HomeMy WebLinkAboutSUNRISE MULTISPECIALISTS MEDICAL CENTER (2)oSURANCE ON FILE N-2021.179-01
WORK MAY PROCEED
UNTIL INSURANCE EXPIRES
S. l 22
CLERK OF COUNCIL
DATE'
FIRST AMENDMENT TO AGREEMENT
APR 1 9 2022 FOR MEDICAL SERVICES AND TESTING
THIS FIRST AMENDMENT to the above -referenced agreement is entered into on April V �,
2022 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. The parties entered into Agreement #N-2021-179, dated September 14, 2021, by which
Consultant agreed 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.
("Agreement"). The Agreement continues through August 11, 2024, and is current and in -
effect.
B. In its efforts to combat and meet safety requirements related to the ongoing COVID-19
pandemic, City has engaged Consultant to provide mandated daily testing for COVID-19 for
the City's correctional officers.
C. The parties now wish to increase the compensation for the Agreement to cover the costs
required for this increased testing related to COVID-19.
The Parties therefore agree:
1. Section 2.a, Compensation, is amended to increase the total amount to be expended under the
Agreement by twenty-five thousand dollars ($25,000.00). The total amount for services to be
provided under this Agreement shall not exceed seventy-five thousand dollars ($75,000).
2. Except as modified by this First Amendment, all terms and conditions of the Agreement shall
remain in full force and effect.
IN WITNESS WHEREOF, the parties hereto have executed this First Amendment to the
Agreement on the date and year first written above.
ATTEST
Daisy Gomez
Clerk of the Council
CITY OF SANTA ANA
pvL 1�_
Kristine Ridge
City Manager
Page 1 of 2
N-2021-179-01
APPROVED AS TO FORM
Sonia R. Carvalho
City Attorney
By:c�l Gnnn�_ �PMI v v
Laura A. Rossini
Chief Assistant City Attorney
NDED FOR APPROVAL
KXCCutive Director
Human Resources Agency
CONSULT
William H. Nuesse, M.D.
William H. Nuesse, M.D. and
Mary Ann Nuesse, D.O., a medical
corporation dba Sunrise Multispecialist
Medical Center
Page 2 of 2
A/"J'90 r®
Francine R. Digitally signed by Francine R.
Villareal
Villareal Date; 2021.06.1017:11:17
-07'00'
CERTIFICATE OF LIABILITY INSURANCE
°Aoerz4(20ZI Y"'
THISCERTINCATEIS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTSUPONTHECERTIFICATE HOLDER,THISCERnFICATE DOES NOTAFFIRMATIVELYOR NEGATIVELY
AMEND, EXTEND ORALTERTHE COVERAGEAFFORDED BYTHE POLICIES BELOW.THISCERTIFICATE OF INSURANCEDOES NOTCONSTITUTEACONTRACT BETWEENTHEISSUING INSURERS),
AUTHORIZED REPRESENTATIVEOR PRODUCER, ANDTHECEROFICATEHOLDER.
IMPORTANT.IfthteeniBataholderlsan ADDmONALINSURED,th%Polley(las)mosthmeADOn10NAL1NSURVDPnMslonswbeendorsed,lfWBRoW[ON1SWAIVED,subja tothetermsand
condilionsofths polity, certain wilcim mayfequiman endorsement Asmlement on thbmrtlBmmdoesnatconh:rfightstothemrUg"teholderin neo ofsuch wdomemmN(s).
