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Home My WebLink AboutTUSTIN-IRVINE MEDICAL GROUP 1A-2010.4 NSURANCE oN FL a A-2010-088 WORK MAY PROCEF JN CE r IQ' S TII_ INS AN CLERK P OU !I FIRST AMENDMENT TO AGREEMENT ^ATL THIS FIRST AMENDMENT TO AGREEMENT is entered into on 1" day of July, 2010, by and between Tustin Irvine Medical Group, a professional corporation ("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 that certain Agreement, dated August 3, 2009,(A-2009-110), (hereinafter "said Agreement") by which Consultant has provided physical examination and treatment services to all sworn Fire personnel and select Police personnel . B. In accordance with the terms and conditions of said Agreement, the parties wish to extend the term of the Agreement for an additional one-year period. WHEREFORE, in consideration of the covenants contained in said Agreement, and subject to all the terms and conditions of said Agreement, except those amended in this First Amendment to Agreement, the parties agree as follows: 1. Section 3, TERM, shall be amended to state as follows: This amended Agreement shall commence on July 1, 2010 and terminate on June 30, 2011, unless terminated earlier in accordance with Section 12, below. Should the maximum agreed upon compensation as set forth in Section 2, COMPENSATION, not be exhausted during this additional term this amended Agreement may be extended upon a writing executed by the Fire Chief and the City Attorney. 2. Except as hereinabove amended, all terms and conditions of said Agreement shall remain in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this First Amendment to Agreement on the date and year first written above. ATTEST: MARIA D. HUIZAR Clerk of the Council APPROVED AS TO FORM: JOSEPH W. FLETCHER City Attorney Jq5 h S,(raka sistant City Attorney CITY OF SANTA ANA DAVID N. REAM City Manager TNE MEDICAL GROUP N) ME: ?,? ? Title: fyw"Co-k Tax ID#: 33 -0"33\31 Gals E..j?".k M.D. 07/14/2010 10 32 FAH 714 83G 3087 1 TIMG TUSTIN lih004/004 PROFESSIONAL UNDERWRITE[ S LIABILITY INSURANCE COMPA V A TOC Camp, my CLAIMS-MADE MEDICAL PROFESSIONAL LIABILITY POLICY Policy Nuriber: Declarations P93605.. 10 Name and Address of Named Insured: Luis E. Rivera, M.D. 800 North Tustin Avert,Ie, Suite A Santa Ana, CA 92705 ? J Retroactive Date: September 1, 2005 NOTICE: This is a CLAIMS.-MADE POLICY. Except to such extent as may be provided otherwise herein, Ih :s insurance is limited to liability for only those CLAIMS TI [AT ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD. Please read and review the Policy : arefully and discuss with your insurance broker or representat, t:. Vm.IVI t-Cf71 VIJ? -•? (MO. DAY YR.) (MO. DAY YR.) From: 09101109 to: 09101/10 12131 A.M., standard time at the address of the named insured as stated lerein. The insured is engaged in the specialty of Dertaral SVr class 3 -1,1_ :I_ and is duly registered and/or licensed to practice his/her profession under the laws of all jurisdictions in which he/she practices, COVERAGE LIMITS OF LIABILITY PREMIUM - Msdical Professional Liability g 1,000,000.00 Each Claim $ 44,887.00 - $ 10,000.00: Deductible S 3,000,000.00: Aggregate CIGA $ N/A ENDORSEMENTS: $ 44,887.00 W102 Change In 31Peclalty Endorsement W1da Addttional Insured Entity Endaraement W151 Aelnsry Pomennel Endorsement W201 Llmaallon Endorsement - No 3urgaly VM: Inclusion or Praeeduraa Endorsement HV20i Locum Tenons Endorsement W213 Amendment of cancellation Period Endorsement W217 Addhlonal Location Endonsmortt W222 Vicarious Liability Endorsement W305 Change 91 Codueilbk endonement W503 Medical eeerd compliance Endareement WHO eustnesa Assoctates Endorsement This policy is made and accepted subject to the foregoing provisions and stipulations and those hereinafter stated, which are hereby nade a part of this policy, together with such provisions, stipulations and agreements as may be added hereto, as provided In INS Policy. Broker: RGI Inauranc# Services Date of Issue: sa tember 2 2mg 23241 South POMte Drive Laguna Mills, CA 92653 Broker Code: 0314 f .DE0001 License Agent or Authorized FtephosentativE 07/14/2010 10 32 FAIT 714 836 3087 TIMG TUSTIN 0 COOPERATIVE OF AMERICAN PHYSICIANS CERTIFICATE OF COVERAGE AND CLAIMS HISTORY Coverage Ibrou=h Deeeaabar31, 2010 low? Member) John G. Alevizos, DO Address: 800 N. Tustin Ave Suite A Santa Ana, CA 92705 IA 002/004 This certificate confirms that, on the date below, the above-namcd physician is a member of the Cooperative of Amen(., n Physicians, Inc. (CAP) and a participant in the Mutual Protection Trust (Nf m. MPT is an unincorporated interindeenni 1, arrangement organimd under California Insurance C7de section 1280.7. This certificate confers no rights upon the member at :1 does not amcnd, extend or alter the coverage afforded undrr the terms, conditions and exclusions of the MPT Agreement Membership Number Medical specialty Coverage Data Retroactive Covsrepe Data 9275 Family Medicine, Wh April I, 1999 October 1, 1993 Surgical Assist Subspecialty COVenye (Claims made and Will Medical Professional Liability Coverage Current Limits of Liability $1,000,000 $3,000,000 for all Claims based upon an Occurrence each calendar year aggregate The member must remain a Member in good standi 16 or arrange for Tail Coverage for any open or Potential Claim that mr, arise during the Coverage Period Neither CAP nor MPT undertake any obligation to advise any parry, other than the names member, of any changes to or termination of this coverage Claims History No Claims Reported 'rbs Claims hlstOry listed above includes all Claims that are currently open and those that were closed within the last five years the Claims history dos not include paymeriN for emergency or other remedial expense, that may have been made to patients through MPT's Patient A99istance Services program, Cooperative of American Physicians, Inc, Hammon P Aeuna Vice President, Membership Scrvicos Mutual Protection Trust December 28. 2009 Date AP COVED TO FO Joseph Straka Assistant City Attorney 07/14/2010 10.32 FAX 714 836 3087 TIMG TUSTIN Fax Server 1/4/2010 4:'52:05 PM PAGE 3/003 Fax Server OTHER RELATED PHYSICIAN CERTIFICATE OF PROFESSIONAL LIABILITY COVERAGE THROUGH MUTUAL PROTECTION TRUST (MPT) Name of Worker Rsndolph Jonas, MO Type of Worker. Other Related Physician Employed by or related to the practice of MPT Member or MRT Entity: John O Alevlzoa DO Inc Membership 0 or Entity d: 901 Effective Date: August,15, 2009 thpeugh 13sq, "ber 91, 2010 DBA(s): East,Edinger Industrial Urgent Oars Tustin-Irvine Meit11ci1 Group, MPT will provide lo the above-named Worker, the Claims defense and Claims payment services described in Part 1 of the MPT Agreement subject to all terms, conditions, and exclusions therein, and subject to payment of al obloa ions required thereby, for any Occurrence, upon which the Claim is based, arising on or after the above-mentioned Effective Dade, 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 profestior al. liability protection services afforded by the MPT Agreement to the above-named MornWr-or Entity..Nottuithsolli tg any requirement, term or condition of any contract or other document %6th respect lo:-Olch this Certificate of Professional Liability Coverage may be issued or pertain, the professional liilb„B,ity protection services afforded by the MPT Agreement described herein are subject to all terms, condii ions, and exclusions of the MPT Agreement. The limit of liability through MPT Is $1 Million per Occurrsnce43 Million Aggregate. Such limit of liability Is shared with the MPT Member. A snared Cantle of l 0100 l means that the AWY Member eh W hiafher limit of liability wRh the Worker for any Oocurrenoo upon welch a Claim against the MPT Member and eta Mlorlaw is b"O. ' - , This Certificate shell remain In force unless canceled or amended by MPT, the MPT Member or the MPT Entity. This Certificate of Professional Liability Coverage is;incorporatod by this reference into the MPT Agreement. MPT does not track Claims asserted against employees oG Other Relab O Rhysicians. The above-named MPT Member or MPT Entity is respoilhtibie for notifying MPT and afi recipients of this Certificate of Professlonst Liability Coverage to that event of the termination of the employment of or other relationship with the above-non?d Mbrkw. Such Member or Entity Is also responsible for notllying all recipients of this Certificate of Prlofeswonal Liability Coverage In the event that any berm of this CertMate of Professional Liability Coverage In modified. Date. January4, 2010 MUTUAL PROTECTION TRUST , mammon P, Acur e .Vice Presidertti,Membership SerVIM 2 003/004