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HomeMy WebLinkAboutCONCENTRA MEDICAL CENTER dba OCCUPATIONAL HEALTH CENTERS OF CALIFORNIADOCUS!9 ip FA70-490C-4COC-A2FC-B16EBFBB678D UNTIL INSURANCE EXPIRES ei eN or Gouucitt. ,ATl r rr. WITH CONCENTRA MEDICAL CENTER DBA OCCUPATIONAL HEALTH CENTERS OF CALIFORNIA T or1+� }i Naac=e.ew THIS AGREEMENT, made and entered into this 16th day of January, 2019 by and between Concentra Medical Center dba Occupational Health Centers of California, a Medical Corporation (hereinafter "Consultant"), and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California (hereinafter "City"). A. The City desires to retain a medical consultant having special skill, knowledge and expertise in the field of medical services to provide a fully comprehensive and legally -defensible medical services review program as an essential part of the City's objective to provide and maintain a qualified work force. B. Consultant represents that Consultant is able and willing to provide such services to the City. C. In undertaking the performance of this Agreement, Consultant represents that it Is knowledgeable in its field and that any services performed by Consultant under this Agreement will be performed in compliance with such standards as may reasonably be expected from a professional consulting firm In the field. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the parties agree as follows: SCONE OF SERVICES Consultant shall organize, schedule, manage, and/or evaluate a comprehensive range of medical services and examinations, including but not limited to: a) For prospective and current City employees to perform the duties of the position for which they are being considered (pre -employment assessments), using pre- determined medical protocols for each job classification; such protocols may be modified by the physician, In consultation with the City's Executive Director of Human Resources, or his/her designee, as Is necessary to make a determination as to suitability for employment; b) For current City employees being considered for employment in Department of Transportation (DOT) and non -DOT positions requiring pre -placement or pre - assignment drug screens; c) Fitness for Duty examinations (industrial and non -industrial), and provide reports and recommendations regarding the suitability of current employees to continue to perform their duties; Agreement between City of Santa Ana and Concentra DocuSign Envelope ID: 5D3BFA70-49OC-4COC-A2FC-B15EBFBB678D d) Urine and breath specimen collection, laboratory analysis and Medical Review Officer (MRO) responsibilities; e) Department of Motor Vehicles (DMV) Driver's License physical examinations; f) DOT -mandated drug and alcohol testing of employees considered 'safety sensitive' as defined under DOT regulations and City policy. Consultant shall ensure all such testing complies with DOT testing procedures as per 49 CFR, Part 40; such testing to include pre -employment and pre -assignment, City shall be responsible for the organization, scheduling, and management of DOT and non -DOT "reasonable suspicion" drug and alcohol testing, and DOT "random" and "post - accident" drug and alcohol testing. Consultant shall facilitate evaluation of the results of said testing by qualified personnel, in accordance with the provisions of the Agreement and relevant laws and regulations. Consultant shall ensure that clinics used for DOT -related drug and alcohol testing maintain a current valid contract with a Substance Abuse and Mental Health Services Administration (SAMSHA)-certified laboratory. Consultant shall ensure turn -around time from specimen collection to obtained test results shall be a maximum of three (3) working days for a negative test, and a maximum of five (5) working days for a positive test. As part of the medical services review program, Consultant shall: 1) Analyze current job classification specifications and make recommendations for the City's use in the medical examination and drug testing process, 2) Provide training to Personnel Services personnel in administration procedures of Consultant's medical services review process. 3) Communicate with City Personnel Services staff regarding applicants' or employees' progress throughout the medical services review process, 4) Communicate directly with applicants and City Personnel Services staff throughout the pre -employment or pre -assignment process in regard to results and medical conditions as ascertained through the medical or physical examinations. 5) Provide an electronic final report in a format established by City Personnel Services staff at its sole discretion, outlining each candidate's pre -employment placement medical evaluation and results. 6) Provide quarterly electronic activity reports, in a format established by Personnel Services in its sole discretion, on the nature and number of examinations conducted, including but not limited to results and final dispositions. 7) Provide a detailed quarterly explanation and summary of charges incurred. 8) Provide all quarterly and annual summaries as required under the DOT; 9) Provide consultation as needed to Personnel Services staff regarding medical services provided and outlined in the Agreement. 10)Consultant solely shall review all pre-employmentipre-placement medical evaluation services and maintain records, pursuant to the Agreement, in accordance with State and Federal laws, or as otherwise reasonably required by the City, and to the fullest extent permitted by law, r Agreement between City of Santa Ana and Concentra DocuSign Envelope ID: 5D33FA70-490C-4COC-A2FC-B15EBFBB678D 11)Consultant agrees to permit duly -authorized agents and employees of the City to review such records. 12)Consultant shall maintain all books, documents, papers, accounting records, and other evidence pertaining to the fees paid under this Agreement. Consultant will make materials available at their offices at reasonable times and notice, during the period of the Agreement and for three (3) years after date of final payment under the Agreement for inspection by the City or by any other governmental entity or Department participating in the funding of the Agreement, or any authorized agents thereof. 13)Consultant's documents shall not be used, duplicated, or disclosed to any other third party without written penr:ission, unless such disclosure is required by law. Consultant shall not be required to create or maintain books and records not required in the ordinary course of Consultant's business operations, nor will the Consultant be required to disclose any information, including but not limited to product cost or pricing data, which Consultant considers confidential or proprietary. 14)Any Agreement changes which are mutually agreed upon by and between the parties shall be incorporated in written amendments to the Agreement, 15)lf the circumstances on a particular hearing and/or court proceeding warrant the presence of a competent and knowledgeable representative of the Consultant, the City may request and contractor shall provide such representative, at the rates provided in Exhibit A and upon proper HIPAA release. Additionally, as part of the medical services review program, Consultant shall: o Maintain a network of qualified and trained medical providers and -medical specialists for necessary exams; o Orient City staff in the legal/medical/risk management and human resources aspects of Consultant services; o Communicate directly with applicants to obtain the confidential medical Information that is needed for clearance for a particular job; a Manage all bill review functions for the medical exams performed by clinics; and, o Provide access for City staff to Consultant's tracking system. Depending on job classification, pre -employment and pre -assignment medical examination processes may include: job profile review; review of medical history; check vital signs; detailed vision exam, Including check of near/far/peripheral vision, Ishihara 14 and primary color; audiogram (if classification has specific occupational noise exposure or critical hearing demands); chest x-ray; EKG or treadmill stress EKG; Spirometry; chem panel 20; CBC w/diff; dipstick UA, or UA w/Micro (to lab); venipuncture & collection. Individual medical exams, such as post exposure, fit for duty, or other examinations, as needed, may include one or more of the following (*See Exhibit A): r Agreement between City of Santa Arta and Concentra DocuSign Envelope ID: 5D3BFA70-49OC-4COC-A2FC-B15EBFBB678D o Audiogram o Back X-ray o *Blood Lead Level ZZP o *Blood screens — 7 panel drug screen o *Blood screens -- 9 panel drug screen o *Blood chemistry profile (SMA 24 or equivalent) o *Complete blood count (CBC w/diff) a Chest X-ray o DMV Physicals o Electrocardiogram o *Hepatitis "A" blood screen o *Hepatitis "B" blood screen o *Hepatitis "B" booster o *Hepatitis "B" titer o *Hepatitis "B" Vaccine (3-injection series) o *Hepatitis "A" Vaccine (2-injection series) o *Hepatitis "C" blood screen o *HIV blood screen o Pulmonary function test o Respirator Fit test a Respirator Physical o Respirator Questionnaire if PX Is not required with clearance o *TB test o Urinalysis: ■ Urinalysis with microscopy (UA w/micro) ■ Urinalysis with dipstick (Dipstick UA) 2. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as total payment for its services, the rates and charges identified in Exhibit A, attached hereto and incorporated by this reference. The total amount to be expended under this Agreement, including the two optional renewals, shall not exceed $500,000, b. Payment by City shall be made within thirty (30) days following receipt of proper invoice evidencing work performed, subject to City accounting procedures. Payment need not be made for work which fails to meet the standards of performance set forth in the Recitals which may reasonably be expected by City. 3. TERM This Agreement shall commence on February 1, 2019 and terminate on January 31, 2022, unless terminated earlier in accordance with Section 12, below. Agreement between City of Santa Ana and Concentra DocuSlgn Envelope ID: 5D3BFA70-490C-4COC-A2FC-B15EBFBB678D The Agreement may be renewed up to two (2) times, for an additional one-year period each time, upon mutual agreement between the parties, and In writing executed by the City Manager, or his/her designee, and the City Attorney, or his/her designee and the Consultant. Consultant shall, during the entire tern of this Agreement, be construed to be an independent contractor and not an employee of the City. This Agreement is not intended nor shall it be construed to create an employer -employee relationship, a Joint venture relationship, or to allow the City to exercise discretion or control over the professional manner In which Consultant performs the services which are the subject matter of this Agreement; however, the services to be provided by Consultant shall be provided in a manner consistent with all applicable standards and regulations governing such services. Consultant shall pay all salaries and wages, employer's social security taxes, unemployment insurance and similar taxes relating to employees and shall be responsible for all applicable withholding taxes. 5, INSURANCE Prior to undertaking performance of work under this Agreement, Consultant shall maintain and shall require Its subcontractors, if any, to obtain and maintain insurance as described below; a. Commercial General Liability Insurance. Consultant shall maintain commercial general liability insurance naming the City, its officers, agents, volunteers, and employees as additional Insured(s) and shall Include, but not be limited to protection against claims arising from bodily and personal Injury, including death resulting therefrom and damage to property, resulting from any act or occurrence arising out of Consultant's operations in the performance of this Agreement, including, without limitation, acts involving vehicles; the insurance shall be primary and non- contributory with respect to Insurance or self-insurance programs maintained by the City; and contain standard separation of insureds provisions. ii, The amounts of insurance shall be not less than the following; single limit coverage applying to bodily and personal injury, Including death resulting therefrom, and property damage, In the total amount of $1,000,000 per occurrence with $2,000,000 In the aggregate. Consultant shall supply City with a fully executed additional insured endorsement in a form approved by the City Attorneys Office, b. Worker's Compensation Insurance. In accordance with the provisions of Section 3300 of the Labor Code, Consultant, if Consultant has any Agreement between City of Santa Ana and Concentra DocuSign Envelope ID: 5D3BFA70-49OC-4COC-A2FC-B15EBFBB678D employees, is required to be Insured against liability for worker's compensation or to undertake self-insurance. Prior to commencing the performance of the work under this Agreement, Consultant agrees to obtain and maintain any employer's liability insurance with limits not less than $1,000,000 per accident. c. Errors and Omissions. Consultant shall maintain professional liability (errors and omissions) insurance, with a combined single limit of not less than $1,000,000 per claim. d. The following requirements apply to the insurance to be provided by Consultant pursuant to this section: (1) Consultant shall maintain all Insurance required above in full force and effect for the entire period covered by this Agreement. (ii) Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved in form by the City Attorney. (111) Certificates and policies shall state that the policies shall not be canceled or reduced in coverage or changed in any other material aspect without thirty (30) days prior written notice to the City. e. If Consultant falls or refuses to produce or maintain the insurance required by this section or fails or refuses to furnish the City with required proof that insurance has been procured and is in force and paid for, the City shall have the right, at the City's election, to forthwith terminate this Agreement. Such termination shall not affect Consultant's right to be paid for its time and materials expended prior to notification of termination. Consultant waives the right to receive compensation and agrees to indemnify the City for any work performed prior to approval of insurance by the City. Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from liability: (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, Including health, and claims for property damage, which may arise from the direct or Indirect operations of the Consultant or its contractors, subcontractors, agents, employees, or other persons acting on their behalf which relates to the services described in section 1 of this Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terms of or effects arising from this Agreement. This indemnity and hold harmless agreement applies to all claims for damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to have been suffered, by reason of the events referred to in this Section or by reason of the terms of, or effects, arising from this Agreement, Consultant further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for special counsel to be selected by the City, regarding any action by a third party challenging the validity of this Agreement, or asserting tyhat personal injury, damages, just compensation, restitution, judicial or Agreement between City of Santa Ana and Concentra DocuSign Envelope ID: 5D3BFA70-490C-4COC-A2FC-B15EBFBB678D equitable relief due to personal or property rights arises by reason of the terms of, or effects arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding, CONFIDENTIALITY Consultant shall conform to all HIPAA requirements regarding examinations performed by Consultants. If Consultant receives from the City information which due to the nature of such information is reasonably understood to be confidential and/or proprietary, Consultant agrees that it shall not use or disclose such information except in the performance of this Agreement, and further agrees to exercise the same degree of care It uses to protect its own information of like importance, but in no event less than reasonable care. "Confidential Information" shall include all nonpublic information. Confidential Information includes not only written information, but also information transferred orally, visually, electronically, or by other means, Confidential information disclosed to either party by any subsidiary and/or agent of the other party is covered by this Agreement. The foregoing obligations of non-use and nondisclosure shall not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fault of the Consultant disclosed in a publicly available source; (c) is in rightful possession of the Consultant without an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (a) is independently developed by the Consultant without reference to Information disclosed by the City, S. CONFLICT OF INTEREST CLAUSE Consultant covenants that it presently has no Interests and shall not have interests, direct or indirect, which would conflictin any manner with performance of services specified under this Agreement. 9, NOTICE Any notice, tender, demand, delivery, or other communication pursuant to this Agreement shall be in writing and shall be deemed to be properly given if delivered in person or mailed by first class or certified mail, postage prepaid, or sent by fax or other telegraphic communication in the manner provided in this Section, to the following persons: To City; Clerk of the Council City of Santa Ana 20 Civic Center Plaza, M-30 P,O, Box 1988 Santa Ana, CA 92702-1988 Fax: (714) 647-6956 I Agreement between City of Santa Ana and Concentra DocuSign Envelope ID: 5D3BFA70-490C-4COC-A2FC-B15EBFBB678D With courtesy copies to: and, Executive Director of Human Resources City of Santa Ana 20 Civic Center Plaza, M-24 P.O. Box 1988 Santa Ana, California 92701-1988 Fax: (714) 647-6930 City Attorney City of Santa Ana 20 Civic Center Plaza, M-29 P.O, Box 1988 Santa Ana, California 92702 Fax: (714) 647-6515 To Consultant: Occupational Health Centers of California, a Medical Corporation 5080 Spectrum Drive, Suite 120OW Addison, Texas 76001 Attn: Legal -Contracting Email: Le alContracts concentra.com A party may change its address by giving notice in writing to the other party. Thereafter, any notice, tender, demand, delivery, or other communication shall be addressed and transmitted to the new address. If sent by mail, any notice, tender, demand, delivery, or other communication shall be effective or deemed to have been given three (3) days after it has been deposited in the United States mail, duly registered or certified, with postage prepaid, and addressed as set forth above. If sent by telefacsimile, any notice, tender, demand, delivery, or other communication shall be effective or deemed to have been given twenty-four (24) hours after the time set forth on the transmission report issued by the transmitting facsimile machine, addressed as set forth above, For purposes of calculating these time frames, weekends, federal, state, County or City holidays shall be excluded. 10. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Consultant, and supersedes any and all other agreements, oral or written, between the parties. In the event of a conflict between the terms of this Agreement and any attachments hereto, the terms of this Agreement shall prevail. This Agreement may not be modified except by written instrument signed by the City and by an authorized 1, Agreement between City of Santa Ana and Concentra 8 DocuSign Envelope ID: 5D3BFA70-490C-4COC-A2FC-B15EBFBB678D representative of Consultant. The parties agree that any terms or conditions of any purchase order or other instrument that are inconsistent with, or in addition to, that terms and conditions hereof, shall not bind or obligate Consultant nor the City. Each party to this Agreement acknowledges that no representations, Inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which are not embodied herein, 11. ASSIGNMENT Inasmuch as this Agreement is intended to secure the specialized services of Consultant, Consultant may not assign, transfer, delegate, or subcontract any interest herein without the prior written consent of the City and any such assignment, transfer, delegation or subcontract without the City's prior written consent shall be considered null and void. Nothing in this Agreement shall be construed to limit the City's ability to have any of the services which are the subject to this Agreement performed by City personnel or by other consultants retained by City. 12. TERMINATION This Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, Consultant shall be entitled to receive and the City shall pay Consultant compensation for all services performed by Consultant prior to receipt of such notice of termination, subject to the following conditions: a. As a condition of such payment, the Executive director may require Consultant to deliver to the City all work product completed as of such date, and in such case such work product shall be the property of the City unless prohibited by law, and Consultant consents to the City's use thereof for such purposes as the City deems appropriate. b. Payment need not be made for work which fails to meet the standard of performance specified in the Recitals of this Agreement, 13. DISCRIMINATION Consultant shall not discriminate because of race„ color, creed, religion, sex (including gender identity and gender expression), marital status, sexual orientation and genetic characteristics (including genetic tests of the individual orthe Individual's family, and manifestation of a disease or disorder in the individual's family members, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in recruitment, selection, training, utilization, promotion, termination or other employment related activities. Consultant affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. Agreement between City of Santa Ana and Concentra g ' DocuSign Envelope ID: 5D3BFA70-49OC-4COC-A2FC-B15EBFBB678D 14. JURISDICTION -VENUE This Agreement and all questions relating to its validity, interpretation, performance, and enforcement shall be government and construed in accordance with the laws of the State of California. This Agreement has been executed and delivered in the State of California and the validity, interpretation, performance, and enforcement of any of the clauses of this Agreement shall be determined and governed by the laws of the State of California. Both parties further agree that Orange County, California, shall be the venue for any action or proceeding that may be brought or arise out of, in connection with or by reason of this Agreement. 15. PROFESSIONAL LICENSES Consultant shall, throughout the term of this Agreement, maintain all necessary licenses, permits, approvals, waivers, and exemptions necessary for the provision of the services hereunder and required by the laws and regulations of the United States, the State of California, the City of Santa Ana and all other governmental agencies. Consultant shall notify the City immediately and in writing of her inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions, Said inability shall be cause for termination of this Agreement. 16. MISCELLANEOUS PROVISIONS a. Each undersigned represents and warrants that its signature herein below has the power, authority and right to bind their respective parties to each of the terms of this Agreement, and shall indemnify City fully, including reasonable costs and attorney's fees, for any injuries or damages to City in the event that such authority or power is not, in fact, held by the signatory or is withdrawn. b. All Exhibits referenced herein and attached hereto shall be incorporated as if fully set forth in the body of this Agreement. IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: CITY OF SANTA ANA- I «. Norma Mitre STEVEN A. MENDOZA Acting Clerk of the Council Acting City Manager [Signatures continue on next page] Agreement between City of Santa Ana and Concentra 16 DocuSign Envelope ID: 5D3BFA70-490C-4COC-A2FC-B15EBFBB678D SONIA R. CARVALHO City Attorney Laura A. Rossini Senior Assistant City Attorney r r •.,. 0: Steven V./Pham . ExecutivV Director - Human Resources Department * x 1 F 4 OCCUPATIONAL HEALTH CEN OF CALIFORNIA, A MEDICAL CORPORATION: �,Do�cu„SigIneE by: t,�t,y (�lai�l.sfuln.l �L� `-25]]SFAABE234B2... Jeffery Wainstein, MD President and Treasurer 77-0469725 Federal ID Number Agreement between City of Santa Ana and 6oncentra 11 DocuSign Envelope ID: 5D3BFA70-490C-4COC-A2FC-B15EBFBB678D Exhibit A Services and PrIcin .eryf` Os PE — BASIC VITALS SNELLEN, UA, EXAM $80 00 PE — DOT $99.00 PR— RESPIRATOR CLEARANCE EXAM ONLY) $80.00 AUDIOGRAM $30,00 REVIEW -• QUESTIONNAIRE — GENERAL $30,00 REVIEW — QUESTIONNAIRE — RESPIRATOR $30.00 RESPIRATOR FIT TEST — QUALITATIVE $50.00 *HEPATITUS A TITER (ANTIBODY) —BLOOD $50.00 *HEPATITUS ABC PANEL (ACTIVE INFECTION/IMMUNUITY TEST) — BLOOD $275.00 *HEPATITIS B —TITER SURFACT ANTIBODY QUANTITATIVE — BLOOD $60.00 *HEPATITIS C — ANTIBODY -- BLOOD $55.00 *HIV $94.00 *VACCINE -- HEPATITIS A (2-DOSE SERIES $138,00 per dose *VACCINE — HEPATITIS B SHOW AS DOSE 1, DOSE 2, DOSE 3 $100.00 er dose *LEAD WITH ZPP — BLOOD $61.00 — CHEM20/CHD/CBD/UA $55.00 w *CBC W/DIFF $25.00 VENIPUNCTURE FEE_ $0.00 COLLECTION — $22.00 *BLOOD CHESMISTERY PROFILE 24_ $80.00 DS — URINE 7 PANEL NON DOT $60.00 DS — URINE 5 PANEL NON DOT $55.00 UA WITH MICRO — URINE $28.00 UA DIP STICK Included in physical CHEST X-RAY 1 VIEW $70.00 VISION — ISHIHARA $22.00 EKG — WITH INTERPRETATION $65,00 PFT SPIROMETRY _ $44,00 CARDIAC STRESS TEST $325,00 *TB SKIN TEST (1 STEP $37, 00 Expert Testimony $254,00 per hour After the Tirst twelve months or MIS Agreement, if the current market price for the above Services change due to market conditions, demand(s) and/or shortage(s), the City will be billed the then current market rate. Agreement between City of Sdnta Ana and Concentra ` 12 AGENCY CUSTOMER ID: CONCGRO-01 LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of AGENCY NAMED INSURED The Graham Company Occupational Health Centers of California, A POLICY NUMBER Medical Corporation, Go Select Medical Corporatio 4716 Old Gettysburg Road Mechanicsburg PA 17055 CARRIER NAIL CODE EFFECTIVE DATE: REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company -Policy #HAZ 4032244600-3; Effective 611/2018-2019 - Each Medical Incident/$600,000 Aggregate Per Insured or Surgeon 1A PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244614-3; Effective 61112018-2019 - Each Medical Incident/$300,000 Aggregate Per Insured or Surgeon CA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244628-3; Effective 6/1/2018-2019 - Each Medical Incident/$600,000 Aggregate Per Insured or Surgeon VANIA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244631-3; 6/1/2018-2019 - Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244659-3; 6/1/2018-2019 - $1,000,000 Per Insured or Surgeon 'COVERAGE: Risk of Physical Loss or Damage to Covered Property subject to policy terms and conditions. COMPENSATION - Occupational Health Centers of California, A Medical Corporation - Policy #WA7-63D-510199-048; Effective: 61112018-2019 Occupational Health Centers of Southwest, P.A. - Policy#WA7-63D-510199-058 and WC7-631-510199-068; Effective: ADDITIONAL WORKERS COMPENSATION POLICIES: of Arkansas — Policy #WC7-631-510199-078; Effective: 6/l /2018-2019 of Southwest (AZ/UT) — Policy 9WC2-631-510199-118; Effective: 6/1/2018-2019 of Delaware — Policy #WC2-631-510199-108; Effective: 61112018-2019 of Georgia/Hawaii — Policy #WC2£31-510199-178; Effective: 611/2018-2019 of Illinois — Policy #WC2-631.510199-198; Effective: 6/1 /2018-2019 of Louisiana — Policy #WC2-631-510199-098; Effective: 6/l/2018-2019 of Michigan — Policy #WC2-631-510199-188; Effective: 6/112018-2019 of Nebraska — Policy #WC2-631-510199-148; Effective: 6/112018-2019 of New Jersey — Policy #WC2-631-510199-138; Effective: 6/1/2018-2019 of North Carolina — Policy #WC7-631-510199-088; Effective: 6/112018-2019 of Southwest (KS) — Policy #WC2-631-510199-128; Effective: 6/1/2018-2019 spy Centers of Southwest I, PA (OR) - Policy #WC2-631-510199-168; Effective: 611/2018-2019 py Centers of South Carolina, PA - Policy #WC2-631-510199-158; Effective: 6/1/2018-2019 LIABILITY- National Union Fire Insurance Company of Pittsburgh, PA - Policy #01-951-89-45; Effective 9125/2017-2018 - Limit: $10,000,000 Security - Endurance American Insurance Company - Policy #PRX10009889401; Effective: 912512017-2018 - Limit: $10,000,000 Each is provided for all medical professionals employed or contracted by the above Named Insured, only while working for or on behalf of the above Named RE: OHC CA/CMC IS BIDDING ON AN RFP #1 B-073 TO PROVIDE MEDICAL SERVICES TO NAMED CLIENT. CITY OF SANTA ANA, ITS OFFICERS, AGENTS, VOLUNTEERS, AND EMPLOYEES IS AN ADDITIONAL INSURED ON THE GENERAL LIABILITY, AUTOMOBILE LIABILITY AND UMBRELLA LIABILITY COVERAGES IF REQUIRED BY WRITTEN CONTRACT. © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Dig{affy signed ba ' e Francine R. R. Villareal Vi I IA real Date: 2022.01.0516.32.27 ACCORD® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/°D/YYYY) 12/30/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER The Graham Company The Graham Building 1 Penn Square West CONTACT NAME: Concentra Unit PHONE FAX A/C No Ext : 215-567-6300 A/C, No : 215-405-2694 ADDE-MRESS: Concentra_Unit@grahamco.com INSURER(S) AFFORDING COVERAGE NAIC# Philadelphia PA 19102- INSURERA: Columbia Casualty Company 31127 INSURED CONCGRO-01 Occupational Health Centers of California, A Medical Corporation d/b/a Concentra, Inc. INSURERB: Liberty Mutual Fire Ins. Co. 23035 INSURERC: Liberty Insurance Corporation 42404 INSURERD: Liberty Mutual Insurance Group 23043 4714 Gettysburg Rd. Mechanicsburg PA 17055 INSURERE: American Guarantee & Liability Ins. Co. 26247 INSURERF: Allied World Assurance Company, AG COVERAGES CERTIFICATE NUMBER: 147834281 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICYNUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y HAZ4032244581-6 1/1/2022 1/1/2023 EACH OCCURRENCE $1,000,000 CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $ 500,000 X MED EXP (Any one person) $ Professional Lia X $1M Claim/$3M Ag PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 PRO- POLICY JECT ❑ LOC X PRODUCTS - COMP/OP AGG $ 3,000,000 $ OTHER: B AUTOMOBILE LIABILITY Y Y AS2-631-510199-321 10/1/2021 4/1/2022 COMBINED SINGLE LIMIT Ea accident $2,000,000 X BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY A X UMBRELLALIAB X OCCUR Y Y HMC4032235752 1/1/2022 1/1/2023 EACH OCCURRENCE $9,000,000 AGGREGATE $ 10,000,000 EXCESS LAB CLAIMS -MADE DED X RETENTION $ $ G D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N Y WA7-63D-510199-351 WC5-631-510199-361 10/1/2021 10/1/2021 4/1/2022 4/1/2022 PER OTH- STATUTE1 ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 E Property ZMDO119116-06 1/1/2022 1/1/2023 SEE BELOW F Excess Liability CO23701-007 1/1/2022 1/1/2023 $10M Each Occurrence $10M Aggregate DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) UMBRELLA LIABILITY COVERAGE includes Excess General Liability on an Occurrence Basis and Excess Professional Liability on a Claims Made Basis. Both Coverages are excess of a $3,000,000 Self -Insured Retention each Occurrence/Claim subject to a $18,000,000 Aggregate. PROFESSIONAL LIABILITY COVERAGE includes Case Management Services including the rendering of case management or utilization review performed by insured for others. INDIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244595-8; Effective 1/1/2022-1/1/2023 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon See Attached... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF SANTA ANA ACCORDANCE WITH THE POLICY PROVISIONS. Risk Management Division 20 CIVIC CENTER PLAZA AUTHORIZED REPRESENTATIVE SANTA ANA CA 92702 IZAManagzmentDMsian REVIEWED & APPROVED BY.- @ 1988-2015 ACORD C, ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD _ _— task Mran gement Analyst AGENCY CUSTOMER ID: CONCGRO-01 LOC #: AGENCY The Graham Company POLICY NUMBER CARRIER ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE NAIC CODE NAMED INSURED Occupational Health Centers of California, A Medical Corporation d/b/a Concentra, Inc. 4714 Gettysburg Rd. Mechanicsburg PA 17055 EFFECTIVE DATE: THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE Page 1 of 1 KANSAS PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244600-8; Effective 1/1/2022-1/1/2023 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon LOUISIANA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244614-8; Effective 1/1/2022-1/1/2023 - $100,000 Each Medical Incident/$300,000 Aggregate Per Insured or Surgeon NEBRASKA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244628-8; Effective 1/1/2022-1/1/2023 - $500,000 Each Medical Incident/$1,000,000 Aggregate Per Insured or Surgeon PENNSYLVANIA PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Columbia Casualty Company - Policy #HAZ 4032244631-8; 1/1/2022-1/1/2023 - $500,000 Each Medical Incident/$1,500,000 Aggregate Per Insured or Surgeon WISCONSIN PHYSICIAN PROFESSIONAL LIABILITY COVERAGE - Continental Casualty Company - Policy #HAZ 4032244659-8; 1/1/2022-1/1/2023 - $1,000,000 Each Medical Incident/$3,000,000 Aggregate Per Insured or Surgeon PROPERTY COVERAGE: Risk of Physical Loss or Damage to Covered Property subject to policy terms and conditions KERS COMPENSATION - Occupational Health Centers of California, A Medical Corporation - Liberty Mutual Insurance Corp. - Policy i-63D-510199-311; Effective: 10/1 /2020-4/1 /2022 WORKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Liberty Insurance Corp. - Policy #WA7-63D-510199-401; Effective: 10/1 /2020-4/1 /2022 WORKERS COMPENSATION - Occupational Health Centers of Southwest, P.A. - Liberty Mutual Insurance Corp. - Policy #WC5-631-510199-251 (WI); Effective: 10/1 /2020-4/1 /2022 �] ► IG1 ��ON] :7 :1 � :i.YK�] di I » ► 69G� � [�] ► � li] � [9 I �91 C of Arkansas— Liberty Insurance Corp. - Policy #WC7-631-510199-281; Effective: 10/1/2020-4/1/2022 C of Southwest (AZ/UT) — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-241; Effective: 10/1/2020-4/1/2022 C of Delaware — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-331; Effective: 10/1/2020-4/1/2022 C of Georgia/Hawaii — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-381; Effective: 10/1/2020-4/1/2022 C of Illinois — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-411; Effective: 10/1 /2020-4/1/2022 C of Louisiana — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-291; Effective: 10/1 /2020-4/1 /2022 C of Michigan — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-271; Effective: 10/1/2020-4/1/2022 C of Nebraska — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-371; Effective: 10/1 /2020-4/1/2022 C of New Jersey — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-261; Effective: 10/1/2020-4/1/2022 C of North Carolina — Liberty Insurance Corp. - Policy #WC7-631-510199-341; Effective: 10/1/2020-4/1/2022 C of Southwest (KS) — Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-421; Effective: 10/1 /2020-4/1/2022 !rapy Centers of Southwest I, PA (OR) - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-391; Effective: 10/1/2020-4/1/2022 !rapy Centers of South Carolina, PA - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-301; Effective: 10/1/2020-4/1/2022 C of Minnesota - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-451; Effective: 10/1/2020-4/1/2022 C of Alaska - Liberty Mutual Fire Insurance Company - Policy #WC2-631-510199-441; Effective: 10/1 /2020-4/1/2022 BER LIABILITY - AIG Specialty Insurance Company - Policy #01-613-93-03; Effective: 9/25/2021-9/25/2022 - Limit: $10,000,000 EXCESS CYBER LIABILITY - Endurance American Specialty Insurance Company - Policy #NVX30011525100; Effective: 9/25/2021-9/25/2022 - Limit $10,000,000 Excess of $10,000,000 Coverage is provided for all medical professionals currently or previously employed or contracted by the above Named Insured, but only for professional services performed for or on behalf of the above Named Insured. RE: OHC OF CA/CMC HAS AN AGREEMENT UNDER # A-2019-006 TO PROVIDE MEDICAL SERVICES TO THE EMPLOYEES OF THE NAMED CLIENT. CITY OF SANTA ANA, ITS OFFICERS, AGENTS, VOLUNTEERS AND EMPLOYEES are all included as additional insureds on the above General Liability, Auto Liability and Umbrella Liability Policies and coverage shall apply on a Primary and Non -Contributory basis if required by written contract. Prior to loss, and if required by written contract, Waiver of Subrogation is provided on General Liability, Auto Liability, Umbrella Liability and Workers Compensation Policies for work performed under contract if permissible by state law. ACORD 101 (2008101) © 2008 ACORD The ACORD name and logo are registered marks of ACORD cF Risk Management Division REVIEWED & APPROVED BY: v --� RFsk janagement Analyst POLICY NUMBER: HAZ 4032244581-5 COMMERCIAL GENERAL LIABILITY CG 20 26 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): ANY PERSON OR ORGANIZATION TO WHOM OR TO WHICH YOU ARE REQUIRED TO PROVIDE ADDITIONAL INSURED STATUS IN A WRITTEN CONTRACT OR AGREEMENT EXECUTED PRIOR TO LOSS, EXCEPT WHERE SUCH CONTRACT OR AGREEMENT IS PROHIBITED BY LAW. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a c ontract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 26 04 13 © Insurance Services Office, Inc., 2012 ew cF RAMwagementDMsian Jy/ 1'x REVIEWED & APPROVED BY: V"° --� Risk janagement Analyst Pnl Iry NI IKARFR- HA7 4032244581-5 032244581-5 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES I Ht IJULK;Y. I'LLASt READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an add itional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. CG 20 01 04 13 © Insurance Services Office, Inc., 2012 ew cF RAMwagementDMsian Jy/\'x REVIEWED & APPROVED BY.- V"° --� Risk janagement Analyst WAIVER OF RIGHTS OF RECOVERY APPLICABLE TO GENERAL LIABILITY COVERAGE FORM The changes set forth below are applicable only to the Commercial General Liability Coverage Form G- 145566-A, G-145567-A). The Healthcare Liability Policy Common Conditions (G-144102-A) are amended as set forth below: Condition XII., Transfer of Rights of Recovery is amended by the addition of the following: Solely within the scope of this endorsement as indicated above, we waive any right of recovery we may have against any person or organization that you have agreed with, in writing, prior to the date of loss, to waive your right to recover against because of payments we make under the Commercial General Liability Coverage Form for injury or damage arising out of your ongoing operations. This endorsement applies only to: All other terms and conditions of the Policy remain unchanged. This endorsement, which forms a part of and is for attachment to the Policy issued by the designated Insurers, takes effect on the effective date of said Policy at the hour stated in said Policy, unless another effective date is shown below, and expires concurrently with said Policy. GSL6554XX (4-11) Page 1 Policy No: Endorsement No: Effective Date: Insured Name: Concentra Group Holdings Parent, LLC © CNA All Rights Reserved. HAZ 4032244581-5 10/01 /2020 cF IZAMwagzmentDMsian Jy/\'x REVIEWED & APPROVED BY.- V"° --� Risk janagement Analyst WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2% of the California workers' compensation premium otherwise due on such remuneration. Schedule Additional premium is a percent of the California Manual Workers Compensation premium. Subject to a minimum premium charge of $ 250 Person or Organization Where required by contract or written agreement prior to loss and allowed by law. Issued by LM Insurance Corporation 27243 Job Description For attachment to Policy No. WA5-63D-510199-311 Effective Date Premium $ Issued to Occupational Health Centers of California, A Medical Corporation WC 04 03 06 Ed: 04/1984 ew cF RAMwagementDMsian 1°x REVIEWED & APPROVED BY. --� Risk janagement Analyst \ 0 ° / = 2 � \ 0 s g m = > @ / a 2 E � E ) / _ s u \ \ \ E \ �_ § g \� }& \ 0 § % \ ) E _ E § 7 0 \ _ ; ; _ 0 \ # § u \ 0 ; § { � ƒ \ \ 2 q ƒ_ � 2 7 2 7 E \ \ / _ \ 2 \ 2 / E \/ u E\ E \{ 2 2 cƒ \ u E S E° u u = 2 c / { u / { E { � ( ( / \ / ° \ } / $ 2 \ / \ / \ o \ '$ ) E E 7 E / E \ s § / / / \ \ § E E \ \ / 7 § CL \ \ m a)ƒ a ; ; ; ; a 3 \ E« t t t \ \ \ u 0\ 7 E 7 E 7 / 2 2 2 ƒ / o %' 3 3 )~ 3 3 3 ) 5 5 ; ° / / / b E > w E = 2 » \ / / WO ± % { % q m % m m m 2 cr / / I $ ? \ \ \ k / 0 / / / \ o 0 0 2 2 2 2 4 / W/ 0 § \ (D 2 q E/ 0 0 0 o 0 0 o o a o± a 6 0= E< E; o a o o a a 0 0 0 0 0 0 0 0 0 0 •• o= o== 0 2 0= z= 2 r4 a o a) o = o I 0 o 3 0 0 0 o o a a a a a \ 6 6= �.$ o 0 o%� 2 a a a / & \ & \ _ \ » & \ » 2 % \ z q o Ln e o tn tn tn m z tn � � � � � � 0 � z � LU r _ LL � / V). I V). E V)- e Ln S 0 � m m � @ e r r4 ¥ ¥ ¥ Ln \ \ 0 0 0 \ / \ \ Ln Ln L 0 0 / \ \ \ \ \ 0 ' ® \ \ \ \ o f // 4 4 4 § u ± < 2 k \ { \ ` ( z z » \ " 00 : 2 2 -0_ \ I I m ) CL $ J / \ \ \ 3 POLICY NUMBER:AS2-631-510199-321 COMMERCIAL AUTO CA20481013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. • • • This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by the endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. SCHEDULE Name Of Person(s) Or Organization(s): Any person or organization whom you have agreed in writing to add as an additional insured, but only to coverage and minimum limits of insurance required by the written agreement, and in no event to exceed either the scope of coverage or the limits of insurance provided in this policy. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision contained in Paragraph A.1. of Section II - Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph D.2. of Section I - Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 © Insurance Services Office, Inc., 2011 ew cF RAMwagementDMsian Jy/\'x REVIEWED & APPROVED BY.- ,v --� Risk janagement Analyst Policy Number: AS2-631-510199-321 COMMERCIAL AUTO CA 04"1013 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US (WAIVER OF SUBROGATION) This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respectto coverage provided by this endorsement, the provisionsof the Coverage Form apply unless modified by the endorsement. SCHEDULE Name(s) Of Person(s) Or Organization(s): Any person or organization for whom you perform work under a written contract if the contract requires you to obtain this agreement from us, but only if the contract is executed prior to the injury or damage occurring. Premium: $ INCL Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The Transfer Of Rights Of Recovery Against Others To Us condition does not apply to the person(s) or organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident' or the 'loss" under a contract with that person or organization. CA 04 44 10 13 © Insurance Services Office, Inc., 2011 Rick ManagmatE Division REVIEWED & NPRDVED BY. i -.----� RiskManagemenCAnalyst NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor Occupational Health Centers of California, A Medical Corporation Name: Project A-2019-006-01 Number: Project Extension of Agreement to Provide Medical Services Review, No. A- Name: 2019-006 The Certificate of Insurance (COI) submitted indicates that the coverages are in compliance with the insurance requirements. No further action is required at this time. The compliant coverage(s) are: EXPIRATION TYPE OF INSURANCE POLICY NUMBER COI DATE FILE NAME DATE CITY-OF-SANTA- ANA_Occupational- GENERAL LIABILITY HAZ40322445817 01/01/2024 01/04/2023 He_1-1-23-1-1-20_1- 4- 2023_1091828540.pdf CITY-OF-SANTA- ANA_Occupational- PROFESSIONAL LIABILITY HAZ40322445817 01/01/2024 01/05/2023 He_1-1-23-1-1-20_1- 4- 2023_1091828540.pdf Occupational Health Center of CA DBA WORKERS COMPENSATION AND WA763D510199352 04/01/2023 03/30/2022 Concentra COI Exp 4- EMPLOYERS' LIABILITY 1-23 RMD04042022.pdf Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 1/10/2023 1:01 PM