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HomeMy WebLinkAbout54324 SUMMITSTONE HEALTH PARTNERS - CONTRACT - AGREEMENT MISC - SUMMITSTONE HEALTH PARTNERSSERVICES AGREEMENT THIS AGREEMENT made and entered into the day and year set forth below by and between THE CITY OF FORT COLLINS, COLORADO, a Municipal Corporation, hereinafter referred to as the "City" and SummitStone Health Partners, hereinafter referred to as "Service Provider". WITNESSETH: In consideration of the mutual covenants and obligations herein expressed, it is agreed by and between the parties hereto as follows: 1. Scope of Services. The Service Provider agrees to provide services in accordance with the scope of services attached hereto as Exhibit "A", consisting of two (2) pages and incorporated herein by this reference. 2. Time of Commencement and Completion of Services. The services to be performed pursuant to this Agreement shall be initiated on July 1st, 2017. The Service Provider shall provide services 40 hours per week. Hours to be mutually agreed upon by the City and SummitStone Health Partners. 3. Contract Period. This Agreement shall commence July 1st, 2017, and shall continue in full force and effect until June 30th, 2018, unless sooner terminated as herein provided. In addition, at the option of the City, the Agreement may be extended for additional one year periods not to exceed four (4) additional one year periods. Renewals and pricing changes shall be negotiated by and agreed to by both parties. Written notice of renewal shall be provided to the Service Provider and mailed no later than thirty (30) days prior to contract end. 4. Delay. If either party is prevented in whole or in part from performing its obligations by unforeseeable causes beyond its reasonable control and without its fault or negligence, then the party so prevented shall be excused from whatever performance is prevented by such cause. To the extent that the performance is actually prevented, the Service Provider must provide written notice to the City of such condition within fifteen (15) days from the onset of such condition. 5. Early Termination by City/Notice. Notwithstanding the time periods contained herein, the City may terminate this Agreement at any time without cause by providing written notice of termination to the Service Provider. Such notice shall be delivered at least fifteen (15) days prior to the termination date contained in said notice unless otherwise agreed in writing by the parties. All notices provided under this Agreement shall be effective when mailed, postage prepaid and sent to the following addresses: Services Agreement - SummitStone Health Partners Page 1 of 10 DocuSign Envelope ID: 29FE13B7-081D-4E15-9CC9-5BAD67D13D02 Service Provider: City: Copy to: SummitStone Attn: Michael Allen, CEO 125 Crestridge Street Fort Collins, CO 80525 City of Fort Collins Attn: Dan Dworkin, Ph.D. PO Box 580 Fort Collins, CO 80522 City of Fort Collins Attn: Purchasing Dept. PO Box 580 Fort Collins, CO 80522 In the event of early termination by the City, the Service Provider shall be paid for services rendered to the date of termination, subject only to the satisfactory performance of the Service Provider's obligations under this Agreement. Such payment shall be the Service Provider's sole right and remedy for such termination. 6. Contract Sum. The City shall pay the Service Provider for the performance of this Contract, subject to additions and deletions provided herein, $ 2,634.84 per month, for a twelve month period of time. Payment shall be billed by the 15th of the month and received no later than 30 days after the time the invoice is submitted. This monthly fee is 1/12th of an employees monthly salary, benefits and SummitStone’s general and administrative costs split between SummitStone, UC Health and Ft Collins Police Department. General and Administrative expenses are calculated center wide and prorated to each program based on generally accepted accounting principles. SummitStone general and administrative (G&A) percentage of overall costs is 18% for fiscal year 2017-2018. G&A costs include Accounting, Human Resources, Marketing and Development, IT, Billing, Executive Management, etc. 7. City Representative. The City will designate, prior to commencement of the work, its representative who shall make, within the scope of his or her authority, all necessary and proper decisions with reference to the services provided under this agreement. All requests concerning this agreement shall be directed to the City Representative. 8. Independent Service provider. The services to be performed by Service Provider are those of an independent service provider and not of an employee of the City of Fort Collins. The City shall not be responsible for withholding any portion of Service Provider's compensation hereunder for the payment of FICA, Workmen's Compensation or other taxes or benefits or for any other purpose. 9. Subcontractors. Service Provider may not subcontract any of the work set forth in the Exhibit A, Scope of Services without the prior written consent of the City. 10. Personal Services. It is understood that the City enters into the Agreement based on the special abilities of the Service Provider and that this Agreement shall be considered as an agreement for personal services. Accordingly, the Service Provider shall neither assign any responsibilities nor delegate any duties arising under the Agreement without the prior Services Agreement - SummitStone Health Partners Page 2 of 10 DocuSign Envelope ID: 29FE13B7-081D-4E15-9CC9-5BAD67D13D02 written consent of the City. 11. Acceptance Not Waiver. The City's approval or acceptance of, or payment for any of the services shall not be construed to operate as a waiver of any rights or benefits provided to the City under this Agreement or cause of action arising out of performance of this Agreement. 12. Warranty. Service Provider warrants that all work performed hereunder shall be performed with the highest degree of competence and care in accordance with accepted standards for work of a similar nature. 13. Default. Each and every term and condition hereof shall be deemed to be a material element of this Agreement. In the event either party should fail or refuse to perform according to the terms of this agreement, such party may be declared in default thereof. 14. Remedies. In the event a party has been declared in default, such defaulting party shall be allowed a period of ten (10) days within which to cure said default. In the event the default remains uncorrected, the party declaring default may elect to (a) terminate the Agreement and seek damages; (b) treat the Agreement as continuing and require specific performance; or (c) avail himself of any other remedy at law or equity. If the non-defaulting party commences legal or equitable actions against the defaulting party, the defaulting party shall be liable to the non-defaulting party for the non-defaulting party's reasonable attorney fees and costs incurred because of the default. 15. Binding Effect. This writing, together with the exhibits hereto, constitutes the entire agreement between the parties and shall be binding upon said parties, their officers, employees, agents and assigns and shall inure to the benefit of the respective survivors, heirs, personal representatives, successors and assigns of said parties. 16. Indemnity/Insurance. a. The Service Provider agrees to indemnify and save harmless the City, its officers, agents and employees against and from any and all actions, suits, claims, demands or liability of any character whatsoever brought or asserted for injuries to or death of any person or persons, or damages to property arising out of, result from or occurring in connection with the performance of any service hereunder. b. The Service Provider shall take all necessary precautions in performing the work hereunder to prevent injury to persons and property. c. Without limiting any of the Service Provider's obligations hereunder, the Service Provider shall provide and maintain insurance coverage naming the City as an additional insured under this Agreement of the type and with the limits specified within Exhibit B, consisting of one (1) page, attached hereto and incorporated herein by this Services Agreement - SummitStone Health Partners Page 3 of 10 DocuSign Envelope ID: 29FE13B7-081D-4E15-9CC9-5BAD67D13D02 reference. The Service Provider before commencing services hereunder, shall deliver to the City's Purchasing Director, P. O. Box 580, Fort Collins, Colorado 80522, one copy of a certificate evidencing the insurance coverage required from an insurance company acceptable to the City. 17. Entire Agreement. This Agreement, along with all Exhibits and other documents incorporated herein, shall constitute the entire Agreement of the parties. Covenants or representations not contained in this Agreement shall not be binding on the parties. 18. Law/Severability. The laws of the State of Colorado shall govern the construction interpretation, execution and enforcement of this Agreement. In the event any provision of this Agreement shall be held invalid or unenforceable by any court of competent jurisdiction, such holding shall not invalidate or render unenforceable any other provision of this Agreement. 19. Prohibition Against Employing Illegal Aliens. Pursuant to Section 8-17.5-101, C.R.S., et. seq., Service Provider represents and agrees that: a. As of the date of this Agreement: 1. Service Provider does not knowingly employ or contract with an illegal alien who will perform work under this Agreement; and 2. Service Provider will participate in either the e-Verify program created in Public Law 208, 104th Congress, as amended, and expanded in Public Law 156, 108th Congress, as amended, administered by the United States Department of Homeland Security (the “e-Verify Program”) or the Department Program (the “Department Program”), an employment verification program established pursuant to Section 8-17.5-102(5)(c) C.R.S. in order to confirm the employment eligibility of all newly hired employees to perform work under this Agreement. b. Service Provider shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or knowingly enter into a contract with a subcontractor that knowingly employs or contracts with an illegal alien to perform work under this Agreement. c. Service Provider is prohibited from using the e-Verify Program or Department Program procedures to undertake pre-employment screening of job applicants while this Agreement is being performed. d. If Service Provider obtains actual knowledge that a subcontractor performing work under this Agreement knowingly employs or contracts with an illegal alien, Service Provider shall: 1. Notify such subcontractor and the City within three days that Service Provider has actual knowledge that the subcontractor is employing or contracting with an illegal Services Agreement - SummitStone Health Partners Page 4 of 10 DocuSign Envelope ID: 29FE13B7-081D-4E15-9CC9-5BAD67D13D02 alien; and 2. Terminate the subcontract with the subcontractor if within three days of receiving the notice required pursuant to this section the subcontractor does not cease employing or contracting with the illegal alien; except that Service Provider shall not terminate the contract with the subcontractor if during such three days the subcontractor provides information to establish that the subcontractor has not knowingly employed or contracted with an illegal alien. e. Service Provider shall comply with any reasonable request by the Colorado Department of Labor and Employment (the “Department”) made in the course of an investigation that the Department undertakes or is undertaking pursuant to the authority established in Subsection 8-17.5-102 (5), C.R.S. f. If Service Provider violates any provision of this Agreement pertaining to the duties imposed by Subsection 8-17.5-102, C.R.S. the City may terminate this Agreement. If this Agreement is so terminated, Service Provider shall be liable for actual and consequential damages to the City arising out of Service Provider’s violation of Subsection 8-17.5-102, C.R.S. g. The City will notify the Office of the Secretary of State if Service Provider violates this provision of this Agreement and the City terminates the Agreement for such breach. 20. Special Provisions. Special provisions or conditions relating to the services to be performed pursuant to this Agreement are set forth in Exhibit "C” - Confidentiality, consisting of one (1) page, attached hereto and incorporated herein by this reference. 21. Confidentiality. a. Record Management The Parties understand and agree that all information and records related to patients are privileged and confidential. To the extent provided by law, the Parties agree to keep confidential and not disclose patient identifiable information to any third party without the prior written consent of the covered individual. The Parties agree that during and after the term of this Agreement, they will keep confidential all clinical records, including but not limited to all statistical data, reports and standards, and any financial information relating to this Agreement. b. Health Insurance Portability and Accountability Act (HIPAA). The Parties may receive from or create on behalf of each other certain health or medical information ("Protected Health Information" or "PHI," as defined in 45 C.F.R. Section 164.501) in connection with the performance of this Agreement. Use or disclosure of this PHI is subject to protection under state and federal law, including the Health Insurance Portability and Accountability Act of 1996, Public Law 104- Services Agreement - SummitStone Health Partners Page 5 of 10 DocuSign Envelope ID: 29FE13B7-081D-4E15-9CC9-5BAD67D13D02 191 ("HIPAA") and regulations promulgated there under by the U.S. Department of Health and Human Services ("Regulations"). The Parties specifically agree that they will take such action as is necessary to implement the requirements of HIPAA, the Regulations, and other applicable laws relating to the security and confidentiality of PHI, whether now or hereafter existing; and c. Federal Alcohol and Drug Confidentiality. The Parties shall be bound by Federal Regulations (42 C.F.R. Part 2 and 45 C.F.R. Parts 160 and 164) on confidentiality of Alcohol and Drug Abuse Client Records, and any relevant state laws as they relate to receiving, storing, or exchange of client information. THE CITY OF FORT COLLINS, COLORADO By:_________________________________________ Gerry Paul DATE:______________________________________ Title: Purchasing Director SUMMITSTONE HEALTH PARTNERS By: Michael G. Allen, MBA, LCSW, CACIII Printed: Title: CEO Date: ATTEST: ____________________ APPROVED AS TO FORM: _____________________ Services Agreement - SummitStone Health Partners Page 6 of 10 DocuSign Envelope ID: 29FE13B7-081D-4E15-9CC9-5BAD67D13D02 Michael Allen 7/12/2017 Assistant City Attorney 7/14/2017 City Clerk EXHIBIT A Scope of Services The Service Provider shall support Fort Collins Police Services as a Mental Health Co- Responder Position Summary: Assist Fort Collins Police Services officers in dealing with individuals experiencing a behavioral health crisis in order to foster the safety of both parties; reduce the frequency of interactions with Jaw enforcement, reduce repeated unnecessary trips to the hospital emergency room, and help those with mental disorders get the most appropriate treatment services. Supervision provided by the FCPS Police Psychologist and SummitStone. Staff Responsibilities: Stationed at Fort Collins Police Services, staff will respond to police requests for field assessments of individuals who are experiencing a behavioral health crisis, develop a treatment plan if warranted including coordinating interventions with appropriate community agencies and providing follow-up. Staff will also field email inquiries for assistance from dispatchers and patrol officers who are concerned about the mental health of individuals they have encountered in the community. A case load will be created from all inquiries and call outs in order to provide case management, follow-up and resolution if possible. Requirements: Masters or Doctorate with license in psychology, social work or counseling Experience in crisis intervention Strong attention to detail, good organizational skills, and ability to follow through Ability to collaborate effectively with law enforcement as well as community mental health, medical and social service community agencies. Duties: 1. Respond quickly to assist police officers who are responding to calls concerning individuals who are in a behavioral health crisis. Make field assessments and recommendations. 2. Follow up on email inquiries for assistance from dispatchers and patrol officers who are concerned about the mental health of individuals they have encountered in the community. Services Agreement - SummitStone Health Partners Page 7 of 10 DocuSign Envelope ID: 29FE13B7-081D-4E15-9CC9-5BAD67D13D02 3. Create a caseload from all inquiries and call outs in order to provide case management, follow-up and resolution if possible. 4. Obtain appropriate information to accomplish above goals from collaboration with community agencies attending the Interagency Group (first Thursday of each month) and the Police Psychologist. 5. Relay pertinent client information to officers I dispatch in a timely manner. Obtain appropriate Releases of Information. 6. Facilitate the input of subject information into the Code 8 section of the department's intranet through appropriate department administrative staff. Enter required documentation into the electronic medical record of SummitStone for billing/tracking purposes. 7. Assist in data collection of designated outcome measures along with the FCPS Police Psychologist and SummitStone staff. Provide data to partners on a monthly basis or as needed. 8. Participate in required trainings and team meetings for both FCPS and SummitStone Health Partners Crisis Services. Services Agreement - SummitStone Health Partners Page 8 of 10 DocuSign Envelope ID: 29FE13B7-081D-4E15-9CC9-5BAD67D13D02 EXHIBIT B INSURANCE REQUIREMENTS 1. The Service Provider will provide, from insurance companies acceptable to the City, the insurance coverage designated hereinafter and pay all costs. Before commencing work under this bid, the Service Provider shall furnish the City with certificates of insurance showing the type, amount, class of operations covered, effective dates and date of expiration of policies, and containing substantially the following statement: “The insurance evidenced by this Certificate will not reduce coverage or limits and will not be cancelled, except after thirty (30) days written notice has been received by the City of Fort Collins.” In case of the breach of any provision of the Insurance Requirements, the City, at its option, may take out and maintain, at the expense of the Service Provider, such insurance as the City may deem proper and may deduct the cost of such insurance from any monies which may be due or become due the Service Provider under this Agreement. The City, its officers, agents and employees shall be named as additional insureds on the Service Provider 's general liability and automobile liability insurance policies for any claims arising out of work performed under this Agreement. 2. Insurance coverages shall be as follows: A. Workers' Compensation & Employer's Liability. The Service Provider shall maintain during the life of this Agreement for all of the Service Provider's employees engaged in work performed under this agreement: 1. Workers' Compensation insurance with statutory limits as required by Colorado law. 2. Employer's Liability insurance with limits of $100,000 per accident, $500,000 disease aggregate, and $100,000 disease each employee. B. Commercial General & Vehicle Liability. The Service Provider shall maintain during the life of this Agreement such commercial general liability and automobile liability insurance as will provide coverage for damage claims of personal injury, including accidental death, as well as for claims for property damage, which may arise directly or indirectly from the performance of work under this Agreement. Coverage for property damage shall be on a "broad form" basis. The amount of insurance for each coverage, Commercial General and Vehicle, shall not be less than $1,000,000 combined single limits for bodily injury and property damage. In the event any work is performed by a subcontractor, the Service Provider shall be responsible for any liability directly or indirectly arising out of the work performed under this Agreement by a subcontractor, which liability is not covered by the subcontractor's insurance. Services Agreement - SummitStone Health Partners Page 9 of 10 DocuSign Envelope ID: 29FE13B7-081D-4E15-9CC9-5BAD67D13D02 new insurance EXHIBIT C CONFIDENTIALITY IN CONNECTION WITH SERVICES provided to the City of Fort Collins (the “City”) pursuant to this Agreement (the “Agreement”), the Service Provider hereby acknowledges that it has been informed that the City has established policies and procedures with regard to the handling of confidential information and other sensitive materials. In consideration of access to certain information, data and material (hereinafter individually and collectively, regardless of nature, referred to as “information”) that are the property of and/or relate to the City or its employees, customers or suppliers, which access is related to the performance of services that the Service Provider has agreed to perform, the Service Provider hereby acknowledges and agrees as follows: That information that has or will come into its possession or knowledge in connection with the performance of services for the City may be confidential and/or proprietary. The Service Provider agrees to treat as confidential (a) all information that is owned by the City, or that relates to the business of the City, or that is used by the City in carrying on business, and (b) all information that is proprietary to a third party (including but not limited to customers and suppliers of the City). The Service Provider shall not disclose any such information to any person not having a legitimate need-to-know for purposes authorized by the City. Further, the Service Provider shall not use such information to obtain any economic or other benefit for itself, or any third party, except as specifically authorized by the City. The foregoing to the contrary notwithstanding, the Service Provider understands that it shall have no obligation under this Agreement with respect to information and material that (a) becomes generally known to the public by publication or some means other than a breach of duty of this Agreement, or (b) is required by law, regulation or court order to be disclosed, provided that the request for such disclosure is proper and the disclosure does not exceed that which is required. In the event of any disclosure under (b) above, the Service Provider shall furnish a copy of this Agreement to anyone to whom it is required to make such disclosure and shall promptly advise the City in writing of each such disclosure. In the event that the Service Provider ceases to perform services for the City, or the City so requests for any reason, the Service Provider shall promptly return to the City any and all information described hereinabove, including all copies, notes and/or summaries (handwritten or mechanically produced) thereof, in its possession or control or as to which it otherwise has access. The Service Provider understands and agrees that the City’s remedies at law for a breach of the Service Provider’s obligations under this Confidentiality Agreement may be inadequate and that the City shall, in the event of any such breach, be entitled to seek equitable relief (including without limitation preliminary and permanent injunctive relief and specific performance) in addition to all other remedies provided hereunder or available at law. Services Agreement - SummitStone Health Partners Page 10 of 10 DocuSign Envelope ID: 29FE13B7-081D-4E15-9CC9-5BAD67D13D02 CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 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). PRODUCER CONTACT NAME: PHONE FAX (A/C, No, Ext): (A/C, No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : INSURED INSURER B : INSURER C : 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 TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSD WVD (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY 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: $ AUTOMOBILE LIABILITY 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) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY STATUTE ER Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N / A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 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 Michael J Schmitt CIC SUMMI-2 OP ID: DP 07/14/2017 Michael J Schmitt CIC Rich & Cartmill Ins of CO of Colorado LLC 8213 W. 20th Street Greeley, CO 80634 Michael J Schmitt CIC 970-356-8030 970-356-8032 Philadelphia Insurance Co SummitStone Health Partners Pinnacol Assurance 125 Crestridge Street Fort Collins, CO 80525 Travelers Casualty & Surety Co A X 1,000,000 X X PHPK1676425 07/01/2017 07/01/2018 100,000 X 5,000 1,000,000 3,000,000 X 3,000,000 3,000,000 A 1,000,000 X X PHPK1676425 07/01/2017 07/01/2018 B X 4044330 07/01/2017 07/01/2018 100,000 100,000 500,000 C 106545865 07/01/2017 07/01/2018 Ea/Agg 2,000,000 A HIPAA PHSD1258312 07/01/2017 07/01/2018 HIPAA 50,000 Certificate holder is listed as additional insured as pertains to the General and Auto Liability policies, per written contract. CIT-FOR The City of Fort Collins Purchasing Department PO Box 580 Fort Collins, CO 80522 970-356-8030 23850 31194 PL Agg Professional Liab Privacy DocuSign Envelope ID: 29FE13B7-081D-4E15-9CC9-5BAD67D13D02 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Michael J Schmitt CIC SUMMI-2 OP ID: DP 06/29/2017 970-356-8030 Michael J Schmitt CIC Rich & Cartmill Ins of CO of Colorado LLC 8213 W. 20th Street Greeley, CO 80634 Michael J Schmitt CIC 970-356-8030 970-356-8032 Philadelphia Insurance Co 23850 SummitStone Health Partners Pinnacol Assurance 125 Crestridge Street Fort Collins, CO 80525 Travelers Casualty & Surety Co 31194 A X 1,000,000 X X 10,000 PHPK1676425 07/01/2017 07/01/2018 X Professional Liab 5,000 1,000,000 3,000,000 X 3,000,000 PL Agg 3,000,000 A 1,000,000 X PHPK1676425 07/01/2017 07/01/2018 B X X 4044330 07/01/2017 07/01/2018 100,000 100,000 500,000 A HIPAA PHSD1258312 07/01/2017 07/01/2018 HIPAA 50,000 C Privacy 106545865 07/01/2017 07/01/2018 Ea/Agg 2,000,000 The State of Colorado/CDLE is listed as additional insured as pertains to the General Liability policy, per written contract. Waiver of subrogation applies on the Workers' Compensation policy. DIV-VOC The State of Colorado/ CDLE 633 17th St Ste 1100 Denver, CO 80202 DocuSign Envelope ID: 29FE13B7-081D-4E15-9CC9-5BAD67D13D02