HomeMy Public PortalAbout2020-14 Selecting KB Soccer, Inc for management of the Village's Youth Soccer ProgramRESOLUTION NO. 2O2O.I4
A RESOLUTION OF' TITF'. VILLAGE COTJNCIL OF THE
VILLAGE OF KEY BISCAYI\TE, FLORIDA, SELECTING KB
soccE& rNc. FoR N{ANAGEMENT OF TIIE VILLAGE'S
YOUTH SOCCER PROGRAM; PROVIDING FOR
AUTHORIZATION; AI\D PROVIDING FOR All
EFFECTIVE DATE.
WHEREAS, the Village of Key Biscayne (the "Village') issued Request for Proposals No.
2020-16 (the "Mp") for management of the Village's youth soccerprogram (the "Services"); and
WHEREAS, on February 27,2020,an Evaluation Committee appointed by the Village
Manager short listed firms and ranked KB Soccer, Inc. (the "Contractor') as the most qualified
firm for the Services; and
WHEREAS, the Village Manager recommends that the Contactor be selected to provide
the Services; and "
WHEREAS, the Village Council desires to select Contractor to provide the Services and
enter into an agreernent with the Contactor consistent with tJre Confractor's proposal attached
hereto as Exhibit "A'o; and
WHEREAS, the Village Council finds that this Resolution is in the best interest and
welfare of the residents of the Village.
NOW, THEREFORE, BE IT RESOLVED By Tm VILLAGE COT NCIL OF TIrE
VILLAGE OF KEY BISCAYNE, FLORIDA, AS FOLLOWS:
S$ction 1. Recital$ That each of the above-stated recitals are hereby adopted,
confirmed, and incorporated herein.
Section 2. Selectioni That the Village Council hereby selects the Contractor for the
Services.
Page I of2
Section 3. Authorization. That the Village Council hereby authorizes the Village
Manager to negotiate and execute an agreement with the Contractor, consistent with the proposal
attached hereto as Exhibit "A," subject to the Village Attorney's approval as to form, content, and
legal sufficiency. If an agreement cannot be reached with the Contractor, the Village Manager is
authorized to negotiate and execute an agreement with the next highest ranked firm(s), in order of
ranking, until an agreement in the best interest of the Village is reached.
Section 4. Effectiye Date. That this Resolution shall be effective immediately upon
adoption.
PASSED and ADOPTED this 9'h day of March ,2020.
I
MICHAEL W. DAVEY
MAYOR
A
CHITA I{. ALVAREZ,MMC
INTERIM VILLAGE CLERK
\
APPROVED AS TO FORM AND LEGAL SUFFICIEN
* , "j
" ;t6t*!- .u?t.*,i -*_
WEISS SEROTA HELFMAN COLE & BIERMAN, P.L.
VILLAGE ATTORNEY
Page 2 of2
CRt 6rNA L C-O?Y
RESPONSE TO VILLAGE OF KEY BISCAYNE
RFP NO. 2020.16 - YOUTH SOCCER PROGRAM
I
TABLE OF CONTENTS
C. Leilter ol lntent
D. Reaponee Checkllst
E. Proposal Narratlve
F. Company Oualificatlone
G. Personnel Ouestions
H. Program Plan
l. Equlpment/llnllorms
J. lnsurance
K. Lltlgatlon Statemeffi
L Forms
M. Flnanclal $lability
N. Warranty
O. Reglstratlon Prlce Proposal
LETTER OF INTENT
Dear Mllage o{ Key Biscayne,
On behalf of KB Soccer, lnc. ("KBS"), we humbly submit this proposal in response to
RFP 2020-16, Youth Soccer Program forthe Village of Key Biscayne.
We believe the enclosed material will show that our history, qualifications, experience and
performance puts us in a unique position to continue to otfer a successful soccer program
in Key Biscayne.
Section 1.4 ol the RFP establishes lour eligibility requirements with which we comply.
#l - Three years of continuaus operation under the same name providing soccer
pragramming. As stated in this proposal, we have operated the Key Biscayne Soccer
Club ("KBSC') since 2010;originally under Key Biscayne Soccer club, lnc., and as KB
Soccer, lnc., since 2A12.
tf7' Proiect team must have at least one year of prior experience within the past ten
years providing soccer programming. As described in more detail in the Program Plan
and Key Staff Form, our Project team has been running the KBSC lor the last four (4)
years..
#3 - Successfully administered at least twoyouth soccer programs having more than
200 annual participants within the past tive years. KBS has run two youth soccer
programs over the past 5 years on Key Escayne: (1) A Recreational program including
a Pee Wee program, an Intramural program, and a Junior Academy program with close
to 400 kids; and a Competitive Travel program with over S00 players.
#4 - Respondent's program manager must have a minimum of five (S) years ot
experience managing youth soccer programming. our program manager, Marcelo
Radice, has been running the KBSC for the last ten years, and was previously the
Soccer Commissioner for the Key Biscayne Athletic Club from 2005-2007.
we are proud to serve Key Biscayne, and proud of being long-term members and
residents of this community. We have no agenda other than making soccer available to
every kid in Key Biscayne, and having them enjoy their experience.
tu
Marcelo Radice
President
KB $occer, lnc.
Form RC
REsPONSE CHECI(UST
Cover Page
Teblc of €ontents
Lefter of lntent
Form RC: Rcsponsc Chcckllst
Proposal Narratlvc {Not to exceed 1 page)
FormCQQ CompanyQuallflcatlonsQuestlonnalre
Form CR; Cllent References (at least 2)
Client lJst
Rclcmnt Euslncss Ucenscs
State Corpontc or other proof of authorlty to do buslnc$s ln Florlda
Form 16: KcV Staff
Organhatlonel Chart
l-paga Raeumes for Kry Staff Mcmbcrs
l-pagc Resumc for Program Mane6cr
Program Plan (Not to exceed 5 pages)
d fqulpm"nt & Unlform tlst
[4 lnsuran.e C.ertlflcates
Jll form DD: Disputc Dlsclcure
C ror en AddendumAcknowtedgmcnt
d Form CoA: ccrtilicatc of Authorlty
il Form cD: Comparry Declaration
d. form sEn: Shgle Erecutlon Affldavit
Z warranty
d Certmca Flnancial Statcmcnt & Most Rccsnt Dun & Bradstreet Rcport {in a separate envelope
. marked "Confidential")
fl Form PP: Reglstration Prlce Proposal
d ntu.trmcnt ps
d
d
d
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ALJ,
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Form RC
PROPOSAL NARRAT]VE
KB Soccer, lnc. ('KBS") wasfounded in June 2}12by a group of Key Biscayne residenb with the
sole purpose of rebuilding the soccerclub afteryears of poor management. We are not motivated
by profit, or special agendas. We operate our club as a cost neutral enterprise for the benefit ol
our kids and our neighbor's kids.
Prior to KBS laking over the soc:cer program, Key Biscayne soccer was operated by a group
licensed underthe AC Milan name, which promlsed a nexus between the professional ttalian club
and Key Biscayne. This never materialized, Worse, the program suflered gravely in quallty. Thls
led to an avalanche of parental dissatisfaction which created a massive exodus of more than 300
kids (dropping enrollment to 250), and a complete abandonment ol the girl's program.
Additionally, the traditional Key Biscayne royal blue colors and logo were dropped after zl0 years,
and replaced by the AC Milan red and black, diminishing our community identity.
Since taking over the proglam we have more lhan tripled our inlramural program, grew our
arnpeiitive travel program from 10 teams to 35, and restored our Key Biscayne historical logo
and colors. Also, expanded our teenager teams for boys up to U19, and we restafied the girl's
prograrn lrom scratch, collaborating with KB Glrls Volleyball and Basketballprograms to ensure
that allgirls have the option to play multiple sports.
During this Ume, we have implemented a tralning philosophy that is executed acros$ all programs
and has led to an impressive tumaround. Our intramural program is almost at capacity and the
heart & soul, exposing our kids to the lun under lormalcoaching. Our competitive travelteams
are playing at the highest level. Over the last three years, the U16-U19 teams have qualilied to
the semi-final or final round round of the Slate Cup. Today, KBSC is considered one of the top
clubs in Soulh Florida.
Although we have enjoyed great success and fast growth overthe last five yeari, our future goals
are to improve the soccerexperience for our kids on Key Biscayne. ln the next live yean we will:
r lmplement a dual management structure which will vastly elevate the quality of coaching and
player development;r Conlinue to grow the girl's program, which has been growing by one team per year, and otfer
play across the entire age spectrum (U9-U18), allowing all girls the opportunig to ptay in a
compelitive environment, and incorporating a lhird practice day per week;. Limiting the boys competitive travel to three teams per age group to tacilitate growth in the
girl's program, focusing on superior coaching quality;. Further enhance our dynamic inlramural program allowing kids and families who do not want
lo do travel, yet tt ant to play soccer, to acqulre team building skills and enioy the game;. lmplementing a unlform club development training model across each lransitlon lrom pee wee
to U19, inlegrating age specific development critieria lhrough all lour programs.
We are proud of our accomplishments, but we're not done yet. We look forward to working with
the Village of Key Biscayne and continulng to provide a fulfilling recreational program and a
dynamic competitlve program for our Key Blscayne fiiends and neighbors.
COM PA NY OUALIFICATIO NS
Form CQQ
GE OF I(EY BISCA
Company Quallffcation Questlonnaire
somG r6ponscs may rcqulre thc inclurlon of scparatc attachmcnb. Scparat€ atbchments rhould be
as concire as posslblg whllo includlng tho requcsted lnformetlon. ln no cvcnt should thc total pate
count of all attachmcnts to thls Form cxcccd flvc {5) pagcs, Some lnformetlon mey not be appllcablr,
ln such anstancrs lnrert uN/A".
1. How many years has your company been in business under its current name and ownership?
5mo<
a. Professional licenses/certifications (include name and license fi]1 lssuance Date
{'lncludc tctlve caadffcatlons of r,nrll or dhrdyrhtag! b{,3lncjs & mm.of erdtylng cnSty}
2, TypeofCompany: Clndividual H Partnershi| {*r\or"tion F lLc f; other
lf other, please describe the type of companyt
a. FEINIEIN Number:*kfllrng
b. Dept of Business Protussional Regulation Category (DBpR):
i. Date Licensed by DBPR:
ii. Ucense Number:
c. Date registered to conduct buslness ln the State of Florida:o
i. Date filed:
li. Document Number:
d. Primary Office location;
3f
33/33
e. Will all goods/services be provided out of the primary office location?
f. lf No, Local Office Location:
g. What is your primary business?
&.r E t'to
Page 1 of4
answer should b€
Form CQQ Rev071719
Form CQQ
VILLAGE (fF I{EY BISCAYI\TE
h. Name and Ucenses of any prior ccmpanies
Name of Company Ucense Name & No.
e
lssuance Date
3. Company Ownership
a. ldentify all owners or partners of the company:
{Attach addltlonel peges lf newry}
Name Tirle 96 of ownership
o
Srf,a tu /r ?a*l-no t 33.31%
b. ls any owner identified above an owner in another company? {r." A uo
lf yes, identiff the name of the owner, other companv names, and % ownership
I
a
Ptanalean 1uuruhbn - lo9"
I
ldentify all individuals authorized to sign for the company, indicating the level of their
signing authority {urcaddluonrl prger/atbchmcng lf ncclr::ry}
Title Signatory Authority
(All, Cost Up to $Amount, No-Cost, Other)
frol<io-- Eulaaa (P 4//
JJ
c.
Name
Page 2 of4 Form CQQ Rev071719
Form CQQ
CE OF I{EY B YI{E
4. Employeelnformation
a. Total No. of Employees:
b. Total No, of Managerial,/Admin. Employees:
c. Total No. of Employees by Trade {Er. 20 coa{hes; s Referees;2 Ars&;ranrs, etc.):
h
5, RecentContracts
a. ldentify the five {51 most recent contracts in whlch your company has provided services
to other public entities. lnclude the Owne/s name and contact person. Use additional
pages if necessary and attach to this form.
€ts
6. lnsurancelnformation:
a. lnsurance Carrier name & address:
tYlork cleq #/en,u( "zgobo
.lr
4
fersha//
0
b, lnsurance
a
c. Number of lnsurance Claims paid out in last 5 years & value:
lnrtfud {773-o
I ; 4,11 1fr,ao
NM
d
Page 3 of4 Form CQQ Re@71719
Form CQQ
VILLA KEY
7 . ln the space below, describe any other experience, not covered by any of the stated submitfal
requirements of the RFP, related to the Services to be performed under the Contract that
Proposer believes is unique to ils organiration and would benefit the Village.
ls
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Pz/ot /t*o
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certifies that the information contained herein i: complete and accurate toBy signing
Signature of Authorized Officer r/Date
frhmlo 0-
Printed Name
Page 4 of4 Form CQQ Rev071719
h
t
Electron ic Articles of Incorporation
F''or
P1200005003
FILED
Mav 31 .2012
SeC. Of Statejrhiverc
5
KB SOCCE& INC.
The_undersigned incoqporator, for the pwpose of forrning s Florida
profit corporation, hereby adopts the following Articles of lncorporation:
Article I
The name of&e coqporation is:
KB SOCCER INC.
Article II
The principal place of business address:
600 GRAPETREE DRTVE
4GS
KEY BISCAYNE, FL. 33149
The mailing address of the corporation is:
P.O. BOX 491?4
KEY BISCAYI{E, FL. 33149
Article III
The purpose for which this corporation is organized is:
4N LXTERNAL COMPANY THAT MANACES THE SOCCER PROGRAI\4S FOR
THE VILLAGE OtlQy,BIlqAyNE IN KEy BISCAyNE, FL, INCLUDINGqEEqEE _rNT84MI-R4,L,_ BEqREATTONAL, cOMpETrTivE'TRAvEL.
COACHINGCLINICS, SOCCER CAMPS, A}ID AFTER SCHOOL PROGRAMS.
Article IV
The number of shares the corporation is auttrorized to issue is:
100
Article V
The uame and Florida sheet address of the registered agent is:
ROBERTO SABELLA
600 GRAPEIREE DRIVE
4GS
KEY BISCAYNE FL. 33149
I certifu that I am fnmiliar with and accept the responsibilities of
registered agent.
i Registered Agent Signature: ROBERTO SABELLA
Article VI
The name and address of the incorporator is:
MARCELO RADICE
4I2 WARREN LA}IE
KEY BISCAYNE, FL 33149
2012
State
ElecFonic Signalure of lncorporulor: MARCELO RADICE
I am the incomorator submittine *rese Articles of Incomoration snd affirm ilrat tre facts stated herein are
true. I am awiue trat false infirimation submitted in e dooument to tre Departnentof Shte constitutes a
third desree felonv as provided for in s.817.155. F.S. I understand &re requirement to file an annual report
benueen-Jsnuary Ist anC tr4ay lst in dre cal€ildar year following fmmatiori of tris corporation and every
year thereafter io mainlain "ictiv€" status.
Article WI
the initial officer(s) snd/or directo(s) ofthe corporation is/are:
Tide: P
ROBERTO SABELLA
600 CRAPETREE DRIVE, APT.4GS
KEY BISCAYNE. FL. 33I49
Title: VP
JACKIE I(ELLOGG
I15 STJNRISE DRIVE,I.]NTT 5A
KEY BISCAYNE FL. 33149
Title: T
MARCELO MDICE
4I2WARREN LANE
KEY BISCAYNE. FL. 33149
Title: S
SOFIA SOFIL
370 WOODCREST ROAD
KEY BISCAYNE, FL. 33149
Article VIII
The effective date for this corporation shall be:
06toIlz0t2
PE RSONNEL QUALIFICATIONS
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ProPoser's Team & KeY Staff
Key staffTable
1. proposer shall complete the following chart with its proposed Key Staff. lf additional space is required, use a duplicate page
and attach to this form.
