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Home My WebLink AboutDocumentation_Pension Public Safety_Tab 18_02/05/2007V~Ilage of Tequesta For the Period: 1011/2005 to 9/30/2006 REVENUE/EXPENDITURE REPORT Page: 1 12R/2006 3:41 pm Original Bud. Amended Bud. YTD Actual CURR MTH Encumb. YTD UnencBal % Bud u i - ~enerai runs Ex ures Dept 160 General Govemment Acct Class: 530 Operating Expenditures/Expense 545.300 Insurance 10/01/2005 GJ OCT 05 PRE PYMT -INSURANCE PARTNE LIABILITY INS 53631.12 3,631.12 11/23/2005 AP ACORDIA SOUTHEAST POLICY#CPP001750010, FY O6 654.00 tNV#: 11102005 11/2312005 AP ACORDIA SOUTHEAST POLICY# PKFL105025050504 FY 06 10,500.00 INV#: 10052005 07!27/2006 BA PER RES # 88-05/O6, FUNDING FOR INSURANCE EXPENSES IN FY 2006 8,586.00 09/07/2006 AP ACORDIA SOUTHEAST #CCP001750012, FY 2007 657.00 INV#: 09062006 Insurance 6,200.00 14,786.00 15,442.12 657.00 0.00 39382 39411 44044 -056.12 104.4 Operating ExpenditureslExpense 6,200.00 14,786.00 15,442.12 657.00 0.00 -656.12 104.4 General Govemment 6,21)0.00 14,786.00 15,442.12 657.00 0.00 -656.12 104.4 Expenditures 6,200.00 14,786.00 15,442.12 657.00 0.00 -656.12 104.4 Net Effect for General Fund -0,200.00 -14,786.00 -15,442.12 -657.00 0.00 656.12 Change in Fund Balance: p 00 i• ~' 2007 ~k-~ke -b~aM Nelms ~Z~~s ~oco - -~y,i s -N,~ -fir -rho V~tlaa~a c,~F - ~ert~itin --(~',nd s. SIB, ~,,~ Q(e co~e~~ ~~atlt~. U tbi- ~ i~c~.2s 601- ~ Ib~I.2S (a02 -`~ I~~, ~ (0~3 -~ I~t~~ 2S co-.er S ~~ ~. ~~ ~~~ Invoice # 09062006' r. Invoice Date Description 09106!2006 #GCP001750012, FY 2007 Distribution Gross: Check Amt Total: Amount 657.00 657.00 Eck #: 72847 ;heck Date: 09/14/2006 Check #: 72847 $657.00 **** I' ~_ ~ ~ - i,~ ,-_ ,,... - ;~, - _ _~-~ ~ - - ~ Total ~~ ~ VILLAGE F E II '~' Vendor #~ _ ~ Dater • ~ ~ • ~3 (C Mail Return t4 Dept. ' Vendor Name: i~G ~ 9 ~ A ~ - ~_ Address: .~D / S(wTN ~~,rt ~. L FR •Q R I ~E .'Sill r~lew _ ', `` s . - :~, - , ~, - Reason fnr Roqucst: (Please attach appropriate docunrentatfiin) _ ,, ~ ~y j.~._~ _ -; ; ~._ ~ ~. ~:afi~ s ~ 4 E _. Charge to Acxount 1Vo. +~~_~ 'Amount: ~i,4'~: v~ - i...~_ r ~ ~. ~ By: APPwed By: Special Instructions: -- REQUESTS RFCEIV~D IN FINANCE BY TUESDAY AT 5:00 PM WILL BY AVAILABLE FOR DISTRIBUTION BY THE FOLLOWING MONDAY AT NOON. PLEASE PLAN YOUR REQUESTS ACCORDINGLY! wPSOU~cysa«~~ ~q~c S01 South Flagler Drive Suite 600 West Prlm Beach, FL 33401 Voice: 561.655.5500 Fax: 561.655.5509 www.acordia.com August 8, 2006 Dan Gallagher ~' 'Village of Tequesta Q.O. Box 3273 Tequesta, FL 33469-0273 1EtE: Crime Policy #CCP001750012 Policy Term: 10/1/2006 - 10/1/2007 Dear Dan: • The Crime policy was automatically renewed for the term referenced above but the carrier needs the enclosed renewal application completed. The application has been partially completed for you. Please complete page 2 and sign page 5. We need the original signed application returned no later than 8/25/06. Please call us if you have any questions Sincerely, Pamela Poe, AAI Account Manager ~ ~~~ :` - i ,,` • VENDOR ~ P~# ~~ INV. DA INV ~~ Z3 D `~ DATE '~ -. !i c 3 ~E.. .. r..J `i .j FINANCE APP. _ A~ Wells Fargo Company ~ Membe, or me ~glabat Network ~' me ' eD is (List all irfsuned, incl ng Employee Benefits Plans) Mailing Address ~ ~~( _?,?7 ~, ~ (No.) " ApptignYs E-maiUWebsite Address b~ ~~~s7-~4- lG ~ -(6i~ for a Commercial Crime Policy to become effective or to be continued ~ of 12:01 a.m. on Name and address of obligee ff other than Insured: Limit of Deductible Agreement 1 -Blanket -Employee Theft (I~n}su~ra~nycey~ Amow~t Agreement 2 -Forgery or Alteration $ ~=~-~+-s~ $ ~'~ Agreement 3 -Inside The Premises -Then of Money & Securities ^ Blanket ~ Schedule $ S Agreement 4 - Inside The Premises -Robbery Or Safe Burglary Of Other property ^ Blanket ~ Schedule $ $ reement 5 -Outside The Premises -Theft of Money 8 Securities A~ Robbery of Other Property ^ Blanket ^ Schedule Agreement 6 -Computer Fraud $ S ~_ Agreement 7 -Money Orders And Counterfeit Paper Currency $ $ $_ S Other Coverages/Endorsements Limit of ped~Me Insurance Amount s s- s s Is Faithful Performance of Duty coverage, as prescribed by law or your constitution and by-laws, requested? Premium Payable: Annual (]Three ear ne d ~ Yes y p Par Three year in equal annual installments DESCRIPTION OF YOUR ORGANIZATION: ', 1. Classify your predominant activity: Manufacturer ^ Processor ^ Wholesaler ~ Retailer ^ Servicer ^ Govemmental~ Other ~ (explain) II 2. Describe the products and services of your predominant busine ss or activity i- Are you a Proprietorship ^ Partnership(] Corporation OtherQ a. If a corporation, does any employee own more than 50% of the stock? Yes ^ No If "Yes", give name and percentage: Number of additional locations? Retail Not Retail .Date you were established • li CR 4724m (Ed. 03-02) Policy No. CCP 0017500 12 FIDELITY AND DEPOSIT COMPANY OF MARYLAND ~ Administrative O COLONIAL AMERICAN CASUALTY AND SURETY COMPANY APPLICATION FOR A COMMERCIAL CRIME POLICY FOR COMMERCIAL AND GOVERNMENT ENTITIES (Courrty) Distributor ^ 1400 American l.n Schaumburg, Il_ 60196 s s s ^ No Page 1 of S 6. • Are there arty foreign loptions? ^ Yes ~o H °Yes", list countries and number of empbyees: Country No. of Employees 1. 2. 3. 4. 5. 6. 7. 8. 1. 2. AUDIT PROCEDURES AND INTERNAL CONTROLS IF A QUESTIQN IS ANSWERED'NO", EXPLAIN WHAT ALTERNATE CONTROL IS IN EFFECT (ATTACH SEPARATE SHEET WITH EXPLANATIONS) Do you have a CPA Audit, at least annualy, made in accordance with generaNy accepted auditing standards and so certified? ..................................................................._..................................................... Are bank accounts reconclled monthly by someone not authorized b deposR or withdraw therefrom? ....................., Is oountersgnatun: of dews required? .............••---....._........._................._............................. Are incoming checks immedatey stamped "For Deposr~ Only' to the credit of applican? ......................................... Are all deposits made in the name of applicant? ..............................~........................... Are securities subject b joint control by two or more responsible employees? ................................................. . ... Is an inventory of merchandise taken at least annrrallyrt ........................._.._..... Is at least one continuous week of vacatbn taken annuaNy try aa ................................................. .~.. employees? .......................................................... COMMERCIAL EMPLOYEE CLASSIFICATIO .A' Number of Officers N~ Number of empbyees in the following dassfications: l`r No. of I No 0 Accountants and Asst Accountants Adjusters • Administrators and Asst. Administrators Appraisers and Clerks acting as Appraisers Altomeys Auditors and Asst Auditors Bookkeepers Bursars and Asst. Bursars Bus Drivers Buyers and Asst Buyers Canvassers (door-to-door Salespeople) Cashiers and Asst Cashiers Chairpersons Chefs who order food Collectors ComPueer Programmers Comptrollers and Asst. Comptrollers Credit Clerks and Mamagers Clistodlans Flood Inspectors Head Phammacists Instn~ctont having custody of money or securities Janibrs Ledger Keepers Locker Room Attendants Maitre d's and Asst Maitre d's Managers and Asst Managers Medical Directors Messengers, outside Payroll Distributors Purchasing Agents and Asst Purchasing Agents i~ Yes Yes Yes ^ Yes Yes ~ Yes ^ Yes ^ Yes No[ No[ Nod Nom Nom No^ No® No^ j No. of Receiving perks Salespeople Security Personnel Service Stafbn Attendants Shipping Clferks Stock Clert~s Storekeepers Storeroom Personnel Superintendents and Asst Supedntendlents Supervisors and Asst Supervisors Taxi Drivers Timekeepers. Truck Drivers Warehouse Personnel Atl other employees not listed who handle, have custody or maintain records of money, securities or other 3. Number of all other empbyees ~°~' GOVERNMENTAL EMPLOYEE CLASSIFICATION Note: Persons required bylaw to be individually bonded and treasurers or tax collectors by whatever title known are automatically excluded from coverage under the Government Crime Policy. 