Okaloosa County BOCC — January 19, 2016 — Access 2 Care Vendor Application — reading text

MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDL SU b TYPE OF INSURANCE NSO M?l; POLICY NUMBER (RO VYY) 1(@'/‘:';%%1 LIMITS A | X | COMMERCIAL GENERAL LIABILITY } EACH OCCURRENCE B 1,000,000 CLAIMS-MADE CCoUR X PFPB02515602 10/01/2015 | 10/01/2016 | DavaceloReeD |5 50,000 1 MED EXP {Any one person) 3 5,000 1 | L PERSONAL & ADVINJURY | § 1,000,000 | GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s 2,000,000 [ X]pouey [ 158% [ ]ice PRODUCTS - COMPIOP AGG | § 2,000,000 OTHER: | $ [ AUTOMOBILE LiABILITY i N i 1,000,000 c ANY AUTO X LFB0017821 10/01/2015 : 10/01/2016 | BODILY INJURY (Per person) | $ j L ONNED SCEDULED BODILY INJURY (Per accident) | § NON-OWNED PROPERTY DAMAGE Py HIRED AUTCS AUTOS __(F'_eracmuan() $ UMBRELLALIAB | X | ocour EACH OCCURRENCE s 5,000,000 B | X | excessLag U ANSIADE XLS0097946 10/01/2015 | 10/01/2016 | AcoREGATE s 5,000,000 WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY YIN X[ St | [ER D | ANY PROPRIETOR/PARTNER/EXECUTIVE TWC3449526 01/01/2015 | 01/01/2018 | gL EACH ACCIDENT 3 1,000,000 OFFICER/MEMBER EXCLUDED? NIA {Mandatory in NH) E.L. DISEASE - EA EMPLOYEE| § 1,000,000 If yes, describe under | DESCRIPTION OF OPERATIONS below £.L DISEASE - POLICY LIMIT | § 1,000,000 DESCRIPTION OF QPERATIONS / LOCATIONS / VEHICLES {ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The County of Okaloosa is Additional insured with respects to ) Commercial General Liability and Auto Liability, where required by written contract. 30 days notice of cancellation, except 10 days for nonpayment, subject to policy terms, conditions and exclusions. CERTIFICATE HOLDER CANCELLATION Okaloosa County 602 C N Pearl Street Crestview, FL 32536 OKALO06 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED [N ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Gatfrt, Rie 2 ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Please print this page for your records. Registration Summary General Vendor Information Vendor Name: Okaloosa County Board of County Commissioners Short Name (Does Business As): Okaloosa County Ariba Network ID: Dun and Bradstreet Number: 613277649 Web Site: http://www.co.okaloosa.fl.us Federal Tax ID Number: F596000765 Name that appears on 1099 Form: Okaloosa County BOCC W39 Status: Valid W-9 on File DFS W9 Last Update Date: May 7, 2014 Business Designation: Government Entity - County Contacts Name Title Phone Fax Email Gary J. Standford Finance Director 850-651-7200 850-689-5882 gstanford@okaloosaclerk.com Marcella B Eubanks Contracts & Grants Manager 850-651-7200 850-689-4272 meubanks@okaloosaclerk.com Locations Contract & Grants Sequence 016 P.O. Info: Remit To: Billing Contact: Orders:EMAIL Fax: Email: Email:meubanks@okalocosaclerk.com Contact:Marcella B Eubanks Fax:850-689-4272 Fax:850-689-4272 Contact:Marcella B Eubanks Contact:Marcella B Eubanks 101 E James Lee Blvd, Room 104 302 N Wilson Street, St 203 101 E James Lee Blvd, Room 104 Crestview, FL 32536 Crestview, FL 32536 Crestview, FL 32536 Okaloosa Okaloosa Okaloosa us uUs us Certified Business Enterprise Info (CBE) Minority Business Designation: Non-Minority Woman Owned Designation: Non-Woman-Owned SDVBE Owned Designation: Non-SDVBE Solicitation Selection Registered for Solicitations: No Registered for VBS: No Solicitation/Sales Contact Email: N/A Florida Terms of Use Accepted: 05/06/2014 by Marcella B Eubanks Commodity Codes 82111600 Non technical writing 84101600 Aid financing 93141501 Social policy services 93151500 Public administration Close Window Copyright © 2009 State of Florida MyFloridaMarketPlace Vendor Registration Customer Service: 866-FLA-EPRO (866-352-3776)