Backup Documents 06/11/2024 Item #16K 4 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 1 6 K
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. .kttach to original document. The completed routing slip and original documents are to be forwarded to the County.Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must he received in the Count Attorney Office no later
than.londay preceding the Board meeting.
**NEW** ROUTING SLIP
Complete routing lines#1 through#2 as appropriate for additional signatures.dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s)(List in routing order) Office Initials Date
2.
3 County Attorney Office County Attorney Office
0019/mob 7//3
4. BCC Office Board of County II
Commissioners fy4 i5/ 7/i`5
5. Minutes and Records Clerk of Court's Office (�t�1�44ti
10/0/?'
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the addressees
above.may need to contact staff for additional or missing information.
Name of Primary Staff Derek D. Perry/County Attorney Office Phone Number 239-252-8066
Contact/ Department
Agenda Date Item was June 11.2024 Agenda Item Number 16K4
Approved by the BCC
Type of Document Release Number of Original l
Attached Documents Attached
PO number or account
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A- in the Not Applicable column,whichever is Yes N/A(Not
appropriate. (Initial) Applicable)
I. Does the document require the chairman's original signature?
2. Does the document need to be sent to another agency for additional signatures? If yes, N/A
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed initialed for legal sufficiency. (All documents to be DDP
signed by the Chairman,with the exception of most letters,must be reviewed and signed
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's N/A
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chairman's signature line date has been entered as the date of BCC approval of the DDP
document or the final negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's DDP
signature and initials are required.
7. In most cases(some contracts are an exception).the original document and this routing slip N/A
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of your deadlines!
8. The document was approved by the BCC on 6-11-24 and all changes made during the WA is not
meeting have been incorporated in the attached document. The County Attorney's �� (, an option for
Office has reviewed the changes,if applicable. tl n this line.
9. Initials of attorney verifying that the attached document is the version approved by the N/A is not
BCC.all changes directed by the BCC have been made,and the document is ready for the I J an option for
Chairman's signature. 'A t* this line.
x6K4
Claim Number: APL000234
RELEASE OF PROPERTY DAMAGE CLAIM
KNOW ALL MEN BY THESE PRESENTS:
That the Undersigned, being of lawful age, for the sole consideration of Twenty Four
Thousand Four Hundred Eight Dollars and Fifty Two Cents ($24,408.52) to the undersigned in
hand paid, receipt whereof is hereby acknowledged, do/does hereby and for my/our/its heirs,
executors, administrators, successors and assigns release, acquit and forever discharge Clear
Blue Specialty Insurance Company, Scott Commercial Contracting LLC and Network Adjusters
their or its agents, servants, successors, heirs, executors, administrators and all other persons,
firms, corporations, associations, or partnerships of and from said property damage claim, actions,
causes of action, demands, rights, damages, costs, which the undersigned now has/have resulting
from the accident, casualty or event which occurred on or about the 24th, March 2020 at or near
10600 Tamiami Trail N.,Naples,FL 34108.
It is understood and agreed that this settlement is the compromise of a doubtful and
disputed claim, and that the payment made is not to be construed as an admission of liability on the
part of the party or parties hereby released, and that said release deny liability therefore and intend
merely to avoid litigation and buy their peace.
The undersigned further declare(s) and represent(s) that no promise, inducement or
agreement not herein expressed has been made to the undersigned, and that this Release contains
the entire agreement between the parties hereto, and that the terms of this Release are contractual
and not a mere recital.
CAUTION READ BEFORE SIGNING BELOW
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE
COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR
STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR
CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY
FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS
A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED
FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
THE UNDERSIGNED HAS READ THE FOREGOING RELEASE AND FULLY
UNDERSTANDS IT.
[Signature Page to Follow]
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t6K4
Signed, sealed and delivered this 11 th day of June 2024.
AT L1 ST: BOARD OF COUNTY COMMISSIONERS
Crystal K.Kinzel, Clerk COLLIER COUNTY, FLORIDA
A
By: By:
Deputy Clerk Chri 11, Chairman
Attest as to Chairman's
signature only
Approved as to Form and Legality:
Derek D. Perry
Assistant County Attorney
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