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HomeMy Public PortalAboutTown of Gulf Stream (5) Renee Basel From:Janice China <Janice@avirom-survey.com> Sent:Thursday, June 2, 2011 1:57 PM To:dbrannon@bngengineers.com Subject:Town of Gulf Stream Attachments:image001.jpg; image002.jpg; image003.jpg; Town of Gulf Stream W-9 and ins certs.pdf Danny, Attached please find our W-9 and requested certificates of insurance. I will mail the originals to you today. Thank you, Janice China Office Manager AVIROM & ASSOCIATES, INC. nd 50 S.W. 2 Avenue Boca Raton, FL 33432 Phone: (561) 392-2594 Fax: (561) 394-7125 http://www.avirom-survey.com This message is intended only for the named recipient. If you are not the intended recipient you are notified that disclosing, copying, distributing or taking any action in reliance on the contents of this information is strictly prohibited. Avirom & Associates, Inc. makes no guarantees that this e-mail and/or attached files are free and clear of the presence of computer viruses, have been tampered with, or contain questionable material or content and accepts no responsibility for the loss or corruption of any data on the addressee's computer as a result of opening this e-mail. All efforts have been made to assure that messages and files generated from this office are free and clear of this type of material. 1 Form W-9 Request for Taxpayer Give Form to the (Rev. January 2011) Identification Number and Certification requester. Do not Department of the Treasury Send t0 the IRS. Internal Revenue Service TIN on page 3. Name (as shown on your income tax return) Emplo Avirom & Associates, Inc. N Business name/disregarded entity name, if different from above v m ro a Check appropriate box for federal tax c O a o classification (required): ❑ Individual/solero rietor ❑ C corporation p p po ❑ S Corporation ❑ Partnership ❑ TmsVestate E]Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership)► El Exempt payee 0 2 -------""---- c e�, or E] Other (see instructions)► Address (number, street, and apt. or suite no.) Requester's name and address (optional) $ 50 SW 2nd Avenue, Suite 102 Town of Gulf Stream 100 Sea Road City, state, and ZIP code N Boca Raton, Florida 33432 Gulf Stream, Florida 33483.7427 List account numbers) here (optionaq Number Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line Lsoclsll to avoid backup withholding. For Individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entitles, It is your employer identification number (EIN). If you do not have a number, see How to get a LL TIN on page 3. Note. If the account Is in more than one name, see the chart on page 4 for guidelines on whose Emplo number to enter. F—F— F7E10�f�Oil�©© Under penalties of perjury, I certify that: 1. The number shown on this form Is my correct taxpayer Identification number (or I am waiting for a number to be Issued to me), and 2. 1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all Interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. 1 am a U.S, citizen or other U.S. person (defined below). Certification Instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all Interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage Interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an Individual retirement arrangement (IRA), and generally, payments other than Interest and dividends, you a{e not required to sign the certification, but you must provide your correct TIN. See the Instructions on page 4. 1 f �qjlj Signature of Here U.S. person 0- r t i `, t /1..e.P Data fJ7 a� General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Purpose of Form A person who is required to file an Information return with the IRS must obtain your correct taxpayer Identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage Interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-9 only if you are a U.S. person (Including a resident alien), to provide your correct TIN to the person requesting It (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be Issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding If you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership Income from a U.S. trade or business Is not subject to the withholding tax on foreign partners' share of effectively connected Income. Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if It is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • An Individual who is a U.S. citizen or U.S. resident alien, • A partnership, corporation, company, or association created or organized in the United States or under the jaws of the United States, • An estate (other than a foreign estate), or • A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business In the United States are generally required to pay a withholding tax on any foreign partners' share of income from such business. Further, In certain cases where a Form W-9 has not been received, a partnership Is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, If you are a U.S. person that is a partner in a partnership conducting a trade or business In the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership Income. Cat. No. 10231X Form W -•J (Rev. 1-2011) 7075 A� " CERTIFICATE OF LIABILITY INSURANCE °A's;ti2011 Y THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s), PRODUCER Commercial Lines - (813) 639-3000 CONTACT AME CT Certificate Dept Wells Fargo Insurance Services USA, Inc, 2502 N. Rocky Point Drive, Suite 400 813.6 9.300 acc° No ExI : 813.639.3000 ac Ne : 855.299.7117 aooeiess: st@wellsfargo.com 06/01/2010 Tampa, FL 33607 P INSURER(S) AFFORDING COVERAGE NAIL N INSuRERA: Valley Forge Insurance Company 20508 INSURED Avirom & Associates, Inc. INSURER B: National Fire Ins. of Hartford -A CNA Co. 20478 INSURERC: Transportation Insurance Company 20494 50 S.W. 2nd Ave., Suite 102 INSURER 0: PRODUCTS -COM PIOP AGG S 2,000,000 INSURER E: Boca Raton FL 33432 INSURER F: COVERAGES CERTIFICATE NUMBER: 2829289 REVISION NUMBER: Rea hm. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCEINSR ADOL SUSHI MD POLICYNUMBER POLICY EFF RAMA)DrYYYY1, POLICY EXP IMM1DImYY)DLIMITS A GENERALLIABILITY X COMMERCIALGENERALLIABILITY CLAIMS -MADE OCCUR C2064155870 06/01/2010 06/01/2011 EACH OCCURRENCE S 1,000,000 DAMAGETORENTE PREMISES Ea occu,rence S 300.000 MED EXP(My one person) $ 5,000 PE RSONAL& ADV INJURY $ 1,000.000 GENERALAGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLI ES PER: PRO- LOC POLICY X JECT PRODUCTS -COM PIOP AGG S 2,000,000 $ B AUTOMOBILE X X LIABILITY ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS HIRED AUTOS % NOWOWNED AUTOS 02064155884 06/01/2010 08101/2011 COMBINED SINGLE LIMB 1,000,000 Ea acddent BODILY INJURY (Per Person) $ BODILY INJURY $ ODPer accident ( ) PROPERTY DAMAGE $ Per acddenl L. UM BRELLA LIAR EXCESS LIAR X Do, UR CWMSdMDE C2064155898 08/01/2010 08/01/2011 EACH OCCURRENCE $ 1,000.000 AGGREGATE $ 1,000,000 DED I I RETENTION$ $ WORKERS COMPENSATION EMPLOYERS' LIABILITY YIN ANYPROPRIETORIPARTNEWEXECUTIVE OFFICEMAEMBER EXCLUDED? (Mandateryln NH) If yes, describe ender DESCRIPTION OF OPERATIONS beta+ NTA VIC STATU- O'S I EL EACH ACCIDEM $ E.L. DISEASE - FA EMPLOYEd $ EL.DISEASE - POLICY LIMIT I $ DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If mora space is r.q.1red) CA 00 Ot 03 06,G-140331 -B 01/09 Town of Gulf Stream Is listed as Additional Insured %ilh respect to General Liability and Automobile Liability. Town of Gulf Stream 100 Sea Road SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Gulf Stream, Florida 33483-7427 AUTHORIZED REPRESENTATIVE 97 I The ACORD name and logo are registered marks Of ACORD @ 1988.2010 ACORD CORPORATION. All riahfs reservRd ACORD 25 (2010/05) (R�u ncrta,z,ey:ce, mGfi�zss zsz93f6 nscea m f/umul " R" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YY) 1 83123/11 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER Aon Risk Services, Inc of Florida 1001 Bdckell Bay Drive, Suite #1100 Miami, FL 33131-4937 CONTACT Aon Risk Services, Inc of Flodda NAME: PHONE 800-743.8130 A/C No. Eat): FAX, 800-522-7514 A1CNo E-MAIL ADDRESS: ADP-COI-Center@Aon.com PRODUCER 10762287 CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE NAIC # INSURED INSURER A: KwS Natimal Insurance Co 23817 ADP TotalSource NH XXVIII, Inc. 10200 Sunset Drive INSURER B: INSURER C: Miami, FL 33173 ALTERNATE EMPLOYER Av'Nom 8 Associates Inc INSURER D: INSURER E: 50 SW 2nd Ave Ste 102 Boca Raton, FL 33432 INSURER F: COVERAGES CERTIFICATE NUMBER: 284593 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I.Mi]SSIWWSAIZE,\SREOUESIED. INSR LTR TYPEOFINSURANCE ADDL INSR SURR YND pOLILYNUMBER POLICYEFFECTNE DATE(MMIWNYYY) POLICYE%PIRATIOH DATE(MMIDDNYYY) LIMITS GENERALLIMUTY EACH OCCURRENCE $ DCOMMERGALGENERALUABIUTY ❑CIJUMSMADE OOCCUR DAMAGE TO RENTED PREMISES (Ea Occurrence) $ MEDEXP(Anyonepeison) $ PERSONALBADVINIURY $ GEN L AGGREGATE LIMIT APPLIES APPLIES PER: $ PRODUCTS-COMPIOPAGG $ DPODCY DPRWECT D LOG $ AUTOMOBILE LIABILITY DANYAUTO COMBINED SINGLE LIMIT (Ea accident) $ D ALL OWNED AUTOS CI SCHEDI&ED AUTOS BODILY INJURY $ (P6' pefson) BODILY INJURY $ (Peraceldenl) D HIRED AUTOS D NON OWNED AUTOS PROPERTY DAMAGE $ (Per accident) ❑UMBRELLALM OCCUR EACH OCCURRENCE $ D "Cass LIAR CIAMSMADE AGGREGATE $ ❑ DEDUCRBLE ❑ RETENTION f A OH AND WORKEEMPLOYERS' EMPLOYERS' LIABILRY LIABILITY ANY PROPRIEREXCLRTNER,E%ECUnVE OFFICERA�MBER E%CIUDEDi VIA � WC 056339950 FL 07/01/10 07/01/11 ®TO YUMT ❑OTHER TORYUMTS WTS E.L.EACH ACCIDENT $ $2,900,000 (MaMabry In MQ Ify .duc umer EL DISEASE-EA EMPLOYEE $ $2,000,000 E.L. DISEASE-POLICY LIMIT $ $2,090,000 DESCRIPTION OF OPERATIONS IHaw DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Atfach ACORD 101, Additional Remarks Schedul a, If more space is required) All worksite employees Working for the above named client company, paid under ADP TOTALSOU RCE, INC.'s payroll, are covered under the above stated policy. The above named client is an alternate employer under this policy. CERTIFICATE HOLDER - CANCELLATION Town Of GUIf Stream Mr. Bill Thrasher, Town Manager SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 100 Sea Road Gulf Stream, FL 33483-7427 AUTHORIZED REPRESENTATIVE p4on�lak�exvicea, QneofC{loaida ACORD 25 (2009109) 01988.2009 ACORD CORPORATION. All rights reserved. I ne ALIURu name and logo are registered marks of AGURD F9lr®R®,v CERTIFICATE OF LIABILITY INSURANCE 3DATC /23/2011 � PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ISU Suncoasl Insuranco Assoc ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. Box 22668 - HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. npa,FL 33622.2668 ,3 260.5200 INSURERS AFFORDING COVERAGE NAIC tl INSURED INSURER A: XL $ eclelt Insurance Com Dan 37885 Avirom &Associates, Inc. INSURER D: 50 S. W. 2nd Avenue, Suite 102 INSURER C: Boca Raton, FL 33432 INSURER D; INSURER E: [HA7gNA[c7�9 THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DCSCRIBED HCREIN IS SUBJECT TO ALL YHE TCRMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREDAYE UAOTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, NIS TYPE OF INSURANCE POUCYNUMBER POLICYEFFECTIVE DATE MMIDD POLIGYEXPIRAYloN DATE IM&UBDffyj LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY CLAIMS RUDE O OCCUR OAMAOE TO RENTEI) PREMIS25 (Ea MED EXP ("me Km.) S PERSONAL& ADV INJURY S OENERALAOGREOATE $ GER'L AGGREGATE LIMIT APPLIES PER: PRODUCTS, COMP/OP AGO S PRO LOC POLICY El AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE LIMIT S (EA 6C6&hq All OWNED AUTOS SCHEDULED AUTOS. BODILY INJURY (Perpeam) S HIREOAUTOS NONOVNEO AUTOS BODILY INJURY q (Per eetldenU PROPERTY DAMAGE S (Pcrycddcnl) GARAGELIABILITY AUTO ONLY, PA ACCIDENT S OTHERTHAN EA"Arc $ ANYAUTO AUTO ONLY: AGO S EXCESSNMBREUA LIABILITY OCCUR CLAIMS MADE EACH OCCURRENCE $ AGGREGATE 5 5 DEDUCTIBLE 5 RETENTION S WORKERS COMPENSATION AND WCSTAN OTTORY LIMITS R EMPLOYERS' LIABILITY E -I. EACH ACCIDENT q ANY PROPRIETORWARTNER/EXECUTIYE OFFICER/MEMBER EXCLUDED? Ifyyu EALPRe SIO BPEC�'WL PROVISIONS UeFiN E.L. DISEASE. EA EMPLOYEE S E.L. DISEASE. POLICY LIMIT S A OTHER Professional Liability I)PR8686208 08/01110 08/01/11 $1,000,000 par claim $1,000,000 annl aggr. DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Professional liability is written on a claims made and reported basis, Town of Gulf Stream Attn: Mr. BIII Thrasher, Town Manager 100 Sea Read Gulf Stream, FL 33483.7427 25 (2001/00) 1 of 7 HR3AA SRO/M OR9n1R SHOULD ANY OF THE ABOVE DESCRID ED POLICIES 8E CANCELLED D ErORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL SNDEAVOR TO MAIL __30_ DAYS WftIiTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, OUT FAILURE TO DO 90 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON YHE INSURER, MAC OR AU ORIZEO REPREA�S,EBHTATIVR �71 06 -BOLL -Ar