Agenda 02/12/2013 Item #16A152/12/2013 16.A.15.
EXECUTIVE SUMMARY
Recommendation to increase the Board - authorized annual expenditures for "Records
Management Services" to Vital Records Control, LLC from $90,000 to an estimated annual
expenditure of $110,000 per fiscal year and to approve a budget amendment from Fund
113 to pay for these contracted services.
OBJECTIVE: To provide records management and storage retrieval services for the Growth
Management Division (GMD)/Planning and Regulation.
CONSIDERATIONS: The County advertised RFP 10 -5424 "Records Management Services"
on January 27, 2010 and sent solicitations to 96 vendors. On February 22, 2010, a selection
committee meeting was held to review the proposals from the two vendors that responded to the
solicitation: Datafile, Inc. and Vital Records Control, LLC (VRC), and ultimately the committee
selected VRC as the winning bidder. The Board of County Commissioners (Board) approved the
award to VRC at its June 8, 2010 meeting (Agenda Item 16.A.5) for an annual expenditure not to
exceed $90,000.
The term of the contract was set for one year with three optional one -year extensions, bringing
the total value of the contract over four years to $360,000. This value was based on historical
data and projected needs as determined by staff at the time. The Board's approval was intended
n as the spending control, but the contract does not reflect spending limits. With the increase in
building activity, it was determined that the original estimates need to be adjusted. In order to
prevent interruptions in payments, staff is updating its annual estimated expenditures for this
contract.
The amount spent since the beginning of the contract on June 8, 2010 through the end of fiscal
year 2012 was $231,836, which leaves only $38,164 eligible to be spent to stay within the
Board- approved $90,000 per year over the three -year period ($270,000) ending June 7, 2013.
The larger than anticipated expenditures were caused by an ever - increasing number of building -
related and land development- related documents that require off -site storage, as well as a
burgeoning demand for retrieving documents from off -site storage to respond to public records
requests from contractors, bank representatives, real estate professionals, and owner - builders.
VRC has been the record storage provider since 2002 for the Growth Management Division/
Planning & Regulation and currently maintains a total storage of greater than 26,000 square feet.
VRC provides next day delivery, is located off Metro Parkway in Lee County within a solid
customized concrete facility (no prefabricated or metal walls) that has a raised foundation of
greater than three feet above base flood elevation, and provides for monitored security twenty -
four hours a day. VRC has controlled access to this facility and provides for GPS tracked
shipments to maintain systematic storage and retrieval, as well as chain of custody requirements
that exceed State Public Records Laws, Chapter 119, F.S.
GROWTH MANAGEMENT IMPACT: There is no growth management impact associated
with this Executive Summary.
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2/12/2013 16.A.15.
n
LEGAL CONSIDERATIONS: This item has been reviewed by the County Attorney's Office,
requires majority vote, and is legally sufficient for Board action. — CMG
FISCAL IMPACT: Funds to support this records management services contract have been
budgeted for FY 13 in the amount of $90,000 in the GMD Operations and Regulatory
Management Department, Fund 113, Cost Center 138931. Funds are available in Fund 113
reserves to cover the additional $20,000 required to increase the FY 2013 spending to $110,000
and would be made available through a budget amendment upon Board approval.
i
RECOMMENDATION: That the Board of County Commissioners approves the Board -
authorized increase of annual expenditures for "Records Management Services" from $90,000 to
an estimated $110,000 per fiscal year and approves a budget amendment fam Fund 113 reserves
for $20,000 to pay for the contracted services.
Prepared By: Kenneth Kovensky, Financial and Operational Support Manger,
Growth Management Division/Planning and Regulation
Attachments: 1) RFP 10 -5424 Notice of Award
2) RFP 10 -5424 2011 First Renewal
3) RFP 10 -5424 2012 Second Renewal
4) Budget Amendment
rdallh
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2/12/2013 16.A.15.
COLLIER COUNTY
Board of County Commissioners
Item Number: 16.16.A.16.A.15.
Item Summary: Recommendation to increase the Board - authorized annual expenditures
for "Records Management Services" to Vital Records Control, LLC from $90,000 to an estimated
annual expenditure of $110,000 per fiscal year and to approve a budget amendment from Fund
113 to pay for these contracted services.
Meeting Date: 2/12/2013
Prepared By
Name: KovenskyKenneth
Title: Management/Budget Analyst, Senior,Operations & Regulatory Management
1/17/2013 4:15:03 PM
Approved By
Name: PuigJudy
Title: Operations Analyst, GMD P &R
Date: 1/24/2013 11:30:17 AM
Name: WardKelsey
Title: Manager - Contracts Administration,Purchasing & Ge
Date: 1/25/2013 12:58:54 PM
Name: FrenchJames
Title: Manager - CDES Operations,Operations & Regulatory
Date: 1/25/2013 1:27:13 PM
Name: WardKelsey
Title: Manager - Contracts Administration,Purchasing & Ge
Date: 1/25/2013 2:48:14 PM
Name: MarcellaJeanne
Title: Executive Secretary,Transportation Planning
Date: 1/28/2013 3:54:58 PM
Name: GreeneColleen
Title: Assistant County Attorney,County Attorney
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Date: 1/29/2013 4:14:16 PM
Name: KlatzkowJeff
Title: County Attorney
Date: 1/30/2013 8:18:52 AM
Name: FinnEd
Title: Senior Budget Analyst, OMB
Date: 1/30/2013 4:51:35 PM
Name: IsacksonMark
2/12/2013 16.A.15.
Title: Director -Corp Financial and Mgmt Svs,CMO
Date: 1/31/2013 12:05:15 PM
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00
June 8, 2010
lee 2/12/2013 16.A.15.
Purchasing Department
3301 Tamiami Trail East
Naples, Florida 34112
Telephone: 239 -252 -8407
Email: jackcurran@colliergov.net
www.colliergov.net
NOTICE OF AWARD
Mr. Raymond Helbig
Vital Records Control of Florida, LLC
11901 Amedicus Lane
Fort Myers, FL 33907
Re: RFP- 10 -5424 "Records Management Services"
Dear Mr. Helbig:
This letter serves as notification that you have been awarded a Purchase Order for Bid #14 -5424,
`Records Management Services" furnishing service, materials, and equipment in accordance with the
terms, conditions and the specifications of the solicitation.
