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HomeMy WebLinkAboutBurton Sobelman, DDS - 2021-04-01 PROFESSONAL SERVICES CONTRACT BETWEEN THE CIfY OF HUNTINGTON BEACH AND Burton 5o6elm4n, DD5 FOR INDEPENDENT MEMICAL EVALUATIONS WITH RESPECT"I'0 WORKERS' COMPENSATION CLAIMS 'PHIS AGREEMENT("Agrecnicnl") is made and entered into by and between the City of Huntington Bcach, a municipal corporation of the State of California, hereinafter referred to as "CITY," andL691 V�_w Hit 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 I-Iuntington 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 NW-157_1 D1A0AA)TF , who shall represent it and be its sole contact and agent in all Consultations with CITY during the performance of this Agreement. APPROVED AS TO FORM/FO M. Aru Y' 4ICHAEL E. GATES CITY ATTORNEY 12-3187/IW Standard Contract - Revised I CITY OF HUNTINGTON BEACH 2. CITY STAPP ASSISTANCE CITY shall assign a staff coordinator to work directly with PHYSICIAN in the performance of-this Agreement. 3. l'I�lli OP 1'I RPORLMANCI3 Time is of the essence of' this Agreement. The services of PHYSICIAN arc to commence on (the "Commencement Date"). This Agreement shall automatically renew three (3) Fears 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 Exhibit "A." This schedule may be amended to benefit the PROJECT if nnuually agreed to in writing by CI"fY and PHYSICIAN. In the event the Commencement Date precedes the FOective Date. PHYSICIAN shall be bound by all terms and conditions as provided herein. 4. CO\4PENSATI0N 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 "it," attached hereto and incorporated by reference into this Agreement. a fee. including all costs and expenses. not to exceed Twenty-nine Thousand Nine-Iiundred Dollars (529,900.00). 5. E\'fRA WORK In the event CITY requires additional services not included in Exhibit "A", or changes in the scope of'scrvices 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. I2-31 SWINtt? Standard Contract - Revised - 04-30-21 2 6. \-II:CI I I01) OP PAYNI N"l- PHYSICIAN shall be paid pursuant to the terms of 1?xhibit I'll." 7. DISPOSITION OF PLANS. AND OTI IGR DOCUNIGNTS PHYSICIAN agrees that title to all materials prepared hereunder including, but not limited to: all original drawings, designs, reports. both field and office notices, calculations, computer code, language, data or prognunsr maps. memoranda, letters and other documents. shall belong to CITY, and ISYSICIAN 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. 3. 1-I0I.D I-IARi l,1 SS PHYSICIAN hereby agrees to protect, defond, indemnify and hold harmless CITY, its officers, elected or appointed officials. employees, agents and volunteers from and against any and all claim& damages. losses, expenses,judgments, demands and defense costs (including without linitationr costs and fees of litigation of cvery nature or liability of any kind or nature) arising out of or in connection AT MYSICIAN's (or PHYSICIAN's subcontractors. if any) negligent (or alleged negligent) performance ofthis Agreement or its failure to comply "Ith 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 ofCffY. PHYSICIAN All conduct all defense at its sole cost and expense and MY 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 ofindemni ention to be provided by PHYSICIAN. 12-318MMG Standard Contract - Revised - 04-30-21 3 9. PROFESSIONAL LIABILITY INSURANCE PHYSICIAN shall obtain and furnish to CITY a professional liability insurance police covering the work performed by it hereunder. This police shall provide coverage for PHYSICIAN's professional liability in an amount not less than One iA4illion Dolhu-s (SL000.000.00) per occurrence and in the aggregate. The above-mentioned insurance shall not contain a self-insured mention without the express written consent ol'CITY: however an insurance police "deductible' ofTen Thousand Dollars ($10,000.00) or Tess is permitted. A claims-made policy shall be acceptable if the police further provides that: A. The policy retroactive date coincides with or precedes the initiation ol'the scope of work (including subsequent policies purchased as renewals or replacements). B. III IYSICIAN shall notifv CITY of circtnnstances or incidents th<a might give rise to future claims. PHYSICIAN will make every elTort to maintain similar insurance during the required extcndcd period ofcovcrage following PRO.IECf completion. Ifinsmance is terminated for anv reason. PHYSICIAN agrees to purchase an extended reporting provision of at 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 lorthwith terminate this Agreement. Such termination shall not affect PI IYSICIAN's right to be paid for its time and materials expended prior to notification of termination. PHYSICIAN waives 12-3137/1NIE Standard Contract - Revised - 04-30-21 4 the right to receive compensation and agrees to indemnilly the CITY for any work perhormed prior to approval of insurancc by the CITY. 10. CERTIFICATES OF INSURANCE' Prior to commencing performance of the work hereunder. PHYSICIAN shall furnish to CITY certificates of insurancc 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 police number o1-each carrier and policy; B. state that the policy is currClldV in forCC; and C. promise that such policy shall not be suspended. voided or caiccled 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 ofcanccllation for n0npaymcnt 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 1'rom PI IYSICIAN's defense. hold harmless and indemnification oblieations 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` insurance. PHYSICIAN shall pay, in it prompt and timely manner, the premiums on the insurance hereinaboyc required. 1 I . INDFATNDfiNl' CONTRACTOR PHYSICIAN is. <utd shall be. acting at all times in the perlonnance of this Agreement as an independent contractor herein and not as an employee of CITY. PI IYSICIAN shall secure at its own cost and expense, and be responsible for any and all payment of all taxes, 12-3 r87/IMIS Standard Contract - Revised - 04-30-21 5 social security. state disability insurance compensation_ unemployment compensation and other payroll deductions for PHYSICb%N and its officers, agents and employees and all business licenses, ifany. Al connection with the PROJF.,CT and/or the services to be performed hereunder. 12. "I'EIZMINATION OF AGREE\ ETV All work required hereunder shall be performed in a good and workmanlike manner. CITY muty terminate PI IYSICIANY services hereunder at any time with or without cause, and whether or not the PRO.fFC'f is fully complete. Any termination ofthis 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 he promptly delivered to it by PHYSICIAN. 13. ASSIGNMENT AND DELEGATION '['his Agreement is a personal service contract and the work 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 hcrcinabove. 14. COI'YRIGI-I'I'S/PA'113NTS 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 I ,\9PLOYI IiS AND OFFICIALS PHYSICIAN shall employ no CITY official nor any regular CITY employee in the work perlormed pursuant to this Agreement. No officer or employee of CITY shall have any 12-3137ANIF Standard Contract - Revised - 04-30-21 6 financial interest in this Agreement in violation of the applicable provisions of (lie California 0overmuent Code, 16. NOTICES Any notices, certificates, or other communications hereunder shall be given either by personal delivery to PHYSICIAN's agent(as designated in Section I hereinabove) or to CITY as (he sltualion shall warrant, or by enclosing the same in a sealed envelope, postage prepaid, and depositing the sanic 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 Huntington Beach _6,14- ,4 ATTN: Risk Manager 0%-60 Vt//L�W1ep— B[ $ f 2000 Main Street X�4 c y �yl-z�s- Huntington Beach, CA 92648 G ` 17. CONSENT f When CITY's consent/approval is required under this Agreement, its consent/approval for 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. MODIFICKnON No waiver or modifiention of any language in this Agreement shall be valid unless in writing and duly executed by both parties. 12-9187/]ME Standard Contract - Revised 7 19. SECTION HEADINGS The titles, captions, section, paragraph and subject headings, and descriptive phrases at the beginning orthe various sections in this Agreement are merely descriptive and are included solely for convenience or reference only and are not representative or matters included or excluded from such provisions. and do not interpret, dcHne, limit or describe. or construe the intent or the parties or aflect the construction or interpretation of any provision of this Agreement. 20. INITEAURETAIION 017 THIS AGRE1;91 NT The language or all parts of this Agreement shall in all cases be construed as a whole, according to its lair meaning. and not strictly for or against any of the parties. If any provision of this Agreement is held by an arbitrator or court or competent jurisdiction to be unenrorccablc, void, illegal or invalid, such holding shall not invalidate or aflect the remaining covenants and provisions orthis Agreement. No covenant or provision Will be deemed dependant 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 orany 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 ARM shall be curtailed and limited only to the extent necessary to bring it within the requirements ofthe law. 21 . DUPLICATF ORIGINAI. The original or this Agreement and one or more copies hereto have been prepared and signed in counterparts as duplicate originals, each orwhich so executed shall, irrespective or 12-31871INIE Standard Contract - Revised - 04-30-21 8 the date of its execution and delivery. be deemed an original. Each duplicate original shall be deemed an original instrument as against any puny who has signed h. 22. INCMIGRATION PHYSICIAN shall he responsible for full compliance with the immigration and naturalization laws of the United States and shall, in particular, comply, with the provisions of the United$rates Code regarding employment verification. 23. LEGAL SERVICES SUBCONTRACTING PROHIBITED 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 HU/71it;loon Beach 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. ATT0RNIi:Y'S FLES In the event suit is brought by either party to construe, interpret and/or enforce the terms and/or provisions or this Agreement or to secure the performance hereof each party shall bear its own attorncy s revs, such that the prevailing party shall not be entitled to recover its attorneys fees from the non-prevailing party. 25. SURVIVAL. Terms and conditions or this Agreement, which by their sense and context survive the termination orthis Agreement, shall so survive. 26. GOVERNING LAW ']'his Agreement shall be governed and construed in accordance with the laws of the. State of California. 12-3187MN411 Standard Contract - Revised - 04-30-21 9 27, SIGNATORIES Eaeli 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 (hat such authority or power is not, in fact, held by the signatory or is witted PHYSICIAN's initials 28. EN"rIRi;'I,Y 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 will 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 oil that party's behalf, which ace not embodied in this Agreement, and that that party has not executed this Agreement it) reliance on any represenldion, inducement, promise, agreement, warranty, tact or circumstance not expressly set forth in this Agreement. This Agreement, find the attached exhibits, contain tle entire agreement between the parties respecting the subject Muller of this Agreement and supersede all prior understandings and agreements Whether oral or in writing between the parties respecting the subject matter hereof. 29. EFFECTIVEDATE This Agreement shall be effective on the dale 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. 1 2-7 1 8 711MP.Standard Contract - Revised 10 p} � c CITY OF HUNTCN01'ON BEACH, a r PF INT►11YtICIA • 16 municipal corporation of the State of California I1A�U �� 1tor of Human Resources APPROVED AS TO FORM: City Attoniey Receive and File q� v��ZG CIW © /z/ 12.3a87/IMe Standard Contract- Revised I PROITSSIONAL SI_:RVICL-:S COIF'l RACT BI-T\VIiEN 'I'l IE CITY OF HUN'TINGTON' 13EACli AND Burton 5obelm4n FOR INDt PLiNDI N h ML:DICAL. EVAL,UATONS WITH RI S1'EC'1"fO \\rORKFRS COM�IPENSA'I'ION CLAIMS We of Contents IScope of Services.....................................................................................................1 2 City Stal't'Assistance................................................................................................2 3 TimeorPerformance ...............................................................................................2 4 Compensation .................................................... .....................................................2 5 I:ixtra Work...............................................................................................................2 6 Method or Pavntem..................................................................................................3 7 Disposition of I Inns, Estimates and Other Documents ...........................................3 SI lold Iiarmless .........................................................................................................3 9 Professional Liability• Insurance......................