City of largo, florida proposal form

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CITY OF LARGO, FLORIDA

PROPOSAL FORM

FOR

WORKERS’ COMPENSATION THIRD PARTY ADMINISTRATION SERVICES

and

LIABILITY MANDATORY MEDICARE REPORTING
RFP # 11-P-370

The undersigned proposer does hereby agree to furnish the City of Largo, Florida, the items listed in accordance with the Specifications shown by the Invitation for Proposal to be delivered to the specified site for the price indicated.

IT IS THE PROPOSERS RESPONSIBILITY TO CHECK THE WEBSITE www.largo.com

FOR FINAL DOCUMENTS AND ADDENDUMS BEFORE SUBMITTAL
THIS PROPOSAL MUST BE SIGNED BY A PERSON AUTHORIZED TO ACT FOR THE COMPANY IN HIS/HER OWN NAME.

PROPOSER NAME:
TAX ID# SSN or EIN:
PROPOSER ADDRESS:
PURCHASE ORDER ADDRESS:
PHONE NUMBER:
FAX NUMBER:
COMPANY WEB SITE:
COMPANY CONTACT (REP):
EMAIL ADDRESS(REP):
SIGNATURE:

CITY OF LARGO, FLORIDA

INSURANCE REQUIREMENTS CHECKLIST

FOR 11-P-370
Items marked "X" must be provided
X General Liability Minimum Limits Required

x Commercial General Liability $ 2,000,000 General Aggregate

x Occurrence Form $ 1,000,000 Product/Completed Operations Agg.

$ 1,000,000 Personal & Advertising Injury

$ 1,000,000 Each Occurrence

$
X Automobile Liability

Owned, Hired & Non-Owned $ 1,000,000 Combined Single Limit per Occurrence

X Worker's Compensation Statutory

and Employer's Liability $ 100,000 Each Accident

$ 500,000 Disease - Policy Limit

$ 100,000 Disease - Each employee
X Professional Liability - Errors & Omissions (*To be completed by Bidder)

* Deductible: $ $ Aggregate

* Claims Made (Y/N): $ Each Claim

* Occurrence (Y/N):

* Defense included in Limits (Y/N):

Builder's Risk - Installation Floater (* To be completed by Bidder)

* Flood Included $ Limit $ 100% of Completed or Installed Value

* Transportation Included $ Limit All-Risk Form

* Storage Included $ Limit

City Must Be A Named Insured. Copy of Policy Will Be Required.
Other
$
$
X The Certificate of Insurance must show "The City of Largo, elected officials and employees" as an additional insured, except for Workers’ Compensation and Professional Liability.
X Certificated must give to the City of Largo 30 days' prior written notice of cancellation, non-renewal, or adverse change.
X Certificates must identify bid number and bid title.
Subcontractors must carry the same Insurance limits.
Insurance Carriers should be A rated.

Statement of Bidder:
We understand the requirements requested and agree to comply fully.

Bidder - Authorized Signature
A complete copy of this form with original signature must accompany bid.

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