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Workers Compensation Bid
City of Sebastian Workers' Compensation RFP Fiscal Year 2012 cm ()F 5Est:.,. -rr s Y HOME OF PELICAN M IW 1225 Main Street Sebastian, Florida 32958 REQUEST FOR PROPOSAL (RFP Workers' Compensation Insurance Program BY CITY OF SEBASTIAN ADMINISTRATIVE SERVICES DEPARTMENT July 2011 City of Sebastian Workers' Compensation RFP Fiscal Year 2012 NOTICE OF INVITATION REQUEST FOR PROPOSAL (RFP) Sealed proposals for a licensed firm to provide a fully comprehensive Workers' Compensation Insurance Program, will be accepted by the City of Sebastian, Administrative Services Department, 1225 Main Street, Florida 32958, until 2:00 P.M. on Tuesday, August 9, 2011. Proposal envelopes are to be marked as follows: RFP: WORKERS' COMPENSATION INSURANCE PROGRAM OPEN: AUGUST 9, 2011 A 2:00 P.M. The City of Sebastian is soliciting proposals from firms licensed to conduct business in the State of Florida, to provide a fully comprehensive Worker's Compensation Insurance program for a one (1) year term with two (2) optional one (1) year extensions, with a maximum period of three years including extensions. Firms interested in responding to this RFP may pick up or request the complete RFP package that contains all details relevant to this RFP from the City of Sebastian, Administrative Services Department, at the address stated above, or by calling 772- 388-8202. Submittals shall include one original and three copies of the proposal. Any proposal received without proof of License to conduct business in Florida, and the executed Public Entity Crime and Drug Free Workplace Forms, may be considered incomplete and immediately disqualified. Form Documents are provided herein. ' All inquiries regarding this RFP should be directed to Debra Krueger at (772) 388- 8202, via fax (772) 388-8249, or via email to dkrueger(o.cityofsebastian.org. Firms interested in submitting a response to this RFP, agree not to contact (lobby) City Council Members or any employee or agent of the City at any time during the solicitation period and selection process, except oral or written inquires may be directed through the Administrative Services Department. Any other contact with the owner will be considered inappropriate and subject your response to rejection/disqualification. Proposals duly submitted will be publicly opened at the date and time specified above at City Hall. The City reserves the right to reject any and all proposals or to accept any proposal or portion thereof deemed to be in the best interest of the City and to waive any non -substantial irregularities or cancel this solicitation in its entirety at will. Debra Krueger, CGFO Administrative Services Director 2 City of Sebastian Workers' Compensation RFP Fiscal Year 2012 DEFINITION OF TERMS 1.1 Authorized Representative: Any representative of the City of Sebastian, whether or not a City employee, designated as the City's Authorized Representative for the purposes of the contract either in a provision of these specifications or in written communication from the City of Sebastian. 1.2 Contract or Agreement: The contract executed by the City of Sebastian and the successful Vendor for the performance of the work. The contract shall be substantially in the form as provided with this RFP package. 1.3 Contractor or Vendor: The person, firm, corporation, organization or agency with which the City has executed a contract for performance of the work or his duly authorized representative. 1.4 Firm or Proposer: Any person, firm, corporation, organization or agency submitting a bid for the work proposed or his duly authorized representative. 1.5 Owner or City: The City of Sebastian, Florida or an authorized agent or representative. 1.6 Specifications: Directions, provisions and requirements contained in the Request for Proposal, Instructions To Proposers, Conditions, Technical Specifications and Proposal Forms, together with any written contact made or to be made setting out or relating to the methods and manner for the services to be carried out. 1.7 Work: Any work, services or materials fumished under and made a part of the contract. II. SPECIFICATIONS: 2.1 Any Firm in doubt as to the true meaning of any part of the Specifications or related documents may submit a written request to Debra Krueger, Administrative Services Director via fax (772) 388- 8249, or via email to dkrueger(a)citvofsebastian.oro for interpretation thereof by the City. Interpretations or responses to questions will be made only by an addendum duly issued and a copy of such addendum will be mailed to each Firm that received a set of the RFP package. City of Sebastian Workers' Compensation RFP Fiscal Year 2012 III. PREPARATION OF PROPOSALS 3.1 A Firm submitting a proposal is responsible to be fully informed as to the requirements of the specifications and failure to do so will be at the Firm's risk. A Firm that submits a proposal shall not expect to secure relief on the plea of error or misunderstanding. 3.2 By submitting a proposal, the Firm declares that the only persons or parties with an interest in the proposal are those named in such proposal and that the proposal is, in all respects, fair and without fraud, and that it is made without any connection or collusion with any other Firm or its representative(s) which is also submitting a proposal for the same RFP, and/or any City employee, official or Agent. 3.3 All submittals shall contain one original Proposal and three copies. Original and copies must be plainly marked by the Firm who will be responsible for their correctness. The Firm's authorized representative must initial in ink next to any erasures or corrections contained in its proposal. 3.4 Only one Proposal from any individual carrier under the same or different name shall be considered. If in the opinion of the City, it appears that any carrier has an interest in more than one of the proposals received; all proposals in which the carrier has interest may be rejected. 3.5 If Subcontractors are allowed, proposals shall be accompanied by a list of all Subcontractors that the Firm proposes to use. Subcontractors shall not be changed without approval of the City. 3.6 Any deviation or change from the requirements of this RFP must be explained in detail on sheets attached to the Proposal Form and labeled "Exceptions" and each deviation or change must specifically refer to the applicable specification paragraph and page. Otherwise, it will be considered that the items offered are in strict accordance and compliance with all the requirements of this RFP and the successful firm will be held responsible for meeting all the requirements of the RFP documents. Any applicable documentation required to supplement Firm's explanation should also be submitted to allow proper consideration. Final determination as to whether the deviations or changes will be accepted or rejected will be solely determined by the City of Sebastian. Any exceptions not contained in the Firm's proposal will not be considered after opening of proposals. 3.7 Proposals shall also include the Firm's or Carrier's Standard Indemnity and Coverage Agreements and/or Standard Terms and Conditions. 2 City of Sebastian Workers' Compensation RFP Fiscal Year 2012 3.8 Proposals shall clearly identify any options or alternates contained therein over and above the RFP requirements. Any necessary clarifications of any particulars relative to any options or alternates or any other requirement of this RFP shall be clearly explained and detailed on sheets attached to the Proposal Form and labeled "Clarifications". Final determination as to whether the proposed options or alternates are accepted or rejected will be solely determined by the City. IV. QUALIFICATION OF PROPOSERS 4.1 The City reserves the right to make such investigations as it may deem necessary to establish the competency and financial capability of any Firm to perform. 4.2 If, after the investigation, the evidence of competency and financial capability of a Firm is not satisfactory as determined only by the City, the City reserves the right to reject the Firm's proposal. V. RECEIPT AND OPENING OF PROPOSALS 5.1 All proposals must be submitted in a sealed envelope, addressed, and mailed or delivered to the City of Sebastian, Administrative Services Department, 1225 Main Street, Sebastian, Florida 32958, as stated in the Notice of Invitation, Request for Proposal. Any Firm may withdraw their proposal either personally or by written communication at any time prior to the established opening deadline stated. The City will not be obligated to consider any proposals received after the opening deadline or faxed. 5.2 The Proposer shall submit their proposal on the form furnished along with all information indicated within this document. VI. CONSIDERATION OF PROPOSALS AND AWARD OF CONTRACTS 6.1 Tabulations of proposals with recommended awards will be available for review by interested parties through the Administrative Services Department and will remain available for a period of 72 hours after the contract is awarded. Failure to file a protest within this 72 -hour period shall constitute a waiver of proceedings. 6.2 Failure on the part of the successful Firm to execute a Contract within fifteen (15) days after the notice of award shall be just cause for annulment of award. The City may then accept the second best proposal as determined by the City or re -advertise for proposals. 5 City of Sebastian Workers' Compensation RFP Fiscal Year 2012 6.3 The City shall in addition to price consider other factors such as competency, financial capability, quality of service, past performance, qualifications and other factors listed under paragraph 11.22 that are necessary to determine, only in the opinion of the City, the best overall proposal in the interest of the City for award recommendation to City Council. The City Council's award decision is final. Accordingly, since other factors in addition to price will be considered, the City reserves the right to award the contract to other than the Firm submitting the lowest price proposal, to accept or reject any proposal or portion thereof, and to negotiate or not negotiate with any Firm. VII. PURCHASING AGREEMENT 7.1 These Conditions shall be for Workers' Compensation Coverage. 7.2 Proposals submitted in response to this RFP shall be binding for a period of sixty (60) calendar days after the proposal opening date and firm for the specified Contract duration. 7.3 Any award made under this RFP shall in no way prevent the City of Sebastian from requesting future proposals/bids on identical or similar items to those covered herein. VIII. PAYMENT 8.1 The Vendor shall be responsible for invoicing the City. 8.2 The Vendor shall invoice the City in four (4) equal quarterly installments. 8.3 Payment may be withheld by the City due to failure by the Vendor to comply with the Contract requirements. The City shall notify the Vendor of any unsatisfactory performance as soon as practicable so that it can be corrected without delaying payment if possible. 8.4 The City of Sebastian has a Visa and American Express purchasing card. Accordingly, Vendors that wish to accept payments in this manner must indicate that they have the ability to accept them or that they will take whatever steps are necessary to accept them before the start of the contract. The City of Sebastian reserves the right to revise and/or cancel this program at any time, and assumes no liability for such action. City of Sebastian Workers' Compensation RFP Fiscal Year 2012 IX. INQUIRIES 9.1 All inquiries for additional information should be directed to Debra Krueger, Administrative Services Director via mail to 1225 Main Street, Sebastian, Florida 32958, via fax (772) 388-8249, or via email to dkrueger(d-)cityofsebastian.org. X. LEGAL REQUIREMENTS 10.1 All Federal, State, County and Local Laws, Ordinances, Rules and Regulations that in any manner affect the items covered herein apply. Lack of knowledge by the Proposer shall in no way be cause for relief from responsibility. 10.2 Vendors doing business with the City of Sebastian shall fully comply with all Federal and State Regulations relative to Nondiscrimination and Equal Employment Opportunity. 10.3 MinorityNVomen's Business Enterprises (MBE/WBE) are encouraged to submit proposals to the City of Sebastian. The City does not discriminate against any Firm because of race, creed, color, national origin, sex or age. 10.4 At the time of the award, the successful Firm must show any necessary additional documentation of such State, County and Municipal licenses as would be required. In addition, all applicable proof of insurance will be required prior to inception of the contract. Copy of license to conduct business in the State of Florida, certificates or permits, or bonding requirements and subsequent costs are to be included within the proposal. XI. ADDITIONAL SPECIFICATIONS 11.1 All coverage limits will be statutory unless otherwise noted within current policy. 11.2 Firms will have the sole responsibility of completing all insurance company applications based on the information provided in this proposal. The City will sign completed applications for the successful Vendor if needed. 11.3 As indicated in the Current Insurance Program Schedule, the policy expires on September 30, 2011. The City is requesting a one-year policy effective October 1, 2011 through September 30, 2012. 7 City of Sebastian Workers' Compensation RFP Fiscal Year 2012 11.4 The City is hereby requesting that Firm's provide two optional proposals to be used for second and/or third year contract extensions, upon mutual consent of the parties, as follows: OPTION 1: to extend contract for second year, effective from October 1, 2012 through September 30, 2013. Proposers must indicate the premium increase over the first year as a % (percentage) and the premium amount in dollars. OPTION 2: to extend contract for third year, effective from October 1, 2013 through September 30, 2014. Proposers must indicate the premium increase over the second year as a % (percentage) and the premium amount in dollars. 11.5 Proposals are to remain valid for a period of thirty (30) days following the expiration date of the current policy, which may be replaced in the event that an extension of coverage is undertaken. 11.6 It is agreed by the undersigned proposer that the signing and delivery of the proposal represents the Firm's acceptance of the terms and conditions of the specifications and if awarded a contract by the City, the RFP package documents and proposal as accepted will represent the agreement between the parties. 11.7 Proposals must be submitted by licensed Florida resident agents, and shall be signed by a duly authorized representative of the insurance company underwriting the program, otherwise will not be considered. 11.8 One hundred twenty (120) days written notice by the insurer is requested prior to any restriction of limits or modification by the insurer resulting in restriction of existing policy terms, premium alterations or provisions. 11.9 One hundred twenty (120) days written notice by the insurer is requested for termination or non -renewal of coverage except for non- payment of premium. 11.10 Please indicate the address, telephone number and name of individuals to whom claims should be reported and the procedures to be followed in notifying the insurer. City of Sebastian Workers' Compensation RFP Fiscal Year 2012 11.11 The City requests that the successful Firm submit quarterly loss reports for each line of coverage insured. Reports should be accompanied by a detailed description of individual paid losses and established reserves for each claim and should be received quarterly by the City within thirty (30) days following the end of the reporting period. The total claims (both number of claims and incurred and reserved costs) should be included. In the event of termination of coverage, loss reports shall continue to be furnished until all open claims have been concluded. It may be requested that claim reports be structured by departments or locations. Firms must include samples of claims reports with proposals. 11.12 The projected payroll as listed in "Exhibit 3" is to be used for all calculations of manual premiums. The City requests the ability to pay actual premiums based on quarterly self -audits in order to defray any additional premiums which may surface after the completion of the annual audit. If this is not possible, the City would like the ability to alter payments throughout the year as necessary should major employee changes affect premium payments. 11.13 The City of Sebastian is interested in reviewing various deductible options. Please provide a complete and detailed premium analysis calculation to include all discounts and deviations for the following options: A) First Dollar Coverage B) $10,000 deductible with stoploss Additionally, the City is interested in any alternative options or proposals that would provide the same or enhanced benefits. Please detail the procedures for the reimbursement of deductibles and verify the billing schedules currently utilized by your company. 11.14 Please provide a listing of classification codes that will be used for this plan year being quoted. 11.15 The City's experience modification as of October 1, 2011 is 1.08 and is included in Exhibit 3. This factor should be used for all calculations. 11.16 The City of Sebastian is a drug-free workplace and has a comprehensive testing plan in place. City of Sebastian Workers' Compensation RFP Fiscal Year 2012 11.17 The City has a safety committee that continually monitors safety issues and enforces a safe working environment. There is a comprehensive safety manual with which all employees are required to be familiar. 11.18 Please list all available discounts and the requirements necessary to earn said discounts. 11.19 The City has the right to remain directly involved with all workers' compensation injuries and will be instrumental in decision making processes, including compensability, funding of lost wages and legal defenses. 11.20 The City will require an audit of classification codes prior to the implementation of the accepted program. 11.21 Agents' Disclosure: Any AGENTS responding who may be dealing directly with the carrier must disclose any and all commissions, fees, service charges or compensation of any type that may be added by the AGENT to the direct quote from the carrier prior to submittal. Additionally, a detailed list of all services to be provided by the submitting AGENT is required in your proposal submission. 11.22 Evaluation of proposals will be based on the following factors: A. Overall premiums including all applied discounts and credits B. Municipal experience and public sector client base C. Duplication of current coverage D. Enhancements to current coverage E. Financial stability and assigned rating of carrier F. Ability to service City working in concert with Agent of Record G. Industry reputation and client recommendations All rating factors will be weighed taking into consideration the specific needs of the City of Sebastian. Firms are encouraged to provide any additional information that will be instrumental in assisting the City in assessing proposals. Supporting documentation may be attached within this proposal for consideration. 10 City of Sebastian Workers' Compensation RFP Fiscal Year 2012 City of Sebastian Exhibit Section Exhibit 1: Proposal Form Exhibit 2: Current Policy Exhibit 3: Projected Payroll & Workers Compensation Experience Rating Exhibit 4: Claims Activity Reports Exhibit 5: Drug -Free Workplace Form Exhibit 6: Public Entity Crimes Statement 11 City of Sebastian Workers' Compensation RFP Fiscal Year 2012 Exhibit 1 Proposal Form City of Sebastian PROPOSER'S DECLARATION AND UNDERSTANDING The undersigned, hereinafter referred to as "Proposer", declares that the only persons or parties interested in this proposal are those named herein, that this proposal is in all respects, fair and without fraud, that it is made without collusion with any official of the City, and the proposal is made without connection or collusion with any person submitting another proposal on this Contract. The Proposer further declares that they have fully examined the Specifications and that this proposal is made according to the provisions and under the terms of the RFP, which Specifications are hereby made a part of this Proposal. Proposer further declares that any deviations from the Specifications are explained on separate sheets labeled "Clarifications and Exceptions" and attached to this Proposal Form and that each deviation is itemized by number and specifically referenced to the applicable specification paragraph page. It is assumed that your Proposal has duplicated the current coverage without variation. If your Proposal has not duplicated the current coverage without attached explanation and disclosure, your proposal may be rejected. Firm Name Address Phone Number Fax Number Signature of Officer Date Printed Name & Title 12 City of Sebastian Workers' Compensation RFP Fiscal Year 2012 Exhibit Current Policy 13 WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICV Policy No. FMIT #0539 EXTENSION OF INFORMATION PAGE ITEM 4. CONTINUED - Page No. 1 Rates Pei Estimated Annual Premium Estimated $100 of Subject to CODE Total Annual Remun CLASSIFICATION OF OPERATIONS NO. Remuneration enation Modification All Other FL -9 Intrastate LD.: 094007518 LOC. 1 Employees: 174 NAICS: 921190 Total Payroll: 6,237,000 FL From10/01/2010 To 10/01/2011 STREET or Road MAINTENANCE OR BEAUTIFICATION & 5509 639,000 8.120 51,887 Drivers AIRCRAFT OR HELICOPTER OPERATION: AIR CARRIER 7403 167,500 4.820 8,074 - SCHEDULED OR SUPPLEMENTAL ALL OTHER EMPLOYEES & Drivers POLICE OFFICERS & Drivers 7720 2,127,000 3.370 71,680 AUTOmobile SERVICE OR REPAIR CENTER & Drivers 8380 80,000 2.890 2,312 CLERICAL OFFICE EMPLOYEES NOC 8810 1,849,000 0.250 4,623 Buildings - Operation by Owner or Lessee 9015 74,000 3.720 2,753 CLUB - COUNTRY, golf, fishing or yacht - & Clerical 9060 263,000 1.740 4,576 PARK NOC -ALL EMPLOYEES & Drivers 9102 486,000 3.340 16,232 CEMETERY OPERATION & Drivers 9220 63,000 6.160 3,881 MUNICIPAL, TOWNSHIP, COUNTY OR STATE 9410 488,500 2.670 13,043 EMPLOYEE NOC AR Adjustment 1.085 15,220 Employer Safety Premium Credit 9765 0.020 -3,886 Drug -Free Workplace Credit 9841 0.050 -9,520 Total After Credits 180,875 Experience Modification Final 9898 1.010 1,809 STANDARD PREMIUM 182,684 Advance Discount 0063 -15,714 Normal Premium 166,970 Expense Constant 0900 200 IncentiveCredit .37,531 Net Premium 129,639 Terrorism Risk Insurance Act 9740 0.000 0 WC nn nn f11A VI00 0� ,.r I WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 09 04 03 A (Ed. 1-08) FLORIDA TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT ENDORSEMENT This endorsement addresses requirements of the Terrorism Risk Insurance Act of 2002 as amended by the Terrorism Risk Insurance Program Reauthorization Act of 2007. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. 1. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and arty amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2007. 2. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, In concurrence with the Secretary of State, and the Attorney General of the United States as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property or Infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carders or vessels. d. The act has been committed by an individual or Individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. 3. "Insured Loss" means any loss resulting from an act of terrorism (including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance Issued by an Insurer if the loss occurs in the United States or at the premises of United States missions or to certain air canters or vessels. 4. "Insurer Deductible" means, for the period beginning on January 1, 2008, and ending on December 31, 2014, an amount equal to 20% of our direct earned premiums, over the calendar year immediately preceding the applicable Program Year. 5. "Program Year" refers to each calendar year between January 1, 2008 and December 31, 2014, as applicable. Limitation of Liability The Act may limit our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a Program Year and if we have met our Insurer Deductible, we may not be liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we may only have to pay a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses exceeds $100,000,000 In a Program Year, the United States Government would pay 85% of our Insured Losses that exceed our Insurer Deductible. 2. Notwithstanding item 1 above, the United States Government may not have to make any payment under the Act for any portion of Insured Losses that exceeds $100,000,000,000. 3. The premium charged for the coverage for Insured Losses under this policy is included in the amount shown In Item 4 of the Information Page or the Schedule below. Schedule Rate per $100 of Remuneration See Schedule A Copyright 2007 National Council oa Compensatlon Insurance, Inc. All Rights Rasonrea. P.no S of 7 WC 09 04 03 A WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-08) This endorsement changes the policy to which it is attached and Is effective on the date issued unless otherwise stated. (The Information below is required only when this endorsement Is Issued subsequent to preparation of the policy.) Endorsement EffectiveDate: 10/01/2010 Policy No. 0539-W10 Policy Effective Date: 10/01/2010 to 10/01/2011 Insured: City of Sebastian DBA: Carder Name] Code: Florida Municipal Insurance Trust WC 09 04 03A (Ed. 1-08) Countersigned by ©2007 Naaorol Council on Compareauon Insurance. Im;. Endorsement No. Premium $ WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0311 A VOLUNTARY COMPENSATION AND EMPLOYERS LIABILITY COVERAGE ENDORSEMENT This endorsement adds Voluntary Compensation Insurance to the policy. A. How This Insurance Applies This insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must be sustained by an employee included In the group of employees described in the Schedule. 2. The bodily Injury must arise out of and in the course of employment necessary or Incidental to work in a state listed in the Schedule. 3. The bodily Injury must occur in the United States of America, Its territories or possessions, or Canada, and may occur elsewhere if the employee is a United States or Canadian citizen temporarily away from those places. 4. Bodily injury by accident must occur during the policy period. 5. Bodily injury by disease must be caused or aggravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily injury by disease must occur during the policy period. B. We Will Pay We will pay an amount equal to the benefits that would be required of you if you and your employees described in the Schedule were subject to the workers compensation law shown In the Schedule. We will pay those amounts to the persons who would be entitled to them under the law. C. Exclusions This insurance does not cover. 1. any obligation imposed by a workers compensation or occupational disease law, or any similar law. 2. bodily injury intentionally caused or aggravated by you. D. Before We Pay Before we pay benefits to the persons entitled to them, they must: 1. Release you and us, in writing, of all responsibility for the Injury or death. 2. Transfer to us their right to recover from others who maybe responsible for the injury or death. 3. Cooperate with us and do everything necessary to enable us to enforce the right to recover from others. If the persons entitled to the benefits of this Insurance fall to do those things, our duty to pay ends at once. If they claim damages from you or from us for the injury or death, our duty to pay ends at once. E. Recovery From Others If we make a recovery from others, we will keep an amount equal to our expenses of recovery and the benefits we paid. We will pay the balance to the persons entitled to it. If the persons entitled to the benefits of this insurance make a recovery from others, they must reimburse us for the benefits we paid them. F. Employers Liability Insurance Part Two (Employers Liability Insurance) applies to bodily Injury covered by this endorsement as though the State of Employment shown in the Schedule were shown in Item 3.A. of the Information Page. O 1997 National Council on Compensation Insurance. Dene 1 of O WC 00 0311 A Employees WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY All officers and employees not subject to the Workers Compensation Law except Masters or members of the crew of any vessel Schedule State of Employment Florida Designated Workers Compensation Law State of Hire This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated (The information below Is required only when this endorsement Is issued subsequent to preparation of the policy.) Endorsement 10/01/2010 Insured City of Sebastian Insurance Company Florida Municipal Insurance Trust WC 00 03 11 A (Ed. 8-91) 01991 Nallonal Counctl on Compensarlon Insurance. Effective Policy No. 0539-W 10 Endorsement No. Premium Countersigned D,-- I —fr City of Sebastian Workers' Compensation RFP Fiscal Year 2012 Exhibit 3 Projected Payroll & Workers Compensation Experience Rating City of Sebastian FY 2011-2012 Workers' Compensation Estimated Salaries Estimated Payroll For Fiscal Year WC Code Description FY 2011-2012 5509 Street or Road Maintenance $551,206 7423 Aircraft or Helicopter Operation 169,793 7720 Crossing Guards 44,000 7720 Police Officers 2,010,209 8380 Automobile Service Repair 97,098 8810 Clerical 1,612,874 8820 Attorney 0 9015 Buildings -NOC 73,933 9060 Country Club, golf fishing or yacht & Clerical 216,225 9102 Park NOC - Employees & Drivers 488,110 9220 Cemetery Operation & Drivers 62,955 9410 Municipal 487,708 Total Salaries by WC Code $5,814,111 14 tfSr WORKERS COMPENSATION EXPERIENCE RATING Risk Name: SEBASTIAN CITY OF Risk ID: 094007518 Rating Effective Date: 10/01/2011 Production Date: 06/16/2011 State: FLORIDA ail "yNt 9RFl Exp"Eicess. Expecfed -. Exp. Pyim Act Exc Losses Ballast Act Inc Losses Act Prim -. Losses - Losses Losses - -` Losses FL 1 .21 0 1170,96 209,7741 38.808 141,7471 39,600 207,3221 65,575 1 jg. C) -Exp Excess (D) Expected (E) Exp Prim (F) Act Exc (G) Ballast )Act Inc (1). Act Prim Lojpes (D - E) Losses Losses Losses (H -1) - Losses Losses .211 I 170,966 209,7741 38,808 141,747 39,600 207,322 65,575 - Piimary Losses Slab zing Value Ratable Excess Totals - (p 0*(1-A)+G (A)'(F) (J) Actual 65,575 174,663 29,767 270,005 (E) Ce(1-A)+G . (A)e(C) (K) Expected 38,808 174,663 35,903 249,374 FLA A - SWRAP_ ._. -MAA P - _--: i -.Exp Mod - (J) ! (K) Factors 1.10 1.08 RATING REFLECTS A DECREASE OF 70% MEDICAL ONLY PRIMARY AND EXCESS LOSS DOLLARS WHERE ERA IS APPLIED. Copydght l9aa.2011, All n2htn reamed. This scxwencs modification factor ucompm ed of conpiladonsand Infocru nn which arethe popdetaryand excluslxe pmpertyof the National Council on Compensation Insurance, Im.(NCC1). Wlurther race. dissemirutian,tale,transfer, asaignmentodkpocition ofNlcexpanenea ntirgmolilkationfaa«oenY partdured MYbeuaedwdheutMewdeenmm td NCCi. NCCI makes no mpmeenfadon orwamanty, expressed or implied, as banYmatlerwhataae+er liwluding Iced not limited b a,eaaungpf snymtomufien, puductorsomce rumishedhereunderand, as to NCCI, reciplentof this experience mfing modification factorsubsodbestoend utilaes the information senice'as Is. Page 1 of 3 WORKERS COMPENSATION EXPERIENCE RATING Risk Name: SEBASTIAN CITY OF Risk ID: 094007518 Rating Effective Date: 10/01/2011 Production Date: 06/16/2011 State: FLORIDA ua-FLVKIUA Firm ID: Firm Name: SEBASTIAN CITY OF Carrier: 31860 Policy No. FMIT0539 Eff Date: 10/01/2007 Exp Date: 10/01/2008 bode EL"R D- - Ratio Payroll Expected Losses Ezp Orion'-: Losse Claim 6ata IJ OF Act Inc - - Losses Act Piim Losses j 5509 2.72 .15 617,097 16,785 2,518 WC200810834 5 F 1 8,840 5,000 7403 1.87 .18 162,498 3,039 547 WC200810789 5 F 15,838 5,000 7720 1.35 .18 2,324,140 31,376 5,648 WC200810875 5 F - 30,962 - .5,000 8380 1.16 .20 81,190 942 188 W0200810877 5 0 79,000 5,000 8810 ` :10 ' .22 1,921,986 - 1,922 423 NO.:4 6 F 1.,834 -1;834 8820 .07 .20 117,369 82 16 WC200810912 6 F 2,132 2,132 9015 1.63 .22 68,096 - 1.1 01 244 WC200810924 6 F - 2,155 -2,155 9060 .79 .24 275,1391 2,174 522 WC200810781 6 F 2,642 2,642 ,9102 1.36 .22 390,739 -8,034 - - 1,767 WC200810787 6 F2,740 - 2,740 9220 2.49 .20 55,7671 1,389 278 WC200710654 WC200810746 6 6 F F 2,755 2,930 - 2,755 •'- 2,930 9402 2.35 .18 M1 21' 4 9410 1.03 .22 655,1411 6,748 1,485 WC200710684 6 F 3,433 3,433 9765 WORKPLACE SAFETY C - -1;609 -298 WC 10753 6 F - 4;870 - _ 4,870 9841 DRUG FREE CREDIT -1.,661 _ -3,942 -730 9841 IDRUG Policy Total: -4,069 Subject 6,870,037 Premium: 294,665 Total Act Inc Losses: 160,131 Policy Total: 09 -FLORIDA Firm ID: Firm Name: SEBASTIAN CITY OF Carrier: 31860 Policy No. FMIT0539 Eff Date: 10/01/2008 Exo Date: 10/01/2009 Code - R D. Ratio Payroll - - ExpA Losses Exp Prim Losses dila-fin ata IJ b _ - Act Inc Losses Act Piim Losses I 5509 2,72 :A5 .650,359 17,690 - .2,654 N0. 2 5 ..3,644 3,644 7403 1 1.87 .18 173,839 3,2511 585 WC200911171 5 F 2,120 2,120 7720 1:35 �,18 -`:2,482,189 33,510 -. 6,032' WCW0911289 5 F 'a 4,086 4,086 8380 1.16 .20 112,429 1,304 267 WC200911294 5 F 74,144 5,000 6810 70 1,945,993 ::1;946 428 WC200810976 5 F 14,892 < 5,000 8820 .07 .20 84,920 59 12 NO. 6 6 5,894 5,894 9015 1.63';'.22 _ 85,084 1;387= - 305 WC2609111 MO 6 F 7,180'. 5,000 9060 .79 .24 1 275,6461 2,178 523 WC200911085 6 F 24,9681 5,000 -9102 .1:36 :22 664,751 4,041 1,989 _ 9220 2.49 .20 64,355 1,602= 320 9402 2.35 ..18 b,3Z5 - _ .126 23 '- - 9410 1.03 .22 696,791 7,177 1,579 9765! WORKPLACE SAFETY C -1.,661 _ ,308 9841 IDRUG FREE CREDIT -4,069 -755 Policy Total: Subject 7,241,731 Premium: 252,905 Total Act Inc Losses: 76,928 Copyright 1 M-2011, All rights reserved. This experience modification factor is comprised of compilations and Information which are the proprietary and exciusim propany of the National Council on Compensation Insurance, Inc. (NCCQ. No further use, dissemination, sale, transfer, assignment or disposition of this experience rating modificabon factor or any part thereof may be used vdthout 0e written consent of NCC1. NCC/ makes no representation orwarranty, expressed or implied, as to any matter whatsoever including but not limked to the accuracy of any information, product of service furnished hereunder and, as to NCCI, reclpient of this experience rating modification factor subscribes to and utiliecs the information service 'as is. -Total by Policy You, of all wses$X00 or less. DD6.. Loss XEx-Metllcal Coverage UUSL@HW CCahsimphic Loss, E Employe.. Liability Loss kLimited Loss Page 2of3 H WORKERS COMPENSATION EXPERIENCE RATING gal Risk Name: SEBASTIAN CITY OF Risk ID: 094007518 Rating Effective Date: 10/01/2011 Production Date: 06/16/2011 State: FLORIDA 09 -FLORIDA Firm ID: Firm Name: SEBASTIAN CITY OF Carrier: 31860 Policy No. FMIT0539 Eff Date: 10/01/2009 Exp Date: 10/01/2010 Code OR . D. Ratio Payrollfapected _ Losses Exp Oim Losses Claim Data _ _IJ O -Ac Snc Losses Act Prim Losses 5509 2.72 .15 640;549 17,423 2,613 NO. 2 5 2,286 2,286I� 7403 1.87 .18 168,032 3,142 566 WC201011493 5 F 5,096 5,000 7720 1.35 .18 .2,368,194 31,971 - 5,755 WC2009113170 5 O 6,329 5,000 8380 1.16 .20 116,433 1,351 270 NO. 7 6 ` 3,407 3,407 8810 .10 ` .22 1;847;582 1.,848 407 8820 .07 .20 105,300 74 15 9015 1.63 .22 x82,410 -. 1,343 .295 9060 .79 .24 260,682 2,059 494 9102 1.36- .22. 570,297 -'- 7{756 - 1,706 9220 249 .20 63,623 1,584 317 9402. 2.35 ,_ .18. ;1;450. `34 .6 9410 1.03 ,22 490,823 5,055 1,112 9765 WORKPLACE SAFETY G 1,568 -292 - 9841 DRUG FREE CREDIT -3;890 -716 Policy Total: Subject 6,715,375 Premium: 204,974 Total Act Inc Losses: 17,120 CopyrightigQ&2011,A11rightsmse,wd. This eaqerience modification factor is comprised of compllalions and lntonnabon which are Na laowietary and exclusive pmperty of the National Council on Compemation Insurance, Inc. (NCCQ. No fuller use, dissemination, sale, transfer, assignment or disposition of this expmmnce rating modification factor or any pad thereof may beuead wIftutmo warden consent oINCO. NCCI makes no representation or wamnty, expressed or implied, as to arty matter whalsoo.e, Including but not limited to doe accuracy of any bdomation, product or service furnished hereunder and, as to NCCi, recipient of this experience rating modncabon factor subscribes band utiles the information service'as is'. 'Tctol by Polley Yearpfallcom.$2000orleoe. DDisease Loss XEx-Medical Coverage UVSLSNW C Catastraphlc Loss EEmployen Liabililylpas BLimlled Lose Page 3of3 City of Sebastian Workers' Compensation RFP Fiscal Year 2012 Exhibit 4 Claims Activity Reports 15 FMIITO 0539 QTY OF SEBASTIAN FMR 80 FLORIDA MUNIQPAL - WORKERS COMPENSATION MEMBERS LOSS REPORT ID/01/2001- 09/30/2002 AS OF MARCH 31, 2011 MTEOF WARY CODE �� PAYMENis M MTE NUMBEA NAME MDER MURY CI!%E FIAT POM MUSE RECEIVED COMP MEDICN. m11ER OmSTANDMG REQWF81E5 FBHIVB UIOFIIED WC2mt0898n MB Erlrnm9 ]aK-)0f-ams POL lW12/2m1 c n 10 99 1WISI 1 mm $1350 iO.DD am $0m m W mtOB9988 CBar W, 23m10t-9U3 TE[M limmml c R m n llp)ml mm On w w 109084 4rmw t Kpt-mt MAMT ll/lWm01 c 4d n 85 11/14/101 mm mm mm %m WQm109D1% Pouta%P ]00010(-w MAMT l2/97/lml c w it 19 1207/2001 am am $162M M1.41 tam am mm mm $Dm s162U NQOOtOm2)1 Rk1HN egls W -M0. u MMT 12/tilml c R 6i % 12/21/2MI s2.TI5.D3 335,21M stml.60 am, am tam VS1.41 $",Wm W Immm im4EPove %%K-1IX-0U8 POL 11/M/Lml C U 98 99 003/003 fa00 mm mm am VIC200209m99 GMyAM 10IXJX-1283 MRDL WORI®trt 03/UMR c )5 14 87 W28/2WZ mm $15137 mm mm mm mm WQD@mlmD JMn Tvemwu M-M4M2 PARl55UPY 03/22/A02 c q9 % n 03/28R0m s36&U S94&m $Mm Sam mm am $151.9 0456633 M MN1021 Vk$x PtlCitt f00( -ICI -0)13 CF82 ASST LLyl]/L3M c R M 56 D4/m/20m mm SS3a30 am mm am $Smm WC Wlml GmNkrE Mu ]DO(d0(-3101 IRT C1Hlk 03R1/mm c l0 % 13 Nm/m02 am $97m am am WR00201223 T P.0. . lIXlt-p(-)4m POL 0v22//ID02 c m m 69 Oi/2u2002 $0.m mm S97m WQm2m12M RRitk RerII 6mFKK-3W0 Pd. Dy22/2m2 c R 30 5851.n t250.m mm mm $1,10i.n m M/23/2m2 am $131&n mm mm mm $1,31U7 WCSm2mt30 30Rdi DBm ]N( -k%-1821 Pgl�OPFILElt O5/m/209E C 73 W 99 OS1lD/2m2 m.m $312% 32m.m tom am 136286 WC WIW Mrte*fiats =Ym 62 P0. 