HomeMy WebLinkAboutSAXE-CLIFFORD, SUSAN 2AGREEMENT TERMINATION
Please complete this form when the attached agreement is no longer in effect
Return form to the Sr. Deputy Clerk of the Council (M-30). CalI641 4238 if you have; °any
questions.
The agreement with
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was completed on � ,and final payment has been ma$�.
Department: 11
Signature: 4 / al_� -
Date: Ili 1'7 /b
City of Santa Ana
Revised 8-7-03 Clerk of the Council
1NSUF1 i4,;E -Nu 1 011 FILE A-2007-040
WORK MAY N01PROCEED
CLERK OF COUNCIL.
DATE: 3/.a/p'7 CONSULTANT AGREEMENT
b` 131 THIS AGREEMENT, made and entered into this 20thday of r VLCevi, , 2007 by
IITf and between Susan Saxe -Clifford, Ph.D., a Professional Corporation (hereinafter "Co sultant"),
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").
RECITALS
A. The City desires to retain a consultant having special skill and knowledge in the field of
psychological evaluation, to perform evaluations and counseling for the City.
B. Consultant represents that Consultant is able and willing to provide such services to the
City.
C. In undertaking the performance of this Agreement, Consultant represents that it is
knowledgeable in its field and that any services performed by Consultant under this
Agreement will be performed in compliance with such standards as may reasonably be
expected from a professional consulting firm in the field.
NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the
terms and conditions hereinafter set forth, the parties agree as follows:
SCOPE OF SERVICES
Consultant shall perform those services as set forth in Exhibit A to this Agreement.
COMPENSATION
a. In consideration for Consultant services, City shall pay Consultant an hourly rate as
follows:
1. For complete pre -employment psychological evaluation, City agrees to pay
Consultant four hundred dollars ($400.00) per applicant.
2. For complete post -traumatic psychological incident review, fitness for duty review,
crisis intervention, City agrees to pay Consultant the hourly rate of two hundred fifty
dollars ($250.00).
3. For expert testimony in Court, City agrees to pay Consultant an hourly rate of three
hundred fifty dollars ($350.00)
b. The total sum payable under this Agreement shall not exceed forty thousand dollars
($40,000.00) for all services and evaluations performed, travel costs and other expenses.
Consultant shall submit a detailed invoice for services performed at the time of submission of
each report.
c. City will pay Consultant within thirty (30) days following the receipt of invoice for
services performed, but not more often than one time per month. City's payment is subject to
review under City's standard accounting procedures.
3. TERM
This Agreement shall commence on the date first written above and terminate on June 30,
2008, unless terminated earlier in accordance with Section 12, below. The term of this
Agreement may be extended upon a writing executed by the Chief of Police 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. Due to the nature of the services, general liability insurance is not required.
b. Worker's Compensation Insurance. In accordance with the provisions of Section
3300 of the Labor Code, Consultant, if Consultant has any employees, is required to be insured
against liability for worker's compensation or to undertake self-insurance. Prior to commencing
the performance of the work under this Agreement, Consultant agrees to obtain and maintain any
employer's liability insurance with limits not less than $1,000,000 per accident.
c. Professional liability (errors and omissions) insurance, with a combined single limit
of not less than $1,000,000 per claim.
d. 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.
(ii) Certificates of insurance shall be furnished to the City upon execution of
this Agreement and shall be approved in form by the City Attorney.
(iii) Certificates and policies shall state that the policies shall not be canceled
or reduced in coverage or changed in any other material aspect without
thirty (30) days prior written notice to the City.
e. 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
and employees from liability 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 negligent performance of the Consultant which
relates to the services described in section I of this Agreement.
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 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 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:
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:
City of Santa Ana Police Department
Attn: Personnel Commander
60 Civic Center Plaza (M-97)
P.O. Box 1981
Santa Ana, California 92702
telefacsimile (714) 245-8090
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: Susan Saxe -Clifford, Ph.D.
17323 Ventura Boulevard, Suite 208
Encino, California 95316-3964
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 telefacsimile, 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
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. Each party to
this Agreement acknowledges that no representations, inducements, promises or agreements,
orally or otherwise, have been made by any parry, 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 either party 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.
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. 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 termination of this
Agreement.
16. MISCELLANEOUS PROVISIONS
a. Each undersigned represents and wan -ants that its signature hereinbelow has the power,
authority and right to bind their respective parties to each of the terns 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.
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 DAVID N. REAM
l7 Clerk of the Council City Manager
APPROVED AS TO FORM:
JOSEPH W.FLETCHER
City Attorney
By: v • = 1.; _i'
Laura Sheedy CONSULTANT
Assistant City Attorney
SUSAN SAXE-CLIFFORD, Ph.D.
Tax ID#
EXHIBIT A
I. SCOPE OF SERVICES
COMPLETE PREEMPLOYMENT PSYCHOLOGICAL EVALUATION
Consultant agrees to perform a complete pre -employment psychological evaluation for
City's Police Department applicants. Said psychological evaluation shall comply with
the California Peace Officer's Standards and Training (P.O.S.T.) Psychological
Screening Manual, as well as any additional psychological suitability criteria specified by
City's Police Department and agreed to by Consultant.
a. For the purpose of this Agreement, a complete pre -employment psychological
evaluation includes, but is not limited to a clinical interview, an administration of
necessary tests, scoring of tests and preparing verbal and written recommendations for
employment.
b. Consultant agrees to provide City's Police Department with a verbal recommendation
of the candidate's psychological suitability for the classification of Police Officer as
well as other classifications within the Police Department within two (2) working days
of said candidate's clinical interview.
c. Consultant agrees to provide City's Police Department with a written report of the
candidate's psychological suitability for the classification of Police Officer as well as
other classifications within the Police Department within five (5) working days of the
candidate's clinical interview.
COMPLETE POST -TRAUMATIC PSHCHOLOGICAL INCIDENT EVALUATION
Consultant agrees to give City's Police Department Employees involved in violent
incidents, such as a life -threatening situation and/or serious injury or death to any person,
complete post -traumatic psychological evaluation.
a. A complete post -traumatic psychological incident evaluation includes, but is not
limited to, clinical interview and post -traumatic counseling.
b. Initial psychological service contact with involved officer(s) shall be made
immediately if possible, but no later than forty-eight (48) hours following the incident.
c. A minimum of three (3) follow-up counseling sessions shall follow, if the Consultant
deems those sessions necessary. Such follow-up sessions shall, whenever possible and
practical, be scheduled by Consultant at Consultant's Orange County office location,
unless otherwise agreed by involved officer(s).
d. In those cases where Consultant deems that immediate follow-up counseling sessions
are not indicated, Consultant shall schedule one (1) follow-up session within a period
of not less than fourteen (14) days and not more than thirty (30) days following the
traumatic incident with the involved officer(s) to assess whether additional sessions
shall be deemed necessary. Such sessions shall, whenever possible and practical, be
scheduled at Consultant's Orange County office location unless otherwise agreed by
involved officer(s). Following such sessions, Consultant shall provide City's Police
Department with verbal recommendation as to the necessity of additional sessions and
an assessment of officer(s)' recommended duty status within forty-eight (48) hours.
A written psychological assessment of the officer(s) evaluated shall be submitted
within five (5) calendar days to City's Police Department upon completion of such
follow-up counseling session(s).
e. Consultant shall provide City's Police Department with a verbal recommendation for
return of said officer(s) involved in traumatic incidents to full or modified duty status
as soon as possible and in no case later than forty-eight (48) hours following the
incident.
f. Consultant shall provide City's Police Department with a written psychological
assessment of officer(s) in question and a recommendation as to their suitability to
return to active duty, full or modified, and need for follow-up treatment within five (5)
days following the post -traumatic counseling session.
g. At the direction and with the consent of City Police Department, Consultant shall
provide similar post -traumatic incident counseling services to immediate family
members of involved officer(s) adversely impacted by the incident. The goal of such
services shall be to stabilize external factors, which might otherwise affect officer(s)
return to duty or recovery and to determine if referral to other private service providers
is warranted. Verbal consultation with City's Police Department is recommended but
no written reports of family member counseling sessions are required unless otherwise
indicated or where the fitness for duty of the officer(s) comes in doubt.
REVIEW OF FITNESS FOR DUTY
Consultant agrees to review background investigations, clinical interviews, administrative
reports and/or other relevant documents to determine an employee's psychological fitness
for duty, when so directed by City.
R
a. For purpose of this Agreement, a fitness for duty review includes, but is not limited to,
clinical interviews, administration of necessary tests, scoring of tests and preparation
of verbal and written recommendation for employment.
b. Consultant agrees to outline all psychological concerns resulting from that review and
submit to City's Police Department a recommendation concerning further testing
and/or evaluation, which may be deemed appropriate.
c. Consultant agrees to provide City's Police Department with verbal notification as to
the above within forty-eight (48) hours, and with a complete written report concerning
reviews of fitness for duty within ten (10) working days following receipt of
documents or the last clinical interview of employee(s) in question.
CRISIS INTERVIEW COUNSELING
Consultant agrees to conduct crisis intervention counseling with authorization and
approval of City's Police Department when a Department employee(s) is believed to be
gravely disabled as a result of psychological disorder or emotional disturbance and
unable to perform any or all of the full range of duties of an employee's classification.
b. Consultant agrees to obtain authorization from City's Chief of Police, or designate,
prior to conducting crisis intervention counseling of City's Police Department
employee(s). Should intervention be requested by employee and not Department,
Consultant agrees to obtain authorization from City's Chief of Police, or designate,
prior to conducting crisis intervention counseling.
EXECUTIVE RISK INDEMNITY INC.
5/30/06 - A PSYCHOLOGISTS PROFESSIONAL LIABILITY POLICY
THIS IS A CLAIMS MADE POLICY - PLEASE READ CAREFULLY
*** RENEWAL ***
NOTICE: A LOWER LIMIT OF LIABILITY APPLIES TO JUDGEMENTS OR SETTLEMENTS WHEN THERE ARE ALLEGATIONS
OF SEXUAL MISCONDUCT (SEE THE SPECIAL PROVISION "SEXUAL MISCONDUCT" IN THE POLICY).
POLICY NO: 008-1741807
ITEM I. (a) NAME AND ADDRESS OF INSURED:
ITEM 3.
ITEM 4.
ITEM 6.
ITEM 7.
SUSAN SAXE-CLIFFORD,PH.D
A PROFESSIONAL CORP.
16530 VENTURA BLVD.
SUITE 203
ENCINO, CA 91436
ACCOUNT NO: CA-SUSA165-0
ITEM 1. (b) ADDITIONAL NAMED INSUREDS:
SUAN SAXE-CLIFFORD,
A- aGb7-o 4 o
A—aoo3-a-q7
0427263B
114:N97
TYPE OFORG: PROFESSIONAL CORPORATION
01/313-/07
POLICY PERIOD: FROM: 03/01/06 TO: 03/01/07
12:01A.M. STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN:
LIMITS OF LIABILITY: (a) $
SCHEDULE:
(b) $
1,000,000 EACH WRONGFUL ACT OR SERIES OF CONTINUOUS, REPEATED
OR INTERRELATED WRONGFUL ACTS OR OCCURRENCE
75,000 DEFENSE
(c) $ 3,000,000 AGGREGATE
CLASSIFICATION
NUMBER
RATE
ANNUAL PREMIUM
1ST PSYCHOLOGIST
1
978.00
978.00
INDEPENDENT CONTRACTORS
4
14.00
56.00
DEFENSE LIMIT
65.00
ADDITIONAL INSUREDS
9
250.00
RETROACTIVE DATE: 03/01/04 TOTAL PREMIUM:
1,349.00
1\V ! L:1VVL
ADDITIONAL PREMIUM (if exercised):$ 2,361.00 NO DISCOUNT INCLUDED.
ITEM 8. POLICY FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY
C22129 (7/95 ED.) C22128 C22092
Y
THIS IS NOT A BILL. PREMIUM HAS BEEN PAID. Aui5i6RIZED COMPANY REPRE NTATIVE
APA22(10/95) AmericaRPmtcss anal Agency' 95 Broadway, Amityville, NY 11701
ENDORSEMENT PAGE 1
THIS ENDORSEMENT EFFECTIVE 12:01 AM 3/01/2006
POLICY NO.: 008-1741807 ISSUED TO: SUSAN SAXE-CLIFFORD,PH.D
BY: EXECUTIVE RISK INDEMNITY INC.
ITEM 2 ADDITIONAL INSUREDS
01. CITY OF BEVERLY HILLS
HUMAN SERVICES
455 N. REXFORD DR. ##210
BEVERLY HILLS, CA 90210
02. CITY OF INGLEWOOD
ONE MANCHESTER BLVD.
INGLEWOOD, CA 90303
03. LOS ANGELES COUNTY
METROPOLITAN TRANS. AUTH
1 GATEWAY PLAZA FL. 9
LOS ANGELES, CA 90012
04. LOS ANGELES COUNTY PROB
DEPT OF PSYCH. CON 73749
9150 E. IMPERIAL HWY
DOWNEY, CA 90242
05. LOS ANGELES SCHOOL
POLICE DEPT.
1330 W. PICO BLVD.
LOS ANGELES, CA 90015
06. CITY OF ORANGE
300 EAST CHAPMAN AVENUE
ORANGE, CA 92866
07. COUNTY OF ORANGE
10 CIVIC CENTER PLAZA
SANTA ANA, CA 92701
D8. SANTA ANA POLICE DEPT.
60 CIVIC CENTER PLAZA
SANTA ANA, CA 92702
09. COUNTY OF SANTA BARBARA
P.O. BOX 6427
SANTA BARBARA, CA 93160
r
AUTHO?IZED REPRESENTATIVE
DECLARATIONS PAGE AMENDED NOV 1 2006
Policy Number
92-92-2579-2
STATE FARM GENERAL INSURANCE COMPANY O
900 OLD RIVER RD, BAKERSFIELD CA 93311-6000
A STOCK COMPANY WITH HOME OFFICES IN BLOOMINGTON, ILLINOIS
Agent Copy
Named Insured and Mailing Address
23-1308-F412 U
CLIFFORD, SUSAN SAXE DR
A PROFESSIONAL CORPORATION
16530 VENTURA BLVD STE 203
ENCINO CA 91436-4535
BUSINESS POLICY - SPECIAL FORM 3
Cov A - Inflation Coverage Index: N/A
Cov B - Consumer Price Index: 199-2
AUTOMATIC RENEWAL - If the POLICY PERIOD is shown as 12 MONTHS, this policy will be renewed automatically
subject to the remiums, rules and forms in effect for each succeedinqq policy period. If this policy is terminated, we will
give you and t9e Mortgagee/Lienholder written notice in compliance wllh the policy provisions or as required by law.
Policy Period: 12 Months The policy period begins and ends at 12:01 am standard time at the
Effective Date: APR 18 2006 premises location.
Expiration Date: APR 18 2007
Location of Covered Premises:
16530 VENTURA BLVD STE 203
ENCINO CA 91436-4535
Coverages & Property
Section I
A Buildings
B Business Personal Property
C Loss of Income - 12 Months
Section II
L Business Liability
M Medical Payments
Products -Completed Operations
(PCO) Aggregate
General Aregate (Other
Than PCgg)
Forms, Options, and Endol
Special Form 3
'Section II Additional Insured
Physicians and Surgeons
Debris Removal Endorsement
Amendatory Endorsement
Policy Endorsement
Business Policy Endorsement
' New Form Attached
Continued on Reverse Side of Page
Limits of Insurance
$ E128uded
900
$ Actual Loss
1,000,000
5000
2,000:000
2,000,000
FP-6143
FE-6609
FE-6407
FE-6451
FE-6205
FE-6506.2
FE-6464
Your policy is amended NOV 1 2006
NUMBER OF ADDL INTERESTS CHANGED
ENDORSEMENT FE-6609 ADDED
upancy:
Deductibles - Section I
$ 500 Basic
In case of loss under this policy, the deductible will be
applied to each occurrence and will be deducted from the
amount of the loss. Other deductibles may apply - refer to
Endorsement Premium
Increase
Discounts Applied:
Renewal Year
Years in Business
Enclosed Building
Protective Devices
Sprinkler
Continued on Reverse
Prepared OTHER LIMITS AND EXCLUSIONS MAY APPLY
NOV 02 2006 Countersii :�NC
06/1990.2C AFCB By
06/1993 EROL A
Your policy consists of this page, any endorsements (310) 5 7s
and the policy form. PLEASE KEEP THESE TOGETHER -
TO
?11
$ 18.40
POLICY
Agent
(oif2172b)
0
N
O
m
WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY O
e / INFORMATION PAGE
POLICY N0. 92-D3-2318-6 COVERAGE IS PROVIDED BY 23-1308-F412
REPLACES N0. 92-EV-1341-9 STATE FARM FIRE AND CASUALTY COMPANY
900 OLD RIVER RD, BAKERSFIELD CA 93311-6000
1. NAMED INSURED & MAILING ADDRESS NCCI CARRIER CODE N0. 14842
SUSAN SAXE CLIFFORD PHD INC FEIN 954072886
ENCINOVCATU91436-4535E 203 LOCATION:
BLVD STE 203
ENCINO CA
INSURED IS A CORPORATION
COPYRIGHT 1987 NATIONAL COUNCIL ON COMPENSATION INSURANCE
----------------------------------------- ----- 2. THE POLICY PERIOD IS FROM 07/01/2006 TO -07/01/2007 12:01 A.M. STANDARD TIME
AT THE INSURED'S MAILING ADDRESS.
----- ------------- ----------- - -----
W
ORKERS 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 $ 500,000 EACH ACCIDENT
BODILY INJURY BY DISEASE $ 500:000 EACH EMPLOYEE
C. OTHER STATES INSURANCE: PARTNTHREEBOFDTHEAPOLICY APPLIOES TOLALL STATES
EXCEPT ME, MT, ND, OH, RI, WA, WV, WY AND STATES LISTED IN 3A.
D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES: WCOOOOOOA
WC040301A FE-4893 WC000404/0484 WC040360A WC040407 WC040601A
WC000422* WC000113*
---------------------------------------------------------*EFFECTIVE 07/01/06 ----------
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.
----------------------------------------------------------
CODE NOS. AND PREMIUM BASIS TO- RATE/$100 ESTIMATED
CLASSIFICATIONS TAL ESTIMATED AN- REMUNERA- ANNUAL
----------------------- NUAL REMUNERATION TION PREMIUM
8810 39---------------------- CLERICAL OFFICE EMPLOYEES - N00522
COMPANY SURCHARGE FOR INCREASED
EMPLOYERS LIABILITY LIMITS
75
12
MINIMUM PREMIUM $ 250 CALIFORNIA TOTAL ESTIMATED ANNUALIPREMIUM $I 609
------------------ ---- ____ -------------------------------------------------
PREMIUM ADJUSTMENT PERIOD SHALL BE ANNUAL DEPOSIT PREMIUM $ 609
STATE FRAUD SURCHAR $ V� 1.00
PREPARED 04/24/2006 SEE SURCHARGE 0 ERFLOW PAGE J V
COUNTERSIGNED
WC 00 00 01 04-84 4'z 80 2151 6738 BY AGENT
FOREIGN TERRORISM PREMIUM 9740
39,229
03
12-15-207 1:40PM FROM SAXE-CLIFFORD,PH_D_ 818 788 BS44
gqPLATTE RIVER INSURANCE COMtPAAyNY
2 / 0 5 / 0 7 - A P syc THISS'[S A C S,A.IMS MAD,POL CYa PLEMI& AD CAREF U1LLYy
NOTICE- A LOWER LIMIT OF LIABILITY APPLIES TO JUDGMENTS OR SETTLEMENTS WHEN THERE ARE ALLEGATIONS
OF SEXUAL MISCONDUCT (SEF THF, SPECIAL PROVISION "SEXUAL MISCONDUCT" IN THE POLICY).
POLICY NO: 5 01- 0 01.013 7
ITEM I_ (a) NAME AND ADDRESS OF INSURED:
SUSAN SAXE-CLIFFORD,PH.D
A PROFESSIONAL CORP.
16530 VENTURA BLVD.
SUITE 203
ENNCINO, CA 91436
ACCOUNT NO: CA- SUSA165 - 0
ITEM 1. (b) ADDITIONAL NAMED INSUREDS:
SUAN SAXE-CLIFFORD,
P_ 2
0427263C
PH.D
TYPE OF ORG: PROFESSIONAL CORPORATION
ITEMS AnnTTInN A 1 IN.'ZT 1V nC-
ITEM 3_ POLICY PERIOD_ FROM: 0 3/ 01 0 7 TO- 0 3/ 01T 0 8
I2:01A.M. STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED ME"IZEIN:
ITEM 4_ LIMITS OF L.IABILJTY: (a) $ 2,000,000 EACH WRONGFUL, ACT OR SERIES OF CONTINUOUS, REPEATLD
OR INTERRELATED WRONGFUL ACTS OR OCCURRENCE
(b) $ 75, 0 0 0 COSTS RELATED TO ANY SINGLE I'ROCEEDJNG
(C) $ 4,000,000 AGGREGATE, �OR ALL CLAIMS AND A* LL PROCEEDINGS
ITEM 5. PREMIUM SCHEDULF--
CLASSIFJCATION NUMBER RATE ANNUAL PREMIUM
1ST PSYCHOLOGIST 1 1-130.00 1,330.00
INDEPENDENT CONTRACTORS 4 26.00 104.00
DEFENSE LIMIT 140.00
ADDITIONAL INSUREDS 9 250.00
ITT 6_ RETROACTIVE DATE: 0 3/ 01 / 0 4 TOTAL PREMIUM: L 1,824.00
ITEM 7. EXTENDED REPORTING PERIOD
ADDITIONAI. PREK41UM (ifexercised)-$_ 3,192,00 NO DISCOUNT INCLUDED
ITEM 8. POLICY FORMS AND ENDORSEMENTS A7A JjZ: Bff PfMpCyo FORM
PRGE2000 (3/2006) PRGe1069 (1/2006)
Laura "-'i,f;
THIS IS NOT A BILL. PREMIUM HAS BEEN PAID. Assistant City
RJZED COMPANY REPRESENTATIVE
PRO)=.2005 (3/2006) Anreric roressiorial Agency * 95 Broadway, Amityville, NY 11701
b 0-1. -207 1 _40PM FROM SAXE—CL I FFORD, PH. D_ 818 788 8544 P_ 3
s _
POLICY NO.:-0010137 ISSUED TO: SUSAN SAXE-CLIFFORD,PH.D
BY: PLATTE RIVER INSURANCE COMPANY
ITEM 2: ADDITIONAL INSUREDS
001. *** See Policy ***
002. *** See Policy ***
003. *** See Policy ***
004. LOS ANGELES COUNTY PROB
DEPT OF PSYCH. CON 73749
9150 E. IMPERIAL HWY
DOWNEY, CA 90242
005. LOS ANGELES SCHOOL
POLICE DEPT.
1330 W. PICO BLVD.
LOS ANGELES, CA 90015
006.
CITY OF ORANGE
300 EAST CHAPMAN AVENUE
ORANGE, CA 92896
007.
COUNTY OF ORANGE
10 CIVIC CENTER PLAZA
SANTA ANA, CA 92701
008.
CITY OF SANTA ANA
20 CIVIC CENTER PLAZA
SANTA ANA, CA 92702
009.
COUNTY OF SANTA BARBARA
P.O. BOX 6427
SANTA BARBARA, CA 93160
PACE 5
AUTH IZED COMPANY I IFTRESENTATI VE.
PPLATTE RIVER INSURANCE COMPAAvNY
1 /:_ / 08 A Psyc THIS 7S A CLAIMS MADE POL CY PLEA E READtCAREFoUlLLV
*** RENEWAL ***
NOTI@IE?-7tMWER LIMIT OF LIABILITY APPLIES TO JUDGMENTS OR SETTLEMENTS WHEN THERE ARE ALLEGATIONS
OF SEXUAL MISCONDUCT (SEE THE SPECIAL PROVISION "SEXUAL MISCONDUCT" IN THE POLICY).
POLICY NO: 5 011— 013 7
ITEM 1. (a) NAME AND ADDRESS OF INSURED:
SUSAN SAXE-CLIFFORD,PH.D
A PROFESSIONAL CORP.
16530 VENTURA BLVD.
SUITE 203
ENCINO, CA 91436
ACCOUNT NO: CA-SUSA165-0 0427263C
ITEM 1. (b) ADDITIONAL NAMED INSUREDS:
SUAN SAXE—CLIFFORD, PH.D
,4 , o?pd3 -On 7
- 0206 3 — ON 7 -C)/
eo6 7®-/"d
TYPE OF ORG: PROFESSIONAL CORPORATION
ITEM 2. ADDITIONAL INSUREDS:
CITY OF BEVERLY HILLS CITY OF INGLEWOOD LOS ANGELES COUNTY
HUMAN SERVICES ONE MANCHESTER BLVD. METROPOLITAN TRANS. AUTH
455 N. REXFORD DR. #210 INGLEWOOD, CA 90303 1 GATEWAY PLAZA FL. 9
BEVERLY HILLS, CA 90210 LOS ANGELES, CA 90012
Continued...
/ ITEM 3. POLICY PERIOD: 2:01 A.M. STAND RD 0 3 0 ME A T THE ADDRESS OOF THE INSURED AS STATED HEREIN:
ITEM 4. LIMITS OF LIABILITY: (a) $ 2,000,000 EACH WRONGFUL ACT OR SERIES OF CONTINUOUS, REPEATED
OR INTERRELATED WRONGFUL ACTS OR OCCURRENCE
ITEM 5
ITEM 6
ITEM 7
(b) $
75,000 COSTS RELATED TO ANY SINGLE PROCEEDING
(c) $ 4, 0 0 0, 0 0 0 AGGREGATE, FOR ALL CLAIMS AND ALL PROCEEDINGS
DDFAATTTTA CCLWTITTI F-
CLASSIFICATION
NUMBERI
RATE I
ANNUAL PREMIUM
1ST PSYCHOLOGIST
1
1494.00 1
1,494.00
INDEPENDENT CONTRACTORS
5
26.00
130.00
DEFENSE LIMIT
140.00
ADDITIONAL INSUREDS
9
250.00
RETROACTIVE DATE: 0 3 / 01 / 04 TOTAL PREMIUM:
2,014.00
EXTENDED REPORTING PERIOD
ADDITIONAL PREMIUM (if exercised):$ 3,525.00 NO DISCOUNT INCLUDED
ITEM 8. POLICY FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY
PRGE2000 (3/2006) PRGe1069 (1/2006)
THIS IS NOT A BILL. PREMIUM HAS BEEN PAID..p6RIZED COMPANY REPRESENTATIVE
PRGE2005 (3/2006) AmericatfProfessional Agency' 95 Broadway, Amityville, NY 11701
POLICY NO.: 5011-0137 ISSUED TO: SUSAN SAXE-CLIFFORD,PH.D
BY: PLATTE RIVER INSURANCE COMPANY
ITEM 2: ADDITIONAL INSUREDS
001. *** See Policy ***
002. *** See Policy ***
003. *** See Policy ***
004.
LOS ANGELES COUNTY PROB
DEPT OF PSYCH. CON 73749
9150 E. IMPERIAL HWY
DOWNEY, CA 90242
005.
LOS ANGELES SCHOOL
POLICE DEPT.
1330 W. PICO BLVD.
LOS ANGELES, CA 90015
006.
CITY OF ORANGE
300 EAST CHAPMAN AVENUE
ORANGE, CA 92866
007.
COUNTY OF ORANGE
10 CIVIC CENTER PLAZA
SANTA ANA, CA 92701
008.
CITY OF SANTA ANA
20 CIVIC CENTER PLAZA
SANTA ANA, CA 92702
009.
COUNTY OF SANTA BARBARA
P.O. BOX 6427
SANTA BARBARA, CA 93160
PAGE 1
AUTH ZED COMPANY REPRESENTATIVE