Loading...
Agenda 10/11/2016 Item #16E 5 16.E.5 10/11/2016 EXECUTIVE SUMMARY Recommendation to renew the annual Certificate of Public Convenience and Necessity (COPCN) for Ambitrans Medical Transport, Inc. to provide Class 2 Advanced Life Support (ALS) inter- facility transport ambulance service for a period of one year. OBJECTIVE: To recommend the renewal of a COPCN for Ambitrans Medical Transport to provide Class 2 ALS inter-facility transport services in Collier County. CONSIDERATIONS: A COPCN may be approved routinely by the Board as provided by Section 50- 60 of the Collier County Code of Laws and Ordinances governing medical transportation services. Ambitrans inter-facility transport was granted a Certificate of Public Convenience and Necessity on October 25, 2011, by the Board. Staff has deemed Ambitrans' renewal application as complete and recommends that the COPCN be renewed for one year. A Class 2 operator provides post-hospital inter- facility medical transfer services,both within and outside the County. Section 50-60 of the Code of Laws and Ordinances provides: Each certificate holder shall file within 90 days of expiration, an application for renewal of his certificate. Renewals shall be based upon the same standards, as the granting of the original certificate along with such other factors as may be relevant. The renewal application shall be accompanied by a $250.00 renewal fee. The renewal certificate may be approved routinely by the board,upon advice of the administrator,or the board may hold a hearing on same. These requirements have been met and the administrator recommends renewal. FISCAL IMPACT: There is no fiscal impact to the Board for the granting of this certificate. The Board is requested to accept and recognize as revenue in Fund (490) the $250.00 application fee with the corresponding application. GROWTH MANAGEMENT IMPACT: There are no Growth Management Impacts associated with this action. LEGAL CONSIDERATIONS: Whether the Board grants the renewal is at the discretion of the Board, as this is a legislative, and not quasi-judicial, matter. A hearing is not required for renewal. If a hearing is held, the Board must find that the standards set forth in Section 50-57 of the Code of Laws and Ordinances have been satisfied based on competent evidence as follows: (1) That there is a public necessity for the service. In making such determination,the Board of County Commissioners shall consider,as a minimum,the following factors: a. The extent to which the proposed service is needed to improve the overall emergency medical services (EMS)capabilities of the County. b. The effect of the proposed service on existing services with respect to quality of service and cost of service. c. The effect of the proposed service on the overall cost of EMS service in the county. d. The effect of the proposed service on existing hospitals and other health care facilities. Packet Pg. 1701 16.E.5 10/11/2016 e. The effect of the proposed service on personnel of existing services and the availability of -- sufficient qualified personnel in the local area to adequately staff all existing services. (2) That the applicant has sufficient knowledge and experience to properly operate the proposed service. (3) That,if applicable,there is an adequate revenue base for the proposed service. (4) That the proposed service will have sufficient personnel and equipment to adequately cover the proposed service area. This item is approved as to form and legality and requires a majority vote for approval. JAB