884-North Seminole Family Practice 2005-06 CONTRACT EXTENSION
CITY OF SANFORD, FLORIDA
This contract extension is hereby entered into this 15th day of September 2005, by North
Seminole Family Practice, hereinafter called the "Contractor" and the City of Sanford hereinafter
called the "City."
WITNESSETH that the Contractor and the City, in consideration of the mutual covenants,
promises and agreements herein contained, agree as follows:
SCOPE OF THE CONTRACT: The Contractor shall provide the goods and or services to the
City as set forth in the Contract Documents required to perform and complete the work/Project
known as: Physician Services.
THE CONTRACT DOCUMENTS, by this reference, SHALL CONSIST OF and constitute the
entire contract:
(1) This signed form
(2) Request for Proposals Number: RFP 02/03-33
(3) The Contractor's Response to RFP 02/03-33
(4) Change Orders if and when they occur
(5) Items of Addenda executed by both parties.
INDEMNIFICATION: The contractor agrees to indemnify, defend and hold harmless the City,
including its officers, agents, and employees, from any claim, damages and actions of any kind or
nature, whether at law or in equity, arising from or caused by the use of any materials, goods,
equipment and/or services of any kind or nature furnished by the contractor, provided that such
liability is not attributable to the sole negligence of the City or failure to use the materials, goods,
or equipment and/or services in the manner already and permanently prescribed by the
contractor.
PAYMENT will be processed as provided by RFP 02/03-33
THE TERM of this extension shall be from October 1,2005 through September 30, 2006.
CONTRACT ADMINISTRATOR: Contract Administration shall be provided by the R sk Manaqer
and the Personnel Officer as applicable to their respective functions.
IN WITNESS WHEREOF, the parties have caused this Contract to be duly executed intending to
be bound thereby.
/ I
CONTRACTOR: ,I ,~ /
Printed Name and Title: ~ O,-ot,...I;bO ~_~ .
OF
/-- ~g~ature ' · ,~ Title:
Printed Name aJTitle: '~'~ ':'~"~2 ~1 ~ AC//~ ~/"
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Clty Of Sanford Purchaglng Office
300 N. Park Avenue (P.O. Box 1788) Room 236, Sanford, FL 32771
N4~I~ Telephone: (407)330-5613 -Facsimile: (407)330-5666-Email: smithb(~,_,ci.sanford, fl.us
REQUEST FOR PROPOSALS
Date Issued: September 1, 2003
The City of San_ford, Florida hereby requests sealed proposals fi.om qualified providers as
indicated below and specified in the solicitation. No formal opening will be held. However,
shortly after the time and date indicated below, the names of entities who submitted proposals
will be released.
SOLICITATION NUMBER: RFP 02/03-33
PHYSICIAN SERVICES
FINAL DUE DATE AND TIME: SEPTEMBER 16, 2003 AT 2:00 P.M.
The City of Sanford (City) hereby requests proposals with pricing from board certified
physicians or medical facilities with board certified physicians to perform medical services
for the City as described and outlined herein.
Solicitation packages including specifications, terms, conditions, general instructions and
proposal submission documents are now available and may be obtained, at no cost, in one of the
following ways:
1. Downloading at the City of Sanford's web site (www. ci. sanford.fl.us)
2. Requesting in person at the Purchasing Agent's Office:
Proposals delivered after the date and time indicated above will not be opened or otherwise
considered. Please note that facsimile, telegraph, email or proposals not enclosed in a sealed
envelope will not be considered. Any uncertainty regarding the time a response is received will
be resolved against the Proposer
PLEASE NOTE: Proposal Documents, addenda issued, tabulation of responses and
subsequent awards, if any, may be found on the City of Sanford's web site
(www. ci.sanford.fl, us/purchasing). This information will not be provided by teiephone or
FAX.
Respectfully,
F. William Smith, Purchasing Agent
TABLE OF CONTENTS
TOPIC PAGE NO
INVITATION I
GENERAL
INTRODUCTION 3
RESERVATIONS 3
1. PREPARATION OF PROPOSALS 3
2. NONDISCRIMINATION STATEMENT 4
3. CERTIFICATION OF INDENPENDENT PRICE DETERMINATION 4
4. ANTI-TRUST 5
5. TESTING AND INSPECTION 5
6. ASSIGNMENT OF CONTRACT 5
7. DEFAULT 5
8. SUBMISSION OF RESPONSES 5
9. WITHDRAWAL OF BID/PROPOSAL 6
10. CHANGES AND ADDENDA 6
1 I. FAILUKE TO ENFORCE 6
12. COMPLIANCE 6
13. TIME IS OF THE ESSENCE 6
14. TAX EXEMPT INFORMATION 6
15. PATENT INDEMNIFICATION 7
16. INVOICING AND DISCOUNTS 7
17. EXTENSION 7
18. PROCUREMENT CARDS 7
19. INDEMNIFICATION 7
20. WARRANTY 7
21. JOINT UTLLIZATION 8
22 LICENSING 8
23. CONTRACTOR QUALII~ICATIONS 8
24. CONTRACTOR STATUS 8
25. CITY'S RIGHT TO TERMINATE CONTRACT 8
26. EVALUATION FACTORS 8
27. LISTING OF MANDATORY FORMS 8
28. GENERAL DESCRIPTION OF CONTEMPLATED SERVICES 9
GENERAL INSTRUCTIONS
INTRODUCTION: The City of Sanford (City) hereby requests proposals with pricing
from board certified physicians or medical facilities with board certified physicians to
perform medical services for the City as described and outlined herein.
The City reserves the following rights:
The obligations of the City as relevant to any award as a result of this
solicitation are contingent upon the availability of appropriated funds for
this project. Also, it is hereby provided that the City of Sanford reserves the
right to negotiate with one or more proposers in an effort to establish a
contract for the procurement of said goods and/or services.
Bo
To reject any and all proposals either in part or in their entirety, to waive
informalities, and to effect an award or to make no award as deemed to be in the
best interests of the City.
To declare any Proposer ineligible at any time during the process where
developments arise which adversely affect the Proposer's responsibility.
To conduct any investigation and consider any evidence relevant to the
qualifications and capabilities of the proposer to perform the work contemplated.
The investigation may include, but is not limited to, a detailed review of
references, current and previous entities for whom similar work has been
performed, an inspection of the proposer's equipment, personnel and any other
evidence including £mancial, technical and other qualifications and abilities of the
proposer.
This solicitation and any resultant contract(s), including purchase orders, shall be
governed by the Laws of the State of Florida and the Purchasing Policy of the
City of Sanford, Florida. Further, the parties hereto agree that the state or federal
courts located in the State of Florida shall have the Exclusive }urisdiction over this
solicitation and any resultant contract(s) including purchase orders. Also, in the
event of any litigation, the venue shall lie in Seminole County, Florida for the
purposes of state court action and the venue shall lie within the United States
District Court for the Middle District of Florida, Orlando, Florida for the purposes
of Federal Court Action
PREPARATION OF PROPOSALS
A. Proposers are expected to examine this Request, samples, specifications, if
any, and all instructions. Failure to do so will be at the Proposer's risk.
Proposers are responsible to make all necessary investigations to inform
themselves thoroughly as to all difficulties involved in the completion of
all work required pursuant to the mandates and requirements of this bid
package. No plea of ignorance or difficulties that may hereafter exist, or
of conditions or difficulties that may be encountered in the execution of
the work pursuant to this request as a result of failure to make the
necessary examinations and iavestigation xvill be accepted as an excuse for
any failure or omission on the part of the contractor to fulfill, in every
detail, all of the requirements of the contract, nor will they be accepted as
Bo
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basis for an~-laims whatsoever for extra compensatt~_ or for an
extension of time.
All prices and negotiations must be in ink or typewritten. No erasure
permitted. Mistakes may be crossed out and corrections typed adjacent
and must be initialed and dated in ink by person signing quotation. All
bids/quotations/proposals must be signed with the firm name and by a
responsible officer or employee. Obligations assumed by such signature
must be fulfilled.
Each response shall provide the information required on the enclosed
Forms and as otherwise required by instructions included or provided by
the Purchasing Manager. Failure to include the required forms,
correctly completed, may disqualify your submission.
(1)
DO NOT RETURN THE ENTIRE REQUEST PACKAGE.
Only the bid documents and forms indicated on the
SUBMISSION CHECK LIST are to be submitted. For
number of originals and copies of the bid, please note the
instructions provided on the RESPONSE SUBMISSION
CHECK LIST.
All costs associated with preparation and submission of the proposal(s) and any
other information shall be borne entirely by the proposer(s).
QUESTIONS: Any Bidder, Proposer or Offeror who is in doubt as to the true
meaning of any part of the Bidding Documents, or f'mds a discrepancy or
omission therein, may contact F. William Smith, Purchasing Manager for an
interpretation or correction~ Said interpretation or correction shall be provided to
all plan-holders as an addendum to the request. Only interprctation~
instructions or correction(s) ~iven, in writinl~, by the Purchasinv Manaller
will be binding. Prospective bidders/proposers are hereby notified that no other
source is authorized to give information concerning, explaining and/or
interpreting this Invkation to bid.
(1).
To enable timely issuance of addenda, questions, requests for clarification
or correction must be submitted seven (7) days prior to the indicated
opening date.
(2).
NOTE;. To ensure that your bid/proposal is responsive, you are urged
to request clarification or guidance on any issues involving this
solicitation before submitting your response. Please note that failure
to provide the requested information in the form and format
requested may render your bid/proposal non-responsive
ANTI-DISCRiNINATION STATEMENT
The City o f S anlbrd is committed to assuring equal opportunity in the award of contracts
and. thereibre, complies with all Federal, State, and Local Laws prohibiting
discrimination on the basis of race. color, religion, national origin, handicap, age and
gender.
CERTIFICATE OF INDEPENDF. NT PRICE DETERMINATION
o
By submission ofth~. 3id/Proposak the Bidder/Proposer cert'.is, and in the case ora
Joint Response, each party thereto certifies as to its own organi?ation, that in connection
with this procurement:
The prices in this Response have been arrived at independently, without
consultation, communication or agreement for the purpose of restricting
competition, as to any matter relating to such prices with any other Offeror or
with any Competitor.
B°
Unless otherwise required by law, the prices which have been quoted in this
Bid/Proposal have not been knowingly disclosed by the Offeror and will not
knowingly be disclosed by the Offeror prior to opening, directly or indirectly to
any other Offeror or to any Competitor; and
No attempt has been made or will be made by the Bidder/Proposer to induce uny
other person or firm to submit a Bid or proposal for purpose of restricting
competition.
ANTITRUST
By entering into a contract, the contractor conveys, sells, assigns, and transfers to The
City of Sanford, Florida all rights, title and interest in and to all causes of action it may
now have or hereafter acquire under the antitrust laws of the United States and the State
of Florida, relating to the particular goods or services purchased or acquired by the City
of Sunford, Florida under said contract.
TESTING AND INSPECTION:
The City of Sanford reserves the right to conduct any test/inspection it may deem
advisable to assure goods and services conform to the specifications.
ASSIGNMENT OF CONTRACT: A contract shall not be assignable by the contractor in
whole or in part without the written consent of the City of Sanford.
DEFAULT
As a result of offers received under this Invitation, the award of the Contract may be
based, in whole or in part, on delivery and specification factors. Accordingly, should the
Offeror/Contractor fail to meet the delivery deadline(s) set forth in the specifications or
fail to perform uny of the other provisions of the specifications and/or other Contract
Documents, the City may declare the Contractor in default and terminate the whole or
any part of the Contract.
Ao
Upon declaring the Contractor in default and terminating the Contract in whole or
in part, the City may procure and/or cause to be delivered the equipment, supplies
or materials specified, services or any substitutions thereof, and the defaulted
contractor shall be liable to the City for any excess costs resulting there from.
SUBMISSION OF RESPONSES
A. Responses and modifications thereof shall be enclosed in sealed
envelopes, with the required forms, addressed to the office specified in the
Solicitation, with the name and address of the Bidder/Proposer, the date
and submission deadline, and the Invitation or Request Number on the
face of the envelope. Responses received after tbe stated time and date
10.
11.
12.
13.
14.
will be ret~-t to the sender unopened. Faosi~nile o~elegrapbio
· Responses will not be accepted.
The Offeror represents that the article(s) to be furnished under this Request is
(are) new and unused (unless specifically so stated) and that the quality has not
deteriorated so as to impair its usefulness. Also, the proposal shall inelnde
identification and descriptive literature including manufacturers
specifications of items to be furnished within the context of this proposal.
WITHDRAWAL OF BID(S)/PROPOSAL(S)
Bids/proposals cannot be altered or withdrawn until sixty (60) days after the stipulated
opening date and time. Withdrawal of a bid or proposal after the opening but, before the
end of the sixty(60) day period of consideration places the Bidder/Proposer in default. It
is noted that the bidder/proposer who withdrew a bid or proposal during the period of
consideration shall be ineligible to submit a response ifa new solicitation is advertised
and shall not perform as a subcontractor or a supplier with regard to the procurement in
question.
CHANGES AND ADDENDA
Addenda will be mailed or otherwise delivered to ali plan holders who received a set of
Submission Documents from the City. Receipt of each Addendum shall be
acknowledged in the Bid/Proposal Form; failure to do so may subject the
Bidder/Proposer to disqualification. It shall be the Bidder's/Proposer's responsibility to
ensure that they have received all Addenda prior to bid.
FAILURE on the part of the City of Sanford to enforce or to notify shall in no way be
construed or interpreted as a waiver of any of the City's rights and remedies.
COMPLIANCE: All work resulting from this solicitation must be in compliance with all
federal, state and local laws, codes, statutes, regulations and authority having jurisdiction
over the work.
PERFORMANCE: Time is of the essence
In the delivery of response to this solicitation, participation in presentation(s)
and/or negotiations if requested by the city and any other information or
documentation as may be requested by the City of Sanford in the evaluation
and/or award process.
In the performance of the contract, and failure to perform in accordance with the
delivery deadline(s) set forth in the specifications or any other contract document
shall constitute default. Unless a written extension is obtained from the City prior
to the delivery deadline(s), there shall be no excuse for untimely performance.
The granting and duration of extensions shall be subject to the exclusive
discretion of the City.
Normal working hours of the City of Sanford is Monday through Friday, except
tbr holidays, 8:00 a.m. to 5:00 p.m.
TAXES
The City is exempt from state and local sales tax. The City of Sanlbrd, Florida, has the
tbllowing tax exemption certificates assigned:
15.
- C, ertifieate of Registry/159-6000425 for tax-free transactions under
Chapter 32, Internal Revenue Codes.
Florida Sales & Use Tax Exemption Certificate Number 69-11-035140-
54C
PATENT INDEMNITY
Except as otherwise provided, the Contractor agrees to indemnify the City and its
officers, agents and employees against liability, including costs and expenses for
infringement upon any letters of patent of the United States arising out of the
performance of this Contract or out of the use or disposal by or for the account of the City
of supplies furnished or construction work performed hereunder.
16. INVOICING AND DISCOUNTS
Trade and time payment discounts will be considered in arriving at new prices
and in making awards, except that discounts for payments within less than 30 days
will not be considered in the award(s).
17.
18.
19.
20.
Specific invoicing procedures and instructions will be provided at the time a
contract is issued. In general an itemized invoice must be submitted for each
patient.
(1) Non workers compensation invoices shall be submitted to the City of
Sanford, Accounts Payable Office.
(2) Workers compensation invoices shall be submitted directly to the insurance
company.
EXTENSION
The term for any contract resulting from this solicitation is one (1) year. The City
reserves the option of extending the contract for additional one (1) year terms.
Additional terms after the third term must be approved by the City Commission. All
pricing, terms and conditions of the Solicitation Documents as well as the mutual
agreement of all parties is necessary for extensions of additional one (1) year terms.
USE OF PROCUREMENT CARDS
The City reserves the right to effect payment for any and all invoices with a
procurement card which uses a VISA platform.
INDEMNIFICATION:
Indemnification: To the fullest extent permitted by law, the Contractor will indemnify
and hold harmless the City of Sanford from and against all claims, damages, losses, and
expenses, including reasonable attorney's fees, arising out of or resulting fi.om the
performance of their operations under this contract.
WARRANTY
The contractor agrees that the goods or services furnished under any award resulting from
this solicitation shall be covered by the most lhvorable commercial warranties the
21.
contractor gives any~:;stomer for such goods or services andCt the rights and remedies
provided therein are in addition to and do not limit those available to the City by any
other clause of this solicitation. A copy of this warranty and all applicable manufacturer's
warranties shall be furnished with the bid.
OTHER PUBLIC ENTITY USE OF CONTRACT PRICING RESULTING FROM THIS
SOLICITATION
The Contractor may, at her/his option, convey the same Contract Pricing to other Public
Entities under the same terms and conditions of the Contract(s) arising from this
Solicitation, thereby allowing interested Public Entities Joint Utilization of said
Contract(s).
22.
23.
24.
25.
LICENSING
Bidder or Offeror must attach copy(s) of licensing and certifications relevant to the
submission.
CONTRACTOR QUALIFICATIONS
In the opinion of the City, the Contractor must have the ability to perform all services in a
professional manner using qualified and certified support personnel as consistent with the
medical profession, with appropriate documentation.
CONTRACTOR STATUS: The contractor and his/her employees are independent
contractors and derive no employee status by virtue of responding to this request and
resulting contract unless explicitly provided in said contract.
RIGHT TO DO WORK OR TO TERMINATE CONTRACT; Any contract resulting
from this solicitation may be terminated by either party upon ninety (90) days written
notification to the other party(s) of the contract. The City reserves the right to terminate
said contract, for cause, on an immediate basis upon notification of the Contractor.
26.
27.
EVALUATION FACTORS
FACTOR
WEIGHTING
Pricing ............................................................................................................................... 30
Company's Understanding of City's needs and Programs ............................................... 25
Reputation of the Company .............................................................................................. 15
Proximity to City Hall, Sanford, FL ................................................................................. 15
Physician responsiveness in scheduling medical services ................................................. 15
Upon completion of the weighting for each company, the companies will be ranked based
on its total score.
The City reserves the right to conduct interviews and negotiations with one or more
companies in the order of ranking. Also, the City reserves the right
compartmentalize the services and to establish a continuing contract with one or
more of the participating companies (providers).
TIIF, FORMS LISTED BELOW ARE MANDATORY ATTACHMENTS ALONG
WITII ADI)I'['IONAL INFORMATION WHICH MAY BE REQUIRED THEREIN TO
28.
PROVIDE AN tABLE RESPONSE TO THIS SOL 't .r^TION:
A. Proposal Submission Forrm ....................................................... 2 pages
B. Insurance and Bonding Requirements ........................................ 1 page
C. Disputes Disclosure Form. ......................................................... 1 page
D. Drug-Free Workplace Form. ....................................................... 1 page
E. Conflict of Interest Form. ............................................................ 1 page
F. Certification of Nonsegregated Facilities .................................... 1 page
G. Florida Statutes, On Public Entity Crimes ................................. 2 pages
GENERAL DESCRIPTION OF THE CONTEMPLATED SERVICES:
The following information about the city's requirements for medical services is broadly
separated into two general categories. That is, general medical services are separated
from medical services associated with work related injuries. It is hereby noted that
offerors may submit a proposal applicable to only one area or an all inclusive
proposal The provider(s) of medical services described herein and who have entered
into an agreement with the City to provide said services shall be referred to as
"Contractor."
A. Contractor shall be responsible for the following General Medical Services:
(1)
performing-routine, pre-employment and fitness for duty evaluations to
determine the capability ofperfornfing the job requirements for specific
jobs with the City of Sanford. This shall include determinations involving
audiometric testing, vision and other physical capabilities relative to the
requirements stated in the position description. Medical Evaluations for
Firefighters must meet NFPA standards.
(2)
Conducting evaluation and treatment of workers compensation illnesses or
injuries. This shall include immediate attention, evaluation, prognosis and
referrals for specialized treatment if needed.
(3)
Conducting pre-employment law enforcement medical examinations
required by the Criminal Justice Standards and Training Commission. In
addition to the physical examination, an electrocardiogram, a skin test for
tuberculosis, and blood testing which includes an analysis of blood cells
and chemistry are included.
(4)
Providing for x-ray, EKG, Laboratory Service, or other extraordinary
medical service. If these services cannot be provided directly by the
physician, the physician must be able to coordinate such services xvith
charges for same billed to the physician and subsequently billed to the
City as outlined in Section V Billing Procedure.
(5) Administer annual flu shots to City employees.
(6)
Provide for Hepatitis Injection and Hepatitis Exclusionary Testing for
Police Officer and Firefighter applicants as a part of their pre-employment
medical certification.
(7)
Provt,_.. for TB Exclusionary resting fo~ Polic~fficer and Firefighter
applicants as a part of their pre-employment medical certification.
(8)
Providing Pre-employment and fitness for duty evaluations within five
working days of making the appointment.
Medical Services associated with work related injuries are defined by and shall be
in compliance with Florida Statute, chapter 440.13. A copy of chapter 440 for the
Florida Statures is available on the intemet at http:www, floridalawonline.net/.
Contractor shall be the Medical Care Coordinator 0VICC) who will be the primary
care provider within a provider network who is responsible for managing the
medical care of an injured worker including referrals for types of specialists or
treatments to which the injured employee will be referred for evaluation or
treatment.
(1)
MCC may be asked fi-om time-to-time by the City or the City's Third Party
Claims Administrator (TPA) to intercede or communicate, consult,
teleconference, etc., with providers to whom the MCC or subsequent
Primary Care Providers (PCP) may have referred the injured employee.
This subsequent activity may also involve a review of medical files of any
and all providers that may provide care to the injured employees.
(2)
MCC will be the Primary Care Provider (PCP) for all work related injuries
unless the MCC refers the injured employee to a type of specialist within
the City's provider network. All referrals must first be made to the City's
TPA for authorization. Even with this referral, the MCC still remains the
MCC on the work related injury.
(3)
Transitional or Light Duty Work: MCC understands that the City has an
active Transitional Duty Program for those employees that have a work
related injury, but have been determined by the provider to be able to work
only a modified duty in lieu of full or regular duty for a specified period
of time. MCC understands only a very small number of injured
employees have injuries that would prevent the employee fi-om returning
to work to at least Transitional or Light Duty.
(4)
MCC understands that that by placing an employee Out- of- Work (OOW)
for any period of time for a work related injury that the employee is to be
determined Totally Disabled, either temporarily or permanently. A full
written explanation for the reason the employee has been determined to be
Totally Disabled is required of the physician.
(5)
Third Party Administrator: Provider will work harmoniously and in
tandem with the City's designated Third Party Claims Administrator and
the City. All referrals by the MCC for other providers or treatment will be
presented to the TPA for authorization.
(6)
MCC understands that the State of Florida has a Workers Compensation
Fee Schedule and agrees no fees will exceed that fee schedule, but the City
may et[ioy li~rther reductions in tkes if mutually agreed upon through
various means including, but not limited to Preferred Provider Discounts.
(7)
MC~ .~ees,/' at the City's option, to hax~e sch ~'Taled meetings with the
City to discuss current claims or other employee work related injury issues
at least three times per year. Each meeting will be at least one hour in
duration, but no more than two hours in duratiom
(8)
MCC understands that all referrals must be for providers within the City's
Network of Providers as provided by the City's TPA under the City's
Managed Care Arrangement.
(9)
MCC understands that all initial treatment for a work related injury must
first be approved by the City, otherwise treatment costs, expenses, fees,
etc. will not be reimbursed. City will only reimburse providers for
authorized treatment only. Authorization for treatment should come fi-om
Risk Management or his/her designee, but if Risk Management is not
available to pmvide authorization, supervisory personnel within that
employees department may authorize it.
(lO)
MCC will provide a Duty Status Report after each and every work related
injury visit by City employees. This can be faxed to Risk Management at
407-330-5622.
(11)
MCC will immediately report any unusual activity, statements, etc. by the
injured employee; as well as cause of injury that contradicts original
statement as to claim cause.
(12) MCC will address causality of employee work related injuries, i.e.
occupational vs. personal medical condition/injury.
(13) MCC understands that all invoices for services rendered will be submitted
on proper form and in timely manner to the City's TPA.
DOCUMENTATION AND RECORDS MAINTENANCE: It shall be the
responsibility of the Contractor to provide and maintain documentation applicable
to the following:
(1)
One copy of the Pre-employment Physical Form is to be returned to the
City after certification of fitness for duty. The Police, Fire or General
employee applicant will be instructed to hand carry this form back to the
City in a sealed envelope. The original is to be retained in the Contractor's
file.
(2)
A summary of medical history contained in the medical history
questionnaire form is completed and signed by the applicant. It is to be
used by the Contractor as a basis for determining potential problem areas.
The original is to be retained by the Contractor with a copy is to be sent
back to the City in a sealed envelope with the applicant.
SOLICITATION NUMBER: IFB 02/03-33
PHYSICIAN SERVICES
FINAL DUE DATE AND TLME: SEPTEMBER 16, 2003 AT 2:00 P.M.
Company: ..(]O~c'~ -~'x~m~.l "3r~m,~ P¢oa~ ~ Phone:
Ad.ess: ~&O~ ~ce~. City: ~~
Bid Sub~ by: ~&~ ~. ~n~,&.~. Title:
~ (~or~q~e)
Sight,e: (~ ~ ~~ Date:
NOTE:
By signing tkis Proposal the Offeror warrants that he/she agrees to provide the
goods and or services indicated herein before and after. The Offeror/bidder
agrees to negotiate with the City in good faith in an attempt to establish a contract
based on his/her proposal.
Any other remarks, terms and conditions of the proposal are to be made on
Proposer's letterhead and attached to this fornz Proposer must return ONE
ORIGINAL, PROPOSAL WITH ALL REQUIRED FORMS AND
DOCUMENTATION AND TWO ADDITIONAL COPIES, with any other
details as may be requested. At the discretion of the Purchasing Agent,
proposal(s) may be deemed non-responsive for failure to follow the instruc~ i(ms
contained herein before and after. It is noted that delivery of the submission ~o
the correct office, indicated below, in a timely manner is the responsibility ,~ ~ the
Proposer.
_MARK THE EXTERIOR OF ENVELOPE CONTAINING YOUR BID RESPONSE:
YOUR COMPANy NAME & ADDRESS AS THE RETURN ADDRESS
ADDRESS OR DELIVER TO:
William Smith, Purchasing Agent
City of Sanford
P.O. Box 1788 (300 N. Park Avenue. Room 236)
Sanford, FL 32771
IN LOWER LEFT CORNER OF ENVELOPE, PROVIDE THE FOLLOWING
RFP 02/03-33 PHYSICIAN SERVICES
Final Due Date and Time: September 16, 2003 at 2:00 p.m.
NOTE: The envelope containing the proposal must be sealed
TItlS FORM MUST lie COMPI,ETED AND RETURNED WITtt YOUR PROPOSAL
SOLICITATION NUMBER: RFP 02/03-33
Company/Practice: ~'~ o c4-~ .~tLrwfnol.~.-'~x~.[ (~)cax~ c~ Phone:
Proposal Submitted by: -'-~--O~v-~.~a ~__. (._~u~ ~, Crx., ~. Title:
(type or print name)
Florida State Medical Board License
Number: L --.
Fees for Medical Services:
A. Routine/Pre-employment ,and~ty Evaluations
D. EKG's ~
E. Hepatitis Injection ~
F. Flu Shot Injection
G. TB Exclusionary Testing
H. Hepatitis Exclusionary Testing
I. Audiometric Testing
J. Medical Clearance for Respiratory Use
J. Lumbar Spine X Ray with Additional Views
Office Hours:
ea.
Monday 'i~ a.m. -~- p.m.
Tuesday ~ a.m. ~- p.m.
_Wednesday ~ a.m. ,5-p.m.
Thursday ~' a.m. ~- p.m.
_Friday ~ a.m. ~-~ p._m.
Saturday ~ a.m. /.,~ P,m
Who Will Provide the Following Services
X Ray
EKG
[.ab Work
THIS FORM MUST BE COMI'I.ETED AND RETLIRNtH) WlTft YOUR PROPOSAl,
'NSURANCE ~AND BONDING RE Ul (i
.t q REMENTS WHICH MUST BE MET
The CONTRACTOR bidder shall be required to provide, to the Purchasing Agent, prior
to signing a contract for or commencing any work, a Certificate of Insurance which
verifies coverage in compliance with the requirements outlined below. Compliance of
said certificate must be acknowledged by the Purchasing Agent pdor to start of work.
Any work initiated without completion of this requirement shall be unauthorized
and the City of Sanford will not be responsible.
The City of Sanford reserves the dght to require coverage and limits as considered to be
in its best interests. Insurance requirements shall be on a case by case basis
determined by the project, conditions and exposure.
Except for Professional Liability Policies, when required, all policies are to be
endorsed to include the City of Sanford as Additional Insured, In the cancellation
clause the number "30" shall be inserted into the blank space provided prior to the
words "days pdor notice...". All contractor policies are to be considered pdmary to City
coverage and shall not contain co-insurance provisions.
In the event that the insurance coverage expires pdor to the completion of the project, a
renewal certificate shall be issued 30 days prior to said expiration date.
Subcontractors retained by the Prime Contractor are the responsibility of said Prime
Contractor in all respects
Insurance requirements:
COVERAGE REQUIRED MINIMUM POLICY LIMITS
Workers' Compensation Statutory
Commercial GeneraI Liability including Contractual Liability, Products and
Completed Operations, and Owners and Contractors Protective $1.000,000
Pr0fessional Liability $1,000,000
NOTE: Except for Professional Liability, all limits are per occurrence and must inclHde
Bodily injury and Property Damage with an aggregate limit of at least $ 2,000,000. All policies
must be written on occurrence form and not on claims made form.)
Bonding: None required for the project identified below
It is noted that failure to provide of an certificate of insurance in compliance with the
above within FOUR(4) days of notification of award and/or to continue the coverage
without a break and at the discretion of the City of Sanford can result is bidder/contractor
being placed in default status.
I hereby certify that if the contractor on whose behalf this information is submitted is
awarded a contract for any portion of the work contemplated, the insurance and bonding
requirements outlined above shall be met as required.
Project, work or service contemplated: Physician Services
// Aut h orizeb--S~(~
Date
Title
I'ttlS FORM MUST BE COMPLI!'I'I;D AND RETURNED WITtt YOIJR PROPOSAL
Dsputes Disclosure Form
Answer the following questions by placing an "X" after "YES" or "NO". If you answer
"YES", please explain in the space provided, or via attachment.
Has your firm, or any of its officers, recoived 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? YES [~ NO ~
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?
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?
If yes, state the nature of Ihexequest 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.
[ 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 fi~rther
consideration of this project: Project: RFP 02/03-33 Physician Services
F~/~ ' Date
(.~/ Authorizdd Signature Officer Title
Printed of Typed Name
This Form Must Igc Completed ,'md Returned with your Proposal
· 'Sep I1,03 02:511o Finance Department
DRUG-FREE WORK PLACE FORM
The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies)
(Name of Busb~ss
Publish a statement notify/rig employees thai the unlawful manufacture,
distribution, dispensing, possession, or use of a contwlled substance is
prohibited in the workplace and specifying the actions that will be taken
against employees for violations ofsuoh prohibition.
Inform employees about the dangers of drug abuse in the workplace, the
busine.~'s policy of maima~;ng a drug-free workplace, any available drug
coanseling, rehabilit~lon, and employee assistance programs, and the
penalties that lllay he ~0osed upon ea~loyees for drug abuse violations.
Give each employee engaged in providing thc commodities or contractual
services ~ha* are proposed a copy of the statement specified in subsection
(~).
In the statement specified in subsection (1), notify the employees tha~ as a
condition of working on the commodities or contractual services that are
under bid, the ¢,qAoyee will abide by the te,~s 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 s~te, for a violation occurring in the
workpl~¢,~ no later than five (5) days after such conviction.
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.
Make a good faith effort to continue to maintain a drug-free workplace
through implementation of thig section
As the person authorized to sign the statement, I eet~fy the~ fully
with the above requirements.~ __ _
Bidder's Printed Name and Title 13J~der's Signature
BID REQUEST NUIVfBER
02/03-33
THIS FORM MUST BE COMPLETED AND RETURNED WITH YOUR BID.
STATE OF FLORIDA
COUNTY OF. ~0.x-cx-~r~oL.e_ )Before me, the undersigned authority, personally appeared
'~o~.~o ~_. G)~_~ ~x~ , who was duly sworn, deposes, and states:
1. Iamthe ID,-ts~a~-k of (h,~tmmoh~t,~t ~t,t,~witha
local office in ~x ~i~, and principal office in -~xcl,~'o-,~, '-4~_. .
2. The above named entity is submitting an Expression of Interest for the City of
Sanford project identified as: RFP 02/03-33 Physician Services, 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 Affront 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. I 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. I 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 Stafford.
10. In the event that a conflict of interest is identified in the provision of services, I,
on behalf of the above named entity, will immediately notify the City of Sanfo, rd in writing.
DATED this }1 '~- day of ~, ,uglre-r'a ~o¢/7) , ~,,v"~°'-%L.
__(/Signaturg (Amant)
Typed Name of Affiant
Title
Sworn to and subscribed before me this
20 0.%
Personally known, v-/ _ or produced identification
identification
day of
.Type of
Notary Public - State of~---a4J,O~aLt, ol.C,.~
My commissioo exnires ¢/k,~,- ~ \ -; ~3
.... ~rinted, typed or s~ommis~ned name ofnotz~ public)
TIIIS FORM MUST BE COMPLETED AND RI~TURNED WITH YO[JR PROPOSAl.
CERTIFICATION OF NONSEGREGATED~FA(~I~ITiES
.Physician Services RFP02/O$-$$
The 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 .... . .
any breac.h of this certification wall be a v~olat~on of the Equal Opportunity clause in
contract resulting from acceptance of this Bid. As used in this certification, the term
"segregated facilities" -.
means any wmtmg 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 identica!
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 I 1375 and as amended, relative to Equal Opportunity for ali
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. 100 I.
Date:
By:
Print Name:
Official Address:
Tit le :___ c a~c~e~cx ~v
(Include Zip Code)
ATTAClt AND INCLUDE FHIS PAGE AS PART OF YOUR SUBMISSION
FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES . · .!,~ ~!
THIS FORM I~UST BE SIGNED AND SWORN TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER k~.~
OFFICIAL AUTHORIZED TO ADMINISTER OATHS.
whose business address is:
1. This sworn statement is submitted to The City of Sanford, Florida) by:
(print indlviduai's name and title)
for
(print name of entity submitting sworn statement)
and (if applicable) its Federal Employer Identification Number (FEIN) is
(If the entity has no FEIN, include the Social Security Number of the individual xigning
this statement: ).
I understand that a "public entity crime" as defined in Paragraph 287.133(1)(g),
Statutes, means a violation of any state or federal law by a person with respect to an~
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. I33(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.
I understand that an "affiliate" as de£med in Paragraph 287.133(1)(a), Florida Statutes~
means: -
A predecessor or successor of a person convicted of a public entity crime: or
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 thir market value under an arm's length agreement, shall be a prima
facie case that one person controls another person. A person who knoxxSngly
enters into a joint venture with a person who has been convicted ora public entity
crime m Florida during the preceding 36 months shall be considered an affiliate.
I 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 othen~se 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.
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.)
x//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 ora 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 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 F~al 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 FOR/vi TO THE CONTRACTING OFFICER FOR THE PUBLIC
ENTITY IDENTWIED IN PARAGRAPH I (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS
[F~OO~DR~ER~.STXNA/~I~HTATHR?UA~G4H p~EE~L~)RT~)I ~O~F~'F_.Ht~.. _CALENDAR YEAR IN WHICH IT~.IS FILED. I ALSO
CON .................... ',4 IP~VUKIVl IHE PUBLIC ENTITY PRIOR NTERING IN
rr~r, tr,~t ~pq ~x~e,~,5 Ut- file THRESHOLD AMOUNT PROVIDED IN (TI'ION ~$t7 n TO A
(date)
County of ~ o..cvxx c~c~l,.j~ State of Florida. On this ~[/'k_K day of ..~o~rnk~.~c-
2003, befbre me, the undersigned Notary Public -
appeared ~"cccv~e~2 ~ . C_xkx_i cxc~ , yh"x. ~ .
xvhose name(s) is/are Subscribed to the within instrument, and he/she/they acknowledge that
he/she/they executed it.
NOTARY PUBLIC SEAL OF OFFICE
(Name of Notary Public: Print,
Stamp,
or Type as Commissioned.)
W/Personally known to me, or
__ Produced identification:
(Type o f Identification Produced)
DID take an oath, or
DID NOT take an oath.
Physician Services, RFP 02/03-33
THIS FORM MUST BE RETURNED WITH YOUR PROPOSAL
Nort( . Seminole Family ractice
James E. Quinn, M.D.
Harvey W..Schefsky, M.D.
Daniel R. Monette, M.D.
2209 French Avenue
Sanford, Florida 32771
(407) 321-4230
Septemberl 1, 2003
City of Sanford
Attn: WiLliam Smith, Purchasing Agent
RE: Proposal for Physician Services
Dear Mr. Smith,
I have enclosed for your review a completed proposal for the physician sot'vic, os to be
provided to the City of Sanford for pre-employment and workmans compensation claims.
This practice will send all invoices via HCFA 1500 claim forms to the appropriate payor but
will be unable to accept payment with procurement cards. This office is currently not
accepting any credit or debit cards. Should this change in the future, we will inform the City
of Sanford and accept the procurement cards for payment.
The Medical Services associated with work related injuries indicated that the MCC would be
obligated (without reimbursement) to participate in scheduled meetings for a minimum of
one hour, three times a year. Our practice would not be available for such meetings,
however, the physician handling an3, individual work comp case would be available via
teleconference to answer any questions regarding work related issues pertaining to that case.
The fees indicated on the second page of the Proposal Submission Form will remain in
effect through March 13, 2004. A Cost of LMng Allowance will be automatically apphed
each year on the 14th of March~ based upon Consumer Price Index Data with a maximum
cap of 3% each year.
In regards to the Insurance and Bonding requirements indicated, this practice wa~ forced to
reduce the limits of liability on malpractice insurance I?om $1,000,000/$3,000,000 to
$250,000/$750,000 as a direct result of the malpractice insurance crisis that is presently
affecting physicians practicing in the State of Florida.
In regards to the Disputes Disclosure Form tiffs practice is currently in the "fact finding
stage" of a claim. Whether or not litigation procedures will be initiated has yet to be
determined. With this in mind, I indicated "NO" on thc third question.
}'lease feel free to contact me with an).' questions or concerns in regard to any of these
Sincerely, ~..~
State Farm Florida Insurance Company
7401 Cy~3reas Ge.Jena Blvd.
Winter Haven, FL 33888-0007
V~ 1924-F352
NORTH SEMINOLE FAMILY
PRACTICE ASSOCIATION PA
2209 S FRENCH AVE
SANFORD FL $2771-fi245
I"lh"l'lh"lh,,h,,Ihl,,I,,I,l,l,,I,l,hlh,,I,Je,lh,I
FU3
Location: 2209 S FRENCH AVE
8ANFORD FL
Mo~gagee:
WAOHOVIA MORTGAGE CORPORATION
ITS SUCCESSORS AND/OR ASSIGNS
Loan No: NVA - Provide Below
Forms, Options, and Endorsements
Special Form 3
Exterior Signs $4,300
Amendatory Endomement
Tree Debris Removal
Business Policy Endorsement
Physicians and Surgeons
Glass Deductible Deletion
Hurricane Deductible
Fungus (Including Mold) Excl
Subcontractor Pd Exclusion
FP-6153
OPT ES
FE-6210.3
FE-6451
FE-6464
FE-6407
FE-6538.1
FE-6537.4
FE-6566
FE-6598
Amendatory Collapse FE-6839
Continued on next page
*Effective: NOV 04 2004
NOTICE: Information concerning changes in your policy language is
you have any questions.
POLI~y NUMBER ~0-N2-0110-~
Business- Office Policy
NOV 04 2004 to NO~' 04 2005
DATE DUE PLEASE PAY THIS AMOUNT
NOV 04 2004 $835.73
Coverages and Limits
Section I
A Buildings
B Business Personal Property
C Loss of Income
Excluded
]1],600
Actual Loss
Deductibles - Section I
Basic
Hurricane
Other dedustibles may
apply - refer to policy
500
2.00%
Section II
L Businese Liability
M Medical Payments
Gan Aggregate (Other than PCO)
Products-Oompleted Operations
(PCO Aggregate)
Annual Premium
Forms, Opts, & Endrsmnt
Bus Liability - Coy L
Previous Balance Due
FL EMPA Fund Surcharge
FL Trust Fund Surchg
Amount Due
Premium Reductions
Your premium has already been reduced
by the following:
Renewal Year Discount
Yrs in Business Discount
:- Cl~irm- ReC0~d D]sc66 nt - :
Cov. A - Inflation Index: N/A
C, ov. B - Consumer Pnoe: 189.7
$500,000
5,000
1,000,000
1,000,000
$684.00
94.00
32.00
20.91
4.00
.82
$835.73
included. Please call your agent if
Agent CLIFF MILLER INS AGENCY INC
Telephone (407) 322-5142
Prepared SEP 01 2004
~'~ 68 3542 8423
See reverge side for important informatk)n.
P/ease keep this part for your record.
First Pmtessionals Insurance (;ompany
TO:
TO WHOM IT MAY CONCERN:
MEMORANDUM OFINSURANCE
NAMED INSURED:
NORTH SEMINOLE FAMILY PRACTICE ASSOCIATES,
2209 FRENCH AVE.
SANFORD, FL 32771
*PoFcy prowdes mdividua coverage
for the physicians listed on the
attached schedule.
This is to advise you that the First Professionals Insurance Company, Inc. has issued to the
named insured the policy enumerated below, subject to all the terms of such policy. This
memorandum neither affirmatively or negatively amends, extends or alters the coverage of such
policy.
POLICY TYPE OF CLAIMS REPORTING
NUMBER INSURANCE LIMITS PERIOD
99281 Professional 250,000 each claim ~r-~'~-? 01/(~':1/-~05
Liability 750,000 aggregate To: 01/01/2006
Retroactive Date: See Schedule
Date issued: 12/30/2004
Authorized Representative
FPIC-9(1/86) 116/2
FL-PC9281
1000 RiYerside Avenue, Sutte 800 ~, /ackst,n~ i[te, Fl,>rida 32204 · (904) 354-5910 - I~800J741-3742 * I"ax (904) 358-6728
EO. Box 44033 * Jacksonv e, Flonda 32231-4033 · ln~erne~ Address: http://www, mcdmaLcom
WORKERS COMPENSATION AND EMPLOYERS LIABILITY
fNFORMATION PAGE'
POLICY NO 98-PH-8821-3
REPLACES ~0. 98 PH-i'023-3
COVERAGE IS PROVIDED BY
SLATE FARM FIRE AND CASUALTy
7401 CYPRESS GDNS BL,WINTER HAVEN
· NCCI CARRIER CODE NO.
1 NAMED INSURED & MAILING ADDRESS RISK ID NO 091373726
NORTH SEMINOLE FAMIly FEIN 592634836
PRACTICE ASSOCIATIOR PA
2209 S FRENCH A~E
SANFORD FL 327/1-4245
WORKP£ACE NO} SHOWN
POLICY
1924-F352 ~
COMPANY
FL 33888-000?
14842
FOR QUESIIONS, PROB INSURED 1S A
COPYRIGHT 1987 NAT ~¢'p~,~FOBMAFiON ABOUT C~VERA F ~ORAT~N-,
2---2 .......... ~2%%%_~UIL UN COMPENSATION INSUraNCeLL; (quT/ 322-5142
z. fHE POLICY PERIOD IS F~&~-$5-'~ ............ ; ....
..... ~_THE INSURED'S MAILING ADD~E~2005 TO 03/19/2006 12:01A.M· STANDARD T~E
B. EMPLOYERS LtABIL
WOR~ IN EACH STA~Y[~A~ECT~R~TWO.~F ~HE ~OL,C, APPLIE
UNDER PART [WO ARE: 'BODILy INO0~ ~'^m~5~[M[IS OF OUR LIA~I~?Ty
~ZV INdURY B~ ~N~' ¢ I~$'~ ~8~H ACCIDENT
muuiLY INdURY ' ,vuu b~cH EMP
c. OTHER STATES tNSUR -- _ BY DISEASE $ 5 LOYEE
EXCEPT ME M ~n A~E,~,~AR~.THREE OF TiE P ..er ;~,'9~ ~OLICY LIMIT
D. THIS POLICY INCLUDES, THESE ENDORSEMFN~ AND SCHEDULES: WCOOOOOOA
WC000414 WC000308 WC090606 WCO00~6¢ WC000112. WC090402. WC000406/0884
.................................... *EFFECTIVE 03/19/0~
· THE PREMIUM ~OR THIS P~LICY W~[L- ~--
RULES, CLASSIFICATIONS BE DETERMINED B~-~ ........
........................... E ~¢ ~m~Hub BY AUDIT
~2 ................................. PREMIUM
HYSICIAN & CLERICAL 5?2,850
1.05 6,015
PREMIUM PRIOR TO EXPERIENCE MO
E~ERIENCE MODIF DIFICATION
.. ICATION: 1
~ ~FFER ~XPERIENCE MODifiCATION 6,015
ISCOUNT ~ 120
TERRORISM PREMIUM 9740 6,135
EXPENSE CONSTANT -124
MINIMUM PREMIUM $ 279 FLORIDA TOTA ESTIMA]ED AN 172
PREMIUM -- -, .......... REMIUM $ 20O
6,383
~ OH~LL ~ ANNUAl_
DEPOSIT PREMIUM $ 6,383
PREPARED 01/19/2005 COUNTERSIGNED .
WORKERS COMPENSAIION AND E~PLOYERS LIABILITY POLICY
INFORMATION PAGE ENDORSEMENF
PAGE 01 -
T~IS FORMS A PART OF 1924-F352 ~
POLICY NO. 98-PH-8821.3 COVERAGE: IS PROVIDED BY
STATE FAR~ FIRE AND CASUALTY COMPANY
7401 CYPRESs GDNS BL,WINTER HAVEN FL. 33888-0007
NAMED
INSURED AND MAILING ADDRESS
NORTH SEMINOLE FAmILy
PRACTICE ASSOCIATION PA
2209 S FRENCH AVE
SANFORD FL 32771-4245
THE EFFEC'FIVE DATE IS 03/19/2005
THE EXPIRATION DATE iS 03/19/2006
LOCATION OF THE INSURED
LOCATION
NUMBER
01 2209 S FRENCH AVE SANFORD FL 32771
ENTITY:ET01 EMP:I SIC:8011
ALL OTHER TERMS AND CONDITIONS
PREPARED 01/19/2005
WC 99 ~0 02 04 84
OF l'H[S POLICY REMAIN) U_.NC NG O