HomeMy WebLinkAboutNicholas Thaler, PhD - 2021-06-15 PROFESSONAL SERVICES CON"1"RACf 13E"fWEliiN
THEi CITY OF I IUNTINGfON BEACH AND
Ni r h o I Qh91�r_,�hD
FOR
INDEPENIDENT MEDICAL, EVALUATIONS WITH
RBSPECT TO WORKERS' COMPENSATION CLAIMS
THIS AGREEMENT ("Agreement") is made and entered into by and between the City of
Huntington Beach,
II amunicipal corporation of the State of California, hereinafter referred to as
and_NL y)4-5 Imo, tu, an individual, hereinafter referred to as "PHYSICIAN."
WHEREAS, CITY desires to engage the services of a physician to provide independent
medical evaluations with respect to workers' compensation claims; and
Pursuant to documentation on file in the office of the City Clerk, the provisions of the
Huntington Beach Municipal Code, Chapter 3.03, relating to procurement of professional service
contracts have been complied with; and
PHYSICIAN has been selected to perform said services,
NOW, THEREFORE, it is agreed by CITY and PHYSICIAN as follows:
1. SCOPE OF SERVICES
PHYSICIAN shall provide all services as described in Exhibit "A," which is
attached hereto and incorporated into this Agreement by this reference. These services shall
sometimes hereinafter be referred to as the "PROJECT."
PHYSICIAN hereby designates IAA �0.�FY1 Irl who shall represent it
and be its sole contact and agent in all consultations with CITY during the performance of this
Agreement.
I2-3I87/I1tE Standard Contract - Revised - 06-02-21 1
2. CITY STAFF ASSISTANCE
CITY shall assign it staff coordinator to work directly with PHYSICIAN in the
performance of(his Agreement.
3. TIrNIE OF PERFORMANCE
Time is of the essence of this Agreement. The services of PF-IYSICIAN are to
commence on G/i5 (the "Commencement Date"). This Agreement shall
automatically renew three (3) years from the Commencement Date, unless terminated as provided
herein. The time for performance of the tasks identified in Exhibit "A" are generally to be shown
in Fxhibit "A." This schedule may be amended to benefit the PROJECT if mutually agreed to in
w1iting by CITY and PHYSICIAN.
In the event the Commencement Date precedes the Effective Date. PHYSICIAN
shall be bound by all terms and conditions as provided herein.
4. COMPENSATION
In consideration of the performance of the services described herein; CITY agrees
to pay PHYSICIAN, on a time and materials basis at the rates specified in Exhibit "B," attached
hereto and incorporated by reference into this Agreement, it fee, including all costs and expenses,
not to exceed Twcnty-nine Thousand Nine-l-Iundred Dollars ($29,900.00).
5. 1EXTRA WORK
In the event CITY requires additional services not included in Exhibit "A", or
changes in the scope ofservices described in Exhibit "A," PHYSICIAN will undertake such work
only after receiving written authorization from CITY. Additional compensation for such extra
work shall be allowed only if the prior written approval of CITY is obtained.
I2-3 t 87/imn: Standard Contract - Revised - 06-02-21 2
6. METHOD OF PAYMENT
PHYSICIAN shall be paid pursuant to the terms of Exhibit "B."
7. DISPOSITION OF PLANS. ESTIMATES AND OTHER DOCUNIENTS
PHYSICIAN agrees that title to all materials prepared hereunder, including, bttt not
limited to: all original drawings, designs, reports, both field and office notices, calculations,
computer code, language, data or programs, maps, memoranda, letters and other documents, shall
belong to CITY, and PHYSICIAN shall turn these materials over to CITY upon termination of
this Agreement or upon PROJECT completion, whichever shall occur first. These materials may
be used by CITY as it sees fit.
S. HOLD HAKNILLSS
11I-1 YSICIAN hereby agrees to protect, defend, indemnify and hold harmless CITY,
its officers, elected or appointed officials, employees, agents and volunteers from and against any
and at] claims, damages, losses, expenses,judgments, demands and defense costs(including without
limitation, costs and fees of litigation of every nature or liability of any kind or nature) arising out
of or in connection with P fYSICIAN's (or PHYSICIAN's subcontractors, if' any) negligent (or
alleged negligent) performance of this Agreement or its failure to comply with any of its obligations
contained in this Agreement by PHYSICIAN, its officers, agents or employees except such loss or
damage which was caused by the sole negligence or willful misconduct of CITY. PHYSICIAN will
conduct all defense at its sole cost and expense and CITY shall approve selection of PI IYSICIAN's
counsel This indemnity shall apply to all claims and liability regardless of whether any insurance
policies are applicable. The policy limits do not act as limitation upon the amount of indemnification
to be provided by PHYSICIAN.
12-3t87/1M1- Standard Contract - Revised - 06-02-21 3
9. PROFESSIONAL LIABILITY INSURANCE
PHYSICIAN shall obtain and furnish to CITY a professional liability insurance
policy covering the work performed by it hereunder. This policy shall provide coverage lot
PI-IYSICIAN's professional liability in an amount not less than One Million Dollars
($1,000,000.00) per occurrence and in the aggregate. The above-mentioned insurance shall not
contain a self-insured retention without the express written consent ofCITY; however an insurance
policy "deductible' of'Ten Thousand Dollars ($10,000.00) or less is permitted. A claims-made
policy shall be acceptable if the policy further provides that:
A. The policy retroactive date coincides with or precedes the initiation of the
scope of work (including subsequent policies purchased as renewals or
replacements).
13. PHYSICIAN shall notify CITY of circumstances or incidents that might
give rise to Future claims.
PHYSICIAN will make every effort to maintain similar insurance during the
required extended period of coverage following PROJECT completion. If insurance is terminated
for any reason, PHYSICIAN agrees to purchase an extended reporting provision ofat least two (2)
years to report claims arising from work performed in connection with this Agreement.
If PHYSICIAN fails or refuses to produce or maintain the insurance required by
this section or fails or refuses to furnish the CITY with required proof that insurance has been
procured and is in force and paid for, the CITY shall have the right, at the CITY's election, to
forthwith terminate this Agreement. Such termination shall not affect PHYSICIAN's right to be
paid for its time and materials expended prior to notification of termination. PHYSICIAN waives
12-3187/INi6 Standard Contract - Revised - 06-02-21 4
the right to receive compensation and agrees to indenmify the CITY for any work performed prior
to approval of insurance by the CITY.
10. CERTIFICAT73S OF INSURANCE,
Prior to commencing performance of the work hereunder, PHYSICIAN shall
Furnish to CITY certificates of insurance subject to approval of the City Attorney evidencing the
foregoing insurance coverage as required by this Agreement; the certificate shall:
A. provide the name and policy number ofeach carrier and policy;
13. state that the policy is currently in force; and
C. promise that such policy shall not be suspended, voided or canceled by
either party, reduced in coverage or in limits except after thirty (30) days'
prior written notice; however, ten (10)days' prior written notice in the event
of cancellation for nonpayment of premium.
PHYSICIAN shall maintain the foregoing insurance coverage in force until the
work under this Agreement is fully completed and accepted by CITY.
The requirement for carrying the foregoing insurance coverage shall not derogate
from PHYSICIAN's defense; hold harmless and indemnification obligations as set forth in this
Agreement. CITY or its representative shall at all times have the right to demand the original or a
COPY of the policy of insuranec. PHYSICIAN shall pay, in a prompt and timely manner, the
premiums on the insurance hereinabovc required.
11. INDEPINllENT CONTRACTOR
PHYSICIAN is, and shall be, acting at all times in the performance of this
Agreement as an independent contractor herein and not as an employee of CITY. IHYSICIAN
shall secure at its own cost and expense, and be responsible for any and all payment of all taxes,
12-3187MME Standard Contract - Revised - 06-02-21 5
social security, state disability insurance compensation, unemployment compensation and other
payroll deductions for PHYSICIAN and its officers, agents and employees and all business
licenses; if any, in connection with the PROJECT and/or the services to be performed hereunder.
12. TERMINATION OF AGRECtVIENT
All work required hereunder shall be performed in a good and workmanlike
manner. CITY❑ZaJ,terminate PHYSICIAN'S services hereunder at any time with or without cause,
and whether or not the PROJECT is fully complete. Any termination of this Agreement by CITY
shall be made in writing, notice of which shall be delivered to PHYSICIAN as provided herein.
In the event of termination, all finished and unfinished documents, exhibits, report, and evidence
shall, at the option of the CITY, become its property and shall be promptly delivered to it by
PHYSICIAN.
13. ASSIGNMENT AND DELEGATION
This Agreement is a personal service contract and the wrorlc hereunder shall not be
assigned, delegated or subcontracted by PHYSICIAN to any other person or entity without the
prior express written consent of CITY. If an assignment, delegation or subcontract is approved,
all approved assignees, delegates and subcontractors must satisfy the insurance requirements as
set forth in Sections 9 and 10 hereinabove.
14. COPYRIGI-I-I'S/PATENTS
CITY shall own all rights to any patent or copyright on any work, item or material
produced as a result of this Agreement.
15. CITY EMPLOYEES AND OFFICIALS
PHYSICIAN shall employ no CITY official nor any regular CITY employee in the
work performed pursuant to this Agreement. No officer or employee of CITY shall have any
12-3187/IMG Standard Contract- Revised - 06-02-21 6
Financial interest in this Agreement in violation of the applicable provisions of' the California
Government Code.
16. NOTICES
Any notices, certificates, or other communications herennder shall be given either
by personal delivery to PHYSICIAN's agent (as designated in Section 1 hereinabove) or to CITY
as the situation shall warrant, or by enclosing the same in a scaled envelope; postage prepaid; and
depositing the same in the United States Postal Service, to the addresses specified below. CITY
and PHYSICIAN may designate different addresses to which subsequent notices. certificates or
other communications will be sent by notifying the other party via personal delivery, a reputable
overnight carrier or U.S. certified mail-return receipt requested:
TO CITY: TO PHYSICIAN:
City of l-luntington Beach (5x- 144i S4- 4log
A"I-FN: Risk Manager �v�}g_ManicrJ riA `IyyQN_
2000 Main Street
1-luntington Beach, CA 92648
17. CONSENT
When CITY',; conscin approval is required under this Agreement, its
consent/approval Im one transaction or event shall not be deemed to be a consent/approval to any
subsequent occurrence of the same or any other transaction or event.
18. MODIFICATION
No waiver or modificationof any language in this Agreement shall be valid unless
in writing and duly executed by both parties.
12-3137/1ME Standard Contract - Revised - 06-02-21 7
19. SECTION ITE'ADINGS
The titles, captions, section, paragraph and subject headings, and descriptive
phrases at the beginning of the various sections in this Agreement are merely descriptive and are
included solely for convenience of reference only and are not representative of matters included
or excluded from such provisions, and do not interpret, define, limit or describe, or construe the
intent of the parties or affect the construction or interpretation of any provision of this Agreement.
20. INTERPRETATION OF THIS AGR,EELNVILNT
The language of all parts of this Agreement shall in all cases be construed as a
whole, according to its fair nhcaning, and not strictly for or against any of the parties. If any
provision of this Agreement is held by an arbitrator or court of competent jurisdiction to be
unenforceable, void, illegal or invalid, such holding shall not invalidate or affect the remaining
covenants and provisions of this Agreement. No covenant or provision shall be deemed dependent
upon any other unless so expressly provided here. As used in this Agreement, the masculine or
neuter gender and singular or plural number shall be deemed to include the other whenever the
context so indicates or requires. Nothing contained herein shall be construed so as to require the
commission of any act contrary to law, and wherever there is any conflict between any provision
contained herein and any present or future statute, law, ordinance or regulation contrary to which
the parties have no right to contract, then the latter shall prevail, and the provision of this
Agreement which is hereby affected shall be curtailed and limited only to the extent necessary to
bring it within the requirements of the law.
21. DUPLICATE ORIGINAL,
The original of this Agreement and one or more copies hereto have been prepared
and signed in counterparts as duplicate originals, each of'which so executed shall, irrespective of
12-3187AN1F. Standard Contract - Revised - 06-02-21 8
the date of its execution and delivery, be deemed an original. Each duplicate original shall be
deemed an original instrument as against any party who has signed it.
22. ININUG RATION
PHYSICIAN shall be responsible for full compliance with the immigration and
naturalization laws of the United Stales and shall, in particular, comply with the provisions of the
United S7ales Code regarding employment verification.
