National.
10) Acordia shall provide the following services related to HIP AA
administration for the Employer's Plan:
a) Provide for the Employer's review, prototype modifications to the
plan document and SPD (Booklet) to address HIP AA
requirements;
9
b)
Perform programming required to the Multi-Claim
System to track the applicable eligibility information and maintain
credited coverage information on both a current and future basis;
c) Coordinate the receipt of all certificates of coverage, or
other proof of coverage, for all new employees enrolling in the
d)
benefit plan;
Perform the administrative requirements to analyze the
determination of pre-existing conditions and establish the waiting
periods that would apply for all new employees and existing
employees having pre-existing conditions;
Develop and distribute to all required parties the
notifications and correspondence documenting pre-existing
conditions;
e)
1)
Issue certificates of coverage for all employees and their
dependents upon termination or upon request;
Prepare and distribute standard reports documenting
completed HIP AA activities; and
Serve as an information resource for HIP AA questions.
g)
h)
11) Subrogation and Fee Negotiation:
a) This will serve to confirm our understanding that the
Employer desires to utilize the subrogation and related services offered by
Healthcare Recoveries, Inc. in connection with the Employer's health plan.
10
b) The administrative fee for Acordia National's Fee
Negotiation Services with health care providers shall be 25% of savings.
12) In the absence ofa designation by the Employer and except for disposition
of disputed claims, Acordia National shall determine the manner in which payment of
benefits shall be made as it shall deem it to be necessary and appropriate in accordance
with provisions of Employer's Plan, and shall not be responsible in the exercise of such
judgement in the absence of willful misconduct on the part of Acordia National.
13) To the extent required by law to purchase such coverage, the Employer
shall name Acordia National as an additional insured under its fiduciary bond which shall
be conditioned upon faithful performance of its duties hereunder, and such fiduciary bond
shall in all respects comply with the requirements of the Employee Retirement Income
Security Act of 1974, as amended.
14) Acordia agrees to defend, indemnify and hold harmless Employer against
all claims, damages, liabilities and expenses actually and reasonably incurred or imposed
on Employer in connection with any actual or threatened claim, action, suit, proceeding,
settlement or compromise thereof which arises from Acordia's administration of claims
under Employer Planes) other than in accordance with Plan provisions as well as the
negligence, willful misconduct of Acordia, its employees, representatives, or agents. The
right to be defended, indemnified and held harmless shall extend to Employer's affiliates
as well as the employees of Employer, their estates, executors, administrators, guardians,
conservators and heirs and shall apply after the employee ceases employment with
Employer with respect to acts or omissions of Acordia prior to such cessation.
11
15) The terms of this Agreement shall be from the effective date hereof and
continue for a period of one year. This Agreement shall be renewed for two (2)
successive one-year periods at the sole discretion of the Employer, unless either party
gives the other notice of cancellation in accordance wit the terms set forth below. If
either party desires to modify or terminate this Agreement, it shall notify the other in
writing at least thirty (30) days prior to the effective date of such modification or
termination. In the case of proposed modification the party receiving the notification of
the proposed modification shall itself notify the other party within ten (10) notice of its
agreement to the proposed modification. Failure to do so shall terminate this Agreement
as of the end of the Employer's Plan Year.
16) This Agreement may be terminated by either the Employer or Acordia
National at any time provided that Acordia National gives the Employer ninety (90) days
prior written notice or that the Employer gives Acordia National at least thirty (30) days
prior written notice. The prior written notice will state the prospective effective date of
the termination. Termination of this Agreement will not terminate the rights or
obligations of either party arising out of the period during which this Agreement was in
effect. Upon the termination of this Agreement, and if the same is not renewed, Acordia
National shall return all files of closed or pending claims covered by this Agreement to
the Employer or their designee.
17) Employer agrees that during the term of this Agreement and for a period of
three years after its termination it will not induce any employee of Acordia National to
leave Acordia National's employment or directly or indirectly assist any other person or
entity in requesting or inducing any such employee of Acordia National to leave such
12
employment.
