HomeMy WebLinkAbout20180099.tiffRESOLUTION
RE: APPROVE AGREEMENT FOR CHILD PROTECTION SERVICES AND AUTHORIZE
CHAIR TO SIGN - RENEW THERAPY CENTER
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with an Agreement for Child Protection
Services between the County of Weld, State of Colorado, by and through the Board of County
Commissioners of Weld County, on behalf of the Department of Human Services, and Renew
Therapy Center, commencing December 1, 2017, and ending May 31, 2018, with further terms
and conditions being as stated in said agreement, and
WHEREAS, after review, the Board deems it advisable to approve said agreement, a copy
of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld
County, Colorado, that the Agreement for Child Protection Services between the County of Weld,
State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf
of the Department of Human Services, and Renew Therapy Center be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said agreement.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 8th day of January, A.D., 2018, nunc pro tunc December 1, 2017.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST: d„Qtehv ) •. 2 O A
Weld County Clerk to the Board
BY:
Deputy Cle
APP :e ED
County Attorney
Date of signature: //
Steve Moreno, C 1a'r
arbara Kirkmey
c _
Sean P. Conway
EXCUSED
Julie A. Cozad
Mike Freeman
or -2q-
2018-0099
HR0089
LciA,Vo\cit (b4 )614
PRIVILEGED AND CONFIDENTIAL
MEMORANDUM
DATE: December 5, 2017
TO: Board of County Commissioners — Pass -Around
FR: Judy A. Griego, Director, Human Services
RE: Weld County Department of Human Services'
Child Protection Agreement for Services with Renew
Therapy Center
Please review and indicate if you would like a work session prior to placing this item on the Board's
agenda.
Request Board Approval of the Departments' Child Protection Agreement for Services with Renew
Therapy Center. The major provisions of the Agreement are as follows:
No.
Term
Service/Funding
Rate
1
December 1, 2017-
May 31, 2018
Neurofeedback
Core
$125.00/Episode (LENS Brain Map. 90 -
minute Department -approved Staffing.)
$60.00/Episode (LENS Treatment Session)
$80.00/Episode (50 -Minute Department -approved
Staffing)
I do not recommend a Work Session. I recommend approval of the Agreement.
Sean P. Conway
Julie A. Cozad, Chair
Mike Freeman
Barbara Kirkmeyer
Steve Moreno, Pro -Tern
Approve
Recommendation Work Session
Schedule
Other/Comments:
2018-0099
Pass -Around Memorandum; December 5, 2017 — ID 1574 Page 1
CHILD PROTECTION AGREEMENT FOR SERVICES
BETWEEN THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES
AND RENEW THERAPY CENTER
This Agreement, made and entered into the( day of 20 Eby and between the Board of Weld
County Commissioners, on behalf of the Weld County Departme t of Human Services, hereinafter referred to as
the "Department' and Renew Therapy Center, hereinafter referred to as the "Contractor".
The parties to this Agreement understand and agree that the provisions of this Agreement specifically
include the following documents: Exhibit A, Contractor's Proposal, Exhibit B, Scope of Services, and Exhibit C,
Payment Schedule. Each of these documents is attached hereto and incorporated herein by this reference.
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 funding to the
Department for Neurofeedback Services.
NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as follows:
1. Term
This agreement shall become effective on December 1, 2017, upon proper execution of this Agreement
and shall expire May 31, 2018, 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 A, 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 Department's Resource Manager, Child Welfare Contract and Services Coordinator, or
through a Team Decision Making (TDM) meeting or Family Team Meeting (FTM). No other
Department staff or other party to the case may authorize services or modifications to services.
c. Contractor agrees to submit an itemized complete billing statement by the 7th of the month,
following the month of service, utilizing billing forms required by the Department.
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d. Contractor agrees to submit a monthly report with the billing statement by the 7th of the month
following the month of service for each client receiving ongoing services. One-time services will be
verified through receipt of the completed product (ex. psychological evaluation, substance abuse
evaluation). Verification of Monitored Sobriety Services will be the test result.
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.
Monthly reports will be submitted through the Department's online reporting system, unless
otherwise directed or agreed to by the Department.
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.
b. Payment shall be made in accordance with Exhibit A, Scope of Services, and Exhibit B, Payment
Schedule, attached hereto and incorporated herein by reference, so long as services are rendered
satisfactorily and in accordance with the Agreement.
c. Payment pursuant to this Agreement, whether in whole or in part, is subject to, and contingent
upon, the continuing availability of said funds for the purposes hereof.
d. The Department may withhold reimbursement if Contractor has failed to comply with any part of
the Agreement, including the Financial Management requirements, program objectives, contractual
terms, or reporting requirements. In the event of forfeiture of reimbursement, Contractor may
appeal such circumstance in writing to the Director of Human Services. The decision of the Director
of Human Services shall be final.
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 A, Scope of Services, and Exhibit B, Payment 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 ACH Form for Colorado Providers, which will be
provided by the Department. Contractor is solely responsible to submit the ACH Form to the State of
Colorado per the directions on the form. Failure to complete and submit this form in a timely and
accurate manner may result in a delay of payment.
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c. Contractor agrees to accept payment through county warrant when funding source does not
allow for direct deposit.
7. Compliance with Applicable Laws
a. At all times during the performance of this Agreement, Contractor will strictly adhere to all
applicable Federal and State laws, order, and applicable standards, regulations, interpretations
and/or guidelines issued pursuant thereto. This includes protection of the confidentiality of all
applicant/recipient records, papers, documents, tapes and any other materials that have been or may
hereafter be established which relate to the Agreement. Contractor shall abide by all applicable laws
and regulations, including, but not limited to the following:
- Title VI of the Civil Rights Act of 1964, 42 U.S.C. Sections 2000d-1 Title VI of the Civil
Rights Act of 1964, 42 U.S.C. Sections 2000d-1 et. seq. and its implementing regulation, 45
C.F.R. Part 80 et. seq.; and
- all provisions of the Civil Rights Act of 1986 so that no person shall, on the grounds of
race, creed, color, sex, or national origin, be excluded from participation in, be denied the
benefits of, or be otherwise subjected to discrimination under the approved Agreement.
- Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. Section 794, and its
implementing regulations, 45 C.F.R. Part 84; and
- the Age Discrimination Act of 1975, 42 U.S.C. Section 6101 et. seq. and its
implementation regulations, 45 C.F.R. Part 91; and
- Title VII of the Civil Rights Act of 1964; and
- the Age Discrimination in Employment Act of 1967; and
- the Equal Pay Act of 1963; and
- the Education Amendments of 1972; and
- Immigration Reform and Control Act of 1986, P.L. 99-603, 42 C.F.R. Part 2; and
- 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.
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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 Core Services.
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. Contract Professional certifies, warrants, and
agrees that it does not knowingly employ or contract with an illegal alien who will perform work under
this contract. Contract Professional 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). Contract Professional 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 Contract Professional that the subcontractor shall not knowingly employ or contract with an illegal
alien to perform work under this Agreement. Contract Professional 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 Contract Professional obtains actual knowledge that a
subcontractor performing work under the public contract for services knowingly employs or contracts
with an illegal alien Contract Professional shall notify the subcontractor and County within three (3)
days that Contract Professional 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. Contract Professional 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. Contract
Professional 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 Contract
Professional participates in the State of Colorado program, Contract Professional shall, within twenty
days after hiring a new employee to perform work under the contract, affirm that Contract Professional
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. Contract Professional shall deliver
to County, 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 Contract
Professional fails to comply with any requirement of this provision or of C.R.S. §8-17.5-101 et seq.,
County, may terminate this Agreement for breach, and if so terminated, Contract Professional 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
Contract Professional receives federal or state funds under the contract, Contract Professional 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 Contract Professional operates as a sole proprietor, it hereby swears
or affirms under penalty of perjury that it: (a) is a citizen of the United States or is otherwise lawfully
present in the United States pursuant to federal law, (b) shall produce one of the forms of
identification required by C.R.S. § 24-76.5-101, et seq., and (c) shall produce one of the forms of
identification required by C.R.S. § 24-76.5-103 prior to the effective date of the contract.
8. Compliance with Child and Family Services Review
The Child and Family Services Review (CFSR) examines child welfare service outcomes in three areas;
Safety, Permanency and Well Being of families. For each outcome, data and performance indicators
measure each state's performance according to national standards and monitor progress over time.
Following the review, a Program Improvement Plan (PIP) will be implemented for the state to enhance
services to families.
Contractor agrees to continually strive for positive outcomes in the areas of Safety, Permanency and Well
Being. Contractor will ensure that any employee or subcontractor of Contractor providing services under
this Agreement will work towards positive outcomes in the aforementioned three areas as outlined under
the Child and Family Services Review (CFSR), and will address the aforementioned three areas when
completing monthly reports as required by Paragraph 3(d) of this Agreement.
9. Insurance Requirements
Contractor and Department agree that Weld County, the Board of County Commissioners of Weld County,
its officers and employees, shall not be held liable for injuries or damages caused by any negligent acts or
omissions of the Contractor, it subcontractor, or their employees, volunteers, or agents while performing
duties described in this Agreement. Contractor shall indemnify, defend and hold harmless Weld County,
the Board of County Commissioners of Weld County, its employees, volunteers and agents.
Contractor shall provide the liability insurances (including professional liability insurances where
necessary) and worker's compensation insurances for all its employees, volunteers, and agents engaged
in the performance of this Agreement which are required under Weld County's Request for Proposal, and
required by the Colorado Worker's Compensation Act. Contractor shall provide the Department with the
acceptable evidence that such coverage is in effect within seven (7) days of the date of this Agreement.
At a minimum, Contractor shall procure, either personally or through its employer as applicable to the
Contractor's business, at its own expense, and maintain for the duration of the work, the following
insurance coverage. Weld County, State of Colorado, by and through the Board of County Commissioners
of Weld County, its employees and agents, shall be named as additional named insured on the insurance,
where permissible the insurance provider.
a. General Requirements: Contractors/Contract Professionals 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/Contract
Professionals 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
5
"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, County must be notified by the Contractor/Contract
Professional. Contractor/Contract Professional shall be responsible for the payment of any
deductible or self -insured retention. County reserves the right to require Contractor/Contract
Professional to provide a bond, at no cost to County, 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/Contract Professional. Contractor/Contract Professional 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/Contract Professional 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 Contract Professional's employees acting within
the course and scope of their employment. If Contractor is an Independent Contractor,
as defined by the Colorado Worker's Compensation Act, this requirement shall not apply.
Contractor must submit to the Department a Declaration of Independent Contractor
Status Form prior to the start of this agreement.
ii.Commercial General Liability Insurance written on ISO occurrence form CG 00 01 10/93
or equivalent, covering premises operations, fire damage, independent Contractors,
products and completed operations, blanket contractual liability, personal injury, and
advertising liability with minimum limits as follows:
- $1,000,000 each occurrence;
- $2,000,000 general aggregate;
- $50,000 any one fire; and
- $500,000 errors and omissions.
iii.Automobile Liability: Contractor/Contract Professional 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 reduce by twenty-five percent (25%) or more
by paid or reserved claims, Contractor shall notify County 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 County.
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 County, whichever is earlier.
c. Contractors/Contract Professionals 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/Contract Professional shall provide a copy of this
information to its insurance agent or broker, and shall have its agent or broker provide proof of
Contractor/Contract Professional's required insurance. County reserves the right to require
Contractor/Contract Professional 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/Contract Professional's insurer shall name County as
an additional insured as follows
f. Waiver of Subrogation: For all coverages, Contractor/Contract Professional's insurer
shall waive subrogation rights against County.
g. Subcontractors: All subcontractors, 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/Contract Professional. Contractor/Contract Professional 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/Contract Professional agrees to provide proof of insurance for all such subcontractors,
independent contractors, sub -vendors suppliers or other entities upon request by the County.
A provider of Professional Services (as defined in the Bid or RFP) shall provide the following
coverage:
Professional Liability: Contract Professional 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 that the request of the Department specific to services
provided under this Agreement. The Department will not compensate the Contractor for said training in
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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 970-352-1551, x6503, 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 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. As the
monitoring agency may in its sole discretion deem necessary or appropriate, such program data, special
analyses, on -site checking, formal audit examinations, or any other reasonable procedures. 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.
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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, Administrator Deanne Helmboldt, MA, LMFT
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) 352-1551
18. Litigation
For Contractor:
Deanne Helmboldt, MA, LMFT
1703 61ST Avenue, Suite 103
Greeley, CO 80634
(970) 302-7448
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 18. 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.
