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Home My WebLink About446619 NORTH RANGE BEHAVIORAL HEALTH - CONTRACT - AGREEMENT MISC - NORTH RANGE BEHAVIORAL HEALTH (2)Official Purchasing Document Last updated 3/2018 Page 1 of 1 AMENDMENT #02 AGREEMENT BETWEEN THE CITY OF FORT COLLINS, NORTH RANGE BEHAVORIAL HEALTH This Second Amendment (Amendment #02) is entered into by and between the CITY OF FORT COLLINS (the “City”) and NORTH RANGE BEHAVIOR HEALTH (the “Service Provider”). WHEREAS, the Service Provider and the City entered into an Agreement effective April 3, 2018 (the “Original Agreement”); and WHEREAS, the parties amended the Agreement (Amendment #01) effective July 1, 2018 to extend the contract period for an additional three months; and WHEREAS, Service Provider and the City desire to amend the Original Agreement to extend the services to be performed under the Original Agreement; and WHEREAS, the Parties wish to extend the term of the Original Agreement by three (3) additional months. NOW, THEREFORE, in consideration of the foregoing recitals and the mutual promises herein contained, the parties agree as follows: 1. Pursuant to paragraph 2 of the Original Agreement, Contract Period, the term is hereby extended for three additional months commencing October 1, 2018 until December 31, 2018. Except as expressly amended by this Amendment #02, all other terms and conditions of the Agreement shall remain unchanged and in full force and effect. In the event of a conflict between the terms of the Agreement and this Amendment #02, this Amendment #02 shall prevail. IN WITNESS WHEREOF, the parties have executed this Second Amendment the day and year shown. CITY OF FORT COLLINS: By: Gerry Paul Purchasing Director DATE: NORTH RANGE BEHAVIORAL HEALTH By: Printed: Title: CORPORATE PRESIDENT OR VICE PRESIDENT Date: DocuSign Envelope ID: A57EAC6E-94C2-48EE-B7F1-82BF85A0D487 Larry Pottorff 10/2/2018 Executive Director 10/2/2018 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 POLICY PRO- 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) 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 POLICY PRO- 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) 6/28/2018 Professional Risk LLC 8213 W.20th St Greeley CO 80634 Donna Birleffi (970)356-8030 (970)356-8032 donna.birleffi@proriskllc.com North Range Behavioral Health 1300 N 17th Avenue Greeley CO 80631 Philadelphia Insurance Co 18058 Pinnacol Assurance Lloyds of London 18-19 All A A X X X Professional Liability X HIPAA X X PHPK1839283 7/1/2018 7/1/2019 PHSD1358091 1,000,000 1,000,000 20,000 1,000,000 3,000,000 3,000,000 HIPAA Limit 50,000 A X X PHPK1839283 7/1/2018 7/1/2019 1,000,000 Medical payments 5,000 A X X X 10,000 PHUB634797 7/1/2018 7/1/2019 2,000,000 2,000,000 B 4044331 7/1/2018 7/1/2019 X 1,000,000 1,000,000 1,000,000 C Privacy ESH02610560 7/1/2018 7/1/2019 Aggregate 3,000,000 City of Fort Collins, Colorado, a Municipal Corporation, is listed as additional insured as pertains to the General and Auto Liability policies, per written contract. Dionne Perez/DP City of Fort Collins, Colorado a Municipal Corporation PO Box 580 Fort Collins, CO 80522 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) 6/28/2018 Professional Risk LLC 8213 W.20th St Greeley CO 80634 Donna Birleffi (970)356-8030 (970)356-8032 donna.birleffi@proriskllc.com North Range Behavioral Health 1300 N 17th Avenue Greeley CO 80631 Philadelphia Insurance Co 18058 Pinnacol Assurance Lloyds of London 18-19 All A A X X X Professional Liability X HIPAA X X PHPK1839283 7/1/2018 7/1/2019 PHSD1358091 1,000,000 1,000,000 20,000 1,000,000 3,000,000 3,000,000 HIPAA Limit 50,000 A X PHPK1839283 7/1/2018 7/1/2019 1,000,000 Medical payments 5,000 A X X X 10,000 PHUB634797 7/1/2018 7/1/2019 2,000,000 2,000,000 B 4044331 7/1/2018 7/1/2019 X 1,000,000 1,000,000 1,000,000 C Privacy ESH02610560 7/1/2018 7/1/2019 Aggregate 3,000,000 City of Fort Collins, Colorado, a Municipal Corporation, is listed as additional insured as their interest may appear, per written contract. Dionne Perez/DP City of Fort Collins, Colorado a Municipal Corporation PO Box 580 Fort Collins, CO 80522 DocuSign Envelope ID: A57EAC6E-94C2-48EE-B7F1-82BF85A0D487