HomeMy WebLinkAboutFlorida Municipal Insurance Trust Application 2004 PE -2004 10 05
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FLORIDA MUNICIPAL INSURANCE TRUST
GOVERNMENT APPLICANT: City of Winter Sonnas
ACCOUNT NUMBER: TYPE OF GOVERNMENTAL ENTITY: Municipality
ADDRESS: 1126 East State Road 434. Winter Sorinas, FL 32708
FEDERAL EMPLOYER IDENTIFICATION NUMBER: 591026364 0 NOTIFICATION TO DEPARTMENT OF COMMERCE
OFFICIALS AUTHORIZED TO EXECUTE CONTRACTS:
I. Name: II. Name:
Title: Title:
PRIOR INSURANCE COVERAGE CARRIED BY: Florida Municioallnsurance Trust
Applicant hereby makes application with the Trust for continuing membership for liability, property, allied lines, automobile physical damage,
workers' compensation, employers' liability, medical, dental, short-term disability, and/or life coverage, to be effective 12:01 a.m. October 1, 2004 and, if
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 periodically 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 late 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 corporate 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 least forty-five (45) days prior to
cancellation; .
(I) 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;
(g) That, jf workers' compensation or employers' 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
(Form Np. LES Form DWe 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 medical, dental, short-term disability, and/or life coverage is placed with the Trust, the probationary per~C?d for ne\V .employee!;. ~I!<!II be:
( ) 30 days' () 60 days ( ) 90 days ( ) other
WITNESSES TO SIGNAT~
CiyofWlo,..SP'09' . .9~' , ~
Name of Applicant .., ame
~~~ ~~ 1126 East State Road 434, Winter Springs, FL 32708
/ . Author" Officer Address
CORPORATE
~L ". .
. d- ,~~ ~~ ~oJa.k
Clerk or Secretary Name
OCTOBER 5, 2004 112 East State Road 434,Winter Springs, FL 32708
. Date Address
IS HEREBY APPROV!::D i=OR MEM9ERSHIP IN THIS TRUST, AND COVERAGE IS EFFECTIVE THE 1ST DAY OF OCTOBER, 2004.
SIGNED THIS DAY OF ,20_
BY:
(10/96) AdministratorfTrustee Centr