Okaloosa County BOCC — 2013 meeting #1140 (date undetermined) — LPA Group Internal Coordination Sheet_Contract Renewal_Certificate of Insurance — reading text

CONTRACT & LEASE INTERNAL COORDINATION SHEET | Contract/Lease Number: C.09- 1736 tracking Number: 653°/F Contractor/Lessee Name: The LPG. Mug (ne. _ Grant Funded: YES__ NO“ a Purpose: JE «a “; fraréviad] Date/term: wi; alh fartmnd) eevee] |, EA GREATER THAN $50.00 Amount: pK (ite ranbe, St hadude 2. (J GREATER THAN $25,000 / Department:_ ay 7t 3. (1) $25,000 OR LESS Lo Shp Dept. Monitor Name: 22. V'aar Document has been reviewed and includes any attachments or exhibits. Purchasing Review pete: 6/3 Risk Managemen? Review Date: AE /t f / / County Attorney Review Date: Z aS/ Dp Following Okaloosa County approval: Contracts & Granis Document has been received: Date: At —— er Contracts & Grants Manager CONTRACT/LEASE RENEWAL FORM May 28, 2013 The LPA Group, Inc. Attn: Mark Kistler 4503 Woodland Corporate Blvd., Suite 400 Tampa, FL 33614 RE: Contract Renewal Dear Mr. Kistler: The Okaloosa County Airports agrees to renew the subject contract, #CO9-1736-AP for an additional term. The contract renewal period will be July 9, 2013 to July 8, 2014. The annual budgeted amount for this contract is $50,000.00. 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 . 4 WG: a, Gr mup NCOP CATE a unt 0 Contractor: MUCNA aker dr Ine peel ves TZ, ft Approved By: Approved By At (as prescribed below on item 1) © < ” V Approved By: Title: / , - (as prescribed below on item 1) Date: Date: 2 P3-13 = County Department insirucitions: , : 1) Obtain signatures from Department Director, authorized Company Representative and then co 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. (lf applicable). 2) Keep a copy of this form for your records. 3) Send original to Purchasing Services Coordinator. lf you have any questions please contact the Purchasing Director at 850-689-5960, Fax: 850- 689-5998, CERTIFICATE HOLDER CANCELLATION ACCOR 1 DATE(MMIDDIYYYY) co CERTIFICATE OF LIABILITY INSURANCE o71g3y2012 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. ff SUBROGATION IS WAIVED, subject to C the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the fe certificate holder in lieu of such endorsement(s). PRODUCER CONTACT 3 Aon Risk Services Central, Inc. PHONE FAX - be pittsburgh PA office _ IMC. No, Ext); (856) 283-7122 | fas Noy: (847) 953-5390 g Dominion Tower, 10th Floor / 7 => E-MAIL wel 625 Liberty Avenue an ‘ ts ADDRESS: : x Pittsburgh PA 15222-3110 USA See Nt . INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: Liberty Mutual Fire Ins Co 23035 The LPA Group Incorporated INSURERB: Liberty Insurance Corporation 42404 Michael Baker Jr., Inc. : > P.O. Box 5805 INSURER C: Lloyds Syndicate No. 2623 1128623 Columbia SC 29250-5805 USA INSURER D: INSURER &: ; INSURER F: COVERAGES CERTIFICATE NUMBER: 570046964816 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. Limits shown are as requested ner TYPE OF INSURANCE aoe aaa POLICY NUMBER ay | (Horo) LIMITS A | GENERAL LIABILITY TB2681004145712 06/30/2012 06/30/2013 BAGH OCCURRENCE $2,000,000 X | COMMERCIAL GENERAL LIABILITY PR GES (oe ceeenance) $1,000,000 CLAIMS-MADE OCCUR MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $2,000,000| © a GENERAL AGGREGATE $4,000,000] = n GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $4,000,000] @ PRO- oo POLICY [x] JECT X | Loc eS A | AUTOMOBILE LIABILITY AS2-681-004145~722 06/30/2012/06/30/2013 COMBINED SINGLE Limit $1,000,000 ‘9 a acciden! 7 ; 1x | any AUTO BODILY INJURY ( Per person) E) [_] ALL OWNED SCHEDULED ‘ BODILY tNJURY (Per accident) o |__| auTos AUTOS - * : PROPERTY DAMAGE |X |HIRED AUTOS | x no Nee a (Per accident) ie : 5 B | x | UMBRELLA LIAB x | occur TH7681004145682 06/30/2012106/30/2013{ EacH OCCURRENCE $10,000,000] © YT] EXGESS LIAB CLAIMS-MADE : AGGREGATE $10,000, 000 DED] [RETENTION $10,000 B | WORKERS COMPENSATION AND WA768D004145692 06/30/2012)/06/30/2013] y | WC STATU- OTH-| EMPLOYERS’ LIABILITY YIN AOS L us [Sev LIMITS Ig ; B | OMMCRMEMBER EXCLUDED!’ EN [neal — |wo7682004145702 06/30/2012| 06/30/2013 [Et EACH ACCIDENT 1,000,000 (Mandatory in NH) WL ELL. DISEASE-EA EMPLOYEE $1,000,000. peeeae ton Or Sp eRATIONS below ‘ E.L, DISEASE-POLICY LIMIT $1, 000 ,000};__. ce | €&O-PL-Primary QC1202675 06/30/2012[06/30/2013|/Per Claim $5,000,000) Professional & Pollution Aggregate $5,000, 000 iil SIR applies per policy terms & conditions set DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, ‘Additional Remarks Schedule, if more space is required) at Contract No. CO06-1351-Pw5-120. Okaloosa County, its officials, employees and volunteers are additional insureds on liability a, coverage with respect to work performed by the Insured. waiver of subrogation included in favor of Okaloosa County. a = Seen = eI ne Ses as SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Okaloosa County 602-C North Pearl Street Crestview FL 32536 USA AUTHORIZED REPRESENTATIVE Birk Servic Central! Ina Ball Execs Ean ACORD 25 (2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD