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PROCARE WORK INJURY CENTER
INSURANCE ON FILE. N-2020-083 WORK MAY PROCEED UNTIL INSURANCE EXPIRES d 3 // fr o7 I CLERKOFCOUNCIL AGREEMENT FOR MEDICAL SERVICES AND TESTING DATE t'.rrvrtrn SawruNYh� Iu�bv} THIS AGREEMENT is made and entered into this 14th day of February, 2020 by and between Cheshire Medical Corporation, a Calili>rnia corporation doing business as ProCare Work Injury Center 7 ("Consultant"), and the City ofSanta Ana, a eharter city and municipal corporation organized and existing a under the Constitution and laws of the State of California ("City"). CA RECITALS N o A. City desires to retain a licensed medical consultant to provide non -industrial medical services including but not limited to Department ofTransportation ("DOT") mandated services, drug tests, respiratory fitness tests, vision testing. post -accident testing. pre -employment examinations, fitness for duly examinations, and similar medical services for employees or applicants for employment. B. 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 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: 1. SCOPE OF SERVICES A. Consultant shall perform medical services including examinations and testing for non- industrial medical services including but not limited to Department of Transportation ("DOT") mandated services, post -accident testing, pre -employment examinations, fitness for duty examinations, and similar medical services for employees or applicants for employment. Each service request will be confirmed in writing between City's Human Resources Department and Consultant prior to Consultant providing services pursuant to this Agreement. Specifically, consultant's services will include: I ) 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; 2) 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; 3) 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; 4) Urine and breath specimen collection, laboratory analysis and Medical Review Officer (MRO) responsibilities; 5) Department of Motor Vehicles (DMV) Driver's License physical examinations; b) DOT -mandated drug and alcohol testing ofemployeesconsidered 'safety sensitive' as definul 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 #5944v1 to include pre-mnployment and pre -assignment. 13. City shall be responsible firr the organization, scheduling, and management of DOT and non -DOT "reasonable suspicion" chug 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 haws and regulations. C. Consultant shall ensure than clinics used for DO'I'-related drug and alcohol testing maintain it current Valid coal raet with a Suhslance Abuse and Mental Flealill Services Administration (SAMSFIA)-verified 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 tivo (5) working clays for a positive test. D. As part of the medical services review program, Consultant shall: 1) Analyze current job classification specifications and make recommendations for the C'itv's use in the medical examination laid drug testing process. 2) Provide training to Risk Management personnel in administration procedures of Consultant's medical services review process. 3) Communicate with City Risk Management staff regarding applicants oremployees' progress throughout the medical services review process. 4) Communicate directly with applicants and City Risk Management 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 forn)at established by City Risk Management staff at its sole discretion, outlining each candidate's pre -employment placement medical evaluation and results. G) Provide quarterly electronic activity reports, in a format established by Risk Management 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 Risk Management staff regarding medical services provided all(] outlined in the Agreement. 10)Consultant solely shall review all pre-employment/pre-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. I I ) Consultant agrees to permit duly -authorized agents and employees of the City to review such records. 12) Consultant shall maintain all books, documents, papas, 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 fair inspection by (lie City or by any other governmental entity or Department participnling in the funding of the Agrecn)crt, or any authorized agents thereof, 13) Consuln)nt's documents shall not be used, duplicated, or disclosed to any other third party without written permission, unless such disclosure is required by law, Consultant shall not be required to create or maintain books and records not N5944v1 required in the orclin:uy course ('('Consultant's business operations, nor will the Consultant he required to disclose ally infionnation, including but not limited to product cost or pricing data. which Consultant considers confidential or proprietary. 14) Any Agreement changes which are annually agreed upon by and between the parties shall he incorporated in written amendments to the Agreement. IS) If the circumstances on a particular hearing an(Por 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 H1PAA release. 16)Maintain a network of qualified and trained medical providers and medical specialists for necessary exams; Orient City staff in the legal/medical/risk management and human resources aspects of Consultant's services; 17) Communicate directly with applicants to obtain the confidential medical intitrnlation that is needed for clearance for a particular job; 13) Manage all hill review functions for the medical exams performed by clinics; and, 19) Provide access for City staff to Consultant's tracking system. E. 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 ofnear/far:!peripheral vision, lshihara 14 and primary color; audiogram (if classification has specific occupational noise exposure or critical hearing demands); chest x-ray: GKG or treadmill stress EKG; Spirometry; Chem panel 20; CBC w/dil'f; dipstick UA, or UA w/Micro (to lab); venipuncture R collection. 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. The total. sumxmnuul amount authorized under this Agreement shall not exceed forty thousand dollars ($40,000) during the tern of this Agreement. b. -rhis Agreement authorizes payment of any services provided by Consultant from January I, 2020 to the (laic orthis Agreement. Q. Payment by City shall be matte within forty-five of days (45) bays following receipt of proper invoice evidencing work performed, subject to City accounting procedures. Payment need not be matte fix work that tails to meet the standards of performance set forth in the Recitals, which may reasonably be expected by City. 3. TERM '['his Agreement shall commence on the date written above and terminate on June 30, 2021, unless terminated earlier in accordance with Section 15. below. 4. INDEPENDENT CONSULTANT Consultant %hall, during the entire term of this Agreement, be construed to be an independent Consultant 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 protossional manner in which Consultant pertimns the services which are the subject matter of this Agreement: however, the services to he provided by Consultant shall be provided in N5944v1 a manner consistent with all applicable standards and regulations governing such services. Consultant shall pay all salaries and wages, employer's socinl security taxes, unemployment insurance and similar taxes relating to employees and shall be responsible fill- all applicable withholding taxes. 5. RESERVED G. INSURANCE Prior to undertaking perfivi n awe of work wider this Agreement, Consultant shall maintain and shall require its subcontractors, irony, to obtain and maintain insurance its described below: a. Commercial General Liability Insurance. Consultant shall maintain commercial general liability insurance naming the City, its officers, employees, agents, volunteers and representatives as additional insurcd(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 policy shall not have till exclusion for sexual molestation. 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. Such insurance shall (it) name the City, its officers, employees, agents, volunteers and representatives as additional insured(s): (b) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City; and (c) contain standard Separation of insureds provisions. b. Business automobile liability insurance, or equivalent roan, with a combined single limit or not less than S1,000,000 per occurrence. Such insurance shall include coverage for owned, hired anti non -owned automobiles. C. Worker's Compensation 1n3UfnnCe. In accordance with the California Labor Code, Consultant, if Consultant has any 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 S 1,000,000 per accident. Professional liability (orrors and omissions) insurance, with a combined single limit of not less than S 1.000.000 per claim with S2,000A00 in the aggregate. C. The hallowing requirements apply to the insurance to be provided by Consultant pursuant to this section: 0) Consultant shall maintain all insurance required above in hill force and effect tin• 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 by the City. (iii) 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. 1:5944v I (iv) Consultant shall supply City will, a fully executed additional insured endorsement. If Consultant fails 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, al the City's election, to 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. 7. INDEMNIFICATION 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 death, and claims for property damage, which may arise from the negligent operations of the Consultant or its, subcontractors, agents, employees, or other persons acting on their behnif which relates to the services describe([ in section I 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. The 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 that personal injury, damages,just compensation, restitution,judicial or equitable relief due to personal or property rights arises by reason of the terns of, or effects arising trom this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. Notwithstanding the foregoing, to the extent Consultant Services are subject to Civil Code Section 2782.8, the above indemnity shall be limited, to the extent required by Civil Code Section 2782.8, to claims that arise out of, pertain to, or relate to the negligence, recklessness, or willful misconduct of the Consultant. 8. RECORDS Consultant shall keep records and invoices in connection with the work to be performed under this Agreement. Consultant shall maintain complete and accurate records with respect to the costs incurred under this Agreement and any services, expenditures, and disbursements charged to the City for a minimum period of three (3) years, or for any longer period required by law, from the date of final payment to Consultant under this Agreement. All such records and invoices shall be clearly identifiable. Consultant shall allow a representative of the City to examine. audit, and make transcripts or copies of such records and any other documents created pursuant to this Agreement during regular business hours. Consultant shall allow inspection of all work, data, documents, proceedings, all([ activities related to this Agreement for a period of three (3) years from the date of final payment to Consultant under this Agreement. #594 by I 9. CON FIDENTi:ILIT1' If Consultant receives from the City information which due to the nature of such information is reasonably understood to he confidential andhrr 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. "C'onfidenlial Intin'niution" shall include all nonpublic information. Confidential information Includes not only written information, but also information transferred orally, visually, electronically, or by other mums. Confidential inlbnnation 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 shalt not apply to any information that (a) has been disclosed in publicly available sources; (b) is, through no fitult of the Consultant disclosed in It publicly available source; (c) is in rightful possession of the Consultant an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (c) is independently developed by the Consultant without reference to information disclosed by the City. 10. CONFLICT OF INTEREST CLAUSE Consultant covenants that it presently has no interests and shall not have interests, direct or indirect, which would conflict in any manner with perlimnance ofservices specified under this Agreement. if. BACKGROUND CHECK REQUIRENIENTS Consultant shall not assign ally employee, agent, subcontractors or volunteer to provide services pursuant to this Agreement, if that employee, agent, subcontractors or volunteer is required to register as a sex offender under California Pewd Code Section 290 er scq, has a conviction for any crime of moral turpitude, has a conviction for a violent felony as defined in California Penal Code Section 667.5(c), or has a conviction for It serious felony as defined in California Pena! Code Section 1192.7(c). Disqualifying convictions include but are not limited to, violations ofCalifornia Penal Code Sections 37, 128, 136.1 with Section 186.22, 187. 190- l 90.4 and 192(a), 205, 206, 207-209.5, 211, 212, 212.5, 213, 214, 215, 218-219, 220, 236.1(b) or 236.1(c), 243.4, 261, 261.5, 273.5, 262, 264.1, 266, 266c, 266h, 266i, 266j, 267, 269, 272, 273a, 273ab, 273d, 285, 286, 288, 288a, 288.2, 288.3, 288.4. 288.5, 288.7, 289, 290, 311.1, 311.2, 311.3, 311.4, 311.10, 311.11, 314. 347(a), 368. 417(b), 451(a).518 with 186.22, 647.6, 653Rc), 664 and 187, 667.5(c), 18745, 18750, or 18755, 12022.53,11418(b)(I) or (b)(2); Buslncss and Pi•oJesslons Code Section 729. Failure to comply with this Section shall be groundS for immediate termination of this Agreement. 12. 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 fox or other telegraphic communication in the manner provided in this Section, to the fallowing persons: To City: Clerk of the City Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, CA 92702-1988 Fax 714• 647-69.56 ✓;5944v1 With courtesy copies to: Executive Director I luman Resources Agency City of Santa Ana 20 Civic Center Plaza (M-34) P.O. Box 1988 Santa Ana, California 92702 And City Attorney City of'Sania Ana 20 Civic Center Plaza (M•29) P.O. Box 1988 Santa Ana, Califiorniu 92702 Fax 714- 647-65 15 To Consultant: D. Winston Cheshire, M.D.. QME, Chief Medical Officer ProCare Work Injury Centers 17232 Red Hills Avenue Tustin, California 92614 Fax: A party may change its address by giving notice in writing to the other party. Thereafter, any communication shall be addressed and transmitted to the new address. If sent by mail, 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 fax, 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 tines frames, weekends, federal, state, County or City holidays shall be excluded. 13. EXCLUSIVITY AND AMENDMENT This Agreement represents the complete and exclusive statement between the City and Consultant regarding the subject matter therein, 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 authorirod 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, the terms and conditions hereof. shall not bind or obligate Consultant or 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 ol'any party, which are not embodied herein. 14. 