Exhibit 5 Bid SubmissionExhibit 5
Ric -Man International
Bid
Submission
alimplr RIC -MAN INTERNATIONAL, INC. 4.1.
GENERAL CONTRACTORS
2601 N.W. 48th Street • Pompano Beach, Florida 33073
BROWARD: (954) 426-1042 • FAX: (954) 426-0717
www.Ric-man.us
Identification Page
Name of Bidder:
Ric -Man International, Inc
Address of Submitting Bidder:
12 Washington Avenue, Suite 200
Miami Beach, FL 33139
E-mail address of Submitting Bidder:
dmancini(a_ric-man.us/ rcastillona.ric-man.us
Phone Number and Facsimile Number of Submitting Bidder:
Phone: (305)535-1742
Fax: (305)535-1745
Federal Tax Identification Number for Submitting Bidder:
FTI # 59-2300398
Declaration Regarding Company Organization:
Ric -Man International, Inc is a corporation
Signa - of an Officer of the Submitting Bidder:
P i - d Name • - - . orized Signing Officer:
David A. Mancini
Title of the Authorized Signing Officer:
President
Date of Signature:
June 22, 2007
Table of Contents:
Please refer to the following page
2
3
4
5
6
7
8
Project Team
Resumes
Construction Team
Prequalification's
Experience
Reference List
Required Forms
dap' RIC -MAN INTERNATIONAL, INC. 4.411.1
GENERAL CONTRACTORS
2601 N.W. 48th Street • Pompano Beach, Florida 33073
BROWARD: (954) 426-1042 • FAX: (954) 426-0717
www.Ric-man.us
Project Team
Introduction
The Ric -Man Team has put together a highly qualified team of construction and
design professionals who are totally committed to the success of this project. All
of the key personnel that we are proposing to carry out this project have
participated in the proposal and bid preparation, giving them already a great deal
of knowledge of this project. Our team brings the following strengths to the
execution of this project:
• Past design and construction experience in the City of Miami Beach
on Streetscape and Utility projects.
• Strong knowledge of the geotechnical and traffic conditions in the
project area.
• Local present and in-house capabilities to self -perform the design
and construction activities required by this project.
• Established working relationship as a result of the Washington
Avenue Design -Build Project for Washington Avenue
Improvements Phase II, IV, & V.
Team Organization
One of the most important factors in the delivery of any project is the close
coordination and timely communication among all parties involved. Our team will
place a strong emphasis on sustaining an excellent communication line with the
City via oral, written or personal contact. Our project manger, Mr. Rene Castillo
will maintain a close communication Zink with all parties involved on this project.
Another important aspect in putting our team together is the past relationship
established between Ric -Man and all of sub -consultants. It is Ric -Man's sole
responsibility to make sure that our sub -consultants comply with the schedule
and quality of their deliveries. Ric -Man has worked with all of the sub -contractors
before and has developed a solid working relationship that will serve as an asset
to the City's needs. Our team is as good as our people.
Our team has been subdivided into three major components as it has been
requested in this ITB.
• Construction Project Manager
• Construction Superintendent
• Estimator
Ric -Man International, Inc.
ORGANIZATIONAL CHART
OFFICE MANAGER
Jerry Wichert
PRINCIPAL
DAVID A.
GENERAL MANAGER
Rene L. Castillo, Sr.
GENERAL SUPERINTENDENT
Remo lafrate
PROJECTS SUPERINTENDENTS
Luis Hernandez, Nelson Liberti, Ron Rossi,
Larry Smith
SHOP SUPERINTENDENT
Jerry Louvine
PROJECT MANAGERS
Albert A. Dominguez, P.E., Rene I Castillo II, Juan
Barreneche, Mike Heitzer
1/30/2007
Staffing Quality
Ric -Man International (RMI) will be responsible for the management and
construction work related to this contract. Ric -Man was established in 1979 and
has in staff over 100 employees.
The team leader selected for this endeavor will be Mr. David Mancini who will
serve as Principal -in -Charge. Mr. Mancini will serve as the primary contact with
the City. Mr. Mancini brings over twenty-five years of experience in the
construction of infrastructure projects and water and sewer main facilities.
Mr. Rene Castillo (Construction Project Manager) & (Estimator) - Mr. Castillo
has over twenty years of experience in construction. Mr. Castillo oversees
estimating, project managers, Operations office, as well as all aspects of bidding,
construction, billing, payment and negotiations.
Mr. Remo lafrate (Construction Superintendent) - Mr. lafrate has over thirty
years experience in the supervision of construction projects managing multiple
crews and contractors simultaneously. Mr. lafrate coordinates and supervises all
construction operations on our sanitary sewer, water mains, storm sewer, pump
stations, microtunnel, jack and bore, directional drilling. He has more than 40
home neighborhood improvements and road projects.
Mr. Nelson Liberti (Underground Utility and Sitework Superintendent)- Mr.
Liberti has over fifteen years of hands-on experience in major construction
projects as both supervisory/planning and worker positions. He was the
Construction Superintendent for the Washington Avenue Project.
Staffing Resumes
Please find attached the Key Staff Personnel Resumes at the enc of this section.
415;11" RIC-MAN INTERNATIONAL, INC. Apilik
GENERAL CONTRACTORS
2601 N.W. 48th Street • Pompano Beach, Florida 33073
BROWARD: (954) 426-1042 • FAX: (954) 426-0717
www.Ric-man.us
RESUME OF DAVID A. MANCINI
1985 — PRESENT RIC -MAN INTERNATIONAL, INC.
PRESIDENT
Oversee all constructing and accounting operations; oversee
General Manager and Controller, direct onsite review of water
mains, sanitary sewer, drainage, pump station, jack and bore,
microtunnel, directional drilling, roadway building, 5
neighborhood improvement projects, subageous crossings,
streetscape, signalization and street lighting
1983 — 1985 SUPERINTENDENT
Supervise foremen constructing water mains, sanitary sewers,
drainage, roadways, and pump stations. Coordinate
subcontractors and suppliers, schedule work phases.
1982 — 1983
1976 — 1982
April 4, 1988
RIC -MAN CONSTRUCTION, INC.
POMPANO BEACH, FL
FOREMAN
Working on projects in Florida
RIC -MAN CONSTRUCTION, INC.
STERLING HEIGHTS
Going to school and working part time as laborer for family
construction business.
Florida State Underground Utility and Excavator Contractor
License # CU -C044220
Broward County Certificate of Competency # 00-1650-W
gar RIC -MAN INTERNATIONAL, INC. 410.
GENERAL CONTRACTORS
2601 N.W. 48th Street • Pompano Beach, Florida 33073
BROWARD: (954) 426-1042 • FAX: (954) 426-0717
www.Ric-man.us
RESUME OF NELSON LIBERTI II
2003 — PRESENT RIC -MAN INTERNATIONAL, INC.
SUPERINTENDENT
Coordinates and supervises all construction operations on our
sanitary sewer, water mains, storm sewers, pump stations,
microtunnel, jack and bore, directional drilling, Signalization,
lighting, streetscape and 300+ home neighborhood
improvements and road projects.
2001 — 2003 RIC -MAN INTERNATIONAL, INC.
FOREMAN
2000 — 2001 RIC -MAN INTERNATIONAL, INC.
OPERATOR
1999-2000 MAGNUM ENVIRONMENTAL
OPERATOR/ MACHINIST
Responsible for running and maintaining S.R.U.(Soil
Remediation Unit). Operated loader to fill S.R.U.
1998-1999
1994-1998
TOWN OF GATE HIGHWAY DEPT.
DRIVER/ EQUIPMENT OPERATOR
Drove snowplow during winter months. Operated heavy
equipment.
ITT AUTOMOTIVE
MACHINE OPERATOR/ ASSEMBLY
Assembled World Class Wiper Motors. Tested air-cooling
motors.
dap' RIC -MAN INTERNATIONAL, INC. 400
GENERAL CONTRACTORS
2601 N.W. 48th Street • Pompano Beach, Florida 33073
BROWARD: (954) 426-1042 • FAX: (954) 426-0717
www.Ric-man.us
RESUME OF REMO G. IAFRATE
2006 — PRESENT RIC -MAN INTERNATIONAL, INC.
GENERAL SUPERINTENDENT
Coordinates and supervises superintendents and construction
operations on our sanitary sewer, water mains, storm sewers,
pump stations, microtunnel, jack and bore, directional drilling, 6
large home neighborhood improvements and road projects.
1990 — 2005 RIC -MAN INTERNATIONAL, INC.
SUPERINTENDENT
Coordinates and supervises all construction operations on our
sanitary sewer, water mains, storm sewers, pump stations,
microtunnel, jack and bore, directional drilling, 6 large home
neighborhood improvements and road projects.
1985 — 1989 D.N. HIGGINS UNDERGROUND CONTRACTORS
FOREMAN
Oversee crews constructing water mains, sanitary sewers,
drainage and roadways.
1980 — 1985 LANZO CONSTRUCTION, DETROIT, MI.
FOREMAN
Oversee crews constructing water mains, sanitary sewers,
drainage and roadways.
1964 — 1980 GREENFIELD CONSTRUCTION, DETROIT, MI.
FOREMAN
Oversee crews constructing water mains, sanitary sewers,
drainage and roadways.
gar RIC -MAN INTERNATIONAL, INC. 446.10
GENERAL CONTRACTORS
2601 N.W. 48th Street • Pompano Beach, Florida 33073
BROWARD: (954) 426-1042 • FAX: (954) 426-0717
www.Ric-man.us
RESUME OF RENE L. CASTILLO, SR.
2004 — PRESENT RIC -MAN INTERNATIONAL, INC.
GENERAL MANAGER
Oversee Estimating, Project Managers, and Operations office.
All aspects of bidding, construction, billing, payment and
negotiations. Oversee $38 Million Dollars of projects per year.
Including sanitary sewers, watermain & Forcemain, Drainage,
Pump Station Directional Drilling, Jack & Bores, microtunnels, 9
large neighborhood improvement projects, streetscape,
signalization, design build and streetscape.
2001 — 2004
FOSTER MARINE CONTRACTORS, INC.
CONSTRUCTION MANAGER
Oversee Project Managers; oversee operations, and purchasing
in Broward County division. Prepare and negotiate claims with
clients. Oversee over 20 million dollars in projects per year.
1993 — 2001 RIC -MAN INTERNATIONAL, INC.
GENERAL MANAGER
CORPORATE SECRETARY, PURCHASING AGENT, CHIEF
ESTIMATOR, PROJECT ENGINEER
Oversee all aspects of underground construction, prepare and
update construction schedules, update pay estimates, coordinate
crews, and schedules. Select and coordinate subcontractors.
Finalize bids. Prepare claims including writing the company's
claims program on Excel, and negotiate with owners. Resolve
project conflicts.
1989 — 1993
RIC -MAN INTERNATIONAL, INC.
PROJECT MANAGER
ESTIMATOR, PURCHASING AGENT
Oversee underground construction supervisors, prepare and
update construction schedules, update pay estimates, coordinate
crews, and schedules. Select and coordinate subcontractors.
Prepare bids including writing the company's bidding program on
Lotus. Prepare claims. Resolve project conflicts.
1986 — 1989 RIC -MAN INTERNATIONAL, INC.
GENERAL SUPERINTENDENT
RESUME OF RENE L. CASTILLO, SR. cont.
1986 — 1987
1983 — 1986
1981 — 1983
1980 — 1981
1971-1980
Coordinate subcontractors and suppliers. Schedule work
phases, prepare claims and schedules. Rough in letters for extra
work claims. Prepare monthly pay estimates.
RIC -MAN INTERNATIONAL, INC.
SUPERINTENDENT
Oversee construction project from $75,000.00 through
$800,000.00. Coordinate subcontractors and suppliers.
Schedule work phases. Prepare monthly pay estimates.
MIAMI-DADE WATER AND SEWER AUTHORITY
PROJECT ENGINEER
Oversee construction projects. Coordinate contractors.
Schedule inspectors. Review monthly pay estimates and claims.
Negotiate with contractors for extra work and claims. Supervise
8 inspectors in all construction in North half of Dade County.
Projects consisted of $300,000.00 through $3,000,000.00.
MIAMI-DADE WATER AND SEWER AUTHORITY
INSPECTOR SUPERVISOR
Oversee construction projects for water and sewer. Schedule
inspectors. Review monthly pay estimates and claims.
Supervise 3 inspectors in all construction in Central Dade
County. Performed diving inspections. Projects consisted of
$300,000.00 through $1,200,000.00.
MIAMI-DADE WATER AND SEWER AUTHORITY
INSPECTOR
Inspect construction consisting of 6" through 48" Ductile iron and
48" through 120" PCCP pipelines for water mains, force mains
and gravity sewers. Inspected plant work including Floating
digester tanks and metering stations.
BEISWENGER, HOCH AND ASSOCIATES, INC.
PARTY CHIEF, Headed 3 man survey crew, INSTRUMENT
MAN, several road projects throughout Florida and Louisiana,
INSPECTOR, on extension of Florida's Turnpike from Old Cutler
Rd. to Florida City, DENSITY MAN, on extension of Florida's
Turnpike from Old Cutler Rd. to Florida City.
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD
1940 NORTH MONROE STREET
TALLAHASSEE FL 32399-0783
MANCINI, DAVID ALLAN
RIC -MAN INTERNATIONAL INC
2601 NW 48TH ST
POMPANO BEACH FL 33073-3017
RECEIVED
AUG 14 2006
Ac# 2675382
(850) 487-1395
STATE OF FLORIDA AC# 2675382
DEPARTMENT OF BUSINESS AND
PROFESSIONAL REGULATION
CUC044220 07/22/06 058090463
CERT UNDERGROUND & EXCAV CNTR
MANCINI, DAVID ALLAN
RIC -MAN INTERNATIONAL INC
IS CERTIFIED under the proviuioni of Ch.489 79.
expiration data: AUG 31, 2008 L06072200870
DETACH HERE
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD SEQ#Lo6o72200870
BATCH NUMBER
LICENSE NBR
07/22/2006 058090463 ICUC044220
The UNDERGROUND UTILITY & EXCAVATION CO
Named below IS CERTIFIED
Under the provisions of Chapter 489 FS.
Expiration date: AUG 31, 2008
MANCINI, DAVID ALLAN
RIC -MAN INTERNATIONAL INC
2601 NW 48TH ST
POMPANO BEACH FL 33073-3017
JEB BUSH
GOVERNOR SIMONNEECMRETAARSSTTILLER
DISPLAY AS REQUIRED BY LAW
STATE OF FLORIDA
DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
CONSTRUCTION INDUSTRY LICENSING BOARD (850) 487-1395
1940 NORTH MONROE STREET
TALLAHASSEE FL 32399-0783
RIC -MAN INTERNATIONAL INC
2601 NW 48TH ST
POMPANO BEACH FL 33073
Ac# 3240989
wpm OF FLORIDA
AG#2 4f�'&`i1
EPARTMEWr OF $tSTNESS AND'
PROFI4BS�ONAIi' AGUL TION
DETACH HERE
(NOT Alitcjipt$E m RrORM WORic.
ALLOWS pMp.A • • • ZUSINEss IF
IT HAS ;'A LIC SED'- QUAL.IFZER • )
ZB QU L-XFIED. uiidwr proviaiO. of -Cb 489 F9
=.tion=a tei-AUG` 31,-_ 2009, L0;70530013-61
GtLTON:::' 6
_ SEQ#z�dyo53ooiai
2007 068192419
The BUSINESS ORGANIZAT
Named below IS QUAL D
Under' the provisions of Cha:
Expiration date: AUG 31, 20.
(THIS IS NOT A LICENSE TO P;
COMPANY TO DO BUSINESS IONUY
RIC -MAN INTERNATIONAL INC
2601 NW 48Th ST
POMPANO BEACH FL 33073
CHAR,LIE'CRIST
GOVERNOR
DISPLAY ASRFOUIREDSY I AW
HOLLY"BENSON
SECRETARY
Florida Department of Transportation
CHARLIE GRIST
GOVERNOR
Ric -Man International, Inc.
2601 NW 48th Street
Pompano Beach, FL 33073
Gentlemen:
605 Suwannee Street
Tallahassee, FL 32399-0450
May 30, 2007
RE: CERTIFICATE OF QUALIFICATION
STEPHANIE KOPELOtSOS
INTERIM SECRETARY
The Department of Transportation has qualified your company for the amount
and the type of work indicated below. Unless your company is notified
otherwise, this rating will expire June 30, 2008. However, the new
application is due April 30, 2008.
In accordance with S.337.14 (1) F.S. your next application must be filed
within (4) months of the ending date of the applicant's audited annual
financial statements and, if applicable, the audited interim financial
statements. Section 337.14(4) F.S. provides that your certificate will be
valid for 18 months after your financial statement date. This gives a two-
month period to allow you to bid on jobs as we process your new application
for qualification. To remain qualified with the Department, a new application
must be submitted subsequent to any significant change in the financial
position or the structure of your firm as described in Section 14-22.005(3),
Florida Administrative Code.
MAXIMUM CAPACITY RATING: $250,000,000.00
WORK CLASS RATINGS:
1. Major Bridges:
a. Bridges which include Bascule Spans
b. Bridges which include Curved Steel Girders
c. Bridges with Multi -Level Roadways
d. Bridges of Concrete Segmental Construction _
e. Bridges which include Steel Truss Construction
f. Bridges which include Cable Stayed Construction _
g. Bridges of conventional construction which are over a water
opening of 1000 feet or more _
2. Intermediate Bridges (Bridges that contain none of the type of
construction listed under Major Bridges and span lengths exceeding
50 feet (center to center of cap) _
3. Minor Bridges (Bridges with span lengths not exceeding 50 feet
(center to center or cap) and total length not exceeding 300 feet.
A Minor Bridge shall not contain any types of construction listed
under Major Bridges or Intermediate Bridges) X
4. Bascule Bridge Rehabilitation _
5. Grading (Includes clearing and grubbing, excavation, and embankment). X
6. Drainage (Includes all storm drains, pipe culverts, culverts, etc.).. X
7. Flexible Paving (Includes limerock and shell base and other optional
base courses, soil -cemented based, mixed -in-place bituminous paving,
bituminous surface treatments, and stabilizing) X
8. Portland Cement Concrete Paving _
9. Hot Plant -Mixed Bituminous Structural and Surface Courses _
www.dot.state.fl.us
Ric -Man International, Inc.
May 30, 2007
Page Two
SPECIALTY CLASSES OR WORK:
Fencing, Guardrail, Grassing, Seeding, Sodding, Jacking, Water Mains, Ooen
Cut Sewers 6' and over, Contamination Remediation, Sewer Rehabilitation &
Pump Stations and Directional Drilling X
Please be advised the Department of Transportation has considered your
company's qualification in all work classes requested. We have evaluated
your company's organization, management, work experience, work performance
and adequacy of equipment as directed by section 14-22.003, Florida
Administrative Code. Based on this evaluation, the Department is not able,
at this time, to prequalify your company for the work classes: Hot Plant -Mix
Bituminous Structural and Surface Courses, Landscaoing, Tunneling and Diving.
To become pre -qualified in the class of Landscaping the contractor shall
provide supportive documentation needed to obtain this class of work. Please
visit www.dot.state.fl.us/cc-admin/prequalified for class requirements.
You may apply, in writing, for a Revised Certificate of Qualification at any
time prior to the expiration date of this certificate according to Section
14-22.0041(3), Florida Administrative Code. Please be advised if
certification in additional classes of work is desired, documentation is
needed to show that your company has done such work with your own forces and
equipment or that experience was gained with another contractor and that you
have the necessary equipment for each additional class of work requested.
Also, refer to the note at the bottom of Page 16 of the Application for
Qualification when supplying additional information.
Sincerely yours,
`, C.
Juanita Moore, Manager
Contracts Administration Office
JM:cs
12/89
(SEE NOTES ON REVERSE SIDE)
SURETY CAPACITY ELIGIBILITY DETERMINATION*
ABILITY SCORE
CURRENT RATIO FACTOR
SURETY CAPACITY FORMULA
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NOTICE OF ADMINISTRATIVE HEARING RIGHTS
You may petition for an administrative hearing pursuant to sections 120369 and 120.57, Florida. Statutes. If you
disagree with the facts stated in the foregoing Notice of Intended Department Action (hereinafter Notice), you may
petition for a formal administrative hearing pursuant to section 120.57(1), Florida Statutes. If you agree with the
facts stated in the Notice, you may petition for an informal administrative hearing pursuant to section 120.57(2),
Florida Statutes. You must file the petition with:
Clerk of Agency Proceedings
Department of Transportation
Haydon Bums Building
605 Suwannee Street, MS 58
Tallahassee, Florida 32399-0458
The petition for an administrative hearing must conform to the requirements of section 120.54(5)(b)4, Florida
Statutes, and either Rule 28-106.201(2) or Rule 28-106.301(2), Florida Administrative Code, and must be filed, with
the Clerk Of Agency Proceedings by 5:00' p.m.-, no later than 10 days after you.received the Notice. The petition for
an Administrative hearing should include a copy of the Notice, and must be' legible, on 8'12 by 11 inch white paper,
and. contain:
1. Your name, address, telephone number, any Department of Transportation identifying number on the
Notice, if known, the name and identification number of each agency affected, if known, and name,
address, and telephone number of your representative, if any; which shall be the address for service
purposes during the course of the proceeding;
2. An explanation alum your substantial interests will be affected by the action described in the Notice;
3. A statement of when and how you received the Notice;
4. A statement of all disputed issues of material fact. If there are none, you must so indicate;
5. A concise statement of the ultimate facts alleged,. including the specific facts the petitioner contends
warrant reversal or modification of the agency's proposed action; as well as an explanation of how the
alleged factsrelate to the specific rules and statutes the petitioner contends require reversal or
modification of the agency's proposed action;
6. A statement of the relief sought, stating precisely the desired action the petitioner wishes the agency
should take in respect to the agency's proposed action.
If there are disputed issues of material fact a formal hearing will be held, where you may present evidence and
argument on all issues involved and conduct cross-examination. If there are no disputed issues of material fact an
informal hearing will be held, where you may present evidence or a written statement for consideration by the
Department.
Mediation, pursuant to section 120.573, Florida Statutes, may be available if agreed to by all parties, and on such
terms as may .be agreed upon by all parties. The right to an administrative hearing is not affected when mediation
does not result in a settlement.
A petition for an administrative hearing shall be dismissed, if it is not in substantial compliance with the
requirements of either Rule 28-106.2.01(2) or Rule 28-106.301(2), Florida Administrative Code, or if the petition
has not been timely filed. If your petition is dismissed you will have waived your right to have the intended action
reviewed pursuant to chapter 120, Florida Statutes, and the action set forth in the Notice shall be conclusive and
final.
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dap' RIC -MAN INTERNATIONAL, INC.
GENERAL CONTRACTORS
2601 N.W. 48th Street • Pompano Beach, Florida 33073
BROWARD: (954) 426-1042 • FAX: (954) 426-0717
www.Ric-man.us
Experience
Ric -Man International
Introduction
For the last twenty-six years, Ric -Man International, Inc. has been involved in the
construction of many projects. In these projects, RMI had to maintain vehicular
and pedestrian traffic at all times. All of the projects shown on the following
pages were completed within the past 5 years. The list of projects demonstrates
that RMI enjoys a great Targe deal of experience in the construction of:
• Roadways, including pavement markings and signing:
• Site concrete work such as curb & gutter and sidewalk:
• Stormwater collection and disposal facilities including pumping
stations;
• Underground utilities, such as water distribution and sanitary sewer
collection systems;
• Landscape features and irrigation systems;
• Street lighting systems
We would also like to show on the following page an article that was published in
the Miami Today where the City of Miami Beach Capital Improvement Director,
Jorge Chartrand is quoted "Ric -Man International has been understanding and
cooperative of the City's needs"
RIC -MAN International (RMI), Inc. Project Experience
CCNIP Washington Park Watermain Replacement &
Stormwater Sewer
Broward County, Florida
Project Location:
Sunrise Boulevard and Sistrunk Boulevard, Broward County, Florida
Description of Work Performed:
Watermain replacement and storm sewer.
6'-8" DIP 15' to 36RCP
Name, Address, Phone & Fax # of Owner or Agency:
Broward County BOCC
115 S. Andrews Ave.
Ft.Lauderdale, FI 33301
Contact Name:
Mr. Pat Macgregor - Project Manager
Phone: (954) 831-0904
Fax: (954) 831-0798
Architect or Landscape Architect, or
Engineering Consultant:
Chen & Associates Consulting Engineers, Inc.
General Contractor (if work performed as sub):
Ric -Man International, Inc.
Name of General Contractor's Project Manager and Field Superintendent
Rene Castillo, Project Manager / Remo Iafrate, Superintendent
Awarded and Final Contract Amount:
$8,000,000 / :,070,004
Explanation for differences between Awarded and Contract Amount, if diff. exceeds 5%:
N/A
Project Completion Date:
November 2002
Checklist of the following types of Construction encountered, If applicable:
Traffic Control
a Maintenance of access for pedestrians to businesses or residences
Underground utility construction
Erosion control and storm water pollution prevention measures
Drainage collection and/or disposal system
Irrigation systems
Landscape planting
Other: List as may apply
RIC -MAN International (RMI), Inc. Project Experience
Watermain and Forcemain Relocation
Miami, Florida
Project Location:
SW 8th Street and 132"d Avenue, Miami -Dade County, Florida
Description of Work Performed:
Installation of 30 -inch DI and Steel Casing
Name, Address, Phone & Fax # of Owner or Agency:
Miami -Dade Water & Sewer Department
3071 SW 38th Avenue.
Room 534
Miami, FI 33146
Contact Name:
Mr. Armando Rubio - Project Manager
Phone: (786) 552-8146
Fax: (786) 552-8641
Architect or Landscape Architect, or Engineering
Consultant:
Miami -Dade Water & Sewer Department
General Contractor (if work performed as sub):
Ric -Man International, Inc.
Name of General Contractor's Project Manager and Field Superintendent:
Ron Bell, Project Manager
Larry Smith, Superintendent
Awarded and Final Contract Amount
$1,027,199
$1,027,199
Explanation for differences between Awarded and Contract Amount, if diff. exceeds 5%:
N/A
Project Completion Date:
Checklist of the following types of Construction encountered, if applicable:
of Traffic Control
d Maintenance of access for pedestrians to businesses or residences
d Underground utility construction
d Erosion control and storm water pollution prevention measures
❑ Drainage collection and/or disposal system
❑ Irrigation systems
❑ Landscape planting
O Other: List as may apply
I
RIC -MAN International (RMI), Inc. Project Experience
NIP North Andrews Gardens
Strom Drainage, Water, Sewer, Paving Improvements
Broward County, Florida
Project Location:
North Andrews Avenue and Cypress Creek, Broward County, Florida
Description of Work Performed:
Construction of 54,663' and 2"-36°
Name, Address, Phone & Fax # of Owner or
Agency:
Broward County BOCC
115 S. Andrews Ave.
Ft.Lauderdale, FI 33301
Contact Name:
Mr. Glenn Cumming - Project Manager
Phone: (954) 357-6070
Fax: (954) 831-0798
Architect or Landscape Architect, or Engineering Consultant:
Miller, Legg & Associates
General Contractor (if work performed as sub):
Ric -Man International, Inc.
Name of General Contractor's Project Manager and Field Superintendent:
Lantera Ford, Project Manager
Larry Smith, Superintendent
Awarded and Final Contract Amount:
$5,813,809
Explanation for differences between Awarded and Contract Amount, if diff. exceeds 5%:
N/A
Project Completion Date:
November 2002
Checklist of the following types of Construction encountered, if applicable:
of Traffic Control
❑ Maintenance of access for pedestrians to businesses or residences
Underground utility construction
Erosion control and storm water pollution prevention measures
Drainage collection and/or disposal system
Irrigation systems
Landscape planting
Other: List as may apply
RIC -MAN International (RMI), Inc. Project Experience
FDOT N.W. 52"d Avenue Bridge
Broward County, Florida
Project Location:
NW 52nd Avenue, Broward County, Florida
Description of Work Performed:
Low level bridge replacement
Name, Address, Phone & Fax # of Owner or
Agency:
Florida Department of Transportation
3400 W. Commercial Blvd.
Ft. Lauderdale, FL 33309
Contact Name:
Mr. Tony Piedra - Project Engineer
Phone: (954) 713-1235
Fax: (954) 713-1238
Architect or Landscape Architect, or Engineering Consultant:
Camp Dresser & McKee, Inc.
General Contractor (if work performed as sub):
r^ j Ric -Man International, Inc.
Name of General Contractor's Project Manager and Field Superintendent:
Lee Sowell, Project Manager
Remo Iafrate, Superintendent
Awarded and Final Contract Amount:
$1,160,229
$1,300,000
Explanation for differences between Awarded and Contract Amount, if diff. exceeds 5%:
N/A
Project Completion Date:
November 2002
Checklist of the following types of Construction encountered, If applicable:
d Traffic Control
❑ Maintenance of access for pedestrians to businesses or residences
Underground utility construction
Erosion control and storm water pollution prevention measures
Drainage collection and/or disposal system
Irrigation systems
Landscape planting
Other: List as may apply
RIC -MAN International (RMI), Inc. Project Experience
CCNIP St. George West
Watermain, Force Main Sanitary and Drainage
Broward County, Florida
Project Location:
Sunrise Boulevard and State Road 7, Broward County, Florida
Description of Work Performed:
Replacement of 15"-36" RCP and 29,000FT of 8" WM.
26000FT 8" of 16"SS
Name, Address, Phone & Fax # of Owner or
Agency:
Broward County BOCC
115 S. Andrews Ave.
Ft.Lauderdale, FI 33301
Contact Name:
Mr. Pat Macgregor - Project Manager
Phone: (954) 831-0904
Fax: (954) 831-0798
Architect or Landscape Architect, or Engineering Consultant:
Chen & Associates Consulting Engineers, Inc.
General Contractor (if work performed as sub):
Ric -Man International, Inc.
Name of General Contractor's Project Manager and Field Superintendent:
Rene Castillo
Awarded and Final Contract Amount:
$7,980,000
Explanation for differences between Awarded and Contract Amount, if diff. exceeds 5%:
N/A
Project Completion Date:
Ongoing
Checklist of the following types of Construction encountered, if applicable:
o. Traffic Control
o Maintenance of access for pedestrians to businesses or residences
Underground utility construction
Erosion control and storm water pollution prevention measures
Drainage collection and/or disposal system
Irrigation systems
Landscape planting
Other: List as may apply
i Inc.
Aar' RIC -MAN INTERNATIONAL, INC. yelp
GENERAL CONTRACTORS
2601 N.W. 48th Street • Pompano Beach, Florida 33073
BROWARD: (954) 426-1042 • FAX: (954) 426-0717
www.Ric-man.us
Best Value Procurement
The information included in this section has been electronically submitted to the
City. This information is shown here for informational purposes and it includes:
• Reference List for Ric -Man International
• Reference List for Rene Castillo
• Reference List for Remo Iafrate
Please Fill out only one of the forms below. If this reference list is for a company, please use the Company form
this reference list is for and individual, please put their information in the second form below. DO NOT fill out
Remember there must be a separate excel file for each individual participating in the process.
Company
Company Name: Ric -Man International, Inc.
Type: Design Build Finn, GCI UUC
Point of Contact: David Mancini (President)
Phone Number. 954-426-1042
Fax Number: 954-426-0717
nc' Mar).US
Email: Dmairn �Ri�r
OR
Individual
Individual Name:
Type:
Company Name:
Phone Number.
Fax Number:
Email:
(A/E Firm, Landscape .
(Project Manager, etc.;
RM -1 Peter
BROWARD
COUNTY BOCC
Moore 954-730-0707 954-730-203 115 S. Andrews
Avenue
Ft. Lauderdale. FL
RM -2 Robert Taylor 954-987-0066 954-987-294
HAZEN &
SAWYER
RM -3 Carlos Gil 305-592-7283 305-593-159 CITY OF MIAMI
BEACH
BROADVIEW
PARK
NEIGHBORHOOD
IMPROVEMENT
JUPITER
DRAINAGE MISC.
STORMWATR
IMPROVEMENT
MIAMI BEACH
LUMMUS
MIAMI DADE INSTALLATION
RM -4 Armando Rubio 786-552-8148 786-552-864 WATER & SEWER OF 30" WM
DEPT. CROSSING MIAMI
RIVER
2006 $ 10,339,172
2006 $ 1,933,043
2006
2005 $ 1,969,098
CITY OF NE 6TH AVENUE
RM -5 John Perez 954-630-4475 954-561-629 OAKLAND PARK DRAINAGE 2007 $ 3,675,949
IMPROVEMENTS
RM -6 Hank Breitankam 954-797-2285 954-797-272 CITY OF
PLANTATION
RM -7 Dave Brobst 561-687-2220 561-687-111
RM -8 Kyle Croce 772-462-2153 772-462-236
WANTMAN
GROUP
ST. LUCIE
COUNTY
TURNPIKE &
SUNRISE BLVD 2006 $ 1,500,100
CROSSING
JUPITER
COUNTRY CLUB
OFF SITE
DIRECTIONAL
BORES
2006 $ 1,768,975
SOUTH 26TH
STREET AREA 2007 $ 2,404,971
IMPROVEMENTS
hv4-9 Aurelio Carmenates 305-673-7000 305-673-707 CITY OF MIAMI
BEACH
PALM BEACH
RM -10 Joe Tanacredi 561-493-6088 561-493-608 WATER
UTILITIES
BROWARD
COUNTY BOCC
RM -11 Pat Sweet 954-831-0973 954-831-079 115 S. Andrews
Avenue
Ft. Lauderdale, FL
PALM BEACH
COUNTY BOCC
RM -12 Joe Tanacredi 561-493-6088 561-493-608 160 Australian Ave
West Palm Beach,
FL
BROWARD
COUNTY BOCC
RM -13 Alan Garcia 954-831-0903 954-831-079 115 S. Andrews
Avenue
Ft. Lauderdale, FL
BROWARD
. A-14 Alan Garcia 954-831-0903 954-831-079 COUNTY BOCC
115 S. Andrews
Avenue
RM -15 LaNetra Ford 954-426-4008 954-698-601 CH2M HILL
RM -16 Armando Rubio 786-552-8148
RM -17 Armando Rubio 786-552-8148
RM -18 Armando Rubio 786-552-8148
RM -19 Armando Rubio 786-552-8148
786-552-864
786-552-864
786-552-864
786-552-864
MIAMI-DADE
WATER & SEWER
DEPT.
4200 Salzedo Street
Coral Gables. FL
MIAMI-DADE
WATER & SEWER
DEPT.
4200 Salzedo Street
Coral Gables, FL
MIAMI-DADE
WATER & SEWER
DEPT.
4200 Salzedo Street
Coral Gables. FL
MIAMI-DADE
WATER & SEWER
DEPT.
4200 Salzedo Street
Coral Gables, FL
MIAMI BEACH
LUMMUS
2006
LAMANCHA
PIPELINE 2006 $ 4,399,018
EXTENSION
ROOSEVELT
GARDENS
NEIGHBORHOOD 2005 $ 8,579,937
IMPROVEMENT
PROJECT
HAGEN RANCH
RD
UTILITY & 2003 $ 12,882,519
STORM SEWER
INSTALLATION
NORTH
ANDREWS
GARDENS
NEIGHBORHOOD
IMPROVEMENTS
WASHINGTON
PARK
WATERMAIN
REPLACEMENT
NW INDUSTRIAL
AREA SANITARY
& STORM
SEWER
IMPROVEMENT
FORCEMAIN
SL1022-A
SW 352ND ST.
NE 164TH ST.
8" FORCEMAIN
NL313
8" FORCEMAIN
EUREKA DRIVE SL
1059
8" & 12"
FORCEMAIN
NW 207TH ST.
NL448
2002 $ 5,813,809
2002 $ 8,000,000
2000 $ 4,335,000
1999 $422,663
1997 $202,890
1997 $239,156
1997 $604,064
Please Fill out only one of the forms below. If this reference list is for a company, please use the Company form
this reference list is for and individual, please put their information in the second form below. DO NOT fill out
Remember there must be a separate excel file for each individual participating in the process.
Company Name:
Type:
Point of Contact:
Phone Number
Fax Number:
Email:
Company
OR
Individual
Individual Name: Rene Castillo
Type: Proloot Manager
Company Name: Ric -Man International
Phone Number: 954.426-1042
Fax Number 954-426-0717
Email: drnancini(pric-man,,us
(A/E Firm, Landscape .
(Project Manager, etc.;
RC -1
Peter
Moore
RC -2 Rolando Nigaglioni
RC -3 Peter Moore
RC -4 Joe Tanacredi
RC -5 Alan
Garcia
RC -6 Alan Garcia
RC -7 Humberto Codispoti
RC -8 Peter Moore
RC -9 Dave Brobst
RC -10 Hank Breitenkam
954-730-0707
954-831-0963
954-730-2030
CHEN &
ASSOCIATES
BROWARD
954-831-0798 COUNTY WATER
& WASTEWATER
954-730-0707 954-730-2030 CHEN &
ASSOCIATES
561-493-6088
954-831-0904
954-831-0903
786-552-8148
954-730-0707
(561) 687-2220
(954) 797-2285
PALM BEACH
561-493-6085 COUNTY WATER
UTILITIES
BROWARD
954-831-0798 COUNTY WATER
& WASTEWATER
BROWARD
954-831-0798 COUNTY WATER
& WASTEWATER
MIAMI DADE
786-552-8641 WATER &
SEWER
BROWARD
954-730-2030 COUNTY WATER
& WASTEWATER
561687-1110 Wantman Group
954-797-2720
CITY OF
PLANTATION
BR�ADVI P 'K
NEIGHBORHOOD
IMPRQVEMENT
BROADVIEW PARK
NEIGHBORHOOD
IMPROVEMENT
SAINT GEORGE
WEST
NEIGHBORHOOD
IMPROVEMENT
LAMANCHA PIPELINE
EXTENSION
SAINT GEORGE
EAST
NEIGHBORHOOD
IMPROVEMENT
PROJECT
48" Design Build
Watermain
Miami River Crossing
48" Design Build
JUPITER COUNTRY
CLUB OFFSITE
DIRECTIONAL
TURNPIKE & SUNRISE
BLVD
CITY BID* 031-05
2006
2006
$ 10,339,172
$10,339,172.00
2005 $7,980,000.00
2006 $4,399,018.00
2006 $7,084,940.00
2006 $4,418,669.00
2005 $1,969,098.00
$4,418,669.00
51,768,975.00
2006
2007
2006 $ 1,500,100
Please Fill out only one of the forms below. If this reference list is for a company, please use the Company form
this reference list is for and individual, please put their information in the second form below. DO NOT fill out
Remember there must be a separate excel file for each individual participating in the process.
Company Name:
Type:
Point of Contact:
Phone Number:
Fax Number
Email:
Company
OR
Individual
individual Name: Remo lafrate
Type: Superintendent
Company Name: Ric -Man International
Phone Number. 954-426-1042
Fax Number 954.426-0717
Email: dmancinb ric-man.us
(NE Firm, Landscape .
(Project Manager, etc.;
RI -1 Rolando Nigaglioni 954-831-0963 954-831-0798
RI -2 Dan Pollio Dan Pollio 954-797-2159 954-797-2157
RI -3 Pat Sweet 954-831-0973 954-831-0798
RI -4 Alan Garcia 954-831-0903 954-831-0798
-5 Armando Rubio 786-552-8148 786-552-8641
BROWARD
COUNTY BOCC
115 S. Andrews
Avenue
Ft. Lauderdale. FL
CITY OF
PLANTATION
400 NW 73rd
AVENUE
PLANTAION, FL
33317
BROWARD
COUNTY BOCC
115 S. Andrews
Avenue
Ft. Lauderdale, FL
BROWARD
COUNTY BOCC
115 S. Andrews
Avenue
Ft. Lauderdale, FL
MIAMI-DADE
WATER & SEWER
3071 SW 38TH AVE.
MIAMI, FL.
BROWARD
COUNTY BOCC
RI -6 Alan Garcia 954-831-0903 954-831-0798 115 S. Andrews
Avenue
Ft. Lauderdale, FL
CITY OF FT.
LAUDERDALE
100 N. ANDREWS
AVE
FT. LAUDERDALE,
FL
Palm Beach County
Utilities
8100 FOREST HILL
BLVD.
WEST PALM
BEACH, FL
RI -7 LaNetra
RI -8
Ford 954-426-4008 954-698-6010
Joe Tanacredi 561-493-6088 561-493-6085
BROADVIEW PARK
NEIGHBORHOOD
IMPROVEMENT
PROJECT
2006 $ 10,339,172
TURNPIKE & SUNRISE
BLVD 2006 $ 1,500,100
CITY BID # 031-05
ROOSEVELT
GARDENS
NEIGHBORHOOD
IMPROVEMENT
ST GEORGE WEST
NEIGHBORHOOD
IMPROVEMENT
PROJECT
2005 $ 8,579,937
2005 $ 7,980,000
LUDLAM CANAL
WATER CONTROL 2004 $ 264,779
STRUCTURE
WASHINGTON PARK
WATERMAIN 2002 $ 8,000,000
REPLACEMENT
NW INDUSTRIAL AREA
SANITARY & STORM
SEWER
IMPROVEMENT
LAMANCHA PIPELINE
EXTENSION
2000 $ 4,335,000
2006 $ 4,399,018
Proiect Manual
B. Does your company agree to insert a similar nondiscrimination provision in any
subcontract you enter into for the performance of a substantial portion of the contractyou
have with the City? Please note: you must answer this question, even if you do not intend
to enter into any subcontracts.
%/
Yes _No
Questions 2A and 2B shoud bo answored YES even if your employees must pay
some or all of the cosof spousaor dornostic partner benefits.
A. Does your company provide or offer access to any benefits to
employees with spouses or to spouses of employees?
V'Yes _No
B. Does your company provide or offer access to any benefits to
employees with (same or opposite sex) domestic partnersor to domestic
partners of
employees?
The term Domestic Partner shall mean any two (2) adults of the same
or different sex, who have registered as domestic partners with a
government body pursuant to state or local law authorizing such
registration, or with an internal registry maintained by the employer of at
least one of the domestic partners. A Contractor may institute an internal
registry to allow for the provision of equal benefits to employees with
domestic partner who do not register their partnerships pursuant to a
governmental body authorizing such registration, or who are located in a
jurisdiction where no such governmental domestic partnership exists. A
Contractor that institutes such registry shall not impose criteria for
registration that are more stringent than those required for domestic
partnership registration by the City of Miami Beach
If vou answered NO' to both Questions 2A and 2B, go to Sectio4/at the
bottom of this page), complete and sign the form, filling in all items
requested.
If vou answered 'YES" to either or both Questions 2A and 2B, please
continue to Question 2C below
Question 2.
C. Please check all benefits that apply to your answers above and Iist in
the 'other" section any additional benefits not already specified: Note:
some benefits are provided to employees because they have a spouse
or domestic partner, such as bereavement leave; other benefits are
provided directly to the spouse or domestic partner, such as medical
insurance.
May 2007 City of Miami Beach Page 59
Proiect Manual
Yes for Yes for Documentation
No, this
Employees Employees with Benefit is Not of this Benefit is
BENEFIT with Domestic Offered Submitted with
Spouses Partners this Form
Health
Dental IV V fl 61/
Vision ir 1.1/ El
Retirement (Pension, E4" El/ fl fl
401(k), etc.)
Bereavement [1 El ie 0
Family Leave 0 0 EV 0
Parental Leave 0 El e fl
Employee Assistance 0 [] [4' 0
Program
Relocation.& Travel [] [1 6V 0
Company Discount, P 0 e 0
Facilities & Events
Credit Union 0 0 EY 0
Child Care [] 0 [V 0
Other ‘ fe 6V 0 fl
S\-17
Note: If you can not offer a benefit in a nondiscriminatory manner because of reasons
outside your control, (e.g., there are no insurance providers in your area willing to offer
domestic partner coverage) you may be eligible for Reasonable Measures compliance.
To comply on this basis, you must agree to pay a cash equivalent, submit a completed
Reasonable Measures Application with all necessary attachments, and have your
application approved by the City Manager, or his designee.
Page 60 City of Miami Beach May 2007
Project Manual
Section 3. Required Documentation
YOU MUST SUBMIT SUPPORTING DOCUMENTATION to verify each benefit marked in Question
2C. Without proper documentation, your company cannot be certified as complying with the City's
Equal Benefits Requirement for Domestic Partner Ordinance. For example, to document medical
insurance submit a statement from your insurance provider or a copy of the eligibility section of your
plan document; to document leave programs, submit a copy of your company's employee handbook.
If documentation for a particular benefit does not exist, attach an explanation.
Have you submitted supporting documentation for each benefit offered?
✓Yes No
Section 4. Executing the Document
I declare under penalty of perjury under the laws of the State of Florida that the foregoing is true and
correct, and that I am authorized to bind this entity contractually.
Executed this r-\& day of , JU/1�, in the year, at 'oM(b'o &j , F1
City State
Signature
a ur c� 1-Ao►nc
Name of Signatory (please print)
Pres;derNA.
Title
May 2007
City of Miami Beach
atpot taw L441'hs4•
Mailing Address
poraV" $edifIX13
City, State, Zip Code
Page 61
BlueCross BlueShield
of Florida
An Independent Licensee of the
Blue Cross and Blue Shield Association
AFFIDAVIT OF DOMESTIC PARTNERSHIP
1, , submit this Affidavit to the
Contractholder and declare to establish as my Domestic Partner (as defined
below) for the purpose of applying for coverage under the Blue Cross and Blue Shield of Florida,
Inc.'s Contract with the Contractholder.
"Domestic Partner" means a person of the same or opposite sex with whom the employee
(herein, Certificateholder) has established a Domestic Partnership.
"Domestic Partnership" means a relationship between a Certificateholder and one other person of
the same or opposite sex, who meet all of the following eligibility requirements:
1. both individuals are each other's sole Domestic Partner and intend to remain so indefinitely;
and
2, individuals are not related by blood to a degree of closeness (e.g., siblings) that would
prohibit legal marriage in the state in which they legally reside; and
3. both individuals are unmarried, at least 18 years of age, and are mentally competent to
consent to the Domestic Partnership; and
4. both individuals are financially interdependent and have resided together continuously in the
same residence for at least 12 calendar months prior to applying for coverage under the Blue
Cross and Blue Shield of Florida, Inc.'s Contract and intend to continue to reside together
indefinitely; and
5. the Certificateholder has completed and submitted this notarized Affidavit Of Domestic
Partnership to the Contractholder and the Contractholder has approved this Affidavit of
Domestic Partnership.
I affirm that we are Domestic Partners and meet the Domestic Partnership eligibility
requirements and reside together at:
(street address)
(city, state, zip).
18708.01-07/99SR 1
I have attached the following documents as evidence of common residence and joint financial
responsibility. These documents are dated no later than 12 calendar months before the date of
this affidavit.
• Residence -any one of the following: copy of mortgage document or lease showing both
names, copies of drivers' licenses, passports, or tax returns showing the same address; and
• Financial responsibility - any one of the following: copy of statement from joint bank
account, credit cards with same account number, a beneficiary designation form for a
retirement plan or life insurance policy signed and completed to the effect that one Domestic
Partner is beneficiary of the other, wills which designates the other as primary beneficiary.
DEPENDENT CHILD(REN) OF DOMESTIC PARTNER - CERTIFICATION
Domestic Partner Dependent Child(ren)
Last Name First Name
Last Name First Name
Last Name First Name
Last Name First Name
MI
MI
MI
MI
We hereby certify that the above named child(ren) of the Domestic Partnership meet all of the
eligibility requirements listed below for coverage under the group health plan.
• The above listed child(ren) reside with us and the Domestic Partner is responsible for the
child(ren)'s well being; or the Domestic Partner is required to provide coverage for the
child(ren) by court order; or
• The child(ren) qualifies as the Domestic Partner's dependent(s) for tax purposes under the
federal guidelines. (Attach a copy of the federal income tax return); and
• The child(ren) meet and continue to meet the eligibility requirements as outlined in the
Dependents Eligibility Class and Extension Of Eligibility For Certain Dependent Children
Subsections of the Contract.
I further acknowledge and understand:
I have an obligation to submit to the Contractholder an Affidavit Of Termination Of Domestic
Partnership within 10 days of when Domestic Partnership eligibility requirements are no longer
met or within 10 days of the death of my Domestic Partner. Coverage of your Domestic Partner
will terminate on the date of death of the Domestic Partner or on the last day of the first month
that the Domestic Partner and/or Domestic Partner's eligible dependent child(ren) fails to
continue to meet all of the applicable Domestic Partnership eligibility requirements.
Blue Cross and Blue Shield of Florida, Inc. has no legal obligation to extend COBRA benefits to
Domestic Partners nor the Domestic Partner's dependent child(ren).
18708.01-07/99SR
1 cannot file another Affidavit of Domestic Partnership for a new Domestic Partner until at least
12 calendar months after a Statement of Death or Termination of Domestic Partnership has been
filed.
Any fraudulent statement, omission or concealment of facts, misrepresentation, or incorrect
information contained in this Affidavit of Domestic Partnership may result in my being
responsible for reimbursement of any expenses paid by BCBSF, or in denial of the claim or
cancellation or rescission of coverage under this Contract.
1 affirm that the information provided above is true and complete to the best of my knowledge.
Signature of Certificateholder Signature of Domestic Partner
Date Date
Signature of Notary Public Date
(SEAL)
18708.01-07/99SR 3
VRlueCross BlueShield
of Florida
BlueOptions
For Large Groups
Benefit Summary Plan 1748 with BlueScript Pharmacy Program
With the BlueOptions Network Advantage Plan, you have the freedom to choose between convenient,
affordable care from your in -network Physician, or other providers for care as you see fit. In order to
take advantage of lower out-of-pocket costs, simply choose an in -network provider.
Benefits for Covered Services
Member Calendar Year Deductibles
In -Network (Per Individual / Family Aggregate)
Out -of -Network (Per Individual / Family Aggregate)
Coinsurance Percentage Paid by Plan
In -Network Providers
Out -of -Network Providers
Physician Office Services Paid by Pian
In -Network Family Physician
In -Network Specialist (no referral needed)
Allergy Injections per visit
Note: Physician Office Services provided by any provider other
than an In -Network Family Physician or Specialist are subject
to the Calendar Year Deductible and Coinsurance.
•
Hospitalization Paid by Plan
Inpatient Hospital Facility Services Per Admission
• Option 1
• Option 2
• Option 3
• Out -of -Network
Outpatient Hospital Facility Per Visit
• Option 1
• Option 2
• Option 3
• Out -of -Network
Physician Services at Hospital and Emergency Room
• In -Network
Physician Services at Locations other than Office,
Hospital and Emergency Room
• In -Network Family Physicians
• In -Network Specialists
Emergency Room Facility Services Per Visit (waived if admitted)
• In -Network
• Out -of -Network
Note: Out -of -Network Physician Services at Hospitals, Emergency
Rooms and Locations other than Office are subject to the Calendar
Year Deductible and Coinsurance.
63239-1004
$0 / $0
$500 / $1,500
100%
60%
100% after $10 Copayment
100% after $20 Copayment
100% after $10 Copayment
100% after $250 Copayment
100% after $500 Copayment
100% after $750 Copayment
100% after $750 Copayment
100% after $100 Copayment
100% after $200 Copayment
100% after $300 Copayment
100% after $300 Copayment
100%
100% after $10 Copayment
100% after $20 Copayment
100% after $50 Copayment
100% after $100 Copayment
1 of 3
9 III oeCross BlueShield
of Florida
BlueOptions
For Large Groups
Benefit Summary Plan 1748 with BlueScript Pharmacy Program
Additional Benefits and Features
BlueScript Prescription Drug Program
In the event your Group has purchased pharmacy coverage from Blue Cross and Blue Shield of Florida,
you'll find a Pharmacy Program information sheet enclosed. Please review it carefully, as you'll find it
contains an overview of your benefits and how to utilize them.
This is not an insurance contract or Benefit Booklet. The above Benefit Summary is only a partial
description of the many benefits and services covered by Blue Cross and Blue Shield of Florida, Inc.,
an independent licensee of the Blue Cross and Blue Shield Association. For a complete description of
benefits and exclusions, please see Blue Cross and Blue Shield of Florida's BlueOptions Benefit
Booklet and Schedule of Benefits; its terms prevail.
63239-1004 3 of 3
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BlueScript Pharmacy �����������
Your Prescription Drug Benefit Plan - 15/30/50 (mail order available)
The plan your employer is offering you incudes a
Prescription Drug benefit plan through BlueScripte — our
Phermacy Program. With a Iarge network of Participating
Pharmacies statewide and nationaily, you can obtain
Prescription Drugs at a Iocation convenient to you.
You may also be able to receive more savings on
Prescription Drugs by purchasng your Drugs through the
mail order program.
Benefit Details:
Deductible $0
Preferred Generic
Prescription Drugs $15($3Omail order)
Preferred Brand Name
Prescription Drugs $30 ($60mail order)
Non -Preferred
Prescription Drugs $5O($lOUmail order)
Advantages of our Pharmacy Program:
With our BlueScript Pharmacy Program, you'II receive
coverage for Preferred Genertc Prescription Drugs,
Preferred Brand Name Prescription Drugs and Non -Preferred
Prescription Drugs, easy access to Participating Pharmacies
throughout Florida and access to National Network
Pharmacies which have over 50,000 Participating Pharmacy
Iocations. PIus, you should always receive negotiated
discount rates.
U
��C���u���d
of Florida
a:
Save by purchasing Preferred Prescription Drugs:
By purchasng Prescription Drugs Iisted on our Preferred
Medication List, you can reduce your out-of-pocket costs.
These Prescription Drugs wift cost you Iess than Drugs that
are not on the Iist. For even greater savings, you wili pay a
Iow Copayrnent for Generic Prescription Drugs that appear
on the Preferred Medication List,
The Preferred Medication List, which is part of the
Medication Guido, will be delivered in your member package
after you enroll. When reviewing the Preferred Medication
List with your doctor(s), ask them to consider a Drug from
the Preferred Medication List, particularly a Preferred
Generic Prescription Drug; it wiU save you money.
The National Pharmacy Network:
The National Pharmacy Network includes 50,000 chain and
independent Pharmacies across the United Stetes, arid is
intended to supplement our statewide network.These
National Network Pharmacies are contracted to provido
Prescription Drug services to our members traveling or
residing outside of Florida.
You pay onty the negotiated cost for Prescription Drugs
acquired at Participating Pharmacies, and in most cases is
not the full cost of the Drug, then file a claim for
reimbursement. Simply present your member ID card
at the time of purchase.
Save through the convenient mail order program:
If you are taking, or plan on taking, Prescription Drugs for
more than athree-month period, the mail order program
offers you a convenient and cost-effective way to fifl these
Prescriptions. This program aliows covered members taking
Prescription Drugs to receive up to a fuU 90 -day supply for
one Mail Order Copayment, Prescription Drugs ordered
through this program are provided by Waigreens Heatthcare
P|un, a subsidiary of Walgreens Co.
63351-/104SU
BlueComplements5m
Discounts and more for Blue Cross and Blue Shield of Florida, Inc.
and Health Options, Inc. members.
As part of our ongoing commitment to bringing
expanded choices and greater value to your
health plan, we are pleased to offer a program of
discounted products and value-added services
called BlueComplements.
BlueComplements is available to you automati-
cally as a plan member at no additional premium
cost. And you can access the services through-
out Florida and, where available, nationwide.
This program includes:
Healthy AltemativessM*: Discounts on alterna-
tive care. Enjoy discounts on thousands of alter-
native medicine products and provider services
through this complementary alternative medicine
discount program provided by American
Specialty Health Networks, Inc. (ASH Networks).
Receive discounts of up to 25% on the custom-
ary fees for acupuncture, chiropractic and
massage therapy. You'll also receive up to 45%
discounts and free standard shipping on vita-
mins, herbal supplements, sports nutrition reme-
dies, fitness products, yoga, pilates, health-relat-
ed books, tapes and videos, and more when
visiting "My Store" at the Healthyroads website.
In order to take advantage of the discounted
wellness product offerings, you may call ASH
Networks toll-free at 1-877-335-2746 to order
products or request a free catalog.
*Healthy Alternatives is administered by ASH
Networks which has been awarded full accredita-
tion by URAC.
Vision One®: Discounts* on vision care.
Receive comprehensive vision care with
significant savings on eye exams and eyewear.
Members pay $35 for eye exams and receive up
to 60% off retail prices for frames and lenses.
Offered through Cole Managed Vision.
BlueCross BlueShield
of Florida
• M 4d.pmdn" llrn.e. a a.
a,. cm...,.. BIw SN WAnod.mn
Visit participating optical departments at Sears,
JCPenney Optical, Pearle Vision Centers and
other independent vision care centers through-
out Florida. To locate participating providers,
please call Cole Managed Vision's toll-free
number for members of Blue Cross and
Blue Shield of Florida at 1-800-793-8622.
HEARx*: Discounts on hearing products.
Learn more about hearing loss and understand
your options for improved hearing in a program
administered by HEARx, the largest hearing care
organization accredited by the Joint Commission
of Accreditation of Healthcare Organizations
(JCAHO). BCBSF members receive free hearing
examinations — a savings of 25% off the retail
price of any hearing aid purchased at HEARx
centers, or special promotional prices that
provide even greater savings.
Find out what you may be missing. Since this is
a discount program through HEARx, it is not a
benefit of your health care plan. Call HEARx
toll-free at 1-800-731-3277.
TruVisionma*: Laser vision correction services.
Explore the possibilities of life without glasses or
contact lenses with affordable laser vision cor-
rection services from TruVision with surgeons
across the country credentialed in refractive sur-
gery. Services include a discounted fee of $895
per eye and now Custom LASIK is also available
at an additional fee. TruVision offers 12 months,
no interest financing upon approved credit.
For more information, call toll-free 1-877-747-2020
to schedule a pre -operative exam or to receive a
free telephone screening to determine if you are
a good candidate for LASIK or Custom LASIK.
SafeGuard
r)CNTAL A VISION
SAFEHEALTH LIFE INSURANCE COMPANY
Post Office Box 30930
Laguna Hills, CA 92654-0930
GROUP ACCIDENT AND HEALTH
PPO/Indemnity Master Policy
The Policyholder is: Ric Man International
Policy Number: 156421
SafeHealth Life Insurance Company ("SafeHealth") insures; subject to the provisions, limitations and
other terms contained herein, certain 'eligible employees and their eligible dependents, and agrees to pay
the benefits described herein upon receipt of due written proof of Toss covered by this Policy.
CONSIDERATION. This Policy is issued in consideration of the payment of premiums specified herein, of
the statements and agreements contained in the application of the Policyholder and of the individual
applications of the insured. 0
•
ADDITIONAL PAGES. The provisions, limitations and other terms set forth in this Policy are a part of this
contract as fully as if appearing over the signature hereto.
IN WITNESS WHEREOF - SafeHealth has caused this Policy to be executed effective at 12:01 A.M.,
Standard Time on November 1, 2004, at the address of the Policyholder for an initial term of one year.
This Policy may be renewed thereafter as herein provided.
If the insured has any questions or would like information about coverage, or needs assistance in
resolving complaints, it may call SafeHealth at 800-880-1800.
Jim Bencher
President
SHL -DENTAL -PPO -MP
03/04
TABLE OF CONTENTS
PAGE
SECTION 1 -- DEFINITIONS 1
SECTION 11 - ELIGIBILITY, EFFECTIVE DATE AND TERMINATION OF COVERAGE 2
A. Eligibility 2
B. EIigiblflty for Medicaid Not Considered 2
C. Effective Date of Coverage 2
O. Dependent Coverage and Effective Date of Coverage for Dependents 2
E. Late Enrollee 3
F. Termlnatlon of Coverage 3
G. Cancellation of PoIicy 4
SECTION H| - PREMIUMS 5
A. Payment of Promiums 5
B. Grace Period 5
C. Employee or Dependont Covered by This Policy in Enor 5
B. Premium Adjustments 6
E. Change In Premium Rates 6
SECTION IV — PAYMENT OF BENEFITS 6
A.
Benefits Payable 6
B. Deductible 6
C. Benefit Maximum 6
Q. Expenses Incurred 6
E. Covered Expenses 7
F. Exclusions and Limitations 7
G. No Loss - No Gain 7
H. Late Appllcant Limitations 7
1. Notice and Proof of Claim 7
J. Payment ofClaims 8
K. Procedures for Review of Claims Which are Denied iri Whole or in Part 8
L. Necessary Dental Care 8
M. Covered Benefits 8
N. Recovery of Benefits Paid By Mistake 8
0. Benefits Available From Other Sources - Subrogation 9
P. Treatment Outside of the United States 9
O. Assignment of E3enefits g
i oxw
SECTION V - COVERED SERVICES AND MATERIALS AND EXCLUSIONS AND LIMITATIONS 10
A. Covered Services and Materials 10
B. Exclusions and Limitations 10
C. Alternate Procedures 10
D. Pre -Determination of Benefits 10
SECTION VI - COORDINATION OF BENEFITS (COB) 10
SECTION VII - STANDARD PROVISIONS 11
A. Entire Contract - Changes and Incontestability 11
B. Waiver of Rights 11
C. Legal Actions 11
D. Physical Exam 11
E. Right of Recovery 12
F. Term of Policy 12
G. Notice of Claim 12
H. Proof of Loss 12
I. Grievances And Appeals 12
J. Right to Examine Records 13
K. Conformity with State Statutes 13
L. Policy Non -Participation 13
M. Certificates 13
N. Waiver of Rights 13
O. Binding Arbitration 13
SECTION VIII - CONTINUATION OPTIONS 13
A. Federal COBRA (Policyholders with 20 or more Employees) 13
B. State "Cal -COBRA" (Policyholders with less than 20 employees) 15
C. Extension of Benefits 17
SECTION IX - STATEMENT OF ERISA RIGHTS 17
SECTION X - FAMILY AND MEDICAL LEAVE CONTINUATION 18
SHL -DENTAL -PPO -MP
I I 01 /04
SECTION I -- DEFINITIONS
GENERAL DEFINITIONS
"Benefit Year" - A Benefit Year for each Covered Person, is the consecutive twelve-month period of
coverage, starting on the date such person first became covered under this Plan, and each consecutive
twelve-month period of coverage thereafter.
"Calendar Year" - Shall mean the 12 month period commencing at 12:01 A.M. on January 1st and
ending at 12:01 A.M. on the following January 1st and each subsequent 12 month period thereafter.
"Contract Year" - Shall mean the 12 month period commencing at 12:01 A.M. on the date of execution
of the contract between the Organization and SafeHealth and ending at 12:01 A.M. on the following 12
month anniversary thereafter.
'"Covered Expenses" - Covered Expenses under this Plan shall be only those that are Medically
Necessary and which are included in the Covered Expense sections of this Plan. Expense is considered
to be incurred on the date service is rendered or supplies are furnished. Except as indicated under
Dental Expense Benefits.
"Covered Person or Individual" - Shall mean an Eligible Covered Person or Eligible Dependent whose
coverage under this Plan is in force with respect to any covered benefits.
"Dentist" - A licensed graduate of a recognized dental facility having received a diploma as a D.D.S.,
D.M.D. or L.D.S., which entitles him to treat teeth and the associated tissues of mouth.
"Dental Hygienist" - Shall mean a qualified dental hygienist who has taken and passed a course in
dental hygiene under a recognized dental facility, and has received a diploma as a qualified dental
hygienist.
"Denturist" - A dental technician specializing in making and fitting dentures as a direct service to the
public rather than through a licensed dentist.
"Eligibility" - Shall mean any person upon becoming a Covered Person of the Policyholder Insurance
Trust, or any person becoming employed by a covered employer is eligible to apply for insurance under
this Plan, subject to underwriting rules and requirements of the Insurance Company.
"injury" - Injury wherever used in this Plan, means bodily injury of a Covered Person caused by an
accident occurring while this Plan is in force and resulting directly and independently of all other causes in
expenses covered by this Plan when said expenses are incurred while this Plan is in force as to the
Covered Person.
"Insured" - Shall refer to the Covered Person eligible to subscribe to the benefits provided under this
Plan. Eligibility will be determined by the employer or Organization. Insured is sometimes referred to as
"Covered Person".
"Medically Necessary" - With respect to each service or supply, the term "Medically Necessary" shall be
defined as those services or supplies which meet all the criteria listed herein:
1. It is rendered for the treatment or diagnosis of a covered injury or illness; and
2. It is appropriate for the symptoms, consistent with the diagnosis, and is otherwise in
accordance with generally accepted medical/dental practice and professionally recognized
standards; and
3. It is the most appropriate supply or level of service needed to provide safe and adequate
care.
SHL -DENTAL -PPO -MP
1 03!04
"Organization" The employer or other entity which has contracted with SafeHealth to insure benefits
under this Plan.
"Plan" - Shall mean the insurance coverage provided by this Policy to a Covered Person.
"Provider" — means any licensed dentist, denturist, or other professional provider of services which are
reimbursable under this Policy.
"Sickness" - Sickness wherever used in this Plan, means a condition or an episode, other than injury,
marked by a pronounced deviation from the Covered Person's normal well state, causing expense
covered by this Plan when said expenses are incurred while this Plan is in force as to the Covered
Person.
"SafeHealth, We, Us, Company, Insurance Company" - Shall mean SafeHealth Life Insurance
Company.
SECTION 11- ELIGIBILITY, EFFECTIVE DATE AND TERMINATION OF COVERAGE
The following provisions set forth the general eligibility provisions under this Policy.
A. Eligibility
The persons eligible to apply for insurance under this Policy are the employees or Covered Persons of
the Policyholder:
• who are actively at work for the Policyholder (or in the case of associations, are Covered Persons
of the association) on the date it becomes a Policyholder; or
• who become employed by this Policyholder (or in the case of associations, when they become
Covered Persons) after it becomes a Policyholder and who have been actively at work for this
Policyholder for the Waiting Period specified by this Policyholder.
The term employee may include individual proprietors, partners, officers, and managers.
If a spouse or child is covered as an eligible employee, he or she may not be covered under the Policy as
a dependent. If both husband and wife are covered as eligible employees, an eligible child may be
insured as the dependent of only one of them.
B. Eligibility for Medicaid Not Considered
SafeHealth shall not consider the availability or eligibility for medical assistance under Medicaid, when
considering eligibility for coverage or making payments under this Policy.
C. Effective Date of Coverage
SafeHealth may impose an initial eligibility requirement for a Covered Person that must be satisfied
before some or all coverage becomes effective under the Policy. In order for coverage to become
effective, a written and signed enrollment application must be received by SafeHealth and any required
premiums must be paid. SafeHealth must receive such enrollment application within 30 days of the date
that each eligible person becomes eligible for coverage. If SafeHealth does not receive it within 30 days,
such person will be considered a late enrollee.
D. Dependent Coverage and Effective Date of Coverage for Dependents
Your Organization is responsible for determining dependent eligibility. In the absence of such a
determination, SafeGuard defines eligible dependents to be:
• The lawful spouse or domestic partner of the Covered Person, if the Organization provides such
coverage.
SHL -DENTAL -PPO -MP
2 03/04
• The children or grandchildren of the Covered Person up to age 25 for whom he or she provides
care (including adopted children, foster children, step -children, or other children for whom the
Covered Person is required to provide dental care pursuant to a court or administrative order.)
• Children who are incapable of self-sustaining employment due to developmental disability or
physical handicap and who are dependent on the Covered Person for their support and
maintenance; and
• Other dependents if the Organization provides benefits for these dependents.
Newborn children and newborn adopted children are covered from birth. Legally adopted children, foster
children, and step -children are covered from the day they are placed with the employee. SafeHealth will
also honor any court ordered coverage for any other dependents.
If a claim is denied due to a handicapped child having reached the age of 25, the policyholder shall
establish that the child is and continues to be disabled.
Addition or deletion of Dependents will be allowed only during open enrollment unless there is a change
in family status such as marriage, birth, adoption, death, divorce, or acquiring or losing coverage due to a
change in the spouse's enrollment status. To enroll dependents, a written enrollment application must be
delivered to SafeHealth and any required premiums must be paid. SafeHealth must receive such
enrollment application within 30 days of the date that the dependent become eligible for coverage,
otherwise the dependent will be considered a late enrollee.
E. Late Enrollee
An employee or dependent who does not enroll during the initial 30 -day enrollment period will be
considered a "late enrollee". A late enrollee will not be eligible to enroll until the next open enrollment
period. Charges not covered due to this provision are not considered covered services.
If an employee or dependent enrolls after the initial 30 -day enrollment period, he or she will not be
considered a late enrollee in the following situations if he or she was covered under another dental plan
during his or her initial enrollment period and;
a) certified during his or her initial enrollment period that coverage under another dental plan was
the reason for declining enrollment;
b) has lost or will lose coverage under another dental plan as a result of: i) termination of
employment of the person: ii) change in employment status of the person; iii) termination of the
other plan's coverage; iv) cessation of an Policyholder's premium contribution toward an
employee's or dependent's coverage; or v) death of a spouse, or divorce; and
c) requests enrollment within 30 days after termination of coverage under another dental benefit
plan; or
d) a court orders coverage be provided for a spouse or child of an insured employee and request for
enrollment under this plan is made within 30 days of the issuance of the court order; or
e) he or she is employed by a Policyholder that offers multiple dental plans and the employee elects
a different plan during an open enrollment period.
F. Termination of Coverage
Coverage will automatically terminate on the earliest of the following dates:
1. the date this Policy is canceled;
2. the date that premiums are not paid, subject to the grace period;
SHL -DENTAL -PPO -MP
3 03/04
3. the date that employees are no longer in an employee class that is eligible for coverage under the
Policy or no longer meet the definition of employee;
4. the date that the employee enters active duty with the armed forces of any country;
5. the last day of the month in which and employee is no longer employed on a full-time basis by the
Policyholder; or
6. the last day of the month in which the employee's employment with the Policyholder terminates;
7. the date a Covered Person becomes covered under another dental plan which is sponsored by
the Policyholder;
8. upon notice from SafeHealth if SafeHealth determines that a Covered Person has performed an
act or practice that constitutes fraud or made an intentional misrepresentation of material fact
under the terms of coverage;
9. upon notice from SafeHealth if a Covered Person permits any other person to use his or her
identification card to obtain services under this dental plan;
10. upon notice from SafeHealth if a Covered Person assaults or threatens bodily injury to one of
SafeHealth's employees or an affiliate or an employee of a provider;
11. on the last day of the month that a Covered Person no longer works or lives within the service
area; or
12. the first premium due date that follows the date a Covered Person's employment status changes
and either he or she become employed less than full time or his or her active work for the
Policyholder ends, except when Note A or Note B below applies.
Note A: If active work ends because an injury or sickness disables the insured so that he or she
is unable to engage in his/her occupation, this insurance may be continued during that disability until the
premium is no longer paid. Coverage for disabled employees will be permitted only if the employer has
rules regarding the length time it will continue coverage for disabled employees.
Note B: If active employment ends because of a temporary lay off, coverage may be continued
while the layoff or leave continues until the earlier of (1) the first premium due date that falls on or that
next follows the 60th day after the date the insured was last actively at work; or (2) the end of the last
month for which premium was paid.
Coverage for employees on layoff or leave may be continued only if the employer has rules regarding the
length of time it will continue coverage for employees on layoff or leave.
Dependent coverage will automatically terminate on the earliest of the following dates:
1. the date that a Covered Person's coverage terminates;
2. the date that a required contribution or payment for dependent premiums is not made;
3. the last day of the month in which a dependent no longer meet the definition of dependent; or
4. the date that a dependent enters active duty with the armed forces of any country.
G. Cancellation of Policy
Except as prohibited by law, the Policy and all of the insurance ends on the earliest of the following:
SHL -DENTAL -PPO -MP 4 03/04
• The date the premium is not paid when due. Unless the Policyholder gives written notice to
SafeHealth to end the Policy, the grace period applies.
• The first premium due date after the Policyholder gives SafeHealth 45 days written notice to end
the Policy. If the Policyholder does not give advance notice and the Policy ends because the
premium is not paid, the grace period applies.
• The first premium due date after SafeHealth gives the Policyholder 45 written notice to end the
Policy if SafeHealth determines the Policyholder has performed an act or practice that constitutes
fraud or made an intentional misrepresentation of material fact under the terms of the coverage.
• The first premium due date after SafeHealth gives the Policyholder 45 written notice to end the
Policy if the Policyholder materially changes its nature of business.
• The first premium due date after SafeHealth gives the Policyholder 45 written notice to end the
Policy if SafeHealth determines the Policyholder has failed to comply with Policyholder
contribution or group participation provisions.
The premium due date that SafeHealth cancels the Policy. SafeHealth must give the
Policyholder advance written notice of at least 45 days before the Policy is to be canceled.
SECTION I11 - PREMIUMS
A. Payment of Premiums
Premiums are due on or before the first day of the month. If a Covered Person's coverage becomes
effective on the 16th day of a month or later, or terminates on the 15th day of a month or before, no
premium will be due for that month for that person. The monthly premium is set forth on the face sheet of
this Policy.
B. Grace Period
If the premium is received by SafeHealth within 31 calendar days of the premium due date, the group
coverage will continue in force. If the premium is not received by SafeHealth within 31 calendar days of
the premium due date, SafeHealth will mail a notice to the employer at least 45 days prior to the date the
policy will terminate. If the premium is not received by the date stated in the notice, the policy will
terminate.
The Covered Person is responsible for any dental expenses which may have been incurred during the
grace period in the event of termination of this policy for non-payment, even if the Employer does not
notify Covered Person of the termination.
C. Employee or Dependent Covered by This Policy in Error
Any person enrolled in error or in violation of this policy is not entitled to any benefits. SafeHealth will
make proper adjustment to cover any premiums paid under such circumstances.
SafeHealth may recover any benefits paid while enrolled in error. SafeHealth's may deduct amount paid
by mistake from future benefits of the employee or from any dependent of the employee's family.
SafeHealth shall have the right, upon notice, to examine the employer's records, including payroll records,
with respect to eligibility and monthly premiums under this Policy. The employer shall have the right,
upon notice, to examine our records pertaining to employer with respect only to enrollment, eligibility and
receipt of monthly premiums under this Policy.
SHL -DENTAL -PPO -MP
5 03/04
D. Premium Adjustments
Refunds in connection with the retroactive or unreported termination of a Covered Person's coverage
under this policy will be limited to the 2 -month period prior to the date the request for refund was made. If
a retroactive termination refund is given, the Employer must: (1) repay SafeHealth the amount of any
claims incurred and paid after a Covered Person's adjusted termination date; and, (2) assume full
responsibility for the terminated Covered Person's unpaid claims, if any.
E. Change in Premium Rates
SafeHealth reserves the right to change premium rates; however, such premium rate shall not be
changed without 45 days advance written notice from SafeHealth to the policyholder. Notice shall be sent
by SafeHealth to the last known address of policyholder. SafeHealth guarantees that it will not increase
the premium rates during the Initial contract year.
SECTION IV — PAYMENT OF BENEFITS
This provision of dental benefits Is subject to all of the terms and provisions of this policy. Services
rendered before the effective date of this policy will not be covered.
A. Benefits Payable
If you, while insured under the Dental Expense Benefits of this Policy, incur expenses for any Dental
Procedure covered in the accompanying Summary of Benefits attached as Exhibit A and Incorporated
herein by reference, and if such procedure is performed by a Dentist who is not a member of the
Participating Panel of Dentists of SafeHealth Life Insurance Company, while this insurance is in force, the
Company will pay the percentage shown in the Summary of Benefits for such expenses incurred in
excess of the Deductible, subject to any applicable Waiting Period and the Exclusions and Limitations
section of the Summary of Benefits and not to exceed the Benefit Maximum for all procedures as shown
in the Summary of Benefits.
B. Deductible
The Deductible is the Amount of Covered Dental Charges to be incurred by a Covered Person in each
Calendar Year or Contract Year before benefits will be payable toward Covered Dental Charges he or
she Incurs during the rest of that year.
No benefits under this Policy will be paid toward Covered Charges used to meet the Deductible.
The Deductible amount for each Covered Person during each Calendar Year or Contract Year Is as
shown in the Summary of Benefits.
No deductible credits will be allowed for dental expenses incurred prior to the effective date of your
coverage under this Policy.
C. Benefit Maximum
The maximum amount payable for all Covered Dental Procedures for each Covered Person shall not
exceed in the aggregate, the Benefit Maximum shown in the Summary of Benefits, during each Calendar
Year.
D. Expenses Incurred
Expenses will be considered to have been incurred on the date the dental service is rendered. However,
certain treatment can take time to complete; therefore, work is considered to have begun as follows:
• For dentures, when the impression is taken.
• For fixed bridges, crowns or gold restorations, when the tooth is first prepared.
SHL -DENTAL -PPO -MP
6 03/04
• For root canal treatment, when the tooth is opened.
Orthodontia Expenses:
Payment for orthodontia treatment, if applicable, will be made in equal installments. Installments will be
paid at the end of each quarter during the course of treatment. Payments will stop if coverage ends. If
treatment stops before completion, benefits will only be paid for services received.
E. Covered Expenses
Except as excluded under the Exclusions and Limitations, expenses covered hereunder are the charges
for the dental services and supplies listed in the Summary of Benefits. The benefit is intended to cover
treatment that is customarily given by Dentists throughout the country to eliminate oral disease and to
replace missing teeth. The Company will compare the charge for each treatment with the charges for
comparable treatment made by the other Dentists in the area. Covered Expenses are charges which are
not more than the amount customarily charged by the majority of Dentists in your area, as determined by
the Company. In most cases, the Dentists charges will be well within the range of prevailing fees in the
area.
However, if the Dentist's charge is more than the customary charges determined by the Company, you
will have to pay the difference. Of course, unusual dental complications will be taken into consideration.
The possibility of an alternate treatment can also affect the amount of the Covered Expense. See
Altemate Procedures for how this works.
F. Exclusions and Limitations
The Exclusions and Limitations for this Policy are listed on the Summary of Benefits, attached as Exhibit
A and incorporated herein by reference.
G. No Loss - No Gain
If Insured has had continuous group dental coverage for the previous 12 months, the Company will apply
any deductible or co-insurance payments credited by the previous carrier in the calculation of its
allowable charges.
H. Late Applicant Limitations
Any person who applies for coverage after his/her eligibility date is subject to at first year benefit limitation
of $100.00. This applies to all levels of coverage: Preventive, General and Major.
1. Notice and Proof of Claim
Written notice of any claim should be given to SafeHealth within 180 days. Notice may be given to
SafeHealth at SafeHealth Life Insurance Company, Post Office Box 30930 Laguna Hills, CA 92654-
0930.
SafeHealth will furnish the Policyholder forms for filing proof of loss, if applicable. A written proof of claim
within the relevant time period will also suffice. Such written proof must cover the occurrence, the
character and the extent of the loss.
SafeHealth will respond to submitted claims as follows:
1. Expedited Claims will be decided upon no later than 72 hours following receipt of the claim. If
additional information is needed to make a determination, SafeHealth will notify the Covered
Person within 24 hours following receipt of the claim.
SHL -DENTAL -PPO -MP
7 03/04
2. Pre -Service Clairns. A Covered Person may, but is not required to, request a pre-treatment
estimate of paymont for proposed services. A pre-treatment estimate of payment wUlbe decided
upon no later than 15 days following receipt of the claim. If additional information is needed to
make a determination, SafeHealth will notify the Covered Person within 15 days following receipt
of the pre-treatment estlmate.
3. Post -Service Claims will be decided upon no later than 30 days following receipt of the claim. If
additional information is needed to make a detenninot\on. SafeHealth will notify the Covered
Person withtn 30 days following reoetpt of the daim. The Covered Person will have uto 45 days
to provide the additional Information. SafeHealth will make afinm\ determination within 15 days
following receipt of the additional information, or within 15 days of the end of the 45 -day period if
the Covered Person has not responded.
J. Payment of Claims
Benefits will be paid directly to the Covered Person, if applicable, unless otherwise directed, for covered
services. SafeHealth canriot require that services be rendered by a particular provider.
Any accrued benefits unpaid at the time of death of a Covered Person may, at SafeHealth's opUon, be
paid to the estate of the Covered Person estate. All other bmn*fit will be payable to the Covered Person.
Any accrued benefits unpaid at death will be paid to the estate of the Covered Person, except as may be
provided in any specific benefits of this Cedificote, or on any attached Certificate Riders or
Endorsements.
K. Procedures for Review of Claims Which are Denied in Whole or in Part
Within 60 days after a Covered Person or hisTher benefuciary receiveda written noticof denial of a claim,
he or she may
1. Request, in wrtting, to review the claim.
2. Revlew pertinent documents.
3. Submit issues and documents, in writing, to us.
SafeHealth will reply no later than 30 days after the receipt of a request for review. In the event special
circumstances require an extension of time for processing a decision will be made as soon as possible
but no later than 60 days after the receipt of a request for review.
The decision made upon review shall be in writing and shall include specific reasons for the
determination, with specific references to the pertinent plan provisions on which determination is based.
L. Necessary Dental Care
Benefits will be allowed only for the expense of services and supplies, which, in the Judgment of
SafeHealth, are Necessary Dental Care. Although a provider may prescribe a service or nupp|y, it does
not make the charge a covered expense.
M. Covered Benefits
Except as excluded under the Exclusions and Lkmbadons, covered benefits are listed in the Schedule of
Benefits.
N. Recovery of Benefits Paid By Mistake
SafeHealth will have the right to recover the payment from the person paicl or anyone else wbo benefited
from it, inctuding a provider of services If:
SHL -DENTAL -PPO -MP
8 03/04
1. SafeHealth makes a payment to which a Covered Person is not entitled under this policy; or
2. SafeHealth pays a person who is not eligible for Benefits at all.
SafeHealth's right of recovery includes the right to deduct the amount paid by mistake from future benefits
of the employee or from any dependent.
O. Benefits Available From Other Sources - Subrogation
Situations may arise in which a Covered Person's dental expenses are the responsibility of a source other
than SafeHealth. SafeHealth may have a legal right to recover the costs of dental expenses from a third
party. For example, the Covered Person may be entitled to care or reimbursement from a govemment
agency or program, including care for military service related conditions if such care Is reasonably
available.
The following rules will apply in such situations.
"injured person" under this section, means a Covered Person who sustains compensable injury.
"SafeHealth's dental expenses" means the expenses incurred and the reasonable value of the Benefits
provided by SafeHealth for the care or treatment of the injury sustained.
If the injured person was injured by an act or omission of a third party giving rise to a claim of legal liability
against the third party, SafeHealth will have the right to recover its dental expenses from the third party.
This right Is commonly referred to as subrogation. SafeHealth will be subrogated to and may enforce all
rights of the injured person to the extent of SafeHealth's dental expenses. SafeHealth's equitable and
contractual rights of subrogation are limited in accordance with Oregon law.
The injured person and his or her agents must cooperate fully with SafeHealth in its efforts to collect
SafeHealth's dental expenses. This cooperation will include, but is not limited to, supplying SafeHealth
with information about any defendants and/or insurers related to the injured person's claim. The injured
person and his or her agents will penult SafeHealth to intervene in any action filed against any third party.
The injured person or his or her agents will do nothing to prejudice SafeHealth's subrogation rights
SafeHealth will not pay any attorneys' fees or collection costs to attorneys representing the injured person
where it has retained its own legal counsel or acts on its own behalf to represent its interests, unless
there is a written fee agreement signed by SafeHealth prior to any collection efforts. When reasonable
collection costs have been incurred with SafeHealth's prior written agreement to recover SafeHealth's
dental expenses, there will be an equitable apportionment of such collection costs between SafeHealth
and the injured person subject to a maximum responsibility of SafeHealth equal to one-third of the
amount recovered on behalf of SafeHealth.
This provision does not apply to occupationally incurred disease, sickness and/or injury.
SafeHealth will not recover anything under this section until the Covered Person has recovered all
damages sustained In connection with the injury.
P. Treatment Outside of the United States
No benefits are payable for dental services and supplies obtained outside the United States, except for
covered charges incurred for emergency treatment, and then only up to the maximum benefit allowance
as shown in the Schedule of Benefits. Payment is based on United States currency.
Q. Assignment of Benefits
No Benefit, right or interest under this policy can be assigned or transferred except to a provider.
SafeHealth will pay benefits to a Covered Person unless an assignment of benefits is signed. If no
assignment of benefits is assigned, all benefits will be paid to the Covered Person.
SHL -DENTAL -PPO -MP
9 03104
SECTION V - COVERED SERVICES AND MATERIALS AND EXCLUSIONS AND LIMITATIONS
A. Covered Services and Materials
Please refer to the Schedule of Benefits attached as Exhibit A.
B. Exclusions and Limitations
Please refer to the Schedule of Benefits attached as Exhibit A.
C. Alternate Procedures
There is often more than one way customarily used by Dentists to treat a dental problem. Different
materials or procedures may be used to correct the same problem.
For example, a tooth could be repaired with an amalgam filling. That same tooth could also be repaired
with a more expensive cap (crown) or gold filling.
The Company will allow as Covered Expenses only the least expensive services and supplies which are
appropriate and meet acceptable dental standards.
You and the Dentist may decide that you want the more expensive treatment. If so, you must pay the
charges which are greater than the Covered Expense for the less expensive treatment.
Because the Company has this Altemate Procedures provision, it is Important for you to use
Pre -Determination of Benefits. It will tell you how much the Company will pay for treatment.
D. Pre -Determination of Benefits
This is a way of telling you ahead of time how much will be paid for dental work. It will help to avoid
surprises. Many times dental work is likely to cost more than $300. If so, you should ask the Dentist to file
for Pre -Determination of Benefits with the Company. Most Dentists know about this procedure.
Here is how it works:
• Get a dental claim form from your employer. Give it to your Dentist. The Dentist will tell the
Company what work needs to be done. This work is called the "treatment plan."
• The Dentist lists the services and charges on the claim form and sends it to the Company.
• The Company tells you and the Dentist what amount the benefit will pay. You should discuss the
treatment plan with the Dentist before the work is done.
If the Dentist changes the treatment plan, the amount of payment may change. If the Dentist makes a
major change, a new dental claim form should be sent to the Company.
If you do not use Pre -Determination of Benefits, payment will be based on whatever information the
Company has about the case.
SECTION VI - COORDINATION OF BENEFITS (COB)
We coordinate our benefits with those who may be entitled to from other policies. This prevents
duplication of payment if a Covered Person is covered by another group insurance plan, no fault
automobile insurance or a government program, not including Medicare or Medicaid. The combined
benefits from all policies may pay up to, but no more than, the total covered expense.
If there is a Policy primary to this one, it will pay first. Then, this Policy will pay the difference between the
primary policy payment and the usual and customary fee that SafeGuard pays its contracted dental care
providers, but no more than it would have paid if there were no other coverage.
SHL -DENTAL -PPO -MP
10
03/04
Which Policy is Primary?
The Policy which covers a person as an employee is primary for that person. For example, if a Covered
Person is covered under his or her spouse's Policy, that Policy is primary for the spouse and secondary
for the Covered Person and this Policy Is primary for the Covered Person and secondary for the spouse.
For dependents covered by both parents' Policies, the parents' birthdays will be used to determine which
Policy is primary. The parent whose birthday falls first In the time of year will be primary for the children.
For example, if the mother's birthday is in June and the father's in July of that same year, the mother's
Policy will be primary for the children. However, if the other Policy does not use this birthday rule, the
father's Policy will be primary for the children. In the case of divorced or separated parents, the Policy of
the parent with custody will pay first, then the Policy of the step-parent with custody, and finally the Policy
of the parent without custody.
If financial responsibility for health and dental care has been assigned to one parent by court order, the
Policy of that parent will pay first.
If a Covered Person covered as an employee under two Policies and both Policies coordinate benefits,
the Policy that covers the Covered Person as an active employee will be primary.
If a Covered Person is covered as an active employee under this Policy and as a retiree or laid off
employee with the other Policy, our Policy will pay before the other Policy. If the other Policy does not
coordinate benefits, that Policy will be primary. If a spouse is also covered as an employee and/or
retiree, those Policies will be primary for the spouse and secondary for the Covered Person.
SECTION VII • STANDARD PROVISIONS
A. Entire Contract - Changes and Incontestability
The Policy, the application of the Policyholder, and the individual applications, if any, of the Insured
Persons make up the entire contract between SafeHealth and the Policyholder. Any statement made by
the Policyholder, or by any Covered Person shall, in the absence of fraud, be deemed a representation
and not a warranty. No such statement shall void the insurance or reduce the benefits under this Policy
or be used in defense to a claim for loss Incurred or disability commencing after the insurance coverage
with respect to which claim is made has been in effect for two years from the date it became effective.
No change in the Policy will be effective until it is approved by one of SafeHealth officers. This change
and approval must be noted on or attached to the Policy. No agent may change the Policy or waive any
of Its provisions.
B. Waiver of Rights
If SafeHealth fails or chooses not to enforce any provision of this Policy, such omission will not affect
SafeHealth's right to do so at a later date, or to enforce any other provision.
C. Legal Actions
No action at law or in equity may be brought to recover benefits prior to the expiration of 60 days after
written Proof of Loss has been furnished. No such action may be brought after the applicable statute of
limitations.
D. Physical Exam
SafeHealth has the right to have any Covered Person examined at SafeHealth's expense while a claim is
pending payment.
SHL -DENTAL -PPO -MP 11
03/04
E. Right of Recovery
SafeHealth has the right to recover any excess benefits paid from any persons to, or for, or with respect
to whom, such payments were made, or from any other insurers, health care service plans or other
organizations.
F. Term of Policy
This policy will remain in effect for the term specified on the Face Sheet. The policy will be renewed
automatically, from year to year thereafter, until terminated.
G. Notice of Claim
Written notice of claim must be given within 20 days after a covered Toss starts or as soon as reasonably
possible. The notice may be given to the insurer at its home office or to the insurer's agent. Notice
should include the name of the insured and the policy number.
H. Proof of Loss
If the policy provides for periodic payment for a continuing loss, written proof of loss must be given to
SafeHeaith within 90 days after the end of each period for which SafeHealth is liable. For any other loss,
written proof must be given within 90 days after such loss. If it was not reasonably possible to give
written proof in the time required, SafeHealth shall not reduce or deny the claim for this reason if the proof
is filed as soon as reasonably possible. In any even, the proof required must be given no later than one
(1) year from the time specified unless the claimant was legally incapacitated.
Grievances And Appeals
SafeHealth's Member Services Department is available to respond to any questions or complaints. If the
problem is not resolved at that level, grievance and appeals rights set forth below apply. SafeHealth will
assist a Covered Person in filing a Grievance when he or she has a complaint and asks for help to put it
in writing.
1. Grievance. A Covered Person aggrieved by an Adverse Benefit Decision has 180 days from the
date of the Adverse Benefit Decision to file a Grievance requesting reconsideration of the
decision. The Covered Person must submit all information in support of the Grievance.
SafeHealth will acknowledge the Grievance within 7 days and report its decision and rationale
within 30 days (72 hours for Expedited Claims). SafeHealth may have an additional 15 days to
resolve the issue if the Covered Person is notified within the first 30 days of the delay and of the
specific reason for the delay. The Covered Person will be informed of the determination in writing
and notified of further appeal rights.
2. Appeal. A Covered Person has 60 days following receipt of the written determination to file a
written appeal. The request will be reviewed by the Appeals Committee, which will involve
different staff than have been involved before. SafeHealth will acknowledge the Appeal within 7
days and will make its review and report its decision and rationale within 30 days. The Covered
Person will be informed of the committee's determination in writing and notified of further appeal
rights as well as the possible right of Covered Persons participating in ERISA -qualified plans to
seek legal redress under Section 502(a) of ERISA.
3. Subsequent Appeal. A Covered Person not satisfied with the determination of the Appeals
Committee has 60 days after receipt of the determination to file a written request with SafeHealth
for further review. The request will be forwarded to an Appeals Committee comprised of different
individuals than the earlier Appeals Committee. The Covered Person or a representative of the
Covered Person may appear before this committee. SafeHealth will acknowledge the Appeal
within 7 days and will make its review and report its decision and rationale within 30 days. The
Covered Person will be informed of the committee's determination and rationale in writing and
SHL -DENTAL -PPO -MP 12 03/04
notified of further appeal. rights as well as the possible right of Covered Persons participating in
ERISA -qualified plans to seek legal redress under Section 502(a) of ERISA.
J. Right to Examine Records
SafeHealth has the right to examine all pertinent medical, dental, or other records of a Covered Person
pertaining to any cases for which Benefits are claimed and discuss matters pertaining to those cases with
the Covered Person's providers. If the Covered Person does not consent to the release of records or
discussions with providers, SafeHealth will be unable to determine the proper payment of any Benefits
and will deny the claim accordingly.
Consent to the release of records and discussion with providers is a condition of payment of any Benefits
by SafeHealth. Neither the consent to nor the actual examination of the records or discussion with
providers will constitute a guarantee of payment.
SafeHealth has the right to examine payroll records at reasonable times regarding premium payments
made under this policy.
K. Conformity with State Statutes
Any provision of the Policy which is in conflict with the laws of the state, in which the Policy was delivered
or issued for delivery, is amended to conform to the minimum requirements of such laws.
L. Policy Non -Participation
The Policy is not in lieu of and does not affect any requirements for coverage by workers' compensation
insurance.
M. Certificates
SafeHealth will issue to the Policyholder, for delivery to the Covered Person an individual certificate
describing the benefits to which the Covered Person is entitled under the Policy and to whom they are
payable.
N. Waiver of Rights
If SafeHealth fails to enforce any provision or condition of the Policy, this failure will not affect its right to
do so at a later date, nor will it affect their right to enforce any other provision or condition of the Policy.
O. Binding Arbitration
Each and every disagreement, dispute or controversy concerning the construction, interpretation,
performance or breach of this Master Policy, or the provision of Dental services may be voluntarily
submitted to arbitration in accordance with the American Arbitration Association rules and regulations,
whether such dispute involves a claim in tort, contract or otherwise. Arbitration shall be initiated by written
notice to the President, SafeHealth Life Insurance Company, 95 Enterprise, Suite 100, Aliso Viejo,
California 92656-2605. The notice shall include a detailed description of the matter to be arbitrated.
SECTION VIII - CONTINUATION OPTIONS
A. Federal COBRA (Policyholders with 20 or more Employees)
1. A Covered Person who would otherwise lose coverage under this policy may continue
uninterrupted coverage upon arrangement with Employer in compliance with the Federal Consolidated
Omnibus Budget Reconciliation Act of 1985 (COBRA). Eligibility is conditioned upon payment of the
applicable monthly premium to Employer. The following are "qualifying events":
SHL -DENTAL -PPO -MP
13
03/04
a) Termination of employment, including lay-off or reduction in hours (except for gross
misconduct);
b) Death of the Covered Employee;
c) Divorce or legal separation;
d) Loss of eligibility of a covered Dependent child; or
e) While covered Dependents are on continuation with the Employee, the Employee
becomes entitled to Medicare benefits.
2. Coverage under COBRA continues only upon timely payment of the applicable monthly premium
to Employer and ends on the earlier of:
a) Termination of this group policy;
b) Coverage under any other group health plan, including Medicare, which does not contain
any exclusion or limitation with respect to any pre-existing condition;
c) Expiration of 36 calendar months of continuation by a covered dependent after the
Employee's death, divorce, legal separation or entitlement to Medicare;
d) Expiration of 18 calendar months after termination of employment, lay-off or reduction in
hours;
e) For a disabled Covered Person, expiration of 29 months after termination of employment
if:
(1)
The Covered Person was totally disabled at the time of the termination of employment
within the meaning of the Social Security Act, or is determined disabled by the Social
Security Administration effective any time within the first 60 days of COBRA continuation
coverage; and
(2) The Member notified employer of the disability within the initial 18 -month continuation
period.
f) When the applicable maximum period of continuation of group coverage has been
exhausted, or at any time during the period of continuation, the Covered Person may
convert to an individual conversion plan.
3. If a retired Covered Person, as a result of employer's Chapter 11 reorganization, loses a
significant portion of retiree benefits, the retiree and any covered Dependents may continue coverage
under the group plan based on the following conditions:
a) The retiree is eligible for continuation coverage for the rest of his or her life;
b) The retiree's covered spouse and covered dependent children are eligible for
continuation coverage for the rest of the retiree's life and for an additional 36 months after
the retiree's death;
c) If the retiree is deceased at the time of employer's Chapter 11 reorganization, the
retiree's covered surviving spouse and covered dependent children are eligible for
continuation coverage for the rest of his or her life.
4. Application for continuation must be made in accordance with the COBRA regulations, and must
be made by written request to Employer within 60 days after any qualifying event. The Employer will
provide the necessary forms. Premiums must be paid within 45 days of election of continuation.
SHL -DENTAL -PPO -MP
14
03/04
P.O. Box 30910
SafeGuard Laguna Hills, CA 92654-0910
Ric Man International
2601 NW 48th St
Pompano Beach FL 33073-3072 05685
111111111111111111111111111111111111111111111111 11111111
SafeGuard Dental & Vision
PO Box 30910
Laguna Hills, CA 92654
(800)750-4303
Group ID: 97156421
SafeGuard Dental & Vision
Statement Reconciliation Instructions
This statement for SafeGuard is comprised of seven sections:
1A Consolidated Summary for all divisions (for organizations with divisional billing)
1 Premium & Payment Summary
2 Eligibility Adjustments - Please review all changes.
3 Manual Adjustments
4 Eligibility Roster with Premium
5 Summary by Plan, Rate Code & Premium
6 Reconciliation Worksheet
If your organization has more than one division, you will receive Sections 1 through 6 for each division.
:h division will have its own group number for identification.
Please follow these steps:
• If you are paying for multiple groups or divisions with one check, please include all detail to help us
allocate your payment appropriately. Please include your group number on your check.
• Credits for terminations and charges for member additions not reflected on this invoice will be
reflected on your next month's invoice.
• If you adjust the amount due, this may result in an overpayment or underpayment, now and on the
next month's billing.
• If you have any billing or eligibility issues, please contact the Group Billing and Eligibility Department
at (800) 750-4303.
To ensure the accuracy of your eligibility and your account balance, please pay as billed.
SafeGuard Dental & Vision
PO Box 30910
Laguna Hills, CA 92654
(800)750-4303
SECTION 1: Premium and Payment Summary From 04/30/07 to 05/31/07
Ric Man International
2601 NW 48th St
Pompano Beach FL 33073-3072
Ric Man International ( Group ID: 97156421 )
Previous Balance:
Payments Received:
Eligibility Adjustments (Section 2):
Other Adjustments (Section 3):
Other Debits:
Adjusted Balance:
Current Premium (Section 4):
Plan
Section 1 - Page 1
Invoice Date 05/31/07
For Month Of June 2007
Invoice Number 1380371
Recipient Group ID 97156421
$ 5,856.81
$
-5,724.21
$ 135.56
$ 0.00
$ 0.00
$ 268.16
$ 2,845.54
Total Due by June 30 $ 3,113.70
SG185A-FL Plan Total
VA2332WS Plan Total
Current Premium (Section 4)
TOTAL DUE:
Make checks payable to: SafeGuard Dental & Vision
Amount Paid:
Check #:
Premium Amount Amount Paid
$253.13
$2,592.41
$2,845.54
$3,113.70 $
Group ID: 97156421
PLEASE RETURN THIS:SU,MMARY:PAGE;1WVIITil:y0t1R'PAYMENT.TO ENSURE;THATIT IS.PRE PERL11::CREDITEO:T :VOUR AECCOUNT;
PLEAS :D NE)T;57APLE•'VOUF;CHE K'I '1HIS;R MtT.SLIP. .: .
additions rieiliiiri4tii if04060.60 .: vill tie sfffctive;.tie;:fsi o !trig:;fi tlowfn g. ontI unress;otherw se;ind sated::
SafeGuard Dental & Vision
PO Box 30910
Laguna Hills, CA 92654
..... 1111 1111 11 ,1
Ramittanra Slin - Please Return Entire Pane
SafeGuard Dental & Vision
PO Box 30910
Laguna Hills, CA 92654
(800)750-4303
SECTION 1: Premium and Payment Summary From 04/30/07 to 05/31/07
Section 1 - Page 1
Ric Man International Invoice Date 05/31/07
2601 NW 48th St For Month Of June 2007
Pompano Beach FL 33073-3072 Invoice Number 1380371
Recipient Group ID 97156421
Ric Man International ( Group ID: 97156421 )
Previous Balance: $ 5,856.81
Payments Received: $ -5,724.21
Eligibility Adjustments (Section 2): $ 135.56
Other Adjustments (Section 3): $ 0.00
Other Debits: $ 0.00
Adjusted Balance: $ 268.16
Current Premium (Section 4): $ 2,845.54
Plan
Total Due by June 30 $ 3,113.70
Premium Amount Amount Paid
SG185A-FL Plan Total $253.13 S
VA2332WS Plan Total $2,592.41 A
Current Premium (Section 4) $2,845.54
TOTAL DUE:
Make checks payable to: SafeGuard Dental & Vision
Amount Paid:
Check #:
$3,113.70
SafeGuard Dental & Vision
PO Box 30910
Laguna Hills, CA 92654
(ustnmar Cnnv - PIaaca kaon for vnur records
SafeGuard Dental & Vision
PO Box 30910
Laguna Hills, CA 92654
(800)750-4303
SECTION 2: Eligibility Adjustments - changes from 04/30/07 to 05/31/07
Group ID: 97156421 / Ric Man International
Invoice Number 1380371 for the month of June 2007
Last
Member ID Name
..ii7st.:::-...•."•••• 14,:ito.,.... • ::
N.44i0: •• • N4ii...*•-•:•:
,.:::::::.::::::i:::::.:,...: .,.:
Additions
264-93-6576
264-93-6576 Reeves Fredrick
267-95-4507 Fernandez Leyani
594-33-7119 Cespedes David
pocfw:
SG185A 10 105/01/07
SG185A 10 05/01/07
VA2332 31 05/01/07
Summary of Eligibility Adjustments
Section 2 - Page 1
I
.-
'::;Ar.t.1006t '.....:'.....: '••••••:POete::.:1:::: :016.0tfis..
..::-.::::-:':::::::.ii;i2:::-:-.. ---.-..i.ii, '.:::1-..-.:::-.'-.::.::::::-..::::.:-..-:'''. :•:...fil .:
$ 13.08 SA
13.08 SA
$ 109.40 SA
Additions $ 135.56
Terminations $ -0.00
Family Status Changes $ 0.00
Total $ 135.56
1.0 1$ 13.08 05/15/07
1.0 $ 13.08 05/01/07
1.0 $ 109.40 05/10/07
135.56
b
SafeGuard Dental & Vision
PO Box 30910
Laguna Hills, CA 92654
(800)750-4303
Group ID: 97156421 / Ric Man International
Invoice Number 1380371 for the month of June 2007
Action Legend for Section 2
SA Add Subscriber
Action Legend - Page 1
SafeGuard Dental & Vision
PO Box 30910
Laguna Hills, CA 92654
(800)750-4303
SECTION 4: Eligibility Roster with Premium
Group ID: 97156421 / Ric Man International
Invoice Number 1380371 for the month of June 2007
Aiken, Gaston
Jonatha
Khalil
Marques
Tamia
Tierra
Yvette
Angilot, Julien
Julien
Bailey, Earcel D
Bobetta
Barnard, Harry E
Barreneche, Juan J
Yvette
Barrett, Terrenc
Julian Dottin
Sedoriu Mills
Benjamin, Lem
Brown, Todd M
Burnley, Trevor
Cameron, Byron W
Sheila
Castillo, Rene L
Castillo, Rene L
Cateura, Edilber
Cespedes, David
Anthony
Morely Baez
Diaz, Jorge
Julia Soto
Dominguez, Albert A
David
Kalla
Kelly
Reuben
Dumais, Richard R
Fernandez, Leyani
Fernandez, Yamile
Gayle, Robert S
Demetri
Larhone
Scott
Gonzalez, Julio
Goulbourn, Denis
'C COBRA Subscriber
Section 4 - Page 1
09/05 97000000 VA2332WS 31 $109.40
09/05 97000000 VA2332WS $0.00
09/05 97000000 VA2332WS $0.00
09/05 97000000 VA2332WS $0.00
09/05 97000000 VA2332WS $0.00
09/05 97000000 VA2332WS $0.00
09/05 97000000 VA2332WS $0.00
01/05 97008459 SG185A-FL 20 $22.90
07/05 97008459 SG185A-FL $0.00
06/06 97009341 SG185A-FL 20 $22.90
06/06 97005123 SG185A-FL $0.00
02/05 97000000 VA2332WS 10 $33.15
06/05 97000000 VA2332WS 20 $66.30
08/06 97000000 VA2332WS $0.00
11/06 97000000 VA2332WS 40 $72.94
11/06 97000000 VA2332WS $0.00
11/06 97000000 VA2332WS $0.00
11/04 97000000 VA2332WS 10 $33.15
04/07 97000000 VA2332WS 10 $33.15
04/06 97011493 S0185A-FL 10 $13.08
11/04 97000000 VA2332WS 20 $66.30
11/05 97000000 VA2332WS $0.00
11/04 97000000 VA2332WS 10 $33.15
11/04 97000000 VA2332WS 10 $33.15
11/06 97000000 VA2332WS 10 $33.15
05/07 97000000 VA2332WS 31 $109.40
05/07 97000000 VA2332WS $0.00
05/07 97000000 VA2332WS $0.00
11/06 97000000 VA2332WS 20 $66.30
11/06 97000000 VA2332WS $0.00
04/05 97000000 VA2332WS 31 $109.40
04/05 97000000 VA2332WS $0.00
04/05 97000000 VA2332WS $0.00
04/05 97000000 VA2332WS $0.00
04/05 97000000 VA2332WS $0.00
02/07 97000000 VA2332WS 10 $33.15
05/07 97040416 SG185A-FL 10 $13.08
09/06 97000000 VA2332WS 10 $33.15
11/04 97000000 VA2332WS 40 $72.94
11/04 97000000 VA2332WS $0.00
11/04 97000000 VA2332WS $0.00
11/04 97000000 VA2332WS $0.00
11/04 97000000 VA2332WS 10 $33.15
05/06 97000000 VA2332WS 10 $33.15
SafeGuard Dental & Vision
PO Box 30910
Laguna Hills, CA 92654
(800)750-4303
SECTION 4: Eligibility Roster with Premium
Group ID: 97156421 / Ric Man International
Invoice Number 1380371 for the month of June 2007
Hernandez, Luis
Jendry Escandon
Junior
Meyda Perez
Hewling, Clive S
Holcombe, Earnest L
Billy
Lakiely
Sharon
Stephan
lafrate, Remo
Anna
Jiminez, Hector
Hector
Priscil
Leon, Tomas
Natalie
Liberti II, Nelson
Audra Liberti
Nelson Liberti I
Lima, Daniel A
Louvierre, Jerry J
Debbie
Love, Jimmie
Maccenat, Ospaul
Christm
Malek; Thomas A
Mancini, David A
Cheryl
David Mancini Jr
Richard
C Melehan, Carol
Kyle
Patrick
Mendoza, Jose E
Nancy
Sergio
Mendoza, Joseph
Jacquel Samedy
Milian, Felix
Irene Ondaz
Montesono, Juan Ca
Laura Rojas
"C CORRA Subscriber
Section 4 - Page 2
11/06 97000000 VA2332WS 31
11/06 97000000 VA2332WS
11/06 97000000 VA2332WS
11/06 97000000 VA2332WS
03/07 97000000 VA2332WS 10
11/04 97000000 VA2332WS 31
11/04 97000000 VA2332WS
11/04 97000000 VA2332WS
11/04 97000000 VA2332WS
11/04 97000000 VA2332WS
11/04 97000000 VA2332WS 20
11/04 97000000 VA2332WS
08/06 97000000. VA2332WS 40
08/06 97000000 VA2332WS
08/06 97000000 VA2332WS
05/06 97000000 VA2332WS 40
05/06 97000000 VA2332WS
11/04 97000000 VA2332WS 31
11/04 97000000 VA2332WS
11/04 97000000 VA2332WS
11/04 97000000 VA2332WS 10
11/04 97000000 VA2332WS 20
11/04 97000000 VA2332WS
11/04 97000000 VA2332WS 10
02/06 97060766 SG185A-FL 20
05/07 97060766 SG 185A -FL
11/04 97000000 VA2332WS 10
11/04 97000000 VA2332WS 31
11/04 97000000 VA2332WS
11/04 97000000 VA2332WS
11/04 97000000 VA2332WS
08/06 97010287 SG185A-FL 40
01/07 97010287 SG 185A -FL
01/07 97010287 SG185A-FL
01/05 97007872 SG185A-FL 31
12/05 97054462 SG185A-FL
12/05 97054462 SG185A-FL
11/06 97000000 VA2332WS 20
11/06 97000000 VA2332WS
11/06 97000000 VA2332WS 20
11/06 97000000 VA2332WS
11/06 97000000 VA2332WS 20
11/06 97000000 VA2332WS
$109.40
$0.00
$0,00
$0.00
$33.15
$109.40
$0.00
$0.00
$0.00
$0.00
$66.30
$0.00
$72.94
$0.00
$0.00
$72.94
$0.00
$109.40
$0.00
$0.00
$33.15
$66.30
$0.00
$33.15
$22.90
$0.00
$33.15
$109.40
$0.00
$0.00
$0.00
$28.12
$0.00
$0.00
$38.59
$0.00
$0.00
$66.30
$0.00
$66.30
$0.00
$66.30
$0.00
SafeGuard Dental & Vision
PO Box 30910
Laguna Hills, CA 92654
(800)750-4303
SECTION 4: Eligibility Roster with Premium
Group ID: 97156421 / Ric Man International
Invoice Number 1380371 for the month of June 2007
C Morris, Fremon
Nace, Eileen
Nace, Joseph L
Ortiz, Hamill E
C Prior, Shawna M
Reeves, Fredric
Reyes, Neftali
Alyssa Benjamin
Sophia
Sanchez, Javier
Smith, Larry
Barbara
Smith, Nathani
St. Louis, Nestor
Stephenson, Neville
Vanderlip, Roger P
Washington, Evlysta
Wichert Jr., Gerard
Nancy Ross
Williams, Marc A
Williams, Wayne
Daegria
Woolley, Warrick S
58 Subscribers
Section 4 - Page 3
08/06 97000000 VA2332WS 10 $33.15
11/06 97060794 S0185A-FL 10 $13.08
11/05 97000000 VA2332WS 10 $33.15
11/06 97056141 SG185A-FL 10 $13.08
07/06 97000000 VA2332WS 10 $33.15
05/07 97004684 SG185A-FL 10 $13.08
11/04 97000000 VA2332WS 31 $109.40
03/06 97000000 VA2332WS $0.00
11/04 97000000 VA2332WS $0.00
11/06 97000000 VA2332WS 10 $33.15
11/05 97000000 VA2332WS 20 $66.30
11/05 97000000 VA2332WS $0.00
01/07 97004646 SG185A-FL 10 $13.08
01/05 97054617 S0185A-FL 10 $13.08
11/04 97000000 VA2332WS 10 $33.15
11/04 97000000 VA2332WS 10 $33.15
05/06 97005757 SG185A-FL 10 $13.08
11/04 97000000 VA2332WS 20 $66.30
11/04 97000000 VA2332WS $0.00
02/05 97000000 VA2332WS 10 $33.15
01/06 97000000 VA2332WS 20 $66.30
01/06 97000000 VA2332WS $0.00
01/05 97005510 SG185A-FL 10 $13.08
Current Premium
'C COBRA Subscriber
$2,845.54
$2,845.54
SafeGuard Dental & Vision
PO Box 30910
Laguna Hills, CA 92654
(800)750-4303
Section 5: Summary by Plan,
Group ID: 97156421 / Ric Man
Invoice Number 1380371 for the
SG185A-FL
Rate Code and Premium
International
month of June 2007
10
20
31
40
9
3
1
1
Plan Totals 14
$13.08
$22.90
$38.59
$28.12
VA2332WS 10 21 $33.15
20 11 $66.30
31 8 $109.40
40 4 $72.94
Plan Totals
Current Premium
Rate Code Legend
10 - Subscriber Only
20 - Subscriber + 1
31 - Subscriber + Family
40 - Subscriber + Children
44
Section 5 - Page 1
$117.72
$68.70
$38.59
$28.12
$253.13
$696.15
$729.30
$875.20
$291.76
$2,592.41
$2,845.54
SafeGuard Dental & Vision
P.O. Box 30910
Laguna Hills, CA 92654-0910
(800)750-4303
Fax: (949)360-3695
SECTION 6: Reconciliation Worksheet
Group ID: 97156421 / Ric Man International
Invoice Number 1380371 for the month of June 2007
Section 6 - Page 1
Record all eligibility terms on this worksheet. Retroactive adjustments will be accepted for only as far back
as the first of the preceding month. Terminations will not be processed unless clearly indicated below.
If applicable, please identify either DENTAL (D) or VISION (V) for the eligibility change
LI .Y...:: .:-i::: ....:• '::'.i.... i.::bUDS.Cr111011-,:: :". '..
:'$$N,..i .i.::'::: :.:'.'.•..:1:';',-:%:•-::!istarti-6.
Additlaiii.:.,iiiiat.:bo.:pr000ssfjd withoutan Enrollment Form 1
Photocopy this page if additional space is needed.
Visit us at: www.safeauard.net
BLUE CROSS AND BLUE SHIELD OF FLORIDA
P.O. BOX 44144
JACKSONVILLE, FLORIDA 32231-4144
RECEIVED
MAY 24201
RG141392003922T
ATTN EILEEN NACE
RIC -MAN INTERNATIONAL INC
2601 WILES RD
POMPANO BEACH FL 33073-3072
B1ueCross BlueShield
of Florida
® M Inaepend0 I LJoeneea d me
&w Croea.01 Blw SJ d.o.ndNbn
YOUR BILL MUST BE PAID ON OR BEFORE THE DUE DATE
Billed Date: 05/19/07 Group: 63669001
Due Date: 06/01/07 Invoice: 15988048
Pays To: 07/01/07 Dist: LGQ
Billed Amount:
APPROVE FOR I PTC idh
PAYMENT
JOB
ACCT#
AMOUNT
COST CAT
32,378.45
To ensure proper application of your group premium payment, please follow the
instructions' below:
1. Write the Group Number and Invoice Number on your check.
2. For all insured deletions, fallow the instructions on the back of this page, complete the
below coupon, and return this entire page with your payment.
3. When paying the exact amount due -Detach the payment coupon below and return it with
your payment.
4. When paying any amount other than the amount billed (not related to insured (leletions) -
Please complete the below coupon and return this entire page with your check to ensure
proper application of your premium payment.
5. For any other changes (I.e. address, additions, coverage changes) not related to your
invoice - please mail there to:
Enrollment Membership & Billing
P.O. Box 44144
Jacksonville, FL 32231-4144
c
r-�
BLUE CROSS AND BLUE SHIELD OF FLORIDA
P.O. BOX 44144
JACKSONVILLE, FLORIDA 32231-4144
ATTN EILEEN NACE
RIC -MAN INTERNATIONAL INC
2601 NW 48TH STREET
POMPANO BEACH FL 33073
Group: 63669001
Invoice: 15988048
Billed: 05/19/07
Due: 06/01/07
Pays To: 07/01/07
2322
B1ueCross BlueShield
of Florida
•
M Independent Licensee d the
Blue Gose end Blue Shied Aeeodalion
YOUR BILL MUST BE PAID ON OR BEFORE THE DUE DATE
Dist Group Invoice Due Billed Amount
LGQ 63669001 15988048 060107 32,378.45
Paid Amount:
GROUP INVOICE
KEEP THIS FOR YOUR RECORDS
CjM Indyrdre Licensee al the
Blue Cross and Blue ShieldMeodYion
B1ueCross BlueShield
of Florida
Page:
Route:
Dist:
GROUP BILLING SUMMARY FOR 06/01/07
A. ROSTER TOTAL 32,960.09
B. MEMBER ADJUSTMENTS 581.64-
C. PRIOR BALANCE .00
D. AMOUNT DUE 32,378.45
E. LESS DELETIONS S
F. ADJUSTED AMOUNT DUE $
LGQ
2
B1RBC01I
RG141392 - 003922 - 002 OF 003
BlueCross BlueShield
of Florida
e M lndepenaeM tmneas d ur
An cae. ndsuwanwa .um
2322
Includes any additional Insurance Coverages, where applicable (shown under "Other ").
offered through Florida Combined Life Insurance Company, Inc
MSG INSURED .:
CODE,- NAME
AIKEN GASTON
AMPARO GERMAN
ANGILOT JULIAN
BAILEY EARCEL D
BAPTISTE RIVIL
BARNARD HARRY E
BARRENECHE JUAN J
BARRETT TERRANCE
BENJAMIN LEM
BERMUDEZ JACQUELINE
BROWN RICHARD
BROWN TODD M
BURNLEY TREVOR
CAMERON BYRON W
CASTILLO RENE L
1" CASTILLO RENE L
CATEURA EDILBERTO
CESPEDES DAVID
DIAZ JORGE L
DOMINGUEZ ALBERT A
DORAH AARON
DUMAIS RICHARD R
;FERNANDEZ LEYANI
'FERNANDEZ YAMILE
.FULMORE JAMES
GAYLE DENROY M
GAYLE ROBERT S
GONZALEZ JULIO R
GOULBOURN DENIS
HEITZLER MICHAEL B
,HERNANDEZ LUIS
MEWLING CLIVE
HOLCOMBE EARNEST L
HOLNESS OMAR R
HUNT TRISTON J
IAFRATE REMO
JIMENEZ HECTOR M
JOHNSON TARON
LEON THOMAS H
LIBERTI II NELSON A
LIMA DANIEL A
LOUVIERRE JERRY J
LOVE JIMMIE L
MACCENAT OSPAUL
MALEK THOMAS A
MANCINI DAVID A
MCDUFFIE JAMES F
MCINNIS URIAH
MENDOZA JOSE
r MENDOZA JOSEPH H
MILIAN FELIX V
MILLER TREVOR H
MONTESINO JUAN C
1
4
iNSURI D •EMPLOYEE.
. NUM$1 R
SSNJALT NUMBER
GROUP INVOICE
Page: 3
RIC -MAN INTERNIJIONAL INC
Group: 63669001
Invoice: 159880 48
Billed:
05/19/07
Due: 06/01/07
Dist: LGQ Pays To: 07/01/07
PKG COV
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
011
01
01
011
011
011
01
01
011
01
011
01
01
011
02
01
01
07
01
01
02
04
01
01
06
01
01
01'
01
01.
01
02
01
02,
01
01'
01
01
01
01
06
01
01
02
02
01
02
061
01
07
01
011
041
02
01
0 7'
04
01
01
02
01
01
06
01
01
01
01
HEALTH{ ! CLAs$ onmx
923.42
290.82
290.82
604.85
290.82
290.82
923.42
549.60
290.82
290.82
549.60
290.82
290.82
290.82
290.82
290.82
290.82
923.42
290.82
923.42
290.82
290.82
290.82
290.82
290.82
290.82
549.60
290.82
290.82
923.42
923.42
290.82
923.42
549.60
290.82
604.85
290.82
290.82
549.60
923.42
290.82
604.85
549.60
290.82
290.82
923.42
290.82
290.82
549.60
290.82
290.82
290.82
290.82
(
.00
.00
.00
.00
.00
.00
.00,
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00
.00.
.00
.00
. 00
.00i
.00'
.001
.001
.001
.001
.001
.00;
.00!
.001
.001
. 001
.00
. 00,
.001
.▪ 00
. 001
.00;
.001
.00i
.00'
001
.00
.00
.00
.00
.00
.00
.00
. 00
TOTAL.
923.42
290.82
290.82
604.85
290.82
290.82
923.42
549.60
290.82
290.82
549.60
290.82
290.82
290.82
290.82
290.82
290.82
-923.42
-290.82
923.42
290.82
290.82
.,290 .82
290.82
290.82
290.82
549.60
290.82
290.82
923.42
923.42
290.82
923.42
549.60
290.82
604.85
290.82
290.82
549.60
923.42
290.82
604.85
549.60
290.82
290.82
923.42
290.82
290.82
549.60
290.82
290.82
290.82
290.82
0 An Independent Licensee of the
Blue Cress and Blue Shield Association
BlueCross B1ueShield
of Florida
2322
Includes any additional Insurance Coverages, where applicable (shown under "Other ").
offered through* Florida Combined Life Insurance Company, Inc.
MSG .INSURED -
CODE NAME
INSURED
GROUP INVOICE
Page: 4
RIC -MAN INTERNATIONAL INC
Group: 63669001
Invoice: 159880 48
Billed:
05/19/07
Due: 06/01/07
Dist: LGQ Pays To: 07/01/07
EMPLOYEE. PKG COY HEALTH. CLASS OTHER TOTAL
SSN/ALT NUMIIER NUMBER
MOREAU DIDIER 01 01 290.82 .00 290.82
NACE EILEEN A 01 01 290.82 .00 290.82
NACE JOSEPH 01 01, 290.82 .00 290.82
NAJARRO ORLANDO B 01 04 549.60 .00 549.60
NESTOR ST -LOUIS 01 011 290.82 .00 290.82
ORTIZ HAMILL 01 01'' 290.82 .00 290.82
PALMER BRENTON 01 01; 290.82 .00 290.82
PEREZ FRANCISCO G 01 01 290.82 .00 290.82
PERKINS ADAM M 01 04 549.60 .00 549.60
REYES NEFTALI 1, 01 02' 923.42 .00 923.42
RODRIQUEZ ERNESTO 01 02' 923.42 .00 923.42
ROSSI RONALD A 01 01 290.82 .00 290.82
SANCHEZ JAVIER 01 01 290.82 .00 290.82
SMITH LARRY E 01 07' 604.85 .00. 604.85
SMITH NATHANIEL D 01 01 290.82 .00' 290.82
?"STEPHENSON NEVILLE G 01 01: 290.82 .00 290.82
JANDERLIP ROGER P 01 01' 290.82 .00 290.82
WASHINGTON EVLYSTA 01 01 290.82 .00 290.82
WATSON MICHAEL 01 01 290.82 .00 290.82
WICHERT GERALD M 01 07' 604.85 .00 604.85
WILLIAMS MARK A 01 01. 290.82 .00, 290.82
WILLIAMS WAYNE A 01 01. 290.82 .00 290.82
WOOLEY WARRICK 01 01. 290.82 .00 290.82
TOTAL DUE THIS PERIOD .... ' 32,960.09 00 32,960.09
NUMBER BILLED FOR THIS PERIOD 1 -PERSON FAMILY 2 -PERSON EMP-CHLDRN EMP -SPOUSE OTHER
PKG 01 BLUEOPTIONS 51 11 0 9 5 0
TOTAL COVERAGE COUNTS 51 11 0 9 5 0
TOTAL MEMBER COUNTS 51 46 0 23 10
*MEMBER AD4UST'MENTS*
******* ** *********
ADDITIONS: EFF DATE
CESPEDES DAVID 050107 01 02: 923.42 .00 923.42
FERNANDEZ LEYANI 050107 01 01 290.82 .00 290.82
DELETIONS:
BARNARD SHAUN A
JONES JOHN
JONES JOSEPH P
MALONE REGINALD
050107
050107
050107
050107
01 01
01 02'
01 01
01 01
290.82-
923.42-
290.82-
290.82-
.00
.00
.00
.00
290.82-
923.42-
290.82-
290.82-
Rn1 a 14Q9-nn'AQ77 nen ()P nn4
MSG
CODE
BIueCross BIueShield
of Florida
vk\® M Indeparidonl tloenaee I hO
tion
2322
Includes any additional Insurance Coverages, where applicable (shown under "Other').
offered through Florida Combined Life Insurance Company, Inc.
INSURED
NAME
TOTAL: ADDITIONS
CHANGES
DELETIONS
TOTAL GRP ADJUSTMENTS
* * *
PRIVACY ALERT
INSURED
SSNIALT NUMBER
GROUP INVOICE
Page: 5
RIC -MAN INTERNATIONAL INC
Group: 63669001
Invoice: 15988048
Billed:
05/19/07
Due: 06/01/07
Dist: LGQ Pays To: 07/01/07
EMPLOYEE PKG COV I-iEALTH CLASS OTHER TOTAL
NUMBER
k** NET MEMS R ADJUSTMENTS ***
1,214.24 .00 1,214.24
.00 .00 .00
1,795.88- .00 1,795.88-
1581.64- .00 581.64 -
IS FOR GROUP EMPLOYER USE ONLY PRIVACY ALERT ***
THIS INFORMATION
VISION ONE DISCOUNT PROGRAM
Administered by Cole Managed Vision, Inc.
1-800-793-8622 (Mon. — Fri. 9am-9pm & Sat. 9am-5pm)
www.cmvc.com- when Plan number requested enter — '47058'
Discount Schedule Effective 1/1/2002
.Franies: -
Priced up to $ 60.99 Retail
Priced from $ 61.00 to $ 80.99 Retail
Stivhigs-
• -- L Ma*MUM MeMbOr .
Cost -
$ 25.00 60%
$ 35,00 55%
Priced from $ 81.00 to $ 100.99 $ 45.00 55%
Retail
Priced from $ 101.00 and over 65% 35%
Lenses (Uncoated plastic)
Single Vision
Bifocal
Trifocal
Lenticular
$ 30.00 50%
$ 50.00 45%
$ 60.00 60%
$100.00 50%
Lens OPtiOus (Add to lens prices 1
above) :•.•• 1
Standard. Progressive (no -line $ 50.00
bifocal)
Polycarbonate
,
-*Scratch Resistant Coating
Anti -Reflective Coating
Ultraviolet Coating
Solid Tint
Gradient Tint
Photo chromic
Glass
Eye ExaMinitlons
Spectacle- Maximum = $ 35
Contact- $ 10 off normal fee
Contact Lenses'
25%
$ 30.00 45%
$ 12.00 1 40%
-L
$ 35.00
$ 12.00
30%
40;A;
$ 8.00 45%
$ 8.00 t 45%
$ 30.00
55%
$ 15.00 60%
20%
20% Discount from regular retail prices. 10% discount on disposables.
All Materials (Sunglasses, accessories, etc,) 20%
20% Discount from regular retail prices.
Discount locations: Sears, ICPenney, Burdines & Target optical departments, Pearle Vision centers & other
independent vision care professionals. Additional information can be found by contacting at Cole Managed
Vision 1-800-793-8622 or www.cmvc.com.
TRUVISION Laser Vision Corrective Services
1-877-747-2020 (Mon. — Sat. 9am — 9pm)
www.truvisioninc.com
This program offers laser vision corrective services to members by participating
LASIK providers at $895.00 per eye.
Follow this process for scheduling an appointment:
• Contact TruVision 1-877-747-2020 to schedule a preoperative exam or for a
free telephone screening.
• Members must make a down payment to TruVision to schedule the
preoperative exam. This fee is fully refundable up to the date of surgery,
should the member decide not to undergo the surgical procedure.
• TruVision offers 100% patient financing upon approved credit with no
payment due in the first six months.
• A comprehensive eye exam, pre and post-operative care and an enhancement
warranty are included in the price of the procedures.
R110703
PARTICIPANT RECORD
r- Ric -Man International, Inc. 401(k) Profit Sharing Plan
Grout) Number
017669
Social Security Number
11 1
..NERAL INFORMATION Please Print or Type
Last
Employee Mr.
Name Mrs.
Mailing
Address
City I
Date of I
Birth
CONTRIBUTIONS
Ms.
Miss.
Marital Status
(M or S)
State
Date of I
Hire
Hartford Life Insurance Company
II'DlRetirement Plan Solutions
P.O. Box 1583
Hartford, CT 06144-1583
Location Code
(Plan Sponsor Use Only)
First
I I
I Zip I
Date of I
Eligibility
M.I.
A. I wish to havel % of my Before -Tax pay deducted each payroll period_
(Must be a whole percentage, 1% - I00%.)
B. E i do not wish to contribute to the Plan at this time.
(Your contributions are subject to the limits under the Plan and the Internal Revenue Code, including if eligible, the Plan's Catch-up
contribution limit. Any amounts deferred in excess of any limit under the plan will be treated as catch up contributions to the
maximum extent allowed under the Interna] Revenue Code.)
C. 1 have a previous retirement account 1 would like to rollover into this plan. (Please complete the enclosed Rollover Submission Form.)
r.^ INVESTMENT ELECTION
I understand that the Plan Sponsor has directed my existing accumulated account balance (if any) under the Plan to be transferred to
' trtford Life and invested in one or more of the funds below as specified by the Plan Sponsor. I elect to have my future contributions
cated based on my selections below. (Must total 100% - Whole percentages only.) (For more information, contact your Plan Sponsor.)
T. Rowe Price Small Cap Stock Inv Opt - 2R
Franklin Small -Mid Cap Growth Inv Opt - 2V
T. Rowe Price Mid Cap Growth Inv Opt - 2K
Hartford Stock HLS Inv Opt - 1E
American Century Value Inv Opt - 2P
Mutual Shares Inv Opt - 2W
Hartford Disciplined Equity HLS Inv Opt - 3Q
Hartford Index HLS Inv Opt - 1A
Hartford Advisers HLS Inv Opt - 1L
Hartford Bond HLS Inv Opt - 1B
Hartford Mortgage Securities HLS Inv Opt - 11)
Hartford Money Market HLS Inv Opt - 1G
T. Rowe Price Personal Strategy Growth Inv Opt - 2N
T. Rowe Price Personal Strategy Balanced Inv Opt - 2.144
T. Rowe Price Personal Strategy Income Inv Opt - 2L
Fixed Account - 10
SALARY REDUCTION AGREEMENT - 401(k) Plans
By execution of this document, the Employee authorizes and the Employer agrees that any Before -Tax Contributions indicated above be
made by reducing the Employee's salary. This agreement shall continue in effect only while employment with the Employer continues or
until it is altered in accordance to your Plan provisions. The Employer reserves the right to make adjustments to the percentage of the
Employee's Before -Tax Contributions in order to ensure the Plan's compliance with the Internal Revenue Code Section 401(k)/401(m).
SIGNATURES
I understand that these elections will be effective as soon as administratively feasible. 1 understand that the investment options are offered
under a group annuity contract issued by Hartford Life Insurance Company. With the exception of the Fixed Account, 1 understand that the
value of my Plan account under this contract is variable, is not guaranteed, and is subject to the investment experience of the various
investment options 1 have selected.
Employee Signature Date
This document has been received and accepted by the Plan Administrator.
Plan Administrator Signature Date
45
5!99
Proiect Manual
00400 BID/TENDER FORM
ITB #: 31e • c, (Cn kodLorykk,
City of Miami Beach, Florida
1700 Convention Center Drive
Miami Beach, Florida 33139
Submitted: - as • v-)
Date
The undersigned, as Bidder, hereby declares that the only persons interested in this bid
as principal are named herein and that no person other than herein mentioned has any
interest in this bid or in the Contract to be entered into; that this bid is made without
connection with any other person, firm, or parties making a bid; and that it is, in all
respects, made fairly and in good faith without collusion or fraud.
The Bidder further declares that it has examined the Contract Documents and all
addenda thereto furnished before the opening of the bids, as acknowledged below; and
that it has satisfied itself about the Work to be performed; and all other required
information with the bid; and that this bid is submitted voluntarily and willingly.
The Bidder agrees, if this bid is accepted, to contract with the City, a political subdivision
of the State of Florida, pursuant to the terms and conditions of the Contract Documents
and to furnish all necessary materials, equipment, machinery, tools, apparatus, means
of transportation, and all labor necessary to construct and complete within the time
limits specified the Work covered by the Contract Documents for the Project entitled:
ITB#: �.S- .o - Otp `Ol
The Bidder also agrees to furnish the required Performance Bond and Payment Bond or
alternative form of security, if permitted by the City, each for not less than the total bid
price, and to furnish the required Certificate(s) of Insurance. The undersigned further
agrees that the bid guaranty accompanying the bid shall be forfeited if Bidder fails to
execute said Contract, or fails to furnish the required Performance Bond and Payment
Bond, or fails to furnish the required Certificate(s) of Insurance within seven (7) calendar
days after being notified of the award of the Contract.
Page 64 City of Miami Beach May 2007
Project Manual
In the event of arithmetical errors, the Bidder agrees that these errors are errors which
may be corrected by the City. Acknowledgment is hereby made of the following
addenda (identified by number) received since issuance of the Project Manual:
Addendum Number
a
The Bidder shall acknowledge this bid by signing and completing the spaces provided
below.
Name of Bidder: Q.'C.- M� %r \(Nk (103-.% (Srk,\
City/State/Zip: MPOkr 0 d &0.c F 3301 3
Telephone No.: Q5q' t -%a ko • ‘OLIa
Social Security No.
or Federal Dun and Bradstreet No.:
(if applicable)
I. D. No.: 5C • a3L O S?
(if applicable)
Bradstreet No.: 01lQ(c.315 1
If a partnership, names and addresses of partners:
May 2007 City of Miami Beach Page 65
Proiect Manual
(Sign below if not incorporated)
WITNESSES:
(Signature)
(Sign below if incorporated)
CORPORATE SEAL)
(Type or Print Name of Bidder)
(Type or Print Name Signed Above)
C:1(-- Ilan \ Atir•O.OrrA,\
(Type or Print Name of Corporation)
ature and Title) presidcn.\-
-,...k,., a tAcirc:,,,.,
(Type or Print Name Signed Above)
Incorporated under the laws of the State of: c CCN', An
Page 66 City of Miami Beach May 2007
Project Manual
00405 CITY OF MIAMI BEACH LICENSES' PERMITS AND FEES
Pursuant to the Public Bid Disclosure Act, each license, permit or fee a Contractor will
have to pay the City before or during construction or the percentage method or unit
method of all licenses, permits and fees REQUIRED BY THE CITY AND PAYABLE TO
THE CITY by virtue of this construction as part of the Contract is as follows:
Building Permits, Public Works Permits, Zoning Permits, and Fees required by the City
for Construction will be reimbursed to the Contractor by the City for the cost of the
Permit/Fee only as a Reimbursable task item 01204-1001 with no marked -ups, meaning
using a Adjustment Factor of 1.0000. The cost for obtaining these Permits is to be
included in the Contractor's Adjustment Factor.
LICENSES, PERMITS AND FEES WHICH MAY BE REQUIRED BY
MIAMI-DADE COUNTY, THE STATE OF FLORIDA, STATE OR OTHER
AGENCIES THAT ARE NOT INCLUDED IN THE ABOVE LIST SHALL
BE REIMBURSED BY THE CITY.
IT IS THE RESPONSIBILITY OF THE CONTRACTOR TO OBTAIN ALL
PERMITS AND REQUIRED DOCUMENTS.
1 Occupational licenses from City of Miami Beach firms will be required to G(
be submitted within fifteen (15) days of notification of intent to award. L
2 Occupational licenses will be required pursuant to Chapter 205.065
Florida Statutes.
May 2007 City of Miami Beach Page 67
Proiect Manual
00407 FORM OF BID
BID FORM 1
SCHEDULE OF PRICES
FOR CONTRACT NUMBER ITB
The Bidder hereby proposes to fumish all labor, materials, equipment,
transportation, supervision, scope documentation services, as required, and
facilities necessary to complete in a workmanlike manner and in accordance with
the Contract Documents, all Job Order Work ordered for the compensation in
accordance with the following schedule of prices: The Contractor bids three (3)
adjustment factors. Two will be applied against the prices set forth in the
Construction Task Catalog® (CTC). One will be for work performed during normal
working hours. The second set will be for work performed during other normal
hours and the third adjustment factors will be used for Non Prepriced Work
Tasks.. These adjustment factors will be considered for the Term Period (12
months from date of contract award)
Line 1 Normal Working Hours Construction: Contractor shall perform any or all
functions called for in the Contract Documents and the individual project
Detailed Scope of Work, scheduled during normal working hours in the
quantities specified in individual Job Orders against this contract for the unit
price sum specified in the Construction Task Catalog® (CTC) multiplied times
the adjustment factor of:
1
0
s
(Specify to four (4) decimal places)
Line 2 Other Than Normal Working Hours Construction.: Contractor shall perform
any or all functions called for in the Contract Documents and the individual
project Detailed Scope of Work, scheduled during other than normal working
hours in the quantities specified in individual Job Orders against this contract
for the unit price sum specified in the Construction Task Catalog® (CTC)
multiplied times the adjustment factor of:
(Speciy to four (4) decimal places)
Page 68 City of Miami Beach May 2007
Project Manual
Line 3 Non Prepriced Work Tasks: Contractor shall perform any or all functions
called for in the Contract Documents and the individual project Detailed
Scope of Work, that are considered a Non Prepriced Work Tasks multiplied
times the adjustment factor of:
I U U O
(Specify to four (4) decimal places)
Line 4 Combined Adjustment Factor (From Line 7 on Bid Form 2)
1 . O 7 5 O
(Specify to four (4) decimal places)
EXAMPLE: Write the Adjustment Factor to four decimal places as the following example
illustrates.
1
0
• 1
Or
9
8
9
9
9
8
9
May 2007 City of Miami Beach Page 69
Proiect Manual
BID FORM 2
COMBINED ADJUSTMENT FACTOR WORKSHEET
FOR CONTRACT NUMBER ITB
For the purposes of determining the low bid the Contractor shall complete the following
worksheet.
(Specify to four (4) decimal places).
1. Normal Working Hours Construction Adjustment Factor
(Found on Bid Form (1) line 1)
2. Multiply Line 1 by (.70)
3. Other Than Normal Working Hours Construction Adjustment Factor
(Found on Bid Form (1) line 2)
4. Multiply Line 3 by (.20)
5. Non Prepriced Work Tasks Adjustment Factor
(Found on Bid Form (1) line 3)
6. Multiply Line 5 by (.10)
7. Add lines 2+4+6
I.o
0.145i
. 095?
,2( 9a,
Igloo
o - I 0
�.o1S
(Combined Adjustment Factor)
Page 70 City of Miami Beach May 2007
7
Project Manual
The Bidder shall complete this Combined Adjustment Factor Worksheet and transfer the
Bid Adjustment Factors, (Line 1, 3, 5,) and Final Combined Adjustment Factor (Line 7)
to the space provided on the Bid Form 1 (Line 4) of this proposal. The lowest Combined
Adjustment Factor will be deemed the lowest bid. The Owner reserves the right to
revise all arithmetic calculations for correctness.
Note: Should there exist a discrepancy in the adjustment factors bid on Bid Form (1)
and Bid Form (2), Bid Form (1) shall take precedent.
Contractor Name: rZ,iC, - \ kr1\-t t r1 lO nc .A
Authorized Signature:
Printed Name:_______%d
Date: 6. A a • 0-)
May 2007 City of Miami Beach Page 71
Proiect Manual
00500 SUPPLEMENT TO BID/TENDER FORM
THIS COMPLETED FORM SHOULD BE SUBMITTED WITH THE BID,
HOWEVER, ANY ADDITIONAL INFORMATION NOT INCLUDED IN THE
SUBMITTED FORM AS DETERMINED IN THE SOLE DISCRETION OF THE
CITY, SHALL BE SUBMITTED WITHIN SEVEN (7) CALENDAR DAYS OF THE
CITY'S REQUEST.
Page 72 City of Miami Beach May 2007
Project Manual
00520 SUPPLEMENT TO BID/TENDER FORM - NON -COLLUSION
CERTIFICATE
Submitted this AA day of .\ t) "W , 2007
The undersigned, as Bidder, declares that the only persons interested in this proposal
are named herein; that no other person has any interest in this proposal or in the
contract to which this proposal pertains; that this proposal is made without connection or
arrangement with any other person; and that this proposal is in every respect fair and
made in good faith, without collusion or fraud.
The Bidder agrees if this proposal is accepted, to execute an appropriate City of Miami
Beach document for the purpose of establishing a formal contractual relationship
between the Bidder and the City of Miami Beach, Florida, for the performance of all
requirements to which the Bid pertains.
The Bidder states that this proposal is based upon the documents identified by the
following number: Bid No. 3(0 • CAR (01 .
SIGNATURE
PRINTED NAME
C..1).14C-4
TITLE (IF CORPORATION)
May 2007 City of Miami Beach Page 73
Proiect Manual
00530 SUPPLEMENT TO BID/TENDER FORM - DRUG FREE
WORKPLACE CERTIFICATION
The undersigned Bidder hereby certified that it will provide a drug-free workplace
program by:
(1) Publishing a statement notifying its employees that the unlawful manufacture,
distribution, dispensing, possession, or use of a controlled substance is
prohibited in the offer or's workplace, and specifying the actions that will be taken
against employees for violations of such prohibition;
(2) Establishing a continuing drug-free awareness program to inform its employees
about:
(i) The dangers of drug abuse in the workplace;
(ii) The Bidder's policy of maintaining a drug-free workplace;
(iii) Any available drug counseling, rehabilitation, and employee assistance
programs; and
(iv) The penalties that may be imposed upon employees for drug abuse
violations occurring in the workplace.
(3) Giving all employees engaged in performance of the Contract a copy of the
statement required by subparagraph (1).
(4) Notifying all employees, in writing, of the statement required by subparagraph
(1), that as a condition of employment on a covered Contract, the employee
shall:
(5)
(i) Abide by the terms of the statement; and
(ii) Notify the employer in writing of the employee's conviction under a
criminal drug statute for a violation occurring in the workplace no later
than five (5) calendar days after such conviction; _
Notifying City government in writing within ten (10) calendar days after receiving
notice under subdivision (4) (ii) above, from an employee or otherwise receiving
actual notice of such conviction. The notice shall include the position title of the
employee.
(6) Within thirty (30) calendar days after receiving notice under subparagraph (4) of
a conviction, taking one of the following actions with respect to an employee who
is convicted of a drug abuse violation occurring in the workplace:
(i) Taking appropriate personnel action against such employee, up to and
including termination; or
Page 74 City of Miami Beach May 2007
(7)
Project Manual
(ii) Requiring such employee to participate satisfactorily in a drug abuse
assistance or rehabilitation program approved for such purposes by a
federal, state, or local health, law enforcement, or other appropriate
agency; and
Making a good faith effort to maintain a drug-free workplace program through
implementation of subparagraphs (1) through (6).
STATE OF C \O r' Ct.
COUNTY OF 2)r0t ock rr
The foregoing instrument was acknowledged before me this a day of, SUl op
20,t)2, LAc-'c\n1 as
Jr- (title) of V? A( - 1iIn4.n 1 r1AcgcncLAWna,1
(name of person whose signature is being notarized) (name of corporation/company), known to me
to be the person described herein, or who produced
as identitication, and who did/did not take an oath.
(Bidder Signature)
(Print Vendor Name)
NOTARY PUBLIC:
(nature)
NOTARY PUBLIC -STATE OF FLORIDA
""'"• Eileen A. Nace
Commission # DD570593
%,•,,,,,,• Expires: AUG. 16, 2010
BONDED THRU ATLANTIC BONDING CO., INC.
/-4-tri(//4/(he
My commission expires:
May 2007 City of Miami Beach Page 75
Proiect Manual
00540 SUPPLEMENT TO BID/TENDER FORM -TRENCH SAFETY ACT
On October 1, 1990 House Bill 3181, known as the Trench Safety Act became law. This
incorporates the Occupational Safety & Health Administration (OSHA) revised
excavation safety standards, citation 29 CFR.S.1926.650, as Florida's own standards.
The Bidder, by virtue of the signature below, affirms that the Bidder is aware of this Act,
and will comply with all applicable trench safety standards. Such assurance shall be
legally binding on all persons employed by the Bidder and subcontractors.
The Bidder is also obligated to identify the anticipated method and cost of compliance
with the applicable trench safety standards.
BIDDER ACKNOWLEDGES THAT INCLUDED IN THE ADJUSTMENT FACTORS OF
THE PROPOSAL ARE COSTS FOR COMPLYING WITH THE FLORIDA TRENCH
SAFETY ACT.
IN ORDER TO BE CONSIDERED RESPONSIVE. THE BIDDER MUST COMPLETE,
THIS FORM. SIGN AND SUBMIT IT WITH THEIR BID DOCUMENT.
-ACVA.
Nam- of Bidder
uthorized Signa u e of Bidder
A
Page 76 City of Miami Beach May 2007
Project Manual
00500 RECYCLED CONTENT INFORMATION
In support of the Florida Waste Management Law, Bidders are encouraged to supply
with their bid, any information available regarding recycled material content in the
products bid. The City is particularly interested in the type of recycled material used
(such as paper, plastic, glass, metal, etc.); and the percentage of recycled material
contained in the product. The City also requests information regarding any known or
potential material content in the product that may be extracted and recycled after the
product has served its intended purpose.
May 2007 City of Miami Beach Page 77
THE AMERICAN INSTITUTE OF ARCHITECTS
AIA DOCUMENT A310
Bid Bond
KNOW ALL MEN BY THESE PRESENTS, that we
Ric -Man International, Inc.
2601 N.W. 48th Street, Pompano Beach, FL 33073
as Principal, hereinafter called the Principal, and
Liberty Mutual Insurance Company
Boston, Massachusetts
A Corporation duly organized under the laws of the State of MA as Surety, Hereinafter called the Surety, are held and
firmly bound unto
City of Miami Beach
as Obligee, hereinafter called the Obligee, in the sum of
Twenty -Five Thousand and 00/100 Dollars ($25,000.00),
for the payment of which sum well and truly to be made, the said Principal and the said Surety, bind ourselves, our heirs,
executors, administrators, successors and assigns, jointly and severally, firmly by these presents.
WHEREAS, the Principal has submitted a bid: H407135CAF — Off site sanitary sewer force main & water main
For the North Andrews Gardens Neighborhood Improvement Project BP No. 9
NOW, THEREFORE, if the Obligee shall accept the bid of the Principal and the Principal shall enter into a Contract with
the Obligee in accordance with the terms of such bid, and give such bond or bonds as may be specified in the bidding or
Contract Documents with good and sufficient surety for the faithful performance of such Contract and for the prompt
payment of labor and material furnished in the prosecution thereof, or in the event of the failure of the Principal to enter
such Contract and give such bond or bonds, if the Principal shall pay to the Obligee the difference not to exceed the
penalty hereof between the amount specified in said bid and such larger amount for which the Obligee may in good faith
contract with another party to perform the work covered by said bid, then this obligation shall be null and void, otherwise
to remain in full force and effect.
Signed and sealed this 15th
#4 (Witness)
(Witness)
day of June 2007
Ric -Man International. Inc.
(Principal) (Seal)
(Title)
Liberty Mutual Insurance Comoanv
(Title)
Arlene M. Touzi, Attorney -in -Fact
AIA Document A310 •BID BOND. AIA •February 1970 ED •THE AMERICAN INSTITUTE OF ARCHITECTS.
THIS POWER OF ATTORNEY IS NOT VALID UNLESS IT IS PRINTED ON RED BACKGROUND.
This Power of Attorney limits the acts of those named herein, and they have no authority to bind the Company except in the manner and to
the extent herein stated.
2101372
LIBERTY MUTUAL INSURANCE COMPANY
BOSTON, MASSACHUSETTS
POWER OF ATTORNEY
KNOW ALL PERSONS BY THESE PRESENTS: That Liberty Mutual Insurance Company (the "Company"), a Massachusetts stock insurance
company, pursuant to and by authority of the By-law and Authorization hereinafter set forth, does hereby name, constitute and appoint
ARLENE M. TOUZI, KAREN C. BRODE, DAVID D. FISCHER, BRENDA AN HUNT, ALL OF THE CITY OF TROY, STATE OF
MICHIGAN
, each individually if there be more than one named, its true and lawful attorney-in-fact to make, execute, seal, acknowledge and deliver, for and on its
behalf as surety and as its act and "deed, anv and all undertakings, bonds, recognizances and other surety obligations in, the penal sum not exceeding
TWENTY FIVE MILLION AND 00/100**"**************** DOLLARS ($ 251000",000.00***** ) each, and the
execution of such undertakings, bonds, recognizances and other surety obligations, in pursuance of these presents, shall be as binding upon the
Company as if they had been duly signed by the president and attested by the secretary of the Company in their own proper persons.
That this power is made and executed pursuant to and by authority of the following By-law and Authorization:
ARTICLE XIII - Execution of Contracts: Section 5. Surety Bonds and Undertakings.
Any officer of the Company authorized for that purpose in writing by the chairman or the president, and subject to such limitations as the
chairman or the president may prescribe, shall appoint such attorneys -in -fact, as may be necessary to act in behalf of the Company to make, co
execute, seal, acknowledge and deliver as surety any and all undertakings, bonds, recognizances and other surety obligations. Such 'a
attorneys -in -fact, subject to the limitations set forth in their respective powers of attorney, shall have full power to bind the Company by their co
o signature and execution of any such instruments and to attach thereto the seal of the Company. When so executed such instruments shall be co
was binding as if signed by the president and attested by the secretary. c
7,3
•C • • a
.0 d By the following instrument the chairman or the president has authorized the officer or other official named therein to appoint attorneys -in -fact:
W co 4-, C
c Pursuant to Article XIII, Section 5 of the By -Laws, Gamet W. Elliott, Assistant Secretary of Liberty Mutual Insurance Company, is hereby co
authorized to appoint such attorneys -in -fact as may be necessary to act in behalf of the Company to make, execute, seal, acknowledge and_c
:It as
•E 3 deliver as surety any and all undertakings, bonds, recognizances and other surety obligations. 0
L o V I—
w S1 That the By-law and the Authorization set forth above are true copies thereof and are now in full force and effect. d W
d > IN WITNESS WHEREOF, this Power of Attorney has been subscribed by an authorized officer or official of the Company and the corporate seal of E E
Liberty Mutual Insurance Company has been affixed thereto in Plymouth Meeting, Pennsylvania this 6th day of March , = C
1 2007 a
O, .
C ie•ci `� LIBERTY MUTUAL INSURANCE COMPANY a
C42 1= ' By(a-2,,.-4- /4/-a.
c E Garnet W. Elliott, Assistant Secretary co o
y COMMONWEALTH OF PENNSYLVANIA ss' ~ .t. C
0) d COUNTY OF MONTGOMERY C _
t -, On this 6th day of March , 2007 before me, a Notary Public, personally came Qarnet W. Elliott, to me known, and acknowledged :' d
o •c that he is an Assistant Secretary of Liberty Mutual Insurance Company; that he knows the seal of said corporation; and that he executed the above ...
_f• Power of Attorney and affixed the corporate seal of Liberty Mutual Insurance Company thereto with the authority and at the direction of said corporation. Iii w
O
IN TESTIMONY WH - . nA' r unto subscribed my name and affixed my notarial seal at Plymouth Meeting, Pennsylvania, on the day and year .c N
17 )ft
•-- v first above written.�v``
> y , t9 �" '; NWEAiTH"OF PENNSYLVANIA E N
15 13-, Tema Postale, Notedy c By 'ii -T4\-6,14 iltdisf-)c coo
Z V Ptya+ottShTwp., Moritp nary Canty
My Mer 28, a - Teresa Pasteila, Notary Publlc v
_ aa�nww. r*rmrnyan nteociatWn of Nota 6" - _ _ 0 V
CERTIFICATE ,° I" `-
I, the undersigned, Assistan cretary of Liberty Mutual Insurance Company; do hereby certify that the original power of attorney of which the foregoing
is a full, true and correct copy, is in full force and effect on the date of this certificate; and I do further certify that the officer or official who executed the
said power of attorney is an Assistant Secretary specially authorized by the chairman or the president to appoint attorneys -in -fact as provided in Article
XIII, Section 5 of the By-laws of Liberty Mutual Insurance Company.
This certificate and the above power of attorney may be signed by facsimile or mechanically reproduced signatures under and by authority of the
following vote of the board of directors of Liberty Mutual Insurance Company at a meeting duly called and held on the 12th day of March, 1980.
VOTED that the facsimile or mechanically reproduced signature of any assistant secretary of the company, wherever appearing upon a
certified copy of any power of attorney issued by the company in connection with surety bonds, shall be valid and binding upon the company
with the same force and effect as though manually affixed.
IN TESI1 1QNY WHEREOF, I have hereunto subscribed my name and affixed the corporate seal of the said company, this
ByQ��'er�r� ./r
David M. Carey, Ass' 't Secretary
day of