_...._................................................4 10 Certificates of Insurance ..........................................................................................5 11 Independent Contractor............................................................................................5 12 Termination orAgmcmcm.......................................................................................6 13 Assignment and Suhconwachng ..............................................................................6 14 Copyrights/Patcnts...................................................................................................6 15 City Implovices and Officials..................................................................................6 16 Notices ................................................. .................................................................. 17 Consent ....................................................................................................................7 ISModification.......................................................................................__..................7 19 Section Headings .....................................................................................................8 20 Interpretation of this Agrecmcnt.............................................................I................8 21 DUplicatc Original........................................._.._......_................................................ 22 Imn igradon..............................................................................................................9 23 Legal SeNces Subcontracting Prohibited...................................... .__...................9 24 Atuxncv's Fees.................................................................................._..................._9 25 Survival....................................................................................................................9 26 Governing Law ........................................................................................................9 27 Signatories........................................._.....................................................................10 28 Fntirctv.....................................................................................................................10 29 Effective Date ..........................................................................................................10 12-3187/75880 STATI'AM :N'T OF WORK: I) AOL— CODE FAAVIS (exams for the detennination of industrial causation). 2) !;valuation for necessity of appropriate medical treatment. 3) Assessment of employee`s present ability to return to work, whether full duty or Modified. ied. 4) Advise on condition of maximum medical improvement stnuus. 5) Determine nature and extent of permanent disability, including factors of apportionment and need for future medical care. 6) RISOIVC Utilization review disputes. 7) Determine the need for spinal surgery pursuant to I.ahor We section 4062(b). PFIYSICIA14 shall perform the evaluation in full accordance with the standards defined by the Division of\Yorkers' Compensation of the State of California and the ANIA Guides to the Lvaluatkn of Permanent Impairment. ITS EdRion. This requires a report of the injure. 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 thing (30) clays of the date of appointment request, and (d) prepare a written report of findings within thirty (30) clays of the date ofcxam or evaluation and provide a copy to the parties within said time frame. 12-3187/75880 P:\LI1131"1' "13" Payment SChedUle I. Missed Appointments • Fee: $503.75 • Code•. N11.200 1I1)plies when: • Interpreter does not appear for evaluation. • Injured worker leaves before completion of tile evaluation. • Cancellation within 6 business days of the scheduled appointment. 2. Comprehensive Medical-Legal [:valuations • Fee: S2.01 5.00 • Code: NI1,201 • Applies to the initial evaluation or the first evaluation in an 18-month period. • The evaluation 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 pa- page. 3. Follow-up iMcdical-Legal Evaluations Pee: $1.316.25 • Code: NI1.,202 • Applies to any subsequent comprehensive evaluation within 18 months of the initial evaluation. • ']'his 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 • Fee: $650.00 • Code: M203 • Does not involve an esamination of the patient. • Results in preparation of a narrative medical report. • Review of records in excess of'50 pages reimbursed at a rate of S3.00 per page. • I"ces 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 rated-legal evaluation. 