PRODUCER
CONTACT
NAME: Theresa Simes
Theresa Simes(9744576)
PHONE
FAX
17165 Newhope St SIR F
(A/C, NO, EXT): 714-966-3000
(A/C, NO): 714-966-3013
E-MAIL
Fountain Valley CA 92708-4230
ADDRESS: tsimes@fannersagent.00m
INSURERS) AFFORDING COVERAGE
NAICR
INSURED
INSURERA: Truck Insurance Exchange
21709
Insurance Exchange
21552
WILLIINSURERS-.Farmers
867 S TUSTIN ST M H NUESSE M.D.
67 S
INSURERC Mid Century Insurance Company
21687
INSURE0.O:
ORANGE CA 92866
INSURERS:
INsURERF:
COVERAGES CERTIFICATE NUMBER. REVISIONNUMBER
THGISTOCERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTOTHE INSURED NAMEABOVEFORTHEPOUCY PERIOD INDICATED. NOTWITHSTANDINGANY
REQUIREMENT, TERM OR CONDITION OFANY CONTRACTOR OTHER DOCUMENT WITH RESPECrTO WHICH THISCERTIFICATE MAYBE ISSUED OR MAY PERTAM,THE INSURANCEAFFORDED BYTHE
POLICIESDESCRIBED HEREIN ISSUBJECTTOALLTHETERMS, EXCLUSIONSAND CONDITIONSOFSUCH POLICIES. LIMITSSHOWN MAYHAVE BEEN REDUCED BYPMDCW MS.
INSR
17R
TYPEOFINSURANCE
ADDTL
INSO
BUBR
WVD
Polio NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
LIMBS
A I
COMMERCIALGENERALLIABILRY
CLAIMS-MADE OCCUR
Y
N
602378275
05/2912021
05/29MO22
EACHOCCURRENCE
S 2,000,00
DAMAGETORENTED
PREMISES(Ea Occurrence)
S
500,00
MEDEXP(Anyonaparson) Is
600
I
PERSONALBADVINJURY
S 2,000.00
GEN'L AGGREGATEUMITAPPUESPER:
POLICY ❑ PROJECT ❑ LOC
OTHER:
GENERALAGGREGATE
$ 4,000.00(
PRODUCTS-COMP/OPAGG
S 2,000.00
S
A
AUTOMCBILEUABIUTY
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AUTS
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ONLY AUTOS ONLY
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602378275
05/2912021
05/2W022
COMBINEDSINGIEUMIT
(Ea accident)
$ 2,000,00
BODRYINJURY(Pe parson)
$
BODRYINJURY(PerarCdent)
$
PROPERTY DAMAGE
(Peracck)ant)
$
S
UMBBELLALIAB
EXCESSI
OCCUR
CWM&MADE
EACH OCCURRENCE
S
AGGREGATE
S
DIED RETENTIONS
S
WORRERSCOMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/ Y/N
EXECUTIVE OFFICER/MEMBER
EXCLUDED? (Mandatory in PH)
Ifyes, describe under DESCRIPTION OF
OPERATIONS belaw
N/A
PER
STATUTE
OTHER
$
E.L. EACH ACCIDENT
S
F.L. DISEASE -EA EMPLOYEE
E.L DISEASE -P06CY LIMIT
S
DESCRIPf WN RATIONS/LOCATIONS/VEHICLES(ACORD 101, Additional Remarks Schedule, may be attached If mom space is requlmd)
67 S TUSTIN ST, ORANGE, CA 92865
ertigcate of insurance shall provide 30 day prior written notice of cancellation
CERTIFICATEHOLDER
20 CIVIC CENTER PLZ
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES
DATE THEREOF NOTICE WILL BE DPIIVVERR]EO�I�jJ ADO
AUT14ORMO REPRESENTATal ,{)y/7A V7�
y.. ACORD 25 (2016/03) ®7988-2015ACORDC �" . �5 REAEWED&APPROVED BY:
31-1769 11-15 The ACORD name and logo are registered marks ofACORD �^A^H^^'c �• �`
Risk Management Analyst
Samantha DigOally signed by
Samantha M. Lambert
AA I amhart Date: 1012.04.18
ACOIed® — tzoa:n ui on
`� CERTIFICATE OF LIABILITY INSURANCE
DATE( MDNYYY)
04/18/2022
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER Calhoun & Associates
CONTACT NAME: Carmen Ponce
DBA: Integrity Advisors
14771 Plaza Drive, Ste C
PHoNo .800-500-9799 uC N,: 714-664-0614
EMAIL carmen Inte rlt advisors.com
ADDRESS: @ 9 Y'
Tustin CA 92780
INSURERS AFFORDING COVERAGE
NAIC#
INSURERA_ EMPLOYERS ASSURANCE CO.
36870
INSURED William H. Nuesse, M.D. and Mary -Ann Nuesse, D.O., A Medical
INSURER e:
867 S TUSTIN ST.
INSURERC:
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
ADDLSUBR
POLICY NUMBER
POLICY EFF
MMIDD/YYYY
POLICY EXP
MMIDD/YYYY
LIMITS
COMMERCIAL GENERAL LIABILITYLi
CL41M5-MADE OCCUR
EACH OCCURRENCE
$
FTU RENTED
PREMISES Ea occunenrs
$
MED EXP (Any one person)
$
PERSONAL & ADV INJURY
$
GEN'L
AGGREGATE LIMIT APPLIES PER:
POLICY JECT LOC
GENERA -AGGREGATE
$
PRODUCTS - COMP/OP AGG
$
$
OTHER:
AUTOMOBILE
LIABILITYLi
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COMBINED SINGLE LIMIT
Ea accident
$
BODILY INJURY (Perpemon)
$
ANYAWO
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AUTOS ONLY AUTOS
(Par )
BODILY INJURY P ccident
$
HIRED AUTOSNON-OWNED LY
AUTOS ONLY AUTOS ONLY
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$
UMBRELLA LIAR
OCCUR
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FACHOCCURRENCE
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CLAIMS -MADE
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A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANYPROPRIETOWPARTNERIEXECUTIVE YIN
OFFICER/MEMBEREXCLUDEm Y❑
(Mandatory in NH)
NIA
EIG267502903
08/01/2021
08101/2022
PER OTF4
STATUTE ER
E.LEACHACCIDENT
$ 1,000,000
E.L. DISEASE -EA EMPLOYEE
$ 1,000,000
If
OF OPERATIONS below
E.L DISEASE -POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
City of Sant Ana
20 Civic Center Plaza (M-34)
PO Box 1988
Santa Ana, CA 92702
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
IISAafytINC+A th4saw
® Rbk Management Super,bor
THIS ENDORSEMENT CHANGESTHE POLICY. PLEASE READ IT CAREFULLY.
POLICY NUMBER: 602378275
FARMERS
INSURANCE
ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS LIABILITY COVERAGE FORM
BUSINESSOWNERS COVERAGE FORM
APARTMENTO WNERS LIABILITY COVERAGE FORM
CONDOMINIUM LIABILITY COVERAGE FORM
SCHEDULE
Name
will be shown in
j7238
1 st Edition
A. The following is added to Paragraph C. Who Is An Insured of the applicable Coverage Form:
Any person(s) or organization(s) shown in the Schedule is also an additional insured, but only with respect to
liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by
your acts or omissions or the acts or omissions of those acting on your behalf in the performance of your ongoing
operations or in 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 Expenses Limits 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 contractor 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.
J7238-ED 1 02-19 Includes copyrighted material of Insurance Services Office, Inc., with its permission.
937238
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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
removed. 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.
91A277 1S1EOI1100 7-02 Indudes Copyrighted Material, heumnaa Sanins OIOte, Inc, with is peralmim.
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93-7100
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
FARM E R 9
17100
2nd Edition
INSURANCE
PRIMARY AND NONCONTRIBUTORY INSURANCE
This endorsement modifies insurance provided under the:
BUSINESSOWNERS POLICY
SCHEDULE
Name of Additional Insured P
CITY OF SANTA ANA, OFFICERS,
-SEE J7105 AMEND TO ADDNL INS
The following is added to Paragraph H. Other Insurance of the Businessowners Common Policy Conditions and supersedes
any provision to the contrary:
Primary and Noncontributory Insurance
This insurance is primary to and will not seek contribution from any other insurance available to the additional insured shown
in the Schedule, provided that:
i. The additional insured shown in the Schedule is a Named Insured under such 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 anything to the contrary. It is otherwise subject to all the terms
of the policy
ry �".yana Rkk I%U&gemenED'MdDn .`
REAEweD&APPROV®BY:
RBA Management Analyst
POLICY NUMBER: 60237-82-75
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ ITCAREFULLY.
FARMERS 17105
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
VOLUNTEERS ARE NAMED AS ADDITIONALLY
INSURED ON THIS POLICY
17105-ED3 05-18 Includes copyrighted material of Insurance Services Office, Inc., with its permission.
93-7105
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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- ScheduledPersonOrOrganization
Additionallnsured - StateorPoliticalSubdivisions Permits
Additionallnsured - StateorPoliticalSubdivisions Permits Relating to Premises
Additional Insured -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.
RIAMtevganadDh6lcn
J7105-ED305-18 Includes co REmexm&ArPRcvm8v:
copyrighted material of l nsurance Services Office, Inc., with its permission, pp
93-7105 it F4111 i•'e.0 ram. va&✓ l
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
Medical Specialty
Coverage Date
Retroactive Coverage Date
21463
Family Medicine, With Minor
February 1, 2012
None
Surgery
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 Date
Vice President, Membership Services
Mutual Protection Trust
December 30, 2020
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Risk Management Analyst
ME
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
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.
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
�\� R4k ManagemenE Dtvirlon
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COOPERATIVE OF
AMERICAN PHYSICIANS
CERTIFICATE OF COVERAGE
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 tinder the terms, conditions and exclusions of the MPT
Agreement.
Membership Number I Medical Specialty
13925 Family Medicine, With Minor
Surgery
Subspecialty
Coverage (Claims made and paid)
Medical Professional Liability Coverage
Coverage Date
April 1, 2004
Current Limits of Liability
$1,000,000
$3,000,000
Retroactive Coverage Date
February 1,2002
for all Claims based
upon an Occurrence
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
RiskMansgementDisisian
CRIgEwED&APPft.OeVf®By.
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Risk Management Analyst
COOPERATIVE OF
AMERICAN PHYSICIANS
CERTIFICATE OF COVERAGE AND CLAIMS HISTORY
Coverage through December 31, 2021
Member: Mary-AnnNuesse, 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 die 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
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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 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
Medical Specialty
Coverage Date
Retroactive Coverage Date
13924
Family Medicine, With Minor
April 1, 2004
February 1, 2002
Surgery
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 Date
Vice President, Membership Services
Mutual Protection Trust
December 30, 2020
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COOPERATIVE OF
AMERICAN PHYSICIANS
CERTIFICATE OF COVERAGE AND CLAIMS HISTORY
Coverage through December 31, 2021 aaj
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 tenons, conditions and exclusions of the MPT
Agreement.
Membership Number
13924
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 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
IN
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REVIEWED&APPRovm Br.
Risk Management Analyst
EMPLOYER:
Workers' Compensation and Employers Liability
Insurance Policy
EMPLOYERS PREFERRED INS. CO.
Policy Number From Policy Period
To
A Stock Company
EIG 2675029 02
08/01/2020 08/01/2021
1 Insi0.1e . s'sheyei�i�ere�n eatthesddms 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
1
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 Expense Constant $ 160
Premium Discount $ -878
Assessments and Taxes $ Total Estimated AnnualPremium $ 13,284
❑ This is a Three Year Fixed Rate Policy
Premium Adjustment Period: ® Annual; ❑ Semiannual; ❑ Quarterly; ❑ Monthly
Countersigned this Day of 44�744��
Issued Date: 08/13/2020 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 (5/98 Ed.)
Page 1 of 4
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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,