A formal contract for this service will not be necessary. The Collier County department will forward
a purchase order which will serve as the County's agreement to your proposal.
Thank you for your interest in Collier County, and congratulations on the award of this solicitation. If
there are any questions, please do not hesitate to contact me at the above number.
Respectfully,
Jack Curran, Pur asing Agent
C: Project Manager
Praying Dq)aririv;t • 3301 Tamiarri Tra'sl East • Naples, Florida 34112 - www.coil€ergov.net-purchasing
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G/ Acquisitions/ I echFormsandLetiers/ AwardLetterBlanketPOwith Ins urance
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2/12/2013 16.A.15.
county
Administrative Services Division
Purchasing
February 15, 2011
Mr. Raymond Helbig
Vital Records Control of Florida, LLC
11901 Amedicus Lane
Fort Myers, FL 33907
Fax: 239.337.4055
Email: rhelbisa0_vrcoffl.com
RE: Renewal of Contract #10 -5424 NRecords Management Services"
Dear Mr. Helbig:
Collier County has been under Contract with your company for the referenced services for the past s-e
four years.
The County would like to renew this agreement under the same terms and conditions for one (1)
additional year In accordance with the renewal clause in the agreement.
If you are agreeable to renewing the, referenced contract, please indicate your Intentions by
providing the appropriate information as requested below:
_X I am agreeable to renewing the present contract for Records
Management Services under the same terms, conditions, and pricing as
the existing contract. The following attached documentation must be
provided with response.
• Provide updated and current insurance certificate, and
• Provide a copy of the company's Department of Homeland Security
executed E- Verify profile page or memorandum of understanding
I am not agreeable to renewal of this contract.
If you are agreeable to renewing the contract, said renewal will be in effect from June 8, 2011 until
June 7, 2012.
,
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rd�asrongDe)MTwt. 3327'Farriami'_._.. __ -. -- - _4112 -4901- www.cdliergov.nedpurchasing
2/12/2013 16.A.15.
Page 2of2
RE: Renewal of Contract #10 -5424 "Records Management Servicesn
Please return this letter to the Purchasing Department with your response, insurance certificate, E-
Verify or MOU at your earliest convenience. Your prompt attention is urgently requested. If you
have any questions you may contact me at 239 - 252 -6020, email brendareaves@collie[gov.net and
fax 239 - 252 -6592 or 239 - 732 -0844.
Best regards,
Brenda Reaves
Contract Technician
Name.of Company
Company Signature
Print Corporate Officer
Name
Signature Date
_Vital Records Control of
_Ray Helbig
_February 15, 2011
LLC
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Contact Name ,Ray Helbig
Telephone Number
_239 -337 -4030
FAX Number
239- 337 -4055
Email Address
—rhelbig@vrcoffl.com
Address
—11901 Amedicus Lane, Ft. Myers FL 33907
c: Ken Kovensky, Planning & Regulation
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2/12/2013 16.A.15.
111 T-0T0 - #
CERTIFICATE OF LIABILITY INSURANCE
INSR
LTR
TYPE OF INSURANCE
02/17/2011
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 oarti icate holder is an ADDITIONAL INSURED, the policAles) must be endamed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endcreemenL A statement on this certificate does not confer rights to the
cerdfloate holder In Neu of such endorsement(s).
PRODUCER
CONTACT
Menard, Gates & Mathis, Inc.
6401 Poplar
Suit 250
e
GENERAL LIABILITY
X COMMERCIALGENERALLIABIUTY
7v--I
CLAIMS-MADE OCCUR
N .C901)761 -3100 „x N ;(901)763 -4576
E-MAIL
wDRESS.
FL & MS #2087949476
Memphis, TN 38119
INSURERS AFFORDING COVERAGE
NAIL s
INSURED
INSURER A: CNA
$ 100
INSURER B :
PERSONAL & ADV INJURY
Vital Records Control, Inc.
868 Mt Moriah
Memphis, TN 38117
INSURER C:
INSURER D:
$ 2 000
INSURER E:
PRODUCTS - COMPNOP AGG
INSURER F:
A
COVERAGES CERTIFICATE NUMBER: 2010 Liabil itY 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
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN* SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
A
BR
POLICY NUr6ER
POUCY EFF
UMTr9
A
GENERAL LIABILITY
X COMMERCIALGENERALLIABIUTY
7v--I
CLAIMS-MADE OCCUR
AVAR/KY/5C/TN#20879S2687
I
FL & MS #2087949476
03/01/1010
0310112010
03/01/2011
03101/2011
_.
EACH OCCURRENCE
$ 11000,000
21111
MEDEXP(Anyonapt a,n)
$ 100
8 .1O OO
PERSONAL & ADV INJURY
S 1 000 O
GENERAL AGGREGATE
$ 2 000
GEN'L AGGREGATE LIMIT APPLIES PER
POLICY 7 JM' F1 LOC
PRODUCTS - COMPNOP AGG
$ 2, O
$
A
AUTOMOBILE
X
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON- OWNEDAUTOS
A
R /KY /SCiiN#12088T5506
FL & MS #208784852
03fMRa10
03/01/2010
o3ro1/2011
0310112011
(Es r)1 T
$ 1,000,00
BODILY INJURY (Per pman)
S
BODILY INJURY (Per aoddeM)
S
PROPERTY DAMAGE
(PersoddeM)
$
X
X
$
S
A
UMBRELLA UAS
EXCESS LIAR
X
OCCUR
CLAIMS MADE
AL
LOCATIONS #208875516
I
03/01/2010
03/0112011
EACH OCCURRENCE
$ 10,000,
AGGREGATE
$ 10 000,00
DEDUCTIBLE
RETENTION $ 10,00
S
X I
g
A
AND �oYERB LIABILITY YIN
ANY PROMEMBE EXCLUDED? RTNE UTTVED
(Mandatory In NH)
If yyeass deser1r, u 'r
DESGRIP'F10N OF OPERATIONS below
N/A
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/KY /SC/TN#208875511
FL & MS #208784851
03101/2010
0=112010,
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03101=11
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E.L. EACH ACCIDENT
$ SOO
EL DISEASE - EA EMPLOYEE
$ 500
EL DISEASE - POUCY UMIT
$ SOO
DESCRIPTION OF OPERATIONS 1 LOCATIONS f VEHICLES (AUach ACORD 101, Adddonst Ramada SchedYN, N norm space Is required)
e: For any and all work performed on behalf of Collier County.
ollier County is named as Additional Insured for Camlercial General Liability where required.
VAIVArCLLA I I VII
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Collier County AUTHORIZED REPRESENTATIVE
Board of County Commissioners
Naples, FL S. Eugene Mathis,
Cda77�:•7:7_II I [•7;�_11iiT� iu ��-s:= ?-- :^.-:A
ACORD 25 (2009109) The ACORD nai ' ' Id matt of ACORD
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2/12/2013 16.A.15.
r.
co ,� caufty
Administrative Services Division
Purchasing
February 28, 2012
Mr. Raymond Helbig
Vital Records Control of Florida, LLC
11901 Amedicus Lane
Fort Myers, FL 33907
Fax: 239- 337 -4058
Email: rhelbiaC04rcoffi.com
RE: Renewal of Contract #10 -5424 "Records Management Services"
Dear Mr. Helbig:
Collier County would like to renew the above agreement under the same terms and conditions for
one (1) additional year in accordance with the renewal clause in the agreement. Per your
agreementtcontract, you may at time of renewal request a price increase.
If you are agreeable please indicate your intentions by providing the appropriate information as
requested below:
I am agreeable to renewing the above referenced contract under the
same terns, conditions, and pricing as the existing contract. The
folbwing attached documentation must be provided with response.
• Provide updated and current insurance certificate, and
• Provide a copy of the company's Department of Homeland Security
executed E Verify profile page or memorandum of understanding.
I am not agreeable to renewal of this contract.
By your signature this contract will be in effect from June 8, 2012 until June 7, 2013.
8 DqM • 3327 TWOM Trd East • Naples, Florida 34112 -4901 • www.cOWerpotcnetlpwe N*V
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2/12/2013 16.A.15.
Page 2 of 2
RE: Renewal of Contract #10 -6424 "Records Managem6nt Services"
Please return this letter to the Purchasing Department with your response, insurance certificate, E-
Verify. or MOU at your earliest convenience. If you have any questions you may contact me at
239 - 252- 8407, email kathleenmullins0collieroov.net and fax 239 - 252 -2861.
Best regards,
Stephen Y. Camel)
Director - Purchasing
. f
T
• • _ ♦. r
i
C: Ken Kovensky, Planning & Regulation
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VII* 2/12/2013 16.A.15.
Company ID Number: A f - 20in-7 833
THE E- VERIFY PROGRAM FOR EMPLOYMENT VERIFICATION
MEMORANDUM OF UNDERSTANDING
ARTICLE I
PURPOSE AND AUTHORITY
This Memorandum of Understanding (MOU) sets forth the �ppoints of agreement betwe�sn
the Department of Homeland Security (DHS) and �Ci ll kp- rii
IT t Employer) regarding the Employer's participation in the Employment Eligibility
Verification Program (E- Verify). This MOU explains certain features of the E- Verify
program and enumerates specific responsibilities of DHS, the Social Security
Administration (SSA), and the Employer. E- Verify is a program that electronically
confirms an employee's eligibility to work in the United States after completion of the
Employment Eligibility Verification Form (Form 1 -9). For covered government contractors,
E- Verify is used to verify the employment eligibility of all newly hired employees and all
existing employees assigned to Federal contracts or to verify the entire workforce if the
contractor so chooses.
Authority for the E- Verify program is found in Title IV, Subtitle A, of the Illegal
Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA), Pub. L. 104 -208,
110 Stat. 3009, as amended (8 U.S.C. § 1324a note). Authority for use of the E- Verify
program by Federal contractors and subcontractors covered by the terms of Subpart
22.18, "Employment. Eligibility Verification ", of the Federal Acquisition Regulation (FAR)
(hereinafter referred to in this MOU as a "Federal contractor with the FAR E- Verify
clause") to verify the employment eligibility of certain employees working on Federal
contracts is also found in Subpart 22.18 and in Executive Order 12989, as amended.
ARTICLE 11
FUNCTIONS TO BE PERFORMED
A. RESPONSIBILITIES OF SSA
1. SSA agrees to provide the Employer with available information that allows the
Employer to confirm the accuracy of Social Security Numbers provided by all employees
verified under this MOU and the employment authorization of U.S. citizens.
2. SSA agrees to provide to the Employer appropriate assistance with operational
problems that may arise during the Employer's participation in the E- Verify program.
SSA agrees to provide the Employer with names, titles, addresses, and telephone
numbers of SSA representatives to be contacted during the E Verify process.
3. SSA agrees to safeguard the information provided by the Employer through the E-
Verify program procedures, and to limit access to such information, as is appropriate by
law, to individuals responsible for the verification of Social Security Numbers and for
evaluation of the E -Verify program or such other persons or entities who may be
authorized by SSA as governed by the Privacy Act (5 U.S.C. § 552a), the Social Security
Act (42 U.S.C. 1306(a)), and SSA regulations (20 CFR Part 401).
Page 1 of 131 E -Verify MOU for Employer I Revision Date 09 /01/09 www.dhS.gOV/E- Verify
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2/12/201316.A.15.
Company ID Number: 41-o?M7883
4. SSA agrees to provide a means of automated verification that is designed (in �.
conjunction with DHS's automated system if necessary) to provide confirmation or
tentative nonconfirmation of U.S. citizens' employment eligibility within 3 Federal
Government work days of the initial inquiry.
5. SSA agrees to provide a means of secondary verification (including updating SSA
records as may be necessary) for employees who contest SSA tentative
nonconfirmations that is designed to provide final confirmation or nonconfirmation of
U.S. citizens' employment eligibility and accuracy of SSA records for both citizens and
non - citizens within 10 Federal Government work days of the date of referral to SSA,
unless SSA determines that more than 10 days may be necessary. In such cases, SSA
will provide additional verification instructions.
B. RESPONSIBILITIES OF DHS
1. After SSA verifies the accuracy of SSA records for employees through E- Verify, DHS
agrees to provide the Employer access to selected data from DHS's database to enable
the Employer to conduct, to the extent authorized by this MOU:
• Automated verification checks on employees by electronic means, and
• Photo verification checks (when available) on employees.
2. DHS agrees to provide to the Employer appropriate assistance with operational
problems that may arise during the Employer's participation in the E- Verrfy program.
DHS agrees to provide the Employer names, titles, addresses, and telephone numbers
of DHS representatives to be contacted during the E- Verify process.
3. DHS agrees to make available to the Employer at the E- Verify Web site and on the E-
Verify Web browser, instructional materials on E- Verify policies, procedures and
requirements for both SSA and DHS, including restrictions on the use of E- Verify. DHS
agrees to provide training materials on E- Verify.
4. DHS agrees to provide to the Employer a notice, which indicates the Employer's
participation in the E- Verify program. DHS also agrees to provide to the Employer anti-
discrimination notices issued by the Office of Special Counsel .for Immigration - Related
Unfair Employment Practices (OSC), Civil Rights Division, U.S. Department of Justice.
5. DHS. agrees to issue the Employer a user identification number and password that
permits the Employer to verify information provided by employees with DHS's database.
6. DHS agrees to safeguard the information provided to DHS by the Employer, and to
limit access to such information to individuals responsible for the verification of
employees' employment eligibility and for evaluation of the E- Verify program, or to such
other persons or entities as may be authorized by applicable law. Information will be
used only to verify the accuracy of Social Security Numbers and employment eligibility,
to enforce the immigration and Nationality Act (INA) and Federal criminal laws, and to
administer. Federal contracting requirements.
Page 2 of 131 E- Verify MOU for Employer I Revision Date 09101109 www.dhs.gov /E- Verify
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Company ID Number: q 1- 2.067 233
7. DHS agrees to provide a means of automated verification that is designed (in
conjunction with SSA verification procedures) to provide confirmation or tentative
nonconfirmation of employees' employment eligibility within 3 Federal Government work
days of the initial inquiry.
8. DHS agrees to provide a means of secondary verification (including updating DHS
records as may be necessary) for employees who contest DHS tentative
nonconfirmations and photo non -match tentative nonconfirmations that is designed to
provide final confirmation or nonconfirmation of the employees' employment eligibility
within 10 Federal Government work days of the date of referral to DHS, unless DHS
determines that more than 10 days may be necessary. In such cases, DHS will provide
additional verification instructions.
C. RESPONSIBILITIES OF THE EMPLOYER
1. The Employer agrees to display the notices supplied by DHS in a prominent place that
is clearly visible to prospective employees and all employees who are to be verified
through the system.
2. The Employer agrees to provide to the SSA and DHS the names, titles, addresses,
and telephone numbers of the Employer representatives to be contacted regarding E-
Verify.
3. The Employer agrees to become familiar with and comply with the most recent
version of the E- Verify User Manual.
4. The Employer agrees that any Employer Representative who will perform employment
verification queries will complete the E- Verify Tutorial before that individual initiates any
queries.
A. The Employer agrees that all Employer representatives will take the refresher
tutorials initiated by the E- Verify program as a condition of continued use of E-
Verify.
B. Failure to complete a refresher tutorial will prevent the Employer from
continued use of the program.
5. The Employer agrees to comply with current Form 1 -9 procedures, with two
exceptions:
• If an employee presents a "List 13" identity document, the Employer agrees to
only accept "List B" documents that contain a photo. (List B documents identified in 8
C.F.R. § 274a.2(b)(1)(B)) can be presented during the Form 1 -9 process to establish
identity.) If an employee objects to the photo requirement for religious reasons, the
Employer should contact E- Verify at 888 -464 -4218.
• If an employee presents a DHS Form 1 -551 (Permanent Resident Card) or Form
1 -766 (Employment Authorization Document) to complete the Form 1 -9, the
Employer agrees to make a photocopy of the document and to retain the
photocopy with the employee's Form 1 -9. The photocopy must be of sufficient
quality to allow for verification of the photo and written information. The employer
will use the photocopy to verify the. photo and to assist DHS with its review of
Page 3 of 131 E -Verify Mou for Employer I Revision Date 09/01/09 www.dhs.gov/E- Verify
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VeJrJFy 2/12/2013 16.A.15.
Company ID Number: 4 1- ID67 S _2�21
photo non - matches that are contested by employees. Note that employees retain ^
the right to present any List A, or List B and List C, documentation to complete
the Form 1 -9. OHS may in the future designate other documents that activate the
photo screening tool
6. The Employer understands that participation in E- Verify does not exempt the
Employer from -the responsibility to complete, retain, and make available for inspection
Forms 1 -9 that relate to its employees, or from other requirements of applicable
regulations or laws, including the obligation to comply with the antidiscrimination
requirements of section 2748 of the INA with respect to Form 1 -9 procedures, except for
the following modified requirements applicable by reason of the Employer's participation
in E- Verify: (1) identity documents must have photos, as described in paragraph 5
above; (2) a rebuttable presumption is established that the Employer has not violated
section 274A(a)(1)(A) of the Immigration and Nationality Act (INA) with respect to the
hiring of any individual if it obtains confirmation of the identity and employment eligibility
of the individual in good faith compliance with the terms and conditions of E- Verify; (3)
the Employer must notify OHS if it continues to employ any employee after receiving a
final nonconfirmation, and is subject to a civil money penalty between $550 and $1,100
for each failure to notify OHS of continued employment following a final nonconfirmation;
(4) the Employer is subject to a rebuttable presumption that it has knowingly employed
an unauthorized alien in violation of section 274A(a)(1)(A) if the Employer continues to
employ an employee after receiving a final nonconfirmation; and (5) no person or entity
participating in E- Verify is civilly or criminally liable under any law for any action taken in
good faith based on information provided through the confirmation system. OHS
reserves the right to conduct Form 1 -9 and E- Verify system compliance inspections
during the course of E- Verify, as well as to conduct any other enforcement activity ^
authorized by law.
