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HomeMy WebLinkAboutCORRESPONDENCE - AGREEMENT MISC - SUMMITSTONE HEALTH PARTNERSAugust 16, 2019 SummitStone Health Partners Attn: Michael G. Allen, CEO 125 Crestridge Street Fort Collins, CO 80525 RE: Contract Renewal, FCPD Mental Health Co-Responder Dear Mr. Allen: The City of Fort Collins wishes to extend the agreement term for the above captioned agreement per the existing terms and conditions and the following: 1) The term will be extended for one (1) additional year, July 1, 2019 through June 30, 2020. If the renewal is acceptable to your firm, please sign this letter in the space provided and include a current copy of insurance certificate naming the City as an additional insured for General and Automotive Liability within the next fifteen (15) 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 this agreement by signing this letter and returning it to Purchasing Division within the next fifteen days.) GSP:kk 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: 46D14D06-9741-4D9A-AFDF-6227C80951EF 8/23/2019 7/8/2019 Professional Risk LLC 8213 W.20th St Greeley CO 80634 Jennifer Hunter (970)356-8030 (970)356-8032 jennifer.hunter@proriskllc.com SummitStone Health Partners 4856 Innovation Drive, Suite B Fort Collins CO 80525 Philadelphia Insurance Co 18058 Pinnacol Assurance 41190 Travelers Casualty & Surety Company of America 31194 19-20 HIPPA A X X X Professional Liability X X PHPK2003065 7/1/2019 7/1/2020 1,000,000 100,000 5,000 1,000,000 3,000,000 3,000,000 Employee Benefits 1,000,000 A X X PHPK2003065 7/1/2019 7/1/2020 1,000,000 B 4044330 7/1/2019 7/1/2020 X 100,000 100,000 500,000 C Privacy 106545865 7/1/2019 7/1/2020 Aggregate $ 2,000,000 A HIPPA PHSD1459940 7/1/2019 7/1/2020 HIPPA Limit $ 50,000 City of Fort Collins is listed as additional insured as pertains to the General and Auto Liability policies, per written contract. City of Fort Collins PO Box 580 Fort Collins, CO 80522 Dionne Perez/DP The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) AUTHORIZED REPRESENTATIVE CANCELLATION CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) JECT LOC PRO- POLICY GEN'L AGGREGATE LIMIT APPLIES PER: CLAIMS-MADE OCCUR COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) $ DAMAGE TO RENTED EACH OCCURRENCE $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ DED RETENTION $ CLAIMS-MADE OCCUR $ AGGREGATE $ UMBRELLA LIAB EACH OCCURRENCE $ EXCESS LIAB DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS PER STATUTE OTH- ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ $ $ ANY PROPRIETOR/PARTNER/EXECUTIVE If yes, describe under DESCRIPTION OF OPERATIONS below (Mandatory in NH) OFFICER/MEMBER EXCLUDED? WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED HIRED AUTOS NON-OWNED AUTOS AUTOS AUTOS COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE $ $ $ $ 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. INSD ADDL WVD SUBR N / A $ $ (Ea accident) (Per accident) OTHER: 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). COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: INSURED PHONE (A/C, No, Ext): PRODUCER ADDRESS: E-MAIL FAX (A/C, No): CONTACT NAME: NAIC # INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INS025 (201401) DocuSign Envelope ID: 46D14D06-9741-4D9A-AFDF-6227C80951EF