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HomeMy WebLinkAboutHALCYON BEHAVIORAL, LLC dba HALCYON BEHAVIORAL ADMINISTRATORS (2)INSURANCE ON FlLE WORK MAY PROCEED aylol / z�ZZ,e..� FIRST AMENDMENT TO AGREEMENT WITH HALCYON BEHAVIORAL, LLC. N-2021- Zol-ay THIS FIRST AMENDMENT TO AGREEMENT is entered into this 161° day of November 2021, by and between Halcyon Behavioral, LLC, a California limited liability company doing business as Halcyon Behavioral Administrators ("Consultant"), and the City of Santa Ana, a charter city and municipal corporation duly organized and existing under the Constitution and laws of the State of California ("City"). Consultant and City are also referred to herein as "Parties" or individually as a "Party.,, na;m�e�)(1)S,`^RECITALS A. On September 21, 2021, the City entered into Agreement No. N-2021-201 ("Agreement") with Halcyon Behavioral, LLC, a California limited liability company doing business as Halcyon Behavioral Administrators, to provide employee wellness program services, and related matters, for the tern of three years. B. The parties desire to amend the scope of services provided by Consultant and the insurance requirements under the Agreement. THE PARTIES THEREFORE AGREE: Section 1, SCOPE OF SERVICES, shall be amended to exclude Biometric Screening Coordination (Exhibit A to the Agreement, Item 2). 2. Section 6, INSURANCE, shall be amended to require Professional Liability Insurance with a limit of no less than $1,000,000 per occurrence or claim, $2,000,000 aggregate. 3. Except as hereinabove modified, the terms and conditions of said Agreement remain unchanged and in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this First Amendment to the Agreement the date and year first above written. ATTEST: CITY OF SANTA ANA z aisy Gomez store Ridge lerk of the Council City Manager APPROVED AS TO FORM: Sonia R. Carvalho, City Attorney Mandon Salvatierra Deputy City Attorney = ORAPPROVAL: Ja n Motsick Executive Director Human Resources Department HALCYON BEHAVIORAL, LLC Jeremy Oswald: CEO and President: Page 1 of 1 Francine R. Digitally signed by Frzntlne R. Villareal Villareal Date: 2021.11.1816:0434-01TOO ACC>Ro CERTIFICATE OF LIABILITY INSURANCE DATE IMr DNYYY) 11/09/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: IT the certificate holder Is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. B SUBROGATION IS WANED, 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 auch andomemar a), PRODUCE0. NAME: TIM FRANZ $fatefdRll TIM FRANZ- AGENT WCNE -559-251-3777 FAx e59. No : 5251-0653 = SUITE A ADORE , TIM.FF NZ.B9HMCSTATEFARM.COM 5534 E KINGS CANYON RD NSURE S AFFORDING COVERAGE twcs FRESNO CA 93727 INSURER t State Farm General Insurance Company 25151 INSURED INSURER B: State Farm Mutual Automobile Insurance Company 25178 INSURER C : HALCYON BEHAVIORAL LLC INSURER D: 1080 W SHAW AVE STE 105 INSURER E: FRESNO CA 93711 INSURER F: COVERAGES CERTIFICATE NUNRERe DFVISION NUMRFR. 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. NSR TYPE OF INSURANCE IADDLSUBR POLICY NUMBER POIJCYEFF fMwDDNYYY1 POLICYEXP IMMIDONY170Ulna q CONMERCIALOENERAL LIABILITY CLAMS -MADE © OCCUR Y Y 9D-C3-N18S-SG 12/09/2020 12/09/2022 EACHOCCURRENCE S 2,000.000 PREMISESIEs S 300,000 MED EXP(My are pae0n $ 6,000 I PERSONAL RAW INJURY S GENT AGGREGATE LIMIT APPLIES PER: POLICY JET LOC OTHER GENERALAOGREOATE $ 4,000.000 PRODUCTS-COAPIOPAGG S 4,000.000 S B AUTOIgBa LIABILITY ANY AUTO OWNED � M OS ONLY "CH ALT HIRED NONOWNED AUTOS ONLY AUTOS ONLY Y 4621262-C74-55 09/14/2021 09114/2022 Ea de s 2,000,000 BODILY INJURY (Par pawn) $ BODILYINJURY(Pereetldmt) S PROPERTYCAMAGE emhlent s S UMBRELLALMB EXCESS LIAR OCCUR CIAIMSMADE EACHOCCURRENCE $ AGGREGATE $ DED 1 1 RETENTIONS $ A WORKERS COMPENSATION AND ENPLOYERS' WBIIJTY 0Y�GyM� TMD�ECU� Y (Mwdatery In NH) n yyes, deacriDe uMer DMMd TON OF OPERATIONS bete. NIA Y 90-EO-M970-5 09/1712021 09,17,2022 I P R OTH- STATU E ER E.L EACH ACCIDENT $ 1.000,ODO E.L DISEASE. EA EMPLOYE $ 1,000,000 E.L DISEASE -POLICY LIMIT $ 1,000,000 T- DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORO 401, AdGItbnH Remark* 6cfadda, may Oa at wN mera war la r"untd) Please see attached endorsements CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Santa Ana AU 10112Fn REPRESENTATIVE Risk Management Division 20 Civic Center Plaza (M-30) Completed by an aut to Farm tative. B signature Sara Ana CA 92702 Is required, please a State F O 1988.2015 ACORD C ACORD 25 (2016103) The ACORD name and logo arc registered marks of ACORD a RWeMMagl»umiDiviskin oI %..E^M� CCREVIEWED6'PR VED Bv/: R. AP aE7L 1 T Risk Management Analyst YPJ Policy No. 90 C3N185 5 1569-FBDC CMP-4786.1 Page 1 of 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CMP-4786.1 ADDITIONAL INSURED — OWNERS, LESSEES, OR CONTRACTORS (Scheduled) This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 90 C3N185 5 Named Insured: HALCYON BEHAVIORAL LLC 1080 W SHAW AVE STE 105 FRESNO CA 93711-3722 Name And Address Of Additional Insured Person Or Organization: CITY OF SANTA ANA RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA PO BOX 1988 SANTA ANA, CA 92702 1988 SECTION II — WHO IS AN INSURED of SECTION ll — LIABILITY is amended to in- clude, as an additional insured, any person or organization shown in the Schedule, but only with respect to liability for 'bodily injury", "property damage", or "personal and advertis- ing injury" caused, in whole or in part, by: a. Ongoing Operations (1) Your acts or omissions; or (2) The acts or omissions of those acting on your behalf; in the performance of your ongoing opera- tions for that additional insured; or b. Products — Completed Operations "Your work" performed for that additional insured and included in the "products - completed operations hazard". However, Paragraph 1. above is subject to the following: a. The insurance afforded to the additional insured only applies to the extent permit- ted by law; b. If coverage provided to the additional in- sured is required by a contract or agree- ment, the insurance provided to the additional insured will not be broader than that which you are required by the contract or agreement to provide for such addition- al insured; and c. If the contract or agreement between you and the additional insured is governed by California Civil Code Section 2782 or 2782.05, the insurance provided to the additional insured is the lesser of that which: (1) Is allowed for the satisfaction of a de- fense or indemnity obligation by Cali- fornia Civil Code Section 2782 or 2782.05 for your sole liability; or (2) You are required by contract or agreement to provide for such addi- tional insured. We have no duty to defend or indemnify the additional insured under this endorsement un- til a claim or "suit' is tendered to us. 0, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. CONTINUED "MOugemadDivisim RenEwED&APPRwm8r. Risk Management Analyst 2. Any insurance provided to the additional in- sured shall only apply with respect to a claim made or a "suit" brought for damages for which you are provided coverage. 3. With respect to the insurance afforded to the additional insured, the following is added to SECTION II — LIMITS OF INSURANCE: If coverage provided to the additional insured is required by contract or agreement, the most we will pay on behalf of the additional insured will be the lesser of the amount of insurance: a. Required by the contract or agreement; or b. Available under the applicable Limits Of Insurance shown in the Declarations. This endorsement shall not increase the ap- plicable Limits Of Insurance shown in the Declarations. 4. With respect to the insurance afforded to the additional insured, the following is added to Paragraph 3. Duties In The Event Of Occur- rence, Offense, Claim Or Suit of SECTION II — GENERAL CONDITIONS: The additional insured must: a. See to it that we are notified as soon as practicable of an "occurrence' or an of- fense which may result in a claim. To the extent possible, notice should include: (1) How, when and where the "occur- rence" or offense took place; CMP-4786.1 Page 2 of 2 (3) The nature and location of any injury or damage arising out of the 'occur- rence" or offense; b. Tender the defense and indemnity of any claim or "suit' to us and to all other insur- ers who may have insurance potentially available to the additional insured; and c. Agree to make available any other insur- ance the additional insured has for de- fense or damages for which we would provide coverage under SECTION II — LIABILITY. 5. With respect to the insurance afforded the ad- ditional insured, the following replaces SEC- TION II —LIABILITY of Paragraph 7. Other Insurance of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: a. This insurance is primary to and will not seek contribution from any other insurance available to the additional insured, provided that the additional insured is a named in- sured under such other insurance. b. Regardless of any agreement between you and the additional insured, this insur- ance is excess over any other insurance whether primary, excess, contingent or on any other basis for which the additional in- sured has been added as an additional in- sured on other policies. There will be no refund of premium in the event this endorsement is cancelled. (2) The names and addresses of any in- jured persons and witnesses; and All other policy provisions apply. CMP-4786.1 1007033 148011 08-21-2014 ®, Copyright, State Farm Mutual Automobile Insurance Company, 2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Rote Management Division REVIEWI &pAP'PIR�0VMBY.' ' ��/'i./N�he ram. Va(XFAFlL ® Risk Management Analyst YPJ Policy No. 90 C3N185 5 90 C3N185 5 CMP-4787 Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY CMP-4787 WAIVER OF TRANSFER OF RIGHTS OR RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Policy Number: 90 C3NI85 5 Named Insured: HALCYON BEHAVIORAL LLC 1080 W SHAW AVE STE 105 FRESNO CA 93711-3722 Name And Address Of Person Or Organization: CITY OF SANTA ANA RISK MANAGEMENT DIVISION 20 CIVIC CENTER PLAZA PO BOX 1988 SANTA ANA, CA 92702 1988 The following is added to Paragraph 10.b. of SECTION I AND SECTION II — COMMON POLICY CONDITIONS: We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for injury or damage arising out of: a. Your ongoing operations; or b. "Your work" done under contract with that person or organization and included in the "products - completed operations hazard". This waiver applies only to the person or organization shown in the Schedule. All other policy provisions apply. CMP-4787 ®, Copyright, State Farm Mutual Automobile Insurance Company, 2008 1006225 137715.1 11-19-2013 Includes copyrighted material of Insurance Services Office, Inc., with its permission. a �'�I _ ���� RWeMawgemattDivisian REVIEWED 6 APPROVED BY. ? � P. U:. IAt Risk Management Analyst ACORH CERTIFICATE OF LIABILITY INSURANCE ll.