7. The Employer agrees to initiate E- Verify verification procedures for new employees
within 3 Employer business days after each employee has been hired (but after the
Form 1 -9 has been completed), and to complete as many (but only as many) steps-of the
E- Verify process as are necessary according to the E- Verify User Manual, or in the case
of Federal contractors with the FAR E- Verify clause, the E- Verify User Manual for
Federal Contractors. The Employer is prohibited from initiating verification procedures
before the employee has been hired and the Form 1 -9 completed. If the automated
system to be queried is temporarily unavailable, the 3 -day time period is extended until it
is again operational in order to accommodate the Employer's attempting, in good faith, to
make inquiries during the period of unavailability. Employers may initiate verificabon by
notating the Form 1 -9 in circumstances where the employee has applied for a Social
Security Number (SSN) from the SSA and is waiting to receive the SSN, provided that
the-Employer performs an E- Verify employment verification query using the employee's
SSN as soon as the SSN becomes available.
8. The Employer agrees not to use E- Verify procedures for pre - employment screening of
job applicants, in support of any unlawful employment practice, or for any other use not
authorized by this MOU. Employers must use E- Verify for all new employees; unless an
Employer is a Federal contractor that qualifies for the exceptions described in Article
I1.0.1.c. Except as provided in Article ILD, the Employer will not verify selectively and will
not verify employees hired before the effective date of this MOU. The Employer
understands that if the Employer uses the E -Verify system for any purpose other than as
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authorized by this MOU, the Employer may be subject to appropriate legal action and
termination of its access to SSA and DNS information pursuant to this MOU.
9. The Employer agrees to follow appropriate procedures (see Article III. below)
regarding tentative nonconfirmations, including notifying employees in private of the
finding and providing them written notice of the findings, providing written referral
instructions to employees, allowing employees to contest the finding, and not taking
adverse action against employees if they choose to contest the finding. Further, when
employees contest a tentative nonconfirmation based upon a photo non- match, the
Employer is required to .take affirmative steps (see Article III.B. below) to contact DHS
with information necessary to resolve the challenge.
10. The Employer agrees not to take any adverse action against an employee based
upon the employee's perceived employment eligibility status while SSA or DHS is
processing the verification request unless the Employer obtains knowledge (as defined
in 8 C.F.R. § 274a.1(I)) that the employee is not work authorized. The Employer
understands that an initial inability of the SSA or DHS automated verification system to
verify work authorization, a tentative nonconfirmation, a case in continuance (indicating
the need for additional time for the government to resolve a case), or the finding of a
photo non - match, does not establish, and should not be interpreted as evidence, that the
employee is not work authorized. In any of the cases listed above, the employee must
be provided a full and fair opportunity to contest the finding, and if he or she does so, the
employee may not be terminated or suffer any adverse employment consequences
based upon the employee's perceived employment eligibility status (including denying,
reducing, or extending work hours, delaying or preventing training, requiring an
employee to work in poorer conditions, refusing to assign the employee to a Federal
contract or other assignment, or otherwise subjecting an employee to any assumption
that he or she is unauthorized to work) until and unless secondary verification by SSA or
DHS has been completed and a final nonconfirmation has been issued. If the employee
does not choose to contest a tentative nonconfirmation or a photo non -match or if a
secondary verification is completed and a final nonconfirmation is issued, then the
Employer can find the employee is not work authorized and terminate the employee's
employment. Employers or employees with questions about a final nonconfirmation may
call E- Verify at 1- 888 - 464 -4218 or OSC at 1- 800 -255 -8155 or 1- 800 -237 -2515 (TDD).
11. The Employer agrees to comply with Title VII of the Civil Rights Act of 1964 and
section 274B of the INA, as applicable, by not discriminating unlawfully against any
individual in hiring, firing, or recruitment or referral. practices because of his or her
national origin or, in the case of a protected individual as defined in section 27413(a)(3) of
the INA, because of his or her citizenship status. The Employer understands that such
illegal practices can include selective verification or use of E -Verify except as provided in
part D below, or discharging or refusing to hire employees because they appear or
sound "Foreign" or have received tentative nonconfirmations. The Employer further
understands that any violation of the unfair immigration- related employment practices .
provisions 'in section 2748 of the INA could subject the Employer to civil penalties, back
pay awards, and other sanctions, and violations of Title VII could subject the Employer to
back pay awards, compensatory and punitive damages. Violations of either section 274B
of the INA or Title VII may also lead to the termination of its participation in E- Verify. If
the Employer has any questions relating to the antidiscrimination provision, it should
contact OSC at 1- 800 - 255 -8155 or 1- 800 -237 -2515 (TDD).
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Company ID Number: g L CA 9-325
12. The Employer agrees to record the case verification number on the employee's Form
1 -9 or to print the screen containing the case verification number and attach it to the
employee's Form 1 -9.
13. The Employer agrees that it will use the information it receives from SSA or DHS
pursuant to E- Verify and this MOU only to confirm the employment eligibility of
employees as authorized by this MOU. The Employer agrees that it will safeguard this
information, and means of access to it (such as PINS and passwords) to ensure that it is
not used for any other purpose and as necessary to protect its confidentiality, including
ensuring that it is not disseminated to any person other than employees of the Employer
who are authorized to perform the Employer's responsibilities under this MOU, except for
such dissemination as may be authorized in advance by SSA or DHS for legitimate
purposes.
14. The Employer acknowledges that the information which it receives from SSA is
govemed by the Privacy Act (5 U.S.C. § 552a(i)(1) and (3)) and the Social Security Act
(42 U.S.C. 1306(x)), and that any person who obtains this information under false
pretenses or uses it for any purpose other than as provided for in this MOU may be
subject to criminal penalties.
15. The Employer agrees to cooperate with DHS and SSA in their compliance
monitoring and evaluation of E- Verify, including by permitting DHS and SSA, upon
reasonable notice, to review Forms 1 -9 and other employment records and to interview it
and its employees regarding the Employer's use of E- Verify, and to respond in a timely
and accurate manner to DHS requests for information relating to their participation in E-
Verify.
D. RESPONSIBILITIES OF FEDERAL CONTRACTORS WITH THE FAR E- VERIFY
CLAUSE
1. The Employer understands that if it is a subject to the employment Verification
terms in Subpart 22.18 of the FAR, it must verify the employment eligibility of any
existing employee assigned to the contract and all new hires, as discussed in the
Supplemental Guide for Federal Contractors. Once an employee has been verified
through E- Verify by the Employer, the Employer may not reverify the employee through
E- Verify.
a. Federal contractors with the FAR E- Verify clause agree to become familiar
with and comply with the most recent versions of the E- Verify User Manual for Federal
Contractors and the E- Verify Supplemental Guide for Federal Contractors.
b. Federal contractors with the FAR E- Verify clause agree to complete a tutorial
for Federal contractors with the FAR E- Verify clause.
c. Federal contractors with the FAR E- Verify clause not enrolled at the time of
contract award: An Employer that is not enrolled in E- Verify at the time of a contract
award must enroll as a Federal contractor with the FAR E- Verify clause in E- Verify within
30 calendar days of contract award and, within 90 days of enrollment, begin to use .E-
Verify to initiate verification of employment eligibility of new hires of the Employer who
are working in the United States, whether or not assigned to the contract. Once the
Employer begins verifying new hires, such verification of new hires must be initiated
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Company ID Number: 41 -20LI Raj
n within 3 business days after the date of hire. Once enrolled in E- Verify as a Federal
contractor with the FAR E -Verify clause, the Employer must initiate verification of
employees assigned to the contract within 90 calendar days from the time of enrollment
in the system and after the date and selecting which employees will be verified in E-
Verify or within 30 days of an employee's assignment to the contract, whichever date is
later.
d. Employers that are already enrolled in E -Verify at the time of a contract award
but are not enrolled in the system as a Federal contractor with the FAR E- Verify clause:
Employers enrolled in E- Verify for 90 days or more at the time of a contract award must
use E- Verify to initiate verification of employment eligibility for new hires of the Employer
who are working in the United States, whether or not assigned to the contract, within 3
business days after the date of hire. Employers enrolled in E- Verify as other than a
Federal contractor with the FAR E- Verify clause, must update E- Verify to indicate that
they are a Federal contractor with the FAR E -Verify clause within 30 days after
assignment to the contract. If the Employer is enrolled in E- Verify for 90 calendar days or
less at the time of contract award, the Employer must, within 90 days of enrollment,
begin to use E- Verify to initiate verification of new hires of the contractor who are
working in the United States, whether or not assigned to the contract. Such verification
of new hires must be initiated within 3 business days after the date of hire. An Employer
enrolled as a Federal contractor with the FAR E- Verify clause in E- Verify must initiate
verification of each employee assigned to the contract within 90 calendar days after date
of contract award or within 30 days after assignment to the contract, whichever is later.
e. Institutions of higher education, State, local and tribal governments and
�. sureties: Federal contractors with the FAR E- Verify clause that are institutions of higher
education (as defined at 20 U.S.C. 1001(a)), State or local governments, governments of
Federally recognized Indian tribes, or sureties performing under a takeover agreement
entered into with a Federal agency pursuant to a performance bond may choose to only
verify new and existing employees assigned to the Federal contract. Such Federal
contractors with the FAR E- Verify clause may, however, elect to verify all new hires,
and /or all existing employees hired after November 6, 1986. The provisions of Article
II.D, paragraphs 1.a and 1.b of this MOU providing timeframes for initiating employment
verification of employees assigned to a contract apply to such institutions of higher
education, State, local and tribal governments, and sureties.
f. Verification of all employees: Upon enrollment, Employers who are Federal
contractors with the FAR E- Verify clause may elect to verify employment eligibility of all
existing employees working in the United States who were hired after November 6,
1986, instead of verifying only new employees and those existing employees assigned
to a covered Federal contract. After enrollment, Employers must elect to do so only in
the manner designated by DHS and initiate E- Verify verification of all existing employees
within 180 days after the election.
g. Form 1 -9 procedures for existing employees of Federal contractors with the
FAR E- Verify clause: Federal contractors with the FAR E- Verify clause may choose to
complete new Forms 1 -9 for all existing employees other than those that are completely
exempt from this process. Federal contractors with the FAR E- Verify clause may also
update previously completed Forms 1 -9 to initiate E -Verify verification of existing
employees who are not completely exempt as long as that Form 1 -9 is complete
--. (including the SSN), complies with Article II.C.5, the employee's work authorization has
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not expired, and the Employer has reviewed the information reflected in the Form 1 -9 ^
either in person or in communications with the employee to ensure that the employee's
stated basis in section 1 of the Form 1 -9 for work authorization has not changed
(including, but not limited to, a lawful permanent resident alien having become a
naturalized U.S. citizen). If the Employer is unable to determine that the Form 1 -9
complies with Article II.C.5, if the employee's basis for work authorization as attested in
section 1 has expired or changed, or if the Form 1 -9 contains no SSN or is otherwise
incomplete, the Employer shall complete a new 1 -9 consistent with Article II.C.5, or
update the previous 1 -9 to provide the necessary information. If section 1 of the Form 1 -9
is otherwise valid and up-to -date and the form otherwise complies with Article II.C.5, but
reflects documentation (such as a U.S. passport or Form 1 -551) that expired subsequent
to completion of the Form 1 -9, the Employer shall not require the production of additional
documentation, or use the photo screening tool described in Article II.C.5, subject to any
additional or superseding instructions that may be provided on this subject in the
Supplemental Guide for Federal Contractors. Nothing in this section shall be construed
to require a second verification using E- Verify of any assigned employee who has
previously been verified as a newly hired employee under this MOU, or to authorize
verification of any existing employee by any Employer that is not a Federal contractor
with the FAR E- Verify clause.
