EAST GATEWAY STORMWATER AND SANITARY IMPROVEMENTS PROJECT - 13-0043-EN - GENERAL RELEASE FCCI USE ONLY
ADJUSTER NmiE
Steve Holloway.
F C.+ I.I.NSE:I�Z.i�-itiTC.I: CAW N[lMER
C00242233.mQl
GENERAL RELEASE
The undersigned .parties to this Release; to wit: City Of Clearwater ,. (hereinafter collectively.referred to as the
"Releasor`'), David Nelson Construction Co. and FCCI Insurance Company (hereafter collectively referred to as the
"Releasee")hereby agree..as.follows;
August 11,
WHEREAS, Releasor has filed a claim against Releasees due to an accident, incident or loss occurring gn�trst��r-
201&at_100 WaverlyWav, Clearwater, 33756. in Pinellas County,.FLORIDA.(hereafter"the.Occurrence");
WHEREAS, the parties wish to compromise.and settle all..c.iaims each may have against the other as.a result of.the.
Occurrence;
NUW,THEREFORE, the parties agree as follows:
SCOPE OF RELEASE
Releasor, for and on behalf of each and. all of his/her/their respective present, former, and future :successors, heirs,.
executors; administrators, guarantors; attorneys, representatives; insurers and assigns (a€J of whom are:also.hereinafter
collectively referred to as the "Releasor"),for and in.consideration of the sum of$.16.152.80 and other good and .valuable
consideration, the.receipt and sufficiency of which is hereby acknowledged, does hereby release, acquit, and forever
discharge Releasee(s), and if Releasees) is/are .a corporation., all of its respective present, former and affiliated:and
subsidiary corporations, divisions and associations,.and each and all .of its pre sent, .former.and future officers, directors,
trustees,. agents, employees, insurers, executors, personal representatives, managers, predecessors, successors,
representatives and assigns(all of whom are also.hereafter collectively referred to as the:."Releasee(s)"}.of and from any
and .all claims; demands, contracts, leases, guaranties, covenants,.suits, causes of actlon; obligations, controversies,
debts, costs, accounts, damages, judgments, losses and liabilities of whatever kind or nature, in law, equity, statutory or
otherwise, whether known or unknown,,which against them,or.any of them, Releasors) clow has, had,.may have had, or
can, shall or may have which were or might or could have been asserted in connection with,.;arising out of or in any way
relating to the Occurrence.
It is the intent of the undersigned Releasor that this is a.general, complete, full, comprehensive and final release of any.
and all liability of the,partles released herein arising from or out of any act performed or omitted by, or on behalf of the
parties.released herein prior to the date hereof, in any way relating to the Occurrence.
OWNERSHIP OF CAUsEs OF ACTION
The undersigned Releasor hereby expressly warrants; represents and covenants to the parties released herein that
Releasor is presently the legal owner andholder of the claims or causes of action released. hereby, and that it has.not
heretofore expressly or impliedly assigned, transferred, pledged or otherwise disposed of .any such rights, claims,.
demands,or causes of action being described herein.and released hereby.
.SATISFACTION OF LIENS
The undersigned Releasor further declare and. represent that any and all hospital liens, worker's compensation liens,
repairmen liens, attorney's liens, governmental liens and/or subrogation rights possessed by any third party have been
.settled or released and that:the undersigned hereby expressly agree to hold harmless and indemnify.the Releasees)from
any such liens or any action drought on account of such liens or subrogation rights, whether or not said.actions allege or
show negligence on the part of Releasees) tri determining the existence or vaiidity of:an.y such liens; said indeiriniffcaticn
to-include.without limitation the amount of the lien(s) and Releasee(s) attorney's fees expended in defending.any such
actions. Releasor(s) hereby agree(s) that the proceeds of this.settlementwill be.used to satisfy any such liens.
ENTIRE AGREEMENT
The undersigned.further.d.eclares and represents that no promise, inducement,or agreement not herein 'expressed has
RELEASORS INITIALS
i-CWT-76:16-NA-64, 3'16 Page 1 of 3
been made to. the undersigned, and that this Release contains the eritire agreement: between the parties hereto and
supersedes any prior oral or written agreernents between the parties, and that the.terms.of the Release are contractual
and not a.mere recital.
The undersigned has read the foregoing Release and fully understands it,
Executed in Clearwater Pinellas County, FL this. 3-rd
day.of June
Releasor [SEIECT APPLI ABLE OPTION OR BLANK]
D.. Sc.ot.t Rice
PRINT OR TYPE NAME
Releasor.[SELECT APPLICABLE OPTION OR BLANK]
PRINT OR TYPE NAME
County of Pinellas
State of Florid .
BEFORE ME,.the undersigned authority, personally appeared, D. Scott. Rice
who, after being duly cautioned and sworn,dopose(9)and
says)helshelthey.haslhave read the above Release and.that helshelthey has/have set hislherltheir hand(s) and seal(s)
thereto for the purposes therein expressed,
The foregoing instrument was acknowledged before me this 3rd day of June ,2Q 19
by D. Scott Rice
x Who is/are personally known to me.or
_W ho produced the following identification and
Who did take an oath or
Who did not take an-oath. i
1
f SIGNATURE OF NOTARY
_f PRINT OR TYPE.NAME OF NOTARY
My Commission Expires: (NO ARrssc,Lf
°Pi� Notary Public State o}Fwrida
Laura M Davis
Icy Commlaslort Gia 038932
w a Expires 0111M02.1
t<CM01-7646-NA-e4, 9116 Page 2 of
Applicable in Alabama: Any person who knowingly presents. a false or fraudulent claim for payment of a loss or benefit or who.
knowingly presents..fa.€se lnforimatian.in an application for insurance is guilty of a crime.and may be subject to restitution fines or
confinement in.prison,or any combination thereof.
Applicable.in.Arkansas:.Any person who knowingly presents a false or fraudulent claim for paymentof a loss or.benefit or knowingly
presents false information in an application for insurance is gulltyof.a.crim.e and maybe subject to fines arid confinement in prison.
Applicable in Florida: Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee,
insurance,corn pany or self insured program,files a statement of clallrm containing any false or misleading.information is guilty of a
felony of the.third degree.
Applicable 1n Genrgiat.In.accord ance with 0.C.G.A.s.33-7-12, insurer notifies the th1rd party cla i mant th At.the 1nsumrdoes.not have
the written.consent of its.insured to the settlement describedin the ReIease:and such.1nsured!s not th e reby precl uded from the further
assertion of.claims against the.third party..claimant arising out of the incident or occurrence described in the Release.
Applicable in Illinois: A person commits the offense of insurance fraud when he or she knowingly obtains, attempts to obtain, or
causes to be obtained.by deception;control:overthe.property of an insu rance.corn pany or self-insured entity by.the making of a false
claim or by causing a false claim to be made:on any policy of insurance.issued.by an insurance company or by the making of a false
claim to a self-insured entity, intending.to deprive an insurance company or seV-insured entity permanently of the use and:benefit.of
that property.
Applicable in Indiana: A person who knowingly and with intent to de.fraud.an insurer,files a statement of claim containing any
false, incomplete,.or misleading information commits.a felony.
Applicable.:in.Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files.a
statement of claim containing,any materially.false.i.nformation or conceals;.for the purpose of misleading, information cone®rnIng
any fact material thereto commits a fraudulent.insurance act,which is a crime.
Applicable in Louisiana:Any:person who knowingly presents.a false orfraudulent clalm::for.payment of'a loss or benefit or knowingly
presents:false 1nfonratlon.1n an application for insurance its guilty ofa.crime.and may be subject to fines and confinement In prison.
Applicable in Maryland: Any person who knowingly or willfully presents a.falseor fraudulent claim for payment.of a loss or benefit or
Who knowl ngly.or willfully presents false information in an application.for Insurance is'6u1Ity of a crime and may be subject to fines and
confinement in prison.
Applicable in Missouri: A person.commits a fraudulent insurance act if such person knowingly presents,causes to be presented,or
prepares with knowledge or beIlef that it will be presented;to or by. an Insurer,purported insurer,.broker,or.any agent thereof, any oral.
or written statement including computer generated.documents.as part of,or in.support of, an application for the issuance of, or the
rating of, an insurance po€icy fo.r commercial or personal insurance, or a claim for payment.or other benefit pursuant to an insurance.
policy for comrrlerciai or personal insurance,. which such person knows to contain materially false informationconcerning any fact
material'thereto or if such.person conceals,'for the.purpose'of misleading another, information concerning any fact material thereto:
Applicable in North Carolina:.Any person who,with the interitto injure,defraud,;or decelve an insureror insurance claimant:
t9 j Presents or causes to be presented a written or oral statement, including computer-generated documents as part-of;-in support of,
or in.opposition to,a.claim for payment or other benefit pursuant.ta.an insurance policy, knowing that the statement.contalns:faise
or misleading information concerning any factor mattermate rial to the.claim,or
{2) Assists, abets, solicits,.or conspires with another person to.prepare or make any written or oral statement that is intended to be.
presented to..an Insurer or insurance claimant in oorinection with,:in support.of, or in:oppositlon..to,.a claim for payrnent or other
benefit pursuant to an insurance policy, knowing:that the statement contains false or misleading Informatlon.concerning a.fact or
matter material to the claim is guilty of a Class H felony.
Applicable in Ohio: Any.peison wild,with intent to defraud or knowing that he.is.facilitating a fraud against an insurer, submits
ari application or:files a claim containing false or deceptive statements,is guilty of Insurance fraud..
ApplicableAn in South .Carolina: A person who knowingly makes a. falsestatement or misrepresentation, and any other person
knowingly, with.an intent to injure, defraud, or:decelve,'or who assists,..abets,..so.licits, or:conspires with a person to make. a false
statement or misrepresentation,is guilty of a misdemeanor or felony,depending upon the circumstances.
Applicable In Tennessee: It is:a crime to knowl ngIy provide.false,incdrn1)ate or misleading information to an insurance company for
the purpose of defrauding the company.Penaities%incIUde imprisonment,fines and denlaI of insurance benefits.
Applicable in.Texas: Any person who knowingly presents a false or fraudulent claim for the payment of.a loss.is%guilty of a:.crime.and
may be subject to fines and confinement in state prison:
Applicable.in Virginia: it!s a crime to knowingly provide false; incomplete or misleading information to an insurance.company far the
purpose.of defrauding the cornpany::Penalties include.imprisonment,fines and denlal.of.insurance Benefits.
Applicable in Washington D.C.: WARNING: It is a crime to.provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Pena#tles.include imprisonment.andfor fines. In addition, an insurer may deny insurance
benefits;if false information materially related to a claim was prov!ded bythe applicant.
Applicable in Ether States: Please Note: Some state laws reouire that we advise all claimants of.the.followino:. Under most slate
laws, a person Who knowingly and with the intent to defraud an insurance.eompany submits a claim or'documentation in.support of a:
claim containing materially false, incomplete or misleading information; commits a fraudulent insurance.-wt, which.ls:a crime and may
subject the person to criminal and/or civil penalties.
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