RECOMMENDATION: That the Board awards a Class 2 Certificate of Public Convenience and Necessity to Ambitrans Medical Transport,Inc.,for a period of one year. Prepared by: Dan E. Summers,Director,Bureau of Emergency Services ATTACHMENT(S) 1.2016-17 Ambitrans COPCN Application(PDF) 2.Ambitrans Permit (PDF) 3.VIN List (PDF) 4.Ambitrans Certificate (PDF) Packet Pg.1702 16.E.5 10/11/2016 COLLIER COUNTY Board of County Commissioners Item Number: 16.E.5 Item Summary: This item requires that ex parte disclosure be provided by Commission members. Should a hearing be held on this item, all participants are required to be sworn in. Recommendation to renew the annual Certificate of Public Convenience and Necessity (COPCN) for Ambitrans Medical Transport, Inc. to provide Class 2 Advanced Life Support (ALS) inter-facility transport ambulance service for a period of one year. Meeting Date: 10/11/2016 Prepared by: Title: Executive Secretary—Emergency Management Name: Kathy Heinrichsberg 09/21/2016 3:49 PM Submitted by: Title: Division Director-Bureau of Emer Svc—Emergency Management Name: Daniel Summers 09/21/2016 3:49 PM Approved By: Review: Emergency Management Daniel Summers Level 1 Add Division Reviewer Completed 09/22/2016 1:02 PM Administrative Services Department Pat Pochopin Level 1 Division Reviewer Completed 09/22/2016 1:26 PM County Attorney's Office Jennifer Belpedio Level 2 Attorney of Record Review Completed 09/23/2016 11:00 AM Administrative Services Department Len Price Level 2 Division Administrator Review Completed 09/23/2016 4:00 PM Office of Management and Budget Valerie Fleming Level 3 OMB Gatekeeper Review Completed 09/27/2016 10:44 AM Office of Management and Budget Laura Wells Level 3 OMB 1st Reviewer 1-4 Completed 09/27/2016 11:56 AM County Attorney's Office Jeffrey A.Klatzkow Level 3 County Attorney's Office Review Completed 09/29/2016 5:04 PM County Manager's Office Nick Casalanguida Level 4 County Manager Review Completed 10/03/2016 11:28 PM Board of County Commissioners MaryJo Brock Meeting Pending 10/11/2016 9:00 AM Packet Pg. 1703 16.E.5.a AMBITRANS MEDICAL TRANSPORT, INC. z U Ct. O U 2016 COPCN Renewal I T. Application c6 Collier County, Florida ca U_ U a O ca id th T O C O Ambitrans Medical Transport,Inc.,submits its 2016 Application for Renewal of its Certificate of Public Convenience and Necessity in and for Collier County,Florida. Packet Pg. 1704 16.E.5.a Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application Sec.50-55 Procedure for obtaining certificate. An applicant for a certificate shall obtain forms from the department to be completed and returned to the division administrator.Each application shall contain: z (1) The name,age and address of the owner of the ambulance or ALS provider,or if the owner a. is a corporation, then of the directors of the corporation and of all of the stockholders holding more than 25 percent of the outstanding shares. For governmental units, this information shall be supplied for members of the governing body. Corporate Officers/Directors 713Michael J.Grant,67,4351 Pinnacle Street,Charlotte Harbor,FL 33980 50% Lorraine B.Grant,61,4351 Pinnacle Street,Charlotte Harbor,FL 33980 50% Alan J.Skavroneck,51,4351 Pinnacle Street,Charlotte Harbor,FL 33980 0% c�a Vanessa Grant Oliver,35,4351 Pinnacle Street,Charlotte Harbor,FL 33980 0% (2) The boundaries of the territory desired to be served. ct Collier County, Florida (3) The number and brief description of the ambulances or other vehicles the applicant will have available. Ambitrans currently has thirty-three (33) licensed ambulances (an increase of 8 a ambulances over last year) available to its fleet. These units are permitted with the Florida Department of Health - Bureau of EMS as Advanced Life Support and Basic Life Support vehicles. o. O U Through the use of the company's computer aided dispatch software,Zoll Data RescueNet Dispatch-Billing",management is able to staff according to anticipated demand. Staffing levels and patterns are determined using historical data and other internal statistics. Vehicles are posted in accordance with direction from our communications center personnel to specified areas to aid in proper deployment and call response. In the event of increased call volume, Ambitrans has the ability to schedule additional N labor and resources to meet any unforeseen increase in market demand. c E A spreadsheet listing each ambulance in our fleet is attached hereto as Exhibit"A." 4 Packet Pg. 1705 16.E.5.a Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application (4) The address of the intended headquarters and any substations. Ambitrans corporate office is located at: U a 4351 Pinnacle Street,Port Charlotte,FL 33980 U L L O To ry k Attimill E I a) L R c 1 c co C R w+ Our Collier County substation is located at: IraQ 2157 Pine Ridge Road,Naples,FL 34109 �., (former NCH ambulance station) c N . 0 „:„... Q �a Q 0() rt ...tea .vy y:, __IC C E Q 6 Our auxiliary substation to backup the Collier County operation is located at: `•I c (i) 935 N.E.7th Terrace,Cape Coral, FL 33909 E o oQ Packet Pg. 1706 16.E.5.a Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application (5) The training and experience of the applicant. Ambitrans Medical Transport, Inc. was incorporated in 1983 to provide Paratransit services to the residents of Charlotte County. In 1988, ownership of the company transferred to its current principals. In 1995, Ambitrans commenced its ambulance t operations. Today, Ambitrans operates in Charlotte, Collier, Lee, Sarasota and Manatee counties. 7-6 Ambitrans is committed to maintaining compliance with all federal,state and local laws ;v and regulations. We are compliant with Florida Statute 401 and Florida Administrative Code 64J in accordance with standards set forth by the Bureau of EMS and Department of Health. Our state license is valid through June 19, 2017. A copy of our state license is attached hereto as Exhibit"B." Ambitrans is a licensed Medicare and Medicaid provider and we have contracts in place CO with many national third-party payors, which enable us to serve all citizens of Collier County.Further,we employ a national law firm specializing in Medicare issues related to the ambulance industry to ensure we remain compliant with all federal laws, rules and a:_ regulations relating to Medicare, as well as in an-house General Counsel to ensure our c. facility contracts and daily operations conform with all federal, state and local (.) regulations. a- 0 U c7 The management team at Ambitrans collectively has over 200 years of experience in the EMS industry. Our Training and Quality Assurance Department reviews patient care -Q reports for quality assurance and adherence to our medical protocols and standards of ti care. Our education team is also responsible for our in-house training, which includes CPR, Advanced Cardiac Life Support, Pediatric Advanced Life Support, Emergency pp Vehicles Operators Course and on-going continuing education units needed for bi-annual m certification renewal. (73a.