Painting & Pressure Cleaning Insurance PolicyJun 19 18, 0431p By Big Lake
UNDERWRITERS
wmv.gicunderwriter.com
8639048800
1; • .
Insurance Carrier: Granada Insurance Company - A FloridAdmitted Company
al
i * . D i '25 FL CO) D311 1 .
,
Quote Summary as of 11/912017 12:31:33 PM
Quote Number: Quoted Online
Date Quoted: 11/9/2017
Named Insured And Address
Painting and Pressure Cleaning By Big Lake
1111 NW 3rd St
Okeechobee, FL 34972
p2
GIC Underwriters.
P.O. Box 558810
Miami, FL 33255-8810
www.gic:underwriters.00m
Tel: (305) 554-0353 (800) 392-9966
Fax (305) 662-3914
Status: Active
Expires On: 12/9/2017
Agent Name And Address
Accurate Insurance Services Inc. (5063)
101 S W Park Street
Okeechobae, FL 34972
Phone: (863) 357-1707
Request To Bind
The agent has no authority to bind coverage . The Agent has no right to =Ice, alter, modify or discharge any contract or policy issued on the
basis of this application.
Any person who knowingly and with intent to injure, defraud, or deceive any insurer tiles a statement of claim or an application containing any
false, Incomplete, or misleading information is guilty of a felony of the third degree.
To Request To Bind: Check the box, place an effective date, sign and fax this four to (305) 662-3914 or email it to
bInd@granadainsurance.com
Please Bind EFFECTIVE DATE OF BIND: ,a/tekti) ‘a--'- 1'2 •
(Effective Dele can not be prior d belied) Agenf's Signature
Note: All requests to bind are subject to final approval by the Underwriting Department of GIC Underwriiers. Coverage is not effective until bound.
Payment information - In order to bind coverage the Down Payment or Full Payment must be submitted with binder request
....._--.____
HOW WOULD YOU UKE TO PAY?
This is a Direct Bill payment plan policy. No other form of Financing acceptable.
BANK DEBIT (AGENCY'S OR INSURED'S ACCOUNT)
0 Personal Checking Account 0 Savings Account 0 Business Account
NPAE 9FPANKC5EPT UNION . . .
ABA
ROUTING wypEF3,
.. -
-
I
CREDIT CARD CARD (AGENCY'S OR INSURED'S CREDIT CARD)
0 Visa 0 Mastercard
0 American Express
CRDrT_PARDII,piYiB.ER P!-NTE,MirTO .
WHAT AMOUNT WOULD YOU LIKE TO PAY?
0 Minimum Down Payment $221.65 (Balance in 9 Monthly Installment)
y in Full $1,411.00
0 Other Amount greater than Down payment $
L . '
By providing the bank account or credit card irformation above, you authorize GIC Underwriters Inc to process a one time payment as soon as the
same day.
if the Initial payment by check or credit card is returned by the bank because of "PAYMENT DISHONORED BY BANK", coverage will be null and void
from inception.
.1i
Parma 1 of
Jun 191v a
u o F-nr FITeas
By Big Lake 8639048800
vuure. - ranting ana Pressure Cleaning - Quoted On: 11!9201712:31:01 PM
P.3
Form of Business: CORPORATION
Business Description: See Class Description
Coverage Summary
Commercial General Liability Coverages:
Policy Fee
Total Premium:
$1,386.00
$25.00
$1,411.00
PLEASE REVIEW THIS QUOTE CAREFULLY AS COVERAGES, LIMITS, ENDORSEMENTS AND DEDUCTIBLES MAY
DIFFER FROM THOSE REQUESTED ON ANY SUBMITTED APPLICATION OR OTHERWISE.
Individual Coverages
General Liability
Limits for General Liability
General aggregate Limit (Other than Products/Completed Operations):
Products/Completed Operations Aggregate Limit:
Personal and Advertising Injury Limit:
Each Occurrence Limit:
Fire Damage Limit (Any One Fire):
Medical Expense Limit (Any One Person):
Location Address
Location: 1
1111 NW3rd St
Okeechobee, FL
Classification Schedule
$500,000
$500,000
$500,000
$500,000
$100,000
$5,000
1
Painting —Interior or Painting
- exterior buildings or
structures three stories or
Less in height
Pressure Cleaning
98304
99952
Premises and
Products
Premises and
Products
16,700
$500
16,700
Payroll
$500
Property Damage
Deductible Per Claim
Property Damage
Deductible Per Claim
Basic Coverage Premium:
Attached Endorsements Premium:
Total General Liability Premium:
$1,386.00
$0.00
$1,386.00
Summary of Users Qualifying Responses
es applicant perform or engage in any work or operation other than those listed In the classification schedule of this app!%cation?
NO
NO
Any new bufd'mg construction operations performed on single-family units including residential condominiums, multi -unit homes, tract
housing, subdivrsions,tovnhouses, or apartment buildings within subdivisions or protects where there are five (5) or more total units?
Forms and Endorsements
Forms and Endorsements Applicable To This Coverage Part
Where'0' a• ears for Location and Buildin•, the described endorsements a
to all Bulidin • s and all locations.
0
0
0
0
0
0
0
0
0
0
CG 00 01
CG 00 68
CG 0220
CG 03 00
CG 21 01
12-07
05-09
03-12
01-95
11-85
Commercial General Uability Coverage
Recording & Distribution of Material or Infor
Fla Chgs-Cancellallon & Nonrenewal
Deductible Liability Insurance
Exclusion - Athletic or Sports Participants
�H
INCL 1
INCL
INCL
INCL
INCL
Dona ? of
Jun 19 18 04:31p
UNDeR.Nan !RS
By Big Lake 8639048800
�e °. 1, r cure t.aea'ung - Quoted On: 11/920171231:01 FM
p.4
0 0
O 0
O 0
o a
0 0
0 0
Q 0
O 0
0 0
0 0
0 0
0 0
0 0
O 0
O 0
O 0
O 0
0 0
0 0
O 0
O 0
O 0
O 0
0 0
0 0
O 0
O 0
0 0
O 0
0 0
0 0
CG 21 07
CG2132
CG 21 36
CG 2139
CG 2143
CG2146
CG 2147
CG 21 50
CG 2167
CG 2186
CG 2196
CG 22 33
CG 2279
CG2294
GICGL832
GICGL841
GIC GL3003
GIC GL 3004
GIC GL 3005
GIC GL3007
GIC GL 3008
GC GL 3011
GIC GL 3018
GIC GLAB 278
GIC GLAP7851
IIP -NOTICE
IL 0003
IL 0017
IL 00 21
JCPP 601 REV
GIC RMP -102
05-14
05-09
03-05
10-93
12-04
07-98
12-07
09-89
12-04
'12-04
03-05
07-98
07-98
10-01
04-14
12-16
01-97
04-95
07-95
06-96
09-96
01-97
03-97
03-97
06-98
04-01
04-98
11-98
09-08
02-09
03-98
Exclusion -Access or Disclosure of Confidential or Personal Information and
Data -Related Liability - Limited Bodily Injury Exception Not Included
Communicable Disease Exclusion
Exclusion - New Entities
Contractual Liability Limitation
Exclusion Explosion, Collapse, Underground
Abuse or Molestation Exclusion
Employment -Related Practices Exclusion
Amendment of Liquor Liability
Fungi or Bacteria Exclusion
Exclusion -Exterior Insulation & Firish System
Silica or Silica -Related Dust Exdusion
Exd Testing or Consulting Errors & Omissions
Exclusion -Contractors -Professional Liability
Exc-Damage to Work by Subcontractors your beh
Amendment Of Employee Definition
Contractor Limitation Endorsement
Punriive Damages Exdusion
Professional Services Exclusion
Exclusion - Lead
Exclusion -- Roofing Operations
Classification Limitation Endorsement
'Insured" - Family Member Exclusion
Two or More Coverage Forms or Policies Issued
Exclusion -Asbestos
Exclusion Pollution
Important Information About Your Privacy
Calculation of Premium
Common Policy Conditions
Nuclear Energy Liability Exclusion End.
JACKET
Risk Management Program
INCL
INCL
INCL
1NCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
INCL
Dorno 4 nr
JIMMY PATRONIS
CHIEF FINANICAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW * *
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 5/13/2018 EXPIRATION DATE: 5/12/2020
PERSON: DONNA HUNT EMAIL: JLOCKHART2004@HOTMAIL.COM
FEIN: 465548309
BUSINESS NAME AND ADDRESS:
PAINTING & PRESSURE CLEANING BY BIG LAKE LLC
1111 NW 3RD STREET
OKEECHOBEE, FL 34972
SCOPE OF BUSINESS OR TRADE:
Painting NOC & Shop
Operations, Drivers
IMPORTANT: Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under
this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt... apply
only within the scope of the business or trade listed on the notice of election to be exempt. Pursuant to Chapter 440.05(13), F.S., Notices of election to be
exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the
person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a
certificate at any time for failure of the person named on the certificate to meet the requirements of this section.
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609
JIMMY PATRONIS
CHIEF FINANICAL OFFICER STATE OF FLORIDA
DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
* * CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW* *
CONSTRUCTION INDUSTRY EXEMPTION
This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law.
EFFECTIVE DATE: 5/13/2018 EXPIRATION DATE: 5/12/2020
PERSON: HUNT WADE G JR
FEIN: 465548309
BUSINESS NAME AND ADDRESS:
PAINTING & PRESSURE CLEANING BY BIG LAKE LLC
1111 NW 3RD STREET
OKEECHOBEE FL
SCOPE OF BUSINESS OR TRADE:
Painting NOC & Shop
Operations, Drivers
34972
IMPORTANT: Pursuant to Chapter 440.05(14), F.S., an officer of a corporation who elects exemption from this chapter by filing a certificate of election under
this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12), F.S., Certificates of election to be exempt.. apply
only within the scope of the business or trade listed on the notice of election to be exempt Pursuant to Chapter 440.05(13), F.S., Notices of election to be
exempt and certificates of election to be exempt shall be subject to revocation if, at any time after the filing of the notice or the issuance of the certificate, the
person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate. The department shall revoke a
certificate at any time for failure of the person named on the certificate to meet the requirements of this section.
DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS? (850)413-1609
ATTACHMENT B
PW 03-00-06-18
ANTI -COLLUSION STATEMENT AND NO GIFTS STATEMENT
Date:
Anti -collusion statement:
No gifts statement:
Firm Name:
By (printed/typed):
By (signature):
Title:
Mailing Address:
City, State, Zip:
Telephone No.:
The below -signed Bidder has not divulged to, discussed, or
compared his/her Bid with other Bidders and has not colluded
with any other Bidder or parties to a Bid whatsoever.
No premiums, rebates, gifts or gratuities are permitted with,
prior to, or after submission of the Bid. Any such violation will
result in rejection of the Bid and removal from the Bid list(s).
Ayaz, zz.c,
R a 1/7
/1/1Al W •-24 ---J.-7(1246
Z_Dka o
043 - 57 - 2 27,3
City of Okeechobee Project No. PW 03-00-06-18
Public Works Department
35
ATTACHMENT C
PW 03-00-06-18
PROPOSER'S CERTIFICATION
I have carefully examined this Request for Bids (BID)/Request for Proposals (RFP)/ Request for
Qualifications (RFQ), which includes scope, requirements for submission, general information and
the evaluation and award process.
I acknowledge receipt of the following addenda.
Addendum # Date: Addendum # Date:
Addendum # Date: Addendum # Date:
Addendum # Date: Addendum # Date:
I hereby propose to provide the services requested in the City's BID/RFP/RFQ and, if awarded, to
enter into the attached draft contract. I agree that the terms and conditions of the City's
BID/RFP/RFQ shall take precedence over any conflicting terms and conditions submitted with my
proposal and agree to abide by all conditions of the BID/RFP/RFQ, unless a properly completed
Exceptions to BID/RFP/RFQ form is submitted. I acknowledge that the City may not accept the
proposal due to any exceptions.
I certify that all information contained in my proposal is truthful to the best of my knowledge and
belief. I further certify that I am duly authorized to submit this proposal on behalf of the Company as
its agent and that the Company is ready, willing and able to perform if awarded a contract.
I further certify, under oath, that this proposal is made without prior understanding, agreement,
connection, discussion or collusion with any other person, Company or Corporation submitting a
proposal for the same product or service; no gratuities, gifts or kick -backs were offered or given by
the Bidder or anyone on its behalf to gain favorable treatment concerning this procurement; no City
Council member, employee or agent of City of Okeechobee or of any other Company is interested in
said Bid; and that the undersigned executed this Proposer's Certification with full knowledge and
understanding of the matters therein contained and was duly authorized to do so.
•
s
Abi
•
Mallin / dress Y 9 7
City, State & Zip Code
_ S�3- 35'% -tea? 9l 3 , 9d9-
Authorized Signature Telephone Number/Fax umber
441 Air, �� E
Name Title, Typed
STATE OF FLORIDA
COUNTY OF ro-e-
I
•
E ail Ai' dress /
The foregoing instru ent was acknowledged and subscribed before me thisk,,,Z)y of ,
who is personally known v O produced
as identification.
City of Okeechobee
Public Works Department
Signature of Notary Public
,id?Lode,,Leut
Name of Notary Typed, Printed, or ja"mped
Y,oranY
STATE OF
FLORIDA
JUDITH LOCKHART
COMMISSION # FF166348
EXPIRES Nov 22, 2018
BONDED THROUGH
RU INSURANCE COMPANY
3A
Commission No.
Project No. PW 03-00-06-18
ATTACHMENT D
PW 03-00-06-18
SWORN STATEMENT PURSUANT TO SECTION 287.133 (2)(a
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.
1. This sworn statement is submitted to CITY OF OKEECHOBEE, FLORIDA by:
ZA.M ) fli,9i .<5' (print Individual's name and title) for:
NI P. A 4, 42
(print name of entity submitting swom statement) whose brisiness addres is:
,t/Gt/i c4e-P-Z,---h-d-ee_ "7---o0 ay 9
and (if (if applicable) its Federal Employer Identification Number (FEIN) is:7 -6-5Y<F3
(If the entity has no FEIN, include the Social Security Number of the Individual signing
this sworn statement: .)
2. 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 of the United States, including but not limited to,
any Bid or contract for goods or services to be provided to any public entity or an agency
or political subdivision of any other state or of the United States and involving antitrust,
fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentations.
3. I understand that "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 guilty or nolo contendere.
4. I understand that an "affiliate" as defined in Paragraph 287.133(1)(a), Florida Statutes,
means:
a. A predecessor or successor of a person convicted of a public entity crime; or
b. 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 for 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. 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
City of Okeechobee Project No. PW 03-00-06-18
Public Works Department
37
United States with the legal power to enter into a binding contract and which Bids or
applies to Bid on contracts for the provision of goods or services 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. (Indicate which statement applies).
n Neither the entity submitting this sworn statement, nor any of its officers, directors,
executives, partners, shareholders, employees, members, or agents who are active in
the management of the entity, nor any affiliate of the entity has been charged with and
convicted of a public entity crime subsequent to July 1, 1989.
❑ The entity submitting this sworn statement, or one or more of its officers, directors,
executives, partners, shareholders, employees, members, or agents who are active in
the management of the entity, or an affiliate of the entity has been charged with and
convicted of a public entity crime subsequent to July 1, 1989.
❑ The entity submitting this sworn statement, or one or more of its officers, directors,
executives, partners, shareholders, employees, members, or agents who are active in
the management of the entity, or an affiliate of the entity has been 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 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 •ECTION 287.017, FLORIDA STATUTES FOR
CATEGORY TWO OF ANY CHANGE I HE FORMATION CONTAINED IN THIS FORM.
Signature
STATE OF FLO�
COUNTY OF
The foregoing int ment wapack owledged and subscribed before me ttlf's & da of
20 by, who is personally known O produced
.L� �
as identification.
Signature of Notary PubIii1. 1 �
of Notary Typed. Printed. or S,Named
City of Okeechobee
Public Works Department
2R
mnussi
LOCKHART
COMMISSION # FFl 63 8
EXPIRES Nov 22, 2018
BONDRU INSURANCE M,
Project No. PW 03-00-06-18
ATTACHMENT E
PW 03-00-06-18
CONFLICT OF INTEREST DISCLOSURE FORM
For purposes of determining any possible conflict of interest, all Bidders must disclose if
any City of Okeechobee employee(s), elected official(s), or any of its agents is also an
owner, corporate officer, director, agent, employee, etc., of their business.
Indicate either "yes" (a City employee, elected official or agent is associated with your
business), or "no". If yes, give person(s) name(s) and position(s) with your business.
YES
Name(s)
NO
Position(s)
Firm Name: ?c., !-e3".3`dry
By (Printed): Ut_i f%t
By (Signature):
Title: D LJ r ser? /rt F/y1,e
// // 4AJ Zr-1
Address:
Phone Number: b6..3 3 J / 277 3.
City of Okeechobee Project No. PW 03-00-06-18
' Public Works Department
39
ATTACHMENT F
PW 03-00-06-18
IMMIGRATION LAW CERTIFICATION
City of Okeechobee will not intentionally award City contracts to any Contractor who
knowingly employs unauthorized alien workers, constituting a violation of the
employment provisions contained in 8 U.S.C. Section 1324 a(e) (Section 274a(e) of the
immigration and nationality act ("INA")).
City of Okeechobee may consider the employment by any Contractor of unauthorized
aliens a violation of Section 274A(e) of the INA. Such violation by the recipient of the
employment provisions contained in Section 274A(e) of the INA shall be grounds for
unilateral cancellation of the contract by City of Okeechobee.
Respondent attests that it is fully compliant with all applicable immigration laws,
specifically relating to the 1986 immigration act and subsequent amendments.
ignature
Title
4);74,//J
Date
STATE OF FLORIDA
COUNTY OF
The foregoing foregoing 12(trort vy9s acknowledged and subscribed before me this P) day of
20/2, by , who is personally known , 9J produced
as identification. F.
Signature of Notary Public
Name of Notary Typed. Printed, or
JuDiffincoeKPAT
NOTARY COMMISSION # FF166348
PUBLIC
STATE OF EXPIRES Nov 22, 2018
FLORIDA BONDED THROUGH
RU INSURANCE COMPANY
City of Okeechobee Project No. PW 03-00-06-18
Public Works Department
40
ATTACHMENT G
PW 03-00-06-18
DRUG-FREE WORKPLACE CERTIFICATION
THE BELOW SIGNED Bidder/proposer CERTIFIES that it has implemented a drug-free
workplace program. In order to have a drug-free workplace program, a business shall:
1. Publish a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance is prohibited in the work place
and specifying the actions that will be taken against employees for violation 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 under quote 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 quote, the employee
will abide by the terms of the statement and will notify the employer of any conviction or
plea of guilty or nolo contendere to any 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, drug abuse assistance
or rehabilitation program if such is available in the employee's community, by an
employee who is convicted.
6. Make a good faith effort to continue to maintain a drug-free workplace through
implementation of this section.
As the person authorized to sign thiss'fitene t, I certify that this Firm complies fully with the
above requirements.
Signature: "11
Compan
Address:
A{2011,2._V Y 97.2)
Date:• i.,925 /V
Title:
Phone Number..Wz- - 8.5V 222S
City of Okeechobee Project No. PW 03-00-06-18
Public Works Department