HomeMy WebLinkAboutGaetke Medical Corporation; 2021-05-03;AGREEMENT FOR NFPA 1582 MEDICAL EXAMS
GAETKE MEDICAL CORPORATION
THI AGREEMENT is made and entered into as of the id, day of
4 -I , 20_91, by and between the CITY OF CARLSBAD, a municipal
corporation, (ctity"), and Gaetke Medical Corporation, a California corporation, ("Contractor").
RECITALS
A.City requires the professional services of a licensed physician that is experienced
in medical tests and physical exams compliant with National Fire Protection Association 1582
Standards for Occupational Medical Programs for Fire Departments.
B.Contractor has the necessary experience in providing professional services and
advice related to specialized medical tests and physical exams for firefighters.
C.Contractor has submitted a proposal to City and has affirmed its willingness and
ability to perform such 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.
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 one year from the date first above
written. The City Manager may amend the Agreement to extend it for one additional one year
period or parts thereof. 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 for the Services to be performed during the initial Agreement term shall not
exceed seventy thousand dollars ($70,000). No other compensation for the Services will be
allowed except for items covered by subsequent amendments to this Agreement. If the City elects
to extend the Agreement, the amount shall not exceed seventy thousand dollars ($70,000) per
Agreement year. The City reserves the right to withhold a ten percent (10%) retention until City
has accepted the work and/or Services specified in Exhibit "A".
Incremental payments, if applicable, should be made as outlined in attached Exhibit "A".
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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. 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
Contractor agrees 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 by any negligence,
recklessness, or willful misconduct 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-:VII"; OR with a surplus
line insurer on the State of California's List of Approved Surplus Line Insurers (LASLI) with a rating
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in the latest Best's Key Rating Guide of at least "A:X"; OR an alien non-admitted insurer listed by
the National Association of Insurance Commissioners (NAIC) latest quarterly listings report.
10.1 Coverage and Limits.
Contractor will maintain the types of coverage and minimum limits indicated below, unless the
Risk Manager 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. The full limits available to the named insured shall also be available
and applicable to the City as an additional insured.
10.1.1 Commercial General Liability (CGL) Insurance. Insurance written on an
"occurrence" basis, including personal & advertising injury, with limits no less than $2,000,000 per
occurrence. If a general aggregate limit applies, either the general aggregate limit shall apply
separately to this project/location or the general aggregate limit shall be twice the required
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 Employer's Liability. Workers' Compensation limits as
required by the California Labor Code. Workers' Compensation will not be required if Contractor
has no employees and provides, to City's satisfaction, a declaration stating this.
10.1.4 Medical Professional Liability. 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 Commercial General Liability
which shall provide primary coverage to the City.
10.2.2 Contractor will obtain occurrence coverage, excluding Professional 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.
10.3 Providing 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 Coverage. 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.
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10.5 Submission of Insurance Policies. City reserves the right to require, at any time, 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 product 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
product 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 notice or to receive written notice on
behalf of City and on behalf of Contractor under this Agreement.
For City For Contractor
Name Nathan Pearson Name Paul Granstrom
Title Division Fire Chief Title President
Department Fire Address 1855 N. McCarran Blvd
City of Carlsbad
Address 2560 Orion Way
Sparks, NV 89431
Phone No. 775-846-3413
Carlsbad, CA 92010 Email paul@1582exam.com
Phone No. 760-931-2141
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.
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16.CONFLICT OF INTEREST
Contractor shall file a Conflict of Interest Statement with the City Clerk in accordance with the
requirements of the City of Carlsbad Conflict of Interest Code. The Contractor shall report
investments or interests in all categories.
Yes 0 No 0
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 whose services are
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 (10) 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 Contractors 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 deliver 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 Agreement
completed. Based upon that finding City will determine the final payment of the Agreement.
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
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put it in order for proper filing and closing and deliver it to 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 otherwise 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.JURISDICTION 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.
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 nor 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.
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ATTEST:
1Y L< /.Gacekt ,itto Sec_
(print name/title)
,..‘/ BAR ARA ENGLESON
City Clerk
6anie
Dept( y C, Clek—
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.
CONTRACTOR CITY F ARLSBAD, a municipal
cor rati n of the State of California
BY
By:
(sign here)
. Ga.e.Ake_. NaN P„
(print name/title)
SCOT WICK
City Manager
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
Chairman,
President, or
Vice-President
Group B
Secretary,
Assistant Secretary,
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:
CELIA A. BREWER, City Attorney
BY:,
Dep /Assistant City Attorney
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EXHIBIT "A"
SCOPE OF SERVICES
Gaetke Medical Corporation will conduct specialized medical tests and physical exams compliant
with National Fire Protection Association 1582 guidelines. The Contractor will provide a mobile
medical clinic to conduct all testing and examinations onsite with a licensed physician over various
shifts and days.
All work performed and pricing for services shall be in accordance with Contractor's proposal
dated February 5, 2021, which includes Contractor's response to RFP #20-07-C24 awarded by
Northwest Fire District, which is attached and incorporated herein by this reference. Annual
agreement compensation shall not exceed seventy thousand dollars ($70,000) per Agreement
year.
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Exhibit B - Proposal 15 82
February 5th, 2021
Attn:
Nathan Pearson
Carlsbad Fire Department .
From:
Paul Granstrom
President
1582
RE: Mutual Use Clause of RFP 20-07-C24 Annual Physical Exam and Occupational Health Services
On-site NFPA 1582 Exams
Chief Pearson,
We're excited at the prospect of serving the Carlsbad Fire Department. We invite you to enact the Mutual
Use Clause of a contract with have with a very large Fire District in Arizona, known as Northwest Fire
District. By enacting this Mutual Use Clause, our California Organization known as Gaetke Medical
Corporation will be conduct the following examination components on the next page. Mark Gaetke, MD
with Gaetke Medical Corporation has approved this Carlsbad Fire Department.
Please be advised that all testing will be conducted ON-SITE at one of your Fire Stations / Training Centers.
We are prepared to conduct examinations on various Battalion Shifts. We'll need to plan out the operation
and based dates to meet the needs of your Department as well as ensuring we have minimum numbers of
patients per day.
We look forward to implementation meetings if the City is interested in Piggybacking on this Contract.
Highlights:
•All members of the Carlsbad Fire Department will receive complete copies of their Medical
Examination with 1582, sealed with Tamper Evident Tape and delivered to Department within 30
days of completion of exam;
•Carlsbad Fire Department will receive annually — 1582 Tier Paperwork / 1582 Respirator
Paperwork via Electronic Portal if you like;
•The members will receive the 1582 REPORT CARD starting in the second year of exam detailing
trends of risk factors from year to year; and
•1582 will provide simplified, easy to understand billing;
Please see the attached details of the Examination Components and Options
Sincerely,
Paul Granstrom
President
1582
(775) 846-3413
Paula 1582exam. corn
EXECUTIVE SUMMARY
I 582's medical staff is aware of how challenging it is to be a firefighter and the risks involved for these
"Industrial Athletes" performing their jobs. The NFPA Guidelines detail (over 775 times) that a Licensed
Physician should be conducting the NFPA 1582 Annual Exams. 1582 will provide a Licensed Physician
to conduct the Annual Exams... rather than a mid-level practitioner, such as a Nurse Practitioner or
Physician Assistant Mid-level practitioners are NOT endorsed by NFPA at all M NFPA 1582 as being
authorized to conduct these exams. 1582 is prepared to meet, if not exceed, all the specifications listed in
RFP # 20-07-C24, Section IV: Group 1 — Annual Exam Services with Carlsbad Fire Department.
PROPOSED SOLUTION
Although 1582 is offering to provide the Annual Physical Exams, this proposal will be based on
providing the Annual Physicals "On-site" within the premises of one or more of the Carlsbad Fire
Department stations. 1582 will provide all services On-Site. There will be no need • to send
your firefighters to other locations or medical providers for any components of the Annual Exams.
COST OF SOLUTION
Price per Annual Physical: Methodology M: $ 625 per exam
OPERATIONAL PLAN
1582 staff will work closely with Carlsbad Fire Departemtn to maximize efficiency regarding
scheduling the Annual Physicals based on your firefighters' various shifts to minimize any disruption of
services to the community. The Annual Physicals will be conducted in two phases over the course of a
year. Phase I (On-Site Date To Be Determined) of the exams will include the blood draws, Skin
Cancer Assessment, Ultrasound Scans, Chest X-Rays, as well as Vision, Audiograms, Pulmonary
Function Tests conducted On-Site. Exams are slot Phase 11 (On-Site Date To Be Determined) will
include the Resting EKG, Stress Treadmill EKG, Fitness Endurance exams and the Physician exams.
Phase II exams will be conducted On-Site.
1582 will meet with representatives of Carlsbad Fire Departemnt to discuss and approve all aspects of the
Annual Physicals including clinical protocols, reporting systems, medical record keeping, and
billing. At the time of their physical, all firefighters will receive their results. All medical
information will be stored and maintained by 1582 at its corporate office. Carlsbad Fire Department will
be notified immediately if any of the firefighters fail to pass their physical based on pre- .
agreed protocols established by your organization. All Fit for Duly Medical Clearance Reports will
be delivered within fourteen (14) working days to Carlsbad Fire Department Each firefighter will
be provided a 1582 Report Card highlighting key elements which will provide a trend analysis from year
to year.
TAB 2
HISTORY OF 1582
Gilbert, Gaetke and Associates of Nevada, MD, LTD (Professional Corporation) d/b/a ARC Health &
Wellness Centers/1582 (hereinafter referred to as "1582") was formed in 2009 to specialize in conducting
NFPA 1582 Annual Heart & Lung Physicals for firefighters and police officers. Our first client was the
City of Sparks located in Northern Nevada. Over the years, our book of business grew rapidly to include
all agencies with the State of Nevada as well as all major cities and counties in Nevada including the Cities
of Las Vegas and North Las Vegas. 1582 then expanded its services in the states of Colorado, Arizona and
California. As a result, 1582 has become the leading provider of NFPA 1582 compliant physical exams in
the Western United States conducting approximately 8,500 annual exams per year.
Currently we have a total of nine (9) offices in Nevada and as well as two (2) satellite offices in Tempe,
AZ.. In addition, 1582 has a fleet of five (5) mobile medical units to provide on-site services for our clients.
We have been serving various clients in Arizona for a number of years including Kingman Fire Department,
Bullhead City Fire Department, Rural Metro Fire Department, Casa Grande Fire Department and others in
the Arizona Market.
Tab 3
STATEMENT OF QUALIFICATIONS
Conducting NFPA 1582 Compliant exams is not merely a product line for 1582, it is our primary business.
As indicated previously, 1582 has been providing the services solicited in this RFP since 2009. Very few
medical providers understand the complexities of conducting NFPA 1582 compliant exams. The
principals/key personnel of 1582 have collectively been conducting these examinations for over 40 years!
1582's dedicated clinical and management team has a depth of expertise which only comes from having,
extensive working experience in the industry they serve. Our Occupational Health team of experts can help
you stay in compliance with all regulations pertaining to the services provided in this RFP.
It takes more than even the key personnel listed in this document to successfully deliver high quality
services to 1582's clients. The checks and balances that have been implemented as part of 1582's Quality
Assurance Program are unsurpassed. 1582's staff of certified x-ray technologists, certified ultrasound
technicians, certified phlebotomists, NlOSH certified pulmonary function technicians, CAOHC certified
hearing conservationists, and cardiovascular technicians, complement the physician and management team
and are critical to the success of 1582.
1582 currently has seven (7) board-certified physicians who provide physical exams...and all are certified
in conducting stress treadmill tests. In the event of the death or disability of a clinical provider, 1582 has
sufficient physician staff to ensure that all services provided under this RFP will remain un-interrupted.
Please see Appendix 1: Statement of Qualifications for expanded details regarding 1582.
TAB 4
1582 SOLUTION: FIREFIGHTER ANNUAL PHYSICAL EXAMS
1582 will customize the services we provide to minimize any disruption to Carlsbad Fire Department
and the community you serve. We recognize that conducting these physicals are time consuming for
your firefighters. 1582 is offering for consideration, three different methodologies for conducting the
Annual Physical Exams:
I.On-site within the premises of one or more of the Carlsbad Fire Department's stations. 1582
will transport, set up all "state of the art" medical equipment and provide all clinical
staffmg to conduct all components of the Annual Exams. There will be no need to send
your firefighters to other locations for any of the services, such as Lab Draws.
II.Dedicated Office: 1582 is willing conduct exams at our dedicated office which would
serve the Carlsbad Fire Department firefighters and other fire
departments in the area by appointment only.
III.Utilizing 1582 Mobile Medical Units on-site at the location(s) rather than
within Carlsbad Fire Department's premises. 1582 will drive its Mobile
Medical Unit to the location(s) designated by Carlsbad Fire Department. All equipment
required is on-board the Mobile Medical Unit and it would not be necessary to utilize Carlsbad Fire
Department's facilities or equipment.
We understand that your current preference is to conduct the Annual Physicals during one defined time
period per year. If you wish to consider other options in the future, 1582 is willing to work with
Carlsbad Fire Department and conduct the Annual Physicals annual basis depending on which at
your Organization
Upon being awarded the contract, 1582 and Carlsbad Fire Department will set up one or more meetings to
discuss all aspects of conducting the Annual Physicals including, but not limited to: scheduling,
time frames, components of the exams, all forms utilized in the Annual Physicals, clinical protocols,
space requirements, medical record system, and approval of the reporting system, etal.
The 1582 Scheduler will work closely with Carlsbad Fire Department to schedule all firefighters based on
their various shifts within the specified time period. The staffing recommendations below will be based on
how many firefighters can be "freed up" daily to conduct the various components of the exam.
These recommendations can be adjusted as needed.
1582 is recommending that the Part I phase of the exam include, at a minimum, the blood draws and chest x-
rays. Two (2) separate areas will be required to conduct the Part I exams: a blood draw area and a room in
which our staff can "shoot" the x-rays against an outside wall. 1582 will provide and set up all medical
equipment including a portable digital x-ray system. 1582 will deliver all blood specimens to LabCorp and
electronically send the x-ray images to SimonMed for the Radiologist Over-reads.
The methodology used for all the physicals as well as the submission of reports and billing will be agreed
to in advance by Carlsbad Fire Department and 1582.
TAB 5
NOT APPLICABLE
TAB 6
APPENDIX 1: STATEMENT OF QUALIFICATIONS
A. FIRM QUALIFICATIONS AND EXPERIENCE
General Overview and History of 1582
Gilbert, Gaetke and Associates of Nevada, MD, LTD d/b/a ARC Health & Wellness Centers was
formed as a Professional Medical Corporation in the State of Nevada in 2009 to provide
Occupational Medicine Services including Annual Heart & Lung Physicals for firefighters and
police officers.
ARC Health & Wellness Centers/1582 was formed as a Nevada Limited Liability Company. 1582
is the Management Services Organization (MSO) that provides all administrative services for the
professional medical corporation. Since our organizations were specializing in providing NITA
1582 Compliant Annual Exams, our management team decided to name MSO company "1582."
1582's growth as a company has been quite remarkable. During the past twelve (12) years, 1582
has grown from conducting only several hundred Annual Physicals per year to over 8,500 Annual
Physicals per year. 1582 serves fire departments in Nevada, California, Colorado and Arizona.
Currently 1582 has eleven (11) offices including one office in Tempe, AZ and one in Monterey,
CA. In addition, 1582 owns and operates five (5) Mobile Medical Units which are transported by
CDL drivers throughout the State of Nevada, California, Colorado and Arizona.
In addition, 1582 provides occupational medicine services for work-related injuries to over 1,500
clients in the State of Nevada.
Number of Employees
Currently 1582 employs approximately thirty-five (35) employees including seven (7) physicians.
Headquarter Location
1582's corporate headquarters are located at 1855 N. McCarran Blvd, Sparks, NV 89431.
Type of Business
Gaetke Medical Corporation is a California Professional Corporation.
Office Serving Carlsbad Fire Department
This proposal is based on 1582 providing in Office Setting for the Annual Physicals for
firefighters on the premises of Carlsbad Fire Department. In addition, 1582 is open to the idea of
providing exclusive workers compensation services for the fire departments in the greater
Tucson area in the future.
B. QUALIFICATIONS OF KEY PERSONNEL
1) The key staff that will be assigned to this contract include:
A)Paul Granstrom — President
B)Mark Gaetke, MD — Corporate Medical Director
C)Megan McCarthy — Cardiac Nurse Practionier, DNP
D)Robert Keller, MD — Staff Physician
E)Brian, Kuhn, MD — Staff Physician
F)Chris Pederson, MD — Staff Physician
G)Tziporah Richmond — Ultrasound Technician
H)Truman Thomson — Ultrasound Technician
1) Amanda Hickson — Phlebotomist/Medical Assistant
J)Stacy Stewart — Heart and Lung Manager
K)Lisa Baysinger — Phlebotomist, X-ray Technician
L)Shasvna Connelly — Phlebotomist, Medical Assistant
Duwayne Love — Logistics Manager
Resumes of each key staff member are included below.
2) The physicians that will be conducting the Physician Exams will be Mark Gaetke, MD and
Robert Keller, MD. Their biographies are listed below.
3) Included above in 42 above.
4) The key staff and technicians biographies are listed below.
5) The staff member responsible for all Summary Reports will be Stacy Stewart under the
supervision of Paul Granstrom, President of 1582.
6) 1582 will NOT need to secure additional staffing for this RFP. The only subcontractors utilized
will be LabCorp for processing all lab specimens and SimonMed to perform the over-reads of
the Chest X-rays.
15 82
MARK J. GAETKE, MD
FAMILY PRACTICE
Medical School Loma Linda University, 1987
Family Practice Residency Loma Linda 1987-1990
Corporate Medical Director / Principal
ARC Health & Wellness Centers — 2010 — Present
1582 — 2018 - Present
Dr. Gaetke has served as Corporate Medical Director of ARC for the past nine (9) years. He is
recognized as one of the leading experts in the area in conducting NFPA 1582 and NRS 617
medical evaluations.
Past Positions:
Medical Director/Staff Physician
Concentra Medical Centers — Reno/Sparks/Carson City, NV 1996-2010
Dr. Gaetke held various staff physician and medical director positions during his 14-
year term of employment with Concentra Medical Centers. He gained extensive
experience in conducting heart and lung physical during his employment with
Concentra.
Hyperbaric Medicine Specialist
US Naval Hospital — Guantanamo Bay, Cuba 1987 - 1990
Certification & Affiliations Medical:
Nevada Medical License - # 6893
California Medical License - #G63790
Alabama Medical Licensure Commission - #MD36984
American Board of Independent Medical Examiners — Certified 1997
Advanced Cardiac Life Support Re-Certification — May 2019
Certified: Stress ECG Testing
Medical Review Office Certification Council
(0 82
ROBERT P.K. KELLER, M.D.
EMERGENCY MEDICINE
Medical School University of Utah College of Medicine, 1974
Surgical Residency University of Utah College of Medicine, Affiliated Hospitals General
Surgery, 1973 - 1975
Emergency Medicine Northwestern-Rush Presbyterian-St. Luke's-Christ Residency
Hospitals, Emergency Medicine Residency Program, Chicago, 1978
Staff Physician / California
ARC Health & Wellness Centers — 2018 - Present
1582 — 2018 - Present
Past Positions:
Chairman, Appointed by the Governor of California
Medical Board of California
Medical Quality Review Committee
Department #8 for the State of
Senior raiiiiiimiMember of the Board, and Staff ED Physician
Monterey Bay Emergency Physicians, Inc
Community Hospital of the Monterey Peninsula
Monterey, CA
Medical Director & CMO
Pebble Beach Company
Health & Wellness Family Practice and Occupational Center
Pebble Beach, CA
Chairman
Community Hospital of the Monterey Peninsula
Emergency Department
Monterey, CA
Medical Director
Community Hospital of the Monterey Peninsula
Employee Health/ Workers Compensation
Monterey, CA
Certification & Affiliations Medical:
California Medical Association
Monterey County Medical Society
AACS - American Academy of Cosmetic Surgery Associate Member
ASLSS - American Society of Lipo-Suction Surgery Member
ACP - American College of Phlebology Member
ACLS — Advanced Cardiac Life Support
ACEP — American College of Emergency Physician
FAA Senior Aviation Examiner
15 4 82
CHRISTOPHER PEDERSON, MD, MPH, DABPM
PREVENTATIVE MEDICINE
Medical School University of Nevada, Reno 1983
Preventative Medicine Fellowship City of Faith Medical Center 1984 - 1986
Family Medicine Residency City of Faith Medical Center 1983 - 1984
Medical Director — Las Vegas
ARC Health & Wellness Centers — 2013 — Present
Staff Physician / California, Nevada, Arizona
1582 — 2018 - Present
Past Positions:
Physician Manager — Onsite Corporate Medical Department (10 years)
Hughes Aircraft/Electronics Corporation - Los Angeles
California Corporate practice of Preventive Medicine in a large company with
responsibilities concentrated in the management, treatment and prevention of
injuries/diseases, employee health promotion/education, medical surveillance
including cardiopulmonary fitness testing, drug-free workplace programs, and pre-
placement health evaluations; Design and implementation of an on-site executive
health evaluation program; Medical benefits analysis and modification including a
worldwide health enhancement initiative; FAA Aviation Medical Examiner; Team
leader for ACOEM Corporate Health Achievement competition - Winner 1997.
Direct supervision and training of clinical staff including physicians, mid-levels,
nurses, technicians including performance appraisals.
Certification & Affiliations Medical:
1995 — Present Nevada Medical License
1986 — Present California Medical License
1993 — Present American Board Certified in Preventive Medicine
2014 — Present Active Physician Liceses: AZ, CO, FL, NM, NY, OR, PA
2014 — Present FMCSA DOT Certification (National Reg. # 5585030956)
1984-1986 - Master's Public Health (MPH)
L) 2
BIOGRAPHY OF MEGAN McCARTHY, NP-c, CVNP-BC
MEGAN MCCARTHY, MSN, RN, NP-C, CVNP-BC
BOARD CERTIFIED CARDIOVASCULAR NURSE PRACTITIONER
Doctorate in Nursing Practice
Cardiovascular Nurse Practitioner
Adult Nurse Practitioner - Masters
Bachelors of Science in Nursing
Associate Degree in Nursing
Grand Canyon University, Expected Graduation 5/2020 —
Doctoral Project with Mesa Fire Department, clinical hours in
the East Valley Wellness Center — Dr Gary Smith
Project Focus: Sudden Cardiac Death Prevention in Firefighters
Board Certified by the American Board of Cardiovascular
Medicine (ABCM), 2011
Board Certified by the American Nurses Credentialing Center
(AN CC), 2008
Arizona State University, 2008
College of St. Benedict, 2003
Rochester Cornmunity College, 1996
1582
Megan McCarthy has just recently joined 1582 as Clinical Director of 1582 Arizona Operations. Her role
with 1582 will be as a Clinical Practitioner conducting 1582 Compliant Firefighter Exams as well as other
leadership functions.
Past Positions:
Consultant
Tactical Athlete Research Institute, LLC: 2019 - Present
Consultant for first responder medical programs, research and clinical practice in the
occupational health and outpatient setting.
Cardiovascular Nurse Practitioner
Heart & Vascular Center —Outpatient Cardiology Practice: 2019 — Present
Cardiovascular Nurse Practitioner providing direct patient care and coverage for in-office
stress testing.
15 4 82
Founder/Co-owner
HeartFit for Duty, LLC: 2010 - 2018
Performed all medical exams, annual physicals, create wellness plans, Cardiopulmonary VO2
stress testing.
Adult Nurse Practitioner
Arizona Sun Medicine Family Practice: 2012 - 2015
Clinical provider with focus on primary and secondary prevention of cardio metabolic
disease and weight loss.
Cardiovascular Nurse Practitioner
Pioneer Cardiovascular Consultants: 2011 - 2012
Adult Nurse Practitioner
CV Research and Private Practice Clinic: 2008 — 2013
Clinical Education Specialist
Mercy Gilbert Medical Center: 2007 — 2008
Certification & Affiliations Medical:
American College of Cardiology Allied Health Fellow
American College of Cardiology— Care of the Athlete Focus
National Lipid Association
BIOGRAPHY OF PAUL GRANSTROM
PAUI. GRANSTROM
PRESIDENT
1582, LLC
EDUCATION: Bethel College, Arden Hills, MN, 1999
Bachelor of Arts Degree
EXPERIENCE:
President/ Principal
ARC Health & Wellness Centers/1582: 2009 — Present
Served as President of 1582 for the past ten (10) years. He has successfully managed ARC Health
& Wellness Centers/1582 in becoming the leading medical provider of NFPA 1582 and NRS 617
Annual Examinations in the Western United States. Currently, ARC/1582 conduct over 8,500
Annual Physical Exams per year in Nevada, Arizona, Colorado and California.
Executive Vice President/Principal
ARC MedCenters, LLC: 2004 - 2009
Managed operations of a network of medical facilities in Northern Nevada which provided urgent
care/family practice/occupational medicine services treating over 50,000 patients per year.
Successfully sold the various practices to two local hospital systems.
Executive
Textron Financial Group: 1998 — 2004
Textron Financial Group is a subsidiary of a Fortune 100 company, Textron, Inc. Served as
Recovery Specialist, Regional Sales Representative and Sr. Account Manager.
Certifications:
Intoximeters Certified Instructor (Evidential Breath Tester/Breath Alcohol Technician)
Urine Specimen Collector Instructor - Department of Transportation (DOT)
Biography of Tziporah Richmond, RVS
Tziporah Richmond
Clinical Director, Ultrasound Imaging
EDUCATION:
2008 PCCTI, Chicago, LI
Certification in Sonography Science, PCCTI IT
& HealthCare
EXPERIENCE:
ARC Health & Wellness/1582
2018 — Present: Clinical Director, Ultrasound Imaging
Tziporah serves as 1582's Clinical Director of Ultrasound Imaging on a part-time basis. She is responsible
for managing 1582's Ultrasound Program and conducts ultrasounds in 1582's offices and on our mobile
medical units. She performs Ultrasound Sonography: Echocardiograms, Small organs: Thyroid, Testicular,
Breast, and Prostate, Obstetrics and Gynecology, Abdominal: Liver, Pancreas, Spleen, Kidneys, Abdominal
Aorta, INC, Urinary bladder, Gall Bladder, and Biliary tree. Upper and lower Extremities. Vascular.2-D
Echocardiograms, as well as proper general and vascular exams.
.Ultraclear Imaging
2016— Present: Clinical Director
Responsible for hiring and training new technicians. Performs 2-D Echocardiograms, as well as proper
general and vascular exams.
Portasonix
2009 — 2016: Ultrasound Technician
Tziporah worked as an Ultrasound Technician performing vascular ultrasound and arterial Doppler; general
ultrasound of upper abdomen and pelvic, using 2-D, measurements and color flow; and 2-D
Echocardiograms including measurements, color flow and dopplcr.
CERTIFICATIONS:
Registered Vascular Specialist (RVS) - Cardiovascular Credentialing International
BIOGRAPHY OF LISA BASINGER
LISA BASINGER
Certified X-Ray Technician/Phlebotomist
EDUCATION
2008 Great Basin College (GBC); Elko, NV
AAS Radiology Technology; ARRT Certified
SAS Management Technology
EXPERIENCE
ARC Health & Wellness Centers/1582
2015— Present: Radiologic Technologist/Phlehotomist/Medical Assistant
Lisa served as a Certified X-ray Technician/Phlebotomist for ARC/1582 serving as an integral part of the team
conducting thousands of Annual Physicals in 1582 various offices and on its mobile medical units. She has extensive
experience in conducting andiograms, puhnonaiy function studies and administering vaccines.
SUMMIT HEALTHCARE OF ARIZONA
2010— 2015 Health Screener/Wellness Coach
Lisa was responsible for setting up the health screening sites, checking in participants, performing Biometrics on
patients, performing finger sticks using Cholestech machine for lipids panel and performing venipuncture. As a
wellness coach she was responsible for coaching patients on glucose, lipids and biometric results with the goal of
helping patients achieve a healthy lifestyle.
Northern Nevada Health Center
2010— 2011: Radiology Technologist/Medical Assistant
CERTIFICATIONS:
Certified X-Ray Technician
Certified Phlebotomist
BIOGRAPHY OF AMANDA HICKSON
AMANDA HICKSON
Certified Phlebotomist/Medical Assistant
EDUCATION
2012 Berkeley College Woodland Park
Certified Clinical Medical Assistant
Certified EKG Technician
Certified Phlebotomy Technician
EXPERIENCE
ARC Health & Wellness Centers/1582
2013 — Present: Clinic Administrator/Phlebotomist/Medical Assistant
Amanda has served as Clinic Administrator/Phlebotomist/Medical Assistant for ARC/1582 serving as an integral part
of the team conducting thousands of Annual Physicals in 1582's various offices and on its mobile medical units. She
has extensive experience in conducting audiograms, pulmonary function studies and administering vaccines.
SUMMIT HEALTHCARE OF ARIZONA
2010— 2075 Health Screener/Wellness Coach
Lisa was responsible for setting up the health screening sites, checking in participants, performing Biometrics on
patients, performing finger sticks using Cholestech machine for lipids panel and performing venipuncture. As a
wellness coach she was responsible for coaching patients on glucose, lipids and biometric results with the goal of
helping patients achieve a healthy lifestyle.
Northern Nevada Health Center
2010 — 2011: Radiology Technologist/Medical Assistant
CERTIFICATIONS:
Certified X-Ray Technician
Certified Phlebotomist
n/A
TAB 7
ANNUAL COSTS
RFP# 20-07-C24
II. STANDARD TERMS AND CONDITIONS (CONT.)
29.TERRORISM COUNTRY DIVESTMENTS:
By entering the contract, Contractor warrants compliance in accordance with A.R.S. 35-392, and hereby certifies that the
Contractor is not in violation of the Export Administration Act and is not on the Excluded Parties List.
30.PROTESTS:
An interested party may file a protest regarding any aspect of a solicitation, evaluation, or recommendation for award in
accordance with the District's Procurement Policy.
31.NON-EXCLUSIVE:
Agreements resulting from this solicitation are non-exclusive and are for the sole convenience of Northwest Fire District
which reserves the right to obtain like goods and services from other sources for any reason.
32.TERMINATION:
District reserves the right to terminate any contract, purchase order, or award, in whole or in part at anytime, when in the
best interests of the District, without penalty or recourse. Upon receipt of written notice, contractor shall immediately cease
all work as directed by the notice, notify all subcontractors of the effective date of termination and take appropriate actions
to minimize further costs to the District. In the event of termination under this paragraph, all documents, data, and reports
prepared by the contractor under the contract shall become the property of and be promptly delivered to the District. The
contractor shall be entitled to receive just and equitable compensation for work in progress, work completed and materials
accepted before the effective date of the termination. The cost principles and procedures defined by A.A.C. R2-7-701 shall
apply.
33.CANCELLATION FOR NON-PERFORMANCE OR CONTRACTOR DEFICIENCY:
The District reserves the right to cancel the whole or any part of this contract due to failure by contractor to carry out any
obligation, term or condition of the contract. The District may issue a written deficiency notice to contractor for acting or
failing to act in any of the following:
•Providing material that does not meet the specifications of the contract
•Providing work and/or material that was not awarded under the contract
•Failing to adequately perform the services set forth in the scope of work and specifications
•Failing to complete required work or furnish required materials within a reasonable amount of time
•Failing to make progress in performance of the contract and/or giving the District reason to believe that contractor will
not or cannot perform the requirements of the contract
•Performing work or providing services under the contract prior to receiving a District purchase order for such work
Upon receipt of a written deficiency notice, contractor shall have ten (10) days to provide a satisfactory response to the
District. Failure to adequately address all issues of concern may result in contract cancellation. Upon cancellation under
this paragraph, all goods, materials, work, documents, data and reports prepared by contractor under the contract shall
become the property of the District on demand.
34.CONFLICTS:
In the event there are inconsistencies between the agreement documents, following is the order of precedence (superior to
subordinate); contract or purchase order; special terms and conditions, standard terms and conditions, instructions to
offerors, request for proposals.
35.COOPERATIVE USE OF RESULTING CONTRACT OR PURCHASE ORDER:
As allowed by law, the District has entered into cooperative procurement agreements that enable other Public Agencies to
utilize procurement agreements developed by the District. The Contractor may be contacted by participating agencies and
requested to provide services and products pursuant to the pricing, terms and conditions defined by the District contract.
Minor adjustments are allowed subject to agreement by both Contractor and Requesting Party to accommodate additional
cost or other factors not present in the District agreement and are required to satisfy particular Public Agency code or
functional requirements and are within the intended scope of the solicitation and resulting agreement. Any such usage shall
be in accordance with State, District and other Public Agency procurement rules, regulations and requirements and shall
be transacted by contract or purchase order between the requesting party and Contractor. Contractor shall hold harmless
the District, its officers, employees, and agents from and against all liability, including without limitation payment and
performance associated with such use.
END OF STANDARD TERMS AND CONDITIONS
Page 8 of 42
RFP# 20-07-C24
APPENDIX II: COST SUMMARY —ANNUAL PHYSICAL EXAM SERVICES
Annual Physical Exams Price Page
Firefighter and Prevention Personnel Requirements
Based on the response to the Questions involving Page 28 # D7 and Page 33 we propose the following
components is what Northwest Fire actually desires for Annual Physical Exam Services.
REQUIRED: COST:
1 - Medical History and Physician Examination (NFPA 1582 Compliant Exam) Included
2-Ultrasound of Heart (Echocardiogram with Cardiology overread) Included
3 - Vital Signs Included
3 - Audiogram Included
4 - Vision Included
5 - Pulmonary Function Test Included
6 EKG 12-Lead Included
7 - CXR (Baseline Year 1 or medically indicated, with Radiology Overread) Included
- Respirator Questionnaire (OSHA) Included
9 - 11112311at Questionnaire Included
10 - Flexibility/Core Strength Testing Included
11 - TB skill test Included
12 - Treadmill — submaximal (WFI Protocol as per NFPA 1582) Included
13- Treadmill — maximal treadmill test (WFI Protocol as per NFPA 1582) Included
15 - PSA — over 40 (Males only — (On-Site Venipuncture) Included
17 - Al C (On-Site Venipuncture) Included
19 - Chest X-Ray with Overread (Duplication from # 7) Included
20 - Maximal Treadmill based on Risk (Duplication from tt 13) Included
21 - Hepatitis B Quantitative Lab Draw (this test included below 7H — Rep. Profile) Included
23 - Cancer screening (Skin Cancer) Included
24 - Sleep & Stress Questionnaires (Mental Health and Sleep Assessment) Included
25 - Cancer & Cardio Disease Risk Reduction Included
Interpreted as a Full Body Ultrasound Screening: Carotid Artery,
Aortic Aneurysm, Thyroid, Liver, Gall Bladder, Spleen, Kidney, Bladder,
External Pelvic (women), Prostate / Testicular (Men)
27 - 12 mets or 42 VO2 max (WFI Protocol as per NFPA 1582)
28 - Alternative to flexibility (not sure what is meant, compared to # 107)
REQUIRED: Pare 28 — Annual Exam (not referenced above)
D4 Lipid Profile — LDL, HDL, TC, Trig, TC/HDL Ratio On-Site Venipuncture
D5 - Body Fat Analysis (Calipers / BMI)
7A - Urinalysis On-Site Collection
7B - Comprehensive Metabolic Panel On-Site Venipuncture
7C - T4 and TSH Thyroid Panel On-Site Venipuncture
7D - BladderChek NMP22 On-Site Collection
7E - C-Reactive Protein On-Site Venipuncture
'TF - Stool Hemoccult (age 40 and older) On-Site Collection
TH - Hep. Profile (Rep A/l3/C infection, Rep A/B Immun.) On-Site Venipuncture
Total Annual Exam Price (all services conducted on-site)
***Pricing will remain fixed for term contract with NO annual increases***
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
$625.00
jggisj
18 - Offer HIV (also known as # 29 Exposure to HIV Testing) 5 + 43.65
16 - Blood Lend — if needed $ + 75.00
22 - Heavy Metal screening (Blood Lead) (Duplication of 16) + 75.00
14 - No Show/Cancellation of physical (Physician Visit Only) $ +100.00
Fitness Evaluations
Included
Unclear if this is done in addition to or instead of the Stress Treadmill Test
26 WEI Submaximal Step Mill test (if substituted for Stress Treadmill)
26 WEI Subnsaximal Step Min test (if in addition to Stress Treadmill) $ + 30.00
SunnieinestarY Tedium / Servial
Respirator Fit Testing (Quantitative via PortaCount) $ + 30.00
Tetanus Vaccination S + 41.25
Hepatitis A Vaccination (each dose) + 72.25
Hepatitis B Vaccination (each dose) $ + 58.20
TwinRix Vaccination (each dose) + 100.88
Commercial Driver License Exam (conducted with Annual Exam) S+ 45.00
Coronary Calcium Score Baseline (on-site CT with interpretation) 5 + 150.00
END OF APPENDIX II
•
•
•
Optional Additional Services Price
Ultrasound Screening Panel*
Aortic Aneurysm Ultrasound*
Pancreas, Liver, Gallbladder, Spleen and Kidney Ultrasound*
Optional: External Pelvic Ultrasound (Females)*
Optional: Prostate Ultrasound (Males)*
Optional: Testicular Ultrasound (Males)*
Echocardiogram Ultrasound Screening*
* denotes this is a non-diagnostic screening only
$ 100.00
$ 50.00
Chapter 8 - Muscular Strength, Endurance & Flexibility $ 50.00
Lab Testing
Hepatitis A Titer $ 30.00
I kpatitis B Titer $ 30.00
Measles, Mumps, Rubella (MMR) Titer $ 80.00
Meningococcal Titer $ 30.00
Polio Titer $ 50.00
Tetanus Diphtheria Titer $ 45.00
Varicella Titer $ 45.00
Testosterone Blood Test $ 35.00
C Reactive Protein (Cardiac) $ 45.00
NMR Lipoprotein $ 75.00
Heavy Metal (24 Hour Urine Occupational Exposure- Hazmat Testing) $ 125.00
Cholinesterase (Hazniat) $ 76.00
Infectious Disease Screening
Hepatitis A Virus Screening Test $ 35.00
Hepatitis B Virus Screening Test $ 35.00
Hepatitis C Virus Screening Test $ . 35.00
hepatitis Profile Screening (Immunization and Infection Hep A,B,C) $ 80.00
HIV Screening $ 40.00
PPD TB Skin Test $ 20.00
QuantiFERON Gold TB Blood Test $ 75.00
Infectious Disease Management
Flu Vaccine $ 25.00
Hepatitis A Vaccination Shot (Series of Two) $ 75.00
Hepatitis B Vaccination Shot (Series of Three) $ 60.00
Meningococcal Vaccine $ 150.00
1\1MR • $ 80.00
TDaP (Tetanus Diphtheria Pcrtussis) Vaccine $ 80.00
TwinRix Vaccination Shot (Series of Three) S 105.00
Varicella Vaccine $ 120.00
Polio Vaccine Booster $ 125.00
Additional Services
Two View Chest X-Ray (PA and LAT) with Overread $ 65.00
Quantitative Fit Test (Porta count) $ 35.00
Non-DOT Urine Drug Screen (with MR0 Review and Reporting) $ 34.00
DOT CDL Examination and Paperwork (Standalone) $ 80.00
1582 Pre-Em lo ment Panel
Laboratory Blood / Urine Testing:
1582
Extended Panel
Complete Blood Count w/ Differential Included
Comprehensive Metabolic Panel Included
Fasting Lipid Panel (LDL, HDL, Trig, Cholesterol) Included
Urinalysis (with Micro if indicated) Included
Diabetes Screening - Fasting Blood Glucose / Hemoglobin A IC Included
Hepatitis Profile Screening (Infection to A,B,C and Immunity to A and B) Included
Urine Drug Testing Included
Occupational Health Testing
Audiogam OSHA Rated Hearing Booth) Included
Biometric Screening (BIVE or Calipers Skinfold) Included
Spiromety (Pulmonary Function Test) Included
Vital Signs Included
Vision Screening Included
Blood Pressure Monitoring Included
Resting EKG Included
TB Testing (PPD) Included
2 View Chest X-Ray (PA and LAT) with Radiologic Interpretation Included
Cardiopulmonary / Fitness Evaluation (Chapter 8)
Stress EKG, WFI Protocol
(Chapter 8.2.2. I - An evaluation of aerobic capacity shall he performed
after appropriate medical evaluation)
Included
Physician Exam - (NFPA 1582 Compliant)
Physical Examination (as outlined in Chapter 7.6) Included
Medical History Review Included
Skin Cancer Assessment Included
Health Promotion Counseling Included
Sleep Disturbance Apnea Questionnaire Included
Cardiac Risk Stratification Included
OSHA Resp. Questionnaire / Clearance Letter Included
Firefighter Medical Clearance — 1582 Tiers Included
PSPRS Paperwork Included
Total Cost per Candidate $650.00
Testing will he conducted at 1582 Office in Tempe, Tucson or any of the Nevada Locations under ARC Plealth
& Wellness or he conducted on-site during Annual Testing at Department. Prehires may be required to go to
SimonMed for Chest X-Rays and LabCorp.for Bloodwork to complete ahead of scheduled appointment time
based on Department need and sense of urgency. Department may elect to have Nurse Practitioner complete
the Pre-Employment exam based on time-sensitivity.
