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HomeMy WebLinkAboutWILLIAM H. NUESSE M.D. AND MARY ANN NUESSE, D.O. dba SUNRISE MULTISPECIALIST MEDICAL CENTER (2) INSURANCE NO-( ON FILE A-2022-152-01 WORK MAY NOT PROCEED CITY CLERK DATE, JUN 12 202; FIRST AMENDMENT TO AGREEMENT WITH WILLIAM H. NUESSE, M.D. AND MARY ANN NUESSE,D.O.,A CALIFORNIA MEDICAL CORPORATION DBA SUNRISE MULTISPECIALIST MEDICAL CENTER THIS FIRST AMENDMENT to the above-referenced agreement is entered into on June , 2025,by and between William H.Nuesse, M.D.and Mary Ann Nuesse,D.O.,a California medical corporation doing business as Sunrise Multispecialist Medical Center("Consultant")and the City of Santa Ana, a charter city and municipal corporation organized and existing under the Constitution and laws of the State of California("City"). RECITALS A. The parties entered into Agreement No. A-2022-152,dated June 7,2022,by which Consultant agreed to provide non-industrial medical services including, but not limited to, Department of Transportation mandated services, drug tests, respiratory fitness tests, vision testing, post- accident testing, pre-employment examinations, Thiess for duty examinations, COVID-19 testing and similar medical services for employees or applicants for employment ("Agreement"). B. The Agreement is current and in-effect,and expires on June 30,2025. C. The parties now wish to amend the term to extend it by six(6)months. The funding previously approved is sufficient to cover the extended term. The Parties therefore agree: 1. Section 3,TERM, is amended to extend the termination date from June 30,2025 to December 31,2025. 2. Except as modified by this First Amendment,all terns and conditions of the Agreement shall remain in full force and effect. o ATTEST CITY ANT IF L. LL ` LVARO NUNEZ City Manager APPROVED AS TO FORM CONSULTANT Sonia R. Carvalho City Attorney y: r L LAURA A. ROSSINI By: Chief Assistant City Attorney Title: [Signatures continue on the next page] Page 1 of 2 RECOMMENDED FOR APPROVAL LO 1 SCHNAIDER Executive Director Human Resources Agency Page 2 of 2 �" DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 09/30/2025 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Calhoun&Associates CONTACT NAME: Carmen Ponce DBA: Integrity Advisors (PHONE.,Ext:800-500-9799 FAX No:714-664-0614 14771 Plaza Drive,Ste C E-MAIL carmen mte ri advisors.com ADDRESS: g ty" Tustin CA 92780 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:REPUBLIC INDEMNITY CO OF AMERICA 19739 INSURED William H.Nuesse,M.D.and Mary-Ann Nuesse,D.O. INSURERB: Sunrise Multispecialist Medical Center INSURERC: 867 South Tustin Street INSURER D ORANGE CA 92866 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD MM/DD COMMERCIAL GENERAL LIABILITY L1 EACH OCCURRENCE $ —1 CLAIMS-MADE ❑ OCCUR -PREMISES DAMAGE TO PREMISES Ea occurrence) ccurrence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ YIEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑ PRO JECT ❑ LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY ❑ COMBINED SINGLE LIMIT $ Ea accident eANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS uHIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY AUTOS ONLY Per accident lul u $ UMBRELLALIAB OCCUR F EACH OCCURRENCE $ u EXCESS LIAB u CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY STATUTE Li ER A ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N 256017-04 08/01/2025 08/01/2026 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? 1 N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 Digitally signed 00 TU Tr an byTuTran Nguyen Date:2025.10.07 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ' 45 The Waiver of Subrogation applies to the City of Santa Ana, its City Council,officers,officials,employees,agents,and volunteers. APPROVED By Tu Tran Nguyen at 10:45 am,Oct 07,2025 CERTIFICATE HOLDER CANCELLATION City of Santa Ana Attention: Human Resources Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE p THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 Civic Center Plaza, CA 92701 ACCORDANCE WITH THE POLICY PROVISIONS. Santa Ana, CA 92701 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule State Person or Organization Job Description California City of Santa Ana, Operations of the named insured Attention: Human Resources Department 20 Civic Center Plaza, CA 92701 Santa Ana, CA 92701 The premium charge for this endorsement shall be $250. This charge will be billed at the final audit. WC 00 03 13 1 of 2 (Ed. 04-84) Insured Copy ©1983 National Council on Compensation Insurance. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13 (Ed. 04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. Republic Indemnity Company of California Company Number 27561 Insured William H Nuesse MD and Mary Ann Nuesse Do, a Medical Corp Policy Number 256017-04 Endorsement Number 12 Endorsement Effective August 01, 2025 Printed On October 03, 2025 Countersigned by WC 00 03 13 2 of 2 (Ed. 04-84) Insured Copy ©1983 National Council on Compensation Insurance.