Fort Walton Beach Resolution — 82-43-Florida Liability Self-Insurance Program — reading text

RESOLUTION NO. 82-43 A RESOLUTION OF THE COUNCIL OF THE CITY OF FORT WALTON BEACH, FLORIDA, AUTHORIZING THE FILING OF AN APPLICATION FOR FLORIDA MUNICIPAL LIABILITY SELF-INSURERS PROGRAM AND NOTIFICATION TO DEPARTMENT OF COMMERCE, PROVIDING THE EFFECTIVE DATE HEREOF NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of Fort Walton Beach, Florida: SECTION 1. That the City Manager, on behalf of the City of Fort Walton Beach, Florida, is hereby authorized to sign and submit an application for the "Florida Municipal Liability Self-Insurers Program" and "Notification to De- partment of Commerce". (Copy of application and notification attached) SECTION 2. This resolution being of an administrative nature shall take full force and effect immediately upon its passage and approval by the Mayor. avopten (Wtrbew 26/792 MAYOR WA Ye. Sf PRO TEM ATTEST: — LAS City Clerk The form and legal sufficiency of the foregoing has been reviewed and approved by the City Attorney. ORO Cone D. Michael Chesser oa IDISPOSTTION FG Ce ent ree DET eae GENRE Re ANE A A TRA I oe top" =e TS A ; APPLICATION TO OW pehbnaat- P ORIDA MUNICIPAL SELF-INSURER’S FUN bdton NOTIFICATION TO Rese ate DEPARTMENT OF COMMERCE ¥2-%3 City of Fort Walton Beach, Florida NAME: ; (Corporation GyOther ACCOUNT NUMBER: FEDERAL, EMPLOYER IDENTIFICATION NUMBER: 59-6000323 107 Miracle Strip Pkwy,S.W., Ft. Walton Beach, ADDRESS: ; -Ft.Watten Beach, F1—_32549 NATURE OF BUSINESS:__ Municipality LIST OFFICIALS OR CORPORATE OFFICERS: L NMteLaVern Bechtel MIL. Name: Kathryn P. Bagley Title.__City Manager Title: Mayor II. Name: Charles H. Evans : IV. Name: i -Finance Director Title: City Clerk-Fina Title: INSURANCE COVERAGE CARRIED By:_Risk Management Services I (we) hereby formally apply for continuing membership for Workers’ Compensation Self-Insurance coverage in the above named fund, to be effective 12:01 a.m., November 1 , 1982 , and, if accepted by its duly authorized representative, do hereby constitute and appoint the Florida League of Cities, Inc., to act as Administrator(s) of the Fund as our agent(s)-in-fact in all matters relating to the Workers’ ompensation Law and/or Employer's Liability Act. I (we) further agree as follows: (a) To accept and be bound by the provisions of the Florida Workers’ Compensation Act; (b) That, by this reference, the terms and provisions of the Indemnity Agreement and/or Amendments thereto filed or which may hereafter be filed with the Division of Workers’ Compensation are hereby adopted, approved, ratified and confirmed by us; and further, I (we) agree to assume all of the obligations set forth therein, and in the event I (we) will pay any premium the date the same shall become due, I (we) will pay all costs of the collection thereof, including reasonable attorney's fee; (c) Toabide by the rules and regulations of the Trustees of the Fund and to conform to the terms of the agreements they may enter into with any authorized service company as long as we remain a member of the Fund; (d) That, in the event of any changes in corporate or business structure, or in legal entity, or if any locations are to be added to or deleted from this coverage, I (we) agree to notify Florida Municipal Self-Insurer’s Fund immediately; I (we) understand that failure to provide notice within thirty (30) days of a change may result in the assessment of a civil penalty not to exceed $100 for each ailure; (e) That should I (we) desire to cancel our coverage, I (we) will give written notice at least 30 days prior to cancellation, and that the Fund will give written notice 30 days prior to cancellation should they desire to cancel our coverage; (f) | That coverage under this membership shall be for Florida operations only; (g) That the Wage Declaration Schedule (Form No. _____) and/or Renewal Certificates, when completed and returned to us by Florida Municipal Self-Insurer’s Fund, become a part of this agreement. City of Fort Walton Beach WITNESSES TO SIGNATURE: y C g feted 5. Pe. CORPORAT li betel « ajc donot ds Leudedtro Bia ia Officials or Corpor, icer, Address 26IL seat, Mauer ep eters, Sally, Wh. Laburtod) \ ‘Charles H. Evafigy/Town Clerk City Clerk-Finance Directo , Name 4. Date:_10=29-82 8. 