Backup Documents 06/23/2009 Item #16F 7
16F 7
MEMORANDUM
Date: July 2, 2009
To: Diana DeLeon
Purchasing Department
From: Ann Jennejohn, Deputy Clerk
Minutes & Records Department
Re: Contract #09-5174: Management Services for
The Pelican Bay Services Division
Dorrill Management Group, LLC
Attached is an original copy of the contract referenced above,
(Agenda Item #16F7) approved by the Board of County
Commissioners on Tuesday, June 23, 2009.
The Minutes and Records Department has kept the other original
document for the Board's permanent record.
If you should have any questions, please contact me at 252-8406.
Thank you.
Attachments (I)
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7
A G R E E MEN T 09-5174
for
Management Services for Pelican Bay Services
THIS AGREEMENT, made and entered into on this 23rd day of June, 2009, by and between
Dorrill Management, authorized to do business in the State of Florida, whose business
address is 5672 Strand Ct. Suite 1, Naples, Florida 34110, hereinafter called the "Consultant"
and Collier County, a political subdivision of the State of Florida, Collier County, Naples,
hereinafter called the "County":
WIT N E SSE T H:
1. COMMENCEMENT. The Consultant shall commence the work upon execution of this
agreement. The contract shall be for a period of (12) months. Additionally, by mutual
agreement and funding availability, the contract may be renewed for three (3) terms of
twelve (12) months each. In no event, including renewal options, shall the contract
exceed four (4) years. The County shall give the Consultant written notice of the
County's intention to extend the Agreement term not less than ten (10) days prior to the
end of the Agreement term then in effect.
2. STATEMENT OF WORK. The Consultant shall provide Management Services in
accordance with the terms and conditions of RFP #09-5174 and the Consultant's
proposal referred to herein and made an integral part of this agreement. This
Agreement contains the entire understanding between the parties and any
modifications to this Agreement shall be mutually agreed upon in writing by the
Consultant and the County Contract Manager or his designee, in compliance with the
County Purchasing Policy and Administrative Procedures in effect at the time such
services are authorized.
3. THE CONTRACT SUM. The County shall pay the Consultant for the performance of
the Agreement the sum of forty-two thousand three hundred dollars ($42,300,00) for the
period of time commencing on June 23, 2009, and ending on June 22, 2010, payable at
the rate of three thousand five hundred thirty-three dollars ($3,533,00) per month,
subject to Change orders as approved in advance by the County. The yearly price shall
be fixed and firm for the duration of the contract and all travel expenses shall be paid at
actual costs with no markup for any travel outside of Lee and Collier County. Payment
will be made upon receipt of a proper invoice and in compliance with Section 218.70,
Fla. Stats., otherwise known as the "Local Government Prompt Payment Act".
Page I of9
TRAVEL AND REIMBURSABLE EXPENSES
Travel expenses shall be reimbursed as per Section 112.061 Fla. Stats.
16F
7
Reimbursements shall be at the following rates:
Mileage $0.445 per mile
Breakfast $6.00
Lunch $11.00
Dinner $19.00
Airfare Actual ticket cost limited to
tourist or coach class fare
Rental car Actual rental cost limited to
compact or standard -size
vehicles
Lodging Actual cost of lodging at single
occupancy rate with a cap of no
more than $150.00 per night
Parking Actual cost of parking
Taxi or Airport Actual cost of either taxi or
Limousine airport limousine
Reimbursable items other than travel expenses shall be limited to the following:
telephone long-distance charges, fax charges, photocopying charges and postage.
Reimbursable items will be paid only after Consultant has provided all receipts.
Consultant shall be responsible for all other costs and expenses associated with activities
and solicitations undertaken pursuant to this Agreement.
4. SALES TAX. Consultant shall pay all sales, consumer, use and other similar taxes
associated with the Work or portions thereof, which are applicable during the
performance of the Work.
5. NOTICES. All notices from the County to the Consultant shall be deemed duly served
if mailed or faxed to the Consultant at the following Address:
Dorrill Management Group, Inc.
