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884 North Seminole Family PracticeI— I k r f gg Y' tin 4� #pq :z PURCHASING DEPARTMENT v TRANSMITTAL MEMOI4NDUM r 4AA CL WTI To: Mayor /C�ty erk RE: Nort amily Practice Amendment Extension & Renewal Agreement RFC 09/10 -08"3' ajfj& wo(pys (20mp 09/(0 -CG 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 d 3 7,<)1J —/ DOCUMENT APPROVAL l 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: Finance hirector ssv Mo / —.7– Z-�C>A, Date k lLha Date 1 2. Date rQ r�l f� 4 i.. alt:t. 4+h. KM 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 ORIA .5 7 6 TAT. G. _ D -PA:R: MRN -HEALTH AVISIO N OF MEDICAL QUALITY,A S URANC E Chadid"Crist DISKAY .1 'ENSE NO. 01/08/2069 ME 318186 272026 Chadid"Crist DISKAY m c m p ,D co D � M:5 c3 z� m- OX 6) K zv M-. riv 0 IS m rD- z cow Dm0 r_X IDS D r D c� Qa C X Z n m Do >XCDv D z2z72. B m -n < 0 o 'gym � a3' °: XX -<o cr m ozg CD F5 s �SD Q'�D n p� < m o D ymm (n s :� m � ° c7L n m {m p �. s'� B CD z o > d o C" �-- D °m m X o Z p -n 3 O C/) CD -nm T r � cn m IV v o "' 3> > ° -� ��u-sq m c m p ,D co D � M:5 c3 z� m- OX 6) K zv M-. riv 0 IS m rD- z cow Dm0 r_X IDS D r D c� Qa C X Z n m ? 7 5 st t 0I~ -LOREIJ w 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 NeWy Pdk - NNo of Fbft . warrlir�wMl�M.r,,,zt, c..irww" • so Ism N1nM1AIro11,yMN�IrMINN�ryMu. 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 0 \ / 0 T ■ a E m O \ C) 0 @ & o ; S 2 > m O r / t W I� 2 Z \ / 2 �§ 3: «. � \ o & @ \ 2 } m � \ Z m } 2 ® A ` f = > > 0 -n ee ■§o�> ƒ ® m >040mc � / k §Er-jgm —m w / ƒ �Z) z0 �2q >m�MQ 9 r, m -1 om c -M > w / - ��M \ /k� ®� --1 �z) -4 § >;u(n m�mrT Z ozx5ow§ =p22q >? >0 @)q 00 §ozozzl 2 O -Ucn- /wZ0o>M �I@wmrT �)zjo m =mmi 0 2 = >0-u < 0 ;u m 0 � a -0 m M _0 �0 m 07 «]co) RK� �•3 | ƒ> n 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 DISPLAY (P. ::REl0u'lk5D >:8.y"I..AW G) 0 < m:m ;a CD z 0 Om ;o . 0 FI) > X m 0 C m C 0 X=) f UJ CD m X 00 Z Ch. G) m. rn cn m > > )< CD 23 z ;u 3m "n < o m CD a -< m m CD Z < M -n 0 0 cn C)- 0 0 > > r CD < m 4 M -n CD (1) —4m co C— C A M 30 5� 0 0 > > z m 0 = ;o " m C: CD Q w > M CD a M - . 0 CD 3 W (D CL 0 0 z 00 n M > -.4 ED -.1 -1 m;u > o 9 m > M n r z lw n -n > -n 0 rte; m > > Cl) z 0 m 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 o0 � ■ � \ �m m k� < Lu ZD�� 0 0 LU a-L) /ca (n 3�0 LU §dEmƒ wmzo0< n =eon= ®$Cf) CY /P2 / /S§ zpS <0 w - F- Z mm0 -w0P R <U -,e0a w / p WLL U) z § Q0�wE��k 2 CIS e w w@ <� «¥0E- « - / «� %k_ o �L222ez» ? �ozeCwQ§ � (n ƒ w p co / § e §LUU)2�2I -j?k�k <§ LU LU \ \ b $ @ S Z \ CO) u I _ kkW - / § Ui \� C CO) O 0 0 o 8 - ^�» 2 a 2 o C4 \ . ■ « CO) 2 LLJ E5 Lu L a \ƒ 0 . � X co / I Z � - w § a , § w e . M9 0 z U/ CA w J 2 / 0 & 4 / \