The URL can be used to link to this page

Home My WebLink AboutFlorida Municipal Insurance Trust Application -1997 01 27,rt- APPLICATION TO FLORIDA MUNICIPAL INSURANCE TRUST GOVERNMENT APPLICANT: City of Winter Springs acc~uNT NuMgER: ~~ 648 TYPE OF GOVERNMENTAL ENTITY: _ Municdpality ADDRESS: 1126 East State Road 434, Winter Springs, FL 32708 FEDERAL EMPLOYER IDENTIFICATION NUMBER: 5 9 -1 (12 h 3 4 OFFICIALS AUl'HORIIED TO EXECUTE CONTRACTS: Name: Ronald W. McLemore Title; City Manager Title: PRIOR INSURANCE COVERAGE CARRIED BY: Florida Municipal Self Insurers Fund and/or Florida Municipal Health Trust Fund Applicant hereby makes appUcation with the Trust for continuing membership far liability, property, allied lutes, automobile physiu~al damage, workers' compensation, employers' liability, medical, dental, short-term disability, and/or life coverage, to bs effective 12:01 a.m. October 1: 1996 and, ff accepted by the Trust's 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 Applicant's. 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 perkxiically by its Board of Trustees, a copy of which Applicant hereby 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 obligations set forth therein; (b) That Applicant will pay all premiums on or before the date the same shall become due and, in the event Applicant fails to do so, will pay any reasonable Tate penalties and charges arising therefrom and all costs of collection 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 Trust's 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 Applicant's ~rporate or business structure, or if any locations are to be added or deleted from any coverage provided by the Trust, will notify the Trust immediately; and that Applicant further understands that, if workers' compensation coverage or employers' liability coverage is provided by the Trust, the failure to provide said notice within thirty (30) days of any such change may result 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 will give written notice to the other at toast forty-five (45) days prior to cancellation; (f) That, by this reference, the Applicant consents to and otherwise approves of the cessation of business of the Florida Municipal Self Insurers Fund and the Florida Municipal Health Trust Fund, and to the transfer of the Funds' management, operations, assets and liabilities to the Trust; (g) 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 attorney's fees, which would have otherwise been incurred by the Trust or the Board hereunder absent such default on the part of the Applicant; (h) That, if workers' compensation oremployers' liability coverage is placed with the Trust, Applicant will accept and be bound by the provisions of the Florida Workers' Compensation Act, that coverage arising from this Application shall be for Florida operations only, and that the Wage Declaration Schedule and/or Renewal Certificates, when completed and returned to Applicant by the Trust, shall become a part of this agreement; and (i) That, if medical, 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 City of venter uprings Name of Applicant G~y' Authorized Officer CORPORATE SEAL Clerk or cretary /~~~'9G Date NOTIFICATION TO DEPARTMENT OF COMMERCE 11. Name: Q ~/ Name Address L 3270 GJ,;~ T~ sP,eiN~s-s, ~ Q0 Name ~ ~a 1. ~. , S .Q . y 3y s.al,~.~... Address ~ 1 oY IS HEREBY APPROVED FOR MEMBERSHIP IN THIS TRUST. AND COVERAGE IS EFFECTIVE THE 1st DAY OF October, 1996 SIGNED THIS 9AY , 19 BY: _ Administrator/Tr stee (10/96) Florida League of Cities, Inc. 201 West Park Avenue Post Office Box 1757 Tallahassee, FL 32302-1757 Telephone (904) 222-9684 Suncom 278-5331 FAX (904) 222-3806 Reply to ~~~ ~c ___ c `'~ V V` E~ F![ORIUA IFAGIIlE OF CITIES TO: Participants Florida Municipal Insurance Trust FROM: Administrator Florida League of Cities, Inc. RE: Signed Application DATE: March 25, 1997 Florida League of Cities, Inc. Public Risk Services 135 East Colonial Drive Post Office Box 530065 Orlando, FL 32853-0065 Telephone (407) 425-9142 Suncom 344-6767 Reply to ~~ ~Yq ~~i ~~~ ~~~, ~ o ~ 9is~M~ti~rFR ~99j gQ~1'~~~cs Enclosed is your signed application to the Florida Municipal Insurance Trust. Please keep this with your Insurance Package. We will also be keeping one in our file. Florida Municipal Self Florida Municipal Health Florida Municipal Pension Florida Municipal Insurance Insurers Fund (Workers' Trust Fund Trust Fund Trust (Liability and Compensation) Property)