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HomeMy WebLinkAboutSUNRISE MULTISPECIALISTS MEDICAL CENTERINSURANCE ON FILE WORK MAY PROCEED UN ANCE EXPIRES N-2021-179 yU CLERK OF COUNCIL k: DATE: 1 r AGREEMENT FOR MEDICAL SERVICES AND TESTING THIS AGREEMENT is made and entered into this f- day of September, 2021 by and between William H. Nuesse, M.D. and Mary Ann Nuesse, D.O., a California medical corporation, doing business as Sunrise Multispecialist Medical Center ("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 ("City"). RECITALS A. City desires to retain a consultant to provide non -industrial medical services including but not limited to Department of Transportation ("DOT") mandated services, drug tests, respiratory fitness tests, vision testing, post -accident testing, pre -employment examinations, fitness for duty 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 Geld 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 Geld. 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: 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; 6) DOT -mandated drug and alcohol testing of employees considered safety sensitive' as defincd under DOT regulations and City policy. Consultant shall ensure all such testing complies with DOT testing procedures as per 49 CPR, Part 40; such testing to include preemployment and pre - assignment. B. 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. C. 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 (SAMShIA)-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 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 City's use in the medical examination and 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' or employees' progress throughout the medical services review process. 4) Communicate directly with applicants and City Risk Management staff throughout the pre -employment or pre-assignunent 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 Risk Management staff at its sole discretion, outlining eaeh candidate's pre- employment placement medical evaluation and results, 6) 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 acquired under the DOT; 9) Provide consultation as needed to Risk Management staffregarding medical services provided and 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 tallest extent permitted by law, 11) Consultant agrees to permit duty 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 corder the Agreement for inspection by the City or by any ether 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 permission, 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) If 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 I•IIPAA release. 16) Maintain a network of qualified and trained medical providers and medical specialists for necessary exams; Orient City staff in the legal/rnedicaUrisk management and human resources aspects of Consultant services; 17) Communicate directly with applicants to obtain the confidential medical information that is needed for clearance for a particular job; 18) Manage all bill 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 of near/far/peripheral vision, Ishihara 14 and primary color; audlogram (if classification has specific occupational noise exposure or critical hearing demands); chest x-ray; EKG or treadmill stress EKG; Spirometry; chern panel 20; CBC w/difE dipstick UA, or UA w/Micro (to lab); venipuncture & 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 annual amount authorized under this Agreement shall not exceed fifty thousand dollars ($50,000) during the term of this Agreement. b, This Agreement authorizes payment of any services provided by Consultant from July 1, 2021, to the date of this Agreement. c, Paymont by City shall be made within forty-five of days (45) days following receipt of proper invoice evidencing work performed, subject to City accounting procedures, Payment need not be made for work that 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 the date written above and terminate on August 11, 2024, unless terminated earlier in accordance with Section 15, below. 4. INDEPENDENT CONSULTANT Consultant shall, 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 professional manor 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 "tanner 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 Coverage shall be at least as broad as: Commercial General Liability (COL): Insurance Services Office storm CC 00 01 covering COL on an "occurrence" basis, including products and completed operations, property damage, bodily injury and personal & advertising injury with limits no less than $2,000,000 per occurrence. If a general aggregate limit applies, either the general aggregate limit shall apply separately to this project/location (ISO CC 25 03 or 25 Oil) or the general aggregate limit shall be twice the required occurrence limit. 1 Automobile Liability: Insurance Services Office Form Number CA 0001 covering, Code 1 (any auto), or if Consultant has no owned autos, Code 8 (hired) and 9 (non owned), with limit no less than $1,0000000 per accident for bodily injury and property damage. 3. Workers' Compensation insurance as required by the State of California, with Statutory Limits, and Employer's Liability Insurance with limit of no less than $1,000,000 per accident for bodily injury or disease. 4. Professional Liability (Errors and Omissions) Insurance appropriates to the Consultant's profession, with limit no less than $1,000,000 per occurrence or claim, $3,000,000 aggregate. If the Consultant maintains broader coverage and/or higher limits than the minimums shown above, the Entity requires and shall be entitled to the broader coverage and/or the higher limits maintained by the contractor. Any available Insurance proceeds in excess of the specified minimum limits of Insurance and coverage shall be available to the Entity. Other Insurance Provisions The insurance policies are to contain, or be endorsed to contain, the following provisions; Additional Insured Status The Entity, its officers, officials, employees, and volunteers are to be covered as additional insureds on the CGL policy with respect to liability arising out of work or operations performed by or on behalf of the Consultant including materials, parts, or equipment furnished in connection with such work or operations. General liability coverage can be provided in the form of an endorsement to the Consultant's Insurance (at least as broad as ISO Form CO 20 10 11 85 or both CG 20 10, CG 20 26, CO 20 33, or CG 20 38; and CG 20 37 forms if later revisions used). Prinmry Coverage For any claims related to this contract, the Consultant's insurance coverage shall be primary insurance primary coverage at least as broad as ISO CO 20 01 0413 as respects the Entity, its officers, officials, employees, and volunteers, Any Insurance or self-insurance maintained by the Entity, its officers, officials, employees, or volunteers shall be excess of the Consultant's insurance and shall not contribute with it. Natlee of Cancellation Each insurance policy required above shall state that coverage shall not be canceled, except with notice to the Entity. Waiver ofSuhrogatlon Consultant hereby grants to Entity a waiver of any right to subrogation which any insurer of said Consultant may acquire against the Entity by virtue of the payment of any loss under such insurance. Consultant agrees to obtain any endorsement that may be necessary to affect this waiver of subrogation, but this provision applies regardless of whether or not the Entity has received a waiver of subrogation endorsement ftom the insurer. Se(( -Insured Retentions Self insured retentions must be declared to and approved by the Entity.'rhe Entity may require the Consultant to purchase coverage with. a lower retention or provide proof of ability to pay losses and rotated investigations, claim administration, and defense expenses within the retention, The policy language shall provide, or be endorsed to provide, that the self -insured retention may be satisfied by either the named insured or Entity, Acceptability of Insurers Insurance is to be placed with insurers authorized to conduct business in the state with a current A.M. Bost's rating of no less than ANIL unless otherwise acceptable to khe Entity. Claims Made Policies If any of the required policies provide coverage on a claims -made basis: I . The Retroactive Date must be shown and must be before the date of the contract or the beginning of contract work, 2. Insurance must be maintained and evidence of Insurance must be provided for at least jive (S) years after completion of the contract of work. 3. If coverage is canceled or non -renewed, and not replaced whh another claims. made policy form with a Retroactive bate prior to the contract effective date, the Consultant must purchase "extended reporting" coverage for a minimum of flve (5) years after completion of contract work, l'erifleatlon of Coverage Consultant shall furnish the Entity with original Certificates of Insurance including all required amendatory endorsements (or copies of the applicable policy language effecting coverage required by this clause) and a copy of the Declarations and Endorsement Page of the COL policy listing all policy endorsements to Entity before work begins, However, £allure to obtain the required documents prior to the work beginning shall not waive the Consultant's obligation to provide them. The Entity reserves the right to require complete, certified copies of all required insurance policies, including endorsements required by these specifications, at any time. Subcontractors ' Consultant shall squire and verify that all subcontractors maintain insurance meeting all the requirements stated herein, and Contractor shall ensure that Entity is an additional insured on insurance required from subcontractors, Special Risks or Circumstances Entity reserves the right to modify these requirements, including limits, based on the nature of the risk, prior experience, insurer, coverage, or other special circumstances. 6. INDEMNIFICATION Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents, employees, consultants, special counsel, and representatives from liability: (1) forpersonal 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 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 duc 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 terms of, or effects arising f-om 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 Cade Section 27818, 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. 7. RECORDS Consultant shalt 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 snake 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, and activities related to this Agreement for a period of three (3) years from the date of final payment to Consultant under this Agreement. 81 CO.Nr[DGN71AlITY 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 an obligation of confidentiality; (d) is required to be disclosed by operation of law; or (e) 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 performance of services specified under this Agreement, 11. BACKGROUND CHECK REQUIREMENTS Consultant shall not assign any 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 Penal Code Section 290 et seq, 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 a serious felony as defined in California Penal Cade Section 1192.7(c). Disqualifying convictions include but are not limited to, violations of California Penal Code Sections 37, 128,136.1 with Section 186.22,187, 190-190 4 and 192(a), 205, 206, 207.209.5, 21.1, 212, 2115, 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, 2661, 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, 311.1 1, 314, 347(a), 368, 417(b), 451(a),518 with 186.22, 647.6, 653f(c), 664 and 187, 667.5(c),18745, 18750, or 18755,12022,53,11418(b)(1) or (b)(2); Business and Professions Code Section 729. Failure to comply with this Section shall be grounds for immediate termination of this Agreement. t2. 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 City Council City of Santa Ana 20 Civic Center Plaza (M-30) P.O. Box 1988 Santa Ana, CA 92702.1988 Fax 714-647-6956 With Courtesy Copy to, Executive Director Roman Resources Agency City of Santa Ana 20 Civic Center Plaza (M-34) P.O. Box 1988 Santa Ana, California 92702 To Consultant: William 11, Nuesse, M,D, or Mary Ann Nuesse, D,O. Sunrise Multispecialist Medical Center 867 South Tustin Sheet Orange, California 92866 Fax:714-771-691.8 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 time frames, weekends, federal, state, County or City holidays shall be excluded. 13. EXCLUSIVITY AND AMENDMUPIT 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 it 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 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 of 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 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. 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 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 that fails to mcet 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, gender Identity, gender expression, 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 ether 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 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. 18, PROFESSIONAL LICENSE 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 its inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cruise 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. b. All Exhibits referenced herein and attached hereto shall be 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 wet signatures. d. Consultant will comply with all applicable federal state and local laws including the Health Insurance Portability and Accountability Act {"EI]PAA"). IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: Daisy Gomez Clerk of the Council APPROVED AS TO FORM: SONIA R. CARVALHO City Attorn DFur(ron Salvatierra Deputy City Attorney RECOMMENDED FOR APPROVAL: Ja n Motsick xecutive Director Human Resources Agency CITY OF SANTA ANA �� W �V- Kristine Ridge City Manager William H. Nuesse, M.D. and Mary Ann Nuesse, D.O., a medical corporation Dba Sunrise Multispecialist Medical Center EXIII[BIT A RATESICHARGES City of Santa Ana Non -industrial Medical .Services f'h s calw, Basic Employer Physical (includes VAdip, distance vision, basic colorvisloni $35,00 Annual Employer Physical linciudes undip, distencavision, basic colo(,visl in) $35,00 Pre-CmploymentPhysical(Includes UA dip, distance vision, hash: color vision) $35.00 F I t For Duty/Return to Work (MUST have copy ofjob description) $40,00 Commercial Driver Exams $55,00 Respit atory Fit Testing:. Respiratory Evaluation (IncludesrMask Pit Test, 05nAquestionnoirereview, PFTI $90.00 PFT $10,00 OShIA Questionnaire Review $25.0(l Mask Fit Test $25.00 ru 5 re E; Breath Alcohol Test $30,00 5 panel Rapid $15,00 10 panel Rapid $20,00 9 Panel Non -Dot k1793N $25.00 10 Panel Nan -Dot #6633N $30.00 DOT Drug Screen $25.00 MRO Interpretation of Positive Drug Screen $25.00 Drug Screen Collection Only (Not on Sunrise's late account) $15.00 Dig- %fisting; Ish1hara $10.00 Near Vlslon $5,00. Jaeger $5.00 Snelten & Basic Color $5100 Qtft r er i e :. Audiograms $20,00 Lift Test — rioor to Waist $5.00 Lift Test — Waist to Chest $5.00 EKG $30,00 Tg/PPD Skin Test $28.00 Chest X-Ray (2 Views rule outTl $30.00 Lumbar X-Ray (4 Views) $50.00 Rev, 08,11.2021 Rev. aa,tl,zpal ymi asp Tdap $95,00 Hepatitis R $85,00 Varlcella $202,00 MMR $144,00 Flu Vaccine $80,00 t err Hepatitis A #85604 $45,00 Hepatitis 8 #8475 $48.00 Hepatitis C #8472 $21.00 MMR 9802, 98624, and #964 $85.00 Varlcella $45.00 Common abjL COO with [jiff #6199 $20.00 Upid Panel 414852 $42 00 Comp Metabolic Panel 410291 $29,00 S��1=. "m Rapid Antigen Testin8 $99,00 PCR $150.00 AI 'jr-%"1-SW Francine R. Digitally slgned by Francine R. R. Villareal Villareal Date: 2021.06.1017:11:17 7''00' � 11i CERTIFICATE OF LIABILITY INSURANCE °"'E`M412021YYY) 05(2412U21 THIS CERTIFICATE IS ISSUED ASA MATTER Of INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CENTIPICATEDOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE ACONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLOER, IMPORTANT: IfthecertlRcateholder is an ADDITtONALINSURED,the poltt0 s)muttImmADDITIONAWNSURED provIslons or be endorsed, It SUBROGATION IS WAIVED, sublectto the termsano camiltiens of the policy, certain policies may require an endomelnenN Astatement on thlscertiaaatedoosnot confer rights to the certificate holder In lieu of such endoraoment(s)- PRODUCER CONTACT NAME: Theresa SIme3 Therese Simes(9744576) PHONE FAX 17165 Newhope St Ste F (A/C, NO, EXT); 714-966.3000 (A/C, NO): 714-966.3013 E-MAIL ADDRESS: tsitneSCfarmersagenLrom Fountain Valley CA 927U6-4230 INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURERA: Truck lnauranco Exchange 21709 WILLIAMHNUESSEM.D. 807 $ TUSTIN ST INSURERS-. Formers Insurance Exchange 21652 INSURERSs Mid Century Insurance Company 21687 INSURERD; ORANGE CA 92866 BLEMRERE.. T INSURER COVERAGES CERTIFICATE NUMBER; REVISIONNUMBER; THISISTO (TWIT YTHATTHEPOLICIESOF INSURANCE LISTED BELOW HAVE BEEN ISSUEDT07HEINSURED NAMEABOVE FORTHE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OFANY CONTRACTOR OTHERDOCUMENTWITH RESPECTTO WHICHTHISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEDHEREIN ISSUBJECTTOALLTHETERMS, EXCLUSIONSANO CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IL1RR TYPEOFINSURANCE �NSDL SOU POLICYNUMBER POLICY EFF (MM/DD/YWY) POUCYEXP (MM/DD/YYYY) LIMITS COMMERCIALGENERALLIABILITY CLAIMS -MADE OCCUR _ EACHOCCURRENCE $ 200D000 DAMAGETO RENTED S(Ea Occurrence) $ 500.000 MEP EXP(Anyone person) $ 500 PERSONALeADVIN)9RY s 2,009,00 A V N 802378275 OW2912021 06/29/2022 ODA AGGREGATELIMHAPPLIESPER: POLICY ❑ PROJECT ❑ WC GENEKALAGGREGATE $ 4,000,000 PRODUCTS -COMP/OPAGG $ 2,000,000 $ OTHER: ODILEUABILITY COMBINEDSINGLE LIMIT (Eanceident) $ 2,000,000 YAUTO ROPILYINJURY(Parperson) $ YEDAUTOS SCHEDULED N 602378275 05/29/2021 06129/2022 BODILYINJURY(Peraccldent) $ PROPERTY DAMAGE (Peracdden@ $ £OAUTOS X NON -OWNED LY AUTOS ONLY S BRELLALIAB PANDEMPLOYSRS'LISADILITY OCCUR EACH OCCURRENCE $ AGGREGATE ¢ �✓ CEaS LIAR CLAIMS -MADE 0 RETENTIRS COMPENSATION LMDILITY PER STATUTE OTHERPLOYERS' OPRIETOR/PARTNER/ Y/N in NH) N/AE.L EACH ACCIDENTIVEOFFICER/MEMBERED7(Mandatory £.L. GISEABE-EA EMPLOYEE E.4' DISEASE •POUCY10AH S escribe underDESCRIPTION OF TIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES WORD 101, Additional Remarks Schedule, may be attached if more space Is required) 87 S TUSTIN ST, ORANGE, CA 02866 Certificate of Insurance shall provide 30 day prior written notice of concellation CERTIFICATEHOLDER CANCELLATION 20 CIVIC CENTER PLZ DATE ACORD 25(2016/03) @1988-2015 ACORDC REVIEWED & APPROVED BY: 31.1769 11-15 The ACORD name and logo are registered marks Risk Management Analyst THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ iTCAREFULLY. POLICY NUMBER: 602378275 MA FARMERS INSURANCE ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSIN ESSOW NERS LIABILITY COVERAGE FORM BUSI N ESSOW NERS COVERAGE FORM APARTMENTOW N ERS LIABILITY COVERAGE FORM CONDOMINIUM LIABILITY COVERAGE FORM 1*10111A01111" Name Of Additional Insured Persons) Or Organization(s): Ty70P75ANTA-AWRl8 MANA-GEK4 Informatianrequired tocompletethisSchedule,ifnotshownabove,willbeshownintheDeclarations, A. The following is added to Paragraph C. Who Is An insured of the applicable Coverage Form: 17238 1st Edition Any person(s) or organization(s) shown in the Schedule Is also an additional insured, but only with respect to liabllityfor "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omisslons of those acting on your behalf in the performance of your ongoing operations Orin connection with your premises owned by or rented to you. However: a. The insurance afforded to such additional insured only applies to the extent permitted bylaw; and b. If coverage provided to the additional insured is required by a contractor 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 Paragraph D. Liability And Medical EXPenso ; Unril Of Insurance of the applicable Coverage Form: 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. This endorsement is part of your policy. It supersedes and controls anything to the contrary. It is otherwise subject to all the terms of the policy. 937S8-ED102-19 Inclines copyrighted material of Insurance Services Office,tek Management Division Inc.,nc., with Its permission. " EEREUIex/eD&{APPROVED BY. s Risk ManagementAmtyst Policy Changes Endorsement Description ADD ADDITIONAL INTEREST ADDITIONAL INSURED-J7100-ED2 CITY OF SANTA ANA, OFFICERS, AGENTS, EMPLOYEES, AND 20 CIVIC CENTER PLZ SANTA ANA, CA 92701 LOCATION: 867 S TUSTIN ST ORANGE, CA 92866 Removal If Covered Property is removed to a new location that is described on this Policy Permit Change, you may extend this insurance to include that Covered Property at each location during the removal. Coverage at each location will apply in the proportion that the value at each location bears to the value of all Covered Property being retrieved. This permit applies up to 10 days after the effective date of this Policy Change: after that, this insurance does not apply at the previous location. 9IA277 ISTEDI➢ON 7-02 IncludesCaW'ghted Mukrial, knemno Services Office, Inc, wish hs permission. E4277EDI ,�3 TtiekManagtmiatiDivleion N � �' REVIEWED&APPROVED RV: '1 ri 'I Flee s c� P" ��-EW Risk Management Analyst J7100-ED2 05-18 Includes copyrighted material of Insurance Services Office, Inc., with its p 93-7100 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. O;N 17l00 FARMERS 2nd Edition INSURANCE PRIMARY AND NONCONTRIBUTORY INSURANCE This endorsement modifies insurance provided under the: BUSINESSOWNERS POLICY SCHEDULE Name of Additional Insured Persons(s) or Organization(s): CITY OF SANTAANA, OFFICERS, *SEEJ7105 AMENDTO ADDNL INS Information required to complete this Schedule, if not shown above, will be shown In the Declarations. The following is added to Paragraph H. Other Insurance of the Businessowners Common Policy Conditions and supersedes any provision to the contrary: Primaryand Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to the additional insured shown in the Schedule, provided that: 1. The additional Insured shown in the Schedule is a Named Insured undersuch other insurance; 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; and 3. The additional insured shown in this Schedule Is also an Additional insured on this policy. The coverage provided under this endorsement Is subject to the terms and conditions of the applicable, underlying Additional Insured endorsement. This endorsement Is part of your policy. It supersedes and controls anythi rig to the contrary. It Is otherwise subject to all the terms of the pol Icy , RiskMansgtmmtD[Wslon S REVIEWED&APPROVIDBY.- {� 'I�}/� ��p F4 MeW P, YM,tN�1iKE. Risk. Management Analyst POLICY NUMBER: 60237-82-75 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AN FARMERS 1710 3rd Edition INSURANCE AMENDMENT OF ADDITIONAL INSURED This endorsement modifies insurance provided under the: BUSINESSOWNERS COVERAGE FORM BUSINESSOWNERS LIABILITY COVERAGE FORM BUILDING AND PERSONAL PROPERTY COVERAGE FORM COMMERCIAL GENERAL LIABILITY COVERAGE FORM APARTMENT OWNERS LIABILITY COVERAGE FORM CONDOMINIUM LIABILITY COVERAGE FORM Name(s) Of Additional Insured Person(s) Or Organization(s): CITY OF SANTAANA, OFFICERS, AGENTS, EMPLOYEES, AND VOLUNTEERSARE NAMED AS ADDITIONALLY INSURED ON THIS POLICY f 7105-ED3 05-18 Includes copyrighted material of Insurance Services Office, Inc., with Its permission. 93-7105 3 BenEWEDM & APPROVED BY: r a i ' flmu ' r.