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Home My WebLink About20192149.tiff1°ACO3 CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND JULIE A. SCROGGGINS, ATTONEY AT LAW, P.C. This Agreement, made and entered into thgl vdayyoof 019, by and between the Board of Weld County Commissioners, on behalf of the Weld County Departmen f Human Services, hereinafter referred to as the "Department' and Julie A. Scroggins, Attorney at Law, P.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 Child Welfare Administration or other funding to the Department for Mediation 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 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. 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 CC: bitze,a-645-D) 2019-2149 )Lilec.©90 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 - Title VII of the Civil Rights Act of 1964; and 3 - 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. 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 4 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 or equivalent, covering premises operations, fire damage, independent Contractors, 6 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. B. 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 Julie A. Scroggins, Attorney at Law 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 9 For Contractor: Julie A. Scroggins, Attorney at Law 710 11th Avenue, Suite 205 Greeley, CO 80631 (970) 353-0216 18. Litigation Contractor shall promptly notify the Department in the event that Contractor learns of any actual litigation in which it is a party defendant in a case that involves services provided under this Agreement. Contractor, within five (5) calendar days after being served with a summons, complaint, or other pleading which has been filed in any Federal or State court or administrative agency, shall deliver copies of such document(s) to the Director of Human Services. The term "litigation" includes an assignment for the benefit of creditors, and filings of bankruptcy, reorganization and/or foreclosure. 19. Termination This Agreement may be terminated at any time by either party giving thirty (30) days written notice to the individuals identified in paragraph 17. No portion of this Agreement shall be deemed to create an obligation on the part of the County of Weld, State of Colorado, to expend funds not otherwise appropriated in each succeeding year, as this Agreement is subject to the availability of funding. Therefore, the Department may terminate this Agreement at any time if the source of funding for the services made available to the Contractor is no longer available to the Department, or for any other reason. Contractor reserves the right to suspend services to clients if funding is no longer available. 20. No Third -Party Beneficiary Enforcement It is expressly understood and agreed that the enforcement of the terms and conditions of this Agreement, and all rights of action relating to such enforcement, shall be strictly reserved to the undersigned parties and nothing in this Agreement shall give or allow any claim or right of action whatsoever by any other person not included in this Agreement. It is the express intention of the undersigned parties that any entity other than the undersigned parties receiving services or benefits under this Agreement shall be an incidental beneficiary only. 21. Governmental Immunity No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental Immunity Act of §§24-10-101 et. seq., as applicable now or hereafter amended. 22. Partial Invalidity of Agreement If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions. The 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 10 not enter into any third -party relationship that gives the appearance of creating a conflict of interest. Upon learning of an existing appearance of a conflict of interest situation, Contractor shall submit to the Department, a full disclosure statement setting forth the details that create the appearance of a conflict of interest. Failure to promptly submit a disclosure statement required by this paragraph shall constitute grounds for the Department's termination, for cause, of its Agreement with the Contractor. A conflict of interest or appearance of a conflict of interest may also apply to personal relationships between providers and clients. If a provider has a personal relationship with a client to whom the Contractor may provide services for, the Contractor must disclose that relationship to the Department. Contractor certifies that Federal appropriated funds have not been paid or will be paid, by or on behalf of Contractor, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of an Federal contract, loan, grant, or cooperative agreement. 24. Storage, Availability and Retention of Records Contractor agrees that authorized local, Federal, and State auditors and representatives shall, during business hours, have access to inspect and copy records, and shall be allowed to monitor and review through on -site visits, all activities related to this Agreement, supported with funds under this Agreement, to ensure compliance with the terms of this Agreement. Contracting parties agree that monitoring and evaluation of the performance of the Agreement shall be conducted by appropriate funding sources. The results of the monitoring and evaluation activities shall be provided to the appropriate and interested parties. All such records, documents, communications, and other materials created pursuant or related to this Agreement shall be maintained by the Contractor in a central location and shall be made available to the Department upon its request, for a period of seven (7) years from the date of final payment under this Agreement, or for such further period as may be necessary to resolve any matters which may be pending, or until an audit has been completed with the following qualifications: If an audit by or on behalf of the Federal and/or State government has begun but is not completed at the end of the seven (7) year period, or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until the resolution of the audit finding. 25. Confidentiality of Records Contractor shall protect the confidentiality of all applicant records and other materials that are maintained in accordance with this Agreement except for purposes directly connected with the administration of Child Protection. No information about or obtained from any applicant/recipient in possession of Contractor shall 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. 11 26. Proprietary Information Proprietary information for the purposes of this Agreement is information relating to a party's research, development, trade secrets, business affairs, internal operations and management procedures and those of its customers, clients or affiliates, but does not include information (1) lawfully obtained from third parties, (2) that which is in the public domain, or (3) that which is developed independently. Neither party shall use or disclose directly or indirectly without prior written authorization any proprietary information concerning the other party obtained as a result of this Agreement. Any proprietary information removed from the Department's site by the Contractor in the course of providing services under this Agreement will be accorded at least the same precautions as are employed by the Contractor for similar information in the course of its own business. 27. Independence of Contractor: Not an Employee of Weld County Contractor agrees that it is an independent Contractor and that Contractor's officers, agents or employees will not become employees of County, nor entitled to any employee benefits from County as a result of the execution of this Agreement. Contractor shall perform its duties hereunder as an independent Contractor. Contractor shall be solely responsible for its acts and those of its agents and employees for all acts performed pursuant to this Agreement. Contractor, its employees and agents are not entitled to unemployment insurance or workers' compensation benefits through County and County shall not pay for or otherwise provide such coverage for Contractor or any of its agents or employees. Unemployment insurance benefits will be available to Contractor and its employees and agents only if such coverage is made available by Contractor or a third party. Contractor shall pay when due all applicable employment taxes and income taxes and local head taxes (if applicable) incurred pursuant to this Agreement. Contractor shall not have authorization, express or implied, to bind County to any agreement, liability or understanding, except as expressly set forth in this Agreement. Contractor shall have the following responsibilities with regard to workers' compensation and unemployment compensation insurance matters: (a) provide and keep in force workers' compensation and unemployment compensation insurance in the amounts required by law, and as set forth in Exhibit A provide proof thereof when requested to do so by County. 28. Entire Agreement This Agreement, together with all attachments hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof, and may not be changed or modified except as state in Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs, legal representatives, and assigns. The Contractor and the Department may not assign any of its rights or obligations hereunder without the prior consent of both parties. 29. Agreement Nonexclusive This Agreement does not guarantee any work, nor does it create an exclusive agreement for services. 30. Warranty The Contractor warrants that services performed under this Agreement will be performed in a manner 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. 12 31. Acceptance of Services Not a Waiver Upon completion of the work, the Contractor shall submit to the Department originals of all tests and results, reports, etc., generated during completion of this work. Acceptance by the Department of reports and incidental material(s) furnished under this Agreement shall not in any way relieve the Contractor of responsibility for the quality and accuracy of the services. In no event shall any action by the Department hereunder constitute or be construed to be a waiver by the Department of any breach of covenant or default which may then exist on the part of the Contractor, and the Department's action or inaction when any such breach or default shall exist shall not impair or prejudice any right or remedy available to the Department with respect to such breach or default; and no assent, expressed or implied, to any breach of any one or more covenants, provisions or conditions of the Agreement shall be deemed or taken to be a waiver of any other breach. Acceptance by the Department of, or payment for, any services performed under this Agreement shall not be construed as a waiver of any of the Department's rights under this Agreement or under the law generally. 32. Employee Financial Interest/Conflict of Interest. C.R.S. §§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. 13 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, 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. 