Okaloosa County BOCC — October 21, 2014 — Final Payment-Emerald Coast CAC — reading text

Registrations are available on a first- ~come, first~ serve basis. Registrations will be confirmed via email; please be sure to include an email address, when registering. Attendees Can register online 5 or fy completing the attached registration form: and submitting it by mail or fax. * Registrations atier July 18th must be faxed or submitted online *Registrations after July 24th will only be accepted on-site Register online, by mail, or fax! Online: www.fncac.org or hitp://register.fucac.org Fax: (850) 671-1224 Mail*: 2940 E. Park Ave., Suife A, Tallahassee, FL, , 32301 (lease print information as you want it on name badge and conference materials.) FLORIDA Wy NETWORK CHILDREN'S ADVOCACY CENTERS Name: Title: Organization: Professional Discipline: { Attorney [ ]CAC Director [ ]CAC Staff [ ]CPI [ ]CPS [ JCPT [ ]Child Advocate [ Forensic Interviewer [ ]GAL [ ]Law Enforcement [ |Nurse [ ]Social Services [ ]Therapist [ ]Other (please specify Address: Zip: City: State: Phone: Fax: Email: Dietary needs: (please specify) Fees: GROUPS MUST REGISTER TOGETHER FOR GROUP RATE. *PURCHASE ORDER MUST NOTE ATTENDEE NAME(S) Registration Fees: [ ] $300 (Individual) [ ] $275 (Group of 4 or more) “Registrations after July 18th must be faxed or submitted online. Registrations after July 24th will only be accepted on-site at the conference. Registrations are transferable, but are non-refundable. Registrations will NOT be accepted without payment. CEU’s will be provided for attending the conference at no cost. Attendees will earn one CEU per hour. Registration. for CEU’s will be on-site. Workshop Selections: Using the numbered workshops on pages 6-9, please write your preferred workshop number in the spaces below for each session, as seating is limited. Wednesday, July 30th: Session 1 Session 2 Thursday, July 31st: Session 3 Session 4 Session 5 Session 6 Se 8 Friday, August Ist: Session 7 Selections are NO’ Payment Method (check one): [ ] P.O. Number: (see fees) Billing Contact: : [ Credit Card: i Visa jl ] MasterCard. 4 ' a ee Card # ‘ : * Exp. Date: _’ 3 Digit Sec. Code Total Amount to be Charged: $ Signature: [ ] Check (Enclosed) Checks made payable and mailed to: Florida Network of Children’s Advocacy Centers (FNCAC) 2940 East Park Avenue, Suite A, Tallahassee, FL 32301 monn NETWORK CHILDREN’S apvocAcY CENTERS The mission of the Florida Network of Children’s Advocacy Centers is fo improve Horida’s respouse to c. rt th and continuatios ans Advocacy. Centers! : FLORIDA ) NETWORK i EMERA-1 OP ID: CH —, . ACOR™ CERTIFICATE OF LIABILITY INSURANCE Dare tumor” 09/17/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(ies) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lisu of such endorsement(s). PRODUCER Park SRNECT Cindy White a Assoclates LLG IME san, 266-428-1013 [HOE nox 256-428-1113 fntyaitle ety et RobNEss; Cwhite@fphins.com David E, Harbarger/CAC Program INSURER(S) AFFORDING COVERAGE Nalco # wsurera:Philadelphia Insurance Company 23850 INSURED Emerald Coast CAC msurer 6 : Hartford Insurance 19682 Children's Advocacy Center P.O, Box 1237 INSURER © Niceville, FL 32588 INSURER D+ INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER; REVISION NUMBER: THIS {8 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR 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, BUBR ae TYPE OF INSURANCE (ae we POLIGY NUMBER UMQDoN Tn ldapDoneen uMITS | GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A |X | COMMERCIAL GENERAL LIABILITY PHPK1105480 12/34/2013 | 12/31/2014 | PANUGETORENTED oa [8 100,000) J CLAIMS-MADE OCCUR MED EXP (Anyone person) | $ 5,000) PERSONAL & ADV INJURY | $ 1,000,000) |X {PROF LIAB $1M/$3M GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | $ 3,000,000 [XT eoucy [| 5: toc $ AUTOMOBILE LIABILITY OMEER SINGLE LIMIT | 1,000,000 A |X] anvauro PHPK1 106480 12/34/2013 | 1231/2044 | BODILY INJURY (Per person) | $ |_| AbkOwNED SCHEDULED BODILY INJURY (Per accident) | § NON-OWNED PROPERTY DAMAGE rs HIRED AUTOS AUTOS {PER ACCIDENT) $ { juwareuiatiaa | | occur EACH OCCURRENCE § EXCESS LIAB CLAIMS-MADE AGGREGATE $ oo | [perewnions $ WORKERS COMPENSATION WO STATU- OTH AND EMPLOYERS' LIABILITY v x ee LIMITS ER B | ANY PROPRIETOR/PARTNER/EXECUTIVE. 24WECAD1670 10/18/2013 | 10/18/2014 | €.L EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? NTA (Mandatory In NH) E,L. DISEASE - EA EMPLOYEE] ¢ 14,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below EL. DISEASE - POLICY LIMIT | $ 1,000,000 A jEmployee PHPK1105480 4213112013 | 12/31/2014 |Limit 50,000) Dishonesty DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space |s required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Okaloosa County Board of ACCORDANCE WITH THE POLICY PROVISIONS. County Commissioners 302 Wilson St. N. AUTHORIZED REPRESENTATIVE Crestview, FL 32539 m0 A haze— : © 1988-2010 ACORD CORPORATION. Ail rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD — EMERA-2 OP ID: KS ACCOR DATE (MM/DD/YY, we CERTIFICATE OF LIABILITY INSURANCE tet7/2044- THIS CERTIFICATE I$ ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT GONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement, A statement on this certificate does not confer rights to the certificate holder In lleu of such ondorsement(s). Niceville Insurance Agence’ NAMES Garrett Floyd 109 Bullock Blvd» y Dp Moca 860-729-2131 TRAX nox 860-720-2134 iceville, I Wail Garrett Floyd ApprEss: Gfloyd@nicevilleinsurance.com INSURER[S) AFFORDING COVERAGE NAIC # wsurer a: Rockhill Insurance Company 28053 INSURED Emerald Coast Childrens INSURER B: Advocacy Center inc PO Box 1237 INSURER G: Niceville, FL 32588-1237 IWSURER D : INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER; REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR 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 SUBR) ‘Y EFF POLICY EX! (hee TYPE OF INSURANCE NSD Wwyp POLICY NUMBER ft RDA) aRDYeY) LIMITS A | X | COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 | CLAIMS-MADE occuR ITHB0002804-03 06/28/2014 | 05/28/2018 | PAIGE TORENTED os 100,000 [| MED EXP (Any one person) $ §,000) PERSONAL & ADV INJURY | $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000) X] poucy | | 58% [__]10c PRODUCTS - COMP/OP AGG | § 2,000,000} OTHER: $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY (Per parson) | $ | ALL OWNED SCHEDULED i Arist ee BODILY INJURY (Per accident) | $ 7 NON-OWNED PROPERTY DAMAGE 3 |__| HIRED AuTos AUTOS (Par accident) $ UMBRELLA LIAB occuR EACH OCCURRENCE 3 EXCESS LIAB CLAIMS-MADE AGGREGATE $ veo |_| aetennions $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY yIN Sthvure |_[ES ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT, $ OFFICER/MEMBER EXCLUDED? NTA {Mandatory in NH} E,L, DISEASE - EA EMPLOYEE] $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | § DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES {AGORD 104, Additional Remarks Schedule, may be attached if more spaca Is required) CERTIFICATE HOLDER CANCELLATION BOARD-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE GANCELLED BEFORE ect THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Board of County Commissioners ACCORDANCE WITH THE POLICY PROVISIONS. of Okaloosa County 302 N. Wilson St Ste 302 Et Crestview, FL 32536 AUTHORIZED REPRESENTATIVE MSanrit- Stl © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD