2016-53 Workers Compensation InsuranceRESOLUTION 2016 -53
A RESOLUTION OF THE VILLAGE COUNCIL OF THE VILLAGE OF
NORTH PALM BEACH, FLORIDA, ACCEPTING THE PROPOSAL OF
PREFERRED GOVERNMENTAL INSURANCE TRUST TO PROVIDE
WORKERS' COMPENSATION INSURANCE FOR THE VILLAGE AND
AUTHORIZING MEMBERS OF VILLAGE ADMINISTRATION TO TAKE
ALL ACTIONS NECESSARY TO IMPLEMENT THE POLICY; PROVIDING
FOR CONFLICTS; AND PROVIDING FOR AN EFFECTIVE DATE.
WHEREAS, the Village requested that The Gehring Group issue a request for proposals for
workers' compensation insurance for the Village; and
WHEREAS, the Village's current provider, Preferred Government Insurance Trust, submitted a
proposal that reduces the overall cost to the Village; and
WHEREAS, the Village Council determines that the acceptance of the proposal submitted by
Preferred Government Insurance Trust is in the best interests of the Village and its residents.
NOW, THEREFORE, BE IT RESOLVED BY THE VILLAGE COUNCIL OF THE VILLAGE
OF NORTH PALM BEACH, FLORIDA as follows:
Section 1. The foregoing recitals are hereby ratified and incorporated herein.
Section 2. The Village Council hereby accepts the proposal submitted by Preferred Governmental
Insurance Trust to provide workers' compensation insurance to the Village in accordance with
the pricing, terms and conditions set forth in the proposal. The Village Council further authorizes
members of Village Administration to take all actions necessary to implement the insurance
policy as of October 1, 2016, including, but not limited to, execution of all required agreements.
Section 3. All resolutions or parts of resolutions in conflict herewith are hereby repealed to
the extent of such conflict.
Section 4. This Resolution shall take effect i
PASSED AND ADOPTED THIS 8TH DAY OF
(Village Seal)
ATTEST:
VILLAGE CLERK
Public Risk Underwriters
PO Box 958455
f Lake Mary, FL 32795 -8455
Phone: 321- 832 -1450
Fax. 321 - 832 -1489
Public Entity Application 08/25/16 2:57 PM
New Member Application Muni [WQ2FL1 0502503 16 -01]
Portal Reference # 211338
Coverage Term 10/01 /2016 -10/01/2017 Page 1
Name:
General Member Information
North Palm Beach, Village of
Mailing:
501 US Highway 1
City /State /Zip:
North Palm Beach, FL 33408 -4906
Physical:
501 US Highway 1
City /State /Zip:
North Palm Beach, FL 33408 -4906
Member Contact Information
Contact: Britoni Garson
Additional Member Information
FEIN: 59- 6017984 NCCI Risk ID:091718421
Title:
Population 12500
Phone #:
Fax #:
County: Palm Beach
Email:
Member Type: Municipality
Agency:
Aqencv Information
Gehring Group
Aqencv Contact Information
Contact: Rodney Louis
Address:
11505 Fairchild Gardens Avenue
Phone #: 561- 626 -6797
Suite 202
Fax #:
City /State /Zip:
Palm Beach Gardens, FL 33410
Email: rodney.louis @gehringgroup.com
Phone #: 561 - 626 -6797 Fax #: 561 -626 -6970
CERTIFICATION
The undersigned being authorized by, and acting on behalf of the applicant and all persons /concerns seeking insurance, has read and
understands this Application, including any appendices and /or supplements, and declares that all statements set forth herein are true, complete
and accurate. The undersigned acknowledges and agrees that the submission and the Trust's receipt of such written report, prior to the
inception of the coverage agreement applied for, is a condition precedent to coverage.
The signing of this Application does not bind the undersigned to purchase the coverage, nor does the review of same bind The Trust to issue a
coverage agreement. This application shall be the basis of the contract, should one be issued.
This Application must be signed by the "Ranking Elected ! Appointed Official" of the Entity making the application (e.g. Chair,
President, Superintendent or Executive Director of the Educational Entity) or the Risk Manager (or ranking official) assigned this
function.
SIGNATURE:
TITLE:
DATE:
L
NOTICE TO APPLICANT
For your protection, the following Fraud Warning is required to appear on this application:
FLORIDA FRAUD STATEMENT
Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an application
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
PARTICIPATION AGREEMENT
Application for Membership in the Preferred Governmental Insurance Trust
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(b) That, by this reference, the terms and provisions of the Amended Interlocal Agreement creating the Preferred
Governmental Insurance Trust date October 1, 2004 are hereby adopted, approved and ratified by the undersigned
local governmental entity. The undersigned local governmental entity certifies that it has received a copy of the
aforementioned Amended Interlocal Agreement and further agrees to be bound by the provisions and obligations of
the Amended Interlocal Agreement as provided therein;
(c) To pay all premiums on or before the date the same shall become due and, in the event Applicant fails to do
so, to pay any reasonable late penalties and charges arising therefrom, and all costs of collection thereof, including
reasonable attorneys' fees',
(d) To ablde by the rules and regulations, adopted, by the Board of Trustees of the Fund;
(e) That should either the Applicant or the Fund desire to cancel coverage, it will give not less than thirty (30) days
prior written notice of cancellation�
(f) That all information contained in the underwriting application provided to the Fund as a condition precedent to
participation in the Fund is true, correct and accurate in all respects,
AA� <MbAl' sy�
Witness, Signatike
No'sigmu
e,
q4 i
Print Name
ot'North Palm Beach
IS HEREBY APPROVED FOR MEMBERSHIP I 'H FUIN',AND 'COVERAQE IS EFFECTIVE THE --L— DAY
OF –LLJL� L-t: �, 1 20 ±Lt
20 J_kj,_, SIGNE T' IS ? DAY OF
By:
Adminis MEMBERSHIP