Okaloosa County BOCC — July 1, 2014 — ACTUARIAL Glicksman — reading text

be deemed to be included in the contract the same as though they are written out in full herein. 3. indemnification & Hold Harmless — Each contractor must submit an executed sworn certification that he will comply with the Hold Harmless Clause in accordance with the provisions of Florida Statutes, Section 725.06. To the fullest extent permitted by law, proposer shall indemnify and hold harmless County, its officers and employees from liabilities, damages, losses, and costs including but not limited to reasonable attorney fees, to the extent caused by the negligence, recklessness, or intentional wrongful conduct of the proposer and other persons employed or utilized by the proposer in the performance of this contract. COMPANY DATA Physical Address & Phone #: Proposer’s Company Name: Physical Address: Contact Person (Typed-Printeq}: Phone #: Cell #: Federal ID or SS #: Proposer’s License #: Fax #: Emergency #’s After Hours, Weekends & Holidays: SAQ_Ly Cowal Palin +H Boca EL atow FE a3fe Sat 444 YBRT Ghekeman Con CCC SAn.2- <steu07 Olicksmen Sank Sol £ob 2)/ LO Ol p72 AL# We O “br 2#2D Sol Kob 40/ CONFLICT OF INTEREST DISCLOSURE FORM For purposes of determining any possible conflict of interest, all bidders/proposers, must disclose if any Okaloosa Board of County Commissioner, employee(s), elected officials(s), or if any of its agencies is also an owner, corporate officer, agency, employee, etc., of their business. indicate either “yes” (a county employee, elected official, or agency is also associated with your business}, or “no”. If yes, give person(s} name(s) and position(s) with your business. NAME(S) POSITION(S) FIRM NAME: GC ti CK man a AN FLCC BY (PRINTED): QB & fl do prary BY (SIGNATURE): TITLE: ~ Aion ADDRESS: S49 _ WW) “(Loa Lelm boca Late Fe PHONE NO. Sul Oay Pgs E-MAIL Seki Ckeman Qo Clickiman sittin, (on DRUG-FREE WORKPLACE CERTIFICATION THE BELOW SIGNED BIDDER CERTIFIES that it has implemented a drug-free workplace program. In order to have a drug-free workplace program, a business shall: 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's policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation and 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 that are under quote a copy of the statement specified in subsection 1. 4, In the statement specified in subsection 1, notify the employees that, as a condition of working on the commodities or contractual services that are under quote, 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 893 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, drug abuse assistance ot rehabilitation program if such is available in employee's community, by any employee who Is convicted. . 6. Make a good faith effort to continue to maintain a drug-free workplace through implementation of this section. As the person authorized to sign this statement, | certify that this firm complies fully with the above requirements. DATE: Cf | a al SIGNATURE; COMPANY: GHirdesmen GON KCC NAME: S Cal Cksmel) avpress; “S4Q (W) Loual Bln _ Ache Proca 0) ema: Sf chaman@ aor (CHS INA Hf, £0, PHONENO: CLL GY UR Glicksm 1) CoN Sutt iy. Copy LIST OF REPRESENTATIVES CONTRACT ADMINISTRATOR: Gary R. Real, Okaloosa County Risk Management Okaloosa County Risk Management Dept. 601-A North Pearl St. Crestview FL 32536 850-689-5977 / 850-689-5973 (F} CONTRACTOR'S REPRESENTATIVE: Stovion 6 \ickgman So | Qe Yrs ESo| Kuo 920/ Slichsman© Clickgmarn CON &u hy CO INDEMNIFICATION AND HOLD HARMLESS To the fullest extent permitted by law, CONTRACTOR shall indemnify and hold harmless COUNTY, its officers and employees from liabilities, damages, losses, and costs including but not limited to reasonable attorney fees, to the extent caused by the negligence, recklessness, or intentional wrongful conduct of the CONTRACTOR and other persons employed or utilized by the CONTRACTOR in the performance of this Agreement. As lidcSmon Con, LLC ‘Bidder's Company Name (C04a( fal SG Q_W Physical Address Poca Ca fon FC Mailing Address Sul G44 UR 9S Phone Number SO( Ke 427 / Cellular Numbe ¢ {22 lly DATE tp &uthorked signature — Manual S Ghekaman Authorized Signature — Typed Aclua— Title 00 Le? 23920 FAX Number SU POC FI0/ After-Hours Number(s) ANTI-COLLUSION STATEMENT: The below signed bidder has not divulged to, discussed or compared his bid with other bidders and has not colluded with any other bidder or parties to bid whatever. (Note: No premiums, rebates, or gratuities permitted either with, prior to, or after any delivery of materials. Any such violation will result in the cancellation and/or return of material (as applicable) and the removal from bid list{s). Glicksman Gon ce = fo Bidder's Company Name ‘Authorized Signature — Manual S99 _W) Coyal Palm A S Clicksman Authorized Signature - Typed Bocq Lato FC S3Ug6 Actua, Address Title a <i KG 271 wo YO. 3920 Phone # Fax # BO OU (rly SClicksman @ Hicksmer Federal ID # or SS # E-mail address bo Sy Hing om