18) Acordia National warrants that it has not employed, retained or otherwise
had acted on its behalf any former County officer subject to the prohibition in Sec 2 of
Ordinance no 10-1990 or any County officer or employee in violation of Sec. 3 Ordinance
10-1990 and that no employee or officer of the County had any interest, financially or
otherwise, in Acordia National except for such interest, permissible by law and fully
disclosed by affidavit attached hereto. For breach or violation of this paragraph, the
County may, in its discretion, terminate this agreement without liability and may also, in
its discretion, deduct from the contract or purchase price, or otherwise recover, the full
amount of any fee, commission, percentage, give or consideration paid to the former
County officer or employee.
19) All notices hereunder shall be in writing and mailed by certified mail,
return receipt requested. Notices to the Employer shall be at the address first above
written and to Acordia National at 602 Virginia Street, East, Charleston, WV 25301,
Attention:
President, or at such other addresses as the parties may from time to time designate in
writing.
20) The Employer and Acordia National agree that this agreement shall
be administered and construed according to the laws of the State of Florida. In the event
that any matter of disagreement arises, it shall be decided by a court of competent
jurisdiction with venue in Monroe County, Florida.
21) In the event this Agreement is terminated, the parties will have the option
of agreeing to completion of claims administration services for claims existing at
13
termination for a ninety (90) day period following termination of this Agreement upon
terms negotiated between the parties.
22) This Agreement, together with the written proposal submitted by Acordia
and the Plan constitute the entire Agreement between the Employer and Acordia
National.
IN WITNESS WHEREOF, the Employer and Acardia National have
caused this Agreement to be executed by their respective proper corporate officers,
effective as of the F ~
day of ""~, 19 91
/
M^tJRoe: GsWnI BoARD
EMPLOYER: ()~ LaU nT'I COM M \S&fotJERS
. A ~\
By ~~~ l>-~
. IA.I;II."IW'I""'~ H_.,I&j
. j$~f;;fj,\[::" .. ." K
ATTEST, l, /,', I.,.. "..1 p\
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~~__~'~~"".~-""-~~CM11~ ......~::',."~ ~~t:',.:~r"'"..J'::.,~M,,..:t~~~1 .
ACORDIA NATIONAL ( ./
By KG/' -id. ~};
Its CII/E;; l,P'eIl-4-r/;J I ~ F,cl CeIL
ATTEST:
8
14
ATTACHMENT 2
PUBLIC GOODS SURCHARGE/COVERED LIVES
ELECTION FORJlrl
FEDERAL TAX
IDENTIFICATION #:
59-6000749
PAYOR NAME:
MONROE COUNTY BOARD OF COMMISSIONERS
DBAs (IF APPLICABLE)
N/A
ADDRESS:
5100 COLLEGE ROAD, ROOM 215
KEY WEST, FLORIDA 33040
CONTACT PERSON:
LEAH M. MARQUESS
PHONE #:
(305) 292-4448 FAX#: (305) 295-4301
By signature below, the above entity elects to make public goods surcharge payments directly to the Department's pool
administI'ator for all its lines of business and agrees to:
1. remit to the Department's pool administrator required surcharge payments for all applicable services on a monthly basis on
or before the 30th day following the calendar month for which monies have been paid to designated providers of service;
2. provide the Department's pool administrator monthly certified reports on or before the 30th day following the calendar month
for which monies have been paid which separately report patient service expenditures for services provided by designated
provider type(s) (i.e., hospital inpatient, hospital outpatient, diagnostic & treatment center, laboratory, or ambulatory surgery
center) by product line;
3. provide the Department with certification of data and access to allowance expenditure data upon request for audit verification
purposes; and
4. the jurisdiction of the state to maintain an action in the courts of the State of New York to enforce any provision of section
2807-j of the Public Health Law.
