Okaloosa County BOCC — May 15, 2013 — Joe Swales Coord Sheet — reading text

RECEIVED MAR 2 8 200) EXHIBIT D . (CONTRACT & LEASE INTERNAL COORDINATION SHEET Contract/Lease Number:_Z fel -DIQD-~AIS Tracking Number: 5°2-/3 Contractor/Lessee Name: be Sweles Purpose: __ £3/0S Odd Ate -. Sie Lense Date/Term: 1, (1) GREATER THAN $50,000 Amount: id a ( a bodes foxes 2, LJ GREATER THAN $25,001 Department: __ (47.5. 3. C) $25,000 OR LESS Dept. Monitor Name: AA ae Feovenat Purchasing Review Date: Leah Date; Y hal 7 ON ee chon 1 CO) PA HOH/) Date: f 3 Courity Astomey Following Okalcosa County approval: Contract & Grant Document has been received: Date: Contracts & Grants Manager ws April 24, 2013 Okaloosa County Water & Sewer Department 1804 Lewis Tumer Bvld, Suite 300 Fort Walton Beach, FL 32547 Re: Swales, Joe Risk Location: 1310-C Oddfellow Rd Fort Walton Beach, FL 32547 Insurer: Penn-America Insurance Company Policy Number: PAC7021718 Dear Sir or Madam: The above referenced general liability insurance policy contans a $300,000 combined single limit of coverage for bodily injury and property damage liability. The policy also contains a $100,000 limit for damage to rented premises. The insurance company does not offer a $200,000 limit for damage to rented premises. A. copy of the current policy declarations page and the commercial general liability coverage form are enclosed. If you have any questions, please contact our office. Thank you, —_- a Bill Rehl Licensed Agent 123 Miracle Strip Pkwy. S. E. ¢ Fort Walton Beach, Florida 32548 Voice (850) 244-2111 © Facsimile (850) 243-5265 « http://HarrisInsurance.com x * * * COMMERCIAL LINES COMMON POLICY DECLARATIONS ve q * INSURANCE IS PROVIDED BY THE COMPANY DESIGNATED BY AN "X": Stock * | lA x [X] PENN-AMERICA INSURANCE COMPANY Company * Group * [_]PENN-STAR INSURANCE COMPANY State Control Number x * ["]PENN-PATRIOT INSURANCE COMPANY A206695 7 HARRIS INSURANCE SERVICES, INC pacss63606 Bala Cynwyd, Pennsyivania 49004 193 MIRACLE STRIP PKWY SE POLICY NUMBER: PAC7021718 FT. WALTON BEACH, FL 32549 41. NAMED INSURED: JOE SWALES DBA: If property coverage is afforded MAILING ADDRESS: 1005 27TH STREET by this policy, the POLICY IS A CO-INSURANCE CONTRACT. NICEVILLE FL 32578 2. POLICY PERIOD: From 04/05/2013 To 04/05/2014 at 12:01 AM. Standard Time at your mailing address shown above. 3. FORM OF BUSINESS: INDIVIDUAL OTHER DESC: 4, BUSINESS DESCRIPTION: WAREHOUSE IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. INFORMATION REQUIRED ON PREMIUM — EVIDENCE OF INSURANCE Commercial General Liability Coverage Part $ 500.00 § 626.924, FLORIDA STATUTES . =o SL Agni Name:Virginia Clancy Commercial Property Coverage Part $ NOT COVERED Si agnt Addr-13577 Feathersound Dr., Commercial Crime Coverage Part $ NOT COVERED Suite 120, Clearwater, FL 33762 Commercial Inland Marine Coverage Part $ WOT COVERED License No.: A206695 Professional Liability Coverage Part $ WOT COVERED procucer NE ALTON BEACH Liquor Liability Coverage Part $ NOT COVERED eeuucer Ader ° , Commercial Umbrella Coverage Part $ NOT COVERED This insurance is issued pursuant to Owners Contractors Protective Coverage Patt $ NOT COVERED the Florida Surplus Lines Law. Persons TRIA , $ NOT COVERED insured by Surplus Lines carriers do — a — not have the protection of the Florida 6. TOTAL PREMIUM PAYABLE AT INCEPTION $ 500.00 insurance Guaranty Act io the extent of . any right of recovery for the obligation Policy Fee $ 35.00 of any insolvent unlicensed insurer. Service/Underwriting $ 65.00 Surplus Lines Tax $ 30.00 SURPLUS LINES INSURERS’ FSLSO Fee $ 1.20 POLICY RATES AND FORMS Florida Hurricane Catastrophe Fund : 7.80 _ ARE NOT APPROVED BY ANY Other: $ FLORIDA REGULATORY TOTAL § 639.00 AGENCY. 7, FORM(S) AND ENDORSEMENT(S) MADE A PART OF THIS POLICY AT THE TIME OF ISSUE:* AS PER FORM COMSCHD(10/00) ATTACHED *Omits applicable Forms and Endorsements if shown in specific Coverage Part/Coverage Form Declarations. THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART COVERAGE FORM(S) AND ED Povey. ENDORSEMENTS, IF TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED PQ . Agency Code: 02195 } Pane Pe TAPCO-FL By P.O. Box 17069 ~~ ‘Ruthorized-Répresentative - Clearwater, FL 33762 SMCBRID 04/02/13 $1100(08/04) PRODUCER COPY YY, ISSUED Stock * Compan ‘ee x COMMERCIAL GENERAL LIABILITY COVERAGE PART Pany * LA, * DECLARATIONS * Group * x * ® POLICY NUMBER: PAC7021718 4. NAMED INSURED: JOE SWALES 2. LIMITS OF INSURANCE - INSURANCE APPLIES ONLY FOR COVERAGE FOR WHICH A LIMIT OF INSURANCE IS SHOWN. General Aggregate Limit (Other than Products/Completed Operations) $__600, 000 Products/Completed Operations Aggregate Limit $_EXCLUDED ==— Each Occurrence Limit —— —g$ 300,000 —— Personal & Advertising Injury Limit § EXCLUDED Damage to Premises Rented to You Limit g 100,000 any one premises Medical Expense Limit $ 5,000 any one person 3. LOCATIONS of all premises you Own, Rent, or Occupy Address City State Zip No. 4310-C ODD FELLOW ROAD FORT WALTON BEACH FL 32547 RATES ADVANCE PREMIUM 4 GLASS* PREMIUM Bere Prod/CO All Other ProdiCO All Other ** If Classifications are Numbered, the coverage applies to the corresponding Location No. No. 68707 a) 1,012 EXCL 44.86 EXCLUDED 400.00 MIN PREM Warehouses - Private - Not-For-Profit Only. No. EXCL FLAT EXCLUDED 100.00 Additional Insured - See Form CG2011 No. No. No. ** If Classifications are Numbered, the coverage applies to the corresponding Location No. TOTAL: $ 500.00 MINIMUM PREMIUM (s) gross sales - per $1000 (c) total cost - per $1000 {m) admissions - per 1000 {e} each (p) payroll - per $1000 (a) area - per 1000 sq. ft. (u) units (0) other Policy may be AUDITABLE () see classification notes in company or iSO Commercial Lines Manual SPECIFIC GENERAL LIABILITY FORMS/ENDORSEMENTS AS PER FORM COMSCHD(10/00) ATTACHED This page alone does not provide coverage and must be attached to a Commercial Lines Common Policy Declarations Common Policy Conditions, Coverage Part Coverage Form(s) and any other applica $2000 (06/01) PRODUCER COPY bie forms and endorsements. COMMERCIAL GENERAL LIABILITY CG 00 01 12 07 COMMERCIAL GENERAL LIABILITY COVERAGE FORM Various provisions in this policy restrict coverage. Read the entire policy carefully to determine rights, duties and what is and is not covered. Throughout this policy the words "you" and "your" refer to the Named Insured shown in the Declarations, and any other person or organization qualifying as a Named Insured under this policy. The words "we", “us" and "our" refer to the company providing this insur- ance. The word "insured" means any person or organization qualifying as such under Section {I — Who Is An Insured. Other words and phrases that appear in quotation marks have special meaning. Refer to Section V -Defini- tions. COVERAGE A BODILY INJURY AND PROPERTY LIABILITY ~ Insuring Agreemen' a. We will pay those sums thai comes legally obligated to pay as dama cause of "bodily injury" or "property damage" which this insurance applies. We will have the tight and duty to defend the insured against any "suit' seeking those damages. However, we will have no duty to defend the insured against any "suit" seeking damages for "bodily injury” or "property damage" to which this insurance does not apply. We may, at our discretion, investigate any “occurrence” and settle any claim or “suit” that may result. But: (i iS pay amages is fim- ited as described in Section WI -Limits Of in- surance; and (2) Our right and duty to defend ends when we have