HomeMy WebLinkAboutSworn StatementIII. Worker's Compensation
Limits of Liability
Statutory -State of Florida
IV. Employer's Liability
A. Limits of Liability
$100,000 for bodily injury caused by an accident, each accident
$100,000 for bodily injury caused by disease, each employee
$500,000 for bodily injury caused by disease, policy limit
NOTE: All certificates of insurance must be provided for review and
approval prior to the effective date of the agreement.
The above policies shall provide the City of Miami with written notice of
cancellation or material change from the insurer not less than (30) days prior to any
such cancellation or material change.
Companies authorized to do business in the State of Florida, with the following
qualifications, shall issue all insurance policies required above:
The company must be rated no less than "A" as to management, and no Less
than "Class V" as to Financial Strength, by the latest edition of Best's Insurance
Guide, published by A.M. Best Company, Oldwick, New Jersey, or its
equivalent. All policies and /or certificates of insurance are subject to review and
verification by Risk Management prior to insurance approval.
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 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, 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 a relation to the entity
submitting this sworn statement. (Please indicate which statement applies).
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, or any
affiliate of the entity has been charged with and convicted of a public entity crime within the past 36 months.
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 within the past 36 months.
AND (Please indicate which additional statement applies).
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
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 within the past 36 months. However, there has been a subsequent
proceeding before a Hearing Officers of the State of Florida, Division of Administrative Hearings and the
Final Order 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. (Attached is a copy of the final order).
1 UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER FOR
THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THE PUBLIC ENTITY
ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR
IN WHICH IT IS FILED AND FOR THE PERIOD OF THE CONTRACT ENTERED INTO, WHICHEVER
PERIOD IS LONGER. 1 ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC
ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT
PROVIDED IN SECTION 287.017, FLORIDA STATUTES, FOR CATEGORY TWO OF ANY CHANGE
IN THE INFORMATION CONTAINED N THIS FORM.
(Signature)
Sworn to me and subscribed before me this 315 day of Act y «.s ►-- ,-if wv.7
Personally known
Or produced identification Notary Public —State of C
(Type of Identification)
CARYLON L'''r1
Il'p A MY COMMISSION
a` EXPIRES: February 1;,'
Bonded T'ru Notary Public Unlerwcr•
My commission expires
(Printed, typed or stamped commissioned name of notary public)
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