05/0/200 c n M 99 OS)lw4W m.m (21633 $25D.m $0.00 am $4%23 W MWIU0 ]0.o D8M0 W.U.1821 POt1a OFF1Cm 06125/2m2 c 10 m 46 OARS/2m2 $2LMn $34503) 3241931.78 $7,900 am $)2,821.8) WQOmm2m3 Nomun C'[W ]MK -]0:-1151 MAIMWpM 07/24/202 c m % 16 07/24/00 am &554.78 5&00 $O.m WQm2021m 1e9a6aPSMNs W -KK -3651 ME 0/01/202 c W R 31 DO/Ol/M am $" mm Sam $554.78 NC2m2m2174 WY Gtnmm 10F10I-36m PIXICESM(.4AHi m/D8/2m2 C 10 % 74 Wow= mm $828.19 mm am mm am am $92.0 %MI9 WC2002m21% UT6"fLtm- kkl-=a Q P0. Og112/2m1 c 10 21 33 0&112/202 $392U ".A 31 S35.m $0.m m.m $,15553 YIQ02m22B9 Kmm16 X6rson YK .WIB M%.]a ORIC➢t ovmr U c n 98 % 9A22M11D2 mm $1,43151 mOD $am Sam WCSm2m2282 J By��X. Ia%dIX-0506 POLaf OfFICHt OBt2W2m2 c )3 48 99 OWN= mm $440).82 m.OD mm mA0 $1,431S1 $11407A2 Wd002m1358 Pouf Gms =%-==-0219 POL owoum2 c R 42 M DIMNZW am shall Sam fOm 60m $11011 WC2m203M14 POBMKY KR-KK-1lm PCL m/mf m C 49 M 0 ORM/M mm 3110.9.93 s m g0am mm $2,18493 WC20m092%4 W6NP 5Nofrll =-2X-8951 M4MIWORM3tu P]/29= c R R % 10101)m mm $1.74 mm mm mm $1.74 RMTO TDTACS: OPBI: 0 CIOSID: M TO Am $24,6)1.19 m293&41 $2.M8 $8,300.0 am WA4mm EARNED PREM MMM $MS.494m FAMEDLp56 MDAM $128,40.0 LOSS MTV M DATE: 0.45 FLORIDA MUNICIPAL- WORKERS ODMPENSATION MEMBERS LOSS REPORT FMR* 0539 CITY OF SEBASTIAN 1DID1/2002 - 09/30/200 AS OF MAROi 31, 2011 FM* BD fly NUMBER NPl4f SSH DEPT WTECf 01510.Y 405E MT OIRA1YC00E POM fN6E MTf REQ19® C[MW PAYM3N75VMO 5[mIFAL OT1®( q RTANOpG RECOVFAIB R6IXY8 INCLRRL-0 WC7m202671 ONaY WM =-M-22M POLic llyli/2002 C 10 50 31 10/14/202 am am am wcm2m2B56 FmPsl Gaon M -n-1530 M 1W3w m c 37 m 0 ll/4rmw am $M45 am 0.0 $0m {ORO am am WQ 29M Me P XIOt-%t- PCl 11/11/202 c 0 56 M ll/17/2m2 am 588642 Som {66.43 W[2m20A18 Thep P.9p . X10 -M-2460 P01. 11117/= c M 1B 19 11/11/202 $O.m am am $M.M WC2m2m3139 Wtlmtl&. W-10-7795 POL 14137202 c M M 19 12/13/202 am 5735m $87.0 Sam am am am am $735m WC2m30932T3 Mtw ltt d =-tt-1213 Pg3aw 01/09/203 c 40 m 74 01/102M am 5354.61 $175.0 $0.0 01-M WC20303435 W Ma W -%A-7397 w 01/27/00 C 52 0 53 0I0um SZWL55 56,7m.m $0.0 s0.m am $62941 W W3m34m Enx4 Go-by =-X6150 PW 02/07203 C 68 0 99 wlwm3 Mm $11137 $0.0 50.0 $9.03.38 Wc2m3093m Sa0y0. Ganlwtlp wamt-zws AOM OVZW=3 C 10 m 31 Dym am am am am $11137 WC2m3m39M Ropat Nym 3X% -%X-210 P[X 04/00/203c 10 m 45 OV06/mJmm 50.0 s412B.0 $O.m SOm $16.0 $om SOm Som SD.m 53,329.0 MT3➢mm4854 l WBaST %I0I-X%i386 7MINf. WOfIRE11 U12V2003 C 52 m 45 01INM am $33833 SO.m $Om am $16m WC2Wmwm WYGa0e8ust l0IX-lOf-0929 fIXl[£OfFl®! MAW= C T3 0 99 MPA am $0m Nm $0m $0.m 533&23 $MW WC2m30mN MM Faits XYX-MAM3 P0. 0419/0m C 0 42 A 0f242003 sD.m $10844 mm am mm $1,081" flOT/TOTALS: OPQ1: 0 C1D5®: 13 TOTN4: am.55 s12,m7.45 5291M am Sam t15,1*lA6 EARNEOPRF70U Mmn; "32,16 W FOAMEOID65FSMmm 515118246 FMR# 0539 CITY OF SEBASTIAN FM# BO FLORIDA MUNICIPAL - WORKERS COMPENSATION MEMBERS LOSS REPORT 10/042603 - OW30/2004 AS OF MARCN 31, 2011 F3LE NUMBER NAn1E 55N DEPT Mp ECP WURY CLOSE NAT INNRRY CODE PART MUSE DATE RECtNED COW PAYMENTS TO DATE MEOIML CM RRSTSTANDIND RECWEt1ES RESERVES INCURRED 5 W3WS634 Axluel &wren MMM -MM -1/95 PDL ll/OWIDD3 C M 37 53 11/0W2M $0.0 11,956.74 om $3.30 "m $1,953.M KQ003095900 Cary Nk MMM -MM -1563 PUUK � N 1]/3W200 C 15 14 87 32/3W20µ3 SOm $260.00 $Om $0.00 SOm i260m V M0 33 Gnat GeAa MIOI-b.1530 PW p1AIW20M C 37 % 82 01/12/2 SOm $9278 Som $Om fOm $9278 MQ00109fi132 V7Rtn .k 1a+!-Mm� POII6P CET 0LIW2W4 C M 55 0 owly 4 $Om $75&42 BISOAO SOAR $om $10&42 HL?001096614 3 n m rr, ,Y. 3MM-MM-M90 POL 05/0V/ C M 55 0 O4/O6/20D4 SOm $146.10 $Om $Dm µ1m 8146.10 KQOD1096667 18ma mumhy I00I-07 MAINTEI 04/07/21104 C 40 w 19 04/071fi 1&00 81,X5.37 50.00 tom µ1m 81325.17 W D96679 CalµmUneSm/ds =-MM-NO2 P OESV.. &3/2272pO4 C 52 31 99 04/OV 80.0 "Mm 5250.00 $am $om $1105470 WT3 Wfim Oa^N AmN] =-M.2521 KX D4/DS/ID01 C 10 S3 99 W15/2µ04 $0m $X7.42 S25Dm $0m $0m 8577.42 KBOD4096730 RRtO'e ReAs W -W -M ROL 04/16Rm4 C 16 36 0 04/16/Lp4 80.0 $1.105.99 $77.45 mm IDm $I'M.M VIC2004W6762 Tkn Mel MMROON MAD9T YA'IN1031 ov2wW C IO 0 45 04/20/2004 $0.00 51150.13 8µm $0m $0m $1115813 NC2W4097421 PMricin P.l %p.=IX 75 CLEUpY A55L5T. W134/2m4 C X 0 31 0/14/2004 $0.W 8106#7 $Mm 8372.00 $µOO 5329.61 wWOM097434 BM k IDX -M4569 MNNT.IHNXIOPµ W/IVM C M X 57 W/16/2m4 $Om 82HA5 $21/70 $Dm Nm $Ql.SS N40D4037461 J9M W6Ln GvivnM, k. =-MM-M90 POE Wr42004 C 7R 55 28 W(LW2004 $4.40.77 $3,96091 SOm $Om µ1m 8475158 VrODD1p98p)fi Cary Alen 100E 4263 MNN.6Yg0031D W/2972µ04 C M 14 87 VVD/2m4 WM $0114 mm Wm W.m 158134 MffoT ALS: OPEI: 0 CLOSED: 14 TOTALS: $21)903) 813,11&R $173495 $33070 50.00 $16.914.14 EARNWP M4TOMM: 546µ715m EARNEDIOSSESTOOATE $16,914.14 LOSS RAT W TD GATE: 0114 FMR* 0539 QTY OF SEBASTIAN FM* 80 FLORIDA MUNICIPAL - WORKERS COMPENSATION MEMBERS LOSS REPORT 10/01/2009 - 09/30/2005 AS OF MARCH 31, 2011 FBF OAMOF MRYm GATE PAYMBnWMTE wMw X E SSX pEY1 MAI0.Y 17L5E NAT PMT OUIfiTAHOBG OFMH( RHDVERIB RE9lVB OplRp® W(Z490981M CA3Mea G. GtlII XXl!-l0(-1053 BMG MSPECTOR 10/03/2005 C R 0 4 lwow Df 52.93219 $0.127.93 $600 00.956N SON i)IBN W000548ifi0 Baan P.Atlds INX.V% l PARRATi610ANF 10/IB/20M C 10 IO 79 1119/145 am S1.2BILll $03622 $1,200.11 $a4 i0.T6.R WQ4948311 JwWi881as, k. 100010(-054 MLIM lw2wR C Q 33 19 Mf2V IM w4 SLIM14 am f1,100.1a wN $0.4 WQ4509K117 BwkPS,L18 W-MAm3 FOL 1WM/245 C 10 30 31 10/26)143 $62.14.0 $5.52533 $4.953.6T f10.195N SON $85.42.95 WQ494M67 30800 F a I04fO 58 PoIICE OFF[CFA lYl3/24a C R 33 5) 11/15/145 w.4 $06.00 $9.4 f86N SON $0.4 WC20009B9)2 hu11.R. %f 01-f%-)BIO MAQTIWORNRll 11/12/2009 C 0 12 55 11/IS/ZOM 50.00 $],4)4.20 $350.00 f2.n4.m SON S350N WQ4R19$SS 9obe1 KY W-KR-2106 POL l2/4/LM9 C 20 90 79 12/09/2005 am $41193.19 $0.4 $9.293.19 am $0.00 WQOM0907B3 J..MG o*tl W-4661 SIRfltN50R WATEO 12/20(245 C 10 90 31 121301111M 561,395.98 $$ZM.6l fi1bam $10,04.00 10.00 f99bam 40200544)0 S4ue ]enMpS IOOfd046)B MgHAlIIC 01/11/245 C 37 32 75 01/12/Lp5 f0.4 $2.856.4 50.4 $2,856.4 iO.W f0.4 YK24S099321 PnfiulVB00BAv X$00 4197 ma(Y1OR 03/15/2005 C n 33 0 4/13/x45 f0.4 am am $0.4 $0.00 WC20050393R 6¢MmCa %KK-IOc4509 PIXI( WPIM 0A215J245 C 73 33 0 03/15/2005 $0.00 $910.00 $0,00 i910N am am $6.4 WQ4499N1 Wiam lursk p�(-IpI{g6g Pq.$CE OFF 03/17/245 C 10 36 2) 03/17245 51.382.29 9.21)2) $02.n WIM4M $0.00 f9112.75 WC143099715 RBCutl Baron p0[-pt-n95 SpL OS/D)/245 C 93 37 fly 4/01/200 30.4 SSA.L $ON $Mll SON $ON 404051470 8 Ge'W %10fa001530 MA00"WORAT3t 4(12/215 C 10 IB 75 09/11(204 50.4 $2.514.0 am $2.514.96 mN 50.4 WC20014)60 CN6e XA 100$-331-2125 MAOIF 400.1{61 [I 4/4/145 [ 32 35 85 4/13/100 50.4 SSM.M $0.4 $554.H am $0.4 RNi*TOTALS: OP6i: 0 CID'a®: 15 IOFAlS: f1262)L03 $97,46.58 $V.6B3.10 $53,909.13 am $19),86258 FA M PREMUM TO MTE: $3M.9754) 641®L055BM DATE 5182,867.59 165 MTOlO MTB: 0.56 FLORIDA MUNICIPAL - WORKS S COMPENSATION MEMBERS LOSS REPORT FMITA 0539 CITY OF SEBASTIAN 10/01/2005 - 09130)2006 AS OF MARCH 31, Zoll FMA 80 iRE DATED, INRRtTC00E MTE PAYMEMMMMn OGRTA M NUMBER RMIE 5512 DEPT IRRIRY OM RAT PART G0X P$EVFD NFP MEDICAI. O3MER PESEiNES WC181RED WQ00161112 BrKan GraKak iKK-XK-8X9 TRAfFlO MAR4T.Tg 10/20120 C 0 55 53 10128720 $0.0 $350.10 $0.00 am m0 5350.10 0(3052102 JMn WIBIam GrlmmkA, Jr. %%K-XK-H90 POL 111L7rZM5 c 90 90 74 11117fM am $1,14323 SOAO 5080 $am $1,11323 W0=01"2 fnnffimY,e Sawvh KKK -1 4402 ROLICE SGf. 17/2/205 c 0 X 0 12/24/MM SOHO SL21829 $17.64 50.00 %.0 $1,235.93 WUM61016M Tim P.RO. XXX -M-7460 PIX 01/04/206 c " 53 n O1/0S%JA0 Sam 521"A9 0.82 IAM $a0 {2,15291 WUM10104 CAft&S" W -m-2235 MALYTWORKER 011"AM% C 52 38 S2 0]/12/206 0.0 $21Nb0 $50000 S12A0 50.0 $2,03.50 WC20610172 &Ian G,7 k W-xx-0X9 TPg1iS Rkw T 91/20/20% c 28 44 25 01/20/200 SOHO $1,73 $350.00 am 5000 $4080.64 WY200107215 OGR.G9 .n =0 -35" "AOR WORKER 03/3012006 C K 30 0 03/30/206 SNI." 511318.0 5425.00 SICU 5080 $2,010." W000104A GhMpIMrfRbsan w---7924 H WORKERII 04/2$120 C 37 17 0 0x126/2005 am 5185.50 50.0 50.0 0A0 $105.50 WMMI1 84 Pab P. Kavt =-XX-2075 tMOITWORK R ownwN C 0 55 31 05/03/200 0,810.14 "1M.