� 9/l/2022 F DATE(NIMnDNYYY) 1 11/9/2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy()es) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Lockton Insurance Brokers, Inc. 400 Capitol Mall Avenue, Suite 2600 Sacramento CA 95814 (213) 689-0550 CONTACT NAME: PHONE FAX ac Na: E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIGp INSURER A: IronshoreSpecialty Insurance Co 25445 INSURED Halcyon Behavioral, LLC 1499172 1080 W Shaw #105 INSURER B: North American Capacity Insurance Co 25038 INSURER C: FIesno CA 97311 INSURER D : 11 INSURER E: INSURER F: COVERAGES PHYCL03 CERTIFICATE NUMBER: 17999165 REVISION NUMBER- YvxxxYv THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR LTR TYPE OF INSURANCE ADDL SUER POLICYNUMBER POLICY EFF MMIDDTYYYY POLICY EXP MMIDDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR NOT APPLICABLE EACH OCCURRENCE $ XXXXXX){ -DAUVES(TO RENTED PREMISES EeoccuD $ i{i{i{i{}{}(}{ MEP EXP (Anyone person) $ XXXXXX){ PERSONAL S ADV INJURY $ XXXXXXX GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ XXXXX) x POLICY PRO- LOC ECT PRODUCTS- $ }Q{Y{}_X X It OTHER: AUTOMOBILE LIABILITY NOT APPLICABLE COMBINED SINGLE LIMIT Ea accident $ XXXX){XX BODILY INJURY (Per parson) $ ]{){){yX'X){ ANY AUTO OWNED SCHEOULEp AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ XXXXXXX HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE Per accident $ XXX)O $ XXXXX) x UMBRELLA LIAB OCCUR NOTAPPLICABLE EACH OCCURRENCE $ XXXX)XSXX AGGREGATE $ X)DCX= EXCE5S LIAB CLAIMS -MADE pEO I RETENTION$ $ xx {){xxx WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PRCPRIETOWPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUCED9 ❑ NIA NOTAPPLICABLE PER FIR STATUTE ER E.L. EACH ACCIDENT $ XXXXXXX E.L. DISEASE - EA EMPLOYEE $ XXXXXXX (Mandatory in NH) It yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT S XXXXXXX A Managed Care E&O Liability N N HC7CAB4HM9002 10/292021 10/29/2022 $1M/$2M B —Prim C-4LRK-041319-CYBER-2021 9/l2021 9/1/2022 $3M Cyber DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101. Additional Remarks Schedule, may be attached if more space Is required) THIS CERTIFICATE SUPERSEDES ALL PREVIOUSLY ISSUED CERTIFICATES FOR THIS HOLDER, APPLICABLETO THE CARRIERS LISTEDAND THE POLICY TERM(S) REFERENCED. HOLDER 17899365 City of Santa Ana Risk Management Division 20 Civic Center Plaza Santa Ana CA 92702 ACORD 25 (2016/03) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED r nuesmrmagc ciudmason �le�l�� I ' ��,, REVIEWEDSAPPROVBDBY: ©f 88-261Ac D c , i'' The ACORD name and logo are registered marks of ACORD ' auk Management Analyst NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor Halcyon Behavioral LLC Name: Project N-2021-201-01 Number: Project First Amendment To Agreement With Halcyon Behavioral, LLC 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 2022 CERT City of AUTOMOBILE LIABILITY 57SBABN5132 01/01/2023 09/27/2022 Santa Ana 09272022.pdf 09282022 CERT City CYBER LIABILITY AX01055004 07/01/2023 09/28/2022 of Santa Ana.pdf 1665748585.0524035- ACORD 0025 2016- CYBER LIABILITY AX01055004 07/01/2023 10/14/2022 03 Acroform- locked.pdf 1665748585.0524035- ACORD 0025 2016- EXCESS TECH E&O / CYBER EKS3445640 07/01/2023 10/14/2022 03 Acroform- locked.pdf 2022 CERT City of GENERAL LIABILITY 57SBABN5132 01/01/2023 09/27/2022 Santa Ana 09272022.pdf 2022 CERT City of WORKERS COMPENSATION AND 57WECAF7PA9 01/01/2023 09/27/2022 Santa Ana EMPLOYERS' LIABILITY 09272022.pdf Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 10/25/2022 11:58 AM NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor Halcyon Behavioral LLC Name: Project N-2021-201-01 Number: Project First Amendment To Agreement With Halcyon Behavioral, LLC 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 2022 CERT City AUTOMOBILE LIABILITY 57SBABN5132 01/01/2023 09/27/2022 of Santa Ana 09272022.pdf 09282022 CERT CYBER LIABILITY AX01055004 07/01/2023 09/28/2022 City of Santa Ana.pdf 2022 CERT City GENERAL LIABILITY 57SBABN5132 01/01/2023 09/27/2022 of Santa Ana 09272022.pdf PROFESSIONAL LIABILITY HC7CAB4HM9002 10/29/2022 09/20/2022 2022 CERT City WORKERS COMPENSATION AND 57WECAF7PA9 01/01/2023 09/27/2022 of Santa Ana EMPLOYERS' LIABILITY 09272022.pdf Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor Halcyon Behavioral LLC Name: Project N-2021-201-01 Number: Project First Amendment To Agreement With Halcyon Behavioral, LLC 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 12192022 CERT City of AUTOMOBILE LIABILITY 57SBABN5132 01/01/2024 12/19/2022 Santa Ana Compliance (CSA - R1351).pdf 09282022 CERT City of CYBER LIABILITY AX01055004 07/01/2023 09/28/2022 Santa Ana.pdf 1665748585.0524035- CYBER LIABILITY AX01055004 07/01/2023 10/14/2022 ACORD 0025 2016-03 Acroform-locked.pdf 1665748585.0524035- EXCESS TECH E&O / CYBER EKS3445640 07/01/2023 10/14/2022 ACORD 0025 2016-03 Acroform-locked.pdf 12192022 CERT City of GENERAL LIABILITY 57SBABN5132 01/01/2024 12/19/2022 Santa Ana Compliance (CSA - R1351).pdf 12192022 CERT City of UMBRELLA LIABILITY 57SBABN5132 01/01/2024 12/19/2022 Santa Ana Compliance (CSA - R1351).pdf POLICY EXPIRATION TYPE OF INSURANCE COI DATE FILE NAME NUMBER DATE 1665748585.0524035- UMBRELLA LIABILITY 57SBABN5132 01/01/2023 10/14/2022 ACORD 0025 2016-03 Acroform-locked.pdf 12192022 CERT City of WORKERS COMPENSATION AND 57WECAF7PA9 01/01/2024 12/19/2022 Santa Ana Compliance EMPLOYERS' LIABILITY (CSA - R1351).pdf Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 12/20/2022 11:41 AM NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor Halcyon Behavioral LLC Name: Project N-2021-201 Number: Project Agreement With Halcyon Behavioral Administrators To Name: Provide Wellness Program Plus Services 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 12192022 CERT City of Santa Ana AUTOMOBILE LIABILITY 57SBABN5132 01/01/2024 12/19/2022 Compliance (CSA - R1351).pdf SIMTH01-City of Santa Ana- EXCESS TECH E&O/CYBER E5K3485033 07/01/2024 07/07/2023 19715405(R).pdf 2022 CERT City of Santa Ana GENERAL LIABILITY 57SBABN5132 01/01/2024 12/26/2022 Compliance (CSA - R1351) 12262022.pdf SIMTH01-City of Santa Ana- TECH E&O/CYBER H23TG3367600 07/01/2024 07/07/2023 19715405(R).pdf 2022 CERT City of Santa Ana UMBRELLA LIABILITY 57SBABN5132 01/01/2024 12/26/2022 Compliance (CSA - R1351) 12262022.pdf WORKERS COMPENSATION AND 12192022 CERT City of Santa Ana 57WECAF7PA9 01/01/2024 12/19/2022 EMPLOYERS' LIABILITY Compliance (CSA - R1351).pdf Thank you, City of Santa Ana Risk Management Division NOTICE OF COMPLIANCE CITY STAFF: PRINT THIS PAGE AND INCLUDE WITH AGREEMENT TO THE CLERK OF THE COUNCIL Contractor Halcyon Behavioral LLC Name: Project N-2021-201-01 Number: Project First Amendment To Agreement With Halcyon Behavioral, LLC Name: The Certificate of Insurance (COI) submitted indicates that the coverages comply with the insurance requirements. The compliant coverage(s) are: POLICY EXPIRATION TYPE OF INSURANCE COI DATE FILE NAME NUMBER DATE City of Santa Ana AUTOMOBILE LIABILITY 57SBAAY4GNC 01/01/2025 12/19/2023 Insurance COI 12.19.2023.pdf City of Santa Ana GENERAL LIABILITY 57SBAAY4GNC 01/01/2025 01/11/2024 COI 01112024 CORRECTED.pdf SIMTH01-City of TECH E&O/CYBER H23TG3367600 07/01/2024 07/07/2023 Santa Ana- 19715405(R).pdf SIMTH01-City of TECH E&O/CYBER H23TG3367600 07/01/2024 07/07/2023 Santa Ana- 19715405(R).pdf City of Santa Ana UMBRELLA LIABILITY 57SBAAY4GNC 01/01/2025 01/11/2024 COI 01112024 CORRECTED.pdf City of Santa Ana WORKERS COMPENSATION AND 37WECAF7PA9 01/01/2025 12/19/2023 Insurance COI EMPLOYERS' LIABILITY 12.19.2023.pdf No further action is required at this time. Thank you, City of Santa Ana Risk Management Division in partnership with CTrax Plus Services Team 1/17/2024 12:11 PM