23. LEGAL. SERVICES SUBCONTRACTING PROHIBffEn
PHYSICIAN and CITY agree that CITY is not liable for payment of any
subcontractor work involving legal services, and that such legal services are expressly outside the
scope of services contemplated hereunder. PHYSICIAN understands that pursuant to Hwuington
Leach City Charter Section 309, the City Attorney is the exclusive legal counsel for CITY and
CITY shall not be liable for payment of any legal services expenses incurred by PHYSICIAN.
24. ATTORNEY'S Fl I3S
In the event suit is brought by either party to construe, interpret and/or enforce the
terms and/or provisions of'this Agreement or to secure the performance hereof, each party shall
bear its own attorneys fees, such that the prevailing party shall not be entitled to recover its
attorney's fees from the non-prevailing party.
25. SURVIVAL
'terms and conditions of this Agreement, which by their sense and context survive
the termination of this Agreement, shall so survive.
26. GOVERNING LAW
This Agreement shall be governed and construed in accordance with the laws of the
State of California.
12-3187MME Standard Contract - Revised - 06-02-21 9
27. SIGNATORIES
Hach undersigned represents and warrants that its signature herein below has the
power; authority and right to bind their respective parties to each of the terms of this Agreement,
and shall indemnify CITY fully for any injuries or damages to CITY in the event that such
authority or power is not, in fact, held by the signatory or is withdrawn.
NIYSICIAN's initials NT
28. Et\'TIIkF"TY
The parties acknowledge and agree that they are entering into this Agreement freely
and voluntarily following extensive arm's length negotiation; and that each has had the opportunity
to consult with legal counsel prior to executing this Agreement. The parties also acknowledge and
agree that no representations, inducements, promises, agreements or warranties, oral or otherwise,
have been made by that party or anyone acting on that part-y's behalf, which arc not embodied in
this Agreement, and that that party has not executed this Agreement in reliance on any
representation, inducement, promise, agreement, warranty, fact or circumstance not expressly set
forth in this Agreement. This Agreement; and the attached exhibits, contain the entire agreement
between the parties respecting the subject matter of this Agreement and supersede all prior
understandings and agreements whether oral or in writing between the parties respecting the
subject matter hereof.
29. EI"FE'CTIVE DA'I-H
']'his Agreement shall be effective on the date of its approval by the City Attorney.
This Agreement shall expire when terminated as provided hereof.
IN' WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed
by and through their authorized officers.
I2-3 187/1bt6 Standard Contract - Revised - 06-02-21 10
PHYSICIAN � I
�p Im 1U CITY OF HUNTINGTON BEACH,a
TY?FJMNr PHYSICIAN'S NAW municipal corporation of the State of California
ire
Signature
Director of Human Resources
APPROVED AS TO FORM:
y torney
Receive and File Q�
7■� vti+��G2lQ. J
City Clerk 7 8 �
12.31871IMS Standard Contract-Revised - 06-02-21 11
PROFI3SSIONAL SERVICES CON'I'FZAC'1' I3l "I'WL EN
THF., CITY OI' I IUNI'INGTON BEACI-I AND
i c_hJ95_TkC E_EdU
FOR
li\'DIr,PI NDI N'I' YII:DICAL EVALUATONS WITH
R13SPECT TO WORKERS' COMPENSATION Cl.,AlivIS
Table of Contents
IScope of Services.....................................................................................................t
2 City Staff Assistance................................................................................................2
3 time of Performance ...............................................................................................2
4 Compensation ..........................................................................................................2
5 Extra Work...............................................................................................................2
6 Method of Payment..................................................................................................3
7 Disposition of Plans; Estimates and Other Documents ...........................................3
8 Hotd Harmless .........................................................................................................3
9 Professional Liability Insurance..............................................................................4
10 Certificates of Insurance ..........................................................................................5
11 Independent Contractor............................................................................................5
12 'termination of Agreement.......................................................................................6
13 Assignment and Subcontracting ..............................................................................6
14 Copyrights/l'atents...................................................................................................6
15 City Employees and Officials..................................................................................6
16 Notices .....................................................................................................................7
17 Consent ....................................................................................................................7
18 Nlodification.............................................................................................................7
19 Section Headings .....................................................................................................8
20 lnterprctation of this Agreement..............................................................................8
21 Duplicate Original....................................................................................................8
22 Immigration..............................................................................................................9
23 Legal Services Subcontracting Prohibited...............................................................9
24 Attorney's Fees.........................................................................................................9
25 Survival....................................................................................................................9
26 Governing Law ..............................................................................:.........................9
27 Signatories................................................................................................................10
28 Entirety.....................................................................................................................10
29 Effective Date ..........................................................................................................10
12-3187/75880
EXHIBIT "A"
STATI:ML'NT OF WORK:
1) AOE— COE EXAMS (exams for the determination of industrial causation).