By signature below, the above entity also agrees to make public goods covered lives payments directly to the Department's pool
administrator in instanccs where it provides inpatient coverage as a corporation organized and operating in accordance with
Article 43 of the Insurance Law, an organization operating in accordance with Article 44 of the Public Health Law, a self-
insured fund or third party administrator acting on behalf of such fund or a commercial insurer licensed to (fo business in New
York State and authorized to write accident and health insurance and whose policy provides inpatient covcragc on an expense
incurred bases. In such instances the above entity agrees to:
1. remit to the department's pool administrator within 30 days after the end of each month one-twelfth of both the individual
and family unit annual assessment amounts for each of the individuals and family units residing in the state which were
included on the payor's membership rolls for all or a portion of the prior month and for which the payor covered general
hospital inpatient care, including retroactive additions and deletions;
2. provide the Department with data certification and access to individual and family unit data, upon request, for audit
verification purposes; and
3. the jurisdiction of the state to maintain an action in the courts of the State of New York to enforce any provision of section
2807-t of the Public Health Law.
By signature below, the Chief Financial Officer of the above entity certifies that the data provided on Attachments #2 through
2.4 has been carefully prepared in accordance with instructions provided, and to the best of his/her knowledge, the information
pr~sented is accurate and correct.
Sign;ture
Date
Chief Financial. Officer
11
ATTACHMENT 2.6
PUBLIC GOODS SURCHARGE/COVERED LIVES
ELECTION FORt"\1
CHANGE OF THJRD PARTY ADMINISTRATOR (TPA) STATUS OF PAYORS
If an electing payor changes their third party administrator (TP A) or administrative
services only organization (ASO), the form below must be completed and submitted to
the Department's pool administrator. NOTE: This form is only to be utilized by payors,
not IP As. The TP A<; should file Attachment #2.4-A or #2.4-B Addendum.
Effective Date: January 1. 1997
File out all applicable information.
--
PAYOR INFORMATION:
Federal Employer Identification #(EIN):59-6000749
Name: Monroe County Board of Commissioners
PREVIOUS TPNASO INFORMATION
Federal Employer Identification #(EIN):rYA
Name: I:!liA.
PRESENT NEW IP A INFORMATION:
Federal Employer Identification #(EIN):55-0579762
Name: Acordia National
Address; PO Box 3262
Charleston, WV 25332
Contact Person: Beverly Burdette
Phone #: 304-353-8781
Check one of the following (if applicable):
.,/ New TP A is assuming responsibility for all pending claims and HCRA reporting
requirements.
Signature of Payor
Date
DOH-4100 (6/97)
An. 2.6-Page 1 of 1
, ~
RISK MANAGEMENT
POLICY AND PROCEDURES
CONTRACT ADMINISTRATION
MANUAL
Gencral Insurancc RequiJ'cmcnts
For
Other Contractors and Subcontractors
As a pre-requisite of the work governed, or the goods supplied under this contract (including the
prc-staging of personnel and material), the Contractor shall obtain, at his/her own expense,
insurance as specified in any attached schedules, which are made part of this contract. The
Contractor will ensure that the insurance obtained, will extend protection to all Subcontractors
engaged by the Contractor. As an alternative, the Contractor may require all Subcontractors to
obtain insurance consistent with the attached schedules.
The Contractor will not be permitted to commence work governed by this contract (including
prestaging of personnel and material) until satisfactory evidence of the required insurance has
been furnished to the County as specified below, Delays in the commencement of work, resulting
from the fai I ure of the Contractor to provide satisfactory evidence of the requ ired insurance, shall
not extend deadlines specified in this contract, and any penalties and failure to perform
assessments shall be imposed as if the work commenced on the specified date and time, except
for the Contractor's failure to provide satisfactory evidence.
The Contractor shall maintain the required insurance throughout the entire term of this contract
and any extensions specified in the attached schedules. Failure to comply with this provision may
result in the immediate suspension of all work until the required insurance has been reinstated or
replaced. Delays in the completion of work resulting from the failure of the Contractor to
maintain the required insurance shall not extend deadlines specified in this contract and any
penalties and failure to perform assessments shall be imposed as if the work had not been
suspended, except for the Contractor's failure to maintain the required insurance.
The Contractor shall provide, to the County, as satisfactory evidence of the required insurance
either:
· Certificate of Insurance
or
. A Certified copy ofthe actual insurance policy.
