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HomeMy WebLinkAboutCORRESPONDENCE - RFP - 7438 MEDICAL PROVIDER - WORKERS COMPENSATION & DOT MEDICAL EXAMS (3)March 9, 2016 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 condition and the following: 1) The term will be extended for one (1) additional year, February 1, 2016 through January 31, 2017. 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: E3367123-09CA-4123-9D23-F9D147CFFD2B 3/10/2016 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) 10/26/2015 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 164 Primrose Ct Longmont CO 80501 Westfield Insurance Company 24112 Pinnacol Assurance. 41190 Medical Protective Company 11843 CL15102106540 A X X X BOP3181479 11/1/2015 11/1/2016 1,000,000 100,000 2,500 1,000,000 2,000,000 2,000,000 Hired/borrowed 1,000,000 A X X X X BOP3181479 11/1/2015 11/1/2016 1,000,000 Uninsured motorist combined 1,000,000 A X X X BOP3181479 11/1/2015 11/1/2016 4,000,000 4,000,000 B N 4006606 10/1/2015 10/1/2016 X 500,000 500,000 500,000 C Malpractice Liability C49126 11/1/2015 11/1/2016 $1,000,000 Each Occurrence 3,000,000 General Aggregate Certificate holder is included as Additional Insured with respect to general liability and automobile liability as required by written contract with respects to liability arising out of work performed by the named insured. N Mosbrucker CIC,CISR City of Fort Collins Purchasing Department PO Box 580 Fort Collins, CO 80522