HomeMy WebLinkAbout2003-253Q. y
CHILDREN'S SERVICES ADVISORY COMMITTEE
C/O Human Services
1840 25`" Street
Vero Beach , Florida 32960-3394
Phone: 561 -567-8000 (Ext. 467 or 524)
Fax: 978-1798
E-Mail : JcadsonObcc.co. indian-river.fl . us
Mmastersonabcc. co.indian-dver.fl . us
To : Beth Jordan
From : Joyce Johnston-Carlson
Date : October 29 , 2003
Re : Grant Contracts 2003 -04
The attached is a Children ' s Service Advisory Committee Grant Contract for:
CEBH — Mental Health Program
Please review the insurance certificate and verify that it is adequate by signing on the line
below . Contact me if you have any questions . Thank you .
�c Beth Jordan Date i/ �.J - y3
Indian River County Grant Contract
This Grant Contract ("Contract" ) entered into effective this 1st day of October 2003 by and between
Indian River County, a political subdivision of the State of Florida , 1840 25th Street, Vero Beach FL ,
32960 ("County") and Center for Emotional & Behavioral Health (" Recipient") ;
of: (Address )
Center for Emotional & Behavioral Health
119037 th Street
Vero Beach , Florida 32960
Mental Health Services
Background Recitals
A. The County has determined that it is in the public interest to promote healthy children in
a
healthy community.
B . The County adopted Ordinance 99- 1 on January 19 , 1999 ("Ordinance") and established the
Children 's Services Advisory Committee to promote healthy children in a healthy community
and to provide a unified system of planning and delivery within which children 's needs can be
identified , targeted , evaluated and addressed .
C . The Children 's Services Advisory Committee has issued a request for proposals from
individuals and entities that will assist the Children 's Services Advisory Committee in fulfilling
its purpose .
D . The proposals submitted to the Children 's Services Advisory Committee and the
recommendation of the Children 's Services Advisory Committee have been reviewed by the
County.
E . The Recipient, by submitting a proposal to the Children 's Services Advisory Committee , has
applied for a grant of money ("Grant" ) for the Grant Period (as such term is hereinafter
defined ) on the terms and conditions set forth herein .
F . The County has agreed to provide such Grant funds to the Recipient for the Grant Period (as
such term is hereinafter defined ) on the terms and conditions set forth herein .
NOW THEREFORE , in consideration of the mutual covenants and promises herein contained , and
other good and valuable consideration , the receipt and adequacy of which are hereby acknowledged ,
the parties agree as follows :
1 . Background Recitals The background recitals are true and correct and form a material
part of this Contract .
2 . Purpose of Grant The Grant shall be used only for the purposes set forth in the
complete proposal submitted by the Recipient attached hereto as Exhibit "A" and
incorporated herein by this reference (such purposes hereinafter referenced as "Grant
Purposes") .
3 . Term The Recipient acknowledges and agrees that the Grant is limited to the fiscal
year 2003/2004 ("Grant Period") . The Grant Period commences on October 1 , 2003
and ends on September 30 , 2004 .
- 1 -
4 . Grant Funds and Payment The approved Grant for the Grant Period is Seventy Six
Thousand Dollars ($76 , 000 ) . The County agrees to reimburse the Recipient from
such Grant funds for actual documented costs incurred for Grant Purposes provided in
accordance with this Contract . Reimbursement requests may be made no more
frequently than monthly. Each reimbursement request shall contain the information , at
a minimum , that is set forth in Exhibit " B" attached hereto and incorporated herein by
this reference . All reimbursement requests are subject to audit by the County . In
addition , the County may require additional documentation of expenditures , as it
deems appropriate .
5 . Additional Obligations of Recipient .
5 . 1 Records . The Recipient shall maintain adequate internal controls in order to
safeguard the Grant . In addition , the Recipient shall maintain adequate records fully
to document the use of the Grant funds for at least three (3 ) years after the expiration
of the Grant Period , The County shall have access to all books , records , and
documents as required in this Section for the purpose of inspection or audit during
normal business hours at the County's expense , upon five (5 ) days prior written
notice .
5 .2 Compliance with Laws . The Recipient shall comply at all times with all applicable
federal , state , and local laws , rules , and regulations .
5 . 3 Quarterly Performance Reports . The Recipient shall submit Quarterly Performance
Reports to the Human Services Department of the County within fifteen ( 15 ) business
days following : December 31 , March 31 , June 30 , and September 30 .
5 .4 Audit Requirements . If Recipient receives $25 , 000 or more in the aggregate from
all Indian River County government funding sources , the Recipient is required to have
an audit completed by an independent certified public accountant at the end of the
Recipient's fiscal year. Within 120 days of the end of the Recipient's fiscal year, the
Recipient shall submit the audit to the Indian River County Office of Management and
Budget. The fiscal year will be as reported on the application for funding , and the
Recipient agrees to notify the County prior to any change in the fiscal period of
Recipient . The Recipient acknowledges that the County may deny funding to any
Recipient if an audit required by this Contract for a prior fiscal year is past due and has
not been submitted by May 1 .
5 .4 . 1 The Recipient further acknowledges that , promptly upon receipt of a
qualified opinion from its independent auditor, such qualified opinion shall
immediately be provided to the Indian River County Office of Management and
Budget . The qualified opinion shall thereupon be reported to the Board of
Commissioners and funding under this Contract will cease immediately. The
foregoing termination right is in addition to any other right of the County to
terminate this Contract.
5 .4 . 2 The Indian River County Office of Management and Budget reserves
the right at any time to send a letter to the Recipient requesting clarification if
there are any questions regarding a part of the financial statements , audit
comments , or notes .
5 . 5 Insurance Requirements . Recipient shall , no later than September 23 , 2003 ,
provide to the Indian River County Risk Management Division a certificate or
certificates issued by an insurer or insurers authorized to conduct business in Florida
- 2 -
that is rated not less than category A- : VII by A. M . Best , subject to approval by Indian
River County's risk manager, of the following types and amounts of insurance :
( i ) Commercial General Liability Insurance in an amount not less than
$ 1 , 000 ,000 combined single limit for bodily injury and property damage ,
including coverage for premises/operations , products/completed operations ,
contractual liability, and independent contractors ;
( ii ) Business Auto Liability Insurance in an amount not less than $ 1 , 000 , 000
per occurrence combined single limit for bodily injury and property damage ,
including coverage for owned autos and other vehicles , hired autos and other
vehicles , non-owned autos and other vehicles ; and
(iii ) Workers' Compensation and Employer's Liability (current Florida statutory
limit)
5 . 6 Insurance Administration . The insurance certificates , evidencing all required
insurance coverages shall be fully acceptable to County in both form and content,
and shall provide and specify that the related insurance coverage shall not be
cancelled without at least thirty (30 ) calendar days prior written notice having been
given to the County. In addition , the County may request such other proofs and
assurances as it may reasonably require that the insurance is and at all times
remains in full force and effect . Recipient agrees that it is the Recipient's sole
responsibility to coordinate activities among itself, the County, and the Recipient's
insurer(s ) so that the insurance certificates are acceptable to and accepted by
County within the time limits set forth in this Contract . The County shall be listed as
an additional insured on all insurance coverage required by this Contract, except
Workers ' Compensation insurance . The Recipient shall , upon ten ( 10 ) days ' prior
written request from the County, deliver copies to the County, or make copies
available for the County's inspection at Recipient's place of business , of any and all
insurance policies that are required in this Contract. If the Recipient fails to deliver or
make copies of the policies available to the County; fails to obtain replacement
insurance or have previous insurance policies reinstated or renewed upon
termination or cancellation of existing required coverages ; or fails in any other regard
to obtain coverages sufficient to meet the terms and conditions of this Contract , then
the County may, at its sole option , terminate this Contract.
5 . 7 Indemnification . The Recipient shall indemnify and save harmless the County, its
agents , officials , and employees from and against any and all claims , liabilities ,
losses , damage , or causes of action which may arise from any misconduct, negligent
act, or omissions of the Recipient , its agents , officers , or employees in connection
with the performance of this Contract.
5 . 8 Public Records . The Recipient agrees to comply with the provisions of Chapter
119 , Florida Statutes ( Public Records Law) in connection with this Contract.