The County, at its sole option, has the right to request a celtified copy of any or all insurance
policies required by this contract.
All insurance policies must specify that they are not subject to cancellation, now-renewal,
material change, or reduction in coverage unless a minimum of thirty (30) days prior notification
is given to the County by the insurer.
The acceptance and/or approval of the Contractor's insurance shall not be construed as rei ieving
the Contractor from any liability or obligation assumed under this contract or imposed by law.
The Monroe County Board of County Commissioners, its employees and officials will be
included as "Additional Insured" on all policies, except for Workers' Compensation.
Any deviations from these General Insurance Requirements must be requested in writing on the
County prepared form entitled "Request for Waiver ofInsurance Requirements" ancl approved by
Ivlonroe County Risk Manager.
~\11
.......
"
1:196 Ed'!I\l1/
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
. - MONROE COUNTY, FLORIDA
AND
ACORDIA NATlOOAL
Prior to the commencement of work governed by this contract, the Contractor shall obtain
General Liability Insurance. Coverage shall be maintained throughout the life of the contract and
include, as a minimum:
Premises Operations
.. Products and Completed Operations
Blanket Contractual Liabilitv
Personal Injury Liability -
Expanded Definition of Property Damage
.
.
.
.
The minimum limits acceptable shall be:
$500,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$250,000 per Person
$500,000 per Occurrence
$ 50,000 Property Damage
. An Occurrence Form policy is preferred. If coverage is provided on a Claims Made policy, its
provisions should include coverage for claims filed on or after the effective date of this contract.
In addition, the period for which claims may be reported should extend for a minimum of twelve
(12) months following the acceptance of work by the County.
The Monroe County Board of County Commissioners shall be named as Additional Insured on all
policies issued to satisfy the above requirements.
, ,
JitT7 ./97
'-{,J
GL2
Administration Instruction
#4709.3
54
...
i Y96 Edilior.
\VORKERS' COMPENSATION
INSURANCE REQUffiEMENTS
FOR
CONTRACT
BETWEEN
MONROE COUNTY, FLORIDA
AND
ACORDIA NATIONAL
Prior to the commencement of work governed by this contract, the Contractor shall obtain
Workers' Compensation Insurance with limits sufficient to respond to the applicable state statutes.
In addition, the Contractor shall obtain Employers' Liability Insurance with limits of not less than:
$500,000 Bodily Injury by Accident
$500,000 Bodily Injury by Disease, policy limits
$500,000 Bodily Injury by Disease, each employee
Coverage shall be maintained throughout the entire term of the contract.
Coverage shall be provided by a company or companies authorized to transact business in the
state of Florida.
If the Contractor has been approved by the Florida's Department of Labor, as an authorized self-
insurer, the County shall recognize and honor the Contractor's status. The Contractor may be
required to submit a Letter of Authorization issued by the Department of Labor and a Certificate
of Insurance, providing details on the Contractor's Excess Insurance Program.
If the Contractor participates in a self-insurance fund, a Certificate ofInsurance will be required.
In addition, the Contractor may be required to submit updated financial statements from the fund
upon request from the County. .
, "
WC2
~fJ1j
Administration mstructlon
#-1709.3
88
1996 EeL lIOn
PROFESSIONAL LIABILITY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
.MONROE COUNTY, FLORIDA
AND
ACORDIA NATlOOAL
Recognizing that the work governed by this contract involves the furnishing of advice or services
of a professional nature, the Contractor shall purchase and maintain, throughout the life of the
contract, Professional Liability Insurance which will respond to damages resulting from any claim
arising out of the performance of professional services or any error or omission of the Coritractor
arising out of work governed by this contract.
The minimum lirrjts ofliability shall be:
$500,000 per Occurrence/$l,OOO,OOO Aggregate
if/if
PR02
Administration instruction
#4709.3
77
1996 Ed.llon
VEHICLE LIABll...ITI'
INSURANCE REQUIREMENTS
FOR
CONTRACT
BETWEEN
. MONROE COUNTI', FLORIDA
AND
ACORDIA NATIONAL
Recognizing that the work governed by this contract requires the use of vehicles, the Contractor,
prior to the commencement of work, shall obtain Vehicle Liability Insurance. Coverage shall be
maintained throughout the life of the contract and include, as a minimum, liability coverage for:
. Owned, Non-Owned, and Hired Vehicles
The minimum limits acceptable shall be:
$300,000 Combined Single Limit (CSL)
If split limits are provided, the minimum limits acceptable shall be:
$100,000 per Person
$300,000 per Occurrence
$ 50,000 Property Damage
The Monroe County Board of County Commissioners shall be named as Additional Insured on all
policies issued to satisfy the above requirements.
" '
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VL2
Administration Instruction
#4709.3
8\
1996 [ot:Jon
EMPLOYEE DISHONESTY
INSURANCE REQUIREMENTS
FOR
CONTRACT
BElWEEN
I\JONROE COUNTY, FLORIDA
AND
ACORDIA NATIOOAL
The Contractor shall purchase and maintain, throughout the term of the contract, Employee Dishonesty
Insurance which will pay for losses to County property or money caused by the fraudulent or dishonest
- acts of the Contractor's employees or its agents, whether acting alone or in collusion of others.
The minimum limits shall be:
$100,000 per Occurrence
,
, '
fJ(/tl
ED2
Administration Instruction
#4709.3
45
PUBLIC ENTITY CRIME STATEMENT
"A person or affiliate who l13s been p13ced Oil the convicted vendor list
rollowing a con\'icti9n for public emit)' crime may not submit a bid on a
contract to provide any goods or services to ;1 public entity, may not submit
a bid on::1 contract with a public entity lar the construction or repair ofa
publ ic building or publ ic work. may not submit bids on leases c f real
propeny to public entity, may not be ;l\varded or perform work as a
contractor, suppl ieL subcontractor, or consult;1Ilt under a contract with any
public entity, and may not trallsact husiness with any public entity in excess
of the threshold alllount provided in Section 2~7.0 17, for CATEGORY
T\VO for a period of 36 months li'om the dUle orbcing placed on the
convicted vendor list."
~,t:1 &/11
IVy '1/
- .'
. .
ATTACHMENT B
DRUG-FREE \VORKPLACE FORM
The undersigned \Tndor in accordance wilh Florida Statute 287.087 hereby cenllies lhal:
kLJ/2);/j- ~176N4~ ~e.
(Name of 1311slncss) /
I. Publish a statemL'nl J1(1tif~'ing employees that Ihe unlawflll l1lanul:1cture. Jislrihution. dispcnsin~.
possession. or use of :J conlrolkd slIbst:lllce is prohibited in the workplace and specifying Ihe anions Ih;1l
will be taken ag:Jinsl L'mplo)'ecs for vinlati<:>ns or such prohibition.
2. Inform cmployces aboul the dangers ofdrllg abuse in the workplace.lhe busincss's policy ofmall1l:1inin~
a drug-free workplace. any available drug counseling. rehabilitation, :lI1d employee assistancc programs.
and the penallies that may be imposed upon employees for drug abuse violations.
3, Give each employee engaged in providing the commodities or contractual services that are under bid a
copy of the statement specified in subsection (I).
4. In the stiilcment specified in subsection (I), notify 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 Ilotify 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 any
state, for a violation occurring in the workplace no later than five (5) days after such conviction.
5. Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation
program if such is available in the employee's community, or any employee who is so convicted.
6. Make a good faith effort to continue to maintain a drug-free workplace through implementation or this
sectioll.
As the person authorized to sign the statement. I cenify that this firm complies fully with the above
requirements.
l3idder's Signature
If/lj If I
I '
Date
"
ATTACHMENT C
OM 13 - MCI'1I5
NON-COLLUSION AFFIDAVIT
/lcd,ebI4 AI/J-??cJAi4c/..zvC.
