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HomeMy WebLinkAboutOCEMT CORP; 2025-03-05;Docusign Envelope ID: 8C5E1501-AE9C-40BC-BD6E-DB94795A5F4C COLLEGE/PREHOSPITAL PROVIDER AGREEMENT TO PROVIDE SUPERVISED FIELD SERVICE EXPERIENCE FOR EMS PROGRAM STUDENTS This COLLEGE/PRE-HOSPITAL PROVIDER AGREEMENT (hereinafter referred to as "Agreement") is entered into by and between the OCEMT CORP, a California corporation, (hereinafter referred to as "COLLEGE") and the City of Carlsbad, a municipal corporation, (hereinafter referred to as "PROVIDER"). The COLLEGE and PROVIDER shall collectively be referred to as "THE PARTIES". The COLLEGE maintains an Emergency Medical Services Program for students studying in the fields of Emergency Medical Technician Basic ("EMT-B"), Emergency Medical Technician Intermediate (''EMT-I"), Emergency Medical Technician Paramedic ("EMT-P") (hereinafter collectively referred to as the "EMS Program"). The EMS Program has certain requirements for students to gain supervised field experience while enrolled in the EMS Program. The PROVIDER supplies emergency medical services to the community which lend themselves to the provision of said supervised field experience for students of the EMS Program. The PROVIDER shall retain complete responsibility for fire protection, disaster preparedness and response, fire prevention, rescue, hazardous materials mitigation, technical rescue response, medical emergency services, and public service assists (hereinafter called "FIRE SERVICES"). Students in the EMS Program are restricted from performing any FIRE SERVICES that are not EMS-related. The student's training experience will provide observation of the day-to-day responsibilities of the PROVIDER as well as provide the required hours and field experience in emergency medical patient care in correlation with the pertinent sections of Division 9 of Title 22 of the California Code of Regulations and Division 2.5 of the California Health and Safety Code. The PROVIDER shall retain ultimate responsibility at all times for the care of all patients receiving EMS treatment. NOW, THEREFORE, in consideration of the mutual covenants contained herein, the Parties hereto agree as follows: AGREEMENT 1. The COLLEGE shall: OCEMT2024 a. Assume full responsibility for the preparation of instructors for positions in EMS Program. Docusign Envelope ID: 8C5E1501-AE9C-40BC-BD6E-DB94795A5F4C b. Be responsible for the development, organization, and implementation of the EMS Program curriculum under the direction of a qualified EMS Program Director. Select test and supervise the students admitted to the EMS Program at the time of admittance and throughout the time prescribed for the student's completion of the EMS Program. c. Provide certified instructors to teach all prescribed courses in the EMS Program, including any instruction or training that may be carried on at the PROVIDER's facilities. The instructors and the Director of EMS Program shall be named, appointed, and assigned by the COLLEGE in accordance with its established procedures for employment of instructional personnel. d. Provide each new instructor an opportunity to participate in an orientation with the PROVIDER. This orientation shall be arranged through mutual agreement of the COLLEGE and the PROVIDER. e. Provide all instructional supplies and equipment as needed for the EMS Program, except those which the PROVIDER hereinafter specifically agrees to provide. f. Provide administrative functions, including admission, counseling, scheduling, attendance, accounting, and achievement records in connection with the EMS Program. Similar to those maintained for all other students at California EMS Academy. g. Furnish copies of class schedules and student rotation assignments to the PROVIDER, prepared by the EMS Program Director after consultation with the PROVIDER. h. Provide documentation that recognizes the EMS Program meets national standards and is an accredited program through CAAHEP and CoAEMSP. i. Provide PROVIDER a copy of the Emergency Notification Form for each student prior to participation in the EMS Program Field Training. j. Provide the students with the proper Personal Protective Equipment (PPE) for their internship 2. The PROVIDER shall provide the following: OCEMT 2024 a. The cooperation and counsel to help ensure success of the EMS Program. Docusign Envelope ID: 8C5E1501-AE9C-40BC-BD6E-DB94795A5F4C b. As broad an experience as possible with opportunities for observation, participation, or independent activity involving day-to-day responsibilities of emergency medical patient care through the program offered by the PROVIDER. c. Always retain complete control and responsibility of victim/patient care as well as supervision and oversight of students' participation. 3. Should emergency treatment be necessary for students in the event of an accident or sudden illness, the cost of such treatment shall be covered by the student. It will be the duty and obligation of the COLLEGE to ensure that a claim is properly filed with the COLLEGE's Risk Management Department. The Parties agree that the standards of the EMS Program shall be maintained at a level equal to or exceeding those required by the state of California as outlined in r le 22 of the Code of Regulations. The student must make notification to their preceptor (while on-duty or off-duty) if the student begins to show signs and symptoms ofCOVID-19. 4. The Parties agree that, while participating in the EMS Training Program, the students and staff of the COLLEGE are not functioning as employees or agents of the PROVIDER, nor shall they become employees or agents of the PROVIDER by virtue of their participation in the EMS Program, but shall be subject to and shall abide by all PROVIDER rules, regulations, ahd policies, including, but not limited to: those governing professional conduct, confidentiality, discrimination, affirmative action, substance abuse, and Blood Borne Pathogen Control Plan. In the event a student fails or refuses to do so, the PROVIDER reserves the right to deny the use of its facilities and services by such student. 5. Each student in the EMS Program, before beginning field training with the PROVIDER, shall have on file, documentation of health status with the College EMS Program Director including documentation of negative TB test within the previous year, and current Hepatitis 8 vaccination. This documentation shall be provided by PROVIDER upon request. 6. The number of students participating in the EMS Program who are assigned to the PROVIDER shall be determined by mutual agreement of the Parties. 7. Per Division 9 of Title 22 of the California Code of Regulations; no more than one (1) EMT student, of any level, shall be assigned to a response vehicle at any one time during the student's field training. 8. Students are not authorized to drive any PROVIDER vehicle but may ride in such vehicles during their participation in this program when driven by a PROVIDER employee. OCEMT 2024 Docusign Envelope ID: 8C5E1501-AE9C-40BC-BD6E-DB94795A5F4C 9. A strict code of confidentiality of victim/patient information shall be maintained by all participants in the EMS Program. a. Students will sign a Statement of Confidentiality as part of the Orientation. This signature binds the student to maintain patient confidentiality throughout the field experience. No copies of patient records shall be made, and no records or copies thereof shall be removed from the PROVIDER. b. The discussion, transmission, or narration in any form by students of any individually identifiable client/patient information, medical or otherwise, obtained during the EMS Program is forbidden. Students shall use de-identified information only in any discussions about the clinical experience with the COLLEGE, its employees, or agents as a necessary part of the practical experience. c. In the event of an individual's failure to comply with the confidentiality requirements, or his/her refusal to enter into a confidentiality agreement required to be entered into with the PROVIDER's resources, as applicable, shall be denied approval to participate under this Agreement. 10. Initial Term and Renewal a. The term of this Agreement shall be from the last date of final execution to December 31, 2029. b. One hundred eighty (180) days before the date of expiration of this Agreement. COLLEGE shall give PROVIDER written notice of whether COLLEGE intends to extend this Agreement or enter into a new agreement with PROVIDER for EMS Program services. 11. Termination Either party to this Agreement may terminate this Agreement by providing a written notice of termination to the other party hereto no less than one (1) month before the expiration of the term hereof. If such notice is given unilaterally by PROVIDER or COLLEGE, PROVIDER agrees those students enrol1ed at the time in the EMS Program may be permitted to complete their field training pursuant to this agreement in the sole discretion of the PROVIDER on the condition the COLLEGE agrees to continue the effectiveness of the provisions of this Agreement with regard to the students. 12. Discrimination OCEMT2024 Docusign Envelope ID: 8C5E1501-AE9C-40BC-BD6E-DB94795A5F4C The COLLEGE employees, agents, and students accessing PROVIDER'S resources shall not discriminate in the provision of services, allocation of benefits, accommodation in facilities, or employment of personnel on the basis of race, religion, medical condition, disability, marital status, sex, age, or sexual orientation and shall comply with all other requirements of law regarding nondiscrimination and affirmative action including those laws pertaining to the prohibition of discrimination against qualified handicapped persons in all programs or activities. For the purposes of this Agreement, distinction on the grounds of race, religion, medical condition, disability, marital status, sex, age, or sexual orientation include, but not limited to, the following: a. Denying an eligible person or providing to an eligible person any service or benefit which is different, or is provided in a different manner or at a different time from that provided to other eligible persons under this Agreement. b. Subjecting an eligible person to segregation or separate treatment in any manner related to his/her receipt of any service or benefit, except when necessary for infection control. c. Restricting an eligible person in any way in the enjoyment of any advantage or privilege enjoyed by others receiving a similar service or benefit. d. Treatment of an eligible person differently from others in determining whether he/she has satisfied any eligibility, membership, or other requirement or condition that individuals must meet to be provided the same or similar service or benefit. e. The assignment of times or places for the provision of services on the basis of race, religion, medical condition, disability, marital status, sex, age or sexual orientation of the eligible person to be served. 13. Insurance COLLEGE shall purchase and maintain during the duration of this Agreement and after the expiration of this Agreement as provided below, the following insurance coverage: OCEMT2024 a. Worker's compensation and employer's liability coverage for COLLEGE's legal and statutory obligations for damages due to bodily injuries either by accident or disease, occurring to COLLEGE's employees, agents, or servants as a result of employment. b. General liability covering COLLEGE, its agents, students, employees, and servants for bodily injury personal injury, or property damage Docusign Envelope ID: 8C5E1501-AE9C-40BC-BO6E-OB94795A5F4C claims ansmg out of the premises, products or activities of the COLLEGE. Minimum limits of liability for the above coverage shall be $1,000,000 per occurrence and $3,000,000 aggregate for bodily injury and property damage. c. Professional liability covering COLLEGE, its agents, employees, and servants for bodily injury and personal injury claims of victim/patients arising out of the rendering or failure to render care by COLLEGE, its agents, students, employees or servants. Minimum limits of liability shall be $1,000,000 per incident and $3,000,000 annual aggregate. If such coverage is through a "claims made policy and is either canceled, replaced or non-renewed, COLLEGE shall obtain and maintain extended coverage ("tail") insurance covering occurrences during the effective period of this Agreement. d. All students performing fieldwork, internships and similar activities who are registered in for-credit courses for which the internships are required are covered with the College's general and /or professional liability insurance with blanket policies. e. The policies required hereunder shall provide for written notice to PROVIDER at least thirty (30) days prior to the cancellation or modification of any above-mentioned insurance. f. College shall provide PROVIDER with certificates of insurance as evidence that all coverage required under this Agreement listed above has been obtained and is in full force and effect. PROVIDER shall be named on all policies required under this Agreement as an additional insured per the requirements of this Agreement. Certificates of Insurance must be supplied within five (5) days of the effective date of this Agreement, and thereafter prior to the expiration date noted upon each certificate. Such policies and the insurers thereunder shall be subject to reasonable and good faith approval by PROVIDER. 14. Indemnification and Hold Harmless To the fullest extent permitted by applicable law, COLLEGE shall and does agree to indemnify, protect, defend and hold harmless PROVIDER, its agencies, departments, directors, officers, agents, elected and appointed officials and representatives ( collectively, "Indemnitees") for, from and against any and all liabilities, claims, damages, losses, liens, causes of action, suits awards, judgments and expenses, attorney and /or consultant fees and costs, taxable or otherwise, of any nature, kind, or description of any person or enemy, directly or indirectly arising out of, caused by , or resulting from (1) the services performed hereunder, by COLLEGE and student, or any part thereof, (2) the Agreement, including any approved amendments or modifications, or OCEMT 2024 Docusign Envelope ID: 8C5E1501-AE9C-40BC-BD6E-DB94795A5F4C (3) any negligent act of omission of COLLEGE, its students, its officers, employees, subcontractors, agents, or representatives (collectively, "liabilities"). Notwithstanding the foregoing, the only liabilities with respect to which COLLEGE'S obligation to indemnify, including the cost to defend, the Indemnities does not apply is with respect to liabilities resulting from the negligence or willful misconduct of an Indemnitee, or to the extent such claims to not arise out of, pertain to or relate to the Scope of Work in the Agreement. To the fullest extent permitted by applicable law, PROVIDER shall and does agree to indemnify, protect, defend and hold harmless COLLEGE, its agencies, districts, special districts and departments, their respective directors, officers elected, and appointed officials, employees, agents and representatives ( collectively, "Indemnitees") for, from and against any and all liabilities, claims, damages, losses, liens, causes of action, suits, awards, judgments, and expenses, attorney and/or consultant fees and costs, taxable or otherwise, or any nature, kind or description or any person or entity, directly or indirectly arising out of, caused by, or resulting from (1) the Services performed hereunder by PROVIDER, or any part thereof, (2) the Agreement, including any approved amendments or modifications, or (3) any negligent act or omission of PROVIDER, its officers, employees, subcontractors, agents, or representatives (collectively, "Liabilities"). Notwithstanding the foregoing, the only Liabilities with respect to which PROVIDER's obligation to indemnify, including the cost to defend, the Indemnitees does not apply is with respect to Liabilities resulting from the negligence or willful misconduct of an Indemnitee, or to the extent such claims do not arise our of, pertain to or relate to the Scope of Work in the Agreement. 15. Disputes COLLEGE shall select and appoint a "Contract Administrator" who shall under the supervision and direction of COLLEGE, be available for contract resolution or policy intervention with PROVIDER, when, upon determination by the Chief that a situation exists under this Agreement in which a decision to serve the interest of COLLEGE has the potential to conflict with PROVIDER interest or policy. Any dispute concerning a question of fact arising under the terms of this agreement that is not disposed of within a reasonable period of time by the COLLEGE and PROVIDER employees normally responsible for the administration of this Agreement shall be brought to the attention of the Chief Executive Officer ( or designated representative) of each organization for joint resolution. For purposes of this provision, a "reasonable period of time" shall be ten (10) calendar days or less. COLLEGE and PROVIDER agree to continue with the responsibilities under this Agreement during any dispute. Disputes that are not resolved informally by and between COLLEGE and PROVIDER representatives may be resolved, by mutual agreement of the parties, through mediation. The costs associated with the selected form of dispute resolution such as mediation or non-binding arbitration shall be shared equally among OCEMT2024 Docusign Envelope ID: 8C5E1501-AE9C-40BC-BD6E-DB94795A5F4C the participating parties. If the alternate form of dispute resolution does not resolve the issue(s), the parties reserve the right to seek remedies as provided by law or in equity. Venue for litigation shall be in San Diego County. Any claims or causes of actions, whether they arise out of unresolved disputes as specified in the Section or claims by third parties that are made against the PROVIDER, shall be submitted to the Office of the Clerk of the Board for the County of Orange in a timely manner. 16. Delivery of Notices Any notices to be served pursuant to this Agreement shall be considered delivered when deposited in the United States mail and address to: PROVIDER City of Carlsbad Fire Department 2560 Orion Way Carlsbad, CA 92010 COLLEGE Orange County EMT 26489 Rancho Parkway Lake Forest, CA 92630 Provisions of this section do not preclude any notices being delivered in person to the addresses shown above. Delivery in person shall constitute service hereunder, effective when such service is made. 17. Entire Contract This agreement contains the whole contract between the parties for the provision of Preceptor Services. It may be amended or modified upon the mutual written consent of the parties hereto. This Agreement does NOT supplement other specific agreements entered into by both parties for equipment or facilities, and excepting those equipment or facilities agreements, this Agreement cancels and supersedes any previous agreement for the same or similar service. This Agreement may be executed in duplicate counterpart originals, each of which is deemed to be an original, and all of which when taken shall constitute one and the same instrument. OCEMT 2024 Docusign Envelope ID: 8C5E1501-AE9C--40BC-BO6E-DB94795A5F4C In WITNESS WHEREOF, the duly authorized officials of the parties hereto have, in their respective capacities, set their hands as of the date first here in above written. 3/5/2025 DATED: ------ OCEMT 2024 ORANGE COUNTY EMT Name: PWY ~LL City of Carlsbad Fire Department Michael Calderwood Name: _________ _ Fire chief Title: __________ _ BY: M,~\\M..\ C.......\Ju-wooJ APPROVED AS TO FORM: CINDIE K. McMAHON, City Attorney Docusign Envelope ID: 8C5E1501-AE9C-40BC-BD6E-DB94795A5F4C ,,.....--, ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/YYYY) ~ 02/10/2025 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 be endorsed. If SUBROGATION I::; 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 NAME-;--• Lindsay Luxenberg Sav-Lux Insurance Services F1J8,NJo, Ext): 949-444-9969 I (IVC, No): 949-420-2156 P.O.Box74913 !:-MAIL Lindsay@savlux.com ADDRESS: INSURER($) AFFORDING COVERAGE NAIC# San Clemente CA 92673 INSURER A: Mesa Underwriters Specialty Insurance INSURED INSURERS: State Compensation Insurance Fund 35076 Orange County EMT INSURER C: American Casualty Company of Reading, Pennsylvania 20427 26489 Rancho Parkway South INSURER D: Unit 150 INSURER E: Lake Forest CA 92630 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. 1LTR ~-(MM/DDNYYY) ,-CAr TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 -~ CLAIMS-MADE ~ OCCUR UAIVlAL,t: I U Kt:N I t:U PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 ~ A y y MP000400701871007 05/28/2024 05/28/2025 PERSONAL & ADV INJURY $ Excluded ~ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 4,000,000 ~ □PRO-LOC PRODUCTS -COMP/OP AGG $ Excluded POLICY JECT OTHER: $ AUTOMOBILE LIABILITY (Ea accidentf'NGLt: LIMI I $ - ANY AUTO BODILY INJURY (Per person) $ ~ ALL OWNED -SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ ~ -NON-OWNED (P~'i';icid1e~trMAGt: $ HIRED AUTOS AUTOS ~ -$ UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ f--- EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION XI STATUTE I I '€It-AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE IT] NIA E.L. EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDED? y 923834820 06/01/2024 06/01/2025 (Mandatory in NH) E.L. DISEASE -EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE -POLICY LIMIT $ 1,000,000 C Professional Liability 0127309331 06/01/2024 06/01/2025 Limit: $2,000,000 Claim/$5,000,000 Agg DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Carlsbad Fire Department ACCORDANCE WITH THE POLICY PROVISIONS. 2560 Orion Way AUTHORIZED REPRESENTATIVE Carlsbad CA 92010 A1u-&a,j1 AtA:ut4€1,f I © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Docusign Envelope ID: 8C5E1501-AE9C-40BC-BD6E-DB94795A5F4C POLICY NUMBER: MP000400701871007 COMMERCIAL GENERAL LIABILITY CG 20 01 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and CG 20 01 0413 © Insurance Services Office, Inc., 2012 Insured Copy Page 1 of 1 POLICY NUMBER: MP000400701871007 COMMERCIAL GENERAL LIABILITY CG 20 10 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED -OWNERS, LESSEES OR CONTRACTORS -SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Location(s) Of Covered Operations Or Or : City of Carlsbad Fire Department Carlsbad and Surrounding Areas Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II -Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; in the performance of your ongoing operations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following additional exclusions apply: This insurance does not apply to "bodily injury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional insured(s} at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. CG 2010 0413 © Insurance Services Office, Inc., 2012 Insured Copy Page 1 of 2 C. With respect to the insurance afforded to these additional insureds, the following is added to Section Ill -Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 10 0413 © Insurance Services Office, Inc., 2012 Insured Copy Page 2 of 2 Docusign Envelope ID: 043A868E-07F4-45B3-8EE8-C2A16A92A5C7 WAIVER REQUEST FORM FACTORS IN SUPPORT OF REQUEST TO MODIFY INSURANCE REQUIREMENT(S) Generally, a modification to the coverage requirement will be accepting a lower limit of coverage or waiving the requirement( s). Requested by: Jennie Marinov 2/24/25 (Name and Department) (Date) Proposed modification( s) to the _a_ut_o_m_o_b_ile _____ requirement( s) for _O_C_E_M_T_C_o~rp ________ _ (Type of insurance) (Name of contract) D Reduce coverage to the amount of: ~$ ______ _ D Waive coverage 00 Other: ---------------------------------- FACTOR(S) IN SUPPORT OF MODIFICATION(S) (check those that apply) □Significance of Contractor: Contractor has previous experience with the City that is important to the efficiency of completing the scope of work and the quality of the work-product. [explain] ______ _ □Significance of Contractor: Contractor has unique skills and there are few if any alternatives. [explain: include number of candidates RFP sent to and number responded if applicable] __________ _ □Contract Amount/Term of Contract: $ _______ . Work will be completed over a period of __ _ □Professional Liability coverage is not available to this contractor or would increase the cost of the contract by $ [explain]. ____________________________ _ 00Other (e.g. explain why exposures are minimal, how exposures are covered in another policy, exposure control mechanisms, and any other information pertinent to your request): This is an EMS training program for EMT students to gain supervised field experience. Students are not authorized to drive any city vehicle but may ride in such vehicles during their participation in this program when driven by a city employee. Approved by Risk Manager for this contract only: 3/5/2025 (Signature) (Date)