#09-5321 (Naples Botanical Gardens)
2010 TOURISM AGREEMENT BETWEEN
COLLIER COUNTY AND NAPLES BOTANICAL GARDEN, INC.
THIS AGREEMENT is made and entered into this 29th day of September, 2009, by and
between Naples Botanical Garden, Inc., a Florida not-for-profit corporation, hereinafter referred
to as "GRANTEE" and Collier County, a political subdivision of the State of Florida, hereinafter
referred to as "COUNTY".
WHEREAS, the COUNTY has adopted a Tourist Development Plan (hereinafter referred
to as "Plan") funded by proceeds from the Tourist Development Tax; and
WHEREAS, the Plan provides that certain of the revenues generated by the Tourist
Development Tax are to be allocated to acquire, construct, extend, enlarge, remodel, repair,
improve, maintain, operate or promote museums owned and operated by not-for-profit
organizations and open to the public; and
WHEREAS, GRANTEE has applied to the Tourist Development Council and the County
to use Tourist Development Tax funds for exhibitions and educational programs to enhance the
quality of life for area residents and attract visitors; and
WHEREAS, the Tourist Development Council has recommended funding for the
promotion of upcoming exhibitions, accompanying national symposia, festivals, special events,
educational programs and workshops; and
WHEREAS, the Board of County Commissioners has made a finding that GRANTEE
qualifies as a museum; and
WHEREAS, The Collier County Board of County Commissioners has approved the
funding request of the GRANTEE and the Chairman was authorized to execute the Tourism
Agreement.
NOW, THEREFORE, BASED UPON THE MUTUAL COVENANTS AND PREMISES
PROVIDED HEREIN, AND OTHER VALUABLE CONSIDERATION, IT IS MUTUALLY
AGREED AS FOLLOWS:
1. SCOPE OF WORK:
(a) In accordance with the authorized expenditures as set forth in the Budget, attached
hereto as Exhibit "F", the GRANTEE shall expend the funds to promote the GRANTEE's
09-5321- Naples Botanical Garden, Inc. 1
Opening (hereinafter "the Project"), to include, out of County advertising and promotion
expenses.
2. PAYMENT:
(a) The maximum amount to be paid under this Agreement shall be a total of One
Hundred Fifty Thousand Dollars ($150,000). GRANTEE shall be paid in accordance with fiscal
procedures of the County for the expenditures incurred as described in Paragraph One (1) herein
upon submittal of a request for funds on the form attached hereto as Exhibit "D" and made a part
hereof, and shall submit vendor invoices and copies of cancelled checks or other evidence of
payment to the Executive Director of the Naples, Marco, Everglades Convention and Visitors
Bureau ("CVB"), or his designee, for review and upon verification by letter from the GRANTEE
that the services or work performed as described in the invoice have been completed or that the
goods have been received and that all vendors have been paid.
(b) The Executive Director of the CVB or his designee shall determine that the
invoice payments are authorized and that the goods or services covered by such invoice ( s] have
been provided or performed in accordance with such authorization. The line item budget
attached as Exhibit "F" shall constitute authorization for the expenditure ( s] described in the
invoice( s].
(c) All expenditures shall be made in conformity with this Agreement.
(d) The COUNTY shall not pay GRANTEE until the Clerk of the Board of County
Commissioners pre-audits all payment invoices in accordance with law.
(e) GRANTEE shall be paid for its actual costs, not to exceed the total amount for
any line item nor the maximum amount budgeted pursuant to the attached "Exhibit F". The
amounts applicable to the various line items of Exhibit "F", subject to the maximum total
amount, may be increased or decreased by up to ten percent (10%) at the discretion of
GRANTEE. Adjustment in excess of ten percent (10%) of any line item may be authorized by
the County Manager or his designee.
(f) All requests for reimbursement must be received prior to September 30,2010 to be
eligible for payment.
3. ELIGIBLE EXPENDITURES:
(a) Only eligible expenditures described in Paragraph One (1) will be paid by
COUNTY.
09-5321- Naples Botanical Garden, Inc. 2
(b) COUNTY agrees to pay eligible expenditures incurred between October 1, 2009
and September 30,2010.
(c) Any expenditures paid by COUNTY which are later deemed to be ineligible
expenditures shall be repaid to COUNTY within thirty (30) days of COUNTY's written request
to repay said funds.
(d) COUNTY may request repayment of funds for a period of up to three (3) years
after termination of this Agreement or any extension or renewal thereof.
4. INSURANCE:
(a) GRANTEE shall submit a Certificate of Insurance naming Collier County Board
of County Commissioners and the Tourist Development Council as additional insureds.
(b) The certificate of insurance must be valid for the duration of this Agreement, and
be issued by a company licensed in the State of Florida, and provide General Liability Insurance
for no less than the following amounts:
BODIL Y INJURY LIABILITY $300,000 each claim per person
PROPERTY DAMAGE LIABILITY $300,000 each claim per person
PERSONAL INJURY LIABILITY $300,000 each claim per person
WORKER'S COMPENSATION AND EMPLOYER'S LIABILITY - Statutory
(c) The Certificate of Insurance must be delivered to the Executive Director of the
CVB, or his designee, with the executed Agreement. The GRANTEE shall not commence
promotional or advertising activities which are to be funded pursuant to this Agreement until the
Certificate ofInsurance has been received by the COUNTY and the Agreement is fully executed.
5. REPORTING REQUIREMENTS:
(a) GRANTEE shall provide to County a preliminary status report on the form
attached hereto as Exhibit "A" within thirty (30) days ofthe effective date of the agreement.
(b) GRANTEE shall provide to County a quarterly interim status report on the form
attached hereto as Exhibit "B".
(c) GRANTEE shall provide to County a final status report on the form attached
hereto as Exhibit "c" no later than October 31, 2010.
09-5321- Naples Botanical Garden, Inc. 3
(d) Each report shall identify the amount spent, the duties performed, the services
provided and the goods delivered since the previous reporting period.
(e) GRANTEE shall take reasonable measures to assure the continued satisfactory
performance of all vendors and subcontractors.
(f) COUNTY may withhold any interim or final payments for failure of GRANTEE
to provide the interim status report or final status report until the County receives the interim
status report or final status report or other report acceptable to the Executive Director of the
CVB.
(g) GRANTEE shall request that visitors to the Naples Botanical Garden, Inc.,
complete the visitor questionnaire attached to this Agreement as Exhibit "E". All completed
visitor questionnaires shall be maintained in accordance with Section 13 of this Agreement.
6. CHOICE OF VENDORS AND FAIR DEALING:
(a) GRANTEE may select vendors or subcontractors to provide services as described
in Paragraph One (1).
(b) COUNTY shall not be responsible for paying vendors and shall not be involved in
the selection of subcontractors or vendors.
(c) GRANTEE agrees to disclose any financial or other relationship between
GRANTEE and any subcontractors or vendors, including, but not limited to, similar or related
employees, agents, officers, directors and/or shareholders.
(d) COUNTY may, in its discretion, object to the reasonableness of expenditures and
require payment if invoices have been paid under this Agreement for unreasonable expenditures.
The reasonableness of the expenditures shall be based on industry standards.
7. INDEMNIFICATION:
GRANTEE shall indemnify and hold harmless Collier County, its agents, officers and
employees from any and all liabilities, damages, losses and costs, including, but not limited to,
reasonable attorneys' fees and paralegals' fees, to the extent caused by the negligence,
recklessness, or intentionally wrongful conduct of the GRANTEE or anyone employed or utilized
by the GRANTEE in the performance of this Agreement. This indemnification obligation shall
not be construed to negate, abridge or reduce any other rights or remedies which otherwise may be
available to an indemnified party or person described in this paragraph.
8. NOTICES:
09-5321- Naples Botanical Garden, Inc. 4
All notices from the COUNTY to the GRANTEE shall be in writing and deemed duly
served if mailed by registered or certified mail to the GRANTEE at the following address:
Brian Holley, Executive Director
Naples Botanical Garden, Inc.
4820 Bayshore Drive
Naples, FL 34112
All notices from the GRANTEE to the COUNTY shall be in writing and deemed duly
served if mailed by registered or certified mail to the COUNTY to:
Jack Wert, Executive Director
Naples, Marco Island, Everglades CVB
2800 N. Horseshoe Drive
Naples, FL 34104
The GRANTEE and the COUNTY may change the above mailing address at any time
upon giving the other party written notification pursuant to this Section.
9. NO PARTNERSHIP: Nothing herein contained shall be construed as creating a
partnership between the COUNTY and the GRANTEE, or its vendors or subcontractors, or to
constitute the GRANTEE, or its vendors or subcontractors, as an agent or employee of the
COUNTY.
10. COOPERATION: GRANTEE shall fully cooperate with the COUNTY in all i
matters pertaining to this Agreement and shall provide all information and documentation
requested by the COUNTY from time to time pertaining to the use of any funds provided
hereunder.
11. TERMINATION:
(a) The COUNTY or the GRANTEE may cancel this Agreement with or without cause
by giving thirty (30) days advance written notice of such termination specifying the effective date
of termination.
(b) If the COUNTY terminates this Agreement, the COUNTY will pay the
GRANTEE for all expenditures or contractual obligations incurred by GRANTEE, with
subcontractors and vendors, up to the effective date of the termination so long as such expenses are
eligible.
09-5321- Naples Botanical Garden, Inc. 5
12. GENERAL ACCOUNTING: GRANTEE is required to maintain complete and
accurate accounting records. All revenue related to the Agreement must be recorded, and all
expenditures must be incurred within the term of this Agreement.
13. AVAILABILITY OF RECORDS: GRANTEE shall maintain records, books,
documents, papers and financial information pertaining to work performed under this Agreement
for a period of three (3) years. GRANTEE agrees that the COUNTY, or any of its duly authorized
representatives, shall, until the expiration of three (3) years after final payment under this
Agreement, have access to, and the right to examine and photocopy any pertinent books,
documents, papers, and records of GRANTEE involving any transactions related to this
Agreement.
14. PROHIBITION OF ASSIGNMENT: GRANTEE shall not assign, convey, or
transfer in whole or in part its interest in this Agreement without the prior written consent of the
COUNTY.
15. TERM: This Agreement shall become effective on October 1, 2009 and shall
remain effective for one year until September 30, 2010. If the project is not completed within the
term of this agreement, all unreleased funds shall be retained by the COUNTY. Any extension of
this agreement beyond the one (1) year term in order to complete the Project must be at the express
consent of the Collier County Board of County Commissioners.
16. The GRANTEE must request any extension of this term in writing at least sixty
(60) days prior to the expiration of this Agreement, and the COUNTY may agree by amendment to
this Agreement to extend the term for an additional one (I) year.
17. EVALUATION OF TOURISM IMPACT: GRANTEE shall monitor and evaluate
the tourism impact of the Project, explaining how the tourism impact was evaluated, providing a
written report to the Executive Director of the CVB or his designee, along with a final budget
analysis by October 31, 2010.
18. REQUIRED NOTATION: All promotional literature and media advertising must
prominently list Collier County and the Tourist Development Council as a source of funding and
the CVB logo with website address to qualify for reimbursement. .
09-5321- Naples Botanical Garden, Inc. 6
19. AMENDMENTS: This Agreement may only be amended by mutual written
agreement of the parties, after review by the Collier County Tourist Development Council if
warranted.
IN WITNESS WHEREOF, the GRANTEE and COUNTY have respectively, by an
authorized person or agent, hereunder set their hands and seals on the date and year first above
written.
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WITNESSES: GRANTEE:
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Printed/Typed Title
09-5321- Naples Botanical Garden, Inc. 7
EXHIBIT" A"
Collier County Tourist Development Council
Preliminary Status Report
EVENT NAME:
REPORT DATE:
ORGANIZATION:
CONTACT PERSON: TITLE:
ADDRESS:
PHONE: FAX:
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On an attached sheet. answer the followina auestions and attach it to your
application.
PRELIMINARY INFORMATION:
Is this a first time project? If not, please give details of past projects.
Do you anticipate using area hotels in support of your project?
If so, what are the estimated hotel room nights generated by project?
What is the estimated revenue generated by this project?
What is the estimated number of participants expected to visit the project?
If project planning is in progress, what has been done, what remains to be done, and are
there any problems?
If the project planning has not been started, why?
List any planned out-of-county advertising, marketing, and/or public relations that will be
used in support of the project.
09-5321- Naples Botanical Garden, Inc. a
EXHIBIT "B"
Collier County Tourist Development Council
Interim Status Report
EVENT NAME:
REPORT DATE:
ORGANIZATION:
CONTACT PERSON: TITLE:
ADDRESS:
PHONE: FAX:
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On an attached sheet, answer the followinQ Questions to identify the status of the
project. Submit this report at least Quarterlv.
INTERIM - These questions will identify the current status of the project. After the TDC
staff reviews this Interim Status Report, if they feel you are behind schedule on the
planning stages, they will make recommendations to help get the project stay on schedule.
Has the planning of this project started?
At what point are you at with the planning stage for this project?
(Percent of completion)
Will any hotels/motels be utilized to support this project?
If so, how many hotel room nights will be utilized?
What is the total dollar amount to date of matching contributions?
What is the status of the advertising and promotion for this project?
Have your submitted any advertisements or printed pieces to the TDC staff for approval?
Please supply a sample and indicate the ad schedule.
How has the public interest for this project been up to this point?
09-5321- Naples Botanical Garden, Inc. 9
EXHIBIT "C"
Collier County Tourist Development Council
Final Status Report
EVENT NAME:
REPORT DATE:
ORGANIZATION:
CONTACT PERSON: TITLE:
ADDRESS:
PHONE: FAX:
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On an attached sheet, answer the followina auestions for each element in your
sco"e of work.
Final - These questions should be answered for your final status report.
Was this a first time project? If not, how many times has this event taken place?
What hotels/motels were utilized to support the project and how many?
What is the total revenue generated for this event?
Total expenses. (Have all vendors been paid?)
List the vendors that have been paid, if not, what invoices are still outstanding and why?
What is the number of participants that visited the project?
What is the percentage of the total participants from out of Collier County?
What problems occurred if any during the project event?
List any out-of-county- advertising, marketing, and/or public relations that was used to
support the project and attach samples.
How could the project been improved or expanded?
09-5321- Naples Botanical Garden, Inc. 10
EXHIBIT "D"
REQUEST FOR FUNDS
COLLIER COUNTY TOURIST DEVELOPMENT COUNCil
EVENT NAME
ORGANIZATION
ADDRESS
CONTACT PERSON TELEPHONE ( )
REQUEST PERIOD FROM TO
REQUEST#
( ) INTERIM REPORT ( ) FINAL REPORT
TOTAL CONTRACT AMOUNT $
EXPENSE BUDGET REIMBURSEMENT REQUESTED
TOTALS
NOTE: Reimbursement of funds must stay within the confines of the Project Expenses outlined in
your application. Copies of paid invoices, cancelled checks, tear sheets, printed samples or other
backup information to substantiate payment must accompany request for funds. The following
will not be accepted for payments: statements in place of invoices; checks or invoices not dated;
tear sheets without date, company or organizations name. A tear sheet is required for each ad for
each day or month of publication. A proof of an ad will not be accepted.
Each additional request for payment subsequent to the first request, Grantee is required to submit
verification in writing that all subcontractors and vendors have been paid for work and materials
previously performed or received prior to receipt of any further payments.
If project budget has specific categories with set dollar limits, the Grantee is required to include a
spreadsheet to show which category each invoice is being paid from and total of category before
payment can be made to Grantee. Organizations receiving funding should take into consideration
that it will take a maximum of 45 days for the County to process a check.
Furnishing false information may constitute a violation of applicable State and Federal laws.
CERTIFICATION OF FINANCIAL OFFICER: I certify that the above information is correct based on
our official accounting system and records, consistently applied and maintained and that the cost
shown have been made for the purpose of and in accordance with, the terms of the contract. The
funds requested are for reimbursement of actual cost made during this time period.
SIGNATURE TITLE
09-5321- Naples Botanical Garden, Inc. 11
EXHIBIT "E"
Naples @
Marco Island
~
Everglades VISITOR QUESTIONNAIRE
PARAD I S E COAST'"
Welcome to the Paradise Coast SM. Thank you for choosing this area for your visit.
Please take a few minutes to complete the following questions so that we can better
serve the needs of future visitors to Florida's Last Paradise SM. PLEASE REFER TO OUR
PARADISE COAST BROCHURES FOR THE LOCATION OF ALL AREA ATTRACTIONS.
NAME:
ADDRESS: CITY ST ZIP
DATE OF ARRIVAL: DATE OF DEPARTURE:
WHERE ARE YOU HOTEURESORT FRIENDS/FAMILY CONDOMINIUM
STAYING?
NAME OF HOTEL AND CITY/AREA:
NAME OF CONDOMINIUMITIMESHARE:
# OF ROOMS OCCUPIED x NUMBER OF NIGHTS STAYING IN COLLIER COUNTY =
HOW DID YOU SELECT THE HOTEL/CONDOMINIUM?
INTERNET ( ) YOUR CHOICE ( ) TRAVEL AGENT ( )
OTHER:
NUMBER OF MEALS YOU & YOUR GROUP WILL EAT OUT:
Number of people in your party =
Number of days of your visit =
Number of meals eaten out each day =
PLANNED AREA ACTIVITIES: (Please circle all that apply)
ARTS & CULTURE WATER SPORTS NATURE FAMILY ATTRACTIONS
von Liebig Art Center Beaches Everglades Tour Naples Zoo
Naples Museum of Art Naples Pier County Parks Naples Botanical Garden
Sugden Theatre Shelling National Park Fun 'n Sun Water Park
Naples Philharmonic Fishing State Parks Swamp Buggy Race
Art Galleries Boating Corkscrew Swamp Mini Golf
Other Kayaking Conservancy of SW King Richard's Fun Park
Other FL Other
Lake Trafford
Other
SHOPPING AND DINING SIGHTSEEING RELAXATION &
Fifth Avenue South LunchlDinner Cruisel ENTERTAINMENT
Third Street South Sunset Cruise Golf
Waterside Shops City Trolley Tour Spa
Venetian Bay Everglades Tour Shelling
Bayfront Segway Tour Seminole Casino
Tin City Dolphin Cruise Lounges & Clubs
Prime Outlets Other Music
Other Other
09-5321- Naples Botanical Garden, Inc. 12
EXHIBIT "F"
Naples Botanical Garden, Inc.
Project Budget
Fundina - Not to Exceed
Advertising and promotion of opening in out of $150,000
Collier County areas, to include but not limited to
out of market advertising and promotional expenses
via print, online and media advertising campaign
Total: $150,000
09-5321- Naples Botanical Garden, Inc. 13
Client#: 38387 NAPB01
ACORDTM CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDNYYY)
09123/2009
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Gulfshore Insurance, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
4100 Goodlette Road North HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Naples, FL 34103 -3303
239 261-3646 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Cincinnati Insurance Company
Naples Botanical Garden, Inc. INSURER B:
4820 Bayshore Drive INSURER C:
Naples, FL 34112-7337 INSURER D:
INSURER E:
COVERAGES
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 CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I~i: DD'L TYPE OF INSURANCE POLICY NUMBER PJ>1-~~1ri~~~8~IE Pg~fJr'f.,~~~N LIMITS
NSRI
A ~NERAL LIABILITY CAP5879977 11/12/08 11/12/09 EACH OCCURRENCE $500 000
lL 3MERCIAL GENERAL LIABILITY DAMAGE WE~~~J,;~ 0' $50 000
- CLAIMS MADE [!J OCCUR MED EXP (Anyone person) $5 000
PERSONAL & ADV INJURY $500 000
GENERAL AGGREGATE $1 000000
~'L AGGREAE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $1 000000
PRO- n
POLICY JECT LOC
A ~TOMOBILE LIABILITY CAP5879977 11/12/08 11/12/09 COMBINED SINGLE LIMIT
~ ANY AUTO (Ea accident) $1,000,000
~ ALL OWNED AUTOS BODILY INJURY
$
SCHEDULED AUTOS (Per person)
~
~ HIRED AUTOS BODILY INJURY
$
~ NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
RRAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
A 0ESS/UMBRELLA LIABILITY CAP5879977 11/12/08 11/12/09 EACH OCCURRENCE $5 000 000
X OCCUR 0 CLAIMS MADE AGGREGATE $5.000.000
$
g DEDUCTIBLE $
X RETENTION $0 $
WORKERS COMPENSATION AND I WC STATU-.I 10J~-
EMPLOYERS' LIABILITY $
ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT
OFFICER/MEMBER EXCLUDED? EL DISEASE - EA EMPLOYEE $
If yes, describe under EL DISEASE - POLICY LIMIT $
SPECIAL PROVISIONS beiow
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Certificate Holder is Named as Additional Insured As Respects to:
General Liability Only
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Collier County Board of County DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ---1D..- DAYS WRITTEN
Commissioners & The Tourist NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
Development Council IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
3301 East Tamiami Trail
Naples, FL 34112 .
ACORD 25 (2001/08) 1 of 2 #S378319/M345157 NSA @ ACORD CORPORATION 1988
WC 000001 A0209
.
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
D New Policy No. 5400000061091
~ Renewal D Reissue 0 Rewrite Prior Policy No: 5400000061081
EVEREST NATIONAL INSURANCE COMPANY (A stock company) Account No: P540409354
NCCI Carrier Code: 28312
477 Martinsville Road
Liberty Corner, NJ 07938-0830
Telephone Number: 800-438-4375
Branch Code: 003
1. The Insured: NAPLES BOTANICAL GARDENS Producer: PBOA, INC.
Mailing address: 4820 BAYSHORE DR Address: 1800 SECOND STREET
NAPLES, FL 34112 SUITE 909
SARASOTA, FL 34236-0000
Sub-producer: PAYCHEX AGENCY INC.
150 SAWGRASS DRIVE
Address: ROCHESTER NY 14620
o Individual 0 Partnership 0 Corporation 0 Joint Venture ~ Other NON PROFIT
FEIN: SEE EXTENSION OF INFORMATION PAGE - NAMED INSURED, IDENTIFICATION NUMBERS AND OTHER WORKPLACES
SCHEDULE.
Other Workplaces not. shown above: SEE EXTENSION OF INFORMATION PAGE - NAMED INSURED, IDENTIFICATION NUMBERS
AND OTHER WORKPLACES SCHEDULE.
2. The policy period is from 02-01-2009 to 02-01-2010 effective 12:01 a.m. Standard
Time at the insured's mailing address. 0 This is a three-year fixed policy
Anniversary Rate Date:
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of
the states or territories listed here:
FL
B. Employers Liability Insurance: Part Two of the policy applies to work in each state or territory listed in Item 3A
The limits of our liability under Part Two are: ~.._-----)
Bodily Injury by Accident $ 100,000 . each accident
Bodily Injury by Disease $ 500,060 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states or territories, if any, listed here:
All states EXCEPT those listed in item 3A of the Information Page and the following states or territories:
HI NC ND OH PR VT VI WA WY
D. This policy includes these endorsements and schedules:
SEE EXTENSION OF INFORMATION PAGE - SCHEDULE OF FORMS AND ENDORSEMENTS.
4. 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.
SEE EXTENSION OF INFORMATION PAGE - CLASSIFICATION SCHEDULE/PREMIUM ELEMENTS.
Minimum Premium $ 515 Total Estimated Annual Premium $ 16,867
Expense Constant $ 200
Total Estimated Charge $ 16,867
If Indicated below, interim adjustments of
premium shall be made:
D Semi-annually D Quarterly D Monthly Deposit Premium $
Counters;gned by ~ ce..... ~
Date LA ~
Includes copyrighted material of National Council on Compensation Insurance, Inc. used with its pe mission @ 1988, 1991 NCCI
INSURED COPY