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PURCHASING DEPARTMENT v
TRANSMITTAL MEMOI4NDUM
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To: Mayor /C�ty erk
RE: Nort amily Practice Amendment Extension & Renewal Agreement RFC 09/10 -08"3'
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The item(s) noted below is /are attached and forwarded to your office for the following action(s):
Development Order ® Mayor's signature
Final Plat (original mylars) 00E Recordi
1121Letter of Credit Bring
Maintenance Bond - Safe keeping (Vault)
Ordinance
Performance Bond
Resolution
® R ' s to Purchasing
pies
Special Instructions:
Need executed signatures
Marisol Ordoliez
From
❑ Payment Bond
�� — /02 ❑ City Manager Signature
® City Clerk Attest/Signature
T:\Dept_ forms \City Clerk Transmittal Memo - 2009.doc
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DOCUMENT APPROVAL
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Contract/Agreement Name: Nort4vamily Practice Amendment Extension & Renewal
Agreement RF009 /10 -0,+ P P-FP o1fiv- d b pr-eek� alKe Phi CtGi y
Approval:
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City Of Sanford /North Seminole Family Practice /Amendment, Extension And
Renewal to Agreement For General Physicians Services (RFP 09/10 -07)
This Extension And Renewal To Agreement (Extension and Renewal) is made
and entered into on this L day of J-0 u a E41 2011, and is to that certain Agreement
styled Agreement For General Physicians Services (RFP 09/10 -07) made and entered into
on the 14th day of June, 2010 (the Agreement), between the City Of Sanford, a municipal
corporation organized and existing under the laws of the State of Florida (hereinafter
referred to as the City), whose address is 300 North Park Avenue, Sanford, Florida 32771,
and/Velsf Sioei _Tawsll ����i, °a Florida corporation, the successor, by merger, entity to
North Seminole Family Practice Associates, P.A., authorized to do business in the State of
Florida, whose principal and local address is 2209 French Avenue, Sanford, Florida 32771
(hereinafter referred to as the Physician).
WITNESSETH:
Whereas, the City and the Physician entered into the above - referenced Agreement
on June 14, 2010 and desire to extend and renew the Agreement so as to enable both
parties to continue to enjoy the mutual benefits that the Agreement currently provides; and
Whereas, the Agreement, in Section 11, and the essential requirements of
contract law provide that any extensions and renewals to agreements shall be expressed in
writing and duly executed by the parties; and
Whereas, the parties desire to extend the term of the Agreement and renew the
Agreement for a specified period of time so as to enable both parties to continue to enjoy
the mutual benefits it provides,
Now, Therefore, in consideration of the mutual understandings and agreements
1
contained herein, and other good and valuable consideration, the receipt and sufficiency of
which is hereby acknowledged, the parties agree to extend and renew the Agreement as
follows:
Section 1. Recitals. The above stated recitals (whereas clauses) to this
Extension and Renewal are hereby adopted and form a material part of this Extension and
Renewal and the consideration hereof upon which the parties have relied.
Section 2. Extension And Renewal. The term of the Agreement, which
was to expire on December 31, 2011, in accordance with the provisions of Section
11 of the Agreement, is extended such as the Agreement will now terminate on
December 31, 2012 and the Agreement is hereby renewed.
Section 3. Effect Of Extension And Renewal. Except as specifically
stated herein in this Extension and Renewal, all terms and conditions of the
Agreement shall remain in full force and effect as originally set forth in said
Agreement.
In Witness Whereof, the parties hereto have executed this instrument for
the purposes herein expressed.
Attest:
A Dpprpriate Corporate Signatory
y ,; , Sw fyo -
APO)
Printed Name and Title
2
North Seminole Family Practice
Associates, P.4--\
Printed Name and Title
Y
Attest:
ki
For the use and reliance of the City of
Sanford only. Approved as to form
and legal sufficiency.
i iam L. Colbert, Cit orn y
3
North Seminole Family Practice Associates PA
2209 S French Avenue
Sanford, Florida 32771
Phone: (407) 321 -4230
Fax: (407)324 -7642
April 15, 2010
Respectfully Submitting Proposal For:
Solicitation Number: RFQ 09/10 -07
Physician Services — General
Due Date and Time: April 19, 2010 at 2:00pm
North Seminole Family Practice Associates PA
2209 S French Avenue
Sanford, Florida 32771
Phone: (407) 321 -4230
Fax: (407)324 -7642
April 15, 2010
City of Sanford Florida
ATTN: F. William Smith, Purchasing Agent
RE: Proposal for Physician Services — General / RFQ 09/10 -07
Dear Mr. Smith,
North Seminole Family Practice Associates PA is a medical facility that has been responding to
the medical needs of the Sanford Community since 1983. We have three Board Certified Family
Practice physicians. Dr. James Quinn has 26 years of relevant experience as he has been in
private practice here in Sanford since 1983. Dr. Harvey Schefsky has been a primary care
physician for 36 years and has been in private practice here in Sanford since 1994. Dr. Daniel
Monette has been in practice here in Sanford for 8 years. Together they have over 70 years of
combined experience in medicine.
North Seminole Family Practice Associates PA currently employs 13 medical assistants
(including 5 certified X -ray technicians and a Registered Nurse) along with nine administrative
personnel who strive to maintain the business functions of this office.
This facility currently performs in- office testing which includes but is not limited to x -rays,
EKG's, phlebotomy, physician performed urinalysis, laceration repairs, excisions and minor
surgeries, annual physicals, immunizations and illness evaluations. We are more than prepared
to handle your work comp injuries with ease. We offer same day appointments for any initial
work comp injury.
We have successfully provided medical care and offered medical recommendations to the City of
Sanford and its employees for over 20 years and look forward to continuing this relationship.
Please feel free to contact me with any questions or concerns.
Sincerely,
OA
J es E. Q ' , M.D.
a•
James E. Quinn, MD-
Curriculum vitae
Date of Birth 2 -18 -51
LOCATION: Cleveland, Ohio
_
COLL EGE. Ohio State UnWerily 1969 to 1973 Social Sciences; B.A. Medical COlIW
of Ohio at Toledo 1973 to 1976 M.D., Lang; Book Award
INTERNSHIP: Naval Aerospace Regional Medical Center (NARMC) 1976 to 1977
FAMILY PRACTICE RESIDENCY: Naval Aerospace Regional Medical Center 1977 to
1979 Board Certified in Fandly Medicine 1979
FAMILY PRACTICE TEACHING STAFF: Naval Aerospace Regional Medical Center
1979 to 1982
A. Clinic Supervisor
B. Intern Coordinator
C. ACLS Instructor and Course Director for NARMC
D. Teacher in the NARMC HAT, BCLS, ICU and Atcolmi
Rehabilitation Program.
E. Teacher of the Year NARMC Family Practice ReNdency 1979
to I980
Past Chari man Emergency Cardiac Care Committee of the AHA for the Panhandle Region
1982 -1983 Trauma Physician at Sacred Heart Hospital Trauma Center - Pensacola, Florida
October 1983 - Present Private Family Practice - Sanford, Florida
HOSPITAL PRIV R EGES
Columbia Medical Center - Sanford, Florida
AHA ACLS Affiliate Faculty for the State of Florida
Team Physician for Seminole Nigh School 1983 -1994 (Volunteer)
Seminole County Medical Society - President 1987
Friends of the St. Johns - Board of Directors
Sanford Unit AHA - President
Lakeview Nursing Home - Medical Director 1984- 1997
Seminole County Schools - Parlrers in Excellence
All Souls School - Board Member 1988 -1994 / Chairman 1994-1995
Sanford Rotary - Board of Directors 1987 -1992 / President 1990-1991
Chamber of Commerce - Executive Committee / Board of Directors
Central Florida Integrated Physicians Assoc• - Chairman of the Board & President
Central Florida Regional Hospital.- Chahmm of Family Practice Dept 1985 & 1998 /
Board of Trustees 1985 -1998 / Chief of Staff 1991 / Chairman of
Credentials Committee 1992 -1997 / Vice Chairman 1995 /
Chairman of the Board 1995 -1998
Harvey W. Schefsky
B.S.
Ohio State University
1962
M.S.
University of Wisconsin
1963
M.D.
Ohio State University
1968
Rotating Internship, U.S. Naval Hospital Jacksonville,
Florida 1968 -69
Family Practice Residency, U.S. Naval Hospital Jacksonville,
Florida 1969 -71
Chief of Family Practice, U.S. Naval Hospital Memphis,
Tennessee 1971 -74
Fancily Practice, Deltona, Florida
Emergency Room Physician, Central Florida Regional
Hospital, Sanford, Florida
Family Practice, Sanford, Florida
President, Seminole County Medical Society
Secretary/Treasurer, Central Florida Regional
Hospital, Sanford, Florida
Vice Chief of Staff Central Florida Regional
Hospital, Sanford, Florida
Chief of Staff Central Florida Regional Hospital
Sanford, Florida
Board Certified A.B.F.P.
Member A.A.F.P.
Member F.A.F.P.
Member F.M.A.
Member A.O.A. Medical Society
Member F.P.A.
Member A- C.E.P.
1974 -91
1991 -94
1994- present
1988
1989
1990
7
1572 Shadowmoss Circle
Lake Mary, FL. 32746 Phone (407)333 -1914
E -mail drmonette&hotrnail.com
Daniel R. Monette, M.D., CAQSM
Education 7/01 — 7/02 Halifax Medical Center, Sports Medicine Fellowship
Daytona Beach, Florida
BC Sports Medicine, April 2003
7/98 — 7/01 Catholic Health Care West, St. Joseph's Family Practice Residency
Phoenix, Arizona
BC Family Practice, July 2001
8/94 — 5/98 University of Colorado Health Sciences Center
Denver, Colorado
Medical Doctorate, May 1998
8/90 — 5/94 University of Colorado at Boulder
Boulder, Colorado
Bachelor of Arts, African American Studies, May 1994
Teaching and 2003 - Pres. Associate Clinical Professor Florida State University
Professional Activities
2001 - 2002 Preceptor for Residents and Students in Sports and Family Medicine
2000 - 2001 Co -Chief Family Practice Resident
2000 - 2001 Catholic Health Care West Leadership Committee
1999 - 2001 Family Practice Clinical Operations Committee
1999 - 2001 CHW Family Practice Admissions Committee
1995 - 1998 Medical Student Council Representative
Publications/ Projects/ 2003 Overuse Injuries,
Presentations
2002 Knee Exam Workshop, Conference on the Beach
2001 Head and Neck Injuries, Annual Volusia County Coaches Workshop
2000 Preparticipation Exams, Family Practice Grand Rounds
1 998 Jones Fractures, Orthopedic Grand Rounds
1998 Osteoporosis lecture, O.B. Grand Rounds
1997 - 1998 "Total Knee Arthroplasty in Hemophilia Patients: Long -Term Follow-
Professional
Memberships
Sports Medicine
Activities
Up." Submission to The Journal of Bone and Joint Surgery
1995 - 1996 NIH project with University of Colorado Sports Medicine, "Clinical vs.
Surgical Evaluation of Chondromalacia Patella"
2002 - Present American Medical Society for Sports Medicine
1999 - Present American Medical Association
1998 - Present American Academy of Family Physicians
2002 - Pres. University of Central Florida Team Physician
2002 - Pres. Seminole High School Team Physician
2003 - Pres. Seminole Community College Team Physician
2001 - 2002 Bethune Cookman College Team Physician
2001 - 2002 Embry Riddle Aeronautical University Team Physician
2001 - 2002 Daytona Beach Community College Team Physician
2001 - 2002 Daytona International Speedway Attending Physician
2001 - 2002 Atlantic High School Team Physician
1998 - 2001 Bourgade Catholic High School Team Physician
2000 - 2001 Coordinator for Resident coverage of High School sports
1999 - 2002 Physicals for High School, College, and Professional Athletes
1999 NASCAR Spectator Urgent Care Physician at P.I.R.
Extracunicular Medical 2001 — 2002 Attending Physician for Exercise Treadmills, Halifax Medical Ctr.
Activities
2001 - 2002 Moonlight Halifax Medical Center
2000 - 2001 Moonlighting St. Joseph's Emergency Department
2000 - 2001 Moonlighting Coordinator with E.D. Director
Awards Received Voted 2006 Best Doctor in Seminole County
Atlantic High School community service award
r
Bourgade Catholic High School community service award
Sachs Foundation Scholarship recipient
Colorado Masonic Benevolent Scholarship Foundation Recipient
University of Colorado, Arnold Weber Scholarship Recipient
Golden Key National Honor Society
Employment 2002 - Pres. North Seminole Family Practice and Sports Medicine
2209 French Avenue Sanford, FL. 32771
9 E::;-F VL O
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TAT. G.
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MRN
-HEALTH
AVISIO N OF MEDICAL QUALITY,A S
URANC E
Chadid"Crist
DISKAY
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'ENSE NO.
01/08/2069
ME 318186
272026
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DEP 2tNFtl T OF. HEALTH
DIVISI:QN QF MEDI:'C QUALITY ASSURA IUE
D,QTE ,
L; :CEIVSE NQ
CO ITI OL No.
09%08/200)
ME 8301:3
272170
Submission Form
PART 1 General
1.01 Description
The following Request for Statements of Qualifications, for the 1 RFQ 09/10 -07 Physicians
Services - General. This Response is submitted by (2) 0 oir &-U uo-4e- IAA
+Ao"1 -32-N-1- Lk2k-30 `�C-.-)L y0 -1 -3a4 -- 0LOLi_-JL1
(1) Title and Solicitation number as shown in the Invitation
(2) Name, address, telephone, fax number and email of Proposer.
1.02 The Undersigned:
A. Acknowledges receipt of
Addenda: Number Dated
Number Dated
B. Has examined the Solicitation Documents and understands that in submitting
his /her Response, he /she waives all right to plead any misunderstanding
regarding the same.
C. Understands that the responsibility for delivering the submission to the City on or
before the specified date and time will be solely and strictly the responsibility of
the Respondent. The City will not be responsible for delays caused by the United
States Postal Office or a delay caused by any other occurrence. Offers by
telephone, fax, email or other electronic means will not be accepted. It is
understood that any deviation from a completed, signed (original signatures)
proposal delivered on or before the designated time, date and place, as provided
herein, to the City will be resolved against the individual or firm submitting the
response.
D. Agrees:
1. To hold this Offer open for 60 calendar days after the opening date.
2. By signing this document the responding individual or firm hereby agrees
to negotiate in good faith, to be bound by specifications, terms,
conditions, scheduling, pricing and representations as stated and
submitted with this form and /or as established by subsequent
negotiations. However, it is understood that the City reserves the right to
declare any submission nonresponsive if exceptions to specifications,
terms, conditions, etc. of the solicitation are not acceptable in the opinion
of the City to meet the requirements of said solicitation.
3. To enter into and execute a contract with the City, if awarded on the basis
of this Offer and /or subsequent negotiations agreed upon by the City and
the Bidder /Proposer.
RFQ 09/10 -07 Physicians Services-General.
4. To accomplish the work or service in accordance with any Contract
resulting from this request.
1.03 Miscellaneous Requirements and Affirmations
Statements of Qualifications shall be submitted using the attached forms and in
compliance with the instructions provided with this request.
• Number of originals and complete copies to submit�"ab�L Procl w�J
�
a. One original and 4 copies and an electronic disc in pdf format all in one
package, to City of Sanford as indica e e owl- -see items 2 and 3 of the
solicitation for details.
1.04 Protests
Protests, if any, shall be submitted in compliance with City of Sanford Purchasing Policy
in all respects. Failure to file protest to the Purchasing Manager within the requirements
a and time prescribed by the City's Purchasing Policy, shall constitute a waiver of
proceedings.
1.05 SUBMITTED, signed n sealed this i S day of Qr ac) I O
�ti i5�avib
Date
_�Six r.,..e.o 'a
Printed Name and Title
r,,n Pre. s) d z %,A-
Corporate/Company Seal
On the Envelope Containing Your Submission:
The Return address — Your Company Name and Address
Address or Deliver To:
William Smith, Purchasing Manager
City of Sanford
P.O. Box 1788 (300 N. Park Avenue, Room 236)
Sanford, FL 32772
In the Lower Left Corner of the Envelope, Provide the Following:
RFQ Number: RFQ 09/10 -07 Physicians Services - General
Open Date: April 19, 2010 Open Time: 2:00 p.m. (Nonpublic Opening)
This Form Must Be Completed and Returned with your Submission
RFQ 09/10 -07 Physicians Services - General.
Disputes Disclosure Form
Answer the following questions by answering "YES" or "NO ". If you answer "YES ", please
explain in the space provided, please add a page(s) if additional space is needed.
1. Has your firm, or any of its officers, received a reprimand of any nature or been
suspended by the Department of Professional Regulation or any other regulatory agency
or professional association within the last five (5) years? . n O
2. Has your firm, or any member of your firm, been declared in default, terminated or
removed from a contract or job related to the services your firm provides in the regular
course of business within the last five (5) years? n D
3. Has your firm had filed against it or filed any requests for equitable adjustment, contract
claims or litigation in the past five (5) years that is related to the services your firm
provides in the regular course of business? n O If yes, the explanation must state
the nature of the request for equitable adjustment, contract claim or litigation, a brief
description of the case, the outcome or status of suit and the monetary amounts or
extended contract time involved.
I hereby certify that all statements made are true and agree and understand that any
misstatement or misrepresentation or falsification of facts shall be cause for forfeiture of rights
for further consideration of the project identified.
�- w. ► Pr a-cam7k C—C lq-S 5 o c % c_+e_ o V0V4
&,0 0 L 1 0
Sidnature Date
J CL Cy'_Q o Y-\ Y-\ Pre S s d-e-
Printed or Typed Name and Title
FORM NO. DSPT 12.204
This Form Must Be Completed and Returned with your Submission
RFQ 09/10 -07 Physicians Services - General.
Drug -Free Work Place
The undersigned, in accordance with Florida Statute 287.087 hereby certifies that the company named
below does:
1. Publish a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance is prohibited in the workplace and
specifying the actions that will be taken against employees for violations of such prohibition.
2. Inform employees about the dangers of drug abuse in the workplace, the business's policy
of maintaining a drug -free workplace, any available drug counseling, rehabilitation, and
employee assistance programs, and the penalties that may be imposed upon employees for
drug abuse violations.
3. Give each employee engaged in providing the commodities or contractual services that are
proposed a copy of the statement specified in subsection (1).
4. In the statement specified in subsection (1), notify the employees that, as a condition of
working on the commodities or contractual services that are under bid, the employee will abide
by the terms of the statement and will notify the employer of any conviction of, or plea of guilty
or nolo contendere to, any violation of Chapter 893 or of any controlled substance law of the
United States or any state, for a violation occurring in the workplace no later than five (5) days
after such conviction.
5. Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or
rehabilitation program if such is available in the employee's community, by any employee who
is so convicted.
6. Make a good faith effort to continue to maintain a drug -free workplace through implementation
of this section.
Authofized Sign fture Date
r� c
F_ - C s r Y, Pre. S 16 -e- r-ti--
Printed or Typed Name and Title
FORM NO. DFWP 14.204
This Form Must Be Completed and Returned with your Submission
RFQ 09/10 -07 Physicians Services - General.
Conflict of Interest Statement
1. �0.rwQ�o • Q &f nr of {{ %,J2rt�� rn��ti �ras�, cA deposes and states that
Name of Affiant Name of Company
2. The above named entity is submitting an Expression of Interest for the City of Sanford project
identified below.
3. The Affiant has made diligent inquiry and provides the information contained in this Affidavit based
upon his own knowledge.
4. The Affiant states that only one submittal for the above project is being submitted and that the above
named entity has no financial interest in other entities submitting proposals for the same project.
5. Neither the Afflant nor the above named entity has directly or indirectly entered into any agreement,
participated in any collusion, or otherwise taken any action in restraint of free competitive pricing in
connection with the entity's submittal for the above project. This statement restricts the discussion of
pricing data until the completion of negotiations and execution of the Agreement for this project.
6. Neither the entity nor its affiliates, nor any one associated with them, is presently suspended or
otherwise ineligible from participating in contract lettings by any local, state, or federal agency.
7. Neither the entity, nor its affiliates, nor any one associated with them have any potential conflict of
interest due to any other clients, contracts, or property interests for this project.
8. 1 certify that no member of the entity's ownership, management, or staff has a vested interest in any
aspect of or Department of the City of Sanford.
9. 1 certify that no member of the entity's ownership or management is presently applying for an
employee position or actively seeking an elected position with City of Sanford.
10. In the event that a conflictnterest is identified in the provision of services, I, on behalf of the above
named entity, will immedigtel notify the City of Sanford in writing.
p yy i /Sao
Signature o? Affiant Date
Q L&► nc1 eLe s to P_ n�"
Typed or Printed Name of Affiant Title
State of Florida, County of &.0_v'Y %yN_eU
On this 1 Si:�' day of Or r, , 20 10, before me, the undersigned Notary Public of the
State of Tlorida, personallyAp- peared
3�rnt5; L_tVJ nn and tS -e 'tea (aL
(Name(s) of individuals who appeared before notary)
whose name(s) is /are Subscribed to the within instrument, and he/she /they acknowledge that he /she/they
executed it.
WITNESS my hand
and official seal.
ARY PUBLI E O ORIDA
NOTARY PUBLIC'��
SEAL OF OFFICE:
— — (Name of Notary Public: Print, Stamp, or Type as Commissioned.)
AOA CAMONE
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F N I 8.
This Form Must Be Completed and Returned with your Submission
RFQ 09/10 -07 Physicians Services - General.
LIS
MEMORANDUM
FINANCE DEPARTMENT - PURCHASING DIVISION
Provide evidence of insurance coverage and levels thereof for:
a. General liability
b. Auto liability Yl) pt
C. Professional liability
d. Workers comp
RFQ 09/10 -07 Physicians Services - General.
State Farm Florida Insurance Company
7401 Cypress Garden Bivd.
Winter Haven, FL 33888 -0007
V -19- 1924 -F612
000888
NORTH SEMINOLE FAMILY
PRACTICE ASSOCIATION PA
2209 S FRENCH AVE
SANFORD FL 32771 -4245
Location: 2209 S FRENCH AVE
SANFORD FL
32771 -4245
Mortgagee: WACHOVIA MORTGAGE FSB NO 526
ITS SUCCESSORS AND /OR ASSIGNS
Loan No: WA -Print on Paystub
U 3 F
Forms, Options, and Endorsements
1
Special Form 3
FP -6153
Exterior Signs $4,300
OPT ES
Amendatory Endorsement
FE- 6210.3
Tree Debris Removal
FE -6451
Business Policy Endorsement
FE -6464
Physicians and Surgeons
FE -6407
Glass Deductible Deletion
FE- 6538.1
Hurricane Deductible
FE- 6537.4
Fungus (Including Mold) Excl
FE -6566
Subcontractor Pd Exclusion
FE -6598
Amendatory Collapse
FE -6839
Inc Cost and Demolition Cov
FE -6587
Continued on back of page
apply - refer to policy
RENEWAL CERTIFICATE
IpCQLt0Y151tl 1i[8£Ft 98 N2 X118 5
1
Business - Office Policy
j
NOV 04 2009 to NOV 04 2010
NOV 04 2009
$1,221.457
Coverages and Limits
Section I
A Buildings
Excluded
B Business Personal Property
129,900
C Loss of Income
Actual Loss
Deductibles - Section I
Basic
500
Hurricane
2.00%
Other deductibles may
apply - refer to policy
Section 11
L Business Liability
$500, 000
M Medical Payments
5, 000
Gen Aggregate (Other than PCO)
1,000 000
Products - Completed Operations
1, 000, 000
(PCO Aggregate)
Annual Premium
$830.00
Forms, Opts, & Endrsmnt
285.00
Bus Liability - Cov L
33.00
FL Guaranty Fund 07
22.96
Citizen 05 Reg Asmt
7.69
FL Guaranty Fund EM
5.63
* *Adl Surchg(See Below)
37.17
Amount Due
$1,221.45
Premium Reductions
Renewal Year Discount
Yrs in Business Discount
Claim Record Discount
Cov. A - Inflation Index: N/A
Cov. B - Consumer Price: 220.0
** FL Guaranty Fund 4.48 FHCF Assessment 11.48
FL Trust Fund Surchg 1.14 FL EMPA Fund Surcharge 4.00
2005 Citizens EM Asmt 16.07
NOTICE: Information concerning changes in your policy language is included. Please call your agent if
you have any questions.
2744 201 2018 i Agent CLIFF MILLER INS AGENCY INC
Telephone (407) 322 -5142
If you have moved, please contact your agent.
See reverse side for important information.
REB Prepared JUL 17 2009
ate Farm Florida Insurance Company
7401 Cypress Gardens Blvd.
Winter Haven, FL 33888 -0007
V -19- 1924-F612
000a89
QUINN, JAMES E & JOAN
2209 S FRENCH AVE
SANFORD FL 32771 -4245
ocation: 2209 S FRENCH AVE
SANFORD FL
32771 -4245
lortgagee: WACHOVIA BANK NA
ITS SUCC WOR ASSIGNS ATIMA
COMMERCIAL INSURANCE SUPPORT
Loan No: 114932929
orms, Options, and Endorsements
U 3 F
pecial Form 3
FP -6153
mendatory Endorsement
FE- 6210.3
ree Debris Removal
FE -6451
usiness Policy Endorsement
FE -6464
lass Deductible Deletion
FE- 6538.1
urricane Deductible
FE- 6537.4
ungus (Including Mold) Excl
FE -6566
ubcontractor Pd Exclusion
FE-6598
mendatory Collapse
FE -6839
,c Cost and Demolition Cov
FE -6587
olicy Endorsement - Business
FE -6610
ist Mat Violat Statues Excl
FE -6655
ontinued on back of page
$2,935.23
FHCF Assessment
FL EMPA Fund Surcharge
RENEWAL CERTIFICATE
NOV 04 2009 to NOV 04 2010
-NOV 04 2009 $2,935.33j
Coverages and Limits
Section I
A Buildings $683,500
B Business Personal Property Excluded
C Loss of Income Actual Loss
Deductibles - Section I
Basic 500
Hurricane 2.00%
Other deductibles may
apply - refer to policy
Section II
L Business Liability
$500,000
M Medical Payments
5,000
Gen Aggregate (Other than PCO)
1,000,000
Products - Completed Operations
1,000,000
(PCO Aggregate)
Annual Premium
$2,714.00
Bus Liability - Cov L
50.00
FL Guaranty Fund
10.78
FL Guaranty Fund 07
55.28
Citizen 05 Reg Asmt
18.52
FL Guaranty Fund EM
13.55
* *Adl Surchg(See Below)
73.10
Amount Due
$2,935.23
Premium Reductions
Renewal Year Discount
Yrs in Business Discount
Claim Record Discount
Cov. A - Inflation Index: 230.2
Cov. B - Consumer Price: N/A
27.64 FL Trust Fund Surchg 2.76
4.00 2005 Citizens EM Asmt 38.70
OTICE: Information concerning changes in your policy language is included. Please call your agent if
)u have any questions.
8 201B i Agent CLIFF MILLER INS AGENCY INC
S8,S9 Talanhnna (4(171 R99-r,1 d9
If you have moved, please contact your agent.
See reverse side for important information.
Prepared JUL 17 2009
F's -4'
IrIP"A6
First Professionals Insurance Company
FIRST PROFESSIONALS INSURANCE COMPANY, INC.
MEMORANDUM OF INSURANCE
North Seminole Family Practice Associates, P.A.
2209 French Ave.
Sanford, FL 32771
POLICY INFORMATION
Named Insured: North Seminole Family Practice Associates, P.A.
Coverage Applicable To: James E. Quinn, M.D.
Policy Number: CL099281
Policy Period: 01 /01 /2010 to 01/01/2011
Retroactive Date: 03/01/1988
Limits of Liability: $250,000 per claim /$750,000 aggregate
Classification: Family Practice - No Surgery
Memorandum of Insurance Issue Date: 12/18/2009
First Professionals Insurance Company, Inc. hereby issues this Memorandum of Insurance to verify that we
have issued a medical professional liability insurance policy to the above named insured with coverage and
limits of liability as set forth above. This Memorandum of Insurance shall not be construed in any way
whatsoever as amending any of the terms, definitions, conditions or exclusions of the policy issued to the above
named insured.
SPECIAL NOTICE TO INSURED
The Policyholder has been provided a copy of the policy. We recommend that you, as an additional
insured, obtain a copy of the policy from the Policyholder and read it carefully in order to fully
understand the terms, definitions, exclusions, conditions and coverage provided. There may also be
endorsements to the policy which should be read carefully because they affect coverage. If you are
unable to obtain a copy of the policy from the Policyholder, please feel free to request a copy of the
policy from us. Such request may be made: in writing mailed to the address listed below; or by phone at
(904) 3545910 x3219 or (800) 741 -3742 x3219; or by facsimile at (904) 358 -6728.
FPIC CONTACT INFORMATION. The following information may be used to contact our company:
First Professionals Insurance Company, Inc., P.O. Box 44033, Jacksonville, Florida 32231 -4033; or
Phone (904) 354 -5910, (800) 741 -3742; or Facsimile (904) 358 -6728.
Yn, .,,t Zdaie-�
Authorized Representative
FPIC -MPL- 103 -FL (12/08)
1000 Riverside Avenue, Suite 800 a Jacksonville, Florida 32204 0 (904) 354 -5910. 1 -800- 741 -3742 • Fax (904) 358.6728
P.O. Box 44033 • Jacksonville, Florida 32231 -4033 • www.firstprofessionals.com
First Professionals Insurance Company
FIRST PROFESSIONALS INSURANCE COMPANY, INC.
MEMORANDUM OF INSURANCE
North Seminole Family Practice Associates, P.A.
2209 French Ave.
Sanford, FL 32771
POLICY INFORMATION
Named Insured: North Seminole Family Practice Associates, P.A.
Coverage Applicable To: Harvey W. Schefsky, M.D.
Policy Number: CL099281
Policy Period: 01/01/2010 to 01/01/2011
Retroactive Date: 06/01/1994
Limits of Liability: $250,000 per claim/$750,000 aggregate
Classification: Family Practice - No Surgery
Memorandum of Insurance Issue Date: 12/18/2009
First Professionals Insurance Company, Inc. hereby issues this Memorandum of Insurance to verify that we
have issued a medical professional liability insurance policy to the above named insured with coverage and
limits of liability as set forth above. This Memorandum of Insurance shall not be construed in any way
whatsoever as amending any of the terms, definitions, conditions or exclusions of the policy issued to the above
named insured.
SPECIAL NOTICE TO INSURED
The Policyholder has been provided a copy of the policy. We recommend that you, as an additional
insured, obtain a copy of the policy from the Policyholder and read it carefully in order to fully
understand the terms, definitions, exclusions, conditions and coverage provided. There may also be
endorsements to the policy which should be read carefully because they affect coverage. If you are
unable to obtain a copy of the policy from the Policyholder, please feel free to request a copy of the
policy from us. Such request may be made: in writing mailed to the address listed below; or by phone at
(904) 354 - 5910 x3219 or (800) 741 - 3742 x3219; or by facsimile at (904) 358 -6728.
FPIC CONTACT INFORMATION. The following information may be used to contact our company:
First Professionals Insurance Company, Inc., P.O. Box 44033, Jacksonville, Florida 322314033; or
Phone (904) 354 -5910, (800) 741 -3742; or Facsimile (904) 358 -6728.
-y4W
Authorized Representative
FPIC -MPL- 103 -FL (12/08)
1000 Riverside Avenue, Suite 800 a Jacksonville, Florida 32204 • (904) 354.5910 • 1- 800 - 741 -3742 • Fax (904) 358 -6728
P.O. Box 44033 • Jacksonville, Florida 32231 -4033 • www.firstprofessionals.com
V0.119
First Professionals Insurance Company
FIRST PROFESSIONALS INSURANCE COMPANY, INC.
MEMORANDUM OF INSURANCE
North Seminole Family Practice Associates, P.A.
2209 French Ave.
Sanford, FL 32771
POLICY IN FORMATION
Named Insured: North Seminole Family Practice Associates, P.A.
Coverage Applicable To: Daniel R. Monette, M.D.
Policy Number: CL099281
Policy Period: 01 /01/2010 to 01/01/2011
Retroactive Date: 07/15/2002
Limits of Liability: $250,000 per claim /$750,000 aggregate
Classification: Family Practice - No Surgery
Memorandum of Insurance Issue Date: 12/18/2009
First Professionals Insurance Company, Inc. hereby issues this Memorandum of Insurance to verify that we
have issued a medical professional liability insurance policy to the above named insured with coverage and
limits of liability as set forth above. This Memorandum of Insurance shall not be construed in any way
whatsoever as amending any of the terms, definitions, conditions or exclusions of the policy issued to the above
named insured.
SPECIAL NOTICE TO INSURED
The Policyholder has been provided a copy of the policy. We recommend that you, as an additional
insured, obtain a copy of the policy from the Policyholder and read it carefully in order to fully
understand the terms, definitions, exclusions, conditions and coverage provided. There may also be
endorsements to the policy which should be read carefully because they affect coverage. If you are
unable to obtain a copy of the policy from the Policyholder, please feel free to request a copy of the
policy from us. Such request may be made: in writing mailed to the address listed below; or by phone at
(904) 354 -5910 x3219 or (800) 741 -3742 x3219; or by facsimile at (904) 358 -6728.
FPIC CONTACT INFORMATION. The following information may be used to contact our company:
First Professionals Insurance Company, Inc., P.O. Box 44033, Jacksonville, Florida 322314033; or
Phone (904) 354 -5910, (800) 741 -3742; or Facsimile (904) 358 -6728.
' 4
Z'
Authorized Representative
FPIC -MPL- 103 -FL (12/08)
1000 Riverside Avenue, Suite 800 a Jacksonville, Florida 32204 • (904) 354 -5910 • 1- 800 -741 -3742 • Fax (904) 358 -6728
P.O. Box 44033 a Jacksonville, Florida 3 223 1 -4033 a www.firstprofessionals.com
First Professionals Insurance Company
FIRST PROFESSIONALS INSURANCE COMPANY, INC.
MEMORANDUM OF INSURANCE
North Seminole Family Practice Associates, P.A.
2209 French Ave.
Sanford, FL 32771
POLICY INFORMATION
Policyholder: North Seminole Family Practice Associates, P.A.
Policy Number: CL099291
Policy Period: 01/01/2010 to 01/01/2011
Retroactive Date: 03/01/1988
Limits of Liability: See Schedule
Classification: N/A
Memorandum of Insurance Issue Date: 12/18/2009
First Professionals Insurance Company, Inc. hereby issues this Memorandum of Insurance to verify that we
have issued a medical professional liability insurance policy to the above named policyholder with coverage
and limits of liability as set forth below for each additional insured. This Memorandum of Insurance shall not
be construed in any way whatsoever as amending any of the terms, definitions, conditions or exclusions of the
policy issued to the above named policyholder.
State
Limits of Liability
Retroactive
License Number
Name of Additional Insured
Per Claim/Aggregate
Date
C9281
North Seminole Family Practice Associates, P.A.
$250,000/$750,000
03/01/1988
83013
Daniel R. Monette, M.D.
$250,000/$750,000
07/15/2002
31886
James E. Quinn, M.D.
$250,000/$750,000
03/01/1988
20023
Harvey W. Schefsky, M.D.
$250,000/$750,000
06 /01/1994
FPIC CONTACT INFORMATION. The following information may be used to contact our company:
First Professionals Insurance Company, Inc., P.O. Box 44033, Jacksonville, Florida 32231 -4033; or
Phone (904) 354 -5910, (800) 741 -3742; or Facsimile (904) 358 -6728.
�
-Yat'w Z' Authorized Representative
FPIC -MPL- 110 -FL (12/08)
1000 Riverside Avenue, Suite 800 a Jacksonville, Florida 32204 a (904) 354.5910. 1- 800.741 -3742 • Fax (904) 358 -6728
P.O. Box 44033 • Jacksonville, Florida 32231 -4033 • www.firstprofessionals.com
POLICY INFORMATION PAGE
WC000001 A
Insurer:
Comp Options Insurance Company, Inc. d/b /a OptaComp
P. O. Box 44291
Jacksonville, FL 32231 -4291
1. The Insured: North Seminole Family Practice Associates, PA
Mailing address: 2209 S. French Avenue
Sanford, FL 32771
Other workplaces not shown above:
POLICY NO.
01 CAI - 219D520 -01
_ Individual _ Partnership
X Corporation or
2. The Policy Period is from 19- Mar -10 to 19- Mar -11 12:01 A.M. at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: FL
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:
Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 each accident
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
D. This policy includes these endorsements and schedules:
WC 99 06 03, WC 00 04 02, WC 00 04 06 A, WC 00 0414, WC 09 06 06, WC 09 04 03 A, WC 00 03 08
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All
information required below is subject to verification and change by audit.
REFER TO CLASSIFICATION SCHEDULE WC 99 06 03
Premium Basis Rate Per Estimated
Code Total Estimated $100 of Annual
Classifications No. Annual Remuneration Remuneration Premium
Total Estimated Annual Premium $2,270
Minimum Premium $235 Expense Constant
r'
Countersigned by:
WC 00 00 01 A
(Ed. 5 -88)
NORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 99 06 03
(Ed. 01 -01)
tem 4 of the Information Page is amended to include the following classifications.
CLASSIFICATION SCHEDULE
Classifications Code Premium Basis Rate Per
Estimated
No. Total Estimated $100 of
Annual
Annual Remuneration Remuneration
Premium
Physician and clerical 8832 $492,758 0.4
$1,971
i
Total Manual Premium
$1,971
increased Employer Limits
$0
Deductible Credit
$0
Drug Free Discount 0.95
$0
Safety Program Credit 0.98
$0
Total Estimated Annual Standard Premium
$1,971
Experience Modification 1.00
$0
Modified Premium
$1,971
FCCAP Credit
$0
Premium Discount
$0
Expense Constant
$200
Terrorism Risk Insurance Act 2002
$99
Total Estimated Premium
$2,270
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The Information below is required only when this endorsement is Issued subsequent to preparation of the policy.)
idorsement Effective Date: 19- Mar -10 Policy Number: 01CA1- 219D520 -01 Endorsement No.:
cured Name: North Seminole Family Practice Associates, PA
surance Company:
IWC 99 06 03
(Ed. 1 -01)
Comp Options Insurance Company, Inc. d/b /a OptaComp
Countersigned by:
Premium:
$2,270
I
Florida Statutes On Public Entity Crimes
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
This sworn statement is submitted to The City of Sanford 0
by �0.r� -v o e • t,�J ri!r-N on behalf of
whose business address is:
and (if applicable) its Federal Employer Identification Number (FEIN) is 5"q- Z63 qg•3 If the entity has
no FEIN, include the Social Security Number of the individual signing this statement: Y\ 1 A
2. 1 understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a
violation of any state or federal law by a person with respect to and directly related to the transaction of
business with any public entity or with an agency or political subdivision of any other state or with the
United States, including, but not limited to, any bid or contract for goods or services, any lease for real
property, or any contract for the construction or repair of a public building or public work, involving antitrust,
fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.
3. 1 understand the "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes, means
a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any
federal or state trial court of record relating to charges brought by indictment or information after July 1,
1989, as a result of a jury verdict, non jury trial, or entry of a plea of guilt or nolo contendere.
4. 1 understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes. means:
1. A predecessor or successor of a person convicted of a public entity crime: or
2. An entity under the control of any natural person who is active in the management of the entity and
who has been convicted of a public entity crime. The term "affiliate" includes those officers,
directors, executives, partners, shareholders, employees, members, and agents who are active in
the management of an affiliate. The ownership by one person of shares constituting a controlling
interest in another person, or a pooling of equipment or income among persons when not fair
market value under an arm's length agreement, shall be a prima facie case that one person
controls another person. A person who knowingly enters into a joint venture with a person who has
been convicted of a public entity crime in Florida during the preceding 36 months shall be
considered an affiliate.
5. 1 understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes. means any natural
person or entity organized under the laws of any state or of the United States with the legal power to enter
into a binding contract and which bids or applies to bid on contracts let by a public entity, or which
otherwise transacts or applies to transact business with a public entity. The term "person" includes those
officers, directors, executives, partners, shareholders, employees, members, and agents who are active in
management of an entity.
6. Based on information and belief, the statement which I have marked below is true in relation to the entity
submitting this sworn statement. (Please indicate which statement applies.)
b// Neither the entity submitting this sworn statement, nor any of its officers, director, executives,
partners, shareholders, employees, members, or agents who are active in the management of the entity,
nor any affiliate of the entity were charged with and convicted of a public entity crime after July 1, 1989.
The entity submitting this sworn statement, or one or more of the officers, directors, executives,
partners, shareholders, employees, members, or agents who are active in the management of the entity, or
any affiliate of the entity was charged with and convicted of a public entity crime after July 1, 1989.
The entity submitting this sworn statement, or one of its officers, directors, executives, partners,
shareholders, employees, members, or agents who are active in the management of the entity, or any
RFQ 09/10 -07 Physicians Services - General.
affiliate of the entity was charged with and convicted of a public entity crime subsequent to July 1, 1989.
However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida,
Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it
was not in the public interest to place the entity submitting this swom statement on the convicted vendor
list. (Attach a copy of the final order.)
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE
PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND,
THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I
ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A
CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN CTION 287.017, FLORIDA
STATUTES FOR CATEGORY TWO OF ANY CHANGE IN THE INFORMATION ON AINED IN THIS FORM.
4,- (L :� /' �11 /'�
1(signatu ,e)
UO L I IsI @L_0 10
(date)
State of Florida CC��
County of
On this 1 S "-�*' day of t2r 1 , 20 /D, before me, the undersigned Notary Public of the State of
Florida, personally appeared
0 and
(Name(s) of individuals who appeared before notary)
whose name(s) is /are Subscribed to the within instrument, and he /she /they acknowledge that he /she /they executed
it.
WITNESS my hand
and official seal.
ARY PUBLIC,_S ORIDA
NOTARY PUBLIC
SEAL OF OFFICE: �1 r dam'
(Name of Notary Public: Print, Stamp, or Type as Commissioned.)
riao---� �! Personally known to me, or
_ Produced identification:
/ ~ (Type of Identification Produced)
_ DID take an oath, or
DID NOT take an oath.
FORM NO. PEC 15.204
This Form Must Be Completed and Returned with your Submission
RFQ 09/10 -07 Physicians Services - General.
Certification of Non - Segregated Facilities
By affixing his signature to this form, the Offeror /Bidder certifies that he does not maintain or
provide for his employees any segregated facilities at any of his establishments, and that he
does not permit his employees to perform their services at any location, under his control, where
segregated facilities are maintained. The Bidder certifies further that he will not maintain or
provide for his employees any segregated facilities at any location under his control where
segregated facilities are maintained. The Bidder agrees that a breach of this certification will be
a violation of the Equal Opportunity clause in any contract resulting from acceptance of this Bid.
As used in this certification, the term "segregated facilities" means any waiting rooms, work
areas, restrooms and washrooms, restaurants and other eating areas, time clocks, locker rooms
and other storage and dressing areas, parking lots, drinking fountains, recreation or
entertainment area, transportation and housing facilities provided for employees which are
segregated by explicit directive, or are in fact segregated on the basis of race, color, religious
disability or national origin, because of habit, local custom, or otherwise. The Bidder agrees that
(except where he has obtained identical certifications from proposed subcontractors for specific
time periods) he will obtain identical certifications from proposed subcontractors prior to the
award of subcontracts exceeding $10,000 which are not exempt from the provisions of the
Equal Opportunity clause, and that he will retain such certifications in his files.
The nondiscriminatory guidelines as promulgated in Section 202, Executive Order 11246, and as
amended by Executive Order 11375 and as amended, relative to Equal Opportunity for all persons and
implementations of rules and regulations prescribed by the United States Secretary of Labor are
incorporated herein.
NOTE: The penalty for making false statements in offers is prescribed in 18 U.S.G. 1001.
Official Address:
,� lido rA'kn I N YkoLa -m I rac ;6ce SSO cic4eS eA
FORM NO. SFAC 16.204
This Form Must Be Completed and Returned with your Submission
RFQ 09/10 -07 Physicians Services - General.
3�_V- 76 YL=
r 0-f
tat
Ori ba
#B'-11part m erct .a f fft tat e
i certify that the attached. is a true and correct copy of the
Articles of Amendment, filed on ,June 1S, 1491, to Articles of
Incorporation for JAMES E. -QUINN, M.D., R.A., changing its name to -
NORTH SEMINOLE PANPLY PRACTICE ASSOCIATES; P.A., a Florida
corporatidfi;: :* aO- shown -ley the records of this' office, .
The documet''ntrrnber'of -this corporation. is .!01333.
CR2E022 (2 -91)
Am 1111ber 111P bar1b ana for
area$ yea( of for sate of- Poriaa,
at allaba #5 r, ithr Capital, tlth t1�c
19th b ,11' Of .June, 1991.
C/
:�Jint �rnz��
5errctZZrl's of :S tat r
F
:1
Mailing Address
City of Sanford
Post Office Box 1788
Sanford, Florida 32772 -1788
Physical Address
City Hall
300 North Park Avenue
Sanford, Florida 32771 -1244
Telephone
407.688.5028
Facsimile
407.688.5021
Email
smithb @sanfordfl.gov
Website
www.sanfbrdfl.gov
City Commission
Linda Kuhn
Mayor
Art Woodruff
District 1
Dr. Velma H. Williams
District 2, Vice Mayor
Randy Jones
District 3
Jack T. Bridges
District 4
Interim City Manager
Tom George
Purchasing Manager
F. William Smith
Request for Qualifications
Date Issued: March 18, 2010
Opening Date and time: April 17, 2010 at 2:00 P.M.
Solicitation Number: RFQ 09/10 -07
Physician Services — General
The City of Sanford, Florida hereby requests statements of qualifications from board
certified physicians or medical facilities with board certified physicians to participate in
a competitive process to establish the basis to establish a continuing contract with a
provider to perform general medical services for the City of Sanford.
Specifications /requirements, submission forms, documents and relevant information
may be obtained by Downloading the solicitation at the Onvia DemandStar web site
which can be accessed through the City of Sanford's web site: www.sanfordfl.gov
under Departments select Purchasing then Sanford Bid Information. Planholder's
Lists, tabulations, addenda issued, short lists, and subsequent awards, if any, may
be found on the City of Sanford's web site. This information will not be provided
by telephone or FAX.
Except where specifically indicated by the solicitation, it is noted that information,
documents, addenda, etc. provided by sites or services other than Onvia
DemandStar, the official site for posting the City of Sanford's solicitations, shall
not have standing in case of conflict or missing notifications regarding addenda.
Providers experiencing difficulty obtaining the solicitation and documents are to
contact the Purchasing Office of the City of Sanford.
Submissions delivered after the date and time indicated above will not be opened or
otherwise considered. Please note that facsimile, telegraph, email submissions will
not be considered. Any uncertainty regarding the time a proposal is received bu the
City of Sanford will be resolved against the proposer.
Responses to RFQ's are not publically opened. However, at the time of the opening
the City will reveal the names of the proposers. No other information will be released
until an award is announced.
Persons with disabilities needing assistance to participate in any of these proceedings
should contact 407.688.5025 at least 48 hours in advance of the meeting.
Respectfully,
F. WILLIAM SMITH, Purchasing Agent
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City Of Sanford /North Seminole Family Practice /Amendment, Extension
And Renewal to Agreement For Workers Compensation Physicians
Services (RFP 09/10 -06)
This Extension And Renewal To Agreement (Extension and Renewal) is
IL
made and entered into on this Zday of &3 and is to that certain
Agreement styled Agreement For Workers Compensation Physicians Services (RFP
09/10 -06) made and entered into on the 14th day of June, 2010 (the Agreement),
between the City Of Sanford, a municipal corporation organized and existing under
the laws of the State of Florida (hereinafter referred to as the City), whose address
fit,- A sfoci �
is 300 North Park Avenue, Sanford, Florida 32771, and v�4 iCX�a
Florida corporation, the successor, by merger, entity to North Seminole Family
Practice Associates, P.A., authorized to do business in the State of Florida, whose
principal and local address is 2209 French Avenue, Sanford, Florida 32771
(hereinafter referred to as the Physician).
WI TNESSETH:
Whereas, the City and the Physician entered into the above - referenced
Agreement on June 14, 2010 and desire to extend and renew the Agreement so as
to enable both parties to continue to enjoy the mutual benefits that the Agreement
currently provides; and
Whereas, the Agreement, in Section 11, and the essential requirements of
contract law provide that any extensions and renewals to agreements shall be
expressed in writing and duly executed by the parties; and
Whereas, the parties desire to extend the term of the Agreement and renew
the Agreement for a specified period of time so as to enable both parties to
1
continue to enjoy the mutual benefits it provides,
Now, Therefore, in consideration of the mutual understandings and
agreements contained herein, and other good and valuable consideration, the
receipt and sufficiency of which is hereby acknowledged, the parties agree to
extend and renew the Agreement as follows:
Section 1. Recitals. The above stated recitals (whereas clauses) to this
Extension and Renewal are hereby adopted and form a material part of this
Extension and Renewal and the consideration hereof upon which the parties have
relied.
Section 2. Extension And Renewal. The term of the Agreement, which was to
expire on December 31, 2011, in accordance with the provisions of Section 11 of the
Agreement, is extended such as the Agreement will now terminate on December 31, 2012
and the Agreement is hereby renewed.
Section 3. Effect Of Extension And Renewal. Except as specifically stated
herein in this Extension and Renewal, all terms and conditions of the Agreement shall
remain in full force and effect as originally set forth in said Agreement.
In Witness Whereof, the parties hereto have executed this instrument for the
purposes herein expressed.
Attest.
kn�' ;T � , ��M
Printed Name and Title
2
North Seminole
Associates, P.A
ppr priate Corp hr
amily Practice
L- " --'
Signatory
Printed Name and Title
Attest:
'WR
For the use and reliance of the City of
Sanford only. Approved as to form
and legal sufficiency.
m L. Colbert, Cify qoMey
? AJ
�A
w
City Of Sanford
North Seminole Family Practice Associates PA
2209 S French Avenue
Sanford, Florida 32771
Phone: (407) 321 -4230
Fax: (407)324 -7642
April 15, 2010
Respectfully Submitting Proposal For:
Solicitation Number: RFQ 09/10 -06
Physician Services — Work Related Injuries
Due Date and Time: April 19, 2010 at 2:OOpm
North Seminole Family Practice Associates PA
2209 S French Avenue
Sanford, Florida 32771
Phone: (407) 321 -4230
Fax: (407)324 -7642
April 15, 2010
City of Sanford Florida
ATTN: F. William Smith, Purchasing Agent
RE: Proposal for Physician Services — Work Related Injuries / RFQ 09/10 -06
Dear Mr. Smith,
North Seminole Family Practice Associates PA is a medical facility that has been responding to
the medical needs of the Sanford Community since 1983. We have three Board Certified Family
Practice physicians. Dr. James Quinn has 26 years of relevant experience as he has been in
private practice here in Sanford since 1983. Dr. Harvey Schefsky has been a primary care
physician for 36 years and has been in private practice here in Sanford since 1994. Dr. Daniel
Monette has been in practice here in Sanford for 8 years. Together they have over 70 years of
combined experience in medicine.
North Seminole Family Practice Associates PA currently employs 13 medical assistants
(including 5 certified X -ray technicians and a Registered Nurse) along with nine administrative
personnel who strive to maintain the business functions of this office.
This facility currently performs in- office testing which includes but is not limited to x -rays,
EKG's, phlebotomy, physician performed urinalysis, laceration repairs, excisions and minor
surgeries, annual physicals, immunizations and illness evaluations. We are more than prepared
to handle your work comp injuries with ease. We offer same day appointments for any initial
work comp injury.
We have successfully provided medical care and offered medical recommendations to the City of
Sanford and its employees for over 20 years and look forward to continuing this relationship.
Please feel free to contact me with any questions or concerns.
Sincerely,
4e/Js E. Quinn, M.D.
James E. Quinn, NLD-
Curriculum vitae
Date of Birth 2 -18 -51
WCATION:. Cleveland, Ohio
COQ Ohio State University 1969 to 19'73 Social ScieBz� ; BdMcdical College
of Ohio at Toledo 1973 to 1976 M.D., Lange
INi-ERNSJMP Naval. Aerospace Reg 01W Medical Center (NARMC) 1976 to 1977
FAMILY PRACTICE RESIDENCY: Naval Aerospace Regional Medical Center 1977 to
1.979 Board Certified in Family Me'-".cine 1979
FAMILY PRACTICE 'TEACHING STAFF: Naval Aerospace Regional Medical Center
1979 to 1982
A. Clinic SuPervisor
B. Intern. Coordinator
C. ACLS Instructor and Course Director for NARMC
D. Teacher in the NARMC WF' BCLS, ICU and Alcohol
Rehabilitation Program.
E. Teacher of the Year NARMC Fly Practice Reardency 1979
to 1980
Past Chairman Emergency Cardiac Care Committee of the AHA for the Panhandle Region
1982 -1983 Trauma Physician at Sacred Heart Hospital Trauma Center - Pensacola, Florida
October 1983 - Present Private Family Practice - Sanford, Florida
HOSPITAL PRT�Ms
Columbia.Medical Center - Sanford, Florida
AHA .ACLS Aff&te Faculty for the State of Florida
Team Physician for Seminole High. School 1.983 -1.994 (Volunteer)
Seminole County Medical Society - President 1987
Friends of the St. Johns - Board of Directors
Sanford Unit AHA - President
Lakeview Nursing Home - Medical Director 1984- 1997
Seminole County Schools- Parbm in Excellence 1994 -1995
All Soule School - Board Member 1988 -1994 / Chairman
Sanford Rotary - Board of Directors 1987 -1992 / President 1990 - 1991.
Chamber of Commerce - Executive Committee / Board of Directors
P trans Assoc. - Chairman of the Board & President
Central Florida � � practice t 198 S & 1998 /
Central Florida Regional Board of �s 1998/ Chief of Staff 1991 / Chairman of
Credentials Committee 1.992-1997 / Vise Chairman 1995 /
Chairman of the Board 1995 -1998
Harvey W. Schefsky
B.S. Ohio State University 1962
M.S. University of Wisconsin 1963
M.D. Ohio State University 1968
Rotating Internship, U.S. Naval Hospital Jacksonville,
Florida. 1968 -69
Family Practice Residency, U.S. Naval Hospital Jacksonville,
Florida
Chief of Family Practice, U.S. Naval Hospital Memphis, s 1971 -74
Family Practice, Deltona, Florida
Emergency Room Physician, Central Florida Regional
Hospital, Sanford, Florida
Family Practice, Sanford, Florida.
President, Seminole County Medical Society
Secretary/Treasurer, Central Florida Region Florida
Hospital, Sanford,
Vice Chief of Staff Central Florida Regional
Hospital, Sanford, Florida
Chief of Staff Central Florida. Regional Hospital Florida
Board Certified A.B.F.P.
Member A.A.F.P.
Member F.A..F.P.
Member F.M.A.
Member A.O.A. Medical Society
Member F.P.A.
Member A.C.E.P.
1974 -91
1991 -94
1994- present
1988
1989
1990
1572 Shadowmoss Circle
Lake Mary, FL, 32746
Phone (407)333 -1914
E-mail do
monetteQ,holmail com
Daniel R. Monette, M.D., CAQSM
Education
Teaching and
Professional Activities
Publications/ Projects /
Presentations
7/01 — 7/02 Halifax Medical Center, Sports Medicine Fellowship
Daytona Beach, Florida
BC Sports Medicine, April 2003
7/98 — 7/01 Catholic Health Care West, St..loseph's Family Practice Residency
Phoenix, Arizona
BC Family Practice, July 2001
8/94 — 5/98 University of Colorado Health Sciences Center
Denver, Colorado
Medical Doctorate, May 1998
8/90 — 5/94 University of Colorado at Boulder
Boulder, Colorado
Bachelor of Arts, African American Studies, May 1994
2003 - Pres. Associate Clinical Professor Florida State University
2001 - 2002 Preceptor for Residents and Students in Sports and Family Medicine
2000 - 2001 Co -Chief Family Practice Resident
2000 - 2001 Catholic Health Care West Leadership Committee
1999 - 2001 Family Practice Clinical Operations Committee
1999 - 2001 CHW Family Practice Admissions Committee
1995 - 1998 Medical Student Council Representative
2003 Overuse Injuries,
2002 Knee Exam Workshop, Conference on the Beach
2001 Head and Neck Injuries, Annual Volusia County Coaches Workshop
2000 Preparticipation Exams, Family Practice Grand Rounds
I998 .Tones Fractures, Orthopedic Grand Rounds
1998 Osteoporosis lecture, O.B. Grand Rounds
1997 - 1998 "Total Knee Arthroplasty in Hemophilia Patients: Long -Term Follow-
Professional
Memberships
Sports Medicine
Activities
Up." Submission to The Journal of Bone and Joint Surgery
1995 - 1996 NTH project with University of Colorado Sports Medicine, "Clinical vs.
Surgical Evaluation ofChondromalacia Patella"
2002 - Present American Medical Society for Sports Medicine
1999 - Present American Medical Association
1998 - Present American Academy of Family Physicians
2002 - Pres. University of Central Florida Team Physician
2002 - Ares. Seminole High School Team Physician
2003 - Pres. Seminole Community College Team Physician
2001 - 2002 Bethune Cookinan College Team Physician
2001 - 2002 Embry Riddle Aeronautical University Team Physician
2001 - 2002 Daytona Beach Community College Team Physician
2001 - 2002 Daytona International Speedway Attending Physician
2001 - 2002 Atlantic High School Team Physician
1998 - 2001 Bourgade Catholic Nigh School Team Physician
2000 - 2001 Coordinator for Resident coverage of High School sports
1999 - 2002 Physicals for High School, College, and Professional Athletes
1999 NASCAR Spectator Urgent Care Physician at P.I.R.
ExtraeurrieularMedical 2001 _ 2002 Attending Physician for Exercise Treadmills, Halifax Medical Ctr.
Activities
2001 - 2002 Moonlight Halifax Medical Center
2000 - 2001 Moonlighting St. Joseph's Emergency Department
2000 - 2001 Moonlighting Coordinator with E.D. Director
Awards Received Voted 2006 Best Doctor in Seminole County
Atlantic High School community service award
Bourgade Catholic High School community service award
Sachs Foundation Scholarship recipient
Colorado Masonic Benevolent Scholarship Foundation Recipient
University of Colorado, Arnold Weber Scholarship Recipient
Golden Key National Honor Society
Employment 2002 - Pres. North Seminole Family Practice and Sports Medicine
2209 French Avenue Sanford, FL, 32771
.° �r r STA►1'E QF FLPR1DA
AG#�. ... DEPT-R'T11I]T OF ;.#AL.TH
6WISION OF Iti miCAL QUALITY, ,A$SLM C.JE
DATE
LICENSE NO.'
C C.4 NO.
01/0812009
ME31886
272025
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Submission Form
PART 1 General
1.01 Description
The following Request for Statements of Qualifications, for the (1) RFQ 09/10 -06 Physicians
Services- Workers om . This Response is su mitted by 2
rl- , �t Yt6L#_ sso c.i o 4e o PA
a D-09 +r'Cnc1-N 1 3 ;Z� 77 1
(1) Title and Solicitation number as shown in the Invitation
(2) Name, address, telephone, fax number and email of Proposer.
