HomeMy WebLinkAbout20161936.tiff/j) �9c
CONTRACT AGREEMENT AMENDMENT
BETWEEN
THE WELD COUNTY DEPARTMENT OF HUMAN SERVICES
AND MILESTONES COUNSELING SERVICES, LLC (NON -CORE)
This Agreement Amendment, made and entered into day 016, by and between
the Board of Weld County Commissioners, on behalf of the Weld Co ty Department of Human
Services, hereinafter referred to as the "Department", and Milestones Counseling Services, LLC.,
hereinafter referred to as the "Contractor".
WHEREAS the parties entered into an Agreement for Relinquishment Counseling (the "Original
Agreement") identified by the Weld County Clerk to the Board of County Commissioners as document
No. 2014-2816, approved on September 15, 2014.
WHEREAS the parties hereby agree to amend the term of the Original Agreement in
accordance with the terms of the Original Agreement, which is incorporated by reference herein, as
well as the terms provided herein.
NOW THEREFORE, in consideration of the premises, the parties hereto covenant and agree as
follows:
• The Original Agreement ended on May 31, 2015.
• The Original Agreement was renewed for the term of June 1, 2015 -May 31, 2016. The
Agreement Amendment is identified by the Weld County Clerk to the Board of County
Commissioners as document No. 2015-1611, approved on June 1, 2015.
• The Amendment, together with the Original Agreement, constitutes the entire
understanding between the parties. The following change is hereby made to the Contract
Documents:
Term
This agreement shall become effective on June 1, 2014, upon proper execution of this
Agreement and shall expire May 31, 2017, unless sooner terminated as provided herein.
2. None
• All other terms and conditions of the Original Agreement remain unchanged.
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2016-1936
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the day, month,
and year first above written.
COUNTY:
ATTEST: dirAgA) iK,
Weld ntyClerk tothe B.ard
By:
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
MSc
Deputy CI rk to the Bo;(7) Mike Freeman, Chair
CONTRACTOR:
JUN 2 2 2086
Milestones Counseling Services, LLC
832 West Eisenhower Boulevard, Suite C
Loveland, Colorado 80537
(970) 403-7656
By:
Date:
a401),,z,A
Addie Campbell, MA, LPC - Owner
oLo/4v-✓431,
HEALTHCARE PROVIDERS SERVICE •J:IPSO
CNA ORGANIZATION PURCHASING GROUP
Certificate .of Jitlqurance Healthcare Pti,vidersService l)rtanitatich-
OCCURENCE POLICY FORM Print Date: 9/08/2015
Producer Branch Prefix
018098 970 HPG
Named Insured and Address:
Adelaide Campbell
904 49th Avenue Ct
Greeley, CO 80634-1912
Medical Specialty:
Licensed Professional Counselor
Excludes Cosmetic Procedures
Policy Number
0299197210
Policy Period
from 09/14/15 to 09/14/16 at 12:01 AM Standard Time
Program Administered by:
Healthcare Providers Service Organization
159 E. County Line Road
Hatboro, PA 19040-1218
1-800-982-9491
www. hpso.com
Code: Insurance is provided by:
80723
American Casualty Company of Reading, Pennsylvania
333 S. Wabash Avenue, Chicago, IL 60604
Professional Liability $1,000,000 each claim
Your professional liability limits shown above include the following:
* Good Samaritan Liability * Malplacement Liability * Personal Injury Liability
* Sexual Misconduct Included in the PL limit shown above subject to $ 25,000 aggregate sublimit
Coverage Extensions
License Protection
Defendant Expense Benefit
Deposition Representation
Assault
Includes Workplace Violence Counseling
Medical Payments
First Aid
Damage to Property of Others
Information Privacy (HIPAA) Fines and Penalties
General Liability
General Liability
Fire & Water Legal Liability
Personal Liability
Total: $ 317.00
$ 25,000
$ 1,000
$ 10,000
$ 25,000
$ 25,000
$ 10,000
$ 10,000
$ 25,000
per proceeding
per day limit
per deposition
per incident
per person
per incident
per incident
per incident
$ 5,000,000 aggregate
$ 25,000
$ 25,000
$ 10,000
$ 25,000
$ 100,000
$ 10,000
$ 10,000
$ 25,000
aggregate
aggregate
aggregate
aggregate
aggregate
aggregate
aggregate
aggregate
$1,000,000 each claim / $1,000,000 aggregate
Included in the GL limit shown above subject to $250,000 aggregate sublimit
$1,000,000 aggregate
Base Premium $317.00
Premium reflects Self Employed , Part Time
Policy Forms & Endorsements(Please see attached list for a general description of many common policy forms and
endorsements.)
G -121500-D
GSL15565
CNA81753
G -121501-C
GSL17101
CNA81758
gur...4•40r.
Chairman of the Board
G -141241-B (03/2010)
G -145184-A
GSL13424
G -121487-B
G -147292-A
CNA80051
G -121504-C
Secretary
Coverage Change Date:
GSL15563
CNA80052
CNA79575
GSL15564
G -123846-005
Keep this document in a safe place. it
and proof of payment are your proof of
coverage. There is no coverage in force
unless the premium is paid in full.ln order
to activate your coverage, please remit
premium in full by the effective date of
this Certificate of Insurance.
Master Policy # 188711433
Endorsement Change Date:
POLICY FORMS & ENDORSEMENTS
The list below contains general descriptions of the policy forms and endorsements that may or may not apply to your
professional liability insurance policy. Please refer to your Certificate of Insurance for the policy forms &
endorsements specific to your state and your policy period. Coverages, rates and limits may differ or may not be
available in all states. All products and services are subject to change without notice.
Think Green —expanded definitions and copies of these policy forms and endorsements are available online at
www.hpso.com/policyforms
COMMON POLICY FORMS& ENDORSEMENTS
FORM # DESCRIPTION
G -121500-D
G -121501-C
G -145184-A
G -147292-A
GSL15563
GSL15564
GSL15565
GSL17101
GSL13424
CNA80051
CNA80052
G -123846-005
CNA81753
CNA81758
CNA79575
Common Policy Conditions
Occurrence Policy Form
Policyholder Notice - OFAC Compliance Notice
Policyholder Notice - Silica, Mold & Asbestos Disclosure
Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs
Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion
Healthcare Providers Professional Liability Assault Coverage
Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies
Services to Animals
Amended Definition of Personal Injury Endorsement
Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement
Colorado Cancellation and Non -Renewal
Coverage & Cap on Losses from Certified Acts Terrorism
Notice - Offer of Terrorism Coverage & Disclosure of Premium
Exclusion of Cosmetic Procedures
OPTIONAL ENDORSEMENTS
FORM #
G -121487-B
G -121504-C
CNA79575
DESCRIPTION
Amendment to Certificate
General Liability Form
Exclusion of Cosmetic Procedures
PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC
TO YOUR STATE AND YOUR POLICY PERIOD.
For NJ residents:
For KY residents:
For WV residents:
For FL residents:
The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance
Guaranty Association.
The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement
Foundation Program Fund and the KY LGPT is the KY Local Government Premium Tax which
includes charges at a municipality and/or county level.
The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge.
The FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association
- 2012 Regular Assessment.
Form#:G-141241-B (03/2010)
Named Insured:Adelaida Campbell
Master Policy#: 188711433 Policy#: 0299197210
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