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 ol'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 45944v1 City's ability to have any (it' the Services, which are the subject to this Agreement pertirmted by City personnel or by other consultants retained by ('ity. 15. TERMINATION Except as otherwise specified herein, this Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, Consultant shall he 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: U. As a condition ofAuch 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, an([ Consultant consents to the City's use thereof for such purposes as the City deems appropriate. b. Payment need not be made for work that fails to meet the standard of performance specified in the Recitals of this Agreement. 16. NONDISCRIMINATION Consultant shall not discriminate because of race, color, creed, religion, sex, marital status, sexual orientation, bender identity, genderexpression, gender, medical conditions, genetic information, or military and veteran status, age, national origin, ancestry, or disability, as defined and prohibited by applicable law, in the recruitment, selection, teaching, training, utilization, promotion, termination or other employment related activities or any services provided under this Agreement. Consultant affirms that it is an equal opportunity employer and shall comply with all applicable federal, state and local laws and regulations. 17. JURISDICTION - VENUE This Agreement has been executed and delivered in the State of California and the validity, interpretation, performance, and enibreement of any or (lie clauses of this Agreement shall be determined and governed by the laws of the Slide 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. 18, 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 inwritingofits innbilitytoobtain or maintain such permits, licenses. approvals. waivers, and exemptions. Said inability shall be cause for termination of this Agreement. 19. 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. #5944v1 h. All Exhibits reterenced herein and attached hereto shall he incorporated as if fully set forth in the body of this Agreement. C. The parties agree that this .Agreement can be signed in counter parts and that electronic or fax signatures can be used in lieu of original wel signatures. d. Consultant will comply with all applicable federal state and local laws including the Health Insurance Portability and Accountability Act ("HIPAA"). IN WITNESS W H GREOF, the parties hereto have executed this Agreement the date and year first above written. ' Daisy Gomez L Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorney By:VJOAr� Laura A. Rossini Senior Assistant City Attorney FOR A Steven Phatnj Executive Di r Human Resources Agency AL: CITY OF SANTA ANA Kristine Ridge City Manager CONSULTANT: %J "//' " "r. -.*—, D. Winston Cheshire, M.D., QME Chief Medical Officer REVIEWED & APPROVED By Risk MANAGEMENT DivisiON a5944vl A 09 020 TT... NgiE AmEdO EXH113rr A RATES/CHARGES REVIEWED & APPROVED By Risk MANAGEMENT DIVISION #5944v1 A 2121 ui ANGIE ACEVEdo ProCare Work Injury Center Pricing Sheet for Medical Services Exhibit A City of Santa Ana Non -Industrial Medical Services Physicals: Basic Employer Physical (includes UA dip, distance vision, basic color vision): Basic Physical: $85 UA:$10 Titmus (color, depth, periphery): S40 of Snellen eye chart $10 Total: $135 or $105 with Snellen instead of Titmus vision exam Annual Employer Physical (includes UA dip, distance vision, basic color vision) Total: $135 or $105 with Snellen instead of Titmus vision exam Pre -Employment Physical (includes UA dip, distance vision, basic color vision) Total: $135 or $105 with Snellen instead of Titmus vision exam Fit For Duty/Return toWork (MUSThave Copy ofjob descnptlon) : Basic Fit For Duty (review of prior medical history, exam and review of job duties) : $250 Complex Fit For Duty (review of prior complex medical history, exam and review of job duties): $500 Commercial Driver Exams: $105 Respiratory Fit Testing: Respiratory Evaluation (includes: Mask Fit Test, OSI IA questionnaire review, PFT): PFT: $45 OSHA Q,: $30 Mask Fit Test: $65 Total: $140 PFT: $45 OSHA Questionnaire Review: $30 Mask Fit Test: $65 Drug Screens: Breath Alcohol Test: $55 (with confirmation) 5 Panel Rapid: $40 10 panel Rapid: $40 9 Panel Non -Dot p1793N: $45 10 Panel Non -Dot 46633N: $45 DOT Drug Screen: $55 MRO Interpretation of Positive Drug Screen: $TAt'EVIEWED & APPROVED By Risk MANAGEMENT DiV1SiON AP 9 2020 ANC{iE ACEVEdo Drug Screen Collection Only : $20 Vision Testing: Ishihara Near Vision Jaeger Snellen & Basic Color: 510 Other Services: Audiograms: $45 Lift Test — Floor to Waist:$25 Lift Test — Waist to Chest :$25 EKG:$50 TB/PPD Skin Test: $45 (includes TB placement and follow up reading) Chest X-Ray (2 Views rule out TB): $40 Lumbar X-Ray (4 Views):$60 Jamar Grip Strength: $40 Vaccines• Tdap:585 Hepatitis B: $85 x3 series Varicella : we don't stock -you would need to let us in advance if you need this vaccine and would need to by 10 doses -as they expire -cost for 10 doses is $2,250.00 Titers: MMR: $130 Flu Vaccine: we don't stock (all pharmacies do it for free with PPO ins) Hepatitis A #35604,.::<<c,r, r, ;r3e ,ar 53<. oui Hepatitis B #8475 $40 Hepatitis C 48472 $38 MMR #802 $38, 98624 $39, and #964 $39 Varicella $36 Common Labs: CBC with Diff #6399 $33.1 Lipid Panel 414852 $38 Comp Metabolic Panel #10231 $35.04 REVIEWED & APPROVED By Risk MANAGEMENT DIVISION AP 9 2020 ANGIE ACEVEdO CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 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 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 Don Gath Insurance Agency 2199 Temple Ave Signal Hill, CA 90755 License #: 0447779 INSURED / INSUR Cheshire Medical Corp VY/ DBA Procare Work Injury Center INSUR 17232 Redhill Ave INSUR Irvine, CA 92614-5628 INSUR INSUR COVERAGES CERTIFICATE NUMBER. nnnnonnn-19RA41 LECTIT1 unAaCCo. 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. ILTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MIDDIYYYY POLICY E%P M OD LIMITS A rCOMMERCIAL GENERAL LIABILITY / CLAIMS -MADE �OCCU Y Y ACPBP07841060710 03/18@020 / 03/18I2021 � EACH OCCURRENCE $ 1,000,000, DAMAGETORENTED PREMISES Ea oavrtenrx $ 300OOO MED EXP (Any one person) $ 1,000 ✓/ PERSONAL &ADV INJURY S 1,000,000 AGGREGATE LIMIT APPLIES PER: POLICY ❑ jEOT LOC GENERAL AGGREGATE S 2000000 GEN'L X PRODUCTS-COMP/OP AGG $ 2,000,000 $ OTHER: B AUTOMOBILE LIABILITY Y Y ACPBP07841050710 03/18/2020 03/1812021 COMBINED SINGLE LIMIT $ 1000000 BODILY INJURY (Perperson) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per amidenp $ X HIRED, X NOFOSWNEO PROPERTY DAMAGE Para dent S 5 UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMSMADE AGGREGATE $ DEC I RETENTIONS $ WORKERS COMPENSATION ANDEMPLOVERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTNE OFFICERIMEMBER EXCLUDED? ❑ NIA PER OTH- GTATUTE I I ER EL EACH ACCIDENT $ E.1- DISEASE - EA EMPLOYEE 3 (Mandatory in NH) If You describe under E.L. DISEASE -POLICY LIMIT $ DESCRIPTION OF OPERATIONS below DESCRIPTION OFOPERATIONS I LOCATIONS IVEHICLES (ACORD ID1, Additional Remarks Schedule, maybe attached If more space is required) Classification: Medical Clinics City of Santa Ana, officers, agents, employees, and volunteers are named as additionally insured on this policy pursuant to written contract, agreement, or memorandum of understanding per PBO448. Such insurance as is afforded by this policy shall be primary, and any insurance carried by City shall be excess and noncontributory per PB0497. Certificate of Insurance shall provide thirty (30) day prior written notice of cancellation per PB2297. By Risk MANAGEMENT Di IISION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Risk Management Division AP 9 2020 ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 1988, M-28 Santa Ana, CA 92701 ZEO REPRESENTATIVE ANGIE ACEVEdO GMG 198#k014 ACORn CORPORATION All rinNee .o..r 4 ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Printed by GMG on March 24, 2020 at 03:18PM CHESMED-01 SPERFZ DAM(MMfDD° u" ik� CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must 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 endorsemen! s . PRODUCER CAP Physicians Insurance 333 S Hope 8th FI Los Angeles, CA 90071 Los NA °i Diana Leo FAX lac°,No,E.t):(213) 473-8653 (A/CC,No:(213)473$619 AADD I . dleonclo@Ca h sicians.com INSURERISI AFFORDING COVERAGE NAC d INSURER A; Hanover INSURED INSURER 8, INSURER C: Cheshire Medical Corporation dba ProCero Work Injury Center 17232 Red HIII Ave. INSURER D: INSURER E Irvine, CA 92614 INSURER F: COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE INSD SUBR INVID POLICY NUMBER POLICY EFF PODGY EXP LIMITS COMMERCIAL GENERAL LIABILITY CLAM&MADE OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES MED EXP (Any one rsen PERSONALAADV INJURY GEN'L AGGREGATE LIMIT APPLIES PER: POLICY El jPCOT LOC OTHER: GENERAL AGGREGATE PRODUCTS-CCMP/OP AGG $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOpSW AUTOS ONLY AUTOS ONE EOMBINED SINGLE LIMIT , accident) $ BODILY INJURY Per rem $ BODILY INJURY Per aafdent PROPERTY DAMAGE Per accitlent UMBRELLA LIAR EXCESS LIAS OCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE If DELI I I RETENTIONS A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANYPROPRIETOR/PARTNERIEXECUTIVE (Mandatory in NH) EXCLUDED? U Yes, describe antler DESCRIPTION OF OPERATIONS EeIgw NIA 3A938083 61112019 ✓ 61112020 PER FERN - X I E.L. EACH ACCIDENT 1,000,000 E.L. DIBEAGE - EA EMPLOYE 1,000.00 E.L. DISEASE -POLICY LIMIT 1,000,000 E DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (ACORD 101, Addition Ro EWEhe e& EIf space Is required) By Risk MANAGEMENT DIVISION AP�/bj ,91020 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. A�UTTHHOR(MEED�(REEPRESENTATIVE ACORD 25 (2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD %wProCare Work Injury Center March 18, 2020 Samantha M. Lambert Risk Management Supervisor 20 Civic Center Plaza Santa Ana, CA 92701 / RE: ProCare Insurance Dear Ms. Lambert Thank you for your inquiry. ProCare does not own any automobiles, and therefore does not carry insurance for 'owned' automobiles. We do, however, carry insurance for'non-owned' and 'hired' automobiles. Please feel free to contact me with any questions. Regards, 9W D. Winston Cheshire, MD QME Chief Medical Officer REVIEWED EVIEWD & APPROVED Risk D R 9 2020 ANGIE ACEVEdo 17122 Beach Blvd., #104 17232 Red Hill Ave. Huntington Beach, CA 92647 Irvine, CA 92614 procareworkcomp.com 714.964. 4448 P 949. 752. 1111 P 714. 963. 3780 F 949. 752, 1133 F COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE AND CLAIMS IJISTORY Coverage through December 31, 2020 / MJ Member: Herbert D. Jennings, MD Address: 17232 Redhill Ave Irvine, CA 92614 This certificate confirms that, effective on the coverage date below, the above -named physician is a member of the Cooperative of American Physicians, hic. (CAP) mid a participant in the Mutual Protection Trust (NTT). MPT is an unincorporated interindemnnt arrangement organized under California Insurance Code section 1280.7. This certificate confers no rights upon the member and does not amend, extend or alter the coverage afforded tinder the terms, conditions and exclusions of the MPT Agreement. Membership Number Medical Specialty Coverage Date Retroactive Coverage Date 17430 Occupational Medicine January 1, 2008 March 13, 2006 subspecialty General Practice, With Minor Surgery Coverage (Claims made and paid) Current Limits of Liability Medical Professional Liability Coverage $1,000,000 for all Claims based f upon an Occurrence $3.000,000 each calendar year aggregate The member must remain a Member or good standing or arrange for Tail Coverage for any open or potential Claim that may arise during the Coverage Period. Neither CAP nor MPT undertake any obligation to advise any party, other than Ore named member, of any changes to or tennination of this coverage. Claims History No Claims Reported The Claims history listed above includes all Claims that are currently open and those that were closed withim the last five years. The Claims history does not include payments for emergency or other remedial expenses that may have been made to patients through MPT's Patient Assistance Services program. Cooperative of American Physicians, Inc. -� cmber 26, 2019 REVIEWED & APPROVE - Alfred De Leon Vice President, Membership Services Mutual Protection Trust AP 0 9 2020 ANC{iE ACEVEdO COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE Coverage through December 31, 2020 Member: David W. Cheshire, MD ✓ Address: 17232 Redhill Ave Irvine, CA 92614 This certificate confirms that, effective on the coverage date below, the above -named physician is a member of the Cooperative of American Physicians, hie. (CAP) and a participant in the Mutual Protection Trust (NTT). MPT is an unincorporated interindemnity arrangement organized under California Insurance Code section 1280.7. This certificate confers no rights upon the member and does not amend, extend or alter the coverage afforded render the terms, conditions and exclusions of the NTT Agreement, Membership Number Medical Specialty Coverage Date Retroactive Coverage Date 17429 Occupational Medicine January 1, 2008 December 15, 1983 subspecialty Family Medicine, With Minor Surgery Coverage (Claims made and paid) Current Limits of Liability $1,000,000 for all Claims based Medical Professional Liability Coverage upon an Occurrence $3,000,000 ✓ each calendar year aggregate The member must remain a Member in good standing or arrange for Tail Coverage for any open or potential Claim that may arise during the Coverage Period. Neither CAP nor NET undertake any obligation to advise any party, other than the named member, of any changes to or termination of this coverage. Cooperative of American Physicians, Inc. December 26, 2019 Alfred De Leon Date Vice President, Membership Services Mutual Protection Trust REVIEWED & APPROVEL By Risk MANAGEMENT DivisiON R 0�2020 ANGIE ACEVEd© EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Janene Arteche Type of Worker: Physician Assistant Employed by or related to the practice of the Member/Covered Entity: Cheshire Medical Corporation Membership # or Entity #: 5077 Effective Date: April 1, 2020 through December 31, 2020 DBA(s): Procare Medical Walk In Inc Procare Onsite Solutions Procare Physical Therapy And Acupuncture Inc Procare Urgent Care & Work Injury Procare Work Injury & Urgent Care Procare Work Injury Center Inc Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named Member/Covered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPT Agreement. The limit of liability through MPT is $1 Million per Occurrence/$3 Million Aggregate. Such limit of liability is shared with the Member/Covered Entity. A shared limit of liability means that the Member/Covered Entity shares his/her limit of liability with the Worker for any Occurrence upon which a Claim against the Member/Covered Entity and the Worker is based. This Certificate shall remain in force unless cancelled or amended by MPT or the Member/Covered Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians The above -named Member/Covered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage in the event of the termination of the employment of or other relationship with the above -named Worker. Such Member/Covered Entity is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage in the event that any term (RUVIEW§ fYt&-AFPR( -Psional Liability Coverage is modified. By Risk MANAGEMENT DivisioN AP 0 g O29 ANGiE ACEVEdo EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Janene Arteche Type of Worker: Physician Assistant Date: April 8, 2020 MUTUAL PROTECTION TRUST By Alfred De Leon Vice President, Membership Services REVIEWED & APPROVED By Risk MANAGEMENT DIVISION APRs 9 �20 ANGIE ACEVEdo OTHER RELATED PHYSICIAN CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Tracy Lee, MD ✓ Type of Worker: Other Related Physician Employed by or related to the practice of the Member/Covered Entity: Cheshire Medical Corporation Membership # or Entity #: 5077 Effective Date: December 19, 2019 through December 31, 2020 Specialty: Occupational Medicine DBA(s): Procare Medical Walk In Inc Specialty: Occupational Medicine Procare Onsite Solutions Specialty: Occupational Medicine Procare Physical Therapy And Acupuncture Inc Specialty: Occupational Medicine Procare Urgent Care & Work Injury Specialty: Occupational Medicine Procare Work Injury & Urgent Care Specialty: Occupational Medicine Procare Work Injury Center Inc Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named Member/Covered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPT Agreement. The limit of liability through MPT is $1 Million per Occurrence/$3 Million Aggregate. Such limit of liability is shared with the Member/Covered Entity. A shared limit of liability means that the Member/Covered Entity shares his/her limit of liability with the Worker for any Occurrence upon which a Claim against the Member/Covered Entity and the Worker is based. REVIEWED & APPROVED By Risk MANAGEMENT DIVISION .2020 ANGIE ACEVEdD OTHER RELATED PHYSICIAN CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Tracy Lee, MD Type of Worker: Other Related Physician This Certificate shall remain in force unless cancelled or amended by MPT or the Member/Covered Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians. The above -named Member/Covered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage in the event of the termination of the employment of or other relationship with the above -named Worker. Such Member/Covered Entity is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage in the event that any term of this Certificate of Professional Liability Coverage is modified. Date: December 30, 2019 MUTUAL PROTECTION TRUST Alfred De Leon Vice President, Membership Services REVIEWED & APPROVED By Risk MANAGEMENT DivisioN A9 2020 �ANGiE ACEVEdO EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Onil Valleciilo � Type of Worker: Physician Assistant Employed by or related to the practice of the Member/Covered Entity: Cheshire Medical Corporation Membership # or Entity #: 5077 Effective Date: September 4, 2019 through December 31, 2020 DBA(s): Procare Medical Walk In Inc Procare Onsite Solutions Procare Physical Therapy And Acupuncture Inc Procare Urgent Care & Work Injury Procare Work Injury & Urgent Care Procare Work Injury Center Inc Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named Member/Covered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPT Agreement. The limit of liability through MPT is $1 Million per Occurrence/$3 Million Aggregate. Such limit of liability is shared with the Member/Covered Entity. A shared limit of liability means that the Member/Covered Entity shares his/her limit of liability with the Worker for any Occurrence upon which a Claim against the Member/Covered Entity and the Worker is based. This Certificate shall remain in force unless cancelled or amended by MPT or the Member/Covered Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians The above -named Member/Covered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage in the event of the termination of the employment of or other relationship with the above -named Worker. Such Member/Covered Entity is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage in the event that any term of this Cert-diW,14£ j?Ggje siionnaPIRLiability OVED Coverage is modified. By Risk MANAgEMENT DIViSiON A R 0 91020 ANGIE ACEVEdO EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Onil Vallecillo Type of Worker: Physician Assistant Date: December 30, 2019 MUTUAL PROTECTION TRUST Alfred De Leon Vice President, Membership Services REVIEWED & APPROVED By Risk MANAGEMENT DIVISION A O g 2020 ANGIE ACEVEdO EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Tina Khosravt Type of Worker: Physician Assistant Employed by or related to the practice of the Member/Covered Entity Cheshire Medical Corporation Membership # or Entity #: 5077 Effective Date: February 22, 2018 through December 31, 2020 DBA(s): Procare Medical Walk In Inc Procare Onsite Solutions Procare Physical Therapy And Acupuncture Inc Procare Urgent Care & Work Injury Procare Work Injury & Urgent Care Procare Work Injury Center Inc Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named Member/Covered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPT Agreement. The limit of liability through MPT is $1 Million per Occurrence/$3 Million Aggregate. Such limit of liability is shared with the Member/Covered Entity. A shared limit of liability means that the Member/Covered Entity shares his/her limit of liability with the Worker for any Occurrence upon which a Claim against the Member/Covered Entity and the Worker is based. This Certificate shall remain in force unless cancelled or amended by MPT or the Member/Covered Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians. The above -named Member/Covered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage in the event of the termination of the employment of or other relationship with the above -named Worker. Such Member/Covered Entity Is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage in the event that any term of this Certificate of Professional Liability Coverage is modified. REVIEWED & APPROVED By Risk MANAGEMENT DIViSiON AP 910 0 EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Tina Khosravi Type of Worker: Physician Assistant Date: December 30, 2019 MUTUAL PROTECTION TRUST Alfred De Leon Vice President, Membership Services REVIEWED & APPROVED By Risk MANAGEMENT DivisiON ,! 0 9 2020 ANGIE ACEVEdO EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Both Fluk '_� Type of Worker: Physician Assistant Employed by or related to the practice of the Member/Covered Entity: Cheshire Medical Corporation Membership # or Entity #: 6077 Effective Date: October 1, 2017 through December 31, 2020 DBA(s): Procare Medical Walk In Inc Procare Onsite Solutions Procare Physical Therapy And Acupuncture Inc Procare Urgent Care & Work Injury Procare Work Injury & Urgent Care Procare Work Injury Center Inc Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named Member/Covered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be Issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPT Agreement. The limit of liability through MPT is $1 Million per Occurrencel$3 Million Aggregate. Such limit of liability is shared with the Member/Covered Entity. A shared limit of liability means that the Member/Covered Entity shares his/her limit of liability with the Worker for any Occurrence upon which a Claim against the MemberlCovered Entity and the Worker is based. This Certificate shall remain in force unless cancelled or amended by MPT or the Member/Covered Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians The above -named Member/Covered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage in the event of the termination of the employment of or other relationship with the above -named Worker. Such Member/Covered Entity is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage in the event that any term of this CG ifj�l to of Professional APPROVED Liability Coverage is modified. ffB((yy RRisk MANAgEMENT DiViSiON AP 0 9 2020 ANGiE ACEVEdO EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Both HulkType of Worker: Physician Assistant Date: December 30, 2019 MUTUAL PROTECTION TRUST Alfred De Leon Vice President, Membership Services REVIEWED & APPROVED By Risk MANAGEMENT DIVISION APW2020 ANGIE ACEVEdO EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Wendy Delgado ✓ Type of Worker: Physician Assistant Employed by or related to the practice of the Member/Covered Entity Cheshire Medical Corporation Membership # or Entity #: 5077 Effective Date: September 25, 2017 through December 31, 2020 DBA(s): Procare Medical Walk In Inc Procare Onsite Solutions Procare Physical Therapy And Acupuncture Inc Procare Urgent Care & Work Injury Procare Work Injury & Urgent Care Procare Work Injury Center Inc Mutual Protection Trust (MPT) will provide to the above -named Worker, the medical professional liability coverage described the MPT Agreement, Part 1, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence upon which the Claim is based, arising on or after the above -mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member/ Covered Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above -named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional liability protection services afforded by the MPT Agreement to the above -named MemberlCovered Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the medical professional liability coverage afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPT Agreement. The limit of liability through MPT is $1 Million per Occurrence/$3 Million Aggregate. Such limit of liability is shared with the Member/Covered Entity. A shared limit of liability means that the Member/Covered Entity shares his/her limit of liability with the Worker for any occurrence upon which a Claim against the Member/Covered Entity and the Worker is based. This Certificate shall remain in force unless cancelled or amended by MPT or the Member/Covered Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or Other Related Physicians The above -named Member/Covered Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage in the event of the termination of the employment of or other relationship with the above -named Worker. Such MemberlCovered Entity is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage in the event that any term of this Ce ificaWED Pofessional APPROVEDLiability Coverage Is modified By Risk MANAGEMENT DiViSiON APvR42020 ANgiE ACEVEdo EMPLOYEE CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker: Wendy Delgado Type of Worker: Physician Assistant Date: December 30, 2019 MUTUAL PROTECTION TRUST 21 Alfred De Leon Vice President, Membership Services REVIEWED & APPROVED By Risk MANAGEMENT DIVISION APR 9 2020 ANqIE AmEd