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21. Governmental Immunity
No term or condition of this contract shall be construed or interpreted as a waiver, express or implied, of
any of the immunities, rights, benefits, protections or other provisions, of the Colorado Governmental
Immunity Act of §§24-10-101 et. seq., as applicable now or hereafter amended.
22. Partial Invalidity of Agreement
If any section, subsection, paragraph, sentence, clause, or phrase of this Agreement is for any reason held
or decided to be unconstitutional, such decision shall not affect the validity of the remaining portions.
The parties hereto declare that they would have entered into this Agreement and each and every section,
subsection, paragraph, sentence, clause, and phrase thereof irrespective of the fact that any one or more
sections, subsections, paragraphs, sentences, clauses, or phrases might be declared to be unconstitutional
or invalid.
23. Improprieties/Conflict of Interest
No officer, member or employee of Weld County and no member of their governing bodies shall have any
pecuniary interest, direct or indirect, in the approved Agreement or the proceeds thereof.
The Appearance of Conflict of Interest applies to the relationship of a Contractor with the Department
when the Contractor also maintains a relationship with a third party and the two relationships are in
opposition. In order to create the appearance of a conflict of interest, it is not necessary for the
Contractor to gain from knowledge of these opposing interests. It is only necessary that the Contractor
know that the two relationships are in opposition. During the term of the Agreement, Contractor shall
not enter into any third -party relationship that gives the appearance of creating a conflict of interest.
Upon learning of an existing appearance of a conflict of interest situation, Contractor shall submit to the
Department, a full disclosure statement setting forth the details that create the appearance of a conflict
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.
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
10
Federal and/or State government has begun but is not completed at the end of the seven (7) year period,
or if audit findings have not been resolved after a seven (7) period, the materials shall be retained until
the resolution of the audit finding.
25. Confidentiality of Records
Contractor shall protect the confidentiality of all applicant records and other materials that are
maintained in accordance with this Agreement except for purposes directly connected with the
administration of Child Protection. No information about or obtained from any applicant/recipient in
possession of Contractor shall be disclosed in a form identifiable with the applicant/recipient or a minor's
parent or guardian unless in accordance with the Contractor's written policy governing access to,
duplication and dissemination of, all such information, in any form, including social networks. Contractor
shall advise its employees, agents, and subcontractor, if any, that they are subject to these confidentiality
requirements.
Contractor shall provide its employees, agents, and subcontractors, if any, with a copy or written
explanation of these confidentiality requirements before access to confidential data is permitted.
Contractor shall have its employees, agents, and subcontractors, if any, sign a written confidentiality
agreement and shall provide a copy of such agreement to the Department, if requested.
26. Proprietary Information
Proprietary information for the purposes of this Agreement is information relating to a party's research,
development, trade secrets, business affairs, internal operations and management procedures and those
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
Contract Professional agrees that it is an independent Contract Professional and that Contract
Professional'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. Contract Professional shall
perform its duties hereunder as an independent Contract Professional. Contract Professional shall be
solely responsible for its acts and those of its agents and employees for all acts performed pursuant to
this Agreement. Contract Professional, 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 Contract Professional or any of its agents or employees. Unemployment
insurance benefits will be available to Contract Professional and its employees and agents only if such
coverage is made available by Contract Professional or a third party. Contract Professional shall pay when
due all applicable employment taxes and income taxes and local head taxes (if applicable) incurred
pursuant to this Agreement. Contract Professional shall not have authorization, express or implied, to
bind County to any agreement, liability or understanding, except as expressly set forth in this Agreement.
Contract Professional 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 provide proof thereof
when requested to do so by County.
11
28. Entire Agreement
This Agreement, together with all attachments hereto, constitutes the entire understanding between the
parties with respect to the subject matter hereof, and may not be changed or modified except as state in
Paragraph 14 herein. This Agreement shall be binding upon the parties hereto, their successors, heirs,
legal representatives, and assigns. The Contractor and the Department may not assign any of its rights or
obligations hereunder without the prior consent of both parties.
29. Agreement Nonexclusive
This Agreement does not guarantee any work nor does it create an exclusive agreement for services.
30. Warranty
The Contractor warrants that services performed under this Agreement will be performed in a manner
consistent with the professional standards governing such services and the provisions of this Agreement.
The Contractor shall faithfully perform the work in accordance with the standards of care, skill, training,
diligence and judgment provided by highly competent individuals and entities that perform services of a
similar nature to those described in this Agreement including Exhibits A, B, C, and D.
31. Acceptance of Services Not a Waiver
Upon completion of the work, the Contractor shall submit to Department originals of all tests and results,
reports, etc., generated during completion of this work. Acceptance by 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 conflict 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
Contract Professional's operations, or authorizes funding to the Contractor.
12
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, Contract Professional agrees that the Weld County District Court shall have exclusive
jurisdiction to resolve said dispute.
35. Subcontractors
Contract Professional acknowledges that County has entered into this Agreement in reliance upon the
particular reputation and expertise of Contract Professional. Contract Professional shall not enter into any
subcontractor agreements for the completion of this project without County's prior written consent, which
may be withheld in County's sole discretion.
36. Attorneys Fees/Legal Costs
In the event of a dispute between County and Contract Professional, 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 Contract Professional under this Agreement or individual work order
shall become or remain (as applicable), the property of County. In addition, all reports, documents, data,
plans, drawings, records and computer files generated by Contract Professional 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 County. Contract Professional shall not make use of such
material for purposes other than in connection with this Agreement without prior written approval of
County.
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.
13
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month, and year first
above written.
COUNTY:
ATTEST: �j,Ad Ci• „_ BOARD OF COUNTY COMMISSIONERS
Weld Co , Clerk to the Boa _J� iC� n� WELD COUNTY, COLORADO
By:
Deputy Clerk the .r• �r(1�L���■eve Moreno, Chair
14
JAN 0S2f
NTRACTOR,
Renew Therapy Center
1703 61n Avenue, Suite 103
Greeley, CO 80634
(970) 302-7448
By:
lea a eirnboldt, MA, LMFT
Date: \ t �"(
ff
EXHIBIT A
CONTRACTOR'S PROPOSAL
Proposal for Provision of Mental Health Services
Deanne Helmboldt, MA, LMFT
1703 61st Avenue, Suite 103
Greeley, CO 80634
97-302-7448
renewtherapv@comcast.net
Degrees and Certifications:
MA Psychology 1991
Licensed Marriage and Family Therapist, State of Colorado 1992 working with individuals, couples and
children with life adjustment issues as well as crisis and trauma.
Certificate —LENS Neurofeedback practitioner January of 2012.
Proposed service for consideration:
Low Energy Neurofeedback System (LENS) is a non invasive treatment which helps the brain to bring
about positive change within its own system, thereby allowing a person to experience change and in
some cases healing of various emotional and physical conditions.
The LENS is not a diagnostic tool nor is it a predictor of change. The power of the LENS is that it allows
the brain to set the course for treatment and build upon its own strength while healing occurs.
Treatment begins with a brain map -21 sites on a person's head are "mapped" meaning that an
electrode, a small metal disk, touches to the skin of the head for 2 seconds. The "impulse" the brain
recognizes is 10,000 times less than a watch battery. There is no electric charge or any type of
detrimental effect from the impulse the electrode emits. Once the electrode touches the head and is
activated by the LENS software the brain responds by sending feedback to the software. When this has
occurred at all 21 sites the software compiles the information the brain has given and creates a brain
map —a 2 dimensional picture of the person's brain at that given time. The brain map will show a graph
with all 21 sites just mapped, and it will show areas of potential trauma. It doesn't matter why the
trauma is there; it can be physical, chemical or emotional; all humans sustain small injuries or levels of
trauma to their brain, the map is showing what the brain is displaying as "visible" that day.
The purpose of the brain map is to know how treatment will be directed. The LENS is non-traditional
Neurofeedback, which means that the brain actually sets the course for itself, rather than a practitioner
arbitrarily deciding due to symptoms what course of treatment the brain should get. Traditional
Neurofeedback is considered braining training, meaning the treatment includes some way that the client
directs their brain to produce an outcome. This is done by the person playing a game, watching a video
or some other activity they are actively involved with and in control of. LENS, being a nontraditional
form of Neurofeedback is considered dis-entrainment. Not only does the practitioner not direct the
course of treatment, the client does not participate in trying to bring about change. Therefore it is a
modality that works well with people of all ages, intellectual and developmental ability. It will work for
someone who is verbal the same as someone who isn't. Change will occur for a person who is
cooperative and inviting the treatment, as well as those who are not capable of that.
A brain map takes approximately 30-50 minutes depending on the client. The time frame of mapping
varies only by the ability of the person to sit relatively still, as well as their sensitivity, reactivity or
hardiness in regards to the treatment. This will be determined both by pre-treatment questionnaire as
well as carefully watching the person's body and reactions during the map. Some people's level of
sensitivity or reactivity could create a need to split a map into several sessions depending on the need of
the individual person. It is not a "positive" or "negative" if someone is able to be mapped in one sitting,
or several, it's simply the reality of that person's brain.
The brain map provides a graph showing the neuron sites that were mapped, they will be in a specific
order according to the brains feedback (it will always be a different order than I mapped them). This will
be the guide for the next sessions.
Subsequent treatments will be the same protocol as the map —the client will sit in a chair with a clip and
ground wire on each ear; the electrode will then be touched to the skin of the head on up to 7 sites,
following the order the brain has given during the mapping. Each site takes approximately 2 seconds.
The treatments are very quick, a typical treatment for an adult will be 5-8 minutes, and for a child it
might take a few moments longer only due to their tendency to be a bit wigglier in the chair. I schedule
20 minutes for a regular, non -map, session but the actual treatment is only minutes. I make myself
available to parents via phone or email between sessions if needed for updates so the child doesn't have
to sit through discussion of what their parent is noticing in them between sessions.
Treatment continues weekly, doing up to 7 sites at a time; going through the 21 sites from the brain
map twice —for approximately 6 sessions then a second brain map is done. For some clients more
sessions may be needed due to treating less than the standard 7 sites —this can only be determined as
they are treated, again due to sensitivity, reactivity or hardiness factors. Number of sessions are also
determined according to the persons goal, and/or experienced change.
A LENS treatment is non-invasive, it produces no pain, nor can it create symptoms that didn't already
exist. Because it is not a diagnostic or directive (training) method the only responsibility of the client is
to pay attention to their self emotionally and physically between treatments. It is not untypical for
someone to notice that emotional triggers are no longer as acute; some have a sense of having a greater
capacity to cope with or move beyond things that previously kept them stuck. There will also often be
improvements in areas that weren't the goals of treatment, things the person wouldn't have thought to
expect. Every person is different and it's never predictable what improvements they will experience.
I have worked with clients with "simple" maladies such as sleep issues, stress or memory problems, as
well as those with more involved difficulties such as dementia, developmental delays, Autism as well as
emotional trauma in adopted children that they can't verbally or intellectually identify. In my opinion
the beauty of this treatment is that a person doesn't have to voice their feelings or emotional condition,
they don't have to relive trauma or explain it in any way if they don't want to. It is the brain bringing
about change in its own system as it is created to do.
To date the youngest person I've treated is 3 years old, the oldest in their 70's. I have seen
improvement in people who had spent many sessions with other types of treatment respond and be
able to move on more quickly emotionally and developmentally.
Rate Schedule:
LENS Map $125.00
LENS Treatment $60.00
I am not a Medicaid provider.
Availability:
I schedule clients according to availability and will typically be able to book a time within a week of a call
to schedule.
EXHIBIT B
SCOPE OF SERVICE
1. Contractor will provide Neurofeedback services to children, youth and adults, as referred by the
Department.
2. Contractor utilizes the LENS (Low Energy Neurofeedback System), a non-invasive treatment which helps
the brain bring about positive change within its own system. The LENS is not a diagnostic took nor a
predictor of change.
3. All services under this agreement will be provided by the Deanne Helmboldt, M.A., LMFT, and will occur at
1703 61st Avenue, Suite 103, in Greeley, Colorado.
4. Services to be provided under this agreement include:
a. A pre-treatment questionnaire.
b. An initial brain map to identify areas of potential trauma and assist in directing treatment. A
brain map can occur over one or multiple sessions depending on the needs of the client.
c. Approximately six (6) LENS treatment sessions following the initial brain map. Each session will
include up to seven (7) sites.
d. A subsequent brain map to assess progress and potential need for additional LENS treatment
sessions.
5. Contractor will make at least three (3) attempts to contact the client and set up services. The
first attempt will occur within 24 hours of receiving the referral (excluding weekends and
holidays). Contractor will document efforts to engage client in referred services. If after three
(3) attempts the client does not respond the Contractor will notify the caseworker and the
Child Welfare Contract and Services Coordinator immediately.
6. 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.
7. 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.
8. 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 (FIDOS), unless
otherwise directed by the Department.
9. 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 serviceontheinitial authorized referral form.Thismayincludean increase ordecrease in
services hours, change in frequency, change in location of services, transportation needs, or any change to
EXHIBIT C
PAYMENT SCHEDULE
1. Funding and Method of Payment
The Department agrees to reimburse the Contractor in consideration of the work and services performed
under this Agreement at the rate specified 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, 2018.
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
$125.00/Episode (LENS Brain Map. 90 -minute Department -approved Staffing.)
$60.00/Episode (LENS Treatment Session)
$80.00/Episode (50 -Minute Department -approved Staffing)
Contractor may not attempt to collect co -pays and/or fees for services for which a Department client is
responsible, but which a particular client refuses or fails to pay.
Contractor will collect any applicable sliding scale co -pays and credit the Department for any payment
received on the monthly billing.
3. Submittal of Vouchers
Contractor shall prepare and submit monthly an itemized voucher, and signed monthly report if
applicable, certifying that services authorized were provided on the date(s) indicated and the charges
made were pursuant to the terms and conditions of Paragraph 3 and Exhibit A.
Contractor shall submit all monthly billings and applicable reports to the Department by the 7th day of the
month following the month the cost was incurred. Failure to submit by the aforementioned deadline may
result in forfeiture of payment.
a. 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.
b. For one-time services, proof of services rendered shall be receipt of the completed product.
c. For Monitored Sobriety services, proof of services rendered shall be the test result.
1
Certificate of Insurance (Proof of Coverage) Date Issued: 12/04/2017
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.
THIS CERTIFICATE DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
Insured Name and Mailing Address*
Program Administrator
Deanne Helmboldt
2150 Montauk Lane Unit 2
Windsor, CO 80550
.
Administered By:
CPH and Associates
711 S. Dearborn, Suite 205
Chicago, IL 60605
P. 312-987-9823 F. M2-987-0902
jgfo(u cphins.eonl
*Additional insured locations are often requested by individual business owners who have more than
one office. Your coverage is portable, meaning that you are covered at any location for practice under
the occupation(s) listed on your policy.
Underwritten By:
Philadelphia Indemnity Insurance
Company
Coverage
Policy #: AR38933 [Effective Date: 09/15/2017 !Expiration Date: 09/15/2018
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 BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Limits of Liability
Coverage Part
EACH OCCURRENCE
(Per individual claim)
AGGREGATE
(Total amount per policy year)
$1,000,000
$3,000,000
Professional Liability
$1,000,000
$3,000,000
Commercial General Liability
Includes: General Liability, Fire & Water Legal Liability
and Personal Liability
$15,000
$15,000
Property Coverage
$1,000,000
$3,000,000
Supplemental Liability
Unlimited
Unlimited
Defense Expense Coverage
$35,000
$35,000
State Licensing Board Investigation Defense Coverage
$15,000
$15,000
Assault Coverage
810,000
835,000
_
Deposition Expense Benefit
$5,000/person
$50,000
Medical Expense Coverage
$15,000
T.. -.....tea.
$15,000
First Aid Coverage
v..oa. y...........yaa.w. a
General Liability Insured Location(s):
1703 6I st Avenue Suite 103 Greeley. CO 80364
Certificate Holder
DIeCL
Cancellation
Weld County
1150 'O' Street
Greeley, CO 80631
Should any of the above described policies be cancelled before the expiration date thereof,
notice will be delivered in accordance with the policy provisions.
Holder has also been added to the policy as an additional insured:**
[ X Yes/No ]
**If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be
endorsed. A statement on this certificate does not confer rights to the certificate holder
in lieu of such endorsement(s).
Pa y
p�'
Authorized Representative
C. Philip Hodson
AIMER.The Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and
the certificate holder, nor does it affirmatively or negatively amend, extend, or alter the coverage afforded by the policies listed thereon.
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