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HomeMy WebLinkAboutContractPr erred COVERED PARTY: AGREEMENT NO.: City of Sebastian QK FL1 0312002 16-01 AGREEMENT PERIOD: 10/01/2016 to 10/01/2017 YOU ARE ELECTING NOT TO PURCHASE CERTAIN VALUABLE COVERAGE WHICH PROTECTS YOU AND YOUR FAMILY OR YOU ARE PURCHASING UNINSURED MOTORISTS LIMITS LESS THAN YOUR BODILY INJURY LIABILITY LIMITS WHEN YOU SIGN THIS FORM. PLEASE READ CAREFULLY. Uninsured Motorist coverage provides for payment of certain benefits for damages caused by owners or operators of uninsured motor vehicles because of bodily injury or death resulting there from. Such benefits may include payments for certain medical expenses, lost wages, and pain and suffering, subject to limitations and conditions contained in the Coverage Agreement. For the purpose of this coverage, an uninsured motor vehicle may include a motor vehicle as to which the bodily injury limits are less than your damages. Florida law requires that automobile liability coverage agreements include Uninsured Motorist coverage at limits equal to the Bodily Injury limits in your coverage agreement unless you select a lower limit offered by the Trust or reject Uninsured Motorist entirely. Please indicate whether you desire to entirely reject Uninsured Motorist coverage, or, whether you desire this coverage at limits lower than the Bodily Injury Liability limits of your Coverage Agreement: ❑✓ a. I hereby reject Uninsured Motorist coverage. ❑ b. I hereby select the following Uninsured Motorist limits which are lower than my Bodily Injury Liability Limits: each person (enter limit if applicable): each accident. ❑ C. I hereby select Uninsured Motorist coverage limits equal to my Bodily Injury Liability limits. (If you select this option disregard the bold face statement above.) ELECTION OF NON -STACKED COVERAGE (Do not complete if you have rejected Uninsured Motorist) You have the option to purchase, at a reduced rate, non -stacked (limited) type of Uninsured Motorists coverage. Under this form if injury occurs in a vehicle owned or leased by you or any family member who resides with you, this Coverage Agreement will apply only to the extent of coverage (if any) which applies to that vehicle in this Coverage Agreement. If an injury occurs while occupying someone else's vehicle, or you are struck as a pedestrian, you are entitled to select the highest limits of Uninsured Motorist coverage available on any one vehicle for which you are a Named Covered Party, covered family member, or covered resident of the Named Covered Party's household. This Coverage Agreement will not apply if you select the coverage available under any other Coverage Agreement issued to you or the Coverage Agreement of any other family member who resides with you. If you do not elect to purchase the non -stacked form, your Coverage Agreement limit(s) for each motor vehicle are added together (stacked) for all covered injuries. Thus, your Coverage Agreement limits would automatically change during the Coverage Agreement term if you increase or decrease the number of autos covered under the Coverage Agreement. ❑ I hereby elect the non -stacked form of Uninsured Motorist coverage. I understand and agree that selection of any of the above options applies to my liability Coverage Agreement and future renewals or replacements of such Coverage Agreement which are issued at the same Bodily Injury Liability limits. If I decide to select another option at so a future time, I must let the Trust or my agent know in writing. Signed (Cevered Party) Joseph Griffin, City Manager % Signed Date: (Covered Party) PGR 398 (07 05) mw brcl tlescnpbm or mvcrage cpnta�nm m tlus tloommt is Emg prwcetl as an amanrmtla4on mtly arc 5 cwt rtrtenEeb ro mvrr w acsaix all Wvcmage Agr[ement tams r+x mgre mmplM ab tl0aike mramatitln rtlaWg ro the scpptl aM limns armacra9e, please re'c tleecbY b Ine Grve29c Agrem�ent tlamnents. Sp.nmen films am available upas retlues. Page 14 tr errea PUBLIC ENTITY aovEeNMEntat SIGNATURE PAGE INSURaNCETRUST Covered Party: City of Sebastian Agreement Number: Coverage Period: QK FL1 0312002 16-01 From: 10/01/2016 to 10/01/2017 I hearby confirm that limits/coverages as shown hereunder, corresponding with the Coverage Agreement, are correct: Property TIV $28,023,940 Buildings & Contents Combined Inland Marine Blanket Unscheduled Inland Marine $803,972 (Subject to $25,000 any one item excludes Watercraft) Scheduled Inland Marine $1,068,126 Total All Inland Marine $1,872,098 Property TRIA (Terrorism Risk Insurance Act) coverage DID Automobile FTI I hereby confirm that I have received a copy of Preferred's Current Interlocal Agreement (which was last amended October 1, 2004) and amendment A (which was effective October 1, 2013). I confirm having read and agreed to the terms as laid out in the attached Preferred Participation Agreement (which also requires a signature) Please remember that a signed copy of the following are also required: • First Page of Preferred application • Uninsured Motorist Rejection / Election form, if applicable • Professional Liability (POL / EPLI or ELL / EPLI) application, if applicable. Signature Joseph Griffin Name City Manager Title Please note: Failure to return this signature page could result in cancellation of coverage. Date iha Cnef tlescnpCon N coverage contained m thrs documant rs hamg provtlM as an aaanmadaWn aMy ab rs nm mlenN.V to corer or descnbe all Coverage Agrornwmt tams. Fm mare mmpkt ar detailed mformatm reWtny to the %W a, times of tv age, pl.. IeW d.Wly tO ft Cov,aage Ag,¢ment do .,mK 5ptt fams aiC avaiL:bN. upon rtAUC9. Page 15 (1 iA� PARTICIPATION AGREEMENT Application for Membership in the Preferred Governmental Insurance Trust The undersigned local governmental entity, certifying itself to be a public agency of the State of Florida as defined in Section 163.01, Florida Statutes, hereby formally makes application with the Trust for continuing workers' compensation, liability, property and/or casualty coverage through membership in the Preferred Governmental Insurance Trust, to become effective 12:01 a.m. (effective date of coverage agreement), and if accepted by the Fund's duly authorized representative, does hereby agree as follows: (a) To accept and be bound by the provisions of the Florida Workers' Compensation Act; (b) That, by this reference, the terms and provisions of the Amended Interlocal Agreement creating the Preferred Governmental Insurance Trust date October 1, 2004 are hereby adopted, approved and ratified by the undersigned local governmental entity. The undersigned local governmental entity certifies that it has received a copy of the aforementioned Amended Interlocal Agreement and further agrees to be bound by the provisions and obligations of the Amended Interlocal Agreement as provided therein; (c) To pay all premiums on or before the date the same shall become due and, in the event Applicant fails to do so, to pay any reasonable late penalties and charges arising therefrom, and all costs of collection thereof, including reasonable attomeys' fees; (d) To abide by the rules and regulations adopted by the Board of Trustees of the Fund; (e) That should either the Applicant or the Fund desire to cancel coverage, it will give not less than thirty (30) days prior written notice of cancellation; (1) That all information contained in the underwriting application provided to the Fund as a condition precedent to participation in the Fund is true, correct and accurate in all respects. Witness Signature Printed Name Witness Signature Printed Name City of Sebastian (Name of Local Governmental Entity) By: ,��/'Slgno&e Joseph Griffin Printed Name Title: City Manager AUTHORIZED PERSONNEL ONLY IS HEREBY APPROVED FOR MEMBERSHIP IN THIS FUND, AND COVERAGE IS EFFECTIVE THE _ DAY OF 20 . SIGNED THIS DAY OF , 20 By: Admi nlstrator/Tru stee (erred Contact Person: Named Covered Party: Term: Quote No.: Telephone Number: Reference Number: 43227 City of Sebastian 10/01/2016 to 10/01/2017 WQ FL10312002 16-01 EMPLOYER WORKPLACE SAFETY PROGRAM PREMIUM CREDIT APPLICATION 6/15/2016 10:48 AM I am submitting a copy of my safety program which meets the requirements of Section 440.1025, Florida Statutes. I certify that this Safety Program has been implemented in the workplace and is being maintained as submitted to "Preferred (The Trust)". This is to certify that the Workplace Safety program meets or exceeds the following provisions as provided for in Section 440.1025, Florida Statutes: 1. Written Safety Policy and Safety Rules 2. Safety Inspections 3. Preventive Maintenance 4. Safety Training 5. First Aid 6. Accident Investigation 7. Necessary Record Keeping A0%t^ The workplace safety program and application is being submitted for the purpose of obtaining a premium credit do not contain any false, incomplete or misleading information. I attest to the accuracy of the information submitted. I am aware that we may be subject to on-site inspections by "The Trust", for the purpose of validation the accuracy of this information. I am aware that any person who submits an application that contains false, misleading or incomplete information provided with the purpose of avoiding or reducing the amount of premiums for workers compensation coverage is a felony of the second degree, punishable as provided in Sections 775.082, 775.083 or 775.084 Florida Statutes, or as otherwise punishable as provided under the law. Name: Joseph Griffin Title: City Manager Date: ti G Signature: State of Florida, County of Indian River Sworn to, or affirmed, and subscribed before me: "1ggttUqfi this 16* day