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HomeMy WebLinkAboutCORRESPONDENCE - RFP - P1089 MEDICAL PROVIDER - WORKERS COMPENSATION (3)City of F6rt ColhnJ October 1, 2010 General Care Medical Clinic Attn: Ms. Lori Van Skike 620 South Lemay Fort Collins, CO 80524 RECEIVED Financial Services Purchasing Division 215 North Mason Street 2nd Floor PO Box 580 Fort Collins, CO 80522 970.221.6775 076121 - fax govcom purc asrng RE: P1089 Medical Provider - Workers Compensation Dear Ms-f+*e: rnS . L h a c, cn The City of Fort Collins wishes to extend the agreement term for the above captioned proposal per the existing terms and conditions. The term will be extended for one (1) additional year, January 1, 2011 through December 31, 2011. If the renewal is acceptable to your firm, please sign this letter in the space provided include a current copy of insurance naming the City as an additional insured and return all documents to the City of Fort Collins, Purchasing Division, P. O. Box 580, Fort Collins, CO 80522, 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, Ja e . O'Neill II, CPPO, FNIGP D'rec orlof Purchasing and Risk Management nature Date (Please indicate your desire to renew P1089 by signing this letter and returning it to Purchasing Division within the next fifteen days.) JBO:II Rev 07/08 From:Valerie Mathiason FaxID:9706359401 Page 2 of 2 Date:11/1/2010 04:42 PM Page:2 of 2 OP ID: VM A0caRO" CERTIFICATE OF LIABILITY INSURANCE DArE(MMlDDNYYY) 11 /01110 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 970-635-9400 ACT NAME, LBNInsurance Agcy-Johnstown 970-635-9401 Thompson Pkwy, Ste 200 Johnstown, CO 80534 Shawn Wotowey PHONE FAX Ext : (A/C, No): LA C4848 E-MAIL ADDRESS: PRODUCER GENER-7 CUSTOMER IDs INSURER(S) AFFORDING COVERAGE NAIC t INSURED Generalcare Health Services, I INSURER A: Hartford Insurance Co. 00914 Generalcare Physicians Group, INSURERB: Pinnacol Assurance 41190 620 S. Lemay Avenue Fort Collins, CO 80524 INSURERC: INSURER D : 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 LTR rypE OF INSURANCEADOL INS WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMEDDNYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FX-1 OCCUR X 34SBAIR0214 01101/10 01/01/11 DAMAGE TO RENTED PREMISES Ea occurrence) $ 300,000 MED EXP (Anyone person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY JO ECT F7 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY (Perperson) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ A X SCHEDULED AUTOS HIREDAUTOS 34SBAIR0214 01101/10 01/01111 PROPERTY DAMAGE (Peraccident) $ A X NON -OWNED AUTOS 34SBAIR0214 01/01/10 01/01/11 $ $ UMBRELLA LIAB I X OCCUR EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 A EXCESS LIAB CLAIMS -MADE 34SBAIR0214 01/01/10 01l01/11 DEDUCTIBLE $ $ X RETENTION $ 10,000 WORKERS COMPENSATION WC STATU- I OTH- B AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNEREEXECU"nVE YF OFFICERIMEMBER EXCLUDED? (Mandatory in NH) N /A 1369942 01/01/10 01/01/11 TORY LIMITS ER E.L. EACH ACCIDENT $ 5,000,000 E.L. DISEASE - EA EMPLOYEE $ 5,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 5,000,000 DESCRIPTION OF OPERATIONS! LOCATIONS !VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space Is required) Medical Provider P1089 If required by written contract or written agreement, the Certificate holder Is Included as Additional Insured for ongoing operations under General Liability. City of Fort Collins Purchasing Division Louisa P0Box 580 Fort Collins, CO 805'. LW_11L L"a4 WL1IN19 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 ©1988-2009 ACORD CORPORATION. All rights reserved ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD