Fort Walton Beach Council agenda — 09-14-2010 Special-City Attorney Condidates — reading text

Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: D. This policy includes these endorsements and schedules: WC 99 06 03, WC 00 04 02, WC 00 04 06 A, WC 00 0414, WC 09 06 06, WC 09 04 03 A 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit REFER TO CLASSIFICATION SCHEDULE WC 99 06 03 Premium Basis Rate Per Estimated Code Total Estimated $ 100 of Annual Classifications No. Annual Remuneration Remuneration Premium Total Estimated Annual Premium 3,222 Minimum Premium 221 Expense Constant Countersigned by: r . r' WC 00 00 01 A Ed. 5-88)  WORKER8 COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 oeo3 Ed. 01 -01) Item 4 of the Information Page is amended to dude the foliawing dassilicatlona CLASSIFICATION scxEDULE ClassiNcattaw Code Premium Basis Rana Per Estimated No. Tots) Edknated $ 100 of Armud Annual Ram on RemunerWon Pr+emhan Attomeya 8820 $ 1. 3151900 0.17 $ 2237 Clerical office employees 8810 $ 174844 025 $ 437 Toot Manual Prsm U074 Increased ErnpkW Lknits s0 Oe le cram s0 thug Free Discount 0.95 so Safety Program Credit 0.96 s0 Toni Edhoo d Annul Standard Premium 2,674 Expe11e11ce Modem 1. 00 s0 ModlNsd Premium M674 FCCAP Credit 0 Prem im DbowiM o Expense C sm Tenorism Risk In u come Act 2002 296 Tout Edlerfe d Pr+ endum 3,172 This wxImsernennt c4rangss the poky to which R In aNached and In efiecdse on the date issued unless otherwise stated. Tice tntorntadon below Is required only when this sndoresnant is tesusd subssqusnt to preprratton of the policy.) 6rslo ment Effective Date: 20-Aug -10 Policy Number: 01 FU3-249D251. 01 Endorsement No.: Insured Now Matthews b Hawkins. PA Premium: 3172 Insurance Company: Camp Options insurance Company. Inc. dWaa OpteComp we ao as os coumr, g sn.d by: LLL Ed. 1- 01)  OptaComp Comp Options Irmmm Company, Inc. The workers' comp affiliate of 0. tis 0 % Blue Cross and Blue Shield of Florida. independent ma oplacmP P.O. Boot 44281 Jaoke --- moo FL 32231 -4291 licensees of the Blue Cross and Blue Shield Association. PH: 1- 88A-207.4215 FX: 14XM4 28-7026 to 4176 Leoendoy Drive GWft Parkway, Suite 101 Dsatln. FL 92541 oo wft. FL 32266 PARTICIPATING PROVISION ENDORSEMENT YOU MAY BE ENTITLED TO PARTICIPATE IN A DISTRIBUTION OF THE SURPLUS OF THE COMPANY TO SUCH AN EXTENT AND UPON SUCH CONDITIONS AS SHALL BE DETERMINED BY THE BOARD OF DIRECTORS OF THE COMPANY PR ) VIDED YOU HAVE COMPLIED WITH ALL THE TERMS OF THE POLICY INCLUDING THE PAYMENT OF PREMIUMS. NEITHER DIVIDENDS NOR ANY FACTORS USED IN THEIR CALCULATION MAY BE GUARANTEED. DIVIDENDS ARE NOT GUARANTEED AND WALL BE DUE AND PAYABLE ONLY FOR A POLICY PERIOD THAT HAS EXPIRED, AND ONLY IF DECLARED BY TIME BOARD OF DIRECTORS OF THE INSURER. Effective Date: 20-Aug-10 Issue Dort- 27-Jul- 10 WC 99 06 06 Ed. 01. 01) p is the format trade name for Comp Options Insurance Company  WORKERS COMPENSATION AND EMPLOYERS UAMUTY INSURANCE POLICY WC 00 04 02 Ed. ANNIVERSARY RATING DATE ENDORSEMENT The pnmnkNn end rates for this policy. Grid the M9 moti icatbn how, y any, may charge on your anniversary rating date shown In the Schedule. Soheduie Anniversery Ratlng Dade August tMonth) 201h ( Day) TW i do me on1 dw*n ft odq %v#A& i b -Wdrdsndb M IN, on Mn dit bsusdu* ss @1 b soar i me e,. an . d eah+ n ets aaw«r « ao. rw. ra a to roar t Endommu t EM m" AW s010 Pfcy Nb. 01FL11240= 1. 01 E Wo me i ont No. cam comr by W0000402 Ro. 4e4y 01est01 —A comd" ClMovolowkwMm.. A  WORKERS COMPENSATION AND EMPLOYERS U40LITY NNSUIRANCE POLICY WC 00 04 06 A Ed. 8-90) PREMIUM DISCOUNT ENDORSEMENT The pro:niunn for Us policy and the mss, N anys listed in Rem 3 of the Schedule may be dgDle for a dismat This endorsement shows your estimated dhoutt In Name 1 or 2 of the Schedule. The final calaulagon of pmmlwn discount will be determined by our manuals and you premium basic as determined by audlL Premium suwa to retroepec rating Is not subject to prenriwn discount. ule 1. Stale FL Estimsled EN91ft Pmvdum M674 First $ 10000 Next 8190 0 * 00 Next $1. 550.000 Over $1. 750000 0.00% 9.10% 11. 30'lf. 12.M 2. Averege percentage discount 0.00% e. 3. Other policies: • ... M 1• 4. If there are no entries in items 19 2 and 3 of the Sc x&ft.see the Premium Discount Endorsement attached to Your policy number. _ .. . This endorsement changes the policy to which It Is allsched and is effective on the dale issued unless otiorvrise stated. The Rnfonmallon below Is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement EffecU" AUG 2010 Policy No. 01 FLO- 24OD251. 01 Endorsement No. cow Opel= awurno Colow" c owa. n. a by WC 000406 A 1ED• W 0 1806 Wo 10 cowman coniOwrwai humm".  WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 0414 Ed. 7.90) NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT to this PO m dMW 4 ftn a change in ownenI or O of one or ft oorobbmd with you for expsrisn©s radn8 purposes. Owage in ownership bidudea sales. ptrrdresam. ollvsr Moshe merger oonsMOM dtssolulion% formations of a new envy and other dwVn WvAded for In the applicable expsrisnoe racing Plan manual. You roust report ant dwgp In amwrg* to us in wrlbng whin 90 deya of such sharps. Fait " b report such dwWs wM ib this period may result In revision of the e3Kper18110 rating mocEicatlon loclor used b determine your premium- 1lusandaa 1 dWI95 We POWm WAfth I1s ahadrdand k oftdo an b dm W mW wbn o Mwwria alloa. OdmminilEffaft AUG 2010 Polo Noy OIRB-20= 1. 01 End nt Ne. Comp OPtaa r CM40V WO 000414 ED. 74P i IM Noland Coin an Ca so i We % Mina.  WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 09 06 06 Ed. 10-96W PLOIRDA EMPLOYMENT AND WAGE INFORMATION RELEASE ENT This policy nrqukes you to release certain empfop rent and wage