1.02 The Undersigned:
A. Acknowledges receipt of:
Addenda: Number
Number
Dated
Dated
B. Has examined the Solicitation Documents and understands that in submitting
his /her Response, he /she waives all right to plead any misunderstanding
regarding the same.
C. Understands that the responsibility for delivering the submission to the City on or
before the specified date and time will be solely and strictly the responsibility of
the Respondent. The City will not be responsible for delays caused by the United
States Postal Office or a delay caused by any other occurrence. Offers by
telephone, fax, email or other electronic means will not be accepted. It is
understood that any deviation from a completed, signed (original signatures)
proposal delivered on or before the designated time, date and place, as provided
herein, to the City will be resolved against the individual or firm submitting the
response.
D. Agrees:
1. To hold this Offer open for 60 calendar days after the opening date.
2. By signing this document the responding individual or firm hereby agrees
to negotiate in good faith, to be bound by specifications, terms,
conditions, scheduling, pricing and representations as stated and
submitted with this form and /or as established by subsequent
negotiations. However, it is understood that the City reserves the right to
declare any submission nonresponsive if exceptions to specifications,
terms, conditions, etc. of the solicitation are not acceptable in the opinion
of the City to meet the requirements of said solicitation.
3. To enter into and execute a contract with the City, if awarded on the basis
of this Offer and /or subsequent negotiations agreed upon by the City and
the Bidder /Proposer.
RFQ 09/10 -06 Physicians Services- Workers Comp,
�coya
4. To accomplish the work or service in accordance with any Contract
resulting from this request.
1.03 Miscellaneous Requirements and Affirmations
Statements of Qualifications shall be submitted using the attached forms and in
compliance with the instructions provided with this request.
e Number of originals and complete copies to submit:
a. One original and 4 copies and an electronic disc in pdf format all in one
package, to City of Sanford as indicated below- see items 2 and 3 of the
solicitation for details.
1.04 Protests
Protests, if any, shall be submitted in compliance with City of Sanford Purchasing Policy
in all respects. Failure to file protest to the Purchasing Manager within the requirements
a and time prescribed by the City's Purchasing Policy, shall constitute a waiver of
proceedings.
1.05 SUBMITTED, signed and sealed th
Bidder /Proposer By (Sig
Printed Name and Title
S day of i2 r i l a U I
;10 10
O Lt) I S) C
Date
Pe s►8er-�
Corporate /Company Seal
On the Envelope Containing Your Submission:
The Return address — Your Company Name and Address
Address or Deliver To:
William Smith, Purchasing Manager
City of Sanford
P.O. Box 1788 (300 N. Park Avenue, Room 236)
Sanford, FL 32772
In the Lower Left Corner of the Envelope, Provide the Following:
RFQ Number: RFQ 09/10 -06 Physicians Services- Workers Comp
Open Date: April 19, 2010 Open Time: 2:00 p.m. (Nonpublic Opening)
This Form Must Be Completed and Returned with your Submission
RFQ 09/10 -06 Physicians Services- Workers Comp.
Disputes Disclosure Form
Answer the following questions by answering "YES' or "NO ". If you answer "YES ", please
explain in the space provided, please add a page(s) if additional space is needed.
1. Has your firm, or any of its officers, received a reprimand of any nature or been
suspended by the Department of Professional Regulation or any other regulatory agency
or professional association within the last five (5) years? v*n D
2. Has your firm, or any member of your firm, been declared in default, terminated or
removed from a contract or job related to the services your firm provides in the regular
course of business within the last five (5) years? n O
3. Has your firm had filed against it or filed any requests for equitable adjustment, contract
claims or litigation in the past five (5) years that is related to the services your firm
provides in the regular course of business? n O If yes, the explanation must state
the nature of the request for equitable adjustment, contract claim or litigation, a brief
description of the case, the outcome or status of suit and the monetary amounts or
extended contract time involved.
I hereby certify that all statements made are true and agree and understand that any
misstatement or misrepresentation or falsification of facts shall be cause for forfeiture of rights
for further consideration of the project identified.
FORM NO. DSPT 12.204
Signature
Firm
I a, c� cA A- os o c.; o� 1�
0
Date
n r Yre s>;8 e YN,.k
Printed or Typed Name and Title
This Form Must Be Completed and Returned with your Submission
RFQ 09/10 -06 Physicians Services- Workers Comp.
Drug -Free Work Place
The undersigned, in accordance with Florida Statute 287.087 hereby certifies that the company named
below does:
1. Publish a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession, or use of a controlled substance is prohibited in the workplace and
specifying the actions that will be taken against employees for violations of such prohibition.
2. Inform employees about the dangers of drug abuse in the workplace, the business's policy
of maintaining a drug -free workplace, any available drug counseling, rehabilitation, and
employee assistance programs, and the penalties that may be imposed upon employees for
drug abuse violations.
3. Give each employee engaged in providing the commodities or contractual services that are
proposed a copy of the statement specified in subsection (1).
4. In the statement specified in subsection (1), notify the employees that, as a condition of
working on the commodities or contractual services that are under bid, the employee will abide
by the terms of the statement and will notify the employer of any conviction of, or plea of guilty
or nolo contendere to, any violation of Chapter 893 or of any controlled substance law of the
United States or any state, for a violation occurring in the workplace no later than five (5) days
after such conviction.
5. Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or
rehabilitation program if such is available in the employee's community, by any employee who
is so convicted.
6. Make a good faith effort to continue to maintain a drug -free workplace through implementation
of this section.
f) o (JAA � 44 Pro- CA--t L O-S s d
Firm
,4,G
Auth !zed ignature Date
7;:Y70.VN", -G E . Q v_ � r-\ r� -Pre S CA -e Y-\,+
FORM NO. DFWP 14.204
Printed or Typed Name and Title
This Form Must Be Completed and Returned with your Submission
RFQ 09/10 -06 Physicians Services - Workers Comp.
Conflict of Interest Statement
1. �OuMeS G.OL&i ran of �o`i���vtOie �.� ASSOCJOA deposes and states that
Name of Affiant Name of Company
2. The above named entity is submitting an Expression of Interest for the City of Sanford project
identified below.
3. The Affiant has made diligent inquiry and provides the information contained in this Affidavit based
upon his own knowledge.
4. The Affiant states that only one submittal for the above project is being submitted and that the above
named entity has no financial interest in other entities submitting proposals for the same project.
5. Neither the Affiant nor the above named entity has directly or indirectly entered into any agreement,
participated in any collusion, or otherwise taken any action in restraint of free competitive pricing in
connection with the entity's submittal for the above project. This statement restricts the discussion of
pricing data until the completion of negotiations and execution of the Agreement for this project.
6. Neither the entity nor its affiliates, nor any one associated with them, is presently suspended or
otherwise ineligible from participating in contract lettings by any local, state, or federal agency.
7. Neither the entity, nor its affiliates, nor any one associated with them have any potential conflict of
interest due to any other clients, contracts, or property interests for this project.
8. 1 certify that no member of the entity's ownership, management, or staff has a vested interest in any
aspect of or Department of the City of Sanford.
9. 1 certify that no member of the entity's ownership or management is presently applying for an
employee position or actively seeking an elected position with City of Sanford.
10. In the event that a conflict of interest is Vidnt ed in the provision of services, I, on behalf of the above
named entity, will immediapely notify thf Sanford in writing.
of Affiant Date
:1,11MP..S E . 0L'o r-) 11) Pre_!Si-A en+
Typed or Printed Name of Affiant Title
State of Florida, County of
On this 1 S 41 day of f 20 � � , before me, the undersigned Notary Public of the
State of Florida, personally��apppeared
(��,, c nr and DP_y--\c i6_k IMcC0.be.,
(Name(s) of individuals who appeared before notary)
whose name(s) is /are Subscribed to the within instrument, and he /she /they acknowledge that he /she /they
executed it.
WITNESS my hand
and official seal. C::�
RY PUB AT F FLORIDA
NOTARY PUBLIC
SEAL OF OFFICE: - (bI
AIDA cARBONE (Name of Notary Public: Print, Stamp, or Type as Commissioned.)
I No" Pubk - 6hN of FWW
* Lt, conXnl Wm E*= mar 11, 2011
com **m f DD 620265
Mr&d 1Mlupb I M1b W NOOMMY A^.
—FURITNO. CFI 18.204
This Form Must Be Completed and Returned with your Submission
RFQ 09/10 -06 Physicians Services- Workers Comp.
MEMORANDUM
FINANCE DEPARTMENT - PURCHASING DIVISION
Provide evidence of insurance coverage and levels thereof for:
1. General liability
2. Auto liability Y\ (�
3. Professional liability
4. Workers comp
RFQ 09/10 -06 Physicians Services- Workers Comp.
State Farm Florida Insurance Company
7401 Cypress Gardens Blvd.
Winter Haven, FL 33888 -0007
V -19. 1924 -F612
000888
NORTH SEMINOLE FAMILY
PRACTICE ASSOCIATION PA
2209 S FRENCH AVE
SANFORD FL 32771 -4245
Location: 2209 S FRENCH AVE
SANFORD FL
32771 -4245
Mortgagee: WACHOVIA MORTGAGE FSB NO 526
ITS SUCCESSORS AND/OR ASSIGNS
Loan No: N/A -Print on Paystub
U 3 F
Forms, Options, and Endorsements
Special Form 3
FP -6153
Exterior Signs $4,300
OPT ES
Amendatory Endorsement
FE- 6210.3
Tree Debris Removal
FE -6451
Business Policy Endorsement
FE -6464
Physicians and Surgeons
FE -6407
Glass Deductible Deletion
FE- 6538.1
Hurricane Deductible
FE- 6537.4
Fungus (Including Mold) Excl
FE -6566
Subcontractor Pd Exclusion
FE -6598
Amendatory Collapse
FE -6839
Inc Cost and Demolition Cov
FE -6587
Continued on back of page
2.00%
RENEWAL c:tKI INUAI c
t.
P.O: ° tC l"1llliltBEFt.. :.8 N
6t 1: 5 ....
Business- Office Policy
NOV 04 2009 to NOV 04 2010
T?ATE DIFE:: E-0
NOV 04 2009
$1,221.45
Coverages and Limits
Section I
A Buildings
Excluded
B Business Personal Property
129, 900
C Loss of Income
Actual Loss
Deductibles - Section I
Basic
500
Hurricane
2.00%
Other deductibles may
apply - refer to policy
Section II
L Business Liability
$500,000
M Medical Payments
5,000
Gen Aggregate (Other than PCO)
1,000,000
Products - Completed Operations
1,000$000
(PCO Aggregate)
Annual Premium
$830.0
Forms, Opts, & Endrsmnt
285.0
Bus Liability - Cov L
33.0
FL Guaranty Fund 07
22.9
Citizen 05 Reg Asmt
7.6
FL Guaranty Fund EM
5.6
*"Adl Surchg(See Below)
37.1
Amount Due
$1,221.4
Premium Reductions
Renewal Year Discount
Yrs in Business Discount
Claim Record Discount
Cov. A - Inflation Index: NIA
Gov. B - Consumer Price: 220.0
FL Guaranty Fund 4.48 FHCF Assessment 11.48
FL Trust Fund Surchg 1.14 FL EMPA Fund Surcharge 4.00
s 2005 Citizens EM Asmt 16.07
NOTICE: Information concerning changes in your policy language is included.
you have any questions.
d
2744 2018 Agent CLIFF MILLER INS AGENCY INC
c ... no Cn — - I1n 11n^ r. wn
Please call your agent if
If you have moved, please contact your agent
See reverse side for important information.
