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Home My WebLink About20192375.tiff/D 4‘dGe5A. CHILD PROTECTION AGREEMENT FOR SERVICES BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES AND NOCO BEHAVIORAL HEALTH LLC This Agreement, made and entered into tl'7r"day of 019, by and between the Board of Weld County Commissioners, on behalf of the Weld County Departme of Human Services, hereinafter referred to as the "Department' and Noco Behavioral Health LLC, hereinafter r erred to as the "Contractor". The parties to this Agreement understand and agree that the provisions of this Agreement specifically include the following documents: Exhibit A, Weld County's Request for Proposal, Exhibit B, Contractor's Response to Request for Proposal, Exhibit C, Scope of Services, and Exhibit D, Rate Schedule. Exhibit B, C, and D are attached hereto and incorporated herein by this reference. Exhibit A is Weld County's Request for Proposal Number B1900025, which is incorporated into this agreement by reference and will be provided upon request to the Department. WITNESSETH WHEREAS, required approval, clearance, and coordination have been accomplished from and with appropriate agencies; and WHEREAS, the Colorado Department of Human Services has provided Core Services or other funding to the Department for Life Skills (Supervised Visitation). NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows: 1. Term This agreement shall become effective on June 1, 2019, upon proper execution of this Agreement and shall expire May 31, 2020, unless sooner terminated as provided herein. The agreement is for a period of three years. However, the agreement must be renewed by both parties, in writing, on an annual basis. 2. Scope of Services Services shall be provided by the Contractor to any person(s) eligible for services in compliance with Exhibit B, Contractor's Response to Request for Proposal and Exhibit C, Scope of Services. 3. Referrals, Billing and Tracking a. Contractor understands and will comply with all aspects of the referral authorization, billing and tracking requirements as set forth by the Department. Failure to comply with all aspects may result in a forfeiture of payment. b. Contractor agrees to receive referrals for services through e-mail and will provide an identified e- mail address prior to the start of this Agreement. Contractor acknowledges that services are not authorized until the Contractor has received an authorized referral form from the Department. Contractor further acknowledges that services provided prior to the authorized start date or outside the scope of services on the referral form will not be eligible for reimbursement. Contractor acknowledges that any and all modifications to an existing referral must be approved through the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400-6210). No other Department staff or other party to the case may authorize services or modifications to services. 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 c,:67()6„.,(kf5D) 2019-2375 /1/2.0oq0 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, its 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 01 10/93 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 Robert Cope, Chief Executive Officer 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: Robert Cope, Chief Executive Officer P.O. Box 273213 Fort Collins, CO 80527 (720) 220-3318 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: dark/t)(1 • "&";41 BOARD OF COUNTY COMMISSIONERS Weld County Clerk to the Board WELD COUNTY, COLORADO By: Deputy Clerk tothoard 15 Q i.L1L�1A- arbara Kirkmeyer, C air Noco Behavioral Health LLC P.O. Box 273213 Fort Collins, CO 80527 (720) 220-3318 Robert ESCope ///, /1Ss<L S7v By: Date: Robert Cope, Chief Executive Officer Apr 21, 2019 ato l l - a. 3 7§- EXHIBIT A WELD COUNTY'S REQUEST FOR PROPOSAL (Weld County's Request for Proposal is incorporated into this agreement by reference and will be provided upon request to the Department.) This page intentionally left blank. EXHIBIT B CONTRACTOR'S RESPONSE TO REQUEST FOR PROPOSAL January 8th 2019 Noco Behavioral Health LLC Introduction for RFP with Weld County Good afternoon, My organization, Noco behavioral Health LLC was formed in June 2016 with the aim of providing mental health services to the Northern, Colorado area. I have worked for Ariel clinical services for the last 2 and half years and enjoyed my time working in conjunction with Weld county. I am building my private practice to build on this relationship and provide mental health services to the weld county community. I have a Master's degree in Social work from Colorado State University and a Bachelor's degree in Psychology from Metropolitan State University. I focused my studies in child and adolescent psychological functioning and health. I also have my LSW (Licensed Social Worker license) and will be serviced by a close friend, Andrea Caggiano whom is an LCSW; and mentor. I am also duly licensed in Wyoming with my PCSW (797) and supervised by Lacey Peterson, LCSW I started in the social work field in 1998, working with at -risk youth on the streets of Denver Colorado. Whereby, I ran a non-profit for 10 years, and served the homeless youth population, 21 years of age and under. After this experience I made the decision to focus on building an organization that will provide mental health support to populations that are hidden and need a helping hand. When I took over as Executive Director, we went from 10 volunteers to over 100, where I redesigned the training program and built a strong relationship with the city and police institutions within Denver. In my time with Ariel, I have been able to build on skills such as relationship building, attachment to primary care providers and communication in the family unit. I will continue to provide services with Ariel in a different format, by only providing home studies for Ariel, while Noco Behavioral Health will be where I focus on providing mental health support to youth, couples and families and at -risk populations. I have experience working with at -risk populations, suicidal ideation, depression, trauma, couples, families and senior populations. As well as adoptive families. The aim of Noco Behavioral Health is to provide an alternative to the structure of community mental health; where I will provide via secure tele-health service provider as well as providing services in the home of the client. Through Ariel Clinical services, I have built a relationship with Weld county, and would be privileged to continue this relationship through my organization Noco Behavioral Health LLC. Thank you for your time and consideration, Sincerely, Robert Cope, HSP, MSW, LSW,PCSW EXHIBIT B PROVIDER INFORMATION FORM Weld County Department of Human Services Noco Behavioral Health LLC AGENCY OR PRIVATE PRACTICE TRAILS PROVIDER ID (If Known) Robert Cope PRIMARY CONTACT- FULL NAME ( 720 ( 220-3318 PHONE NUMBER nocobehavioralhealth@gmail.com PRIMARY CONTACT -E-MAIL ADDRESS P.O Box 273213 AGENCY MAILING ADDRESS CEO PRIMARY CONTACT- TITLE EXT. FAX NUMBER AGENCY/PRACTICE WEB ADDRESS (IFAPPLICABLE( Fort Collins CITY 8O527 ZIP Robert Cnpe REFFERA. CONTACT- FULL NAME (970 )400-1944 REFERRAL CONTACT- PHONE NUMBER EXT. REFERRAL CONTACT CEO REFERRAL CONTACT - TITLE nocobehavioralhealth@gmail.com REFERRAL CONTACT -E-MAIL ADDRESS BILUNG CONTACT Robert Cope BILLING CONTACT - FULL NAME 970 400-1944 BILLING CONTACT- PHONE NUMBER EXT. CEO BILLING CONTACT- TITLE nocobehavioralhealth©gmail.com 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 Comissioners shall give preference to resident Weld County bidders in all cases where the bids are compete in price and quality. Signature of Authorized Representative: Date of Signature: 2/3/2019 Bid No.: B1900025 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 1. Bidder's legal entity name: 2. Program name or service type being proposed: Noco Behavioral Health LLC Adolescent therapy services 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. 4. Cognitive behavioral therapy, Gestalt, motivational interviewing, solution focused interventions, 5. Psychotherapy 6. Anticipated frequency of the service (ex. 4 hours/week). 4 hours per week 7. Anticipated duration of the service (ex. 3-4 months). 12 months 8. Goals of the service. Provide a safe environment for adolescent specific therapy is to help them identify triggers and learn skills to work through trauma and learn to have better daily functioning with mental health disorders. As well as work through perceptions of others, and learn to prepare for adulthood, and move past risky behaviors. 9. Outcomes of service. 10. For client to demonstrate the ability to identify triggers and manage mental health disorders in a better way that promotes positive community integration. While also learning to identify and correct negative choice, look through a new conceptual lens and at how actions in the present affect long term goals. 11. Target population for service. Adolescent therapy services are aimed toward Male, Female and LGBTQ populations between the ages of 12 to 19 years of age. 12. Service access. The geographic region is Greeley, Evans, Longmont, and Johnstown and within the weld county borders. Client will visit with this writer via tele-health or at their residence. 13. Languages service is available in. Expert proficiency in English Language. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 14. Medicaid eligibility of service. No Medicaid ability at the current time, bidder accepts Aetna and United Insurance. 15. Transportation of clients. This bidder provides services via secure tele-health and in -home therapy services, no transportation is needed to service site. This writer will drive to client's site or conduct therapy services via tele-health provider. 16. Rates of service. Adolescent therapy services is billed at $95 an hour. The first session is considered the intake and is 1.5 hours and not charged for new clients. A minimum of 6 months is required for services. Client will be required to see therapist once, every two weeks at minimum. Cancellations within 24 hours are not charged, over 24 hours cancellations will be at charged a rate of $15. Mileage will be billed at 20 cents per mile, starting from the clients home to the clinical office and resuming at the clients home. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 1. Bidder's legal entity name: 2. Program name or service type being proposed: Noco Behavioral Health LLC Individual therapy 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. Cognitive behavioral therapy, Gestalt, motivational interviewing, solution focused interventions, Psychotherapy 4. Anticipated frequency of the service (ex. 4 hours/week). 6hours/week 5. Anticipated duration of the service (ex. 3-4 months). 12 months 6. Goals of the service. Provide a safe environment for individuals to identify triggers and learn skills to work through trauma and learn to have better daily functioning with mental health disorders 7. Outcomes of service. For client to demonstrate the ability to identify triggers and manage mental health disorders in a better way that promotes positive community integration. 8. Target population for service. Age range is 18 to 60 years of age, Genders: Male, Female, LGBTC., and disabled individuals. 9. Service access. The geographic region is Greeley, Evans, Longmont, and Johnstown and within the weld county borders. Client will visit with this writer via tele-health or at their residence. the geographic region is Greeley, Evans, Longmont, and Johnstown and within the weld county borders. 10. Languages service is available in. English, expert proficiency 11. Medicaid eligibility of service. No Medicaid ability at the current time. 12. Transportation of clients. This bidder will provide services via tele-health or in -home therapy services. Bid No.: 81800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 13. Rates of service. The cost for individual therapy is $95 an hour. The first session is considered the intake and is 1.5 hours and not charged for new clients. A minimum of 6 months is required for services. Client will be required to see therapist once, every two weeks at minimum. Cancellations within 24 hours are not charged, over 24 hours cancellations will be at charged a rate of $15. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 1. Bidder's legal entity name: 2. Program name or service type being proposed: Noco Behavioral Health LLC At- risk youth populations therapeutic support 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. Short term and crisis interventions using Cognitive behavioral therapy, Gestalt, motivational interviewing 4. Anticipated frequency of the service (ex. 4 hours/week). 1 to 2 hours per week 5. Anticipated duration of the service (ex. 3-4 months). 12 months 6. Goals of the service. To provide short term therapeutic support on a crisis basis for at -risk youth who have suicidal or depressive tendencies, individuals who have been hospitalized or incarcerated and in need of therapeutic to aid the individual in preparing for transition to the home or residential program. This is not a crisis service, but stabilization over the time of hospitalization or incarceration 7. Outcomes of service. To provide adolescent with coping skills to stabilize, discuss and help them prepare for transition to back to the home or to a lower level of care. 8. Target population for service. Any individual who has been hospitalized, after the initial day of entry on the 72 hour hold, or first 24 hours incarcerated. The ideal age range is 14 to 19 years of age. All genders are applicable, especially those whom are LGBTQ, transgender, or suicidal youth whom are identified at potential risk of suicide or in need of therapeutic support to prepare for transition to a lower level of care. 9. Service access. This is a community based service and extend to the first 1 to 2 days of returning home or placed in the lower level care as appropriate. The geographical region is Greeley, Evans, Longmont, and Johnstown and within the weld county borders. This region may be extended to Denver and Westminster if appropriate placement is needed to ensure a smooth transition of service providers. 10. Languages service is available in. Expert proficiency in English Language. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 11. Medicaid eligibility of service. No Medicaid ability at the current time. 12. Transportation of clients. Transportation will not be provided to clients for this service. 