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Home My WebLink About20130862.tiffRESOLUTION RE: APPROVE APPLICATION FOR TIER III EMERGENCY MEDICAL SERVICES LICENSE AND AUTHORIZE CHAIR TO SIGN - COLORADO MOTOCROSS MEDICS, LLC WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, pursuant to Section 7-2-100 of the Weld County Code, the Weld County Department of Public Health and Environment and the Weld County Emergency Medical/Trauma Service Council have reviewed the application of Colorado Motocross Medics, LLC, for a Tier Ill Emergency Medical Services License and recommend approval, and WHEREAS, after review, the Board deems it advisable to approve said Application for a Tier Ill Emergency Medical Services License, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the application of Colorado Motocross Medics, LLC, for a Tier Ill Emergency Medical Services License be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said license. The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 3rd day of April, A.D., 2013. BOARD OF COUNTY COMMISSIONERS WELD COUNTY, COLORADO ATTEST: Weld County Clerk to the Board BY: Deputy C APPROV to the Bo ty Attorney Date of signature: APR 1 1 2013 EXCUSED William F. Garcia, Chair can P. Conway ike Freeman Barbra Kirkmeyer al 1 `ilt, 2013-0862 HL0042 ILLLILLILLLLILALLLIL WELD COUNTY DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT License to Operate Ambulance Service TIER III COLORADO MOTOCROSS MEDICS, LLC Name of Service 729 REMINGTON ST. FORT COLLINS, COLORADO 80524 Address JOEL D. PAINTER Name of Owner IS LICENSED UNTIL DECEMBER 31, 2013, TO OPERATE AN AMBULANCE SERVICE IN WELD COUNTY IN ACCORDANCE WITH EXISTING WELD COUNTY RULES AND REGULATIONS. v 1-2i = * N H DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 N. 17th Avenue Greeley, CO 80631 Web: hflo://www.eo.weld.co.us/Deeertments/HealthEnvironment/indexhtml Health Administration Public Health & Clinical Environmental Health Commwleatba, emergency Pmparednas Vital Records erviws UM= Education & Planning & Response 1St 970.304.6410 Tel: 970.3049420 Tie: 970.304.6115 TW: 970.304.6470 Tele: 070.304.6420 Fez 970.3043412 Fax 970304.6419 Far 970.304.6411 Far 9703049457 Fax 970.3041469 Our Mon: Totem wlh Ins communities an serve, we n working b make Wed County:S hoe/Nest p/aca b /Ae. Mary nak and ploy. March 15, 2013 Barry Schaefer Chair Weld County Emergency Medical/Trauma Service Council Via email: bschaefer®nlattevalleyfire.org SUBJECT: 2013 Colorado Motocross EMS Application NOTICE OF EMERGENCY MEDICAL SERVICES LICENSE APPLICATION TO THE WELD COUNTY EMERGENCY MEDICAL/TRAUMA SERVICE COUNCIL The Weld County Department of Public Health and Environment has received and is in process of reviewing an Emergency Medical Service License Application from Colorado Motocross. Attached to this document are the Ambulance Service License Application, and Maps of its proposed Service Area. On behalf of the Board of County Commissioners, the Department is requesting the Emergency Medical/Trauma Service Council review the attached documents in accordance with Section 7-2-100.B.5. of the Weld County Code (enumerated below). The Department will forward your recommendation to the Comrniccioners. Below are the most applicable portions of the code: Weld County Code, 7-2-100.BS The recommendation of the Weld County Emergency medical/Trauma Service (EMffS) Council as to whether or not the issuance of the license will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County. The EM/TS Council shall also provide: a. Recommended Service Area. b. Recommended Tier of License. Weld County Code, 7-2-10. No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so issued by the Board of County Commissioners, except as provided in Section 7-2-80 below. The fee for said license shall be set by separate ordinance. The license shall issue only in the following tiers of service: Tier I: Licensure authorizing for Primary Care, as defined in Section 7-1-30 of this Chapter. Tier II: Licensure authorizing for transports of patient(s) to and from licensed medical facilities. This licensure does not provide for Primary Care, as defined in Section 7-1-30 of this Chapter. Tier III: Licensure authorizing for Standby Service, as defined in Section 7-1-30 of this Chapter. A. The Board of County Commissioners reserves the right to amend these rules and regulations and any other individual conditions of licensing as applied to any particular license, as needed in keeping with its legislative function and in order to implement the policy of the State of Colorado that the regulation and control of ambulance licenses is in the exclusive purview of the boards of county commissioners. Persons or firms seeking application and approval of any ambulance license under this Chapter acknowledge that Weld County may contract with specific ambulance service provider(s) which will serve the emergency ambulance need of Weld County and participating municipalities. Please forward the Councils recommendation to the Department. Please do not hesitate to call me should you have any questions. Sincerely, Shana Fassman Environmental Health Specialist Environmental Health Services Recommended Level of Service: Tier 1 Tier 2 'er 3 Recommended Service Area: As listed in the application. Will the service contribute to an efficient, effective, and coordinated emergency medical response to residents of the County? Council's recommendation: This agency provides standby ambulance coverage. It is recommended for a Tier III application, with the exclusion from Amendment Section 7-2- 80 Section C, whereas in a major catastrophe or mass casualty incident rendering services when permitted ambulances are insufficient, that this agency can transport in the absence of a permitted transport agency. Other EMTS Council recommendations or comments: None Recommendation By: `" �`�'` Recommendation Date: 3443 Memorandum TO: FROM: DATE: Board of County Commissioners Dr. Mark Wallace March 25, 2013 SUBJECT: Colorado Motocross 2013 Application for Ambulance Service License Colorado Motocross, located at 729 Remington Street, Fort Collins, Colorado, has applied for an Ambulance Service license pursuant to Chapter 7, of the Weld County Code (WCC). Chapter 7 pertains to Emergency Medical Services. The Department has reviewed this application and has deemed the ambulance service to have met all applicable licensure application requirements found in Chapter 7. As such, I am recommending for licensure. The Weld County Emergency Medical/Trauma Service (EM/TS) Council reviewed this application on March 20, 2013. The Council recommended (see attached) that Colorado Motocross receive a Tier III license. Attached: Recommendation by EM/TS Council DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT 1555 N. 17t Avenue Greeley, CO 80631 n...rt. ..w,M. ,na Web: htto://www.co.weld.co,ustseoartments/HealthEnvironment/Indexhtral HSSSAdmii4Valbn /„Hb huh, & CSMaI Enviraunatal Huh, aivast0wwiq Mat *iti . d VRaadl Santa Sawba C IS 970.9044410 TS: 970304220 Taw 970304.6116 TOa 970.904.0470 TOE 979.3115420 Fac 970.7044412 Far. 9702042416 Roc 570.3045411 Fat W03045452 Fac 970.9042489 Or MNtn: Threw win me con,tntS N 46rm we an wawa to me mw County So 6a.09fpae b M, bump 69r9 'WOW March 15, 2013 Bony Schaefer Chair Weld County Emergency Medical/Trauma Service Council Via email: bcchaefer(alolattevallevfire,org SUBJECT: 2013 Colorado Motocross EMS Application NOTICE OF EMERGENCY MEDICAL SERVICES LICENSE APPLICATION TO THE WELD COUNTY EMERGENCY MEDICAL/TRAUMA SERVICE COUNCIL The Weld County Department of Public Health and Environment has received and is in process of reviewing an Emergency Medical Service License Application from Colorado Motocross. Attached to this document are the Ambulance Service License Application, and Maps of its proposed Service Area. On behalf of the Board of County Commissioners, the Department is requesting the Emergency Medical/Trauma Service Council review the attached documents in accordance with Section 7-2-1003.5. of the Weld County Code (enumerated below). The Department will forward your recommendation to the Commissioners. Below are the most applicable portions of the code: Weld County Code, 7-2.100.B.5 The recommendation of the Weld County Emergency medicaVPrauma Service (EMITS) Council as to whether or not the issuance of the license will contribute to an efficient, effective, and coordinated emergency medical response to residents of the County. The EMITS Council shall also provide: a. Recommended Service Area. b. Recommended Tier of License. Weld County Code, 7-2-10. No person shall provide or operate an ambulance service publicly or privately in the County unless that person holds a valid license to do so Issued by the Board of County Commissioners, except as provided in Section 7-2-80 below. The fee for said license shall be set by separate ordinance. The license shall issue only in the following tiers of service: Tier I: Licensure authorizing for Primary Care, as defined in Section 7-1-30 of this Chapter. Tier II: Licensure authorizing for transports of patient(s) to and from licensed medical facilities. This Lcensure does not provide for Primary Care, as defined in Section 7-1-30 of this Chapter. Tier Ili: Licensure authorizing for Standby Service, as defined in Section 7-1-30 of this Chapter. A. The Board of County Commissioners reserves the right to amend these rules and regulations and any other individual conditions of licensing as applied to any particular license, as needed in keeping with its legislative function and in order to implement the policy of the State of Colorado that the regulation and control of ambulance licenses is in the exclusive purview of the bomb of county commissioners. Persons or firms seeking application and approval of any ambulance license under this Chapter acknowledge that Weld County may contract with specific ambulance service provider(s) which will servo the emergency ambulance need of Weld County and participating municipalities. Please forward the Councils recommendation to the Department. Please do not hesitate to call me should you have any questions. Sincerely, Shane Fassnian Environmental Health Specialist Environmental Health Services Recommended Level of Service: Tier 1 Tier 2 Recommended Service Area: As listed in the application. Will the service contribute to an efficient, effective, and coordinated emergency medical response to residents of the County? Council's recommendation: This agency provides standby ambulance coverage. It is recommended for a Tier III application, with the exclusion front Amendment Section 7-2- 80 Section C, whereas in a major catastrophe or mass casualty incident rendering services when permitted ambulances are insufficient, that this agency can transport in the absence of a permitted transport agency. Other EMTS Council recommendations or comments: None Recommendation By:�' Recommendation Date: 3/243 WELD COUNTY DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT Permit to operate an Emergency Medical Vehicle (Ambulance) This Certifies: COLORADO MOTOCROSS MEDICS, LLC Motor Number: I FDKE30FSTHB09338 MEETS WELD COUNTY STANDARDS FOR EMERGENCY MEDICAL VEHICLES (AMBULANCES). THIS PERMIT WILL EXPIRE DECEMBER 31, 2013. Ynu,. Izg2,a eR cTh Director, Weld County Department of Public Health and Environment 3/ Zlo/'3 Date Must Be Posted In Vehicle Renewal Application fi str„ COLORADO DEPARTMENT OF PUBLIC HEALTH & ENVIRONMENT 1555 N. 17th Avenue Greeley, CO 80631 WEBSITE: ADMINISTRATION: (970) 304-6410 FAX: (970) 304-6412 PUBLIC HEALTH EDUCATION & NURSING: (970) 304-6420 FAX: (970) 304-6416 ENVIRONMENTAL HEALTH SERVICES: (970) 304-6415 FAX: (970) 304-6411 AMBULANCE SERVICE LICENSE RENEWAL APPLICATION Date of application: 03/05/13 Name of Ambulance Service: Colorado Motocross Medics, LLC Owner: Name: Joel D. Painter Address: 729 Remington Street, Fort Collins, Colorado 80524 Phone Number: 970-484-8427 ioel(a�iacobcenter.org Operations Manager: Name: Joel D. Painter Address: 729 Remington Street, Fort Collins, Colorado 80524 Phone Number: 970-484-8427 ioel(a�iacobcenter.org Pursuant to Section 7-2-150 of Weld County Code Ordinance, any change of ownership requires a new application for ambulance service license. Date Received: / / (For Office Use Only) Documents Checked: Remarks: Approved Recommended (Y/N): Date Referred to B.O.C.C.: / / Licensing Agent Page 2 Name and address of each stockholder of partner owning 10% or more of the outstanding stock of the company of having more than a 10% ownership interest (if applicable): Joel D. Painter 729 Remington Street, Fort Collins, Colorado 80524 100% What area of Weld County will be served by this company? Please attach a map indicating the service area. I. Valley Dirt Riders Track 20125,1-25 Frontage Road, Berthoud, Colorado 2. Island Grove Regional Park North l4'" Ave. Greeley Colorado 80631 How many ambulances do you operate? 1 Location and description of the place(s) from which this ambulance service will operate. If there are more than two locations, attach a separate sheet with the above information. Location 41: Street Number: 20125 1-25 Frontage Road City: Berthoud State: Colorado Location #2: Street Number: 14th North Ave. Phone: 217-7484 City: Greeley State: Colorado Phone: 217-7484 Medical Director: Name: Dr. Kelby Bethards, MD Address: 729 Remington Street, Fort Collins, Colorado 80524 Phone Number: 1-970-484-8427 7-2-170 Annual renewal. All licenses and permits shall be renewed annually, shall expire on December 31 of the year issued, and shall not be renewed until the application has been approved by the Department. All applications for renewal of licenses and permits shall be made not later than sixty (60) days prior to the date of expiration. The department shall notify, be certified mail, return receipt requested, each licensee of renewal requirements of this section within ninety (90) days prior to the date of expiration (Weld County Code ordinance 2007-8). 7-2-180 Change of Medical Director An ambulance service must report any change of medical director, including name, address and telephone number, to the Director within fifteen (15) calendar days of such change. (Weld County Code Ordinance 2007-8) Page 3 Please read carefully and provide the following: G. As required in Section 7-2-90 (G) of the Weld County Code Ordinance, a list of all emergency medical service providers who may be called upon to respond to an emergency with the ambulance service. This list shall include the following information on each person: 1. Complete name, address and date of birth 2. The highest level of certification, licensure or training attained. 3. A copy of current EMT -B, EMT -I or EMT -P certificate issued by the Colorado Department of Public Health and Environment; nurse licensure or an Advanced First Aid card from the American Red Cross; or a First Responder course completion certificate issued by a Division -recognized training center or training group. 4. Proof of valid Colorado driver's license. 5. A statement of criminal complaint or convictions, including Class I and II traffic violations, within the previous twelve (12) months. * H. As required in Section 7-2-90 of the Weld County Code Ordinance, Proof of insurance, as required in section 7-3-60 of this Chapter. (Worker's compensation insurance, Public liability and property damage bodily injury, Property damage, Professional liability, and Ambulance vehicles coverage.) I. As required in Section 7-2-90 (1) of the Weld County Code Ordinance, provide a current copy of EMT or Paramedic protocols adopted by the ambulance service in accordance with standards approved by the ambulance service's medical director. J. As required in Section 7-2-90 (J) of the Weld County Code Ordinance, provide a current copy of the ambulance service's training standards in accordance with the requirements approved by the ambulance service's medical director. All training must be through a state -certified emergency medical services training center. K. As required in Section 7-2-90 (K) of the Weld County Code Ordinance, make available for review by the Department current records of compliance with the current EMS Laws. L. As required in Section 7-2-90 (L) of the Weld County Code Ordinance, copies of any judgments entered against the licensee or license applicant within the previous twelve (12) months, including findings of fact, conclusions of law and order by any court or other tribunal. M. As required in Section 7-2-90 (M) of the Weld County Code Ordinance, such other information as the Department may require to make a fair determination. O. As required in Section 12.9.2 E 1 of the Weld County Rules Pertaining to Emergency Medical Services, provide a current copy of the ambulance service's pharmacological agents and delivery devices per medial director protocol. * Please note Section 7-3-50 Criminal record of ambulance crew member. Unless waived by the Board of County Commissioners, no person shall be employed by an ambulance service as an ambulance crew member who has been convicted of any of the following offenses within the previous twelve (12) months from the date of application: felony, misdemeanor or Class I or Class II traffic offense. Page 4 I HEREBY CERTIFY THAT I AM AUTHORIZED TO SUBMIT THE FORGOING APPLICATION AND THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND CONTAINS NO WILLFUL MISREPRESENTATION OR FALSIFICATION. IN ADDITION, I CERTIFY THAT I HAVE READ AND UNDERSTAND THE PROVISIONS AND REQUIREMENTS OF WELD COUNTY CODE CHAPTER 7, INCLUDING, BUT NOT LIMITED TO, SECTION 7-8-10, WHICH ENCOURAGES ALL LICENSED AGENCIES PROVIDING EMS RESPONSE IN WELD COUNTY TO MAKE A GOOD FAITH EFFORT TO EXECUTE WRITTEN MUTUAL AID AGREEMENTS WITH ALL OTHER EMS PROVIDERS LOCATED WITHIN OR BORDERING ON THEIR AREAS OF RESPONSE. DETERMINATION THAT AN AMBULANCE SERVICES LICENSE HAS BEEN ISSUED BASED ON FALSE INFORMATION CONSTITUTES GROUNDS F,pR LICENSE REVOCATION AND POSSIBLE CRIMINAL PROSECUTION. I Signature of Applicant 3,1513 Date SUBSCRIBED AND AFFIRMED BEFORE ME THIS 0-44' , 20 ! 3 , IN THE COUNTY OF , STATE OF COLORADO. i tur/e of N�ry My Commission expires: e9 / cp"/ Colorado Motocross Medics 729 Remington Street, Fort Collins, Colorado 80524 1-303-907-9694 comamedics(ilmsn.com November 1, 2011 Kevin: Per your request, Colorado Motocross Medics, LLC is a quick response rescue team which assisted injured riders at motocross and supercross events. We safely get the injured rider to our medical unit and call Weld County EMS if transport is needed. The only time we would transport a patient is if local EMS was dealing with a mass casualty situation and could not send a transport ambulance. Our medical director is usually on track with us at events or directly available by phone. Joel DL'ainter Colorado Motocross Medics, LLC Map of Service Area Map of Island Grove Park, N 14th Ave Greeley, CO by MapQuest Page 2 of 2 MAtQYEST. z N ... Cdc-5 Jere.. _. c a y° i� 8 St 8 5 g o 'C 9 ¢'i 6th St.__ 0"2009 MapQuest Inc:— - 4%?s: gl 200 m 600 ft • _ — z '_tst Sty„ 0 Q. _.__._.Map Data -O 200874AVTEQ- or TNeAtlas All rights reserved. Use subject to License/Copyright Map Legend Directions and maps are informational only. We make no warranties on the accuracy of their content, road conditions or route usability or expeditiousness. You assume all risk of use. MapQuest and its suppliers shall not be liable to you for any loss or delay resulting from your use of MapQuest Your use of MapQuest means you agree to our Terms of Use http://www.mapquest.com/maps?name=Island+CrrOve+Park&city--Greeley&state=CO&a... 10/29/2009 Map of 20125 W Frontage Rd # I-25 Berthoud, CO by MapQuest Page 2 of 2 MA►Quoit f44 O 2009 MapOuest Inc. 750 OE l400 tza0 n jq _ Map Data O 2009 PIAV TEQ or leleAlas All rights reserved. Use subject to License/Copyright Map Legend Directions and maps are informational only. We make no warranties on the accuracy of their content, road conditions or route usability or expeditiousness. You assume all risk of use. MapQuest and its suppliers shall not be liable to you for any loss or delay resulting from your use of MapQuest Your use of MapQuest means you agree to our Terms of Use http://www.mapquest.com/maps?city=Berthoud&state=Co&address=20125+I-25+Fronts... 10/29/2009 Ambulance Vehicle Permit Renewal List 11az; `k COLORADO AMBULANCE VEHICLE PERMIT RENEWAL LIST Name of Ambulance Service: Colorado Motocross Medics, LLC Application Year: November 2012 Vehicle #1 Year: 1996 Make: FORD Model: E350 4 Wheel Drive (Y/N): N Manufacturers Identification Number (V.I.N.): 1 FDKE30FSTHB09338 Colorado State License Number (Registration No.): COMXMED Motor Vehicle Chassis Number: Registered with the State of Colorado as an emergency vehicle (Y/N): YES Date Ambulance placed in service: 05/ 01 / 09 Normal Location of Ambulance: 729 Remington Street, Fort Collins, Colorado 80524 Vehicle # Year: Make: Model: 4 Wheel Drive (Y/N): Manufacturers Identification Number (V.I.N.): Colorado State License Number (Registration No.): Motor Vehicle Chassis Number: Registered with the State of Colorado as an emergency vehicle (Y/N): Date Ambulance placed in service: Normal Location of Ambulance: Vehicle # Year: Make: Model: 4 Wheel Drive (Y/N): Manufacturers Identification Number (V.I.N.): Colorado State License Number (Registration No.): Motor Vehicle Chassis Number: Registered with the State of Colorado as an emergency vehicle (Y/N): Date Ambulance placed in service: Normal Location of Ambulance: 7-2-120 Additional or replacement vehicles. If an ambulance is added to a service's fleet, an application for an ambulance vehicle permit shall be filed with the Department prior to the new ambulance being placed in service, but in no event later than thirty (30) days of receipt of the new ambulance. The completed application shall include a description of the ambulance replaced. Upon receipt of a new ambulance vehicle permit application, the Department shall inspect the new ambulance and issue the new ambulance vehicle permit, if appropriate. (Weld County Code Ordinance 2007-8) 7-2-130 Additional Inspections. In addition to the inspection required at the time of application, the Department may also visit or contact all ambulance services at any other time during the year, at which time an inspection may or may not be performed. The inspections of the ambulances and related equipment shall cover but not be limited to the following items: condition of the ambulance, safety and warning systems and minimum equipment for the relevant ambulance. Each service shall provide evidence of an adequate ongoing vehicle safety and maintenance program. This shall be a log which shows the dates of the service and list of service performed. The Department may modify this regulation or adopt additional requirements with the consent of the Board of County Commissioners. . (Weld County Code Ordinance 2007-8) F \Motocross\Ambulnrce\Wdd County 2 Ambulance Vehicle Renewal Application doc Medical Director Information Colorado Motocross Medics 729 Remington Street, Fort Collins, Colorado 80524 Dr. Kelby Bethards, M.D. 729 Remington Street Fort Collins, Colorado 80524 1-303-907-9694 comxmedics'amsn.com Medical Director Proof of Insurance HEALTH CARE PROFESSIONAL LIABILITY POLICY ALLIED HEALTH PROFESSIONALS - PREFERRED INFORMATION PAGE THIS POLICY CONTAINS COVERAGES WRITTEN ON A "MODIFIED CLAIMS -MADE" BASIS. IT IS REGISTERED AND DELIVERED AS SURPLUS LINES INSURANCE COVERAGE IN ACCORDANCE WITH THE SURPLUS LINES INSURANCE LAWS OF YOUR STATE. THE COMPANY: ProAssurance Specialty Insurance Company, Inc. POLICYHOLDER: Colorado Motocross Medics, LLC POLICY NUMBER: AFC8827512 POLICY PERIOD BEGINNING: 8/21/2012 THIS CONTRACT IS DELIVERED AS SURPLUS LINE INSURANCE UNDER THE NONADMITTED INSURANCE ACT. THE INSURER ISSUING THIS CONTRACT IS NOT LICENSED IN COLORADO BUT IS AN APPROVED NONADMITTED INSURER. THERE IS NO PROTECTION UNDER THE PROVISIONS OF THE COLORADO INSURANCE GUARANTY ASSOCIATION ACT. PRA-APE-INFO.CO 04 11 Health Care Professional Liability Policy Allied Health Professionals - Preferred Information Page © ProAssurance Specialty Insurance Company, Inc. Page 1 of 1 HEALTH CARE ENTITY LIABILITY POLICY ALLIED HEALTH PROFESSIONALS COVER PAGE THIS POLICY CONTAINS COVERAGES WRITTEN ON A "MODIFIED CLAIMS -MADE" BASIS. IT IS REGISTERED AND DELIVERED AS SURPLUS LINES INSURANCE COVERAGE IN ACCORDANCE WITH THE SURPLUS LINES INSURANCE LAWS OF YOUR STATE. In consideration of the payment of the premium, and in reliance upon the statements and representations in the applications for insurance and the Coverage Summary, we agree to provide the insurance contained in the policy. THE COMPANY: ProAssurance Specialty Insurance Company, Inc. POLICYHOLDER: Colorado Motocross Medics, LLC POLICY NUMBER: AFC8827512 POLICY INVOICE DATE: 8/27/2012 POLICY PERIOD BEGINNING: 8/21/2012 POLICY ISSUE DATE: 8/27/2012 The policy consists of this Cover Page and the following forms (together with any endorsements issued from time to time). Title Colorado Information Page Allied Health Cover Page Allied Health Coverage Summary Allied Health Definitions Allied Health General Conditions Allied Health General Exclusions Allied Health GL Coverage Part Allied Health PL Coverage Part Legal Defense Coverage Part Coverage Limitation Endorsement Employee Benefits Coverage Endorsement PSA Coverage Endorsement Form Number PRA-APE-INFO.CO 0411 PMC-APE-010 0411 PMC-APE-020 0411 PMC-APE-025 0411 PMC-APE-030 0411 PMC-APE-035 0411 PMC-APE-100 0411 PMC-APE-200 0411 PMC-APE-300 0411 PRA -APE -554 0411 PMC-APE-580 0411 PMC-APE-590 0411 If any provision of the policy changes, we will issue an endorsement stating the effective date of any changes. Terms appearing in the policy in bold face print are defined in the Definitions section. IN WITNESS WHEREOF, we have caused the Cover Page to be signed by our President and Secretary. The policy is effective only if countersigned on the Coverage Summary by our duly authorized representative. Q fotaS KATHRYN A. NEVILLE, J.D., CPCU HOWARD H. FRIEDMAN, ACAS, MAAA Secretary President PMC-APE-010 04 11 Health Care Entity Liability Policy Allied Health Professionals — Cover Page ©2011 ProAssurance Specialty Insurance Company, Inc. Page 1 of 1 HEALTH CARE ENTITY LIABILITY POLICY ALLIED HEALTH PROFESSIONALS COVERAGE SUMMARY Policyholder and Address: Colorado Motocross Medics, LLC 729 Remington Street Fort Collins, CO 80524 2. Policy Number: AFC8827512 3. Policy Period: From 8/21/2012 to 8/21t2013 12:01 a.m. Standard Time at the address of the Policyholder as stated above. 4. Premium: Health Care Facility General Liability Coverage Part: COVERAGES A, B and C Health Care Facility Professional Liability Coverage Part: Total Premium: Policy Fee: Total: 5. Limits of Liability: $ 520.00 $ 2,983.00 $ 3,503.00 $ 200.00 $ 3,703.00 Health Care Facility General Liability Coverage Part (COVERAGES A, B and C): (1) Each Occurrence Limit (Coverage A) $ 1,000,000 (2) Fire Damage Limit (Coverage A) $ 50,000 (3) Personal Injury and Advertising Injury Limit (COVERAGE B) $ 1,000,000 (4) Medical Expense Limit (Coverage C) $ 5,000 (5) General Aggregate Limit $ 3,000,000 Health Care Facility Professional Liability Coverage Part: (1) Each Professional Incident $ 1,000,000 (2) General Aggregate Limit $ 3,000,000 6. Deductibles (if applicable): Health Care Facility General Liability Coverage Part (COVERAGES A and B only; no deductible applies to COVERAGE C) (1) Each Occurrence (Coverage A) (2) Personal Injury and Advertising Injury to any one person or organization (Coverage B) (3) General Aggregate Deductible Health Care Facility Professional Liability Coverage Part (1) Each Professional Incident (2) General Aggregate Deductible 7. Coverage Effective Date: 8. Retroactive Dates (if applicable): $ 1,000 $ 1,000 $ N/A $ 1,000 $ N/A 8/21/2012 PMC-APE-020 04 11 Health Care Entity Liability Policy Allied Health Professionals —Coverage Summary ©2011 ProAssurance Specialty Insurance Company, Inc. Page 1 of 2 Judgments against Licensee or License Colorado Motocross Medics 729 Remington Street, Fort Collins, Colorado 80524 March 12, 2013 To Whom It May Concern: 1-303-907-9694 comxmedics4imsn.com Pursuant to the requirements of Sec. 7-3-50 and 7-2-90 of the Weld County Code, Colorado Ambulance Service attests to the following: • No employees of Colorado Ambulance Service have had any criminal complaint or convictions, including Class I and II traffic violations, within the previous twelve (12) months. Each employee's criminal background check and motor vehicle records have occurred within 45 days of submittal of this application. • Colorado Ambulance Service has not had any judgments entered against us within the previous twelve (12) months, including findings of fact, conclusions of law and order by any court or other tribunal. Sincerely, Joel ainter CEO Colorado Motocross Medics, LLC Hello