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HomeMy WebLinkAbout2002-09-24; City Council; 16905; Third Party Administration of Workers' Comp ClaimsCITY OF CARLSBAD - AGENDA BILL &.T .,’ ,B # 16,qnc. DEPT. HDU J.6 TITLE: ITG. 9-24-02 CITY AT RATIFICATION OF AND CONTRACT FOR THIRD PARTY IEPT. HR ADMINISTRATION OF WORKERS’ COMPENSATION CLAIMS IECOMMENDED ACTION: Approval of Resolution No. 2002-287awarding the contract for the third party administration of workers’ compensations claims to TRISTAR Risk Management. ITEM EXPLANATION: The current contract with TRISTAR Risk Management, administrator of the City’s workers’ compensation claims, expired on June 30, 2002. Contractor has been performing the work since July 1,2002, without the benefit of an agreement and the parties desire to ratify this work. Staff distributed a request for proposal for workers’ compensation benefits administration on February 25, 2002, and subsequently received responses from four (4) firms. The proposals were evaluated based on quality of the proposals, experience, staff qualifications and level of services available. Two of the four firms were invited to a panel interview: TFUSTAR Risk Management and Hazelrigg Risk Management Services. Representatives from Human Resources, Police and Fire interviewed the top two firms. Based on the results of the evaluation process and the ability to enter into a three year contract, staff is recommending that Council approve the agreement with TRISTAR Risk Management as shown as Exhibit 2. The proposed workers’ compensation administrative fee for fiscal year 2002/2003 is $90,000. The attached agreement also includes an increase in the administrative fees for the second and third years of the contract of three percent (3%) per year. The annual workers’ compensation administrative fee has remained at $60,000 since 1997. The proposed increase in administrative fees to $90,000 reflects: 1) an increase in the total number of City of Carlsbad employees since 1997 and, therefore, an increase in the number of workers’ workers’ compensation administration field. compensation claims, and 2) significant salary increases given to employees who work in the FISCAL IMPACT: The annual cost of the workers’ compensation administrative fee for fiscal year 2002/2003 is 2003/2004 and 2004/2005 will be $92,700 and $95,481, respectively. $90,000. The annual cost of the workers’ compensation administrative fee in fiscal years Funding for the fiscal year 2002/2003 expenses, due to the proposed outline above, is included in the fiscal year 2002/2003 budget. Future fiscal year impacts will be reflected during the annual budget process. EXHIBITS: 1. Resolution No. 2002-287 2. Ratification of and Agreement with TRISTAR Risk Management I I ! 1( 1‘ 1; 1: 14 15 1E 17 10 19 20 21 22 23 24 25 26 27 28 RESOLUTIONNO. 2002-287 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF CARLSBAD, CALIFORNIA, AUTHORIZING AWARD OF CONTRACT TO TRISTAR RISK MANAGEMENT. WHEREAS, the City Council has determined that the City requires professional services of a third party administrator that is experienced in managing and administering the City’s workers’ compensation claims. NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of Carlsbad, California, as follows: I. That the above recitation is hue and correct. 2. That the City Council approves the attached Ratification of and Agreement (Exhibit 2) awarding the contract to TRISTAR Risk Management to provide third party administration of workers’ compensation claims. NOW, THEREFORE, BE IT RESOLVED by the City Council for the City of Carlsbad, California, as follows: 1. That the above recitations are hue and correct. Ill Ill Ill Ill Ill Ill Ill Ill l- 1 2 c 4 C E 7 e 9 la 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 2. That the award of contract to provide Third Party Administration services with TRISTAR Risk Management is hereby approved . PASSED, APPROVED, AND ADOPTED at a regular meeting of the Carlsbad City Council held on the Xhday of SEPTEMBER , 2002; by the following vote, to wit: AYES: Council Members Lewis, Finnila, Hall NOES: None ABSENT: Council Members Kulchi ATTEST: M. WOOD, City Clerk Resolution No. 2002-287 RATIFICATION OF AND AGREEMENT FOR THIRD PARTY ADMINISTRATIVE SERVICES TRISTAR Risk Management THIS AGREEMENT is made and entered into as of theeday 3129 ?&&@a of 2002, but is effective as of July 1,2002, by and between the CITY OF CARLSBAD, a municipal corporation, ("City"), and TRISTAR Risk Management, a privately held Corporation. RECITALS A. City requires the professional services of a third party administrator that is experienced in managing and administering the City's workers' compensation claims. B. Contractor has the necessary' experience in providing professional services and advice related to workers' compensation. C. Selection of Contractor is expected to achieve the desired results in an expedited fashion. D. Contractor has submitted a proposal to City and has affirmed its willingness and ability to perform such work. E. Contractor has been performing the work since July 1,2002, without the benefit of an agreement and the parties desire to ratify this work. NOW, THEREFORE, in consideration of these recitals and the mutual covenants contained herein, City and Contractor agree as follows: 1. SCOPE OF WORK City retains Contractor to perform, and Contractor agrees to render, those services (the "Services") that are defined in attached Exhibit "A", which is incorporated by this reference in accordance with this Agreement's terms and conditions. Any services performed since July 1,2002, are hereby ratified. 2. STANDARD OF PERFORMANCE While performing the Services, Contractor will exercise the reasonable professional care and skill customarily exercised by reputable members of Contractor's profession practicing in the Metropolitan Southern California Area, and will use reasonable diligence and best judgment while exercising its professional skill and expertise. 3. - TERM The term of this Agreement will be effective for a period of three (3) years from the date first above written, subject to the annual appropriation of funds by the City Council. The City Manager may amend the Agreement to extend it for two (2) additional one (1) year periods or parts thereof in an amount not to exceed one hundred ten thousand dollars 1 of 28 ($1 10,000) per Agreement year. Extensions will be based upon a satisfactory review of Contractor's performance, City needs, and appropriation of funds by the City Council. The parties will prepare a written amendment indicating the effective date and length of the extended Agreement. 4. TIME IS OF THE ESSENCE Time is of the essence for each and every provision of this Agreement. 5. COMPENSATION The total fee payable monthly in advance for the services to be performed during the initial Agreement term will be: Year One (1): $90,000.00/12 = $7500.00 Year Two (2): $92,700.00/12 = $7725.00 Year Three (3): $95,481.00112 = $7956.00 This fee covers handling of all new and continuing indemnity files, and all medical only files for the period of the Agreement. Also, this fee was premised on an estimated annual (open) claims volume of 108 indemnity files and 40 medical only files. Should the actual claim volumes be less than or exceed these estimates by 15% due to an acquisition or sale of facilities by the City, a significant change in the number of employees or as a result of a catastrophic loss, then both parties will agree to negotiate in good faith, as to a reasonable fee adjustment. No other compensation for the Services will be allowed except for items covered by subsequent amendments to this Agreement. The City reserves the right to withhold a ten percent (10%) retention until City has accepted the work andlor Services specified in Exhibit "A". Incremental payments, if applicable, should be made as outlined in attached Exhibit "A. 6. STATUS OF CONTRACTOR Contractor will perform the Services in Contractor's own way as an independent contractor and in pursuit of Contractor's independent calling, and not as an employee of City. Contractor will be under control of City only as to the result to be accomplished, but will consult with City as necessary. The persons used by Contractor to provide services under this Agreement will not be considered employees of City for any purposes. The payment made to Contractor pursuant to the Agreement will be the full and complete compensation to which Contractor is entitled. City will not make any federal or state tax withholdings on behalf of Contractor or its agents, employees or subcontractors. City will not be required to pay any workers' compensation insurance or unemployment contributions on behalf of Contractor or its employees or subcontractors. 2 of 28 c Contractor agrees to indemnify City within thirty (30) days for any tax, retirement contribution, social security, overtime payment, unemployment payment or workers' compensation payment which City may be required to make on behalf of Contractor or any agent, employee, or subcontractor of Contractor for work done under this Agreement. At the City's election, City may deduct the indemnification amount from any balance owing to Contractor. 7. SUBCONTRACTING Contractor will not subcontract any portion of the Services without prior written approval of City. If Contractor subcontracts any of the Services, Contractor will be fully responsible to City for the acts and omissions of Contractor's subcontractor and of the persons either directly or indirectly employed by the subcontractor, as Contractor is for the acts and omissions of persons directly employed by Contractor. Nothing contained in this Agreement will create any contractual relationship between any subcontractor of Contractor and City. Contractor will be responsible for payment of subcontractors. Contractor will bind every subcontractor and every subcontractor of a subcontractor by the terms of this Agreement applicable to Contractor's work unless specifically noted to the contrary in the subcontract and approved in writing by City. 8. OTHER CONTRACTORS The City reserves the right to employ other Contractors in connection with the Services. 9. INDEMNIFICATION Except as otherwise provided in Exhibit "C", Audit Unit Penalty Assessment Guidelines, Contractor aarees to indemnify and hold harmless the City and its officers, officials, - employees and volunteers from and against all claims, damages, losses and expenses including attorneys fees arising out of the performance of the work described herein caused in whole or in part by any willful misconduct or negligent act or omission of the Contractor, any subcontractor, anyone directly or indirectly employed by any of them or anyone for whose acts any of them may be liable. The parties expressly agree that any payment, attorney's fee, costs or expense City incurs or makes to or on behalf of an injured employee under the City's self- administered workers' compensation is included as a loss, expense or cost for the purposes of this section, and that this section will survive the expiration or early termination of this Agreement. 10. INSURANCE Contractor will obtain and maintain for the duration of the Agreement and any and all amendments, insurance against claims for injuries to persons or damage to property which may arise out of or in connection with performance of the services by Contractor or Contractor's agents, representatives, employees or subcontractors. The insurance will be obtained from an insurance carrier admitted and authorized to do business in the State of California. The insurance carrier is required to have a current Best's Key Rating of not less than "A-:V". 3 of 28 10.1 Coveraues and Limits. Contractor will maintain the types of coverages and minimum limits indicated below, unless City Attorney or City- Manager approves a lower amount. These minimum amounts of coverage will not constitute any limitations or cap on Contractor's indemnification obligations under this Agreement. City, its officers, agents and employees make no representation that the limits of the insurance specified to be carried by Contractor pursuant to this Agreement are adequate to protect Contractor. If Contractor believes that any required insurance coverage is inadequate, Contractor will obtain such additional insurance coverage, as Contractor deems adequate, at Contractor's sole expense. 10.1. General Liabilitv Insurance. $1,000,000 combined single-limit per occurrence for bodily injury, personal injury and property damage. If the submitted policies contain aggregate limits, general aggregate limits will apply separately to the work under this Agreement or the general aggregate will be twice the required per occurrence limit. 10.1.2 Automobile Liability (if the use of an automobile is involved for Contractor's work for City). $1.000.000 combined single-limit per accident for bodily injury and property damage. 10.1.3 Workers' Compensation and Emplover's Liability. Workers' Compensation limits as required by the California Labor Code and Employer's Liability limits of $1,000,000 per accident for bodily injury. Workers' Compensation and Employer's Liability insurance will not be required if Contractor has no employees and provides, to City's satisfaction, a declaration stating this. 10.1.4 Professional Liabilitv. Errors and omissions liability appropriate to Contractor's profession with limits of not less than $1,000,000 per claim. Coverage must be maintained for a period of five years following the date of completion of the work. 10.2. Additional Provisions. Contractor will ensure that the policies of insurance required under this Agreement contain, or are endorsed to contain, the following provisions: 10.2.1 The City will be named as an additional insured on General 10.2.2 Contractor will obtain occurrence coverage, excluding Professional Liability. Liability, which will be written as claims-made coverage. 10.2.3 This insurance will be in force during the life of the Agreement and any extensions of it and will not be canceled without thirty (30) days prior written notice to City sent by certified mail pursuant to the Notice provisions of this Agreement. 4 of 28 10.3 Providinq Certificates of Insurance and Endorsements. Prior to City's execution of this Agreement, Contractor will furnish certificates of insurance and endorsements to City. 10.4 Failure to Maintain Coveraae. If Contractor fails to maintain any of these insurance coverages, then City will have the option to declare Contractor in breach, or may purchase replacement insurance or pay the premiums that are due on existing policies in order to maintain the required coverages. Contractor is responsible for any payments made by City to obtain or maintain insurance and City may collect these payments from Contractor or deduct the amount paid from any sums due Contractor under this Agreement. 10.5 Submission of Insurance Policies. City reserves the right to require, at anytime, complete and certified copies of any or all required insurance policies and endorsements. 11. BUSINESS LICENSE Contractor will obtain and maintain a City of Carlsbad Business License for the term of the Agreement, as may be amended from time-to-time. 12. ACCOUNTING RECORDS Contractor will maintain complete and accurate records with respect to costs incurred under this Agreement. All records will be clearly identifiable. Contractor will allow a representative of City during normal business hours to examine, audit, and make transcripts or copies of records and any other documents created pursuant to this Agreement. Contractor will allow inspection of all work, data, documents, proceedings, and activities related to the Agreement for a period of three (3) years from the date of final payment under this Agreement. 13. OWNERSHIP OF DOCUMENTS All work products produced by Contractor or its agents, employees, and subcontractors pursuant to this Agreement is the property of City. In the event this Agreement is terminated, all work products produced by Contractor or its agents, employees and subcontractors pursuant to this Agreement will be delivered at once to City. Contractor will have the right to make one (1) copy of the work product for Contractor's records. 14. COPYRIGHTS Contractor agrees that all copyrights that arise from the services will be vested in City and Contractor relinquishes all claims to the copyrights in favor of City. 15. NOTICES The name of the persons who are authorized to give written notices or to receive written notice on behalf of City and on behalf of Contractor under this Agreement. .. - 5 of 28 For City: Deborah A. Harvey Benefits Administrator Human Resources Department City of Carlsbad 1635 Faraday Avenue Carlsbad, CA 92008 (760) 602-2435 TRISTAR Risk Management: Name: Thomas J. Veale Title: President Address 100 Oceangate Suite 700 Long Beach, CA. 90802 Phone No. (562) 495-6600 Each party will notify the other immediately of any changes of address that would require any notice or delivery to be directed to another address. 16. CONFLICT OF INTEREST City will evaluate Contractor‘s duties pursuant to this Agreement to determine whether disclosure under the Political Reform Act and City’s Conflict of Interest Code is required of Contractor or any of Contractor‘s employees, agents, or subcontractors. Should it be determined that disclosure is required, Contractor or Contractor’s affected employees, agents, or subcontractors will complete and file with the City Clerk those schedules specified by City and contained in the Statement of Economic Interests Form 700. Contractor, for Contractor and on behalf of Contractor’s agents, employees, subcontractors and consultants warrants that by execution of this Agreement, that they have no interest, present or contemplated, in the projects affected by this Agreement. Contractor further warrants that neither Contractor, nor Contractor’s agents, employees, subcontractors and consultants have any ancillary real property, business interests or income that will be affected by this Agreement or, alternatively, that Contractor will file with the City an affidavit disclosing this interest. 6 of 26 17. GENERAL COMPLIANCE WITH LAWS Contractor will keep fully informed of federal, state and local laws and ordinances and regulations which in any manner affect those employed by Contractor, or in any way affect the performance of the Services by Contractor. Contractor will at all times observe and comply with these laws, ordinances, and regulations and will be responsible for the compliance of Contractor's services with all applicable laws, ordinances and regulations. Contractor will be aware of the requirements of'the Immigration Reform and Control Act of 1986 and will comply with those requirements, including, but not limited to, verifying the eligibility for employment of all agents, employees, subcontractors and consultants that the services required by this Agreement. 18. DISCRIMINATION AND HARASSMENT PROHIBITED Contractor will comply with all applicable local, state and federal laws and regulations prohibiting discrimination and harassment. 19. DISPUTE RESOLUTION If a dispute should arise regarding the performance of the Services the following procedure will be used to resolve any questions of fact or interpretation not otherwise settled by agreement between the parties. Representatives of Contractor or City will reduce such questions, and their respective views, to writing, A copy of such documented dispute will be forwarded to both parties involved along with recommended methods of resolution, which would be of benefit to both parties. The representative receiving the letter will reply to the letter along with a recommended method of resolution within ten (IO) business days. If the resolution thus obtained is unsatisfactory to the aggrieved party. a letter outlining the disputes will be forwarded to the City Manager. The City Manager will consider the facts and solutions recommended by each party and may then opt to direct a solution to the problem. In such cases, the action of the City Manager will be binding upon the parties involved, although nothing in this procedure will prohibit the parties from seeking remedies available to them at law. 20. TERMINATION In the event of the Contractor's failure to prosecute, deliver, or perform the Services, City may terminate this Agreement for nonperformance by notifying Contractor by certified mail of the termination. If City decides to abandon or indefinitely postpone the work or services contemplated by this Agreement, City may terminate this Agreement upon written notice to Contractor. Upon notification of termination, Contractor has five (5) business days to make available for pick-up any documents owned by City and all work in progress to City address contained in this Agreement. City will make a determination of fact based upon the work product delivered to City and of the percentage of work that Contractor has performed which is usable and of worth to City in having the Agreemenbcompleted. Based upon that finding City will determine the final payment of the Agreement. 7 of 28 Either party upon tendering thirty (30) days written notice to the other party may terminate this Agreement. In this event and upon request of City, Contractor will assemble the work product and put it in order for proper filing and closing and make claims available for pick by the City. Contractor will be paid for work performed to the termination date; however, the total will not exceed the lump sum fee payable under this Agreement. City will make the final determination as to the portions of tasks completed and the compensation to be made. 21. COVENANTS AGAINST CONTINGENT FEES Contractor warrants that Contractor has not employed or retained any company or person, other than a bona fide employee working for Contractor, to solicit or secure this Agreement, and that Contractor has not paid or agreed to pay any company or person, other than a bona fide employee, any fee, commission, percentage, brokerage fee, gift, or any other consideration contingent upon, or resulting from, the award or making of this Agreement. For breach or violation of this warranty, City will have the right to annul this Agreement without liability, or, in its discretion, to deduct from the Agreement price or consideration, or othewise recover, the full amount of the fee, commission, percentage, brokerage fees, gift, or contingent fee. 22. CLAIMS AND LAWSUITS By signing' this Agreement, Contractor agrees that any Agreement claim submitted to City must be asserted as part of the Agreement process as set forth in .this Agreement and not in anticipation of litigation or in conjunction with litigation. Contractor acknowledges that if a false claim is submitted to City, it may be considered fraud and Contractor may be subject to criminal prosecution. Contractor acknowledges that California Government Code sections 12650 et seq., the False Claims Act applies to this Agreement and, provides for civil penalties where a person knowingly submits a false claim to a public entity. These provisions include false claims made with deliberate ignorance of the false information or in reckless disregard of the truth or falsity of information. If City seeks to recover penalties pursuant to the False Claims Act, it is entitled to recover its litigation costs, including attorney's fees. Contractor acknowledges that the filing of a false claim may subject Contractor to an administrative debarment proceeding as the result of which Contractor may be prevented to act as a Contractor on any public work or improvement for a period of up to five (5) years. Contractor acknowledges debarment by another jurisdiction is grounds for City to terminate this Agreement. 23. JURISDICTIONS AND VENUE Any action at law or in equity brought by either of the parties' for the purpose of enforcing a right or rights provided for by this Agreement will be tried in a court of competent jurisdiction in the County of San Diego, State of California, and the parties waive all provisions of law providing for a change of venue in these proceedings to any other county. .~ 8 of 28 24. SUCCESSORS AND ASSIGNS It is mutually understood and agreed that this Agreement will be binding upon City and Contractor and their respective successors. Neither this Agreement or any part of it nor any monies due or to become due under it may be assigned by Contractor without the prior consent of City, which shall not be unreasonably withheld. 25. ENTIRE AGREEMENT This Agreement. together with any other written document referred to or contemplated by it, along with the purchase order for this Agreement and its provisions, embody the entire Agreement and understanding between the parties relating to the subject matter of it. In case of conflict, the terms of the Agreement supersede the purchase order. Neither this Agreement nor any of its provisions may be amended, modified, waived or discharged except in a writing signed by both parties. 26. AUTHORITY The individuals executing this Agreement and the instruments referenced in it on behalf of Contractor each represent and warrant that they have the legal power, right and actual authority to bind Contractor to the terms and conditions of this Agreement. ent, a privately held Corporation 0 y: Sign Here Lcssw C nri)n-’&LC. (Print Name and Title) (Print Name and Title) ’ I corporation of the State of California ATTEST: n r 11 L&F&INE M. WOOD City Clerk 9 of 28 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT 0 1994 National NDlaN AIBDCiallOn. 0236 Rernmel Aue.. P.O. Box 7184 * Canoga Park. CA 91309-7189 Prod No 5907 Reorder. Call Toll-Free 1-800-076-6827 dpersonally known to me - OR -0 proved to me on the basis evidence to be the person(s) executed the .executed the instrument. OPTIONAL Though the information below is not required by law, it may prove valuable to persons mMng on the document and could prevent fraudulent removal and reattachment of lhis form to another daumwnt. Description of Attached Document 'J Document Date: Number of Pages: - .d Signer@) Other Than Named Above: Capacity(ies) Claimed by Signer(s) 0 Ndividual 0 Attorney-in-Fact 0 Trustee 0 Guardian or Conservator 0 Other: I I Signer Is Representing: I/ I I I Titk(s): 0 Partner - Limited 0 General 0 Attorney-in-Fact 0 Trustee 0 Other: Guardian or Conservator Signer Is Representing: I I If required by City, proper notarial acknowledgment of execution by contractor must be attached. If a Corporation, Agreement must be signed by one corporate officer from each of the following two groups. *Group A. **Group 6. Chairman, Secretary, President, or Assistant Secretary, Vice-president CFO or Assistant Treasurer Otherwise, the corporation must attach a resolution certified by the secretary or assistant secretary under corporate seal empowering the officer(s) signing to bind the corporation. APPROVED AS TO FORM: . BALL, City Attorney By: 8eeblryCityAttorney 4- LC -oz 10 of 28 EXHIBIT “A” SCOPE OF SERVICES 1. CLAIMS ADJUSTING AUTHORITY AND RESPONSIBILITIES OF TRISTAR 1.1 Subject to all the terms and conditions of this Agreement, TRISTAR shall have the authority and responsibility to provide claims adjusting and administration services to conclusion for the City in connection with claims or losses relating to occurrences during the period proscribed in Exhibit A. 1.2 In connection with its authority and responsibilities under this Agreement, TRISTAR shall: [a] Receive and examine, on behalf of the City, all claims reported to it and initiate procedures for the proper servicing of each claim. [b] Investigate and adjust, settle or deny all claims in accordance with applicable insurance laws. [c] Upon approval of the City, engage the services of persons or firms outside its organization for work in connection with investigations and adjustment of claims and to incur other “Allocated Loss Adjustment Expense” (as hereinafter defined) at the City’s expense. The City shall have the right to require TRISTAR to terminate the employment of any person or firm considered unsatisfactory by the City. [dl Establish and adequately reserve a claim file for each claim for which there is injury and/or anticipated liability and/or a formal claim has been made and code such claim in accordance with The City’s statistical data requirements as may be mutually agreed upon, such agreement not to be unreasonably withheld by either party. [e] Make timely payments of valid claims for compensation, rehabilitation expenses, and 11 of 28 other required benefits payable under applicable insurance laws, together with Allocated Loss Adjustment Expenses, out of funds provided by the City hereof subject to the limitations and requirements of this Agreement. If an authorized representative of the City directs in writing that any payment not be made, and if after receipt of such notice TRISTAR nevertheless makes such payment, the City shall be under no obligation to repay TRISTAR for such payment. [fJ Maintain an accurate and complete claim file on each reported claim which shall be available during normal business hours for inspection by the City, its representatives or by appropriate regulatory authorities. The City shall have the right to copy any and all claims files or any documents related to any claim. TRISTAR shall maintain and store closed claim files for no less than one year after the expiration of the statute of limitations applicable to each claim file or as otherwise directed by state. The provisions of this subsection may be restricted by state laws in which case the applicable law will govern. [g] Provide all forms necessary for efficient claims administration and prepare and timely file all legally required forms and reports with the appropriate state and federal agencies, including but not limited to filings required by Section 6041 of the Internal Revenue Code. [h] In connection with the performance of its obligations under this Agreement, provide claims examiners and perform the services to be rendered herein under in good faith, and in accordance with all applicable laws and regulations. [I] Protect and pursue any subrogation rights to the City which may arise upon payment of claims and notify the City of any subrogation 12 of 28 rights which, through litigation or otherwise, may be available to the City. Perform all administrative and clerical work in connection with Qualified Claims including the preparation of checks andlor drafts drawn on the loss fund established herein; and Respond immediately to any inquiry, complaint or request received from an Insurance Department. other Regulatory Agency, the City, claimant, agent, broker, or other interested party relating to a claim serviced under this Agreement; a copy of both the original inquiry and the TRISTARs response shall be provided in a timely manner to the City. Upon prior approval of the City, engage the services of licensed and/or Certified Health and Rehabilitation firms or individuals for Rehabilitation Management as required by state regulations. Report all cases involving suspected fraud to the appropriate state mandated agency. Settlement authority is not permitted on cases of suspected fraud unless TRISTAR receives written authority from the City. When operating in states that require fraud to be reported to the state insurance department. TRISTAR must maintain an internal special investigative unit or contract with an entity to provide such services. II. CLAIM SETTLEMENT AUTHORITY 2.1. Unless otherwise advised by the City or in cases of suspected fraud, TRISTAR shall have authority and control in all matters, pertaining to the handling of claims under this Agreement, except which involve or which are expected to involve aggregate expenditures (of loss and Allocated Loss Expenses) in excess of $20.000 unless otherwise agreed to by the City. For claims in excess of this amount, TRISTAR shall provide the City with a Narrative Serious Loss Report and a copy of the claim file. The Narrative Serious Loss 13 of 28 Report shall be in a form as may be mutually agreed upon, such agreement not to be unreasonably withheld by either party. Additional Narrative Serious Loss Reports shall be submitted whenever there is a change in the reserve on such claims. Unless otherwise advised by the City, TRISTAR shall continue to handle the claim but shall not settle the claim without first obtaining the approval of the City. 2.2 The City shall retain ultimate settlement authority for all claims serviced under the Policy. Notwithstanding the authority delegated to TRISTAR under this Agreement, The City shall have the option of taking over the handling and TRISTAR. settlement of any or all claims upon written notice to 2.3 TRISTAR shall comply with claims procedures and guidelines attached hereto as Exhibit 6, and such amendments or replacements thereto as may be agreed to by TRISTAR, such agreement not to be unreasonably withheld. V. DRAFT AUTHORITY AND ISSUANCE 3.1 TRISTAR shall have authority to draw upon a trust account (the “Loss Payment Account”), which shall be established for the payment of the City’s claims. Such authority may be revoked at any time by the City upon written notice. The Loss Payment Account will be replenished monthly by the City to an amount equal to two and one-half (2-1/2) months estimated paid losses based on an average of the last three months paid losses upon receipt of required monthly accountings. The City may review the adequacy of the account at any time and increase or decrease the account as necessary. TRISTAR shall be required, upon request of the City, to remit promptly any funds in the account in excess of the required amount as determined by the City. 3.2 Individual or aggregate loss payments in excess of $20.000 shall require the prior approval of The City. 3.3 All checks shall be accounted for by TRISTAR as on hand, issued, voided, or canceled. TRISTAR shall provide a monthly account to the City within fifteen (15) days after the end of the month for which the account is given. TRISTAR 14 of 28 shall have the responsibility for balancing the Loss Payment Account. A duplicate copy of all bank statement shall be sent to the City by TRISTAR. Copies of checks shall be made available to The City by TRISTAR upon City's request. IV. REPORTING REQUIREMENTS 4.1 4.2 4.3 TRISTAR shall provide monthly loss run reports to The City - - by hard copy on paper or in an acceptable electronic data format -- detailing by report period and inception to date, the following information by accident date: claim number, state, location number, total incurred expense, broken down by loss coveragelperil, allocated loss adjustment expense, outstanding reserves (loss and loss adjustment), salvage, subrogation, and such other information requested by The City. TRISTAR shall provide to The City monthly documentation identifying all loss payments and allocated loss expenses. TRISTAR agrees to provide The City with copies of all loss payments checks and allocated loss expense checks, refunds, recoveries and voided checks upon The City's request. Monthly loss reports shall be due within eight (8) business days after the end of the month for which they relate. 15 of 28 EXHIBIT B GENERAL CLAIMS PROCEDURES & GUIDELINES This exhibit describes general claims handling guidelines utilized by TRISTAR on our clients' behalf. TRISTAR will comply with all nrles, regulations and reporting requirements promulgated by state regulatory authorities as to adjusting, licensing, tenancy and claim settlement in each state where claims handling activities are contemplated or where claims adjusting takes place. All claims must be handled in compliance with these guidelines, incorporating the authority and reporting criteria outlined in the individual account contracts, as well as any special handling instructions agreed to by TRISTAR and its client where they may differ from these guidelines. CONTACTS & INVESTIGATIONS: 0 Upon first notice of injury or claim, the examiner must contact the employer (client) within 24 hours in order to substantiate causationlcompensability and evaluate subrogation possibilities. This contact should also be utilized to facilitate return to work as soon as possible, reinforce prompt reporting and the use of designated medical providers. Within 24 hours, contact with the injured worker should be made. This contact sets the tone for positive communication and will provide the examiner the opportunity to establish a good relationship with the injured worker, which may eliminate future problems that could lead to litigation. 0 Within three (3) working days, contact with the treating medical provider should occur. The purpose of this contact is to evaluate the nature and extent of injury, verify causal relationship, determine disability status and treatment plan, including diagnosis and prognosis, and to provide any necessary authorization. Discussion of return to work should also occur with an effort to identify current physical restrictions with a consideration of potential modified or alternate work. 0 Initial investigation should be completed and a reserve established within five (5) working days. 16 of 28 Prompt follow-up work should be accomplished to complete or investigate new or ongoing issues. Appropriate field investigations should be conducted in order to properly evaluate and defend questionable claims, to develop and advance subrogation and contribution claims. All coverage issues must be identified, investigated and evaluated. Refer any actual or potential coverage issues to the Client, with recommendations. RESERVING: a Initial reserves should be promptly established (within five (5) working days in most cases), and should reflect the estimated ultimate value of each reported claim. Reserving should be realistic and should be established based on the available evidence in the file along with the experience and expertise of the examiner handling the case. Revisions to outstanding case reserves must be made immediately when significant developments occur that change the established ultimate value of a claim. Claims exceeding the authority level indicated within the Agreement must be reviewed and approved by the Client. Reporting requirements should be followed as outlined below. REPORTING GUIDELINES: TRISTAR will provide a Narrative Serious Loss Report when loss and allocated loss reserves meet or exceed. the designated authority level established within the Claims Servicing Agreement and/or when one or more of the following situations exist regardless of the level of reserving. Severe head injury involving loss of consciousness and/or hospitalization. a Death claim. a Spinal cord injury resulting in paraplegia or quadriplegia, either partial or complete. 17 of 28 Major amputations. Burn unit cases. Bilateral extremity fractures. ICU or CCU hospitalization. AIDS. Employer Liability (Coverage B) claims. Bad faith actions. Questionable coverage claims. All lawsuits naming the Client as a defendant. e TRISTAR will notify the Client by phone or fax within 24 hours of their knowledge of a reportable claim. This notification will be followed by the required written information within ten (IO) working days. 9 The Narrative Serious Loss Report will include the following information: 9 TRISTAR Claim Number and Client Claim Number, if available. 9 Coverage confirmation. 9 Complete description of how accident occurred. 9 Information regarding the injured worker, including but not limited to age, occupation, date of hire, average weekly wage and compensation rate. 9 Description of injury, treatment plan, and prognosis. 9 Discussion of all outstanding issues and the plan of action to resolve. 9 Reserve calculations including loss and expense paid 18 of 28 to date. The report should clearly indicate on what the reserves are based. For example, if permanent disability reserves are indicated, provide the PD rating equation and the reasoning behind the level of estimated PD. Subsequent Reports will be provided upon request. MEDICAL MANAGEMENTlCOST CONTAINMENT PROGRAMS: Treatment should be performed and supervised by certified medical care providers of the highest caliber and quality. Medical treatment should be directed toward the best result possible, aiming at a return to pre-injury status whenever possible. Where possible, given the limitations of litigation and legislated constraints, directing and guiding the injured worker as to the appropriate treating physician should occur. Use of Medical Management Nurses is a valuable tool in coordinating medical care and getting injured workers back to work. Cases appropriate for referral may involve: hospitalization or surgery (pre/post). Home care nursing requested or needed. pain management program or substance abuse detoxification. non-compliance with physician’s recommended treatment. unclear medical diagnosis or prognosis. frequent extensions of disability by the physician where the injured worker reports little or no improvement. pre-existing condition is complicating recovery or multiple problems are not being adequately addressed by the 19 Of 28 treating physician. W all catastrophic cases: spinal cord injury blindness major amputations severe head injuries severe burns multiple fractures or crush injuries massive internal injuries severe hand injuries W Cost containment Programs should be utilized on all claims. These programs will include but not be limited to, bill reviews for reduction of billing overcharges, use of PPOlHMO programs when possible, and utilization reviews. Use of independent medical evaluations are appropriate in certain circumstances. RETURN TO WORK PROGRAMS: W Every effort should be made to identify modified work the injured worker can perform while recuperating from his or her industrial injury. A modified job might consist of a modification of the duties or hours worked in the employee’s customary job, or it could be an alternative job that meets the worker’s physical requirements. W When an injured worker is medically eligible for vocational rehabilitation services, the service company should work with the employer and employee to permanently modify or alternate his or her job whenever possible to meet vocational rehabilitation benefit requirements. W When a vocational rehabilitation specialist or counselor is required, the service company should timely secure the services of a qualified individual. If required by state regulations, rehabilitation counselors should be properly certified or licensed. LITIGATION MANAGEMENT: W Cases requiring legal representation will be assigned to an attorney selected from an approved panel, which is maintained and reviewable on an annual basis. Attorneys on the approved panel should provide quality services, be familiar with the Workers’ Compensation jurisdiction of the selected case, and charge reasonable rates relative to the local market. 20 of 28 0 All assignments to attorneys should contain specific instructions and direction. Discovery and legal activity should be limited to that which is needed to best defend and resolve the pertinent issues of the case. 0 Responsibility for maintaining control of defense counsel and expenses remain with TRISTAR. unless the City Attorney determines it is in the best interest of client for the City Attorney’s Office to assume this control. 0 Consultation with Client should occur when the exposure exceeds the authority outlined in the Claims Servicing Agreement. SUBROGATION AND CONTRIBUTION: 0 Potential subrogation and contribution situations should be identified and investigated as soon as possible. 0 TRISTAR is responsible for developing evidence to support recovery. Assignments to appropriate investigators should occur. Consideration must be given to the quality of the case, the value of the case, and the cost of various aspects of the investigation. Authority levels must be adhered to as stated in the Claims Servicing Agreement. As with the settlement of claims, the final decision to pursue subrogation or contribution rests with the client. 0 All recoveries must be posted to the claims file and reported in the monthly reconciliation report required by the Claims Servicing Agreement. DOCUMENTATION AND FILE MATERIALS: e Every claim file should be thoroughly documented. Mandatory forms should be completed and copied to the file. All phone conversations and investigative work should be summarized within the file. Medical information should be updated on a regular basis. Copies of all correspondence should be within the file. All supporting documentation for defending or supporting our position on various issues should be in the file. All bills and payment information should be within the file. 0 File documentation can consist of hardcopy paper files, computerized information, or a combination of both. 0 TRISTAR will maintain confidentiality of all data, which is of a protected class. This includes work product in litigated and third party cases and medical reports and records relating to the injured employees. 21 of 28 Confidentiality of medical records will be maintained pursuant to applicable state laws. EXHIBIT C AUDIT UNIT PENALTY ASSESSMENT GUIDELINES Under the guidelines of legislation regarding Workers' Compensation in the State of California effective January 1, 1990 there are procedures for the assessment of penalties in varying amounts for specific violations of either claim practices or the timely, accurate, and effective provision of benefits to the injured Employees as determined through the audit process of the Department of Workers Compensation Audit Unit. It has been clearly stated by the Audit Unit that in the case of a self-insured Employer whose claims are administered by a third party administrator (TPA) that "the penalty imposed shall be joint and several, and shall be served upon both the self-insured and third party administrator." This is to say that both parties will have the obligation to resolve the payment of the assessment, pay the penalty assessed or to lodge the appropriate defense against such payment if the penalty is felt to be either inappropriate or unreasonable under the specific circumstances that have given rise to the assessment of the penalty in question. In the event that the penalty assessed( is for work done or not done properly by a prior administrator, where there has been a subsequent change in third party administrators the penalty again will be issued as a joint and several document with notice being served upon both the self-insured and the &r administrator. The schedule of penalties has once again been refined and it is possible that it will be further refined as The Audit Unit continues to draft its procedure manual for the conduction of an audit and the determination of penalty assessment. In order to determine in an orderly manner who should be responsible for the payment of any penalties assessed, the following guidelines will be utilized by TRISTAR. NATURE OF VIOLATION AND RESPONSIBLE PARTY Failure to pay full 10% self-imposed increase As this would appear to be a calculation error and therefore the responsibility of the claims examiner, the penalty would be paid by the TRISTAR. However, in the event that the calculation error was based on incorrect information provided by the CLIENT, which TRISTAR had no ability to verify, the penalty would appear appropriate for payment by the CLIENT. 22 of 28 Self-imposed penalty not paid If the penalty was not paid because the CLIENT had not notified TRISTAR of the return of the claim form from the claimant and TRISTAR had no reason to prompt the CLIENT for this information, then this penalty would be paid by the CLIENT. Where the failure to pay the self-imposed penalty is a calculation error by the claims examiner and all information has been timely provided the examiner, the payment of the assessment would be the responsibility of the TRISTAR. Failure to advance permanent disability when due Where the file is clearly documented and the failure to pay is an examiner error then the penalty assessed is the TRISTAR responsibility. If the knowledge of permanent disability is withheld from the examiner by either the CLIENT and TRISTAR had no other reasonable means of discovering the permanent disability, the penalty is the CLIENT'S responsibility. No CLIENT date received on Employee claim form It should be noted that for this assessment to apply, the claim form must have been returned to the CLIENT and the CLIENT, in sending the CarriernPA copy of the form, will have neglected to complete the appropriate information required. This penalty would be appropriate for CLIENT payment. Additionally, it should be noted that from time to time TRISTAR may receive a claim form from sources other than the CLIENT (Le. doctors or Applicant's Attorney). When that occurs, TRISTAR will document the file that the claim form was originally received from a source other than the CLIENT, forward a copy of the claim form, completed by the Employee, to the CLIENT for completion of the appropriate information and for return to TRISTAR. If the form is not returned to TRISTAR with the required information, the CLIENT will be responsible for the payment of the assessment. Failure to respond to written Employee request for treatment within 20 days If the written request is received by TRISTAR the payment of this penalty will be paid by TRISTAR. However, if the written request is received by the CLIENT and it is not communicated and sent to TRISTAR in sufficient time for TRISTAR to meet the response time, the penalty should be paid by the CLIENT. Failure to pay requested and uncontested medical mileage 23 of 28 If the mileage request is sent by the Employee directly to TRISTAR rather than to any other party, TRISTAR will pay the penalty assessment. If the mileage request is sent first to the CLIENT and the CLIENT does not communicate and send the mileage request to TRISTAR in sufficient time for TRISTAR to meet the payment deadline, the penalty will be paid by the CLIENT. Payment at less than maximum T.D. rate without documentation in addition to the Employer's Report This penalty assumes that there is not ample documentation to support such a payment. It is TRISTAR 's procedure to pay all temporary disability benefits at maximum unless an adequate wage statement has been provided and in our possession at the time that any indemnity benefit is paid. In light of this policy the payment of the penalty assessed is the responsibility of TRISTAR unless the wage information provided by the CLIENT is inaccurate and TRISTAR has no reasonable basis for questioning the accuracy, and in that case the CLIENT would be responsible for the payment of the assessment. Failure to pay first T.D. payment within 14 days of date of knowledge of injury and disability This date of knowledge is determined to be the CLIENT's date of knowledge. Where the information has been provided to TRISTAR by the fifth business day following the CLIENT's date of knowledge, the penalty assessed by the Audit Unit will be paid by TRISTAR. Where TRISTAR is not provided notice and sufficient information within five business days of the CLIENT's date of knowledge, or where it is determined after investigation or discovery that the CLIENT's date of knowledge was actually earlier than stated, the penalty will be the responsibility of the CLIENT. Failure to comply with any rule or regulation of the A.D. This is certain to be the area of most discussion in any penalty assessment. TRlSTAKs ability to control the receipt of much of the information identified is difficult if not impossible to control. In light of the ambiguous nature of this penalty, the determination of who is responsible for payment will have to be determined on a case-by-case basis. The following guidelines on specific areas will be the starting point for determining responsibility. No Employee Claim Form, or document is given to Employee by CLIENT, or sent by claims administrator The legal obligation to provide a claim form to an injured Employee has been placed on the CLIENT. TRISTAR has provided guidelines for the documentation of the claim form use of both the Claim Form log and the six-part Claim Form. TRISTAR will not provide the Claim Form to the Employee except on specific 24 of 28 request by the Employee or the Employee's representative, otherwise the claims examiner will advise the requesting party to notify the CLIENT while at the same time the claims examiner will call the CLIENT identifying the request so that documentation provision of the Claim Form can be maintained at the CLIENT's premises. If the CLIENT utilizes the suggested procedures then all files should have appropriate documentation of the Claim Form and no penalty should arise. If the CLIENT is not following the suggested procedures or has not provided TRISTAR with any proof that the Claim Form has been provided for the claim file this penalty will be paid by the CLIENT. Untimely provision of the Claim Form to the Employee by the CLIENT Penalty assessment will be the CLIENT's responsibility. No Employer Report Penalty assessment will be the CLIENT's responsibility. No, or missing medical reports In many cases obtaining medical reports from doctors can only be achieved after it is made absolutely clear that there will be no payment for medical services unless the appropriate reports are provided. Even then, some doctors resist the obligation. Where the offending medical facility is selected by the CLIENT, penalties assessed will be the responsibility of the CLIENT. If the medical provider has been selected by TRISTAR, TRISTAR will be responsible. Incomplete or no record of payment (includes missing bills) Penalty assessment will be the TRISTARs responsibility. No copy of W.C.A.B. Order and Award If there is proof that service of the W.C.A.B. Order and Award was provided to TRISTAR, than payment of the penalty will be TRISTARs responsibility. No copy of Application for Adjudication of Claim Where there is proof that service of the application was provided to TRISTAR, or where the CLIENT is served a copy of that application provided to TRISTAR, the penalty assessment will be TRISTAR's responsibility. No DIA (DWC) 500 sent Penalty assessment will be TRISTARs responsibility. 25 of 28 DIA (DWC) 500 sent, but inaccurate (DON, DOK, BNU#, periods rates, etc.) Where TRISTAR has access to accurate information and provides inaccurate information TRISTAR will be responsible for penalties. Where date of notice and date of knowledge are not accurately provided to TRISTAR by the CLIENT or their representative, penalty assessment will be the CLIENT'S responsibility. No DIA (DWC) 510 sent Penalty assessment will be the CLIENT'S responsibility. Failure to pay or object to medicalllegal expense within 60 days of receipt of billing. (Must be reasonable objection) If first receipt is TRISTARs receipt, TRISTAR will bear the responsibility. If the CLIENT has first receipt and provides TRISTAR with the billing in sufficient time for TRISTAR to meet the payment or objection deadline, then CLIENT bears the responsibility for the assessment. Failure to pay or object to medical expenses within 60 days (Must be reasonable). See above medical/legal expense. Each payment due. Failure to pay within 10 days any indemnity due, which is not specified above. Includes Maintenance Allowance, Interest on Awards, subsequent to first T.D. payments. If all available and accurate information has been provided to TRISTAR then this assessment would be the responsibility of TRISTAR. Where the required information is within the knowledge of the CLIENT but has not been provided to TRISTAR, and TRISTAR has no reason to request this information from CLIENT, the CLIENT will bear the responsibility of the assessment. No claim log provided within 5 days of request Penalty assessment will be TRISTARs responsibility. Each denied claim not designated on claim log Penalty assessment will be the TRISTARs responsibility. Each other omission or misdesignation on claim log Penalty assessment will be the TRISTARs responsibility. 26 of 28 Failure to comply with Rehabilitation time and notice requirements each occurrence TRISTARs responsibility where all required information is available. Where TRISTAR does not have information that is available to the CLIENT and that information has not been provided to TRISTAR, after TRISTAR requests it, CLIENT will bear the responsibility for this assessment. Failure to pay or appeal Notice of Assessment within 15 days of the issue date Any penalties will have to be evaluated on an individual basis and determination made both as to appropriateness of the penalty and identification of the party responsible. The need to act promptly is imperative and any party that delays action in such determination of liability or the need to appeal any notice of assessment will bear the responsibility of this penalty. For purposes of this paragraph, a dispute between the parties over who should pay the penalty does not constitute a “delay” of action. If liability for the penalty assessment is agreed upon and payment is appropriate the party responsible for the payment of the assessment will pay the penalty. Failure to comply with or appeal any final order of the W.C.A.B. within 30 days of service If the issue is simply the late payment of an uncontested W.C.A.B. Order or Award this penalty would be the responsibility of TRISTAR if TRISTAR had the Order within the time frame allowed for payment or compliance of same. If TRISTAR did not have service of the Order but the CLIENT did make such Order available to TRISTAR within the time frame allowed, and TRISTAR has no reason to request the Order from CLIENT, such penalty would be the responsibility of the CLIENT. Insufficient documentation to support denial of liability for a claim The determination to deny a claim is generally the result of both TRISTAR and CLIENT involvement. Where TRISTAR acts unilaterally in the denial of a claim, this penalty would be TRISTAR’s responsibility. Where the CLIENT has participated in the decision, the penalty would be a shared responsibility. In the event that the CLIENT insists upon denial of a claim against recommendation of the TRISTAR the entire penalty would be the CLIENT’S responsibility. No documentation indicating service of denial on the injured worker or hislher agent 27 of 28 Penalty assignment will be TRISTARs responsibility. Failure to comply with or appeal any lawful written request of the A.D. regarding a claim filed within 30 days These penalties are TRISTARs responsibility provided that TRISTAR has access to the information requested. If the information or action requested requires information within the control of the CLIENT and that information is not provided to TRISTAR in a timely manner so that the written request can be complied with in the time allowed, the penalty assessment will be the responsibility of the CLIENT. Failure by a claims administrator, to provide a claim form within 24 hours upon request of an injured worker or hislher agent. Penalty assessment will be TRISTARs responsibility. 28 of 28 F ACORD, CERTIFICATE OF LIABILITY INSURANCE DATE IMMIOWYI) PHODWER (310)393-9477 FAX (310)393-7186 07/23/2002 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. White & Conpany Insurance Inc P 0 Box 70 Santa Monica, CA 90406-0070 Tewanna Wade CISR, Ext. 151 INSURERS AFFORDING COVERAGE INSURED Tristar Risk Management (a Corp.) INSURERC: National Union Long Beach, CA 90802 INSURER& American Cas Co of Reading PA 100 Oceangate 1700 INSURERA: Transportation Ins Co - INSURER0 I INSURER E: COVERAGES - MERCIAL GENERAL LlABlLl NON-OWNEDALITOS CLAIMS MADE DEDUCTIBLE RETENTION I t I I WORKERS COMPENSATION AND EMPLOYERS LIAWLIN I %K#S I I0:R" E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYE I f E.L. DISEASE - WLlCY LIMIT S . Progssional Liability om 794890 Ol/01/2002 01/01/2003 $5,000,000 each Wrongful Act $5,000,000 Aggregate I I I I I iSCRlPTlON OF OPERITIDNSlLOCATlONJHlCLESIU(CLUSl0NS AWED BY ENDORSEMENTISPECIAL PROWSIONS ,xcept 10 Days Written Notice of Cancellation for Non Payment of Premium. rtificate Holder its officials, enployees and volunteers are Additional Insured with respects to ability arising out of activities performed by or on behalf of the Named Insured. ERTIFICATE HOLDER I ADMTIONALINSUREO; INSURER LETrER: CANCELLATION SHOULD bNV OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF. THE ISSUING CDMPANY WILL ENDEAVOR TO MAIL '30 DAYS WRIlTEN NOTICE TO THE CERTIFICATE HOLDER NAME0 TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. City of Carlsbad Human Resources Department Deborah A. Harvey, Benefits Administrator 1635 Faraday Avenue Carlsbad, CA 92008-7314 AUTHORIZED REPRESENTATIVE n lcarolyn B. Crowe ACORD 25-5 (7197) OAC@D CORPORATION 1988 IMPORTANT If the Certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVEO. subject to the terms and conditins 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). DISCLAIMER The Certiflcate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s). authorized representative or producer, and the certificate holder. nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. THE PARTIES SPECIFIED HEREUNDER AGREE THAT ALL REQUIRED NOTICES ARE THE RESPONSIBILITY OF THE “COMPANIES AFFORMNG COVERAGE. THE TATIVE OR NOT, BEARS NO RESPONSIBILITY FOR ANY NOTICE. PRODUCERWHETHERANAUTHORIZEDREPRESEN-