+ Our in-house billing department is knowledgeable and responsive and available Monday through Friday to answer any questions our customers may have. Packet Pg. 1707 16.E.5.a Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application Our personnel and managers have diverse experiences that take them well outside of Southwest Florida. Michael Grant, our President and CEO, was recently elected to the z U Florida House of Representatives,District 75. a U Our Chief Operating Officer,Alan Skavroneck,serves as the immediate Past-President for the Florida Ambulance Association and recently completed his term as State Surgeon General appointee to the Emergency Medical Services Advisory Council. Governor Rick Scott appointed and the Florida Senate confirmed Vanessa Oliver, our °' ns General Counsel, as a consumer member of the State Board of Funeral, Cemetery and Consumer Services. y c Dr.Daniel V.O'Leary serves as our medical director of record as mandated under Florida Statute 401.265. This is in addition to his normal day-to-day duties as an emergency room physician at Peace River Medical Center in Port Charlotte as well as serving as the Medical Director for Charlotte County Fire and EMS. 0 (6) The name and addresses of three Collier County residents who will act as references for a the applicant. Patricia Davis o. 212 Napa Ridge Road East 0 Naples,FL 34119 Representative Matt Hudson 3301 East Tamiami Trail Naples, FL 34112 d Senator Garrett Richter E U f4 2320 Harrier Run Naples,FL 34105 Packet Pg. 1708 16.E.5.a Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application (7)A schedule of rates which the service intends to charge. z U Code Service Description Rate o U A0428 Basic Life Support Base Rate $395.00 A0429 Basic Life Support Base Rate $425.00 A0426 Advanced Life Support Base Rate $395.00 A0427 Advanced Life Support Base Rate $500.00 A0433 Advanced Life Support Base Rate-Level 2 $725.00 A0434 Specialty Care Transport Base Rate $900.00 A0425 Per Loaded Mile $10.00 In 0 A0999 Oxygen $45.00 0 c� U A0999 Drugs $10.00 -$25.00 Q. c. IV Supplies $20.00 -$25.00 a. O 1.`3. r-+ () U Packet Pg. 1709 1 6.E.5.a Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application (8)Such other pertinent information as the administrator may require. No additional information was requested by the administrator at the time of submission. a.However,for your convenience,Ambitrans has attached hereto a copy of its Certificate of U Insurance as Exhibit "C" and its Certificate of Worker's Compensation Insurance as Exhibit"D." To (9)An application or renewal fee of$250.00. (Exception Collier County EMS). Ambitrans'check in the amount of$250.00 is enclosed with this Renewal Application. cn(10) Financial data including assets and liabilities of the operator. A schedule of all debts encumbering any equipment shall be included. M Ambitrans'financial data is attached hereto as Exhibit"E." c 0 Q n. z U a_ 0 U y co L t-. lc E d E V f0 r+ Packet Pg. 1710 16.E.5.a Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application Schedule of Exhibits Exhibit"A" List of Ambulances in Fleet a Exhibit"B" State License Exhibit"C" Certificate of Insurance Exhibit"D" Certificate of Worker's Compensation Insurance o Exhibit"E" Financial Data N O U a O cn ca 25 a+ d Rf Packet Pg. 1711 16.E.5.a --fl% riidgeffield Employers Insurance Company® A Member of Great American Insurance Group A Stock Insurer•P.0,Box 988•Lakeland, FL 33802-0988 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE carrier code 31 2677 Polcy number .830-38697 Z Item 1. Insured a Prior policy number U Name Ambitrans Medical Transport, Inc. RISK i.u. 097488436 and Address 4351 Pinnacle St __ Individual X Corporation Punta Gorda, FL 33980-2902 _Partnership Subchapter"S" To Other Other workplaces not shown above: SEE EXTENSION OF INFORMATION PAGE ITEM 1 FEIN 65-0571130 item 2. Policy period ro From 12/27/15 to 12/27/16 12:01 a.m.standard time at the address of the insured as stated herein. ro i.J Item 3. Coverage ;? A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed �E here: Florida 61) B. Employers Liability Insurance:Part Two of the policy applies to work in each state listed in Item 3.A.The limits of our N liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 each employee Bodily Injury by Disease $ 1,000,000 policy limitcd C. Other States Insurance:Part Three of the policy applies to the states, if any, listed here: Alabama Arkansas Georgia Kentucky Louisiana Mississippi North Carolina South Carolina Tennessee D. This policy includes these endorsements and schedules; nV. SEE EXTENSION OF INFORMATION PAGE ITEM 3.D O 0 Item 4. Premium The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.All information required below is subject to verification and change by audit. E PTeasls: Totalrengun Estlmaled RnN Per$100 Etmmebd h.. Claosllleallons Code No. Annual Remuneration of Remuneration Annual Premium SEE EXTENSION OF INFORMATION PAGE ITEM 4 s Total Estimated Annual Premium $ `d Q Minimum Premium $11111111111111111111_ Expense Constant $ Countersigned by Date 10/09/15 T- 2242 Roger Bouchard Insurance Inc. crs Date Prepared:10/09/15 WC 00 00 01 A 105(881 Includes copyright material of the National Council on Compensation Insurance.Used wth l Packet Pg. 1712 0 1987 National Coundt on Compens 16.E.5.a Ambitrans Medical Transport, Inc. List of Vehicles in Fleet-2016 Name License Type License Effective Date 1FDSS3ESODDA41561 VEHICLE PERMITS (BLS) 4956 2/18/2016 1FDSS3ES1BDB27801 VEHICLE PERMIT(ALS) 17027 12/8/2011 1FDSS3ES3BDA26145 VEHICLE PERMITS(BLS) 4355 2/24/2011 1FDSS3ES3CDA18371 VEHICLE PERMITS(BLS) 4832 4/8/2015 1FDSS3ES4BDA26137 VEHICLE PERMITS (BLS) 4775 7/31/2014 1FDSS3ES5ADA25626 VEHICLE PERMITS(BLS) 4677 8/1/2013 1FDSS3ES5CDA18372 VEHICLE PERMITS(BLS) 4954 2/18/2016 a 1FDSS3ES6ADA31208 VEHICLE PERMITS (BLS) 4678 8/1/2013 0 1FDSS3ES6BDA26138 VEHICLE PERMITS(BLS) 4475 3/29/2012 U 1FDSS3ES6BDB36820 VEHICLE PERMITS (BLS) 4955 2/18/2016 -0•, 1FDSS3ES7BDB27799 VEHICLE PERMITS (BLS) 4777 7/31/2014 0` 1FDSS3ES7BDB27804 VEHICLE PERMIT(ALS) 17026 12/8/2011 1FDSS3ES7DDB06017 VEHICLE PERMIT(ALS) 18017 7/23/2013 1FDSS3ES8DDB02266 VEHICLE PERMITS(BLS) 4776 7/31/2014 C 1FDSS3ES9EDA22265 VEHICLE PERMITS(BLS) 4823 3/10/2015 1FDWE35F92HA44797 VEHICLE PERMITS(BLS) 4133 12/19/2007 C 1FDWE3FS1ADA32547 VEHICLE PERMIT(ALS) 18534 7/31/2014 c0 1FDWE3FS3ADA32551 VEHICLE PERMITS(BLS) 4822 3/10/2015 C 1FDWE3FS5ADA69150 VEHICLE PERMIT(ALS) 18536 7/31/2014 15 1FDWE3FS6BDA87O27 VEHICLE PERMITS(BLS) 4821 3/10/2015 E 1FDWE3FS7ADA69148 VEHICLE PERMIT(ALS) 18535 7/31/2014 •• 1FDWE3FS7BDA91166 VEHICLE PERMIT(ALS) 18895 3/10/2015 c 1FDWE3FS8BDA09607 VEHICLE PERMIT(ALS) 18896 3/10/2015 N 1FDWE3FS9ADA34661 VEHICLE PERMIT(ALS) 19943 6/6/2016 0 1FDWE3FSXADA32546 VEHICLE PERMITS(BLS) 5037 8/25/2016 cis 1FDWR3FSXBDA09608 VEHICLE PERMIT(ALS) 19338 8/24/2015 v 2. 