13. Rates of service. The at -risk population therapeutic support is billed at a rate of $95 per hour. Mileage will be billed at a rate of 20 cents a mile to the location of service only. There is not charge for cancellations or no shows due to the potential that the adolescent will be on hospital hold or incarcerated and supervised by medical or juvenile detention staff. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 1. Bidder's legal entity name: 2. Program name or service type being proposed: Noco Behavioral Health LLC Group therapy services 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. Using the Yalow model of group services plus Cognitive behavioral therapy, Gestalt, motivational interviewing, in an organic format. 4. Anticipated frequency of the service (ex. 4 hours/week). 3 hours per week 5. Anticipated duration of the service (ex. 3-4 months). 12 months 6. Goals of the service. The goal of the groups would be to allow individuals and families who have lost a child(through death or removal from the home), adopted a difficult child that they are struggling to build bonds with or navigating the adoption world to come together, learn to communicate their feelings, discuss the issues at hand and learn skills of acceptance and moving forward. 7. Outcomes of service. To help families or individual to gain coping skills to help them have better functioning while working with a difficult and traumatized child or learning to accept the loss and honor the memory of the child. 8. Target population for service. The target population is any individual, parent or family that has experience a loss of a child, struggled with adoption/conceiving or struggled with a traumatized child and need a community of families outside of other services to gain support and learn coping skills. All ages and genders are welcome. 9. Service access. Groups will be arranged and take place in a HIPPA secured location, that will be determined prior to group start date. Transportation will not be provided to and from group location 10. Languages service is available in. Expert proficiency in English Language. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 11. Medicaid eligibility of service. No Medicaid ability at the current time. 12. Transportation of clients. Transportation will not be provided for groups. 13. Rates of service. Group therapy is billed at a rate of $90 and hour per single member; families of more than two are billed at a single rate of $95 an hour. The groups will be 2 hours in length and take place once per week, on Tuesday evenings between 6pm and 7:30 pm. The groups will run for 6 weeks, with two weeks off between the start of the next group. Each group will be provided with journals at a rate of $2 per member and billed directly to the group member; each group member will have access to one free therapy session during the 6 week group timeline. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 1. Bidder's legal entity name: 2. Program name or service type being proposed: Noco Behavioral Health LLC Family service care taker meetings 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. Communicate the successes or struggles of the client through therapeutic lenses 4. Anticipated frequency of the service (ex. 4 hours/week). 4 hours per week 5. Anticipated duration of the service (ex. 3-4 months). 12 months 6. Goals of the service. The goal of this service is to provide information on how well the client is meeting goals of service with the provider and whether they are able to apply skills. 7. Outcomes of service. To assist client in identifying how they have learned skills and communicate the clients ability to follow treatment protocols, and their success or failures in service. 8. Target population for service. All populations are appropriate, ages 0 to 60 years of age that this clinical is working with at the time of the service provider meetings. 9. Service access. This provider will travel to the meetings in a community based service or at the Weld County human services department. 10. Languages service is available in. Expert English level proficiency 11. Medicaid eligibility of service. No, this provider is not a Medicaid provider 12. Transportation of clients. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) No transportation will be provided to clients to or from the service provider meetings. 13. Rates of service. Family team care taker meetings at billed at a rate of $65. No mileage will be charged. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 1. Bidder's legal entity name: 2. Program name or service type being proposed: Noco Behavioral Health LLC Family therapy services 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. Cognitive behavioral therapy, Gestalt, motivational interviewing, solution focused interventions, Psychotherapy. I also use a Minuchin family systems and attachment theory to help build bonds, attachment and structure while also building boundaries. 4. Anticipated frequency of the service (ex. 4 hours/week). 2 hours per week 5. Anticipated duration of the service (ex. 3-4 months). 12 months 6. Goals of the service. 7. Provide a safe environment for individuals and families to learn communication skills and work through the relationship disruption that has caused a rift in the overall family structure, identify triggers and learn skills to work through trauma and learn to have better daily functioning 8. Outcomes of service. For family members to be able to learn positive communication skills and overcome or learn ways to move past the issue that brought them into service. 9. Target population for service. The families targeted are 16 years of age to 60 years of age, either with child, expecting child or grieving the loss of a family member as well as struggling with family member attachment to the family unit.. All genders (Male,Female and LGBTQ), as well as disabled veterans. 10. Service access. Family therapy will be home based services are available to individuals who are indigent or unable to access public transportation. The geographic region is Greeley, Evans, Longmont, and Johnstown and within the weld county borders. 11. Languages service is available in. Expert proficiency in English Language. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 12. Medicaid eligibility of service. No Medicaid ability at the current time 13. Transportation of clients. This bidder can provide transportation to individual whom are not of driving age or are under restricted driving provisions. 14. Rates of service. The cost for Family therapy is $120 an hour. The first session is considered the intake and is 1.5 hours and not charged for new clients. A minimum of 6 months is required for services. Families will be required to see therapist once, every two weeks at minimum. Cancellations within 24 hours are not charged, over 24 hours, cancellations will be charged at a rate of $15. Mileage will be billed at a rate of 20 cents per mile, starting at the clients home and ending at the clients home. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 1. Bidder's legal entity name: 2. Program name or service type being proposed: Noco Behavioral Health LLC Couples therapy services 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. Cognitive behavioral therapy, Gestalt, motivational interviewing, solution focused interventions, Psychotherapy as well as a Minuchin inspired format of family systems theory. Couples will be required to purchase the book "all about us" at their expense, to use as a format for rebuilding the foundations of the relationship. 4. Anticipated frequency of the service (ex. 4 hours/week). 4 hours per week 5. Anticipated duration of the service (ex. 3-4 months). 12 months 6. Goals of the service. Provide a safe environment for couples to learn communication skills and work through the relationship disruption that has caused a rift in the overall family structure, identify triggers and learn skills to work through trauma and learn to have better daily functioning, as well as learn what has brought them into services and how to overcome immediate challenges. 7. Outcomes of service. S. For couples to be able to learn positive communication skills and overcome or learn ways to move past the issue that brought them into service. 9. Target population for service. The target population is Heterosexual, Same sex and transgender couples. The couples can be both voluntary and court ordered to attend services. The couple does not need to have any specific traits, but must have a relationship need that they wish to address and work on with the therapist. 10. Service access. Couples therapy services will be community based and home based services are available to individuals who are indigent or unable to access public transportation. The geographic region is Greeley, Evans, Longmont, and Johnstown and within the weld county borders. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 11. Languages service is available in. Expert proficiency in English Language. 12. Medicaid eligibility of service. No Medicaid ability at the current time 13. Transportation of clients. No transportation will be provided to individuals who are engaged in couples therapy. 14. Rates of service. Couples therapy is billed at a rate of $110 dollars an hour.. The first session is considered the intake and is 1.5 hours and not charged for new clients. A minimum of 6 months is required for services. Couples will be required to see therapist once, every two weeks at minimum. Cancellations within 24 hours are not charged, over 24 hours, cancellations will be charged at a rate of $15. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 1. Bidder's legal entity name: 2. Program name or service type being proposed: Noco Behavioral Health Supervised visitation of individuals or families 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. Prompts and teaching of appropriate boundaries, rules and communication styles, utilizing Cognitive behavioral therapy, Gestalt, motivational interviewing, in an organic format. 4. Anticipated frequency of the service (ex. 4 hours/week). 6 hrs a week 5. Anticipated duration of the service (ex. 3-4 months). 12 months 6. Goals of the service. To help client and family learn to build appropriate relationships, boundaries and rule setting. As well as assisting parents or caretakers to learn appropriate parenting and communication that is age appropriate and cognitively applicable to the child or children. 7. Outcomes of service. For parent or care provider to learn how to set limits, rules and boundaries that builds attachment, repair relationships and strengthens the bonds of family for a long term strong family structure. 8. Target population for service. Families or individual caretakers who are trying to regain custody or visitation with their children. The children most appropriate are between the ages of 0 to 18 and parents/care takers between the ages of 16 to 60 years of age. 9. Service access. The supervised visits are available in community based as appropriate and defined by the GAL or caseworker. The geographical region served is Greeley, Evans, Longmont, and Johnstown and within the weld county borders. 10. Languages service is available in. Expert proficiency in English Language. 11. Medicaid eligibility of service. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) No Medicaid ability at the current time. 12. Transportation of clients. The bidder will provide transportation to children, from their foster or biological home to the home or site of the visit and return them home after the visit to the foster or biological home. 13. Rates of service. The supervised visits are billed at a rate of $110 for 1 and 2 hour visits per each session. Visits that are 3 hours are billed at a rate of $150 per each visit. Mileage for transporting clients to and from visits will be charged at a rate of 20 cents per mile, to and from the location of the child at the beginning of the visit. Visits will be arranged in accordance with the agreed upon schedule that accommodates both the caregiver or biological parents and the individual or family whom is court ordered to participate in the visit. No shows to visits will be charged at a rate of $15 per session, cancellations within 24 hours are not charged, over 24 hours, cancellations after this 24 hour window will be charged at a rate of $15. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 1. Bidder's legal entity name: 2. Program name or service type being proposed: 3. Modalities, curriculum or tools that will be utilized in the delivery of the service. Prompts and teaching of appropriate boundaries, rules and communication styles, utilizing Cognitive behavioral therapy, Gestalt, motivational interviewing, in an organic format. 4. Anticipated frequency of the service (ex. 4 hours/week). 6 hrs a week 5. Anticipated duration of the service (ex. 3-4 months). 12 months Noco Behavioral Health Supervised visitation of individuals or families 6. Goals of the service. To help client and family learn to build appropriate relationships, boundaries and rule setting. As well as assisting parents or caretakers to learn appropriate parenting and communication that is age appropriate and cognitively applicable to the child or children. 7. Outcomes of service. For parent or care provider to learn how to set limits, rules and boundaries that builds attachment, repair relationships and strengthens the bonds of family for a long term strong family structure. 8. Target population for service. Families or individual caretakers who are trying to regain custody or visitation with their children. The children most appropriate are between the ages of 0 to 18 and parents/care takers between the ages of 16 to 60 years of age. 9. Service access. The supervised visits are available in both the office located at 710 11th Avenue Suite 304, Greeley, CO 80631 or community based as appropriate and defined by the GAL or caseworker. The geographical region served is Greeley, Evans, Longmont, and Johnstown and within the weld county borders. 10. Languages service is available in. Expert proficiency in English Language. Bid No.: B1800058 EXHIBIT C PROPOSAL TEMPLATE (Bidder must use this template for each service proposed. Maximum of 3 pages per proposed service.) 11. Medicaid eligibility of service. No Medicaid ability at the current time, bidder will be applying to Medicaid by August 15Y,2018. 