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HomeMy WebLinkAboutCORRESPONDENCE - AGREEMENT MISC - NORTH RANGE BEHAVIORAL HEALTH (13)January 2, 2018 North Range Behavioral Health Attn: Larry Pottorff 1300 North 17th Avenue Greeley, CO 80631 RE: Contract Renewal, North Range Behavioral Health Substance Abuse Professional Services Agreement Dear Mr. Pottorff: The City of Fort Collins wishes to extend the agreement term for the above captioned proposal per the existing terms and conditions and the following: 1) The term will be extended for two (2) additional months, January 1, 2018 through February 28, 2018. 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 on General Liability and Automobile 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 Doug Clapp, CPPB, Senior Buyer at (970) 221-6776 if you have any questions regarding this matter. Sincerely, Gerry 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: 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: BD7D3F65-F82F-49D4-BC3A-520075B3D95C 1/5/2018 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 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 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 NORTH12 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 North Range Behavioral Health Pinnacol Assurance 1300 N 17th Avenue Greeley, CO 80631 Lloyds of London A X 1,000,000 X 1,000,000 X PHPK1676246 07/01/2017 07/01/2018 X Professional Liab 20,000 X HIPAA PHSD1258227 1,000,000 07/01/2017 07/01/2018 3,000,000 X 3,000,000 HIPAA 50,000 A 1,000,000 X X PHPK1676246 07/01/2017 07/01/2018 A XX 2,000,000 PHUB590527 07/01/2017 07/01/2018 2,000,000 X 10,000 B X 4044331 07/01/2017 07/01/2018 100,000 100,000 500,000 C Privacy ESG01269611 07/01/2017 07/01/2018 Privacy 3,000,000 The City of Fort Collins is listed as additional insured as pertains to the General and Auto Liability policies, per written contract. CIT-FOR City of Fort Collins-Financial Services Purchasing Division 215 N Mason St. --2nd Floor PO Box 580 Fort Collins, CO 80522 DocuSign Envelope ID: BD7D3F65-F82F-49D4-BC3A-520075B3D95C 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 NORTH12 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 North Range Behavioral Health Pinnacol Assurance 1300 N 17th Avenue Greeley, CO 80631 Lloyds of London A X 1,000,000 X 1,000,000 X PHPK1676246 07/01/2017 07/01/2018 X Professional Liab 20,000 X HIPAA PHSD1258227 1,000,000 07/01/2017 07/01/2018 3,000,000 X 3,000,000 HIPAA 50,000 A 1,000,000 X PHPK1676246 07/01/2017 07/01/2018 A XX 2,000,000 PHUB590527 07/01/2017 07/01/2018 2,000,000 X 10,000 B X 4044331 07/01/2017 07/01/2018 100,000 100,000 500,000 C Privacy ESG01269611 07/01/2017 07/01/2018 Privacy 3,000,000 City of Fort Collins, Colorado, a Municipal Corporation, is listed as additional insured as their interest may appear, per written contract. CIT-FMU City of Fort Collins, Colorado A Municipal Corporation 300 LaPorte Ave PO Box 580 Fort Collins, CO 80522 DocuSign Envelope ID: BD7D3F65-F82F-49D4-BC3A-520075B3D95C