% 56,345.63 $250 $0.00 $13,00.8 W[2061026N Cpsbnxie Snwtls =-X-NO PoIlCESGf. 05/2/206 c 10 % N 0524/20 540 "6739 50.0 50.0 0A0 avM WC2O610 t9K0e AKfllel W-XX-IM7 IMOtTEREME 05/30/206 C 0 0 N 051371206 5899.35 $203443 $3aM 500 SOAP $3,246.18 WC2061E117 Sa5PAC4WRwtl9 10061062396 ADR 07/14/20 C 33 91 82 02/21/206 am 50.0 $265m m0 fOAp W13061E132 1 WG. RtaNs =4X4-3651 Mf41 02/14/300 c IO 0 65 02/21/20% $LW4.% 00116.X 54X.0 50.0 $0.0 $265.0 512,366.51 WO206101236 S wRoA 1001062670 M Rlc 04/02/20 C 35 0 0NJ/206 500 3289381 50.0 500 SOHO $289381 WC20623N7 sy.M,K X0!.WI 78 M WWORIEtO 0/24/20 c 52 53 0 00/02/200 $3.803.08 5191862" S1,LT00 5a0 am $N.297.17 0[200610320 KaN F4m XXXW -262 REGS6PERVISp1 OBM120 C 0 0 0 0/08/20 5080 $3"M 52500 500 SAAB $627M 0[20610330 J3m65MFA XXK4KK- 0 GAMAH 08,21/2006 c 32 M 85 00122/20 50.0 591203 SOHO am 50.0 3942.03 WT20610340 W LGSRn XXX W47" MAIM WORKER OB/N/206 c 0 0 19 0129/20 f00 $1,686% a.0 500 50.0 $1,686% WC2061E598 Lx l Nm LOK#4968 REC2ffAT1 MDE E/Iy20 C " X 0 E/19/20 50.0 $3,"1." am $0.0 50.0 $3,991.94 MRS TOTALS: BPM: 0 LJ.OS®: L9 TOTALS: $6.5246> 557.994.T2 ".997.59 s17666 50.0 $76386.93 EME®PRBD>MTO04TE: $296,126A0 TiWNEAlU MCAT£ $74366.93 1059RAT10TOMTE: 026 FMR# 0539 CITY OF SEBASTIAN FM# 80 FLORIDA MOMCIPAL - wORK9LS COMPENSATION MEMBERS LOSS REPORT 10/01/2006 - 09/30/2007 AS OF MARCH 31, 2011 FILE DA3 OF INWRYC PAYMENTS M Mn NUMBER HAMf SSN OFR INWNY CIDSE NAT PARI U E RC$V® CQw M®ICAC OTHER gECDJERtg OUISrANOP1G RESDM INOl0.gED wC2W6101851 Peul l.4 Plene %IIX-X1(•180I MAIXIW.q n 10124/2Wfi C 40 11 70 10/24/2006 moo 1661.03 10.00 w 00710N41 R96bl Sn5db %II-IOf3K5 MgO1i XV rl 01119/1000 C 25 14 01 04191m fOm f1sm 50.00 VLOO moo {600 wm 1661m WCIDI0105135 P FM 10IX-10f4785 IAWEMfORC D4/Ifi72W7 C R W 0 0017= $600 180.95 U0.50 00[20001043! GHOm HlW I00f-1011/01 MAAPfT 04/30/2807 C 52 42 56 05/01)2)0) 10.00 W.W am $80.95 WC20p)IORIO Jme$A Byes, Jr. Xfp1-pFp506 pOl 65/01)2000 C 10.00 $Om $1,384.76 10 S3 53 65/0]/E0p) 10.00 Woo .7B 70 fl.>4GJ0 $3W.W 1150.00 1600 fOm {7,096.)0 00[2007105457 Wn maw.19A M-m4p26 POL 05/VaW7 C A 12 45 OS/11/ 10.00 $23)•62 30.00 $600 $0.00 $mm W[20WIW563 W.lMqust, k. )Wf-%Iti91] m MU/=7 C 10 90 50 O6/ll/200=)7 $0.00 ".65fi5 $600.00 Spm 00[2000105954 loon WbnWutl JOOf 9706 MAIM. WORKS( 0)/24/BI.) C 37 90 82 07/271 o W.W $319.55 30.00 $0.00 $0.0011.129.65ln.9 00[200)106005 Can. 00)0001.1263 MAOI.WOgYHtu 05/00/2007 c q9 % 60 WDI/2W) 3600 mm mm $om %.W $319.55 WC2002106148 rWNINYW.sy =--0 4118 MMpI W/m/200) C 49 53 W 08/16/2007 $1,8)1.65 $5.0147 $3,766.88 $pm $0.00 $0.00 mm 311,109.80 FNAB TOTALS: 0086: D Qf15®: l0 TOTALS: $1,071.5 $10,95384 $5,516.88 $0.00 $O.W $1AMI.I6 EARNED PR9NIIM 3p MlE: $305,381.00 EARN®ID95B RI OAiE fl&N1.16 Ills RArroTOMTE; p.W FMTI'k OS39 CITY OF SEBASTIAN FMA 80 FLORIDA MUNICIPAL- WORKERS COMPENSATION MEMBERS LOSS REPORT 10/01/2007 - 09/30/2008 AS OF MARCH 31, 2011 FUE pp�pF 04AIRY COOS MrE PAYfffi MMM OIrt MDMG NUMBER Nary$ Sjry pBT DUIIRT CLOSE INT pART 005E RECENED (17100 I9mfCAL OD6t RRSN9liB RBEAVB INCwI® WQm)1O6M5 IWRHN ]OMb2n %IOFMX-0618 $DUCE ORi®t IWL6/Wm C IN N m 1dV/2� am $2359.56 am am $00 $;75156 W 11MM1 a Hew. =m -Mn P0L tl/WIM07 C R N W 11/m/ZON am $3,93335 am am $0.W $3,93335 WQm31N990 AAmn SDenbn gmVb l POL 12/UIfM7 C 43 N R 12/m/NO3 am M8 $cm am am Mb W 71m2R pabkl9 P.l gO6MM-2W5 MA04T WgG'ER t2/377dm7 C R m 93 0419/20m am $75M 59m.0O am am 593559 WQm71m586 MdtU TaybMMLw1A qIX-g1.9113 OOL mRawm08 C 19 M 74 02/M/2W8 $O.m 5090 am am Om f0A0 99Qm81m963 Oe hHu qIX-gF8450 KX 02/01/1/300 C m m 93 02/11/EWB am $293DA5 $=W $D.m am $3,230.95 WCWN1035B3 M TaybM9 W-W4113 POL 03/26/2008 C 99 N 39 m/26RmB am f4.8m.M am am am Pl WM WC2WBIm580 Wlk Depw W-WM s M w mRVM C 10 R 31 03/36/2008 $0.00 $1.030.19M0. $3m $0.m fm f11m3.19 WQOOBIOM29 RusaeO Daher qIX-%X-2159 MAAINT m/18/21pB C R 92 56 OyM/1/ge fO.W $25950 $37smm anry.W f6N.m WII000103810 WO SMR =-=M 5 M4AIM 03/2WM C 25 14 w 00/26/2006 $G.W vlM 12 am 5aW am R,MLu WC2IX5107835 9 GW W-n-1002 POL 03/25/ZWB C R W m 03/25/2008 $0.00 $2,35684 M25.00 am am 53,18189 W 1)01071W GL Al %qPM%-1263 MAIN.WO Il N/m/WN C R N 93 N10412006 $8,100.69 $7.32350 $1,613.35 am $D80 $13,517.92 W[200lO BMa Gr k W-V( ffi M OS/271M C H 53 31 05/29/2008 5130.8$ $3,9M.38 $522W $6.50 $080 $9,255.13 WCZWBIN7R 9" M* gIXJp 78 6WNTWOR 11 m/15/Wm C 10 W 31 07/1/W= $11315.81 Ra1R.m $WlJ $lam am $31,82951 WC2W81N773 MG qO-MANZ pO2 07/161= 0 52 N 45 D7/t7/20W $13M.W $17,Mn93 $4-W13 am $75,SR.M Sm,mO.W W lm127 OaaiNA MM-2m POl 0612-VM C 13 33 W W135.12m6 $O.m $213215 am $O.m aw 8,13215 00[200810291 TMnN9 Pope XKK-lIX-07)8 POl m/WMW C 59 42 31 m/OB/3m0 am $2,15535 PlaW 03.00 am $2,W535 FMITA TOTNS: Opal: 1 CIOSm: 16 TOTALS: $222D6D5 $781$48.00 $9,IM33 $137.0 $75,562.99 $385,$43.18 FAIINm PIlP w M3 : $292,010 FAmm30556TOMTE $385.$4138 I059MMMLKTE 0.63 ga;qg v�N$ - q & I � q » # y �3 R� 111&»11,111111111x1 g _gg��8g888m8�- a g � &tee G38 G=°:R3RB� 8 IX R 9 IX IX� g S e e a a e_ W I.............. VVVVVUUVVUVVU 6� II a iE19,1o10 1$8 IIII�s112-A3II 11111111111 3I ems FMR*0539 CM OF SERAMAN FM* 80 FLORIDA MUNICIPAL - WORKERS COMPFNSATI01 MEMBERS 1.055 REPORT 10/01/2009 - 09/30/2010 AS OF MARO131, 2011 FOE 521,428.3% EARNEDPBB4oMm0A 816,A3.W DATEOF 521,42837 LO%MMMDAM INKAO'CODE �� PA1344115MMTF CArt5TAX003G NU9�G NM1E SAI COT IN1pY CLOSE NAT PART CAWE REmV® COW MEDICAL 00033 0.H.OVEQIES N613IVES NL'IAIA® WC2W9113M2 5[rye We , KObXK+ 18]waC 12/14/3189 0 R M % 12/35/MW SSA.W t5,24173 t549.n 5018 tmn MMM N 10114M dfai frasht w -VW S T6 0/12/2010 c R M W o2/1&Oo10 fom R59m 10m R&W SOm 523100 W 10114332 E,ts91NYb lW(-0OWIR2 POL 0/2/2010 c 43 M 19 02/22/2010 W.W t121m WX VIM W.W 5R1.W K 10114691 aa,00vn lIXK-%If-fl2/ WONPWOKNBIQ oy30/MIIO 0 M 14 B2 03/3 MIC tLLW Slol, 0 1&00 W.W t598.fO t2WA0 N 0114931 CmI Hal Xla(-lOf-IMO NAAM! 04/10/2010 c 10 42 8S 20(21/2010 $131M $4,96623 f22m WM W.W S5,1Mn 19C20101149% 20/1)/2010 c R 42 55 d/12/2010 5636.10 $1,001/2 S3,Mw S&W om H,BO W 10MIM 3020 W0vyrt41 NXKJIX-9386 MAQIC.WgIKEA 05/11/2010 c R 9 0 05/11/2030 =4.16 5343m t24m W.W tom SI,AlS V lmislls GvyN W---1261 WUN. NORI09tN mA3/MIO O 10 42 7) 05/18/2.010 fOm SIMMWIM 5&W tom f$%M S Wm31mi55W FpwdN 0ra0b�[k 100f -10f -%A fidF mllgS WJ16/Mla O 40 54 i9 06/30/2010 f&W f20lm t&W W.W 59918 m f300.W Y Im15642 WAlhm pe9Nb KKK.KU1296 IIAAMT o622&R010 c 43 35 19 MOW= fOm 51120&IS MW W.W W.M SIAM15 W 1011W15 emkmm 00h0 =.1112 K40fT10E 0/20/2180 c 43 M 85 oB/m=10 5018 f2W.92 5&W W.W tam 528092 FMR, 30IN.5: OPEN: 4 CIWW: 2 TOCALS: $1,8132 $14,251% $4,385.30 MM $1,346.82 521,428.3% EARNEDPBB4oMm0A 816,A3.W EARNED1 S WTE 521,42837 LO%MMMDAM 010 FLORIDA Ml1NIQPAL- WOPJ(ERS WMPENSATION MEMBERS LOSS REPORT FMR* 0539 QTY OF SEBASTIAN 10/01/2010 - 09/30/2011 AS OF MARCH 31, 2011 FMA 80 FRE NUMBER NAME STN DEPT MA Oi OIWRy ❑OSE NAT VWRy Cl7f1E PART CA45E OATS RECEI9E0 O3MP PAYMENI5T009TE MEDICAL DRIER 0121 MDING RFCOlBBB RESERYS //INBRED W 010116852 Mak vmt 100t-)0(-1299 CONST WORK 10/13/X110 O 43 35 19 10/13IM10 $3,020.88 $4,250.16 $13.25 $DAO $17,21521 $251mA0 W 1011895 P[9an Gro /LXX-Xf U7 DM ll/30/WIO 0 90 W 31 1430/2010 $9.W $2,24459 $3%W $O.W $4,MS96 $2,WOA0 WCW1011T Mhn dryer XIIX-f 0650 MANNt IZO/2010 0 R 42 R 121W/2030 $2.421.24 $11069.51 $311.W $O.W $28,642.25 $22,SW.W W 1011248 Oe8vra6 Hush XIX-MX� PM 12/19/2010 O 10 M 81 12/19/2010 $0.W $1,954.99 $DW $O.W $16,045.01 $1810 W0011112526 Gay AOen XXX -XX -1263 MAIN. WORI®IQ 01/10/2011 0 W W 31 0410/2011 $1,562.32 $4,543.13 $8.25 $0.00 $988L" 8161W0A0 W lll17619 K Mn Msl9AnAA06 W -X% 28 F0. 0414f2011 O 19 A 31 01/14/2011 $O.W $2M52 $0.W $0.W $6,295.48 $2,000AO $/0011112656 BrianGUk XkX-XNE99 SANTA 01/19/2011 0 R 25 56 01/19/2011 $116.09 $1,W232 $13050 $O.W $2,151,24 $3,210.00 WC20111122R Ka Mr0 ,h =-MN 328 POL 043020/1 0 40 25 20 0430/2011 $O.W $26558 ".W $O.W $1,233.42 $2.400.00 W00111182R Wl10m W, XX% -X%-5328 SPWR 03/29/2011 0 90 W 19 03229/2011 $D.W $DAO $D.W 0.0 tow $OAO Mao RJTAJS: OPFN: 9 CWSID: 0 '![BALs; $2,125.98 $16,9585 $1,11350 $O.W $26,32482 slol,2WA0 FARNEDPREMM1Mmm: $83,356.40 FABN®LOS9ESmmm $101,EW.00 1055 MMTO DATE: 131 City of Sebastian Workers' Compensation RFP Fiscal Year 2012 Exhibit Drug -Free Workplace Form The undersigned, in accordance with Florida Statute 287.087 hereby certifies that does: 1. Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition. 2. Inform employees about the dangers of drug abuse in the workplace, the business' policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, employee assistance programs and the penalties that may be imposed upon employees for drug abuse violations. 3. Give each employee engaged in providing the commodities or contractual services a copy of the statement specified in Paragraph 1. 4. In the statement specified in Paragraph 1, notify the employees that, as a condition of working on the commodities or contractual services that the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contendere to any violation of Chapter 1893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction. 5. Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee's community, by any employee who is so convicted. 6. Make a good faith effort to continue to maintain a drug-free workplace through implementation of Paragraph 1 through 5. As the person authorized to sign this statement, I certify that this firm complies fully with the above requirements. Date: 16 Name and Title City of Sebastian Workers' Compensation RFP Fiscal Year 2012 Exhibit 6 Public Entity Crimes Statement Any person submitting a quote, bid, or proposal in response to this invitation or a contract, must execute the enclosed form PUR. 7069, sworn statement under section 287.133(3) (a), FLORIDA STATUTES ON PUBLIC ENTITY CRIMES, including proper check(s), in the space(s) provided, and enclose it with his quote, bid, or proposal. If you are submitting a quote, bid or proposal on behalf of dealers or suppliers who will ship commodities and receive payment from the resulting contract, it is your responsibility to see that copy(ies) of the form are executed by them and are included with your quote, bid, or proposal. Corrections to the form will not be allowed after the quote, bid, or proposal opening time and date. Failure to complete this form in every detail and submit it with your quote, bid, or proposal may result in immediate disqualification of your bid or proposal. The 1989 Florida Legislature passed Senate Bill 458 creating Sections 287.132 - 133, Florida Statutes, effective July 1, 1989. Section 287.132(3) (d), Florida Statutes, requires the Florida Department of General Services to maintain and make available to other political entities a "convicted vendor" list consisting of persons and affiliates who are disqualified from public contracting and purchasing process because they have been found guilty of a public entity crime. A public entity crime is described by Section 287.133, Florida Statutes, as a violation of any State or Federal law by a person with respect to and directly related to the transaction of business with any public entity in Florida or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any bid or contract for goods or services to be provided to any public entity or with an agency or political subdivision and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. By law no public entity shall accept any bid from, award any contract to, or transact any business in excess of the threshold amount provided in Section 287.017, Florida Statutes, for category two with any person or affiliate on the convicted vendor list for a period of 36 months from the date that person or affiliate was placed on the convicted vendor list unless . that person or affiliate has been removed from the list pursuant to Section 287.133(3) (f), Florida Statutes. Therefore, effective October 1, 1990, prior to entering into a contract (formal contract or purchase order in excess of the threshold amount for category two) to provide goods or services to THE CITY OF SEBASTIAN, a person shall file a sworn statement with the contracting officer or Purchasing Director, as applicable. The attached statement or affidavit will be the form to be utilized and must be properly signed in the presence of a notary public or other officer authorized to administer oaths and properly executed. THE INCLUSION OF THE SWORN STATEMENT OR AFFIDAVIT SHALL BE REJECTION OF YOUR QUOTE, PROPOSAL OR BID. 17 City of Sebastian Workers' Compensation RFP Fiscal Year 2012 SWORN STATEMENT UNDER SECTION 287.133(3) (a), FLORIDA STATUTES. ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. 1. This sworn statement is submitted with the Worker's Compensation Insurance Program Proposal for THE CITY OF SEBASTIAN. 2. This sworn statement is submitted by ., whose business address is and (if applicable) its Federal Employer Identification (FEIN) is 3. My name is (please print name of individual signing) and my relationship to the entity named above is 4. I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. 5. I understand that "convicted" 'or "conviction" as defined in Paragraph 287.133(1) (b), Florida Statutes means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere. 6. I understand that an "affiliate" as defined in Paragraph 287.133(1) (a), Florida Statutes means: (1) A predecessor or successor of a person convicted of a public entity crime; or (2) An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term "affiliate" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate. 18 City of Sebastian Workers' Compensation RFP Fiscal Year 2012 7. 1 understand that a "person" as defined in Paragraph 287.133(1) (e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity. 8. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. (Please indicate which statement applies.) Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management of the entity, nor any affiliate of the entity have been charged with and convicted of a public entity crime subsequent to July 1, 1989. The entity submitting this swom statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members or agents who are active in management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989, AND (Please indicate which additional statement applies). There has been a proceeding concerning the conviction before a hearing officer of the State of Florida, Division of Administrative Hearings. The final order entered by the hearing officer did not place the person or affiliate on the convicted vendor list. (Please attach a copy of the final order.) The person or affiliate was placed on the convicted vendor list. There has been a subsequent proceeding before a hearing officer of the State of Florida, Division of Administrative Hearings. The final order entered by the hearing officer determined that it was in the public interest to remove the person or affiliate from the convicted vendor list. (Please attach a copy of the final order.) The person or affiliate has not been placed on the convicted vendor list. (Please describe any action taken by or pending with the Department of General Services.) (Signature) Date: 19 City of Sebastian Workers' Compensation RFP Fiscal Year 2012 STATE OF FLORIDA COUNTY OF The foregoing instrument was acknowledged before me this 2011 by (title) on behalf of He/she is personally known to me or has produced identification and did ( ) did not ( ) take an oath. (Notary Signature) Name: My Commission Expires: Commission Number: Q17 day of KK