REB Prepared JUL 17 2009
ate Farm Florida Insurance Company
7401 Cypress Gardens Blvd.
Winter Haven, FL 33888 -0007
V -19- 1924 -F612
000889
QUINN, JAMES E & JOAN
2209 S FRENCH AVE
SANFORD FL 32771 -4245
Location: 2209 S FRENCH AVE
SANFORD FL
32771 -4245
Mortgagee: WACHOVIA BANK NA
ITS SUCC WOR ASSIGNS ATIMA
COMMERCIAL INSURANCE SUPPORT
Loan No: 114932929
U 3 F
Forms, Options, and Endorsements
Special Form 3
FP -6153
Amendatory Endorsement
FE- 6210.3
Tree Debris Removal
FE -6451
Business Policy Endorsement
FE -6464
Glass Deductible Deletion
FE- 6538.1
Hurricane Deductible
FE- 6537.4
Fungus (Including Mold) Excl
FE -6566
Subcontractor Pd Exclusion
FE-6598
Amendatory Collapse
FE -6839
Inc Cost and Demolition Cov
FE -6587
Policy Endorsement - Business
FE -6610
Dist Mat Violat Statues Excl
FE -6655
Continued on back of page
apply - refer to policy
RENEWAL CERTIFICATE
t�t,tcY lttIMQEF�
Business- Office P0110y
NOV 04 2009 to NOV 04 2010
t7 1T19 DtiE; .....: ... .. tmiM.l �At ANGE RUB N4TI�fT
NOV 04 2009
$2,935.23
Coverages and Limits
Section I
A Buildings
$683,500
B Business Personal Property
Excluded
C Loss of Income
Actual Loss
Deductibles - Section I
Basic
500
Hurricane
2.00%
Other deductibles may
apply - refer to policy
Section 11
L Business Liability
$500,000
M Medical Payments
5,000
Gen Aggregate (Other than PCO)
1,000,000
Products- Completed Operations
1,000,000
(PCO Aggregate)
Annual Premium
$2,714.0(
Bus Liability - Gov L
50.01
FL Guaranty Fund
10.7!
FL Guaranty Fund 07
55.21
Citizen 05 Reg Asmt
18.5;
FL Guaranty Fund EM
13.51
* *Adl Surchg(See Below)
73.11
Amount Due
$2,935.2:
Premium Reductions
Renewal Year Discount
Yrs in Business Discount
Claim Record Discount
Cov. A - Inflation Index: 230.2
Cov. B - Consumer Price: N/A
** FHCF Assessment 27.64 FL Trust Fund Surchg 2.76
3 FL EMPA Fund Surcharge 4.00 2005 Citizens EM Asmt 38.70
NOTICE: Information concerning changes in your policy language is included. Please call your agent if
you have any questions.
u
27480e oe 201B i _ Agent CLIFF MILLER INS AGENCY INC
If you have moved, please contact your agent.
See reverse side for important information.
❑FP Prepared JUL 17 2009
*41
mail
F ilrbl'a !;"A a
First Professionals lnsurarncc Co"Vilny
FIRST PROFESSIONALS INSURANCE COMPANY, INC.
MEMORANDUM OF INSURANCE
North Seminole Family Practice Associates, P.A.
2209 French Ave.
Sanford, FL 32771
POLICY INFORMATION
Named Insured:
North Seminole Family Practice Associates, P.A.
Coverage Applicable To:
James E. Quinn, M.D.
Policy Number:
CL099291
01/01 /2010 to 01/01/2011
Policy Period:
Retroactive Date:
03/01/1988
Limits of Liability:
$250,000 per claim /$750,000 aggregate
Classification:
Family Practice - No Surgery
Memorandum of Insurance Issue Date:
12/18/2009
First Professionals Insurance Company, Inc. hereby issues this Memorandum of Insurance to verify that we
have issued a medical professional liability insurance policy to the above named insured with coverage and
limits of liability as set forth above. This Memorandum of Insurance shall not be construed in any way
whatsoever- as amending any of the terms, definitions, conditions or exclusions of the policy issued to the above
named insured.
SPECIAL NOTICE TO INSURED
The Policyholder has been provided a copy of the policy. We recommend that you, as an additional
insured, obtain a copy of the policy from the Policyholder and read it carefully in order to fully
understand the terms, definitions, exclusions, conditions and coverage provided. There may also be
endorsements to the policy which should be read carefully because they affect coverage. If you are
unable to obtain a copy of the policy from the Policyholder, please feel free to request a copy of the
policy from us. Such request may be made: in writing mailed to the address listed below; or by phone at
(904) 354 -5910 x3219 or (800) 741 -3742 x3219; or by facsimile at (904) 35 8-6728.
FPIC CONTACT INFORMATION. The following information may be used to contact our company:
First Professionals Insurance Company, Inc., P.O. Box 44033, Jacksonville, Florida 32231 -4033; or
Phone (904) 354 -5910, (800) 741 -3742; or Facsimile (904) 358 -6728.
4orized—Representative
FPIC -MPI.- 103 -FL (12/08)
1000 Riverside Avenue, Suite 800 • Jacksonville, Florida 32204 • (904) 354-5910 • 1- 800 - 741 -3742 • Fax (904) 358 -6728
P.O. Box 44033 • Jacksonville, Florida 32231 -4033 • www.firstprofessionals.com
F 11sr'l
Fii,Sr Professionals Insirrance Cc.x1)Pm1y
FIRST PROFESSIONALS INSURANCE COMPANY, INC.
MEMORANDUM OF INSURANCE
North Seminole Family Practice Associates, P.A.
2209 French Ave.
Sanford, FL 32771
POLICY INFORMATION
Named Insured: North Seminole Family Practice Associates, P.A.
Coverage Applicable To: Harvey W. Schefsky, M.D.
Policy Number: CL099281
Policy Period: 01/01/2010 to 01/01/2011
Retroactive Date: 06/01/1994
Limits of Liability: $250,000 per claim /$750,000 aggregate
Classification: Family Practice - No Surgery
Memorandum of insurance Issue Date: 12/18/2009
First Professionals Insurance Company, Inc. hereby issues this Memorandum of Insurance to verify that we
have issued a medical professional liability insurance policy to the above named insured with coverage and
limits of liability as set forth above. This Memorandum of Insurance shall not be construed in any way
whatsoever as amending any of the terms, definitions, conditions or exclusions of the policy issued to the above
named insured_
SPECIAL NOTICE TO INSURED
The Policyholder has been provided a copy of the policy. We recommend that you, as an additional
insured, obtain a copy of the policy from the Policyholder and read it carefully in order to fully
understand the terms, definitions, exclusions, conditions and coverage provided. There may also be
endorsements to the policy which should be read carefully because they affect coverage. If you are
unable to obtain a copy of the policy from the Policyholder, please feel free to request a copy of the
policy from us. Such request may be made: in writing mailed to the address listed below; or by phone at
(904) 354 -5910 x3219 or (800) 741 -3742 x3219; or by facsimile at (904) 358 -6728.
FPIC CONTACT INFORMATION. The following information may be used to contact our company:
First Professionals Insurance Company, Inc., P.O. Box 44033, Jacksonville, Florida 32231 -4033; or
Phone (904) 354 -5910, (800) 741 -3742; or Facsimile (904) 358 -6728.
Authorized Representative
FP1C -MPI: 103 -FI. (12/08)
1000 Riverside Avenue, Suite 800 - Jacksonville, Florida 32204 - (904) 3.54.5910 - 1- 800 - 741 -3742 - Fax (904) 358 -6728
P.O. Box 44033 - Jacksonville, Florida 32231 -4033 • www.firstprofessionals.com
F rAFE'.. C5
First Professionals Insurance C::omh,�my
FIRST PROFESSIONALS INSURANCE COMPANY, INC.
MEMORANDUM OF INSURANCE
North Seminole Family Practice Associates, P.A.
2209 French Ave.
Sanford, FI, 32771
POLICY INFORMATION
Named Insured:
North Seminole Family Practice Associates, P.A.
Coverage Applicable To:
Daniel R. Monette, M.D.
Policy Number:
CL099281
Policy Period:
01/01/2010 to 01/01/2011
Retroactive Date:
07/15/2002
Limits of Liability:
$250,000 per claim /$750,000 aggregate
Classification:
Family Practice - No Surgery
Memorandum of Insurance Issue Date:
12/18/2009
First Professionals Insurance Company, Inc. hereby issues this Memorandum of Insurance to verify that we
have issued a medical professional liability insurance policy to the above named insured with coverage and
limits of liability as set forth above.
This Memorandum of Insurance shall not be construed in any way
whatsoever as amending any of the terms, definitions, conditions or exclusions of the policy issued to the above
named insured.
SPECIAL NOTICE TO INSURED
The Policyholder has been provided a copy of the policy. We recommend that you, as an additional
insured, obtain a copy of the policy from the Policyholder and read it carefully in order to fully
understand the terms, definitions, exclusions, conditions and coverage provided. There may also be
endorsements to the policy which should be read carefully because they affect coverage. If you are
unable to obtain a copy of the policy from the Policyholder, please feel free to request a copy of the
policy from us. Such request may be made: in writing mailed to the address listed below; or by phone at
(904) 354 -5910 x3219 or (800) 741 -3742 x3219; or by facsimile at (904) 358 -6728.
FPIC CONTACT INFORMATION. The following information may be used to contact our company:
First Professionals Insurance Company, Inc., P.O. Box 44033, Jacksonville, Florida 32231 -4033; or
Phone (904) 354 -5910, (800) 741 -3742; or Facsimile (904) 358 -6728.
'�Kw 14"1-
Authorized Representative
FPIC -MPL: 103 -FL (12/08)
1000 Riverside Avenue, Suite 800 a Jacksonville, Florida 32204 • (904).354-5910 • 1- 800 -741 -3742 • Fax (904) 358 -6728
P.O. Sox 44033 • Jacksonville, Florida 32231 -4033 • www.firstprofessionals.com
F r / �I�
Firsr. Pry >fcssicmals Insurance Company
FIRST PROFESSIONALS INSURANCE. COMPANY, INC.
MEMORANDUM OF INSURANCE
North Seminole Family Practice Associates, P.A.
2209 French Ave.
Sanford, FL 32771
POLICY INFORMATION
Policyholder: North Seminole Family Practice Associates, P.A.
Policy Number: CL099281
Policy Period: 01/01/2010 to 01/01/2011
Retroactive Date: 03/01/1988
Limits of Liability: See Schedule
Classification: N/A
Memorandum of Insurance Issue Date: 12/18/2009
First Professionals insurance Company, Inc. hereby issues this Memorandum of Insurance to verify that we
have issued a medical professional liability insurance policy to the above named policyholder with coverage
and limits of liability as set forth below for each additional insured. This Memorandum of Insurance shall not
be construed in any way whatsoever as amending any of the terms, definitions, conditions or exclusions of the
policy issued to the above named policyholder.
State
Limits of Liability
Retroactive
License Number
Name of Additional Insured
Per Claim /Aggregate
Date
C9281
North Seminole Family Practice Associates, P.A.
$250,000/$750,000
03/01/1988
83013
Daniel R. Monette, M.D.
$250,000/$750,000
07/15/2002
31886
James E. Quinn, M.D.
$250,000/$750,000
03/01/1988
20023
Harvey W. Schefsky, M.D.
$250,000/$750,000
06/01/1994
FDIC CONTACT INFORMATION. The following information may be used to contact our company:
First Professionals Insurance Company, Inc., P.O. Box 44033, Jacksonville, Florida 32231 -4033; or
Phone (904) 354 -5910, (800) 741 -3742; or Facsimile (904) 358 -6728.
lauo
Authorized Representative
FPIC -MPL -I I0 -FL (12/08)
1000 Riverside Avenue, Suite 800 • Jacksonville, Florida 32204 • (904) 354 -5910 • 1 -800- 741 -3742 • Fax (904) 358 -6728
P.Q. Box 44033 • Jacksonville, Florida 32231-4033 • www.fit-tprofessionals.com
POLICY INFORMATION PAGE
WC 00 00 01 A
Insurer: POLICY NO.
Comp Options Insurance Company, Inc. d /b /a OptaComp 01CA1- 219D520 -01
P. O. Box 44291
Jacksonville, FL 32231 -4291 " Individual Partnership
1 2.
13
14.
The Insured: North Seminole Family Practice Associates, PA X Corporation or
Mailing address: 2209 S. French Avenue
Sanford, FL 32771
Other workplaces not shown above:
The Policy Period is from 19- Mar -10 to 19- Mar -11 12:01 A.M. at the Insured's mailing address.
A. Workers Compensation insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: FL
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:
Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 each accident
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
D. This policy includes these endorsements and schedules:
WC 99 06 03, WC 00 04 02, WC 00 04 06 A, WC 00 04 14, WC 09 06 06, WC 09 04 03 A, WC 00 03 08
The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All
information required below is subject to verification and change by audit.
REFER TO CLASSIFICATION SCHEDULE WC 99 06 03
Classifications
Minimum Premium
WC 00 00 07 A
(Ed. 5 -88)
Premium Basis
Code Total Estimated
No. Annual Remuneration
Total Estimated Annual Premium
$235 Expense Constant
Countersigned by:
Rate Per Estimated
$100 of Annual
Remuneration Premium
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
Item 4 of the information Page is amended to include the following classifications.
WC 99 06 03
(Ed. 01 -01)
CLASSIFICATION SCHEDULE
Rate Per Estimated
Classifications Code Premium Basis 100 of Annual
No. Total Estimated $ Premium
Annual Remuneration Remuneration 0 4 $1,971
Physician and clerical 8832 $492,758
Total Manual Premium
$1,97'
Increased Employer Limits
$(
$1
Deductible Credit
$
Drug Free Discount 0.95
$
Safety Program Credit 0.98
Total Estimated Annual Standard Premium
$1,97
Experience Modification 1.00
$
Modlfled Premium
$1,97
FCCAP Credit
Premium Discount
$2C
Expense Constant
$�
Terrorism Risk Insurance Act 2002
Total Estimated Premium
$2,27
This endorsement changes the oonly when this endorsement is issued subsequent to preparation of the policy.)
(The information below is required Y
Endorsement Effective Date: 19- Mar -10 Policy Number: 01 CAI- 2190520 -01 Endorsement No.:
Insured Name: North Seminole Family Practice Associates, PA
Premium: $2,2
Insurance Company: Comp Options Insurance Company, Inc. d/b /a OptaComp
WC 99 06 03 Countersigned by:
(Ed. 1 -01)
Florida Statutes On Public Entity Crimes
THIS FORM MUST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER
OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
This sworn statement is submitted to The City of Sanford
by ..70. QS E Q,.kl rn on behalf of 0n r'44, Sc' ywy,66 o y .44 P ce Xssocl�
whose business address is: vZ. a- 0 g --+ r2 in C-V-) A%H • r(4
S ox v1 f oy-c '4"L- -3 a - 7 ►
and (if applicable) its Federal Employer Identification Number (FEIN) isS_9-2+!o3y$3 0 (If the entity has
no FEIN, include the Social Security Number of the individual signing this statement: ✓t / 11 ).
I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a
violation of any state or federal law by a person with respect to and directly related to the transaction of
business with any public entity or with an agency or political subdivision of any other state or with the
United States, including, but not limited to, any bid or contract for goods or services, any lease for real
property, or any contract for the construction or repair of a public building or public work, involving antitrust,
fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.
I understand the "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida Statutes, means
a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any
federal or state trial court of record relating to charges brought by indictment or information after July 1,
1989, as a result of a jury verdict, non -jury trial, or entry of a plea of guilt or nolo contendere.
4. 1 understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes. means:
1. A predecessor or successor of a person convicted of a public entity crime: or
2. An entity under the control of any natural person who is active in the management of the entity and
who has been convicted of a public entity crime. The term "affiliate" includes those officers,
directors, executives, partners, shareholders, employees, members, and agents who are active in
the management of an affiliate. The ownership by one person of shares constituting a controlling
interest in another person, or a pooling of equipment or income among persons when not fair
market value under an arm's length agreement, shall be a prima facie case that one person
controls another person. A person who knowingly enters into a joint venture with a person who has
been convicted of a public entity crime in Florida during the preceding 36 months shall be
considered an affiliate.
5. 1 understand that a "person" as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural
person or entity organized under the laws of any state or of the United States with the legal power to enter
into a binding contract and which bids or applies to bid on contracts let by a public entity, or which
otherwise transacts or applies to transact business with a public entity. The term "person" includes those
officers, directors, executives, partners, shareholders, employees, members, and agents who are active in
management of an entity.
6. Based on information and belief, the statement which I have marked below is true in relation to the entity
submi ' g this sworn statement. (Please indicate which statement applies.)
Neither the entity submitting this sworn statement, nor any of its officers, director, executives,
partners, shareholders, employees, members, or agents who are active in the management of the entity,
nor any affiliate of the entity were charged with and convicted of a public entity crime after July 1, 1989.
The entity submitting this sworn statement, or one or more of the officers, directors, executives,
partners, shareholders, employees, members, or agents who are active in the management of the entity, or
any affiliate of the entity was charged with and convicted of a public entity crime after July 1, 1989.
The entity submitting this swom statement, or one of its officers, directors, executives, partners,
shareholders, employees, members, or agents who are active in the management of the entity, or any
RFQ 09/10 -06 Physicians Services- Workers Comp.
affiliate of the entity was charged with and convicted of a public entity crime subsequent to July 1, 1989.
However, there has been a subsequent proceeding before a Hearing Officer of the State of Florida,
Division of Administrative Hearings and the Final Order entered by the Hearing Officer determined that it
was not in the public interest to place the entity submitting this sworn statement on the convicted vendor
list. (Attach a copy of the final order.)
I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR THE
PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND,
THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED. I
ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A
CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN PEqTION 287.017, FLORIDA
STATUTES FOR CATEGORY TWO OF ANY CHANGE IN THE TATION CCiNTAINED IN THIS FORM.
(signatur
(date)
State of Florida
County of
On this 1 S+A..N day of _ (� A �� 20 , before me, the undersigned Notary Public of the State of
Florida ersonally appeared
0.r�eS Q u.i e-\,rN and *Zr ► 5-e IOAC- -6-e__
(Name(s) of individuals who appeared before notary)
whose name(s) is /are Subscribed to the within instrument, and he /she /they acknowledge that he /she /they executed
it.
WITNESS my hand
and official seal.
NARY PU F FLORIDA
NOTARY PUBLIC
bor-L
SEAL OF OFFICE:
(Name of Notary Public: Print, Stamp, or Type as Commissioned.)
AIDICARBONE
� Personally known to me, or
Nofsry PubMc - SWe of Bodes
Produced identification:
• MI CftWJ w Erp nUw 11, 2011
C0MM Ils" / DO 620255
(Type of Identification Produced)
" lou111e7Mma *N UM No" lam
take an oath, or
-7 DID NOT take an oath.
FORM NO. PEC 15.204
This Form Must Be Completed and Returned with your Submission
RFQ 09/10 -06 Physicians Services- Workers Comp.
Certification of Non - Segregated Facilities
By affixing his signature to this form, the Offeror /Bidder certifies that he does not maintain or
provide for his employees any segregated facilities at any of his establishments, and that he
does not permit his employees to perform their services at any location, under his control, where
segregated facilities are maintained. The Bidder certifies further that he will not maintain or
provide for his employees any segregated facilities at any location under his control where
segregated facilities are maintained. The Bidder agrees that a breach of this certification will be
a violation of the Equal Opportunity clause in any contract resulting from acceptance of this Bid.
As used in this certification, the term "segregated facilities" means any waiting rooms, work
areas, restrooms and washrooms, restaurants and other eating areas, time clocks, locker rooms
and other storage and dressing areas, parking lots, drinking fountains, recreation or
entertainment area, transportation and housing facilities provided for employees which are
segregated by explicit directive, or are in fact segregated on the basis of race, color, religious
disability or national origin, because of habit, local custom, or otherwise. The Bidder agrees that
(except where he has obtained identical certifications from proposed subcontractors for specific
time periods) he will obtain identical certifications from proposed subcontractors prior to the
award of subcontracts exceeding $10,000 which are not exempt from the provisions of the
Equal Opportunity clause, and that he will retain such certifications in his files.
The nondiscriminatory guidelines as promulgated in Section 202, Executive Order 11246, and as
amended by Executive Order 11375 and as amended, relative to Equal Opportunity for all persons and
implementations of rules and regulations prescribed by the United States Secretary of Labor are
incorporated herein.
NOTE: The penalty for making false statements in offers is prescribed in 18 U.S.C. 1001.
Date: A D r i t 1 c4 D 1
By:
r,I Pr e S ; cAer+
Print Name
Official Address:
1 o � vn +lr�d�st v',r.►'1u �ro� vl -►C.� i-iS S o G� 0. PA
�-2-0 9 '_:4zY e.r.cA A-y-e
0,V-SCM-C) . —+L
FORM NO. SFAC 16.204
This Form Must Be Completed and Returned with your Submission
RFQ 09/10 -06 Physicians Services- Workers Comp.
rare.. Ta, ba
,rzrzrrt�n� a�r�ze
I certify that the attachact is a true and correct copy of the
Articles of Amendment, filed can ,tune 19, 1Q97, to Articles of
Incorporation for JAMES E. - QUINN, M.D., P.A., 'ch'anging its name to -
NORTH SEMI MOLE FAMILY PRACT(CE ASSOCIATES; P.A:, a Florida
corpora ;ian;:as• shown by the records of this' office:,
The d4cumeni''numbei '-o #..This corp oration. is .101333.
CR2E022 (2-31)
. c�ibett �ttia�r tttp h�xtA and ter
Onea.t moral of ti)r -4)tatr a - lbriba,
at allaba #srr, thr Capital, tl)i;!e fl c
19th bap of June, 1907.
.jint �SrrtW7
;rcretarll of ;5tatr
P '
Request for Qualifications
Mailing Address
Date Issued: March 18, 2010
City of Sanford
Post Office Box 1788
Sanford, Florida 32772 -1788
Opening Date and time: April 19, 2010 at 2:00 P.M.
Physical Address
Solicitation Number: RFQ 09/10 -06
City Hall
Physician Services — Work Related
y
300 North Paris Avenue
Sanford, Florida 32771 -1244
Injuries
•
The City of Sanford, Florida hereby requests statements of qualifications from board
Telephone
407.688.5028
certified physicians or medical facilities with board certified physicians to participate in
a competitive process to establish the basis to establish a continuing contract with a
Facsimile
provider to perform subject services associated with work related injuries for the City
407.688.5021
of Sanford.
Email
smithb @sanfordfl.gov
Specificationstrequirements, submission forms, documents and relevant information
Website
may be obtained by Downloading the solicitation at the Onvia DemandStar web site
www.sanfbrdfl.gov
which can be accessed through the City of Sanford's web site: www.sanfordfl.gov
•
under Departments select Purchasing then Sanford Bid Information. Planholder's
Lists, tabulations, addenda issued, short lists, and subsequent awards, if any, may
City commission
be found on the City of Sanford's web site. This information will not be provided
Linda Kuhn
by telephone or FAX.
Mayor
Except where specifically indicated by the solicitation, it is noted that information,
Art woodruff
documents, addenda, etc. provided by sites or services other than Onvia
District 1
DemandStar, the official site for posting the City of Sanford's solicitations, shall
Dr. Velma H. Williams
not have standing in case of conflict or missing notifications regarding addenda.
District 2, Vice Mayor
Providers experiencing difficulty obtaining the solicitation and documents are to
Randy Jones
contact the Purchasing Office of the City of Sanford.
District 3
Submissions delivered after the date and time indicated above will not be opened or
Jack T. Bridges
otherwise considered. Please note that facsimile, telegraph, email submissions will
District 4
not be considered. Any uncertainty regarding the time a proposal is received bu the
•
City of Sanford will be resolved against the proposer.
Interim City Manager
Tom George
Responses to RFQ's are not publically opened. However, at the time of the opening
the City will reveal the names of the proposers. No other information will be released
until an award is announced.
Purchasing Manager
F. William Smith
Persons with disabilities needing assistance to participate in any of these proceedings
should contact 407.688.5025 at least 48 hours in advance of the meeting.
Respectfully,
F. WILLIAM SMITH, Purchasing Agent
LL
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