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HomeMy WebLinkAboutTUSTIN IRVINE MEDICAL GROUP -2009A-2009-110 INSURANCE ON Fllk WORK MAY PROCEED ~ CONSULTANT AGREEMENT > UNTIL INSURANCE EXPIRE.: ~ CLERK OF COUNCIL ~,~rF 2~09'THIS AGREEMENT, made and entered into this 3`d day of August, 2009 by and between PUG ~.~stin Irvine Medical Group, a professional corporation (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"). ~ ~ RECITALS A. The City desires to retain a consultant having special skill and knowledge in the field of health services to provide comprehensive physical evaluations and communicable disease prevention. 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: 1. SCOPE OF SERVICES Consultant shall provide comprehensive physical examinations for all Fire sworn personnel and for those Police sworn personnel who elect to see Consultant as part of the annual wellness program, as set forth in Exhibit A, attached hereto and incorporated by this reference. Additionally, Consultant shall treat City personnel who maybe exposed to communicable diseases in their employment, as set forth in Exhibit B, attached hereto and incorporated by this reference. Consultant will also provide an annual flu vaccination clinic for City employees. 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. "I'he total sum to be expended under this Agreement shall not exceed $70,000.00 during the term of this Agreement. b. Payment by City shall be made within thirty (30) days following receipt of proper invoice evidencing work performed, subject to City accounting procedures. Payment need not be made for work which fails to meet the standards of performance set forth in the Recitals which may reasonably be expected by City. 3. TERM This Agreement shall commence on July 1, 2009 and terminate on June 30, 2010, unless terminated earlier in accordance with Section 12, below. The term of this Agreement may be extended upon a writing executed by the Fire Chief 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. Commercial General Liability Insurance. Consultant shall maintain commercial general liability insurance which shall include, but not be limited to protection against claims arising from bodily and personal injury, including death resulting therefrom and damage to property, resulting from any act or occurrence arising out of Consultant's operations in the performance of this Agreement, including, without limitation, acts involving vehicles. The amounts of insurance shall be not less than the following: single limit coverage applying to bodily and personal injury, including death resulting therefrom, and property damage, in the total amount of $1,000,000 per occurrence, $2,000,000 in the aggregate. Such insurance shall (a) name the City, its officers, employees, agents, volunteers and representatives as additional insured(s); (b) be primary with respect to insurance or self-insurance programs maintained by the City; and (c) contain standard separation of insureds provisions. b. Business automobile liability insurance, or equivalent form, with a combined single limit of not less than $1,000,000 per occurrence. Such insurance shall include coverage for owned, hired and non-owned automobiles. c. 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. d. Professional liability (errors and omissions) insurance, with a combined single limit of not less than $1,000,000 per claim. 2 e. 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. l~. 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: (1) 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 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 1 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 Consultant shall conform to all HIPPA requirements regarding examinations performed by Consultant. 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: and Fire Chief City of Santa Ana 1439 S. Broadway (M-80) Santa Ana, California 92702 telefacsimile (714) 647-5779 Personnel Services Agency Risk Management Division City of Santa Ana 20 Civic Center Plaza (M-28) P.O. Box 1988 Santa Ana, California 92702 telefacsimile (714) 647-5311 Chief of Police City of Santa Ana 60 Civic Center Plaza Santa Ana, California 92702 (714)245-8007 To Consultant: Tustin Irvine Medical Group 800 N. Tustin Avenue, #A Santa Ana, California 92705 Telefacsimile (714) 285-0400 Attn: Rose Barrio 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. 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 has been executed and delivered in the State of California and the validity, interpretation, performance, and enforcement of any of the clauses of this Agreement shall be determined and governed by the laws of the State of California. Both parties further agree that Orange County, California, shall be the venue for any action or proceeding that may be brought or arise out of, in connection with or by reason of this Agreement. 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 ol~ Santa Ana and all other governmental agencies. Consultant shall notify the City immediately and in writing of its inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination 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 F,xhibits 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. HEAL DAVID N. Clerk of the Council City Manager APPROVED AS TO FORM: JOSEPH W.FLETCHER City Attorney i ~ ~" Teresa Judd Deputy City Attorn~'{ TUSTIN IRVINE MEDICAL GROUP ~~~E ~~--°~ (NAME) ~~~~ ~ ---~G~-v~~ (Title) ~ cG~~J ~y ~~~-<!a~s Tax ID# ~ ~~~~/ ~=~" ~°~ Tustin Irvine Medical Group Employee Health 800 N. Tustin Avenue, Suite A Santa Ana, California 92705 EXHIBIT A TUSTIN IRVINE MEDICAL, GROUP shall provide comprehensive physical evaluations and additional tests as necessary, for all Santa Ana Fire Department sworn personnel as part of the annual wellness program, and for those Santa Ana Police Department sworn personnel who choose Medical Center of Santa Ana to perform the physical as part of the voluntary annual wellness program*, as follows: Comprehensive Physical Evaluations that include: • Review the results of the Santa Ana College fitness assessment • Review of employee's detailed medical history • Review of the twelve-lead ECG from graded treadmill exercise test • Height and weight measurements • Blood pressure and heart rate measurements • Review of the screening procedures (listed below) • Review of the body's medical systems, including cardiovascular, respiratory, gastrointestinal, genitourinary, endocrine, hematology and musculoskeletal Proposed Bid: $40.00 Screening Procedures include: • Urinalysis • Hemocult • Heavy Metal Screening (bloodworm) • TB test • Vision test • Hearing test • Chest X-Ray (two views) • EKG reading by cardiologist • Complete exam, which includes all components necessary in order to satisfy the DMV Commercial Driver's License Class A Proposed Bid $110.00 Additional Testing • Flexible Sigmoidoscopy or Colonoscopy • Treadmill -refer to Cardiologist • Flu Vaccine (optional at employer's site) • PPll • "Tetanus toxoid • Ilepatitis B Surface Antibodies (blood work) $200.00 N/A $20.00 $15.00 $20.00 $20.00 *Medical Center of Santa Ana will not commence any evaluations of Police personnel files until it receives notice from the individual that he/she will be undergoing the physical at the Medical Center of Santa Ana. 8 EXHIBIT B SCOPE OF SERVICES TUSTIN IRVINE MEDICAL GROUP shall perform communicable disease exposure services, including the following, for City of Santa Ana personnel as requested by the Executive Director of Personnel Services or his designee: Evaluation Off ce Visit (Follow Up Visits as necessary) Respirator Exams Pulmonary Function Test EKG U/A (Culture & Sensitivity if necessary) Post Exposure "fB Screen (including any necessary x-rays) Post Exposure Blood Screens (including HIV, Hepatitis A / B / C) Heavy Metal Testing Blood Lead Level Rubella Titer Rubeola Titer Varicella Titer Wound Culture & Sensitivity Vaccines (as required) Medications (as required) COMPENSATION Consultant shall he compensated for all services rendered as set forth in the Schedule of Fees (EXI~IIBI"f B)* 9 EXHIBIT B FEE SCHEDULE ~o Protocol: EXPOSURE S ..: Y'. ! ji. ~~"~ ~ ~ ~ ~~.lllt~~illll SII;S ~ . ._ _ _~ , 4. _. 90782 INJt~.:minFee ADMIN FEE FOR INJECTIONS 20.00 99000 LAL3C;&II COLLECTION AND HANDLING 20.00 93000 TSEKG EKG W/Interpretation 50.00 99205 OVNI'Comp* OV COMPREHENSIVE, NEW 186.73 9<>215-93 OVComp/Inter OV COMPREHN,EST/INTERPET 103.86 99204 OVNPExt* OV EXTENDED, NEW 146.12 99202 OVN1'Lim* OV LIMITED, NEW 70.19 57; '.6-C LAF3" f l 6 LAB HEP A&B PANEL #3416 58.00 83655 I,AT:599* LAB BLOOD LEAD#899 QUESTLAB 37.00 8 G ; •~ 7 LAB ; ~l3 S' LAB VARICELLA*TITER IgG#4439/2008 48.00 8;:-:;2 I,A}' ~~02 I,AB RUBELLA IGG AB*TITER#802/2008 25.08 86''03-1 LAI". 9728 LAB HIV 1/2 AB W/RFLS#19728* 37.05 ' 82?00 3460 LAB CADMIiJM BLD#3470 PACTOX 60.00 Employer 82195 3470 LAB CHROMIUM BLD#3470 PACTOX 45.00 8^ '.'S-A LAI3 ;080 LAB CHROMIUM URINE(PACTOX) 115.00 87056 LAI3CulUrine LAB CULTURE & SENSIT(URINE) 43.65 8~7~5 LAB964 LAB MEASL/RUBEO*TITER#964/2008 28.00 8:~'^5 LAB~'ercury$1 LAB MERCURY BLOOD 180.00 Employer 8~~'"'S LA?3`'fcrcuryUr LAB MERCURY URINE 21.44 5 ' `'`2 LA?'.:'7.P LAB ZZP-ZINC PROTOPRPH BLD LAB 82.00 8.`f''S LAP,`-399 LABCI3C{DIFF/PLT)#6399* 15.00 80"53 LAI310231 LAB COMP METABOLIC PANEL 25.00 8<?04 LAT~136709P LAB HEP AIgivl ANTIBODY#512*P 26.50 86"IOS LAI34848P LAB HEP B CORE IGM AB#4848*P 30.00 87"' ^0 LAP? ;95P LAB HEP BSURF ANTG W/CONF#498*P 17.32 8G.'')3 LABF472P LAB HEP C VIRUS AntiBod#8472*P 27.30 906 8 VXFI~; FLU VACCINE (3 Yrs & Above) 20.00 ~'''~'~7 VXI~~''1R MMRVACCINE 76.00 `'"~`'J VX'~^imps MUMPS VIRUS VACCINE, LIVE 30.00 9""~"0/13 MS" ~~.~,~ ues Q Res uator p' y Questionnaire 20.00 9n,~; ~ 0 T~c,~ ~-,-:;,etry SPIROMETRY 20.00 8'~~ ">0 TB]': ?~Intrad TB "Pest Intraderrmal (1'PD) 12.00 Date 03/23/09 Tustin Irvine Medical Group Page 2 - ~ f;11~). ~x Company: CITY OF SANTA ANA - EXPOSURES/LYNN HW1 I'.O. BOX 1988, M-41 S:~N"I'A ANA, CA 92702 Pr loco]: t : ~ I'OSURE S 90718-A 907 : S-A "Tetanus & Diptheria Absorbed/Adult WC 40.00 90716 VXvaricclla VARICELLA/Chicken Pox Vaccine 135.00 AG260 OV WoundClur WOUND CLEANSER, ANY TYPE 20.00 81001 I,~~' ~''~? 18 URINALYSIS WITH MICRO 10.00 71020 X:~::.~est2v XR CI-TEST 2 VIEWS 60.00 Other: _ Fax: Special Instructions: FRONT OFFICE: FAX .1 S0 (MARKED .XI'OSURE) AND OTHER PAPERWORK TO LYNN HWANG AT ABOVE NUMBER. TI:L:N E-MAIL LYyN I IWANG WITH 1FORMATION ABOUT THE EXPOSURE. BACK OFFICE: FOR BI i'UDBORNI PA" 1 fOGEN EXPOSURES ALWAYS DO BLOODWORK. THIS SHOULD INCLUDE A CI;'', CMP, HEP A L, AND HIV. IF WITHIN THE GOLDEN HOUR AND DOCTOR WANTS TO DIS ENSE COMBIVIR, YOU MAY GIVE THE EXPOSED EMPLOYEE ONE OR TWO PILLS. TI-IF, REMA' `ER OF THI? '" ?\' i [DS TO BE CALLED INTO THE PHARMACY. MEDICATIONS: WI-I IsN ~:: ~LLING IN M 1: i ~ 1 C;1"PION TRY 'I'O USE RITE-AID , SAV-ON OR WALGREENS. MAK]? A ? " TE OF THE I': ,;'.!?'~.1ACY NUMBER IN THE PATIENT'S FILE AND ON THE FRONT SCREEN OI~' "11 I : ~: X)MPLU'I'E FO:; ; U PURE USE. ALSO GET TAE PI~IARMACY'S FAX NUMBER SO THAT DE1~9 c GRAPHICS AI`, D BILLING/CLAIM INFORMATION CAN BE FAXED TO THEM. 1 / b / G V V ~ ~ : V ~ : ~k l YP7 YACi l', COOPF RA'1'EVE C:)F .p1.t`~lliZ(CAN E'HY~1(l:~.NS 4/VVb rax server CERTIFICATE OF COVERAGE Coverage through December 31, 2009 Member: John G. Alevizos, DO Address: 800 N. Tustin Ave Suite A Santa Ana, CA 92?OS This certificate confirms that, on the date below, the above-named phgsicivt is a tuetnber of the Cooperative of Atnerican Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (MP'T). MY'1' is au tututwrporated iuterutdentnit~• arrangement organized under California Insurance Code section 1280.7. 11us certificate touters uo rigltts upon Ute metnber and does not amend, extend or alter the coverage afforded under the terms, conditions and exclusions of the MPT Agreement. Membership Number 9275 Medical Specialty Family Medicine, With Surgical Assist Coverage Date April 1, 1999 Retroactive Coverage Date October 1, ] 993 subspecialty Coverage (Claims made and paid) Curren< 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 tneutber ttutst remain a. Metuber itt good statxiittg or an<utge for "fail Coverage for arty open or potential Claitn tltat uta}- arise dtuing the Coverage Period. Neither CAP nor MPT undertake any obligation to advise any party, other tl><vt the ttameti member, of any changes to or tetmittation of this coverage. Cooperative of American Physicians, Tnc. ~~ ~G~.•-~y- Januan~ 06. 2UU9 on cone Vice President, Membership Services Mutual Protection Trust Laura Stitt Speedy Assistant City Attorney SAN DIEGO I ORANGE t LOS ANGELES 1 SAN JOSE I SACRAMENTO (.`~Oi,f'~R;11'It j=. ~,f ;1v~c:.fi:(~':11V fl~!)`SICl~:1"';. iVC' 3.53 `~ (ti.•~• ~ "~ I•.....,; t 5 C 1/b/LVV~ ~l~lb Yl•1 YHVG J/ 1~ QA UGi V Gi OTHER RELATED PERSON CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) r ax Server Name of Worker Randolph Jones, MD Type of Worker Other Related Persons Employed by or related to the practice of MPT Member or MPT Entity: John G Alevizos DO Inc Membership # or Entity #: 901 Effective Date: August 15, 2008 through December 31, 2009 DBA(s): East Edinger Industrial Urgent Care Tustin-Irvine Medical Group Inc MPT will provide to the above-named Worker, the Claims defense and Claims payment services described in Article VIII of the MPT Agreement, subject to all terms, conditions, and exclusions therein, and subject to payment of all obligations required thereby, for any Occurrence, upon which the Claim is based, arising on or after the above-mentioned Effective Date, in the conduct of Professional Services by such Worker, provided that such Worker was acting within the course and scope of his or her duties and licensure as an actual employee of such Member or Entity at the time of the Occurrence. This Certificate of Professional Liability Coverage is not a contract of insurance or of liability protection services as between MPT and the above-named Worker and does not afford membership in the Cooperative of American Physicians, Inc. (CAP) to such Worker. This Certificate of Professional Liability Coverage does not amend, extend or alter the professional Fiability protection services afforded by the MPT Agreement to the above-named Member or Entity. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this Certificate of Professional Liability Coverage may be issued or pertain, the professional liability protection services afforded by the MPT Agreement described herein are subject to all terms, conditions, and exclusions of the MPT Agreement. The limit of liability through MPT is $1 Million per Occurrence/$3 Million Aggregate. Such limit of liability is shared with the MPT Member. A shared limit of liability means that the MPT Member shares his/her limit of liability with the Worker for any Occurrence upon which a Claim against the MPT Member and the Worker is based. This Certificate shall remain in force unless cancelled or amended by MPT, the MPT Member or the MPT Entity. This Certificate of Professional Liability Coverage is incorporated by this reference into the MPT Agreement. MPT does not track Claims asserted against employees or other related persons. The above-named MPT Member or MPT Entity is responsible for notifying MPT and all recipients of this Certificate of Professional Liability Coverage in the event of the termination of the employment of or other relationship with the above-named Worker. Such Member or Entity is also responsible for notifying all recipients of this Certificate of Professional Liability Coverage in the event that any term of this Certificate of Professional Liability Coverage is modified. ____. - _ _ __ __ Date: January 6, 2009 PRO ~ ~,~ a ~ r: ~3 V i.:z~ %t.;~ g ~~ Laura Stitt Shec-d Assistant C:ily ~~rt`?r:~e1 MUTUAL PROTECTION TRUST ~~~~ ey Hammon P. Acuna Vice President, Membership Services 232k ~ South Pointe Olive Laguna Hills, CA 92653 CA Agency Lir0743913 fns~a,~~cE sfs~lces February 9, 2009 Via Mail and Fax 714-751-9050 Luis Rivera, M.D. Attn: Jane 2222 S. Main Street Santa Ana, CA 92707 RE: PUL[C Policy #P93605-09 Dear Jane: Enclosed is an endorsement, effective 2/2/09; which amends this policy as follows: - Additional [nsured Entity Endorsement -Ancillary Personnel Endorsement -Additional Location Endorsement -Change of Address Endorsement -Vicarious Liability Coverage Endorsement Please review these endorsements carefully and file them with your insurance policy. Should you have any questions, I can be reached at 949-600-8341. Sincerely, Allison Worobey, C[SR, CWCS Account Manager ~~Q ~ ~ CLC RQST Endorsement L1R SKri n PROfESSIONAI UNDERWRITERS / \ LIABILITY INSURANCE COMPANY b TOC Company Additional Insured Entity Endorsement It is hereby understood and agreed that the following Entity: Retroactive Date Cancellation Date September 1, 2005 February 2, 2009 Medical Center of Santa Ana February 2, 2009 John G. Alevizos, D.O., Inc. dba: East Edinger Industrial Urgent Care &Tustin-Irvine Medical Group, Inc. (hereinafter referred to as "said Entity"), is an Insured under this Policy. However, coverage for said Entity is subject to the following provisions: 1) said Ent ry shall (become legallyfobligated to pay as Damages because ofil abil~ty milposedlupon the Namedlch insured for a Claim against the Named Insured for Injury resulting from an Incident involving the Named _•Insured's-rendg~Pt'~ssistnal.Services; -__ __ _ - _ - -- 2) Subject to said Entity's compliance with tfie terms of this Policy, and su~ll defend said (Entity aga nst any defined, and subject to the deductible provisions stated, the Company Claim made against both said Entity and the Named Insured which is reported to the Company during the Claims Reporting Period. even if the allegations of the Claim are groundless, false or fraudulent; 3) This Endorsement does not increase the Limits of Liability stated on the Dedarations Page; 4) The Limits of Liability apply to any Claim against the Named Insured and to any Claim against the Entity; there is only one set of limits and that set applies to both the Named Insured and the Entity, not individually but jointly; 5) If the Named Insured does not have coverage for a Claim, the Entity also does not have coverage for that Claim; 6) If the Company does not defend, or ceases to defend, the Named Insured against a Claim, then the Company shall not have an obligation to defend (or to continue to defend) said Entity against that Claim; 7) The Company may utilize the same defense counsel assigned to the Named Insured in defending the Entity even though the Entity did not participate in or authorize the Professional Services from which the Claim arises; 8) The Company may settle a Gaim against the Entity without its consent; and, 9) Said Entity shall not be considered a Named Insured Entity under this Policy. •- This-Endorserttentsu{ze_rssdes and replaces Endorsement #2 in its entirety. Pagel of t W150 1198 All ether terms and conditions remain urrchan Endorsement No. t 1 Attached to and forming part of Poricy N°• P93605-09 Date processed: February 4.2009 IF EFFECTIVE AFTER INCEPTION DATE OF POLICY: Issued to: Luis E. Rivera, M.O. Effective: Februa 2, 2009 - ~~/ ey PROFESSIONAL UNDERWRITERS \IABILITY INSURANCE COMPANY A TDC Company Additional Location Endorsement It is hereby understood and agreed that coverage is provided for Claims which arise from Professional Services rendered at the following location: --- Retroactive Date 15751 Rockfield Blvd., #100 February 2, 2009 Irvine, CA 92618 February 2, 2009 1530 East Edinger Avenue, #1 ..Santa Ana, CA 92765 _ _ _ . Page 1 of 1 W217 1198 All other terms and conditions remain unchan ed. E~dorsemenl No. 73 Attached to and forming part of Pa6cy No. P93605-09 Oale processed: February 4, 2009 IF EFFECTIVE AFTER INCEPTION DATE OF POLICY: Issued to: Luis E. Rivera, M.O. E((ective: Februa 2, 2009 sr A'CORD CERTIFICATE OF LIABILITY INSURANCE OPID cs DATE(MM/DDlYYYY) ALEVI-2 11/14/08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Kosmos Insurance - COCIA ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE License #OE83671 HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR 1913 E . 17th Street, Suite 213 , ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Santa Ana CA 92705 Phone: 714-972-0950 Fax:714-541-5597 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A Oregon Mutual Ins . Co . wsuRERe Oak River Insurance Co 34630 John G AleVl ZOS D . O . IIIC . INSURER C 800 N. Tustin Ave. , Suite A Santa Ana CA 92705 wsuRERD r~~ irei w `. ~~. INSURER E. 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 MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH , POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NS TYPE OF INSURANCE POLICY NUMBER OL F C IVE PATE MMIDDM' LICY PIRA I N DATE MM/DD LIMBS GENERAL LIABILITY EACH OCCURRENCE $ 2000000 A X X COMMERCIAL GENERALUABILITY BSP704154 08/12/08 08/12/09 PREMISES (Eaoccurence) $ 100000 CLAIMS MADE ~ OCCUR MED EXP (Any one person) $]000 PERSONAL&ADV INJURY $200QQQQ X Non Owned $2 , OOO , GENERAL AGGREGATE $ 4000000 GEN'LAGGREGATELIMITAPPLIESPER. PRODUCTS-COMPlOPAGG $ 3000000 POLICY JECT LOC AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT $ AtJY AUTO (Ea accident] ~ ALL OWNED AUTOS ~ ~ }~.,, iW ` SCHEDULED AUTOS ~~~ "'~ ~ BODILY INJURY (Per person} $ HIRED AUTOS ~~ NON-OWNED AUTOS V~ V A prR l'~11 / ~ / / BODILY INJURY (Per accdent} $ ~ ~~v --- S ~Z ' -•• PROPERTY DAMAGE $ ~~Y ~<•.', • ~. (Per accident) GARAGE LIABILTIY ~au 11,V AUTO ONLY - EA ACCIDENT $ ANY AUTO ~: 1 OTHER THAN EA ACC $ AUTO ONLY: qGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ~ CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND W S A 11 - EMPLOYERS' LIABILITY TORY LIMITS ER B ANY PROPRIETOR/PARTNERlEXECUTIVE OFFICER/MEMBEREXC 2200021717-081 lO/O1/OS ZO/O1/O9 E.LEACHACCIDENT $ ZOOOOOO LUDED? If yes, describe under E.L. DISEASE-EA EMPLOYEE $ ZOOOOOO SPECIAL PROVISIONS below EL.DISEASE-POLICY LIMIT $~,000OOO OTHER DESCRIPTION OF OPERATIONS /LOCATIONS !VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT !SPECIAL PROVISIONS Certificate Holder is named as Additional Insured but only as respects to agreement with the City of Santa Aaa. *except 10 days notice of cancelation if due to non-payment of premium f CDTI L'1/"A TC LIA1 11CG _ _ _._-_ _ _-_ _ CITOFI7 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3O * DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL City of Santa Ana PO BOX 19 8 8M-41 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, TFS AGENTS OR santa Ana CA 92702 REPRESENTATIVES. ACORD 25 {2001108) ©ACORD CORPORATION 19E