4 LL on, FA Address IZLE VE (Signature may be notarized in place of witnesses) IS HEREBY APPROVED FOR MEMBERSHIP IN THIS FUND, AND COVERAGE IS EFFECTIVE THE DAY OF , 19 SIGNED THIS _____ DAY OF , 19 BY: Fund Administrator/Trustee ’ e) APPLICATION TO FLORIDA MUNICIPAL LIABILITY SELF-INSURERS PROGRAM ye) Wack mant 4s ; Reseofutisw NAME: City of Fort Walton Beach, Florida | 427° «3 Municipality ACCOUNT NUMBER: TYPE OF GOVERNMENTAL ENTITY: 107 Miracle Strip Parkway,SW.,Fort Walton Beach, Fl 32548 ADDRESS: Post Office box 4009, Ft. Walton Béach, FT 32549 LIST OFFICIALS AUTHORIZED TO EXECUTE CONTRACTS: 1 Name. M. LaVern Bechtel ill, Name: Kathryn P. Bagley Title: City Manager witle: Mayor “Il. Name: _ Charles H. Evans iV. Name: tite: City Clerk-Finance Director Title: INSURANCE COVERAGE CARRIED BY: _Risk Management Services | (we) hereby formally apply for continuing membership for liability self-insurance coverage in the above named Fund, to be effective 12:01 A.M., ovember 1 ,19 82 » and, if accepted by its duly authorized representative, do . hereby constitute and appoint the Florida League of Cities, Inc., to act as Administrator(s) of the Fund as our agent(s)-in-fact in all matters relating to discharge of tort and wrongful death liability. 1 (we) further agree as follows: (a) That, by this reference, the terms and provisions of the Indemnity Agreement and/or Amendments thereto filed or which may hereafter be filed are hereby adopted, approved, ratified and confirmed by us; and further, | (we) agree to assume all of the obligations set forth therein, and # (we) will pay any premium the date the same shall become due, | (we) will pay all costs of the collection thereof, including reasonable attorney's fees and the maximum rate of interest allowed by law on any past due premiums; (b) To abide by the rules and regulations of the Trustees of the Fund and to conform to the terms of the agreements they may enter into with any authorized service company as long as we remain a member of the Fund; | : (c) That, in the event of any changes in corporate or business structure, or in legal entity, or if any locations are to be added to or deleted from this coverage, | (we) agree to notify Florida Municipal Liability Self-Insurers Program immediately ; (d) That should § (we) desire to cancel our coverage, I (we) will give written notice at least 30 days prior to cancellation, and that the Fund will give written notice 30 days prior to cancellation should they desire to cance! our coverage; and (e) We agree to save and hold harmless the Trust Fund and the Board of Trustees from any and all damages, causes of action, claims, delinquencies or expenses, including reasonable attorney's fees, which would otherwise be incurred by the Trust Fund or the Board of Trustees by reason of any default hereunder on our part. City of Fort Walton Beach we eave (mae i 22. ¢ Cored Or, J, Hf Witten Loh pe IE ¢ 3 M.LaVe Bechtel] Authorized Officer City Manager Address CORPORAT, Ce 7 (\b7_ ans | salt behuroed ‘har les~H. Evans ‘ity Clerk-Finance Wiractor?” Name 10-29-82 5 PK I255 Date IS HEREBY APPROVED FOR MEMBERSHIP IN THIS FUND, AND COVERAGE JS EFFECTIVE THE DAY OF . ,19 mc SIGNED THIS DAY OF : ,19 BY: