The URL can be used to link to this page

Browse Search

Home My WebLink About20211580.tiffCHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND SALVED MEDICAL GROUP, INC. DBA BRIGHTSTAR CARE OF GREELEY This Agreement, made and entered into the/ 4' day of 2021, by and between the Board of Weld County Commissioners, on behalf of the Weld Coun epartment of Human Services, hereinafter referred to as the "Department" and Salveo Medical Group, Inc. DB BrightStar Care of Greeley, hereinafter referred to as the "Contractor". The parties to this Agreement understand and agree that the provisions of this Agreement specifically include the following documents: Exhibit A, Weld County's Request for Proposal, Exhibit B, Contractor's Response to Request for Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule. Exhibit B, C, and D are attached hereto and incorporated herein by this reference. Exhibit A is Weld County's Request for Proposal Number B2100042 which is incorporated into this agreement by reference and will be provided upon request to the Department. WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Services has provided Core Services or other funding to the Department for Home Based Intervention. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This agreement shall become effective on June 1, 2021, upon proper execution of this Agreement and shall expire May 31, 2022, unless sooner terminated as provided herein. The agreement is for a period of three years. However, the agreement must be renewed by both parties, in writing, on an annual basis. 2. Scope of Services Services shall be provided by the Contractor to any person(s) eligible for services in compliance with Exhibit B, Contractor's Response to Request for Proposal and Exhibit C, Scope of Services. 3. Referrals, Billing and Tracking a. Contractor understands and will comply with all aspects of the referral authorization, billing and tracking requirements as set forth by the Department. Failure to comply with all aspects may result in a forfeiture of payment. b. Contractor agrees to receive referrals for services through e-mail and will provide an identified e- mail address prior to the start of this Agreement. Contractor acknowledges that services are not authorized until the Contractor has received an authorized referral form from the Department. Contractor further acknowledges that services provided prior to the authorized start date or outside the scope of services on the referral form will not be eligible for reimbursement. Contractor acknowledges that any and all modifications to an existing referral must be approved through the Quality Assurance Team(HS-CWQualitvAssurance(aweldgov.com). No other Department staff or other party to the case may authorize services or modifications to services. c. Contractor agrees to submit a complete Request for Reimbursement and supporting documentation by the 7th of the month, following the month of service, utilizing billing forms required by the Department. Contractor agrees to utilize the Client Verification Form for all scheduled and unscheduled face-to-face services with the exception of home studies and monitored sobriety testing. Contractor agrees that original complete Client Verification Forms are to be submitted with the elAae),(,(1-k-o) 2021-1580 /11-kto 93 Request for Reimbursement. Requests for Reimbursement and Client Verification Forms received after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet 60 -day deadline may result in termination of the Agreement. d. Contractor agrees to submit a monthly report by the 7th of the month, following the month of service, for each client receiving ongoing services. Monthly reports will be submitted through the Department's online reporting system, unless otherwise directed or agreed to by the Department. Monthly reports for ongoing services must include the following information, entered in the "Narrative" box for each date of service: a. Date and time of service b. Where the service took place c. Clinician/therapist name d. Clients participating e. What interventions were used, recommendations and/or goals discussed f. Any and all safety concerns One-time services will be verified through receipt of the completed product (ex. psychological evaluation, substance abuse evaluation, home study). Verification of Monitored Sobriety Services will be the test result. A completed home study may be a full, partial or denied study, as determined by the Department. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under the Agreement. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately to the caseworker AND on the required monthly report. 4. Payment a. The Department and the Contractor agree that all benefits from private insurance and/or other funding sources such as Medicaid (if Contractor is a Medicaid eligible provider) or Victim's Compensation must be exhausted before Core Services or other Department funds can be accessed for services. Exceptions to this Paragraph may include, if approved by the Department, the following: i. The service being provided by the contractor is not a Medicaid eligible service; ii. The service is not deemed medically necessary; iii. The Court with jurisdiction over the case has ordered that a non -Medicaid provider or service be used; iv. A Medicaid provider is not available to provide the needed service; v. Medicaid is exhausted for the needed service; or vi. Medicaid denied service. vii. The client is not eligible for Medicaid. b. Payment shall be made in accordance with Exhibit A, Weld County's Request for Proposal, Exhibit B, Contractor's Response to Request for Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule, attached hereto and incorporated herein by reference, so long as services are rendered satisfactorily and in accordance with the Agreement. c. Payment pursuant to this Agreement, whether in whole or in part, is subject to, and contingent upon, the continuing availability of said funds for the purposes hereof. d. The Department may withhold reimbursement if Contractor has failed to comply with any part of the Agreement, including the Financial Management requirements, program objectives, contractual terms, or reporting requirements. In the event of forfeiture of reimbursement, Contractor may appeal such circumstance in writing to the Director of Human Services. The decision of the Director of Human Services shall be final. 2 5. Financial Management At all times from the effective date of the Agreement until completion of the Agreement, Contractor shall comply with the administrative requirements, cost principles and other requirements set forth in the Financial Management Manual adopted by the State of Colorado. The required annual audit of all funds expended under this Agreement must conform to the Single Audit Act of 1984 and OMG Circular A-133. 6. Payment Method Unless otherwise provided in Exhibit B, Contractor's Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule: a. If services are funded through Core Services, Contractor agrees to accept reimbursement through ACH direct deposit one time per month. b. If Contractor is not currently set up with the State of Colorado to accept direct deposit, Contractor agrees to complete and submit a State of Colorado direct deposit enrollment form, which will be provided by the Department, with a voided check. Failure to complete and submit this form and voided check in a timely and accurate manner may result in a delay of payment. c. Contractor agrees to accept payment through county warrant when funding source does not allow for direct deposit. 7. Compliance with Applicable Laws a. At all times during the performance of this Agreement, Contractor will strictly adhere to all applicable Federal and State laws, order, and applicable standards, regulations, interpretations and/or guidelines issued pursuant thereto. This includes protection of the confidentiality of all applicant/recipient records, papers, documents, tapes and any other materials that have been or may hereafter be established which relate to the Agreement. Contractor shall abide by all applicable laws and regulations, including, but not limited to the following: - Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45 C.F.R. Part 80 et. seq.; and - all provisions of the Civil Rights Act of 1986 so that no person shall, on the grounds of race, creed, color, sex, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under the approved Agreement. - Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its implementing regulations, 45 C.F.R. Part 84; and - the Age Discrimination Act of 1975, 42 U.S.C. Section 6101 et. seq. and its implementation regulations, 45 C.F.R. Part 91; and - Title VII of the Civil Rights Act of 1964; and - the Age Discrimination in Employment Act of 1967; and the Equal Pay Act of 1963; and the Education Amendments of 1972; and Immigration Reform and Control Act of 1986, P.L. 99-603, 42 C.F.R. Part 2; and 3 - all regulations applicable to these laws prohibiting discrimination because of race, color, national origin, sex, religion, and handicap, including Acquired Immune Deficiency Syndrome (AIDS) or AIDS related conditions covered under Section 504 of the Rehabilitation Act of 1973, as amended, cited above. If necessary, Contractor and the Department will resist in judicial proceedings any efforts to obtain access to client records except as permitted by 42 C.F.R. Part 2. 45 C.F.R. Part 74, Appendix G 9, which requires that affirmative steps be taken to assure that small and minority businesses are utilized, when possible, as sources of supplies, equipment, construction and services. This assurance is given in consideration of and for the purpose of obtaining any all Federal and/or State financial assistance. - Colorado Revised Statute (C.R.S.) 26-6-104, requiring criminal background record checks for all employees, contractors and sub -contractors. b. Contractor is further charged with the knowledge that any person who feels that s/he has been discriminated against has the right to file a complaint either with the Colorado Department of Human Services or with the United States Department of Health and Human Services, Office for Civil Rights. c. Contractor assures that it will fully comply with all other applicable Federal and State laws which may govern the ability of the Department to comply with the relevant funding requirements. Contractor understands the source of funds to be accessed under the Agreement is determined by the Department. d. Contractor assures and certifies that it and its principals: - Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transaction by a Federal or State department or agency; and - have not, within a three-year period preceding this Agreement, been convicted of or had a civil judgment rendered against them for commission of fraud or criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or Local) transaction or contract under public transaction; violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; and - are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state or local) with commission of any of the offenses enumerated in this certification; and - have not, within a three-year period preceding this Agreement, had one or more public transactions (federal, state, or local) terminated for cause or default. e. Public Contracts for Services C.R.S. §8-17.5-101. Contractor certifies, warrants, and agrees that it does not knowingly employ or contract with an illegal alien who will perform work under this contract. Contractor will confirm the employment eligibility of all employees who are newly hired for employment in the United States to perform work under this Agreement, through participation in the E - Verify program or the State of Colorado program established pursuant to C.R.S. §8-17.5- 102(5)(c). Contractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or enter into a contract with a subcontractor that fails to certify with Contractor that the subcontractor shall not knowingly employ or contract with an illegal alien to perform work under this Agreement. Contractor shall not use E -Verify Program or State of Colorado program procedures to undertake pre -employment screening or job applicants while this Agreement is being performed. If Contractor obtains actual knowledge that a subcontractor performing work under the public contract for services knowingly employs or contracts with an illegal alien Contractor shall notify the subcontractor and the Department within three (3) days that Contractor has actual knowledge that a subcontractor is 4 employing or contracting with an illegal alien and shall terminate the subcontract if a subcontractor does not stop employing or contracting with the illegal alien within three (3) days of receiving notice. Contractor shall not terminate the contract if within three days the subcontractor provides information to establish that the subcontractor has not knowingly employed or contracted with an illegal alien. shall comply with reasonable requests made in the course of an investigation, undertaken pursuant to C.R.S. §8-17.5-102(5), by the Colorado Department of Labor and Employment. If Contractor participates in the State of Colorado program, Contractor shall, within twenty days after hiring a new employee to perform work under the contract, affirm that Contractor has examined the legal work status of such employee, retained file copies of the documents, and not altered or falsified the identification documents for such employees. Contractor shall deliver to the Department, a written notarized affirmation that it has examined the legal work status of such employee and shall comply with all of the other requirements of the State of Colorado program. If Contractor fails to comply with any requirement of this provision or of C.R.S. §8-17.5-101 et seq., the Department, may terminate this Agreement for breach, and if so terminated, Contractor shall be liable for actual and consequential damages. f. Except where exempted by federal law and except as provided in C.R.S. § 24-76.5-103(3), if Contractor receives federal or state funds under the contract, Contractor must confirm that any individual natural person eighteen (18) years of age or older is lawfully present in the United States pursuant to C.R.S. § 24-76.5-103(4), if such individual applies for public benefits provided under the contract. If Contractor operates as a sole proprietor, it hereby swears or affirms under penalty of perjury that it: (a) is a citizen of the United States or is otherwise lawfully present in the United States pursuant to federal law, (b) shall produce one of the forms of identification required by C.R.S. § 24- 76.5-101, et seq., and (c) shall produce one of the forms of identification required by C.R.S. § 24-76.5- 103 prior to the effective date of the contract. 8. Compliance with Child and Family Services Review The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas; Safety, Permanency and Well Being of families. For each outcome, data and performance indicators measure each state's performance according to national standards and monitor progress over time. Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance services to families. Contractor agrees to continually strive for positive outcomes in the areas of Safety, Permanency and Well Being. Contractor will ensure that any employee or subcontractor of Contractor providing services under this Agreement will work towards positive outcomes in the aforementioned three areas as outlined under the Child and Family Services Review (CFSR), and will address the aforementioned three areas when completing monthly reports as required by Paragraph 3(d) of this Agreement. 9. Insurance Requirements Contractor and the Department agree that Weld County, the Board of County Commissioners of Weld County, its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or omissions of the Contractor, it subcontractor, or their employees, volunteers, or agents while performing duties described in this Agreement. Contractor shall indemnify, defend and hold harmless Weld County, the Board of County Commissioners of Weld County, its employees, volunteers and agents. Contractor shall provide the liability insurances (including professional liability insurances where necessary) and worker's compensation insurances for all its employees, volunteers, and agents engaged in the performance of this Agreement which are required under Weld County's Request for Proposal, and required by the Colorado Worker's Compensation Act. Contractor shall provide the Department with the acceptable evidence that such coverage is in effect within seven (7) days of the date of this Agreement. At a minimum, Contractor shall procure, either personally or through its employer as applicable to the Contractor's business, at its own expense, and maintain for the duration of the work, insurance coverage 5 listed in this agreement. The Board of County Commissioners of Weld County and its Officers/Employees shall be named as additional insured. a. General Requirements: Contractors must secure, at or before the time of execution of any agreement or commencement of any work, the following insurance covering all operations, goods or services provided pursuant to this request. Contractors shall keep the required insurance coverage in force at all times during the term of the Agreement, or any extension thereof, and during any warranty period. The required insurance shall be underwritten by an insurer licensed to do business in Colorado and rated by A.M. Best Company as "A"VIII or better. Each policy shall contain a valid provision or endorsement stating "Should any of the above -described policies by canceled or should any coverage be reduced before the expiration date thereof, the issuing company shall send written notice to the Weld County Director of General Services by certified mail, return receipt requested. Such written notice shall be sent thirty (30) days prior to such cancellation or reduction unless due to non-payment of premiums for which notice shall be sent ten (10) days prior. If any policy is in excess of a deductible or self -insured retention, the Department must be notified by the Contractor. Contractor shall be responsible for the payment of any deductible or self -insured retention. The Department reserves the right to require Contractor to provide a bond, at no cost to the Department, in the amount of the deductible or self -insured retention to guarantee payment of claims. The insurance coverages specified in this Agreement are the minimum requirements, and these requirements do not decrease or limit the liability of Contractor. Contractor shall maintain, at its own expense, any additional kinds or amounts of insurance that it may deem necessary to cover its obligations and liabilities under this Agreement. b. Types of Insurance: Contractor shall obtain, and maintain at all times during the term of any Agreement, insurance in the following kinds and amounts: i.Workers' Compensation Insurance as required by state statute, and Employer's Liability Insurance covering all of Contractor's employees acting within the course and scope of their employment. If Contractor is an Independent Contractor, as defined by the Colorado Worker's Compensation Act, this requirement shall not apply. Contractor must submit to the Department a Declaration of Independent Contractor Status Form prior to the start of this agreement. ii.Commercial General Liability Insurance written on ISO occurrence form CG 00 01 10/93 or equivalent, covering premises operations, fire damage, independent Contractors, products and completed operations, blanket contractual liability, personal injury, and advertising liability with minimum limits as follows: $1,000,000 each occurrence; $2,000,000 general aggregate; $50,000 any one fire; and $500,000 errors and omissions. iii.Automobile Liability: Contractor shall maintain limits of $1,000,000 for bodily injury per person, $1,000,000 for bodily injury for each accident, and $1,000,000 for property damage applicable to all vehicles operating both on County property and elsewhere. iv.Additional Provisions: Policies for all general liability, excess/umbrella liability, liquor liability and pollution liability must provide the following: - If any aggregate limit is reduced by twenty-five percent (25%) or more by paid or reserved claims, Contractor shall notify the Department within ten (10) days and reinstate the aggregates required; - Unlimited defense costs in excess of policy limits; - Contractual liability covering the indemnification provisions of this Agreement; A severability of interests provision; - Waiver of exclusion for lawsuits by one insured against another; 6 A provision that coverage is primary; and A provision that coverage is non-contributory with other coverage or self-insurance provided by the Department. v.For all general liability, excess/umbrella liability, liquor liability, pollution liability and professional liability policies, if the policy is a claims -made policy, the retroactive date must be on or before the contract date or the first date when any goods or services were provided to the Department, whichever is earlier. c. Contractors shall secure and deliver to County's Risk Administrator ("Administrator") at or before the time of execution of this Agreement, and shall keep in force at all times during the term of the Agreement as the same may be extended as herein provided, a commercial general liability insurance policy, including public liability and property damage, in form and company acceptable to and approved by said Administrator, covering all operations hereunder set forth in the related Bid or Request for Proposal. d. Proof of Insurance: Contractor shall provide a copy of this information to its insurance agent or broker and shall have its agent or broker provide proof of Contractor's required insurance. The Department reserves the right to require Contractor to provide a certificate of insurance, a policy, or other proof of insurance as required by the County's Risk Administrator in his sole discretion. e. Additional Insureds: For general liability, excess/umbrella liability, pollution legal liability, liquor liability, and inland marine, Contractor's insurer shall name County as an additional insured. f. Waiver of Subrogation: For all coverages, Contractor's insurer shall waive subrogation rights against County. g. Subcontractors: All subcontractors, independent contractors, sub -vendors, suppliers or other entities providing goods or services required by this Agreement shall be subject to all of the requirements herein and shall procure and maintain the same coverages required of Contractor. Contractor shall include all such subcontractors, independent contractors, sub -vendors, suppliers or other entities as insureds under its policies or shall ensure that all subcontractors maintain the required coverages. Contractor agrees to provide proof of insurance for all such subcontractors, independent contractors, sub -vendors, suppliers or other entities upon request by the Department. A provider of Professional Services (as defined in the Bid or RFP) shall provide the following coverage: Professional Liability: Contractor shall maintain limits of $1,000,000 for each claim, and $2,000,000 aggregate limit for all claims. 10. Certification Contractor certifies that, at the time of entering into this Agreement, it has currently in effect all necessary licenses, approvals, insurance, etc., required to properly provide the services and/or supplies covered by this Agreement. Copies of all necessary licenses shall be provided to the Department by the Contractor prior to the start of any Agreement. 11. Training Contractor may be required to attend training at the request of the Department specific to services provided under this Agreement. The Department will not compensate the Contractor for said training in the form of registration fees, time spent traveling to and from training, attending the training or any other associated costs unless otherwise agreed to by the Department. 7 12. Subpoenas Contractor will, on behalf of its employees and/or officers, accept any subpoena for testimony from the Weld County Attorney's Office by e-mail and will return a waiver of services within 72 business hours. For this purpose, Contractor will designate an e-mail address prior to the start of this Agreement. If the Contractor receives a subpoena via e-mail but will only accept personal service, the Contractor will contact the Weld County Attorney's Office immediately at (970) 336-7235 and advise that the subpoena must be personally served. 13. Monitoring and Evaluation Contractor and the Department agree that monitoring and evaluation of the performance of this Agreement shall be conducted by the Contractor and the Department. The results of the monitoring and evaluation shall be provided to the Board of Weld County Commissioners, the Department and the Contractor. Contractor will collaborate in a timely manner with the Department to resolve issues pertaining to service delivery, service quality, documentation, and invoicing during referral period and after services have concluded. The Contractor will require clients sign releases of information. Contractor understands that the Department will not reimburse for services rendered to Department clients until releases of information are obtained. Contractor shall permit the Department, and any other duly authorized agent or governmental agency, to monitor all activities conducted by the Contractor pursuant to the terms of this Agreement. The monitoring agency may, if in its sole discretion deems necessary or appropriate, have access to any program data, special analyses, on -site checking, formal audit examinations, or any other reasonable procedures for purposes of monitoring. All such monitoring shall be performed in a manner that will not unduly interfere with the work conducted under this Agreement. 14. Modification of Agreement All modifications to this Agreement shall be in writing and signed by both parties. 15. Remedies The Director of Human Services or designee may exercise the following remedial actions should s/he find the Contractor substantially failed to satisfy the scope of work found in this Agreement. Substantial failure to satisfy the scope of work shall be defined to mean incorrect or improper activities or inaction by the Contractor. These remedial actions are as follows: - Withhold payment to the Contractor until the necessary services or corrections in performance are satisfactorily completed. - Deny payment or recover reimbursement for those services or deliverables, which have not been performed and which due to circumstances caused by the Contractor cannot be performed or if performed would be of no value to the Department. Denial of the amount of payment shall be reasonably related to the amount of work or deliverables lost to the Department. - Incorrect payment to the Contractor due to omission, error, fraud, and/or defalcation shall be recovered from Contractor by deduction from subsequent payments under this Agreement or other agreements between the Department and Contractor, or by the Department as a debt due to the Department or otherwise as provided by law. 16. Representatives For the purpose of this Agreement, the individuals identified below are hereby designated representatives 8 of the respective parties. Either party may from time to time designate in writing a new or substitute representative(s). For Department: For Contractor: Heather Walker, Child Welfare Director Shantay Danielle Marcos, RN, Director of Nursing 17. Notice All notices required to be given by the parties hereunder shall be given by certified or registered mail to the individuals at the addresses set forth below. Either party may from time to time designate in writing a substitute person(s) or address to whom such notices shall be sent. For Department: Jamie Ulrich, Director P.O. Box A Greeley, CO 80632 (970) 400-6510 18. Litigation For Contractor: Shantay Danielle Marcos 918 13th Street, Suite 6 Greeley, Colorado 80631 (970) 999-0535 Contractor shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 19. Termination This Agreement may be terminated at any time by either party giving thirty (30) days written notice to the individuals identified in paragraph 17. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the Contractor is no longer available to the Department, or for any other reason. Contractor reserves the right to suspend services to clients if funding is no longer available. 20. No Third -Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental Immunity Act of §§24-10-101 et. seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The 9 parties hereto declare that they would have entered into this Agreement and each and every section, subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional or invalid. 23. Improprieties/Conflict of Interest No officer, member or employee of Weld County and no member of their governing bodies shall have any pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof. The Appearance of Conflict of Interest applies to the relationship of a Contractor with the Department when the Contractor also maintains a relationship with a third party and the two relationships are in opposition. In order to create the appearance of a conflict of interest, it is not necessary for the Contractor to gain from knowledge of these opposing interests. It is only necessary that the Contractor know that the two relationships are in opposition. During the term of the Agreement, Contractor shall not enter into any third -party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, Contractor shall submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with the Contractor. A conflict of interest or appearance of a conflict of interest may also apply to personal relationships between providers and clients. If a provider has a personal relationship with a client to whom the Contractor may provide services for, the Contractor must disclose that relationship to the Department. Contractor certifies that Federal appropriated funds have not been paid or will be paid, by or on behalf of Contractor, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of an Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records Contractor agrees that authorized local, Federal, and State auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement, to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by the Contractor in a central location and shall be made available to the Department upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the Federal and/or State government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records Contractor shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection. No information about or obtained from any applicant/recipient in possession of Contractor shall 10 be disclosed in a form identifiable with the applicant/recipient or a minor's parent or guardian unless in accordance with the Contractor's written policy governing access to, duplication and dissemination of, all such information, in any form, including social networks. Contractor shall advise its employees, agents, and subcontractor, if any, that they are subject to these confidentiality requirements. Contractor shall provide its employees, agents, and subcontractors, if any, with a copy or written explanation of these confidentiality requirements before access to confidential data is permitted. Contractor shall have its employees, agents, and subcontractors, if any, sign a written confidentiality agreement and shall provide a copy of such agreement to the Department, if requested. 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by the Contractor in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by the Contractor for similar information in the course of its own business. 27. Independence of Contractor: Not an Employee of Weld County Contractor agrees that it is an independent Contractor and that Contractor's officers, agents or employees will not become employees of County, nor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall perform its duties hereunder as an independent Contractor. Contractor shall be solely responsible for its acts and those of its agents and employees for all acts performed pursuant to this Agreement. Contractor, its employees and agents are not entitled to unemployment insurance or workers' compensation benefits through County and County shall not pay for or otherwise provide such coverage for Contractor or any of its agents or employees. Unemployment insurance benefits will be available to Contractor and its employees and agents only if such coverage is made available by Contractor or a third party. Contractor shall pay when due all applicable employment taxes and income taxes and local head taxes (if applicable) incurred pursuant to this Agreement. Contractor shall not have authorization, express or implied, to bind County to any agreement, liability or understanding, except as expressly set forth in this Agreement. Contractor shall have the following responsibilities with regard to workers' compensation and unemployment compensation insurance matters: (a) provide and keep in force workers' compensation and unemployment compensation insurance in the amounts required by law, and as set forth in Exhibit A, provide proof thereof when requested to do so by County. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as state in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. The Contractor and the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 29. Agreement Nonexclusive This Agreement does not guarantee any work nor does it create an exclusive agreement for services. 30. Warranty The Contractor warrants that services performed under this Agreement will be performed in a manner 11 consistent with the professional standards governing such services and the provisions of this Agreement. The Contractor shall faithfully perform the work in accordance with the standards of care, skill, training, diligence and judgment provided by highly competent individuals and entities that perform services of a similar nature to those described in this Agreement including Exhibits A, B, C, and D. 31. Acceptance of Services Not a Waiver Upon completion of the work, the Contractor shall submit to the Department originals of all tests and results, reports, etc., generated during completion of this work. Acceptance by the Department of reports and incidental material(s) furnished under this Agreement shall not in any way relieve the Contractor of responsibility for the quality and accuracy of the services. In no event shall any action by the Department hereunder constitute or be construed to be a waiver by the Department of any breach of covenant or default which may then exist on the part of the Contractor, and the Department's action or inaction when any such breach or default shall exist shall not impair or prejudice any right or remedy available to the Department with respect to such breach or default; and no assent, expressed or implied, to any breach of any one or more covenants, provisions or conditions of the Agreement shall be deemed or taken to be a waiver of any other breach. Acceptance by the Department of, or payment for, any services performed under this Agreement shall not be construed as a waiver of any of the Department's rights under this Agreement or under the law generally. 32. Employee Financial Interest/Conflict of Interest. C.R.S. U24-18-201 et seq. and &24-50-507 The signatories to this Agreement aver that to their knowledge, no employee of Weld County has any personal or beneficial interest whatsoever in the service or property which is the subject matter of this Agreement. The Contractor has no interest and shall not acquire any interest direct or indirect, which would in any manner or degree with the performance of the Contractor's services and the Contractor, shall not employ any person having such known interests. During the term of this Agreement, the Contractor shall not engage in any in any business or personal activities or practices or maintain any relationships which actually conflicts with or in any way appear to conflict with the full performance of its obligations under this Agreement. Failure by the Contractor to ensure compliance with this provision may result, in the Department's sole discretion, in immediate termination of this Agreement. No employee of the Contractor nor any member of the Contractor's family shall serve on a County Board, committee or hold any such position which either by rule, practice or action nominates, recommends, supervises Contractor's operations, or authorizes funding to the Contractor. 33. Board of County Commissioners of Weld County Approval This Agreement shall not be valid until it has been approved by the Board of County Commissioners of Weld County, Colorado. 34. Choice of Law/Jurisdiction Colorado law, and rules and regulations established pursuant thereto, shall be applied in the interpretation, execution, and enforcement of this Agreement. Any provision included or incorporated herein by reference which conflicts with said laws, rules and/or regulations shall be null and void. In the event of a legal dispute between the parties, Contractor agrees that the Weld County District Court shall have exclusive jurisdiction to resolve said dispute. 35. Subcontractors Contractor acknowledges that the Department has entered into this Agreement in reliance upon the particular reputation and expertise of Contractor. Contractor shall not enter into any subcontractor agreements for the completion of this project without the Department's prior written consent, which may be withheld in the Department's sole discretion. 36. Attorney's Fees/Legal Costs 12 In the event of a dispute between the Department and Contractor, concerning this Agreement, the parties agree that each party shall be responsible for the payment of attorney fees and/or legal costs incurred by or on its own behalf. 37. Ownership All work and information obtained by Contractor under this Agreement or individual work order shall become or remain (as applicable), the property of the Department. In addition, all reports, documents, data, plans, drawings, records and computer files generated by Contractor in relation to this Agreement and all reports, test results and all other tangible materials obtained and/or produced in connection with the performance of this Agreement, whether or not such materials are in completed form, shall at all times be considered the property of the Department. Contractor shall not make use of such material for purposes other than in connection with this Agreement without prior written approval of the Department. 38. Interruptions Neither party to this Agreement shall be liable to the other for delays in delivery or failure to deliver or otherwise to perform any obligation under this Agreement, where such failure is due to any cause beyond its reasonable control, includiig but not limited to Acts of God, fires, strikes, war, flood, earthquakes or Governmental actions. 39. Severability If any term or condition of this Agreement shall be held to be invalid, illegal, or unenforceable by a court of competent jurisdiction, this Agreement shall be construed and enforced without such provision, to the extent that this Agreement is then capable of execution within the original intent of the parties. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: Ci• .�i/1i�r� BOARD OF COUNTY COMMISSIONERS Weld C.. a Clerk to the Board -� / '� WELD COUNTY, COLORADO By: Deputy Clerk to t s Board 13 teve Moreno, Chair CONTRACTOR: JUN 1 6 2021 Salveo Medical Group, Inc. DBA BrightStar Care of Greeley 918 13th Street, Suite 6 Greeley, Colorado 80631 (970) 999-0535 By: Chris Jackson (Jun 7, 2021 12:00 MDT) Chris Jackson, Owner Jun 7, 2021 Date: etecv —/5-16 EXHIBIT A WELD COUNTY'S REQUEST FOR PROPOSAL (Weld County's Request for Proposal is incorporated into this agreement by reference and will be provided upon request to the Department.) This page intentionally left blank. Exhibit B Contractor's response to the Request for Proposal Exhibit B contains the following documents: • Attachment B — Provider Information Form (PIF) • Attachment C — Proposal • Attachment D — Staff Data Sheet • Certificate of Insurance (COI) ATTACHMENT B WELD COUNTY DEPARTMENT OF HUMAN SERVICES - PROVIDER INFORMATION FORM (PIF) AGENCY INFORMATION Agency Name: t g aBr;c o —S r(r Provider Contact Full Name: j.e.,..1% V1' -r, t-1 a-rwAc Primary Phone Number (10 -digit): 9 70 -g/ S-$ 13 \. Ext.: Primary Contact Email: ss.ic_ck.t4c,rrks Gbn Web Address: br%fjj,1fSrCare. ,COR"/rife) Trails Provider ID (if known): Title: P.,►J LASe_ l6{ncric Fax Number (10 -digit): 7a 6 Agency Location Address (Street, city, state, zip): Agency Mailing Address (Street, city, state, zip): S1 -0,r Co. re- ct/X 13 6, 6rrt.it,t cr, n6 i SPnrv-t_ c -S U. be.y Agency Type (pick one): n Public Company n Private Non -Profit [1 Private for Profit Referral Contact Name: Send Referrals for Service to: Ho ins , Referral Phone Number (10 -digit): q 7U _y( 15 6' 13 j Ext.: Title: R U (4 _ &o iO- ` - b r < �c.rY-- t S+trr Email: p:R qC rn r L-�-c,rw, S .rstti Billing Contact Name: Billing Contact Ckr;-s ,\ Billing Phone Number (10 -digit): 170 - i 9 9 - V s S Title: G �ryA Ext.: Email :((,1r 5 CERTIFICATION I certify that the services proposed for intended use by the Weld County Department of Human Services will meet all the j specifications it has so indicated in this bid form. I further affirm intention to enter into an agreement with Weld County, on behalf of the Welpi County Department of Human Services, and comply with all requirements of the contract, if awarded. IThe Board of Weld County Commissioners reserve the right to reject any or all bids, to waive any informality in the bids, and to j accept the bid, or part of a bid, that, in the opinion of the Board, is in the best interests of the Board and of the County of Weld, State of Colorado. The Board of Weld County Commissioners shall give preference to resident Weld County bidders in all cases where the bids are competitive in price and quality. I {� Authorized Rep. Pull Name: _�k041-1-G', Dr1,, n ; •P I ( n lai,coS Title: R ) , On j:) 1 � i Authorized Rep. Email: SkL'�I 4\y a 1�/1(WCo S 6,3 b Ci �M I- S \--0,..r", Phone (Z0-digit).9 /(j • qt) -cam Ext.: u c Cs - V tJ-e- - -U W\ i Authorized Rep. Address (Street, city, state, zip): q j ) 3 4",. S v" }-e L,. G r -e Ct 7 ,- ( a , g' C) 3 , Signature of Authorized Rep.: Date: g--,4Aesz REV. NOVEMBER 2020 ATTACHMENT C - PROPOSAL Please typ ;wL y 4 ur answers in the boxes below or check the appropriate box. Bidder's Le al Name: Progra ... Area: SECTI N 1 a Provider and Progr m Area Inf relation Salve® Medical Group, Inc. dba BrightStar Care of Greeley Home -Based Intervention Number of services red on this Attachment C (max 5): Program Areas are listed j,r : column 1 of the table located in Item XI of the Request You may complete another Attachment C of you have more than 5 for Proposal starting on page 13. 3 If the s SECTION 2 — Service N r e(s) and Inform rvice is a monthly packa=ge, please offer different leis® state a specific minimum number of direct servic Service #1 Name: ti • fl h o th ly urs® p ckages ages st RN Skilled Assessment, Intervention and Evidence Based Practice Education 2.1a M •:dalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Focused or general physical assessment, Equipment used may include: Stethoscope, sphygmomanometer, pulse oximeter, thermometer, ect. Interventions will be based off of client need and may include anything within RN sc*pe sf practice. Education will be provided for families and individuals for their specific needs. Elsivier program will be used for Evidence Based Education and teaching materials. 2.1b Anticipated frequency *f direct service time with the client/family per week, nt including professional staffing time, administrative_ tim verhead, or travel time (i.e. 4 hours/w: ek). Of th t service has levels, be specific for each level: Varies off of needs requested by county. 2.1c Anticipated duration of service (i.e. 3-4 months): Varies off of needs requested by county. 2.1d Three (3), or more, specific goals f the service (DO use bullet points): *Identify problems or potential prohlems*Monitor clinical progression*Track trends*Promote independence of family 2.1e Three (3), or more, specific outctrnes of service: Address known or unknown physical issues*increase well-being by timely intervention*Prevent physical decline 2.1f Target populatin f the servic including age and gender: Children and families who are under service of Weld County Human Services. Children 0-18, Male, Female or other identifying gender. 2.1g Languages service is available in (please list proficiency and if interpreter services are available): English, Spanish 2.1h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: BrightStar Care does not accept Medicare or Medicaid Service #2 Name: Clinical Case Management 2.2a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): RN Case Manager will make necessary phone calls, file reports, coordinate with care team, file reports and complete documentation as required. 2.2b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: Varies off of needs requested by county. 2.2c Anticipated duration of service (i.e. 3-4 months): Varies off if needs requested by county. 2.2d Three (3), or m re, specific goals of the service (DO use bullet points): *Communicate with health care providers associated in each case *Communicate with Case worksers and involved personnel *Maintain documentation that meets county, state and federal requirements. 2.2e Three (3), or more, specific outcomes 'A' f service: *Fulfilled provider orders *Clear and concise communication provided to interdisciplinary team *Care coordination will be provided. 2.2f Target population of the service: Children and families who are under service of Weld County Human Services and their care team including case workers. Children 0-18, Male, Female or other identifying gender. 2.2g Languages service is available in (please list proficiency and if interpret 7w` r services are available): REV. NOV OV 2020 1 ATTACHMENT C - PROPOSAL English, Spanish 2.2h Medicaid eligibility list blether the service is eligible for Medicaid in whole or in part: BrightStar Care does not accept Medicare or Medicaid Service #3 Name: Nurse Consultation 2.3a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): Meet in person to coordinate with case workers and Weld County employees to ensure a team approach is being used to provide optimal care to families under Weld County assistance. 2.3b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: Weekly or as requested by Weld County 2.3c Anticipated duration of service (i.e. 3-4 months): Ongoing, as requested by Weld County 2.3d Three (3), or more, specific goals of the service (DO use bullet points): *Discuss current cases *Discuss how to improve client outcomes *Create mutual goals with all team members 2.3e Three (3), or more, specific outcomes of service: *Improved team communication*Improved clinical outcomes for Weld clients *Improved shared goals for Weld clients. 2.3f Target population of the service: Weld County workers on behalf of their clients 2.3g Languages service is available in (please list proficiency and if interpreter services are available): Englis h, Spanish 2.3h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: BrightStar Care does not accept Medicare or Medicaid Service #4 Name: 2.4a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.4b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.4c Anticipated duration of service (i.e. 3-4 months): 2.4d Three (3), or more, specific goals of the service (DO use bullet points): 2.4e Three (3), or more, specific outcomes of service: 2.4f Target population f the service: 2.4g Languages service is available in (please list proficiency and if interpreter services are available): 2.4h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part: Service #5 Name: 2.5a Modalities, curriculum, tools used in delivery of service (DO NOT list company history; DO use bullet points): 2.5b Anticipated frequency of direct service time with the client/family per week, not including professional staffing time, administrative time, overhead, or travel time (i.e. 4 hours/week). If the service has levels, be specific for each level: 2.5c Anticipated duration of service (i.e. 3-4 months): 2.5d Three (3), or more, specific goals of the service (DO use bullet points): 2.5e Three (3), or more, specific outcomes of service: 2.5f Target population of the service: REV. NOV 2020 2 ATTACHMENT C - PROPOSAL 2.5g Languages service is available in (please list proficiency and if interpreter services are available): English, Spanish 2.5h Medicaid eligibility — list whether the service is eligible for Medicaid in whole or in part BrightStar Care does not accept Medicare or Medicaid Section 3 — Service Access and Transportation 3.1 Will you charge Weld County for transporting clients or mileage? Check one: 3.2 Will you conduct services in a client's home or in the community? Check one: 3.3 Will you transport clients to and/or from services? Check one: YES 3.4 How many miles are you willing to travel round trip? List a specific number of miles. 3.5 When you calculate mileage, what is your starting point address? YES ■ YES NO 60 ■ ■ Miles NO NO RN home address SECTION 4 - SERVICE RATES All rates need to include administrative work (i.e. scheduling or report writing) and overhead. Rates cannot be per episode, except for home studies and monitored sobriety testing. Only hourly or monthly rates will be accepted for services, except for those listed above. • For hourly rates complete section(s) 4.1-4.5. • For monthly rates complete section 4.6. • For Home study providers complete section 4.7. • For monitored sobriety testing providers complete section 4.8. 4.1 Hourly Service #1 Name: RN Skilled Assessment, Intervention and Evidence Based Practice Education 4.1a In-Office/Video: 4.1b In -Office with Transportation: In -Home or Community: 4.1c FTM, TDM, Prof. Staffing: 4.1d No show: 4.1e Mileage rate: $ Amount 105.00 105.00 105.00 105.00 70.00 0.60 U nit Type per Hour per Hour per Hour per Hour per No Show per Mile No. of miles included in rate: N o. of miles included in rate: 20 20 This is paid after the miles listed above. miles miles 4.2 Hourly Service #2 Name: Clinical Case Management 4.2a In-Office/Video: 4.2b In -Office with Transportation: 4.2c In -Home or Community: 4.2d FTM, TDM, Prof. Staffing: 4.2e No show: 4.2f Mileage rate: $ Amount 85.00 85.00 85.00 85.00 70.00 0.60 U nit Type per Hour per Hour per Hour per Hour per No Show per Mile N o. of miles included in rate: N o. of miles included in rate: 20 20 This is paid after the miles listed above. miles miles 4.3 Hourly Service #3 Name: Nurse Consultation 4.3a In-Office/Video: 4.3b In -Office with Transportation: 4.3c In -Home or Community: 4.3d FTM, TDM, Prof. Staffing: 4.3e No show: 4.3f Mileage rate: $ Amount 105.00 105.00 105.00 105.00 70.00 0.60 U nit Type per Hour per Hour per Hour per Hour per No Show per Mile N o. of miles included in rate: N o. of miles included in rate: 20 20 This is paid after the miles listed above. miles miles 1 REV. NOV 2020 3 ATTACHMENT C - PROPOSAL 4.4 Hourly Service #4 Name: $ Amount Unit Type 4.4a In-Office/Video: per Hour 4.4b In -Office with Transportation: per Hour No. of miles included in rate: miles In -Home or Community: per Hour No. of miles included in rate: miles 4.4c FTM, TDM, Prof. Staffing: per Hour 4.4d N• show: per No Show 4.4e Mileag: rate: per Mile This is paid after the miles listed above. 4.5 Hourly Service #5 Name: $ Amount Unit Type 4.5a In-Office/Video: per Hour 4.5b In -Office with Transportation: per Hour No. of miles included in rate: miles 4.5c In -Home or Community: per Hour No. of miles included in rate: miles 4.5d FTM, TDM, Prof. Staffing: per Hour 4.5e No show: per No Show 4.5f Mileage rate: per Mile This is paid after the miles listed above. 4.6 Monthly Service Rates (each level must be listed): Service Name with Level Rate per Month No. of Direct Service Hours: 4.6a 4.6b 4.6c 4.6d 4.6e 4.6f 4.6g 4.6h 4.61 4.6j 4.7 Home Study Providers — List your rates in the box below. 4.8 Monitored Sobriety Providers — List your rates in the box below. Provider special notes: REV. NOV 2020 4 ATTACHMENT D - STAFF DATA SHEET Bidder Must List All Staff Who Will Administer the Proposed Service(s) BIDDER'S LEGAL NAME (As it appears on the W-9):._ [het Miarlt,iut_c 6.)rovprIOc. _ AGENCY CONTACT: c,(p` I4c rVltic -. PHONE NUMBER: cl 7a_g f [ _%i 3 i EMAILC. ;co.,. ii,m,1'i,„S 6 1„,...,„,444...4s 4..„,- PROPOSED SERVICE(S):�-'`a. - Su_; }I l Ikus n�trcvk / ctcn.�,c0--leui w ,dcF, 01 r�exu�ni-. v�e�^ Care Cam;,^ Legal Last Name Middle Initial Previous Legal Last Name (If applicable) Legal First Name Service Type Licensure/ Credentials DORA It (If applicable) hP.ja g; `- !I; fir i-40,- I'M iKr ;i'rerl RN M 1:r evi 1e a 19 Ci 5 Q b F r Md il.n D f+nCC tc� € t _ O IqGptG°j GG,rc'rG� V C. e . l R Iv RN i 'eft(I .C_ I i 5 3 Si 6 P r u1,N,S IIA ��a,_ ft N RN t; l e Se . ,1 JD t - 3 \akk /14-e_ N/ik l r -i-n-f r2k‘, P,Kv I c.e►2 i i c 'A o 3, i e G+n t.e i o S Fcc Iti Y\ RU 19-I\ k C.E Lei 3 , rtaA N- L R r> n p 0,. aIv ikki ii Leo _ r nc)cl i 73'iS CHILD WELFARE REQUEST FOR PROPOSAL 2021-22 - VARIOUS SERVICES BID NO. 82100042 A� o® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 08/11/2020 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 West's Insurance Agency, Inc. 1225 Tri State Parkway, site 500 Gurnee II, 60031 CONTACT NAME: Amber Griffin PHONE FAX (A/C No Ext): (847) 623-0456 I (A/C,No►: (847) 623-5600 E-MAIL ADDRESS: amber®west insurance. corn INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Cincinnati Insurance Company 10677 INSURED (970) 999-0535 Salveo Medical Group, Inc dba BrightStar Care of Greeley 918 13th St, Ste 6 Greeley CO 80631 INSURERB:GUARD Insurance 11981 INSURERC: INSURERD: INSURERE: INSURER F : COVERAGES CERTIFICATE NUMBER: Cert ID 11840 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 LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MD/ MIDYYYY) POLICY EXP (MMIDD/YYYYI LIMITS A X COMMERCIAL GENERAL UABILITY Y ETN 0548319 08/15/2020 08/15/2021 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L X AGGREGATE POLICY OTHER: LIMIT APPLIES PRO- JECT PER: LOC GENERAL AGGREGATE $ 3, 000, 000 PRODUCTS-COMP/OPAGG $ 3,000,000 $ A AUTOMOBILE X LIABILJTY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY X SCHEDULED AUTOS NON -OWNED AUTOS ONLY ETA 0548319 08/15/2020 08/15/2021 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ A X UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS -MADE ETN 0548319 08/15/2020 08/15/2021 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DED X I RETENTION$ 10,000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y/N N IA SAWC112771 08/15/2020 08/15/2021 X H STATUTE ER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE -POLICY LIMIT $ 500,000 A A Professional Liability Crime/Employee Dishonesty ETN 0548319 ETD 0548319 08/15/2020 08/15/2020 08/15/2021$1,000,000 08/15/2021 occ Per claim $ 3,000,000 $ 25,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate Holder and Board of County Commissioners of Weld County and its Officers/Employees as additional insured on the General Liability policy only as required in signed, written contract CERTIFICATE HOLDER CANCELLATION Weld County 1150 O Street Greeley CO 80631 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 Page 1 of 1 ftc' !erkshire Hathaway GUARDInsurance Companies Worker's Compensation and Employer's Liability Policy NorGUARD Insurance Company - A Stock Co. Policy Number SAWC 112771 Renewal of SAWCO28363 NCCI No. [25844], Policy Information Page [1]Named Insured and Mailing Address Salveo Medical Group Inc DBA/TA BrightStar Care of Greeley 918 13th St Greeley, CO 80631-4667 Federal Employer's ID XX-XXX2097 Additional Names of Insured (N2) BrightStar Care of Greeley Agency WEST'S INSURANCE AGENCY 1225 Tri-State Pkwy. Suite 500 Gurnee, IL 60031 Agency Code: ILIROQ17 Insured is Corporation [2] Policy Period From August 15, 2020 to August 15, 2021, 12:01 AM, standard time at the insured's mailing address. (3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Colorado B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $500,000 Bodily Injury by Disease - each employee $500,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [4] Premium The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium Total Surcharges/Assessments Total Estimated Cost $ 3,596 $ 0.00 $ $3,596.00 INTERNAL USE XX MGA : SAWC112771 Date : 07/11/2020 Page - 1 - Information Page WC 000001A Issuing Office: P.O. Box A -H, 39 Public Square, Wilkes-Barre, PA 18703-0020 • www.guard.com ftc" VBerkshire Hathaway GUARDInsurance Companies Worker's Compensation and Employer's Liability Policy NorGUARD Insurance Company - A Stock Co. Policy Number SAWC 112771 Renewal of SAWCO28363 NCCI No. [25844], Policy Information Page Extension of Information Page Schedule of Forms WC000000C - STANDARD POLICY WC000001A - INFORMATION PAGE WC000115 - NOTICE OF PENDING LAW CHANGE TO TRIPRA * WC000403 - EXPERIENCE RATING MODIFICATION FACTOR * WC000404 - PENDING RATE CHANGE ENDORSEMENT * WC000414A - NOTIFICATION OF CHANGE IN OWNERSHIP ENDT * WC000419 - PREMIUM DUE DATE ENDORSEMENT WC000421D - CATASTROPHE(OTHER THAN CERT ACTS OF TERR WC000422B - TERR RISK INS PROG REAUTHORIZATION ACT WC000424 - AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT * WC000425 - EXP. RATING MODIF. FACTOR REVISION END'T * WC050402 - CO CLASSIFICATION ENDORSEMENT * WC050403 - CO PREM CREDIT FOR CERT RISK MGMT PROG * WC990000 - AUTHORIZATION AND ATTESTATION END'T * As part of our ongoing commitment to environmental responsibility throughout our operations, we have chosen not to reprint those forms (marked with an asterisk) that have not changed and were previously sent to you. You can obtain a new copy of any of these forms by accessing your account information at our Policyholder Service Center (a selection available via our website at www.guard.com). Please be aware that you will be asked to enter your policy number, policy inception date, and federal ID number in order to log on to this secure portion of our site. Alternatively, you can contact us via phone at 800-673-2465; our Customer Service Representatives will either be able to help you locate a document yourself or can send a copy to you. As always, we thank you for selecting us as your insurer. We look forward to serving you! Remember, we make a variety of loss control services available to you at no additional charge, including educational resources accessible from our Policyholder Service Center at https://policyholder.guard.com. INTERNAL USE XX MGA : SAWC112771 Date : 07/11/2020 Page - 2 - Information Page WC 000001A Issuing Office: P.O. Box A -H, 39 Public Square, Wilkes-Barre, PA 18703-0020 • www.guard.com �v" erkshire Hathaway ,' GUARD Insurance Companies [4] Premium (cont.) Worker's Compensation and Employer's Liability Policy NorGUARD Insurance Company - A Stock Co. Policy Number SAWC112771 Renewal of SAWCO28363 NCCI No. [25844], Policy Information Page Colorado Classification Code Premium Basis: Total Estimated Annual Remuneration Rate per $100 Remuneration Estimated Annual Premium Effective: 08/15/2020-08/15/2021 CLERICAL OFFICE EMPLOYEES NOC 8810 106,500.00 0.13 138 HOMEMAKER SERV-PHYSICAL ASSISTANCE 8835 150,000.00 2.43 3,645 Increased Limits Emp Liability, 500K/500K/500K 9807 0.8% 30 Amt to Bal Inc Lim 45 Certified Risk Management Program Credit - Exp/Sched Elig 0.95 -193 Certified Risk Management Program Credit - not Exp/Sched 0.9 -367 Total Estimated Annual Premium for CO 3,298 Policy Totals Total Estimated Standard Premium for Colorado 3,298 Expense Constant 225 Catastrophe 9741 0.02 256,500 51 Terrorism CO 9740 0.0084 256,500 22 Minimum Premium CO $785 Total Estimated Annual Premium 3,596 Total Estimated Cost for SAWC112771 3,596 INTERNAL USE XX MGA : SAWC112771 Date : 07/11/2020 Page - 3 - Information Page WC 000001A Issuing Office: P.O. Box A -H, 39 Public Square, Wilkes-Barre, PA 18703-0020 • www.guard.com 4"/Berkshire Hathaway Insurance f`A GUARD Companies INTERNAL USE XX MGA : SAWC112771 Date :07/11/2020 Worker's Compensation and Employer's Liability Policy NorGUARD Insurance Company - A Stock Co. Policy Number SAWC112771 Renewal of SAWCO28363 NCCI No. [25844], Policy Information Page Policy Payment Terms Payment Option: Direct Draft Under our Direct Draft Program, your account will be debited directly. Approximately 20 days prior to your payment due date, you will receive a Notice of Premium Due which states the amount and due date of the debit. Installment Plan (prepared 07/11/2020) Down Payment received - $0.00 719.20 08/14/2020 1,438.40 09/16/2020 1,438.40 10/16/2020 Since your expiring coverage was with GUARD, please be aware that any audit premium for that policy must be paid by the date shown on the Final Audit Billing Statement to keep your current coverage in force. *Includes surcharges and state fees, if any. Page - 4 - Issuing Office: P.O. Box A -H, 39 Public Square, Wilkes-Barre, PA 18703-0020 • www.guard.com WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 01 15 (Ed. 1-20) NOTIFICATION ENDORSEMENT OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2015 This endorsement is being attached to your workers compensation and employers liability insurance policy. This endorsement does not replace the separate Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 B) that is attached to your current policy and which remains in effect as applicable. The Terrorism Risk Insurance Act of 2002 (TRIA), as previously amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2015 (TRIPRA 2015), provides for a program under which the federal government will share in the payment of insured losses caused by certain acts of terrorism. In the absence of affirmative US Congressional action to extend, update, or otherwise reauthorize TRIPRA 2015, in whole or in part, TRIPRA 2015 is scheduled to expire on December 31, 2020. Since the timetable for any further Congressional action regarding TRIPRA 2015 is presently unknown, and exposure to acts of terrorism remains, we are providing policyholders with relevant information concerning their workers compensation policies in the event of the TRIPRA 2015's expiration. Your policy provides coverage for workers compensation losses caused by acts of terrorism, including workers compensation benefit obligations dictated by state law, except in Pennsylvania, where injuries or deaths resulting from certain war -related activities are excluded from workers compensation coverage. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy. The premium charge for the coverage that your policy provides for terrorism losses is shown in Item 4 of the policy Information Page or the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 B) Schedule that is attached to your policy. This amount may continue or change for new, renewal, and in -force policies in effect on or after December 31, 2020, in the event of TRIPRA 2015's expiration, subject to regulatory review in accordance with applicable state law. You need not do anything further at this time. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Insured Policy No. SAWC112771 Endorsement No. Premium: Insurance Company Countersigned by WC 00 01 15 (Ed. 1-20) ® Copyright 2018 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 21 D (Ed. 1-15) CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of a Catastrophe (other than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism). This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 B), attached to this policy. For purposes of this endorsement, the following definitions apply: • Catastrophe (other than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified Act of Terrorism, or Catastrophic Industrial Accident, which results in aggregate workers compensation losses in excess of $50 million. • Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. • Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of Treasury pursuant to the Terrorism Risk Insurance Act of 2002 (as amended) but that meets all of the following criteria: a. It is an act that is violent or dangerous to human life, property, or infrastructure; b. The act results in damage within the United States, or outside of the United States in the case of the premises of United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Act of 2002 (as amended); and c. It is an act that has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. • Catastrophic Industrial Accident: A chemical release, large explosion, or small blast that is localized in nature and affects workers in a small perimeter the size of a building. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Schedule below. State Co Schedule Rate 0.020 Premium 51.00 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Insured Policy No. SAWC112771 Endorsement No. Premium: Insurance Company Countersigned by WC 00 04 21 D (Ed. 1-15) C Copyright 2015 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 22 B (Ed. 1-15) TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT DISCLOSURE ENDORSEMENT This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2015. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers compensation losses caused by Acts of Terrorism, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act. If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2015. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, property or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers compensation) that is covered by primary or excess property and casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2015, and ending on December 31, 2020, an amount equal to 20% of our direct earned premiums, during the immediately preceding calendar year. Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of the Treasury. Policyholder Disclosure Notice 1. Insured Losses would be partially reimbursed by the United States Government. If the aggregate industry Insured Losses exceed: a. $100,000,000, with Government would b. $120,000,000, with Government would c. $140,000,000, with Government would d. $160,000,000, with Government would e. $180,000,000, with Government would f. $200,000,000, with Government would respect to such pay 85% of our respect to such pay 84% of our respect to such pay 83% of our respect to such pay 82% of our respect to such pay 81% of our respect to such pay 80% of our Insured Losses occurring in calendar year 2015, the Insured Losses that exceed our Insurer Deductible. Insured Losses occurring in calendar year 2016, the Insured Losses that exceed our Insurer Deductible. Insured Losses occurring in calendar year 2017, the Insured Losses that exceed our Insurer Deductible. Insured Losses occurring in calendar year 2018, the Insured Losses that exceed our Insurer Deductible. Insured Losses occurring in calendar year 2019, the Insured Losses that exceed our Insurer Deductible. Insured Losses occurring in calendar year 2020, the Insured Losses that exceed our Insurer Deductible. United States United States United States United States United States United States ® Copyright 2015 National Council on Compensation Insurance, Inc. All Rights Reserved. WC 00 04 22 B (Ed. 1-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY 2. Notwithstanding item 1 above, the United States Government will not make any payment under the Act for any portion of Insured Losses that exceed $100,000,000,000. 3. The premium charge for the coverage your policy provides for Insured Losses is included in the amount shown in Item 4 of the Information Page or in the Schedule below. State Co Schedule Rate 0.008 Premium $22.00 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective Policy No. SAWC112771 Insured Endorsement No. Premium Insurance Company Countersigned by WC 00 04 22 B (Ed. 1-15) @ Copyright 2015 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 24 (Ed. 1-17) AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT Part Five -Premium, Section G. (Audit) of the Workers Compensation and Employers Liability Insurance Policy is revised by adding the following: If you do not allow us to examine and audit all of your records that relate to this policy, and/or do not provide audit information as requested, we may apply an Audit Noncompliance Charge. The method for determining the Audit Noncompliance Charge by state, where applicable, is shown in the Schedule below. If you allow us to examine and audit all of your records after we have applied an Audit Noncompliance Charge, we will revise your premium in accordance with our manuals and Part 5 -Premium, E. (Final Premium) of this policy. Failure to cooperate with this policy provision may result in the cancellation of your insurance coverage, as specified under the policy. Note: For coverage under state -approved workers compensation assigned risk plans, failure to cooperate with this policy provision may affect your eligibility for coverage. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 08/15/2020 Policy No.: SAWC112771 Endorsement No.: Insured: Premium Insurance Company: NorGUARD Insurance Company WC 00 04 24 Countersigned by (Ed. 1-17) © Copyright 2016 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 24 (Ed. 1-17) WC 00 04 24 (Ed. 1-17) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY State(s) CO Schedule Basis of Audit Noncompliance Maximum Audit Noncompliance Charge Charge Multiplier Estimated Annual Premium Two Times Of $ 3,596 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective: 08/15/2020 Policy No.: SAWC112771 Endorsement No.: Insured: Premium Insurance Company: NorGUARD Insurance Company WC 00 04 24 Countersigned by (Ed. 1-17) © Copyright 2016 National Council on Compensation Insurance, Inc. All Rights Reserved. Contact Us! 0-&25-9900 x. 1475 losscontol@guard.com tim/ ecio-ttul I As an insurer, we recognize that one of the best ways to protect our policyholders is by helping to prevent losses from occurring. While all claims cannot be eliminated (accidents happen!), certain proactive loss control measures can reduce the likelihood or the frequency/severity of occurrences. In other words, safety really does matter. At Berkshire Hathaway GUARD, we offer a wide range of loss control resources and professional support at no additional charge. From online safety videos and downloadable educational flyers to risk -management help lines and policy -specific recommendations, we can help "a little" or "a lot" depending upon the need and level of interest from our policyholders and their agent. On -Line Resources Self-help tools available from our Agency and Policyholder Service Centers (accessible via www.guard.com) include: A large library of loss control videos (350 to be exact!) that can be streamed online and provide valuable advice on workplace safety, human resources issues, property management, driver safety, and more. Dozens of educational flyers and posters — most available in English and Spanish. A "Do -It -Yourself" Workers' Comp Loss Control Program Guide designed for smaller businesses and complete with easy -to -use accident investigation reports, hazard surveys, safety do's/don't's, and more. Customized Plans For larger and more complicated accounts, the scope of our loss control efforts can encompass a number of activities such as regular risk -management consultations, analysis of loss data to review past incidents and identify recurrent patterns, assistance with recommendations, and help with implementing a formal safety committee or return -to -work program. Professional Support/Help Lines Need assistance getting started? Simply contact our expert Loss Control Unit at 570-825-9900 x. 1475 or losscontrol@guard.com with questions related to Workers' Comp, Property/Liability, or Commercial Auto coverage. Specialized help lines are also available for those seeking advice about Professional Liability issues. (Visit our Agency/Policyholder Service Centers for details.) ''/Berkshire Hathaway wiGUARD Insurance talk P Com anies AmGUARD • EastGUARD • NorGUARD • WestGUARD Insurance Companies Inspections While the majority of our policyholders do not require a formal inspection of their operation or premises, certain characteristics, such as high property values or annual sales and certain cooking exposures, may warrant a telephonic or on -site loss control survey. In those cases, our Loss Control Unit will work closely with a preferred local partner and the policyholder to arrange an appointment. If we are unable to reach someone after repeated attempts, we will contact the agent for assistance. Boiler Inspections Businessowner's policyholders in need of a boiler inspection should contact Hartford Steam Boiler Inspection and Insurance Company at 1-800-333- 4677 or by e-mail at HSCINSP_HOTLINE@HSB.COM. Be sure to include policyholder name, policy number, effective date, address, contact name and phone number, agency name and phone number in the e-mail. The subject line should read: BOILER INSPECTION REQUEST. Loss Control Recommendations When reviewing the potential hazards associated with an insurance risk, our loss control recommendations are always made with the safety and protection of our policyholders in mind. Mandatory recommendations are a condition of our insurance contract and must be completed in order to maintain coverage with us. For instance, installation of a central station alarm system' or TiPS' training for employees may be required. Typically, we provide up to 60 days and accept documentation such as photos, invoices, certificates, etc., to verify compliance. When extenuating circumstances exist that may cause a delay in implementation, an extension may be considered by contacting our Loss Control Unit. Advisory recommendations are not a condition of coverage, but we strongly advise our customers to consider all suggested preventative measures to best protect their interests. While we make every effort to ensure that our recommendations are clear and necessary, questions sometimes occur. In those situations, we encourage you to contact our Loss Control Unit for further explanation or for an update on the status of compliance. Please note that copies of loss control reports cannot be provided to external parties. Frequently Asked Questions 'A central station alarm system is monitored by a commercial security company 24/7 and uses devices/circuits to automatically signal an alarm activation so that police or fire officials can be immediately notified. When a local alarm is activated, someone needs to be aware and notify the proper authorities. 'TIPS° (Training for Intervention Procedures) is a skills -based training program designed to prevent intoxication, underage drinking, and drunk driving. Additional information can be obtained by visiting www.gettips.com. -fl rn Berkshire Hathaway GUARD Insurance Companies • P. O. Box A -H, Wilkes-Barre, PA 18703-0020 • www.guard.com © WestGUARD Insurance Company. All rights reserved. July 2018. A VBerkshire Hathaway 14' G UARD Insurance 0`A Companies Berkshire Hathaway GUARD P.O. Box A -H • 39 Public Square Wilkes-Barre, PA 18703-0020 570-825-9900 (Toll -Free 800-673-2465) FAX 570-823-2059 www.guard.com Important Alert for Policy #SAWC112771 Please read this important advance notice which outlines our policy for handling Workers' Compensation premium for subcontractors*. If you have any questions or do not understand any portion of the explanation, we suggest you contact your agent immediately because the cost of your coverage may be affected at final audit time. Premium Charge for Subcontractors If you hire subcontractors who do not have their own Workers' Compensation insurance, your premium calculation will be modified to include any amounts paid for their labor. This additional premium is addressed in Part Five C 2 of your policy and compensates us for the risk that one or more of these subcontractors (or one of the subcontractor's employees) will file a claim for benefits under your coverage. Although subcontractors may appear to be independent businesses, claims filed by them (or their employees) are common after an injury. Under Workers' Compensation law, the legal definition of "employee" is much broader than the common understanding of that term. In addition, many states make you - as the contractor - automatically responsible for certain expenses due to work -related injuries to your independent subcontractors or their employees. Regardless of the state law, Berkshire Hathaway GUARD Insurance Companies must pay legal fees under Part One of your policy to defend these claims and must also pay Workers' Compensation benefits in many cases. For these reasons and in accordance with Part Five C 2 of your policy, we will charge appropriate additional premium unless the subcontractors have their own in -force Workers' Compensation coverage during your entire policy period, and you are able to provide acceptable proof of this coverage to us prior to completion of your final audit. Evidence of general liability insurance, pre -determinations or statements of independent contractor status, hold harmless agreements, etc. are not acceptable substitutes, and no exceptions will be made for sole proprietors or others on the grounds that such parties are not required to purchase (or cannot purchase) Workers' Compensation insurance. The risk of a claim against your policy from an uninsured subcontractor is the same, regardless of his or her reason for having no coverage. Furthermore, these additional charges will be imposed when applicable, even if exceptions have been granted to you by us or by another carrier in the past. Please realize that premium may be charged for subcontractors hired by uninsured entities owned or controlled by you. Premium will be charged if the Rating Bureau rules in your state require the related entity to be combined in a single policy with the company we are insuring. Ultimately, we believe this policy is in the best interests of all parties, and we hope that this advance notification will prevent any misunderstandings at a later date. As always, we thank you for selecting Berkshire Hathaway GUARD Insurance Companies, and we look forward to serving you during the upcoming policy year. *Note: A "subcontractor" is a person or organization paid to assist you in providing a product or service to your customer or client (and not just to you). Workers' Compensation laws in most states presume that such vendors are "employees" who, therefore, often file claims seeking benefits. PolAlert Ed. 3 2/12 COLORADO WORKERS' COMPENSATION DISCLOSURE FORM IMPORTANT NOTICE TO POLICYHOLDERS I. Notice of Change in Rate by Classification If you desire information whenever there is a change in your workers' compensation insurance rate by classification, you must request such information from your insurer. This request for information must be in writing. 2. Notice of Policyholder's Right to Appeal Classification Your insurer can charge and collect any additional amount of money not included in the initial premium charged as a result of job misclassification. If you have any questions regarding the employee classification assigned to calculate your workers' compensation insurance premium, you need to direct your questions to your insurer or the insurer's authorized representative within either thirty (30) days after the anniversary date of the policy or the date of receipt by you of notice of a change in job classification. Within thirty (30) days after receipt of your request for information, your insurer or the insurer's authorized representative must explain to you why a particular employee classification was used. If you disagree with your insurer or the insurer's authorized representative on the employee classification assignment, you may appeal to the Workers' Compensation Classification Appeal Board by filing written notice with said board within thirty (30) days after you have exhausted all appeal review procedures provided by the insurer. Your request should be send to the Secretary of the Colorado Workers' Compensation Classification Appeals Board, Tim Hughes, c/o National Council on Compensation Insurance, 10920 W. Glennon Drive, Lakewood, CO 80226. Written instructions for your appearance before the Colorado Workers' Compensation Classification Appeals Board will be furnished by the Secretary of the board. The board will render a decision as to whether a misclassification has occurred. A decision by the board is final and not subject to appeal unless you or the insurer provides written notice of appeal within thirty (30) days after the board's decision to the office of the Commissioner of Insurance, 1560 Broadway, Suite 850, Denver, CO 80202. The Commissioner shall review any decision of the board properly appealed. 3. Notice of Medical Case Management Services The case management services provided by your insurer include the Coordination of Care by the Designated Medical Provider selected by the insured business (and shown in the signed Acknowledgement Form). v��Berkshire Hathaway �41GUARD Insurance 4.1. Companies PRIVACY POLICY P.O. Box A -H Wilkes-Barre, PA 18703-0020 570-825-9900 800-673-2465 www.guard.com Rev. February, 2020 WHAT DO BERKSHIRE HATHAWAY GUARD INSURANCE COMPANIES DO WITH YOUR PERSONAL INFORMATION? FACTS Berkshire Hathaway GUARD Insurance Companies include: AmGUARD Insurance Company, AZGUARD Insurance Company, EastGUARD Insurance Company, NorGUARD Insurance Company, WestGUARD Insurance Company, GUARDCo, Inc., (a medical management affiliate). Why? Financial Companies choose how they share your personal information. Federal and State law gives consumers the right to limit some, but not all, sharing. Federal law also requires us to tell you how we collect, share, and protect your personal information. Please read this notice carefully to understand what we do. What? The types of personal information we collect and share depend upon the product or service you have with us. This information can include: • Social Security Number, date of birth, driving record, income • Credit history, credit -based insurance scores, insurance claim history, payment history When you are no longer our customer, we continue to share your information as described in this notice. How? All financial companies may need to share customers' personal information to run their everyday business. In the section below, we list the reasons insurance companies share their customers' personal information; the reasons we choose to share; and whether you can limit this sharing. REASONS WE CAN SHARE YOUR PERSONAL INFORMATION Does a Berkshire aw Hathaway u Can thi limit this sharing? GUARD share? For our everyday business purposes — such as to process your transactions, maintain your account(s), respond to court orders and legal investigations, comply with government agency examinations/procedures, or report your creditworthiness. Yes No For our marketing/processing purposes — to offer our products and services to you. (We may also disclose information received from you with companies that perform services for us.) Yes No For our affiliates' everyday business purposes — information about your transactions and experiences. Yes No For our affiliates' everyday business purposes — information about your creditworthiness. Yes Yes For our affiliates to market to you Yes Yes For non -affiliates to market to you Yes Yes To limit our sharing Call Customer Service at 1-800-673-2465 or visit us online at www.guard.com/privacy/. Please note: If you are a new customer, we can begin sharing your information 30 days from the date we provided this notice. When you are no longer our customer, we continue to share your information as described in this notice in accordance with applicable law. However, you can contact us at any time to limit our sharing in accordance with the table above. Questions? Call Customer Service at 1-800-673-2465. Includes Copyrighted Material of the National Association of Insurance Commissioners BHGIC-672-02-20 PAGE 2 Who we are Who is providing this notice? Berkshire Hathaway GUARD Insurance Companies (including property and casualty licensees AmGUARD Insurance Company, AZGUARD Insurance Company, NorGUARD Insurance Company, EastGUARD Insurance Company, and/or WestGUARD Insurance Company as well as GUARDCo, Inc.) is providing this notice. References in this form to "us", "we" or "our" refers to these companies. What we do How do we protect your personal information? To protect your personal information from unauthorized access and use, we implement security measures that comply with applicable law. These measures include computer safeguards and secured files and buildings. How do we collect your personal information? We collect your personal information, for example, when you: • apply for insurance • pay insurance premiums • file an insurance claim • give us your income information • give us your contact information. We also collect your personal information from others (such as credit bureaus, affiliates, or other companies) including, for example, from: • your insurance agent or producer • your transactions with our affiliates listed below or other consumer reporting agencies. Why can't I limit all sharing? Applicable law gives you the right to limit only: • sharing for affiliates everyday business purposes - information about your creditworthiness and insurability • affiliates from using your information to market to you • sharing for non -affiliates to market to you. What happens when I limit sharing for a policy I hold jointly with someone else? Your choices will apply to everyone on your policy. Definitions Affiliates Companies (other than the companies identified in "Facts" above) that are related to us by common ownership or control of Berkshire Hathaway Inc. Affiliates can be financial and nonfinancial companies. Non-affiliatesCompanies not related to us by common ownership or control, which can be financial and nonfinancial companies. Marketing The promotion or advertising of insurance products or services to you. Marketing partners may include, but are not limited to, insurance licensees such as insurance agents appointed by us or their affiliates. Other Important Information Important Information about Credit Reporting: We may report information about your account to credit bureaus. Late payments, missed payments or other defaults on your account may be reflected in your credit report. For California Residents: If you opt out, we will not share information we collect about you with nonaffiliated third parties, except as permitted by California law, such as to process your transactions or to maintain your account. Please visit www.guard.com/privacy-policy/ to review our California Privacy Policy. For Vermont Residents: We will not disclose information about your creditworthiness to our affiliates and will not disclose your personal information, financial information, credit report, or health information to nonaffiliated third parties to market to you, other than as permitted by Vermont law, unless you authorize us to make those disclosures. Includes Copyrighted Material of the National Association of Insurance Commissioners BHGIC-672-02-20 SEPARATOR PAGE wc000000c WC000001A l WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY PLEASE READ THE POLICY CAREFULLY. Quick Reference Beginning On Page Information Page General Section 1 A. The Policy 1 B. Who is Insured 1 C. Workers Compensation Law 1 D. State 1 E. Locations 1 Part One -Workers Compensation Insurance 1 A. How This Insurance Applies 1 B. We Will Pay 1 C. We Will Defend 1 D. We Will Also Pay 1 E. Other Insurance 1 F. Payments You Must Make 2 G. Recovery From Others 2 H. Statutory Provisions 2 Part Two -Employers Liability Insurance 2 A. How This Insurance Applies 2 B. We Will Pay 2 C. Exclusions 3 D. We Will Defend 3 E. We Will Also Pay 3 F. Other Insurance 4 G. Limits of Liability 4 Beginning On Page Part Two -Employers Liability Insurance 4 (Cont'd.) H. Recovery From Others 4 I. Actions Against Us 4 Part Three -Other States Insurance 4 A. How This Insurance Applies 4 B. Notice 4 Part Four -Your Duties If Injury Occurs 4 Part Five -Premium 5 A. Our Manuals 5 B. Classifications 5 C. Remuneration 5 D. Premium Payments 5 E. Final Premium 5 F. Records 5 G. Audit 5 Part Six -Conditions 6 A. Inspection 6 B. Long Term Policy 6 C. Transfer of Your Rights And Duties 6 D. Cancelation 6 E. Sole Representative 6 Important: This Quick Reference is not part of the Workers Compensation and Employers Liability Insurance Policy and does not provide coverage. Refer to the Workers Compensation and Employers Liability Insurance Policy itself for actual contractual provisions. WC 00 00 00 C © 2013 National Council on Compensation Insurance. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY In return for the payment of the premium and subject to all terms of this policy, we agree with you as follows: GENERAL SECTION A. The Policy This policy includes at its effective date the Infor- mation Page and all endorsements and schedules listed there. It is a contract of insurance between you (the employer named in Item 1 of the Infor- mation Page) and us (the insurer named on the In- formation Page). The only agreements relating to this insurance are stated in this policy. The terms of this policy may not be changed or waived except by endorsement issued by us to be part of this policy. B. Who is Insured You are insured if you are an employer named in Item 1 of the Information Page. If that employer is a partnership, and if you are one of its partners, you are insured, but only in your capacity as an em- ployer of the partnership's employees. C. Workers Compensation Law Workers Compensation Law means the workers or workmen's compensation law and occupational disease law of each state or territory named in Item 3.A. of the Information Page. It includes any amendments to that law which are in effect during the policy period. It does not include any federal workers or workmen's compensation law, any fed- eral occupational disease law or the provisions of any law that provide nonoccupational disability benefits. D. State State means any state of the United States of America, and the District of Columbia. E. Locations This policy covers all of your workplaces listed in Items 1 or 4 of the Information Page; and it covers all other workplaces in Item 3.A. states unless you have other insurance or are self -insured for such workplaces. PART ONE WORKERS COMPENSATION INSURANCE A. How This Insurance Applies This workers compensation insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. Bodily injury by accident must occur during the policy period. 2. Bodily injury by disease must be caused or ag- gravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily in- jury by disease must occur during the policy period. B. We Will Pay We will pay promptly when due the benefits required of you by the workers compensation law. C. We Will Defend We have the right and duty to defend at our expense any claim, proceeding or suit against you for benefits payable by this insurance. We have the right to in- vestigate and settle these claims, proceedings or suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. D. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding or suit we defend: 1. reasonable expenses incurred at our request, but not loss of earnings; 2. premiums for bonds to release attachments and for appeal bonds in bond amounts up to the amount payable under this insurance; 3. litigation costs taxed against you; 4. interest on a judgment as required by law until we offer the amount due under this insurance; and 5. expenses we incur. E. Other Insurance We will not pay more than our share of benefits and costs covered by this insurance and other Page 1 of 6 ® Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WC 00 00 00 C WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY (Ed. 1-15) insurance or self-insurance. Subject to any limits of liability that may apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is exhausted, the shares of all remaining insurance will be equal until the loss is paid. F. Payments You Must Make You are responsible for any payments in excess of the benefits regularly provided by the workers compensation law including those required because: 1. of your serious and willful misconduct; 2. you knowingly employ an employee in violation of law; 3. you fail to comply with a health or safety law or regulation; or 4. you discharge, coerce or otherwise discriminate against any employee in violation of the workers compensation law. If we make any payments in excess of the benefits regularly provided by the workers compensation law on your behalf, you will reimburse us promptly. G. Recovery From Others We have your rights, and the rights of persons enti- tled to the benefits of this insurance, to recover our payments from anyone liable for the injury. You will do everything necessary to protect those rights for us and to help us enforce them. H. Statutory Provisions These statements apply where they are required by law. 1. As between an injured worker and us, we have notice of the injury when you have notice. 2. Your default or the bankruptcy or insolvency of you or your estate will not relieve us of our du- ties under this insurance after an injury occurs. 3. We are directly and primarily liable to any per- son entitled to the benefits payable by this in- surance. Those persons may enforce our duties; so may an agency authorized by law. Enforce- ment may be against us or against you and us. 4. Jurisdiction over you is jurisdiction over us for purposes of the workers compensation law. We are bound by decisions against you under that law, subject to the provisions of this policy that are not in conflict with that law. 5. This insurance conforms to the parts of the workers compensation law that apply to: a. benefits payable by this insurance; b. special taxes, payments into security or oth- er special funds, and assessments payable by us under that law. 6. Terms of this insurance that conflict with the workers compensation law are changed by this statement to conform to that law. Nothing in these paragraphs relieves you of your du- ties under this policy. PART TWO EMPLOYERS LIABILITY INSURANCE A. How This Insurance Applies This employers liability insurance applies to bodily injury by accident or bodily injury by disease. Bodily injury includes resulting death. 1. The bodily injury must arise out of and in the course of the injured employee's employment by you. 2. The employment must be necessary or inci- dental to your work in a state or territory listed in Item 3.A. of the Information Page. 3. Bodily injury by accident must occur during the policy period. 4. Bodily injury by disease must be caused or ag- gravated by the conditions of your employment. The employee's last day of last exposure to the conditions causing or aggravating such bodily in- jury by disease must occur during the policy period. 5. If you are sued, the original suit and any related legal actions for damages for bodily injury by ac- cident or by disease must be brought in the United States of America, its territories or pos- sessions, or Canada. B. We Will Pay We will pay all sums that you legally must pay as damages because of bodily injury to your employ- ees, provided the bodily injury is covered by this Employers Liability Insurance. The damages we will pay, where recovery is permit- ted by law, include damages: 1. For which you are liable to a third party by rea- son of a claim or suit against you by that third party to recover the damages claimed against Page 2 of 6 43 Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) such third party as a result of injury to your employee; 2. For care and loss of services; and 3. For consequential bodily injury to a spouse, child, parent, brother or sister of the injured em- ployee; provided that these damages are the di- rect consequence of bodily injury that arises out of and in the course of the injured employee's employment by you; and 4. Because of bodily injury to your employee that arises out of and in the course of employment, claimed against you in a capacity other than as employer. C. Exclusions This insurance does not cover: 1. Liability assumed under a contract. This exclu- sion does not apply to a warranty that your work will be done in a workmanlike manner; 2. Punitive or exemplary damages because of bodi- ly injury to an employee employed in violation of law; 3. Bodily injury to an employee while employed in violation of law with your actual knowledge or the actual knowledge of any of your executive officers; 4. Any obligation imposed by a workers compensa- tion, occupational disease, unemployment com- pensation, or disability benefits law, or any simi- lar law; 5. Bodily injury intentionally caused or aggravated by you; 6. Bodily injury occurring outside the United States of America, its territories or possessions, and Canada. This exclusion does not apply to bodily injury to a citizen or resident of the United States of America or Canada who is temporarily outside these countries; 7. Damages arising out of coercion, criticism, de- motion, evaluation, reassignment, discipline, defamation, harassment, humiliation, discrimina- tion against or termination of any employee, or any personnel practices, policies, acts or omissions; 8. Bodily injury to any person in work subject to the Longshore and Harbor Workers' Compensation Act (33 U.S.C. Sections 901 et seq.), the Nonap- propriated Fund Instrumentalities Act (5 U.S.C. Sections 8171 et seq.), the Outer Continental Shelf Lands Act (43 U.S.C. Sections 1331 et seq.), the Defense Base Act (42 U.S.C. Sections 1651-1654), the Federal Mine Safety and Health Act (30 U.S.C. Sections 801 et seq. and 901- 944), any other federal workers or workmen's compensation law or other federal occupational disease law, or any amendments to these laws; 9. Bodily injury to any person in work subject to the Federal Employers' Liability Act (45 U.S.C. Sec- tions 51 et seq.), any other federal laws obligat- ing an employer to pay damages to an employ- ee due to bodily injury arising out of or in the course of employment, or any amendments to those laws; 10. Bodily injury to a master or member of the crew of any vessel, and does not cover punitive damages related to your duty or obligation to provide transportation, wages, maintenance, and cure under any applicable maritime law; 11. Fines or penalties imposed for violation of fed- eral or state law; and 12. Damages payable under the Migrant and Sea- sonal Agricultural Worker Protection Act (29 U.S.C. Sections 1801 et seq.) and under any other federal law awarding damages for viola- tion of those laws or regulations issued there- under, and any amendments to those laws. D. We Will Defend We have the right and duty to defend, at our ex- pense, any claim, proceeding or suit against you for damages payable by this insurance. We have the right to investigate and settle these claims, proceed- ings and suits. We have no duty to defend a claim, proceeding or suit that is not covered by this insurance. We have no duty to defend or continue defending after we have paid our applicable limit of liability under this insurance. E. We Will Also Pay We will also pay these costs, in addition to other amounts payable under this insurance, as part of any claim, proceeding, or suit we defend: 1. Reasonable expenses incurred at our request, but not loss of earnings; 2. Premiums for bonds to release attachments and for appeal bonds in bond amounts up to the limit of our liability under this insurance; 3. Litigation costs taxed against you; 4. Interest on a judgment as required by law until we offer the amount due under this insurance; and 5. Expenses we incur. Page 3 of 6 © Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WC 00 00 00 C (Ed. 1-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY F. Other Insurance We will not pay more than our share of damages and costs covered by this insurance and other in- surance or self-insurance. Subject to any limits of li- ability that apply, all shares will be equal until the loss is paid. If any insurance or self-insurance is ex- hausted, the shares of all remaining insurance and self-insurance will be equal until the loss is paid. G. Limits of Liability Our liability to pay for damages is limited. Our limits of liability are shown in Item 3.B. of the Information Page. They apply as explained below. 1. Bodily Injury by Accident. The limit shown for "bodily injury by accident —each accident" is the most we will pay for all damages covered by this insurance because of bodily injury to one or more employees in any one accident. A disease is not bodily injury by accident unless it results directly from bodily injury by accident. 2. Bodily Injury by Disease. The limit shown for "bodily injury by disease —policy limit" is the most we will pay for all damages covered by this insurance and arising out of bodily injury by dis- ease, regardless of the number of employees who sustain bodily injury by disease. The limit shown for "bodily injury by disease —each em- ployee" is the most we will pay for all damages because of bodily injury by disease to any one employee. Bodily injury by disease does not include dis- ease that results directly from a bodily injury by accident. 3. We will not pay any claims for damages after we have paid the applicable limit of our liability un- der this insurance. H. Recovery From Others We have your rights to recover our payment from anyone liable for an injury covered by this insurance. You will do everything necessary to protect those rights for us and to help us enforce them. I. Actions Against Us There will be no right of action against us under this insurance unless: 1. You have complied with all the terms of this poli- cy; and 2. The amount you owe has been determined with our consent or by actual trial and final judgment. This insurance does not give anyone the right to add us as a defendant in an action against you to deter- mine your liability. The bankruptcy or insolvency of you or your estate will not relieve us of our obliga- tions under this Part. PART THREE OTHER STATES INSURANCE A. How This Insurance Applies 1. This other states insurance applies only if one or more states are shown in Item 3.C. of the Infor- mation Page. 2. If you begin work in any one of those states after the effective date of this policy and are not in- sured or are not self -insured for such work, all provisions of the policy will apply as though that state were listed in Item 3.A. of the Information Page. 3. We will reimburse you for the benefits required by the workers compensation law of that state if we are not permitted to pay the benefits directly to persons entitled to them. 4. If you have work on the effective date of this pol- icy in any state not listed in Item 3.A. of the In- formation Page, coverage will not be afforded for that state unless we are notified within thirty days. B. Notice Tell us at once if you begin work in any state listed in Item 3.C. of the Information Page. PART FOUR YOUR DUTIES IF INJURY OCCURS Tell us at once if injury occurs that may be covered by this policy. Your other duties are listed here. 1. Provide for immediate medical and other ser- vices required by the workers compensation law. 2. Give us or our agent the names and addresses of the injured persons and of witnesses, and other information we may need. 3. Promptly give us all notices, demands and legal Page 4 of 6 ® Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 00 00 C (Ed. 1-15) papers related to the injury, claim, proceeding or suit. 4. Cooperate with us and assist us, as we may re- quest, in the investigation, settlement or defense of any claim, proceeding or suit. 5. Do nothing after an injury occurs that would in- terfere with our right to recover from others. 6. Do not voluntarily make payments, assume obli- gations or incur expenses, except at your own cost. PART FIVE —PREMIUM A. Our Manuals All premium for this policy will be determined by our manuals of rules, rates, rating plans and classifica- tions. We may change our manuals and apply the changes to this policy if authorized by law or a gov- ernmental agency regulating this insurance. B. Classifications Item 4 of the Information Page shows the rate and premium basis for certain business or work classifi- cations. These classifications were assigned based on an estimate of the exposures you would have during the policy period. If your actual exposures are not properly described by those classifications, we will assign proper classifications, rates and premium basis by endorsement to this policy. C. Remuneration Premium for each work classification is determined by multiplying a rate times a premium basis. Remu- neration is the most common premium basis. This premium basis includes payroll and all other remu- neration paid or payable during the policy period for the services of: 1. all your officers and employees engaged in work covered by this policy; and 2. all other persons engaged in work that could make us liable under Part One (Workers Com- pensation Insurance) of this policy. If you do not have payroll records for these persons, the con- tract price for their services and materials may be used as the premium basis. This paragraph 2 will not apply if you give us proof that the em- ployers of these persons lawfully secured their workers compensation obligations. D. Premium Payments You will pay all premium when due. You will pay the premium even if part or all of a workers compensa- tion law is not valid. E. Final Premium The premium shown on the Information Page, schedules, and endorsements is an estimate. The final premium will be determined after this policy ends by using the actual, not the estimated, premi- um basis and the proper classifications and rates that lawfully apply to the business and work covered by this policy. If the final premium is more than the premium you paid to us, you must pay us the bal- ance. If it is less, we will refund the balance to you. The final premium will not be less than the highest minimum premium for the classifications covered by this policy. If this policy is canceled, final premium will be de- termined in the following way unless our manuals provide otherwise: 1. If we cancel, final premium will be calculated pro rata based on the time this policy was in force. Final premium will not be less than the pro rata share of the minimum premium. 2. If you cancel, final premium will be more than pro rata; it will be based on the time this policy was in force, and increased by our short -rate cancelation table and procedure. Final premium will not be less than the minimum premium. F. Records You will keep records of information needed to com- pute premium. You will provide us with copies of those records when we ask for them. G. Audit You will let us examine and audit all your records that relate to this policy. These records include ledg- ers, journals, registers, vouchers, contracts, tax re- ports, payroll and disbursement records, and pro- grams for storing and retrieving data. We may con- duct the audits during regular business hours during the policy period and within three years after the pol- icy period ends. Information developed by audit will be used to determine final premium. Insurance rate service organizations have the same rights we have under this provision. Page 5 of 6 ® Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. WC 00 00 00 C (Ed. 1-15) WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY PART SIX -CONDITIONS A. Inspection We have the right, but are not obliged to inspect your workplaces at any time. Our inspections are not safety inspections. They relate only to the insurabil- ity of the workplaces and the premiums to be charged. We may give you reports on the conditions we find. We may also recommend changes. While they may help reduce losses, we do not undertake to perform the duty of any person to provide for the health or safety of your employees or the public. We do not warrant that your workplaces are safe or healthful or that they comply with laws, regulations, codes or standards. Insurance rate service organiza- tions have the same rights we have under this provision. B. Long Term Policy If the policy period is longer than one year and six- teen days, all provisions of this policy will apply as though a new policy were issued on each annual anniversary that this policy is in force. C. Transfer of Your Rights and Duties Your rights or duties under this policy may not be transferred without our written consent. If you die and we receive notice within thirty days af- ter your death, we will cover your legal representa- tive as insured. D. Cancelation 1 You may cancel this policy. You must mail or de- liver advance written notice to us stating when the cancelation is to take effect. 2. We may cancel this policy. We must mail or de- liver to you not less than ten days advance writ- ten notice stating when the cancelation is to take effect. Mailing that notice to you at your mailing address shown in Item 1 of the Information Page will be sufficient to prove notice. 3. The policy period will end on the day and hour stated in the cancelation notice. 4. Any of these provisions that conflict with a law that controls the cancelation of the insurance in this policy is changed by this statement to com- ply with the law. E. Sole Representative The insured first named in Item 1 of the Information Page will act on behalf of all insureds to change this policy, receive return premium, and give or receive notice of cancelation. Page 6 of 6 ® Copyright 2013 National Council on Compensation Insurance, Inc. All Rights Reserved. EXHIBIT C SCOPE OF SERVICES Contractor will provide Home Based Intervention as referred by the Department. 1. Registered Nurse (RN) Skilled Assessment, Intervention and Evidence Based Practice Education a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Focused or general physical assessment. ii. Equipment used may include: Stethoscope, sphygmomanometer, pulse oximeter, and thermometer. iii. Interventions will be based off of client need and may include anything within RN scope of practice. iv. Education will be provided to families and individuals for their specific needs. v. Elsevier program will be used for Evidence Based Education and teaching materials. b. Anticipated Frequency of Services: i. Will vary based on the needs of the Department. c. Anticipated Duration of Services: i. Will vary based on the needs of the Department. d. Goals of Services: i. Identify problems or potential problems. ii. Monitor clinical progression. iii. Track trends. iv. Promote independence of family. e. Outcomes of Services: i. Address known or unknown physical issues. ii. Increase well-being by timely intervention. iii. Prevent physical decline. f. Target Population: i. Children and families who received Department services. ii. Children ages zero (0) to eighteen (18). iii. Male, female, or other identifying gender. g. Language: i. English and Spanish. h. Medicaid Eligibility: i. Service is not eligible for Medicaid. i. Service Access and Transportation: i. Contractor will conduct services in the client's home. Contractor is also able to transport clients. Mileage will be calculated based on Registered Nurse's (RN) home address. Provider is willing to travel sixty (60) miles round trip. 2. Clinical Case Management a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: 1 i. Registered Nurse (RN) Case Manager will make necessary phone calls, file reports, coordinate with care team, file reports and complete documentation as required. b. Anticipated Frequency of Services: i. Will vary based on the needs of the Department. c. Anticipated Duration of Services: i. Will vary based on the needs of the Department. d. Goals of Services: i. Communicate with health care providers associated in each case. ii. Communicate with Case workers and involved personnel. iii. Maintain documentation that meets county, state and federal requirements. e. Outcomes of Services: i. Fulfilled provider orders. ii. Clear and concise communication provided to interdisciplinary team. iii. Care coordination will be provided. f. Target Population: i. Children and families who received Department services. ii. Children ages zero (0) to eighteen (18). iii. Male, female, or other identifying gender. g. Language: i. English and Spanish. h. Medicaid Eligibility: i. Service is not eligible for Medicaid. i. Service Access and Transportation: i. Contractor will conduct services in the client's home. Contractor is also able to transport clients. Mileage will be calculated based on Registered Nurse's (RN) home address. Provider is willing to travel sixty (60) miles round trip. 3. Nursing Consultation a. Contractor will utilize the following modalities, curriculum, and tools in the delivery of services under this agreement: i. Meeting will take place in person to coordinate with Contractor's case workers and Department's employees to ensure a team approach to provide optimal care to families under the Department's assistance. b. Anticipated Frequency of Services: i. Weekly or as requested by the Department. c. Anticipated Duration of Services: i. Ongoing as requested by the Department. d. Goals of Services: i. Discuss current cases. ii. Discuss how to improve client outcomes. iii. Create mutual goals with all team members. e. Outcomes of Services: i. Improved team communication. 2 ii. Improved clinical outcomes for the Department's clients. iii. Improved shared goals for the Department's clients. f. Target Population: i. Department's employees. g. Language: i. English and Spanish. h. Medicaid Eligibility: i. Service is not eligible for Medicaid. i. Service Access and Transportation: i. Contractor will conduct services at the Department. Mileage will be calculated based on Registered Nurse's (RN) home address. Provider is willing to travel sixty (60) miles round trip. Terms 1. Contractor will respond to the Quality Assurance Team (HS-CWQualitvAssurance(aweldeov.com within three (3) business days regarding the ability to accept the received referral. 2. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral period, the Contractor will notify the caseworker and the Quality Assurance Team 1!S - C W QualitvAss u rance(aweldeov.com. 3. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understands that the Department will not reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows", or up to two (2) hours, on the part of case participants who cancel without 24 hour notice. After three (3) "no-shows", Contractor will place client on a behavioral plan requiring attendance or discharged client from services. Contractor must inform the caseworker and the Quality Assurance Team HS-CWQualityAssurance(a weldeov.com. 4. Contractor understands that the Department will not reimburse Contractor for cancelled appointments either on the part of the client or the Contractor. If the cancellation is generated from the Contractor, a "makeup" session/episode, to occur within 30 days of the cancellation, will be offered to the client (excluding session/episodes that fall on holidays). If the cancellation is generated from the client, the Contractor must request a makeup session from the Department prior to the makeup session occurring (excluding session/episodes that fall on holidays). After three (3) cancellations, Contractor will inform the caseworker and the Quality Assurance Team HS-CWQualitvAssurance(a,weldeov.com immediately via email, to discuss service continuation. 5. Contractor will identify in detail areas of continued concern and make recommendations to the Department regarding continuation of services and/or the need for additional services. 6. Contractor will document in detail any and all observed or verbalized concerns regarding any child whom the Contractor is working with under an active referral. Areas of concern may include, but are not limited to, any physical, emotional, educational or behavioral issues. Areas of concern should be reported immediately AND on the required monthly report. 3 7. Contractor will submit reports on a monthly basis for each active referral for ongoing services. Reports will be submitted per the online format required by the Department, unless otherwise directed by the Department. 8. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Core Service Coordinator or any member of the Quality Assurance Team. Any changes to visitation referrals will be approved by the caseworker, their supervisor, or the Family Support and Visitation Center. A change is defined as anything outside of the approved documented service on the initial authorized referral form. This may include an increase or decrease in services hours, change in frequency, change in location of services, transportation needs, or any change to the initial referral or subsequent authorizations. 9. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Bid Meetings, Professional Staffings, Family Team Meetings and/or Team Decision Making meetings. The Department will reimburse for actual participation in the meeting only so long as there is written authorization from the Quality Assurance Team, and the Contractor obtains the Facilitator's signature on the Client Verification Form (if in person) at the time of the meeting and participation in the meeting is deemed appropriate and necessary by the Department. The Facilitator will be responsible for filling out the time attended on the Client Verification Form. Staffings and/or meetings other than those listed above are not considered reimbursable unless otherwise approved by the Child Welfare Contract and Services Coordinator. Contractor may participate by phone, if approved by the Department. 10. Contractor will notify the Quality Assurance Team HS-CWQualityAssurance(a weldgov.com of new staff who will manage and/or administer the services with the following information: a. Staff member name and contact information b. Education level/degree (if applicable) c. Licensure/credentials (if applicable) d. Department of Regulatory Authority (DORA) number (if applicable) e. Supervisor name and contact information The Department reserves the right to decline the new staff members managing and/or administering services to Department clients. 4 EXHIBIT D RATE SCHEDULE 1. Funding and Method of Payment The Department agrees to reimburse the Contractor in consideration of the work and services performed under this Agreement at the rate specific in Paragraph 2, below. The total amount to be paid to the Contractor during the term of this Agreement shall be reported by the Department after May 31, 2022. Expenses incurred by the Contractor prior to the term of this Agreement are not eligible Department expenditures and shall not be reimbursed by the Department. Payment pursuant to this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availability of said funds for the purposes hereof. In the event that said funds, or any part thereof, become unavailable as determined by the Department, the Department may immediately terminate the Agreement or amend it accordingly. 2. Fees for Services Nurturing Program Rate Unit Type Service Name $85.00 Hour Clinical Case Management $105.00 Hour Family Team Meeting (FTM), Team Decision Making (TDM) Meeting, Professionals Staffing - Assessment or Nurse Consultation $85.00 Hour FTM, TDM, Prof. Staffing - Clinical Case Management $0.60 Mile Mileage, outside 20 miles from Registered Nurse's (RN) home address $70.00 Each No Show $105.00 Hour Nurse Consultation $105.00 Hour Registered Nurse (RN) Skilled Assessment, Intervention and Evidence Based Practice Education 3. Submittal of Vouchers Contractor shall prepare and submit monthly a Request for Reimbursement, Client Verification Form, other supporting documentation, and monthly report if applicable, certifying that services authorized were provided on the date(s) indicated and the charges were made pursuant to the terms and conditions of Paragraph 3 and Exhibit A. Contractor shall submit all Requests for Reimbursement and supporting documentation to the Department by the 7th day of the month following the month of service, but no later than 60 days from the date of service. Requests for Reimbursement and/or supporting documentation received after 60 days from the date of service may result in delay or forfeiture of payment. Consistent failure to meet the 60 -day deadline may result in termination of the Agreement. For ongoing services, proof of services rendered shall be a Client Verification Form signed by the client and a monthly report submitted in accordance with Paragraph 3(d) of this Agreement. For one-time services, proof of services rendered shall be receipt of a Client Verification Form and the completed product. For Monitored Sobriety services, proof of services rendered shall be the test result. Contract Form Entity Information New Contract Request Entity Name* Entity ID* BRIGHTSTAR CARE OF GREELEY L.00042549 ❑ New Entity? Contract Name* Contract ID BRIGHTSTAR CARE OF GREELEY (NEW CHILD PROTECTION 4836 AGREEMENT) Contract Status CTB REVIEW Contract Desorption* BID# B2100042. TERM: 6/1/21-5131/22. Contract Description 2 MEMO WAS PRESENTED TO Contract Type* AGREEMENT Amount* $0.00 Renewable* YES Automatic Renewal Contract Lead* APEGG Contract Lead Email apegg@weldgov.com; cobbx xlkC'weldgov.com THE BOCC BY PURCHASING ON 4/7,`2021 TYLER ID: 2021-0307. Department HUMAN SERVICES Department Email CM - H umanServices 'weldgov.co m Department Head Email CM-HumanServices- DeptHeadgweldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COU NTYATTORN EYWELDG OV.COM If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Requested BOCC Agenda Date* 06,+16,2021 Parent Contract ID 20210307 Requires Board Approval YES Department Project # Due Date 06,,12 2021 Will a work session with BOCC be required?' NO Does Contract require Purchasing Dept. to be included? Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in On Base Contract Dates Effective Date Termination Notice Period Contact Information Contact Info Contact Name Purchasing Purchasing Approver CONSENT Approval Process Department Head JAMIE ULRICH DH Approved Date 06111/2021 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 06,`16/2021 Originator APEGG Contact Type Review Date* 04 01 2022 Committed Delivery Date Contact Email Finance Approver CONSENT Renewal Date* 05. 31x'2022 Expiration Date Contact Phone 1 Purchasing Approved Date 06111,2021 Finance Approved Date 06/11 ;2021 Tyler Ref It AG 061621 Legal Counsel CONSENT Contact Phone 2 Legal Counsel Approved Date 06/11/2021 Hello