used up the applicable limit of insur- ance in the payment of judgments or settie- ments under Coverages A or B or medical expenses under Coverage C. No other obligation or liability to pay sums or perform acts or services is covered unless explicitly provided for under Supplementary Payments — Coverages A and B. b. This insurance applies to “bodily injury" and "property damage" only if: (1) The "bodily. injury” or "property damage” is caused by an “occurrence” that takes place in the "coverage territory"; (2) The "bodily injury" or "property damage” Oc- curs during the policy period; and (3) Prior to the policy period, no insured fisted under Paragraph 1. of Section Il Whe Is An Insured and no "employee" authorized by you to -give or receive notice of an “occur- rence” or claim, knew that the "bodily injury” or "property damage" had occurred, in whole or in part. If such a listed insured or author- ized “employes” knew, prior to the policy pe- tiod, that the "bodily injury" or "property damage" occurred, then any continuation, change or resumption of such "bodily injury" or "property damage" during or after the poli- cy period will be deemed to have been known prior to the policy period. ¢."Bodily injury" or "property damage" which occurs during the policy period and was not, prior to the policy period, known to have occurred by any insured listed under Paragraph 1. of Section Il - Who Is An Insured or any "employee" author- ized by you to give or receive notice of an "oc- currence" or claim, includes any continuation, change or resumption of that “bodily injury" or "property damage" after the end of the policy pe- riod. d. "Bodily injury" or "property damage" will be deemed to have been known to have occurred at the earliest time when any insured listed under Paragraph 1. of Section Il -Who Is An In- sured or any "employee" authorized by you to give or receive notice of an "occurrence" or claim: (1) Reports ail, or any part, of the "bodily injury" or "property damage” to us or any other in- surer; (2) Receives a written or verbal demand or claim for damages because of the "bodily injury" or "property damage"; or (3) Becomes aware by any other means that "bod- ily injury" or "property damage" has occurred or has begun to occur. PRODUCER COPY CG 00 01 12 07 © 1SO Properties, Inc., 2006 Page 1 of 16 oR er ACORD CERTIFICATE OF LIABILITY INSURANCE 41512012 DATE MMIDDYY) | PRODUCER . . Harris Insurance Services, Inc. Fort Walton Beach, FL 32548 123 Miracle Strip Parkway 3. E. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Phone - (850)244-2111 Fax - (850)243-5265 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: lapco c/o Penn America Swales, Joe INSURER B. INSURER C: 1005 27Th St jceville, FL_32578 pnsuReS Niceville, INSURER &: COVERAGES 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 TC 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, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - POLICY EFFECTIVE [POUCY BEPIRATION esr | RO. TYPE OF INSURANCE POLUCY NUMBER SATE aD DATS MMDDNYY) . UMITS GENERAL LIABILITY 7 EAGH OCCURRENCE 3 rO00 to HFIIH 4/5/2012 4/5/2013 [DAMAGE TORENTED 300.0 X | COMMERCIAL GENERAL LIABILITY Preaeces (es occurrence PS 400,000 alx “] CLAIMS MADE occur WED EXP (Any one person) |S 5,000 PERSONAL & ADVINJURY |S Excluded GENERAL AGGREGATE $ 600,000 ——$_ GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP/OP AGG $____ Excluded jroucy — f [PROJECT I | Loc AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT | « ANY AUTO (Ea accident) ALL OWNED AUTOS {BODILY INJURY 5 Lennard (Ea person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY (Per accident} $ NGN-OWNED AUTOS PROPERTY DAMAGE (Per accident} $ GARAGE LIABILITY [AUTO ONLY-EA ACCIDENT |$ || ANY