(! II /l4-~;5?- ;r-cyJ, 1.1/01
/
I,
of the city.
of
according to law on my oath, and under
penalty of perjury, depose and say that;
1) I am /lQY~//l N4-?7&U!1S :.J;v e. , the bidt'er making the
Proposal for the project described as follows:
l?e<;Ve>T ~);C &b Ib rOrfl'L //6/1-L>7( /u1reJ eL4r'cL/~ Ae;,1//;v; ,-S1X4?76V
''Ob'7Y'i7f-L1 rlild/,! d--!r7'rY46&2) ru-,-ec-F /ht/j) U77L/Z'.4176V ~dV/ad :/
/f,uj) L4d-6€ MP6-- J-I~/l66";l'-IE:V/ lQI:.')e///C~?
2) 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;
3) 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; and
4) No attempt has been made or will be made by the bidder to induce any other
person, partnership or corporation to submit, or not to submit, a bid for the purpose of
restricting competition;
5) 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 project.
STATEOF \ll'EM- VlIrql(\,CI U -;J {;ta
COUNTY OF
kCiV\a whet
(Signature of Bidder)
SI~t/fj
DATE
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
Pi ck H. LeClVl who, after first being sworn by me, (name of
individual signing) affi;td hIs/her signature In the space provided above on thiS
l~ day of Apvi \
I
IO.eNmiS ~. ()''ff
NOTARY PUBLIC
,19 qq
OMB - MCP FORM #1
~~ rnrumissinn.expires:_.___.....\
/1.;",.-......,.. a--Ie."" C'~"l
~~t..~rt:-a.... ro" I,.... ..L"'. ~
o)Y--'<.;'; NOT/\RY FU2.tlC '
.1""-....;( ~ 1', '...}",\ ~
it:'.r:/(~"8 (),,,;, . ~'; STATE 0.= Wf.ST \,1:,GIN1,\ \
t.;;I\.7...;~.:..~.;....}~..:.:;.:.\:..)..::.'.: Dc'~NI3 II. nC.U3S \
.. 1801 \V("st P.ivcrvi':"/I Or. I
'~~'.,;>:":;,;'y. 'j Il,,"~. WV 250i5
"~f<i::i:> My Co",mr"ion bplr., 7-1o\-2co:J
----------- ~
ATTACHMENT 0
. .'
SWORN ST:\TUvll~NT t :NDER ORDIN/\NCl ~(). 10-1 l)l)()
MONROF COUNTY. rL01(1D:\
ETIIICS CLAUSE
./I t2CU?~)-/1 #.I9-77bv/,9~/ JA/C. warrants that hclit has not employed. retained
Gr otherwise had act on his/its hL'llalr any former County officer or employee in violation of
Section 2 of Ordinance no. 10.1 l)l)(l or :lny <- 'ollnty officcr or employee in violation of
Secli\)1l 3 or Ordinance No. I ().I l)l)(} Fnr hreaeh or violation of this provision thc COllnty
may. in its discretion. termin:lle lhis Clllltracl without liabililY and may also. ill its'discretion.
deduct from lhe contract or plln:h:lsc price. or olherwise recover. the 1'1111 :\111011111 of any fee.
commission. pcrccntagc. girl. or consideration paid to the fonner Counly officcr or employee.
;f?J 1/ ~'"7'
(sjgnature)~
yt}.c/J7
/
Date:
STATE OF Wet7}- Vll"tiltl"U
COUNTY OF Kaha\)..iht{
PERSONALLY APPEARED BEFORE ME. the undersigned authority,
RIck H. ~
who, after first being sworn by me, affixed his/her
signalllre (name of individual signing) in the space provided above on this 2Co
day of
April
.19!EL.
t6R1WVl ~ S W - (?f~tj
NOTARY PUBLIC
:-'1y commission expires:
..--,---:- ~ ~ .....,~ .,......-...-
OMB - ~lCr FORM #4
~i'~~J
,
O:;:lCI"~.~ S[..;t
"
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STA"-E or- WEST Yi~G\li!A \
()~i'~r..u3 1-;' I!OG"'~s.
laOl \'J~s: Rbo;,..d~" Or.
Il~!l~, V1V 25015
1.\y Ccmr.lt:sicn EJ.p~rc~ 7.14-2CC3
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