1FDXE4FS2BDB29932 VEHICLE PERMIT(ALS) 19699 1/19/2016 a 1FDXE4FS3BDB29941 VEHICLE PERMIT(ALS) 19758 2/18/2016 z 1FDXE4FS3BDB35786 VEHICLE PERMIT(ALS) 19759 2/18/2016 a 1FDXE4FS4BDB35781 VEHICLE PERMIT(ALS) 19757 2/18/2016 0 V 1FDXE4FS6CDA90604 VEHICLE PERMIT(ALS) 19956 6/20/2016 c 1FDXE4FS8BDB35783 VEHICLE PERMIT(ALS) 19957 6/20/2016cz 1FDXE4FS9EDA75257 VEHICLE PERMIT(ALS) 18361 5/6/2014 E <t r,• cO 0 N C d) E 0 cis .4? a� Q Packet Pg. 1713 16.E.5.a BRIAN W. CROSLAND, CPA, PL CERTIFIED PUBLIC ACCOUNTING&CONSULTING 201 W.MARION AVENUE,SUITE 1204 PUNTA GORDA,FL 33950 PHONE:941.629.1197 FACSIMILE:941.205.5279 AMERICAN INSTITUTE OF CERTIFIED PUBLIC ACCOUNTANTS FLORIDA INSTITUTE OF CERTIFIED PUBLIC ACCOUNTANTS Kxls'fI L.SCOT MEDICAL GROUP MANAGEMENT ASSOCIATION SHAWN NI.COOLEY,CPA COMMUNITY ASSOCIATIONS INSTITUTE Z U INDEPENDENT ACCOUNTANTS' COMPILATION REPORT o U L To the Board of Directors .c Ambitrans Medical Transport, Inc. Charlotte Harbor, Florida 3 a> c a: We have compiled the accompanying statement of assets and liabilities of the ambulance o transportation operations of Ambitrans Medical Transport, Inc. and subsidiaries as of May 31, 2016. This financial statement has been prepared on the income basis of accounting utilized by c the Company for federal income tax reporting purposes. We have not audited or reviewed the accompanying financial statement and, accordingly, do not express an opinion or provide any c assurance about whether the financial statement is in accordance with the income tax basis of accounting. E Q Management is responsible for the preparation and fair presentation of the financial statement in accordance with the income tax basis of accounting and for designing, implementing, and v.)c maintaining internal control relevant to the preparation and fair presentation of the financial N statement. L 0 Our responsibility is to conduct the compilation in accordance with Statements on Standards for fts Accounting and Review Services issued by the American Institute of Certified Public u Accountants. The objective of a compilation is to assist management in presenting financial Q information in the form of a financial statement without undertaking to obtain or provide any Z assurance that there are no material modifications that should be made to the financial statement. U IZ The accompanying statement was prepared for the purpose of presenting the assets and liabilities O of the ambulance transportation operations of Ambitrans Medical Transport, Inc. and subsidiaries, Go and is not intended to be a complete presentation of Ambitrans Medical Transport, Inc. and F subsidiaries consolidated assets and liabilities. Accordingly, this report and related financial statement is restricted for use only by known third parties with knowledge of these restrictions E Q and should not be used for any other purpose. r ch O N /5077. 173 7-L----- o ca Q July 28, 2016 Punta Gorda, Florida EXCELLENCE SINCE 1984 Packet Pg. 1714 I6.E.5.a Ambitrans Medical Transport, Inc. and Subsidiaries Statement of Assets and Liabilities of the Ambulance Transportation Operations Income Tax Basis of Accounting May 31, 2016 (Unaudited) Assets z U Current Assets: a U Cash available for ambulance transportation operations $ 875,000 L 0 Property and Equipment: Office equipment and computers 168,954 Machinery and equipment 323,510 7.6 Medical transportation vehicles 1,657,996 2,150,460 Less accumulated depreciation (2,034,787) Property and Equipment, net 115,673 Total Assets $ 990,673 0 0 z 0 Liabilities 0 0 Current Liabilities: z Accrued profit sharing $ 121,484 0 Other liabilities 35,000 v Notes payable to banks 566,366 c 722,850 Lonq Term Liabilities: cn Notes payable to banks 587,520 c Less current portion above "' (566,366) .� 21,154 E s U t6 Total liabilities 744,004 Net Assets Over Liabilities, income tax basis $ 246,669 Read Independent Accountants' Compilation Report Packet Pg. 1715 16.E.5.a Client#: 16583 GRANTMED2 ACORD, CERTIFICATE OF LIABILITY INSURANCE DATE(MM1DD/YYYY)6/2912016 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 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 CONTACTNAME: Bouchard Insurance :SAR PHONE 941 922-0245 I FAX No.) .941 923-4126 (SAR) (AIC, E Ext): (. __. _....... .-.-_ 5310 Clark Road,Suite 1 AODRIess: cicerts@bouchardinsurance.com Z — U Sarasota,FL 34233 INSURER(S)AFFORDING COVERAGE NAIC# Q. 941 922-0245 INSURER A:Arch Insurance Company 11150 ai INSURED INSURER B: .) Ambitrans Medical Transport,Inc. — INSURER C: a) Grant Medical Transportation,Inc. INSURER D: O 4351 Pinnacle Street INSURER E: '*- Charlotte Harbor,FL 33980 INSURER F: `c COVERAGES CERTIFICATE NUMBER: 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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS i. CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, fQ EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. = POLICY EFF POLICY EXP LTR TYPE OF INSURANCE NSR SUBRI POLICY NUMBER (MM!DD/YYYY)I(MM/DD/YYYY)I LIMITS R jINSR WVD A GENERAL LIABILITY iMAPK08386900 07/01/2016107/01/2017EEACHOCCURRENCE 51,000,000 to I DAMAGE TO RENTEDa X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $100,000 1 CLAIMS-MADE I X OCCUR MED EXP(Any one person) 55,000 _ t' X Professional Liab i MAPK08386900 07/01/2016 07/0112017 PERSONAL&ADV INJURY x1,000,000 E II'GENERAL AGGREGATE 53,000,000 Q GENII AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMP/OP AGG $3,000,000 M $ X1 POLICY I 7:27 LOC I ' OMBINED SINGLE OMIT N A AUTOMOBILE LIABILITY MAPK08386900 07/01/2016 07/01/2017 (Ea accidenq 151,000,000 BODILY INJURY(Per person) III S G ANY AUTO ALL OWNED x SCHEDULED BODILY INJURY(Per accident)I S ;0 .._, NON-O ---................ - 15 CO AUTOS PROPERTY DAMAGE X NON-OWNED (Per accident) _ HIRED AUTOS X AUTOS A X UMBRELLA LIAR X OCCUR MAUM08509600 07/01/2016 07/01/2017 EACH OCCURRENCE s2,000,000 Q EXCESS LIAB CLAIMS-MADE AGGREGATE $2,000,000 Z DED , X RETENTIONSNOne5 0- WORKERS COMPENSATION I WC STATU- 10TH- 0 TORY LIMITS lER U AND EMPLOYERS'LIABILITY E.L.EACH ACCIDENT S ANY PROPRIETORIPARTNERIEXECUTIVEIY I N y OFFICER/MEMBER EXCLUDED? N/A E.L.DISEASE-EA EMPLOYEE 5 = (Mandatory in NH) C - s If yes,describe under E.L.DISEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS below -O E r+ ..-- DESCRIPTION DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CO **Supplemental Name** c Policy#MAPK08386900-:Ambulance Management Services, LLC&Venice Ambulance Service,Inc. N Policy#MAUM08509600-:Ambulance Management Services, LLC&Venice Ambulance Service,Inc. m E U RS (See Attached Descriptions) +t CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EVIDENCE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN XXXX ACCORDANCE WITH THE POLICY PROVISIONS. XXXXX XXXXXXXXXXXXXXXXXXX, AUTHORIZED REPRESENTATIVE y.l+a"" ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORD SUSCA #S475606/M475588 Packet Pg. 1716 I6.E.5.b COLLIER COUNTY FLORIDA Renewal of Class"2"COPCN Name of Service: Ambitrans Medical Transport,Inc. Name of Owner: Michael and Lorraine Grant Principle Address of Service: 4351 Pinnacle Street, Charlotte Harbor, FL 33980 Business Telephone: (941)743-3665 Description of Service: Inter-facility and out-of-county transport for Collier County Number of Ambulances: (33)Thirty-three See attachment "A"for description of vehicles. This permit,as provided by Ordinance No. 2004-12, as amended, shall allow the above named Ambulance Service to operate inter-facility and out of county transports for a fee or charge for the following area(s): Collier County for one year from the date executed hereon,except that this permit may be revoked by the Board of County Commissioners of Collier County at any time the service named herein shall fail to comply with any local,state or federal laws or regulation application to the provisions of Emergency Medical Services. Issued and approved this day of 2016 AITEST: BOARD OF COUNTY COMMISSIONERS a DWIGHT E. BROCK,CLERK COLLIER COUNTY, FLORIDA d-. ,Deputy Clerk Donna Fiala, Chairman Q Approved as to form and legality: RI r n w Jennifer A. Belpedio Assistant County Attorney 2N Packet Pg. 1717 1 6.E.5.c Attachement A Ambitrans Medical Transport,Inc. List of Vehicles in Fleet-2016 Name License Type License Effective Date 1FDSS3ESODDA41561 VEHICLE PERMITS(BLS) 4956 2/18/2016 1FDS53ES1BDB27801 VEHICLE PERMIT(ALS) 17027 12/8/2011 1FDSS3ES3BDA26145 VEHICLE PERMITS(BLS) 4355 2/24/2011 1FDSS3ES3CDA18371 VEHICLE PERMITS(BLS) 4832 4/8/2015 1FDSS3ES4BDA26137 VEHICLE PERMITS(BLS) 4775 7/31/2014 1FDSS3ESSADA25626 VEHICLE PERMITS(BLS) 4677 8/1/2013 1FDSS3ES5CDA18372 VEHICLE PERMITS(BLS) 4954 2/18/2016 1FDSS3ES6ADA31208 VEHICLE PERMITS(BLS) 4678 8/1/2013 1FDSS3ES6BDA26138 VEHICLE PERMITS(BLS) 4475 3/29/2012 1FDSS3ES6BDB36820 VEHICLE PERMITS(BLS) 4955 2/18/2016 1FDSS3ES7BDB27799 VEHICLE PERMITS(BLS) 4777 7/31/2014 - 1FDSS3ES7BDB27804 VEHICLE PERMIT(ALS) 17026 12/8/2011 a. 0 1FDSS3ES7DDB06017 VEHICLE PERMIT(ALS) 18017 7/23/2013 U 1FD553ES8DD802266 VEHICLE PERMITS(BLS) 4776 7/31/2014 1FDSS3ES9EDA22265 VEHICLE PERMITS(BLS) 4823 3/10/2015 r 1FDWE35F92HA44797 VEHICLE PERMITS(BLS) 4133 12/19/2007 ,o 1FDWE3FS1ADA32547 VEHICLE PERMIT(ALS) 18534 7/31/2014 3 1FDWE3FS3ADA32S51 VEHICLE PERMITS(BLS) 4822 3/10/2015 c 1FDWE3FSSADA69150 VEHICLE PERMIT(ALS) 18536 7/31/2014 m 1FDWE3FS6BDA87027 VEHICLE PERMITS(BLS) 4821 3/10/2015 1FDWE3FS7ADA69148 VEHICLE PERMIT(ALS) 18535 7/31/2014 c 1FDWE3FS7BDA91166 VEHICLE PERMIT(ALS) 18895 3/10/2015 co 1FDWE3F58BDA09607 VEHICLE PERMIT(ALS) 18896 3/10/2015 r 1FDWE3FS9ADA34661 VEHICLE PERMIT(ALS) 19943 6/6/2016 1FDWE3FSXADA32546 VEHICLE PERMITS(BLS) 5037 8/25/2016 QE 1FDWR3FSXBDA09608 VEHICLE PERMIT(ALS) 19338 8/24/2015 1FOXE4FS2BDB29932 VEHICLE PERMIT(ALS) 19699 1/19/2016 c 1FDXE4FS3BDB29941 VEHICLE PERMIT(ALS) 19758 2/18/2016csi 1FDXE4F53BDB35786 VEHICLE PERMIT(ALS) 19759 2/18/2016 N 1FDXE4F54BDB35781 VEHICLE PERMIT(ALS) 19757 2/18/2016 -:i 1FDXE4FS6CDA90604 VEHICLE PERMIT(ALS) 19956 6/20/2016 1FDXE4FS8BDB35783 VEHICLE PERMIT(ALS) 19957 6/20/2016 1FDXE4FS9EDA75257 VEHICLE PERMIT(ALS) 18361 5/6/2014 c R .. Q S Packet Pg. 1718 16.E.5.d 0 o c � i •0 -0 0 �' •c y c b LjC) pa L { c ,_ 0 0O U c Z ,o ›^ a, '13 ti O y O :n 0 L. O 0 N 0 al gmc .U u y "z o C _ a s W v o o 14 F Z 4)a z° 1- x Q Z s L "- C/) W 0w � o 4 U 0 71 cr O O (Nal N Nc. S 0 E W a) o `° L. U .. H oCo O 8 cU 0 O .J O aG 'i.+ U ' 0 =aN ; • ai cz wm a m al cts O 0 WY L c ._, O .9 o a) o O 71 o a cj 0 3 > � Q s a� ' o > L rw = . 0F- 0 c) 4.) Z U - O O 0:1 U oQ � U ] W EO c ,0 o T 0 bo N 0 N :d 4 11 d A U : Z C C E A N G� 0 � 0 CO C4 - a' N 2O U 94 W 4° C C V W Q cd y v c_V CZ '_ U Q . u o C) - •U .D 04 4) Uu al 0 vs U u U o 0 o C aL.. E- a E o U si E � � T E w¢ o u a a o > g a E � • . Q c 0. E s 0 U 0 Q H 0 ° 0 a - ¢ 4-vis v5' U o W � ¢ Ua a x -9. o x x EA 33 •<t CI a Si '� Packet Pg. 1719