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Home My WebLink AboutDocumentation_Regular_Tab 06E_10/07/2004 ��aFr,� � v _ '�' ��'`s �` N � "' 9 , �- � �' Q � a ' � ,�`. A.: q �v RANDUM ��y �au�K� � M E M O A TO: Robert Garlo FROM: Daniel J. Gallagher� DATE: 9/28/04 SUBJECT: Dentallnsurance Attached is an application to Florida Municipal Insurance Trust for Dental Insurance Coverage for our Village which will, if approved become effective October 1, 2004. It is worth noting that we will maintain the same cost per individual of $32.30 that we paid in the year 2003-2004. RESOLUTION NO. OS -04/OS A RE50LUTION OF THE VILLAGE COUNCIL OF THE VILLAGE OF TEQUESTA, PALM BEACH COUNTY, FLORIDA, AWARDING A ONE-YEAR EXTENSION OF THE CONTRACT FOR DENTAL 1NSURANCE TO FLORIDA MUNICIPAL INSURANCE T RUST, A PPROXIMATELY IN THE AMOUNT OF $23,000.00 FOR FY 2004/2005 BUDGET ALLOCATION, AND AUTHORIZING THE VILLAGE MANAGER TO EXECUTE THE CONTRACT ON BEHALF OF THE VILLAGE. NOW, THEREFORE, BE IT RESOLVED BY THE VILLAGE COUNCIL O�' THE VILLAGE OF TEQUESTA, PALM B EACH C OUNTY, F LORIDA, A� FOLLOWS: Section 1. The Florida Municipal Insurance Trust renewal quote attached hereto a� Exhibit "A" and incorporated by reference as a parl. of this Resolution is hereby approved and the Village Manager of the Village of Tequesta is authorized to execute the same on behalf of the Village of Tequesta. THE FOREGOING RESOLUTION WAS OFFERED by Councilmemb�r , who moved its adoption. The motion was seconded by Councilmember , and upon being put to a vote, the vote was as follows: FOR ADOPTION AGAINST ADOPTION The Mayor thereupon declared the Resolution duly passed and adopted this 7th day of October, A.D., 2004. MAYOK OF TEQUESTA Pat Watkins ATTEST:. Gwen Carlisle, Village Clerk � FLORIDA LEAGLIE OF CITIES� INC. P[1BLIC RISK SERVICES ❑ Administration/ September 17, 2004 Marketing 0 Risk Controi l� Underwriting Mr. Daniel J. Gallagher Property & Casualty Human Resources Admin' t tor Health Village of Tequesta Post Office Box 530065 250 Tequesta Dr, Ste 3000 Orlando, FL 32853-0065 Tequesta, FL 33469-2766 800-445-6248 407-425-9142 Suncom 344-0725 i�ear Member: Fax 407-425-9378 ❑ Health Claims As the administrator of the Florida Municipal Insurance Trust, part of our due diligence Post Office Box 538140 requires that we maintain updated documentation. As part of this function, we request Orlando, FL 32853-8140 that you update your current Participation Agreement. Please find enclosed, two original 800-756-3042 agreements that need to be signed in order to satisfy this requirement. One of the 407-245-0725 originals will be fully executed and returned to you for your records. Suncom 344-0725 Fax 407-425-9378 Portions of the application have already been completed. This was done to eliminate as many questions as possible and to facilitate a timely response. Please review the entire ❑ Workers' agreement, checking the already completed portions for accuracy and then filling in any Compensation Claims incomplete blanks. If you have any questions or have any problems completing the Post Office Box 538135 Orlando, FL 32853-8135 agreement, please contact Ms. Valerie Morrison in our Underwriting Department at 1- 800-756-3042 800-445-6248, 407-245-0725 Suncom 344 Please return both completed and signed agreements in the stamped, self Fax 407 envelope attached. ❑ Property & Liability Claims We appreciate your timely attention and response to this request. Post Office Box 538135 �, Orlando, FL 32853-8135 Si ce�e , 800-756-3042 407-245-0725 Suncom 344-0725 Fax 407-425-9378 Donald Lund CPA, CPCU, RMPE Director of Finance Enclosure Florida Municipal Insurance Trust APPLICATION TO FLORIDA MUNICIPAL INSURANCE TRUST GOVERNMENT APPLICANT: VillaQe of Te4uesta ;COUNT NUMB�R: FIUIIT 0596 TYPE OF G�VERNfviE:N i AL EN i I�Y: 'v7uni�ipal�:y ADDRESS: 250 Teauesta Dr Ste 3000 Teauesta FL 33469-2766 FEDERAL EMPLOYER IDENTIFICAT{ON