12-3187/75880 1 5. Medical-Legal Testimony Pee: S455.00 per hour (or physician's usual and customary fee; if lower) • Codc: A11,204 Physician is entitled to bill a minimum of 2 hours for deposition. If the deposition is canceled within Icwer than 8 calendar days prior notice, physician is entitled to bill I hour of time. 6. N'ledical-Legal Review of Sub Rosa Evidence • ]:cc: $325.00 per hour (or physician's usual and customary fce. if lower) • Code: N1I,205 No minimum tulle allotment. Physician must capture time spent reviewing evidence to the nearest quarter-hour, verified trader penalty of perjury. • The fee does not include production of a medical-legal report. The The for time spent reviewing the recording will be included in the billing Ibr the initial. follOw-up or supplunental medical- report. 7. Court-Ordered b; aluations When a medical-legal evaluation is ordered by a AV'orkers' Compensation Judge, the Judge has authority and discretion to apply the appropriate modifier to that evaluation. S. The parties agree that the Cite is not obligated to pay 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 exalt sub?jccts PI-IYSICIrVV, to non- payment for services rendered. 9. P1YSICIAN billing shall conform to the rcquimnwnts listed in section 9795 ofTitle S of the California Code of Regulations. Charges for services rendered will be reviewed in accordance with section 9795 to determine appropriate level of service. IQ City shall pay PHYSICIAN within forrv-live (45) days Ibllowing receipt from PHYSICIAN of invoices IN services rendered and Ibr which payment has not previously been made, provided that PHYSICIAN shall submit all invoices within ninety (90) days after the date of service. 12-3 1 87/758SO 2 AEJ CERTIFICATE OF LIABILITY INSURANCE 11117/2020 PRODUCER/A( NT THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY Dentist's Advantage AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 1100 Virginia Drive,Suite 250 CERTIFICATE DOES NOT AMEND,EXTEND END OR ALTER THE COVERAGE Fort Washington,PA 19034 AFFORDED BY THE POLICIES BELOW. INSURE RD INSURED INSURER A: American CasuAlly Company of Reading.Pennsylvania Burton R Sobelman,DDS INSURER B: 8500 Wilshire Blvd Suite 1004 INSURERC: Beverly Hills,CA 90211 MSURER D: INSURER E: COVERAGES THE POUCIFS OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE PoR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDTON OF ANY CONTRACTOR 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.E)(CLL'SIONS AND CONDTONS OF SUCH POI2CIFS.LINHIS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. AGGREGATE RODl1.T} =AtnOWbTL1UABR� i INSUIIANfr. ro1.ICY rTF.CtTI'I. FOLICI"R¢EIMTpt roUCY NUMBER DATE, iMMA1pY1'I DATILiMhWm'Y1 LIMITS TY .m' rxTI OCLTntRENCE NM IrclRdod GENEAAL UARRL TDIANTS'IEGALU"W" Ndlmkltd ❑OCCURRENCE MED EX P IAn wN Not 1rc%ded lADV TNRMMY NdI GENERA(.AGGRFI�ATE Ndlrclded PROOIIRS-CQIIgE AGO NIX lrcldledTE L MIT APPLIES PEA.Fm1FLT ❑lAC AtnOM0aI1EUABRL LTJMVM SINGLE LIMB ❑ANY AUTO 1F:h ertideNl ❑All OWNED ALTOS aOpLY IN/L'RY 1A. IN —' NIX IrchHkd ❑S LIED ALTOS ALI'INIURY Nd Included Pv—. ) HIRED AUTOS ❑NONa D AUTOS A OPROVED AS TO MOPEATY DAMAGE ❑ IPn rcMeN) GARAGE UAa1LRY -- AlIr001LY CH ACCIDENT_ ❑ANY AUTO �• ❑ MICHAEL E. GA EA ACC CITY ATTORN OTHIZA THAN AUTO ONLY: PXCT3S UARRrrY — AGO EACH OCCURRENCE ❑ CLAIMS MADE Cl OCCURRENCE AGGREGATE ❑ DEGUL'DBIE ❑ REEEN m S WORKEMftO ERs UAI NSAnON AND EAIPLOYER'a UABIUT'( U VC STATUTORY C3 GT1[R EL LACH ACCRNERT EL MSEASE-EACH EMPLOYEE DA oT1FR EL DMFASE-POLICY LIT A Mod.Malpractice DPA W322YI IF OIA110021 - UTAiIRO±± Per Claim: SI.DOOpuG RevoaeHivc bM<: Aggregate: S.1.000.000 DEScwIErION OE OEGAnoN¢.'LOCAnoNSAT.NI CLUSIONS AWM aY ENOOIISF11ENr S1En AL PROIISI}S Insured Dentist: Relre Dale: Insured Location: Burton R.Sobelman,DDS 09/01/1998 8500 Wilshire Blvd Suite 1004.Beverly Hills CA 90211 CERTIFICATE HOLDER ADmrIONAL R SMILD:MSORU LRTTaa._ CANCELLATION WE C¢RTVKAn M MOVIDRO AN Moor THAT A POLICY of MSURANCs IS OR HAS ac¢N IN MRMK4NOTAGIHARAN THATTMMCOV"AGECONTINt'ESMFORCE FI'RTHERMOaa, City of Huntington Beach YAC vnCAT¢NOLDLR,Tot!.wu (Tu¢Mo%mmx,,IIncRSHOtt TH¢ ICfSLl NCa COVUAGRMCKIRLDBaMMMATLO. 2000 Main Street Huntington Beach, CA 92648 Dentist's Advanu e