12. Transportation of clients. The provider will provide transportation to children, from their foster or biological home to the home or site of the visit and return them home after the visit to the foster or biological home. Transportation will include multiple stops and have a catchment area of 30 miles. Transportation outside the catchment area will be charged at $0.56 per mile. 13. Rates of service. The supervised visits are billed at a rate of $110 for up to 2 -hour visits. Visits that are 3 hours are billed at a rate of $150 per visit. Visits will be arranged in accordance with the agreed upon schedule that accommodates both the caregiver or biological parents and the individual or family whom is court ordered to participate in the visit. Bid No.: B1800058 STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposeE tWib; One Staff Data Sheet per proposed service. Bidder should not combine services.) PROPOSED SERVICE OR SERVICE TYPE: Individival Therapy services BIDDER LEGAL ENTITY NAME: Noco Behavioral Health LLC OR CONTRACTOR INFORMATION SUPE1R 1, w yam, 1 No. Last Name First Name Work# Work Email Education Level Degree Focus F Licensuro ll Credentials DORA # If applicable) / AOre .%R �^ r ! ` . �Y / FC n. Y r . 4 / �, ♦ s r. f , .,'I!C' 1 Cope Robert 970-400-1944 nocobehavioralhealth@gmail.com MSW Masters of Social wor LSW LSW.0009922012 Cope Robert 2 PCSW 797(Wyoming) 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 B1800058 STAFF DATA SHEET (Bidder must list all applicable staff who will manage and/or administer the proposeEkititaiied0 One Staff Data Sheet per proposed service. Bidder should not combine services.) -;,,,s, • - ,J.,7 p Off.' ! Sr i 720-220-3318 nocobehavioralhealth@gmail.com B1800058 PROPOSED SERVICE OR SERVICE TYPE: BIDDER LEGAL ENTITY NAME: Last Name First Name Noco Behavioral Health LLC Work# rar- APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION Robert 720-220-3318 nocobehavioralhealth@gmail.com Education Level MSW f Masters of Social woi Licensure/ Credentials 5� pggy+ .x��1(�c,�1..,,4'^ 3:r., (p��, gg:3t 2�2r x�gdYfG.,.}��(+g� 4 J ra s IONt.�0�fE $T�+6'1 �Hfl�k' ,r /? DORA (if applicable) �. �u,.P..r.n, e'°�M' ,<,>1Ny L tj ;� 12 ,v*' nisi nxea>.�A, , a' m F /. n's,'.r ;fik :W rr lSc y a , " LSW.0009922012 Cope Robert 720-220-3318 nocobehavioralhealth@gmail.com I I 4 PROPOSED SERVICE OR SERVICE TYPE: BIDDER LEGAL ENTITY NAME: Nom Last Name 1 Cope 2 3 4 5 Degree Focus Licensure,; Credentials LSW First Name Adolescent specific therapy services Noco Behavioral Health LLC Work# APPLICABLE STAFF MEMBER OR CONTRACTOR INFORIMMATION Education Level 720-220-3318 nocobehavioralhealth@gmail.com MSW yyy55}��gfy�-jyl� �[] yp�,�{p� '4�Q■y�gjl\yyia^��${"gi. q' �q-c y( /Gy!! -)i M1l ti R INFO RM 6II`(ei0'. - .9 2/ /Si�F k. / i. � �" ��LT"19'/%/ fY.Gn II (4am.•c�ha ,�j,,�[, applicable) ,/�,+2.�v, L * ✓ / t / ✓ �.J4//4..�del��//'��9'��y � -y'Gy L s m , .4 �+•w✓�+nn r _ �/''iss�� F s @-/ / .[ � �e>�.vm�s � .f.,�'�i��A/ 4 f //,L:�E' /�/:// / /., ji C .� .,.�. s ;� cd c { 3 / ,. (�. % n l .' / .✓� '� �'�G� Q /(If o4yWWh�•a'D. ^;ei�A/Wtia L.f ..a .•,:3� i, ry n LSW.0009922012 Cope Robert 720-220-3318 nocobehavioralhealth@gmail.com { 1 Degree Focus Llcensuref Credentials LSW PROPOSED SERVICE OR SERVICE TYPE: BIDDER LEGAL ENTITY NAME: Group Therapy Noco Behavioral Health LLC Last Name First Name Work# Cope Robert APPLICABLE STAFF MEMBER OR CONTRACTOR INFORMATION 720-220-3318 nocobehavioraihealth@gmail.com Education Level MSW r�r f .. .. y'�$} xi��eff* v e.. $$a .. :,... >)%)f v S LJ ::EEL 0. W 6 4 .-. R FO ' A ' / it / / ..+,..w..! /rl � °P. � (if applicable)("$¢ / i .., -r� g� �r /? 3.i��.� ,.: '� i t � u, �f ` /rfl ..w»..n�.rw..w...•..,..xi......•n. uR ��,.. H ...St �fe.� roz�'!i6+i> / _.. -., : �� <�4rY �tltc.� �.S � '/i�� w`y .... >.; Ml€ � 6��.6.�u%gF �!�� LSW.0009922012 Cope Robert 720-220-3318 nocobehavioralhealth@gmail.com V I • i PROPOSED SERVICE OR SERVICE TYPE: BIDDER LEGAL ENTITY NAME: Robert 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Supervised visitation services Noco Behavioral Health LLC APPLICABLE STAFF I IIEIVIBER OR CONTRACTOR INFORMATION 720-220-3318 Education Level nocobehavioralhealth • gmail.com MSW Masters of Social wor r!'. � l ,Z i ' e i' x %�6 YT' H/.4D S C' �gp+yf, �y�g ,�Q y< "n° ,�/: rzlP�i_," / �q.r. 4.li�i3`I...__ LIP 6,,V/r%'i_.vdEF' f Kr7y ��R� applicable) i / yf/ ✓j, / f ✓ /r/G 9'� •! y. 4 �_. � Q, �. t4% ° �� y n,. J a39?' �/ / fB/%� z � 1- y ?' £ ! 7/ -- < k �� ≥, / ,>r., /i / ✓r5F;i� ✓rX .7 /f x..%! ✓�� o Y i of as sH :. .pppp; j$'� 0. Wort, - //i i, i r k / s /i !�/�y p''�°p u.i ,✓ l,,,///✓N // .Yp 1K Em .., �u3.' . . /fi r/ r „„ , ,i /�, fi x, LSW.000992201 -- Cope Robert 720-220-3318 nocobehavioralhealth@gmail.com I PROPOSED SERVICE OR SERVICE TYPE: Couples thera BIDDER LEGAL ENTITY NAME: OR CONTRACTOR INFORMATION services Noco Behavioral Health LLC No. Last Name First Name Work# Work Email Education Level Degree Focus Licensure/ Credentials 1 Cope Robert 720-220-3318 nocobehavioralhealth@gmail.com MSW Masters of Social wor LSW 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 SUPS�7wy-4frygS'� RT . / g¢�; 8 /// rLc✓YP! ✓j.r / ii -W dn. �j[aj{l�y./ ✓ iF 0 N/x ��7F"� e f�� • /f✓ 4. s �'� /i; •' 2iu- •. '. �.NA pg��p/��(g' x; i.es'Td YY m;':;. (1f applicable) ry'l '�4. j., /,: / yj/f /i. s -',��s ,/�n� •: '„ l�P�l'u9%/lf� r yi.'9xy-_• �7• > ::✓. 3 .t ► s 7 4'b i s ..��Yiy .a's:c / / ii • r< 8 7 L% :!� �i ..., .?/ .'• M ,`i; - .,.x ......... .n.�...awwo. v a _ .... man /�' t •�!! r; ` ?'.'�/�/ �/ v ,./s // ./, 4 '` zp l ,. s, /1' A /; ",y .: f% ( ,x .4` _ f .'S .,x / %/ /� y / f�Y i5'f �.fL}/F � � '/'T^�� 4:<' Tom./ �wl /�; �,,;;��, .. .il... LSW.000992201 Cope Robert 720-220-3318 nocobehavioralhealth@gmail.com s Mal No. Last Name First Name Work# Work Email Education Level Degree Focus Licensuref Credentials 1 Cope Robert 720-220-3318 nocobehavioralhealth@gmail.com MSW Masters of Social wor LSW 2 3 4 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 pew' dit INFORMATION .. 6Y/ , • N�if '$ q. /Ca�i nf) � Lyi:i / 2/f 9�Y"/./ �t Y p !'e".' �^.[ uvHwvnl aSi.'tr�.r, ..vRP�% nY V'SM. witmmvnwsrra¢<Nsa ��pp$ DO ��e�RY i g(� yg s �g � Y applicable) p licab a Y` % %l II f �. 0 //� ..'� ✓r Z ..� j�i�j�F i'��4:/3°%T�'.'�•^Y �py�g �°�",�^ $Y/ � � Fi � GVC4a ,a s 3 i pJp .�' / yS""�\ �.v h/ ii < ./6 y yr,..r, _ . t / �¢ � � /� �. Sa' 1 s. 5/ ii !. `v N .�S / Cr'If .//� r/R'/41a �'%�.}y��ugis /E^ F :'Y. :. r d�.s�1'e"N'� � y?l a 5 f r 9., (O r ✓ n ,, t :i?0 /N „i„:„ / / r if≥� t�J~ a jam( Vpp ¢y.� ��Aj$��6{ {j gg� r/:.`.. Q � i 6� � .✓��yr se A' 4X / r r3r /r/" i� ra'' D 'J F/ r, ri ct,, LSW.000992201. Cope Robert 720-220-3318 nocobehavioralhealth@gmail.com 1 PROPOSED SERVICE OR SERVICE TYPE: Family team meetings BIDDER LEGAL ENTITY NAME: Noco Behavioral Health LLC , �, , OR CONTRACTOR INFORMATION SlilRE4�'t�l5O� IINI~ >, x No. Last Name , First Name Work# Work Email Education Level Degree Focus Lrcensure/ Credentials DORA # (If applicable) .4. 'r, � J • .... ...._ , 1 Cope Robert 720-220-3318 nocobehavioralhealth@gmail.com MSW Masters of Social wor LSW LSW.0009922012 Cope 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23l 24 25 26 27 28 TION First Name Work # (Work Email Robert 720-220-3318 inocobehavioralhealth@gmail.com ___U TA NASW Insurance Company, RRG NASW RRG Plan Administrator 1200 E. Glen Avenue Peoria Heights, IL 61616-5348 5/29/2018 Customer ID: 3Z3XPKTBDT Noco Behavioral Health LLC 710 11th Avenue Ste 304 Greeley, CO 80631 Dear Robert E Cope, Thank you for purchasing your Professional Liability policy with the NASW Risk Retention Group. Enclosed please find your policy documents (proof of coverage). We thank you for having considered NASW for your Professional Liability needs; if you have any questions regarding this matter, please contact us at 888.278.0038. Sincerely, NASW RRG Plan Administrator 888.278.0038 customerservice@naswinsure.comre.com NASW Insurance Company, RRG Customer ID: 3Z3XPKTBDT SOCIAL WORKERS PROFESSIONAL AND SUPPLEMENTAL LIABILITY INSURANCE POLICY DECLARATIONS - CLAIMS MADE AND REPORTED Policy Number: P-GRO3Z455VYQHB-00 Effective Date: 06/01/2018 Expiration Date: 06/01/2019 Retroactive Date: 06/01/2018 Named Insured: Noco Behavioral Health LLC Address: 710 11th Avenue Ste 304 Greeley, CO 80631 NOTICE: A LOWER LIMIT OF LIABILITY APPLIES TO JUDGEMENTS OR SETTLEMENTS WHEN THERE ARE ALLEGATIONS OF SEXUAL MISCONDUCT. (SEE POLICY FOR DETAILS) THE POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED, THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. Liability Per Claim Limit Liability Aggregate Limit $64.00 $1,000,000.00 $1,000,000.00 $3,000,000.00 Deposition Expense $5,000 per deposition/$35,000 per policy period Subpoena Expense $400.00 per policy period State License Board Investigation Defense $35,000.00 per policy period Emergency First Aid $15,000.00 per policy period Health Information - HIPAA $25,000.00 per policy period First Party Assault $15,000.00 per policy period Medical Payments $5,000 per incident/$50,000 per policy period Wage Loss and Expense $1,000 per day/$35,000 per policy period TOTAL PREMIUM FOR THIS COVERAGE PART: $64.00 NOTICE: THIS POLICY IS ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT BE SUBJECT TO ALL OF THE INSURANCE LAWS AND REGULATIONS OF YOUR STATE. STATE INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE FOR YOUR RISK RETENTION GROUP. ATTENTION: THE POLICY OF INSURANCE IDENTIFIED ABOVE HAS BEEN ISSUED TO THE NAMED INSURED FOR THE POLICY PERIOD INDICATED. ALL INSUREDS ARE SUBJECT TO THE LIMITS OF LIABILITY THAT ARE APPLICABLE TO THE POLICY. THE LIMITS OF LIABILITY MAY NOT BE STACKED TO INCREASE THE AMOUNT WE WILL PAY FOR ANY CLAIM. THE AGGREGATE LIMIT MAY HAVE BEEN REDUCED BY PAID CLAIMS. Regarding Cancellation: Should the policy be cancelled before the expiration date thereof, notice will be delivered in accordance with the policy provisions to the Named Insured. Authorized Representative: Tony Benedetto Brokered and Administered by: ■ NASW Insurance Company, RRG NASW RRG Plan Administrator 1200 E. Glen Avenue Peoria Heights, IL 61616-5348 License: CA# 0F76076, AR# 1322 The NASW RRG Inc. supports this policy with its full faith, credit and assets. This policy is reinsured by Swiss Re America. Swiss Re Policy Form: RRG PLI-1131 (January 9, 2017); ACORD® 4.---- CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 05/29/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policyties) must haw ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WANED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements. PRODUCER NASW RRG Plan Administrator 1200 East Glen Avenue Peoria Heights, IL 61616-5348 CONTACT NAME: PHONE FA)( (A/C, No, Est): WC, No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURED Noco Behavioral Health LLC 710 11th Avenue Ste 304 Greeley, CO 80631 INSURER A: NASW Risk Retention Group 14366 INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: CUSTOMER ID: 3Z3XPKTBDT THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR IAP/D POLICY NUMBER POLICY EFF (MMIDD P Y) POLICY EXP (MMIDEVYYYY) LIMITS COMMERCIAL GENII GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea Occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INIURY $ GENERAL AGGREGATE $ EPLI - OCCUR PRODUCTS - COMP/OPAGG $ AGGREGATE LIMIT APPLIES PER: ❑ PROIECT ❑ LOC OTHER $ }POLICY AUTOMOBILE LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY SCHEDULED ' COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ UMBRELLA LWB IXCESS LAB DED n RETENTION HOCCUR CLAIMS -MADE $ EACH OCCURRENCE $ AGGREGATE $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETOR/ PARTNER/ ❑ EXECUTIVE OFFICER/ MEMBER EXCLUDED? If yes, describe under (Mandatory in NH}Description of Operations below N/A I PER STATUTE (OTHER E.L. EACH ACCIDENT $ E.L. DISEASE - EACH EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A Professional Liability Insurance Retroactive Date: 06-01-2018 Y N P-GRO3Z455WQHB-00 06/01/2018 06/01/2019 Per Claim Limit Aggregate Limit State Licensing Board Limits $1,000,000.00 $3,000,000.00 $35,000.00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE NUMBER: P-GRO3Z455WQHB-00 REVISION NUMBER: 001 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF NOTICE WILL BE DELIVERED ON ACCORDANCE WITH POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD - 9 ACORD 4....------ CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 05/29/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND ORALTERTHE COVERAGE AFFORDED BYTHE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER NASW RRG Plan Administrator 1200 East Glen Avenue Peoria Heights, IL 61616-5348 CONTACT NAME: PHONE FAX WC, No, Eutk WC, No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURED Noco Behavioral Health LLC 710 11th Avenue Ste 304 Greeley, CO 80631 INSURER A: NASW Risk Retention Group 14366 INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: CUSTOMER ID: 3Z3XPKTBDT CERTIFICATE NUMBER: P-GRO3Z455VYQHB-00 REVISION NUMBER 001 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WAD POLICY NUMBER POUCY EFF (MM/DOAYYY) POLICY ET (MMIDINYYYY) LIMITS COMMERCIAL GENT GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑ OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES (Ea Occurrence) $ MED EXP (Anyone person) $ PERSONAL & ADV INIURY $ GENERAL AGGREGATE $ EPLI - OCCUR PRODUCTS - COMP/OP AGG $ AGGREGATE LIMIT APPLIES PER: POLICY ❑ PROTECT ❑ LOC OTHER $ AUTOMOBILE LIABILITY ANY AUTO SCHEDULED COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ UMBRELLA I LIAR EXCESS LIAB DED El RETENTION OCCUR CLAIMS -MADE $ EACH OCCURRENCE $ AGGREGATE $ $ "1OTHER WORKERS COMPENSATION AND EMPLOYERS LIABILITY Y/N ANY PROPRIETOR/ PARTNER/ ❑ EXECUTIVE OFFICER/ MEMBER EXCLUDED? If yes, describe under (Mandatory in NH)Description of Operations below N/A PER STATUTE E.L EACH ACCIDENT $ E.L. DISEASE - EACH EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A Professional Liability Insurance Retroactive Date: 06-01-2018 Y N P-GRO3Z455WQHB-D0 06/01/2018 06/01/2019 Per Claim Limit $1,000,000.00 Aggregate Limit $3,000,000.00 State Licensing Board Limits $35,000.00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION Tyler And Thomas LLC 710 11th Avenue Ste 304 Greeley CO 80631 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED ON ACCORDANCE WITH POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NOTICE: This policy is issued by your risk retention group. Your risk retention group may not be subject to all of the insurance laws and regulations of your state. State insurance insolvency guaranty funds are not available for your risk retention group. NASW Risk Retention Group, Inc. (the Company) District of Columbia CLAIMS MADE AND REPORTED SOCIAL WORKERS PROFESSIONAL AND SUPPLEMENTAL LIABILITY POLICY NOTICE: THIS POLICY PROVIDES SOCIAL WORKERS PROFESSIONAL LIABILITY CLAIMS MADE AND REPORTED COVERAGE. COVERAGE IS LIMITED GENERALLY TO LIABILITY FOR CLAIMS ARISING FROM A PROFESSIONAL INCIDENT HAPPENING ON OR SUBSEQUENT TO THE RETROACTIVE DATE STATED IN THE POLICY AND BEFORE THE END OF THE POLICY PERIOD WHEN THE CLAIM IS FIRST MADE AGAINST YOU AND REPORTED TO US IN WRITING DURING THE POLICY PERIOD OR ANY APPLICABLE EXTENDED REPORTING PERIOD. A LOWER LIMIT OF LIABILITY APPLIES TO SOME OF THE COVERAGES IN THIS POLICY. THIS POLICY IS SUBJECT TO ARBITRATION IN ACCORDANCE WITH THE PROVISIONS SET FORTH BELOW IN SECTION VII(K). PLEASE REVIEW THIS POLICY CAREFULLY AND DISCUSS THIS COVERAGE WITH YOUR LEGAL OR INSURANCE ADVISOR. Throughout this Policy, the words You, Your, and Insured refer to each person or entity that is an Insured under this Policy. The words We, Us, and Our refer to the Company providing this insurance. Bolded words and phrases used in this Policy have special meaning as defined in this Policy, including in Section III, Definitions. In consideration of the payment of premium, the undertaking of the Insured to pay any applicable Deductible to the degree one is stated in the Declarations, and in reliance on all of the statements made and information You furnished to Us, including all representations made in the Application, and subject to the Limits of Liability as set forth in the Declarations and described in Section IV of this Policy, and the terms, conditions and other provisions of this Policy, We and You agree as follows: I. INSURING AGREEMENT Coverage Part A: Professional Liability Coverage We will pay on Your behalf those amounts that You become legally obligated to pay as Damages for a Claim alleging a Professional Incident in Your provision of Professional Services to others, provided: A. The Professional Incident takes place on or after the Retroactive Date and before the end of the Policy Period, and RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 1 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. B. The Claim is first made against You and reported to Us in writing during the Policy Period or any applicable Extended Reporting Period pursuant to the reporting procedures set forth in Section VII.A. Coverage Part B: Supplemental Liability for Business Invitees The coverage under Coverage Part B does not apply to any Claim or Damages that is covered under Coverage Part A or Coverage Part C. A. Bodily Injury and Property Damage Coverage for Business Invitees We will pay on Your behalf those amounts that You become legally obligated to pay as Damages, for a Claim alleging Bodily Injury or Property Damage to a Business Invitee that takes place while You are providing Professional Services, provided: 1. The Professional Services take place on or after the Retroactive Date and before the end of the Policy Period, 2. The Bodily Injury or Property Damage takes place in the Workplace where Professional Services are being rendered to the Business Invitee or another person that the Business Invitee is accompanying, 3. The Bodily Injury or Property Damage occurs before the end of the Policy Period, and 4. The Claim is first made against You and reported to Us in writing during the Policy Period or any applicable Extended Reporting Period pursuant to the reporting procedures set forth in Section VII.A. B. Personal Injury Coverage for Business Invitees We will pay on Your behalf those amounts that You become legally obligated to pay as Damages for a Claim alleging Personal Injury to a Business Invitee that takes place while You are providing Professional Services, provided: 1. The Professional Services take place on or after the Retroactive Date and before the end of the Policy Period, 2. The Personal Injury takes place in the Workplace where Professional Services are being rendered to the Business Invitee or another person that the Business Invitee is accompanying, 3. The Personal Injury occurs before the end of the Policy Period, and RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 2 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. 4. The Claim is first made against You and reported to Us in writing during the Policy Period or any applicable Extended Reporting Period pursuant to the procedures identified in Section VII.A. Coverage Part C: Additional Coverages The additional coverages set forth in Coverage Part C are each subject to a separate Limit of Liability set forth in the Declarations for that Coverage Part C Subpart. Each such separate Limit of Liability for an additional coverage set forth in Coverage Part C is in addition to, and does not reduce, the Limits of Liability applicable to Coverage Parts A and B. If there is no Limit of Liability set forth in the Declarations for an additional coverage under Coverage Part C, then there is no coverage under this Policy for that additional coverage. The coverage under Coverage Part C does not apply to any Claim or Damages that is covered under Coverage Part A or Coverage Part B. A. Emergency First Aid We will pay for those expenses that You have voluntarily incurred for first aid rendered as a result of Bodily Injury to a Business Invitee in the Workplace used principally in the Named Insured's practice as a social worker, provided: 1. The incident that causes the Bodily Injury takes place on or after the Retroactive Date and before the end of the Policy Period; 2. The first aid was provided within a 48 -hour period from the time the Bodily Injury first happened; 3. Documentation of the expenses is timely provided to Us; and 4. The incident was timely reported to Us in writing during the Policy Period or any applicable Extended Reporting Period pursuant to the procedures identified in Section VII.A. B. Health Information- HIPAA 1. We will pay for reasonable attorney's fees, costs, expenses or fees that You incur in responding to a Claim first made by a regulator against You for any Privacy Wrongful Act, provided: (a) the Privacy Wrongful Act arises solely out of Your performance of Professional Services; (b) the Privacy Wrongful Act took place on or after the Retroactive Date and before the end of the Policy Period; and RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 3 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. (c) the Claim for a Privacy Wrongful Act was first made against You and reported to Us in writing during the Policy Period or any applicable Extended Reporting Period pursuant to the procedures identified in Section VII.A. 2. We will pay those reasonable amounts that You incur in notifying Your clients of a Privacy Wrongful Act as mandated by any U.S. federal or state privacy protection statutes or regulations, provided: (a) The Privacy Wrongful Act arises solely out of Your performance of Professional Services; (b) the Privacy Wrongful Act took place on or after the Retroactive Date and before the end of the Policy Period; and (c) The Privacy Wrongful Act was reported to Us in writing during the Policy Period or any applicable Extended Reporting Period pursuant to the procedures identified in Section VII.A. Coverage under this Coverage Part C, Subpart B.2 applies regardless of whether or not a Claim for a Privacy Wrongful Act is made against You. We will not, however, pay for any penalties, fines or other fees assessed against You by any regulatory or other authority arising from, caused by, or related to a Privacy Wrongful Act. C. State Licensing Board Investigation Defense Subject to our right to select counsel, We will pay Your Claim Expenses to respond to an investigation or proceeding by a state licensing board, or other regulatory body that licenses or regulates Your work as a social worker, concerning Your provision of Professional Services, provided: 1. The Professional Services take place on or after the Retroactive Date and before the end of the Policy Period, and 2. Notice of the investigation or proceeding is first received by You and reported to Us in writing during the Policy Period or any Applicable Extended Reporting Period, pursuant to the reporting procedures set forth in Section VII.A. We will not, however, pay for any penalties, fines or other fees assessed against You by any licensing board or regulatory body. Under no circumstances does this coverage extend to any criminal proceeding or Medicaid or Medicare investigation. D. First Party Assault RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 4 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. We will pay for any: 1. Medical expenses incurred as a result of Bodily Injury to You; and 2. The repair or replacement of damaged or stolen personal property owned by You; as a result of an Assault by, or at the direction of, a person other than You, that occurs during the Policy Period, and which happens at Your Workplace or elsewhere while You are conducting Professional Services, provided that the Assault was reported to Us in writing during the Policy Period or any applicable Extended Reporting Period pursuant to the procedures set forth in Section VII.A. This coverage does not apply to Bodily Injury or to damage or theft of personal property arising from any type of transportation used by You to go to or from Your Workplace, or to damage, theft of any business or personal property owned, leased or rented by any other person or entity while in Your possession. E. Medical Payments We will pay for any amounts that You are legally obligated to pay as medical payments arising from Bodily Injury suffered by a Business Invitee, where such Bodily Injury occurred in Your provision of Professional Services to others in Your Workplace, provided that: 1. The incident that causes the Bodily Injury takes place on or after the Retroactive Date and before the end of the Policy Period; 2. Documentation of the medical payments is timely provided to Us; and 3. The incident was timely reported to Us in writing during the Policy Period or any applicable Extended Reporting Period pursuant to the procedures identified in Section VII.A. F. Wage Loss and Expense We will pay for Your lost wages per day, plus reasonable costs and expenses, caused by Your attendance at Our request at any trial(s), hearing(s), mediation(s), or arbitration proceeding(s) involving any Claim against You for Damages covered under this Policy, regardless of the number of Insureds, mediations, trials, hearing or arbitration proceedings, provided that documentation of these expenses is timely provided to Us. RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 5 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. G. Deposition Expense We will pay for Your reasonable legal expenses incurred by You for Your subpoenaed and legally required appearance at a deposition to provide testimony involving Your provision of Professional Services during the Policy Period, provided that: 1. A Claim has not been asserted against You; 2. The treatment about which You will testify could, in Our judgment, reasonably lead to a Claim being asserted against You which would otherwise be covered under this Policy; and 3. The deposition expense coverage is subject to Our right to select counsel. H. Subpoena Expense Reimbursement We will reimburse You for reasonable legal expenses incurred and paid by You for legal assistance in complying with any subpoena, including but not limited to You providing medical record information, and for any other subpoena request, provided that: 1. You receive the subpoena during the Policy Period and report Your receipt of the subpoena and intent to seek reimbursement to Us in writing during the Policy Period pursuant to the reporting procedures set forth in Section VILA; 2. You provide satisfactory documentation of the legal fees incurred in responding to the subpoena and Your payment of same, along with a valid, executed W9; and 3. The total reimbursement for all subpoena expenses under this Policy shall not exceed $400.00, regardless of the amount expended by You or the number of subpoenas received during the Policy Period. DEFENSE, CLAIM EXPENSES, SETTLEMENT A. The following applies only to Coverage Parts A and B: We will have the right and duty to defend You, including the right to select counsel, against any Claim brought against You to which this Policy applies regardless of whether the Claim is groundless, false or fraudulent. We will have no duty to defend You against any Claim for which there is no coverage under this Policy. We have the right to conduct any investigation or negotiation and, with the written consent of the first Named Insured, which consent will not be unreasonably withheld, make any settlement of a Claim. If We recommend a settlement to You that is acceptable to the claimant and You refuse to consent to the settlement and elect to contest the Claim or continue any legal proceedings in connection with such Claim then, subject to the Limits of Liability section of this Policy, Our Limit of Liability for that Claim will not exceed the amount for which that Claim could have been settled, plus the Claim Expenses incurred by Us to defend that Claim. RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 6 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. B. We will have the right, but not the duty, at Our sole discretion to investigate any Damages, Claim or Potential Claim. C. We will have the right, but not the duty, to appeal any judgment or award against You. D. You may not incur any Claim Expenses, admit liability, make any payment, or settle any Claim without Our prior written consent, which will not be unreasonably withheld. We will not be liable for any expense, settlement, assumed obligation or admission to which We did not consent. E. Subject to the applicable Limit of Liability, We will pay all Claim Expenses that We incur in the investigation and defense of any Claim under Coverage Parts A or B or that We incur under Coverage Part C. Claim Expenses are within the Limit of Liability. F. You agree to cooperate with Us in defending, investigating and settling any Claim and agree, as a condition of coverage under this Policy, to submit to Us upon request any information and documentation that We may require in the investigation and defense of any Claim. G. If We exercise Our right to appeal, We will pay the premiums for any appeal bonds for the covered part of the judgment, but We have no obligation to apply for, furnish or have any court approve of such bonds or provide any collateral for such bonds. H. Our duty to defend You ends upon exhaustion of the applicable Limit of Liability in the payment of Damages and Claim Expenses, which can include tendering the Limit of Liability into court. II. POLICY TERRITORY This Policy applies to Professional Incidents, Bodily Injury, Property Damage, Privacy Wrongful Acts, Personal Injury, or Assaults that take place anywhere in the world, but only if the Claim is made and the Suit is brought or the licensing board or regulatory investigation or proceeding is conducted in the United States of America, its territories or possessions, or Puerto Rico. III. DEFINITIONS A. Assault means any willful attempt or threat to inflict Bodily Injury upon the person of another, when coupled with an apparent present ability to do so, and any intentional display of force that would give the victim reason to fear or expect immediate bodily harm. B. Bodily Injury means physical injury, sickness, disease, mental illness or emotional distress sustained by any person, including death resulting therefrom. RRG PLI Claims Made Policy: "RRG PLI -1131 (January 9, 2017)" Page 7 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. C. Business Invitee means any natural person to whom You are rendering Professional Services, or who is accompanying a natural person to whom You are rendering Professional Services, solely in their capacity as one who is invited by the Insured to enter into and remain in the Workplace for a purpose directly connected with the rendering of Professional Services. A Business Invitee will not include any person who enters the Workplace without an Insured's knowledge or permission, or any person who is an Insured. D. Claim(s) means 1. a written demand for money or services, naming You and alleging Damages caused by a Professional Incident, but solely as respects Coverage Part A; 2. a written demand for money or services naming You and alleging Damages for Bodily Injury or Property Damage to a Business Invitee, but solely as respects Coverage Part B; or 3. a regulatory proceeding or formal investigation concerning a Privacy Wrongful Act arising solely out of Your performance of Professional Services, but solely as respects Coverage Part C., Subpart B.1. 4. an administrative proceeding or formal investigation concerning Your provision of Professional Services commenced by a regulator, but solely as respects Coverage Part C, Subpart C. A Claim will be considered first made when notice of such Claim is first received by any Insured, if it is reported to the Company in writing in accordance with the terms and conditions of this Policy. All Claims arising out of the same Professional Incident will be considered as having been made at the time the first report of such a Claim, whenever made. Claim also means a Potential Claim involving a Professional Incident, which You report to Us as soon as practicable during the Policy Period. The report of such a Potential Claim must include: 1. The date, time and place of the Potential Claim and the identity of any Insured involved; 2. A description of the Professional Services that You performed; 3. The type of Claim You anticipate; and 4. The name and address of the injured party and any witnesses. RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 8 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. If You submit written notice to Us containing the information listed in 1-4 above, then any Claim that may subsequently be made against You arising out of the same Professional Incident will be deemed, for the purposes of insurance under the Policy, to have been made during the Policy Period in effect at the time such written notice was submitted to Us. E. Claim Expense(s) means the reasonable and necessary fees charged by an attorney(s) or independent adjustor(s) designated by Us and all other fees, costs, expenses resulting from the investigation, adjustment, defense and appeal of a Claim, including costs taxed against an Insured and all interest on the entire amount of any judgment rendered against an Insured, if incurred by Us, or by You with Our prior written consent. The reasonableness of the fees paid to counsel will be determined by the rates We actually pay to attorneys retained by Us in the jurisdiction where the Suit, administrative proceeding or investigation is pending for similar Claims. Claim Expense(s) does not include: 1. expenses of or relating to the institution or prosecution of a counterclaim or cross -claim by an Insured, including a counterclaim or cross -claim in a Suit that is covered by the Policy, unless the Company has provided prior written consent to the institution and prosecution of such counterclaim or cross -claim; or 2. salary charges or expenses of Your regular employees or officials. F. Damages means monetary compensatory judgments, awards, or settlements. Damages does not include: 1. Costs of complying with requests, demands or orders for injunctive relief; 2. Fines and penalties, including but not limited to contractual, regulatory and statutory civil or criminal fines, penalties and sanctions; 3. Exemplary, multiple or statutory damages; 4. Punitive damages; 5. Restitution, return or forgiveness of fees, expenses or costs paid to or charged by an Insured; disgorgement or loss of profits by an Insured; or other costs of doing business; 6. Consequential damages; or 7. Matters or Damages deemed uninsurable under the law pursuant to which this Policy is construed. RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 9 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. If a Suit, however, is brought against the Insured to which this insurance applies seeking both compensatory and punitive or exemplary damages, then We will afford a defense to such action, subject to all other terms and conditions of the Policy, without any liability for payment of such punitive or exemplary damages. G. Insured, You and Your mean: 1. The Named Insured; 2. An employee of the Named Insured while acting in the scope of its employment by the Named Insured, but solely for its conduct in providing Professional Services on behalf of the Named Insured; 3. An officer or director of the Named Insured but solely for its conduct in providing Professional Services on behalf of the Named Insured. In order to qualify as an Insured under this Policy, an individual must either: 1. hold an MSW, DSW, MA or MS degree in the field of social work from an accredited educational institution, and have earned the degree more than two (2) years before the inception date of the Policy; 2. In the case of a social worker with less than two (2) years of social work services experience, an individual who graduated from college within the two (2) years prior to the inception date of the Policy and does not yet have its license to practice independently; 3. Hold a BSW, BA or BS degree in social work if the individual is providing social work services within the scope allowed by state regulatory boards; or 4. Be a social worker or psychologist who also holds a masters degree or doctorate degree in social work or psychology. H. Limit of Liability means the amounts set forth in the Declarations of this Policy for the applicable Coverage Part and Subpart, and as described in Section V, Limits of Liability. I. Named Insured means any organization or individual indicated in the Declarations." J. Personal Injury means injury, other than Bodily Injury, arising out of one or more of the following offenses: 1. False arrest, detention or imprisonment; 2. Malicious prosecution; RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 10 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. 3. The wrongful eviction from, wrongful entry into, or invasion of the right of private occupancy of a room, dwelling, or premises that a person occupies committed by or on behalf of its owner, landlord or lessor; 4. Oral or written publication of material that slanders or libels a person or organization or disparages a person's or organization's goods, products or services; or 5. Oral or written publication of material that violates a person's right of privacy. K. Policy means this insurance contract issued by Us to the Named Insured, including the Declarations page(s) and all endorsements to it. L. Policy Period means the period from the inception date of this Policy set forth in the Declarations to the expiration date of this Policy as set forth in the Declarations or the cancellation or termination date, whichever occurs first. M. Pollutants means any solid, liquid, gaseous, biological, radiological or thermal irritant or contaminant, including smoke, vapor, soot, fumes, acids, mold, silica, spores, asbestos, dust, fibers, fungi, alkalis, chemicals, nuclear materials and waste, including but not limited to medical waste and materials to be recycled, reconditions or reclaimed. N. Potential Claim means a Professional Incident that has not yet resulted in a Claim but that an Insured has reason to believe may give rise to a Claim covered by this Policy, or that an Insured should reasonably foresee might be the basis of a Claim covered by this Policy. O. Privacy Wrongful Act means an act, error or omission by the Insured that results in a breach or violation of the Health Insurance Portability and Accountability Act of 1996 or any regulation promulgated thereunder (collectively, "HIPAA") in connection with the collection, use or security of "protected health information" of patients or clients, as that term is defined in HIPAA. Such information must be under the Insured's care, custody or control and must be related to rendering of Professional Services to the patients or clients whose personally identifiable information and/or personal health insurance is at issue. All such acts, errors or omissions, as referenced in this definition, that are actually or allegedly caused, committed or attempted by or claimed against one or more Insureds arising out of the same or relating to the same or series of related facts, circumstances, situations, transactions or events will be deemed to be the same Privacy Wrongful Act. RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 11 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. P. Professional Incident means any act, error or omission in the providing of, or the failure to provide, Professional Services by You. This includes Your responsibility for anyone acting under Your direction and control. All Related Professional Incidents arising out of the provision of Professional Services to any one person will be considered one Professional Incident, irrespective of the number of Claims made or the number of Claimants or number of Insureds. The Limit of Liability for all Claims alleging Related Professional Incidents will be the Each Claim Limit as set forth in the Declarations, regardless of the number of Claims, claimants, Suits, Insureds, or Coverage Parts involved. Q. Professional Services means solely those social work services rendered to others by a social worker who qualifies as an Insured under this Policy. R. Property Damage means 1. physical injury to or destruction of tangible property including the loss of use thereof of property that is physically injured. All such loss of use will be deemed to occur at the time of the physical injury that caused it; and 2. loss of use of tangible property that is not physically injured. All such loss of use will be deemed to occur at the time of the incident that caused it. For the purposes of this insurance, electronic data is not tangible property. S. Related Professional Incidents means any actual or alleged separate, continuous, repeated or series of Professional Incidents directly arising out of or related to the same or similar service, transaction, event, representation, statement, practice, advice, decision or circumstance, or to a series of services, transactions, events, representations, statements, practices, advice, decisions or circumstances concerning the same patient or client. The determination of whether or not a Professional Incident constitutes a Related Professional Incident will not be affected by the identity or number of claimants, the identity or number of Insureds involved, or the existence of a separate duty or professional relationship. T. Retroactive date means the date specified in the Declarations. U. Sexual Misconduct means 1. any type of physical touching or caressing, or attempt thereof, or suggestion thereof, which could be considered sexual or erotic in nature, including consensual sexual activity or sexual activity in contravention of a professional code of ethics or conduct; or 2. any act of sexual assault, harassment or molestation. RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 12 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. V. Suit means a civil proceeding seeking monetary damages, and includes an arbitration, mediation, or any other alternative dispute resolution procedure seeking such damages to which You submit with Our consent. Suit does not include an administrative hearing. W. Workplace means the office where You provide Your Professional Services. IV. LIMITS OF LIABILITY A. Coverage Part A - Professional Liability Coverage Limits of Liability Each Claim Limit The Limit of Liability stated in the Declarations as the Each Claim Liability Limit for Coverage A is the most We will pay under Coverage Part A for all Damages and Claim Expenses arising out of, or in connection with, the same Professional Incident or Related Professional Incidents, regardless of the number of Claims, claimants, Suits, or Insureds involved. B. Coverage Part B — Supplemental Liability for Business Invitees Limits of Liability Each Claim Limit The Limit of Liability stated in the Declarations as the Each Claim Liability Limit for Coverage B is the most We will pay under Coverage Part B for all Damages and Claim Expenses arising out of, or in connection with, the same incident or any related incidents, regardless of the number of Claims, claimants, Suits or Insureds involved, or Business Invitees that incur Bodily Injury, Property Damage or Personal Injury. C. Coverage Part C - Additional Coverages Limits of Liability The Limit of Liability stated in the Declarations for each Subpart of Coverage Part C is the most that We will pay under that Subpart, regardless of the number of Professional Incidents, Insureds, claimants, Business Invitees, Claims, incidents, Privacy Wrongful Acts, licensing investigations, proceedings, or Assaults. If the Declarations identifies a "per incident" limit for a Subpart of Coverage Part C, that is the most that We will pay for any one incident or related incidents for which there is coverage under that Subpart of Coverage Part C of this Policy. If the Declarations identifies a "per day" limit for a Subpart of Coverage Part C, that is the most that We will pay for any one day of expenses for which there is coverage under this Policy. RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 13 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. If the Declarations identifies a "per policy period" limit for a Subpart of Coverage Part C, that is the most that We will pay for all Insureds for any number of matters during each Policy Period for that particular Subpart. D. Aggregate Limit of Liability The Limit of Liability stated in the Declarations as the Aggregate Limit is the most We will pay for all Damages and Claim Expenses under Coverage Parts A and B, regardless of the number of Claims, Professional Incidents, Insureds, Suits, claimants, incidents or Business Invitees that incur Bodily Injury, Property Damage or Personal Injury. E. Sexual Misconduct Aggregate Limit The most We will pay under this Policy for all Damages for Claims involving Sexual Misconduct is $25,000, as set forth in Section VI.J, regardless of the number of Claims, Professional Incidents, Insureds, Suits, claimants, or incidents. Any Claim Expenses paid for a Claim involving Sexual Misconduct are in addition to this $25,000 aggregate limit for Damages for Claims involving Sexual Misconduct. This $25,000 aggregate limit for Damages for a Claim involving Sexual Misconduct afforded by the Policy shall be part of, and not in addition to, the Limit of Liability shown in the Declarations as the Aggregate Limit. We shall not be obligated to pay any Claim Expenses or any other amounts and will no longer have any duty to defend any Insured for any Claim involving Sexual Misconduct after this $25,000 aggregate limit has been exhausted by payment or tender of Damages included within this aggregate limit for a Claim involving Sexual Misconduct. F. All Claims arising from Related Professional Incidents will be treated as one Claim. Such Professional Incidents will be considered to have taken place when the earliest such Professional Incident commences. The applicable Limit of Liability will be the one from the Policy Period during which the first Claim was first made. G. If any combination of Coverage Parts A, B and C, as shown in the Declarations applies to the same Claim or matter, Our liability is limited as follows: 1. In no event will the limits of liability of Coverage Parts A, B and C be added together, combined or stacked to determine the applicable Limit of Liability. 2. The total limits of liability under Coverage Parts A, B and C will not exceed the highest applicable limit of Coverage Part A, B or C, and RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 14 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. 3. We, in Our sole discretion, will determine which Coverage Part and Subpart applies. V. COVERAGE EXTENSIONS A. Estates and Legal Representatives This Policy will afford coverage for a Claim to which this Policy applies if made against Your estate, heirs or legal representatives if You are deceased, or against Your legal representatives if You are incompetent or bankrupt, to the extent that in the absence of such death, incompetence, or bankruptcy, such Claim would have been covered by this Policy. B. Spousal and Domestic Partner Liability VI. EXCLUSIONS We will not be liable to make any payment in connection with any matter, Claim or Damages based upon, arising out of or related to any actual or alleged: A. Criminal, malicious, fraudulent, knowingly wrongful, or dishonest act(s) or omission(s), or willful violation(s) of any statute or regulation committed by You or with the knowledge, consent or approval of You. However, this exclusion will not apply unless there is a judgment, final ruling or admission adverse to You in any judicial, administrative or alternative dispute resolution proceeding establishing that such acts or omissions were malicious, fraudulent, knowingly wrongful or dishonest, or willful, or that You approved, consented to or had knowledge of such conduct. We will not be required to appeal any such adjudication, judgment or ruling. The conduct or knowledge of one Insurediwill not be imputed to another Insured. B. Criminal proceedings, regardless of the allegations made against You; C. Unjust enrichment, or obtaining any profit, remuneration or advantage to which You were not legally entitled. This exclusion, however, will not apply unless there is a judgment, final ruling or admission adverse to You in any judicial, administrative or alternative dispute resolution proceeding establishing that there was in fact unjust enrichment or obtaining of profit, remuneration or advantage to which such Insured was not legally entitled; D. Liability as an owner or proprietor of any clinic with bed and board facilities, sanitarium, nursing home or laboratory, or for any acts, errors or omissions arising out of or in the course of any trade, business, employment or profession other than as a social worker; RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 15 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. E. Medical, surgical, dental, x-ray or nursing service or treatment, the furnishing of food or beverages in connection therewith or the furnishing or dispensing of any drugs or medical, dental or surgical devices, supplies or components. This exclusion does not include any services performed by You at the direction of a physician or the use of any biofeedback equipment that You use in Your social worker practice; F. Claim, Potential Claim, Professional Incident or Damages that reasonably should have been known or foreseen by any Insured prior to the inception date of this Policy to be likely to give rise to a Claim or other matter that otherwise would be covered by this Policy. The conduct or knowledge of one Insured will not be imputed to another Insured; G. Damages that were expected or intended, or that should have been reasonably expected or intended, from the standpoint of an Insured; H. Liability assumed by You under any contract or agreement, whether written or oral, except to the extent that You would have been legally liable in the absence of such contract or agreement. This exclusion does not apply to any liability You assume under a contract with a Health Maintenance Organization, Health Insurance Company, or any other similar organization that is attributable to Your alleged negligence in the performance of Your work as a social worker; Liability for services other than as a social worker. This exclusion includes, but is not limited to, services as a psychiatrist, physician, dentist, nurse, podiatrist, chiropractor, nurse anesthetist, nurse -midwife, midwife, perfusionist, sonographer, osteopath, or healthcare aide; J. Sexual Misconduct or molestation, except as follows, and subject to a policy maximum of $25,000 for Damages for Claims involving Sexual Misconduct as set forth in Section IV.E.: 1. We will pay Claim Expenses and Damages that You are legally obligated to pay, as a result of any Claims against You involving any Sexual Misconduct arising out of or related to Professional Services rendered by You, provided: (a) the Sexual Misconduct has not been determined to have occurred by any trial verdict, court ruling, regulatory ruling or legal admission, whether or not it has been appealed, regardless of the legal theory or basis upon which the Insured is alleged to be liable; (b) the alleged Sexual Misconduct took place on or after the Retroactive Date and before the end of the Policy Period; RRG PLI Claims Made Policy: "RRG PLI - 1131 (January 9, 2017)" Page 16 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. (c) the Claim involving Sexual Misconduct was first made against You and reported to Us during the Policy Period or any applicable Extended Reporting Period pursuant to the procedures identified in Section VIII.A; and (d) the Claim does not allege or involve Sexual Misconduct by anyone other than You; and 2. This exclusion does not apply if the Claims against You are solely for actual or alleged vicarious liability by You for the Sexual Misconduct of another, or for any other actual or alleged liability of You for the actions of someone else, including but not limited to allegations of improper or negligent hiring, employment or supervision if they are otherwise covered under this Policy. K. Liability for employment practices, including but not limited to refusal to employ, wrongful termination or employment, coercion, demotion, evaluation, reassignment, discipline, harassment, libel, slander or other employment -related practices, policies or conduct. This exclusion applies to independent contractors as well as employees; L. Libel, slander, oral or written publication of defamatory or disparaging material, invasion of privacy, wrongful entry or eviction, violation of rights of occupancy, false arrest, false imprisonment, malicious prosecution, malicious use of or abuse of process, Assault, battery, or any resulting loss of consortium, disability, shock, humiliation, embarrassment, mental injury or anguish, emotional distress or injury to personal or business reputation or character; M. Liability based upon or arising out of any alleged infringement or use of any copyright, patent, trademark, trade name, trade dress, service mark or any other infringement, misappropriation of any other intellectual property right; N. Liability based upon or arising out of any of the following: 1. false, deceptive or unfair trade practices; 2. unfair competition, impairment of competition, restraint of trade or antitrust violations; 3. violation of the Sherman Anti -Trust Act, the Clayton Act, the Robinson-Patman Act, including as may be amended, and any similar federal, state or local statutes or regulations in the U.S. or outside the U.S.; 4. violation of consumer protection laws; or 5. deceptive or misleading advertising. RRG PLI Claims Made Policy: "RRG PLI -1131 (January 9, 2017)" Page 17 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. O. Liability for any Claim by an Insured against any other Insured P. Liability for any Claim by any entity: 1. That is operated, managed or controlled by You or that You have an ownership interest in; 2. in which You are an officer or director; or 3. that wholly or partly owns, operates or manages You; Q. Express warranties and guarantees. This exclusion, however, does not apply to Your warranty or guarantee that Your Professional Services are in conformity with the standard of care applicable to Your Professional Services; R. Professional Services or other services provided while Your license or certification to perform Your social worker duties is suspended or revoked; S. Duties that You owe as a proprietor, owner, partner, manager, superintendent, director or officer or of any entity not specified as an Insured in this Policy; T. Failure or infection of any computer, server, operating system, network, hardware, software, or any loss of or damage to, or loss of use of any electronic data or any work product due to the failure or infection of any such computer, computer, server, operating system, network, hardware, or software; U. Failure to protect, unauthorized disclosure or use of, or improper collection of, any personally identifiable information or confidential corporate information that is in Your care, custody or control. V. Design, manufacture, sale, supply, or distribution of any goods or products, including but not limited to products or goods designed or manufactured by You or by others under license or trade name from You. W. War or any act of war, invasion, act of foreign enemy, hostilities (whether or not a war is declared), strike, riot or civil commotion, civil war, rebellion, revolution, insurrection, military or usurped power or terrorism; X. Discrimination, including but not limited to the violation of any law, whether statutory or common law, including but not limited to, race, color, religion, national origin, age, sex, marital status, sexual orientation, harassment, handicap, or pregnancy; Y. Inability or failure of You or others to collect or pay money, or any issues involving reimbursement requests, overbilling and other fee -related matters; RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 18 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. Z. Threatened or actual discharge, dispersal, release or escape of Pollutants; or direction or request to test for, monitor, clean up, remove, contain, treat, detoxify or neutralize Pollutants; AA. Bodily injury or property damage arising out of the ownership, maintenance, use, operation, loading or unloading of any motor vehicle , aircraft or watercraft; BB. Property damage to: 1. Property used by You or in Your care, custody or control; 2. Property owned or occupied by or rented/leased to You; or 3. Premises sold, given away or abandoned by You, if the Property Damage arises out of any part of those premises; CC. Any business relationship or venture with any prior or current client or patient; or DD. Professional Incident while You were under the influence of an illegal drug or substance or while You were intoxicated. EE. Violation of 1. The Telephone Consumer Protection Act (TCPA), including any amendment of or addition to such law; 2. The CAN-SPAM Act of 2003, including any amendment of or addition to such law; 3. The Fair and Accurate Credit Transaction Act of 2003 (FACTA), part of The Fair Credit Reporting Act (FCRA), 15 U.S.C. 1681 et. seq., including any amendment of or addition to such law; or 4. Any statute, ordinance or regulation other than the TCPA, FACTA, FCRA or CAN- SPAM Act of 2003 that prohibits or limits the recording, sending, transmitting, communicating, or distribution of material or information, or the inclusion of full credit card numbers or credit card expiration dates on any receipts provided to customers at the time of a credit card transaction or handling of or dissemination of personal financial or other information. FF. Violation of the Employee Retirement Income Security Act of 1974, (ERISA) including any amendments or additions to such law, and any rules or regulations promulgated pursuant to such law. GG. Liability for therapies or activities that involve equine therapy or canine therapy. RRG PLI Claims Made Policy: "RRG PLI -1131 (January 9, 2017)" Page 19 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. HH. Except to the extent provided under Coverage Part C, Subpart B for Privacy Wrongful Acts, any liability or expenses arising out of any access to or disclosure of any person's or organization's confidential or personal information, including patents, trade secrets, processing methods, customer lists, financial information, credit card information, health 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 disclosure of any person's or organization's confidential or personal information. VII. CONDITIONS A. Duties in the Event of a Claim or Potential Claim Under Coverage Parts A, B, or C, or Receipt of a Matter under Coverage Part C It is a condition precedent to Our obligations and Your rights under the Policy that You give to Us written notice during the Policy Period or any applicable Extended Reporting Period of the following, as soon as practicable and without delay: 1. If, during the Policy Period or any applicable Extended Reporting Period, a Suit is brought or other Claim made against You, You must notify Us of such Suit or other Claim and such notice must contain: (a) All written notice and communications related to the matter received by the Insured(s), including but not limited to any demands, notices, and summonses; (b) The identity of the Insured(s) involved and the identity of the claimant; and (c) The date of and location where the alleged incident took place; 2. If, during the Policy Period or any applicable Extended Reporting Period, You first receive notice of a matter that is covered under Coverage Part C, You must notify Us in writing of that matter and such notice must contain: (a) All written notice and communications related to the matter received by the Insured(s), including but not limited to any demands, notices, and summonses; (b) The identity of the Insured(s) involved and the identify of any individual(s) or entity(ies) to whom the Insured could be obligated to make any RRG PLI Claims Made Policy: "RRG PLI -1131 (January 9, 2017)" Page 20 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. payment for which the Insured would seek coverage under Coverage Part C; and (c) The date, location, circumstances and any other information regarding where the alleged incident at issue took place; 3. All notices under this section must be in writing and sent to the attention of the plan administrator on behalf of the NASW Risk Retention Group, Inc. B. Cooperation of the Insured 1. It is a condition precedent to Our obligations and Your rights under the Policy that all Insureds will cooperate with the Company, including, but not limited to, the following: (a) Immediately send Us copies of any demands, notices, summonses, legal papers received in connection with the Claim or Suit; (b) Authorize Us to obtain records and other information; (c) Cooperate with Us in the investigation, settlement or defense of any Claim or Suit; (d) Assist Us, upon Our request, in the enforcement of any right against any person or organization that may be liable to You because of injury or damage to which this insurance may also apply; and (e) Attend hearings and trials and assist in securing and giving evidence and obtaining the attendance of witnesses. 2. No Insured will: (a) Prejudice Our position, potential or actual right of recovery, legal obligations or rights; (b) Settle any Claim, incur any Claim Expenses, or otherwise assume any contractual obligation or admit any liability with respect to any Claim without Our written consent; or (c) Voluntarily make any payments, assume any obligation or incur any expense, except those done at Your own cost. C. Other Insurance RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 21 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. Any payment due under this Policy is specifically excess of and will not contribute with any other valid and collectible insurance, unless such other insurance is written only as specific excess insurance over the Limits of Liability of this Policy. D. Bankruptcy Bankruptcy or insolvency of the Named Insured will not relieve Us of Our obligations under the Policy, subject to the right of termination of the Policy for material change in condition or control of the Named Insured. E. Sole Agent The Named Insured will act on behalf of all Insureds for all purposes, including but not limited to the payment or return of premium, the receipt and acceptance of any endorsements issued to form a party of the Policy, giving and receiving notice of cancellation and non -renewal, and providing any consent to settlement that may be required or requested. F. Changes Notice to any agent or broker or knowledge possessed by any agent or broker or by any other person will not effect a waiver or change in any part of this Policy or estop Us from asserting any right under the terms of this Policy, nor will the terms of this Policy be waived or changed, except by endorsement issued to form a part of this Policy. G. Cancellation and Nonrenewal 1. Cancellation (a) You may cancel this Policy within sixty (60) days of the effective date of the Policy by mailing or delivering to Us advance written notice of cancellation, as long as evidence of the cancellation is received by Us within the first sixty (60) days after the Policy's effective date. (b) We may cancel this Policy by mailing by first-class mail or delivering to You written notice of cancellation stating the reason for cancellation, to the last address known to Us, at least: (a)Ten (10) days before the effective date of the cancellation if We cancel for nonpayment of premium; or (b)Thirty (30) days before the effective date of cancellation if We cancel for any other reason. RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 22 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. (c) Notice of cancellation will state the effective date of the cancellation. The Policy Period will end on the date of cancellation. (d) If this Policy is cancelled, We will send the first Named Insured any premium refund due. If We cancel, the refund will be the pro rata unearned premium. If the first Named Insured cancels, the refund may be less than pro rata. The cancellation will be effective even if We have not made or offered a refund. (e) A certificate of mailing from the U.S. postal service or certified mail receipt will be sufficient proof of notice. 2. Nonrenewal We may decide not to renew this Policy for any legally permissible reason. If We decide not to renew this Policy, We will mail, through first-class mail to You, written notice of the nonrenewal at least thirty (30) days before the expiration date. H. Legal Action Against Us No person or organization has a right under this Policy: 1. To join Us as a party or otherwise bring Us into a Suit asking for Damages or other damages from an Insured; or 2. To sue Us on this Policy unless all the terms and conditions have been fully complied with. A person or organization may sue Us to recover on an agreed settlement or on a final judgment against an Insured obtained after an actual trial; but We will not be liable for any damages that are not payable under the terms of this Policy or that are in excess of the applicable Limit of Liability. An agreed settlement means a settlement and release of liability signed by Us, You, and the claimant or the claimant's legal representative. I. Conformance with Statutes and Laws Any terms of this Policy which are in conflict with the statutes or laws of the state or province wherein this Policy is issued are hereby amended to conform to such statutes and laws. J. Representations By accepting this Policy, You agree that: RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" © 2017 NASW Risk Retention Group, Inc. All rights reserved. Page 23 of 26 1. The statements in the Application and Declarations are true, accurate and complete; 2. Those statements are based upon representations You made to Us; 3. That the representations made are deemed to be material, and that We have issued this Policy in reliance upon the truth, accuracy and completeness of such statements. 4. Any and all relevant provisions may be voided by Us in any case of fraud, intentional concealment, or misrepresentation of material fact by You. K. Arbitration Any dispute arising out of, under or relating to this Policy, including but not limited to a dispute as to the meaning, interpretation, application or validity of any term, condition, definition, exclusion or any other provision of this Policy, will be resolved only by binding arbitration, such arbitration to be held in accordance with the Commercial Arbitration Rules of the American Arbitration Association ("AAA") in effect at the time of the demand for arbitration, except as amended here. Such arbitration proceedings are to be held in either the District of Columbia or Chicago, Illinois, at the election of the Company. No award of punitive damages will be made in any such arbitration. Each party will bear its own fees and costs in connection with any such arbitration, but the costs and fees incurred through the AAA will be shared equally by Us and You unless the arbitration award provides otherwise. The arbitration award is final and binding. Any award may be confirmed and enforced in a federal court of competent jurisdiction within the District of Columbia or in Chicago, Illinois. L. Choice of Law In the event that the Company and an Insured dispute the meaning, interpretation or application of any term, condition, definition, exclusion or any other provision of this Policy, the Insured and the Company agree that the law of the District of Columbia will apply, without regard to any conflicts or choice of law rules or principles. M. Interpretation This Policy is to be interpreted and construed in an even-handed manner as between the parties. If the language of this Policy is deemed ambiguous or otherwise unclear, the issue will be resolved in the manner most consistent with the relevant provisions of the Policy without regard to authorship of the provisions and without any RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 24 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. presumption or arbitrary interpretation or construction in favor of either any Insured or the Company. N. Subrogation and Assignment 1. If the Insured has rights to recover all or part of any payment that the Company has made under this Policy, those rights are transferred to Us. All Insureds will fully cooperate with the Company in its pursuit of recovery rights in its or the Insured(s) name, including but not limited to the execution of such documents necessary to enable the Company to effectively bring suit, prosecute claims or otherwise obtain recovery. No Insured will prejudice Our subrogation rights. 2. No Insured may assign any interest in this Policy unless We give Our prior written consent and an endorsement is attached to the Policy effecting assignment. O. Extended Reporting Periods 1. If this Policy is canceled or not renewed for any reason other than non-payment of premium, fraud or material misrepresentation, We will provide the Insured with an Automatic Extended Reporting Period of 60 days and, at Our discretion, may provide the Insured with a Supplemental Extended Reporting Period of a longer duration, as described below. To be eligible for a Supplemental Extended Reporting Period, the Insured must give Us a written request within 60 days after the end of the Policy Period. Each Insured must apply separately for a Supplemental Extended Reporting Period. 2. The Automatic Extended Reporting Period does not extend the Policy Period or reinstate or increase the Limits of Liability. The Limits of Liability applicable to any Claim or matter reported to Us during the Automatic Extended Reporting Period shall be part of, and not in addition to, the applicable Limits of Liability for such Claim or matter, including the Aggregate Limit, stated in the Declarations for this Policy. 3. The Automatic Extended Reporting Period is provided automatically without additional charge. The Automatic Extended Reporting Period starts with the end of the Policy Period and lasts for 60 days. The Automatic Extended Reporting Period does not apply to Claims, Claim Expenses, Privacy Wrongful Acts, Assaults, or any other matters that are covered under any other insurance, or that would be covered but for exhaustion of the amount of insurance applicable to such matters. 4. At Our discretion, we may provide the Insured with a Supplemental Extended Reporting Period of a greater duration, but only by an endorsement and for an RRG PLI Claims Made Policy: "RRG PLI -1131 (January 9, 2017)" Page 25 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. extra charge. Each Insured must apply separately for a Supplemental Extended Reporting Period. We reserve the right to deny a Supplemental Extended Reporting Period for any Insured based on our underwriting rules. To be eligible for a Supplemental Extended Reporting Period, the Insured must give Us a written request within 60 days after the end of the Policy Period. 5. A Supplemental Extended Reporting Period does not extend the Policy Period. However, it will reinstate the Limits of Liability for the Insureds for whom a Supplemental Extended Reporting Period is provided. If more than one Insured is named on an endorsement granting a Supplemental Extended Reporting Period, the reinstated Limits of Liability will be shared by all such Insureds. We reserve the right to require Insureds to purchase separate Supplemental Extended Reporting Periods. 6. If a Supplemental Extended Reporting Period is provided, it will start when the Automatic Extended Reporting Period ends. The Supplemental Extended Reporting Period will not go into effect unless the Insured pays the additional premium promptly when due. Once that premium is paid, We will consider it to be fully earned, and the Supplemental Extended Reporting Period may not be canceled. We will determine the additional premium in accordance with Our rules and rates. 7. If a Supplemental Extended Reporting Period is in effect, insurance provided by this Policy will be excess insurance over any part of any other insurance whose policy period begins or continues after the start of the Supplemental Extended Reporting Period. It will do so whether the other insurance applies on a primary, excess, contingent or any other basis. P. Titles of Paragraphs Titles of paragraphs are inserted solely for the convenience of reference and are not be deemed to limit, expand or otherwise affect the provisions to which they relate. END RRG PLI Claims Made Policy: "RRG PLI- 1131 (January 9, 2017)" Page 26 of 26 © 2017 NASW Risk Retention Group, Inc. All rights reserved. Subpoena Notification Email the completed form to: customerservice@a naswinsure.com OR Overnight mail to: NASW RRG Plan Administrator, 1200 E. Glen Ave., Peoria IL 61616 FORM INSTRUCTIONS: All must be answered. If a question does not apply, enter N/A. To attach additional information, please attach to this form. Name: Expiration date of Current Policy: Policy Number(s): Retroactive Date of Current Policy: Phone: Email Address: 1.) Prior Carriers and effective dates of coverage with each: 2.) Date Subpoena was received: 3.) Location of Subpoena (State): 4.) Dates of Treatment/Evaluation of Involved Client(s)*: *Be as accurate as possible with dates of treatment. ✓ Please be advised that in order for coverage to apply, report or discovery of the subpoena must occur during the policy period; AND dates of treatment or incident resulting in any claim must have occurred subsequently to any retroactive date on your policy (if applicable). ✓ If you were not insured with NASW RRG at the time the claim was made against you or discovered, please contact the insurance carrier with whom you were insured at that time. ***Please forward a copy of the subpoena received along with this report. Treatment notes and records and other patient Private Health Information are not necessary at this time.*** PLEASE READ AGREEMENT AND CHECK ONE ANSWER: The insured declares the information contained in the incident report is true and that no material facts have been suppressed or misstated. ❑ I Agree ❑ I Do Not Agree Signature: Today's Date: Professional Liability Initial Incident Report Email the completed form to: customerservicela'�,naswinsure.com OR Overnight mail to: NASW RRG Plan Administrator, 1200 E. Glen Ave., Peoria, IL 61616 FORM INSTRUCTIONS: All questions must be answered. If a question does not apply, enter N/A. To submit additional information, please attach to this form. 1) Policy Number (please submit all active policy numbers) or Policy ID: 2) Name of Insured (as it appears on the declaration page): 3) DBA ("Doing Business As" — other name used): 4) Contact Name: 5) Home Phone: 6) Work/Business Phone: Other Phone Number: 7) Email Address: 8) Current Policy Effective Date: 9) Current Policy Expiration Date: 10) Retroactive Date of Coverage: 11) State in which Incident occurred: 12) Prior Carrier(s) Information: Please identify prior Professional Liability Carriers: 13) Have any specific procedures or elements of practice been excluded from coverage under any of your prior carriers? O Yest ❑ No tlf yes, include the name of the carrier and the specific procedure or element of practice excluded. 14) Have any of your prior carriers defended any claims or paid any settlements or judgments on your behalf? ❑ Yest O No tlf yes, include the name of the carrier and amounts paid, and provide details of the particular claim, suit, or complaint. 15) Do you currently have any other pending professional liability claims, suits, or board investigations other than the information being reported on this Initial Incident Report? O Yestt O No tt/f yes, please provide a full explanation of the matter including the name of the court or board with which the suit or complaint was filed, the caption and docket number of the case (if any), the outcome or current status of the case, and any other relevant details. 16) Date of Incident in Question*: 17) Dates of Treatment/Evaluation of Involved Client(s)*: * Please be as accurate as possible with dates of incident/treatment. • Please be advised that in order for coverage to apply, report or discovery of the claim must occur during the policy period; AND dates of treatment or incident resulting in any claim must have occurred subsequently to any retroactive date on your policy (if applicable). • If you were not insured with NASW RRG at the time the claim was made against you or discovered, please contact the insurance carrier with whom you were insured at that time. -1of3- 18) Type of Claim (check all that apply): ❑ Professional Liability ❑ Deposition Expense ❑ Medical Expense ❑ Assault Coverage ❑ GL — Bodily Injury, Property Damage, Personal Injury, Advertising Injury, or host Liquor Liability. **If you check this box, you must complete page 3 of this form** ❑ State Licensing Board Investigation Expense ❑ First Aid Coverage 19) Have you received any of the following written documentation?*** (check all that apply): ❑ Summons / Letter of intent ❑ Notice of complaint If so, what date was it delivered? mm /dd/yyyy ***Please include with this form documentation received directly from a court, attorney, complainant, and/or regulatory agency. NOTICE: Treatment notes and records and other patient Private Health Information are not necessary at this time. ❑ Subpoena for deposition ❑ Other (describe): / / 20) Do you suspect that a claim or suit may arise out of the incident or treatment in question? 0 Yes 0 No 21) Please print/type here a brief description of Incident or Claim, and reasons why you suspect a claim or suit may arise: (Please attach additional sheets as needed.) PLEASE READ AGREEMENT AND CHECK ONE ANSWER: The insured declares the information contained in the incident report is true and that no material facts have been suppressed or misstated. I Agree Signature: I Do Not Agree Today's Date: PLEASE SUBMIT ALL SUPPORTING DOCUMENTATION, SUCH AS COURT DOCUMENTS AND RELATED CORRESPONDENCE (FROM A LICENSING BOARD AND ITS AGENTS OR INVESTIGATORS, THE COMPLAINANT'S ATTORNEY, OR OTHER RELEVANT PARTIES). - 2 of 3- PAGE 3: SUPPLEMENTAL FORM FOR BODILY INJURY, PROPERTY DAMAGE, PERSONAL INJURY, ADVERTISING INJURY, PERSONAL LIABILITY, OR HOST LIQUOR LIABILITY INCIDENTS. 22) Location (street, suite #, city, state, zip code): 23) Do you rent or own this location? ❑ Rent El Own 24) If you own this location, what percentage of the building is owned by you? El 100% El Other: List names of all co -owners: 25) If the incident type is bodily injury or property damage, did the incident occur?: El On Premises? Where did the injury take place? El Off Premises? Where did the injury take place? Did this injury involve a vehicle? El YES El NO Who witnessed the incident? 27) List all services which are provided at this location: 28) Name of therapist(s) involved in incident: 29) Name of therapist(s) involved in treatment of injured client: 30) Describe your relationship to the injured party: 32) Prior Commercial General Liability Carrier(s) Information: PLEASE READ AGREEMENT AND CHECK ONE ANSWER: The insured declares the information contained in the incident report is true, and no material facts have been suppressed or misstated. I Agree El I Do Not Agree Signature: Today's Date: -3of3- THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. GENERAL PURPOSE ENDORSEMENT This endorsement modifies insurance provided under the following: This information is completed only when this endorsement is issued subsequent to preparation of the policy: POLICY CHANGES ARE INDICATED BY AN "X": [ X ] Endorsement(s) is/are amended as shown below. The Additional Insured is hereby added solely for Damages arising out of a Professional Incident covered under this policy. The Professional Incident must arise out of services provided by the Insured, under contract with the Additional Insured. NAME OF ADDITIONAL INSUREDS ADDRESS OF ADDITIONAL INSUREDS Tyler And Thomas LLC 710 11th Avenue Ste 304 Greeley, CO 80631 All other terms and conditions of this Policy remain unchanged. This endorsement is part of your Policy and takes effect on the effective date of your policy, unless another effective date is shown below. Policy: P-GRO3Z455VYQHB-00 Effective on and after: 06-01-2018 Issued to: Noco Behavioral Health LLC Expiration: 06-01-2019 Customer ID: 3Z3XPKTBDT By: NASWRRG UE-001 5/29/2018 Tony Benedetto, Authorized Representative (Copyright) 2015 NASW Risk Retention Group, Inc.; All rights reserved. Important: NASW Risk Retention Group. Inc. Membership Confirmation Notice NASW Risk Retention Group, Inc. (the "Company") is a mutual captive insurer and risk retention group organized under District of Columbia law. As a policyholder, you are a member of the Company for so long as your policy remains in force. As a member, you are entitled to vote in person or by proxy on all matters, including the election of directors, brought before the membership for a vote at any meeting of the members. An Annual Meeting of the members is held every September. You will receive notice of the Annual Meeting at your address on record with the Company. Members of the Company also are entitled to participate in any dividend declared by the Company's Board of Directors, subject to any conditions established by the Board of Directors and the approval of the Company's District of Columbia regulator. If the policyholder is an entity, an officer or other authorized representative of the entity may exercise the entity's membership rights on its behalf. You can find the corporate Governance Standards and a Code of Business Conduct and Ethics adopted by the Company's Board of Directors at https://www.naswrrg.org/governance. EXHIBIT C SCOPE OF SERVICES 1. Contractor will provide Life Skills (Supervised Visitation) to individuals and families, as referred by the Department. 2. Frequency of Service: Six (6) hours per week. 3. Duration of Service: Twelve (12) months. 4. Goal of Services: a. Assist client and family learn to build appropriate relationships, boundaries and rule setting. b. Assist parents and caretakers to learn appropriate parenting ad communication that is age appropriate and cognitively applicable to the child(ren). 5. Outcomes of Service: Parent or caregiver will demonstrate ability to set limits, rules and boundaries that build attachment, repair relationships and strengthen the bonds of family for a long-term strong family structure. 6. Target Population: a. Families or individual caretakers who are trying to regain custody or visitation with their children. b. Children, ages 0 to 18 and parents/caretakers between the ages of 16 and 60 years of age. 7. Service Access: Office -based at 710 11th Avenue, Suite 304, Greeley, Colorado 80631, or community - based in the Greeley, Evans, Longmont, and Johnstown communities, and within the borders of Weld County. Visits will be arranged in accordance with the agreed upon schedule that accommodates both the caregiver or biological parents and the individual or family who is court ordered to participate in the visit. 8. Languages: English only. 9. Medicaid Eligibility: Service is not Medicaid -eligible. 10. Transportation: Contractor can transport children from their foster or biological home to visit location and back. Transportation will include multiple stops with a catchment area of 30 miles. Transportation outside the catchment area will incur additional charges. 11. Contractor will respond to the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400- 6210) within three (3) business days regarding the ability to accept the received referral. 12. Upon acceptance of a referral, Contractor will offer an initial appointment within seven (7) days of receiving the referral. The first attempt to contact the client will occur within 24 hours of receiving the referral (excluding weekends and holidays). Contractor will document efforts to engage client in referred services. If the client does not respond after three (3) attempts in the first seven (7) days of the referral period, the Contractor will notify the caseworker and the Quality Assurance Team Supervisor (hainleid@weldgov.com, 970-400-6210). 13. 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 1 Schedule, then Contractor understand that the Department will no reimburse for "no shows". Contractor understands that the Department will only reimburse Contractor for up to two (2) "no-shows" on the part of the client per month. After three (3) "no-shows, "Contractor will place client on a behavioral plan requiring attendance or discharged client from services. Contractor must inform the caseworker and the Quality Assurance Team Supervisor (hainlejd@weldgov.com, 970-400-6210). 14. 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. 15. 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. 16. 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. 17. 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. 18. 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. 19. 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. 20. Contractor will notify the Quality Assurance Team Supervisor (hainlejd@weldgov.com, 970-400-6210) of new staff who will manage and/or administer the services with the following information: a. Staff member name and contact information b. Education level/degree (if applicable) c. Licensure/credentials (if applicable) d. Department of Regulatory Authority (DORA) number (if applicable) e. Supervisor name and contact information The Department reserves the right to decline the new staff members managing and/or administering services to Department clients. 2 EXHIBIT D RATE SCHEDULE 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 $110.00/Episode (Supervised Visitation up to 2 hours) $150.00/Episode (Supervised Visitation, minimum of 3 hours) $ .56/Mile (Transportation) 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 Contract Form New Contract Request Entity Information Entity Name* NOCO BEHAVIORAL HEALTH Contract Name* Entity ID* @CC/040014 ❑ New Entity? Contract ID NOCO BEHAVIORAL HEALTH (CHILD PROTECTION 2552 AGREEMENT FOR SERVICES) Contract Status CTB REVIEW Contract Lead CULLINT,A Contract Lead Email cullinta cLr o weld co us Parent Contract ID 20190707 Requires Board Approval YES Department Project # Contract Description* CONSENT_ NEW AGREEEMENT FOR SERVICES. FUNDING CORE/OTHER TERM 06/01/19 05/3=1/20. Contract Description 2 BID NO. B190002.5 Contract Type* AGREEMENT Amount .* S0 00 Renewable* YES Automatic Renewal Grant IGA Department HUMAN SERVICES Department Email C M- Hum3nSerericesaweldgo corn Department Head Email Clv1-HumanSer. ices- DectHeadEa v4dgo. corn County Attorney GENERAL COUNTY ATTORNEY EMAIL County Attorney Email CM- OOUNTYA I € ORNEY&A'ELD GOV COM Requested BOCC Agenda Date* 05/C6/2019 Due Date 0D/02'201' Will a work session with BOCC be required?* NO Does Contract require Purchasing Dept. to be included? If this is a renewal enter previous Contract ID If this is part of a MSA enter MSA Contract ID Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts are not in On Base Contract Dates Effective Date Review Date* 04/D1/2020 Termination Notice Period Committed Delivery Date Renewal Date* 061O1/2020 Expiration Date Contact Information Contact Info Contact Name Purchasing Purchasing Approver CONSENT Approval Process Department Head JUDY GRI EGO ON Approved Date 06/19/2019 Final Approval BOCC Approved YES BOCC Signed Date 06/24/2019 BOCC Agenda Date 1)624/2019 Originator CULLINTA. Contact Type Contact Email finance Approver CONSENT Contact Phone 1 Purchasing Approved Date 05/19,(2019 Finance Approved Date 06/19/2019 Tyler Ref # 2019-2375 Legal Counsel CONSENT Legal Counsel Approved Date 06/19/2019 e2 Submit Hello