HomeMy WebLinkAbout20152474.tiff RESOLUTION
RE: APPROVE AGREEMENT FOR PROFESSIONAL SERVICES AND AUTHORIZE CHAIR
TO SIGN - LIFE'S HOPE THERAPEUTIC SERVICES
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 Professional 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 Life's Hope
Therapeutic Services, commencing June 1, 2015, and ending May 31, 2016, 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 Professional 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 Life's Hope Therapeutic Services, 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 29th day of July, A.D., 2015, nunc pro tunc June 1, 2015.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST:vdt 11J v• jC,GLD; ���'c�'
arbara t meye , Chair
Weld County Clerk to the Board
Pr(k4(-144.12,----
• Tc. ike Freeman, Pro-Tem
BY: 4°.0
uty Clerk to th Board SED
ea P. Conway
AP OV RM:
e A. Cozad
Aft-
ou Attorney
8// Steve Moreno
Date of signature:
C C .f J; -I&r.. 34? 2015-2474
HR0086
etratact Ib 4g
MEMORANDUM
DATE: July 13,2015
et,_,
A TO Board of County Commissioners—Pass-Around
tp L.P r
FR: Judy A.Griego, Director, Human Services
RE: Weld County Department of Human Services' Agreement for
Professional Services with Life's Hope Therapeutic Services
Please review and indicate if you would like a work session prior to placing this item on the
Board's agenda.
Request Board Approval for the Agreement for Professional Services with Life's Hope
Therapeutic Services.The major provisions are as follows:
Term Service/Funding Rates
June 1,2015,through and until l...ife Skills or Mental $50.00/Hour(Therapeutic
May 31,2016 Flealth Services Visitation/Licensed Counselor)
Core/Medicaid $75.00/Hour
(Family Therapy, EMDR)
$65.00/I lour(Individual
Therapy)
$40.00/Hour(Court
Facilitation/Court
Staffing/Family Team
Meetings/Team Decision Making
Meetings)per unit of service for
a maximum amount of$2,000.00
(Maximum reimbursement of all
services authorized and provided:
I do not recommend a Work Session. I recommend approval of this Agreement.
Approve Re L.4.10.1
C W rk ssio
Sean Conway
Steve Moreno
Barbara Kirkmeyer
Mike Freeman
Julie Cozad
Pass-Around Memorandum;July 13,2015 Page 1
2015-2474
AGREEMENT FOR PROFESSIONAL SERVICES
THIS AGREEMENT is made by and between the County of Weld, State of Colorado,
whose address is 1150 O Street, Greeley, Colorado, 80631 ("County"),by and through the
Board of County Commissioners of the County of Weld, on behalf of the Weld County
Department of Human Services, and Life's Hope Therapeutic Services whose address is 9975
Wadsworth Parkway,Unit K2, PMB 427,Westminster, Colorado 80021, ("Contractor").
WHEREAS, County desires to retain Contractor as an independent contractor to perform
services as more particularly set forth below; and
WHEREAS,Contractor has the time available to timely perform the services, and is
willing to perform the services according to the terms of this Agreement.
NOW THEREFORE,in consideration of the mutual promises and covenants contained
herein,the parties hereto agree as follows:
1. Engagement of Contractor. County hereby retains Contractor, and Contractor
hereby accepts engagement by County upon the terms and conditions set forth in this Agreement.
2. Term. The term of this Agreement shall be from June 1 2015,through and until
May 31, 2016.
3. Services to be Performed. Contractor agrees to perform the Services listed or
referred to in Exhibit A,attached hereto and incorporated herein.
4. Compensation.
a. County agrees to pay Contractor for services performed as set forth on
Exhibit A at the rate of$50.00/Hour(Therapeutic Visitation/Licensed Counselor),
$75.00/Hour(Family Therapy,EMDR), $65.00/Hour(Indivdual Therapy), $40.00/Hour
(Court Facilitation/Court Staffing/Family Team Meetings/Team Decision Making
Meetings). Charges shall be based on the time actually spent performing the services,but
shall exclude travel time.
b. Mileage may i a no' (circle one)be charged to and from any required
job site at a rate of 0.00 cents per mile. Contractor shall not be paid any other expenses
unless set forth in this Agreement.
c. Payment to Contractor will be made only upon presentation of a proper
claim by Contractor, itemizing services performed and mileage expense incurred.
d. Payment for services and all related expenses under this Agreement shall
not exceed$2,000.00.
1
5. Additional Work. In the event the County shall require changes in the scope,
character, or complexity of the work to be performed, and said changes cause an increase or
decrease in the time required or the costs to the Contractor for performance, an equitable
adjustment in fees and completion time shall be negotiated between the parties and this
Agreement shall be modified accordingly by a supplemental Agreement. Any claims by the
Contractor for adjustment hereunder must be made in writing prior to performance of any work
covered in the anticipated supplemental Agreement. Any change in work made without such
prior supplemental Agreement shall be deemed covered in the compensation and time provisions
of this Agreement.
6. Independent Contractor. Contractor agrees that Contractor is an independent
contractor and that neither Contractor nor Contractor's agents or employees are, or shall be
deemed to be, agents or employees of the County for any purpose. Contractor shall have no
authorization, express or implied,to bind the County to any agreement, liability, or
understanding. The parties agree that Contractor will not become an employee of County,nor is
Contractor entitled to any employee benefits from County as a result of the execution of this
Agreement.
7. Warranty. 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.
8. Reports County Property. All reports,test results and all other tangible materials
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. Contractor
shall not make use of such material for purposes other than in connection with this Agreement
without prior written approval of County.
9. Acceptance of Product not a Waiver. Upon completion of the work, Contractor
shall submit to County originals of all test results,reports, etc., generated during completion of
this work. Acceptance by County of reports and incidental material furnished under this
Agreement shall not in any way relieve Contractor of responsibility for the quality and accuracy
of the work. Acceptance by the County of, or payment for, any services performed under this
Agreement shall not be construed as a waiver of any of the County's rights under this Agreement
or under the law generally.
10. Insurance and Indemnification. Contractor shall defend and indemnify County, its
officers and agents, from and against loss or liability arising from Contractor's acts, errors or
omissions in seeking to perform its obligations under this Agreement. Contractor shall provide
necessary workers' compensation insurance at Contractor's own cost and expense.
11. Termination. Either party may terminate this Agreement at any time by providing
the other party with a 10 day written notice thereof. Furthermore,this Agreement may be
2
terminated at any time without notice upon a material breach of the terms of the Agreement. In
the event of an early termination, Contractor shall be paid for work performed up to the time of
notice and County shall be entitled the use of all material generated pursuant to this Agreement.
12. Non-Assignment. Contractor may not assign or transfer this Agreement, any
interest therein or claim thereunder,without the prior written approval of County.
13. Access to Records. County shall have access to Contractor's financial records as
they relate to this Agreement for purposes of audit. Such records shall be complete and available
for audit 90 days after final payment hereunder and shall be retained and available for audit
purposes for at least five years after final payment hereunder.
14. Time of Essence. Time is of the essence in each and all of the provisions of this
Agreement.
15. 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.
16. Notices. Any notice required to be given under this Agreement shall be in writing
and shall be mailed or delivered to the other party at that party's address as stated above.
17. Compliance. This Agreement and the provision of services hereunder shall be
subject to the laws of Colorado and be in accordance with the policies,procedures,and practices
of County.
18. Non-Exclusive Agreement. This Agreement is nonexclusive and County may
engage or use other contractors or persons to perform services of the same or similar nature.
3
19. Certification. Contractor certifies that Contractor is not an illegal immigrant, and
further, Contractor represents,warrants, and agrees that it has verified that Contractor does not
employ any illegal aliens. If it is discovered that Contractor is an illegal immigrant, employs
illegal aliens or subcontracts with illegal aliens, County can terminate this Agreement and
Contractor may be held liable for damages.
20. Entire A2reement/Modifications. This Agreement contains the entire agreement
between the parties with respect to the subject matter contained in this Agreement. This
instrument supersedes all prior negotiation,representation, and understanding or agreements with
respect to the subject matter contained in this Agreement. This Agreement may be changed or
supplemented only by a written instrument signed by both parties.
21. Funding Contin2encv. No portion of this Agreement shall be deemed to create an
obligation on the part of County to expend funds not otherwise appropriated or budgeted for.
22. No Conflict. No employee of Contractor nor any member of 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 Contractor.
23. Severability. If any term or condition of this Agreement shall be held to be invalid,
illegal, or unenforceable,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.
24. Governmental Immunity. No portion of this Agreement shall be deemed to
constitute a waiver of any immunities the parties or their officers or employees may possess.
25. No Third Party Beneficiary. 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.
4
IN WITNESS WHEREOF, the parties hereto have duly executed the Agreement as of the
day, month,an year first above
wrrittten.
�• `'�+"�';� COMMISSIONERS
ATTEST:. BOARD OF COUNTY CO M .
Weld Co.nty� Clerk to the Board W •L.D COUNTY,C LORADO
I
BI i ALL � .�/:.rli��/� _.,._____
&Eta Kirkmey r,Chair 29Z915
PPROVED A TO ]ND ' 0 C I PPROVED AS TO SUBSTANCE:
���.:.!•.442
JO ." �� irk r•-
Controller '�� � / 1c t d Offic a or De rtment ead
AP t OVE AS TO FORM: �►. ,,I Al A
iS Director of General Services
i .
County Attorney
-' / 7 ,I irr 3i.l1oPE T 1'RAPEd C SE ICES
/ l% J ,,
,� ,Ch /stir urphy PC ",/,--
r
5
•
EXHIBIT "A"
CONTRACTOR:
Name: Life's Hope Therapeutic Services(Trails Provider ID: PENDING)
Address: 9975 Wadsworth Parkway, Unit K2, PMB 427,Westminster, Colorado 80021
Tax I.D. or Social Security Number:
1. Services to be Provided by Contractor: Behavioral Health Services (Changing Leads Group Lessons)
To Name of Client: M.G.,J.T.,A.T.,N.J.,D.G., and H.H. (Trails Case ID 1788667)
Location of Services to be provided to the Client: Office, Community or Home setting as deemed
appropriate.
2. County agrees to purchase and Contractor agrees to furnish up to TBD units of Life Skills or Mental
Health Services at the cost of$50.00/Hour(Therapeutic Visitation/Licensed Counselor), $75.00/Hour
(Family Therapy,EMDR), $65.00/Hour(Individual Therapy), $40.00/Hour(Court Facilitation/Court
Staffing/Family Team Meetings/Team Decision Making Meetings)per unit of service for a maximum
amount of$2,000.00(Maximum reimbursement of all services authorized and provided).
3. The parties agree that payment pursuant to this Contract is subject to and contingent upon the continuing
availability of funds for the purpose thereof. The payment of such services shall be from:
X Core Services as defined in Rule Manual Volume 7 Section 7.303 and, if appropriate,the
Colorado Department of Human Services approved County Core Services Plan.
Child Welfare Administration
X Other as defined as Medicaid(once contractor is approved as a Medicaid provider).
4. County agrees:
a) To determine child eligibility and as appropriate,to provide information regarding rights to fair
hearings.
b) To provide Contractor with written prior authorization on a child or family basis for services to be
purchased.
c) To provide Contract with referral information including name and address of family, social,medical,
and educational information as appropriate to the referral.
d) To monitor the provision of contracted service.
e) To pay Contractor after receipt of billing statements for services rendered satisfactorily and in
accordance with this Contract.
5. Contractor agrees:
a) Not to assign any provision of this Contract to a subcontractor.
b) Not to charge clients any fees related to services provided under this Contract.
c) To hold the necessary license(s)which permits the performance of the service to be purchased,
and/or to meet applicable Colorado Department of Human Services qualification requirements.
1
d) To comply with the requirements of the Civil Rights Act of 1964 and Section 504, Rehabilitation
Act of 1973 concerning discrimination on the basis of race, color, sex, age, religion,political beliefs,
national origin, or handicap.
e) To provide the service described herein at cost not greater than that charged to other persons in the
same community.
f) To submit a billing statement in a timely manner, no later than forty-five(45)days after services.
Failure to do so may result in nonpayment.
g) To safeguard information and confidentiality of the child and the child's family in accordance with
rules of the Colorado Department of Human Services and the County Department of Human
Services.
h) To provide County with reports on the provision of services as follows:
Not applicable.
i) To provide access for any duly authorized representative of the County or the Colorado Department
of Human Services until the expiration of five(5)years after the final payment under this Contract,
involving transactions related to this Contract.
j) Indemnify the County and the Colorado Department of Human Services from the action based upon
or arising out of damage or injury, including death,to persons or property caused or sustained in
connection with the performance of this Contract or by conditions created thereby, as based upon
any violation of any statute,regulation, and the defense of any such claims or actions.
6. In addition to the foregoing,the County and Contractor also agree:
a) Core Services Program expenditures will not be reimbursed when the expenditures may be
reimbursed by some other source. (As set forth in Rule Volume 7, at 7.414, B (12 CCR 2509-5).
b)
c)
2
Certificate of Insurance(Proof of Coverage) Date Issued: (5/18/2015)
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
Name Christina Murphy Administered By:
Street 9975 Wadsworth Parkway CPH and Associates
711 S.Dearborn,Suite 205
Unit K2 PMB 427 Chicago,IL 60605
City Westminster P.312-987-9823 F.312-987-0902
State Colorado info@cphins.com
Zip 80021
Underwritten By:
Philadelphia Indemnity Insurance Company
aW
*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.
Coverage
Policy#:E140515 'Effective Date:(5/31/2015) 'Expiration Date:(5/31/2016)
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Limits of Liability
Each Occurrence Aggregate
(Per individual claim) (Total amount per policy year) Coverage Part
$1,000,000.00 $5,000,000.00 Professional Liability
$1,000,000.00 $3,000,000.00 General Liability
Includes:General Liability,Fire&Water Legal Liability and
Personal Liability
$15,000 $15,000 Property Coverage
$1,000,000.00 $5,000,000.00 Supplemental Liability
Unlimited Unlimited Defense Expense Coverage
$100,000 $100,000 State Licensing Board Investigation Defense Coverage
$15,000 $15,000 Assault Coverage
$10,000 $35,000 Deposition Expense Benefit
$5,000/person $50,000 Medical Expense Coverage
$15,000 $15,000 First Aid Coverage
Description/Special Provisions:
General Liability Insured Location(s):
1)907 30th Ave Unit 102 Greeley,Co 80634
Certificate Holder Cancellation
Proof of Coverage 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:** Aritk,
( O_Yes/XN0 .**If the certificate holder is an ADDITIONAL INSURED,the l
policy(ies)must be endorsed.A statement on this certificate does Authorized Representative
not confer rights to the certificate holder in lieu of such C.Philip Hodson
endorsement(s).
DISCLAIMER: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.
THIS ENDORSEMENT CHANGED THE POLICY.PLEASE READ IT CAREFULLY
Additional Insured Endorsement
This endorsement modifies insurance provided under the following:
ALLIED HEALTHCARE PROVIDERS PROFESSIONAL
AND SUPPLEMENTAL LIABILITY POLICY
In consideration of the premium paid,this policy is amended as follows:
Weld County is hereby added as an Additional Insured,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 Weld County.
Additional Insured Name and Mailing Address:
Weld County
315 N. 11th Ave
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:E 140515
Effective on and after:5/31/2015
Issued to:Christina Murphy
Expiration date:5/31/2016
PI-PHCP-03(03/01)
By:
Robert O'Leary,Authorized Representative
c Line Road• Hatboro,PA 19040-1218
159 East County
Healthcare Providers Service Organization" 1-800.982-9491 •Fax 1-800-739-8818 •www.hpso.com
02/17/15
Tania Sossi
1000 E 18th Ave Apt 201
Denver, CO 80218-1071
Dear Tania Sossi:
Enclosed is the replacement certificate of insurance that you requested.
If you have any questions or need assistance, please call us toll free at 1-800-982-9491. Our
Customer Service Representatives are available weekdays from 8:00 a.m. to 6:00 p.m., EST.
Sincerely,
Customer Service
Enclosure
Q032
Dedicated To Serving The Insurance Needs of Healthcare Providers
Healthcare Providers Service Organization is a division of Affinity Insurance Services,Inc.;in NY and NH,AIS Affinity Insurance Agency;
in MN and OK,AIS Affinity Insurance Agency,Inc.;and in CA,AIS Affinity Insurance Agency,Inc.dba Aon Direct Insurance Administrators
License 00795465.
HEALTHCARE PROVIDERS SERVICE 0IHPSO
CNA ORGANIZATION PURCHASING GROUP
Certificate of 3 n$urance Healthcare Providers Service Organiatinn-
OCCURENCE POLICY FORM Print Date: 2/17/2015
Producer Branch Prefix Policy Number Policy Period
018098 970 HPG 0617344420 from 01/12/15to 01/12/16 at 12:01 AM Standard Time
Named Insured and Address: Program Administered by:
Tapia Sossi Healthcare Providers Service Organization
1000 E 18th Ave Apt 201 159 E.County Line Road
Denver, CO 80218-1071 Hatboro, PA 19040-1218
1-800-982-9491
www.hpso.com
Medical Specialty: Code: Insurance is provided by:
Clinical Counselor/LPCC 80723 American Casualty Company of Reading, Pennsylvania
333 S. Wabash Avenue, Chicago, IL 60604
Excludes Cosmetic Procedures
Professional Liability $1,000,000 each claim $3,000,000 aggregate
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 $25,000 per proceeding $25,000 aggregate
Defendant Expense Benefit $ 1,000 per day limit $25,000 aggregate
Deposition Representation $ 10,000 per deposition $10,000 aggregate
Assault $ 25,000 per incident $25,000 aggregate
Includes Workplace Violence Counseling
Medical Payments $ 25,000 per person $ 100,000 aggregate
First Aid $ 10,000 per incident $ 10,000 aggregate
Damage to Property of Others $ 10,000 per incident $ 10,000 aggregate
Information Privacy(HIPAA) Fines and Penalties $ 25,000 per incident $25,000 aggregate
Workplace Liability
Workplace Liability Included in Professional Liability Limit shown above
Fire&Water Legal Liability Included in the PL limit shown above subject to $150,000 aggregate sublimit
Personal Liability $1,000,000 aggregate
Total:$ 163.00
Base Premium $163.00
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 G-121503-C G-121501-C G-145184-A G-147292-A GSL15563
GSL15564 GSL15565 GSL17101 GSL13424 G-123846-005 GSL3886
GSL3908 CNA79575
•
Keep this document in a safe place.lt
and proof of payment are your proof of
1444"141/41 I14490 .4 OZ.I coverage. There is no coverage in force
unless the premium is paid in full.In order
Chairman of the Board Secretary to activate your coverage,please remit
premium in full by the effective date of
this Certificate of Insurance.
Master Policy#188711433
G-141241-B(03/2010) Coverage Change Date: 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 Common Policy Conditions
G-121503-C Workplace Liability Form
G-121501-C Occurrence Policy Form
G-145184-A Policyholder Notice-OFAC Compliance Notice
G-147292-A Policyholder Notice-Silica, Mold &Asbestos Disclosure
GSL15563 Information Privacy Coverage Endorsement HIPAA Fines, Penalties&Notification Costs
GSL15564 Sexual Misconduct Sublimits of Liability Professional Liability&Sexual Misconduct Exclusion
GSL15565 Healthcare Providers Professional Liability Assault Coverage
GSL17101 Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies
GSL13424 Services to Animals
G-123846-005 Colorado Cancellation and Non-Renewal
GSL3886 Coverage&Cap on Losses from Certified Acts Terrorism
GSL3908 Notice-Offer of Terrorism Coverage&Disclosure of Premium
CNA79575 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: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property&Liability Insurance
Guaranty Association.
For KY residents: 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.
For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge.
shown on the Certificate of Insurance is the FL Insurance Guaranty
ion
For FL residents: The FIGA Assessment y Association
-2012 Regular Assessment.
Form#:G-141241-B(03/2010) Named Insured:Tania Sossi
Master Policy#:188711433 Policy#:0617344420
Hello