NUMBER: ��-/� 0�/ ❑ NOTIFICATION TO dEPARTMENT OF COMMERCE OFFICIALS AUTHORIZED TO EXECUTE CONTRACTS: I. Name: II. Name: Title: Title: PRIOR INSURANCE COVERAGE CARRIED BY: Florida Munici�al Insurance Trust Applicant hereby makes application with the Trust for continuing membership for liability, property, atlied lines, automobile physical iiamage, workers' compensation, employers' liability, medical, dentai, short-term disability, and/or life coverage, to be effective 12:01 a.m. October 1, 2004 and, � accepted by the TrusYs duly authorized representative, does hereby constitute and appoint the Florida League of Cities, Inc., to act as Administrator of said Trust and to act as ApplicanYs agent-in-fact in all matters relating to its participation in said Trust and agent-in-fact to the extent any such coverage is placed with the Trust. Applicant, by execution of this Agreement, further agrees: (a) That, by this reference, the terms and provisions of the Agreement and Declaration of Trust creating the Florida Municipal Insurance Trust, as may be amended periodically by its Board of Trustees, a copy of which Applicant herebq acknowledges receipt, is hereby adopted, approved, ratified, and confirmed by Applicant; and further, Applicant will accept, assume, abide by and be bound by the provisions and obligatioos set forth therein; (`J) Ti�at App�icaii4 wi�t � ay - i3li - j�iETi4ITi� Cil �a� `UEfv`f'c fh2 i'i8i6 i� c �sha;f ,~.�^� �'i£��::2 0f?G',�il^, �~f,' 2:a!i. ::��iLEf:� `2t�3 t9 �J�SP,� ;�t:l r8�-3fl� . reaso�able late penalties and cfiarges arising therefrom and all costs of collectian thereof, including reasonable attorney's fees; (c) That Applicant, as long as it remains a member of the Trust; will abide by the rules and regulations adopted by the TrusYs Board and will conform its conduct to the terms of any agreements entered into by the Board to administer the Trust; (d) That Applicant, in the event of any changes in the ApplicanYs corporate or business structure, or if any locations are to be added or deleted from �y coverage provided by the Trust, will notify the Trust immediately; and that Applicant further understands that, if workers' compensation coverage or ,np{oyers' liability coverage is provided by the Trust, the failure to provide said notice within thirty (3�) days of any such change may resuit in the assessment of a civil penalty not to exceed $100 for each failure; (e} That should either the Applicant or the Trust desire to cancel coverage, it wi►I give written notice to the other at least forty-five (45) days prior to cancellation; (� That, should Applicant default hereunder, Applicant agrees to save and hold harmless the Trust and the Trust's Board from any and all damages, causes of action, claims, delinquency or expenses; including reasonable attomey's fees, which would have otherwise been incurred by the Trust or the Board hereunder absent such default on the part of the Applicant; (g) That, if workers' compensation or employers' iiability coverage is placed with the Trust, Appiicant wili accept and be bound by the provisions of the Florida Workers' Compensation Act, that coverage arising from this Application shail be for Florida operations only, and that the Wage Declaration Schedule (Form No. LES Form DWC 1A (11/96)) and/or Renewal Certificates, when completed and returned to Applicant by the Trust, shall become a part of this agreement; and (h) That, if inedical, dental, short-term disability, and/or life coverage is placed with the Trust, the probationary period for new employees shall be: () 30 days () 60 days �� 90 days () other WITNESSES TO SIGNATURE Village of Tequesta Name oi Applicant ^ Vame Authorized Officer Address CORPORATE SEAL Clerk or Secretary Name Date Address IS HEREBY APPROVED FOR MEMBERSHIP IN THIS TRUST, AND COVERAGE IS EFFECTIVE THE 1ST DAY OF OCTOBER, 2004. SIGNED THIS DAY OF , 20 _ BY: (10/96) AdministratorlTrustee