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Home My WebLink AboutWELLDYNERX (2)A-2018-131-01 INSURANCE NOT ON FILE WORK MAY NOT PROCEED CLERK OF COUNCIL MAYOR DATE - MAY" Oa PION JUI f� 2 2019 Jum ILM BE COUNRs Csdaa Iglesias paW Penalara Ykenta saawamn JOSG sak rw PUBLIC WORKS AGENCY 2aaft canter Pmaa Santa Ana, California 927a4 wrw.santa una.ora Jerre 4, 2019 x • 4 ff„a..a. a ., ,.....ta. Dear Ms. Fernandez, Pursuant to the tuns detailed in the Fourth Amendment to Agreement No. A-2007-278 (°`Fourth Amendmenfl (#A-2018-131) entered into by WellDyneRx and the City of Santa Ana, dated May 15, 2018, the time period for Agreement #A-2007.27B CAgrectrumfl was extended until June 30, 2020, with an option to extend for one year. By operation of this hater, the parties hereby agree to extend the Agreement for an additional one (1) year period until June 30, 2021. 11c insurance certificates are required to be extended and/or renewed to cover this extension. All other terms and conditions of said Agreement, as amefiorA, remain unchanged and in Rill, force and effect. Director, Public Works Agency CPTY O� SANTA ANA: stine Ridge City Manager "PROVED - Sonia City Attorney J<fn X. Funk Assistant City Attorney WJ LLDYNE Rx _ t Title. A 'r-*; ATTEST: Norma Mitre Acting Clark of the Council SAWI A ANA CITY COUNCIL v4vw&rq" Jun valow l4, ftn116mu exitl aarza4>u faC4aA Ue[x°M 6:a NJkttlw.� MOW hft ePe®Z®n.Wadaa W&d1 W&'4� W043 WaW4 W,�q@y }aaa __4--.....„'�^-a..reatts�.aa mxw9:uaea.�H.amaau �mmm ACORO CERTIFICATE OF LIABILITY INSURANCE 11..� 2/16/2Ul PATE (Mnvop YYVY) 2/13/2020 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 Lockton Companies 8110 E Union Avenue Suite 700 Denver CO 80237 (303) 414-6000 CONTACT PHONE FAX A/c No E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIL N INSURERA: Arch Specialty Insurance Company 21199 INSURED WeIlDyneRX, LLC. 1424829 500 Eagles Landing Drive Lakeland, FL 33810 INSURER B: Zurich American Insurance Company 16535 INSURER c: National Union Fire Ins Cc Pitts. PA 19445 INSURER 0: Berkley Insurance Company 32603 INSURER E : INSURER F: a.vrEKAGES Uer$nr•ICA I e NUmtltH: 16191579 REVISION NUMB" • THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY P RIO IOD 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 ADpL INSO SUER WVD POLICY NUMBER POLICY EFF IMMUDOMWI POLICY EXP INIMIDWYYYY)LIMBS A X COMMERCWLGENERALLIABIDTV CLAIMS4sADE 1XI OCCUR N N FLP006017703 2/16/2020 2/16/2021 E EACH OCCURRENCE S 1 00O 000 -IAAMAGET ENTEO PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ $ 000 PERSONAL B ADV INJURY $ 1000000 AGGREGATE LIMIT APPLIES PER: POLICY E JECT Lee GENERAL AGGREGATE $ 3000000 GEN'L PRODUCTB-COMP/OPAGG $ 3000000 $ OTHER: A AUTOMOBILE X LIABILITY ANY AUTO OWNED LED AUTOS ONLYMASICTOSIDU HIRED NON -OWNED AUTOS ONLYAUTOS ONLY N N FLP006017703 2/162020 2✓1620LIMITEa COMBINED SINGLE LIMIT accident $ 1000000 BODILY INJURY (Per person) $ XXXXXX7C BODILY INJURY (Per accident) $ } PROPERTY DAMAGE IPerapoitlent $ xxxXxxX $ xxli� A X UMSRELLALWB N OCCUR N N FLP006017703 2/16/2020 2/16/2021 EACH OCCURRENCE $ 10000000 EXCESS LMB CLAIMS -MADE AGGREGATE $ 10,000,000 DEO I I RETENTION $ $ X%X%XRX B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN AN OFFICEWEMBER EXCLUDED'XCECUTIVE ] (Mandatory In NH) If yes, describe under NIA N V✓C014390903 2/162020 2/162021 _ X STATUTE 'ER" EL. EACH ACCIDENT $ 1000000 E.L. DISEASE -EA EMPLOYEE $ 1 000 000 E.L. DISEASE - POLICY LIMB $ 1000000 DESCRIPTION OF OPERATIONS below A C D Pharmacy Prof. Liab. PBM E&O Liab. Crime N N FLP006017703 039969656 BCCR4500242323 2/16/2020 2/162020 2/16/2020 2/16/2021 2/16/2021 2/162021 $IM/$3M Limit: $5M/Ret $250K Limit: $2M per Occ. DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If mom space is required) By RIEWMD & APPRpOYEl) 16191579 City of Santa Ana Risk Management Division 20 Civic Center Plaza, M-28 P.O. Box 1988 Santa Ana, CA 92702 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. rinhfa •n--A ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD ...,...,.. »...;«..«...:� a'f<. ^+a "vaxlnn arsuiv$pHi:.a:(i $f$f,E70Q: MarHSOt X-,GRi'Q Digitally signed Ac"Mor CERTIFICATE OF LIABILA W E DATE (MMIDDIYYYY) �.,.,,� /l4 3 n 11Q2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS WRIGHTS UPON TF c -FxRTIFICATE H LDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGF AF,Qex*tQPOLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A ZITRACT BETWEEN THE ' UING Ii:`zURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy es) A DI D provisions c: be en orsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may rer,uire an en(yeP q,,:4tten�tt7► �J 7.lJo.`} �J lJ D this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).CONTACT PRODUCER Lockton Companies _ NAME, PHONE FAX A/C No): 8110 E Union Avenue Suite 100 Denver CO 80237 E-MAIL ADDRESS: (303) 414-6000 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Arch Specialty Insurance Company 21199 INSURED WellDyneRX, LLC 1477414 500 Eagles Landing Drive INSURER B : Zurich American Insurance Company 16535 INSURER C : ACE American Insurance Company 22667 INSURER D : Berkley Insurance Company 32603 Lakeland, FL 33810 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 14516082 REVISION NUMBER: XXXxxS x 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 POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY N N FLP006017705 2/16/2022 2/16/2023 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE 1XI OCCUR DAMAGE T PREM SESOEa occurrDence $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 POLICY n PRO - POLICY F-1 LOC PRODUCTS - COMP/OP AGG $ 3,000,000 $ OTHER: A AUTOMOBILE LIABILITY N N FLP006017705 2/16/2022 2/16/2023 COMBINED SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ XXX)CS XX ANY AUTO OWNED SCHEDULED AUTOS ONLYNAUTOS BODILY INJURY (Per accident) $ XXX�CSCSCS� Xr PROPERTY DAMAGE Per accident $XXXXXXX HIRED NON -OWNED AUTOS ONLYAUTOS ONLY $ XXXyCS xx A X UMBRELLA LIAB X OCCUR N N FLP006017705 2/16/2022 2/16/2023 EACH OCCURRENCE $ 10,000,000 A EXCESS LIAB CLAIMS -MADE Prof. Liab. RetroDate: 2/16/20 X AGGREGATE $ 10,000,000 DED RETENTION $ $ XXXXX� B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N / A N WC014390905 2/16/2022 2/16/2023 EROTH- X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 A Pharmacy Prof. Liab. N 2/16/2022 2/16/2023 $1M/$3M Retro Date: 2/16/2020 C PBM E&O Liab. =FLPOR046017705 2508130002 2/16/2022 2/16/2023 Limit: $3M/Ret $250K D Crime 500242325 2/16/2022 2/16/2023 Limit: $2M per Occ. DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached if more space is required) Per Agreement Master Agreement A-2007-278 and current agreement A-20180-131-01 with the City of Santa Ana, Proof of Worlcers' Compensation Coverage. 14516082 City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana CA 92701 ACORD 25 (2016103) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE,— Risk M8118gement DMskrn +� �m REVIEWED & APPROVED BY: @ 1 s88-2o ACo The ACORD name and logo are registered marks of ACORD r Risk Management Specialist off IN Miscellaneous Attachment: M577149 Master ID: 1477414, Certificate ID: 14516082 Excess Liability Schedule Carrier Policy Number Limit Lloyd's of London MCFAL1000459 $25,000,000 Lloyd's of London B0180PC2209645 $30,000,000 m Risk Management DlMsian REVIEWED & APPROVED BY: r Risk Management Specialist