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Staff they will substitute for, where substitution is required due to attrition, turnover, or specific request frorn the Village'
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3. ln the chart below, provide the requested infiormation Key Staff membe/s
concurrently with the Village's Services.uitt Bis
Page 2 of3
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Page 3 of3 Form l(S
KEY STAFF RESUMES
!. Marcelo Radice I mradiceSE@gmail.com. I gos-ooe-ooae
Marcelo Radice was born in Buenos Aires, Argentina and raised in a soccer family in
Bethesda, Maryland; a highly recruited high school player that played collegiate soccer
at American University and University of Maryland. He played prolessionally at 18 for
2nd Division Bundesliga team, Gottingen 05. He coached youth soccer in Maryland/DO
and Miamiareas.
ln 1995, he moved to Key Biscayne with hisfarnily and spent 17 years on the island as
an active parent in youth soccer and swimming programs. ln 2007-08, he participated
as a board member of the KB Athletic Club and soccer commissioner for Girls' Soccer.
Professionally, Marcelo has dedicated over 30 years as a marketing executive lor
leading multinational companies: L'Oreal, MasterOard lnternational, Occidental Hotels &
Resorts and University ol Miami and Tratlic Sports. He lounded and operated several
start-up companies and maintains a marketing consulting practice lor 19 years. ln 201 1,
he was awarded the South Florida Business Leader of the Year by Business Leader
Magazine in Biotechnology. He ls cunently the President and Founder ol KB, Soccer,
lnc., managing the KBSC progr:m forthe Village of Key Biscayne.
9qgggr,Fxperiencq
2010-20
2008-9
2008
2007
1991-92
Plalter Exoerience
1981-84
1980
1980
1979
1977-79
Education
1988
't984
KBSC Board Member, President and lounding member of KB $occer, lnc.
Asslstant Girls'Soccer Goach - Tropical Park Blaze (U12 & U13)
Girls Soccer Commissioner and KBAC Board Member
KBAC Board Member
Asslstant Soccer Coach, Columbus High School
Varsity Soccer - University of Maryland, College Park, MD
Gottingen 05 12na Division Bundesliga), Gottingen, Germany
Varsity Soccer - American University, Washington, DC (NCAA QFinals)
Senior Captain, Walt Whitman High School, State Finalists; All-Met and
All-County, Washington Post and Montgomery Journal
Maryland All-State team selection and Middle Atlantic All-Hegionalteam
M.B.A. General Management, University of Miami
B.S, Zoology, Unlversity of Maryland
Jacqueli ne Kel logg-G ross I Jacguel ine. lrelloqg @ gmall.com I gos-gz z-zzzz
Jackie Kellogg has been a Key Biscayne resident since 1975. She has been involved in
soccer tor over 25 years, including as a high school and collegiate player at Guilford
College. ln 2002, she returned to live on Key Biscayne with her husband and 3
children. She has been a volunteer team parent at KBSC and President of the Key
Biscayne Athletic Club. She was an active member ol Village Athletic Advisory Board,
helping to shape the development sf athletics on Key Biscayne. Allof her children have
played soccer at KBSC over the last 14 years and she continues to pour her energy in
youth athletics on Key Biscayne.
Professionally, Jackie spent 15 years working for non-prolit organizations in the areas
on membership, marketing and development in Washington, DC, Mexico City, Coral
Gables, Curacao and Miarni Beach. She has also served on many boards,
including: Montessori Schools, Tortola, BVl, St. Christopher's Montessori-Key
Biscayne, Girl Scout Service Unit Leader, Key Biscayne K-8 center PTA, ESSAC,
Parent advocacy Panel MASTKey Biscayne (representing Key Biscayne to the School
Board ol Miami-Dade), Barnacle House Society, Nature Center, Cape Florida Friends,
KBAC, Vice President and President, KBYAAB. She is cunently a board member and
founder of KB, Soccer, lnc., managing the KBSC program lorthe Village ol Key
Biscayne.
Soccer Elpgrience
2009-Present KB Youth Athletic Advisory Board Member
2010-16 KBSC Board Member and lounding member of KB Soccer, lnc,
2006-16 KBAC Board member and President
USSF Fleferee Ucense
USSF F & E Licenses, U12 FYSA Certilication, NAYS,
parent/coach certitication
2011-2013 Chair lor the Dade Youth Soccer Association - Division 3 League
tor Dade County
Plaver Exoerience
1999-2001
1986-1990
1982-86
1976-1986
Education
2013
1986
1986
British Virgin lslands National Team
Varsity Soccer, Guillord College, Greensboro, NC, NCAA Division ll
Coral Gables Sr, High - Varsity
Awarded All-Miami Dade player (1 986)
KBAC soccer player and coach
Elementary Education, Miami Dade
B.S. Economics, Guilford College
B,A. English Literature, Guilford College
i Juan Acosta I ihmyasorilla@gmall.com I zas+eo+gt+
Born in Uruguay, Juan "Pichi'Acosta has become alamiliar icon at KBSC. He started
coaching at the club in 2005 working with the KBAC management. He was recruited by
as Recreation/lntramural coach for AC Mihn Key Biscayne inZOO7 and was promoted
to Director ol Coaching lor the Recreation program. ln 2010, he joined the KB Soccer,
lnc. team as the Director of Coaching of lntramural prograrns. He was instrumental in
leading the creation ol the Pee Wee program for 3-5 year old's, where our kids could
have first interaction with soccer under controlled superuision. This early participation
has helped develop excellent players into our Recreation/lntramural program.
Pichi played prolessionally from 1987-1996 with clubs in Uruguay and is a liletime
member ol the Uruguayan Football Association.
Under his leadership, the Recreation programs has almost reached fullcapacity. He
applies coaching methods to focus on the critical skills they must master il they wish to
advance into Recreation or Competitive Travel levels. ln addition, he created a
dedicated team ol coaches exclusively for the Girls'program. Today, more than 80 girls
participate and this has allowed the Girls program to grow by placing at least one team
each year into Competitive Travel. He has an uncanny knack of developing talented
players and eaming the respect of the parents in the community.
ln addition, Pichi directs the Summer Camp program, a program that registers over 200
kids ages 3-12, and provides a valuable service for the KB community.
Soccer Experience
2010-2A Director of Coaching, Recreation, KBSC
Summer Camp Director
AC Milan Key Biscayne, Soccer Coach,
Head Coach, Recreation Program
Key Biscayne Athletic Club, Soccer Coach
20a7-2010
Player Experience
1987-1996 Prolessional player in 2nd Divsion League in Uruguay
(C.S. Cerrito, C.S. Rentistas, l.A. Sudamerica, C.A Fenix, C.S. ltaliano,
and C.D.S. Rodo)
Certif icatesllicenses
2006-07
2011
2008
2006
NYSA, lnitial Level Clinic
NSCAA State Diploma
FIFA License, Uruguay, AUF
Jimmy Asprilla I iimmy.aspri[qggmail.com I zse-6eo-astl
Jimmy Asprilla was born inZarzal, Colombia and played prolessionally in Colombia with
teams in the Liga DiMayorfrom 1999-2012. ln addition, he was selected to play for the
U20 Colombian NationalTeam lrom 1997-1999. He moved to Miami, FL in 2013.
Since joining the KBSC as coach of our U9-U12 boys teams, he has demonstrated a
talent to quickly teach and develop players, and achieve wonderful results on the field.
ln 2019, he took over our U13 teams, leading them to league championships and
multiple tournament championships. He has a unique ability to connect with the players
and help them understand the lundamental concepts ol soccer. Additionally, over the
last three years he has been a coach in the Jr Academy Recreation Program, using his
tried and true coaching methods to accelerate player development. Many of his players
graduated into the Competitive Travel program.
During the last two summer camp seasons, he has been instrumental in helping us
locus on girls development, leading them to a more competitive levelof play.3
Soccer Experience
2016.-24
2018-19
2013-14
2010-12
Player Experience
1999-2012
1999-20
1997
KBSC, Soccer Coach (U9-U13 Boys)
KBSC, Summer Camp Girls Program
Kendall $occer Coalition, Soccer Coach
Santa Ana Sport Club, Cali, Colombia, Soccer Coach
Prolessional player in DiMayor League
(Atletico Huila, Once Caldas, Deportivo Cali, Sport Boys, Estudienates de
Merida, Atletico Bucaramanga, Millonarios, Deportivo Pastor, Cucuta
Deportivo)
Colombia NationalTeam, U20 Player
Colombia NationalTeam, U17 Player
Certif icates/Licenses
2016 USSF D License equivalency
2014 lnternational Congress of Sports Applied Sciences, Santiago de Cali,
Colombia2012 Sports Monitor Diploma, Santiago de Cali
2008 Soccer Arbitration Seminar, Santiago de Cali, Colombia
2005 lnternational Sports Training Seminar, Del Valle University
2A04 lnternational Seminar on the Future ol Colombian Football, $antiago de
Cali, Colombia & Seminar on Sports Medicine and Rehabilitation,
Santiago de Cali University (May 2004)
Juan Carlos Gonzalez ldoc@reyblscaynesoccerctub..or I g0s€25-g441
JC Gonzalez is a native of Bogota, Colombia and raised in Miami, FL. He played high
school soccer in Miami and collegiately at Miami-Dade College.
JC was named the lirst men's soccer coach in ASA Miami's history in May of 2O14.
Before moving to the college ranks, JC served as the boy's head soccer coach at Felix
Varela High Schoolwhere he was named the Miami Herald Dade County Boys High
School Coach of the Year in 2009 & z9fi. ln 2011 , Gonzalez led Varela to the State
Championship game against Cypress Bay High School.
Belore becoming the boy's coach at Varela Gonzalez served as the Directorof $occer
at Archbishop Carroll HS from 2002-2008. ln 2006 he was named Miami Herald Dade
County Girls High School Coach ol the Year.
Gonzalez served as the Director of Coaching lor SAA Real Madrid in Kendall, FL.
Today, he is the Director of Coaching for KBSC Competitive Travel and JR Academy
programs. He has been critical in charting our plan to expand the Competitive Travel
program lrom 10 to 35 teams. He has been very beneficial in hiring coaches and
working with Village statf to assist in league match calendars, and managing
tournament schedules and coach overlap.
Soccer Experience
2016-20 KBSC, Director of Coaching, Jr Academy and Competitive Travel,
KBSC, Summer Camp
ASA, Head Coach, Mens'Soccer
Women's Soccer Assistant Head Coach, Johnson & Wales University
Felix Varela HS, Head Coach, Boys'Soccer
Archbishop Carroll HS, Director ol Soccer
Certif icates/Licen ses
USSF C License
2014-20
24fi-14
2008-1 1
2002-a7
RUBEN BETANCOR I Rubenbetancor@hotmall.com | (gosl 915-3263
Soccer Experience
2006 - current
1984 - current
1985 - 1996
1984-2014
Technical Director
Soccer Coach
Soccer Athletic performance
Physical Education teacher
Certifications
Physical Therapy Aid & Adult CPH/AED - Florida Department ol Education official
Skills & Activities
Sports Facilities Management, including design, organization and procedures for fitness
lacilities.
Spoft performance analysis
Orner and Executive Director - Gym & Pool
Strength & Conditioning
PersonalTrainer
Field Hockey Coach
Fitness Equipment Sales
Computer skills
Marketing and Sales
Languages: English, Spanish and Portuguese
Education
Management ol Educational and Sports Centers - Udelar, Uruguay - 2001
Post Degree Soccer Coaching FIFA License Udelar - Uruguay 1995
B.S. - Physical educatlon, Udelar, Uruguay 1983
PROGRAM MANAGER Qardo KaCrca
Proleseional Relerene
Todd Hotferberth
Director of Parks, Recreation and Open Spaces
Village of Key Biscayne
thotferberth @keybiscayn-e. fl. gov
305-365-8900/ext. 1 21 3
Wlliam Castano
President
Concept Enterprises
wi I I iam @cgnc_ept-ebiZ. com
786-280-5505
Keith Rubin, MD
cEo
lliad Biosciences
keith@iliadbio,com
917-913-8511
Matthew Louis
Managing Partner
ISG5
nlpt.tis@.gmAil.Cp.m
551-400-5340
PROGRAM PLAN
Coaching and Adminletratlon Management
KB Soccer consists of seasoned group of prolessionals that have played andlor
coached at the highest levels, administrators that bring corporate skills from top
companies and non-profits, and over 90 years ol collective experience. Ourteam will
focus on the lollowing areas:
Coaches & Players
Coachino DeveloBment: DOCs are responsible for recruiting top licensed
coaches who adhere to our training methodology and teaching them the
lundamental best practlces which concentrate on ball possession and technical
mastery and physical conditioning. Evaluations take place 2x per year.
We are creating a mentor system and succession plan to identify top performing
coaches and recommend promotions when possible to take on larger
management roles, cornbined with incentives to encourage continuing education
and licensing.
Player Development:Technical Director will lead a group of head coaches lor
diflerent age groups and execute a training plan with specific milestones to
evaluate player progress and have quantifiable measurement to benchmark a
player's progress. Reports will be generated 2-3x per year to each parent to
monitor the players development and the training program will be shared with the
parent at the beginning of each season to establish clear development goals and
expectations.
Administration
. General Management, Finance, Branding & Sponsorships. Operations & Marketing
Site Director/Fl ef eree Assignor
Site Director/Assignor plays a critical role of securing referees for all home games
scheduled on our fields. ln addition, this person is responsible for supervising the lield
conditions and set-up benches, goals, comer flags, player tents, sponsor boards and
bleachers to ensure a professional managed site and ma,rimum enfoyment.
Programmlng
Competitive Travel
Designed for boys and girls ages U9-U18 who exhibit a talent and ma$ery ol the core
skills and are cornmitment to participate in competitive leagues in South Florida and at
the state level. All teams are trained by licensed coaches and the program lasts 9-10
months split into three (3) seasons:
Early Season (2.5 months): August 15 - October 15
FallMinter (4 months): October 16 - February 2O
Spring (3 months): February 21 - May 31'
Annual Registration Fees:
Eloys/Girls U9-U12 $1,300
Ebys/Girls U13-U18 $1,350
Eloys Elite U16-U18 $1,300
All teams cunently play in the SFYUSA, Miami-Dade League or FSPL, based on the
skill-appropriate league. Plus, they will play in 3-6 tournament events. At least one will
be a stay-over event. Travel will be required on most weekends dudng the league
season. The Competitive Travel Program requires a major time commitment from the
player and parent(s). All players understand that s/he is committing to pafticipate in all
team functions, including oflicial practices, league games, and tournaments. Many
league games require travel in the tri-county or across the state, and many tournaments
are scheduled over Holiday weekends.
Practices:
Fields:
Time:
(Uniforms and practice T-shirts purchased separately)
Monday - Wednesday - Friday
Village Green, St. Agnes, Crandon Park & MAST Academy
4:00pm - 9:30pm
Jr. Academy (Recreation)
A program created exclusively lor boys ages U10-U15. Designed for the development of
players at the beginner/intermediate levels that are not ready lor Competitive Travelor
because they prefer to train but not commit to the travel requirements. Stress is put on
the fundamental soccer skills, with an emphasis on self-esteem and emotional well-
being. The atmosphere is collegial, exposing players to all aspects of the gane,
ennphasizing skill development.
FallMinter (5 months): August 15 - February 20
Spring (3 months): February 21 - May 20
Annual Registration Fees:FallMinter $575Spring $325
Practices:
Fields:
Tuesday - Thursday - Saturday
Village Green
Time: 7:00pm - 8:15Pm
(Uniforms and practice T-shirts purchased separately)
Recreatlonal (lntramural)
A program created exclusively for boys ages U6-U9 and girls U6-U15. The
program locuses on developing ag+'appropriate technical and tactical abilities of the
participants in an environment that will instill sportsmanship and the importance ol
'team.'Teams will practice twice a week and play games on Friday evenings in a7v.7
or 9v.9 format.
U10- U15. Designed for the development of players at the beginnerlintermediate levels
that are not ready for Competitive Travel or because they prefer to train but not commit
to the travel requirements. Stress is put on the lundamental soccer skills, with an
emphasis on self-esteem and emotional well-being. The atmosphere is collegial,
exposing players to all aspects of the game, emphasizing skill development.
FallMinter (5 months): August 15 - February 2O
Spring (3 months): February 21 - May 20
Annual Registration Fees:
FallM/inter $575Spring $325
Practices: Tuesday -Thursday - Friday or Saturday
Fields: Village Green or K8 Community School
Time: 4:00pm - 7:00Pm
(Uniforms and practice T-shirts purchased separately)
Pee Wee
This program otfers soccer to boys and girls ages 3-5. The Pee'Wee Program is
designed to introduce children to organized soccer and improve age appropriate
technical and tactical abilities ol the participants in an environment that will foster an
appreciation and enjoyment ol the game while focusing on lun and coordination. Teams
will practice twice a week.
3 Sessions per season: September - November
December - February
March - May
Annual Registration Fees: $260 per Session
Practices
Fields:
Monday - Wednesday
Village Green
Time: 4:00pm - 6:00pm
(Uniforms and practice T-shirts purchased separately)
Tournaments & Cupe
The tournament schedule will vary by team, but we encourage teams to play lrom 3-6
tournaments, and one should be a stayover event.
Projected Toumam ents/Cups :
. West Pines Tournament, Sunrise, FL. Disney Qualifier, Orlando, FL. Disney Slpwcase, Orlando, FL. DimitriCup, Naples, FL. Weston Cup, Weston, FL
' President's Cup. State Cup. Disney Memorial Day, Orlando, FL
September
September
December
January
February
February - April
February - April
May
Top Elite Teams may select other Showcase tournaments:. Adidas Cup, Atlanta, GA November. Bethesda Cup, Germantown, MD November
$ummer Campe
Are designed with age specific training over an 9-week period from midJune to mid-
August.
Morning Session: 9:00am - 12:00pm
Days: Monday - Friday
Fees: $125 per week
Afternoon Session: 5:00pm - 8:00pm
Days: Monday -Thursday
Feos: $100 per week
NEW PHOGRAMS
Co-Ed Teen Tlme
ln an effort to encourage exercise, wellness, friendships among the older teens, we are
proposing a free 9Sminute practice session on the 3d Thursday of each month. This
co-ed experience is designed to attract 15-18 year old's and offer exercise in a
pressure-free environment, and to disconnect from daily anxieties from high school. The
practice will be supervised by one of our coaches and rotate as volunteers.
j
Seaeon Endlng Award Ceremony
At the end ol each program season fihird week ol May), we organize a soccer party on
the Mllage Green or Community Center with food and beverages to recognize the
coaches, players and parents'participation, Certificates, medals and awards are
distributed, and games or skills challenges are setup for the kids.
REGISTRATON FEES
Our lees are processed online through our website provider, League Apps. They
process alltransactions with Stripe. We accept all major credit cards. However, we do
provide the option for parents to pay with cash or check. Also, parents have the option
to pay in tull or through a 6-9 month payment plan,
The registration lee covers alloperational expenses, except unilorms and
tournamenVstate cup fees, referees and travel expenses. When we calculate the
Flegistration Fee, we include the following expenses:
FYSA Association Dues, League Fees, Fleferee Fees, FYSA lnsurance, Coaches, Staff,
and Site lnspector compensation, Prolessional Services, Eguipment, Training
accessories, Office Supplies, Social Media, EmailService, Elookkeeper, Closing
Ceremony, Medals & Trophies, Website maintenance, Statf travel, Advertising, Parent
nights, Food & Beverage for meetings.
SPONSOHSHIP FEES
Due to generous corporate partners, we collect sponsorship revenue to undenvrite the
cost for financial aid and Team Parent Discounts.
i EQUIPMENT/UNIFOHMS
Please refer to breakdown below of the uniforms items that are required by each player.
We willcontract with an apparel kit provider, in return lor excellent pricing discounts and
the players will to purchase the uniforms on the online store for each program.
Additional equipment must be purchased directly by the players:
Soccer Shoes
Shin Guards
{
MandatoryBrooklyn Strip Home Game Jersey
CS One Away Game Jersev Mandatory
MandatorvMatch Shorts
Match Sock Mandatory
MandatorvTraining Jerseys
Trainine Shorts Mandatory
MandatorvTraining Socks
4 Cube Backpack Mandatory
TravelPolo Optional
TravelWarm-u
Basic Jersey - Royal Mandatory
OptionalI
CS One Short - Royal Mandatory
CS One Soft Socks - Roval Mandatory
Baslc Jersey - Roval Mandatory
CS One Short - Roval Mandatory
CS One Soft Socks - Royal Mandatory
Hish Quality Gotton TeE Mandatory
Miniball Giveawav Mandatory
Hieh QualiW Cotton Tee
Mandatory
Mandatory
Mandatory
Mandatory
Mandatorv
Mandatory
Mandatory
Mandatory
CS Game Dav Polo Shirt Mandatory
MandatoryI
CS Practice Jersevs MandEtorv
Match Shorts Mandatory
Match Sock Mandatorv
Practice Shorts Mandatory
Rain eear Mandatorv
Shoes Optional
OptionalBackpack
i lNsuBANcE
Current attached policy is in force, per contract with the Village of Key Biscayne and KB
Soccer, lnc.
ACOG GERTIFICATE OF LIABILITY INSURANCE
O 19lt-2010 ACORO CORpORATION. All rlohtt re.oryod.
The ACOf,II nemc and togo en rrglctsrtd mrrltr of ACORD
CERTIFICATE HOLDER
DAtE(ifrDo/F Yrl
e/18t2019
-RI\.ANO'i OIi[f AID EI'NFENS NO RIGHTS UFOH IHE C€RTFICAIE HOLOER. THIS
CERNFICATE OOES NOT AFFIRICAIWELY OR NEGATTVELY AIIEND, EXIEND OR ALTER TIIE COI'ERAGE AFFORDED AY ilE POLICIES
8ELOW. THIS cER'titFtCAtE OF NSURAHCE OOES NOT COilSTTUTE A COHTRAST SgTmEil llIE ISSUHG lt{SURERlsl, AUTHORtrED
REPRESEITITATN|E OR PRODUCEIL AI,ID THE CERTIFICATE HOLOER
ll{XtRTAt{I: It tho cortflcsb holdsr lr rn ADOITIOIIAL NSURED, fhe pollcylb} murt b. andoned. lf SUBROGATION lS IYAIVED. eublect
to the tarmr and condtllonr ol th. pollcy, cartaln pollcle a may r.qul.r rn cndoE.mrnt A ltrttm.nt on lhlr crrdllsab do3l not contrr .lghtB
to th. c.rtltlcrlo hold.r lfi lhu ol such andotramendrl.
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211t 3rNSuREil ! United States Flre lnsurance
PROOUCEN
IIIAGAYA INSURANCE SERVICES INC
7950 ttw 53RD ST STE 300
ttltAtiti FL 331804790
7863030500
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Int PARNCFANNG UET€ER6:
KB Soccrr, lnc
70 Bay Helghtr Dr
illaml, FL 33133
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IHIS IS fO CERTIFY THAT THE POTICIES OF INSUfiAi{CE LISIEO BELol|, HAVE SEEN TSSUED TO IHE INSURED NAMED ASOVE FOR THE POUCY PERIOD
II'IOICATEO. i{OTWITHSTANOING Al{Y REOUIREMENT, T€Ril OR CONOIIIOiI OF ANY CONTRACT OR OftIEA DOCIJ|I'IENT WIH RESPEGT TO WHCH
lHlS C€RTFICA1E t{AY BE lssuED OR tttAY PERTAIN, IHE INSURANCE AFFORDED BY lHE POLICIES oESCRIBED HEREIN ls SUBJEGT TO ALl lHE
IERT'S. EXCLIJSIONS AND CONDITIONS OF SI,,CH POLICIES. LIMIIS SHOWN MAY HAVE EE€N REDI,ICEO BY PAID CLAIHS,
TYPEOFtilSUi lcE ru POLIgY ilUABfT lqgltt
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KB Ssc6r, lnc
70 Bay Helghts Dr
Mlaml, FL 3313.i
SHOULD AN? OF THE ABOYE OEsCRlaED POUCIEA SE CAflCELIED
SEFORE THE EXPIRANOT DAIE THEREOF. NONCE MLLEE OETIVEf,ED fi
ACCORDAT{CE Y$TH IHE POLICY PROVISIONS.
Aulrlontrto iEpn$EXTAtwE
Magaya Insurance Services Inc
ACORD 25 (2010103) Y'141120.001
E CRUttl&FORSTEFrfi$ifcom
NAMED INSURED MEMBER
CERTIFICATE OF COVERAGE
t
CERTIFICATE#: USP3O6212 MASTER POUCY #: SRPGAP[IL-101-0719
Pollcyholden
Sporls and RecreaUon Podders Assoclaflon Purchadng Group
17/6 Soutr NapeMlle Road, Bldg-B
Whealon, lL 60187
l{arncd lnzurrd [Trm ber:
KB Soccet lnc
70 Bay Helghts Dr
Miaml FL 33133
CerfffcataGornragePrdod: 10/0612019 12:01 AM to10/06/2020 12:01 AM EttziolA.M.stth€mdtrqaddrsssorths
Nam6d lnsutad llbmbsrshown sbove.
Master Pollc,y lseued By: united Stales Fire lnzuranca Company
Certlfleate of Goveragr lssucd By:
Francis L. Dean & Associates, lnc
1?-fG Sorrlh Naperville Road, Bldg-B
P.O. Box 4200
Whealon, lL 60189
Telephone: t63O) 665-701 1
Locallon I Dercrlptlon of Operatlons: Youth Soccer
See Endorsement Schedule bdol for any exdusions or limitations
covERAGE(Sl
lnsurance is ptovided only fur those coverages fur which a limit or lhe lrord lnduded" is shoum belou
General Llabllltv
Llmlls of lnsurance
$2,000,000.00 General Aggregate Limit (OUrer Than Producls-Gompleled Operations)
$2,000,000.00 Products-CompletedOperationsAggregateLimit
$1,000,000.00 Personal And Advertising lnjury Limit
$1,000,000.00 EechOccunenceLimit
$300,000.00 DamageTo Premlses Rented To You Limit
$5,000.00 MadicalExpense Limit
Llmltc of lncurams - Optlonal CoveriageeExcluded Abuse & Mdesbtion Coverage - Each Occunenca LimitExcluded Abuse & Mdeslation Coverage - Aggegate Limitlncluded Bodily lnjury To Athletic Or Sporls Pariicipanls
$1,000,000.00 Each Sporta, Hedlh, Fihess And Wellness Services lncirjent Limit
$1,000,000,00 SpoG, Heallh, Fitness And Wdlness $ervices Aggregale Limit
Prrnrlum
94,600.00 Total Estimatad Commerclal General Llablllty Premltrn Duc From Member
Hlred / Non€wned Automoblle Llabllltv
Llmltr of lnsurancr
$1,000,000.00 Covered Autos Liabilig Limit
Prsnlum1850.00 ToEl Ertimabd Hlrsd / Non-Onnsd Artomoblle Uablllty Premlum Due Frorn Member
Llouor Llabllltv
Llmlts of lnsuranco (the applicable slatutory limit or the limit as shown bdow, wtichever is less)Excluded Each Cornmon CauseExcluded Aggregate Llmil
Premlum10.00 Tobl Estlmatrd Llquor Llablllty Premlum Drn Frorn ilember
MG 05 009 07 17 Page 1 of2
Effigs&FoRsrE*
NAMED IN$URED MEMBER
CERTIFICATE OF COVERAGE
This Certificate of Coverage evidences y(rur csrerage as a Nnned lnsured Member under the Master Policy
described herein.
United States Fire lnsurance Cornpany certifies that the Named lnsured Member as shorn herein is insurad
under the Sports & Recrsation Providers Associatlon Purchaslng Group Master Policy. The Limfts of
Insurance, Premium and Effectfue Date of co\rerage appllcable to lhe Named lnsured Member are as specified
above. This Certificate of Cwerage, together with the Common Policy Conditions, Coverage Part{s),
Coverage Form(s) and Endorsements attached to lhe Mastar Policy, complete the above numbered insurance
contract.
The Master Policy, containing the terms and conditions of coverage, has been fumished to the Policyholder
and a copy d that policy accompanies this Certificale of Coverage. All claims are pald according to the terms
and conditions of the Mastar Policy.
Crum & Forsler is part of FairFax Financial Holdings Limited. C&F and Crum & Forster are registered lrademarks of Unlted
States Fire lnsurance Company.
Schedula of Addlllonal lnsurads
ThB entilias shoiln bdow are added as Additional lnsureds, but only in respec't to liebility caused by operaticns of the
Named lnsurcd Mernber during he cerlificate policy pedod.
Form Number Dcgcrlptlon
FSPG 101,0,0007
Deslqnated Person/Onn
Nams Of Additional lnEured Person{s'l Or Orqanization{s):
FSPG 10't.0,0008
Designaled Person/Og
{CA Gwt)
Name Of Additional lnzured Gowmmental EnliMiesl:
FSPG 101.0.0009
State/Govt Agency/ SubdMsion
Name of Additional lJrsured Stala Or Go,\remFenld,Aoencv OrSubdMsion or
Political SubdMslm:
FSPG 101.0.0010
Vendors
Name Of Addilional lnqred Person(s) OrOrcanizalionls'l:
FSPG 101.0.0011
Managers or Lessors of
Premises
Narne Of AdCilional ln+rrqd Pgrson(s) Or Oroanization(s]:
FSPG 101,0.0012
Lessor d Leased Equipmant
Name Of Additlonal lngrred Person{s} Or Oroanizstion{s):
EndonsmqnlSchiduls
Form Number Descrlption
cG2144
Limilation To Designated
Premises, Prcjects, Operations
Premises:
Projecl OrOoeratiqn:
cG 21 53
Exdusion - DesQnated
Ongoing Oparations
Descrlption of Designated Onooina Ooeration(s): lnflalabla Amusement Devices,
Carnival Rides, Knockerball/BubblE Soccer, Bungee Devices,Firaworks,
Mechanical Bucking Devices: including Multi Ride Attachmenls, Permanenl &
Mobile Rock Wall Structures, Securig Servicas Other Than Contracted Law
Enforcement fficers, Trampolines, and Zip Lines.
Soecified Location (lf Aoplicable):
MG 05 009 07 17 Pqe2ot2
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
SCHEDULED ACTIVITIES EXCLUSION
This endorsament modifies insurance provided under tha following:
COMMERCIAL GENEML LIABILITY COVERAGE PART
SCHEDULE
The followlng excluslon is added to the policy:
2. Excluslons
This insurance does not apply to:
SCHEDULED AGTIVITIES
'Bodily lnjurf , 'Proper$ Damage" or'Personal and Advsrtising lnju4f resulting from or arising
out of any activities listed in the above Schedule of this endorsement that are or wers ananged
and/or conducted by, or on bahalf of, the "Named lnsursd Member".
All other terms and conditions remain unchanged
Descrlptlon Of Activltles:
Any aotivity specifically described in the Named lnsurad Member Certiftcate of Coverage
{FM 101.0.0029) as an activi$ that is not covered under the Commercial General Liability
policy.
lnflatable Amusement Devices, Camival Rides, KnockerbalUBubble Soccer, Bungee
Devices,Fireworks, Mechanlcal Bucking Devices: including Multi Ride Attachments, Permanent
& Mobile Rock Wall Structures, Security Services OtherThan Conhacted Law Enforcement
fficers, Trampolines, and Zip Lines.
With Respect to Certificate USP306212
lnfunnstion reouired to comolete this Schedule. if nol shown abotre. wilf be shown in the Declarations.
FSPG 101.0.00)0( 09 14 Page 1 of 1
UNITED STATES FIRE INSURANCE COMPANY
AdminislraUve ffices: 5 Christopher Way . Eatonlorvn, NJ 07724
BI.ANKET BENEFITS
ACCIDENT ONLY POLICY
Policy Number
Policyholden
Policy Effeclive Dale:
Policy Expiration Date:
us1298602
KB Soccor, lnc
70 Bay Hrlghts Or
Mlaml, FL 33'133
l0r0g201g l2:01 AM
101061202012:01 Al$
This Policy is issued in the state of Florida and shall be govemed by its laws.
This poliry contains the lerms under which lhe lnsuranca Company agrees lo insure certain Persons and pay
benefils.
The lnsurance Company and the Policyholder hava agreed lo all the terms of ttis Policy'
THIS IS AN ACCIDENT ONLY POLICY AND CONTAINS
DEDUCTIBLE AND EXCESS INSURANCE PROVISIONS.
PLEASE READ IT CAREFULLY.
BENEFITS ARE NOT PAYABLE FOR LOSS DUE TO SICKiIESS.
THIS POLICY PAYS BENEFITS FOR SPECIFIC LOSSES FROilI ACCIDENT ONLY.
Signed for Tha Unltod States Flra lnsurance Company By:
d."q- M Ua a /^,,,,
Douglas M. Libby
Chairman and CEO
James Kraus
Secrelary
GAP 26932+L
TABLE OF COITITENTS
Schedde of Benefita
Deffnltions
Soope of Coverage
Provisione Conceming Insureds
Descriplion of Hazar6
Deseiption of Benefils
Exclusions
Additlonal Exclusions
Limitations
Premium Provislons
Gene.El Pollcy Provisions
Claim Provisions
Page Number
3
5
7
7
I
I
't1
12
13
14
14
15
GAP28932fL
SCHEDULE OF BENEFITS
BENEFIT PERIOD:
PREMIUM:
DEDUGTIBLE ATIIOUNT:
COII{SURANCE PERCENTAGE:
It'$(Ii/lUIll BENEFIT AMOUNT:
ELIGIBLE PERSON$:
Policyholdef s Prog rams
SPECIFIED AGNVFY:
Frovided trealrnenl begins within 90 days from lhe date
of lnjury, Benefits are payable fur 1 Year from the date ol
an lnjury. The lnjury must occur afler the Efiective Dala
and prior to the Expiralion Date and care must be
Medically Necessary.
s1,745.00
$s00.00
100Yo of Usual, Reasonable & Customary Charges,
URC
$25,000.00
All Players, Caacheq Managers, Volunteers of the
Youlh Soccer
The Followlng Benefits Are Provlded ForS!9ESE_S!I:
MEOICAL E)(PENSE EENEFIT
Hospital Room & Board Daily Maximum Benefit Amount:
lntensive Care Room & Board Daily Maximum Benefit Amount
Hospital Miscellaneous Maximum Benefil Arnount:
Outpatient Hospital Emergency Room Maximum BenefttAmounL
Oulpatieni Pr+.Admission Testing Benefi t Amount
Surgical Benefits
Primary Surgeons Maximum Benefit Amsunl:
Assistant Surgeon, Second Surgical Opinion, Gonsullalion
Maximum Benefit:
Anesthesia Maximum Benefi I Amount:
Surgical Facility Maximum Benelit Amounl:
Doclor's Visils
ln-Hospibl Maximurn Benefi t Amounl:
Oifica Visib Maximum Benefii Amount:
Maximum for All In-Hospital and Offica Doctor's Visits:
X-ray and Laboratory Maximum Benefit Amount:
Nursing Maximum Benelit Amount:
Physiolherapy Benefrt
URC
URC
URC
URC
URC
URC
URC
URC
URC
URC
URC
URC
URC
GAP 26932.F1
URC
Pollry3
Maximum Benefit Amount (hospitral inpatient):
Maximum Benefit Amount {outpatient):
Ambulance Maximum Benefit Amount:
Medical Equipment Rantal Charges Maximum BenefilAmount
Medical Servicas and Supplbs Maximum Benefit Amount
tBlood, Blood Transfusions, Orygen)
Dental Treatmenl Maximum Benefit Amount:
URC
URC
URC
URC
URC
URC
OUT+ATIENT PRESCRIPTION DRUG BENEFIT
Maximum Benefit Amount URC
ACCIDENTAL DEATH, OlStrlEItlBERt El.lT, LOSS OF SlcHT, SPEECH OR HEARING BENEFTTPrincipalSum: $10,000,00
Benefits pairJ under the
Usual, Reasonablo and
policy may
Customary
be based on Usual, Reasonable and Cuslomary charges. The defnition of a
Charge is shown in the DEFINITIONS section.
I
To determine lhis charge, we use standard industry dahabases that calculate lhe average cost for a given service
or supply wilhin the geogmphical area in which the charge is made. lf the acfual charge made by lhe provkler is
more than lhe usual, reasonable and ctslomary chargg, we will use lhe usual, reasonable and ctstomary charge
emount as a basis of our payment. lt is that amount to which we will apply any deduclible or coinsurance
percentage thai may apply. You are lhen responsible fon (a) the deduc'tible or coinsurance amounts lhai are
applied; (b) any billed amounts above lhe usual, reasonable of cuslsmary charge.
ln lhe event you need to contacl Eomeone about lhis insurance for any reason please contact your agent, lf no
agent uras involved in lhe sale of thls insurance, or if you have additional questions you may conlact lhe
insurance company issdng lhis insurance at lhe following address and lelephon€ numben
United Stat$ Flre lnsurance Company
5 Chrlrtopher Way
Eatontown, New Jereey
Phons: 732.9184717 (collcct calls acceptrd)
4GAP 26932.F1 Pollcy
DEFlltllTloils
The terms shown below shall have lhe meaning given in this section whsnsver they appear in this Policy.
Additional terms may be defined within the provision to which they apply.
"Accldont" means an event which is the dirsct cause, independenlly of Sickness or lnjury that
(1 ) Causea lnjury lo ens or rnore Govered Persons; and
i2) Occurs while coverage is in effect for he Covered PerEon.
"Btnefit Period" means lhe period of time, from the date of lnjury, shown in lhe Schedula of Benefits.
"Cov€rsd Psrson" means a person eligible for coverage, for whom proper premium payment has been made,
and who is therafore insured under lhis Policy.
"Deductlble Amounf' means the amounl of Etigible Expensas which must ba paid by the Covered Person
before benefiB are payable under lhis Policy. li applies separately to each Covered Person.
"Doclof' means a licensed prac'titioner of the healing arts acling within lhe scope of his license. Doctor does not
include:
{1)The Covered Person;
{2)Tha Covered Person's Spouse, child, parent, brolher, or sisten or
{3i A person living with a Covered Person.
"Ellglble E{p€ns€r" means th€ Usual, Reasonable and Customary charges br services or supplies, which are
incuned by the Covered Person for the Medically Necessary trsalment of lnjury. Eligible Expense-s must be
incuned while thls Policy is in force.
"H!", *h18" and "hlm'indudes'she", "hsf and'hers."
"Health Carr Plan" msans any contracl, poliry or other anangement for benefits or services for medicsl or denlal
care or lrealment und€n
(1) Group or blankel insurance, whelher on an insurEd or self-funded basis;
(2) Hospital or mdicd service organizalions on a group basis;
(3) Haalth Maintenance Organizations on a group basis,
(4) Group labor managemenl plans;
{5) Ernployee benefl organization plan;
(6) Professional assoclation plans on a grcup basis; or
(7) Any other group amployee welfare benefit plan as defined in the Employee Relirement lncome Searity
Act of 1974 as amended.
"Hoepltal" means an instihrtion which:
('1) ls operated pursuant to law;
{2) ls primarily and conlinuously engagad in pmvkling medical care and treatment to sick and injured persons
on an inpatient basie;
{3) ls under the supervision of a slaff of doctors;
(4) Provides 24-hour nursing sarvice by or under lhe supervision of a graduate registered nurse, (R.N.);
(5) Has on its premises, medical, diagnostic and treatmenl facilities, including major surgical facilities,
available lo il on a prearranged basis. A clinic or facility for rehabilitative trsetment is a hospital whether
or not it indudes major surgical facilities; and
(6) Charges for its serviccs.
Hospital doss not include:
(1) A dinic or facilig fiot:
{a) Convalescent, cuslodial, educational or nursing care:
5GAP 26932.FL Policy
{b) The aged, drug addicls or alcoholics; or
(2) A mililary or vElerans hospital or a hospital conlracled for or operaled by a nalional govemment or its
agency unless:
(a) The seMces are rendered on an emsrgency basis; and
(b) A legal liabilily exisls for the ctrarges made to the individual br ths seryices given in the absence of
ineurance.
"Hoapllal Staf'means a Medically Nacessary ovemlght confinernent in a Hospital wh6n room and board and
general nursing care a.B provided for which a par diem charge is made by the Hospital.
"lnJury' means bodily harm, which results, direclly and independenlly of all olhal causes, from an Accident. All
injuries to the same Covered Penson sustainad in one accident, including all related conditions and recuning
symptoms of the lnjuries will be consldered one lnjury.
"lnsund" moans a Covered Person for whom insurance is in forca undar lhis Poliry.
"llledlcally Nrcessary" or "lilsdlcal Ncccssftlf means the service or supply is:
(1) Prescribed by a Doctor br the featment of the lnjury; and
(2) Appropdate, accordlng to convenlional medical practice for the lnjury in lhe locality in whlch lhe service or
supply is given.
"Nutse" means eilher a prcfessional, licensed, graduala regislered nurse (R.N.) or a professional, licensed
practical nurse {L,P,N.).
"School" means the parliclpating School or School Distrlct wherc lhe Covared Person is enrolled or employed.
The School must be a duly accrediled (slate ceilified or accrediled) primary, elementary, secondary, or collegiale
School.
"Slckness' means illness or disease which first manifesls itself afler coverage is in force under this Policy for the
Coverad Person. Slckness indudes normal pregnancy and complicadons of pregnancy. All related condilions and
recuning symptoms of sickness to lhe sarne person will be considered one sickness.
"Supervlsed or Sponsorod Actlvlty' mean6 an authorized function by a Policyholder or School:
(1) ln which the Covered Person padicipates;
(2) Which is organized by or under its auspices; and
(3) Which is within the scope of crslomary aclivities fur such entig,
"Usual, Reasonable and Customary ("U&C") means;
(1) With respect to fees or charges, feaE for medical sarvices or supplies which are;
(a) Usually charged by the providerbr lhe seruice or supply given; and
(b) The avetage charged for the service or supply in the locality in which the service or supply is
recelved; or
(2) With respecl lo trcatment or medical selices, lreatment which is reasonable in elationship to ths service
or supply given and the severity of the condition.
uGAP 26932.F1 Policy
SCOPEOF COVERAGE
We will provide lhe benefits described in this Policy to all Covered Persons who sulfer a covered loss which:
{1} ls wilhin the scope of the DESCRIPTION OF BENEFITS PROVISIONSi and resulls, dircctly and
independently of all othercauses, from bodily lnjury which is suffered in an Accklenl; and
(2) Occurs while the person is a Csvered Person under this Policy; and
(3) ls wilhin the scope of the risks set forth in lhe DESCRIPTION OF HAZARDS provisions.
Full Excsss Medlcal Expense
lf an lnjury to the Covered Person resulb in his incuning Eligible Expenses fur any of lhe services in the Schedule
Of Beneftls, we will pay the Eligible Expanses incuned, subject lo lhe Deductible Amount and Coinsurance
Percentage (if any), that are in excsss of Eligible Expenses payable by any olher Health Gare Plan, regardless of
any Coordination of Benefita pmvision conlained in such Heallh Gare Plan.
The Covered Person musl be under lhe care of a Doc,lor whan the Eligible Expenses are inared. The Expense
must be incuned solely for the treatm€nt of a coverd lnjury:
(1) While the person is insured: or
(2) During lhe Benelit Period stated on the Schedule of Benelits.
The first Ellgible Expense must be incuned within lhe lime frama shoivn on lhe Schedule of Benafils.
The total cf all medical benatits payable under this Policy is shown on the Schedule of Banefib and are:
(1) Subject to lhe specilic maxlmums shown on the Schedule of Benefits; and
{2) Subjecl to compliance with the requirement, eel forlh in ths Limilations seclion of this Policy,
Non.Dupllcation of Benefltg Provlsion
This provision applies if a Covered Person:
(1) ls covered by any other blankel or group health care plan; and
(2) Would, as a result, recaive total medical sxp€nse or service benefits in excess of lhe axpenses ac{ually
incuned.
ln lhis case, lhe medical expense benefits We will pay under lhis Policy, will be reduced by such excass, fiis
provision doea not apply if we would be primary under any coordinalion of benefil guklelines contained in lhe
othar health care plans,
PROVISIONS CONCERNING INSUREDS
Ellglblllty:
Persons ellgible lo be insured under this Poliry ara lhose persons described in an ELIGIBLE CLASS on the
Appllcalion who have compleied any applicable service waiting pedod. This includes anyone who may become
eligible while this Policy is in force.
Effsctiva Dateg:
A Covered Person will become an lnaured under thie Policy, provided poper premium paymenl is made, on the
latest oi
(1) The Policy Effec-tive Date; or
(2) The day he becomes eligible according to the referencsd dale shown in the Applicalion.
Tcrmlnatlonl
lnsurance for an lnsured will end on lhe earliest ot
TGAP 26S32fL Pollcy
(1) The date he is no longer in an Eligible Clasa.
(2) The date he repoils for active duty in any 4smgd Fores, according to the referencsd date shown in the
Appticalion. We will refund, upon receipt of proof of service, any premium paid, calculated Fom lhe dale
ac{ive dug begins unlil the earlierof
(a) The date lha premium is tully eamed; or
(b) The Policy expiration dale.
This does not indude Reserve or Nalional Guard duty br training;
(3) The end of the period for which the last premium contribution is made; or
{a) The date this Policy is teminated.
OESCRIPTION OF HAZARDS
SPORTS COVERAGE
Subject lo all other provisions of this Poliry, covemge is pmvided fur a Covered Person while he is:
(1) Taking parl in:
(a) A regularly scheduled athletic game or oompetition; or
{b) A praclice session for an athlatic team or dub:
(2) Traveling to or from such a game, compelilion or practice session pmvided he is:
(a) Traveling with thE athletic team or dub; and
(b) Under the direct and immediale supervision ot
(i) The athletic ieam or dub; or
(ii) An adult authorized by lhe athlelic team or club; or
(3) Traveling direcfly, wilhout interruption:
(a) Between his home and a scheduled game, competilion or praclice session;
{b) ln a vehicle which is
(i) Designated or tumished by the alhlelic team or club;
{ii) Openled by a pmperly licensed, adult driver; or
(iii) Undertha direct supervision of the athletic team or club; or
{c) ln a vehicle other lhan that described in {3)(b} when operated by a pmpedy licensed driver.
"Travcl tlme'includes lhe time:
{i) To or from homs, a scheduled game, competilion or practice ssssion;
(ii) Before required atendance time;
{iii} Aftar lhe Covered Person is dismbsed: and
(iv) Afrer the Covered Person completes extra duties assQned by the School.
lnjuries, which result over a period of time (such as blislen, lennis elbo,v, etc.), and which. are a normal,
foreseeable result of the spoil, are not covered,
Unless olhen ,ise slated, we will pay benefils for a mvered loss, only once, even if coverage was provid€d undsr
more lhan one Description of Hazarde,
DESCRIPTION OF BENEFITS
BENEFITA: ACCIDENTAL DEATH, DISMEMBERiIENT, LOSS OF SIGHT, SPEECH OR HEARIIIIG BENEFIT
lf, wlthin 1-year from the dete of an Accident covered by this Policy, lnjury from such Accident, resulls in a loss
lisled below, we will pay the p€rcaniage of the Principal Sum set opposite the loss in lhe trable below. lf the
Covered Person sustains more lhan one such Lose as lhe result of one Accident, Ws will pay only one amount,
IGAP 26932.F1 Pollcy
lhe largest lo which he is entilled. This amountwill nol exced the Principal Sum, shown in the Schedule of
Benefils, which applies for lhe Covered Person.
Loss Percentaoa of Prlncloal Sum
LossofLib 1O0%
LossofBolh Hands 100%
Loss of Bolh Feet 100D/n
Loss of Entira Sight of Both Eyes 1W%
Loasotone Hand andOne Foot 100%
Loss of One Hand and Enlire Sight of One Eye 't00%
Loss of One Foot and Entire Sight of One Eye 100%
Loss of Speech and Hearing (both ears) lOO'/o
Lossofone Hand 50%
LossofOne Foot 50%
Lsss of Entire Sight of One Eye 50%
Loss ofSpeech 507o
Loss ofHearing (both ears) 50%
Loss of Thumb and lndex Finger of lhe Same Hand 25%
Loss of a hand orfoot means compleie Severance lhrough or above lhe wrisl or ankla joint.
Loss of slght means lhe total, permanent loss of sighl of tha eye. fie loss of sight musl be irracoverable by
natural, surgical or artificial means.
Loss of spoech means lotal, permanent and inecoversbla loss of audibla communicalion.
Loss of hearlog msans total and permanent loss of hearing in bolh ears which cannot be conected by any
mBan8,
Loss of a thumb and lndex ffnger means complele Severanca through or absve lhe melacarpophalangeal
joints (the joints between lhe fingers and the hand).
"severanc.o means the complete separation and dismemberment of the part from the body.
MEDICAL EXPENSE BENEFTT
We will pay, Eligible Expenses br a Covered Penson's lnjury, subject lo the Daduclible Amount and Coinsurance
Percantage, if any, shown in lhe Schedula sf Banefits. Eligible Expanses indude:
(1 ) Hospltal Room and Board - charges br the mosl common semi-privata daily room rale fur each day of lhe
Hospital Stay, up to the Ma,rimum Daily Benelit Amount shown in lhe Schedule of Benefits for Hospital Room
and Board.
(2) lntenslvc Care Room and Board - charges br each day of lnlensive Cara Unit conftnemanl, up to the Daily
Maximum Benefil Amount shown in lhe Schedule of Benefits for lhe Intensive Care Room and Board benefil.
This paymenl is in liau of payment fior the Hospital Room and Board charges tur those days,
(3) Hospltal Mlscollanoous - charges during a Hospilal Stay, up to tha Maximum Daily Benefii Amounl shown in
the Schedule of Benefits for the Hospilal Miscellaneous benefit. Miscelhneous charges do not indude
charges for telophona, radio or television, extra beds or cots, meals br guests, lake home ilems, or other
convenience items.
(4) Oulpatlent Hospltal Enpcnres - charges by a Hospilal fot:
(a) Pr+edmission lesting (confinement musl occur within 7 days of the testing); or
G4P26932#L PollcyI
(b) Emergency room tr€alment, up lo the Madmum Benefit Amounl per ernergenry sho.vn in the SchEdule of
Benefits br the Outpatienl Emeryency Room Treatrnent benefil.
(5) Surglcal Bcnrffts - charges fun
(a) A Doctor, for primary performanca of a surgical procadure, up b lhe Maximum Benefit Amount shown in
the Schedule of Benefils per procedure. Tvro or mor€ suqical procedures thmugh the same incision will
be consklered as one pmcedure. However, we will pay up to 50% of the surgical procedure charge whan
more lhan one surgical pmcedure thrcugh diffarenl operating fields are performed during the samo
surgical session.
(b) A Doclor, for: (i) assistant surgeon autes; (ii) a second surglcal opinion; or (iii) consultalion, up to the
Maximum Benefit shown in the Schedule of Benefib for en Assistant Surgeon, Second Surgical Opinion,
and Consultaiion.
(c) Aneslhesia and ib administration, up lo the Maximum Benefil Amount shown in thE Schedule sf Benefits
for lhe Aneslhesia benefil.
(c) Use of surgical facililies, up to the Maxlmum Benefit Amount per operaling session, shown in the
Schedule of Benefils tor lhe Surgical Facility benefit.
(6) Doctor's Vlslts - charges by a Doclor for othsr than pra- or post-opgrative cars:
(e) For in-Hospital visits, up to the Maximum Benefit Amount shown in the Schedule of Benefils for Doctor's
Visit- ln-Hospilal.
{b) For oflice visib, up to the Maximum Banefit Arnount shown in the Schedule of Benefits for Doc{o/e ffice
Visib.
Total visits par lnjury will nol exceed lhe combined Maximum shown in the Schedule of Benefils for All ln-
Hospital and Office Doclor's Visits.
(7) X.Ray and Laboralory - charges forX-ray and laboratory lests, up lo the Maximum Benelit Amount shown in
lhe Schedule sf Benefits for lhe X-ray & Laboratory benelit.
(8) Nurslng Servlces - Charges for nursing servioss {otherthan routine Hospibl care) by or under the
supervision of a llcensed graduale registered nurs€, up lo the Maximum B6nelit Amounl shown on the
Schedule of Benefils fur lhe Nursing benefit.
(9) Physlotherapy - Charges for physiotherapy:
(a) While Hospital confined, up lo fie Maximum Benefil Amount shorrrn in lhe Schedule of Benefib for lhe
Hospiial Inpalient Physiolherapy beneft;
(b) As an outpatient, up to lhe Maximum Benefit Amount shown on lhe Schedule of Benefits br lhe
Outpalient Physiotherapy bgnefi t.
Physiolherapy includes:
{a) Heat treatment;
{b) Diathermy;
(c) MicrolhErm:
(d) Ullrasonic;
(e) Adjuslmang
{f) Manipulation;
{g) Massage tierapy and
(h) Aarpunobrre.
Total trealment per lnjury will nol exceed lhe Physiotherapy Maxlmums shown in the Schedule of Benefits.
GAP 26932-FL 10 Pollcy
I
(10)Ambulancr - from lhe placa whera the lnjury occured to lhe Hospibl, up to lhe Maximum Benefti Amount
shown in the Schedule of Benefits for lhe Ambulance benefit.
(1 1)Medlcal Equlpment Rentel - charges for medical aquipment fot:
{e) A whaelchaiq
(b) An iron lung;or
(c) Other medlcal equipmentforwhich prior approval by us has been given;
up to lhe Maximum Benefit Amount shown in ihe Schedule of Benefits for the Medical Equipmenl Renlal
benefit.
(1Z)Mcdlcal Sorvlcrs and Supplies - Charges for medical services and supplies fon
(a) Oxygen and its administration;
(b) Blood and blood transfi.rsions;
up to the Maximum Benefit Amount shourn in lhe Schedule of Bensfils for lhe Medical Service & Supply
beneft.
(l3)Dcntal Treabnant - Charges for dental lrealment for lnjury to a looth which was sound and natural at the time
of lnJury, up to lhe Maximum Benefit Amount shorrrn in the Schedule of Benelits for the Denlal Treatment
banefit.
The amounls payable under lhe Medical Expense Benefit could be greatly reduced if lhe Covered Person does
not comply with the requirements in the Limilalions sec{ion of this Policy.
OUTPATIENT PRESCRIPTION DRUG BENEFIT
We will pay lhe Eligible Expanses. subject to the Deduc{ible Amount and Coinsurance Percenlage, ff any, for a
Prescription Drug or medication when prescribed by a Doc'lor, on an ouFpatient basis.
"Prrscrlptlon Drug" means a drug which:
(1) Under Fedenl law may only be dispensed by writlen prescription; and
(2) ls ulilized for the specific purposE appmved br general use by lhe Food and Drug Adminbtralion,
The Prescription Drug must be dispensed for out-palient use by lhe Covered Person by a licensed pharmacy
provkler.
Benefils are payable up to the Maximum Benefit Amounl shown in the Schedule ol Benefils for the Out-paliant
Prescripiion Orug Benefit.
The amounl payable under thie benefit could be greally reduced if the Cqvercd Person does nol comply with the
requiremenls in the Limitalions seclion of this Policy.
EXCLUSTONS
Benefits will noi be paid br a Covered Person's loss which:
(1) ls caused by or resulb from the Coversd Person's own:
(a) lntentionally sellinflicted lnjury, suicide or any attempt ther6at:
(b) Volunbry self-administration of any drug or chemical substance, not prescribed by, and taken
according to the direc{ions of, a docior {Accidental ingeslion of a polsonous substance is not
excluded.);
(c) Commission or attempt to commit a felony;
(d) Pariioipalion in a riot or insuneclion:
GAP 26932.F1 11 Pollcy
{e) Driving under the infiuence of a controlled substance unless adminislered on the advice of a Doc{ofi
ot
(Q Driving while lnloxicated;
(2) ls caused by or resulb fiom:
(a) Declamd or undadared war or act of wac
tb) An Accident, which ocorrs while the Covered Person is on ac{ive duty servica in any Armed Forces.
{Reserve or Nalional Guad aclive duly br lraining is nol excluded unless it extends beyond 31
days.);
{c) Aviat'ron, except as specifically provided in this Policy;
(d) Sickness, disease, bodily or mental infirrnig or medicel or surgical lreatmeni thereof, bacterial or viral
infeclion, regardless of hortr contrasted, This does not include baclerial infeclion that is the natural
and foreseeable result of an accidenlal Extemal bodily injury or accklenlal food poisoning.
(e) Nuclear reaclion or lhe release of nuclear energy, Howeyer, this exclusion will not apply if lhe loss is
suslained wilhin 180 days of the initial incident and:
(i) The loss was caused by fire, heal, explosion or other physical tnauma which rrvas a result of lhe
release of nudear eneqy; and
(ii) The Covered Pereon was within a Z$mile radius of lha site of tha ralease eithen
1) At the lime of the talease: or
2) Within 24 hours of the start of lhe relesse.
AI}DITIONAL EXCLUSIONS
Benefits will not be pald br
1. Normel heallh check-ups;
2. Dental care or lreatment olher than care of sound natural teeth and gums requimd on accounl of lnjury
resulting ftsm an Acckient while lhe Covered Porson is covered urder this Policy, and rendered within 6
monlhs of lhe Accident:
3. Services or trealrnenl rendered by a Doclor, nurse or any olher person who is:
a, Employed or relained by lhe Policyholder; or
b. Who is the Coverad Person or a member of his immediate family;
4. Charges which:
a. The Covered Person would nol have lo pay if he dkl not haye insurance; or
b. Are in excess of Usual, Reasonabla and Customary charges.
5, An lnjury that is caused by flight in:
a. An aircrsff, €xc€pl as a fare-paying pessenger;
b. A space craft or any crafl deslgned fur navigalion above or beyond the earlh's almosphere; or
c. An ultra lQht, hanggliding, parachuling or bungl-cord jumping;
6. Travel in orupon:
a. A snowmobile;
b. Anytwoorthreewheeled motorvehide;
c. Any ofi-road motorized vehicle not requlring licensing as a motor vehlcle;
7, Any Accident whore lhe Coverad Person is lhe operalor of a molor vehlcle and does nol possess a
cunent and valid motor vehicle operalofs licanse;
8. That parl of medical expense payable by any aulomobile insurance Policy withoul regerd to fault. {Does
,not apply in any sble where prohibited);
S. lnjury lhat is:
GAP 26932.FL '12 Pollcy
a. ThB result ol lhe Covered Person being lntoxicated; or
b. Gaused by any narcolic, drug, poison, gas or fumes voluntarily taken, administered, absorbed or
inhaled, unless prescribed by a Doctoc
10. Practice or play in any sporls activity, including travel lo and from lhe activity and praclice, unless
specifically provided for in this Policy;
11. Expenses lo the exlent lhat lhay are paid or payable under other valid and collec,tible group insurance or
medical prepaymenl plan:
12. Blood or Elood plasma, excapt fur charges by a Hospital for the proessing or adminislration of blood;
13. Elective tr€etment or surgory, health lreatmenl, or examination where no tnjury is involved;
'14. lnjury suslained while in the service of the armed brces of any counlry, When lhe Covered Person
enlers lhe srmed forces of any country, We will rafund the uneamed pro rab pramium upon requesl:
15. Eyeglasses, contsci ienses, hearing aids, braes, appliances, or examinations or prescriptions lherebre;
15. Treatment in any Velerans Admlnislralion or Federal Hospilal, excapt if thera is a legal obligalion to pay;
17. Treatment of temporomandibular joint [TMJ) disorders involving the inshllation of crowns, pontics,
brkiges or abutments, or lhe insbllation, maintenanca or removal of orthodsntic or ocelusal appliances or
equili bration therapy;
18. Cosmetic surgery, excapt br reconstructive surgery due to an lnjury;
19. Any loss which is covered and paid by slate or federal worke/s compensalion, smployers liability,
occupalional disease law, or similar laws;
20. The repair or replacement of exisling arlificial limbs, orlhopedic braces, or orthotic devices;
2'l . Rast cures or cuetodial care;
22. The repair or replacement of existing dentures, pariial dentures, braces or fixed or removable bridges:
23. Expenses ina.rred affer the Benefit Period, except as shown in the Schedule of Benefits;
24. Orthopedic appliances, which are used mainly to ptotect an lnjury so that a covared student can take part
in interscholastic or intercollagiate sporb;
25. Services and supplies fumished by he School infirmary, its employees, or Doc.tor who worfts for lhe
School;
26. Hemia of any kind;
27. Prescriplion medicines unless specilically provided for under lhis Policy.
LIIIITATIONS
Any benefits payable under lhis Policy will be limiled to the foiletring:
{1i The medical bsnefib olhenrvise payable under this Policy will be reduced by 50% it
(a) Excess insurence is provided under lhis Policy; and
(b) The Covered Person has coverage under another plan providing medical expanse benefitsi and
(c) The olher plan is an HMO, PPO or similer anangement ('PPGPrefened ProviJer Organization'
means an Organization offering health care services through designated health cars provklers who
agree lo perform these services at rates lower than non-prebned providen.); and
{d) The Covered Person does not use lhe facililies or services of the HMO, PPO or slmilar anangement
for the pmvision of benefils.
The Covered Person's limitation does nol apply to emergency lrealrnenl required within 24 hours afler an
Accidenl, which occuned outside the geographic area sarviced by the HMO, PPO or similar anangement.
GAP 26932+L 13 Pollcy
(2) Costs that exceed the Usual, Reasonable and Customary charges in lhe area where the services are
fumished or supplies provided. Sarvices, supplies and equipment must be;
a) Medically necessary fur the care or lraatment of a covered lnjury;
b) Reseived wbile coverage is in iorca under lhiE Policy; and
c) Rendered and/or prescribed by a licensed Doctor olher than 8re Covered Person {or a member of his
houeehold or immedials fiamily) in accordancs with cunent medical standards and prac,tices.
(3) The application of lhe Coordination of Benefits or Non0uplicatbn of Benefits provision.
{4) lf lhe Covered Person is admitted inlo the Hospital on a Friday or a $aturday on a non-emeqancy basis
and the procedure br which he is Edmitted ls not performed on the day of or the day afler admisslon, we
will not pay lhe Hospltal charges br room and board or miscalaneous Hospital charges br the initial
Friday or Salurday preceding lhe procadure.
PREI,IIUM PROVISIOHS
GRACE PERIOD:
A grace period of not less than 31 days is granled for each premium due afler the lirst premium dre dale.
Coverage will sby in furce durlng this period unless noUce has been sent, in accordance with tha POLICY
TERMIMTION provision, of the inlent to terminate coverage under lhis Policy. Coverage will end if lhe premium
is not paid by he end of fre graoe pariod.
CI{ANGES IN MTES:
We have the right to change the premium rales on any premium due date:
(1) Afler lhe first 12 monlhs insurance is in eftuct;
{2) Coinciding wilh a change in the coverage provided or dasses eligible; or
(3) Coinciding wilh a change in the risks we have assumed.
We will give 45 days written notice of any change under {1) above. Notice will be sent lo the Poliryholdeis most
recent addrass in our Fcords.
GENERAL POTICY PROVISIONS
ENTIRE CONTRAGT; CHANGES:
This Policy, the application of the Policyholder {a copy of which is attachd}, endorsemenls, riders and atteched
papers constitute lhe entire contract belween the parlies, lf an application of an lnsurcd is required, lhe
application of any lnsured, at ouroplion, may also be made a parl of lhis conbact.
All slstements made by lhe Pollcyholder or by a Covered Person ers deemed represenlalions and nst lnarranties.
No such slalement will cause us to deny or reduce benefils or be ueed as a debnse to a claim unless a copy of
the instrument contalnlng lhe stalemenl is or has been fumished lo such peson; or, in lhe evenl of hls dealh or
incapacity, his beneficiary or r€presentalive. After two years from the Covered Person's efieclive date of
coverage, no such slalement, except in lhe case of fraud or wilh respecl lo eligibilig for coverag€, will cause such
coveraga lo be conlested,
No change in this Policy will be valid until epproved by one of our executive officerc, This approval musl be
endorsed on or atlached to lhis Poliry. No agent may change this Policy or waive any of its pmvisions,
I/YORKERS' COMPET{SANON F,ISURANGE:
This Policy is not in lieu of and does not afiect any requiremenl br coverage under any Workers Compensation
lnsurance.
GAP 26932.F1 14 Pollcy
POLICY TERMINATION:
We may termlnate covsrage on or afler lhe anniversary of any pmmium due date. The Policyholder may
terminate ils coverage on any premium due date. Wdtlen noliqe must be given at lEasl 45 days prior to such
pramium due dale. Failure by the Policyholder to pay premiums when due or within lhe grace period shall be
deemed notice lo us to tarminate coverage at lhe end of the period fur which premium was paid. Terminalion of
coverage will not affecl a claim for an lnsured lhat occurs ellher behre or aflar such lermination if that loss r€sults
fmm an Accident thal occurred while the lnsured's covertsge was in force,
CONFO R'II ITY WIftI STATE STATUTES:
Any provision of this Policy in confricl on the Policy Effec{ive Dale, with lhe laws of the state where it is delivered,
is amended to conbrm to the minimum requirements of such laws.
CLAIM PROVISIONS
NOTICE OF CLAIITI:
Written notice must be given lo us wilhin 30 days afler a covered loss ocqJrs or begins or as soon as raasonably
possible. Notice can be given at our administralive office at lrving, Texas or lo our agenl, Notice should include
the Poliryholde/s name and number and the lnsured's name and address.
CLAIM FORMS:
When we reeive tha notlce of claim, we will send forms for filing proof of loss. lf claim forms are nol sent wilhin
15 days afler notice is given, lhe proof requirements will be met by zubmitting, wilhin the tima required under
PROOF OF LOSS, written pmof of the nature ard extent of the loss.
PROOF OF LOSS:
Written proof of loss must be fumished b us in the case of a daim fior loss hr which this Poliry provides pedodic
paymenl contingent upon continuing loss within 90 days afrer the end of the period for which we are liable.
Written proof that the loss continues must bo fumished to us at lnlervals required by us.
ln case of claim br any other loss, proof must be fumished within 90 days affer tha date of such loss.
lf that is not reasonably possible, we will not deny or raduca any claim if pnoof is fumished as soon as reasonably
possible. Proof must, in any casa, be fumished nol more then one year later, excapt for lack of legal capacity.
TIME OF PAYMENT OF CLAIMS;
Benefits due under this Policy for a loas, other lhan a loss for which lhis Poliry provirJes lnstallmenls, will be paid
immediately upon receipt of due writlen proof of such loss,
Subject lo written proof of loss, all accrued benefls fur loss fur which lhis Pollry provides inslallments will be pald
Monlhly; any balance remaining unpaid upon lhe termination of liabllity will be paid immediately upon receipl of a
written proof of loss, unless olhennrise slated in the Oescription of Benefils.
PAYMENT OF CI.AI[iI$;
Benefits hr the lnsured's loss of life will be paid trc the beneficiary named in our remrds. ff any, al the time of
payment. The beneftls can be paid in one sum or, at the lnsured's writlen request, in accordance wilh one of our
ssttlement plans. lf the lnsured has nol requested aoy settlemenl plan, the beneficiary can do so in writing afier
the lnsuredb dealh. lf there is no named beneficiary or surviving beneficiary, the lnsured's loss cf life benefits will
be paid in one sum to the first surviving dass of ioltotving in lhe oder shown belotu
(1) The beneficiary named to recsive the lnsured's proceeds;
(2) Spouse;
(3) Child or childrcn;
GAP 26932+L 15 Policy
{4) Motherorfalher;
(5) Sisters or bmthers; or
(6) The estate; of the lnsured.
lf we are to pay benefits to the esbte or lo a person who is incapable of giving a valid release, we mey pay up to
$1,000 to a rehtive by blood or maniage whom we believe is equilably enti[ad. This good fuith payment satisfies
our legal duty to the extent of that paymant.
PAYiIEITIT OF CLAIIIS: OTHER BENEFITS:
All other benefils will be paid to the Covered Person, if he ls living, if not, we will pay his beneficiary or his estate.
CHANGE OF BENEFICIARY:
The lnsured can change lhe beneliciary at any time by giving us writlen nolice. The beneficiary's consent is not
raquired for this or any other change which the lnsured may make udess lhe designalion of beneficiary is
inevocable or olhennise required by law.
PHYSICAL EI(AIiIINATION AND AUTOPSY:
We will pay the cost and have the right lo have the Covered Person examined as oflen as reasonably nEcessary
while the claim is pending. We can have an autopsy made at our expense unless pmtribited by law.
LEGAL ACTIONS:
No adbn at law or in equity shall ba brought to recover benefib under lhis Poliry less than 60 days affer writlen
proof of loss has been fumished as required by this Poliry. No such action shall be broughl after lhe expiration of
the appllcable statute of limibtions Fom lha tima wriften prcof of bss is nguired to be fumished.
CONDITIONAL C I.AIiI PAYMENT:
lf a Covered Person incurs expenses br lnjuries received in a covered Accident, and in our opinion a lhird party
may be liable, we will pay benefits if
(1) The Covered Person first agrees in writing to refund the lesser oi
(a) The amount we actually paid for such expensss; or
(b) The amount actually received from tha lhird party for such expenses; and
(2) The lhird party's liability is delermined and sstisfi€d whether by setllement, judgment, arbitration or
othen,ise.
However, prlor to our payment of benefits under lhis Policy, if lhe third parq/s liabilily is satlsfied in an amount
lass lhan lha benefits payable underthis Policy, we will pay lhe difierence.
RECOVERY OF BENEFITS:
We raservE the right to remver from a Covered Person any benefits we have paid lo him br injuries;
(1) Received in a covered Accident; and
(2) Which are covered unden
(a) workers compensallon orsimilar stalutory remedies availabla under law; or
b) Any employe/s lhbility lnsurance,
It will be assumed thal lhe Govered Parson is in receipt of such benefits unloss he gives us pmof such beneftts
have been denled to him.
SUBROGATION:
lf we have paid benefits to a Covered Parson br lnJuries rec€ived in a covered Accident, and in Our opinion a
thkd party may be llablE, Wa will be subrcgaled to the exlent of such payment and to all of the righls of he
Covered Person regadlng the recovery of benafib paid or to any seldement or judgment which resulls tom lhe
oxsrcise of these rights. The Covered Person agrees to sign papers and do whatever dse is neessary lo
transfer his rights to Us. Wa will exercise such righb on his behalf. He further agrees lo fumish Us with all
relevant information and documenls.
GAP 26932.F1 16 Pollcy
When used throughout this document.The Compant', 'Our", 'W8', or "Us" means:
Unlted States Fire lngurance Company
PRIVACY POLICY Al,lD PRACTICES
Thc Gompany values your buslneos and your trust. ln order to admlnletar insuranco pollclas and provldc
you wlth efroctlvc customsr scrylcs, wr must collact ccrtaln lnfiormatlon about our customsrs. Wg want
you to know that we aro comrnltted to protectlng your privata lnformadon and wc wlll comply wlth all
fuOeral and state prlvacy laws. Below is a Prlvacy Notlce dcscriblng our pollcy regardlng thc collection
and dlsclosure of personal lnformatlon, Please revlaw thls Notlce and krap 8 coPy of lt wlth your
recordc,
Your Privacy ls Our Concem
When you apply to The Company br insuranca or make a daim against a policy witten by The Company, you
disclos-e information aboul yourself to us. There are legal requiramenls governing the collection, use, and
disclosure of such information. The Company maintains physhal, eleclronic, and pmcedural safeguards lhal
comply wilh state and federal regulalions to guard your personal informetion. We also limit amployee access to
personally identiliable information to thos6 wilh a business reason for kno+ring such infurmation. The Company
instructs our employees as to the importance of the confidenliality of personal infonnalion, and lekes measures to
enlorce employee privary responsibilities.
What kind of information do we collect rbout you and from whom?
We obtain most of our infonnrtion from you. The npplication or claim form you complete, as well ss any addi$onal
infomation you pmvidc, gencrally givcs us most of the infonaation wc need to know. Sometimcs we rnay conlsrt you by
pbone or mail to obtain additionsl infonuation, Wc may use infomstion about you Bom otlrer trsnsactions rvitlt us, our
affiliates, or othcrs. Dcgending on the nahuc of your hsurance trtnsaction, we may nced additional inforoation about you or
otlrer individuals propoeed for covorge. We may obtain thc additiond inliomation wc nccd Fom third parties, such os olhcr
insuronce companies or agerts, govcmment agcncics, medical pcrsonnel, 0re statc motor vehicle dcpartn€n! infsrmsrion
clearinghouses, credit reporting egcncies, courts, or public records. A report ftom t consumcr rc,porting agcrrcy mly contain
infonnation as to creditworthincss, crcdit sl;rndiry, crcdit capacityt chiraclcr, gencral rcpulation, hobbies, occupation,
personal charactcristics, or modc ofliving,
What do rve do with the lnformation collecttd ebout you?
If coverage is dcclincd or the chargc for covcmgc is increascd bccause of inforuation containcd in a consumcr tePort we
obtained, wc will infonn yorl as required by st6t€ law or [re fedcrsl Fah Ctedit Repo*iag Ac[ We will also give you the
nsrue End ad&ess of the consurner reporting agency rneking thc rcporl We may retain infomation sbout our former
customsn and may disclose tlut infonnation to alliliates and non-a{filiatcs only as described in this noticc.
To whom do we disclose informrtlon about you?
We mly disclosc all the infonnation that we collcct about yoq as dcscribcd above. We may disclosc such infomation about
you to our afElirted companies, such as:o Insurancccompaniesio Insuranccagcncies;. Thind party administraton;r Mcdicsl billrwiew companics; ondr Rcinsurancccompanies.
We may also disclosc nonpublic pcrsonal infonnation about you to alliliated and nona{Iiliatcd 0thd panics as pcrmittcd by
lsw. You hsve a right to access and correct the personal information we collcct, meintain, snd disclosc lbout you.
How to contact Us
You may obtain e morc detailed description of thc information practiccs prescribed by lew by contacting us at the address
below. Remembcr to include your narnc, address, policy numbcr, and dayrime phonc number.
Privacy Policy Coordinuor
GAP 26932-FL
Fairmont Spcciality
5 Christophcr Way, 3d Floor
Eatontown, Newlcncy 0??24
t
I GAP 26932.F1 18 Pollcy
When used throughout lhis documant "Companf, "Ouf, 'We', or uUs' moans
Unlted States Fire lnsurance Company
GRIEVAT\ICE PROCEDURES
When you submit a claim and that claim is denied, we will povida a writlen slalement containing the reasons for
lhe Adverse Delermination. You have lhe righl to requesl a review of any Company declsion or aclion perleining to
our contraclual relationahip and to appeal any adverse clalm dalerminalion we've made by filing a Grievance.
These procedures have been developed to ensur€ a full invesligalion of a Grlevanca thrcugh a formal process.
DEFII\nTTONS
A "Griovance' is a written cofiplaint requesting a change to a previous claim decls'ron, claims payment, the
handllng or reimbursemant of health care services, or olher matters perlaining to your covarage and our conkactual
relationship.
An "Adver:e Dctormlnatlon" is a delermination by the Company or its designaled utilizalion review oganizalion
lhat {i) a servica, tr€alment, drug, or device, is experimental, investigational, specifically limited or exduded by your
coverage; or (ii) a facility admission, the availability of care, conlinued stay or other health care services proposed
or furnished have bsan reviewed and, based upon the inbmation provided, does not meet the contnaclual
requiremenls br medical necessity, appropriateness, heallh care setting, level of cane or effeclheness and
therefora, lhe beneftt coverage is denied, reducad or terminatad in whole or in pad.
INFORMAL GRIEVANCE PROCEDTJRE
You, your aulhorized reprcsentaiive, or a provirler acling on your behalf may submit an oral complaint to us wilhin
GGdays after an event lhat causes a dispule. Telephoning allows you to discuss your complaint or concerns and
gives us the opporlunlg to irnmediately rcsolve the problem.
lf ws don't have all tha lnformatlon nocossary to rcvlew your complalnt, wa wlll requatt any addltlonal
lnformatlon wlthln 5 buslness days of recelvlng your complalnl Afrer wc recelve all the necesaary
lnformatlon, wg wlll provlde you, your authorlzed rrpresentadve! or a provlder acllng on your behalf wlth
ourwrltten dsclslon wlthln 30.dayr aftcr rucelvlng the complalnt and all nsotssary lnfonnadon.
lf the problem cannot be resolved in lhis manner, you slill have he dght lo submit a written request br lhe
complaint to be reviewed through lhe Formal Grievance Pmcedure. as outlined below.
FORMAIT GRIEYANqE PROCEDTjRE
A formal Grlevanca may ba submlttrd by you, yourauthodzed repraeentathe, or ln tht evrnt of an Advarsa
Drtormlnatlon, by a provldor actlng on your brhalf.
lf you fllc a formal Grievanco, you wlll havc the oppcrtunlty to eubmlt wrltten comments, documenls,
records and olhrr lnformatlon you frol aro relsvant to the Grlcvancs, regardless of whoiher thosa materlals
were consldered ln lhe lnltlal Adverss D,sterminatlon.
Flrrt Level Review
Wilhin 3 working business days afier receiving lhe Grievance, we must acknowledge lhe Grievance and provide
you, your aulhorized represenlative or a provider wilh the name, address, and talephone number of the coordinalor
handling the Grievsnce and infurmation on how to submit writlen material. The person(s) who reviews the
Grievance will not be the same person(s) who made the initial Adverse Determinalion. During the review, all
inbrmalion, documents, and other materials submitled relating to the daim will be considered, regardless of
whEther th€y were conak ered in making lhe previous ddm decision. The lnsured will not be allowed to athnd, or
have a representative attend, a First Level Review, The lneured may, honever, submit written material for
consideration by the reviewe(s],.
Grievance
When the Grievance is basad in whole or in part on a medical judgment, the review will be conducted by, or in
consullation with, a medical doctorwith appropriate training and experlise to evaluale the matter.
Follonring our review of your Gnevance, we musl issue a writen decision lo you and, if applicable, to your
rePr€sentative or provider, wilhin 2Odays afler recoiving the Grievanoe. The written decision must indude:
(1) The name(s), tide(s) and pmfessional qualificalions of any person(s) participaling in the Firsl Level
Review process.
{2) A sbtement of lhe reviawer's understanding of lha Grie\ranca.
(3) The specific reason(s) br lhe raviewe/s decision in clear terms and the conlraclual basis or medical
rationale used as the basis for lhe dscision in suflicient delail for lhe lmured to respond further to our
posilion.
(4) A refarence to the evidence or documenlalion used ae lhe basis for the decision.
(5) lf the claim denial is based on medical necessig, experimenlal lreatment or similar exclusion,
insiructions for requesting an explanatlon of the sclentific or clinical rationale used lo make the
delerminalion.
(6) A stalemenl advislng you of your rQht to request a Second Level Review. if applicable, and a
description of the procedura and timeframes fur requesting a Second Level Review.
Second Level Revlew
The Second Level ReviEw pft)cass is aveilable if you are nol satisfed with the oulcome of the First
levsl Review for an Adversa Datermination, Within ten buslness days afler receaving a ruqusst br a Second Lavel
Review, we will advise you of the fullowing:
(1) lhe rame, address, and telephone number of a person designated to coordinale lhe Gdevance review
for the Company;
{2) a statement of your righb, lnduding lhe right to:. attend the Second Lgvel Reviewr ptes€flt hislher case lo lhe review panel;. submit supporting malerials bebre and al the review meeling;r ask questions of any member of the review panel;
r be assisled or represenled by a person of hidher choice, lncluding a provider, tamily member,
employer representative, or altomey.. reguest and receive fom us free of chsrg€, copies of all relevant documonls, r€cotds and othar
lnbrmation lhat is not confidenlial or privileged lhal were considered in making the Adveise
Determinatlon.
We must oonvene a review panel and hold a review meeling wilhin 45{ays after receiving a request fur a Second
Level Revlew. We will notify you in writing of the meEling date at least lS-days prior to the dale. The review
meeling will be held during regular business hours at a localion raasonable aocessible to you, ln csses whers a
face-lo-faco meeling is not practical for geographic reasons, we will offer you the opportunig to communicale with
the review panel at our exp€nse by conferenoe call or other appropriale technology. Your right to a full revisw may
not be conditioned on whethel or not you appear at the meeting.
lf you choose lo be represented by an atlomey, we may also be represented by an atlomay. lf we choose to have
an atlomay present lo represent our interesls, we will noti! you at least 15 r,rlorking days in advance of lhe review
that an atlomey will be presenl and that you may wish to obtain legal represenlation of your own.
The panel must be comprised of persons who:
{1) were not previously involved in any matler giving rise to the Second Level Revigwi
(2) are not employeas of thE Company or Ulilization Review Oqanizaffon; and
(3) do not have a ffnancial interest in the oulcome of the review.
iI
A person previously involved in lhe Grievance rnay appear bebre the panel to presanl information or answsr
queslions.
All persons reviewing a Seeond Level Grievance involving a UUlization Review non-carlilicalion or a clinical issue
will be providers who hsve appropriate expsrtise, induding at least one clinical peer. lf we usa a cllnical peer on an
appeal of a Utilization Review non-cerlification or on a Firsl Level Review, we may use one of our employees on
the Second Levd Review panel if the panel is comprised of 3 or more persons,
Grlevanca
Wa must issue a written decision to you and, if applicable, to your reprcsentative or provider, within 10 business
days after mmpleling the review meeting. Th6 decision must include:
{1) lhe name(s), ti[e{s) and qualiffing credenlials of lhe membsrs of the review panel;
{2) a statemEnl of the review panel's undemtanding of the nature of the Grievance and all pedineni facls;
(3) the review panel's recommendalion to the Cornpany and lhe ralionale behind the recommendalion;
{4) a descdplion of, or rstsrence to, lhe evktence or docurnentaiion consldEred by the review panel in
making the recommendallon;
(5) in lhe review of a Utilizalion Review non-cerlification or olher clinical matler, a written statement of the
dinical rationale, induding the clinicat review crileria, lhat was used by lhe review panal lo make the
deterrnination;
(6) the rationala for the Company's deEision if it difrrs fmm lhe review panel's recommendalion:
(7) a slatsment lhat the decision is the Company's finat delermination in ihe matter;
(8) nolice of the availability of lhe Gommission€fs office for assistance, including the lelephone number
and address of lhe Cornmissione/s ofrice.
i EXPEDITED RE\'IEW
You are eligible for an expodiled revlew when the limeframes fur an lnformal, formal First Level review or Second
Level review would reasonably appear to seriously jeopadize your life or health, or your abili$ lo regain maximum
func,lion. An expedited review is also availabte for all Grievances concaming an admission, availabilig of care,
conlinued slay or health care service for a person who has received Bmergency services. but who has nol been
discharged from a iacilig,
A request for an expeditad review may be submitted orally or in writing. An expedited review musl be evaluated by
an appmpriate clinical peer in lhe same or similar specially as would typically manage the case being raviewed, lf
we don't have the information neceasary lo decide an appeal, we will sand you notification of precisely what is
required within Z4-hours of our receipt of your Grievance. All necessary information, induding our decision, will be
transmitled by telephone, hcsimile, or the mosl axpaditious mathod available. Provided we have enough
infurmalion to make a decision, you, your aulhorized repreeentalive, or a prcvider ac{ing on your behalf will be
nolified of lhe determination as expediliously as lhe medical condilion requires, but in no event rnore than 72-hours
afier the review has mmmencad. Writlen confirmation of our decision will be pmvided within 2 working business
days of the decision and will conlaln the same items described in lhe writtan decision requirements fur First Level
reviews.
lf lhe expedited review does not resolva lhe siluation, you, your represenlatlve or a pmvider acting on your behalf
may submit a written Grievance.
We witl not provide an expedited review for relrospective revlews of Adverse Determinations,
Grlevance
:. LITIGATION STATEMENT
No litigation or regulatory action has been filed against KB Soccer, Inc. over the last
three (3) years.
However, in November 4, 2015, a cause of action was filed by Axel Blume and Allison
Blume v. KB, Soccer, lnc., Florida Youth Soccer Association, City of Miami, Sports and
Recreation Providers Association, Markel lnsurance Company and/or Crum & Forster,
Case No. 201 8-006295-CA-01
Court: 11m Judicial Circuit Court, Miami-Dade County, Florida
This action was in reference to a personal injury to a KBSC player prior to a practice
session at MAST Academy. This action was settled on July 18, 2019^
FORMS
FffiM DD
orsPrftE DtsctoouRE
Annrcr tht follourlnt qucstlons by placlng an "X" aftcr "YeC' or "Nol. lf you lnfilrcr oY!s", please cxplaln
on a separatc shcet attrched to this form.
1. Has your firm or any of its officers, received a reprimand of any nature or been suspended by the
Department of Professional Regulations or any other regulatory agency or prohssional ass6ciations within
the lastfive (51 years? I
t I YEs lrfr'ro
2. Has your flrm, or any member of your firm, been declared in default, terminated or removed from a
contract or job related to the services your firm provides in the regular course of business within the last
five (S)years? /
t lYEs V{no
3. Has your firm had against it or filed dny requests for equitable adjustment, contract clalms, Bid protests,
or litigation in the past five (5) years that is related to the services your firm provides in the regular course
ofbusiness? /
r tYEs Pf*o
lf yes, state the nature of the reguest for equitable adJustment, contract clalm, litigation, or protest, and
state a brief descriptlon of the case, the outcome or stetus of the suit and the monetary amounts of
extended contract time involved.
4. Has your firm or any of its officers, been under investigation, charged, or convisted by any lary
enfotcement ageney or public entity for violations of the law, other than traffic violations? /
t I YEs fro
5., Has your firm, oI any of lts principals, failed to qualfi as a responsible Proposer/Eidder on any
solicitation in the pastfive (5) years? /
I lYEs Mro
6. Has your firm, or any ofits principals, declared bankruptcy or reorganized under Chapter 11? ,/
I IYEs !{*o
I hereby certify that all statements made are true and agree and understand that any mlsstatement or
mirrepresentation of falsification of f,acts shall be cause for forfeiture of rights for further consideration of
this Proposal/Bid for the Village of Key Biscayne.
Firm:
Authorhcd Slgnrturc;
prtntorrypc n ^", fVQ.fee^lo Far{eu
Tltl€:
D3t€:u/ry/roro
{Form DD
//
AODENDUM ACKNOWTEDGEMENT FORM
Solicltation Tltle:
Sollcitation No.:
Addendum wo. I
Addendum no. L
Addendum No.-
Addendum No.
-
Addendum No.-
Addendum No.
-
Addendum No"-
Addendum No,
-
Addendum No,
-
Addendum No. . .
Addendum No.
ilsf&zo
2'Wwzo
fwrn
Listed below are the dates of issue for each Addendum received in connection with this Solicitation:
Dated
Dated
Dated
Dated
Dated
Dated
Dated
Dated
Dated
Dated
Dated
Firm's Name:
D tto Addendum issued for this Solicitation
KB fuor 84.
Authorlzed
Title:
Authorized Signature:
Form AA
GE OF I(EY BISCAYI\rE
RF'.P 2020-16
Youth Soccer Progrem
Addendum #1
Dge, Dqle:.2:00BIU. Februsry 10. 2020
This addendum is incorporated into and made a part of the above rcferenced solicitation. Thc following
may include clarifications, revisions, additions, deletions, or answers !o questions received relative to lhc
solicitntion, which take precedence over fte soliciation documents. Underlined word(s) indicate
additions. Deletions are indicatsd by stikethrough.
Clnrificatlons:
L Section 10.2, Tcrmination by Contractor, on page 5 of the draft Agreement is hereby
amendcd as follows:
'@ Contractor may terminate this Agreernent
upon *irgr-(3O) one hr$dred eightv (180) days' written notice lo the
Village. Any ureamed fees must be refunded to progrsm participurts."
of SignatoryEwdwf
titte Name ofRespondent
Date
!
RFP2020-16
Yotxh Socco Progmm
Date Postpd: lnln0z0
Page I ofl
Addendun #1
VILLAGE OF KEY
RFP 2020-16
Youth Soccer Program
Addendum #2
Due Date: 2:00PM. Februarv 10.2020
This addendum is incorporated into and made a part of the above referenced solicitation. The following
may include clarifications, revisions, additions, deletions, or answem io queslions received relative lo the
solicitotion, which tako precedencc over the solicitation documenls. Underlined word(s) indicate
additions. Deletions are indicated by suiketkough.
Quesdons & Answer$:
l. What is the total cost of field space lor the current year of play (September of 2019 through May
20e of2020)?
Response: The sclscted vendor will not pay the Village for field space.
2, How are the Field Space costs salculated?
Response: See question #1 above.
3. Can the management agrcement be automatically renewed after the agreed upon term has
expired?
Responre: No.
4. Are there any restrictions on lhe number of non-Village residcnls thstcan play with the club?
Response: Each tean must be comprised of no less than 7096 of Village residenls unless thc club
can demons$ate that it would not be able to field a specific age group without etceeding ?07o.
5. What is the term (how many years/rnonths) lor the soccer club't contact with the uniform
supplier?
Rerponre: The selected vendor is not bound by any agreemenls entercd into by the existing club
with the exception of all of the rules and by-laws of the Florida Youh Soccer League.
6. What is the term for lhe soccer club's contract with lhe registration softwsre provider?
Responre: See responsc to question 6 above.
7. If the contract is awarded, who does the Program Manager and the Key Stalf report and the Key
Staffreporl to at ttrc Village to coordinatc fte openation and administration of tre club?
Response: The Village Parks, Rccrealion, and Open Spaces Director or desipee.
L What is the corporate sructure of the club? Is it wholly owned or managed by the Village? Is it
struchred as a non-profit with a board of directors?
Response: The club alfiliation with FYSA is owned and menaged by the Village, The corporate
struchr€ of the club is at the discretion of the club managemenl.
9, How many participants does lhe club have in the Pee Wee and Jr Academy Programs?
Responre: See estimatcd registration participant table bslow.
RFP2020-I5
Yourh Soccer Program
Dste Posted: U5|2A2A
Page I of3
Addcndum #?
VTLLAGE OF KEY BTSCAYI.{E
Pee Wee League
Regular {Fall} Season 55
Sprlng Season 70
SummerCamp 70
Recreatlonal League
Begular (Fall) Season 297
Sprlng Season 200
Summer Camp 150
Competitlve League
Female League 85
Male league 175
10. If the name, logo, and colors of the club rqnain the same, is there possibiliry for my managernent
group to partner or affiliale with and co-brand the club wiih n high-profile elite level inlernstionat
soccerbrand, with the final approval of the Villagc of Key Biscayne?
Responre: The request should be disclosed and described in the Response lo the Rf.P.
I l. Are lhere any existing relationships or contracls in force that would supersede the Youth Soccer
Club's use ofany and all field/court space?
Response: The Village has two joint-use agreements with Miami-Dade Public Schools and the
Archdioceses of Miami. These agreements provide for the use of field space at St. Agnes Catholic
Cburch, MAST Academy, and the Key Biscayne K-8 facitities.
12. Are therc any field maintenance costs that need to be paid by the club?
Response: Thc Village will cover the cost forrcgular field maintenance.
13. In the event of exheme wealher damage to fields, does lhe Villqge have a contingency plan to
clean up and rcpair the fields?
Rerponse The Village has a Comprehensive Emergency Management Plan, CEMP, available on
the Village's website at h,ttp.:/4g:vbiscay[c.lI.Sovlindex.phn?src*ecndocs&reltDocCenter..NFIP-
CRs&categorv-Doflmcntcentcr. The Village returns fields to playable condition as soon &s
reasonably practicable aRer an exlrsme wetlher evenl
I4. Are there any permits that the Village are awsre of that the msnag€ment of lhe club needs to
secure to operate the club and to use the fields and cour8 that are cunently being used by the
club?
Response: The Villagc is not aware of any permils that would be requircd (o perform services
under this Agreement" however, the Respondent shatl be solely responsible for any and all
permils that may be reguired at law m in the nrtes and bylaws of the FYSA lo operate the club or
use the fields.
I
RFP2020-16
Youth Soccer Program
Date Postcd: ASl2020
Pagc 2 of3
Addendum #2
VTLLAGE ()F KEY BISCAYI{E
15. Will the Viltage sccept a respondent lhat has administered two youth soccer programs under the
same club organizrtion as having satisfied the eligibility requirement in ii,em #3 of Section 1.4 of
the RFP?
Response: Yes.
Acknowledge ment:
Name of
4rciofe-n*MrvJb.(art'oz.-
Title Name of Respondent
0z 0Q Soeo
Date
RFP2020-r6
Youth Socccr Progrrm
Date Posted: A5l202A
Pagc 3 of3
Addsndum #2
cErnflcATE oF AUft Ontry ltF ConFof,rrloNl
I HEREBY CERTIFY tftat at a mecdng of Ore Board ol Dlrectors
a corporatbn organlzcd and cxlsUng undcr the laws of the
state of Ft€k4t- hetd on tre{/aay ar
of
adopted authorirlng
@"nsolutlon was duty passed and
Fn 't Tr6irfp,'n h or tau
corporatlon to execute blds on behalf of the corporatlon and prorldlng that hk/her executlon thereof, aftcstcd
by the secretary ofthe corporatlon, shall be the offlclal act rnd deed ofthe corporadon. I further certlfo that
sald resolqtlon remalns ln full force and effecL
lN WITNESS WHEREOF, I have he,rcunto set my hand thb .{,20fu
Sccrctary:Prcddent:
Prrnr Name: l:/a'ue?1fu gadd'o?Wry.Prlnt Name:
GERnFKATE OF AUTltORry ltF pARrilEnsHtpl
I HEREBY CERTIFY that at a mectlng of the Partncrsof
a partnerchlp organlzcd and exlstlng under the laws of the
State of - held on the
-day
of
-
-
a resolutlon was duly passed and adopted
authorlzing of thc to execute blds on
behalf of the partrershlp and provldes that hls/her exccutlon thereof, attested by a partner. shall be the official
act and decd ofthe partnenhlp,
I further cerUfu that sald paficrchlp agrccmrnt remalns ln ftrll forcc and cfhct
lN WITNESS WHEREOF, I have hereunto sct my hand thls- day of
-
20_.
Partncn Partner:
PrlntName:Prlnt Name:
i, Form COA
I HEREBYCERTIFYthat, I
ldlblal s
bound by the terms of the Bid to which this attestation is attached.
tN wrlNESS
Slgned:
cEsTrFrcATE OF AUftiORnY {rF rNDtVtDUArl
$.^.t lT/&rnp-/D {r*y'rla
Y4gmzAo Fartt cu
ln thc prcscncc of:
Witness S1:
Signature:
Print:l#
Witness f2:
Signature
Print:
lndividualfu and doing business as
Applicable) have executed and am
hereunto ret my hand ttris f, . ary or R !4{**1.-l$..}3
Print:
Form COA
ACKNOwl.TDGMETTTT
State of
County &
on this-afl*dayof 2&t;before me the undersigned,
whose namets) is/arepersonally appeared
subscribed to the instrument, and he/she/they acknowledge that helshe/theV executed it.
Witness my hand and official seal:
Stemp, orTypc es Commlsioncd)
known to me; or
-Produced
identification {Type of ldentification: -, I
Did take an oath; or
Did not take an oath
,tr K fitt^ltst
No.lary pubth Shb ol Ftortds
0ommllslont cG Jt tZlS
ily cofin e4t rsApR. 01. A0A
Form COA
FORM CD
COMPANY DECIARATION FORM
I certifu that any and all information contained in this Response is true, I certiff that this Response ls made
without prior understandin& agreement, or connections with any corporatlon, firm or person submitting a
Response for the same rnaterials, supplles, equipment or services and is in all respects fair and without
collusion or fraud. I agree to abide by all terms and conditions of the solicitatlon and certiff that I am
authorized to sign for the Propose/s firm. Please print the following and sign your name:
Kfr t"^rrof Ync.
FIRM NAME
P$ilClPAI
905- boE. bo+b
^/4TEIIPHONEFACSIMIIE
fvl arqd|e e 8- kaL{ bi S @t1r7 4to ee a r C I v b. rryn
I
EMAILADDRESS
4a-oq r g sls
FEDERAL I.D. NO.
OR SOCIAI 5ECURITY NUMBER
MUNICI PAL BI.ISIN$S TN( RECEIPT
oR occt PATI(X{AL ucENsE trto.
lfJaree lo [?arlire-.
NAME
ftosi drn l*
Form CD
FORMS€A
$ ilCU EXECUNON ASFIDAVIT5
Tgr ronla MUsr BE slcNtD AtIo swoFN To tH tHE pRESENGE oF A titorAny puauc
OR OTHER OFflCIAL AUTHORTZEO TO ADMINISIER OATHS.
ITII9 FORM COMEI'IIES SEVERAT AFTIDAVTT STATEMEITITS TO BE SWORT{ TO 8Y THE PROPO6ER OR EIDDER
AND NOTAREED BELow. lN THE EvEItlT IHE PROFOSER OR EIDDER CAI{lrl(II SWEAR TO ANY OF THESE
AFFIDAVIT STATEMENTS, THE PBOPOSER OR BIDDER IS DEEMED TO BE NOfII.RESPONSIBTE ATIID IS NOT
EUGIBTE TO SUBMff A PROFOSAUBID.
T}IESE slN€tE EXECUTION AFFIDAVITS ARE SUBMITTED TO THE V|LI-AGE OF KEY BISCAYITIE AllD ARE
STATEMENTS MIIDE:
By:
For (Name of Proposing or Bidding Entity):
Whose business address D ,33
And (if applicablef iE Fedenl Empbyer tdentification Number (FE|N) is:
(if the entity does not have an FEIN, include the Social Security Number of the individual signing this s,vorn
statement. SSf: - l
Amcricans whh Disebllhlce Act Comollancc Affldavlt
The above named firm, corporation or organization ls in compliance with and agrees to continue to comply
with, and assure that any subcontractor, or thlrd party contractor under thls proJect complles with all
applicable requirements of the laws llsted below lncluding but not limlted to, those provlsions pertalnlng to
employment, provision of programs and services, transportation, communications, access to facllities,
renovations, and new construction.
r The American with lxsabllities Act of 1!xl0 (ADAI, pub. L 101€36, 104 Stat 322 42 usc U101U2UI
and 47 USC Sectjons 225 and 561 induding Title I Employmenq fide ll Public Servkes; fiUe lll,
Public Accommodatiom and Services Opeftrtcd by Prirrate en6ties; fitle lV, Telecommunications;
and Title V, Miscellaneous Prodsions.
r The Florida Amedcans with Disabilities Accessibllity lmplementation Act of 1993, Section 553.501-
553.5U1, Florida Statutes:
. lhe Rehabilltation Act otL973,229 USCSection 794;
r The Federal Tnnsit Act as amended 49 USC Sectbn 161,2;
. The Fair Housing Act as amended 42 USC Section 3601-363L
,
Proposer lnitiels
{ FormSEA
Rrbllc Endtv Crirne Atfidrvit
I understand that a "public entity crime" as defined in Paragraph 287.133{U{e), Flodda Statutes, means a
violation of any state or federal law by a person wlth respect to and directly related to the transaction of
business with any public entity or with an agency or political subdivision of any other state or of the United
States, including but not limited to, any bid or contract for goods or services to be provided to any public
entity or an agency or political subdivision of any other state or of the United States and involving antltrust,
fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentations.
I understand that "convicted" or "@nviction" as defined in Paragraph 287.133(1xbl. Florida Statutes,
mesns a finding of guilt or a convlction of a public entity crime, with or without an adjudication of guilt, in
any federal or state trial court of record relating to charges brought by indirtment or information after July
1, 1989, as a result of a jury verdict, non-jury trial, or entry of a plea of guilty or nolo contendere.
I understand that an "affiliate" as defined ln Paragraph 287.133(1)(a), Florida Statutes, means:
1. A predecessor or successor of a person convicted of a public entity crime; or
2. An entity under the control of any natural person who is actlve in the management of the entity and who
has been convicted of a public entity crime- The term "affiliate" lncludes those officers, dlrectors,
executives, partners, shareholders, employees, members, and agents who are active ln the management of
an affiliate. The ownership by one person of shares constitutlng a controlling lnterest in another petson, or
a pooling of equipment or income among persons when not for falr market value under an arm's length
agreement, shall be a prima facie case that one person controts another person. A person who knowingly
enters into a joint venture with a person who has been convlcted of a public entity crime in Florida during
the precedlng 36 months shall be considered an affiliate.
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 wlth the legal power to €nter
into a binding contrast and which bids or applies to bid on contracts for the provision of goods or services
let by a public entity, or which othenrvise transacts or applies to transact business with a public entity. The
term "person" includes those officers, directors, executives, and partners, shareholders, employees,
members, and agents who are active in mana8ement of an entity.
Bassd on information and bellef, the statement, which I have marked below, is true in relations to the entity
submitting this sworn statement.
(tNDICATE WHrCH STATEMENT APPUES.I
$ *",,n., 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,
nor any affiliate of the entity has been charged with ad convicted of a public entity crime subsequent to July
1, 1989.
I I The entity submitting this sl ,orn statementf or one or more of its offiers, directors, executives,
Form SEA
partners, shareholders, employees, member, or agents who are active ln the management of the entlty, or
an affiliate of the entity has been charged with and convicted of a public entity cdme subsequent to July 1,
1989.
[ ] The entity submitting thh sr rorn statem€nt, or one or more of its officers, directors. executivet
partners, shareholders, employees, membe6, or agcntr who are active in the management of the entity, or
an affiliate of the entity has been charged with and convicted of a publlc entlty crime subsequent to July 1,
1989. However, therc has been a subsequent proceeding before a Hearlng Ofiicer of the State of Florida ,
Division of Administrative Hearings and the final Order entered by the Hearlng Officer determined that it
was not in the public intelest to place the entity submitting this sworn statement on the convicted vendor
list {attach a copy of the final order}.
I understand that the submission of this form to the contracting officer for the public entity identified in
paragraph 1 above is br that public entity only and that this form is valid through December 3X of the
calendar year in which it is filed. I also understand that I am required to inform the publlc entlty prior to
entering into a contract in excess of the threshold amount provided in Section 287,0I7, Florida Statutes for
category two of any change in the informatlon contained in this form.
WH
Proposer lnitlals
No Conflict of lnt-clc$t or,C*nllnrcnt F,cp gftid?Vlt
Proposer warrants that neither it nor any princlpal, ernployee, agent, representative nor family member has
paid or wlll pay any fee or consideration that is contingent on the award or executlon of a contract arising
out of this solicltatlon. Proposer also warrants that neither it nor any principal, employee, agent
representative nor famlly member has procured or attempted to proorre this contract in violation of any of
the provisions of the Miami-Dade County conflict of interest or code of ethics ordinances. Further, Proposer
acknowledges that any vlolation of these warrants will result in the termination of the contract and
forfeiture of funds paid or to be paid to the Proposer should the Proposer ba selected for the performance
of this contract.
JM
Proposer lnitials
Businese Entlhr Afffdevlt
Proposer hereby recognlzes and certifies that no elected oflicial, board member, or employee of the Village
of Key Biscayne {the " Village"} shall have a financial interest directly or indlrectly ln thls transaction or any
compensation to be paid under or through this transaction, and further, that no Village employee, nor any
elected or appointed offlcer {includlng Vlllage board members} of the Vlllage, nor any spouse, parent or
chlld of such employee or elected or appolnted offcer of the Village, may be a partner, officer, director or
proprietor of Proposer or Vendor, and further, that no such Village employee or electcd or appointcd
officer, or the spouse, parent or child of any of them, alone or in combination, may have g material intcrert
Form SEA
1
in the Vendor or Proposer. Materlal int€rest means direst or lndirect ownershlp of more than 5% of the
total assets or capltal stock of the Proposer, Any exception to these above described restrictions must be
expressly provided by applicable law or ordinance and be confirmed in writing by Village. Further, Proposcr
recognizes that with respect to this transaction or bid, if any Proposer violates or is a pafi to a violation of
the ethics ordinances or rules of the Village, the provisions of Miami-Dade County Code Section 2-11.1, as
applicable to Village, or the provbions of Chapter 112, part lll, Fla. Stat., the Code of Ethics for Public
Officers and Employees, such Proposer mey be disqualified from hrrnishing the goods or services for which
the bid or proposal is submitted and may be further disqualified from submitting any ftiture bids or
proposals for goods or services to Village,
W,q{
Proposer lnitials
Anti{olluslon Affl drvlt
1. Proposer/Bidder has personal knowledge of the matters set forth in its ProposafBid and is fully
informed respecting the preparation and contents of the attached ProposaUBid and all pertlnent
circumstances respecting the Proposal/Bid;
2. The Proposal/Bid ir genuine and is not a collusive or sham Proposal/8id; and
3. Neither the Proposer/Eidder nor any of its offfcers, partners, owner, agents, representatives,
employees, or parties in interest, includlng Afffant, has ln any way colluded, conspired, connived, or
agreed, dlre*ly or indirectly wlth any other Proposer/Bldder, firm, or person to submlt a ollusive or
sham ProposafBid, or has in any m6nner, direcly or lndirectly, sought by agrcement or collusion or
communication or conference with any other Proposer/8idder, firm, or person to ftx the price or prices
ln the attached PrsposafBid or of any other Proposer/Bidder, or to fix any overhead, profit, or cost
element of the Proposal/Bld prica or the Proposa[Bid price of any other Proposer/Bidder, or to secure
through any collusion, conspiracy, connivance or unlawfulagreement any advantage against the Village
of Key Bircayne or any person interested in the proposed Contract.
WLfu
Proposer lnitials
Scrutinlzed Comoenv Ccrtiffcatlon
1, Proposer certifies that it and its subcontractors are not on the Scrutinized Companies that Soycott lsrael
[ist, Pursuant to Section 287.135, F.5., the VillaSe may immedlately t€rminate the Agreement that may
result from this RFP at its sole option if the Proposer or its subcontrastors are found to have submitted
a false certification; or if the Proposer, or itr subconfactors are placed on the Scrutinized Companies
that Boycon brael Ust sr is engaged in the boycott of lsrael during the term of the Agfeement.
2, lf the Agreement that may result from thls RFP is for more than one million dollars, the Proposer
certifies that h and hs subcontractors are also not on the Scrutinized Companles with Activities in
Sudan, Scrutinized Companies with Activiths in the lran Petroleum Energy Sector [ist, or engaged with
business opentions in Cuba or Syria as identified in Section 287.U15, F,S, pursuant to Sectlon 287,135,
F.S., the Vlllage may lmmediately terminate the Agreement that may result from this RFP at its sole
option if the Proporer, its affiliates, or its subcontractors are found to have submltted a false
Form SEA
{
certification; or if the Proposer, ic affiliates, or its subcontractors are placed on the Scrutinized
Companies with Activities in Sudan List, or Scrutinized Companies with Actlvities in the lran Petroleum
Energy Sector List, or engaged wlth business operations in Cuba or Syria during the term of the
Agreement.
3. The Proposer agrees to observc the above requirements for applhable subcontracE entered into for
the perbrmancc of work under the Agreement that may result from this RFP. As provided in Subsection
287.fi15(81, F5., if federal law ceases to authorize the above-stated contracting prohibitions then they
shall become inoperative.
ty'ywd_
Proposer lnitials
Askno!fllc&ment, Wrrrentv. i.nd Acccfr ncc
1. Contractor werants that it is wllling and able to comply with all applicable state of Florida laws, rules
and regulations.
2. Contractsr wanants that it has read, understands, and is willing to 6mply with all requirements of RFP
No. 202G16 and any addendum/addenda related thereto.
3, Contractor warrants that it wlll not delegate or subcontract its responsibilities under an agreement
without the prior written pgrmlssion of theVillagc Council orVillage Manager, as applicable.
4, Contractor warrants that all information provided by lt in connecdon with this Proposal is true and
accurate.
tltuk
Proporer lnitials
9wom Sknature of Proooslnr EndW RForcscntetivc end Notedratlon
fg.f ell rborc Affidrvltl follows on thc naft prrr.
r FormSEA
ln thc prescnrc of: .W
Lutnfq flt prtnt tt"me. d qh-t ItfU
U"A,L &,**
by:
Pdnt il.me
l,Vltnerr {2 Prlnt Name 6fr7aeS
ACI(NOWTEDGMENT
State of
County of
Witness my hand and oflrrral seal
'"tr
KAHiIAf,ITI
Notary PrfiSc, Stals ol Flodda
Commhggff Gg 3ll7t8
My csim. oqirss APf," 0 I . e(}A
!r/ P"rron.lly known lo me, or
_Produced rdentifrcatron {lype ol identlfication
t1 -oiatake an oath; {rr
-*Did
not take an o,rlh
undersigned,
subscrlbed
ry {Prlnt, Stamp, or Type as €ommlsslonedf
o
Form SEA
WARRANTY
{ February 10,2O2O
Mllage of Key Biscayne
Village Hall, Suite 220
Key Biscayne, FL33149
Dear Mllage of Key Biscayne,
This letter hereby serves as Warran$ that KB Soccer, lnc. is not insolvent, is not in
Bankruptcy proceedings or receivership, nor it is engaged in or threatened with any
litigationor other legal or administrative proceedings or investigations of any kind that
would have an adverse effect on its ability to perform its obligations under a contract
with the Village of Key Biscayne.
Signatory on next page
FORM PF
REGISTR'ITIOIII PRICE PROPOSAL
The Proposer shall provide the registration ftes requestcd below for all proposed programming. Thesefees shall lnclude Propose/s proflt margin and cover all overhead including,'brt not timiteo to,Ihe costof all labor, equipment, kits, supcrvision, maintenance, fue!, dellvery costs, iravel time, per diem and anyother mlscellaneous exPenses. No other fees tlan those shown below wlli be charged to pargclpants.
UNE-IIEM MTES: Complete Form pp - MS &cel prlce proposal Form.
The Proposer must complete and submlt wfth thls form an electronlc version of the Ms Excel prlce
Proposal Form (separate Attachment) to be responsive. A prlnted copy of the MS Excel prlce proposal
Form should also be included as part of the response. Do not csnvert the Ms Excel prlce proposal iormto a .pdf form.
TOTA! PROECTED FEES:'lt
ADDITIONAI PROGRA MMIT{G:
lnclude any addltional programming not included in Attachment pS and their assoclated reglstration
fees below.
PFrtlcloant Base Rateg
The underslgned attests to hldher authorlty to submit thls proposal and to blnd the firm herein namedto perform as per contract, lf the finn is awarded the agreement by the Vlllage. The undersigned further
certlffes that helshe has read the Reguest fur Proposal relating to this rcguest and this proposal issubmltted whh full knowledge and understandlng of the requirements and tlme constraints noted
hereln.
By slgning this form, the proposer hereby declares that thls proposal is made without collusion wlth anyother person or entity submltting a proposal pursuant to this RFp.
Flrm:
Authorlzed Slgnaturc:
prtntorrypcN " ., fUAfce.[O Padt(,a-
t
Prorrrm$llg
I /z $a
5
2
tu a
Form PP
Detc:DzCI
Vlltqr of tby Ekcrynr
RFP2ltXr"1G
Youth Soccer h4nm
Attachment PS
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Competlllve league
Recreatlonal Laagua
Pee Wee Leagre
Male Lemue
Female Leafl,c
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5prlng Soason
ReBUlarlFal[ Seson
SummerCamD
Spdng Scason
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