5672 Strand Ct. Suite 1
Naples, Florida 34110
Telephone: 239-592-9115
Attn: William N. Dorrill
Fax: 239-594-4122
Page 2 of9
All Notices from the Consultant to the County shall be deemed duly served if mailed or
faxed to the County to:
Collier County Government Center
Purchasing Department - Purchasing Building
3301 Tamiami Trail, East
Naples, Florida 34112
Attention: Steve Carnell, Purchasing/ GS Director
Telephone: 239-252-8371
Facsimile: 239-252-6584
16F
7
The Consultant and the County may change the above mailing address at any time
upon giving the other party written notification. All notices under this Agreement must
be in writing.
6. NO PARTNERSHIP, Nothing herein contained shall create or be construed as creating
a partnership between the County and the Consultant or to constitute the Consultant as
an agent of the County.
7. PERMITS: LICENSES: TAXES. In compliance with Section 218,80, F.s., all permits
necessary for the prosecution of the Work shall be obtained by the Consultant. Payment
for all such permits issued by the County shall be processed internally by the County.
All non-County permits necessary for the prosecution of the Work shall be procured
and paid for by the Consultant. The Consultant shall also be solely responsible for
payment of any and all taxes levied on the Consultant. In addition, the Consultant shall
comply with all rules, regulations and laws of Collier County, the State of Florida, or the
U. S. Government now in force or hereafter adopted. The Consultant agrees to comply
with all laws governing the responsibility of an employer with respect to persons
employed by the Consultant.
8. NO IMPROPER USE. The Consultant will not use, nor suffer or permit any person to
use in any manner whatsoever, County facilities for any improper, immoral or offensive
purpose, or for any purpose in violation of any federal, state, county or municipal
ordinance, rule, order or regulation, or of any governmental rule or regulation now in
effect or hereafter enacted or adopted. In the event of such violation by the Consultant
or if the County or its authorized representative shall deem any conduct on the part of
the Consultant to be objectionable or improper, the County shall have the right to
suspend the contract of the Consultant. Should the Consultant fail to correct any such
violation, conduct, or practice to the satisfaction of the County within twenty-four (24)
hours after receiving notice of such violation, conduct, or practice, such suspension to
continue until the violation is cured. The Consultant further agrees not to commence
operation during the suspension period until the violation has been corrected to the
satisfaction of the County,
9. TERMINATION. Should the Consultant be found to have failed to perform his
services in a manner satisfactory to the County as per this Agreement, the County may
terminate said agreement immediately for cause; further the County may terminate this
Agreement for convenience with a thirty (30) day written notice. The County shall be
sole judge of non-performance.
Page 3 of9
10.
NO DISCRIMINATION. The Consultant agrees that there shaH be no dislttttiOn 7
as to race, sex, color, creed or national origin.
11.
INSURANCE. The Consultant shall provide insurance as follows:
A. Commercial General Liability: Coverage shall have minimum limits of $1,000,000
Per Occurrence, Combined Single Limit for Bodily Injury Liability and Property
Damage Liability. This shall include Premises and Operations; Independent
Consultants; Products and Completed Operations and Contractual Liability.
B. Business Auto Liability: Coverage shall have minimum limits of $1,000,000 Per
Occurrence, Combined Single Limit for Bodily Injury Liability and Property
Damage Liability. This shall include: Owned Vehicles, Hired and Non-Owned
Vehicles and Employee Non-Ownership.
C. Workers' Compensation: Insurance covering all employees meeting Statutory
Limits in compliance with the applicable state and federal laws.
The coverage must include Employers' Liability with a minimum limit of $500,000
for each accident.
D. Professional Liability: Coverage shall have a minimum limit of $1,000,000
Special Requirements: Collier County shall be listed as the Certificate Holder and
included as an Additional Insured on the Comprehensive General Liability
Policy.
Current, valid insurance policies meeting the requirement herein identified shall
be maintained by Consultant during the duration of this Agreement. Renewal
certificates shall be sent to the County thirty (30) days prior to any expiration date.
There shall be a thirty (30) day notification to the County in the event of
cancellation or modification of any stipulated insurance coverage.
Consultant shall insure that all subcontractors comply with the same insurance
requirements that he is required to meet. The same Consultant shall provide
County with certificates of insurance meeting the required insurance provisions.
12. INDEMNIFICATION. To the maximum extent permitted by Florida law, the
Consultant shall indemnify and hold harmless Collier County, its 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 Consultant or anyone
employed or utilized by the Consultant 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.
This section does not pertain to any incident arising from the sole negligence of
Page 4 of9
Collier County.
13.
liF 7
CONTRACT ADMINISTRATION. This Agreement shall be administered on behalf
of the County by Pelican Bay Management Services Division.
14.
CONFLICT OF INTEREST: Consultant represents that it presently has no interest and
shall acquire no interest, nor give the appearance of conflict of interest either direct or
indirect, which would conflict in any manner with the performance of services required
hereunder. Consultant further represents that no persons having any such interest shall
be employed to perform those services.
15,
COMPONENT PARTS OF THIS CONTRACT. This Contract consists of the attached
component parts, all of which are as fully a part of the contract as if herein set out
verbatim: Consultant's Proposal, Insurance Certificate, RFP #09-5174, Exhibit A Scope
of Services and Addendum! Addenda.
16.
SUBJECT TO APPROPRIATION. It is further understood and agreed by and
between the parties herein that this agreement is subject to appropriation by the Board
of County Commissioners.
17,
PROHIBITION OF GIFTS TO COUNTY EMPLOYEES. No organization or
individual shall offer or give, either directly or indirectly, any favor, gift, loan, fee,
service or other item of value to any County employee, as set forth in Chapter 112,
Part III, Florida Statutes, Collier County Ethics Ordinance No. 2004-05, and County
Administrative Procedure 5311. Violation of this provision may result in one or more
of the following consequences: a. Prohibition by the individual, firm, and! or any
employee of the firm from contact with County staff for a specified period of time; b.
Prohibition by the individual and! or firm from doing business with the County for a
specified period of time, including but not limited to: submitting bids, RFP, and! or
quotes; and, c. immediate termination of any contract held by the individual and! or
firm for cause.
18.
IMMIGRATION LAW COMPLIANCE. By executing and entering into this agreement,
the Consultant is formally acknowledging without exception or stipulation that it is
fully responsible for complying with the provisions of the Immigration Reform and
Control Act of 1986 as located at 8 U.s.e. 1324, et seq. and regulations relating thereto,
as either may be amended. Failure by the Consultant to comply with the laws
referenced herein shall constitute a breach of this agreement and the County shall have
the discretion to unilaterally terminate this agreement immediately.
19, OFFER EXTENDED TO OTHER GOVERNMENTAL ENTITIES. Collier County
encourages and agrees to the successful proposer extending the pricing, terms and
conditions of this solicitation or resultant contract to other governmental entities at the
discretion of the successful proposer.
20. AGREEMENT TERMS. If any portion of this Agreement is held to be void, invalid, or
otherwise unenforceable, in whole or in part, the remaining portion of this Agreement
shall remain in effect.
Page 5 of9
21, ADDITIONAL ITEMS/SERVICES. Additional items and/ or services may be added to
this contract upon satisfactory negotiation of price by the Contract Manager and
Consultant. 16 F 7
22. DISPUTE RESOLUTION. Prior to the initiation of any action or proceeding permitted
by this Agreement to resolve disputes between the parties, the parties shall make a
good faith effort to resolve any such disputes by negotiation. The negotiation shall be
attended by representatives of Consultant with full decision-making authority and by
County's staff person who would make the presentation of any settlement reached
during negotiations to County for approval. Failing resolution, and prior to the
commencement of depositions in any litigation between the parties arising out of this
Agreement, the parties shall attempt to resolve the dispute through Mediation before
an agreed-upon Circuit Court Mediator certified by the State of Florida. The
mediation shall be attended by representatives of Consultant with full decision-
making authority and by County's staff person who would make the presentation of
any settlement reached at mediation to County's board for approval. Should either
party fail to submit to mediation as required hereunder, the other party may obtain a
court order requiring mediation under section 44.102, Fla. Stat.
Any suit or action brought by either party to this Agreement against the other party
relating to or arising out of this Agreement must be brought in the appropriate federal
or state courts in Collier County, Florida, which courts have sole and exclusive
jurisdiction on all such matters.
23. KEY PERSONNEuPROTECT STAFFING: The proposer's personnel and management
to be utilized for this project shall be knowledgeable in their areas of expertise. The
County reserves the right to perform investigations as may be deemed necessary to
insure that competent persons will be utilized in the performance of the contract.
Selected firm shall assign as many people as necessary to complete the project on a
timely basis, and each person assigned shall be available for an amount of time
adequate to meet the dates set forth in the Project Schedule. Firm shall not change Key
Personnel unless the following conditions are met: (1) Proposed replacements have
substantially the same or better qualifications and/ or experience. (2) that the County is
notified in writing as far in advance as possible. Firm shall make commercially
reasonable efforts to notify Collier County within seven (7) days of the change. The
County retains final approval of proposed replacement personnel.
Page 6 of9
16F 7
IN WITNESS WHEREOF, the Consultant and the County, have each, respectively, by an
authorized person or agent, hereunder set their hands and seals on the date and year first above
written.
A ITEST:
Dwight El\BTode~~ of Courts
BY:.'~~'('
Da~.Y-~.'. . .. ..-.
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1'/ .. {,' t; 3 ~l S~\~.,,",
BOARD OF COUNTY COMMISSIONERS
COLLIERCO NTY,FLORIDA
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By:
Donna Fiala, Chairman
Dorrill Management Group
/1
L:' I~~.____
By:
:::.:s- do. ___ sA. po.,) .....,10'...(".$__
Type/print witness name
j)Qh~v~ C oI~'flI~Yv
Second Witness
JlJ I i SDr1 C. 0/ ~rY} Q /1
Type/ print witness name
~eil Dorrill, President
Typed signature and title
Approved as to form and
legal sufficiency:
~f)~~
Assistant County Attorney
Jennifer White
'tem' \ (.?f-\
~~--Ct-3-
Page 7 of9
~
Exhibit A
Scope of Services
l'F
7
This Scope of Services addresses the duties and responsibilities of the newly titled
Administrator of the Pelican Bay Services Division, hereinafter called the "Administrator",
formerly titled "Manager", effective JU.nE ~3, 20<;.,C( .
DUTIES OF THE ADMINISTRATOR
The Administrator's duties and responsibilities include the following:
1) It will be the Administrator's main responsibility to implement the policies of the
PBSD, as directed by the Pelican Bay Services Division Board.
2) The Administrator shall prepare the necessary organizational structure and interview
and recommend personnel to be hired and employed by the County for the PBSD, The
Administrator shall supervise the personnel employed by the PBSD in accordance
with all Federal, State and County laws, rules and regulations where applicable, The
Administrator shall request approval of the PBSD Board for any significant changes in
size or makeup of the organization, Currently, the Administrator has the following
people reporting to him - one (1) Superintendent, one (1) Operations Analyst, one (1)
Administrative Assistant and sixteen (16) field employees.
3) The Administrator. shall implement all policies established by the County In
connection with the operation of the PBSD.
4) The Administrator shall be expected to make recommendations on a regular basis for
programs to improve the Pelican Bay Community
5) The Administrator shall participate in meetings, discussions, project site visits,
workshops and hearings as may pertain to the administration of the services being
provided and report results to the PBSD Board.
6) The Administrator shall attend regular and special meetings of the Board of County
Commissioners when issues arise regarding PBSD activities and report results to the
PBSD Board. The Administrator will suggest that a PBSD Board member join the
Administrator at the meeting if the Administrator deems that such joint representation
would be desirable.
7) The Administrator shall review outside contractor bids and make recommendations
for approval or disapproval to the PBSD Board.
8) The Administrator shall work with the Chairperson of the PBSD Board in the
preparation of the Board's agenda and collaborate with the Chair in selecting items
and priorities.
Page 8 of9
9) The Administrator shall prepare and administer the PBSD's Annual Budget(s) in
accordance with all Federal, State and County laws, rules and regulations where
applicable. 1 , F 7
10) The Administrator will have an understanding of Florida County government
operations, good management principals and skills, as well as knowledge and skills in
personnel relations, public relations, and accounting and computer software
operations,
11) The Administrator's performance may be critiqued by any Board member at a regular
monthly Board meeting. Any Board member may meet privately with the
Administrator to discuss Administrator's performance.
12) The Administrator shall devote such time as necessary to complete the duties and
responsibilities assigned according to the specifications of this RFP, The Administrator
shall spend a minimum of three hundred twelve (312) hours a year on the duties
specified. Hours spent over the minimum are not entitled to extra compensation
unless approved in written by the PBSD Board. The Administrator should detail on a
monthly basis the time spent in the performance of these duties. The PBSD currently
provides an office and staff for the Administrator in Pelican Bay, but is not
contractually required to do so.
13) The Administrator shall respond to any request for information or data from the
County Managers office.
14) The Administrator may be called on to provide assistance to any or all other
committees that are currently and may be created by PBSD Board.
Page 9 of9
From:Erin McElroy, GISR, GIG FaxID:356-2126
Dawson of Florida; Naples
6609 Willow Fark Drive
Naples FL 34109
Fhone:239-261-6116 Fax:239-261-2803
INSURED
ACORD.
PRODUCER
Page 2 of3
Date:6/3012009 03:38 PM page:2 of 3
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM IYYYY)
DORRI-1 06/30/09
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
NAIC#
10677
Dorrill Management Group, Inc.
5672 Strand Court ste. ~
Naples FL 34110
COVERAGES
INSURER A:
INSURER B:
INSURER C
INSURER 0:
INSURER E
Cincin:nati Insurance Company
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. N01WITHSTANDING
ANY REQUiREMENT, TERM OR CONDITION OF ANY CONTRACT OR O:HER 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
LTR NS-Ri TYPE OF INSURANCE POLICY NUMBER I PD~';!li(MMlDDIYY) 'DATI: (MMlDDIYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $1,000,000
-
A ~ COMMERCiAL GENERAL L1,o.BILITY CAF5162891 10/06/08 10/06/09 PREMISES 'I E~a~~~'c'u~ence 1 $500,000
f-- :=J CLAIMS MADE ~ OCCUR MED EXP (Anyone person) $ 10,000
PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $2,000,000
II nPR().. nLOC
POLICY JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
f-- $1,000,000
A ANY AUTO CAF5162891 10/06/08 10/06/09 (Ea aCCident)
f--
ALL OWNED AUTOS BODIL Y INJURY
f-- $
SCHEDULED AUTOS (Per person)
f--
~ HI RED AUTOS BODIL Y INJURY
$
~ NON-OWNED AUTOS (Per accident)
'--- PROPERTY DAMAGE $
I Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACC IDENT $
R ANY AUTO OTHER THAN EA ACC $
AUTO ONL Y: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $1,000,000
A ~ OCCUR D CLAIMS MADE CAF5162891 10/06/08 10/06/09 AGGREGATE $1,000,000
$
R DEDUCTIBLE $
ix RETENTION $Nil $
WORKERS COMPENSATION AND ITORYl'IMI'TS I IUJit
EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERlEXECUTIVE EL EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? E.L DISEASE - EA EMPLOYEE $
If yes, describe under
SPECIAL PROVISiONS below E.L. DISEASE - POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADOED BY ENDORSEMENT I SPECIAL PROVtSloNS
Collier County Board of Commissioners is named as additional insured per
endorsement form GA 210 2/07
COLLI19 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING tNSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
Collier County Board of -
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
Commissioners IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
3301 E. Tamiami Trail
Naples FL 34112 REPRESENTATIVES.
AU~RIZED REPRES\:'-r::E h....
_ .:*.""'-.<r<...., : R ~,
CERTIFICATE HOLDER
ACORD 25 (2001/08)
CANCELLATION
@ACORDCORPORATION1988
From:Erin McElroy, CISR, CIC FaxID:356-2126
Page 3 of 3
16 F Date:TI2009 03:38 PM Page:3 of 3
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
....~
ACORD 25 (2001/08)
ACORD",
CERTIFICATE OF LIABILITY INSURA
DATE (MMJDDlYYYY)
DORlU-1 06 24 09
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
121001/002
06/24/2009 WED 14:30 FAX 239 261 7574
PRODUCER
Oswald Trippe and Company, Ino
4089 Tamiami Trail North A203
Naples FL 34103
Phone: 239-261-0428 Fax: 239-261-7574
INSURERS AFFORDJNGCOVERAGE
NAIC#
INSURED
INSURER "'-
INSURER B:
INSURER C:
INSURER D:
INSURER E:
United States Liability Ins Co
Dorrill Management Group Inc
w. Neil DorrJ.ll
5672 Strand Court, Suite 1
Naples FL 34110
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 WHtCH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICJES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITtONS OF SUCH
POLICIES. AGGREGATE LIMITS SH01NN MAY HAVE BEEN REDUCED BY PAID ClAtMS.
POLICY NUM BER 'DAiE1MMiD~ N LIMITS
LTR NSR TYPE OF INSURANCE DATE (MMlDDIY(J
GENERAL LIABILITY EACH OCCURRENCE $
- PREMlSES 'tE~~~~ncel
COMMERCIAL GENERAL LIABILITY . $
- :=J CLAIMS MADE D OCCUR
MED EXP (Anyone person) $
-
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEl'lL AGGREGATE LIMIT APPUES PER: PRODUCTS - COMP/OP AGG $
II POLICY n ~:g: n LOC
AUTOMOBilE L1AB1UTY COMBINED SINGLE UMIT
I-- $
ANY AUTO (Ea accident)
f--
ALL OWNED AUTOS BODILY INJURY
~ $
SCHEDULED AUTOS (Per person)
-
HtRED AUTOS BODILY INJ URY
- $
NON-OWNED AUTOS (Per accident)
-
- PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EAACCtDENT $
==1 ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGO $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
tJ OCCUR D CLAIMS MADE AGGREGATE $
$
q DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND I TORY LIMITS I lu~1t
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
OFFICERlMEMBER EXCLUDED? E.L, DISEASE - EA EMPLOYEE $
g~~I~r~~OV~~~S below Eol. DISEASE - POLICY LIMIT $
OTHER
X Professional Liab PM1001795B 10/12/08 10/12/09 Limi t : $2,000,000
DESCRIPTION OF OPERATIONS 1 LOCATIONSl VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS
CERTIFICATE HOLDER
Collier County
Board of County Commissioners
3301 East Tamiami Trail
Naples FL 34112
CANCELLATION
COL3 3 0 1 SHOULD ANY OF THE ABOVE DESCRt BED POLICIES BE CANCELLED BEFORE THE EXPIRA nON
DATE TIlEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL !.Q........ DAYS WRITTEN
NOTice TO TIle CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE m DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
ACORD 25 (2001/08)
@ACORD CORPORATION 1988
06/24/2009 WEP 14: 30 FAX 239 261 7574
ll:lI002/002
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement{s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon,
ACORD 25 (2001/08)
-r-.--
~
COLL IER INS SVCS
ZS9Z61ZS03
05.~ZZ/0S
02:01pm P.
0016F
7
NOTICE OF ELECTION TO BE EXEMPT
Please refer to the writteu instructions prepared by the
Division ofWork.ers' Compensation before completing tbis form.
EffectiveJIssue Date:
Expiration Date:
By riling this appUtJrtiOll, you elect to be exempt from tbe provisions of Cbspter 440,
Florida Statutes and waive any right you may have to workers' compensation bellefifS in Control Number:
the State: or F19rids should you, become iAjllred 011 the job. Any DUlIon who knowinrlv lilnd
with intent to lnlttre. defnaud. or deceive the Division or llOY '~Dlovl&J'. enlDlovee. or Postmark: Date:
msurlln.:e cnmnl1nv or puf'OOlles 1)1'02ram. files II Nql:ke elf Eledioa 10 be Exempt
eOJluinin2. "'JIY fa1$.e or misleftdin~ information i$ 2Uilty of Jl felonv of the thitd dnree. Received Date:
CeruiA <loeumentstion is required by law to be ;tttllcbed to tbls .pplication-refer to the
m.strtletiOft sheet ror more detnils.
I lUll applying for ex.:mption as Q (check only one box in thi! section):
COf'llSTRUCTION INDUSTRY ($ 50.00 FEE REQUIRED)
L-;;:iolc Proprietor 0 Partner 0 Corporate Officer (your corp. title: ) -OR-
NON-CONSTRUCTJON INDUSTRY ( NO FEE REQUIRED)
9 Co rate Officer our co . title: \
CORPORATE OFFICERS AND 'ARTNER..<;j: List the registration number of your business on file with tbe Division of Corporations,
Department of State's Office ~]:f.; YOllr pal'\oersbil' may not have one., but all corporations must have one. IfyOUT partnership doesn't
ba"cone,state"NfA"):~OCOOOO 5'L.~ ..'.
Are you OT a qualifier for your business required by the county or the municipality in which your bu~ matting address is
located to have an occlIp<J.tionat li~~c for the business which is the subject of this application? [3"No 0 Ycs:
YOU MUST ATTACH A COPY OF A CURRENT OCCUPATIONAL LICENSE
Are you an cd ~ any solc proprietorship, partnership, corporatiQn or bu~incss entity othcr thlln the business to which this application
applies? NO 0 YES list the name of all other businesses ill which you :are emplQyed:
~~ lCA~~~ 51 B ^oF fLORIDA, COUNTY OF !!- OLt...-, .Ef!-
Swom t<1 s.Jm""ibcd before ~ ihis~ day ot((T; AI€. , 7- 00 3 . by trJ \ Nt' L-'p oee ( LA....-
pe~OWtJlYKnown~~r - I '. '" Typeofldentdio;ationJ>~
NOTARYSIGNATUR1I' /~ MyCommL<:siollExpires I Z//7 ios-
!/ I
J .
AFFIDAVIT OF APPLICANT: I hereby certify that tile iDformaliolll:Olltllifte4 berem i$ tI'IIe sad eorrect to tbe best of my
knowledge ad beliefl that this c:kctiOD ~ Dot exceed eUlDption Iidlits for corponte officers or partners liS provided ill ~.02
Florida Sututes; lInd that 1 will secure the payment of workers' compclISlI'ion benefits. pursuant to Chapter 440, Florida Statutes,
for ;lOY employee I now bave or may hE:Dll ~r c ire. fo~ h\ my bu;iness is required I>y Florida law to S~U7 ; lbe.s:-~
mo. dAY yr.
DA. n:. OF BIKHl
DWC 250 Revised SCptcmbcr,1001
m~~~...".., JESSICA RUSSO
! '\ Notary PUb..lic.. - s.tate of.. Florida
~ . . E My Ccm:ni&&iln EJ;Rs Os:: 17, 2005
~ CO< ~/ ~~sal~' OD 112:l&.1i
~....~,. B=s;-~E},'1tat!tll1alNotary ~
..... -
.~:~_..