2. The Employer understands that if it is a Federal contractor with the FAR E- Verify
clause, its compliance with this MOU is a performance requirement under the terms of
the Federal contract or subcontract, and the Employer consents to the release of
information relating to compliance with its verification responsibilities under this MOU to
contracting officers or other officials authorized to review the Employer's compliance
with Federal contracting requirements.
ARTICLE III
REFERRAL OF INDIVIDUALS TO SSA AND DHS
A. REFERRAL TO SSA
1. If the Employer receives a tentative nonconfirmation issued by SSA, the Employer
must print the notice as directed by the E- Verfy system and provide it to the employee
so that the employee may determine whether he or she will contest the tentative
nonconfirmation. The Employer must review the tentative nonconfirmation with the
employee in private.
2. The Employer will refer employees to SSA field offices only as directed by the
automated system based on a tentative nonconfirmation, and only after the Employer
records the case verification number, reviews the input to detect any transaction errors,
and determines that the employee contests the tentative nonconfirmation. The Employer,
will transmit the Social Security Number to SSA for verification again if this review
indicates a need to do so. The Employer will determine whether the employee contests
the tentative nonconfirmation as soon as possible after the Employer receives it.
3. If the employee contests an SSA tentative nonconfirmation, the Employer will provide
the employee with a system- generated referral letter and instruct the employee to visit
an SSA office within 8 Federal Government work days. SSA will electronically transmit
the result of the referral to the Employer within 14 Federal Government work days of the ^
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Company ID Number
referral unless it determines that more than 10 days is necessary. The Employer agrees
to check the E -Verify system regularly for case updates.
4. The Employer agrees not to ask the employee to obtain a printout from the Social
Security Number database (the Numident) or other written verification of the Social
Security Number from the SSA.
B. REFERRAL TO DHS
1. If the Employer receives a tentative nonconfirmation issued by DHS, the Employer
must print the tentative nonconfirmation notice as directed by the E- Verify system and
provide it to the employee so that the employee may determine whether he or she will
contest the tentative nonconfirmation. The Employer must review the tentative
nonconfirmation with the employee in private.
2. If the Employer finds a photo non -match for an employee who provides a document
for which the automated system has transmitted a photo, the employer must print the
photo non -match tentative nonconfirmation notice as directed by the automated system
and provide it to the employee so that the employee may determine whether he or she
will contest the finding. The Employer must review the tentative nonconfirmation with the
employee in private.
3. The Employer agrees to refer individuals to DHS only when the employee chooses to
contest a tentative nonconfirmation received from DHS automated verification process or
when the Employer issues a tentative nonconfirmation based upon a photo non - match.
The Employer will determine whether the employee contests the tentative
nonconfirmation as soon as possible after the Employer receives it.
4. If the employee contests a tentative nonconfirmation issued by DHS, the Employer will
provide the employee with a referral letter and instruct the employee to contact DHS
through its toll -free hotline (as found on the referral letter) within 8 Federal Government
work days.
5. If the employee contests a tentative nonconfirmation based upon a photo non - match,
the Employer will provide the employee with a referral letter to DHS. DHS will
electronically transmit the result of the referral to the Employer within 10 Federal
Government work days of the referral unless it determines that more than 10 days is
necessary. The Employer agrees to check the E- Verify system regularly for case
updates.
6. The Employer agrees that if an employee contests a tentative nonconfirmation based
upon a photo non - match, the Employer will send a copy of the employee's Form 1 -551 or
Form 1 -766 to DHS for review by:
• Scanning and uploading the document, or
• Sending a photocopy of the document by an express mail account (paid for at
employer expense).
7. If the Employer determines that there is a photo non -match when comparing the
photocopied List B, document described in Article II.C.S with the image generated in E-
Verify, the Employer must forward the employee's documentation to DHS using one of
�-. the means described in the preceding paragraph, and allow DHS to resolve the case.
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ARTICLE IV
SERVICE PROVISIONS
SSA and DHS will not charge the Employer for verification services performed under this
MOU. The Employer is responsible for providing equipment needed to make inquiries.
To access E- Verify, an Employer will need a personal computer with Internet access.
ARTICLE V
PARTIES
A. This MOU is effective upon the signature of all parties, and shall continue in effect for
as long as the SSA and DHS conduct the E- Verify program unless modified in writing by
the mutual consent of all parties, or terminated by any party upon 30 days prior written
notice to the others. Any and all system enhancements to the E- Verify program by DHS
or SSA, including but not limited to the E- Verify checking against additional data sources
and instituting new verification procedures, will be covered under this MOU and will not
cause the need for a supplemental MOU that outlines these changes. DHS agrees to
train employers on all changes made to E -Verify through the use of mandatory refresher
tutorials and updates to the E-Verify User Manual, the E -Verify User Manual for Federal
Contractors or the E -Verify Supplemental Guide for Federal Contractors. Even without
changes to E- Verify, DHS reserves the right to require employers to take mandatory
refresher tutorials. An Employer that is a Federal contractor with the FAR E- Verify clause
may terminate this MOU when the Federal contract that requires its participation in E-
Verify is terminated or completed. In such a circumstance, the Federal contractor _with
the FAR E- Verify clause must provide written notice to DHS. If an Employer that is a
Federal contractor with the FAR E- Verify clause fails to provide such notice, that
Employer will remain a participant in the E -Verify program, will remain bound by the
terms of this MOU that apply to participants that are not Federal contractors with the
FAR E- Verify clause, and will be required to use the E -Verify procedures to verify the
employment eligibility of all newly hired employees.
B. Notwithstanding Article V, part A of this MOU, DHS may terminate this MOU if
deemed necessary because of the requirements of law or policy, or upon a
determination by SSA or DHS that there has been a breach of system integrity or
security by the Employer, or a failure on the part of the Employer to comply with
established procedures or legal requirements. The Employer understands that if it is a
Federal contractor with the FAR E -Verify clause, termination of this MOU by any party
for any reason may negatively affect its performance of its contractual responsibilities.
C. Some or all SSA and DHS responsibilities under this MOU may be performed by
contractor(s); and SSA and DHS may adjust verification responsibilities between each
other as they may determine necessary. By separate agreement with DHS, SSA has
agreed to perform its responsibilities as described in this MOU.
D. Nothing in this MOU is intended, or should be construed, to create any right or
benefit, substantive or procedural, enforceable at law by any third party against the
United States, its agencies, officers, or employees, or against the Employer, its agents,
officers, or employees.
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Company ID Number: P L2L6 g ;3
�.� E. Each party shall be solely responsible for defending any claim or action against, it
arising out of or related to E- Verify or this MOU, whether civil or criminal, and for any
liability wherefrom, including (but not limited to) any dispute between the Employer and
any other person or entity regarding the applicability of Section 403(d) of IIRIRA to any
action taken or allegedly taken by the Employer.
F. The Employer understands that the fact of its participation in E- Verify is not
confidential information and may be disclosed as authorized or required by law and DHS
or SSA policy, including but not limited to, Congressional oversight, E- Verify publicity
and media inquiries, determinations of compliance with Federal . contractual
requirements, and responses to inquiries under the Freedom of Information Act (FOIA).
G. The foregoing constitutes the full agreement on this subject between DHS and the
Employer.
H. The individuals whose signatures appear below represent that they are authorized to
enter into this MOU on behalf of the Employer and DHS respectively.
To be accepted as a participant in E- Verify, you should only sign the Employer's
Section of the signature page. If you have any questions, contact E Verify at 888-
464 -4218.
!Employer
Name (Please Type or Print)
We
HQ lbi ;
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ignature
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ate
e artment of Homeland Securi — Verification Division
ame (Please Type or Print) l Title
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Company ID Number: `Y' 206783
Information Required for the E- Verify Program
r
f
Information refatin�to —Your Company ——
a
Company Name: �!"n
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Cam an Facili Address:
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Company Alternate
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Number of Sites Verified
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Are you verifying for more than 1 site? If yes, please provide the number of sites verified for
pin each State:
State Number of sites _ Site(s)�_
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Company ID Number. _4L 906 7 Y a
�lntbrmation relating to the Program Administrato
lperatiotional problems: r(s) for your Company on policy questions or
Name:
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Information relating to the Program Administrators) for your Company on policy questions or
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Fax Number•
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AC RD► 2/12/201316.A.15.
`,� CERTIFICATE OF LIABILITY INSURANCE 1 2/24/2012
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.
APORTANT: 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 NTACT
NAME.
Menard, Gates & Mathis, Inc. PHONE (901)761-3100
6401 Poplar E -Main No; (901)888 -3263
ADDRESS:
Suite 250 PRODUCER
TN 38119
INSURED
Vital Records Control, Inc.
868 Mt Moriah
Memphis, TN 38117
COVFRAGFIC ?%M22
A •rlationa.L Fire Ins. of Hartford
B:Travelers Prop & Cas Co of Ame
c: Transportation Insurance Co
D:The Travelers Indem Co of Conn
Kt= VISIUN 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
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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR
LTR ! TYPE OF INSURANCE B POLICY NUMBER MNOI/uDDYiYYYY MM DDY EXP LIMITS
GENERAL LIABILITY X 087852687 03/01/2012 3/01/2013 EACH OCCURRENCE $ 1, 000,000
X COMMERCIAL GENERAL LIABILITY
PREMISES Ea occurrence $ 100,000 DAMAGE TO RENTED
A CLAIMS -MADE FZ OCCUR MED EXP (Any one parson) $ 10,000
PERSONAL & ADV INJURY I $
1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO- I � X LOC
GENERAL AGGREGATE Is
PRODUCTS - COMP /OP AGG $
$
2,000,000
2,000,000
4UTOMOBILE
X
LIABILITY
ANY ADO
P- 810- 962J460- 6- TIL -12
3/01/2012
03/01/2013
COMBINED SINGLE LIMIT
(Ea accident)
$
1,000,000
BODILY INJURY (Per person)
$
B
ALL OWNED AUTOS
BODILY INJURY (Per accident)
$
SCHEDULED AUTOS
X
IPROPERTY DAMAGE
accident)
$
HIRED AUTOS
NON -OWNED AUTOS
$500 Ct� DIED
ISl , 000 COLL DED
X(Per
$
Is
C I
D
X
EXCESS UMBRELLA B X OCCUR
EXCESS LIAB CLAIMS -MADE
I
N / A
I
I
I
�C088755164
A- UB- 3B97440 -5 -12
03/01/2012
I
3/01/2012103/01
03/01/20131
/2013
EACH OCCURRENCE j
$
10,000,000
AGGREGATE Is
10,000,000
DEDUCTIBLE
X RETENTION $ 10 000
WORKERS COMPENSATION
I
AND- EMPLOYERS, LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
H yes, describe under
DESCRIPTION OF OPERATIONS bebw
Is
X WC STATU- OTH-
IM T
$
E.L. EACH ACCIDENT
$
500 000
E.L. DISEASE - EA EMPLOYEE
$
500,000
E.L. DISEASE - POLICY LIMIT
$
500 000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space Is required)
Re: For any and all work Performed on behalf Of Collier County. Collier County is named as Additional Insured for
Commercial General Liability where required.
CFRTIFICATF i ni nx:P
Collier County
^1 Board of County Commissioners
Naples, EL
ACORD 25 120n9/n91
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Eugene Mathis, Jr /C -
INS025 (2oosos) The ACORD name Packet Page -1260- marks of ACORD Ku wRPORATION. All rights reserved.
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