HomeMy WebLinkAbout2021 Agreement LORIDA MUNICIPAL INSURANCE TRUST
PARTICIPATION AGREEMENT
GOVERNMENTAPPLICANT: CiidSebastan
ACCOUNT NUMBER: 0539 TYPE OF GOVERNMENTAL ENTRY: Municipality
ADDRESS: 1225 Main Steel Sebastian, FL 329M
NUMBER 59-60D00477
OFFICIALS AUTHORIZED^ TO EXECUTE CONTRACTS:
I. Name: �A UL L GARLISLt�
II. Nome:
True: c I) 1-? Mh•IAt:6PC,
Tate:
PRIOR INSURANCE COVERAGE CARRIED BY: P+-yl
Applicant hereby makes application with the Trust for continuing membership for Ikbllty, property, ailed Imes, automobile In IpI More ,
workers' compensation, employers' liability, noical, dental, shoMemi disability, and/or life octerege, to be effective 12:01 a.m. /0 0( G and, M
accepted by the Trusts duty authorized representative, does hereby constitute aid appoint the Florida League of Ctba. II to ash as Ad 'n'aVelor of sold
True) and to ad as Applicants agenti in all maam holding to its participation in sail Trust and agmti to the extent any such coverage Is placed
with the Trust.
Applicant, by execution of this Agreement, further agrees:
(a) That, by this reference, the lames and prnvklons of the Coverage Agreement including Conditions of Coverage, and the Agreement and
Declaration of Trust creating the Florida Municipal Insurance Trust, as may be amended periodically by is Board of Trustees, a copy of which Applicant
hereby acknowledges receipt, are hereby adopted. approved, ratified, aid confirmed by Applicant: and further, Applicant will accept assume, abide by and
be bound by the provklons and obligations set forth therein;
(b) That Applicant witl pay all premiums on or before the dale the same shell become clue end, in to avant Applicant talk to do so, will pay any
reasonable late panties and charges arising Mershon and all tusk of collection thereof, Including reasonable attomey's fees;
(c) That Applicant as long as t remains a member of the Trust wit abide by the rules and regulations adopted from time to fine by the Taste Board
and will conform is conduct to the terms of any agreements entered into by the Board to adcrumer the Trust;
(d) That Applicant in the event of any changes in is corporate or business structure, including any change in number of employees or any additions
or deletions of locations from any coverage Provided by the Twat, will notify the Trust Irunediately or may be subject to panty by the Trust;
(a) That, except In the case of Applicant's non-payment of sums owed to the Twat. should ether the Applicant or the Trust desire to cancel coverage,
It will give written notice to the other at least forty-five (45) days prior to cancellation;
(0 That, should Applicant default hereuntler. Applicant agrees to Save and hold harm as the Trust and the Trust's Board from my and ell damages,
causes of action, claims, delinquency or expenses, Including masmable attorneys leas, which would have othmwke been incurred by the Trust or the
Board hereunder absent such default on the pad of the Applicant;
(g) That, dworkers' compere aeon or employes' Iiabifly, ceverege is placed with me Trust, Applicant will accept and be bound by the provision of the
Florida Workers Compensation At,, that coverage arising from this Application shall be for Florida operations only, and that the Wage Daciasticn Schedule
(Forth No. endfor Renewal Certificates, when compared! ! and returned to Applicant by the Trust, shall become a pad of this agreement.
IMTNESSE SIGN RE
PRVL CA2l (SL� GJ�.
Name of Applicant Name
Gf-t-0 MArJAC5'C—i-.
Authorized Officer
CORPORATE
�SEAL p��
j`Cvv or ow ry .a""'n.
4/Z9/Z021
/aaSMRyd.s�r�f s�ansr„A� � 3a9Sr
Address
Name
laa�MAyd sTI� sass
.. Date Address
IS HEREBYAPFADVED FOR MEMBERSHIP IN THIS TRUST, AND COVERAGE IS EFFECTIVE THE let DAY OF OctoberjD20,
SIGNED THIS DAY OF 20 a -I
BY:
as Administrator of Florida Municipal Insurance Trust