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HomeMy WebLinkAboutForensic Nurse Specialists, Inc. - 2023-10-01 . AGREEMENT FOR FORENSIC EXAMINATION SERVICES by FORENSIC NURSE SPECIALISTS, INC. This Agreement for Forensic Examination Services is made and entered into as of the 1st day of October; 2023 (the `Effective Date"), by and between FORENSIC • NURSE SPECIALISTS, INC., a California corporation doing business as FORENSIC NURSE SPECIALISTS,INC ("FNS"), a privately owned minority (woman) professional corporation, and the CITY OF HUNTINGTON BEACH, a California Municipal Corporation ("City"), .on behalf of the Huntington Beach Police Department ("Department"), with respect to the following; WHEREAS, Department requires the collection of forensic evidence with respect to victims of sexual assault and other forms of interpersonal violence; - WHEREAS, this is a mandatory expense as failure to provide a victim of sexual assault with an examination by a qualified healthcare professional would be a violation of the California Penal Code; WHEREAS, Department does not have the capability to collect the aforesaid forensic evidence internally; WHEREAS, FNS. has specialized training and expertise in the forensic examination services and Department desires to contract such services from FNS; and WHEREAS, FNS is the sole source providing this service in Orange County and there are no specific registries that. utilizes forensic nurses solely for the purpose of exams. NOW, THEREFORE, in consideration of the mutual promises, covenants, and conditions contained herein, the parties hereto agree as follows: 1, Services. FNS agrees to provide the following services (collectively, the "Services") to the Department: 1.1. Examination. FNS agrees to provide the Department approved forensic-medical exams 24 hours per day, 7 days per week (i.e. continuously) to sexual assault and other types of victims with a one hour response to a mutually agreed upon examination location, 1'he exam is to include digital imaging of injuries and physical findings. The examination will be conducted by forensic nurses • who are trained and competent in the California State Protocol established by CALOES (California Office of Emergency Services). 1.2. Evidence. All evidence collected during the examination will be packaged, labeled and scaled according to the state and local crime • lab requirements and submitted to the on-site evidence storage refrigerator with appropriate chain of custody documentation. - Evidence for mobile exams(off site)or courtesy cases will be relinquished at the conclusion of that examination to the authorizing Department. Digital photographs will be available upon request by Department investigators. • • 1.3. Equipment and Supplies. FNS will provide all equipment and • supplies to conduct all services listed in Exhibit A. 1.4. Testimony. FNS agrees to provide competent court testimony as requested by the Department (upon receipt of subpoena). 2. Compensation. In exchange for. the Services to be provided by FNS pursuant to Section 1 above, Department, through City, shall compensate FNS according Exhibit A "FEE SCHEDULE — 2023-2024". Services can be added at any time per Department request and at negotiated rates. 2.1. Rate Adjustment. Department acknowledges and agrees that INS is entitled to adjust the rates set forth in this Section 2, Exhibit A. All fee adjustments are subject to prior written mutual agreement of the parties. FNS shall use reasonable efforts to give Department at least sixty (60) days advance written notice of any increase or adjustment to rates. 3. Payment. FNS shall invoice Department monthly for all Services performed in each previous month. Department shall remit payment to FNS within forty- five(45) days of receipt of an invoice, unless Department reasonably disputes the validity .or veracity of the information on the invoice. Department shall provide FNS with notice • of any such disputed information or amount within thirty (30) days of receipt of an invoice. 4. •Term. This Agreement shall he for a term of one year, commencing on the Effective Date and expiring on the first anniversary thereof(the "Initial 'Perm"). This Agreement shall be renewable only upon the mutual written agreement of both parties hereto (each, a "Renewal Term".and together with the Initial Term,the"Term"). 4.1. Termination. Either party may terminate this Agreement without cause at any time during the term of this Agreement by providing the other party at least thirty (30)days prior written notice of termination, 5. Indemnification. The parties each shall indemnify, defend, and hold the other party harmless from and against any and all claims, liability, loss, damages, costs, -. and expenses (including reasonable attorneys' fees) caused, or alleged to be caused, by the negligence or wrongful acts or omissions of such indemnifying party or its • employees, officers or agents. The provisions of this Section S shall survive the expiration or termination of this Agreement. 6. Insurance. FNS shall procure and Maintain at its own expense the following insurance: 6.1. Commercial General Liability Insurance in an amount not less than $1,000,000 per each occurrence and $2,000,000 general aggregate (claims made and modified occurrence policies are not acceptable) Insurance companies must be approved by the CITY, admitted and licensed in California, and have a 13est's Guide Rating of A-,Class VII or better, as approved by the CITY. • 6.2. Workers Compensation Insurance as required by the California Labor Code and employer's liability insurance in an amount not less than $1,000,000. This policy shall be endorsed to state that the insurer waives its right of subrogation against the City, its boards and commissions, and its officials, employees, and agents, • 6.3. •Professional Iiability or errors or omissions insurance in an amount not less than$1,000,000 per claim. 7. Confidentiality of Patient Information. None of the parties shall disclose any confidential patient health information to any third party, except where permitted or • • required by law or where the patient expressly approves such disclosure. FNS and the Department shall comply with all federal and state laws and regulations regarding the confidentiality of such information, including without limitation the Health Insurance .portability and Accountability Act (I-IIPAA)of 1996. • • 8. Non-Discrimination. By signing this Agreement, FNS certifies that.it does not discriminate in hiring or treatment on the basis of race, color, creed, religion, sex, • sexual orientation, age, mental status, national origin, ancestry, physical handicap, medical condition, or any other classification protected by State or Federal law. • 9: Non-Exclusivity. This Agreement is not exclusive, and nothing herein shall preclude either party from contracting with any other person or entity for any purpose. • 10. Notices. Any notices required or desired lb be given under this Agreement shall be in writing and personally delivered or deposited in the US Postal Service, first class. IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the date first written above. FORENSIC NURSE SPECIALISTS, CITY OF HUNTINGTON BEACH INC, (FNS) a professional Corporation POLICE DEPARTM e ' in the State of California "DEPARTMENT" /a1By 0�4-.4, tics, 4 By Name: Malinda Wheeler -- Title: President Name: zi C C, Ache 4 Title: OF POL-/CC- APPROVED as TO RM ( ✓ ICH L E.OA1 S CITY ATTORNEY rY Qf HUNTINGTON I3 ACN Receive and File 47s 9444414.40 City Clerk .EXHIBIT A- FEE SCHEDULE— 2023-2024 Service Definition Rate Sexual Assault Forensic Evidence collection, clothing, DNA reference $1200.00 Exam samples, blood and urine toxicology, digital photography, medical-forensic (All ages, reported or non- documentation using state mandated reported cases to law forms, healthcare treatment for STI enforcement) prevention, HIV prevention and pregnancy prevention provided at the time of the exam. • 7.1,21-CALOES REIMBURSES EACH • POLICE AGENCY$1127.00 PER EXAM Mobile Trauma Exam A forensic exam conducted at any Orange $1400.00 County hospital in the ER or ICU when a patient is severely injured and admitted to that other hospital for on-going medical care. (Requests for Mobile exams in nursing • homes and psychiatric facilities will be • conducted on a case-by-case basis.) Dry Run Department calls out the on-call forensic $300.00 nurse to perform a case and through no fault of FNS,the victim changes their mind, refuses to permit the examination, does not • want the examination, or does not permit forensic nurse to conduct the examination. Domestic Violence/ A forensic exam focused on body injury and $600.00 Strangulation Exam (DAFE) assessment with specific written and photographic documentation on strangulation injury. • Testimony Expert witness testimony by the forensic $500.00/day nurse upon receipt of subpoena form the in court on District Attorney's office the stand � ® A�Ro DATE(MM/ODJYYYY)CERTIFICATE OF LIABILITY INSURANCE 8/29/2023 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 policy(ies)must have ADDITIONAL INSURED provisions or be 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 lieu of such endorsement(s). PRODUCER CONTACT Customer Service Aon Affinity Insurance Services, Inc. PHONE FAX 1100 Virginia Drive,Suite 250 Wc.NL.ExL): 1-888 288 3534 (A/C.No): Fort Washington,PA 19034-3278 ADDRESS: customer.service@hpsocover.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: INSURED INSURER B Forensic Nursing Specialist In 10413 Los Alamitos Boulevard INSURERC: Los Alamitos,CA 90720 INSURER D: United States INSURER E:American Casualty Company of Reading,PA 20427 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP (.(NITS LTR INSR WVD POLICY NUMBER (MMIDO/YYYYI IMM(DD/YYYYI COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 0732542425 DAMAGE TO RENTED CLAIMS-MADE X OCCUR 03/03/2023 03/03/2024 PREMISES(Ea occurrence) $ General Liability Endorsement MED EXP(Any one person) $ X PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,00,0000 POLICY PRO-JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE S EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY PER ER 1 N ANYPROPRIETOR/PARTNERIEXECUTIVE f ) N f A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Professional Liability 0732542425 03/03/2023 03/03/2024 Liability(Each claim)1,000,000 E Liability(Aggregate)6,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) APPROVED AS TO FORM Certificate Holder included as Additional Insured to the General Liability per the policy terms and conditions. i MICHAEL E.GATES CITY ATTORNEY CITY OF HUNTINGTON BEACH CERTIFICATE HOLDER CANCELLATION City of Huntington Beach SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2000 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Huntington Beach,CA,92648 AUTHORIZED REPRESENTTAATIVEE // ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ACCIPRDe CERTIFICATE OF LIABILITY INSURANCE DATE(A1it/DDIYf 9/30/2023 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 policy(les)must have ADDITIONAL INSURED provisions or be 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 lieu of such endorsement(s). PRODUCER CONTACT Malinda Wheeler Pie Insurance Services NM E: , 1755 Blake Street PHONE FAX 5th Floor (NC,No.Ext: WC,No): Denver, Co 80202 Email FNSMALINDA@GMAIL.COM Address: 00001 INSURERS)AFFORDING COVERAGE NAIC# INSURER SIRIUSPOINT AMERICA INSURANCE COMPANY 38776 INSURED INSURER B: Forensic Nurse Specialists Inc. INSURERC: 10912 Los Alamitos Blvd INSURERD: Los Alamitos, CA 90720-2112 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER REVISION NUMBER THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOA/ 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. LIMITSSHOWN MAYHAVE BEEN REDUCED BY PAID CLAIMS. INS TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP UMITS LTR INSRL WVD (MM/DD/YY) (MMIDD/YY) COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ CLAIMS-MADE C OCCUR DAMAGE TO RENTED $ PREMBES!Ea acCurreneel MED.EXP(My one person) $ PERSONAL&ADV INJURY $ 1 GEN'L AGGREGATE UMR APPLIES PER: GENERAL AGGREGATE $ POLICY [ ]PROJECT [] LOC PRODUCTS-COMP/OPAGG. $ OTHER $ AUTOMOBILE UABUTY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ — OWNS — SCHEDULED BODILY INJURY(Per accident) $ — AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ — EXC ESS UAB CLAIMS-MADE AGGREGATE $ DED I rIRETENTICN $ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABLITY Y I N STATUTE ER A ANY PROPRIETOR/PARTNER/E(ECUTNE N I A P:C19880-04 10/2/2023 10/2/2029 E.L EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) EL DISEASE-EACH EMPLOYEE $ 1,000,000 If yes,describe under DEMRIPTICN CF OPERATIONS helow EL oISFaSF-POLJCY uAI(T $ 1,000,000 ' DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) OUTPATIENT FORENSIC NURSING CERTIFICATE HOLDER CANCELLATION THE CITY OF HUNTINGTON BEACH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2000 MAIN ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. HUNTINGTON BEACH, CA 92648-2702 AUTHORIZED REPRESENTATIVE _ -- s__,. �� ©1968-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • Ac o® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 05/03/2023 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 policy(ies)must have ADDITIONAL.INSURED provisions or be 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 lieu of such endorsement(s). PRODUCER. CONTACT Deb Puglia Aon Affinity Insurance Services, Inc. PHONE 1-888-288-3634 FAX 1100 Virginia Drive, Suite 250 (A1C.No.Mitt: LAIC.No): Fort Washington,PA 19034-3278 ADDRESS: OUstomer.service@hpsacover.com INSURER(S)AFFORDING COVERAGE NAIL 11 INSURER A:American Casualty Company of Reading,PA 20427 INSURED INSURER B: Forensic Nursing Specialist Inc DBA Forensic Nurse 10413 Los Alamitos Boulevard INSURER C: Los Alamitos,CA,90720 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR IMPW DI VD POLICY NUMBER (MMIDDIYYYYI (MM!OYYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 0732542426 03/03/2023 03/03/2024 DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ General Liability-Occurrence MED EXP(Any one person) $ A PERSONAL&ADVINJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,000,000 X POLICY jECT LOC PRODUCTS-COMPIOPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ AWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) $ UMBRELLALIAB _ OCCUR EACH OCCURRENCE $ EXCESS LJAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION PER ERH AND EMPLOYERS'LIABILITY Y I N ANYPROPRIETORIPARTNERIEXECUTIVE N!A E.L.EACH ACCIDENT $ RMEM OFF ICERBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ I1 yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Professional Liability 0732542425 03/03/2023 03/03/2024 Liability(Each claim):$1,000,000 A Liability(Aggregate):$6,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space Is required) APPRO ED RM NIIC EL E. GATES CITY ATTORNEY CITY OF HUNTINGTON REACH CERTIFICATE HOLDER CANCELLATION The City of Huntington Beach SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2000 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Huntington Beach,CA,92648 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVES ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD 0 CERTIFICATE OF LIABILITY INSURANCE DATE 5/ /2023 YY) 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 policy(Ies)must have ADDITIONAL INSURED provisions or be 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 endorsement(s), PRODUCER " racT Malinda Wheeler Pie Insurance Services NNE: - - 1755 Blake Street PHONE FAX 5th Floor 1A'C,No,Ext1: (NC,No): Denver, CO 80202 Email . FNSMALINDA@GMAIL,COM Address: 00001 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:SIRIUSPOINT AMERICA INSURANCE COMPANY 38776 INSURED INSURER B: Forensic Nurse Specialists Inc. INSURER C: 10912 Los Alamitos Blvd INSURERD: Los Alamitos, CA 90720-2112 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 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. LIMITSSHOWN MAYHAVEBEEN REDUCED BY PAID CLAIMS. INS TYPE OF INSURANCE �DL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSRD WVD (MM/DDIYY) (MMIDD/YY) COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ CIAIMS-MADE El OCCUR DAMAGETORENTED PRFM ISES lEa nccurrencal MED.EXP(My one person) $ PERSONAL&ADV INJURY $ ' GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ HPOLICY [J PROJECT.. p LOC PRODUCTS-COMP/OP AGG. - $ OTHER'. $ COMBINED SINGLE OMIT AUTOMOBILE LIABILITY $ (Ea accident) ..__ MY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON•OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY (Per accident) $. UMBRELLA LIPS I I OCCUR EACH OCCURRENCE _$ • EXC ESS LIAR I�--(CLAIMS-MADE AGGREGATE $ DED 1 1 RETENTION $ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY Y!N STATUTE ER A ANY PROPRIETOR/PARTNER/EXECUTIVE I ' NIA WC19880-02 10/2/2022 10/2/2023 EL EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) EL DISEASE•EACH EMPLOYEE $ 1,000,000 If yes,describe under DESCWPTION of OFERATIONS below EL DISEASE•POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) OUTPATIENT FORENSIC NURSING CERTIFICATE HOLDER CANCELLATION THE :CITY OF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE HUNTINGTON BEACH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 2000 MAIN ST AUTHORIZED REPRESENTATIVE -•^7 HUNTINGTON BEACH, CA 92648-2702 A .. ©1988-2015 ACORD CORPORATION.AII rights reserved. ACCORD 25(2016/03) The ACORD name and logo are registered marks of ACORD • WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 21 F (Ed. 08-2022 Countrywide, Ed. 07-2022 in Texas) Catastrophe(Other Than Certified Acts of Terrorism) Premium Endorsement This endorsement is notification that we are charging premium to cover the losses that may occur in the event of a Catastrophe(Other Than Certified Acts of Terrorism)as that term is defined below.Your policy provides coverage for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism). Coverage for such losses is subject to all terms,definitions, exclusions, and conditions in your policy, and any applicable federal and/or state laws, rules, or regulations.This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement attached to this policy. For purposes of this endorsement, Catastrophe(Other Than Certified Acts of Terrorism) is defined as:A single event or peril resulting in a group of claims with'aggregate workers compensation losses in excess of$50 million. This$50 million threshold applies per occurrence, across all states for which claims arise from a single event or peril. The premium charge for the coverage your policy provides for workers compensation losses,caused by a Catastrophe (Other Than Certified Acts of Terrorism)is shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium CA . 02 $99 This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 10-02--22 Policy No.WC19880 Endorsement No. 002 Insured Forensic Nurse Specialists Inc. Premium $Incl. Insurance Company SiriusPoint America Insurance Company Countersigned By Page 1 of 1 WC 00 04 21 F (Ed.08-2022 Countrywide, Ed.07-2022 in Texas) ©Copyright 2021 National Council on Compensation Insurance,Inc.All Rights Reserved. WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 0403 06 (Ed. 04-84) WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named In the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE PERSON OR ORGANIZATION JOB DESCRIPTION Any Person or Organization as required by written contract within , states covered, under this policy -This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 10-02-22 Policy No.WC 19880 03 Endorsement No. 002 Insured Forensic Nurse Specialists Premium $ Incl. Insurance Company SiriusPoint America Insurance Company Countersigned By 01998 by the Workers'Compensation Insurance Rating Bureau of California. All rights reserved. From the WCIRB's California Workers' Compensation Insurance Forms Manual O 1999.