Okaloosa County BOCC — January 7, 2014 — Contract Renewal Form and Certificate of Insurance

CONTRACT/LEASE RENEWAL FORM 2 Fieriteertms am) S CONTRACT # C12-1935-WS Date: 10/15/13 FORT BEND SERVICES, INC. PROVIDE FBS C1282 POLYMER FORT BEND SERVICES EXPIRES: 01/16/2015 Attn: _DAVID JAMES 13303 Redfish, PO Box 1688 STAFFORD, TX. 77477 RE: FBS ©1282 Polymer, C12-1935-WS Dear David James: The Okaloosa County Water & Sewer agrees to renew the subject contract/lease, #C12-1935-WS for an additional term. The contract renewal period will be 1/17/2014 to 1/16/2015. The annual budgeted amount for this-contract is $200,000. 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. ery Uteall Contractor:foer Bewo Seguices (NC. Signature: \ I - rane Approved a Jif? Approved By: Muckpome- DAVO James {as prescribed below on iterh 1) Y Approved By: Title: Polymer. Saees Mawacen (as prescribed below on item 1} ‘ Date: 72/30/73 Date: October. Al AUB County Department Instructions: 1) Obtain signatures from Department Director, authorized Company Representative and then Purchasing Director <$25K and less, County Administrator <$50K and less or Board >S50K, 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). 2) Keep a copy of this form for your records. 3) Send original to Purchasing Services Coordinator. If you have any questions please contact the Purchasing Director at 850-689-5960, Fax: 850- 689-5998, ACORD, CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 06/18/2013 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. certificate holder in lieu of such endorsement(s). IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION 1S WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer tights to the PRODUCER hanes Mary Fiddes Bell Insurance Agency Tae Go, exy; 972.581.4800 x4956 [[ae, No): 972.581.4850 16980 Dallas Parkway Abouess, tf iddes@bel I group.com Dallas, TX 75248 INSURER(S) AFFORDING COVERAGE Nalc # INSURER A! Hartford Fire Ins. Co. 19682 wwsurep Fort Bend Services, Inc. INSURER B : P.O. Box 1688 INSURER C: Stafford, TX 77497-1688 INSURER D: INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 13/14 Master REVISION NUMBER: THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 10 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 TADDL|SUBR) POLICY EFF | POLICY EXP LIR ‘TYPE OF INSURANCE INSR|WYD POLICY NUMBER (MMIDBIVYTY} (ANDO) UiMiTs GENERAL LIABILITY EACH OCCURRENCE $ TORENTED COMMERCIAL GENERAL LIABILITY PREMRES (Eaocourrence) | $ CLAIMS-MADE [J OCCUR MED EXP (Any ono person) —_| $ PERSONAL & ADV INJURY | $ |_—J GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | $ POLICY ied Loc $ AUTOMOBILE LIABILITY eeacaden) NGIEMMT Ts ANY AUTO. BODILY INJURY (Per person} | $ ares AUTOS. BODILY INUURY (Per accident)| $ PROPERTY GE HIRED AUTOS AUTOS: (Per accident) $ $ UMBRELLA LIAB OccuR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ veo | _[ ReTENTION$ $ WORKERS COMPENSATION WC STATU- ‘OTH- AND EMPLOYERS" LIABILITY vin 46WBCRU2001] 07/03/2013 | 07/03/2014 X l TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIV! E.L. EACH ACCIDENT $ 0 A | OFFICER/MEMBER EXCLUDED? IN] NIA 1,000 ,000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE] $ 1,000 , 000 ifyes, describe under DESCRIPTION OF OPERATIONS below ELL, DISEASE - POLICY LIMIT | $ 1,000 , 000; Contract: DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedulo, If more space Is required) FBS C1282 Polymer, C12-1935-WS, Contract renewal period: 1/17/2013 to 1/16/2014 CERTIFICATE HOLDER CANCELLATION Okaloosa County Water & Sewer Dept Attention: Mark Griffin 1808 Lewis Turner Blvd. Fort Walton Beach, FL 32547 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE ese Caen Vincent V. Bell /MTF ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ) @ ACORD Ne CERTIFICATE OF LIABILITY INSURANCE DATE (MW/DDIVYYY) 6/24/2013 REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. THIS CERTIFICATE 1S 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 certificate holder in lieu of such endorsement(s). 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 PRODUCER Carroll Insurance Agency, Ltd. 14906 FM 529 CONTACT NAME: PHONE ex, (281) 656-3000 FAR oy: (281) 656-3001 Fie ss: service@carrollins.com INSURER(S) AFFORDING COVERAGE NAIC # Houston TX 77095 INSURERA:ZUYich American Insurance 116535 INSURED IWsuRERB Steadfast Insurance Company 26387 Fort Bend Services, Inc. INSURER C: P. O. Box 1688 INSURER D: 13303 Redfish Lane INSURER E: Stafford {X_ 77497 INSURER Fs COVERAGES CERTIFICATE NUMBER: 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 ADDLISUBR] LTR TYPE OF INSURANCE INSR| WD. POLICY NUMBER (HMIDB NCO | eID LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X_| COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) | $ 100, 000 A ] cLais-mave occur sno 5431774-09 16/21/2013 [6/21/2014 | menexp (any one person) | $ 5,000) PERSONAL & ADV INJURY _| $ 1,000,000) GENERAL AGGREGATE $ 2,000,000, GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG | $ 2,000,000) POLICY FBS | x [Loo $ COMBINED SINGLE LIMiT AUTOMOBILE LIABILITY FOMBINED § $ 1,000,000 EN X | any auto BODILY INJURY (Per person) | $ [_| Ae ownen SCHEDULED BAP5431776-09 6/21/2013 [6/21/2014 [goniLy INJURY (Per accident)| § rx] NON-OWNED PROPERTY DAMAGE X | nireo autos AUTOS (Per accident) s Uninsured motorist combined _| $ B UMBRELLA LIAB | X | occur EACH OCCURRENCE $ 1,000,000) X | EXCESS LIAB CLAIMS-MADE: SE05834567-01 6/21/2013 06/21/2014) aqgrecaTE $ 1,000,000) X[oeo | [retentions NI § WORKERS COMPENSATION Wo STATU- OTH AND EMPLOYERS’ LIABILITY YIN TORY LIMITS. ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EAC! IDEN’ $ OFFICER/MEMBER EXCLUDED? NIA HACCIDENT (Mandatory In RH} E.L, DISEASE - EA EMPLOYER $ Ifyas, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY Limit | $ DESCRIPTION OF OPERATIONS | LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedute, If more space ls required} See attached Comments/Remark page (Form OFREMARK) for additional information. CERTIFICATE HOLDER CANCELLATION Okaloosa County Attn: Mark Griffin 1808 Lewis Turner Blvd. Fort Walton Beach, FL 32547 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE ID Carroll, CIC, CRM/G _oee a (Boog? L ACORD 25 (2010/05) INS025 nino 1 © 1988-2010 ACORD CORPORATION. All rights reserved. Tha &2CARN name and fann ara ranietarad marke af ACORD