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HomeMy WebLinkAboutCORRESPONDENCE - AGREEMENT MISC - UCHEALTH MEDICAL GROUP (3) May 9, 2022 Poudre Valley Medical Group, LLC DBA UCHealth Medical Group Attn: Michael T. Randle, M.D. 2315 E. Harmony Road, Suite 200 Fort Collins, CO 80528 RE: Contract Renewal, Occupational Health Clinic Provider - Dr. Randle Dear Dr. Randle: The City of Fort Collins wishes to extend the agreement term for the above captioned contract pursuant to the existing compensation rates, terms and conditions for one (1) additional year, August 20, 2022 through August 19, 2023. If the renewal is acceptable to your firm, please sign this letter in the space provided and attach a current copy of your insurance certificate naming the City as an additional insured on General Liability and Automobile Liability and including proof of Workers’ Compensation/ Employers’ Liability Insurance within the next fifteen days. If you wish to propose any changes to the existing agreement prior to renewal, please do not sign this renewal and provide details of your requested change for review and consideration. If you do not want to renew this contract, please provide written notification stating the reason for non-renewal. Please contact Beth Diven, Buyer II at (970) 221-6216 or bdiven@fcgov.com if you have any questions regarding this matter. Sincerely, Gerry Paul Purchasing Director __________________________________________ ____________________________ Signature Date (Please indicate your desire to renew this agreement by signing this letter and returning it to Purchasing Division within the next fifteen days.) GP: kr 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: 04E61B07-BB36-49C6-94B7-023BAE4E4FD0 5/17/2022 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 9/30/2021 Beecher Carlson Insurance Services 1500 Broadway, 21st Floor New York, NY 10036 Beecher Carlson Insurance Services, LLC Poudre Valley Hospital, Inc. 1024 S. Lemay Ave. Fort Collins CO 80524 64322302 Professional liability limits include errors and omissions coverage. City of Fort Collins Risk Management Occupational Health 215 N. Mason Fort Collins CO 80524 Per written agreement with the Named Insured, The City of Fort Collins is added as additional insured for General Liability coverage. A 1,000,000Self Insured Retention 7/1/2021 7/1/20223 3 3,000,000 B TC2J-CAP-9F337354-TIL-21 10/1/2021 10/1/2022 2,000,000 3 TJ-BAP-9F337366-TIL-21B 10/1/2021 10/1/2022 C UB-9K398980-21-51-K 10/1/2021 10/1/2022 3 $500K Deductible 1,000,000N 1,000,000 1,000,000 A Professional Liability Self Insured Retention 7/1/2021 7/1/2022 Each Occ: $1,000,000 Agg: $3,000,000 Self Insured Retention Travelers Property Casualty Co of Amer 25674 Travelers Indemnity Company 25658 64322302 | 21-22 GL PL AU WC (Poudre) | Robert Schwartz | 9/30/2021 6:28:08 PM (PDT) | Page 1 of 1 DocuSign Envelope ID: 04E61B07-BB36-49C6-94B7-023BAE4E4FD0 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 10/1/2021 Beecher Carlson Insurance Services 1500 Broadway, 21st Floor New York, NY 10036 Beecher Carlson Insurance Services, LLC Poudre Valley Health Care, Inc. d/b/a Poudre Valley Health System and Poudre Valley Hospital 2315 E. Harmony Rd., Suite 200 Fort Collins CO 80528 64340529 3 Per written agreement with the Named Insured, the policy provides automatic additional insured status to the certificate holder. City of Fort Collins ATTN: Purchasing Department PO Box 580 Fort Collins CO 80522 RE: Services provided to the Occupational Health Clinic, 256 W. Mountain AVE, Fort Collins, CO 80521 $10,000,000Limit $1,000,000Retention A Cyber Liability W30706210101 10/1/2021 10/1/2022 Beazley Insurance Company, Inc.37540 64340529 | 21-22 Cyber | Robert Schwartz | 10/1/2021 9:31:14 AM (PDT) | Page 1 of 1 DocuSign Envelope ID: 04E61B07-BB36-49C6-94B7-023BAE4E4FD0