6 . Termination . This Contract may be terminated by either party, without cause , upon
thirty (30 ) days prior written notice to the other party. In addition , the County may
terminate this Contract for convenience upon ten ( 10 ) days prior written notice to the
Recipient if the County determines that such termination is in the public interest .
7 . Availability of Funds . The obligations of the County under this Contract are subject
to the availability of funds lawfully appropriated for its purpose by the Board of
County Commissioners of Indian River County.
3 -
8 . Standard Terms , This Contract is subject to the standard terms attached hereto as
Exhibit C and incorporated herein in its entirety by this reference .
IN WITNESS WHEREOF , County and Recipient have entered into this Contract on the date
first above written .
INDIAN RIVER COUNTY BOARD OF COUNTY
COMMISSPIERS
By : z1ga
Kenneth Fk . 9adht , Charman
Attest : J . K. Barton , Clerk
B .
Deputy Clerk
Approved : anauaQUI �p '
J es Cliandler, County Admi trat r
A pro"tond legal sufficiency :
isn orney
RECIPIENT :
Center for Emotional & Behavioral Health
119037 th Street
Vero Beach , Florida 32960
r
By:
R/aymorto Dean , MD J�
CA re'
Title
- 4 -
EXHIBIT A
[Copy of complete proposal/application]
- 1 -
EXHIBIT B
[From policy adopted by Indian River County Board Of County Commissioners on February 19 ,
2002]
" D . Nonprofit Agency Responsibilities After Award of Funding
Indian River County provides funding to all nonprofit agencies on a reimbursement basis
only.
All reimbursable expenses must be documented by an invoice and/or a copy of the canceled
check . Any expense not documented properly to the satisfaction of the Office of Management &
Budget and/or the County Administrator may not be reimbursed .
If an agency repeatedly fails to provide adequate documentation , this may be reported to the
Board of Commissioners . In the event an agency provides inadequate documentation on a
consistent basis , funding may be discontinued immediately. Additionally, this may adversely
affect future funding requests .
Expenditures may only be reimbursed from the fiscal year for which funding was awarded . For
example , no expenditures prior to October 1St may be reimbursed with funds from the following
year. Additionally, if any funds are unexpended at the end of a fiscal year, these funds are not
carried over to the next year unless expressly authorized by the Board of Commissioners .
All requests for reimbursement at fiscal year end (September 301h) must be submitted on a timely
basis . Each year, the Office of Management & Budget will send a letter to all nonprofit agencies
advising of the deadline for reimbursement requests for the fiscal year. This deadline is typically early
to mid October, since the Finance Department does not process checks for the prior fiscal year
beyond that point .
Each reimbursement request must include a summary of expenses by type . These summaries
should be broken down into salaries , benefits , supplies , contractual services , etc . If Indian River
County is reimbursing an agency for only a portion of an expense (e . g . salary of an employee ) , then
the method for this portion should be disclosed on the summary. The Office of Management &
Budget has summary forms available .
Indian River County will not reimburse certain types of expenditures . These expenditure types are
listed below.
a . Travel expenses for travel outside the County including but not limited to ; mileage reimbursement ,
hotel rooms , meals , meal allowances , per Diem , and tolls . Mileage reimbursement for local travel
(within Indian River County) is allowable .
b . Sick or Vacation payments for employees . Since agencies may have various sick and vacation
pay policies , these must be provided from other sources .
c . Any expenses not associated with the provision of the program for which the County has awarded
funding .
d . Any expense not outlined in the agency's funding application .
The County reserves the right to decline reimbursement for any expense as deemed necessary. "
- 1 -
EXHIBIT C
STANDARD TERMS FOR GRANT CONTRACT
1 . Notices : Any notice , request , demand , consent , approval or other
communication required or permitted by this Contract shall be given or made
in writing , by any of the following methods : facsimile transmission ; hand
delivery to the other party; delivery by commercial overnight courier service ;
or mailed by registered or certified mail ( postage prepaid ) , return receipt
requested at the addresses of the parties shown below:
County: Joyce Johnston - Carlson , Director
Indian River County Human Services
184025 th Street
Vero Beach , Florida 32960-3365
Recipient :
Center for Emotional & Behavioral Health
119037 th Street
Vero Beach , Florida 32960
Attention : Dr. Dean , Executive Director
2 . Venue : Choice of Law: The validity, interpretation , construction , and effect
of this Contract shall be in accordance with and governed by the laws of the
State of Florida , only. The location for settlement of any and all claims ,
controversies , or disputes , arising out of or relating to any part of this
Contract , or any breach hereof, as well as any litigation between the
parties , shall be Indian River County, Florida for claims brought in state
court , and the Southern District of Florida for those claims justifiable in
federal court.
3 . Entirety of Agreement: This Contract incorporates and includes all prior and
contemporaneous negotiations , correspondence , conversations ,
agreements , and understandings applicable to the matters contained herein
and the parties agree that there are no commitments , agreements , or
understandings concerning the subject matter of this Contract that are not
contained herein . Accordingly, it is agreed that no deviation from the terms
hereof shall be predicated upon any prior representations or agreements ,
whether oral or written . It is further agreed that no modification ,
amendment or alteration in the terms and conditions contained herein shall
be effective unless contained in a written document signed by both parties .
4 . Severability: In the event any provision of this Contract is determined to be
unenforceable or invalid , such unenforceability or invalidity shall not affect
the remaining provisions of this Contract , and every other term and
provision of this Contract shall be deemed valid and enforceable to the
extent permitted by law. To that extent, this Contract is deemed severable .
5 . Captions and Interpretations : Captions in this Contract are included for
convenience only and are not to be considered in any construction or
interpretation of this Contract or any of its provisions . Unless the context
- 1 -
indicates otherwise , words importing the singular number include the plural
number, and vice versa . Words of any gender include the correlative words
of the other genders , unless the sense indicates otherwise .
6 . Independent Contractor, The Recipient is and shall be an independent
contractor for all purposes under this Contract . The Recipient is not an
agent or employee of the County , and any and all persons engaged in any
of the services or activities funded in whole or in part performed pursuant to
this Contract shall at all times and in all places be subject to the Recipient's
sole direction , supervision , and control .
7 . Assignment . This Contract may not be assigned by the Recipient without
the prior written consent of the County.
- 2 -
Job Description for Outpatient Child/Adolescent Psychiatrist
This agreement will begin October 1 , 2003 for a term of 1 year expiring September 30,
2004 . This position will be for Director of the Child and Adolescence Outpatient
Services, currently held by Dr. Judy Linger, that will include 8 hours of outpatient clinic
per week. This grant funded position for outpatient psychiatric services will target the
underinsured child/adolescent population of Indian River County. The amount awarded
for this grant will be $76, 000 per year.
The psychiatrist will be required to obtain/maintain (a) valid and unrestricted license to
practice medicine in the State of Florida, (b) active membership in good standing on the
IRMH medical staff, (c) DEA license and (d) board certification by the American Board
of Psychiatry and Neurology.
The Physician as Medical Director for the Child and Adolescence Outpatient Services,
shall have specific service responsibilities, including, but not limited to, the following :
• To direct and coordinate all clinical activities of the Child and Adolescence
Outpatient Psychiatric Service at CEBH, including review and assessment of the
appropriateness, quality and effectiveness of care rendered.
• To implement and support a program of continuous quality improvement in the
delivery of clinical outpatient services at CEBH.
• To support and collaborate on a routine basis with the Executive Director of CEBH,
as well as Indian River County Health Department and the Director of Indian River
County Human Services .
• To cause CEBH to comply with any and all governmental and Joint Commission on
Accreditation of Healthcare Organizations ("JCAHO"), record keeping, reporting
requirements as well as accreditation standards applicable to CEBH.
• To serve as a liaison between Indian River County Health Department, the Director
Of Indian River County Human Services and CEBH, promoting effective
communication and understanding about the service and its objectives .
• To evaluate the outpatient services and programs of CEBH and advise Indian River
County Health Department and Indian River County Human Services promptly of
any deficiencies in either.
• To develop a system for utilization of Global Assessment of Functioning scores
(GAP), as a measurement of progress and ultimate outcome. This assessment tool
will be included in the initial assessments and on subsequent quarterly reviews of
progresses made of each child/adolescent patient involved in the clinic .
• To assist Indian River County Human Services in the promotion and development of
the children/adolescent outpatient program at CEBH.
• To maintain and submit the appropriate monthly documentation that documents
duties performed on behalf of the children/adolescent outpatient program at CEBH.
• In fulfilling the responsibilities hereunder, the Physician shall do so in accordance
with the standards accepted by the American Board of Psychiatry, the standards of the
Joint Commission on Accreditation of Healthcare Organizations and other regulatory
and accrediting bodies with jurisdiction and in accordance with the bylaws, rules and
regulation of the Hospital and its medical staff.
• The Physician who is performing in the capacity as a Medical Director for the
Children/Adolescent Outpatient Psychiatric Program of CEBH shall be present on the
premises of CEBH not less than eight (8) hours per week.
• Based on benchmarked performance levels this could serve an average of two to three
children/adolescent per hour, or an overall estimate of one hundred ( 100)
children/adolescents per year.
• Accept referrals from Indian River county Health Department and/or from agencies
funded by Indian River County Children ' s Services Advisory, Committee.
• To meet quarterly with Indian River County Health Department and Indian River
County Human Services Director to discuss any inadequacies or possible changes
needed to improve communications or referral process to the Program.
10/ 10/2003 15 : 16 HCIR. 4 17725634564 N0 . 143 1?02
ACO1�P_ - INSURANCE BINDER OPIo DATE
10 / z0 / n3
YHIS BINDER 15 A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM.
TI
PRODUCER I_Ag No E 800 - 729 - 4149 COMPANY af1+DFRz 80411
704 - 365 - 7124 Fireman ' s Fund Ins . Cos .
DATE TIME EXPIRATION
T@IRATI TIME
E4cNeasy Healthcare - FL " I-�------� --
6525 Morrison Blvd . , suite 200 AM Is:o, Alrf
Charlott® NC 28211 10 / 12 / 03 PM 12 / 11 / 03 it NOON
Florida_ Hospital Aasoai-aHE
tion THIS BINDER 16 ISSUED TO EXTEND COVERAGE IN TAFtOVENAMEDCOMPANY
�.� SUB CODE, PEREXPIRINGPOLICYO: MZG80819831
CODE; I
AGENCY• DESCRIPTION OF OPERATIONWEHICLESIPROPERTY (InduMnp Location)CUSTOMER M : INC) ZA` 1
INSURED
Indian River Memorial Hospital
Greg Morgan
1000 36th Street
Vero Beach FL 32960
COVERAGES [ IMl I
type OF INSURANCE COVERAGEJFORMS DEDUCTIBLE COINS U AMOUNT
PROPERTY CAUSES OF LOSS
l BASIC _ BROAD SPEC
GENERAL LIABILITY I EACH OCCURRENCE S
COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Any one fire) S
I I CLAIMS MAD[ I i OCCUR MED EXP (Any 9m parson) $
I PERSONAL a AOV INJURY S
—� GENERAL AGGREGATE_ $
+� RETRO DATE FOR CLAIMS MADE: PRODUCTS • COMP/OP AGG $
AUTOMOBILE LIABIUTY COMBINED SINGLE lIM(T S 2 , OOO � OOO
�(
ANY AUTO ROPILY INJURY (Pot pm6oAI -- 1 S
ALL OWNED AUTOS BODILY INJURY (Pe, aceidea)
SCHEDULED AUTOS PROPERTY DAMAGE s
" -
HIRED AUTOS MEDICAL PAYMENTS I L 5 , 000
.� .�.
