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Home My WebLink About20193343.tiffPRIVILEGED AND CONFIDENTIAL MEMORANDUM ntrac+ #c-Aco- 1 DATE: April 20, 2021 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Agreement Amendment with Aspen Summit and Wellness Counseling Services, LLC Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval of the Department's Agreement Amendment with Aspen Summit and Wellness Counseling Services, LLC. The Department entered into a Child Protection Agreement for Services with Aspen Summit and Wellness Counseling Services, LLC, identified as Tyler ID 2019-3343 on July 24, 2019. The Agreement was amended on April 27, 2020 to extend the term date through May 31, 2021 and to amend the Scope of Services and Rate Schedule. The Agreement is now being amended to renew for a third and final year, for the period of June 1, 2021 through May 31, 2022, and to make changes to the Scope of Services and Rate Schedule as noted below. The Human Services Advisory Commission (HSAC) has reviewed and approved this information. Scope of Services Changes: Service Access was updated for each service to include the following information: • In Office: 1120 38`'' Avenue, Suite 3, Greeley, CO 80634 • Video-conferencing, )late Schedule Changes: $70.00/Hour (Individual Mental Health Session, In -office or Telehcalth) $55.00/110 Pass -Around Memorandum; April 20, 2021— ID 4677 r>?en-+ o�(@ColaI ce Page 1 00 - 33`13 H 80090 PRIVILEGED AND CONFIDENTIAI. I do not recommend a Work Session. I recommend approval of this Agreement Amendment. Approve Schedule Recommendation Work Session Perry L. Buck Mike Freeman Scott K. James, Pro-Tem Steve Moreno, Chair Lori Saine Lit Pass -Around Memorandum; April 20, 2021 — ID 4677 Other/Comments: Page 2 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND ASPEN SUMMIT WELLNESS AND COUNSELING SERVICES, LLC This Agreement Amendment, made and entered into OCO d y of r i ( 2021 by and between the Board of Weld County Commissioners, on behalf of the Weld County Department of Human Services, hereinafter referred to as the "Department", and Aspen Summit Wellness and Counseling Services, LLC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Mental Health Services, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2019-3343, approved on July 24, 2019. WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the Original Agreement and any previously adopted amendment, which is incorporated by reference herein, as well as the terms provided herein. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: • The Original Agreement was set to end on May 31, 2020. • The Original Agreement was amended on: April 27, 2020 to extend the term date through May 31, 2021 and to amend the Scope of Services and Rate Schedule. The Amendments are identified by the Weld County Clerk to the Board of County Commissioners as document number 2019-3343. • These Amendments, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement: 1. Term This agreement is being renewed for a third and final year, for the period of June 1, 2021 through May 31, 2022. 2. Exhibit C, Scope of Services, is hereby amended as attached. 3. Exhibit D, Rate Schedule, is hereby amended as attached. • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST. Weld o7y By: BOARD OF COUNTY COMMISSIONERS lerk to the Board WELD COUNTY, COLORADO Steve Moreno, Chair APR 2 6 2021 TOR: Aspen Summit Wellness and Counseling Services, LLC 1120 38th Avenue, Suite 3 Greeley, Colorado 80636 By: Date: oan,e )49"oz: 1o.z Mo.1 Daniel Lechleiter, Owner Apr 9, 2021 ogo /9-- 6,5 V3 EXHIBIT C SCOPE OF SERVICES 1. Contractor will provide Mental Health Services, as referred by the Department. 2. Services available under this agreement include: a. Mental Health Evaluations i. Capacity for Services: Up to six (6) hours per week, or three (3) reports per week. lit. Goals of Service: To identify and provide a written report of the referred client's mental health status, needs, and treatment recommendations. HI Outcomes of Service: A written report regarding the referred client's mental health status, as well as treatment recommendations utilized data gathered, including: 1. Brief summary of: a. Mental health history b. Social history c. Substance use history 2. DSM-5 Mental Health Diagnosis 3. Mental health treatment recommendations 4. SASSI-4 Interpretation and recommendations for referral and further assessment if warranted iv. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Adolescents (Age 12-17) 2. Young Adults (Age 18-25) 3. Adults (26-65) 4. Elderly (65+) v. Service Access: 1120 38th Avenue, Suite 3, Greeley, CO 80634 vi. Language: English only. b. Mental Health Assessment i. Capacity for Services: Up to six (6) hours per week, or two (2) reports per week. ii. Goals of Service: To identify and provide an in-depth written report of the referred client's mental health status, needs, and treatment recommendations. iii. Outcomes of Service: A written report regarding the referred client's mental health status, as well as treatment recommendations utilized data gathered, including: 1. In-depth summary of: a. Mental health history b. Social history c. Family history d. Relationship history e. Educational history f. Criminal history (if any) 2. Substance use history a. SASSI-4 interpretation and recommendations for referral and further assessment if warranted 3. DSM-5 Mental Health Diagnosis 4. Psychological assessment interpretation and summary 5. Mental health treatment recommendations iv. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Adolescents (Age 12-17) 2. Young Adults (Age 18-25) 3. Adults (26-65) 4. Elderly (65+) v. Service Access: 1120 38`h Avenue, Suite 3, Greeley, CO 80634 vi. Language: English only. c. Seeking Safety Group: 18 -week course designed to assist individuals who have co-occurring disorders of Post -Traumatic Stress Disorder (PTSD) and substance use. i Capacity for Services: Two (2) 90 -minute groups per week (one for males and one for females) ii- Goals of Service: To assist individuals with a history of substance use and trauma recovery through the use of health coping skills to reduce harmful behaviors such as substance use or self -injurious behaviors. iii. Outcomes of Service: 1. Certificate of Completion 2. A client -driven, written self -care plan 3. Reduction in harmful behaviors related to substance use and traumatic histories 4. Development and demonstration of application of healthier coping skills iv. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Adolescents (Age 12-17) 2. Young Adults (Age 18-25) 3. Adults (26-65) 4. Elderly (65+) Groups will be gender specific; male and female. Contractor will form a third group for LGBTQ clients if referred more than three (3) LGTBQ clients. v. Service Access: 1120 38`h Avenue, Suite 3, Greeley, CO 80634 vi. Language: English only. d. Individual Mental Health Sessions i. Capacity for Services: Up to 10 hours per week. ii. Goals of Service: To assist individuals process and work through identified problems as a result of a mental health evaluation or assessment, and/or part of a recommendation of a similar report. iii. Outcomes of Service: To assist individuals in developing healthy coping skills, self - compassion, assertive communication skills, and reduce mental health symptoms such as anxiety and depression. iv. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Adolescents (Age 12-17) 2. Young Adults (Age 18-25) 3. Adults (26-65) 4. Elderly (65+) v. Service Access: 1. In Office: 1120 38th Avenue, Suite 3, Greeley, CO 80634 2. Video-conferencing vi. Language: English only. e. Domestic Violence Impact Course: A course taught using the manual, "Proprietary Manualized Treatment", written by Daniel Lechleiter. The manual is standardized to cover the primary areas of domestic violence. i. Anticipated Frequency of Service per Week: Up to 12 hours. ii. Anticipated Duration of Service: 6 weeks. Goals of Service: 1. Educate the individual about the impact of domestic violence. 2. Increase the individual's knowledge on ways they can recognize domestic violence and red flags. 3. Improve the individual's understanding of the different types of domestic violence. 4. Explore the individual's personal history of domestic violence and the overall impact it has on them and others. iv. Outcomes of Service: 1. Domestic Violence Cycle: Individuals will learn about the cycle of violence and identifying the various stages. 2. Types of Domestic Violence: Education on the various types of inter -partner domestic violence including financial abuse, physical abuse, emotional abuse, child abuse, and psychological abuse. 3. Time -Outs: A tool to assist the individual in recognizing when to "walk away" from a situation, and how to return to the situation once the individual has calmed down. 4. Domestic Violence Impact on Self, Children, and Others: Individuals will learn how all their behaviors affect others. 5. Personal Domestic Violence History and Exploration (Including a Genogram): Assists the individual in identifying patterns of abuse in their family in order to allow them to have a better understanding of how they may have learned their behaviors. Also encourages individuals to accept responsibility for their behaviors and assist in the reduction of minimizing their behaviors. v. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Parental Units — 18 years and older 2. Individuals accused of domestic violence but have not been charged. 3. Victims of domestic violence. vi. Service Access: 1. In Office: 1120 38th Avenue, Suite 3, Greeley, CO 80634 2. Video-conferencing Language: English only. f. Cogniive Behavioral Therapy Individual Course: Curriculum includes Cognitive Behavioral Therapy, Psychotherapy, and Psychoeducation. i Anticipated Frequency of Service per Week: One (1) hour per week. ii. Anticipated Duration of Service: Twelve (12) weeks. iii. Goals of Service: 1. Learn and/or increase knowledge of: Basics of Cognitive Behavioral Therapy (CBT), application of CBT, common cognitive disorders, and application of CBT to everyday cognitive distortions. 2. Utilize CBT to approach issues with a rational thought pattern. iv. Outcomes of Service: 1. Improve overall behavioral interactions. 2. Improve self -care through stress management tools. 3. Decrease significant mental health symptoms related to: Anger, depression, and anxiety. v. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Adolescents (12-17) 2. Adults (18-60) vi. Service Access: 1. In Office: 1120 38th Avenue, Suite 3, Greeley, CO 80634 2. Video-conferencing vii. Language: English only. 3. Contractor w_ll respond to the Quality Assurance Team Supervisor (hainlejd@weldgov.com, 970-400- 6210) within three (3) business days regarding the ability to accept the received referral. 4. 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 Supervisor (hainlejd@wekigov.com, 970-400-6210). 5. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for visitation services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understand that the Department will no reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows" on the part of the client per month. 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 Supervisor (hainlejd( ,weldgov.com, 970-400-6210). 6. 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 teat 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 Supervisor (hainlejd(&,,weldgov.com) immediately via email, to discuss service oontinuation. 7. Contractor will identify in detail areas of continued concern and make recommendations to the Department regarding continnation of services and/or the need for additional services. 8. 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. 9. Contractor will smbmit 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. 10. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. 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. 11. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Court Staffings, Family Team Meetings and/or Team Decision Making meetings. Contractor may participate by phone, if approved by the Department. 12. Contractor will notify the Quality Assurance Team Supervisor (hainlejd@weldgov.com, 970-400-6210) 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. Supersasor name and contact information The Department reserves the right to decline the new staff members managing and/or administering services to Department clients. 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 pursuantto this Agreement, whether in whole or in part, is subject to and contingent upon the continuing availarility 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 Mental Health Services Rate Unit Type Service Name $70.00 Hour Individual Mental Health Session, In -office or Telehealth $80.00 Hour Individual Mental Health Session, Intake $600.00 Episode Mental Health Assessment $175.00 Episode Mental Health Evaluation $80.00 Hour Cognitive Behavioral Therapy Individual Course $40.00 Hour No Show — Mental Health Services $30.00 Episode Seeking Safety Group $80.00 Episode Seeking Safety Group, Intake $70.00 Hour FTM, TDM, Prof. Staffing Domestic Viioience Intervention Rate Unit Type Service Name $80.00 Hour Domestic Violence Impact Course $70.00 Hour FTM, TDM, Prof. Staffing $40.00 Hour No Show - Domestic Violence Impact Course 3. Submittal of Vouchers Contractor %hal: 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) adicated 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 cf die month following the month of service, but no later than 60 days from the date of service. Requests fcr 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. New Contract Request Entity lnforrnat on Entity Name* ASPEN SUMMIT WELLNESS AND COUNSELING Entity ID* ��00041019 ❑ New Entity? Contract Name* Contract ID ASPEN SUMMIT WELLNESS AND COUNSELING SERVICES. LLC 4677 (AGREEMENT AMENDMENT) Contract Status CTB REVIEW Contract Description* BID #61900025 TERM: 6/1,21-5;31 22, Contract Lead* APEGG Contract Lead Email apegg@weldgov.com;cobbx xik' ,weldgov.com Contract Description 2 CONSENT. PA IS BEING ROUTED THROUGH NORMAL PROCESS. ETA TO CTB 4:'22, 21. Contract Type* AMENDMENT Amount 50.0 Renewable* NO Automatic Renewal Grant IGA Department HUMAN SERVICES Department Email CM- HumanServices, weidgov.co to Department Head Email CM-HumanServices- DeptHea:dg:weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COU NTYA I I O RN EY wWELDG OV. COM Requested BOCC Agenda Date* 05;26;2021 Parent Contract ID 20193343 Requires Board Approval' YES Department Project Due Date 05122/2021 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? If this is a renewal enter previous Contract ID If this is part of a MSA enter NSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Review Date* 04e01:2022 Renewal Date Termination Notice Period Contact Information Contact Info Contact Name Purchasing Purchasing Approver CONSENT Approval Process Department Head JAMIE ULRICH DH Approved Date 04 ;' 19.' 2021 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date ?4 26 2021 Originator APEGG Committed Delivery [date Contact Type Contact Email Finance Approver CONSENT Expiration Date* 05 31:2022 Contact Phone 1 Purchasing Approved Date 04 19 2021 Finance Approved Date 04119:2021 Tyler Ref #7` AG 042621 Legal Counsel CONSENT Contaa Phone 2 Legal Counsel Approved Date 04 19 2021 of/z77_,2 PRIVILEGED AND CONFIDENTIAL 35/7 MEMORANDUM DATE: April 7, 2020 TO: Board of County Commissioners — Pass -Around FR: Jamie Ulrich, Director, Human Services RE: Agreement Amendment with Aspen Summit Wellness & Counseling Services, LLC Please review and indicate if you would like a work session prior to placing this item on the Board's agenda. Request Board Approval of the Department's Agreement Amendment with Aspen Summit Wellness & Counseling Services, LLC. The Department entered into a Child Protection Agreement for Services, identified as Tyler ID 2019-3343, on July 24, 2019, for the term June 1, 2019 through May 31, 2020, with the option to extend annually upon written agreement for a total period not to exceed three years. The Department wishes to extend the agreement for the term of June 1, 2020 through May 31, 2021 and, the vendor has requested to add the following rates for the following services: - $80.00/Hour (Cognitive Behavioral Therapy Individual Course) - $80.00/Hour (Domestic Violence Impact Course) - $70.00/Hour (FTM, TDM, Prof. Staffing) - $40.00/Hour (No Show - Domestic Violence Impact Course) I do not recommend a Work Session. I recommend approval of this Amendment and authorize the Chair to sign. Mike Freeman, Chair Scott James Barbara Kirkmeyer Steve Moreno, Pro-Tem Kevin Ross Approve Schedule Recommendation Work Session m� Other/Comments: Pass -Around Memorandum; April 7, 2020 - CMS 3517 C, aufoA,O 6'k'D) `/--0? 7 -2D Page 1 2m19- 3,5 .3 µ14o0q0 AGREEMENT AMENDMENT BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND ASPEN SUMMIT WELLNESS & COUNSELING SEVICES, LLC This Agreement Amendment, made and entered intoQ(, / ' day of 2020 by and between the Board of Weld County Commissioners, on behalf of the Weld County epartment of Human Services, hereinafter referred to as the "Department", and Aspen Summit Wellness & Counseling Services, LLC, hereinafter referred to as the "Contractor". WHEREAS the parties entered into an Agreement for Mental Health Services, (the "Original Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document No. 2019-3343, approved on July 24, 2019. WHEREAS the parties hereby agree to amend the term of the Original Agreement in accordance with the terms of the Original Agreement and any previously adopted amendment, which is incorporated by reference herein, as well as the terms provided herein. NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: • The Original Agreement will end on May 31, 2020. • These Amendments, together with the Original Agreement, constitutes the entire understanding between the parties. The following additional changes are hereby made to the current Agreement: 1. Term This agreement is being renewed for a second full year term, for the period June 1, 2020 through May 31, 2021. 2. Exhibit C, Scope of Services, is hereby amended as attached. 3. Exhibit D, Rate Schedule, is hereby amended as attached. This agreement is being renewed for a second full year term, for the period June 1, 2020 through May 31, 2021. • All other terms and conditions of the Original Agreement remain unchanged. IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: dialf44) `�' ~I' y�`�'� BOARD OF COUNTY COMMISSIONERS Weld C • my k to - : • a . �'� �,� WELD COUNTY, COLORADO Deputy Clerk the Bo.rd Mike Freeman, Chair CONTRACTOR: APR 2 7 2020 Aspen Summit Wellness & Counseling Services, LLC 1120 38`'' Avenue, Suite 3 Greeley, CO 80634 By: Daniel Lechleiter, Owner Date: MarImo G2o/1_, .334 EXHIBIT C SCOPE OF SERVICES 1. Contractor will provide Mental Health Services, as referred by the Department. 2. Services available under this agreement include: a. Mental Health Evaluations i. Capacity for Services: Up to six (6) hours per week, or three (3) reports per week. ii. Goals of Service: To identify and provide a written report of the referred client's mental health status, needs, and treatment recommendations. iii. Outcomes of Service: A written report regarding the referred client's mental health status, as well as treatment recommendations utilized data gathered, including: 1. Brief summary of: a. Mental health history b. Social history c. Substance use history 2. DSM-5 Mental Health Diagnosis 3. Mental health treatment recommendations 4. SASSI-4 Interpretation and recommendations for referral and further assessment if warranted iv. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Adolescents (Age 12-17) 2. Young Adults (Age 18-25) 3. Adults (26-65) 4. Elderly (65+) v. Service Access: 1120 38th Avenue, Suite 3, Greeley, CO 80634 vi. Language: English only. b. Mental Health Assessment i. Capacity for Services: Up to six (6) hours per week, or two (2) reports per week. ii. Goals of Service: To identify and provide an in-depth written report of the referred client's mental health status, needs, and treatment recommendations. iii. Outcomes of Service: A written report regarding the referred client's mental health status, as well as treatment recommendations utilized data gathered, including: 1. In-depth summary of: a. Mental health history b. Social history c. Family history d. Relationship history e. Educational history f. Criminal history (if any) 1 2. Substance use history a. SASSI-4 interpretation and recommendations for referral and further assessment if warranted 3. DSM-5 Mental Health Diagnosis 4. Psychological assessment interpretation and summary 5. Mental health treatment recommendations iv. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Adolescents (Age 12-17) 2. Young Adults (Age 18-25) 3. Adults (26-65) 4. Elderly (65+) v. Service Access: 1120 38th Avenue, Suite 3, Greeley, CO 80634 vi. Language: English only. c. Seeking Safety Group: 18 -week course designed to assist individuals who have co-occurring disorders of Post -Traumatic Stress Disorder (PTSD) and substance use. i. Capacity for Services: Two (2) 90 -minute groups per week (one for males and one for females) ii. Goals of Service: To assist individuals with a history of substance use and trauma recovery through the use of health coping skills to reduce harmful behaviors such as substance use or self -injurious behaviors. iii. Outcomes of Service: 1. Certificate of Completion 2. A client -driven, written self -care plan 3. Reduction in harmful behaviors related to substance use and traumatic histories 4. Development and demonstration of application of healthier coping skills iv. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Adolescents (Age 12-17) 2. Young Adults (Age 18-25) 3. Adults (26-65) 4. Elderly (65+) Groups will be gender specific; male and female. Contractor will form a third group for LGBTQ clients if referred more than three (3) LGTBQ clients. v. Service Access: 1120 38th Avenue, Suite 3, Greeley, CO 80634 vi. Language: English only. 2 d. Individual Mental Health Sessions i. Capacity for Services: Up to 10 hours per week. ii. Goals of Service: To assist individuals process and work through identified problems as a result of a mental health evaluation or assessment, and/or part of a recommendation of a similar report. iii. Outcomes of Service: To assist individuals in developing healthy coping skills, self - compassion, assertive communication skills, and reduce mental health symptoms such as anxiety and depression. iv. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Adolescents (Age 12-17) 2. Young Adults (Age 18-25) 3. Adults (26-65) 4. Elderly (65+) v. Service Access: 1. In Office: 1120 38th Avenue, Suite 3, Greeley, CO 80634 2. Video-conferencing vi. Language: English only. e. Domestic Violence Impact Course: A course taught using the manual, "Proprietary Manualized Treatment", written by Daniel Lechleiter. The manual is standardized to cover the primary areas of domestic violence. i. Anticipated Frequency of Service per Week: Up to 10 hours. ii. Anticipated Duration of Service: 4 weeks. iii. Goals of Service: 1. Educate the individual about the impact of domestic violence. 2. Increase the individual's knowledge on ways they can recognize domestic violence and red flags. 3. Improve the individual's understanding of the different types of domestic violence. 4. Explore the individual's personal history of domestic violence and the overall impact it has on them and others. iv. Outcomes of Service: 1. Domestic Violence Cycle: Individuals will learn about the cycle of violence and identifying the various stages. 2. Types of Domestic Violence: Education on the various types of inter -partner domestic violence including financial abuse, physical abuse, emotional abuse, child abuse, and psychological abuse. 3. Time -Outs: A tool to assist the individual in recognizing when to "walk away" from a situation, and how to return to the situation once the individual has calmed down. 3 4. Domestic Violence Impact on Self, Children, and Others: Individuals will learn how all their behaviors affect others. 5. Personal DV History and Exploration (Including a Genogram): Assists the individual in identifying patterns of abuse in their family in order to allow them to have a better understanding of how they may have learned their behaviors. Also encourages individuals to accept responsibility for their behaviors and assist in the reduction of minimizing their behaviors. v. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Parental Units —18 years and older 2. Individuals accused of domestic violence but have not been charged. 3. Victims of domestic violence. vi. Language: English only. f. Cognitive Behavioral Therapy Individual Course: Curriculum includes: Cognitive Behavioral Therapy, Psychotherapy, and Psychoeducation. i. Anticipated Frequency of Service per Week: 1 hour per week. ii. Anticipated Duration of Service: 12 weeks. iii. Goals of Service: 1. Learn and/or increase knowledge of: Basics of Cognitive Behavioral Therapy (CBT), application of CBT, common cognitive disorders, and application of CBT to everyday cognitive distortions. 2. Utilize CBT to approach issues with a rational thought pattern. iv. Outcomes of Service: 1. Improve overall behavioral interactions. 2. Improve self -care through stress management tools. 3. Decrease significant mental health symptoms related to: Anger, depression, and anxiety. v. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Adolescents (12-17) 2. Adults (18-60) vi. Language: English only. 3. Contractor will respond to the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400- 6210) within three (3) business days regarding the ability to accept the received referral. 4. 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 4 period, the Contractor will notify the caseworker and the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400-6210). 5. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for visitation services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understand that the Department will no reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows" on the part of the client per month. 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 Supervisor (hainleid@weldgov.com, 970-400-6210). 6. 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 Supervisor (hainleid@weldgov.com) immediately via email, to discuss service continuation. 7. 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. 8. 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. 9. 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. 10. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. 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. 11. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Court Staffings, Family Team Meetings and/or Team Decision Making meetings. Contractor may participate by phone, if approved by the Department. 12. Contractor will notify the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400-6210) 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) 5 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. 6 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, 2021. 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 $70.00/Hour (Individual Mental Health Session, In -office) $55.00/Hour (Individual Mental Health Session, Video -conference) $80.00/Hour (Individual Mental Health Session, Intake) $600.00/Episode (Mental Health Assessment) $175.00/Episode (Mental Health Evaluation) $80.00/Hour (Cognitive Behavioral Therapy Individual Course) $40.00/Hour (No Show — Mental Health Services) $30.00/Episode (Seeking Safety Group) $80.00/Episode (Seeking Safety Group, Intake) $70.00/Hour (FTM, TDM, Prof. Staffing) $80.00/Hour (Domestic Violence Impact Course) $70.00/Hour (FTM, TDM, Prof. Staffing) $40.00/Hour (No Show - Domestic Violence Impact Course) 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 7m 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 Farm New Contract Request Entity Information Entity Name* ASPEN SUMMIT WELLNESS AND COUNSELING Entity ID* @t10041019 Contract Name* ASPEN SUMMIT WELLMESS & COUNSELING SERVICES, LLC (CHILD PROTECTION AGREEMENT FOR SERVICES) Contract Status CTB REVIEW Contract ID 3517 Contract Lead* CULLINTA Contract Lead Email cullinta@coweld.co.us New Entity? Parent Contract ID 20193343 Requires Board Approval YES Department Project # Contract Description* CONSENT. AGREEMENT AMENDMENT. FUNDING CORE/OTHER. RENEWAL FOR THE PERIOD 06/01;20 THROUGH 05/31/21 Contract Description 2 BID NO. 2000037 Contract Type* AGREEMENT Amount * $0.00 Renewable* YES Automatic Renewal Grant IGA Department HUMAN SERVICES Departrnent Email CM- HumanServices@weldgov com Department Head Email CM-HumanServices- DeptHead@weldgov.com County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATTORNEY @WELD GOV. COM Requested BOCC Agenda Date* 04115/2020 Due Date 04/11/2020 Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in OnBase Contract Dates Effective Date Review Date* 04101/2021 Termination Notice Period Committed Delivery Date Renewal Crate* 06/0112021 Expiration Date Contact Information Contact Info Contact Name Purchasing Purchasing Approver Approval Process Department Head JAMIE ULRICH DH Approved Date 04/21/2020 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 04./27/2020 Originator SNYDERKL Contact Type Contact Email Finance Approver BARB CONNOLLY Contact Phone 1 Contact Rhone 2 Purchasing Approved Date Finance Approved Date 04/22/2020 Tyler Ref # AG 042720 Legal Counsel GABE KALOUSEK Legal Counsel Approved Date 041'22/2020 Submit rot 0aziffq CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND ASPEN SUMMIT WELLNESS &'FOUNSELING SERIVCES, LLC /'TH This Agreement, made and entered into th� day o 2019, by and between the Board of Weld County Commissioners, on behalf of the Weld County Departm t of man Services, hereinafter referred to as the "Department' and Aspen Summit Wellness & Counseling S rvices, C, 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 B1900025, 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 Mental Health Services. 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, 2019, upon proper execution of this Agreement and shall expire May 31, 2020, 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 Supervisor (hainleid@weldgov.com, 970-400-6210). No other Department staff or other party to the case may authorize services or modifications to services. 2019-3343 e%/: lot,164,a_, 040) 7"a4--'9' 7 aq I9 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 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. 2 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. 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 an, 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 3 - 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 - 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. 4 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 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. 5 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, the following insurance coverage. Weld County, State of Colorado, by and through the Board of County Commissioners of Weld County, its employees and agents, shall be named as additional named insured on the insurance, where permissible the insurance provider. 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 0110/93 6 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; - 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 as follows 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. 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 970-400-6503, 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 8 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 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 Division Head Daniel Lechleiter, Owner 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: Judy A. Griego, Director P.O. Box A Greeley, CO 80632 (970) 400-6510 For Contractor: Daniel Lechleiter, Owner 1120 38th Avenue, Suite 3 Greeley, CO 80634 (720) 598-2792 18. Litigation Contractor shall promptly notify the Department in the event that Contractor learns of any actual 9 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 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 10 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 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 11 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 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 12 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. §§24-18-201 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 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, 13 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, including 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: �� /• KC/449;G1 BOARD OF COUNTY COMMISSIONERS Weld C• . y Clerk to the Board WELD COUNTY, COLORADO Deputy Clerk to 14 arbara Kirkmeyer, CONTRACTOR: hair Ai 2 4 2099 Aspen Summit Wellness & Counseling Services, LLC 1120 38th Avenue, Suite 3 Greeley, CO 80634 (720) 598-27 2 By: Date: Daniel Lech leiter, LPC (Apr 25, 2019) Daniel Lechleiter, Owner Apr 25, 2019 col 91.- (3,3(/3 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 REQUEST FOR PROPOSAL Weld County Department of Human Services Bid No. B1900025 Aspen Summit Wellness & Counseling Services, LLC Daniel Lechleiter 1120 38th Ave Suite 3 Greeley, CO 80634 To Board of Weld County Commissioners: January 16, 2019 My name is Daniel Lechleiter, and I am the owner and sole proprietor of Aspen Summit Wellness & Counseling Services, LLC (ASWC). I am a Licensed Professional Counselor with over five years of experience in the field. While in the field, I have worked in several different settings to include a community mental health center (North Range Behavioral Health) and a smaller population -specific agency (Perklen Center for Psychotherapy). Aspen Summit Wellness & Counseling provides mental and behavioral health services to the greater Greeley, Colorado population. The agency specializes in services for the Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQI+) populations, in addition to all individuals who seek services regardless of sexual orientation, gender, race, and ethnicity. ASWC serves ages 12 to 50+ years old. ASWC practices from evidence -based theories including Cognitive Behavioral Therapy (CBT), Person - Centered Therapy (PCT) and Trauma -Informed Care. ASWC utilizes an electronic -medical records (EMR) system to manage all paper -work requirements, including scheduling. This system also allows for a client portal, where clients can access and pay for their services, schedule appointments, and send/receive secure communication. New clients are scheduled for, or offered, an appointment within 24 hours of initial contact. Scheduled and offered appointments are generally set out no more than one week from the first date of contact. I appreciate your review of my bid for services and thank you for your time. Sincerely, Dan Lechleiter, MA, LPC Owner of Aspen Summit Wellness & Counseling Services, LLC 720.598.2792 Dlechleiter@aspenswc.com www.aspenswc.com EXHIBIT B PROVIDER INFORMATION FORM Weld County Department of Human Services Aspen Summit Wellness & Counseling Services, LLC AGENCY OR PRIVATE PRACTICE TRAILS PROVIDER ID (If Known) Daniel Lechleiter, MA, LPC- PRIMARY CONTACT— FULL NAME (720.598.2792)(TEL) PHONE NUMBER Dlechleiter@aspenswc.com PRIMARY CONTACT— E-MAIL ADDRESS 1120 38th Ave Suite 3 Greeley, CO 80634 AGENCY MAILING ADDRESS Owner PRIMARY CONTACT - TITLE (844-783-0806) EXT. FAX NUMBER www.aspenswc.com AGENCY/PRACTICE WEB ADDRESS (IF APPLICABLE) CITY ZIP REFERRAL CONTACT Daniel Lechleiter, MA, LPC REFFERAL CONTACT — FULL NAME Owner REFERRAL CONTACT - TITLE (720.598.2792) dlechleiter@aspenswc.com REFERRAL CONTACT — PHONE NUMBER EXT. REFERRAL CONTACT— E-MAIL ADDRESS BILLING CONTACT Daniel Lechleiter, MA, LPC BILLING CONTACT— FULL NAME Owner BILLING CONTACT - TITLE (720.598.2792) dlechleiter@aspenswc.com BILLING CONTACT — PHONE NUMBER EXT. BILLING CONTACT— E-MAIL ADDRESS I certify that the services proposed for intended use by the Weld County Department of Human Services will meet all the 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 Weld County Department of Human Services, and comply with all requirements of the contract, if awarded. The Board of Weld County Commissioners reserve the right to reject any or all bids, to waive any informality in the bids, and to 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 tare cgtf ti • in price and duality. c. Signature of Authorized Representative: Date of Signature: C. -- Bid No.: B1900025 EXHIBIT C PROPOSAL TEMPLATE 1. Bidder's legal entity name: Aspen Summit Wellness & Counseling Services, LLC 2. Program name or service type being proposed: Mental Health Evaluations 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. Motivational Interviewing, Mini Mental Status Examination, Substance Abuse Subtle Screening Inventory (SASSI-4), Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder (GAD -7) , Trauma -Informed Care 4. Capacity to Provide Services (ex. 4 hours/week). Up to 6 hours per week, or 3 reports per week 5. Goals of the service. To identify and provide a written report of a client's mental health status, needs, and treatment recommendations 6. Outcomes of service. A written report regarding client's mental health status and treatment recommendations from a Licensed Professional Counselor (LPC) utilizing data gathered to include: • Brief Summary of ■ Mental Health History ■ Social History ■ Substance Use History • DSM-5 Mental Health Diagnosis • Mental Health Treatment Recommendations • SASSI-4 Interpretation and Recommendations for Referral and Further Assessment if warranted 7. Target population for service. Adolescents (12-17), young adults (18-25), adults (26-65), and elderly (65+) regardless of race, gender, and sexual orientation 8. Service access. All mental health evaluations will be office -based at: 1120 38th Ave Suite 3 Greeley, CO 80634 Note: Bidder must indicate capacity for video conferencing, phone conferencing and in person. If office -based, bidder should provide full physical addresses for all locations. If provided outside the office, bidder should note home -based and/or community -based, and geographical area(s) bidder is willing to travel to. 9. Languages service is available in. English Note: Bidder should note the language and level of proficiency. 10. Rates of service. Bid No.: 1900025 EXHIBIT C PROPOSAL TEMPLATE $175.00- 120 minute interview, one report Note: Bidder should include fee for service, staffing, mileage, and any other applicable costs bidder would like considered. Rates must be an exact amount and must include the unit of cost (i.e., hour, day, month, episode). Approximate rates or a range of rates for a service will not be accepted. Bid No.: 1900025 EXHIBIT C PROPOSAL TEMPLATE 1. Bidder's legal entity name: Aspen Summit Wellness & Counseling Services, LLC 2. Program name or service type being proposed: Mental Health Assessment 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. Motivational Interviewing, Mini Mental Status Examination, Substance Abuse Subtle Screening Inventory (SASSI-4), Shipley Institute of Living Scale -2, Milton Multi -Axel Clinical Inventory (MMCI-IV), Trauma -Informed Care 4. Capacity to Provide Services (ex. 4 hours/week). Up to 6 hours per week, or 2 reports per week 5. Goals of the service. To identify and provide an in-depth written report of a client's mental health status, needs, and treatment recommendations 6. Outcomes of service. A written report regarding client's mental health status and treatment recommendations from a Licensed Professional Counselor (LPC) utilizing data gathered to include: • In -Depth Summary of ■ Mental Health History ■ Social History ■ Family History ■ Relationship History ■ Educational History ■ Criminal History (if any) • Substance Use History ■ SASSI-4 Interpretation and Recommendations for Referral and Further Assessment if warranted • DSM-5 Mental Health Diagnosis • Psychological Assessment Interpretation and Summary • Mental Health Treatment Recommendations 7. Target population for service. Adolescents (12-17), young adults (18-25), adults (26-65), and elderly (65+) regardless of race, gender, and sexual orientation 8. Service access. All mental health evaluations will be office -based at: 1120 38th Ave Suite 3 Greeley, CO 80634 Note: Bidder must indicate capacity for video conferencing, phone conferencing and in person. If office -based, bidder should provide full physical addresses for all locations. If provided outside the Bid No.: 1900025 EXHIBIT C PROPOSAL TEMPLATE office, bidder should note home -based and/or community -based, and geographical area(s) bidder is willing to travel to. 9. Languages service is available in. English Note: Bidder should note the language and level of proficiency. 10. Rates of service. $600.00 for interview and report (testing and interpretation of all items listed above) Note: Bidder should include fee for service, staffing, mileage, and any other applicable costs bidder would like considered. Rates must be an exact amount and must include the unit of cost (i.e., hour, day, month, episode). Approximate rates or a range of rates for a service will not be accepted. Bid No.: 1900025 EXHIBIT C PROPOSAL TEMPLATE 1. Bidder's legal entity name: Aspen Summit Wellness & Counseling Services, LLC 2. Program name or service type being proposed: Seeking Safety Group 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. Seeking Safety 18 Week Course, Trauma -Informed Care 4. Capacity to Provide Services (ex. 4 hours/week). Two 90 -minute groups per week (one for male clients and one for female clients) 5. Goals of the service. To assist individuals with a history of substance use and trauma recovery through the use of healthy coping skills to reduce harmful behaviors such as substance use or self -injurious behaviors 6. Outcomes of service. Certificate of Completion for an 18 week Seeking Safety Course with: • A client driven, written self -care plan • Reduction in harmful behaviors related to substance use and traumatic histories • Development and demonstration of application of healthier coping skills 7. Target population for service. Adolescents (12-17), young adults (18-25), adults (26-65), and elderly (65+) regardless of race, gender, and sexual orientation. For this specific service, the groups will be gender specific —one for males, and one for females. A third group for LGBTQ clients can also be formed if referred more than 3 LGTBQ clients. Seeking Safety was designed to assist individuals who have co-occurring disorders of PTSD and Substance Use. 8. Service access. All groups will be office -based at: 1120 38th Ave Suite 3 Greeley, CO 80634 Note: Bidder must indicate capacity for video conferencing, phone conferencing and in person. If office -based, bidder should provide full physical addresses for all locations. If provided outside the office, bidder should note home -based and/or community -based, and geographical area(s) bidder is willing to travel to. 9. Languages service is available in. English Note: Bidder should note the language and level of proficiency. 10. Rates of service. $80.00 per intake (one-time fee) per person* (not applicable if intake was completed as part of MH evaluation or MH assessment, or MH Individual sessions) $30.00 per person per group (18 groups) Bid No.: 1900025 EXHIBIT C PROPOSAL TEMPLATE Note: Bidder should include fee for service, staffing, mileage, and any other applicable costs bidder would like considered. Rates must be an exact amount and must include the unit of cost (i.e., hour, day, month, episode). Approximate rates or a range of rates for a service will not be accepted. Bid No.: 1900025 EXHIBIT C PROPOSAL TEMPLATE 1. Bidder's legal entity name: Aspen Summit Wellness & Counseling Services, LLC 2. Program name or service type being proposed: Individual Mental Health Sessions 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. Motivational Interviewing, Narrative Therapy, Cognitive Behavioral Therapy, Trauma -Informed Care 4. Capacity to Provide Services (ex. 4 hours/week). 10 hours per week 5. Goals of the service. Sessions to assist individuals process and work through identified problems as a result of a mental health evaluation or assessment, and or part of a recommendation from a similar report. 6. Outcomes of service. To assist individual in developing healthy coping skills, self -compassion, assertive communication skills, reduction in mental health symptoms (such as anxiety, depression, etc.). 7. Target population for service. Adolescents (12-17), young adults (18-25), adults (26-65), and elderly (65+) regardless of race, gender, and sexual orientation 8. Service access. Sessions are available via in -person and HIPAA Compliant Video-Conferencing Office -based (in person) sessions will be held at: 1120 38th Ave Suite 3 Greeley, CO 80634 Note: Bidder must indicate capacity for video conferencing, phone conferencing and in person. If office -based, bidder should provide full physical addresses for all locations. If provided outside the office, bidder should note home -based and/or community -based, and geographical area(s) bidder is willing to travel to. 9. Languages service is available in. English Note: Bidder should note the language and level of proficiency. 10. Rates of service. $80.00 for intake per 60 minutes $70.00 for office -based session per 60 minutes $55.00 for video -conference session per 60 minutes (60 minutes=1 unit) Note: Bidder should include fee for service, staffing, mileage, and any other applicable costs bidder would like considered. Rates must be an exact amount and must include the unit of cost (i.e., hour, day, month, episode). Approximate rates or a range of rates for a service will not be accepted. Bid No.: 1900025 STAFF DATA SHEET EXHIBIT D (Bidder must list all applicable staff who will manage and/or administer the proposed service. One Staff Data Sheet per proposed service. Bidder should not combine services.) PROPOSED SERVICE OR SERVICE TYPE: Mental Health Services BIDDER LEGAL ENTITY NAME: Aspen Summit Wellness & Counseling Services, LLC APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION - SUPERVISOR INFORMATION No. Last Name First Name World! ." Work Email Education Level Degree Focus Licensure/ Credentials DORA X (If applicable) Last Name First Name Work 0 Work Email 1 Lechleiter Daniel 7205982792 dlechleiter@aspei MA Clinical Counsel LPC 13273 Lechleiter Daniel 7205982792 dlechleiter@asper 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Bid No.: B1900025 HEALTH December 19, 2018 Daniel LechleiterAspen summit Ilc 3257 S Parker Rd, Apt 4-406 Denver, CO 80014-3239 Certificate #: 105-2018284-01 RE: Your ACHP-sponsored Professional Liability Insurance Certificate Dear Policyholder: Thank you for your support of the Professional Liability Insurance Program endorsed by ACHP. The following is your official Professional Liability Insurance Certificate, which includes an Evidence of Insurance to serve as your Proof of Coverage. Please be sure to read your entire insurance packet very carefully so you have a complete understanding of the coverage afforded you through this program. At the first notice of a claim, lawsuit or potential claim, please contact one of our customer service representatives immediately. We will assist you by obtaining the necessary information which will help us get your claims process started. Our claims staff is dedicated to listening, understanding and taking action to route your claim to the necessary experts that will be working on your behalf. Should you have any questions regarding your policy or the ACHP-sponsored Professional Liability Insurance Program, please be sure to contact us at 1-800-253-5486. Our professional staff is available to assist you from 8:00 a.m. through 5:00 p.m. CST, Monday through Friday. You may also e-mail us yourquestionsatLockton_info@locktonaffinity.com. Besureto includeyourcertificatenumberinyour correspondence. Sincerely, Your Customer Service Representative Account /42538875 ACHP .,HEALTH Claim Reporting Allied Health Professional Liability and General Liability Insurance Important Reminder: prompt reporting of a claim or potential claim reduces loss and expense. Claim Reporting Contact Information Phone 1-800-253-5486 Fax 1-913-652-3966 Email Lockton_info@locktonaffinity.com Lockton Affinity, LLC Mail PO Box 410679 Kansas City, MO 64141-0679 Insurance Program Administered by Lockton Affinity, LLC Account# 2538875 CERTIFICATE OF INSURANCE Master Policy Named insured National Professional Purchasing Group Association, Inc. THIS CERTIFICATE IS ISSUED AS A MATTER OF c/o Lockton Affinity, LLC INFORMATION ONLY AND CONFERS NO RIGHTS UPON P. O. Box 410679 THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES Kansas City, Missouri 64141-0679 NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE CERTIFICATE DESCRIBED BELOW. Named Insured Member: Daniel Lechleiter Aspen summit Ilc INSURERS AFFORDING COVERAGE: 3257 S Parker Rd, Apt 4-406 Certain Underwriters at Lloyd's, London Denver, CO 80014-3239 Member Certificate Number: 105-2018284-01 Primary Occupation: Licensed or Certified Professional Counselor THE CERTIFICATE OF INSURANCE LISTED BELOW HAS BEEN ISSUED TO THE MEMBER NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS DOCUMENT MAY PERTAIN, THE INSURANCE AFFORDED BY THE CERTIFICATE ISSUED TO THE MEMBER NAMED ABOVE IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF THE MASTER POLICY TO WHICH IT REFERS TO. AGGREGATE LIMITS MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1. Unique Market Reference Number: B0713GLOPR1800702 2. Policy Period: The Policy Period shall commence during the Policy Period set forth below. Coverage shall commence from the date upon which the Named Insured holds a valid RPG membership during the Policy Period and shall continue up to but not exceeding 365 days in all. From: 12/15/2018 To: 12/15/2019 Both dates at 12:01 a.m Local Time at the address stated in Item 1 above. 3. Policy Administrator: Lockton Affinity, LLC P.O. Box 410679 Kansas City, MO 64141-0679 4. Insuring Agreements and Limits of Liability A. Professional Liability: i. Each Claim includes Claims Expenses $1,000,000 ii. Aggregate Limit of Liability includes Claims Expenses $3,000,000 B. General Liability (includes Host Liquor Liability) i. Each Claim includes Claims Expenses $1,000,000 ii. Aggregate Limit of Liability includes Claims Expenses $3,000,000 C. Fire/Water Damage Legal Liability from any one fire or Water Damage includes Claims Expenses $100,000 D. Medical Expense Payments i. Each Person $2,000 ii. Aggregate Limit of Liability $50,000 E. Policy Aggregate Limit of Liability includes Claims Expenses $3,000,000 Supplementary payments are in addition to these limits. CERTIFICATE HOLDER CANCELLATION PROOF OF COVERAGE SHOULD THE ABOVE DESCRIBED POLICY BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS AUTHORIZED REPRESENTATIVE �} / LII 482 Certificate of Insurance (10-13) SCHEDULE OF INSURERS LLOYD'S POLICY This Policy (hereinafter referred to as "certificate") is effected with certain Underwriters at Lloyd's, London. Limited Authorization. This Certificate is issued in accordance with the limited authorization granted to the Authorized Representative (hereinafter referred to as "Correspondent") by certain Underwriters at Lloyd's, London whose syndicate numbers and the proportions underwritten by them can be ascertained from the office of the said Correspondent (such Underwriters being hereinafter called "Underwriters") and in consideration of the premium specified herein, Underwriters hereby bind themselves severally and not jointly, each for his own part and not one for another, their Executors and Administrators. The Insured is requested to read this Certificate, and if it is not correct, return it immediately to the Correspondent for appropriate alteration. Inquiries. All inquiries regarding this Certificate should be addressed to the following Correspondent: Lockton Affinity, LLC 1-800-253-5486 P.O. Box 879610 Kansas City, Missouri 64187-9610 Signature Required. This Certificate shall not be valid unless signed by the Correspondent on the attached Declarations Page Correspondent Not Insurer. The Correspondent is not an Insurer hereunder and neither is nor shall be liable for any loss or claim whatsoever. The Insurers hereunder are those Underwriters at Lloyd's, London whose syndicate numbers can be ascertained as hereinbefore set forth. As used in this Notice of Insurance Certificate "Underwriters" shall be deemed to include incorporated as well as unincorporated persons or entities that are Underwriters at Lloyd's, London. Cancellation. If the insurance described herein provides for cancellation and if said insurance is cancelled after the inception date, earned premium must be paid for the time the insurance has been in force. Assignment. The insurance described herein shall not be assigned either in whole or in part without the written consent of the Correspondent endorsed hereon. Attached Conditions Incorporated. The insurance described in this Certificate is subject to all provisions, conditions and warranties set forth herein, attached, or endorsed, all of which are to be considered incorporated herein as further descriptive of the insurance the placement of which is evidenced by this Certificate. Name of Insurer and Percentage Participation on this Risk and Authority Reference Number: Certain Underwriters, Llo/ds, London Syndicate Number Liability signing Beazley Furlonge Ltd AFB 2623 82% Beazley Furlonge Ltd AFB 623 18% SCHED 11-11 Page 1 of 1 POLICY NUMBER: IL 09 85 01 15 THIS ENDORSEMENT IS ATTACHED TO AND MADE PART OF YOUR POLICY IN RESPONSE TO THE DISCLOSURE REQUIREMENTS OF THE TERRORISM RISK INSURANCE ACT. THIS ENDORSEMENT DOES NOT GRANT ANY COVERAGE OR CHANGE THE TERMS AND CONDITIONS OF ANY COVERAGE UNDER THE POLICY. DISCLOSURE PURSUANT TO TERRORISM RISK INSURANCE ACT SCHEDULE SCHEDULE — PART I Terrorism Premium (Certified Acts) $ 0 This premium is the total Certified Acts premium attributable to the following Coverage Part(s), Coverage Form(s) and/or Policy(ies): General Liability Additional information, if any, concerning the terrorism premium: SCHEDULE — PART II Federal share of terrorism losses Federal share of terrorism losses Federal share of terrorism losses 82 81 80 (Refer to Paragraph B. in this endorsement.) % Year: 20 18 % Year: 20 19 % Year: 20 20 A. Disclosure Of Premium In accordance with the federal Terrorism Risk Insurance Act, we are required to provide you with a notice disclosing the portion of your premium, if any, attributable to coverage for terrorist acts certified under the Terrorism Risk Insurance Act. The portion of your premium attributable to such coverage is shown in the Schedule of this endorsement or in the policy Declarations. B. Disclosure Of Federal Participation In Payment Of Terrorism Losses The United States Government, Department of the Treasury, will pay a share of terrorism losses insured under the federal program. The federal share equals a percentage (as shown in Part II of the Schedule of this endorsement or in the policy Declarations) of that portion of the amount of such insured losses that exceeds the applicable insurer retention. However, if aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year, the Treasury shall not make any payment for any portion of the amount of such losses that exceeds $100 billion. IL 09 85 01 15 © Insurance Services Office, Inc., 2015 Page 1 of 2 C. Cap On Insurer Participation In Payment Of Terrorism Losses If aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year and we have met our insurer deductible under the Terrorism Risk Insurance Act, we shall not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rata allocation in accordance with procedures established by the Secretary of the Treasury. Page 2 of 2 © Insurance Services Office, Inc., 2015 IL 09 85 01 15 LLOYD'S PRIVACY POLICY STATEMENT UNDERWRITERS AT LLOYD'S, LONDON The Certain Underwriters at Lloyd's, London want you to know how we protect the confidentiality of your non-public personal information. We want you to know how and why we use and disclose the information that we have about you. The following describes our policies and practices for securing the privacy of our current and former customers. INFORMATION WE COLLECT The non-public personal information that we collect about you includes, but is not limited to: • Information contained in applications or other forms that you submit to us, such as name, address, and social security number • Information about your transactions with our affiliates or other third -parties, such as balances and payment history • Information we receive from a consumer -reporting agency, such as credit -worthiness or credit history INFORMATION WE DISCLOSE We disclose the information that we have when it is necessary to provide our products and services. We may also disclose information when the law requires or permits us to do so. CONFIDENTIALITY AND SECURITY Only our employees and others who need the information to service your account have access to your personal information. We have measures in place to secure our paper files and computer systems. RIGHT TO ACCESS OR CORRECT YOUR PERSONAL INFORMATION You have a right to request access to or correction of your personal information that is in our possession. CONTACTING US If you have any questions about this privacy notice or would like to learn more about how we protect your privacy, please contact the agent or broker who handled this insurance. We can provide a more detailed statement of our privacy practices upon request. 06/03 LSW1135B rr CERTIFICATE OF INSURANCE EFFECTED WITH CERTAIN UNDERWRITERS AT LLOYD'S, LONDON FOR THE MEMBERS OF THE RISK PURCHASING GROUP ALLIED HEALTH PROFESSIONAL LIABILITY AND GENERAL LIABILITY CLAIMS MADE AND REPORTED INSURANCE This Certificate of Insurance is issued as a Notice of Insurance for information only. It does not constitute a legal contract of insurance. The Master Policy, Declarations and Application of the Named Insured, if any, form the entire contract. This Certificate is furnished in accordance with, and in all respects is subject to all terms, conditions and exclusions of the Master Policy, a copy of which is attached hereto. The original Master Policy may be inspected at the offices of the Risk Purchasing Group (the "RPG"). This Certificate is to notify the member named below (the "Named Insured") that the following insurance has been effected with certain Underwriters at Lloyd's, London (not incorporated) (the "Underwriters") for the Policy Period specified below under the Master Policy (the "Master Policy") issued to the RPG. The attached Master Policy provides coverage on a claims made and reported basis and apply only to Claims first made against the Insured during the Policy Period or the Extended Reporting Period (if applicable) and reported to underwriters during the Policy Period or otherwise provided in clause XII. of the attached Master Policy. Unique Market Reference Number: 80713GLOPR1800702 1. Named Insured: Daniel LechleiterAspen summit Ilc Address: 3257 S Parker Rd, Apt 4-406 City/State/Zip: Denver, CO 80014-3239 Master Policy Number: GLOPR1800702 Membership Number: 105-2018284-01 Risk Purchasing Group: National Professional Purchasing Group Association, Inc. 2. Policy Period: The Policy Period shall commence during the Policy Period set forth below. Coverage shall commence from the date upon which the Named Insured holds a valid RPG membership during the Policy Period and shall continue up to but not exceeding 365 days in all. From: 12/15/2018 To: 12/15/2019 Both dates at 12:01 a.m Local Time at the address stated in Item 1 above. 3. Insuring Agreements and Limits of Liability A. Professional Liability: i. Each Claim includes Claims Expenses $1,000,000 ii. Aggregate Limit of Liability includes Claims Expenses $3,000,000 B. General Liability (includes Host Liquor Liability) i. Each Claim includes Claims Expenses $1,000,000 ii. Aggregate Limit of Liability includes Claims Expenses $3,000,000 C. Fire/Water Damage Legal Liability from any one fire or Water Damage includes Claims Expenses $100,000 D. Medical Expense Payments i. Each Person $2,000 ii. Aggregate Limit of Liability $50,000 E. Policy Aggregate Limit of Liability includes Claims Expenses $3,000,000 Supplementary payments are in addition to these limits. 4. Deductible Each Claim/Accident/ Deductible includes Claims Expenses: $1,000 Per Claim S. Policy Administrator: Lockton Affinity, LLC P.O. Box 410679 Kansas City, MO 64141-0679 6. Retroactive Date: 12/15/2017 7. Extended Reporting Period Options Options (a) through (c) below apply to Insuring Agreement A.1. Option (d) below applies to Insuring Agreements A.2., A.3. and A.5. a. 12 Months for a Charge of 1OO0/0 Expiring Premium b. 24 Months for a Charge of 15O0/0 Expiring Premium c. 36 Months for a Charge of 2OO0/0 Expiring Premium d. Unlimited for a Charge of 200% Expiring Premium 8. Notifications under this Policy (Cancellation and Request for Extended Reporting Period ) to: Lockton Affinity, LLC P.O. Box 410679 Kansas City, MO 64141-0679 Fax: 913-652-3966 Email: Lockton_info@locktonaffinity.com 9. Territory: This insurance applies to negligent acts, errors, omissions or Accidents which take place anywhere in the world, provided the Claim is first made against the insured within the United States of America, its possessions and territories, - Puerto Rico and Canada. 10. Service of process in any suit shall be made upon: Lloyds Illinois, Inc., 115 La Salle Street, Chicago, IL 60603 11. Choice of Law State: Illinois 12. Terrorism Coverage: Included for General Liability Coverage Part 13. Claim Notifications under this Policy shall be given to: Beazley Group, 30 Batterson Park Road, Farmington CT 06032 Email: CLAIMS@BEAZLEY.COM FAX: 1-866-910-1397 14. Premium: $189.00 Administrative Fee: $20.00 15. Attached Policy Forms and Notices : LH 482 (07-13) Professional Liability & General Liability Policy Wording LII 482 B (10-13) Illinois Amendatory Endorsement LII 482 D (07-13) Cap On Losses From Certified Acts of Terrorism AIF 2657 (10/05) War and Terrorism Exclusion Endorsement SCHED 11-11 Schedule of Insurers IL 09 85 01/15 TRIA Disclosure Form LSW1135B 06 03 Lloyd's Privacy Policy Statement The Master Policy contains the following exclusions: A. Exclusions applicable to Insuring Agreement I.A.1: a. Bodily Injury, Property Damage or Advertising Liability, except with respect to Bodily Injury arising out of any negligent act, error or omission of any Insured in rendering or failing to render Professional Services. b. Criminal, dishonest, fraudulent or malicious acts, error or omissions. c. Contractual liability d. Claims based upon an express or implied warranty or guarantee, or breach of contract in respect of an agreement to perform work for a fee e. Insured's activities as a trustee, partner, officer, director or employee of any trust, charitable organization, corporations, company or business other than that of the Named Insured f. Financial or investment advice g. Libel or slander h. Plagiarism, misappropriation of likeness, infringement of any intellectual property right, including patent, trademark, trade secret, trade dress and copyright i. Not valid license for the performance of Professional Services j. Rendering or failing to render Professional Services to Professional Athletes k. Rendering or failing to render Professional Services to Nursing Homes, Assisted Living Housing and/or Independent Living Housing facilities B. Exclusions applicable to Insuring Agreement I.A.2, General Liability I.A.3, Fire and Water Damage Liability and I.A.5, Host Liquor Liability: a. Professional Liability b. Use of force or intended from the standpoint of the Insured c. Automobile, Aircraft and Watercraft exclusion d. Ownership, maintenance, operation, use, loading or unloading of any Mobile Equipment, operation or use of snowmobile, moped or motorized bicycle or trailer designed for use therewith e. Transportation of Mobile Equipment by any Automobile f. Alcoholic beverages exclusion g. Personal Injury to any employee or volunteer h. Property Damage to property owned, rented or temporarily occupied by the Insured, premises given away, sold or abandoned by the Insured, property loaned to the Insured i. Loss of use of tangible property which has not been physically injured or destroyed resulting from a delay in or lack of performance by or on behalf of the Named Insured of any contract or agreement; or the failure of the Named Insured's products to meet the level of performance, quality, fitness. j. Property Damage to the Named Insured's Products k. Withdrawal, recall, inspection, repair, replacement or loss of life of the Named Insured's Products. I. Aircraft Products C. Exclusions applicable to Insuring Agreement I.A.4, Medical Expenses: a. Medical expenses for Bodily Injury to any Insured, to any person injured on that part of the premises the Named Insured owns or rents b. Benefits payable under worker's compensation or disability laws c. War d. Prisoners D. Exclusions applicable to all Insuring Agreements: a. Claims against or in connection with any business enterprise not named in the Declarations which is Insured or in which any Insured is a trustee, partner, officer, director or employee b. Employee Retirement Income Security Act 1974 and amendments c. Claim or circumstance in respect of which any Insured has given notice to any insurer of any other insurance prior to the inception date d. Claim or circumstance known to the Insured prior to the inception date e. Acts, error, omissions or Accidents which first took place prior to the Retroactive Date f. Discrimination g. Insolvency or Bankruptcy of the Insured h. Sexual abuse or molestation i. Punitive and exemplary damages, fines, sanctions, taxes, costs or expenses j. Employer -employee relations, policies, practices, acts or omissions. k. Violation of Securities Acts, of Racketeer Influenced and Corrupt Organizations Act I. Anti-trust m. Regulatory actions n. Product Liability o. Pharmacy services owned by the policy or self- p. Manufacture, handling sale or distribution of Phenylpropanolamine, Phenylpropanolamine Hydrochloride, PPA or any product or drug containing any of these substances q. Asbestos, Mould, Electromagnetic Field or Radiation, Pollution. r. Insured vs Insured s. HIV, AIDS, hepatitis or any other infectious disease or any complex or syndrome related. PLEASE NOTE THIS IS NOT AN EXHAUSTIVE LIST OF THE EXCLUSIONS AND YOU SHOULD READ THE MASTER POLICY FOR FULL DETAILS. The underwriters shall have the right and duty to defend any Claim against the Insured seeking Damages. Underwriters will pay Claims Expenses with respect to any Claim seeking Damages which are payable under the terms of the Master Policy. Claims Expenses shall reduce and may exhaust the Limits of Liability and are subject to the Deductible. If any payment is made under the Master Policy and there is available to the Underwriters any of the Insured's rights of recovery against any other party, then the Underwriters shall maintain all such rights of recovery. The Insured shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights. The Insured shall do nothing after an incident or event giving rise to a Claim to prejudice such rights. By acceptance of the attached Master Policy, all Insureds agree that the statements contained in the Application are their agreements and representations, that they shall be deemed material to the risk assumed by the Underwriters, and that the Master Policy is issued in reliance upon the truth thereof. NO ADMISSION OF LIABILITY, ASSUMPTION OF OBLIGATION OR PROMISE TO PAY EITHER EXPRESS OR IMPLIED MAY BE MADE EITHER VERBALLY OR IN WRITING. IF THE INSURED RECEIVES ANY NOTICE OF A CLAIM OR IS AWARE OF A CIRCUMSTANCE WHICH MAY RESULT IN A CLAIM FULL DETAILS OF THE CLAIM, CIRCUMSTANCE OR INCIDENT SHOULD BE SENT IMMEDIATELY IN WRITING BY EMAIL OR LETTER (INCLUDING THE INSURED MEMBERSHIP NUMBER) TO THE ADDRESS STATED IN ITEM 13 OF THIS CERTIFICATE OF INSURANCE. NOTE: THE MASTER POLICY APPLIES IN EXCESS OF ANY OTHER VALID AND COLLECTIBLE INSURANCE AVAILABLE TO ANY INSURED. r�znc, 12/19/2018 Signature of Authorized Representative Issue Date LH 482 Cert (07-13) ART _ ALLIED HEALTH PROFESSIONAL LIABILITY AND GENERAL LIABILITY CLAIMS MADE AND REPORTED INSURANCE NOTICE: This is a Claims Made and Reported Policy. Except to such extent as may otherwise be provided herein, the coverage afforded under this insurance policy is limited to those Claims which are first made against the Insured and reported to the Underwriters during the Policy Period. Damages and Claims Expenses shall be applied against the Deductible. Certain words and phrases which appear in bold type have special meaning; please refer to Section VI., Definitions. Please review the coverage afforded under this insurance policy carefully and discuss the coverage hereunder with your insurance agent or broker. In consideration of the payment of premium and reliance upon the statements, representations and warranties made in the application which is made a part of this insurance policy (hereinafter referred to as the "Policy" or "insurance") and subject to the Limit of Liability, exclusions, conditions and other terms of this insurance, the Underwriters agree with the Named Insured (set forth in Item 1 of the Declarations, made a part hereof) as follows: I. INSURING AGREEMENTS A. Coverage 1. Professional Liability The Underwriters will pay on behalf of the Insured Damages and Claims Expenses which the Insured shall become legally obligated to pay because of any Claim or Claims for Bodily Injury first made against any Insured during the Policy Period and reported to the Underwriters during the Policy Period or any applicable Extended Reporting Period, arising out of any negligent act, error or omission of the Insured in rendering or failing to render Professional Services for others, on behalf of the Named Insured designated in Item 1 of the Declarations, except as excluded or limited by the terms, conditions and exclusions of this Policy. 2. General Liability The Underwriters will pay on behalf of the Insured Damages and Claims Expenses which the Insured shall become legally obligated to pay or assumed by the Insured under contract because of any Claim or Claims first made against any Insured during the Policy Period and reported to the Underwriters during the Policy Period or any applicable Extended Reporting Period, for Personal Injury, Property Damage or Advertising Liability caused by an Accident, except as excluded or limited by the terms, conditions and exclusions of this Policy. 3. Fire and Water Damage Legal Liability The Underwriters will pay on behalf of the Insured Damages and Claims Expenses which the Insured shall become legally obligated to pay because of any Claim or Claims first made against any Insured during the Policy Period and reported to the Underwriters during the Policy Period or any applicable Extended Reporting Period, for Property Damage to the premises, while rented to the Insured or temporarily occupied by the Insured with permission of the owner, arising out of any one fire or any one Water Damage that occurs during the Policy Period except as excluded or limited by the terms, conditions and exclusions of this Policy. 1 Under no circumstances will this coverage be extended to cover First Party Property Damage or Property Damage to personal property. 4. Medical Expenses The Underwriters will pay medical expenses as described below for Bodily Injury caused by an Accident: a. On premises the Insured owns or rents; b. On ways next to the premises the Insured owns or rents; or c. Because of the Insured's operations; Provided that: a. The Accident takes place in the Coverage Territory and during the Policy Period; b. The Accident is reported to the Underwriters during the Policy Period. c. The expenses are incurred and reported to the Underwriters within three years of the date of the Accident; d. The injured person submits to an examination, at Underwriters expense, by physicians of Underwriters choosing as often as the Underwriters reasonably require. The Underwriters will make these payments regardless of fault. These payments will not exceed the applicable Limit of Liability stated in the Schedule. Underwriters will pay reasonable expenses for: a. first aid administered at the time of the Accident; b. necessary medical, surgical, x-ray and dental services, including prosthetic devices; and c. necessary ambulance, hospital, professional nursing and funeral services. 5. Host Liquor Liability The Underwriters will pay on behalf of the Insured Damages and Claims Expenses which the Insured shall become legally obligated to pay because of any Claim or Claims first made against any Insured during the Policy Period and reported to the Underwriters during the Policy Period or any applicable Extended Reporting Period, for Personal Injury or Property Damage arising out of the giving or serving of alcoholic beverages at functions incidental to the Insured's Professional Services, providing the Insured is not engaged in the business of manufacturing, distributing, selling or serving of alcoholic beverages. This coverage will not apply to liability imposed because of the violation of a statute, ordinance or regulation pertaining to the manufacturing, sale, gift, distribution or use of any alcoholic beverage including the selling, serving or giving of any alcoholic beverage to a person under the legal drinking age. 2 B. Defense and Settlement 1. The Underwriters shall have the right and duty to defend the Insured subject to the Limit of Liability, for any Claim first made against the Insured seeking payment under the terms of this insurance, even if any of the allegations of the Claim are groundless, false or fraudulent. The Underwriters shall choose defense counsel in conjunction with the Insured, but in the event of a dispute, the decision of the Underwriters is final. 2. It is agreed that the Limit of Liability available to pay Damages shall be reduced and may be completely exhausted by payment of Claims Expenses. Damages and Claims Expenses shall be applied against the Deductible set forth in Item 4 of the Declarations. 3. The Underwriters shall have the right to make any investigation they deem necessary, including, without limitation, any investigation with respect to coverage and statements made in the application. 4. If the Insured refuses to consent to any settlement or compromise recommended by the Underwriters and acceptable to the Claimant and elects to contest the Claim, the Underwriters' liability for any Damages and Claims Expenses shall not exceed the amount for which the Claim could have been settled, less the remaining Deductible, plus the Claims Expenses incurred up to the time of such refusal, or the applicable Limit of Liability, whichever is less, and the Underwriters shall have the right to withdraw from the defense of the Claim by tendering control of said defense to the Insured. 5. Subject to the Limit of Liability of this Policy, the Underwriters shall pay all premiums on bonds to release attachments, all premiums on appeal bonds required in any such defended suit, but without any obligation to apply for or furnish such bonds, all costs taxed against the Insured in any suit, all interest accruing after entry of judgment until Underwriters have paid, tendered or deposited in courts such part of such judgment as does not exceed the Underwriters' Limit of Liability. 6. Subject to the Limit of Liability of this Policy, the Underwriters shall reimburse the Insured for all reasonable expenses, other than loss of earnings, incurred at the Underwriters' request. 7. It is further provided that the Underwriters shall not be obligated to pay any Damages or Claims Expenses, or to undertake or continue defense of any Claim after the applicable Limit of Liability has been exhausted by payment of Damages or Claims Expenses or after deposit of the remaining applicable Limit of Liability in a court of competent jurisdiction, and that upon such payment, the Underwriters shall have the right to withdraw from the further defense of the Claim by tendering control of said defense to the Insured. II. SUPPLEMENTARY PAYMENTS - INSURING AGREEMENTS I.A.1 AND I.A.2 1. Underwriters will pay, with respect to any Claim that Underwriters investigate or settle, or any Suit against an Insured that Underwriters defend: 3 a. Actual loss of earnings and reasonable expenses due to the Insured's attendance at mediation meetings, arbitration proceedings, hearings and trials. The maximum the Underwriters will pay is $500 per day for all Insureds and up to a total of $10,000 for each Claim. b. Actual loss of earnings and reasonable expenses due to the Insured's attendance at a deposition. The maximum the Underwriters will pay is $5,000 for each Deposition and up to a total of $25,000 during any one Policy Period. 2. Underwriters will pay up to $500 for each Accident, subject to a $5,000 Aggregate Limit of Liability during any one Policy Period, for Property Damage occurring during the Policy Period to property of others in the care, custody or control of the Insured. However, Underwriters will not pay for Property Damage to property of others in the care, custody or control of the Insured: a. Caused intentionally by any Insured who has reached the age of majority in the Insured's state; or b. Who are tentants of, or residents, in the Insured's premises; or c. Arising out of the ownership, use, maintenance or entrustment to other of an Automobile, Mobile Equipment, watercraft or aircraft. 3. Underwriters will pay up to $5,000, subject to a $10,000 aggregate limit during any one Policy Period, for fees, costs and expenses associated with each investigation or proceedings brought by a state licensing board or other regulatory body in relation to the Insured's Professional Services license. However, Underwriters will not pay any expenses or fees arising out of or resulting from criminal proceedings. These supplementary payments will not reduce the limits of liability. III. PERSONS INSURED Each of the following is an Insured under this insurance to the extent set forth below: A. if the Named Insured designated in Item 1 of the Declarations is an individual, the person so designated but only with respect to the conduct of the business of which he or she is the sole proprietor, and the spouse of the Named Insured with respect to the conduct of such a business, and any employee, student, intern or volunteer worker while acting within the scope of his or her duties as such; B. if the Named Insured designated in Item 1 of the Declarations is a partnership or joint venture, the partnership or joint venture so designated, any Predecessor Firm, and any partner or member thereof but only with respect to his or her liability as such and any employee, student, intern or volunteer worker while acting within the scope of his or her duties as such; C. if the Named Insured designated in Item 1 of the Declarations is other than an individual, partnership or joint venture, the organization so designated, any Predecessor Firm, and any executive officer, director, stockholder, employee, 4 student, intern, administrator or volunteer worker thereof while acting within the scope of his or her duties as such;; D. any person who previously qualified as an Insured under (c) above prior to the termination of the required relationship with the Named Insured, but solely with respect to: 1. Professional Services performed on behalf of the Named Insured designated in Item 1 of the Declarations, or 2. an Accident arising solely out of the Named Insured's operations occurring prior to the termination of the required relationship with the Named Insured; E. the estate, heirs, executor, administrators, assigns and legal representatives of any Insured in the event of the Insured's death, incapacity, insolvency or bankruptcy, but only to the extent that such Insured would otherwise be provided coverage under this Policy; and F. An Additional Insured, but only as respects the vicarious liability of such individual or entity: i. for Bodily Injury caused by negligent acts, errors or omissions of the Named Insured otherwise covered under Insuring Agreement I.A.1 Professional Services Liability of this policy. ii. For Personal Injury, Property Damage or Advertising Liability caused by an Accident otherwise covered by Insuring Agreement I.A.2, General Liability of this policy. iii. For Property Damage arising out of any one fire or any one Water Damage as covered by Insuring Agreement I.A.3, Fire and Water Damage Legal Liability of this policy. This Policy shall not apply to any liability arising out of the conduct of any partnership or joint venture of which the Insured is a partner or member and which is not designated in this Policy as a Named Insured. IV. TERRITORY This insurance applies to negligent acts, errors, omissions or Accidents which take place anywhere in the world, provided the Claim is first made against the Insured within the United States of America, its possessions and territories, - Puerto Rico and Canada. V. EXCLUSIONS 1. Exclusions applicable to Insuring Agreement I.A.1, Professional Liability The coverage under this Policy does not apply to Damages or Claims Expenses incurred with respect: a. to any Claim arising out of Personal Injury, Property Damage or Advertising Liability, except with respect to Bodily Injury arising out of any negligent act, error or omission of any Insured in the rendering or failing to render Professional Services; 5 b. to any Claim arising out of any criminal, dishonest, fraudulent or malicious act, error or omission of any Insured, committed with actual criminal, dishonest, fraudulent or malicious purpose or intent. However, notwithstanding the foregoing, the insurance afforded by this Policy shall apply to Claims Expenses incurred in defending any such Claim, but shall not apply to any Damages which the Insured might become legally obligated to pay; c. to any Claim arising out of or relating to any liability under any contract or agreement, whether written or oral, unless such liability would have attached to the Insured in the absence of such contract or agreement; d. to any Claim based upon an express or implied warranty or guarantee, or breach of contract in respect of any agreement to perform work for a fee; e. to any Claim arising out of any Insured's activities as a trustee, partner, officer, director or employee of any trust, charitable organization, corporation, company or business other than that of the Named Insured; f. to any Claim arising out of failure to pay any bond, interest on any bond, any debt, financial guarantee or debenture; g. to any Claim arising out of any financial or investment advice given, referrals, warranties, guarantees or predictions of future performance made by any Insured as regards specific and identifiable investment items including but not limited to personal property, real property, stocks, bonds or securities; h. to any Claim arising out of the actual or alleged publication or utterance of libel or slander or other defamatory or disparaging material, or a publication or utterance in violation of an individual's right to privacy; i. to any Claim arising out of actual or alleged plagiarism, misappropriation of likeness, breach of confidence, or misappropriation or infringement of any intellectual property right, including patent, trademark, trade secret, trade dress and copyright. J� to any Claims arising out of any negligent act, error or omission of any Insured in the rendering or failing to render Professional Services, if the Insured did not hold a valid license or certificate at the time of the performance of the Professional Services, except as provided for in Section XXVII, Licensure. k. to any Claim arising out of any negligent act, error or omission of any Insured in the rendering or failing to render Professional Services to Professional Athletes. I. to any Claim arising out of any negligent act, error or omission of any Insured in the rendering or failing to render Professional Services to residents of Nursing Homes, Assisted Living Housing and/or Independent Living Housing facilities. However, this exclusion does not apply if the Professional Services provided are counseling or pastoral counseling. 6 2. Exclusions applicable to Insuring Agreement I.A.2, Insuring Agreement I.A.3 and Insuring Agreement I.A.5 The coverage under this Policy does not apply to Damages or Claims Expenses incurred with respect: a. to any Claim arising out of the rendering of or failure to render Professional Services by any Insured or by any person or organization for whose acts or omissions the Named Insured is legally responsible; b. to any Claim arising out of Personal Injury or Property Damage resulting from the use of force expected or intended from the standpoint of the Insured; c. to any Claim for liability arising out of Personal Injury or Property Damage arising out of ownership, maintenance, operation, use, loading or unloading of: 1. any Automobile, Aircraft or Watercraft owned or operated by or rented or loaned to any Insured; or 2. any other Automobile, Aircraft or Watercraft operated by any person in the course of his or her employment or volunteer duties for any Insured; d. to any Claim arising out of Personal Injury or Property Damage arising out of: 1. the ownership, maintenance, operation, use, loading or unloading of any Mobile Equipment while being used in any prearranged or organized racing, speed or demolition contest or in any stunting activity or in practice or preparation for such contest or activity; or 2. the operation or use of any snowmobile, moped or motorized bicycle, or trailer designed for use therewith; e. to any Claim for Personal Injury or Property Damage arising out of and in the course of the transportation of Mobile Equipment by any Automobile owned or operated by or rented or loaned to any Insured; f. to any Claim arising out of Personal Injury, Property Damage or Advertising Liability for which the Insured or his or her indemnitee may be held liable: 1. as a person or organization engaged in the business of manufacturing, distributing, selling, or serving alcoholic beverages; or 2. if not so engaged, as an owner or lessor of premises used for such purposes, if such liability is imposed by, or because of the violation of, any statute, ordinance or regulation pertaining to the sale, gift, distribution or use of any alcoholic beverage; 9� to any Claim arising out of Personal Injury to: 1. any employee or volunteer of the Named Insured arising out of and in the course of his employment or retention by the Named Insured; or 2. the spouse, child, parent, brother or sister of the employee as a consequence of above. This exclusion applies: (i) whether the Insured may be liable as an employer or in any other capacity; and (ii) to any obligation to share Damages with or repay someone else who must pay Damages arising out of such liability; h. to any Claim arising out of Property Damage to: 1. property owned , rented or temporarily occupied by the Insured with permission of the owner, including fixtures permanently attached thereto, any costs or expenses incurred by the Insured, or any other person, organization, entity for repair, replacement, enhancement, restoration or maintenance of such property for any reason, including prevention of injury to a person or damage to another's property 2. Premises given away, sold or abandoned by the Insured if the Property Damage arises out of any part of those premises 3. Property loaned to the Insured; 4. that particular part of real property on which the Insured or any contractors or subcontractors working directly or indirectly on behalf of the Insured or temporarily occupied by the Insured as to premises rented to the Insured or temporarily occupied by the Insured with permission of the owner if such Property Damage arises out of those operations. 5. that particular part of any property that must be restored, repaired or replaced because the Insured's work was incorrectly performed on it. Paragraph 1, 2 and 3 of this Exclusion does not apply to Property Damage to premises rented to the Insured or temporarily occupied by the Insured with permission of the owner, if such Property Damage arises out of fire or Water Damage. Paragraph 2.of this Exclusion does not apply if the premises are the Insured's work and were never occupied, rented or held for rental by the Insured. Paragraphs 3, 4, & 5.. of this Exclusion does not apply to liability assumed under a sidetrack agreement. i. to any Claim arising out of Property Damage to premises owned or alienated by the Named Insured arising out of such premises or any part thereof. However, in relation to coverage I.A.3 (Fire and Water Damage Legal Liability) this exclusion does not apply to Property Damage to structures or portions thereof rented to or occupied by the Named Insured, including fixtures permanently attached thereto, if such Property Damage arises out of fire or Water Damage; to any Claim arising out of loss of use of tangible property which has not been physically injured or destroyed resulting from: 8 1. a delay in or lack of performance by or on behalf of the Named Insured of any contract or agreement; or 2. the failure of the Named Insured's Products or work performed by or on behalf of the Named Insured to meet the level of performance, quality, fitness or durability warranted or represented by the Named Insured; but this Exclusion does not apply to loss of use of the other tangible property resulting from the sudden and accidental injury to or destruction of the Name Insured's Products or work performed by or on behalf of the Named Insured after such products or work have been put to use by any person or organization other than the Insured; k. to any Claim arising out of Property Damage to the Named Insured's Products, or for the cost of inspecting, repairing or replacing any defective or allegedly defective product or part thereof or for loss of use of any defective or allegedly defective product; I. to any Claim arising out of Property Damage to work performed by or on behalf of the Named Insured arising out of the work or any portion thereof, or out of materials, parts or equipment furnished in connection therewith; m. to any Claim arising out of the withdrawal, recall, inspection, repair, replacement or loss of life of the Named Insured's Products or work completed by or for the Named Insured or of any property of which such products or work form a part, if such products, work or property are withdrawn from the market or from use because of any known or suspected defect or deficiency therein; n. to any Claim arising out of Aircraft Products, including, but not limited to, consequential loss of use thereof resulting from Grounding; o. to any Claim relating to Advertising Liability arising out of: 1. failure of performance of contract; provided, however, that this Exclusion shall not apply to the unauthorized appropriation of ideas based upon alleged breach of an implied contract; 2. infringement of patent, trademark, service mark, and trade name, other than titles or slogans by use thereof on or in connection with goods, products or services sold, offered for sale or advertised; or 3. incorrect description or mistake in advertised price of goods, products or services sold, offered for sale or advertised. 3. Exclusions applicable to Insuring Agreement I.A.4 Medical Payments The Underwriters will not pay expenses for Bodily Injury: a. To any Insured; b. To a person hired to do work for or on behalf of any Insured or a tenant of the Insured; c. To a person injured on that part of the premises the Named Insured owns or rents that the person normally occupies; 9 d. To a person, whether or not an Employee of any Insured, if benefits for the Bodily Injury are payable or must be provided under a workers' compensation or disability benefits law or a similar law; e. Due to war, whether or not declared, or any act or condition incidental to war. War shall include civil war, insurrection, rebellion or revolution; f. Excluded under the Professional Liability Coverage; or g. To any prisoner. 4. Exclusions applicable to all insuring agreements. The coverage under this Policy does not apply to Damages or Claims Expenses incurred with respect: a. to any Claim made by or against or in connection with any business enterprise (including the ownership, maintenance or care of any property in connection therewith), not named in the Declarations, which is owned by any Insured or in which any Insured is a trustee, partner, officer, director or employee; b. to any Claim arising out of the Employee Retirement Income Security Act of 1974 and its amendments or any regulation or order issued pursuant thereto; c. to any Claim or circumstance which might lead to a Claim in respect of which any Insured has given notice to any insurer of any other policy or self -Insurance in force prior to the effective date of this Policy; d. to any Claim or circumstance which might lead to a Claim known to any Insured prior to the inception of this Policy and not disclosed to the Underwriters at inception; e. to any Claim or circumstance that might lead to a Claim arising out of any negligent act, error or omission or Accident which first took place, or is alleged to have taken place, prior to the Retroactive Date as set forth in Item 6 of the Declarations; f. to any Claim arising out of discrimination including but not limited to discriminatory employment practices, allegations of actual or alleged violations of civil rights or acts of discrimination based entirely or in part on the race, gender, pregnancy, national origin, religion, age or sexual orientation; 9. to any Claim directly or indirectly arising out of: 1. the actual, alleged or threatened discharge, dispersal, release or escape or failure to detect the presence of Pollutants, provided that this Exclusion shall not apply to: (i) Personal Injury sustained by any patient, visitor or invitee; and (ii) Personal Injury or Property Damage arising out of heat, smoke or fumes from a Hostile Fire; 2. the manufacture, distribution, sale, resale, rebranding, installation, repair, removal, encapsulation, abatement, replacement or handling of, exposure to or testing for 10 Pollutants contained in a product, carried on clothing, inhaled, transmitted in any fashion or found in any form whatsoever; or 3. any governmental or regulatory directive or request that the Insured or anyone acting under its direction or control to test for, monitor, clean up, remove, contain, treat, detoxify or neutralize said Pollutants; h. to any Claim arising out of the insolvency or bankruptcy of any Insured or of any other entity including but not limited to the failure, inability, or unwillingness to pay Claims, losses or benefits due to the insolvency, liquidation or bankruptcy of any such individual entity; i. to any Claim arising out of or resulting from: 1. any conduct, physical act, gesture, or spoken or written words of a sexual or physically violent nature by any Insured, including but not limited to, sexual intimacy (whether or not consensual), sexual molestation, sexual or physical assault or battery, sexual or physical abuse, sexual harassment or exploitation; or 2. the Insured's actual or alleged negligent employment, investigation, supervision, hiring, training or retention of any Employee, Insured or person for whom the Insured is legally responsible and whose conduct falls within paragraph (1), above. to any Claim for punitive or exemplary Damages, or Damages which are a multiple of compensatory Damages, fines, sanctions, taxes or penalties, or the return of or reimbursement for fees, costs or expenses charged by any Insured; k. to any Claim arising out of Personal Injury to any employee or volunteer worker of the Insured arising out of and in the course of his employment by the Insured, or under any obligation for which the Insured or any carrier as his insurer may be liable, under any Workers' Compensation, Unemployment Compensation, Disability Benefits Law or under any similar law; I. to any Claim based upon or arising out of a violation or alleged violation of the Securities Act of 1933 as amended, or the Securities Exchange Act of 1934 as amended, or any State Blue Sky or securities law or similar state or Federal statute and any regulation or order issued pursuant to any of the foregoing statutes; m. to any Claim or actual or alleged violation of the Racketeer Influenced and Corrupt Organizations Act, 18 U.S.C. §1961 et seq., and any amendments thereto, or any rules or regulations promulgated thereunder; n. to any Claim arising from costs of complying with physical modifications to any premises or any changes to the Insured's usual business operations mandated by the Americans with Disabilities Act of 1990, including any amendments, or similar federal, state or local law; o. to any Claim based upon or arising out of any actual or alleged violation of any federal, state, or local anti-trust, restraint or trade, unfair competition, or price fixing law, or any rules or regulations promulgated thereunder; p. to any Claim caused directly or indirectly, in whole or in part, by: 11 1. any fungus(es) or spore(s); 2. any substance, vapour or gas produced by or arising out of any fungus(es) or spore(s); or 3. any materials, product, building component, building or structure that contains, harbours, nurtures or acts as a medium for any fungus(es) or spore(s); regardless of any other cause, event, material, product and/or building component that contributed concurrently or in any sequence to that injury or Damages. For the purposes of this Exclusion, the following Definitions are added: "Fungus(es)" includes, but is not limited to, any form of mold, mushroom or mildew. "Spore(es)" mean any reproductive body produced by or arising out of any fungus(es). This Exclusion shall not apply to Claims arising from medical research activities that would otherwise be covered hereunder; q. to any Claim based upon or arising out of any action or proceeding brought by or on behalf of any federal, state or local governmental, regulatory or administrative agency, regardless of the name in which such action or proceeding is brought, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996, the Social Security Act, 42 U.S.C. §1320a, et. seq., or similar state or federal statute, regulation or executive order promulgated thereunder. However this exclusion does not apply to those costs, fees and expenses otherwise covered under Section II. Supplementary Payments, Paragraph 3. r. to any Claim based upon or arising out of any Insured's data processing services, including but not limited to: 1. conversion of data from source material into media for processing on the Insured's electronic data processing system; 2. processing of data by the Insured on the Insured's electronic data processing system; or 3. design or formulation of an electronic data processing program or system; s. to any Claim for Personal Injury, Property Damage or Advertising Liability based upon or arising out of the Named Insured's Products; t. to any Claim based upon the manufacture, handling, sale or distribution of Phenylpropanolamine, Phenylpropanolamine Hydrochloride, PPA or any product or drug containing any of these substances; u. to any Claim arising out of any actual or alleged act, error or omission in the rendering or failing to render pharmacy services, including the manufacture, sale, distribution, handling or resale of any pharmaceuticals or drugs, whether on a wholesale, retail, over-the-counter or illegal basis; v. to any Claim based on the willful non-compliance of any Insured with any Food and Drug Administration (FDA) rules, regulations, and statutes found at Food and Drugs, 21 C.F.R. Chapter 1 § 1.1 to § 1299, as amended and revised, or treating a patient 12 with drugs, medical devices, biologics or radiation -emitting products that have been disapproved or not yet approved by the FDA; w. to any Claim based upon or arising out of any Insured gaining any profit, remuneration or advantage to which such Insured was not legally entitled; x. to any Claim against any subsidiary designated in the Declarations or its past, present, or future employees, directors, officers, trustees, review board or committee members, or volunteers acting in his or her capacity as such, which are based upon, arise out of, directly or indirectly result from, are in consequence of, or in any way involve any fact, circumstance, situation, transaction, event, Accident, or negligent acts, errors or omissions or series of facts, circumstances, situations, transactions, events, Accidents or negligent acts, errors or omissions happening before the date such entity became a subsidiary; y. to any Claim relating to or arising out of asbestos, silica or lead; z. to any Claim associated with implementation of any compliance program or any policies, procedures or practices relating to participation as a provider of medical services to a managed care organization or under a healthcare benefit program, whether initiated voluntarily or pursuant to direction by, order of, or in settlement with a government body, hospital, healthcare facility or managed care organization; aa. to any Claim based upon, arising out of, resulting from, any actual or alleged: (1) failure to obtain, effect, or maintain any form, policy, plan or program of insurance, stop loss or provider excess coverage, reinsurance, self-insurance, suretyship, or bond; (2) commingling, mishandling of or liability to pay, collect or safeguard funds; or (3) failure to collect or pay premiums, commissions, brokerage charges, fees or taxes; bb. to any Claim for Personal Injury, Property Damage or Advertising Liability due to war, whether or not declared, civil war, insurrection, rebellion or revolution or to any act or condition incident to any of the foregoing; cc. to any Claim brought against any Insured by any other Insured hereunder; dd. to any Claim arising out of or resulting from the distribution of unsolicited email, direct mail or facsimiles, or telemarketing; ee. to any Claim arising out of or resulting from the existence, emission or discharge of any electromagnetic field, electromagnetic radiation or electromagnetism that actually or allegedly affects the health, safety or condition of any person, or the environment, or that affects the value, marketability, condition or size of any property, provided this Exclusion shall not apply to any patient receiving Professional Services including but not limited to the medical administration of radiation therapy ff. to any Claim arising out of or resulting from or in relation to Acquired Immune Deficiency Syndrome (AIDS), meaning the potential or actual transmission of or exposure to Human Immunodeficiency Virus (HIV), AIDS -Related Complex (ARC), hepatitis or any other infectious disease or any complex or syndrome related thereto, or the use or misuse or confidentiality of any information relating to HIV, ARC, AIDS, hepatitis or any other infectious disease, including the failure to disclose the health status of the Insured. 13 VI. DEFINITIONS Wherever used in this Policy, the bolded terms have the meaning provided: a. "Accident" means an event or happening, including continuous or repeated exposure to substantially the same general harmful conditions, which involves one or more persons or entities, and which results in Personal Injury, Property Damage or Advertising Liability to such persons or entities. b. "Additional Insured" means: 1. any natural person or entity that the Named Insured has expressly agreed in writing to add as an Additional Insured under this policy in the Certificate of Insurance provided by Underwriters prior to the commission of any act for which such person or entity would be provided coverage for under this Policy, but only to the extent the Named Insured would have been liable and coverage would have been afforded under the terms and conditions of this Policy had such Claim been made against the Named Insured; and 2. any other person or entity added as an Additional Insured by endorsement to this Policy c. "Advertising Liability" means injury arising out of one or more of the following, committed in the course of the Insured's advertising activities: (1) libel, slander or defamation; (2) infringement of copyright, title slogan, trade dress, or advertising idea; (3) piracy or idea misappropriation under an implied contract; or (4) invasion of right of privacy, subject always to Exclusion V.4.q. d. "Aircraft Products" means any aircraft whether or not heavier than air (including spacecraft and missiles) and any ground support, guidance, control or communications equipment used in connection therewith, and also includes parts, supplies, or equipment installed in or on or used in connection with aircraft, including tools, training aids, instructions, manuals, blue prints and other data, engineering and other advice, services and labor used in the operation, maintenance or manufacture of such products. a. "Allied Health Professional" is a professional who is licensed and/or certified to work in any of a wide range of professions in relation to healthcare or its related services, other than nursing, pharmacy and medicine. Allied Health Professional does not include services such as a physician, physician assistant, surgeon, dentist, osteopath, podiatrist, orthodontist, chiropractor, psychiatrist, psychologist, pharmacist, EMT, nurse, nurse practitioner, midwife, engineer, engineering consultant, safety inspector, jobsite safety trainer or consultant, environmental inspector or consultant or other services excluded by endorsement to this policy. 14 b. "Assisted Living Housing and/or Independent Living Housing" means any residential apartment, home, condominium or other dwelling wherein an individual or group(s) of individuals receive personalized supportive services and health care designed to meet the needs of those who need help with activities of daily living. c. "Automobile" means a land motor vehicle, trailer or semi -trailer designed for travel on public roads (including any machinery or apparatus attached thereto), but does not include Mobile Equipment, as hereinafter defined. d. "Bodily Injury" means physical injury (including death at any time resulting therefrom), mental injury, mental illness, mental anguish, humiliation, emotional upset, shock, sickness, disease or disability. e. "Claim" means a written notice received by any Insured of an intention to hold the Insured responsible for compensation for Damages, including the service of suit or institution of arbitration proceedings against the Insured. f. "Claims Expenses" means: (1) reasonable and customary fees charged by an attorney(s) designated and agreed by the Underwriters in consultation with the Insured, but subject always to the Underwriters' final decision; and (2) all other fees, costs and expenses resulting from the investigation, adjustment, defense and appeal of a Claim, if incurred by the Underwriters, or by the Insured with the written consent of the Underwriters. Claims Expenses does not include any salary, overhead or other charges by the Insured for any time spent in co-operating in the defense and investigation of any Claim or circumstance which might lead to a Claim notified under this insurance. g. "Damages" means a civil monetary judgment, award or settlement and does not include: (1) the restitution of compensation and expenses paid to the Insured for services and goods; and (2) judgments or awards deemed uninsurable by law. h. "Extended Reporting Period", if applicable, means the period of time stated in item 7 the Declarations page after the end of the Policy Period for reporting Claims, arising out of negligent acts, errors or omissions or Accidents which take place prior to the end of the Policy Period but subsequent to the Retroactive Date identified in Item 6 of the Declarations. i. "Grounding" means the withdrawal of one or more aircraft from flight operations or the imposition of speed, passenger or load restrictions on such aircraft because of the existence of or alleged existence of a defect, fault or conditions in any Aircraft Product. 1� "Hostile Fire" means a fire which becomes uncontrollable or breaks out from where it was intended to be. 15 k. "Mobile Equipment" means a land vehicle (including any attached machinery or apparatus) whether or not self-propelled: (1) not subject to motor vehicle registration; (2) maintained for use exclusively on premises owned by or rented to the Named Insured, including the ways immediately adjoining; (3) designed for use principally off public roads; or (4) designed or maintained for the sole purpose of affording mobility to equipment of the following types forming an integral part of or permanently attached to such vehicle: (i) power cranes, shovels, loaders, diggers and drills; (ii) concrete mixers (other than the mix -in -transit type), graders, scrapers, rollers and on the road construction or repair equipment; (iii) air -compressors, pumps and generators including spraying, welding and building cleaning equipment; or (iv) geophysical exploration and well servicing equipment. I. "Named Insured" means the entity or person who, as an Allied Health Professional, is identified in Item 1 of the Declarations and who is a Specified Member of the Risk Purchasing Group identified in the Declarations. m. "Named Insured's Products" means goods or products manufactured, sold, handled or distributed by the Named Insured or by others trading under its name including but not limited to vitamins, dietary supplements, performance enhancing drugs and automated external defibrillators. Named Insured's Products includes any container thereof (other than a vehicle), but shall not include a vending machine or any property, other than such container rented to or located for use of others but not sold. n. "Nursing Home" means a residence or dwelling that provides rooms, meals and help with the daily living activities and recreation for residents who have physical or mental problems that keep them from living on their own and who require daily assistance. o. "Personal Injury" means: (1) Bodily Injury; (2) false arrest, false imprisonment, wrongful eviction, detention or malicious prosecution; (3) libel, slander, defamation of character or invasion of right of privacy, unless arising out any advertising activities; or (4) wrongful eviction from, wrongful entry into, or invasion of the right of private occupancy of a room, dwelling or premises that a person occupies, committed by or on behalf of its owner, landlord or lessor. 16 P. "Policy Period" means the period of time between the inception date and the effective date of termination, expiration or cancellation of this insurance shown in Item 2 of the Declarations and specifically excludes any Extended Reporting Period. q� "Pollutants" means any solid, liquid, gaserous or thermal irritant or contaminant, including but not limited to asbestos and/or lead (or products containing asbestos and/or lead whether or not the asbestos and/or lead is or was at any time airborne as a fibre or particle, contained in a product, carried on clothing, inhaled, transmitted in any fashion or found in any form whatsoever), smoke, vapour, soot fumes, acids, alkalis, toxic chemicals and waste (waste includes materials to be recycled, reconditioned or reclaimed). r. "Predecessor Firm" means any sole proprietorship, partnership, corporation, professional association, limited liability corporation or limited liability partnership engaged in Professional Services and to whose financial assets and liabilities the Named Insured is the successor in interest. s. "Professional Athlete" means an individual or group(s) of individuals who have been paid $25,000 or more per year in the past 36 months, or is likely to be paid $25,000 or more in the future, from a professional sports organization, club or team for the performance of athletic activities. t. "Professional Services" means those professional services performed by the Insured as an Allied Health Professional and listed in the Application, prior written approval from the Underwriters. Professional Services include services as an educator or as a member of a formal accreditation, standards review or similar board or committee. u. "Property Damage" means: (1) physical injury to or destruction of tangible property, including consequential loss of use thereof; or (2) loss of use of tangible property which has not been physically injured or destroyed. v. "Water Damage" means discharge, leakage or overflow of water or steam from a plumbing, heating, refrigeration or air conditioning system; or rain which enters directly into the building through open doors, windows, skylights, transoms or ventilators. VII. LIMIT OF LIABILITY A. Policy Aggregate Limit The Policy Aggregate Limit of Liability stated in Item 3.E of the Declarations is the Underwriters' combined total limit of liability payable under all Insuring Agreement under this Policy. B. Professional Liability Limit 17 1. The sublimit of liability stated in Item 3.A (i) of the Declarations as "Each Claim" is the Underwriters' sublimit of Liability payable under Insuring Agreement I.A.1 Professional Liability. 2. The sublimit of liability stated in Item 3.A (ii) of the Declarations is the Underwriters' aggregate sublimit of liability payable under Insuring Agreement I.A.1 Professional Liability. C. General Liability (includes Host Liquor Liability) 1. The sublimit of liability stated in Item 3.B (i) of the Declarations as "Each Accident" is the Underwriters' sublimit of liability payable under Insuring Agreement I.A.2 General Liability and Insuring Agreement I.A.5 Host Liquor Liability 2. The sublimit of liability stated in Item 3.B (ii) of the Declarations is the Underwriters' aggregate sublimit of liability payable under both Insuring Agreement I.A.2 General Liability and Insuring Agreement I.A.5 Host Liquor Liability D. Fire and Water Damage Legal Liability The sublimit of liability stated in Item 3.C of the Declarations is the maximum limit of Underwriters' liability for all Damages and Claims Expenses payable under Insuring Agreement I.A.3, Fire and Water Damage Legal Liability coverage resulting from any one fire/water damage. E. Medical Expenses 1. The sublimit of liability stated in Item 3.D (i) of the Declarations as "Each Person" is the Underwriters' sublimit of liability payable under Insuring Agreement I.A.4, Medical Expenses. 2. The sublimit of liability stated in Item 3.D (ii) of the Declarations is the Underwriters' aggregate sublimit of liability payable under Insuring Agreement I.A.4 Medical Expenses F. The Limit of Liability for any Extended Reporting Period shall be part of, and not in addition to, the Underwriters' Limit of Liability for the Policy Period. G. In the event a Claim triggers coverage under more than one coverage section, only one Limit of Liability shall apply and the Underwriters' liability under such coverage sections combined shall not exceed the amount of the largest of the applicable Limits of Liability. VIII. DEDUCTIBLE As a condition precedent to the payment by the Underwriters of any amounts due hereunder the Deductible amount stated in Item 4 of the Declarations shall be satisfied by payments by the Insured of Damages and/or Claims Expenses resulting from each Claim first made and reported to the Underwriters during the Policy Period and/or any applicable Extended Reporting Period. The Underwriters shall be liable only for the amounts in excess of such Deductible subject to the Underwriters' Limit of Liability in Item 3 of the Declarations. The Deductible is in addition to the Underwriters' Limit of Liability and not part thereof. The Insured shall make direct payments within the Deductible to appropriate parties designated 18 by the Underwriters. The Deductible is to be uninsured, unless otherwise agreed to by the Underwriters. Under no circumstances shall Underwriters be called upon to pay the Deductible, but the Underwriters may do so at their sole discretion. Such payment shall in no way affect the Underwriters' ability to collect the Deductible from the Insured. The existence of "other insurance" shall not affect or abrogate the obligation of the Insured to pay the Deductible as required. In the event a Claim triggers coverage under more than one coverage section, only one Deductible shall apply and such Deductible shall be the largest Deductible applicable to such Claim. IX. INNOCENT INSURED Whenever coverage under this insurance would be excluded, suspended or lost: A. because of Exclusion V 1. (b) or Exclusion V 2. (b) relating to intentional, criminal, dishonest, fraudulent or malicious acts, errors or omissions by any Insured, and with respect to which any other Insured did not personally participate or personally acquiesce or remain passive after having personal knowledge thereof; or B. because of non-compliance with any condition relating to the giving of notice to the Underwriters with respect to which any other Insured shall be in default solely because of the failure to give such notice or concealment of such failure by one or more Insureds responsible for the loss or damage otherwise covered hereunder; the Underwriters agree that such insurance as would otherwise be afforded under this Policy shall be paid with respect to those Insureds who did not personally participate in committing or personally acquiesce in or remain passive after having personal knowledge of (a) one or more of the acts, errors or omissions described in any such exclusion; or (b) such failure to give notice, provided that the condition be one with which such Insured can comply, and after receiving knowledge thereof, the Insured entitled to the benefit of Section IX shall comply with such condition promptly after obtaining knowledge of the failure of any other Insured to comply therewith. With respect to this provision, the Underwriters' obligation to pay in such event shall be in excess of the full extent of any assets of any Insured to whom the exclusion applies and shall be subject to the terms, conditions and limitations of this Policy. X. EXTENDED REPORTING PERIOD A. In the event of cancellation or non -renewal of this insurance by the Underwriters, the Named Insured designated in Item 1 of the Declarations shall have the right to a 12, 24 or 36 month Extended Reporting Period for Claims first made against any Insured and reported to the Underwriters during the Extended Reporting Period, subject to the conditions set forth in the definition of Extended Reporting Period herein. In order for the Named Insured to invoke the Extended Reporting Period option, the payment of the additional premium set forth in Item 7 (a) (b) or (c) of the declarations for the Extended Reporting Period must be paid to the Underwriters within 30 days of the non -renewal or cancellation. B. The Limit of Liability for the Extended Reporting Period shall be part of, and not in addition to, the Underwriters' Limit of Liability for the Policy Period. 19 C. The quotation by the Underwriters of a different premium or Deductible or Limit of Liability or changes in Policy language for the purpose of renewal shall not constitute a refusal to renew by the Underwriters. D. The right to the Extended Reporting Period shall not be available to the Named Insured where cancellation or non -renewal by the Underwriters is due to non-payment of premium or failure of an Insured to pay such amounts in excess of the applicable Limit of Liability or within the applicable Deductible. E. All notices and premium payments with respect to the Extended Reporting Period shall be directed to the Underwriters through the entity named in Item 8 of the Declarations. F. At the commencement of the Extended Reporting Period, the entire premium shall be deemed earned, and in the event the Named Insured terminates the Extended Reporting Period for any reason prior to its natural expiration, the Underwriters will not be liable to return any premium paid for the Extended Reporting Period. XI. OTHER INSURANCE This insurance shall apply in excess of any other valid and collectible insurance or self- insurance available to any Insured, unless such other insurance is written only as specific excess insurance over the Limit of Liability of this Policy. The insurance provided for Property Damage to the structures or portions thereof rented to or temporarily occupied by the Insured, including fixtures permanently attached thereto, where coverage is provided under Coverage I.A.3. above, shall be excess insurance over any valid and collectible property insurance (including any deductible portion thereof) available to the Insured. XII. NOTICE OF CLAIM, OR CIRCUMSTANCE THAT MIGHT LEAD TO A CLAIM A. If any Claim is made against the Insured, the Insured shall immediately notify the Underwriters in writing through persons named in Item 8 of the Declarations and forward even/ demand, notice, summons or other process received by the Insured or its representative. The Insured's duty to provide notice in accordance with this provision is a condition precedent to coverage. B. If during the Policy Period the Insured first becomes aware of a negligent act, error or omission or an Accident that could lead to a Claim, it must give written notice to the Underwriters through persons named in Item 8 of the Declarations during the Policy Period of: (1) the specific, negligent act, error, or omission, or Accident; (2) the injury or damage which may result or has resulted from the negligent act, error, or omission or Accident; and (3) the circumstances by which the Insured first became aware of the negligent act, error or omission or Accident. 20 Any subsequent Claim made against the Insured which is the subject of the written notice shall be deemed to have been made at the time written notice was first given to the Underwriters. C. A Claim or circumstance that might lead to a Claim shall be considered to be reported to the Underwriters when notice is received by the Underwriters through persons named in Item 8 of the Declarations. D. All Claims arising out of the same, continuing or related negligent act, error or omission or arising out of the same, continuous or related Accident shall be considered a single Claim and deemed to have been made at the time the first of the related Claims is reported to the Underwriters. Such related Claims shall be subject to the each claim Limit of Liability identified in the Declarations. E. In the event of non -renewal of this insurance by the Underwriters, the Insured shall have thirty (30) days from the expiration date of the Policy Period to notify the Underwriters of Claims made against the Insured during the Policy Period which arise out of any negligent act, error or omission or Accident occurring prior to the termination date of the Policy Period and otherwise covered by this insurance. F. If any Insured shall make any Claim under this Policy knowing such Claim to be false or fraudulent, as regards amount or otherwise, this Policy shall become null and void and all coverage hereunder shall be forfeited. XIII. ASSISTANCE AND CO-OPERATION OF THE INSURED The Insured shall co-operate with the Underwriters in all investigations, including regarding the application and coverage under this Policy, and upon the Underwriters' request, assist in making settlements, in the conduct of suits and in enforcing any right of contribution or indemnity against any person or organization other than an employee of any Insured who may be liable to the Insured because of negligent acts, errors or omissions or Accidents with respect to which insurance is afforded under this Policy. The Insured shall attend hearings and trials and assist in securing and giving evidence and obtaining the attendance of witnesses. The Insured shall not, except at its own cost, admit liability, make any payment, assume any obligation, incur any expense, enter into any settlement, stipulate to any judgment or award or otherwise dispose of any Claim without the consent of the Underwriters. XIV. ACTION AGAINST THE UNDERWRITERS No action shall lie against the Underwriters unless, as a condition precedent thereto, there has been full compliance with all terms of this insurance, nor until the amount of the Insured's obligation to pay shall have been finally determined either by judgment or award against the Insured after actual trial or arbitration or by written agreement of the Insured, the claimant and the Underwriters. No person or organization shall have any right under this insurance to join the Underwriters as a party to an action or other proceeding against the Insured to determine the Insured's liability, nor shall the Underwriters be impleaded by the Insured or its legal representative. XV.BANKRUPTCY Bankruptcy or insolvency of the Insured or of the Insured's estate shall not relieve the Underwriters of their obligations hereunder. 21 XVI. SUBROGATION In the event of any payment under this insurance, the Underwriters shall be subrogated to all the Insured's rights of recovery against any person or organization, and the Insured shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights. The Insured shall do nothing before or after the payment of Damages by the Underwriters to prejudice such rights. XVII. CHANGES Notice to any agent or knowledge possessed by any agent or by any other person shall not effect a waiver or a change in any part of this insurance or estop the Underwriters from asserting any right under the terms of this insurance; nor shall the terms of this insurance be waived or changed, except by endorsement issued to form a part of this insurance, signed by the Underwriters. XVIII. MERGERS AND ACQUISITIONS A. If during the Policy Period, the Named Insured merges or acquires an entity and (1) the revenues of the merged or acquired entity do not exceed 10% of the Named Insured's annual revenues as set forth in its most recent application for insurance; (2) the business operations of the merged or acquired entity are of a similar nature to those of the Named Insured as set forth in its most recent application for insurance; and (3) the merged or acquired entity is located in the same state as the Named Insured or any subsidiary, then this Policy will automatically cover the merged or acquired entity, subject to the policy terms, conditions and limitations, from the date such merger or acquisition becomes final but only for negligent acts, errors or omissions or Accidents that take place subsequent to the merger or acquisition. In the event the total amount of revenues of all merged and acquired entities during the Policy Period exceed 25`)/0 of the Named Insured's annual revenues as set forth in its most recent application for insurance, the above provision shall no longer apply and any further mergers or acquisitions will be subject to Paragraph B., below. B. In the event during the Policy Period the Named Insured mergers or acquires an entity that does not fall within the criteria detailed in Paragraph A. above, or where Paragraph A. above no longer applies by virtue of the provision contained in the last sentence of Paragraph A. above, then the Named Insured shall be required to give written notice to the Underwriters prior to the completion of a merger or acquisition of the Named Insured, and the Underwriters expressly reserve the right to request additional premium and/or to apply amended terms and conditions if this insurance is to remain in force subsequent to any merger or acquisition. 22 XIX. ASSIGNMENT The interest hereunder of any Insured is not assignable. If the Insured shall die or be adjudged incompetent, this insurance shall cover the Insured's legal representative as the Insured, as would be permitted by this Policy. XX.CANCELLATION 1. For the Risk Purchasing Group A. This Policy may be cancelled by the Underwriters by mailing or delivering to the Risk Purchasing Group at the address shown in the Declarations written notice stating when, not less than sixty (60) days thereafter, such cancellation shall be effective. However, if the Underwriters cancel this Insurance because the Insured has failed to pay a premium when due, this Policy may be cancelled by the Underwriters by mailing a written notice of cancellation to the Risk Purchasing Group at the address shown in the Declarations stating when, not less than ten (10) days thereafter, such cancellation shall be effective. Mailing of notice shall be sufficient proof of notice. The time of surrender or the effective date and hour of cancellation stated in the notice shall become the end of the Policy Period. Delivery (where permitted by law) of such written notice either by the Risk Purchasing Group or by the Underwriters shall be equivalent of mailing. B. In the event of the cancellation of this master policy, the coverage hereunder shall run to its natural expiry date as specified in the declarations. C. The Risk Purchasing Group may cancel this master policy by surrender thereof to the Underwriters or by mailing or delivering to the Underwriters through the entity named in Item 8 of the Declarations, written notice stating when the cancellation shall be effective. In such event, we will retain the premium at short rate or 25% of the premium whichever is greater. 2. For the Named Insured A. This insurance may be cancelled by the Named Insured at any time by written notice or by surrender of this contract of insurance to the Underwriters through the entity named in Item 8 of the Declarations. This insurance may also be cancelled with or without the return or tender of the unearned premium by Underwriters by mailing notice of cancellation to the Named Insured at the last mailing address known by Underwriters. The Correspondent shall maintain proof of mailing of such notice on a recognized U.S. Post Office form and a copy of such notice shall be sent to the Named Insured's producer. The mailing of such notice as aforesaid shall be sufficient proof of notice and this insurance shall terminate at the date and hour specified in such notice. B. Notice of cancellation must be mailed at least 30 days prior to the effective date of cancellation during the first 60 days of coverage. After coverage has been effective for 61 days or more, all notices must be mailed at least 60 days prior to the effective date of cancellation. Where cancellation is for non-payment of premium, 10 days' notice shall be given. C. In the event of cancellation, Underwriters shall refund the paid premium less the earned portion thereof on demand. The earned premium shall be calculated as follows: (A) If this insurance is cancelled by the Named Insured, Underwriters shall retain the short rate proportion of the premium hereon, or of any minimum premium stipulated herein, in accordance with the table below. (B) If this insurance is cancelled by Underwriters, 23 Underwriters shall retain the pro rata proportion of the premium hereon, or of any minimum premium stipulated herein. The premium shall be deemed fully earned if any Claim under this Policy is reported to Underwriters on or before the date of cancellation. D. If this insurance has been in effect for 60 days, Underwriters can cancel only for one of the following reasons: (a) non-payment of premium; (b) the insurance was obtained through material misrepresentation; (c) the Insured violated any of the terms and conditions of the contract of insurance; (d) the risk originally accepted has measurably increased; (e) certification to the Director of Insurance of the State of Illinois of the loss of reinsurance by Underwriters which provides coverage to Underwriters for all or a substantial part of the underlying risk insured; or (f) a determination by the Director of Insurance of the State of Illinois that the continuation of this insurance could place Underwriters in violation of the insurance laws of the State of Illinois. E. If Underwriters elect not to renew this insurance, they will mail written notice of nonrenewal to the Named Insured at the last mailing address known by Underwriters. The notice of nonrenewal shall be mailed at least 60 days prior to the expiration date of this insurance. and shall state the reason for nonrenewal. The Correspondent shall maintain proof of mailing of such notice on a recognized U.S. Post Office form and a copy of such notice shall be sent to the Named Insured's producer. This paragraph shall not apply, if Underwriters have manifested their willingness to renew to the Named Insured and the Named Insured has failed to comply with the terms of the renewal offer XXI. SINGULAR FORM OF A WORD Whenever the singular form of a word issued, herein, the same shall include the plural when required by context. XXII. ENTIRE CONTRACT By acceptance of this Policy, the Insured agrees that the statements in the Declarations and application are his or her agreements and representations, that this insurance is issued in reliance upon the truth of such representations and that this Policy embodies all agreements existing between the Insured and the Underwriters relating to this insurance. XXIII. NUCLEAR INCIDENT EXCLUSION The insurance provided by this Policy does not apply: A. To injury sickness, disease, death or destruction: with respect to which an Insured under this Policy of insurance is also an Insured under a nuclear energy liability insurance issued by Nuclear Energy Liability Insurance Association, Mutual Atomic Energy Liability Underwriters or Nuclear Insurance Association of Canada or would be an Insured under any such insurance but for its termination upon exhaustion of its limits of liability; or ii. resulting from the hazardous properties of nuclear material and with respect to which (i) any person or organization is required to maintain financial protection pursuant to the Atomic Energy Act of 1954, or any law amendatory thereof, or (ii) the Insured is, or had this insurance not been issued would be, entitled to indemnity from the United States of America, or any agency 24 thereof under any agreement entered into by the United States of America, or any agency thereof, with any person or organization. B. Under any Medical Payments Coverage, or under any Supplementary Payments Provision relating to immediate medical or surgical relief, to expenses incurred with respect to bodily injury, sickness, disease or death resulting from the hazardous properties of nuclear material and arising out of the operation of a nuclear facility by any person or organization. C. To injury, sickness, disease, death or destruction resulting from the hazardous properties of nuclear material, if (1) the nuclear material (i) is at any nuclear facility owned by, or operated by or on behalf of, an Insured or (ii) has been discharged or dispersed there from; (2) the nuclear material is contained in spent fuel or waste at any time possessed, handled, used, processed, stored, transported or disposed of by or on behalf of an Insured; or (3) the injury, sickness, disease, death or destruction arises out of the furnishing by an Insured of services, materials, parts or equipment in connection with the planning, construction, maintenance, operation or use of any nuclear facility, but if such facility is located within the United States of America, its territories or possessions or Canada, this exclusion (3) applies only to injury to or destruction of property at such nuclear facility. D. As used in this Section: "hazardous properties" include radioactive, toxic or explosive properties; "nuclear material" means source material, special nuclear material or by- product material; "source material", "special nuclear material" and "by-product material" have the meanings given them in the Atomic Energy Act of 1954 or in any law amendatory thereof, "spent fuel" means any fuel element or fuel component, solid or liquid, which has been used or exposed to radiation in a nuclear reactor; "waste" means any waste material (i) containing by-product material and (ii) resulting from the operation by any person or organization of any nuclear facility under paragraph (1) or (2) thereof; "nuclear facility" means (1) any nuclear reactor; (2) any equipment or device designed or used for (i) separating the isotopes of uranium or plutonium, (ii) processing or utilizing spent fuel, or (iii) handling, processing or packaging waste; (3) any equipment or device used for the processing, fabricating or alloying of special nuclear material if any time the total amount of such material in the custody of the Insured at the premises were such equipment or device is located consists of or contains more than 25 grams of plutonium or uranium 233 of any combination thereof, or more than 250 grams of uranium 235; or (4) any structure, basin, excavation, premises or place prepared or used for the storage or disposal of waste; and includes the site on which any of the foregoing is located, all operations conducted on such site and all premises used for such operations; "nuclear reactor" 25 means any apparatus designed or used to sustain nuclear fission in self-supporting chain reaction or to contain a critical mass of fissionable material. With respect to injury to or destruction of property, the word "injury" or "destruction" includes all forms or radioactive contamination of property. It is understood and agreed that, except as specifically provided in the foregoing to the contrary, this Section is subject to the terms, exclusions, conditions and limitations of the insurance to which it is attached. XXIV. SERVICE OF SUIT A. It is agreed that in the event of the failure of the Underwriters hereon to pay any amount claimed to be due under this insurance, the Underwriters hereon, at the request of the Named Insured, will submit to the jurisdiction of a court of competent jurisdiction within the United States. This Condition does not constitute and should not be understood to constitute an agreement by the Underwriters that an action is properly maintained in a specific forum, nor may it be construed as a waiver of the Underwriters' rights to commence an action in a court of competent jurisdiction in the United States, to remove an action to a United States District Court, or to seek a transfer of a case to another court as permitted by the laws of the United States or of any state of the United States, all of which rights the Underwriters expressly reserve. It is further agreed that service of process in such suit may be made upon the designated entity in Item 10 of the Declarations, and that in any suit instituted against any one of them upon this contract, the Underwriters will abide by the final decision of such court in the event of an appeal. B. The Entity designated in Item 10 of the Declarations is authorized and directed to accept service of process on behalf of the Underwriters in any such suit and/or upon the request of the Named Insured to give written undertaking to the Named Insured that they will enter a general appearance upon Underwriters' behalf in the event such a suit shall be instituted. Further, pursuant to any statute of any state, territory or district of the United States which makes provision therefore, the Underwriters hereon hereby designate the Superintendent, Commissioner or Director of Insurance or other officer specified for that purpose in the statute or his successor or successors in office, as his or her true and lawful attorney upon whom may be served any lawful process in any action, suit or proceedings instituted by or on behalf of the Named Insured or any beneficiary hereunder arising out of this contract of insurance, and hereby designates the Entity, designated in Item 10 of the Declarations, as the person to whom the said officer is authorized to mail such process or a true copy thereof. XXV. CHOICE OF LAW Any disputes involving this Policy shall be resolved applying the law designated in Item 11. of the Declarations. XXVI. SEVERAL LIABILITY Insurer's liability several not joint The liability of an insurer under this contract is several and not joint with other insurers party to this contract. An insurer is liable only for the proportion of liability it has underwritten. An insurer is not jointly liable for the proportion of liability underwritten by any other insurer. Nor is an insurer otherwise responsible for any liability of any other insurer that may underwrite this contract. 26 The proportion of liability under this contract underwritten by an insurer (or, in the case of a Lloyd's syndicate, the total of the proportions underwritten by all the members of the syndicate taken together) is shown next to its stamp. This is subject always to the provision concerning "signing" below. In the case of a Lloyd's syndicate, each member of the syndicate (rather than the syndicate itself) is an insurer. Each member has underwritten a proportion of the total shown for the syndicate (that total itself being the total of the proportions underwritten by all the members of the syndicate taken together). The liability of each member of the syndicate is several and not joint with other members. A member is liable only for that member's proportion. A member is not jointly liable for any other member's proportion. Nor is any member otherwise responsible for any liability of any other insurer that may underwrite this contract. The business address of each member is Lloyd's, One Lime Street, London EC3M 7HA. The identity of each member of a Lloyd's syndicate and their respective proportion may be obtained by writing to Market Services, Lloyd's, at the above address. Proportion of liability Unless there is "signing" (see below), the proportion of liability under this contract underwritten by each insurer (or, in the case of a Lloyd's syndicate, the total of the proportions underwritten by all the members of the syndicate taken together) is shown next to its stamp and is referred to as its "written line". Where this contract permits, written lines, or certain written lines, may be adjusted ("signed"). In that case a schedule is to be appended to this contract to show the definitive proportion of liability under this contract underwritten by each insurer (or, in the case of a Lloyd's syndicate, the total of the proportions underwritten by all the members of the syndicate taken together). A definitive proportion (or, in the case of a Lloyd's syndicate, the total of the proportions underwritten by all the members of a Lloyd's syndicate taken together) is referred to as a "signed line". The signed lines shown in the schedule will prevail over the written lines unless a proven error in calculation has occurred. Although reference is made at various points in this clause to "this contract" in the singular, where the circumstances so require this should be read as a reference to contracts in the plural. XXVII. LICENSURE A. It is a condition of the coverage afforded under the Policy that the facilities of the Named Insured and any Insured requiring a license to practice shall be licensed in accordance with all relevant federal, state and local requirements. The Named Insured warrants that as of the inception date of this Policy it has secured all relevant licenses. This provision does not apply to an allied health student or unlicensed or uncertified Allied Health Professional who is under the direct supervision of a physician, nurse or other licensed or certified Allied Health Professional, or a teacher or who is employed at a hospital or other licensed health care provider. B. If, during the Policy Period, any Insured's licensure status is altered by withdrawal, revocation, denial, suspension or failure to renew, the Named Insured shall give written notice of such change to Underwriters' Representative within thirty days of the change becoming effective. Following receipt of such notice, the Underwriters may elect, at their sole option, to revise any Insuring Agreements. Definitions, Exclusions, Endorsements or other Conditions of this Policy with respect to the Insured, with effect from such date of such 27 withdrawal, revocation, denial, suspension or failure to renew. Such action does not waive the Underwriters' option to invoke the provisions of Section XX of this Policy. Furthermore, the Underwriters will have no obligation to respond to any Claim arising out of Professional Services or an Accident which took place subsequent to the date of withdrawal, revocation, denial, suspension or failure to renew. XXVIII. MULTIPLE INSURANCE POLICIES APPLYING TO THE SAME CLAIM In the event a Claim triggers coverage under this Policy and under any other policy issued by the Underwriters, the Underwriters' liability under this Policy and such other policy combined shall not exceed the amount of the largest of the applicable Limits of Liability. LII 482 (07/13) 28 Effective date of this Endorsement: * This Endorsement is attached to and fortes a part of Policy Number: * Certain Underwriters at Lloyds, London Referred to in this endorsement as either the "Insurer" or the "Underwriters" ILLINOIS AMENDATORY ENDORSEMENT This endorsement modifies insurance provided under the following: ALLIED HEALTH PROFESSIONAL LIABILITY AND GENERAL LIABILITY INSURANCE 1. The first paragraph of Item 3. B i) and Paragraph 3.C Limit of Liability in the Declarations is revised to delete the words "and Claims Expenses," 2. Item 3.E of the Declarations is deleted in its entirety. 3. Section VII. Limit of Liability, Paragraph A is deleted in its entirety. 4. The first paragraph of Item 4. Deducible in the Declarations is revised to delete the words "and Claims Expenses:" but only in relation to General Liability coverage (Insuring Agreement I.A.2), Fire and Water Damage Legal Liability (Insuring Agreement I.A.3) and Host Liquor Liability (Insuring Agreement I.A.5). 5. The first sentence of Clause I. INSURING AGREEMENTS B. Defense and Settlement 1. is deleted and replaced with the following but only in relation to General Liability coverage (Insuring Agreement I.A.2), Fire and Water Damage Legal Liability (Insuring Agreement I.A.3) and Host Liquor Liability (Insuring Agreement I.A.5). 1. The Underwriters shall have the right and duty to defend the Insured, at the Underwriters expense, for any Claim first made against the Insured seeking payment under the terms of this insurance, even if any of the allegations of the claim are groundless, false, or fraudulent. The underwriters shall choose defense counsel in conjunction with the Insured, but in the event of a dispute, the decision of the Underwriters is final. 6. Clause I. INSURING AGREEMENTS B. Defense and Settlement 2. is deleted in its entirety and replaced with the following but only in relation to General Liability coverage (Insuring Agreement I.A.2), Fire and Water Damage Legal Liability (Insuring Agreement I.A.3) and Host Liquor Liability (Insuring Agreement I.A.5). 2. Damages shall be applied against the Deductible set forth in Item 4. of the Declarations. Claims Expenses shall not be applied against such Deductible. 7. Clause I. INSURING AGREEMENTS B. Defense and Settlement 4. is amended to delete the words, "and Claims Expenses" following the word "Damages" but only in relation to General Liability coverage (Insuring Agreement I.A.2), Fire and Water Damage Legal Liability (Insuring Agreement I.A.3) and Host Liquor Liability (Insuring Agreement I.A.5). 8. Clause I. INSURING AGREEMENTS B. Defense and Settlement 5. is amended by deletion of the reference to "interest" at the end of the fourth line of this Clause. 9. Clause I. INSURING AGREEMENTS B. Defense and Settlement 7. is deleted in its entirety and replaced with the following but only in relation to General Liability coverage (Insuring Agreement I.A.2), Fire and Water Damage Legal Liability (Insuring Agreement I.A.3) and Host Liquor Liability (Insuring Agreement I.A.5). 7. It is further provided that the Underwriters shall not be obligated to pay any Damages after the applicable Limit of the Underwriters' Liability has been exhausted by payment of Damages or after deposit of the remaining applicable Limit of Liability in a court of competent jurisdiction. In the event that the Underwriters shall not be obligated to pay Claims Expenses, or to undertake or continue defense of any Claim under this Policy for any reason, the Underwriters shall tender control of said defense to the Insured. In tendering such control, the Underwriters shall provide for the orderly transfer of said defense duties to the Insured. 10. Clause III. PERSONS INSURED (a) is amended to add the following: In applying the foregoing, parties to a civil union as recognized under Illinois Law shall be included within the meaning of "spouse" for purposes of this section. 11. Clause V. EXCLUSIONS 2. (g) is amended by the addition of the following: In applying the foregoing, parties to a civil union as recognized under Illinois Law shall be included within the meaning of "spouse" for purposes of this exclusion. Page 1 of 4 12. Clause V. EXCLUSIONS 2. (b) is amended by the addition of the following: This exclusion does not apply to Bodily Injury resulting from the use of reasonable force to protect persons or property. 13. Clause V. EXCLUSIONS 4. (i.1) is amended by the addition of the following: This exclusion does not apply to vicarious liability imposed on the Insured. 14. Clause V. EXCLUSIONS 4. (j) is amended by the addition of the following at the end thereof: Except that is a suit is brought against the Insured on a Claim falling within the coverage thereof, seeking both compensatory and punitive damages, then Underwriters will afford a defense to such action, without liability, however, for such punitive damages; provided further, that Underwriters obligation to provide such defense for punitive damages shall terminate when the claim for compensatory damages in such action is terminated or paid through judgment or settlement and, in no event, shall Underwriters afford a defense for punitive damages after the limit of Underwriter' liability for compensatory damages has been paid. 15. Clause V. EXCLUSIONS 4. (ee) is deleted in its entirety 16. Clause VI. DEFINITIONS (f) Claims Expenses is amended by the addition of the words "or Underwriters" after the words "charges by the Insured". 17. Clause VIII. DEDUCTIBLE is amended to delete the words, ""and/or Claims Expenses" but only in relation to General Liability coverage (Insuring Agreement I.A.2), Fire and Water Damage Legal Liability (Insuring Agreement I.A.3) and Host Liquor Liability (Insuring Agreement I.A.5). 18. Clause IX. INNOCENT INSURED, last paragraph is deleted in its entirety and replaced with the following: With respect to this provision, the Underwriters' obligation to pay in such event shall be in excess of the full extent of any assets recovered of any Insured to whom the exclusion applies and shall be subject to the terms, conditions and limitations of this Policy. 19. Clause X. EXTENDED REPORTING PERIOD is deleted and replaced with the following: X (A). EXTENDED REPORTING PERIOD — ALL INSURING AGREEMENTS EXEPT INSURING AGREEMENT A2 GENERAL LIABILITY, INSURING AGREEMENT A3. FIRE AND WATER DAMAGE LEGAL LIABILITY AND INSURING AGREEMENT A5. HOST LIQUOR LIABILITY. A. In the event of cancellation or non -renewal of this insurance, the Named Insured designated in Item 1 of the Declarations shall have the right to a 12, 24 or 36 month Extended Reporting Period for Claims first made against any Insured and reported to the Underwriters during the Extended Reporting Period, subject to the conditions set forth in the definition of Extended Reporting Period herein. In order for the Named Insured to invoke the Extended Reporting Period option, the payment of the additional premium set forth in Item 7 (a) (b) or (c) of the declarations for the Extended Reporting Period must be paid to the Underwriters within 30 days after the non - renewal or cancellation. B. The Limit of Liability for the Extended Reporting Period shall be part of, and not in addition to, the Underwriters' Limit of Liability for the Policy Period. C. All notices and premium payments with respect to the Extended Reporting Period shall be directed to the Underwriters through the entity named in Item 8 of the Declarations. D. At the commencement of the Extended Reporting Period, the entire premium shall be deemed earned and the Underwriters will not be liable to return any premium paid for the Extended Reporting Period. X(B). EXTENDED REPORTING PERIOD — INSURING AGREEMENTS A2. GENERAL LIABILITY, INSURING AGREEMENT A3. FIRE AND WATER DAMAGE LEGAL LIABILITY AND INSURING AGREEMENT A5. HOST LIQUOR LIABILITY. A. In the event of a Termination of Coverage for any reason by the Underwriters or the Named Insured the Named Insured designated in Item 1. of the Declarations shall have the right to purchase an Extended Reporting Period, for the premium stated in Item 7. (d) of the Declarations, with respect to all Claims first made against any Insured and reported in writing to the Underwriters during the Extended Reporting Period, and arising out of any Accident committed on or after the Retroactive Date and before the end of the Policy Period, subject to the conditions set forth in the definition of Extended Reporting Period herein. Page 2 of 4 The Named Insured will be offered an Extended Reporting Period for an unlimited duration, in addition to other options being offered. The premium for the Extended Reporting Period shall be priced as a factor of the expiring annual premium. The premium for the Extended Reporting Period for an unlimited duration shall be capped at two -hundred precent (200`)/o) of the annual premium. B. The Limit of Liability for the Extended Reporting Period shall be part of, and not in addition to the Underwriters' Limit of Liability for the Policy Period. However, in the event an Extended Reporting Period for an unlimited duration is applicable to this Policy, the Limit of Liability for the Extended Reporting Period shall be reinstated in the amount of one -hundred percent (100%) of the aggregate expiring Limit of Liability. C. As a condition precedent to the right to purchase the Extended Reporting Period, the total premium for this Policy must be paid and any money paid for the Extended Reporting Period will be applied first to any amount owing for the Policy Period. The right to purchase the Extended Reporting Period shall terminate unless written notice together with full payment of the premium for the Extended Reporting Period is given to the Underwriters within sixty (60) days from the effective date of the Termination of Coverage. If such notice and premium payment is not so given to the Underwriters, there shall be no right to purchase the Extended Reporting Period. Any Extended Reporting Period shall apply only in regard to that coverage subject to the Termination of Coverage. If the Termination of Coverage is due only to a decrease in the aggregate Limit of Liability, the aggregate Limit of Liability for the Automatic and any purchased Extended Reporting Period shall be no greater than the amount of such decrease. D. The Extended Reporting Period shall be non -cancelable except for nonpayment of premium, and the entire premium for the Extended Reporting Period shall be deemed fully eamed at inception. If similar insurance to that provided by this Policy is in force during the Extended Reporting Period, the coverage afforded by this Policy shall be excess over any such valid and collectible insurance. E. All notices and premium payments with respect to the Extended Reporting Period shall be directed to the Underwriters through the entity named in Item 8. of the Declarations. 20. Clause XI. OTHER INSURANCE second paragraph is deleted in its entirety and replaced by the following: If the Insured has insurance provided by other insurers against a loss covered by this insurance, the Underwriters shall not be liable under this insurance for a greater proportion of such loss and Claims Expenses than the applicable limit of liability stated in the declarations bears to the total applicable limit of liability of all valid and collectible insurance against such loss, provided however that if the Insured has insurance provided by other insurers whose insurance is stated as excess over any other insurance available to the Insured, this insurance shall also apply solely in excess of such insurance, unless such other insurance is written as specific excess over the limit of liability of this insurance" 21. Clause XII. NOTICE OF CLAIM, OR CIRCUMSTANCE THAT MIGHT LEAD TO A CLAIM A. is amended by deleting the word "immediately" and replacing such word with the phrase, "as soon as reasonably practicable". 22. Clause XII. NOTICE OF CLAIM, OR CIRCUMSTANCE THAT MIGHT LEAD TO A CLAIM F. is deleted it its entirety and replaced with the following: If any Insured shall make any Claim under this Policy knowing such Claim to be false or fraudulent, as regards amount or otherwise, such Claim shall be denied under this Policy, 23. Clause XVIII. MERGERS AND ACQUISITIONS, Paragraph B. The words "and/or to apply to amended terms and conditions" towards the bottom of this Paragraph is deleted. 24. Clause XX. Cancellation 1. For the Risk Purchasing Group is deleted in its entirety and replaced with the following: 1. For the Risk Purchasing Group A. This insurance may be cancelled by the Risk Purchasing Group at any time by written notice or by surrender of this Master Policy to the Underwriters through the entity named in Item 8 of the Declarations. This insurance may also be cancelled with or without the retum or tender of the uneamed premium by Underwriters by mailing notice of cancellation to the Risk Purchasing Group at the last mailing address known by Underwriters. The Correspondent Page 3 of 4 shall maintain proof of mailing of such notice on a recognized U.S. Post Office form and a copy of such notice shall be sent to the Risk Purchasing Group's producer. The mailing of such notice as aforesaid shall be sufficient proof of notice and this insurance shall terminate at the date and hour specified in such notice. B. Notice of cancellation must be mailed at least 30 days prior to the effective date of cancellation during the first 60 days of coverage. After coverage has been effective for 61 days or more, all notices must be mailed at least 60 days prior to the effective date of cancellation. Where cancellation is for non-payment of premium, 10 days' notice shall be given. C. In the event of cancellation, Underwriters shall refund the paid premium less the earned portion thereof on demand. The earned premium shall be calculated as follows: (A) If this insurance is cancelled by the Risk Purchasing Group, Underwriters shall retain the short rate proportion of the premium hereon, or of any minimum premium stipulated herein, in accordance with the table below. (B) If this insurance is cancelled by Underwriters, Underwriters shall retain the pro rata proportion of the premium hereon, or of any minimum premium stipulated herein. The premium shall be deemed fully earned if any Claim under this Policy is reported to Underwriters or any act, error or omission or Accident incurred under this Policy on or before the date of cancellation. D. If this insurance has been in effect for 60 days, Underwriters can cancel only for one of the following reasons: (a) non-payment of premium; (b) the insurance was obtained through material misrepresentation; (c) the Risk Purchasing Group violated any of the terms and conditions of the contract of insurance; (d) the risk originally accepted has measurably increased; (e) certification to the Director of Insurance of the State of Illinois of the loss of reinsurance by Underwriters which provides coverage to Underwriters for all or a substantial part of the underlying risk insured; or (f) a determination by the Director of Insurance of the State of Illinois that the continuation of this insurance could place Underwriters in violation of the insurance laws of the State of Illinois. E. If Underwriters elect not to renew this insurance, they will mail written notice of nonrenewal to the Risk Purchasing Group at the last mailing address known by Underwriters. The notice of nonrenewal shall be mailed at least 60 days prior to the expiration date of this insurance and shall state the reason for nonrenewal. The Correspondent shall maintain proof of mailing of such notice on a recognized U.S. Post Office form and a copy of such notice shall be sent to the Risk Purchasing Group's producer. This paragraph shall not apply, if Underwriters have manifested their willingness to renew to the Risk Purchasing Group and the Risk Purchasing Group has failed to comply with the terms of the renewal offer. F. In the event of the cancellation of this master policy, the coverage hereunder shall run to its natural expiry date as specified in the Declarations." This Amendatory Endorsement takes precedence over any provision in this Policy, including any endorsements to this Policy whenever added, to the extent that such provision is inconsistent with the provisions of this Amendatory Endorsement, unless such provision complies with the requirements of the applicable Insurance Laws and Regulations. All other terms and conditions of this Policy remain unchanged. Information required to complete this Endorsement at inception, if not shown, will be shown in the Declarations 'F�unGr Authorized Representative LII 482 B (10/13) Page 4 of 4 Effective date of this Endorsement: * This Endorsement is attached to and forms a part of Policy Number: * Certain Underwriters at Lloyds, London referred to in this endorsement as either the "Insurer" or the "Underwriters" CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM This endorsement modifies insurance provided under the following: ALLIED HEALTH PROFESSIONAL LIABILITY AND GENERAL LIABILITY CLAIMS MADE AND REPORTED INSURANCE If aggregate insured losses attributable to terrorist acts certified under the federal Terrorism Risk Insurance Act exceed $100 billion in a Program Year (January 1 through December 31) and we have met our insurer deductible under the Terrorism Risk Insurance Act, we shall not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rata allocation in accordance with procedures established by the Secretary of the Treasury. "Certified act of terrorism" means an act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State and the Attorney General of the United States, to be an act of terrorism pursuant to the federal Terrorism Risk Insurance Act. The criteria contained in the Terrorism Risk Insurance Act for a "certified act of terrorism" include the following: 1. The act resulted in insured losses in excess of $5 million in the aggregate, attributable to all types of insurance subject to the Terrorism Risk Insurance Act; and 2. The act is a violent act or an act that is dangerous to human life, property or infrastructure and is 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. All other terms, exclusions and conditions of this Policy remain unchanged. * Information required to complete this Endorsement at inception, if not shown, will be shown in the Declarations Authorized Representatives LII 482 D (07/13) Effective date of this Endorsement: * This Endorsement is attached to and forrns a part of Policy Number: * Certain Underwriters at Lloyds, London referred to in this endorsement as either the "Insurer" or the "Underwriters" WAR AND TERRORISM EXCLUSION ENDORSEMENT This endorsement modifies insurance provided under the following: ALLIED HEALTH PROFESSIONAL LIABILITY AND GENERAL LIABILITY CLAIMS MADE AND REPORTED INSURANCE Notwithstanding any provision to the contrary within this insurance or any endorsement thereto it is agreed that this insurance excludes loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any of the following regardless of any other cause or event contributing concurrently or in any other sequence to the loss; 1. war, invasion, acts of foreign enemies, hostilities or warlike operations (whether war be declared or not), civil war, rebellion, revolution, insurrection, civil commotion assuming the proportions of or amounting to an uprising, military or usurped power; or 2. "an act of terrorism". However, this exclusion 2 shall apply only when one or more of the following are attributed to such act of terrorism. (i) The total of "insured damage" to all types of property exceeds US$25,000,000. In determining whether the US$25,000,000 threshold is exceeded, Underwriters will include all insured damage sustained by property of all persons and entities affected by the terrorism and business interruption losses sustained by owners or occupants of the damaged property. For the purpose of this provision, "insured damage" means damage that is covered by any insurance plus damage that would be covered by any insurance but for the application of any terrorism exclusions; or (ii) Fifty or more persons sustain death or "serious physical injury". For the purposes of this provision, "serious physical injury" means: (a) Physical injury that involves a substantial risk of death; or (b) Protracted and obvious physical disfigurement; or (c) Protracted loss of or impairment of the function of a bodily member or organ; or (iii) The terrorism is carried out by means of the dispersal or application of radioactive material, or through the use of a nuclear weapon or device that involves or produces a nuclear reaction, nuclear radiation or radioactive contamination; or (iv) Radioactive material is released, and it appears that one purpose of the terrorism was to release such material; or AIF 2657 (10/05) Page 1 of 2 (v) The terrorism is carried out by means of the dispersal or application of pathogenic or poisonous biological or chemical materials; or (vi) Pathogenic or poisonous biological or chemical materials are released, and it appears that one purpose of the terrorism was to release such materials. With respect to this exclusion 2, paragraphs (i) and (ii) describe the thresholds used to measure the magnitude of an incident of "an act of terrorism" and the circumstances in which the threshold will apply for the purpose of determining whether this exclusion will apply to that incident. For the purpose of this endorsement, "an act of terrorism" means a violent act or an act that is dangerous to human life, property or infrastructure that is committed by an individual or individuals and that appears to be part of an effort to coerce a civilian population or to influence the policy or affect the conduct of any government by coercion. Multiple incidents of "an act of terrorism" which occur within a seventy-two hour period and appear to be carried out in concert or to have a related purpose or common leadership shall be considered to be one incident, for the purpose of determining whether the thresholds in paragraphs 2(i) or 2(ii) are exceeded. This endorsement also excludes loss, damage, cost or expense of whatsoever nature directly or indirectly caused by, resulting from or in connection with any action taken in controlling, preventing, suppressing or in any way relating to 1 and/or 2 above. If the Underwriters allege that by reason of this exclusion, any loss, damage, cost or expense is not covered by this insurance the burden of proving the contrary shall be upon the Assured. In the event any portion of this endorsement is found to be invalid or unenforceable, the remainder shall remain in full force and effect. All other terms, exclusions and conditions of this Certificate remain unchanged. * Information required to complete this Endorsement at inception, if not shown, will be shown in the Declarations. ibee 'Rgnl Authorized Representative AIF 2657 (10/05) Page 2 of 2 ACORD® CERTIFICATE OF LIABILITY INSURANCE `� DATE (MM/DD/YYYY) 01/10/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER HISCox Inc. 520 Madison Avenue 32nd Floor New York, NY 10022 CONTACT NAME: AX ,PHONEa No. Extl: (888) 202-3007 ( AA/C, No): ADDRESS: Contact@hiscox.Com INSURER(S)AFFORDING COVERAGE NAIC0 INSURER A: Hiscox Insurance Company Inc 10200 INSURED Aspen Summit Wellness & Counseling Services, LLC 1120 38th Ave Suite 3 Greeley CO 80634 INSURER B : INSURER C: INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR MD POLICY NUMBER POLICY EFF IMM/DD/YYYY) POLICY EXP (MMIDDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY UDC-4035789-CGL-19 01/10/2019 01/10/2020 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 CLAIMS -MADE �/ X OCCUR MED EXP (Any one person) $ 5,000 PERSONAL 8, ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L X AGGREGATE POLICY OTHER: LIMIT APPLIES PRO - JECT PER: LOC PRODUCTS - COMP/OP AGG $ S/T Gen. Agg. $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below YIN N /A PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD EXHIBIT C SCOPE OF SERVICES 1. Contractor will provide Mental Health Services, as referred by the Department. 2. Services available under this agreement include: a. Mental Health Evaluations i. Capacity for Services: Up to six (6) hours per week, or three (3) reports per week. ii. Goals of Service: To identify and provide a written report of the referred client's mental health status, needs, and treatment recommendations. iii. Outcomes of Service: A written report regarding the referred client's mental health status, as well as treatment recommendations utilized data gathered, including: 1. Brief summary of: a. Mental health history b. Social history c. Substance use history 2. DSM-5 Mental Health Diagnosis 3. Mental health treatment recommendations 4. SASSI-4 Interpretation and recommendations for referral and further assessment if warranted iv. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Adolescents (Age 12-17) 2. Young Adults (Age 18-25) 3. Adults (26-65) 4. Elderly (65+) v. Service Access: 1120 38th Avenue, Suite 3, Greeley, CO 80634 vi. Language: English only. b. Mental Health Assessment i. Capacity for Services: Up to six (6) hours per week, or two (2) reports per week. ii. Goals of Service: To identify and provide an in-depth written report of the referred client's mental health status, needs, and treatment recommendations. iii. Outcomes of Service: A written report regarding the referred client's mental health status, as well as treatment recommendations utilized data gathered, including: 1. In-depth summary of: a. Mental health history b. Social history c. Family history d. Relationship history e. Educational history f. Criminal history (if any) 1 2. Substance use history a. SASSI-4 interpretation and recommendations for referral and further assessment if warranted 3. DSM-5 Mental Health Diagnosis 4. Psychological assessment interpretation and summary 5. Mental health treatment recommendations iv. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Adolescents (Age 12-17) 2. Young Adults (Age 18-25) 3. Adults (26-65) 4. Elderly (65+) v. Service Access: 1120 38th Avenue, Suite 3, Greeley, CO 80634 vi. Language: English only. c. Seeking Safety Group: 18 -week course designed to assist individuals who have co-occurring disorders of Post -Traumatic Stress Disorder (PTSD) and substance use. i. Capacity for Services: Two (2) 90 -minute groups per week (one for males and one for females) ii. Goals of Service: To assist individuals with a history of substance use and trauma recovery through the use of health coping skills to reduce harmful behaviors such as substance use or self -injurious behaviors. iii. Outcomes of Service: 1. Certificate of Completion 2. A client -driven, written self -care plan 3. Reduction in harmful behaviors related to substance use and traumatic histories 4. Development and demonstration of application of healthier coping skills iv. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Adolescents (Age 12-17) 2. Young Adults (Age 18-25) 3. Adults (26-65) 4. Elderly (65+) Groups will be gender specific; male and female. Contractor will form a third group for LGBTQ clients if referred more than three (3) LGTBQ clients. v. Service Access: 1120 38th Avenue, Suite 3, Greeley, CO 80634 vi. Language: English only. 2 d. Individual Mental Health Sessions i. Capacity for Services: Up to 10 hours per week. ii. Goals of Service: To assist individuals process and work through identified problems as a result of a mental health evaluation or assessment, and/or part of a recommendation of a similar report. iii. Outcomes of Service: To assist individuals in developing healthy coping skills, self - compassion, assertive communication skills, and reduce mental health symptoms such as anxiety and depression. iv. Target Population: Regardless of race, gender or sexual orientation, Contractor serves these populations: 1. Adolescents (Age 12-17) 2. Young Adults (Age 18-25) 3. Adults (26-65) 4. Elderly (65+) v. Service Access: 1. In Office: 1120 38`h Avenue, Suite 3, Greeley, CO 80634 2. Video-conferencing vi. Language: English only. 3. Contractor will respond to the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400- 6210) within three (3) business days regarding the ability to accept the received referral. 4. 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 Supervisor (hainleid@weldgov.com, 970-400-6210). 5. Contractor understands that "no shows" are defined as unexcused and unplanned/uncommunicated absences for visitation services. If a rate for "no shows" is not specifically stated in Exhibit D, Rate Schedule, then Contractor understand that the Department will no reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows" on the part of the client per month. 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 Supervisor (hainlejd@weldgov.com, 970-400-6210). 6. 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 3 caseworker and the Quality Assurance Team Supervisor (hainlejd@weldgov.com) immediately via email, to discuss service continuation. 7. 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. 8. 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. 9. 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. 10. Contractor agrees any change to an existing referral must be pre -approved through the Child Welfare Contract and Services Coordinator, a Department -facilitated Team Decision Making (TDM) or Family Team Meeting (FTM), or by court order. 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. 11. Contractor agrees to attend meetings when available and as requested by the Department. Such meetings include Court Facilitations, Court Staffings, Family Team Meetings and/or Team Decision Making meetings. Contractor may participate by phone, if approved by the Department. 12. Contractor will notify the Quality Assurance Team Supervisor (hainlejd@weldgov.com, 970-400-6210) 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, 2020. 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 $70.00/Hour (Individual Mental Health Session, In -office) $55.00/Hour (Individual Mental Health Session, Video -conference) $80.00/Hour (Individual Mental Health Session, Intake) $600.00/Episode (Mental Health Assessment) $175.00/Episode (Mental Health Evaluation) $30.00/Episode (Seeking Safety Group) $80.00/Episode (Seeking Safety Group, Intake) 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 Farm New Contract Request Entity Information Entity Name* ASPEN SUh1M1T WELLNESS AND COUNSEL /NG Contract Name* ASPEN SUMMIT V ELLNESS & Contract Status CTB REVIEW Entity ID* (x011019 ❑ New Entity? Contract ID t NSELING SERVICES. LLC 2850 Contract Lead* CULLNTA Contract Lead Email cull nta@co weld co us Parent Contract ID 20140707 Requires Board Approval YES Department Project # Contract Description* CONSENT. NEW AGREEMENT FOR SERVICES. FUND NG COREO T HER TERM: JUNE 1. 2019 -MAY .31 2020. Contract Description 2 BID NO. 51900025 Contract Type* AGREEMENT Amount * $0 00 Renewable* YES Automatic Renewal Grant Department HUMAN SERVICES Department Email CM- HurnanServices(a) eldgovcorn Department Head Email C Ivt-Hurn anSerric es- DeptHead@wedgov cc�m County Attorney ':GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- COUNTYATT _?RNENr"@ ELL, GOV. COM Requested BOCC Agenda Date* 0`/26,2019 Due Date 06122/2019 Will a worts session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are riot in OnEase Contract Dates Effective Date Review Date* 04'01/2020 Termination Notice Period Committed Delivery Date Renewal Date* 06/12.11.7.070 Expiration Date Contact Information Contact Info Contact Name Purchasing Purchasing Approver CONSENT Approval Process Department Head JUDY GRIEGC DH Approved Date 07.1912019 Final Approval BOCC Approved BOCC Signed Date BOCC Agenda Date 07/2,4/2019 Originator CULLINTA Contact Type Contact Email Finance Approver CONSENT Contact Phone 1 Purchasing Approved Date 07119/2019 Finance Approved Date 0711912019 Tyler Ref # AG 072419 Legal Counsel -ONSENT Contact Phone 2 Legal Counsel Approved Date 0711'9'2€919 Submit Hello