2) Evaluation for necessity of appropriate medical treatment.
3) Assessment of ernployec's present ability to return to work, whether full duty or
modified.
4) Advise on condition of maximum medical improvement status.
5) Determine nature and extent of permanent disability, including factors of apportionment
and need for future medical care.
6) Resolve utilization review disputes.
7) Determine the need for spinal surgery pursuant to Labor Code section 4062(b).
PHYSICIAN shall perform the evaluation in full accordance with the standards defined by the
Division of Workers' Compensation of the State of California and the A1NIA Guides to the
Evaluation of Permanent Impairment, Fifth Edition. This requires a report of the injury, prior
status, clinical chronology, current status, and past medical history. The physical examination
will document all pertinent positive, negative, and non-physiological findings. For extremity
injuries, measurements must be documented bilaterally. Additionally, PHYSICIAN agrees to:
(i) provide that medical exams will be set within thirty (30) days of the date of appointment
request, and (ii) prepare a written report of findings within thirty (30) days of the date of exam or
evaluation and provide a copy to the parties within said time frame.
12-3187/75880
F,r111131T "1v
Payment Schedule
1. Missed Appointments
• Fee: $503.75
• Code: M1.,200
flpplies when:
• Interpreter does not appear for evaluation.
• Injured worker leaves before completion of the cvaluation.
• Cancellation within 6 business days of the scheduled appointment.
2. Comprehensive Medical-Legal Evaluations
• Fee: $2.015,00
• Code: iN41-201
• Applies to the initial evaluation or the first evaluation in an I8-month period.
• The cvaluation includes review of up to 200 pages of records.
• It must involve an examination of the employee.
• Review of records in excess of 200 pages is reimbursed at a rate of$3.00 per page.
3. Follow-up Medical-Legal Evaluations
• Fcc: $I,316.25
• Code: M1,202
• Applies to any subsequent comprehensive evaluation within 18 months of the initial
evaluation.
• This fee includes review of up to 200 pages of records that were not reviewed as part of
the initial evaluation.
• Review of records in excess of 200 pages (records not reviewed at initial evaluation)
reimbursed at a rate of$3.00 per page.
4. Supplemental Medical-Legal Evaluations
• Fcc: $650.00
• Code: N1203
• Does not involve an examination of the patient.
• Results in preparation of a narrative medical report.
• Review of records in excess of 50 pages reimbursed at a rate of$3.00 per page.
• Fees for a supplemental report are not allowed if:
o Records reviewed were provided to the physician for review before the initial or
follow-up evaluations.
o Supplemental report addresses an issue the parties asked the physician to address
in a prior med-legal evaluation.
12-3187/75880 1
5. i�7edical-Legal Testimony
• Fee: $455.00 per hour (or physician's usual and customary fee, if lower)
• Code: iNIL204
• Physician is entitled to bill a minimum of 2 hours for deposition.
• If the deposition is canceled within fewer than 8 calendar days prior notice, physician is
entitled to bill I hour of time.
G. Medical-Legal Review of Sub Rosa Evidence
• Pee: $325.00 per hour (or physician's usual and customary fee, if lower)
• Code: il7L205
• No minimum time allotment.
• Physician must capture time spent reviewing evidence to the nearest quarter-hour;
verified under penalty of perjury.
• The fee does not include production of a medical-legal report. The fee for time spent
reviewing the recording will be included in the billing for the initial. follow-up or
supplemental medical- report.
7. Additional Fee A9odificrs
• Interpreter
o Fees for evaluation requiring an interpreter are increased by 10%.
• Agreed Nledical Evaluator
o Fees for evaluations performed by an ANME are increased by 35%.
• Psychiatrists and Psychologists
o When psychiatric/psychological evaluation is the primary focus of the exam, fees for
evaluation are doubled (100%).
• Toxicologists and oncologists
o When toxicology or oncology is the primary focus of the exam and the physician is
an internal medicine specialist, fees are increased by 50%.
8. Court-Ordered Evaluations
• When a medical-legal evaluation is ordered by a Workers' Compensation Judge, the
Judge has authority and discretion to apply the appropriate modifier to that evaluation.
9. The parties agree that the City is not obligated to pity compensation to the PHYSICIAN
except for agreed upon medical services and care. Failure of PHYSICIAN to provide a
written medical report within 30 days of the date of the exam subjects PHYSICIAN to non-
payment for services rendered.
10. PHYSICIAN billing shall conform to the requirements listed in section 9795 ofTitic 8 of
the California Code of Regulations. Charges for services rendered will be reviewed in
accordance with section 9795 to determine appropriate level of service.
12-3187/75880 2
AE✓
.4coRd CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDOIYYYYI
0710712021
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE
AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE
ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les)must have ADDITIONAL INSURED provisions or
he endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an
endorsement. A statement on this certificate does not confer rights to the certificate holder in Ileu of such endomement(s).
PRODUCER CONTACT
NAME.Trust Risk Management Services,Inc
Trust Risk Management Services, Inc. doing business in CA PHONE FAX
LAIC.No_E.tl:877.637.9700 ,NP:877.251.6111
as TRMS Insurance Agency EMAIL --
1791 Paysphere Circle ADDRESS:IA Irme?ro.cPm
Chicago, IL 60674 _ INSURE B AFFORDING COVERAGE NAR;a
INSURER A:ACE American Insurance Company 7.2667
INSURED INSURER B'
Dr. Nicholas S Thaler INSURER
2950 S Bentley Ave Apt 10
Los Angeles, CA 90064-4072 INSURER D_
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT
TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT
TO ALL THE TERMS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
FAR POLICY EFF PO-J EXP
LTR TYPEOFINSURANCE al wil POLICY NUMBER IM"arr ) ("aaaeYYVYJ tons
COMMERCIAL GENERAL LIABILITY EACHOCCURRENCE S
CLAIMS MADE ❑OCCUR DAMAGE TO RENTED f
PREMISES Eaornarano
MED EXP JAI,.Panon) f
PERSONAL A ADV IWURY f
GEN-L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATEPRO S
f
POLICY ❑JECT ❑LOC PRODUCTS PIOP AGO
OTHER
AUTOMOBILE OABOUTY COMBINED SINGLE UNIT f
Es awOant
ANY AUTO BODILY INJURY(Par Pandn) f
ALLZMD SCHEDULED BODILY INJURY PM f
AUTOS AUTOS
HIRED AUTOS NON-0WNED PROPERTY DAMAGE S
AUTOS PK
f
du��
OCCUR EACH OCCURRENCEA CLAIMS-MADE AGGREGATE S
ENTIONS f
WORKERS COMPENSATION 1PER Oi f
AND EMPLOYERS LIABILITY YIN ISTATUTE JER
ANY PROPRIETOR:PARTNERIEXECUTIVE ❑ NIA ELEACHACCIDENT S
OFFICERNEMBER EXCLUDED? By: EL Di EF E WPLOY EEIf
cr.na.aly aN Nro �j EL E.GA
DESCPIPTIONOOPERATIONSd AT EL DISEASE-POLICY LIMI S
crryur
Pryichtimows Prdeswonal Lwwft Y 58G26063711 04/15/2021 04/15/2022 Each Incident 51,000,000
A Retroactive Date 0411 5/20 1S Annual 53,000,000
Aggregate
DESCRIPTION OF OPERATIONSI LOCATIONS VEHICLES IACORD 101.Additional RemaAs S<eedula,nuy as aftactiad B mon span Ia nn wivd)
CERTIFICATE HOLDER CANCELLATION
Additional Insured SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
City of Huntington BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE
2000 Main St DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
Huntingtn Beach, CA 92648
S i Ia`
ACORD 25 (2016103) c0 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD