Backup Documents 09/22/2015 Item #16K6 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLS l
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO16
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach 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 be received in the County Attorney Office no later
than Monday 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
1.
2.
3. County Attorney Office County Attorney Office KN 9/22/15
4. BCC Office Board of County -(\(
Commissioners 11\1 /
c \- \ S
5. Minutes and Records Clerk of Court's Office nA /
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 Kevin Noell,Assistant County Attorney Phone Number 252-8400
Contact/ Department
Agenda Date Item was 9/22/15 V Agenda Item Number 16-K-6 f�
Approved by the BCC
Type of Document Release of Property Damage—Check Number of Original One of each
Attached Documents Attached
PO number or account
number if document is h 4%,
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)
1. Does the document require the chairman's original signature? KN
2. Does the document need to be sent to another agency for additional signatures? If yes, KN See not
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet. below
3. Original document has been signed/initialed for legal sufficiency. (All documents to be KN
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 KN
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 KN
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 KN
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip KN
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 9/22/15 and all changes made during the KN N/A is not
meeting have been incorporated in the attached document. The County Attorney's an option for
Office has reviewed the changes,if applicable. is line.
9. Initials of attorney verifying that the attached document is the version approved by t KN E'-4 ' s not
BCC,all changes directed by the BCC have been made,and the document is ready 'sr the `+ ` an o r ion fox
Chairman's signature. • •P 'AI me,
PLEASE PROVIDE CERTIFIED COPY OF RELEASE AND THE C . TO R I : SHELEY
CLERKS OF COURTS/FINANCE-252-8438
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12
MEMORANDUM
K
Date: September 24, 2015
To: Kevin Noell, Assistant County Attorney
County Attorney's Office
From: Martha Vergara, Deputy Clerk
Minutes & Records Department
Re: Release of Property Damage— Lori I. Chaffin
Attached is certified copy of the document referenced above, (Agenda Item #16K6)
approved by the Board of County Commissioners on Tuesday, September 24, 2015.
An original has been kept by the Minutes and Record's Department as part of the
Board's Official Records.
If you have any questions, please contact me at 252-7240.
Thank you.
1
RELEASE OF PROPERTY DAMAGE CLAIM 16W 6
Claim Number: 0268143190101118 Adjuster Code: J569L
The undersigned is over the age of 18 and has authority to execute this document on behalf of all
persons or entities entitled to make a property damage claim arising out of the motor vehicle accident
identified below.
The undersigned, in consideration for payment of Seven Thousand Seven Hundred Thirty-One and
79/100 dollars ($7,731.79), forever releases, acquits and discharges Michael Chalfin, Tyler Chalfin, and
GEICO General Insurance, their agents, servants, successors, heirs, executors, administrators, persons,
firms, corporations, associations or partnerships, of and from any and all property damage claims and/or
causes of action for property damage, which now exist and/or which may accrue on account of, or in any
way arising out of, the motor vehicle accident that occurred in Collier County, Florida on or about
Thursday, March 13, 2014.
This settlement is a compromise of a disputed claim. Payment is not an admission of liability. The parties
hereby released deny any and all liability to the undersigned upon all claims which have been asserted or
might hereafter be asserted pertaining to the aforementioned motor vehicle accident.
It is understood and agreed that all liens which may be outstanding against the property for which this
settlement is made will be satisfied from the aforementioned sum and that no other provision of any
nature whatsoever has been made for the payment of such liens, and that the undersigned will indemnify
and hold harmless the released parties for all such liens.
The undersigned voluntarily accepts the sums offered for the purpose of making a full and final settlement
and acknowledges that no promise, inducement, representation or agreement not contained in this
document has been made to the undersigned or his/her representative, that this Release contains the
entire agreement between the parties to this Release, and that the terms of this Release are contractual
and not a mere recital. The undersigned acknowledges reading and understanding this Release.
Each party to this Release is responsible for their own attorneys fees and costs, if any.
THIS IS A RELEASE FOR CLAIMS OF PROPERTY DAMAGE, ONLY.
Any person who knowingly and with intent to injure, defraud, or deceive any insurer,files a statement of
claim containing any false, incomplete or misleading information is guilty of a felon of the third degree.
7:e %GGC-f."—
Board of County Commissioners of
Collier County TIM NANCE, CHAIRMAN
STATE OF FLORIDA
COUNTY OF COLLIER
br-f'
On theme ay of �' ,2015, before me personally appeared TIM ,who
voluntaril executed this document, under oath.
CIy
Z�y & 1-e My Commission Expires: tc)`-22D\\--\
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(Print,Type, or Stamp Name of Notary Public Or XXx� personally known
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Approved as to form and legality: , ;`, Y pw,, VIRGINIA A.MEET.-- -- --C=9/4"/1 E
�:. Notary Public-State of Florida f
' -1:9"1, _My Comm.Expires Jun 23,2017 '
Kevin Noell v.; -�� °s. Commission A�FF 11938
� %4 Bonded Through National Notary Assn.
Assistant County Attorney 09/08
Detailed Payment Summary
6K
GEICO GENERAL INSURANCE CO NO. pi 17339094
Field Claim Center: 08 Florida
Date: 04/20/2015
ONE GEICO CENTER Claim #: 0268143190101118
MACON, GA 31296-0001 Date of Loss: 03/13/2014
0
0
0
o Claimant Name: Collier County Bocc Pay To:
Insured Name: Ms. Lori I Chalfin COLLIER COUNTY BOARD COUNTY
Tax ID/SS#/ XX-XXX0558 COMMISSIONER
Atty ADJ Code:
Adjuster Code: J035
N
0
0
0
Total Amount:
Law Office Of Quentin Fairchild $****7,731.79
1500 Jackson ST Ste 300 Payment Type:
Fort Myers FL 33901-2939 LOSS
IP AND FEATURE AND AMOUNT
04 APD $***7731.79
In Payment Of
Property Damage Coverage
Payment of PD in
BOCC vs Chalfin
_ Visit geico.com
;*++ Now, parties involved in a GEICO claim can track the progress of the claim, view damage
A. photos and more at geico.com! *GEICO policyholders can make a payment, change drivers or
vehicles and request additional coverages.* Not insured with GEICO? 15 minutes could save
you 15% or more on car insurance. Of course, we're also available for policy or claim service
24/7 at 1-800-841-3000.
* These online services are unavailable to Assigned Risk policyholders.
clmschck PLEASE DETACH AND KEEP FOR YOUR RECORDS
GEICO GENERAL INSURANCE CO Bank of America
ONE GEICO CENTER 51-44
NO. N 173390941
MACON,GA 31296-0001 Hartford, CT 06120 119 CT VOID AFTER 180 DAYS
Claim Number: 0268143190101118
Claimant: Insured Name: Date:04/20/2015
Collier County Bocc Ms.Lori I Chapin Amount:
Feature Symbol&Amount
APD$***7731.79 $****7,731.79
**SEVEN-THOUSAND-SEVEN-HUNDRED-THIRTY-ONE*AND'79/100 LLA
Pay to the Order of: In Payment of:
COLLIER COUNTY BOARD COUNTY Property Damage Coverage
COMMISSIONER Payment of PD in
BOCC vs Chalfin
Mail To:
1a Office Of Quentin Fairchild
1500 Jackson ST Ste 300 oiev2.," wkj1/4..ta
Fort M}ers FL 33901-2939