1. Number of officials/officers, not required by law to be individually bonded, who are authored to manage, govern or camtrol the Insured's empbyees _L_ ,`~mber of empbyees who handle, have custody or maintain records of money, securities or other property; department and division ds; assistant department and division heads; and peace officers (including patrolmen when Faithful Performance of Duty Coverage is being written) ~_ 3. Number of all other employees (including patrolmen, when written for Honesty Coverage only) 41 CCR 4724m (Ed. 03-02) Page 2 of 5 ," ~ MONEY -SECURITIES TER THE EXPOSURES FOR EACH CATEGORY. AMOUNTS ENTERED SHOULD BE MAXIMUM E~OSURE TYPE MONEY CHECKS FOR CHECKS FOR PAYROLL MONEY DEPOSIT ACCOUNTS PAYABLE (NECKS OVERNIGHT ~..~~~~~ MESSENGER #2 PROPERTY s sECURmEs GENERAL INFORMATION AVGiI CHECKS FREQUENCY NIGHT ANNUAL GROSS SALES DOES PREMISES BUSINESS HOURS EMPLOYEES STAMPED FOR OF DEPOSITORY OR RE~pTg FOR HAVE DOUBLE CYL- ON DUTY DEPOSIT ONLY DEPOSITS USED LAST FISCAL YEAR INDER DOOR LOCKS? OTHER MrFORMATKRI YES NO 8: 3~- s: so yEs Aa~L ,' x ~AFENAULT MANUFACTURER LABEL CLAgg ~~ ~~ COMBINATION LOCKS '-1~11 ROUND I SQUARE OUTER I TIMER I CHEST ~..~ ~~ WALL MESSENGER PROTECTION MESS'GR tROFGUARDS # PER MESSENGER PRIVATE SAF~y CONVEYANCE SATCHEL PRIVATE MESS'GR # OF GUARDS SAFETY USED? USED? # PER MESSENGER CO ~ ANCE SA~II~ USEp7 YES ^ NO ^ YES ^ NO PREMISES/SAFE PROTECTION ^ YES ^ NO ^ YES ~ NO ALARM TYPE ALARM DESCRIPTION EXTENT OF PROTECTION r'R~E ALARM INSTALLED AND SERVICED BY HOLD-UP LOCAL GONG SAFEIVAULT PREMISES # GUARDS WATCHPERSON; PREMISES CENTRAL STATION RPfICEIYf ST SAFE POLICE CONNECT PNiiM1L 1 2 3 pp~E # WATCH PERSONS CLOCK HRLY WITH KEYS ACCESSIBLE OPENINGS 8 PROT DG7VTSIGNAL CERTiFlCATE NUMBER ECTION OTHER PROTECTION (Fences Floodlights, ste.~ i• SCR 4724m (Ed. 03-02) Page 3 of 5 ~, 3. ~~ PRIOR CRIME INSURANCE HISTORY Has any similar ins ~n~it to that being applied for been declined or cancelled in the last three years? (not applicable in the state Missouri) YesQ N1~ ff ~~w expla in 2. List all bsses sustained during the past three years, whether reimbursed or not, from Check if non@~ tsnetry tlescribe each loss and explain corrective measures on Dat e Amount Amok Amount of of Recovered of Loss Los Loss from Insurance Pending s tf this policy replaces similar crime insurance, list the prior insurer. (month,day,year) (month,day,year) Amount Recovered from other than Insurance ~~ D If Loss occurr~ Type at other than of Head Office, Loss Fate location Check if none ^ Will this Policy supplement a spedal mutU-peril or other package policy? M "Yes", name insurer. Yes ^ No Effective Date Policy No. n is understood that the first premium upon the Policy applied tor, and subsequent premiums thereon, are due at the beginning of each premium period, that the Company is entitled b additional premiums bezause of any unusual increase in the number of Empbyees or Premises and that the Applicant agrees b pay all such premiums Promptly. The Empbyees of the Applicant have aq, b the best of the Applicant's knowledge and beNef, while in the service of the Applignt always performed their respective duties ho~Uy There has never come b its rrotice or knowledge any information which in the judgment of the Applicant indicates that any of fhe said Empbyees are dishonest. Such knowledge as any officer signing for the Applicant may now have in respect b his own personal acts or conduct, unknown b the Applcant, is not imputable b the Applicant FRAUD NOTICES: Prtor to signing this Proposal Form, please review the following statutory fraud notices as they may apply to the Company's domicile: ARKANSAS: Any person who knowingly presents a false or firaudulent claim for payment of a bss benefit or knowingly presents false infomnatbn in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information b an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information b a policy holder or claimant for the purpose of defrauding or attempting b defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported b the Colorado Division of Insurance within the Department of Regulatory Agencies. DISTRICT OF COLUMBIA: WARNING: It is a crime b provide false or misleading information b an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false i^`--rmation materially related to a claim was provided by the applicant. DA: Any person who knowingly and with intent b injure, defraud or deceive any insurer files a statement of claim or an application c~iing any false, incomplete or misleading statemerrt is guilty of a febny of the third degree. KENTUCKY: Any person who knowingly and with intent b defraud any insurance company or other person files an application for insurance containing materially false information or conceals for the purpose of misleading, information concerning any fact material CCR 4724m (Ed. 03-02) Page 4 of 5 thereto commits a fraudulent insurance act, which is a crime. LOUISIANA: Any person who knowingly Presents a false or fraudulent claim for payment of a kiss or benefit or knowingb Pm~nts fats ~nforrnation in an application for insurance is guilty of a rxirne and may be subject to fines and confinement in prison. ~AINE: h is a crime to knowingly provide false, incomplete or misleadingpifom~atkm to an insurance company for the purpose of defrauding the company. Penalties may include imprisonrmer~, fines or a denial of insurance benefits. NEW JERSEY: Any person who includes any false or misleading infomnation on an applcation for an insurance policy is subject to criminal and dull penalties. NEW MEXICO: Any person who knowingly preserds a false or fraudulent claim for payment of a bss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NEW YORK Any person who knowingly and with intent b defraud any insurance company or other person files an application 6or insurance or statement of claim containing materially false information or conceals for the purpose of misleading. information concemirig any fact material thereto. commits a fraudulent insurance ad:, wMch is a crime, and shah also be subject iJO a dull penalty not bo exceed five thousand dollars and the stated value of the claim for each such violation. claim contains a false or d intent b defraud or knowing tlrat lte is facilitating a fraud against an insurer, submits an application or files s ng eceptive statement is guilty of insurance fraud. OIaAHOM~I• Arty person who knowingly and with intent to injure. defraud or deceive any Insurer, makes any claim for the proceeds of a insurance policy, containing false, incomplete or misleading information is guiKy of a felony. PENNSYLVANIA: Any person who knowingly and with irrtent b defraud any insurance company or other person files an application firer insurance or sbtement of claim containing materially false information or conceals for the purpose of misleadng, information concerning any fact material thereto, commits a fraudulent insurance ad; which is a crime and subjects such person to criminal and dal penalties. TENNESSEE: ft is a crime to knowingly Provide false, incomplete or misleading inforrrration to an insurance company for the Purpose of defrauding the company. Penalties include knprisonmer~ fines and denial of insurance benefits. VIRGINIA It is a cxime to knowingly Provide false, incomplete or misleading information to an insurance company for the purpose o defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. Dat this day of • T~'~d~ srx- , ~LsR~oyt- ~ ~ SFP~MB ~R ~~ ~.Lq ~ ~ mF -s~'~d~r~ (Insured) (FL 8 IA Only) Ucensed Agent or Broker (FL Only) License Number. _• ~~~~ cK (Name and Title) .~ ~~- ~OZ $ ~~ ~ CCR 4724m (Ed. 03-02) Page 5 of 5