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HomeMy WebLinkAboutCORRESPONDENCE - RFP - 7438 MEDICAL PROVIDER - WORKERS COMPENSATION & DOT MEDICAL EXAMS (2)June 25, 2015 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 conditions. The term will be extended for one (1) additional year, February 1, 2015 through January 31, 2016. 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: jg 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: D5C9E573-D217-4554-A4C9-B2337A0EEFFE 6/26/2015 CERTIFICATE HOLDER ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. 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 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 (Attach ACORD 101, Additional Remarks Schedule, if more space is required) INSR LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS WC STATU- TORY LIMITS 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. INSR ADDL WVD SUBR N / A $ $ (Ea accident) (Per accident) 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). The ACORD name and logo are registered marks of ACORD 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 (201005).01 6/26/2015 Flood and Peterson PO Box 578 Greeley CO 80632 Nikki Mosbrucker, CIC,CISR (970)356-0123 (970)330-1867 NMosbrucker@floodpeterson.com Workwell Occupational Medicine 275 S. Main Street, Suite 201 Longmont CO 80501 Westfield Insurance 24112 Medical Protective Company CL1533001595 A X X X X BOP3181479 11/1/2014 11/1/2015 1,000,000 100,000 2,500 1,000,000 2,000,000 2,000,000 A X X BOP3181479 11/1/2014 11/1/2015 1,000,000 Uninsured motorist combined 1,000,000 A X X 0 X BOP3181479 11/1/2014 11/1/2015 4,000,000 4,000,000 B Malpractice Liability C49126 11/1/2014 11/1/2015 Each Occurrence $1,000,000 General Aggregate $3,000,000 Certificate holder is included as Additional Insured as required by written contract with respects to liability arising out of work performed by the named insured. W Morgan, CISR/WMORGA City of Fort Collins PO Box 580 Fort Collins, CO 80524 DocuSign Envelope ID: D5C9E573-D217-4554-A4C9-B2337A0EEFFE