= I', Vt" �- Risk Management Analyst The person or organization listed above Is added to the Schedule of the following endorsement: Additional Insured - Controlling Interest Additional Insured - Co -Owner of Insured Premises Additional Insured - Designated Person or Organization Additional Insured - Engineers, Architects Or Surveyors Not Engaged By The Named Insured Additional Insured - Grantor Of Franchise Additional Insured - Lessor of Leased Equipment Additional Insured - Managers or Lessors of Premises Additional Insured - Mortgagee, Assignee or Receiver Additional Insured - Owners, Lessees Or Contractors Additional Insured - Owners or Other Interests from Whom Land Has Been Leased Additional Insured - Primary and Noncontributory X Additionallnsured - Scheduled Person Or Organization Additionallnsured - State or Political Subdivisions Permits Additionallnsured - State or Political Subdivisions Permits Relating to Premises Additionallnsured -Vendors Waiver of Rights Recovery Other This endorsement is part of your policy. It supersedes and controls anything to the contrary. It Is otherwise subject to all the terms of the policy. .10 Rlek Managenent Division f%d a� Remo&APPROVm Br. J7105-ED305-18 Includes copyrighted material ofInsurance Services Office,Inc.,withitspermission. oaa�'µQu, 93-7105 Risk Management Analyst COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE Coverage through December 31, 2021 Member: Kenneth E. Grubbs, DO Address: 867 S Tustin Ave, Orange, CA 92866 This certificate confirms that, effective on the coverage date below, the above -named physician is a member of the Cooperative of American Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MPT). 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 under the terms, conditions and exclusions of the MPT Agreement. Membership Number 21463 Medical Specialty Family Medicine, With Minor Surgery Coverage Date February 1, 2012 Retroactive Coverage Date None Subspecialty 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 MPT 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. Alfred De Leon Vice President, Membership Services Mutual Protection Trust Date December 30, 2020 Ptak Management niivieinn 3� s p er�dg�� �e BeAmEo & APPROVED Br. F4"O 8 1; rAa R• V+ �� Risk ManageurentAnatyst COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE AND CLAIMS HISTORY Coverage through December 31. 2021 Member: Kenneth E. Grubbs, DO Address: 867 S Tustin Ave, Orange, CA 92866 This certificate confirms that, effective on the coverage date below, the above -named physician is a member of the Cooperative of American Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MPT). MPT is an unincorporated interiudemnity 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 under the terms, conditions and exclusions of the MPT Agreement. Membership Number 21463 Medical Specialty Family Medicine, With Minor Surgery Coverage Date February 1, 2012 Retroactive Coverage Date None Subspecialty 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 MPT undertake any obligation to advise any pity, other than the named member, of any changes to or termination 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 within 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. December 30, 2020 Alfred De Leon Date Vice President, Membership Services Mutual Protection Trust RlskManagmreutDivieion , REVIEWED&APPRovm BY: A'"M Risk Management Analyst COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE Coverage through December3l, 2021 Member: Mary -Ann Nuesse, DO Address: 867 S Tustin Ave, Orange, CA 92866 This certificate confirms that, effective on the coverage date below, the above -named physician is a member of the Cooperative of American Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MPT). 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 under the terms, conditions and exclusions of the MPT Agreement. Membership Number 13925 Medical Specialty Family Medicine, With Minor Surgery Coverage Date April 1, 2004 Retroactive Coverage Date February 1, 2002 Subspecialty 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 MPT undertake any obligation to advise any party, other than the named member, of any charges to or termination of this coverage. Cooperative of American Physicians, Inc. Alfred DeLeon . Date Vice President, Membership Services Mutual Protection Trust December 30, 2020 lilak Management DtWaion fit, €€Remo&Aelg: P!a'�wrmB ill + l �ahes.4•C z Y Risk Management Anatyst COOPERATIVE Or AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE AND CLAIMS HISTORY Coverage through December 31, 2021 Member: Mary -Ann Nuesse, DO Address: 867 S Tustin Ave, Orange, CA 92866 This certificate confirms that, effective on the coverage date below, the above -named physician is a member of the Cooperative of American Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MPT). 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 under the terms, conditions and exclusions of the MPT Agreement. Membership Number I Medical Specialty 13925 Family Medicine, With Minor Surgery Subspecialty Coverage Date I Retroactive Coverage Data April 1, 2004 1 February 1, 2002 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 MPT undertake any obligation to advise any party, other than the named member, of any changes to or termination 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 within 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. December 30, 2020 Alfred De Leon Date Vice President, Membership Services Mutual Protection Trust tRhliFak D&Appliov lelmr rrR�EVIEWED & MPR.CWe�rm 9Y: N r4 t"nFNYtif•e . VM dhQ Risk Management Analyst COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE Coverage through December 31, 2021 Member: William H. Nuesse, MD Address: 867 S Tustin Ave, Orange, CA 92866 This certificate confirms that, effective on the coverage date below, the above -named physician is a member of the Cooperative of Americatr Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MPT). MPT is an unincorporated interindetmrity 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 under the terms, conditions and exclusions of the MPT Agreement. Membership Number 13924 Medical Specialty Family Medicine, With Minor Surgery Coverage Date April 1, 2004 Retroactive Coverage Data February 1, 2002 Subspecialty 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 MPT 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. Alfred De Leon Vice President, Membership Services Mutual Protection Trust Date December 30, 2020 u R1skMv gsnmtDMalun RimEwno&APPRcvm Br. 8 i F'.ssyta•e k. va" AWROMRisk Management Analyst ME) COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE AND CLAIMS HISTORY Coverage through December 31, 2021 Member: William H. Nuesse, MD Address: 867 S Tustin Ave, Orange, CA 92866 This certificate confirms that, effective on the coverage date below, the above -named physician is a member of the Cooperative of American Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MPT). 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 under the terms, conditions and exclusions of the MPT Agreement. Membership Number 13924 Medical Specialty Family Medicine, With Minor Surgery Coverage Data April 1, 2004 Retroactive Coverage Date February 1, 2002 Subspecialty 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 MPT undertake any obligation to advise any party, other than the named member, of any changes to or termination of this coverage. Claims History No Claims Reported The Claims history listed above includes all Claims (hat are currently open and those that were closed within the last five yews. 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. December 30, 2020 Alfred De Leon Date Vice President, Membership Services Mutual Protection Trust s'" ae RiekManageraarED[vie[an ^` IffIII � rrR��EVIEWED&ppAPPRciV��m� S�Y�/e: ll�rt e� f'1kiYn.6�2 P" vk" 4'-----w Rsk Management Analyst I"MRLOYERS@ Workers' Compensation and Employers Liability Insurance Polley EMPLOYERS PREFERRED INS. CO. Policy Number From olicy PeriodToA Stock Company EIG 2675029 02 08/01//g20tlr�20 08/01/2021 Ins red'se's t,114 i,d In eattheetleress ofthe Transaction AMENDED DECLARATIONS Effective: 08/01/2020 NCCI Carrier # 31283 WCIRB CARRIER# 00920 PRIOR POLICY NUMBER EIG267502901 1. Named Insured and Address Agent WILLIAM H NUESSE, MD AND MARY NORTH RANCH INS SVCS INC 6860001 ANN NUESSE, DO, A MED CORP 32110 AGOURA RD 867 S TUSTIN ST WESTLAKE VILLAGE, CA 91361 ORANGE CA 92866-3426 Telephone: 8008012300 Customer # Carrier# FEIN # Risk ID # Entity of Insured 31283 330893191 264066 CORPORATION Additional Locations: 2. The Policy Period is from 08/01/2020 to 08/01/2021 12:01 a.m. Standard Time at the Insured's mailing address. 3. A. Workers Compensation Insurance: Part ONE of the policy applies to the Workers Compensation Law of the states listed here: CA B. Employers Liability Insurance: Part TWO of the policy applies to work in each state listed in Item 3A. The limits of our liability under Part TWO are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance: Part THREE of the policy applies to the states, if any, listed here: All states except ND, OH, WA, WY and states listed in item 3.A. D. This policy includes these endorsements and schedules: See attached schedule. 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates, and Rating Plans. All information required below is subject to verification and change by audit. SEE EXTENSION OF INFORMATION PAGE Minimum Premium $ 750 Assessments and Taxes $ ❑ This is a Three Year Fixed Rate Policy Premium Adjustment Period: ® Annual; Countersigned this Day of Issued Date: 08/1312020 Expense Constant $ 160 Premium Discount $ -878 Total Estimated AnnualPremium $ 13,284 ❑ Semiannual; ❑ Quarterly; ❑ Monthly Authorized Representative Issuing Office EMPLOYERS PREFERRED INS. CO. 2550 PASEO VERDE PARKWAY, SUITE 100 HENDERSON, NV 89074-7117 issued Date 08/1312020 AGENT COPY WC990630 (5198 Ed.) Page 1 of 4 �y Rtak Msautg nit Dividan '+l RENAMED &APPROVED BY: f4M ec ,e Z VLEFanak@ Risk Management Analyst 0 CERTIFICATE OF LIABILITY INSURANCE DATEIMM/DDYYYY) 06/10/2021 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($), 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 18 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 Calhoun & Associates CONTACNAME;T Carmen Ponce DBA: Integrity Advisors 14771 Plaza Drive, Ste C PHONE Ean. 800.500-9799 ac No, 714.664-0614 E-MAIL carmen ante nt advisors.com ADDRESS: g y' Tustin CA 92780 INSURERS AFFORDING COVERAGE NAIC# INSURERA: EMPLOYERS 31283 INSURED William H. Nuesse, M.D. and Mary -Ann Nuesse, D.O., A Medical INSURERS: 867 S TUSTIN ST. INSURER C ORANGE CA 92866 INSURER D: INSURER E: 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 LTR TYPE OF INSURANCE ADD L SUBR POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDOPYYY LIMITS COMMERCIAL GENERAL LIABILITYLi EACH OCCURRENCE $ CLAIMS -MADE OCCUR EaoD PREMISESS Ea occurrence $ MED EXP (Any one person) $ PERSONAL &ADV INJURY $ AGGREGATE LIMIT APPLI ES PER: GENERALAGGREGATE $ GEN'L POLICY PRJECT O- ❑ LOC PRODUCTS-COMP/OP AGG $ $ OTHER: AUTOMOBILELIABILITY COMBINED SINGLE LIMIT Ea ..;dent $ BODILY INJURY (Per person) $ ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ UMBRELLALIAB OCCUR Li EACHOCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOWPARTNEWEXECUTIVE YIN OFFICEMMEMBER EXCLUDED? yJ (Mandatory In NH) NIA EIG 2675029 02 08/01/2020 08/01/2021 PER I OTH- STATUTE ER E.L EACHACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, deacrus under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,OOQ000 I� E:] I--] DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Santa Ana Risk Management Division 20 Civic Center Plaza, 4th floor Santa Ana, CA 92701 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ©1988.2015 ACORD CI ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD auto RiekManagtmlentDlvleloR /R'EviEwED &rI� ?PRc/v�mBYp: . FdiC4v.�.i.Q R. V+.CtN/taA4 ' Risk Management Analyst NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor William H. Nuesse, M.D. and Mary-Ann Nuesse, D.O. Name: Project N-2021-179-01 Number: Project First Amendment To Agreement For Medical Services And Testing Name: 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: POLICY EXPIRATION TYPE OF INSURANCE COI DATE FILE NAME NUMBER DATE Sunrise COI Exp AUTOMOBILE LIABILITY 602378275 05/29/2023 01/11/2023 05-29-23.pdf Sunrise COI Exp GENERAL LIABILITY 602378275 05/29/2023 05/13/2022 05-29-23.pdf 2023 CAP MPT - Doctors - PROFESSIONAL LIABILITY COC 12/31/2023 01/10/2023 Certificate of Coverage.pdf City of Santa WORKERS COMPENSATION AND 25601701 08/01/2023 10/03/2022 Ana, Risk EMPLOYERS' LIABILITY Management.pdf Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 1/11/2023 5:55 PM NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor William H. Nuesse, M.D. and Mary-Ann Nuesse, D.O. Name: Project N-2021-179-01 Number: Project First Amendment To Agreement For Medical Services And Name: Testing 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: POLICY EXPIRATION TYPE OF INSURANCE COI DATE FILE NAME NUMBER DATE 2023.05.15 sunrise coi l AUTOMOBILE LIABILITY 602378275 05/29/2024 05/15/2023 AI city of SA.pdf 2023.05.17 sunrise coi l GENERAL LIABILITY 602378275 05/29/2024 05/17/2023 AI City of SA updated.pdf 2023 CAP MPT - PROFESSIONAL LIABILITY COC 12/31/2023 01/10/2023 Doctors - Certificate of Coverage.pdf WORKERS COMPENSATION AND City of Santa Ana, Risk 25601701 08/01/2023 10/03/2022 EMPLOYERS' LIABILITY Management.pdf Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 5/31/2023 1:28 PM NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor William H. Nuesse, M.D. and Mary-Ann Nuesse, D.O. Name: Project N-2021-179 Number: Project Agreement For Medical Services And Testing Name: 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: POLICYEXPIRATION TYPE OF INSURANCECOI DATEFILE NAME NUMBERDATE 2023.05.15 sunrise coi l AUTOMOBILE LIABILITY60237827505/29/202405/15/2023 AI city of SA.pdf 2023.05.17 sunrise coi l GENERAL LIABILITY60237827505/29/202405/17/2023 AI City of SA updated.pdf 2023 CAP MPT - PROFESSIONAL LIABILITYCOC12/31/202301/10/2023Doctors - Certificate of Coverage.pdf WORKERS COMPENSATION ANDCity of Santa 2560170108/01/202407/17/2023 EMPLOYERS' LIABILITYAna.pdf Thank you,