__ • NON-OWNED AUTOS PERSONAL WJURY PROT S
� UNINSUREDMbTORIST s1 , 000 , 000
I i
AUTO PHYSICAL DAMAGE DEDUCTIBLE X j ALL VEHICLES SCHEDULED VEHICLESX ACTUAL CASH VALUE
Xy COLLISION- 500 STATED AMOUNT $
X I OTHER THAN COL' 2.5 0 _ OTHER
GARAGE LIABILITY I AUTO ONLY . EA ACCIDENT S
ANY AUTO OTHER THAN AUTO ONLY
EACH ACCIDENT f
••' - � - -- AGGREGATE S
EXCESS LIABILITY EACH OCCURRENCE S
UMORELLA FORM AGGREGATE S
OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE : SELF •INSURED RETENTION 3
WC STATUTORY LIMITS
WORXER66 COMPENSATION E.L EACH ACCIDENT j ;AND
^
EMPLOYER'S LIABILITY E.L. DISEASE - EA EMPLOYEE S
E.L, DISEASE • POLICY LIMIT 5
SPECIAL rHY6ICAT. DAMGE ( COti' ' T ) : ALmbulanoaa G Heavy Units : $ 500 Dad _ Comp 6 $ 1000 FEES S
CONDITIONS! ped C011iSiOn Ambulance Equipment : $ 102 , 470 scheduled Equipment / 01 , 000 TAXES S
OTHER ped except $ 5 , 000 as re eCta wind/hail and flood / " Broad Form "
COVERAGES
ESTIMATED TOTAL PREMIUM 5
NAME 8 ADDRESS
MORTGAGEE ADDRIONALINSUREO
LOSS PAYEE —..._ . . . , .. . --LOANS
AUT D EPRETA•
Fl ida HospitaI Vociation
ACORO 75-S ( 1198 ) NOTE : IMPORTANT STATE INF ORMA ION ON REVERSE SIDE @ACORO CORPORATION 1993
1,
Internal Revenue Service
District Director Department of the Treasury
Date: 'MM 2 6 1985
EmPlorer Identification Number.
59- 2496294
Accounting period Ending:
September 30
Form 990 Required: ® Yes 0 No
Indian River Memorial Hospital , Inc .
1000 36th Street Person to Contact:
Vero Beach , FL 32960 Brenda Wilcox/cdt
pct TtIePhone Number.
(404) 221 - 4516
File Folder Number :
580062333
Dear Applicant :
Based on information supplied
and assuming Your operations will be as stated
in Your application for recognition of • Px
from Federal income tax under' ' *
501 ( c ) ( 3 ) -ofwtheaInternal mined You are exempt
Revenue Code .
We have further determined that you are not a
meaning of section 509 ( x ) of the Code , because private foundation within the
section 170 (b ) ( 1 ) (A) (iii) S 509 (a) ( u , You are an organization described in
If your sources of support , or your
PurPchange , please let us know so we can consider othe � effectcof the changeter , or
on Your
d of operation
exempt status and foundation status . Also , you should inform us of l changes in
Your name or address . i
As of January 1 , 1984 , You are liable for taxes under the Federal Insurance
Contributions Act ( social security taxes ) on remuneration of $ 100 or more
each of employees g
Imposed Yourunder the employees al during alcalendar year . You are not liable for thetax
to
Unemployment Tax Act ( FUTA ) .
Since you are not a private foundation , You are not subject to the excise taxes
under Chapter 42 of the Code . However
Federal excise taxes . If ' You are not automatically exempt from other
Federal taxes , You have any questions about excise , employment , or other
please let us know .
Donors may deduct contributions touas pov `
Bequests , legacies , devises , transfers , orgiftsrtoiYou or d u or section 1for your ussection of the Code
.
deductible for Federal estate and gift tax e are
provisions of sections 2055 , 2106 , and tax PurposesCif they meet the applicable
The box checked in the heading of this letter shows whether you must file Form
9909 Return of Organization Exempt from Income Tax ,
required to file Form 990 only if If Yes is checked , you are
than $ 25 , 000 . If a return is required ,r gross must receipt
ifiledabh year are normally more
month after the end of q Y the 15th day of the fifth
$ 10 a dg Your annual accounting period . The law imposes a I
y , le up to s maximum of $ 590lay , , when a return is filed late , unless of i
is reasonable cause for the delay .
I
Client#: 5887 INDIARIV1
ACORDrM CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY)
06/12103
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Palmer SO Cay of FL, LLC HOLDER. THIS CERTIFICATE DOES NOT AMEND , EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
1500 Mahan Drive , Suite 111
Tallahassee , FL 32308 INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A. American Cas Co of Reading PA
Indian River Memorial Hospital INSURER R National Union Fire Ins Co Pa
1000 36th Street
INSURFR C .
Vero Beach , FL 32960
INSURER D .
INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING
ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN . THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS , EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES . AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS .
TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
LTR NSR DATE MM/DD/YY DATE MM/DD/YY LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED ncel $
CLAIMS MADE a OCCUR MED EXP (Any one Fw.rson) $
PERSONAL R ADV INJURY $
GENERAL AGGREGATE $
GENS AGGREGAfF I IMIT APPI lES PH? PRODUCTS - COMP/OP AGG $
PRO-
PO-ILICY JECT I ( W
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO ( Fa accident )
AI. I OWNED At ITOS
BODILY IN. IURY $
SCHFDIJI FD M ITO ^ ( Per person )
HIRFD AIITOS
BODII Y INJURY $
NON r IWNI " 11 At H ( Y, ( Per artcldenl )
PROPERTY DAMAGE
(Per acodent)
GARAGE LIABILITY AUI O ONLY - !iA M ;CIDF NT
ANY AttTO O1HER THAN FA ACC $
AUTO TO ONI Y AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR aCI. AIMS MADE AGGREGATE $
$
DEDUCTIBLE
$
RF TFNTION $ $
A WORKERS COMPENSATION AND WC247857798 01 /01 /03 01 /01 /04 WRYLIMI I ( 1114
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXFCIITIVF - 1: I FAGII ACC: IDENF A1000yo- 00
OFF ICER/MF MHFR F X/CI . I IDFD "�
11 L 1 DISI: ASI FA F MPI rIYCF $ 1 , 000 ,000
YPs. desr'ribe under
SPECIAL PROVISIOWS below 1 . 1 DL'7F ASF POI IC:Y ( IMIT $ 1 , 000 ,000
B OTHER Medical Prof CNM7055124 12/01 /02 12/01 /03 $ 1 , 0004000
$ 3 , 000, 000 Aggregate
Shared Limit
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
** Supplemental Name **
Indian River Memorial Hospital
Indian River Hospital District
Indian River Hospital Foundation , Inc .
( See Attached Descriptions )
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Indian River Memorial DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _10_ DAYS WRITTEN
Hospital , Inc NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO DO SO SHALL
1000 36th Ave IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Vero Beach , FL 32961 REPRESENTATIVES .
AUTHORIZED REPRESENTATIVE
r /
ACORD 25 ( 2001 /08 ) 1 of 3 # S35512 /M35510 21 KPW r> ACORD CORPORATION 1988
IIMHIndian Lee M . Klinetobe
River Chairman, l3wrd of 0irec lots
Memorial
Jeffrey L . Susi
r.9001. Hospital President, Chwl Eviculive Oth (—el
We 're Here for Life
October 28 . 2003
Indian River County
Board ol ' ( ' ounly ( ' onuilissioners
1 840 25 ' x ' Slrcct
Vero [ 3each . I I , 32900
Re : ( ' amp Manatee
Dear Ms . .loIlnston - Carlsoil :
The intent of this letter is to verily general liability inscn,ance coverage liir Indian IZIVC14
Memorial I lospital . Inc . ( IRMI I ) . IRMII ' s general liability insurance program presently
consists of '.
• A sell- insured retention ( SIR ) with coverage limits ol ' $ 5 , 000 . 000
0 An umbrella insurance policy issuccl by Admiral Insurance Company ( Rated A L
VIII by A . M . Best and hart ol ' thc Berkley Group ol ' companics )
providing coverage of ' $ 10 . 000 . 000 in cxccss our SIR subject t« an annual
aggregate or $ 10 . 000 , 000 ol ' claims paid .
• An excess liability insurance policy issued by Steadfast Insurance Company
( Rated A XV by A . M . lest and part ol ' the Illl' ICI1 C11-oup ) providing coverage or
$ 10 . 000 , 000 in cxccss or our Admiral policy subject to an annual aggregate or
$ 10 . 000 . 000 claims paid .
The current policy period is Octohcr 12 . 2003 to October 12 . 2004 . 1 trust that this
will
salisly vour rcyucsl liar insurance inl,6rmation relating to Indian River Memorial I lospital .
Inc . II ' you have any yucslions regarding this matter. please call n ► c at ( 772 ) 567 - 431
1
extension 1153 .
Very Truly Yours .
Gregory=01' 4
Director I financial Reporting
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ViFJoll : 1 , 11