14 IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first above written. COUNTY: ATTEST: if JeltKDI,BOARD OF COUNTY COMMISSIONERS Weld Co t Clerk to the Board 1: / WELD COUNTY, COLORADO. By: Deputy Clerktot j Bord CONTRACTOR: 15 Barbara Kirkmeyer, C':ir JO I 02D19 Julie A. Scroggins, Attorney at Law, P.C. 710 11th Avenue, Suite 205 Greeley, CO 80631 (970)353-0216 c7aie,4 (2/D /Hf Julie A. Scroggins (May 3!"1019) By: Date: Julie A. Scroggins, Attorney at Law, P.C. May 3, 2019 (2o/? Z14-9 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. EXHBIT B CONTRACTOR'S RESPONSE TO REQUEST FOR PROPOSAL JULIE A. SCROGGINS ATTORNEY AT LAW. E.C. 71011th Avenue, Suite 205 Greeley, Colorado 80631 Phone: (970) 353-0216 • Fax: (970) 353-4025 jsc ogginslanwgmaiLcam January 25, 2019 To Whom It May Concern: I am bidding on providing mediation services for the Weld County Department of Human Services I graduated from University of Colorado School of Law in May of 1983 and have been a member of the Colorado Bar since October 1983. When I was first admitted to the bar, I was an Associate with Thomas Mon, practicing in the area of water law. Since that time I have worked in Risk Management for Monfort and then Con Agra, served for two years as the municipal judge for the Town of Ault, and beginning in November 1998, I joined the Greeley office of the firm of Brega & Winters practicing primarily family law. In 2007, I became a partner of Winters, Hellerich, & Hughes, LLC, the successor firm to the Greeley office of Brega & Winters. In June of 2014, I returned to my sole practice of Julie A. Scroggins, Attorney at Law, P.C. Since 1998, family law has been my primary practice. Both my corporation and my practice are in good standing. I currently do not have professional liability insurance. I of course had it with my former firm when I had 4 partners, but since I went solo four years ago, I have not gotten any. I am applying for it at this time. For the general liability insurance, we have requested an updated Certificate of Liability but have not yet received it. I am enclosing our current policy and the prior Certificate of Liability for this same policy endorsing Weld County. I have participated in numerous mediations and family meetings in the course of my work. In addition I have provided mediation services from time to time in the area of family law. Beginning January 2019, I have been conducting mediation for DHS and families and we have provided requested mediation services within a timely and professional manner. My office has the capacity to provide mediation to larger family groups and their representatives and my staff is used to scheduling and facilitating such events and timely providing notice of such. I enjoy the practice of family law, believing it gives me an opportunity to help good people going through tough times. From time to time my cases/clients have come within the orbit of the Department of Human Services and I have helped guide my clients through the cases. C Julie ' . Scroggi EXHIBIT B PROVIDER INFORMATION FORM Weld County Department of Human Services Julie A. SoroaOMS, Attorney at Law, P.C. AGENCY OR PRIVATE PRACTICE Julie A. scroggins PRIMARY CONTACT —FULL NAME Provider B - 1728357 I Trails Contract R -19772 TRAILS PROVIDER ID (If known) Owner PRIMARY CONTACT -TITLE 970 ' 353-0210 f 970 1353-4025 PHONE NUMBER EXT. FAX NUMBER jscrogainsi awgigmaiLmm PRIMARY CONTACT— E-MAIL ADDRESS 710 11th Avenue, Ste 205 AGENCY MAIUNG ADDRESS AGENCY/PRACTICE WEB ADDRESS (IF APPUCARLE) Greeley 80631 CITY ZIP ERRAL CONTACT I Christy Dixon Legal Assistant REFFERAL CONTACT— FULL NAME REFERRAL CONTACT - TITLE 070 ; 353-0216 }≤lawpc(Apmail.carn REFERRAL CONTACT— PHONE NUMBER EXT. REFERRAL CONTACT — E-MAIL ADDRESS BIWNG CONTACT Christy Dixon Legal Assistant BILUNG CONTACT —FULL NAME BIWNG CONTACT- TITLE 970 ) 35'3-0216 islawoc9IRrnaiteom BILUNG 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 the bids are competitive in price and quality, Signature of Authorized Representative: Date of Signature: Bid No.: B1900025 EXHIBIT C PROPOSAL TEMPLATE 1. Bidder's legal entity name: 2. Program name or service type being proposed: Julie A. Scroggins, Attorney at Law, P.C. Mediator 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. To provide mediation services for the Department of Human Services, to help facilitate agreements between family members for the benefit of the child/children. 4. Capacity to Provide Services (ex. 4 hours/week). As needed, hours of office operation — 8:00 a.m. to 4:00 p.m. Monday through Friday. 5. Goals of the service. Good faith agreements between family members and/or the Department. 6. Outcomes of service. See Above. 7. Target population for service. Note: Please include age range, applicable genders, and any specific characteristics/traits/needs. Parents and extended family of all ages and genders. 8. Service access. 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. 710 11th Avenue, Ste 205, Greeley, Colorado, 80631— office based 9. Languages service is available In. Note: Bidder should note the language and level of proficiency. English 10. Rates of service. 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. $250.00 per hour 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 Mediation BIDDER LEGAL ENTITY NAME: Julie A. Scroggins, Attorney at Law, P.C. APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION No. Last Name 1 2 3 Scroggins Dixon First Name Julie Christy Work# Work Email Education Level Degree Focus 970-353-0216 970-353-0216 lscropginslaw@amail.com jslawpc@gmail.com Post Grad JD 12th grade Law Colorado Bar Licensure/ Credentials DORA # (if applicable) 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 81800058 Colorado Supreme Court Office of Attorney Regulation Counsel Home Complaints / Discipline Previous Page Promotingq �Professionalism. .Aim,- Public Name License Status SCROGGINS, JULIE A Active Future Lawyers About Us Lawyers New Search (/Search/AttSearch.asp) Registration / Bar Number 13459 Is in Private Practice Carries Professional Liability Lowrance Yes No (What does this mean? - Click Here for more information) (/Search/PLI Notice.asp) Business Information Phone (970) 353-0216 Firm Name Julie A Scroggins PC Business Address 710 11th Avenue Suite 205 Greeley, CO 80631 Admission Date: 10/31/1983 Fax (970) 353-4025 J There is no public disciplinary history on file for this attorney within the state of Colorado. PSICI Professional Solutions INSURANCE COMPANY 14001 University Ave., Clive, IA 50325-8258 Toll -Free 800-510-8240 Toll -Free FAX 800-480-2232 LAWYERS PROFESSIONAL LIABILITY POLICY DECLARATIONS This is a claims made and reported policy. Please review your policy carefully. It applies only to those claims that are both first made and reported in writing to the Company during the policy period. Policy Number: LPL7199547 Named Insured and Practice Address: Julie A Scroggins Attorney at Law PC 710 11th Avenue Ste 205 Greeley, CO 80631 Effective Date: 11/14/2018 Policy Period: 11/14/2018 to 11/14/2019 at 12:01 A.M. Standard Time at the address shown above Retroactive Date: 11/14/2018 Limits of Liability: $1,000,000 Each Claim $1,000,000 Aggregate X Claim expenses are included within the limit of liability (CE1L) Claim expenses are in addition to the limit of liability (CEOL) Deductible: Abatement: $5,000 Each Claim NA Aggregate X Deductible applies to both damages and claims expenses Deductible applies to damages only So Policy Premium: $801.00 Forms and Endorsements Attached to this Policy: Please see attached Schedule of Forms and Endorsements Who to contact if you have a claim: Claims Department (800) 510-8240 AttomeyShield Fax: (877) 367-9654 14001 University Avenue Email: claims@attomeyshield.com Clive, IA 50325-8258 Agent: Ahern Insurance Brokerage, LLC 9655 Granite Ridge Drive Suite 500 San Diego, CA 92123 PSIC-LAW-Dec (05/13) Print Date: 11/14/2018 Agent ID: 908 Agent Phone & Fax: 8585719030 8585719010 uthd'rized Representative Policy underwritten by: PINN/AC©L ASSURANCE ITEM 1. INSURED Julie A. Scroggins, Attorney at Law P.C. 710 11th Ave Greeley, CO 80631 ITEM 2. POLICY PERIOD: FROM: October 2, 2018 to October 2, 2019 12:01 A.M. MOUNTAIN STANDARD TIME Questions about your policy? cakeinsure.com 1833-230-2253 support@cakeinsure.com October 2, 2018 Policy #: 2501611 ITEM 3. A. Workers' Compensation Insurance: Part One of the policy applies to the workers' compensation law of the states listed here: COLORADO Affinity/0 B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3 A. The limits of our liability under part two are: BODILY INJURY BY ACCIDENT $100,000 EACH ACCIDENT BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: NONE (Please contact us for information on coverage outside the state of Colorado) D. This policy includes the attached endorsements and schedules: 414 Notification of Change in Ownership Endorsement 511 Other State Endorsement CAT09 Catastrophe (Other than Certified Acts of Terrorism) TRPRA Terrorism Risk Insurance Program Reauthorization Act of 2015 1 of 7 10/2/2018 7:37:17 AM 2501611 Insurance Policy I+dw,nation Page P401 Coverage by Pinnacol Policy underwritten by: PINNI.LCOL ASSURANCE Questions about your policy? cakeinsure.com 1833-230-2253 support@cakeinsure.com ITEM 4. We will determine the premium for this policy by our manuals of rules, classifications, rates and rating plans. All Information required below is subject to change by audit. The statements of estimated advanced premium are also part of this policy. Coverage Information for Julie A. Scroggins, Attorney at Law P.C. Location: 710 11th Ave Greeley, CO 80631 Period: 10/02/2018 - 10/02/2019 Class RT Description Emp Payroll Rate Prem Charge 8820 EM Attorney's Office 1.00 $42,000 $0.192000 $81 Total for Julie A. Scroggins, Attorney at Law P.C. $42,000 $81 Description Period Adjustment Amount Ratable Manual Premium 10/02/2018 - 10/02/2019 $81 Designated Provider Discount 10/02/2018 - 10/02/2019 .975 $2 - Annual Policy Fee 10/02/2018 - 10/02/2019 $195 Terrorism Insurance Coverage 10/02/2018 - 10/02/2019 $2 Catastrophe Insurance Coverage 10/02/2018 - 10/02/2019 $4 Net Estimated Annual Premium 10/02/2018 - 10/02/2019 $280 2 of 7 10/2/201e 7:37:17 AM 2501611 Insurance Policy Information Page P401 Coverage by Pinnace Policy underwritten by: PINN/ACOL ASSURANCE Julie A. Scroggins, Attorney at Law P.C. 710 11th Ave Greeley, CO 80631 Questions about your policy'? cakeinsure.com 1833-230-2253 support@cakeinsure.com NCCI#WC0004228 Policy#: 2501611 ENDORSEMENT: Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 B) This endorsement addresses the requirements of the Terrorism Risk Insurance Act of 2002 as amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2015. It serves to notify you of certain limitations under the Act, and that your insurance carrier is charging premium for losses that may occur in the event of an Act of Terrorism. Your policy provides coverage for workers' compensation losses caused by Acts of Terrorism, including workers' compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy, and any applicable federal and/or state law, rules, or regulations. Definitions The definitions provided in this endorsement are based on and have the same meaning as the definitions in the Act If words or phrases not defined in this endorsement are defined in the Act, the definitions in the Act will apply. "Act" means the Terrorism Risk Insurance Act of 2002, which took effect on November 26, 2002, and any amendments thereto, including any amendments resulting from the Terrorism Risk Insurance Program Reauthorization Act of 2015. "Act of Terrorism" means any act that is certified by the Secretary of the Treasury, in consultation with the Secretary of Homeland Security, and the Attorney General of the United States as meeting all of the following requirements: a. The act is an act of terrorism. b. The act is violent or dangerous to human life, propriety or infrastructure. c. The act resulted in damage within the United States, or outside of the United States in the case of the premises of United States missions or certain air carriers or vessels. d. The act has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. "Insured Loss" means any loss resulting from an act of terrorism (and, except for Pennsylvania, including an act of war, in the case of workers' compensation) that is covered by primary or excess property and 3 of 7 10/2/2018 7:37:17 AM 2501611 Insurance Policy Information Page P401 Coverage by Pinnacol Policy underwritten by: PINNIACOL ASSURANCE Questions about your policy? K cakeinsure.com 1833-230-2253 support@cakeinsure.com casualty insurance issued by an insurer if the loss occurs in the United States or at the premises of United States missions or to certain air carriers or vessels. "Insurer Deductible" means, for the period beginning on January 1, 2015, and ending on December 31, 2020, an amount equal to 20% of our direct eamed premiums, during the immediately preceding calendar year. Limitation of Liability The Act limits our liability to you under this policy. If aggregate Insured Losses exceed $100,000,000,000 in a calendar year and if we have met our Insurer Deductible, we are not liable for the payment of any portion of the amount of Insured Losses that exceeds $100,000,000,000; and for aggregate Insured Losses up to $100,000,000,000, we will pay only a pro rata share of such Insured Losses as determined by the Secretary of Treasury. Policy Disclosure Notice 1. Insured Losses would be partially reimbursed by the United States Government If the aggregate industry Insured Losses exceed: a. $140,000,000, with respect to such Insured Losses occurring in calendar year 2017, the United States Government would pay 83% of our Insured Losses that exceed our Insurer Deductible. b. $160,000,000, with respect to such Insured Losses occurring in calendar year 2018, the United States Government would pay 82% of our Insured Losses that exceed our Insurer Deductible. c. $180,000,000, with respect to such Insured Losses occurring in calendar year 2019, the United States Government would pay 81% of our Insured Losses that exceed our Insurer Deductible. d. $200,000,000, with respect to such Insured Losses occurring in calendar year 2020, the United States Government would pay 80% of our Insured Losses that exceed our Insurer Deductible. State CO Schedule Rate $0.005 Effective Date: October 2, 2018 Pinnacol Assurance has issued this endorsement October 2, 2018. Premium $2 4 of 7 1W2/2018 7:37:17 AM 2501611 Insurance Policy Information Page P401 Coverage by Pinnacol Policy underwritten by: PINNhLCOL ASSURANCE Julie A. Scroggins, Attorney at Law P.C. 710 11th Ave Greeley, CO 80631 bout your policy? cakeinsure.com 1833-230-2253 support@cakeinsure.com NCCI#WC000421D Policy#: 2501611 WORKERS' COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of a Catastrophe (other than Certified Acts of Terrorism) as that term is defined below. Your policy provides coverage for workers' compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism). This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 B) attached to this policy. For purposes of this endorsement, the following definitions apply: Catastrophe (other than Certified Acts of Terrorism): Any single event, resulting from an Earthquake, Noncertified Act of Terrorism, or Catastrophic Industrial Accident, which results in aggregate workers' compensation losses in excess of $50 million. Earthquake: The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. Noncertified Act of Terrorism: An event that is not certified as an Act of Terrorism by the Secretary of Treasury pursuant to the Terrorism Risk Insurance Act of 2002 (as amended) but that meets all the following criteria: a. It is an act that is violent or dangerous to human life, property, or infrastructure. b. The act results in damage within the United States, or outside the United States in the case of the premises of the United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Act of 2002 (as amended); and c. It is an act that has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. 5 of 7 1012(2018 7:37:17 AM 2501611 Insurance Policy Information Page P401 Coverage by Pinnacol Policy underwritten by: PINK CCOL ASSURANCE Questions about your policy"? cakeinsure.com 1833-230-2253 support@cakeinsure.com Catastrophic Industrial Accident A chemical release, large explosion, or small blast that is localized in nature and affects workers in a small perimeter the size of a building. The premium charge for the coverage your policy provides for workers' compensation losses caused by a Catastrophe (other than Certified Acts of Terrorism) is shown in Item 4 of the Information Page or in the Schedule below. State CO Thank you for your business. Pinnacol Assurance 6 of 7 10/2/2018 7:37:17 AM 2501611 Schedule Rate $0.010 Premium $4 Insurance Policy Information Page P401 Coverage by Pinnacot Policy underwritten by: PINN/ICOL ASSURANCE Julie A. Scroggins, Attorney at Law P.C. 710 11th Ave Greeley, CO 80631 Questions about your policy% cakeinsure.com 1833-230-2253 support@cakeinsure.com NCCI#WC000414 Policy#: 2501611 ENDORSEMENT: NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity and other changes provided for in the applicable experience rating plan manual. You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes within this period may result in revision of the experience rating modification factor used to determine your premium. 7 of 7 10/2/2018 7:37:17 AM 2501611 Insurance Policy Information Page P401 Coverage by Pinnacol Insured's Name and Address Donald Janklow 710 11th Ave Ste 205 Greeley, GO 80631 CERTIFICATE OF LIABILITY INSURANCE American Family Insurance Company D American Family Mutual Insurance Company, Si. if selection box is not checked. 6000 American Pky Madison, Wisconsin 63783-0001 Agent's Name, Address and Phone Number (Agt./Dist.) Less Ringkjob Agency, Inc 375 E Horsetooth Rd Bldg 6100 Fort Collins, CO 80525 (970) 223-0940 (O31/309) This certificate is issued as a matter of infonnation only and confers no rights upon the Certifleate Holder. This certificate does not amend, extend or alter the coverage afforded by the policies listed below. COVERAGE Ths atonality Temmm document Mud policies of insurance baled rasped bi whch the certificate blow hive sit ve bean Waled to e insured named above for the edict Pedal Irdicpeed, m4 on issued or may pertain, the hssenca retarded byte policies described noMebandng any rayulrerranL term or eonddm a any mntns or other heroin is subject a at Me termt malaria*, and conditions or such palates, TYPE OF INSURANCE POLICY DATE POLICY NUMBER AF Cdr+ to Y gti LIMITS OF LIABILITY Homeowners/ Moblishomeawners soar laic' end Property Damage Liability Each Occurrence Boatowrlers Liability ,000 Bode/ Injury and Property Damage Each Onmrreee $ Personal Umbrella Liability ,000 Bony Spry end Properly Dyr,ega Each OOWrenes $ ,000, Fein liana), a Personal Luedtp Farm/Ranch Liability Each 0cauxe,ce $ O00 Farm Emproyer'e Cathay Each Occurrence $ ,000 Statutory Workers Compensation and Employers Liability t Earn Acaa.nt .000 olesse-EachEm$ pbyse ,000 Dbeaes- Poky line $ General Liability ❑ Commercial 000 General Aggregate $ 000 General Liability (occurrence) Products - Completed Opener's Aggregae $ 000_ 0 Personal and Advateing Ireury $ 000{ 0 Each Occurrence$ ,000 Damage to Pianism Rented to You $ 000 Medical Expense (Arm On° Parson) $ 000 BushwasownsrsLiability 05-X66837-01 07/09/2018 07/09/2019 , Fand.Dpy 'na1t $ 1,000.000 Astor aTT S 2,000 Liquor Liability ,000 Common Cauca Lime $ ,000 Aggregate Lima $ Automobile Liability ❑ My Auto ❑ A8 Owned Aube O00 Bodly Injury - Each Persq n $ 000 eddy Injury - Each Accident$ ,D00 ❑ Scheduled Autos ElHired Auto Properly Damage $ 000 0 Nonowned Autos Body Injury and Properly Damao Cambhed $ ,000 Excess Liability ❑ Commercal Blanket Excess Each OcananociAggragete0 $ 000 Other (Miscellaneous Coverages) DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES 1 RESTRICTIONS/ SPECIAL ITEMS Weld County is named as additional insured t'hB^drn+ual a paTM°re ❑Have shown es rnaued Waded to be covered under able pa a,. U tare not i P odesoCompaed Operdbrs apgretp.e a aqua to each occurrence limit and e rnduded in Parry aggregate CERTIFICATE HOLDER'S NAME AND ADDRESS CANCELLATION Weld County U Should any of tha above deemed policies be cancatied before the expiration date PO Box 1167 thereof, See company win endeavor to doss 'I days) widen notice to the Certificate Holder named, bed failure to mull such notice sham Impose no obligation or labilky of any kind Greeley CO 80632e =AMY, se agents a npmaenMlMea VO dap Unless different natter or days U This canines coverage on rite dale of en" only The sbOVe described policies ere ertblecl to oncelehon In conformity with their Verne and by the awe of the stale of moue. DATE ISSUED AUTHORIZED REPRESENTATIVE 10/03/2018 Lesa Ringkjob, A.R.M. U-201 Ed. WOO Stock No. 06668 Rev. 7/02 572 POLICY NUMBER 0586683701 06X6683701 15 000 UNATRE AMERICAN FAMILY MUTUAL INSURANCE COMPANY, S.I. MADISON, WISCONSIN 53783-0001 BUSINESSOMINERS POLICY DECLARATIONS CUSTOMER BILUNG ACCOUNT 012-645-605 07 NAMED DONALD JANKLOW INSURED JAMES PEYTON MICHAEL LAZAR JULIE SCROGGINS MAILING 710 11TH AVE STE 205 ADDRESS GREELEY, CO 80631-3200 POLICY PERIOD FROM 07-09-2018 TO 07-09-2019 12:01 A.M. Standard Time at your mailing address shown above. FORM OF BUSINESS PARTNERSHIP In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the Insurance as stated in this policy. SECTION I PROPERTY ALL PROPERTY COVERAGES ARE SUBJECT TO THE FOLLOWING: COVERED CAUSES OF LOSS SPECIAL - RISK OF DIRECT PHYSICAL LOSS COVERAGE LIMIT OF INSURANCE PREMIUM OPTIONAL COVERAGE EMPLOYEE DISHONESTY $10,000 $117.00 ADDITIONAL COVERAGE - HIGHER LIMITS FORGERY AND ALTERATION $10, 000 $29.00 COVERAGE PROVIDED INSURANCE AT THE FOLLOWING DESCRIBED PREMISES ONLY FOR COVERAGES FOR WHICH A LIMIT OF INSURANCE IS SHOWN UNLESS COVERAGE IS PROVIDED BY AN ENDORSEMENT. DESCRIPTION OF PREMISES PREMISES NO. 0001 BUILDING NO. 001 LOCATION 710 11TH AVE STE 205 GREELEY, CO 80631-3200 BUILDING INTEREST TENANT PREDOMINANT OCCUPANCY ATTORNEY/ LAWYER OFFICE CONSTRUCTION JOISTED MASONRY CERTIFIED ACTS OF TERRORISM $3.00 POLICY PROPERTY DEDUCTIBLE $250 OTHER PROPERTY DEDUCTIBLE(S) OPTIONAL COVERAGE/GLASS DEDUCTIBLE AGENT 031-309 LESA RINGKJOB AGENCY, INC 375 E HORSETOOTH RD BLDG 6100 FORT COLLINS, CO 80525-6800 BP AF 018517 $500 PHONE PAGE 0001 970-223-0940 BRANCH UNATRE RENW 970-353-0032 ENTRY DATE 04-11-2018 INSURED Stock No. 15141 572 POUCY NUMBER 05X6683701 05X6683701 15 000 UNATRE AMERICAN FAMILY MUTUAL INSURANCE COMPANY, S.I. MADISON, WISCONSIN 53783-0001 BUSINESSOWNERS POLICY DECLARATIONS COVERAGE BUSINESS PERSONAL PROPERTY REPLACEMENT COST AUTOMATIC INCREASE IN COVERAGE 4% ADDITIONAL COVERAGE BUSINESS INCOME OPTIONAL COVERAGES MONEY AND SECURITIES INSIDE THE PREMISES OUTSIDE THE PREMISES LIMIT OF INSURANCE $41,215 UNIT OF INSURANCE ACTUAL LOSS SUSTAINED LIMIT OF INSURANCE $10,000 $5,000 CUSTOMER BILLING ACCOUNT 012-645-605 07 Property forms and endorsements applying to this premises and made part of this policy at time of issue: Any endorsement followed by a state abbreviation will only apply to coverages within this state. BP 85 17 09 15 BP 84 10 07 98 BP 85 11 12 08 TOTAL ADVANCE PROPERTY PREMIUM $323.00 Property forms and endorsements applying to all premises and made part of this policy at time of issue: Any endorsement followed by a slate abbreviation will only apply to coverages within this state. BP 06 01 01 07 BP 83 01 07 98 BP 83 02 01 07 PREMIUM $138.00 PREMIUM INCLUDED PREMIUM $36.00 INCLUDED INCLUDED SECTION II LIABILITY AND MEDICAL EXPENSES Except for Damage To Premises Rented To You, each paid claim for the following coverages reduces the amount of insurance we provide during the applicable annual period. Please refer to Section II Lability in the BUSINESSOWNERS COVERAGE FORM and any attached endorsements. COVERAGE AGGREGATE LIMIT (OTHER THAN PRODUCTS COMPLETED OPERATIONS) PRODUCTS -COMPLETED OPERATIONS AGGREGATE LIMIT LIMIT OF INSURANCE $2,000,000 $2,000,000 DAMAGE TO PREMISES RENTED TO YOU - ANY ONE PREMISES SEE BP 04 55 UABIUTY - EACH OCCURENCE LIMIT $1,000,000 PREM 0001 BLDG 001 MEDICAL EXPENSES - ANY ONE PERSON $5,000 LOCATION PREMIUM BASIS RATE ADVANCE PREMIUM PREMISES NO. 0001 BUILDING NO. 001 1000 SQUARE FOOTAGE $21.00 AGENT 031-309 LESA RINGKJOB AGENCY, INC 375 E HORSETOOTH RD BLDG 6100 FORT COLLINS, CO 80525-6800 BPAF010517 PHONE PAGE 0002 970-223-0940 BRANCH UNATRE RENW 970-353-0032 ENTRY DATE 04-11-2018 INSURED Stock No. 15141 572 POLICY NUMBER 0586683701 05X6683701 15 000 UNATRE AMERICAN FAMILY MUTUAL INSURANCE COMPANY, 5.1. MADISON, WISCONSIN 53783-0001 BUSINESSOWNERS POLICY DECLARATIONS CUSTOMER BILLING ACCOUNT 012-645-605 07 CERTIFIED ACTS OF TERRORISM APPLICABLE BUSINESS LIABILITY ENDORSEMENT CHARGES TOTAL ADVANCE BUSINESS LIABILITY PREMIUM $1.00 $94.00 S116.00 Liability forms and endorsements applying to all premises and made part of this policy at time of issue: Any endorsement followed by a state abbreviation will only apply to coverages within this state. BP 04 37 07 02 BP 04 39 07 02 BP 04 48 01 06 BP 04 55 01 06 BP 04 93 01 06 BP 05 17 01 06 BP 10 05 07 02 BP 14 60 06 10 BP 15 04 05 14 BP 85 04 07 10 BP 85 05 07 98C0 BP 85 10 07 98 BP 88 04 02 15 IL 75 26 12 05 BP 04 54 01 06 BP 05 77 01 06 BP 84 24 01 07 BP 85 12 01 06 TOTAL ADVANCE BUSINESS PREMIUM $439.00 This premium may be subject to adjustment. Forms and endorsements applying to property and liability at all premises and made part of this policy at time of issue: Any endorsement followed by a state abbreviation will only apply to coverages within this state. BP IN 01 01 06 BP 00 03 01 06 BP 01 81 11 13 BP 05 01 07 02 BP 05 15 01 15 BP 05 23 01 15 BP 05 38 01 15 BP 80 01 05 17 AUTHORIZED REPRES£NTATNE AGENT 031-309 LESA RINGR70B AGENCY, INC 375 E HORSETOOTH RD BLDG 6100 FORT COLLINS, CO 80525-6800 BP AF 01 0517 tbUNTERSNmNED LICENSED RESIDENT MEW PHONE PAGE 0003 970-223-0940 BRANCH IINATRE RENT'S 970-353-0032 ENTRY DATE 04-11-2018 INSURED Stock No. 15141 572 05X6683701 15 000 UNATRE BUSINESSOWNERS BP 15 04 05 14 This ENDORSEMENT CHANGES THE POUCY. PLEASE READ IT CAREFULLY. EXCLUSION — ACCESS OR DISCLOSURE OF CONFIDENTIAL OR PERSONAL INFORMATION AND DATA -RELATED LIABILITY —WITH LIMITED BODILY INJURY EXCEPTION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM A. Exclusion B.1.q. of Section II — Liability is replaced by the following: This insurance does not apply to: q. Access Or Disclosure Of Confidential Or Personal Information And Data -related Uability (1) Damages, other than damages because of 'personal and advertising injury', arising out of any access to or disclosure of any person's or organization's confidential or personal information, inducting patents, trade secrets, processing methods, customer lists, financial information, credt card information, heath information or any other type of nonpublic information; or (2) Damages arising out of the loss of, loss of use of, damage to, corruption of, inanity to access, or inabiity to manipulate electronic data This exclusion applies even if damages are claimed for notification costs, credit monitoring expenses, forensic expenses, public relations expenses or any other loss, cost or expense incurred by you or others arising out of that which is described in Paragraph (1) or (2) above. However, unless Paragraph (1) above applies, this exclusion does not apply to damages because of 'bodily injury". As used In this exclusion, electronic data means information, facts or computer programs stored as or on, created or used on, or transmitted to or from computer software (including systems and applications software), on hard or floppy risks, CD-ROMs, tapes, drives, cells, data processing devices or any other repositories of computer software which are used with electronically controlled equipment The term computer programs, referred to in the foregoing description of electronic data, means a set of related electronic instructions which direct the operations and functions of a computer or device connected to it, which enable the computer or device to receive, process, store, retrieve or send data. B. The following is added to Paragraph B.1.p. Personal And Advertising Injury Exclusion of Section II — Uabiity: This insurance does not apply to: p. Personal And Advertising Injury 'Personal and advertising bits!: Arising out of any access to or disclosure of any person's or organization's confidential or personal information, inducing patents, trade secrets, processing methods, customer lists, financial information, credit card information, heath information or any other type of nonpublic information. This exclusion applies even if damages are claimed for notification costs, credit monitoring expenses, forensic expenses, public relations expenses or any other loss, cost or expense Incurred by you or others arising out of any access to or &closure of any person's or orgarization's confidential or personal information. BP 150400514 © Insurance Services Office, Inc., 2013 Stock No. 38338 572 05x6683701 15 000 UNATRE BUSINESSOWNERS BP 01811113 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. COLORADO CHANGES This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM A. Section II- Liability is amended as follows: The term "spouse" is replaced by the following: Spouse or party to a civil union recognized under Colorado law. B. Section III - Common Policy Conditions is amended as follows: 1. Paragraph A.2. Cancellation is replaced by the following: 2. If this policy has been in effect for less than 60 days, we may cancel this policy by mailing or delivering to the first Named Insured written notice of cancellation at least: a. 10 days before the effective date of cancellation if we cancel for nonpayment of premium; or b. 30 days before the effective date of cancellation if we cancel for any other reason, 2. The following is added to Paragraph A. Cancellation: 7. Cancellation of Polities In Effect for 60 Days or More a If this policy has been in effect for 60 days or more, or is a renewal of a policy we issued, we may cancel this policy by mailing through first-class mat to the first Named Insured written notice of cancellation: (1) Including the actual reason, at least 10 days before the effective date of cancellation, if we cancel for nonpayment of premium; or (2) At least 45 days before the effective date of cancellation if we cancel for any other reason. We may only cancel this policy based on one or more of the following reasons: (1) Nonpayment of premium; (2) A false statement knowingly made by the insured on the application for insurance; or (3) A substantial change in the exposure or risk other than that incicated in the application and underwritten ritten as of the effective date of the policy unless the first Named Insured has notified us of the change and we accept such change. 3. Paragraph C. Concealment, Misrepresentation Or Fraud is replaced by the foaming: C. Concealment, Nisrepreeentation Or Fraud We will not pay for any loss or damage in any case of: 1. Conce knent or misrepresentation of a material fact; a 2. Fraud Committed by you or any other insured at wry time and relating to coverage under this policy. 4. The following Paragraph is added and supersedes any other provision to the contrary: NONRENEWAL If we decide not to renew this policy, we will mail through first-class mail to the first Named Insured shown in the Declarations written no- tice of the nonrenewal at least 45 days before the expiration date, or its anniversary date if it is a policy written for a term of more than one yea or with no fixed expiration date. If notice is mailed, proof of mailing will be sufficient proof of notice. 5. The following paragraph is added: INCREASE IN PREMIUM OR DECREASE IN COVERAGE We will not increase the premium unilaterally or decrease the coverage benefits on renewal of this policy unless we mail through first-class mail written notice of our intention, including the actual mason, to the first Named i sured's last mailing address known to us, at least 45 days before the effective data Any decrease in coverage during the policy term must be based on one or more of the following reasons: a. Nonpayment of premium; b. A false statement knowingly made by the insured on the application for insurance; or c. A substantial change in the exposure or risk other than that indcated in the application and underwritten as of the effective date of the policy unless the first Named Insured has notified us of the change and we accept such change. If notice is mailed, proof of mailing wil be sufficient proof of notice. BP 0181 11 19 5 BO Properties, Inc„ 2013 Stock No. 38018 05X6683701 15 000 UNATRE 572 POLICY NUMBER: 05X6683701 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): THOMAS & TYLER LLC WELD COUNTY PO BOX 1167 GREELEY CO 80632 BUSINESSOWNERS BP 04 48 0106 information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following Is added to Paragraph C. Who Is An Insured in Section II — LiabiNty: 3. Any person(s) or organization(s) shown In the Schedule is also an additional insured, but only with respect to liability for "bodily injury", "property damage" or °personal and advertising injury caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf in the performance of your ongoing operations or in connection with your premises owned by or rented to You. BP 0440 0100 O ISO Properties, Inc_, 2004 Stock No, 13799 05X6683701 15 000 UNATRE 572 POLICY NUNBER: 05x6683701 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BROADENED COVERAGE FOR DAMAGE TO PREMISES RENTED TO YOU This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM BUSINESSOWNERS BP 04 55 01 06 SCHEDULE A. Premises: B. Limit Of Insurance (Per Occurrence): 0001 BLDG. NO. 001 $100,000 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. With respect to the coverage provided under this endorsement, Section II — Liability is emended as follows: A. The final paragraph of B.1. Exclusions —Applicable To Business Liability Coverage Is deleted and replaced by the following: With respect to the premises shown in the Schedule of this endorsement which are rented to you or temporarily occupied by you with the permission of the owner, Exclusions c., d., a., g., h., k., I., m., n. and o. do not apply to "property damage". B. Paragraph Di Liability And Medical Expenses Limits Of Insurance is deleted end replaced by the following with respect to damage to the premises shown in the Schedule of this endorsement: The most we will pay under this endorsement for the sum of all damages because of all 'property damage' to premises while rented to you or temporarily occupied by you with the permission of the owner Is the Limit of Insurance shown in the Schedule. C. With respect to the premises shown in the Schedule of this endorsement, Paragraph D.3. is deleted. BP 04 55 0108 0 ISO Properties, Inc., 2004 Stack Na. 13930 05X6683701 15 000 UNATRE 572 POLICY NUMBER 05X6683701 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BUILDING AND BUSINESS PERSONAL PROPERTY CHANGES This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM BUSINESSOWNERS BP 85 11 12 08 SCHEDULE* Premises. Building No. No. Auxiliary Building/Structure Description Auxiliary Auxiliary Buildings Business Building/ Personal Property Structure Limit Limit Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Declarations. BP 85111208 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 1 of 2 Stock No. 19225 572 05X6683701 15 000 UNATRE Section I - Property is amended as follows: A Paragraph Al. Covered Property Is replaced with the following: Covered Property includes Building as described under Paragraph a. below, Business Personal Property as deserted under Paragraph b. below, Auxiliary Buiktngs&Siructures as described under Paragraph c. below, Auxiliary Buildngs Business Personal Property as deserted under Paragraph d. below, or all four, depending on whether a Limit of Insurance is shown in the Declarations for that type of property. Regardless of whether coverage is shown in the Declarations for Bullrings, Business Personal Property, Auxiliary Bulklings/Structures, Auxiliary Buildings Business Personal Property, or all four, there is no coverage for property described under Paragraph Al. Property Not Covered. a. Building, means the described building shown in the Declarations, including: (1) Completed additions; (2) Fixtures, Including outdoor fixtures; (3) Permanently installed: (a) Machinery; and (b) Equipment; (4) Your personal property in apartments, rooms or common areas furnished by you as landlord; (5) Personal property owned by you that is used to maintain or service the described building or the premises, inducing: (a) Fire extinguishing equipment; (b) Outdoor furniture; (c) Floor coverings; and (d) Appliances used for refrigerating, ventilating, cooking, dishwashing or laundering; (8) If not covered by other insurance: (a) Additions under construction, alterations and repairs to the described building; (b) Materials, equipment, supplies and temporary structures, on or within 100 feet of the described premises, used for making additions, alterations or repairs to the described building. b. Business Personal Property located in or on the described building at the premises shown in the Declarations or in the open (or in a vehicle) within 100 feet of the described premises, including: (1) Property you own that Is used in your business; (2) Property of others that is in your care, custody or control, except as otherwise provided in Loss Payment Property Loss Condition E.5.d.(3)(b); (3) Tenant's impovements and betterments. Improvements and betterments are fixtures, alterations, installations or additions: (a) Made a pert of the described building you occupy but do not own; and (b) You acquired or made at your expense but cannot legally remove; (4) Leased personal property for which you have a contractual responsibility to Insure, unless otherwise provided for under Paragraph 1.b.(2); and (5) Exterior building glass, if you are a tenwit and no Limit of Insurance is shown In the Declarations for Building property. The glass must be owned by you or in your care, custody or control. c. Auxiliary Buildings/Structures, meaning the auxiliary buikings/structures described In the above Schedule located at the premises shown in the Declarations, including: (1) Completed additions; (2) Fixtures; (3) Permanently installed: (a) Machinery; and (b) Equipment; (4) Personal property owned by you that is used to maintain or service the auxillay buildings/ structures, inducing: (a) Fire extinguishing equipment (b) Floor coverings; and (c) Appliances used for refrigerating, ventilating, cooking, ddshwashing or laundering; (5) If not covered by other insurance: (a) Additions under construction, alterations and repairs to the auxiliary buildings/structures; (b) Materials, equipment, supplies and temporary structures, on or within 100 feet of the auxiliary buildings/struchres, used for making addition, alterations or repairs to the auxiliary buikings/structures. d. Auxiliary Buildings Business Personal Properly located In or on the auxiliary buildings/structures described in the above Schedule located at the premises shown in the Declarations, including: (1) Property you own that is used in your business; (2) Property of others that is in your care, custody or control, except as otherwise provided in Loss Payment Property Loss Condition E.5.d.(3)(b); (3) Leased personal property for which you have a contractual responsibility to insure, unless otherwise provided for under Paragraph 1.b.(2). B. The following is added to E3., Property Loss Conditions — Duties In the Event of Loss or Damage: (10) Keep records of your property in such a way that we cm accurately determine the amount of any loss. BP 8511 1208 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Page 2 of 2 Stock No. 19225 572 05X6683701 15 000 UNATRE POLICY NUMBER: 05X6683701 BUSINESSOWNERS BPS:040215 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EMPLOYMENT PRACTICES LIABILITY INSURANCE THIS ENDORSEMENT PROVIDES CLAIMS FIRST MADE AND REPORTED COVERAGE PLEASE READ THE ENTIRE FORM CAREFULLY This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE LIMIT OF LIABILITY (INCLUDES COST OF DEFENSE): Each Insured Event Limit $100,000 Aggregate Limit of Liability $100,000 Self -Insured Retention (Includes Cost of Defense): Any One Insured Event $5,0 Prior Knowledge Date: 07109/2015 Retroactive Date: 07/0912015 Extended Reporting Period: Yes ❑ No Authorized Representative: American Family Claims Department Information required to complete This Schedule, if not shown above, will be shown in the Declarations For the purposes of the coverage provided by this endorsement, Section II — Liability is amended as follows: A. The following is added to Paragraph A. Coverages: 1. WHAT IS COVERED We will pay Loss amounts that an Insured is legally obligated to pay on account of a Claim because of an Insured Event to which this endorsement applies. However, the amount we will pay is limited as described in the LIMIT OF LIABILITY and SELF INSURED RETENTION paragraphs of this endorsement 2. This endorsement applies only if: a. A Claim is first made against an Insured in accordance WHEN COVERAGE IS PROVIDED in this endorsement b. The Claim is reported in accordance with WHEN COVERAGE IS PROVIDED and the Duties in the event of a Claim Condition of this endorsement; c. A Claim is first made against an Insured in accordance with WHERE COVERAGE IS PROVIDED; and d. A Claim is first made against an Insured based upon an Insured Event that first occurred on or after the Retroactive Date set forth in the Schedule of this endorsement 3. Defense. We have the right and duly to defend any Claim for an Insured Event made or brought against any Insured to which this endorsement applies. We have the right to choose counsel to defend a Claim that we are covering. We have no duty to provide other services or take other actions. Our duty to defend any Claim ends when the LIMIT OF LIABILITY that applies has been exhausted, and in such event, the Named Insured shall, upon notice from us, promptly take over control of the defense. We have the right to investigate and to settle any Claim for an Insured Event in the manner and to the extent that we believe is proper, contingent upon the consent of the Named Insured as defined in this endorsement This includes the right to agree to post a notice of compliance, provided such notice does not contain an admission of liability. BP a 0402 15 Includes copyrighted material of Insurance Services Office, with its permission. Page 1 of 7 Stock No, 35392 572 05X6683701 15 000 UNATRE You may take over control of any outstanding Claim previously reported to us only if we both agree that you should if required under law or if a court orders you to do so. If your LIMIT OF LIABILITY is exhausted, we will notify you of all outstanding Claims so that you can take over control of their defense. We will help to transfer control to you. 4. During the transfer of control. We agree to take whatever steps are necessary to continue the defense of any outstanding Claim and avoid a default judgment during the transfer of control to you. If we do so, you agree to pay reasonable expenses that we incmr for taking such steps after the LIMIT OF UABIUTY is exhausted. 5. Duty to pay. We have the duty to pay any Loss (after you pay the applicable self -insured retention) that results from any Claim for an Insured Event made or brought against any Insured to which this policy applies. Our duty to pay ends when the applicable LIMIT OF LIABILITY has been exhausted We will not pay more than the applicable OMIT OF UABILITY. We have the duty to pay Defense Costs incurred (after you pay the applicable self -insured retention) for the defense of any Claim that is controlled by us. My payment of Defense Costs is included in the LIMIT OF LIABILITY, it is not in addition to the LIMIT OF LIABILITY. 6. Recommended Settlements. As respects any Claim for which we recommend that a settlement offer be accepted but you do not gve your consent to such settlement, and the Claim later results in a judgment or settlement in excess of the recommended settlement, our liability for Loss on acootnt of such Claim shall not exceed the recommended settlement ambit plus Defense Costs incurred as of the date we recommended the settlement This provision shall not apply unless the total Loss, including the recommended settlement, would exceed the applicable SELF INSURED RETENTION amount. 7. WHEN COVERAGE IS PROVIDED This endorsement applies only to Claims arising out of an Insured Event first made or brought during the Poficy Period and which are reported to us in accordance with the notice provisions as set forth in E.1. Duties in the Event of a Claim of this endorsement. Claims are considered to be first made when it is first served or received by the Insured, a. All Claims because of One Insured Event will be considered to have been made or brought on the date that the first of those Claims was first made or brought. b. Limited Reporting Period For the purposes of the coverage provided by this endorsement, Limited Reporting Period means the tidy (30) day period after the policy ends, doing which Claims because of Insured Events which happen or commence doing the Policy Period and are reported in accordance with Paragraph A. and Paragraph E. of this endorsement can be made. BP 0e 04 0215 c. Extended Reporting Period For the purposes of the coverage provided by this endorsement, the following Extended Reporting Period provisions are added: (1) If this endorsement is cancelled (for masons other than non-payment of premium), non - renewed, or renewed with less favorable terms, you shall have the right to buy an Extended Reporting Period providing: (a) An extended reporting period of up to thirty six (36) months from the end of the Policy Period; or (I) The effective date of cancellation, whichever is eerier, in exchange for your payment of an additional premium. (2) The Extended Reporting Period will not be enforced unless: (a) we receive a written request for it within thirty (30) days after this endorsement is cancelled or non -renewed; nor (I) will it take effect unless the additional Premium is paid within thirty (30) days after this endorsement is cancelled a non -renewed. The Extended Reporting Period is activated by checking the appropriate box on the Schedule of this endorsement. Once that Premium is paid the Extended Reporting Period may not be cancelled and the additional Premium will be fully earned. The additional premium for a 36 month Extended Reporting Period will be two hundred percent (200%) of the premium charged for the last Policy Period. However, the Extended Reporting Period will not apply to any Claim if other instrarce you buy covers you or world cover you If Its limits of coverage had not been exhausted. Coverage under the Extended Reporting Period is with respect to Claims first made against an Insured during the Policy Period or Extended Reporting Period and first reported by an Insured during the Extended Reporting Period, provided always that Claims reported during the Extended Reported Period are limited to hsured Events which happen or commence before the original Policy Period ends by either cancellation or non -renewal and which are otherwise covered by this endorsement The UNIT OF LIABIUTY that applies at the end of the Policy Period is not renewed or increased and the Limits, as shown in the Schedule of this endorsement, shall not be increased in any way by the Limited Reporting Period or the addition of the Extended Reporting Period. 8. If, during the Policy Period, any of the following changes occur a. the acquisition of an Insured, or of all or substantially all of its assets, by another entity, or the merger or consolidation of an Insured into or with another entity such that the Insured is not the surviving entity; or Includes copyrighted material of Insurance Services Office, with its permission. Page 2of7 Stock No. 35392 572 O5X66837O1 15 OOO UNATRE b. the obtaining by any person, entity or affiliated group of persons or entities of the right to elect, appoint or designate over fifty percent (50%) of the drectors of an Insured. coverage under this endorsement with respect to such Insured will continue in full force and effect with respect to Claims for Insured Events committed before such change, but coverage with respect to such Insured will cease with respect to Claims for Insured Events committed after such change. After any such change, this endorsement may not be cancelled and the entire Premium for the endorsement will be deemed fully earned. 9. WHERE COVERAGE IS PROVIDED This endorsement covers Claims made and Insured Events occurring anywhere in the Orated States of America or its territories. B. For the purposes of the coverage provided by this endorsement, the following is added to Section II. Liability Paragraph B. Exclusions: 1. Worker's CompensaffonIERISAIFLSAMRLAIWARWCOBRAIO SIiA. Tits endorsement does not cover any Loss wising out of any Claim alleging violation of any: i) worker's compensation, disability benefits or unemployment compensation law, social security and other employment benefits law; ii) the Employee Retirement Income Security Act of 1974 Pblic Law 93-406; Ni) the Fair Labor Standards Act (except the Equal Pay Act); (hi) the National Labor Relations Act (v) the Worker Adjustment and Retraining Notification Act (vi) the Consolidated Omnibus Budget Reconciliation Act of 1985; (vii) the Occupational Safety and Health Act (viii) any other federal, state or local statute or law sharer to any statute or law described in (i) through (vii) of this exclusion; provided, however, this exclusion shall not apply to any Claim for any actual or alleged retaliatory treatment of the clamant on account of the claimants exercise of rights pursuant to such statute, law, rule or regulation. 2. Contractual Liability. This endorsement does not cover any Lass based upon, arising out of, directly or indrectly in connection with, related to, or in any way involving any Claim any insured is obligated to pay by reason of the assumption of anther's Nobility for an Insured Event in a contract or agreement. This exclusion will not apply to liability for damages because of an Insured Event that any Insured would have without the contract or agreement. 3. Consequential Loss. This endorsement does not cover any Loss resulting from or attributable to any allegations made by or solely for the benefit of a claimants domestic partner, spouse, child, parent, brother or sister. t Wage and Hour Law. This endorsement does not cover any Loss arising out of a claim based upon, arising out of, directly or indirectly in connection with, related to or in any way alleging violation of any state or local wage and hour law, however, in the event such Claim also alleges an Insured Event otherwise covered by this endorsement, notwithstanding the provisions of Paragraph A.3. Defense, and subject to all other terms, conditions and exclusion contained in this endorsement, BP 08040215 we agree to pay loss solely for that portion of the claim involving such Insured Event. 5. Stan Options. This endorsement does not cover any Loss resulting from or attributable to stock options, inducing, without limitation, 1) the failure to grant stock options andlor 2) amounts attributable to unvested stock options which options did not vest because of the actual or alleged wrongful termination of an Employee. 6. Fraud and Collusion. This endorsement does not cover any Loss based upon, arising out of, directly or indirectly in connection with, related to, or in any way involving any Claim alleging fraud, collusion, dishonest, criminal or malicious acts by or at the direction of an Insured. Without limiting the foregoing, we will pay Defense Costs incused relating to allegations of fraud, collusion, dishonest, criminal or maidous acts to defend an imocent Insured named in such Claim so long as such Claim also contains allegations against that innocent Insured involving an Insured Event otherwise covered by this endorsement 7. Prior Knowledge. This endorsement does not cover my Loss wising out of Insured Events of which any Insured who is a principal, partner, officer, director, trustee, in -Crouse counsel, Employee(s) within the Human Resource or Risk Management department or Employees) with personnel and risk management responsibilities was aware by actual knowledge of the facts or circumstances of such Insured Event prior to the Prior Knowledge Date, as shown In the Schedule of this endorsement 8. Prior Notice. This endorsement does not cover any Loss arising out of Insured Events that have been the stbject of any notice given under any other policy prior to the inception date of this endorsement. 9. Retroactive Date. This endorsement does not cover any Loss arising out of any Insured Events that first occurred before the Retroactive Date as set forth in the Schedule of this endorsement For the purposes of this exclusion, related Insured Events are excluded it the first related Insured Event took place or is alleged to have taken place prior to the Retroactive Date. C. For the purposes of the coverage provided by this endorsement, Section IL Liability Paragraph B. Who Is An Insured is amended to include as an insured: 1. Individual. If you as shovm in the Declarations as an individual, you and your spouse are Insureds but only for the concisct of a business of which you are the sole owner. 2. Corporation. If you are shown In the Declarations as a corporation or organization other than a partnership or joint venture, you are an Insured You' stockholders are also Insureds, but only with respect to their liability as your stockholders. 3. Partnership or Joint Venture. If you are shown in the Declarations as a partnership or joint venture, you am an Insured. Your partners or co -venturers and their spouses are also Insureds, but only for the conduct of your business. Includes capyn hied material of insurance Services Office, with its peimrssan. Page 3,317 Stock No. 35392 572 05X6683701 15 000 UNATRE However, no person or organization is covered for the conduct of any current or past partnership or ioint ventue not named in the Declarations. 4. Other. If you are a Limited Liability Corporation (LW), or a Limited Liability Partnership ('LLP) of the Named Inured and you are shown in the Declarations as 'Other you are an insured. Your members, partners and shareholders are also Insureds but only with respect to the conduct of your business. 5. Employees. Your Employees, executive officers, (rectors and your trustees are Insureds only for the conduct of your business within the scope of their employment. Your Employee's status as an Insured will be detemfined ea of the date of the Discrimination, Harassment, Inappropriate Employment Conduct, which caused an Insured Event. 6. Mergers and Acquisitions. Any organization that you newly acquire, faun or merge with while this endorsement is in effect that has less than 10% of the total number of your Employees as of the inception date of this endorsement shall be an Insured at the time of such acquisition, merger or formation if you own at least fifty one percent (51%) of it. Within thirty (30) days prior to the expiration of the policy, the Insured shall give us written notice as to all such organizations. If you acquire, form or merge with any organization that has more than 10% of the total number of you Employees as of the inception date of this endorsement, such organization is also an Insured if you own at least fifty one (51%) of it; provided, however, no such organization is covered for more than forty five (45) days or the remainder of the Policy Period, whichever is less, from the date acquired, merged or formed unless we agree to cover such acquisition or newly formed organization within such forty five (45) day period in consideration of an ad(tional Premium to be determined by us. Nolwithstan(ng the foregoing, any acquired or formed organization is neither covered for Loss that results from an Insured Event that happened or first commenced before the Insured acqured or formed it nor for Loss covered under any other insurance. This provision does not apply to a partnership or joint venture. Nor does it apply to any organization once it is shown in the Declarations. 7. Subsidiary. Any organization more than 50% owned by the Named Insured and listed in the Application shall be an Insured. D. For the purposes of the coverage provided by this endorsement, Section IL Liability Paragraph D. Liability And Medical Expenses Limits of Insurance is replaced by the following: 1. Limn of Liability a. The amount shown in the Schedule of this endorsement as the 'Each Insured Event Limit" is the most we will pay for Claims first made or brought during the Policy Period for Loss that results from any One Insured Event regardless of the number of Claims. BP as 04 02 15 b. The amount shown in the Schedule of this endorsement as the 'Aggregate Limit of Liability' is the most we will pay for the combined total of all Claims first made or brought during the Policy Period for Loss that result from all Insured Events. If this Policy Period is extended, the Limits, as shown in the Schedule of this endorsement shall not in any way increase. For purposes of the LIMIT OF LIABILITY, any policy extension is considered to be pat of and not in attrition to the former Policy Period. 2. Self Insured Retention Our obligation to pay under this endorsement applies only to covered amounts in excess of any Self Insured Retention amount that the insured must pay, as shown in the Schedule of this endorsement, and the LIMIT OF LIABILITY will not be reduced by the amount of such Self matted Retention. The Self Insured Retention amount will apply separately to each Claim made, however, it will only apply once to all Claims arising out of any One Insured Event regardless of the number of claimants who allege damages. If, prior to terminating or demoting an Employee the Insured consults with and follows the advice of the EPL hotline and/or a labor law attorney approved by our Authorized Representatives, as shown in the Schedule of this endorsement, then the Insured's Self Insured Retention is reduced by 50% in the event the insured faces a Claim involving such termination or demotion. E. For the purposes of the coverage provided by this endorsement, the following are added to Paragraph E. Liability And Medical Expenses General Conditions: 1. Duties in the event of a Clam a. You must see to it that we or our Authorized Representatives, as shown in the Schedule of this endorsement, are notified as soon as practicable but in no event more than thirty days (30) after any Insured who is a principal, partner, officer, director, trustee, in house counsel, Errployee(s) within the HR Risk Management department or Employees) with personnel and risk management responsibilities, becomes aware that a Claim has been made. Your notification should include: (1) the identity of the person(s) alleging Discrimination, Harassment, Inappropriate Employment Conduct; (2) the identity of any Insured(s) who allegedly committed the Discrimination, Harassment, Inappropriate Employment Conduct; the identity of any witnesses to the alleged Discrimination, Harassment, Inappropriate Employment Conduct; and (4) the date(s) an Insured Event took place. (3) Includes copyrighted material of Insurance Services Office, with its permission. Page 4 of 7 Stock No, 35392 572 05X6683701 15 OOO UNATRE b. You and any other Insured must: (1) immediately send us or our Authorized Representatives, as shown in the Schedule, copies of any demands, notices, summonses or legal papers received in connection with the Claim: (2) authorize us or our Authorized Representatives, as shown in the Schedule of this endorsement, to obtain statements, records end other information; co-operate with us or our Authorized Representatives, as shown in the Schedule of this endorsement, in the irwestigation or defense of the Claim; and (4) assist us or our Authorized Representatives, as shown in the Schedule of this endorsement, In the enforcement of any right against any person or organization which may be liable to an Insured because of Loss to which this endorsement may also apply. c. No Insured will, except at their own cost, voluntarily make a payment, assume any obligation, or incur any expense without our consent. Subsequent payments that are deemed by us as having been prejudiced by any such voluntary payment will also be the sole responsibility of the Insured. 2. Report of a Potential Claim Solely at an Insured's option, an Insured may within the Policy Period report an oral complaint by an Employee, framer Employee or applicant for employment alleging Discrimination, Harassment and/or inappropriate Employment Conduct If such report Is received by us or our Authorized Representatives, as shown In the Schedule of this endorsement, within the Policy Period then any Claim subsequently arising from such oral complaint will be deemed to be made on the date such report was received. Such report must inckide the identity of the person(s) making the oral complaint. In no event, however, is an Insured entitled to coverage under this endorsement based on a Laundry List Notification. 3. Legal Action Against Us a. No person or organization has the right under this endorsement: (1) to join us as a party or otherwise bring us into a suit asking for damages from an Insured; or (2) to sue us on this endorsement unless all of its terms have been fully corrblied with. b. A person or organization may sue us to recover on an agreed settlement or on final judgment against an Insured obtained after an actual trial, but we will not be liable for damages that are not payable under the terms of thus endorsement or that are in excess of the applicable LIMIT OF UABILITY. An agreed settlement means a settlement and release of liability signed by us, an insured and the claimants legal representative. (3) BP m 040215 4. Other Insurance This endorsement shall be deemed primary insurance In connection with covered Claims by Employees against an Insured because of en insured Event In connection with any other covered Claim, this endorsement shall apply in excess of all indemnity rights of an insured and in excess of any other valid or collectible insurance available to any Insured. Nothing herein is intended to make this endorsement subject to the terms, conditions and limitations of any other insurance, and nothing herein is intended to limit our or any insureds right to c ntrbution or indemnity from any other party, insurer or indernnitor. 5. Representations By accepting this endorsement you agree: a. The statements in the Policy Declarations and this endorsement are accurate and complete; b. Those statements are based upon representations you made to us; and c. We have issued this endorsement in reliance upon your representations. 6. Transfer Of Rights Of Recovery Against Others to Us If any Insured has rights to recover all or part of any payments we have made under this endorsement, those rights are transferred to us; the Insured must do nothing after a Loss to impair them. At our request, any insured will bring suit or transfer those rights to us and help us to enforce them. 7. Bankruptcy Bankruptcy or insolvency of any Insured or of an Insured's estate will not relieve us of our obligations under this endorsement, except as excluded in Paragraph B. of this endorsement 8. False Or Fraudulent Claims If any Insured shall proffer any Claim knowing the same to be false or fraudulent as regards amount or otherwise, this endorsement will become void in Its entirety and all coverage hereunder shall be forfeited. F. For the purposes of the coverage provided by this endorsement, the following is added to Section II. Liability Paragraph F. LiabiityAnd Medical Expenses Definitions: 1. Claims) means a written complaint or written charge made against an Insured or a written demand made against an Insured in which damages are alleged or where specific charges of Discrimnation, Harassment, Inappropriate Employment Conduct are brought Claim Includes a civil action, suit or administrative proceeding, to which any Insured must submit or to which any Insured submits with our consent But Claim shall not mean any labor or grievance arbitration subject to a collective bargaining agreement; or any complaint, writ or other proceeding in which an Insured is alleged to have committed or engaged in a criminal offense or violation of a federal, state of local penal law. Includes copyrighted material of Insurance Services Office, with its emission. Page 5 of 7 Stock No. 35392 572 05X6683701 15 000 UNATRE 2. Defense Costs means those reasonable and necessary expenses that result from the investigation, settlement or defense of a specific Clam inducing attorney fees and expenses, the cost of legal proceedings, the cost of appeal bonds, the cost of bonds to release property being used to secure a legal obligation (but ordy for bond amounts within the LIMIT OF LIABILITY that applies). We have no obligation to furnish any bonds. The following are not Defense Costs: costs incurred by any insured before notice is provided to us; salaries and expenses of your employees, including in-house and/or coverage attomeys, salaries and expenses of our employees, or our in-house or coverage attorneys or the fees and expenses of Independent adjusters we hire. 3. Discrimination means termination of the employment relationship, a demotion, a failure or refusal to hire or promote, denial of an employment benefit or the taking of my adverse or differential employment action because of race, color, religion, age, sex, cisabiity, pregnancy, sexual orientation, national origin, or any other basis prohibited by federal, state or local law occurring on or after the Retroactive Date as shown in the Schedule of this endorsement. This insurance covers retaliation claims based on unlawful discrimination occurring on or after the Retroactive Date as shown on the Scheele of this endorsement except as excluded in Paragraph B. of this endorsement. 4. Employee means an individual whose labor or service is engaged by and directed by the Named Insured, or any covered entity. This includes volunteers, part time, seasonal and temporary Employees as well as any individual employed in a supervisory, managerial or confidential position. Independent contractors and subcontractors are not Employees mess they are dedicated agents or representatives of an insured. Employees who are leased to another employer are not Employees. 5. Harassment means unwelcome sexual or non -sexual advances, requests for sexual or non -sexual favors or other verbal, visual or physical conduct of a sexual or non -sexual nature, where such harassment occurs on or after the Retroactive Date as shown in the Scheduled of this endorsement and is based on a factor or category prohibited by law (inducing sex, race, age, national origin, disability, etc.), that (1) a olictlty or implicitly are made a condition of employment, (2) are used as a basis for employment decisions, or (3) create a work environment that interferes with performance. 6. Inappropriate Employment Conduct means any of the following occurring on or after the Retroactive Date as shown in the Schedule of this endorsement a. actual or constructive termination of an employment relationship in a manner which is alleged to have been against the law or wrongful or in breach of an implied employment contract or breach of the covenant of good faith and fair dealing In the employment contract b. allegations of wrongful demotion, or wrongful cisdpline; BP 66040215 c. allegations of misrepresentation made by an Employee, a former Employee or an applicant for employment which arise from an Insured's employment decision to hire, fire, promote or demote; d. allegations of infliction of emotional distress, mental injury, mental anguish, shock, sickness, disease or disability made by an Employee, a former Employee or an applicant for employment which arise from an Insured's employment decision to hire, fire, promote or demote; e. allegations of false imprisonment, detention or malicious prosecution made by an Employee, a former Employee or an applicant for employment which arise from the Insured's an employment decision to hire, fire, promote or demote; f. allegations of libel, slander, defamation of character or any invasion of right of privacy made by an Employee, a former Employee or an applicant for employment which arise from an Insured's employment decision to hire, fire, promote or demote; or g. other personal injury allegations made by an Employee, a former Employee or an applicant for employment which arise from an Insured's employment decision to hire, fire, promote or demote. Inappropriate Employment Conduct :hall not include any allegations other than those set forth above. 7. Insured Event means actual or alleged acts of Discrimination, Harassment, andlor Inappropriate Employment Conduct, by an Insured against an Employee or former Employee or appicant for employment with an Insured entity occurring on or after the Retroactive Date as shown in the Schedule of this endorsement. Insured Event shall not include Claims for actual or alleged violation of any federal, state or local wage and hour laws or regulations. 8. Laundry List Notification means any attempt by an Insured to report multiple matters under this policy in a summary fashion that does not comply with Paragraph E.1. Duties in the event of a Claim or Paragraph E.2. Report of a Potential Claim. By way of example, a Laundry List Notification may consist of a report by an Insured that lists purported potential claimants, either in the absence of a Claim, or in the absence of an oral complaint. 9. Loss means damages, judgments (inducing prepdgment and post judgment interest awarded against an Insured on that part of any judgment paid by us), settlements, we authorize or agree to, statutory attorney fees and Defense Costs. However, Loss does not include anything specifically excluded in Paragraph B. of this endorsement, or any of the following: a. salary or wages of the Insured; b. non -monetary relief (this provision does not apply to Defense Costs where non -monetary relief is sought for alleged Harassment, Discrimination, Inappropriate Employment Conduct includes copyrighted material of Insurance Services Office, with its permission. Page 6 of 7 Stock No. 35392 572 O5X66837O1 15 O0O UNATRE c. payment of insurance plan benefits by or on behalf of retired Employees, or that to which a claimant would have been entitled as an Employee had any Insured provided the claimant with a continuation ofinsurance; d. liquidated damages where there is a finding of willfulness; e. costs incurred by an insured to modfy or adapt any buildng or property in order to make such building or property more accessible or accommodating to any dsabled person; coats associated with eliminating non -essential duties from the job description of a dsa led person; costs associated with prowling a disabled person with reasonable workplace accommodations; and costs associated with lost productivity by an employer as the result of making a reasonable workplace accommodation for a dsaded person; f. matters which may be deemed uninsurable accordng to the law under which this policy Is construed; 0. h. j• amounts owed under federal, state or local wage and hour laws; amounts owed under a contract of employment; commissions, bonuses, profit sharing or benefits pursuant to a contract of employment, inducing but not limped to vacation, holiday, and/or sick pay; severance payments or obligations to make payments; k. amounts that are sought or deemed to be owed under partnership, stock or other ownership agreements; I. fines, penalties and taxes. 10. One Insured Event means (1) one or more covered allegations of Discrimination, Harassment and/or Inappropriate Employment Conduct which are related by an unbroken chain of events or (2) class action or multiple claimant or multiple plaintiff suits arising out of related Mewed Events. 11. Subsidiary means any organization more than 50% owned by tte Named Insured listed in the ApplIcation. BP Ba 04 0215 Includes copyrighted material of Insurance Services Office, with ils permission. Page 7 of 7 Stock No, 35392 572 05%6683701 15 000 UNATRE POLICY PERIOD - RENEWAL OF COVERAGE Insurance begins and ends at 12:01 A.M., Standard Time, at your mailing address and for the policy period shown in the declarations. The first Named Insured shown in the declarations may continue this policy for successive policy periods by paying the required premium on or before the effective date of each renewal policy period. If the premium is not paid when due, this policy expires at the end of the last policy period for which the premium was paid. The premium for each policy period will be based on our current rates and rules. If this policy replaces coverage in other policies terminating at 12:00 Noon (standard time) on the inception date of this policy, this policy shall be effective at 12:00 Noon (standard time) instead of at 12:01 A.M., Standard Time. Includes copyrighted material of Insurance Services Office, Inc., with its permission. BP 80010517 Page 3 of 4 Stock No. 14744 572 05%6683701 15 000 UNATRE Special Provisions For American Family Mutual Insurance Company, S.I. Policyholders 1. MEMBERSHIP AND VOTING While this policy is in force, each insured named in the Declarations is considered an owner or policyholder and a member of the American Family Insurance Mutual Holding Company (AFIMHC) of Madison, Wisconsin. As a member, you are entitled to one vote at all meetings either in person or by proxy. You can only cast one vote regardless of the number of potties or coverage you purchased. If two or more persons quaity as a member under a single poky, they are considered one member for purposes of voting. The owner of a group poky wil have one vote regardless of the minter of persons insured or coverage purchased. Fractional voting is not allowed. If you are a minor, any vote will be given to your parent or legal guardian. 2. ANNUAL MEETINGS The Annual Meetings are held at the Home Office: 6000 American Parkway, Madison, Wisconsin, on the first Tuesday of March at 2:00 P.M. Central Standard Time. Notice in this policy shall be sufficient notification. 3. DIVIDENDS If any dividends are declared, you will share in them according to law and under conditions set by the Board of Directors. This policy is signed at Madison, Wisconsin, on our behalf by our President and Secretary. If it is required by law, it is countersigned on the declarations by our authorized representative. <#11" President Secretary This is not a complete and valid contract without accompanying DECLARATIONS properly executed. BPSI010517 Page 4 of 4 Stock No. 14744 572 O5X66837O1 15 O0O UNATRE BUSINESSOWNERS POLICY Non -assessable policy Issued by AMERICAN FAMILY MUTUAL INSURANCE COMPANY, S.I. 6000 American Pkwy Madison WI 53783-0001 (608) 249-2111 Member of American Family Insurance Group BP 80 01 05 17 Stock No. 14744 EXHIBIT B PROVIDER INFORMATION FORM Weld County Department of Human Services Julie A. Scroggins, Attorney at Law, P.C. Provider JJ - 1728357 / Trails Contract a -19772 AGENCY OR PRIVATE PRACTICE Julie A. Scroggins PRIMARY CONTACT - FULL NAME j 970 M 353-0216 PHONE NUMBER jstrogginslaw @gmail.com PRIMARY CONTACT — E-MAIL ADDRESS 710 11th Avenue, Ste 205 AGENCY MAILING ADDRESS TRAILS PROVIDER ID (If Known) Owner PRIMARY CONTACT - TITLE ( 970 1353-4025 EXT. FAX NUMBER AGENCY/PRACTICE WEB ADDRESS (IF APPLICABLE) Greeley CITY 80631 ZIP Christy Dixon REFFERAL CONTACT — FULL NAME ( 970 ) 353-0216 REFERRAL CONTACT — PHONE NUMBER REFERRAL CONTACT EXT. Legal Assistant REFERRAL CONTACT - TITLE jstawac@gmail.com REFERRAL CONTACT — E-MAIL ADDRESS Christy Dixon BILLING CONTACT — FULL NAME ( 970 ) 353-0216 BILLING CONTACT— PHONE NUMBER BILLING CONTACT Legal Assistant BILLING CONTACT - TITLE jslawpc@ionail.com 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 the ire competitive ity,�rice and quality. Signature of Authorized Representative Date of Signature: M? Bid No.: B 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 Mediation BIDDER LEGAL ENTITY NAME: Julie A. Scroggins, Attorney at Law, P.C APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION No. Last Name First Name Work# Work Email Education Level Degree Focus Licensure/ Credentials DORA II (If applicable) 2 3 Scroggins Dixon Julie Christy 970-353-0216 970-353-0216 scrogginslaw@gmail.row sac@gmail.com Post Grad JD 12th grade Law Colorado Bar Self Scroggins Julie 970-353-0216 jscrogginslaw(agrr 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 B1800058 EXHIBIT C SCOPE OF SERVICES 1. Contractor will provide Mediation services to Weld County families in Dependency and Neglect cases as referred by the Department. 2. Contractor will accept calls directly from the Court for the purpose of scheduling mediations and will notify the Department that mediation has been scheduled. The Department will provide the Contractor with a formal referral authorizing the services to be billed to the Department. 3. Contractor agrees to be organized, responsive and to quickly and successfully schedule mediations. 4. Contractor is available Monday through Friday, 8:00 a.m. to 4:00 p.m. 5. Mediation sessions are generally scheduled for one (1) to two (2) hours in length; however, Contractor can accommodate longer sessions up to one (1) day in length under special circumstances, with Department approval. 6. Contractor will provide adequate, local and appropriately secure space for mediations to occur in. 7. Contractor agrees to bill for face-to-face mediation services only and further agrees that the rate reflected in Exhibit D -Payment Schedule is inclusive of all scheduling, preparation and post -mediation requirements and documentation. 8. All mediation services will be provided by Julie Scroggins, Attorney at Law. 9. Goal/Outcome of Service: Good faith agreements between family members and/or Department. 10. Target Population: Parents and extended family of all ages and genders. 11. Service Access: All services will be provided at 710 11th Avenue, Suite 205, Greeley, Colorado 80631. 12. Language: English only. 13. Medicaid Eligibility: Services are not eligible for Medicaid. 14. Transportation: Contractor does not transport clients. 15. Contractor agrees to confirm upon receipt of a request and/or referral for mediation services that he does not have any conflict of interest with any party to the mediation. 16. Contractor will submit documentation that notes the date and time of the mediation, participating parties, and whether or not agreement or partial agreement was reached for each referral. This documentation will be submitted with each monthly billing. 17. Contractor will 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. 1 18. 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@weldgov.com, 970-400-6210). 19. 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). 20. 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. 21. 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. 22. 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. 23. 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. 24. 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. 25. 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. 26. 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: 2 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. 3 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 $250.00/Hour (Mediation Services) 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. 1 Hello