of Au 20 1, by Expirl ion of Commission Z - 2 8- 19 i' #PF t WA /w*, the ErM} Eenipwn of co�age eontanee,n itus daument,s bang Provde0 as an atmrma0aw" my am ,s no[,n[abed ro wra a Eesaib=all Covera5e lu�ren�n[ terms. ra mac -"' amWl orb dotlukb mfamanoo rCUM to tm z orb loots of coverage, PW- ref- &CCUY m tM Coverage ngreanent dmm:nS SP ' forms are avmWGc upon request Page 9 Reference Number: 48227 6/15/2016 10:48 AM Pr erred Named Covered Parry: City of Sebastian Term: 10/01/2016 to 10/01/2017 M Quote No.: WQ FLS 0312002 16-01 DRUG-FREE WORKPLACE PREMIUM CREDIT PROGRAM APPLICATION Testing: Procedures for drug testing have been established and/or drug testing has been conducted in the following areas: Job Applicant Reasonable suspicion Routine fitness for duty Follow-up testing to Employee Assistance Program Notice of Drug Testing Policy: Copy to all employees prior to testing Posted on/at employers premises Copy to job applicants prior to testing General notice given 60 days prior to testing Show notice of drug testing on vacancy announcements Copies available to personnel office or other suitable locations No notice required because drug testing program in place prior to July 1, 1990 Education: Resource file on providers ^^^ Employee Assistance Program Education Name of Medical Review Officer: Name of approved Agency for Health Care Administration lab or United States Department of Health and human Services Certified Laboratory: Phone Number: Address: Your certification is subject to physical verification by -Preferred (The Trustj-. Your coverage agreement is subject to additional premium for reimbursement of premium credit, and cancellation provisions of the Coverage Agreement if it is determined that you misrepresented your compliance with Florida law. Any person who knowingly and with intent in injure, defraud or deceive, and/or files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. /% Name: Joseph Griffin Date: /O / /_ 'a Z_ Title: City Manager Signature: The above signed certifies that this information is a true and factual depic Ion of their current program. r NURul4� I��3c,P.•'.LSSIO,V'• tary Publics Signature Date Expiration of Commission a �pW y28?� x ; � � 03 /`� �y't, IIFFtIK48S pain - Trac Mief descnpbon of coverage con prion in Nis dmement is being porn v as a-, accominodaton only and is nal intended to cover or cescnW all Coverage AgrdementiQr/➢ p�E complete and detailed i ociona on reiaum to Inc scop and 4mds of covefagq przse refer doecUlf m the Coverage Agreernot donm:arts. 5p dnd, forms are assist id up 1+1N ;pal 4�� PARTICIPATION AGREEMENT Application for Membership in the Preferred Governmental Insurance Trust The undersigned local governmental entity, certifying itself to be a public agency of the State of Florida as defined iii Section 163.01, Florida Statutes, hereby formally makes application with the Trust for continuing workers' compensation, liability, property and/or casualty coverage through membership in the Preferred Governmental Insurance Trust, to become effective 12:01 a.m. (effective date of coverage agreement), and if accepted by the Fund's duly authorized representative, does hereby agree as follows: (a) To accept and be bound by the provisions of the Florida Workers' Compensation Act; (b) That, by this reference, the terms and provisions of the Amended Interlocal Agreement creating the Preferred Governmental Insurance Trust date October 1, 2004 are hereby adopted, approved and ratified by the undersigned local governmental entity. The undersigned local governmental entity certifies that it has received a copy of the aforementioned Amended Interlocal Agreement and further agrees to be bound by the provisions and obligations of the Amended Interlocal Agreement as provided therein; (c) To pay all premiums on or before the date the same shall become due and, in the event Applicant fails to do so, to pay any reasonable late penalties and charges arising therefrom, and all costs of collection thereof, including reasonable attorneys' fees; (d) To abide by the rules and regulations adopted by the Board of Trustees of the Fund; (e) That should either the Applicant or the Fund desire to cancel coverage, It will give not less than thirty (30) days prior written notice of cancellation; (f) That all information contained in the underwriting application provided to the Fund as a condition precedent to participation in the Fund is true, correct and accurate in all respects. Witness Signature Printed Name Witness Signature Printed Name City of Sebastian (Name of Local Governmental Entity) J§Vey: ature Joseph Griffin Printed Name Title: City Manager AUTHORIZED PERSONNEL ONL IS HEREBY APPROVED FOR MEMBERSHIP IN THIS FUND, AND COVERAGE IS EFFECTIVE THE _ DAY OF , 20 . SIGNED THIS DAY OF , 20 _. By: Ad ministrator/Trustee