HomeMy WebLinkAboutCOLUCCI, DENNIS A. 1-2003
INSURANCE ON FILE
WORK MAY PROCEED
UNTIL INS~RAN E EXPIRES
39 'I .,
CLERK OF CO~ 9~ CONSUL T ANT AGREEMENT
DATE: ð'/Š/O b
THIS AGREEMENT, made and entered into this30tv day of JZttlV ,2003 by
and between Dennis A. Colucci (hereinafter "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 (hereinafter "City").
N-2003-063
RECITALS
A. The City desires to retain a consultant having special skill and knowledge in the field of
audiology, to perfollll hearing evaluation and diagnostic testing of City employees.
B. Consultant represents that Consultant is able and willing to provide such services to the
City.
C. In undertaking the perfollllance of this Agreement, Consultant represents that it is
knowledgeable in its field and that any services perfolllled by Consultant under this
Agreement will be perfolllled in compliance with such standards as may reasonably be
expected from a professional consulting fillll in the field.
NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the
telllls and conditions hereinafter set forth, the parties agree as follows:
1.
SCOPE OF SERVICES
Consultant shall perfollll those services as set forth in Exhibit A to this Agreement.
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 sum to be expended under this
Agreement, shall not exceed $10,000.00 during the tellll of this Agreement.
b. Payment by City shall be made within thirty (30) days following receipt of proper
invoice evidencing work perfolllled, subject to City accounting procedures. Payment need not
be made for work which fails to meet the standards of perfollllance set forth in the Recitals
which may reasonably be expected by City.
3.
TERM
This Agreement shall commence on the date first written above and tellllinate on June 30,
2006, unless tellllinated earlier in accordance with Section 12, below. The tellll of this
Agreement may be extended upon a writing executed by the Executive Director of Personnel and
the City Attorney.
4.
INDEPENDENT CONTRACTOR
Consultant shall, during the entire term of this Agreement, be construed to be an
independent contractor 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 manner 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 manner 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
Prior to undertaking performance of work under this Agreement, Consultant shall
maintain and shall require its subcontractors, if any, to obtain and maintain insurance as
described below:
a. Professional liability (errors and omissions) insurance, with a combined single limit
of not less than $1,000,000 per claim.
b. The following requirements apply to the insurance to be provided by Consultant
pursuant to this section:
(i)
Consultant shall maintain all insurance required above in full force and
effect for the entire period covered by this Agreement.
Certificates of insurance shall be furnished to the City upon execution of
this Agreement and shall be approved in form by the City Attorney.
Certificates and policies shall state that the policies shall not be canceled
or reduced in coverage or changed in any other material aspect without
thirty (30) days prior written notice to the City.
(ii)
(iii)
c. If Consultant fails or refuses to produce or maintain the insurance required by this
section or fails or refuses to furnish the City with required proof that insurance has been procured
and is in force and paid for, the City shall have the right, at the City's election, to forthwith
terminate this Agreement. Such termination shall not effect Consultant's right to be paid for its
time and materials expended prior to notification of termination. Consultant waives the right to
receive compensation and agrees to indemnify the City for any work performed prior to approval
of insurance by the City.
6.
INDEMNIFICATION
Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents,
employees, consultants, special counsel, and representatives from liability: (I) for personal
injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims
for personal injury, including health, and claims for property damage, which may arise from the
2
direct or indirect operations of the Consultant or its contractors, subcontractors, agents,
employees, or other persons acting on their behalf which relates to the services described in
section I of this Agreement; and (2) from any claim that personal injury, damages, just
compensation, restitution, judicial or equitable relief is due by reason of the terms of or effects
arising from this Agreement. This indemnity and hold harmless agreement applies to all claims
for damages, just compensation, restitution, judicial or equitable relief suffered, or alleged to
have been suffered, by reason of the events referred to in this Section or by reason of the terms
of, or effects, arising from this Agreement. The Consultant further agrees to indemnify, hold
harmless, and pay all costs for the defense of the City, including fees and costs for special
counsel to be selected by the City, regarding any action by a third party challenging the validity
of this Agreement, or asserting that personal injury, damages, just compensation, restitution,
judicial or equitable relief due to personal or property rights arises by reason of the terms of, or
effects arising from this Agreement. City may make all reasonable decisions with respect to its
representation in any legal proceeding.
7.
CONFIDENTIALITY
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 perfOlmance 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 without 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.
8.
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.
9.
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 telefacsimile or other
telegraphic communication in the manner provided in this Section, to the following persons:
3
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
telefacsimile (714) 647-6956
With courtesy copies to:
Risk Manager
City of Santa Ana
20 Civic Center Plaza (M-28)
P.O. Box 1988
Santa Ana, California 92701
telefacsimile (714) 647-5317
and,
City Attorney
City of Santa Ana
20 Civic Center Plaza (M-29)
P.O. Box 1988
Santa Ana, California 92702
telefacsimile (714) 647-6515
To Consultant:
Dennis A. Colucci, M.A." F AAA
24902 Moulton Parkway
Laguna Woods, California 92653
A party may change its address by giving notice in writing to the other party. Thereafter,
any notice, tender, demand, delivery, or other communication shall be addressed and transmitted
to the new address. If sent by mail, any notice, tender, demand, delivery, or other
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 telefacsimile, any notice, tender, demand, delivery, or
other 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.
10.
EXCLUSIVITY AND AMENDMENT
This Agreement represents the complete and exclusive statement between the City and
Consultant, and supersedes any and all other agreements, oral or written, between the parties. In
4
the event of a conflict between the terms of this Agreement and any attachments hereto, the
terms of this Agreement shall prevail. This Agreement may not be modified except by written
instrument signed by the City and by an 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 nor
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.
11. 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.
12.
TERMINATION
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 which fails to meet the standard of performance
specified in the Recitals of this Agreement.
13.
DISCRIMINATION
Consultant shall not discriminate because of race, color, creed, religion, sex, marital
status, sexual orientation, age, national origin, ancestry, or disability, as defined and prohibited
by applicable law, in the recruitment, selection, training, utilization, promotion, termination or
other employment related activities. Consultant affirms that it is an equal opportunity employer
and shall comply with all applicable federal, state and local laws and regulations.
14.
JURISDICTION - VENUE
This Agreement and all questions relating to its validity, interpretation, performance, and
enforcement shall be governed and construed in accordance with the laws of the State of
California. This Agreement has been executed and delivered in the State of California and the
5
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.
15.
PROFESSIONAL LICENSES
Consultant shall, throughout the term of this Agreement, maintain all necessary licenses,
permits, approvals, waivers, and exemptions necessary for the provision of the services
hereunder and required by the laws and regulations of the United States, the State of California,
the City of Santa Ana and all other governmental agencies. Consultant shall notify the City
immediately and in writing of her inability to obtain or maintain such permits, licenses,
approvals, waivers, and exemptions. Said inability shall be cause for tern1ination of this
Agreement.
16.
MISCELLANEOUS PROVISIONS
a. Each undersigned represents and warrants that its signature hereinbelow 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.
II
II
II
II
II
II
II
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IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year
first above written.
ATTEST:
CITY OF SANTA ANA
/~~
~..~..
. PATRICIA E. HEALY
Clerk of the Council
~~
City Manager
APPROVED AS TO FORM:
JOSEPH W. FLETCHER
City Attorney
By:~~Jt,)'~7
Lau a Sheedy
Assistant City Attorney
RECOMMENDED FOR APPROVAL:
CONSULTANT
Tax ID#
~Ý6 oJ- 7 S ) I
.
7
EXHIBIT A
SCOPE OF SERVICES
Consultant shall perform services as outlined in his letters dated May 1,2003 and May 8, 2003,
attached hereto.
The audiological reports and a copy of the exam results shall be sent to:
Risk Manager
20 Civic Center Plaza, M-28
Santa Ana, California 92701
Attn: Loss Control Analyst
8
ß5/,ß5/2ßß3
ß8:58
g4g-83ß2324
DENNIS COLUCCI MA
PAGE
ßI/ßl
Dennis A. Colucci, M.A., FAAA
D¡'gno,tlc Audiology 8nd "Armg Rendilittlllon
SfMrd C,rtifl«lln AUdiology
Patient:
Date:
24902 Moulton Parkw~y
Laguna Wooda, Ca 92853
849 830.5770 941 830-2324 FAX
licen... AU 348/ HA 1028
55N:
DaB:
Physician
M.D. UPIN:
Lie.
0 92557 Comprehcn:ç,jvc Hearing E"atuulOO 10.00 0 92582 PedÎltTÌc Bv,ru3rjon 155.00
0 92552 Air Conduction Test 2900 0 92583 PiCtUre Selection T~st 58.00
0 92553 Air 8(\d BOf'le Conduction Tcs~ 5800 0 92506 Au.dltory Pcrcepuon Evah,l8llion 110.00
0 92562 ABLB nOD 0 92507 AudiMry Therapy Number of UnitS
- -
0 92563 Tone Decay T~$ts 2500 0 92579 Visual ,Rcu-.forcement Alldiomefry 125.00
0 92565 Stenger, Pu~ Tone 2600 0 92596 Ear Protection ArttnlJ.lor Mceures 39.00
0 92577 Speech S"na"' 47.00 0 92572 Stacs''''d Spond.ic Word Tes' (SSW) 75.00
0 92567 Tympaoom<:h'y 4500 0 92576 Synlhcric; Sen(enct Identification Teu (551) M.OO
0 92568 ACOl1StiC Rct1~u 3500 0 92571 Filh:rcd Speech T~t 4000
0 92569 Aroush.c Refle" Decsy 35.00 0 92589 Comoel;na S IC<Ch T ", (ICM) 45.00
0 92584 ElcctrocochltQgt8phy 200.00 0 92589 Binaural ScpBMlltion TeSt (CCM) 45.00
0 92586 Auditory BrainSltm Evoked POlennaJs (LUl'ulcd) 200 00 0 92589 Pitch Pancrn Percc;ptiol1 Test 45.00
0 92585 Auditory Brain!itcm Bvalred Potenti.l. (Complex) 250.00 0 92589 Sequential Di¡ib Test 45.00
0 92531 R.ecOtdcd Fjstula Test 9000 0 92589 Hunng In Noise Test (HINT) 4 150.00
0 92541 Sponl.n.eouS Nystagmus 1'<:,ts 91.00 0 692.10 Cerumen M.I..MI¡cn\elu Procedurc $J5 I $45 1 -
0 92542 PositiON! Nystagmus T cau 9200 0 99243 ConsultatlOrl. 1Ðt, Exam, Decision, CaJcuJanon!i 1 -
0 92543 Bithcm'lalCalorics 4 18000 0 9259ß Hearing Aid Ev,luation, MOI1lJJtt.l ) 15000
0 92544 Optolcinetic Teate 75.00 0 92591 Beanng Aid EvaJuation, Bjnauf,l 300.00
0 92545 Oscillatlog Tflckmg Tests 6900 0 92592 Hearing Aid Conformity Bvalulllon, Mooaural 250.00
0 91546 Sinusoidal Vertical/HotÌzornal Axis Rotation Tu(S 6 240.00 0 92593 Heacins Aid Conformity Evaluacion. Binauul 500.00
0 92547 0 92594 Elc:erro-Acouscic Or Probe Mic Testing, Monaural 50.00
0 92595 ElectrO-Acoustic or Probe Mic Te,lins, Binaural ]00.00
0 92599 He81jng Aid Cle8O.Íns MOI1ôWraI 25.00
0 225.1 A,cou!tic Neurom. 0 92599 Hcarldg Aid CJellling Binaural 4000
0 38602 ActiVe: Meniere's DiseNe 0
92599 Earmold, MonlutaJ 65.00
0 388.43 Auditory DlScriJnnacion ~fcc;il
0 38914 Central .onfhe$$ 0 92599.22 EatTholds 8maural 130.00
0 3890 Conductive Hearing Lon 0 99202 New patient Office Vi,it 7000
0 8728 Ear Trauma 0 992'2 RepClt Office VI'II 40.00
0 381 81 Eust8c.hian Tuhe Dy,funttlon 0 92599 lo-lio.,. Repair $25 I $35/ $45 I $55 I $100
0 38841 Hyperaeu9¡'
0 92599 factory RepaIr 1200 / $250 I $300 / $350
0 380.4 JmpSCled CerumcJ1
0 3892 Muced Hcuißg Loss 0 92599 S8tœritS 10 312 13 675 x
0 38912 Neurøl He..,;"! Loss 0 99002 P,oduet DI'pen.9ing
0 3801 OtitíJExtema 0 92599
0 382.9 OlEtr. Media 0 92599
0 3872 OfosclerOf;9
0 384.2 Perforated i)mp,,,ic Mc:mbrane
0 389.1I SenSOry Hearing Lo" CHARGES
0 389.13 Sensory tnd Neural Hearing Lou
0 388.31 Subjective Tlnnitu9 AMOUNT PAlO
0 388.2 Sudden Sen~orineural Hearing Lou SA LAl'iCE DUE
0 780.4 v. !Disc 1.1- llnum
Dennis A. Colucci, ALA., FAAA
Hearing and Balance Laboratory
Board Certified in Audiology
24902 Moulton Parkway
La9una Woods, Ca 92653
949 830-5770 FAX 830-2324
May 5, 2003
Ms. Emilyn Buenafe
Loss Control Technician
City of Santa Ana
P.O. Box 1988 M-28
Santa Ana, Ca 92702
RE: Consulting Agreement
Dear Ms. Buenafe:
I just realized after getting your fax that I am making this confusing. The $175.00 still applies to
cases of determining the STS. Should you need a Worker's Compensation Evaluation with
causation information, apportionment, and reporting, a longer evaluation and more documentation is
needed. I forgot to tell you that the higher fee is for a Worker's Compensation Evaluation not for the
STS. So, our agreement should include a basic STS evaluation for a base of $175.00 with further
discovery up to an additional $150.00. Additionally, if any of the cases become a Worker's
Compensation claim that average fee is $500.00 with an additional $250.00 for needed evaluations
and case research. I hope I cleared up the confusion.
Sin
ennis Colucci, M.A., FAAA
, Clinical Audiologist, AU 348
EXHIBIT A
..
Dennis A. Colucci, MA., FAAA
Hearing and Balance Laboratory
Board Certified in Audiology
24902 Moufton Parkway
Laguna Woods, Ca 92653
949 830-5770 FAX 830-2324
May 1, 2003
Ms. Emilyn Buenafe
Loss Control Technician
City of Santa Ana
P.O. Box 1988 M-28
Santa Ana, Ca 92702
. . '4
RE: Consulting Agreement
Dear Ms. Buenafe:
Thank you for your help conceming the renewal of my consulting agreement. Attached is my fee
schedule for services provided in my office. These are factored from the Medicare actuary rate
tables to insure balance in the fee structure for time spent on testing and interpretation. Since my
last contract, I have changed the minimum evaluation procedures to equal those provided in my
Medical-Legal practice. As an expert witness, I am called upon to testify in depositions and in court
on cases related to hearing loss and noise exposure. This requires that appropriate documentation
and evidence be provided conceming the relationship of the hearing loss to employment and
apportionment for medical and non-industrial causations. Typically, the average cost per patient will
be approximately $500.00. Should further testing or a long report with research may be an
additional $250.00.
I am currently the expert witness for the ARCO Medical Group, Valero-Wilmington Refinery, the
State of Califomia Speech Pathology and Audiology Board, as well as witness for both defense and
applicant personal injury cases. I am also in the final stages of finishing my dissertation for my
Clinical Doctorate from Central Michigan and Vanderbilt Universities. I also possess 29 years
experience. I have attached my resume for your review.
Attached is my malpractice insurance information and as you will see, I have already named the City
of Santa Ana into my additional insured. I would like the term of the agreement to be longer than a
yea, possibly 3 years. If I can be of further assistance please do not hesitate to call.
ß51,ß5/2ßß3
ß8:58
g4g-83ß2324
DENNIS COLUCCI MA
PAGE
eifel
Dennis A. Colucci, M.A., FAAA
D~nD'tlc Autllology .nd HfNrlng R~;JiQlJon
Board '8tfiNed I,. Audiology
24902 Moulton Parkway
Laguna Woods, Ca 92853
849 830-5770 948 830-2324 FAX
licen... AU 348 I HA 1028
Patient:
Date:
SSN:
DaB:
PhysicIan
M.D. UPIN:
Lie.
0 92557 Comprehensive Hearing Evaluation ) 1000 0 92582 Pediatric Evalualion 155.00
0 92552 A;r Conducti(lJ1 Test 2900 0 92583 PiC(IJl't Seleclion Test 5800
0 92HJ Air 8t\d Boot Conduction Tesrs 5800 0 92506 Auduory Perception Evaluation 110.00
0 92562 ABLB 27.00 0 92507 Auditory Th<.r.py Number ofUnics
- -
0 92563 Tone Decay Tcsts 2500 0 92579 Visual RcinfOrumcnt AlJdiornmy 125.00
0 92565 Stenger, P\lfY: TOl'le 2600 0 92596 Ear Ptoh:ct.iOq Atttnbltor Mcuures 39.00
0 92577 Speech Stonaer 47.00 0 92572 Steaa...d Spond.ic Wo,d rest (SSW) 75.00
0 92567 T}'IDpaIlo",e"Y 4500 0 92576 Synlhcric Scnletlce Idcntific.ation Te't (SSI) 6/).00
0 92568 Acouslic Reflexes 35.00 0 92571 Fllh::rcd Speech TC$t 4000
0 92569 A..œush.c Reftn Decay 35.00 0 92589 Competin8 Speech T .,t (rCM) 45.00
0 92584 Elcc:trocochleography 200.00 0 92589 Bin..,aJ Scp""'';on re" (CCM) 45.00
0 92586 Audllo()' 8rainslt.m Evoked POlennals (LlITulc:d) 200 00 0 92589 Pitch Panun Percc:ptiol1 Tcst 45.00
0 92585 Auditory BrairUitcm Evoked Potential, (Complex) 250.00 0 92589 Sequentilll Digits Test 45.00
0 92531 R.tcorðt:d Fjstula Test 9000 0 92589 Heanng Irt Noise Test (HINT.> 4 J5000
0 92541 Sponl."couS Nystagmus Tc,t, 91.00 0 69210 Cerumen Man.geMent Procedure 535 I 145 1
-
0 92542 Positional NystlgmU3 T esU 9200 0 99243 Consullalloo,1ix. Bxam, Deciaioo, CaJcuJauon!i 1
-
0 92543 BithconaJ Calories 4 18000 0 92590 Hqring Aid Ev.luadon, Monaural 15000
0 92544 Opfokinetic T ellltlll 75.00 0 92591 Hearmg Aid Evaluation, Binau(&1 300.00
Oscillating nicking Tesls 6900 0 92592 Hearing Ajd ConfolTl'lity B'II8Jul.tlon. Monaural 250.00
Sinusoidal VerticallHafltolJtal Axis Rotation Tens 6 240.00 0 92593 Heacìns Aid Conformity Evalu,uion, Binaunllt 500.00
0 92594 Elecrro-Acousric 01 probe Mic Testing, Monaural 50.00
0 92595 ,ElcctrO-Acoustic Or P'oÐC Mic Tesling, Binaural 100.00
0 92599 J-{c8lins Aid Cldruns MonauraJ 25.00
0 2251 A,COVStic Neuroma 0 92599 Hearmg Aid CJcll1il'lg Binaural 4000
0 386.02 ActJ'IIe Meniere's Dise8$c 0
92599 Earmold, Monaural 65.00
0 388.43 Auditory DtscrÍ1nnarion DefccH
0 38914 Central Onfheu 0 92599.22 Eamtold!, Binaural 130.00
0 389.0 Conductive Hearing LOt! 0 99202 New p.tient Office V¡,it 7000
0 872.8 Ear Traum8 0 99212 Repeat Office V,'II 40.00
0 3818) Ew~jan Tube Dy,functlon 0 92599 '.-Hou,", Repair $l5 I 135 I 145 I 555 I SIOO
0 )8841 Hypeflcu,¡,
0 0 92599 factory RcpaJr 5200 I $l50 I $300 1$350
380.4 'rn.p-,rcd Ccrumcn
0 3892 MiJeed Hearing Loss 0 92599 B8tterios 10 312 IJ 675 X
0 389.12 Ncurøl HCRin! Lo.ss 0 99002 P1oduÇ{ Dllpcn.9illg
0 380.1 OtitiJlExlem8 0 92599
0 382.9 Olit ,Medía 0 92599
0 387.2 Oto.sGler~j,
0 384,2 Ferion'cd Tympal'Jlc Membran~
0 )89.11 Sensory Hearing Lo" CHARGES
0 38913 Sen.roty end Neural Hear;o8 Loss
0 388.31 SubjeCtIve Tlnnitu, AMOUNT PAID
0 3882 Sudden Sen"orineural He.ring Loss BALANCtDUE
0 780.4 Ve. ISC u' 'bnurn
05/09/2003 01:05 949-8302324
08/09/03 14:11 FAX 781 4497908
DENNIS COLUCCI MA
LANDY INStTRANCE
PAGE 02
",",uu.c
CERTIFICATE OF INSURANCE
ISSUE DATE 06/09/2003
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO
RIGHTS UPON TH~ CERTIFICATE HOLDER. THIS C~RTIFrCATE DOES NOT AMEND, EXTEND
OR ALTER XHE COVERAGE AFFORDED BY THE POLICIES BELow.
PRODUCER
Herbert H. Landy Ins. Agency, Inc.
75 Second Avenue, *410
Needham, MA 02494-2876
COMPANIE9 AFFORDING COVERAGE
Chicago Insurance Co.
INSURED
Dennis A Colucci
24902 Moulton Parkway
Laguna Wooda
2nd Floor
CA 92653
COVERAGES
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTEP 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 AFFORbED BY TRE POLICIES DESCRIBED HEREIN IS SUB~ECT
TO ALL THE TBRMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN
MAX HAVE BEEN REDUCED BY PAID CLAIMS.
~OLICY NO. AHL 2600269
POLICY TERM: 03/19/2003 - 03/19/2004
LIMI~S OF LIABILITY; $ 2,000,000.00
$ 01,\,000,000.00
PRIOR ACTS DATE~ 03/19/2000
coverage is on an occurrence baai9.
each claim;
annual aggregate;
DESCRIPTION OF OPERATIONS
Audiology
CERTIFICATE HOLDER
APPROv LU !\S iO FORM
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES
BE CANCBLLED BEFORE THE EXPIRATION DATE
THEREOF, THE ISSUING COMPANY WILL ENDEAVOR
TO MAIL àó' DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE
NO OBLIGATION OR LIABILITY OF ANY KIND
UPON THE COMPANY, ITS AGE~~S OR
REPRESRNTÞ.TIVES.
City of Santa Àna
PO Box 1988 M-28
Santa Ana, CA 92702
z~~~
Deputy City Attorney
AUTHORIZ~
07/2g/2003 04:07
g4g-8302324
DENNIS COLUCCI MA
PAGE 01/01
Dennis A.. Colucci, M.A., F AAA
Hearing and Balance Laboratory
Board Certìfied in Audiology
24902 Moulton P8ri(w8y
Laguna Woods, C8 92653
949830-5770 FAX 830-2324
July 2B, 2003
Ms. Emilyn Buenafe
LOBS Control Technician
City of Santa Ana
P,O. Box 1988 M-2B
Santa Ana, Ca 92702
RE: Consulting Agreement- Certificate of Insurance Supplement
Dear Ms. Buenafe:
This is to inform you that my malpractice rnsurance carrier is unable to make the changes requested
by your legal department concerning the 30-day cancellation notice. This letter is to provide
assurance to the City of Santa Ana that in the event my insurance carrier or I cancel the policy (44-
2010129) for any reason that I will mail 30-days written notice to Risk Management at City of Santa
Ana. I have never had a cancellation of a policy since I started practice in 1974 or a malpractice
action against me. I hope this clears up the matter. If I can be of further assistance do not hesitate
to call up me.
.,-( -'H)R',\¡j
~ .1'.' ~
- c c t' ({ (;V - af.:---...........---
_.'."=--~~>~"'1
La . . r"'"
~ -)(' P':.::! V (~1tj'A tlnfdt.-,y
¡ f
. JUN-01-2004 19:27
DONNA-DENNIS COLUCCI
Healthcare Providers Service
Organization Purchasing Group
949 770 8708
P,01/01
~NA
CNA PI,,:ta,
Chkago, It 6(1695
Qterti fi'cate 0'£ ~ ltfiltr ttttr:e
IIHPSO
11~~'(~~~~~o...."'M"""
. Producer Brancb Prefix .: . Policv Nùß1bet' .. . . :,:J?åijcy'Periöø,' :..
froJD: 12:01 AM Standard Tiøe on: 05/03/04
018098 970 HPG 273732971-8 to: 12:01 AM Standard Tiøe on: 05/03/05
Named Insured and Address " .. .' ':,' PrdRrabl' Ädmiiiisttator'
. .. .'
¡J .- öÙ)03-lJ tv3 Healthcare Providers Service Organization
DENNIS A COLUCCI 159 East countô Line Road
23291 COBBLEFIELD Hatboro, PA 19 40-1218
M¡SSIO~ VIEJO CA 92692-1674
Medical Specialty: Code: : '~s1iranœ. J?ro=yjdèd þy
Alldiologist 80714 American Casualty Co. of Reading, PA
CNA Plaza 26S Chicago, IL 60685
COVERAGE PARTS ',::.:" . :: .'LiWr:S "QF LIABIl1tY
:
A. PROFESSIONAL LlABIUTY
Professional Liabilit
Good Samaritan Liability
Personal Injury Liability
a p acement L1a i 1ty
$1 000 000.00 each claim
Included above
Included above
Inc u e a ove
000.00
a
rate
B. Covera c Extensions
License Protection
Defendant ~en~e Benefit
Deposition Representation
Assa.ult
Medical Payntent$
F1rst Aid
Dama e to Pro art of Others
$10,000.00 $25 000.00 a re ate
:', $10,000.00 ag regate
. ",
$2,500.00 per deposition $5,000.00 aggregate
$10,000.00 er incident $25 000.00 a :r-e ate
$2,000.00 per person $100,000.00 a r ate
,'. : $2,500.00 aggregate
. .
er incident $10 000.00 a re ate
C. WORKPLACE LIABILITY
Workplace Liability
1re an Water Legal
Personal Liabilit
Liability
Coverage part C. does not a Iy if Covera e art D. is made part of this policy.
Included in A. Professional Liability Limit shown above
Included,above subject to $150,000 sub-limit
. .,:: $1 000,000.00 a re ate
. "'.
Hired Auto & Non Owned Auto
F~re & Water Lega L~a ~ ~ty
Personal Liability'
None
None
art C. is made part of this policy.
None
D. GENERAL LIABILITY
Covera e part D. does not a
~vor]::plac'~ Liabilit~l
,'"
, .
C-144S72-A C-145184-A C-121500C
G-147292-A
',"
None
None
Total Premium $129.00
. Policy forms and endorsements attached /it' ~'.
QVESTION~? CALL: 1-800-982-9491
G-123846D-04 G-121503C
He;I\UJ<are Pr<McJel!¡ ~IC. OI'$a.o,.illÍOII ÍII a diYialw\ ot AffiWty InBUtIItICi SeMt.-u, W.; ill NY oIIId NH. At:! AffiniIy IIl3IWllce A;ißq: in MN and OK, AlS Atfinity lnsurmt<:i
A&ißC)l. Inc.: 81d ÙI CA, AI:! AftiNty hU\JN/1G4I Agcrwy. Inc. "b. Aon DirOÇ\ Imtnncc Atlministretcms J..ic0l\$ll! ¡¡O79~5.
$129.00 PREMIUM
$0.00 CIGA SURCHARGE
Master Policy: 1887H433
MJ~n(
Chairman of the Board
~~~~
Keep this document in a safe place. Trus and
your cancelled check act as proof of coverage.
Secretary
602 X)(
0OOOOO8-N O~OS24 NENHCP 8/01 H19~RH 04145
TOTAL P.01
/. Healthcare Providers Service
'~NA Organization Purchasing Group IIHPSO
<!I.ertifi:cat.e of ~n5uran.c.e
CNA Plaz"", HaJtb,... 1"0.;.1", S.",i<oO<QaJ~,..i""'-
Chicago, IL 60685
OCCURRENCE POLICY FORM
Producer Branch Prefix Policv Number Policy Period
from: 12:01 AM Standard Time on: 05/03/05
018098 970 HPG 273732971-8 tn. '? n, 'M "~on"ow' '1"mA nn. n<'--'..-
Named Insured and Address Program Administrator
N -~ d 003 ~()03 Healthcare Providers Service Organization
DENNIS A COLUCCI 159 East counto Line Road
23291 COBBLEE'IELD Hatboro, PA 19 40-1218
MISSION VIEJO CA 92692-1674 Insurance Provided by
Medical Specialty: Code:
Audiologist 80714 American Casualty Co. of Reading, PA
CNA Plaza 26S Chicago, IL 60685
COVERAGE PARTS -- LIMITS OF LIABILITY
-------- -------- --..-- .-- .-- -~-'- ,-------
~l'KUt tSSIONALLIABILITY-'-- -
;nn~' T.i~t;' ;~" ~, nnn nnn _ nn ..~,.,h nlo'm ,,,'- nnn nnn no
Good Samaritan Liabi1itv Included above
Personal Iniurv Liabilitv Included above
Ma1p1acement Liability Included above
B. Coverage Extensions
T< n. '.inn "" n non nn nA~ n~n, ..., .- ~?, nnn nn
Defendant Expense Benefit s10 000.00 aaarenate
Deposition Representation $2 500.00 per deposition $5,000.00 aaareaate
. ,,. ~, n nnn nn n"~ in,.... -'- ~ ~?, nnn nn
Medical Pavments s2 000.00 ner nerson sioo 000.00 aaarenate
First Aid $2.500.00 aaarenate
tn nf" nt""~" ~'nn nn n"~ in,....-'- ~ ~'n nnn nn
C. WORKPLACE LIABILITY Coverage part C. does not apply if Coverage part D. is made part of this policy.
Workplace Liabi1itv Included in A. Professional Liabilitv Limit shown above
Fire and Water Legal Liability Included above subject to $150,000 sub-limit
Personal Liabi1itv ~1 ana 000.00
D. GENERAL LIABILITY Coverage part D. does not apply if Coverage part C. is made part of this policy.
-,----- -WOr]{nTa-C"Lrall1.ln:'r - -- - -'-'- ---~- - - Non-"-' -..- -t-u !fone -- _._m
Hired Auto & Non Owned Auto None
Fire & Water Legal Liability None None
Personal Liabilitv "nnA
Total Premium $129.00
Policy forms and endorsements attached at inception OUESTIONS? CALL: 1-800-982-9491
G-144872-A G-145184-A G-121500C G-121501C G-123846D-04 ,-~503C
G-147292-A 4 P VcE!) AS, TO FORM
~Q-~
Heallhcare Providers Service Organization is a division of Affutity Im1P1lllce Services, Inc.; in NY and NH, AIS Affinity Insurance Agency; in MN and OK: _ -~ s. Affinity Ins~ce
Agency, Inc.; and in CA, AIS Affinity Insurance Ageney, Inc. dbaAon Direct Insw"Wlce Administrators License #0795465. ". --, - . ..- . f ___...
~!tHiiI ~,itt Shliedy
$129.00 PREMIUM $0.00 CIGA SURCHARGE Master !.\JhPlffi.8Ip\ljl4\li\,;rn.,
~n/:::l!i ~~[A;h Keep this document in a safe place. This and
your cancelled check act as proof of coverage.
Secretary
604 XX 0000088-R 050224 RENHCP 1/05 R136HM 05055
.
./ Healthcare Providers Service
~NA Organization Purchasing Group LtHPSO
Olertificate of ~nsurance
CNA Plaza, HoolIla....',.,wIonSOrvl<ao.p....-
Chicago, IL 60685
OCCURRENCE POLICY FORM
Producer Branch Prefix Policy Number Policy Period
from: 12:01 AM Standard Time on: 05/03/05
018098 970 HPG 273732971-8 "~. 1?n1'M "'im~ ~n. n.,nom..
Named Insured and Address Pro~ram Administrator
Healthcare Providers Service Organization
DENNIS A COLUCCI 159 East countg Line Road
23291 COBBLEfIELD Hatboro, PA 19 40-1218
MISSION VI~JO CA 92692-1674 Insutance Prllyided by
Medical Specia ty: Code:
Audiologist 80714 American Casualty Co. of Reading, PA
CNA Plaza 26S Chicago, IL 60685
COVERAGE PARTS ... LIMITS OF liABILITY
---- ,.----- ".. ---.-- -------------.---...-- -.
A. J.'KUtoc~~IUN!\L LL'ffiILrr-r--~.~.~n_-.
., a.. ~, nnn nnn nn ~'rh rhim .c nM Mn un
Good Samaritan Liabi1itu Included abo"e
Personal Iniuru Liabilitu Included above
Ma1e1acement Liability Included above
B. Coverage Extensions
,.. n~ __ SI0.00000 n~~ lin~ o?< nnn un
Defendant ~Ynense Benefit 010 000.00 aaareaate
Denosition Renresentation $2,500.00 ner denosition S5 000.00 aaareaate
., S10 000 nn n~'" i__i"__" 0". nun un
Medical Pauments $2 OOO.OOnernerson s100000 00 an"renate
first Aid ~2 500.00 aaareaate
>n nF S<nn no n~~ i, . . ~'o nnn nn
C. WORKPLACE LIABILITY Coverage part C. does not aooly if Coverage oart D. is made Dart of this ooliev.
Workolace Liabilitu Included in A. Professional Liabilitu Limit shown above
fire and Water Leaal Liabilitv Included above subiect to $150,000 sub-limit
. . .~.".'.. I ., unn nnn nn
D. GENERAL LIABILITY Covera e Dart D. does not applv if Coverage Dart C. is made nart of this policy.
- .-_. -. N"""- --'- --+- - -~. - .- "" .- --- ....--- .
Hired Auto & Non Owned Auto None
fire & Water Leaal Liabilitv None None
'.i....i1,... ..,
Total Premium $129.00
Policy 'forms and endorsements attached at incention QUESTIONS? CALL: 1-800-982-9491
G-144872-A G-145184-A G-121500C G-121501C G-l23846D-04 4hi)~Sb
G-147292-A _.&?~ 'f(') FORM
\ ,,~~,.
HeaIlhc1n Providem Servic. OJpJitalion ill a diviaion of Affinity IJUjI)tlllll:a Sarvicell. ln~.: in NY Ill4 NH. AlS AfIinily lIlsuranI;c ,,&enCy; in MN:md OK. ~ ~ Wul'anI;e 7
Ag,tncy, inc.; II1d in CA. AlS Affinity btautance Agency. Inc. dba AM Direct Inruranco ~ LiceDM IW079S46S. . __H'~ ___ -
, . ~lIrll ~!ill Sheedy'
$129.00 PREMIUM $0.00 CIGA SURCHARGE Master lil\Jiji3!lll~1O\1j1~6rnev
~nJ:::l!i ~kztlJ~ Keep this document in a safe place. This and
your cancelled check act as proof of coverage.
Secretary
604 XX 0000088-R 050224 RENBCP 1/05 R136HK 05055