HomeMy WebLinkAboutDocumentation_Regular_Tab 06G_10/07/2004 RESOLUTION NO. 07 -04/OS
A RESOLUTION OF THE VILLAGE COUNCIL OF THE
VILLAGE OF TEQUESTA, PALM BEACH COUNTY, FLORIDA,
AWARDING A ONE-YEAR EXTENSION OF THE CONTRACT
FOR WORKER'S COMPENSATION INSURANCE TO
PREFERRED GOVERNMENTAL 1NSURANCE TRUST, IN THE
AMOUNT OF $211,300.00 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 OF
THE VILLAGE OF TEQUESTA, PALM B EACH C OUNTY, F LORIDA, A S
FOLLOWS:
Section 1. The Preferred Governmental Insurance Trust renewal quote attached
hereto as Exhibit "A" and incorporated by reference as a part 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 Councilmember
, 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.
MAYOR OF TEQUESTA
Pat Watkins
ATTEST:
Gwen Carlisle, Village Clerk
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TO: Robert Garlo
FROM: Daniel J. Gallagher
DATE: 9/28/04
SUBJECT: Workers' Compensation Insurance
Attached is a Renewal Quote and an application for Workers' Compensation
Insurance for our Village which will, if approved, become effective October 1,
2004.
It is worth noting that the total premium is $21 1,300.00, which is less than we
paid last year in 2003-2004 of $227,903.00, is a savings of approximately .074%
9/16/04
P
G PREFERRED GOVERNMENTAL INSURANCE TRUST
I WORKERS' COMPENSATION APPLICATION
T
Producer Information:
Agency: Acordia Phone: 561-655-5500
Address: 501 South Flagler Dr., Suite 600 FEIN:
West Palm Beach, FL 33401 Fax: 561-655-5509
Agent ContacdProducer. Brian Cottrell Email: brian cottrell ,acordia.com
Apalicant Information:
Phone: 561-575-6209
Named Insured: Village of Tequesta
Physical Address: 357 Tequesta Dr. Fax: 561-575-6203
Tequesta, FL 33458
Mailing Address: P.O. Box 3273 FEIN: 596044081
Tequesta, FL 33469 NCCI Risk ID: 90280082
County: Palm Beach
Email: dgallagher tequesta.org
Contacts: Dan Gallagher
Underwriting: same Billing: same
Claims: same Loss Control: same
Policv Information:
Proposed Proposed Normal Anniversary
Effective Date: ]0/01/04 Expiration Date: 10/O1/OS Date: 10/O1
Employer's Liability Coverage Limits: lmil Each Accident
(ProgramLimitsare$1M/$IM/$1M) Imil DiseasePolicyLimit
Imil Disease Each Employee
Prior Carrier/Loss Historv Information -Provide hard couv for the roast 5 vears:
# of Claims
ANNUAL MED TOTAL
YEAR CARRTER PREMIUM Mod. ONLY IND. PAID RESERVES INCURRED
03/04 PGIT 227,903 1.30 3 1 10,627 46,584 57,211
02/03 PGI7 221,533 1.15 7 1 5,791 20,656 26,447
01-02 PGI7 134,330 1.03 11 3 61,150 11,779 72,929
00-01 PGIT 90,842 0.81 11 2 125,094 76,996 202,090
99-00 PGI7 93,048 0.83 13 3 194,106 0 194,106
*Note - details must be included on all individual claims in excess of $25,000 (See attch'd large loss sheet).
*If any year was subject to a deductible-please show both gross and net claims (attach additional sheet).
Page 1
9/16/04
PREFERRED GOVERNMENTAL INSURANCE TRUST
WORKERS' COMPENSATION APPLICATION
Volunteer Data:
1 Number of volanteer firefighters* I 1 *$1500 min. charge per vol firefighter and police
2 Number of volunteer police* 1
3 Number of all other volunteers
General Information:
Explain all "Yes" responses below. Yes No
I. Does a licant own, o erate or lease aircraft/watercraft? X
2. Do past, present, or discontinued operations involve storing, treating, discharging, applying, X
dis osin , or trans ortin hazardous materials?
3. An work erformed under round ar above 15 feet? X
4. An work erformed on docks, bar es, vessels, brid es, or over water? X
5. Are sub-contractors used? X
6. Are COI's re uired for sub-contractors? X
7. Do em lo ees travel out of state? X
8. Do ou lease em lo ees to or from other em lo ers? X
9. Is an labor rovided b work-release inmates? �
10. An rou trans ortation rovided? X
11. Are physicals required after offers of employment are made? If yes, list which departments
or ositions re uire h sicals below. x
12. Are volunteers utilized? If es, describe duties below. X
13. Are there an e of health or mental health faciiities? X
14. Is there a formal dru free ro ram in o eration? X
15. Is a formal safe ro ram in o eration? X
16. Does em lo er have a safe committee? X
17. Is there a formal Return to Work-Li ht Du ro ram in lace for all o erational areas? X
18. Is this a lication the result of an RFP? If es, attach RFP. X
Remarks•
Page 2
9/16/04
PREFERRED GOVERNMENTAL INSURANCE TRUST
WORKERS' COMPENSATION APPLICATION
RATING INFORMATION:
Check plan(s) desired:
Experience
X Guaranteed Cost Modification Factor: tbd
X Deductible $25,000
Retrospective Rating Plan Experience Effective Date: 1-Oct
°W� 1����HT� : �C� , :
# Full-time and 10/1/04-05
Class Code Descri tion Part-time Em lo ees Annual Pa roll
5509 Street or Road Maintenance 1 Y 157,428
7520 Watenvorks O erations 17 511,094
7704 Firefi hter & Drivers 25 1 029,814
7720 Police Officers & Drivers 26 999,308
8810 Clerical 31 1 207,551
9102 Park Noc-Em lo ees & Drivers 9 l88 I 12
9410 Munici al Noc 1 40 410
8742 Outside Sales 1 0
TOtals: 111 4,133,717
Please circle prefened billing payplan for new business - 25& 9/ Qtrly / Annual
Sienatures:
Upon acceptance of this application by PGIT, the undersigned applicant agrees to assume the obligations of
membership in PGIT and to be bound by the terms and conditions of the Interlocal Agreement dated August 1, 1999.
Applicant's Signature Date
Produ s Signature L/ —_ t Date
9 �z� a �
Page 3
9/16/04
PREFERRED GOVERNMENTAL INSURANCE TRUST
WORKERS' COMPENSATION APPLICATION
SUPPLEMENT
Manaeement•
Xes No
1 Written and Ado ted Safet Incentive Pro ram "�
2 Safe Director / Risk Mana er �'
3 Personnel Director
4 Disci lina Action Taken for Unsafe Acts �
5 Annual MVR for Authorized Drivers �
6 Post Em lo ment Ph sical Re uired �
7 Annual Em lo mentTurnover> 5% x
8 Employees Required to immediately Notify Supervisors of any X
Work lace Accidents Whether In'ured or Not
9 Formal Review of all Work lace Accidents
10 Any outstanding or Non Compliance with Mandatory Loss X
Controi Recommendations
Medical Facilities
12 Medicai Clinic on Premises ��
13 Firemen/Paramedics Personnel X
14 Police Personnel X
15 First Aid Kits Each De artment
16 Nearest Emer enc Room +/- IS Miles X
Other:
17 Is evidence of WC Covera e re uired of all Contractors erformin work X
on behalf of the enti ?
18 An work erformed under round or 15 feet or more above ound? X
19 Are employees prohibited from using their personal autos for business
u oses? x
20 An la offs, strikes, or labor dis utes within the ast 3 ears? �
21 Average Ratio of Lost Time Cases to Medical Only cases greater �
than L4?
EMPLOYEE TRAINING:
Describe (list) all Employees Safety Training Programs (workshops, seminars, video, etc)
completed within the past 36 months.
1.
2.
3.
4.
5.
Examales: Defensive Driving Proper Hiring Techniques
Job Hazard Analysis Proper Lifting Techniques
Accident Investigation OSHA Compliance
Recreational Safety
Page 4
PGIT - Preferred Governmental Insurance Trust
���� Premium Summary
p +�������� Guaranteed Cost Plan
GQYFRNM��,7�?.�.
�N�!t�^��:�--��? Current Options
NAME: Village of Tequesta POLICY DATE 10/01/03-04
MBR #:
AGENCY: Acordia, Inc. ANNIVERSARY 10/01
501 S. Flager Dr. #600 RATING DATE
West Palm Beach, F� 33401
CLASS ESTIMATED ES7IMATED %each code Net Net
CODE DESCRIPTION RATES PAYROLL PREMIUM to gross Premium Rate
5509 CT-STREE7lROAD MAINTENANCE-MUNICIPAL,COI. $ 11.34 149,514 $16,955 5.83°!0 $13,298 $8.89
7520 WATERWORKS OPERATION & DRIVERS $ 6.33 473,665 $29,983 10.32% $23,516 $4.96
7704 FIREFIGHTERS & DRIVERS $ 11.18 967,235 $708,137 37.21% $84,813 $8.77
7720 POLICE OFFICERS & DRIVERS $ 11.18 973,720 $108,862 37.46% $85,382 $8.77
8810 C�ERtCAI QFFICE EMP�OYEES NOC $ 0.62 1,076,152 $6,672 2.30°/u $5,233 $0.49
9102 PARK NOC - ALL EMPIOYEES & DRIVERS $ 10.37 160,848 $16,680 5.74% $13,082 $8.13
9410 MUNICIPAL,TOWNSHIP,COUNTY OR STATE EMPLC $ 73.91 23,633 $3,287 1.13% $2.578 $10.91
TOTALS 53,824,767 5290,576 100.00% $227,903
ESTIMATED MANUAL PREMIUM $290,576
EMPLOYERS' LIABILITY $290,576
$1,000, 000/$1,000,000/$1,000,000
DEDUCTIBLE $25,000 18.50% $53,757 $236.819
$236,819
SAFETY CREDIT 2.00% $4,736 $232,083
DRUG FREE WORKPLACE 5.00% $11,604 $220,479
10/03 EXPERIENCE MODIFICATION 1.30 $66,144 $286,623
ESTIMATED MODIFIED PREMIUM $286,623
PGIT DISCOUNT $28,662 $257,961
STOCK VOLUME DISCOUNT $30,258 $227,703
ESTIMATED DIRECT PREMIUM $227,703
EXPENSE CONSTANT $z00
ESTIMATED TOTAL PREMiUM SZ27,903
Optional Ded. Plan: $2,500 Ded Estimated Premium 5268,918
Optional Ded. Plan: $25,000 with estimated annual premium: 5229,854
Presumption Ded. Plan: $50,000 on afl presumption ctaims 5260,538
Ex erience Modification Factor is sub'ect to verification.
The above quote may inciude Safety and/or Orug Free Workpiace credits.
The final amount of ciedit is de endent u on com Ilance with io ram re uirements.
Pa roU sub ect to Final Premlum Audit.
Payment Plan: 25°/a Down and 9 equal instaliments
Due October 1 $70,518.50 $67,379.47 $65,284.53
8 monthly pmts @ $23,439.50 $22,393.17 $21,694.83 �
Last pmt. Due 7/1/04
No Ded. $2,500 Ded. Presumption Plan
- 9/16/04 10:02 AM
���� PGIT - Preferred Governmental Insurance Trust
Premium Summary
P�E����EO Guaranteed Cost Plan
� .4YEFNME -�
vsuRaNCE RusT Gd1Pf8/1! �/�tf�;t?S
NAME: t/illage oi �'z�y:�esta POIICY DATE 10/01/04-05
M8R #:
AGENCY: s'�ccrdia, Inc, ANNIVERSARY 10/01
501 S. Flager Dr. #6Q0 RATING DATE
Wesi Paim Beach, FL 334A1
C�p� ESTIMATED ESTIMATED %each code Net Net
CODE DESCRIPTION RATES PAYROLL PREMIUM to gross Premium Rate
55U9 CT-STREETlROAD MAINTENANCE-MUNICIPAL,COI. $ 11.34 15i $17,852 5.76% $12,161 $7J4
7��2J WATERWORKS OPERATION & DRIVERS $ 6.33 511,094 $32,352 10.45% $22,075 $4.32
?704 FIREFIGHTERS 8. DRIVERS $ 11.18 i.029,&14 $115,133 37.18% $78,558 $7.63
i I`�i:� POLICE OFFICERS & DRIVERS $ 11.18 a99.308 $111,723 36.08% $76,232 $7.63
881i:; CLERICAL OFFICE EMPLOYEES NOC $ 0.62 1.�Oi 57,487 2.42°h $5,109 $0.42
9102 PARK NOC - ALL EMPLOYEES & DRIVERS $ 10.37 1t38.1" $19,507 6.30% 513,310 $7.08
:742 SALESPERSONS - OUTSIDE $ 1.21 � #DIVlO!
9r'.0 MUNICIPAL,TOWNSHIP,COUNTY OR STATE EMPLC $ 13.91 40,410 $5,621 1.82°h $3,835 $9.49
TOTAlS 54,733,71T 5309,675 �00.00% $211,300
ESTIMATED MANUAL PREMIUM $309,675
EMPLOYERS' LIABIIITY $309,675
Qi ooa.orc�;�;,oceoc;e;c; ,�ne,r�i,r
DEDUCTIBLE $25,000 ?9 SO?/o $57,290 $252,385
$252,385
SAFETY CREDIT �.00°1� $5,048 $247,337
DRUG FREE WORKPLACE 5.00% $12,367 $234,970
10/04 EXPERIENCE MODIFICATION 1 13 $30,546 $265,516
ESTIMATED MODIFIED PREMIUM $265,516
PGIT DISCOUNT $26,552 8238,964
STOCK VOLUME DISCOUNT $27,864 $211,100
ESTIMATED DIRECT PREMIUM 5211,100
EXPENSE CONSTANT $200
ESTIMATED TOTAI PREMIUM SZ11,300
Annuai PrPmi�_im v�ith NcJ deduc4ible S2B8,590
Savings with Deductible 557,290
Avg. 4.5 years Out of Pocket 547,684
Ex rlence Mod/fication Factor ls sub'ect to verification.
The above quote may fnclude Safety and/or D�ug Free Workplace credits.
The flnal amount o/ credit is de ndent u n com /iance with m re ulrements.
Pa !1 sub ect to Final Premlum Audit
Payment Pian: 25% Do�vn 9 Equal �nstaliments
Due Oct.1 �52,9i4.Si
9 �tonthiy Insfaliments �17,�91.67
Last paymznt due 7/1/05
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