Okaloosa County BOCC — August 19, 2014 — Medical Insurance Agent of Record - Barnes Insurance - Contract Renewal — reading text

CONTRACT & LEASE INTERNAL COORDINATION SHEET Contract/Lease Number: Cos-lebt- RM Brtnos Sno Contractor/Lessee Name: Tracking Number: [064-4 Grant Funded: YES NO x purpose_Nadewn ) x Syn Date/Term: fot ~ Yoo) 1. [RereaTer THAN $50,000 2. LI GREATER THAN $25,000 amount? 54 ncex?) Department: He KR 3. L] $25,000 OR LESS Dept. Monitor Name: Godin | Mm * Var Document has been reviewed and includes any attachments or exhibits. Procurement i) a 1A OX. WU CAA an Purc “Dirvector#r Designee Purchasing Review Date: 3 +fa-/¥ Joanne Kublik Risk Management Review Approved as written: (ou Gabe BoAB-14 Date: Risk Manager or designee \ \plcen 5 GC yy rey ot County Attorney Review ote * 4-14 County Reyer : Gregory T. Stewart Followi ng Okaloosa County approval: Document has been received: Contracts & Grants Date: Contracts & Grants Manager _Approved By:. approved by —_ EF g CONTRACT/LEASE RENEWAL FORM August 7, 2014 Barnes Insurance and Financial Services Attn: Dennis Barnes, President 1582 Airport Boulevard Pensacola, FL 32504 RE: Contract #C08-1666-RM Renewal Dear Mr. Barnes: The Okaloosa County Board of County Commissioners agrees to renew the subject contract/lease, #C08-1666-RM for an additional term. The contract renewal period will be October 1, 2014 to September 30, 2015. The annual budgeted amount for this contract is $59,800. If you are in agreement, please sign below and return this form along with a current Certificate of Insurance listing Okaloosa County as co-insured (if applicable). COUNTY REPRESENTATIVES AUTHORIZED COMPANY REPRESENTATIVE Dept. Director . Contractor: Pav eS \Wswance POS (cod 5 Signature: c (as prescribed below on item 1) Approved By: Title: Or ociheur (as prescribed below on item 1) Date: Date: gSlal i County Department Instructions: 1) Obtain signatures from Department Director, authorized Company Representative and then 2) 3) Purchasing Director <$25K and less, County Administrator <$50K and less or Board >$50K, as necessary. If Board approval is required, the Chairman and County Administrator's signatures are required. Make sure the company provides a current Certificate of Insurance. (If applicable). Keep a copy of this form for your records. Send original to Purchasing Services Coordinator. lf you have any questions please contact the Purchasing Director at 850-689-5960, Fax: 850- 689-5998. i i | 1 | i | i | i i ; MD. TRAVELERS J WORKERS COMPENSATION ONE TOWER SQUARE AND HARTFORD, CT 06183 EMPLOYERS LIABILITY POLICY TYPE V INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (IHUB-0756M13-5~14) RENEWAL OF (IHUB-0756M13-5-13) INSURER: THE TRAVELERS INDEMNITY COMPANY OF AMERICA 1 NCCI CO CODE: 13439 INSURED: PRODUCER: BARNES INSURANCE & FINANCIAL GREENE~HAZEL ASSOCS INC SERVICES, LLC 10739 DEERWOOD PARK BLVD 1582 AIRPORT BLVD SUITE 200 PENSACOLA FL 32504 JACKSONVILLE FL 32256 Insured Is A LIMITED LIABILITY COMPANY Other work places and identification numbers are shown In the schedule(s) attached. 2. The policy period Is from 02-01-14 to 02-01-15 12:01 A.M. at the Insured’s mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applles to the Workers Compensation Law of the state(s) listed here: Fl 9 B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed In item 3.A. The limits of our liability under Part Two are: ita Bodily Injury by Accident: $ 1000000 Each Accident = Bodily Injury by Disease: $ 1000000 Policy Limit —— Bodily Injury by Disease: $ 1000000 Each Employee | C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: AL AR AZ CA CO CT DC DE GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC NE NH NU NM NV NY OK OR PA RI SC SD TN TX UT VA VT WI D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE ih 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required Information |s subject to verification and change by audit to be made ANNUALLY. inline DATE OF ISSUE: 12-06-13 Pu OFFICE: TAMPA FL 247 DIRECT BILL PRODUCER: GREENE-HAZEL ASSOCS INC G4518 oo2sae ACORD [ae CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 6/13/2014 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 policy(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 lieu of such endorsement(s). PRODUCER Greene Hazel Insurance Group 10739 Deerwood Park Blvd Ste 200 Jacksonville FL 32256 CONTACT NAME: Joanie Newton PHONE | (AIG, No, Ext):904-398-1234 | (AG, No):904-396-7432 E-MAIL. ADDREsSimn@greenehazel.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :Old Dominion Insurance Co 40231 INSURED BARNE-2 INSURER B: Barnes Insurance & Financial INSURER C : Services, LLC wt INSURER D: 1582 Airport Blvd Pensacola FL 32504 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: 1748500095 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. INSR ADDL|SUBR| POLICY EFF | POLICY EXP LTR TYPE OF INSURANCE INSR | WVD POLICY NUMBER (MM/DDIYYYY) | (MM/DDIYYYY) LIMITS A GENERAL LIABILITY BPG1180C 1 4/3/2013 jt 1/3/2014 EACH OCCURRENCE $1,000,000 va DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) _| $500,000 | CLAIMS-MADE OCCUR MED EXP (Any one person) $5,000 PERSONAL & ADVINJURY _| $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | $2,000,000 X | pouicy FRO. Loc $ TOMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ ANY AUTO BODILY INJURY (Per person) | $ ALL OWNED SCHEDULED , ‘AUTOS AUTOS BODILY INJURY (Per accident) | $ NON-OWNED PROPERTY DAMAGE 3 HIRED AUTOS AUTOS {Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED. | | RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? NIA (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE! $ If yes, describe under DESGRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION Okaloosa County P.O. Box 4730 Fort Walton Beach FL 32549 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE OELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD