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HomeMy WebLinkAboutCORRESPONDENCE - RFP - 7438 MEDICAL PROVIDER - WORKERS COMPENSATION & DOT MEDICAL EXAMS (4)August 14, 2017 Workwell Occupational Medicine Attn: Stephen Pottenger steve.pottenger@workwellworks.com 205 S Main Street #G Longmont, CO 80501 RE: Renewal, 7438 Medical Provider - Workers Compensation & DOT Medical Exams Dear Mr. Pottenger: The City of Fort Collins wishes to extend the agreement term for the above captioned proposal per the existing terms and condition and the following: 1) The term will be extended for one (1) additional year, February 1, 2017 through January 31, 2018. If the renewal is acceptable to your firm, please sign this letter in the space provided and include a current copy of insurance naming the City as an additional insured for both general and automotive liability within the next fifteen days. If this extension is not agreeable with your firm, we ask that you send us a written notice stating that you do not wish to renew the contract and state the reason for non-renewal. Please contact me at (970) 221-6779 if you have any questions regarding this matter. Sincerely, Gerry S. Paul Director of Purchasing __________________________________________ ________________ Signature Date (Please indicate your desire to renew 7438 by signing this letter and returning it to Purchasing Division within the next fifteen days.) GSP: bd Financial Services Purchasing Division 215 N. Mason St. 2nd Floor PO Box 580 Fort Collins, CO 80522 970.221.6775 970.221.6707- fax fcgov.com/purchasing DocuSign Envelope ID: 10586315-6141-47B3-BBFC-143920EB2442 8/15/2017 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: PHONE FAX (A/C, No, Ext): (A/C, No): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXP TYPE OF INSURANCE (MM/DD/YYYY) (MM/DD/YYYY) LIMITS AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- LOC JECT PRODUCTS - COMP/OP AGG OTHER: $ COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $ $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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). COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 08/16/2017 (970) 635-9401 36064 Workwell Occupational Medicine 164 Primrose Court Longmont, CO 80501 41190 A 1,000,000 OH4D075522 11/01/2016 11/01/2017 300,000 10,000 1,000,000 2,000,000 2,000,000 EPLI 1,000,000 A 1,000,000 OH4D075522 11/01/2016 11/01/2017 A 4,000,000 OH4D075522 11/01/2016 11/01/2017 4,000,000 B 4006606 10/01/2016 10/01/2017 500,000 500,000 500,000 C Professional Errors C49126 11/01/2016 Medical Professional 1,000,000 If required by written contract, the Certificate Holder is included as Additional Insured for ongoing operations under General Liability and Designated Insured under Automobile Liability (except Hired and Non-Owned Automobile). City of Fort Collins Financial Services Purchasing Division P O Box 580 Fort Collins, CO 80522 WORKOCC-01 SLUNDER PFS Insurance Group 4848 Thompson Parkway Suite 200 Johnstown, CO 80534 Valerie Mathiason valeriem@mypfsinsurance.com Hanover American Ins. Co. Pinnacol Assurance Co Medical Protective Company X 11/01/2017 X X X X X X