Okaloosa County BOCC — August 4, 2015 — COI-Big Bend Community Center — reading text

CERTIFICATE OF COVERAGE ISSUED ON: 7/24/2015 coveraae PrOVIDED BY: PREFERRED GOVERNMENTAL INSURANCE TRUST PACKAGE AGREEMENT NUMBER:PX FL1 0461046 14-05 COVERAGE PERIOD: 10/1/2014 TO 10/1/2015 12:01 AM COVERAGES: This Is to certify that the agreement below has been Issued to the designated member for the coverage 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 coverage afforded by the agreement described hereln subject to alt the terms, exclusions and conditions of such agreement, Mail to: Certificate Holder Designated Member Big Bend Community Based Care, Ince, QOkaloosa County BOCC 525 North Martin Luther King Jv, Blvd, 801-A North Pearl Street Tallahassce, FL 32301 Crestview, FL 32526 LIABILITY COVERAGE WORKERS' COMPENSATION COVERAGE X Comprehensive General Liability, Bodily Injury, Property Damage and Personal Injury Limit $1,000,000 $100,000 SIR X Self Insured Workers' Compensation Public Officials Liability $500,000 Self Insured Retention Limit X Statutory Workers' Compensation Employment Practices Liability Limit X Employers Liability_ X Employee Benefits Liability $1,000,000 Each Acclden( . 0,000 $100,000 SIR $1,000,000 By Disease Limit $1,000, 00,000 § $1,000,000 Aggregate Disoase X Law Enforcement Liability Limit $1,000,000 $100,000 SIR PROPERTY COVERAGE AUTOMOBILE COVERAGE Buildings & Personal Property Automobile Liability Limit Limit $1,000,000 $50,000 SIR Note: See coverage agreement for details on wind, flood, and other X All Owned dedhctibles. Specifically Described Autos Renfed, Berrowed and Leased Equipment X Hired Autos Limit X Non-Owned Autos All other Inland Maxine Automobile Physical Damage Limit X Comprehensive See Schedule for Deductible X Collision See Schedute for Deductible CRIME COVERAGE X Hired Auto with limit of $35,000 Emiployee Dishonesty Forgery or Alterntivn Garage Koepers Liability Limit Theft Di PNC i reft Disappearance & Destruction Lisbility Deductible Comprehensive Deductible s Fraud Computer Frau Collision Deductible NOTE:The most we will pay is further limited by the limitations set forth in Section 768.26(6), Florida Statutes (2010) or the equivalent limitations of successor law which are applicable at the time of the joss, Description of Operations/ Locations/ Vehicles/Spacial items: Proof of coverage. This section completed by member's agent, who bears complele responsibilily and liability for its accuracy. This certificate is issued as a matter of information only and confers no rights upon the cetificate holder. This certificate does not amend, extend or alter the coverage afforded by the agreement above, Adminlstrator élf}géflgméog\bl T OF THE ABOVE DESCRIBRD AGRREMENT BB CANCELLUD BEFORF, THR EXPIRATION 1, KT OF THE ABOVE DESCRIBRD AGRF “ANCELLED BEFORF THE EX| ON DATE THRREOF, Publig: Risk Underwriters® PREFERRED GOVE{NMENTAL INSURANCF, TRUST WILL ENDEAVOR TO MAIL 60 DAYS WRITTEN NOTICE, OR 10 DAYS P.CO. Box 968465 WRITTEN NOTICE FOR NON-PAYMENT QF PREMIUM, TO THE CERTIFICATIS HOLDRR NAMED ABOVE, BUT FALLURE TO MAIL ‘Lake Mary, FL 32795-8455 SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIADILITY OF ANY KIND UPON THE PROGRAM, IT$ AGENTS OR REPRESENTATIVES, Producer . Public Risk Insurance Agency ; B == P. 0. Box 2416 W - & ..éf' Daytona Beach, FL 32116 = — AUTHORIZED REPRESENTATIVE PGIT-CERT (1 1/09) PRINT FORM 7124/2015 Ve ACORD CERTIFICATE OF LIABILITY INSURANCE s 7/24/2015 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: I the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must be endotsed. 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 cettlflcate holder in lieu of such endorsement(s). PRODUCER CONTACT Byittany O'Brien Public Risk Insurance Agency PHONE . (386)252-6176 [ FA% oy (386) 239-4049 P. O. Box 2416 AL s INSURER(S) AFFORDING COVERAGE NAIC # Daytona Beach FL 32115 insurer A Western World Insurance Co INSURED INSURER B : Okaloosa County BOCC, DBA: Okaloosa County INSURER G : 601-A North Pearl Street INSURER D : INSURER E ; Crestview FL 32536 INSURER F ; COVERAGES CERTIFICATE NUMBER:CL1410200936 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN |SSUED 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 POLIGIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLIGIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSH [AGDL[SUBR POLICY EFF_| POLICY EXP LTR TYPE OF INSURANCE INSR | WVD POLICY NUMBER (MM/DD/YYYY) (MMIDD)'VYVV) LIMITS GENERAL LIABILITY EACH CCCURRENGE $ — DAMAGE TO RENTED COMMERGIAL GENERAL LIABILITY PREMISES (Ea occurrence) | $ | CLAIMS-MADE OCCUR MED EXP (Any one person) | § PERSONAL & ADV INJURY | § GENERAL AGGREGATE $ GEN'L. AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | § POLICY | B LOG : COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea socidenl) s ANY AUTO ' BODILY INJURY (Per person) { $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accldent} | § NON-OWNED PROPERTY DAMAGE y HIRED AUTOS AUTOS (Per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I | RETENTION $ $ WORKERS COMPENSATION WG STATU- O1h- AND EMPLOYERS' LIABILITY YIN wielhive| B8 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEH $ (f yes, descrlbe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | $ A |[Public Officials Liab/ BRLO007706 10/1/2014 [10/1/2015 | aggregate $1, 000,000 Employment Pract. Liab DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Addlllonal 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 . . ACCORDANCE WITH THE POLICY PROVISIONS. Big Bend Community Based Care, Inc. 525 North Martin Xuther King Jr. Blvd. AUTHORIZED REPRESENTATIVE Tallahassee, ¥FL 32301 Paul Dawson/HWILLS M-—/‘/‘;k.«-—'————w ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD