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HomeMy WebLinkAboutU.S. HEALTHWORKS 6 - 2016DocuSign Envelope ID: E6 3EEB4G- 6DE4- 4BE1- A8C8- 30ACB3F24BIO j'c'r3A0 Q cx. om , 2.3 `A CONSULTANT AGREEMENT ! • t + THIS AGREEMENT is made and entered into this 290' day of April, 2016 by and between U.S. Healthworks Medical Group, Prof. Corp., a California 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 City desires to retain a consultant having special skill and knowledge in the field of medical services for job related injuries and illnesses. B. Consultant represents that it is able and willing to provide such services to the City. C. The City acknowledges that it has received billing from Consultant prior to the date of this Agreement commencing as of July 1, 2015, and City intends that any rmpaid sums owed to Consultant for prior services commencing July 1, 2015 shall be covered under this Agreement. The previous agreement with the Consultant terminated sooner than expected due to unanticipated demands for the Consultant's services which resulted in increased expenses. D. 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 in the same 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 preventative medical services to City employees who may be exposed to communicable diseases, as 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 $25,000.00 during the term of this Agreement. b. Payment by City shall be made within thirty (30) days following receipt of proper invoice evidencing work perfonmed, 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. DocuSign Envelope ID: E63EEB4C- 6DE4- 4BE1- A8C8- 30ACB3F24610 c. The City aclalowledges that it has received billing from Consultant prior to the date of this Agreement and intends this Agreement to cover services commencing as of July 1, 2015, and City intends that any unpaid sums receivable by Consultant for services commencing July 1, 2015 shall be covered under this Agreement. 3. TERM This Agreement shall commence on the date first written above and terminate on June 30, 2017, unless terminated earlier pursuant to Section 12, below. The term of this Agreement may be extended upon a writing executed by the City Manager and the City Attorney for up to one (1) year. 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 its 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 and $2,000,000 in the aggregate. Such insurance shall (a) name the City, its officers, employees, agents, volunteers and representatives as additional insured(s); and (b) be primary and not contributory with respect to insurance or self - insurance programs maintained by the City. b. Worker's Compensation Insurance. In accordance with California State law, 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 2 DocuSign Envelope ID: E63EEB4C- 6DE4- 4BE1- A8C8- 30ACB3F24B10 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. e. Professional Liability (errors and omissions) insurance, with a combined single limit of not less than $1,000,000 per claim and $2,000,000 annual aggregate shall be maintained. 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. Certificates of insurance shall be furnished to the City upon execution of this Agreement and shall be approved in form by the City. (ii) 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 terminate this Agreement. Such termination shall not affect 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, defend, and hold harmless the City, its officers, agents, employees, consultants, counsel, and representatives from liability for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims: (1) for personal injury, including death, and claims for property damage, arising from the direct or indirect operations of the Consultant or its contractors, subcontractors, agents, employees, or other persons acting on its 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 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. The Consultant further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for counsel to be selected by the City, regarding any action by a third party 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. DocuSign Envelope ID: E63EEB4C- 6DE4-4BE1- A8C8- 30ACB3F24B10 CONFIDENTIALITY If Consultant received 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 infonnation 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 and disclosed 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 interest 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 facsimile 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, California 92702 -1988 Facsimile (714) 647 -6956 Copies to: Executive Director of Personnel Services City of Santa Ana 20 Civic Center Plaza (M -24) P.O. Box 1988 DocuSign Envelope ID: E63EEB4C- 6DE4- 4BE1- A8C8- 30ACB3F24B10 To Consultant: Santa Ana, California 92702 Facsimile (714) 647 -5311 City Attorney City of Santa Ana 20 Civic Center Plaza (M -29) P.O. Box 1988 Santa Ana, California 92702 -1988 Facsimile (714) 647 -6515 U.S. Healthworks — East Edinger Attn.: Michelle Harrison, Clinic Supervisor 1619 E. Edinger Ave. Santa Ana, California 92705 Facsimile (714) 541 -5313 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 facsimile, 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 regarding the subject matter herein, and supersedes any and all other agreements, oral or written, between the parties. hr the event of a conflict between the terms of this Agreement and any attachments hereto, the terms of this Agreement shall prevail and will serve to fully supersede existing Agreement. 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 or 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 DocuSign Envelope ID: E63EEB4C- 6DE4- 4BE1- A8C8- 30ACB3F24810 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 with thirty (30) days written notice of termination to the Consultant. a. As a condition of such payment, the City may require Consultant to deliver to the City all the 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 that fails to meet the standard of performance specified in the Recitals of this Agreement. 13. NON DISCRIMINATION Consultant shall not discriminate because of race, color, creed, relation, 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 or any activities under this Agreement. 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 Sates, the State of California, the City of 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. [Signature Page to Follow] DocuSign Envelope ID: E63EEB4C- 6DE4- 4BE1- A8C8- 30ACB3F24B10 IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. ATTEST: MARIA D "HUIZ,AR Clerk of the Council APPROVED AS TO FORM: City R.CARVALHO RA M. S'CHWARZMANN Assistant City Attorney FOR APPROVAL: Executive Director Personnel Services Agency CITY OF SANTA ANA DAVID CAV City Manager CONSULTANT D 5,.d by: q�s " 'Jug�PIPTMIAllas President and Secretary Tax ID #95- 4643269 DocuSign Envelope ID: E63EEB4C- 6DE4- 4BE1- A8C8- 30ACB3F24B10 FEESCHEIDULE TYPE OF MEDICAL PROCEDURE COST PER TEST AUDIOGRAM $ 25.00 BACK X -RAY $ 72.00 BLOOD LEAD LEVEL ZZP $ 61.00 BLOOD SCREENS- 7 panel drug screen $ 86.00 CHFSTX -RAY $ 55.00 CORE EXAM* $ 80.00 DMV $ 99.00 HEP A BLOOD SCREEN $ 50.00 HEP B BLOOD SCREEN $ 55.00 HEP B BOOSTER $ 100.00 HEP 3TITER $ 55.00 HEP B VACCINE $ 100.00 HEP AVACCINE $ 132.00 HEP C BLOOD SCREEN $ 55.00 HIV BLOOD SCREEN $ 45.00 PULMONARY FUNCTION TEST $ 70.00 RESPIRATOR FIT TEST $ 50,00 RESPIRATOR PHYSICAL (requires Pulmonary Function Test) $ 80.00 RESPIRATOR QUESTIONIARE IF PX IS NOT REQUIRED W /CLEARANCE $ 28.00 TB $ 28.00 URINALYSIS $ 15.00 URINE COLLECTION FEE $ 28.00 "Core exams are basic physicals: include vital signs, vision testing, physical exam, and urinalysis. 8 I T ® CERTIFICATE OF LIABILITY' INSURANCE DATE (MM /DDIYYYV) s)DATE(Ms 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 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 InterWest Insurance Services License #01301094 222 Court Street CONTACT Michelle Goodwin CIC CISR CPSR PHONE ,g31- 635 -2247 FAX .831- 638 -6801 P.0 EMAIL . mgoodwin @iwins.com INSURER (S) AFFORDING COVERAGE NAIC q Woodland CA 95695 INSURER A: Liberty Mutual Fire Ins Co 23035 $_1,00_0L. 000 INSURED USHEA -1 INSURER B:Liberty Insurance Corporation 42404 INSURER C:Safety National Casualty Corp 15105 U.S. Healthworks Holding Company, Inc. 25124 Springfield Ct., Ste 270 Valencia CA 91355 INSURER D $1,000000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY [:] JPECOT T LOC OTHER: GENERAL AGGREGATE $2000,000 INSURER E: $2,000,000 INSURER F: $ • COVFRAr;FR CERTIFICATE NIIMBF_R- 863365504 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. IL3R TYPE OF INSURANCE INSD WIG POLICY NUMBER MMfDDYEFV MMDDYEYY LIMITS • X COMMERCIAL GENERAL LIABILITY CLA1MS-MADE T OCCUR Y TB2691450294035 9/1/2015 9/1/2016 EACH OCCURRENCE $_1,00_0L. 000 DAMAGE TO RENTED PREMISES Ea occurrencel . $1,000,000 MED EXP Anyone arson $10,000 PERSONAL B ADV INJURY $1,000000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY [:] JPECOT T LOC OTHER: GENERAL AGGREGATE $2000,000 PRODUCTS - COMP /OP AGO $2,000,000 $ • AUTOMOBILE X X IAUTOS LIABILITY ANY AUTO ALL OWNED SCHEDULED HIRED AUTOS X NON -OWNED AS2691450294045 9/1/2015 9/1/2016 EU as tleo1S NGLE LIMIT $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ $ B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE TH7691450294055 9/1/2015 9/112016 EACH OCCURRENCE $25,000,000 AGGREGATE $25,000,000 DEO X I RETENTION $10,000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA LDC4042721 9/112015 9/1/2016 X STATUTE ER E.L. EACH ACCIDENT $2,000,000 E.L. DISEASE - EA EMPLOYEE $2,000,000 E.L. DISEASE- POLICY LIMIT $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Certificate holder is included as additional insured as required by written contract per the attached endorsement Re: 1619 East Edinger, Santa Ana, CA 92705 CERTIFICATE HOLDER CANCELLATION `10 days notice for nonpayment @ 1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD p- tj�e"xA. cp- �(.Irt�i. Y"1 rwtU�^�.- l �� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. 20 Civic Center Plaza Santa Ana CA 92701 AUTHORIZED REPRESENTATIVE @ 1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD p- tj�e"xA. cp- �(.Irt�i. Y"1 rwtU�^�.- l �� THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: C OMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization (s): Location(s) Of Covered Operations As Required By Written Contract As Required By Written Contract Information required to complete this Schedule if not shown above will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury ", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf, in the performance of your ongoing operations for the additional insured(s) at the location(s) desig- nated above. B. With respect to the insurance afforded to these additional insureds, the following additional exclu- sons apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equip- ment furnished in connection with such work, on the project (other than service, mainte- nance or repairs) to be performed by or on be- half of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. This endorsement is executed by the Premium N/A Effective Date 09101/15 -16 For attachment to Policy No. TB2691450294035 Audit Basis O ISO Properties, Inc., 2004 CG 20 10 07 04 gh I T ACOR CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDA'YYY) 4/28/2016 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(les) must 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 InterWest Insurance Services License #0801094 222 Court Street CA FACT Michelle Goodwin, CIC, CISR, CPSR PHONE . 831- 635 -2247 FAX 6831- 636 -6801 . mgoodwin @iwins.com R:,ggoodwin@iwins.com INSURERS AFFORDING COVERAGE NAICq Woodland CA 95695 INSURERA:NORCAL Mutual Ins Company 33200 INSURED USHEA -1 INSURER B: $ INSURER C: CLAIMS -MADE 0 OCCUR U.S. Healthworks, Inc. 25124 Springfield Ct., Ste 200 Valencia CA 91355 INSURER 0 INSURER E: $ INSURER F: MED EXP lAny one person) $ COVERAGES CERTIFICATE NUMBER: 880317952 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 R TYPE OF INSURANCE Santa Ana CA 92701 POLICY NUMBER POLICY D EYY MMLDOY EYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE 0 OCCUR DAMAGE TO RENTED PREMISES IE c $ MED EXP lAny one person) $ PERSONAL &ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑ PRO- ECT ❑ LOG PRODUCTS - COMP /OP ASS $ $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LI Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL AUTOS OWNED AUTOSULED BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DUD RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN I PER OTH- STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER /MEMBER EXCLUDED? ❑NIA E.L. DISEASE -EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DE SCRIPTION OF OPERATIONS below E. L. DISEASE - POLICY LIMIT $ A A Medical Malpractice Professional Liability 721820E 721823N 5/1/2016 5/1/2016 5/1/2017 5/112017 Aggregate $3,000,000 Limit $1,000,000 $150,000 Ded IL /CAFrX/FL /WA Ded. -All Other Slates $100,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Add ltlonal Remarks Schedule, may be attached If more space Is required) Although multiple policies are shown above, the person or organization identified above as the Insured qualifies as an Insured under only one of those policies shown, and the coverages and limits of liability for such coverages of only one of those policies will apply to that Insured. Re: 1619 East Edinger, Santa Ana, CA 92705 CERTIFICATE HOLDER CANCELLATION 10 Days for Non Payment of Premium ACORD 25 (2014/01) @ 1988.2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 Civic Center Plaza ACCORDANCE WITH THE POLICY PROVISIONS. Santa Ana CA 92701 AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) @ 1988.2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AC °D® CERTIFICATE OF LIABILITY INSURANCE ggTE (MMIDDIYYYY) 8/31/2016 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 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 InterWest Insurance Services License 40B01094 222 Court Street NAME: Michelle Goodwin, CIC, CISR, CPSR PHDNE 831 -635 -2247 F4X 831-638-6801 E -MAIL . mgoodwin @iwins_com INSURE R($) AFFORDING COVERAGE Me# Woodland CA 95695 INSURERA:Liberty Insurance Corporation 42404 $1,000,000 INSURED USHEA -1 INSURER B:Liberty Mutual Fire Ins Co. 23035 U.S. Healthworks Holding Company, Inc. INSURER c:Safety National Casualty Corp 15105 25124 Springfield Ct., Ste 270 Valencia CA 91355 INSURER D PERSONAL $ADVINJURY INSURER E GEN'L AGGREGATE LIMIT APPLIES PER: POLICY E PEA LOC OTHER' INSURER F $2,000,000 COVERAGES CERTIFICATE NUMBER: 810747776 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF MMfDO POLICY EXP MM1DDNYYY LIMITS B X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR Y TB2691450294036 9/1/2016 9/1/2017 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $1,000,000 MED FRCP (Any one person) $10,000 PERSONAL $ADVINJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY E PEA LOC OTHER' GENERAL AGGREGATE $2,000,000 PRODUCTS - COMPIOPAGG $2,000,000 $ B AUTOMOBILE LIABILITY ANYAU70 AUT OWNED SCHEDULED HIRED AUTOS X NON -OWNED AUTOS AS2691450294045 9/1/2016 9/1/2017 COMBINED SINGLE LIMIT Eaacci ED $ 1,000,000 X BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ $ A X UMBRELLA LIAR EXCESS LIAR X OCCUR CLAIMS -MADE 1 TH7691450294056 9/1/2016 9/1/2017 EACH OCCURRENCE $25,000,000 AGGREGATE $25,000,000 DED I X I RETENTION 10,000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERlEXECUTIVE OFFICEFJMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA LDC4042721 9/112016 9/1/2017 PER OTH- X STATUTE ER E.L. EACH ACCIDENT $2,000,000 E.L. DISEASE - EA EMPLOYEE $2,000,000 E.L. DISEASE - POLICY LIMIT $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Addltlonal Remarks Schedule, may be attached if more space is required) Re: 1619 East Edinger, Santa Ana, CA 92705 Certificate holder is included as additional insured when required by written contract per the attached endorsements. %Imr% 1 Ir141p% I C nvLLJMM L,AIYL rLLAI IVIV IV VaYa IIVLH,G IVI IIVII V[1VIIItNII City of Santa Ana 20 Civic Center Plaza Santa Ana CA 92701 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE bkluVLZ ©1988 -2094 ACORD CORPORATION. All rights reserved. ACORD 25 (2014181) The ACORD name and logo are registered marks of ACORD 4 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS -- SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: C OMMERCIAL GENERAL LIABILITY COVERAGE PART cr-uirniri P Name Of Additional Insured Person(s) Or Os anization s : Location(s) Of Covered Operations As Required By Written Contract As Required By Written Contract Information remilred to complete this Schedule, if not shorn above, will be shown in €he Declarations. A. Section Il — Who Is An Insured is amended to include as an additional insured the person($) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insureds) at the location(s) desig- hated above. S, With respect to the insurance afforded to these additional insureds, the following additional exclu- sions apply: This insurance does not apply to "bodily injury' or 'property damage" occurring after: 1. Ali work, including materials, parts or equip - ment furnished in connection with such work, on the project (other than service, mainte- nance or repairs) to be performed by or on be- half of the additional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its in- tended use by any person or organization other than another contractor or subcontractor en- gaged in performing operations for a principal as a part of the same project. This endorsement is executed by the Premium N/A Erroctive Date 9/1/16 For attachment to Policy No, TB2691450294036 Audit Basis © ISO Properties, Inc., 20D4 CG 2010 07 04 ���