PUBLIC SAFETY PERSONNEL RETIREMENT SYSTEM (PSPRS)
Medical Examination Pre-Existing Medical Condition Report
EMPLOYEE NAME:
15082
DATE:
POSITION TITLE:
SOCIAL SECURITY NUMBER:
This .firefighter declares the following pre-existing health/medical condition(s); to clarify,
this means any conditions existing prior to this initial entry into PSPRS. Failure to inform
examiner of any pre-existing condition(s) may result in disciplinary action up to, and
including, termination.
EXAMINER RECOMMENDATIONS
NO PRE-EXISTING CONDITIONS IDENTIFIED
7 DECLARED NOTED PRE-EXISTING CONDITIONS
THE ABOVE WAS REVIEWED WITH ME AND SHALL BE DISCLOSED TO THE PSPRS
LOCAL BOARD FOR REVIEW:
Employee Name Employee Signature Date
EXAMINER'S NAME PRINTED:
EXAMINER'S SIGNATURE:
7 Meets the medical and physical requirements for acceptance as a Full-time /
Probationaiy Firefighter
Does not meet medical and physical requirements for acceptance as a Full-
time /Probationary Firefighter.
FOR LOCAL PENSION BOARD USE ONLY
RECORD REVIEWED:
Date:
Signature - Board Chairman or Local Board Secretary
LOCAL PENSION BOARD ACCEPTED: Date:
Signaturc - lioerd Chan man or Local }Mani Secretary
Thyroid Ultrasound Appearance:
RIGHT: LEFT:
[ ] Normal Appearance [ ] Normal Appearance
[ ] Heterogenous [ ] Heterogenous
[ ] Enlarged [ ] Enlarged
[ ] Possible Cyst [ ] Possible Cyst
[ ) Possible Nodule [ ] Possible Nodule
Follow up with physician is recommended in months.
cartilage
thyroid
gland
trachea .
(windpipe) -
front view
Patient Name:
Date:
15 82
Thyroid gland:
The thyroid is a butterfly shaped gland located at the bottom of your neck. The gland has both a right and left lobe
connected by a narrow band of tissue, called an isthmus. Besides revealing if the gland is enlarged, an ultrasound of the
thyroid will detect if there are any nodules, cysts, or any changes in the texture of the thyroid tissue. Thyroid cysts are
fluid filled and mostly benign. The majority of thyroid nodules do not require treatment. Only a small percentage of
nodules maybe problematic and need further attention.
If a cyst or nodule is identified, we will advise you
to consult your physician for a follow up.
Aortic Aneurysm Appearance:
The main artery in our body is called the
Aorta. The Aorta extends from the heart
and continues through the abdomen and
supplies blood to all the abdominal organs.
The ultrasound examines the abdominal
section of the aorta, from the breastbone
to the umbilicus. The Aorta should
measure less then 3cm in diameter. If it
measures more then 3cm, then an
abdominal aneurysm is suspected.
Aortic Aneurysm Appearance
[ ] Normal Appearance Size: cm
(Abdominal Aorta measuring 2.4 cm or less)
[ ] Ectasia Size: cm
(Dilation/distention of the abdominal aorta)
[ ] Possible Aneurysm Size: cm
[ ] Fusiform [ 1 Saccular
Follow up with your physician will be recommended if an abdominal aortic aneurysm is detected.
Pancreas:
back of the abdomen, plays an
stomach, it may be difficult to
examine due to stomach gases. During the exam we will analyze
the pancreas to determine if there are any abnormalities in size
and texture. We will also be evaluating for any tumors or cysts.
Pancreas Results:
[ ] Normal
[ ] Echogenic
[ ] Enlarged
[ ] Unable to Visualize
[ ] Follow up with your physician is
recommended in months.
The pancreas, located in the
essential role in digestion. It
also produces insulin and
uses it to regulate the
glucose, or sugar, in our
bloodstream. Due to the
pancreas's position, in the
back of our body, below our
If any abnormalities are noted you should consult with your physician.
Gallblader Ultrasound Scan:
[ ] Normal
[ 1 Thickened Wall
[ ] Contractacted (due to normal digestion)
El Possible Stone(s)
Possible Polyp(s)
Possible Sludge
[ ] Gallblader Removed
[ I Follow up with your physician is
recommended in months.
15482
gallbladder
gallstones
bile duct
Slonsach
liver
ir „ver
common
bile duct
gallbladder
bladder
Kidney Results:
Right: cm Left: cm
[ ] Possible Cyst(s): [ ] Possible Cyst(s):
[ 1 Possible Mass(s): [ ] Possible Mass(s):
[I Possible Stone(s): [ ] Possible Stone(s):
[ ] Enlarged [ ] Enlarged
[ ] Atrophy [ ] Atrophy
[ ] Follow up with your physician is recommended in months.
Patient Name: Date:
Gallbladder:
The Gallbladder is a small pear-
shaped organ located under the
liver. Its primary purpose is to
collect and store bile that is
produced by the liver. It then
squeezes the bile into the
intestines via a duct. The
common bile duct creates a path for the bile to exit from the
gallbladder into the intestinal tract. When we eat food, the
gallbladder works quickly to aid in digestion and contract -
therefore the ability to evaluate this organ will depend on
when the patient last ate. Ultrasound imaging reveals if the
gallbladder has polyps, sludge, or stones — which is a sand like
material that can irritate the GB walls.
It is recommended to follow up with your doctor if stones, sludge, or any other abnormal findings are detected.
Liver:
The liver is the largest organ in our
body and sits on the right side just
under the rib cage. The liver is split
into two sections, the right and left
lobes. The liver's primary functions
are to filter the blood from toxic substances, aid in digestion, and
produce proteins important for our bodies. An abdominal
ultrasound can detect many liver conditions including cancer,
cirrhosis, and fatty liver. It will also determine the size, texture, and
blood flow of the liver.
Liver Ultrasound Scan:
[ ] Normal
[ ] Enlarged
[ ] Fatty Infiltration
[ ] Cyst: cm
[ ] Mass: cm
[ ] Follow up with your physician is
recommended in months.
If the liver is found to be enlarged or have any other abnormalities, we will advise you to follow up with your doctor to
evaluate if any further testing is necessary.
Kidneys:
The kidneys, which are bean shaped, can be found on both the left and right side of the
spine. The kidneys main function is to filter our blood stream and remove any wastes, or
toxins via
our urine.
Each kidney
has a duct known as a ureter which is used as
a path for the waste to exit into our bladder.
Ultrasound imaging is used to evaluate the
kidneys for size, cysts, tumors, stones, and
texture. If a kidney is too small or too large it
may not be functioning properly.
If any abnormal findings are detected,
follow up with your physician is
suggested.
Testes Results:
Left Right
[ ] Normal Appearance [I Normal Appearance
[ ] Heterogenous [ ] Heterogenous
[ ] Enlarged [ ] Enlarged
[ ] Hydrocele [ ] Hydrocele
[ ] Spermatocele (epi cyst) [ ] Spermatocele. (epi cyst)
[ ] Cyst or Nodule: [ ] Cyst or Nodule:
[ ] Follow up with your physician
is recommended
In months
Patient Name: Date:
15082
Spleen
The spleen, which is part of the
lymphatic system, is located near the
upper left side of the abdomen below
the diaphragm. The spleen helps to
remove waste, maintain fluid balance, and is involved in the
body's immune response. It stores red blood cells and
produces white blood cells to help the body fight infection.
We will examine the spleen with the ultrasound to evaluate
the size of the spleen, if it is enlarged, or if there are any
changes in texture including cysts and tumors.
Spleen Results:
[ ] Normal
[ ] Enlarged
[ ] Echogenic
[ ] Mass(s)
[ ] Cysts(s)
[ ] Follow up with your physician is
recommended in months.
Follow up with your physician if any abnormal findings are detected.
Prostate
The prostate is a walnut sized, reproductive organ, with its
main purpose being to secrete fluid and protect sperm. The
urethra travels through the center of the prostate gland which
is located between the bladder and the rectum. It is helpful to
have a full bladder upon examination as this will ensure a good
window to see the prostate. An ultrasound of your prostate is
useful to examine the gland for any abnormalities such as an
enlarged prostate also known as benign prostatic hypertrophy
(BPH), cancer, or other prostate related conditions.
Prostate Results:
( ] Normal
[ ] Enlarged (BPH)
[1 Calcified
[ ] Nodule:
[ ] Mass:
[ ] Follow up with your physician is
recommended in months.
If any abnormalities are revealed, we recommend consulting your physician for a follow up.
Testicles
The testicles (testes) are part of a man's
reproductive system. The testicles
produce sperm and testosterone. During
the ultrasound exam we will be
evaluating both testes and the
epididymis, which is a tube that
ultimately connects the testicles to the
urethra. A testicular ultrasound is the
primary imaging method used to observe
and detect any abnormalities such as,
cysts, tumors, size and texture.
If any abnormalities are found, follow up with your doctor is suggested.
External carotid arteay
C.emnion ox04
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carotid
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Patient Name: Date: 15482
CAROTID ARTERIES
Carotid Arteries travel from
the heart up both sides of the
neck. The carotid artery will
split into two arteries, the
Internal Carotid Artery (ICA),
which supplies blood flow to
the brain, and the External
Carotid Artery (ECA), which supplies blood flow to the neck and
face. Carotid artery disease occurs when plaque builds up on the
artery walls. Too much plaque in the artery can cause a blockage,
or stenos's. If plaque is found it will be reported as either mild
(0-50%), moderate (51-70%) or severe (70% or greater). A mild
amount of plaque is normal for adults as they age.
Carotid Artery Evaluation:
RIGHT CIMT: mm
RIGHT STENOSIS:
% of Plaque: [ ] Mild [ } Moderate [ ] Severe
LEFT CIMT: mm
LEFT STENOS'S: %
% of Plaque: [ ] Mild [ } Moderate [ ] Severe
If you have moderate or severe findings, we recommend you follow up with your doctor to determine if
further evaluation is necessary.
ULTRASOUND SCREENING CONDUCTED BY: TRUMAN THOMPSON
ULTRASOUND SCREENING REVIEWED BY: MARK GAETKE, MD
Thank you for allowing 1582 to take part in your journey of pursuing a healthy lifestyle! We hope your ultrasound
screening was a positive and educational experience. Enclosed you will find information regarding each of your
screening tests that were performed today. There is a section, after each exam description that explained your
results in a simple manner. We may have detected pathology or an abnormal finding, in this situation we always
recommend you follow up with your personal care physician. If your tests were normal — congratulations, we
encourage you to share your results with your doctor at your next health visit.
It is important to us that you understand your results. Please do not hesitate to ask if you have any questions or
would like some more information regarding our service.
Exhibit C - RFP #20-07-C24 Response
15 4 82
November 12,2019
Northwest Fire District
5225 W. Massingale Road
Tucson, Arizona 85743
RE: RFP 20-07-C24 Annual Physical Exams
and Occupational Health Services
To Whom It May Concern:
Gilbert, Gaetke and Associates of Nevada, MD, LTD (Professional Medical Corporation) d/b/a ARC Health
and Wellness Centers and 1582 (Management Services Organization) (hereinafter collectively referred to
as 1582) are pleased to present to Northwest Fire District our proposal to provide Annual Physical Exams
under Section IV: Group 1: Annual Physical Exam Services which adheres to all specifications and includes
all relevant attachments.
1582 is the leading provider of 1582 Compliant Exams for firefighters in the Western United Shifts serving
fire departments in Arizona, Nevada, Colorado and California. In accordance with the NFPA 1582
guidelines, 1582 linty utilizes Lkensed Physidans in conducting the Annual Physical Exams.
1582 is currently conducting approximately 8,500 annual physical exams per year in the Western United
States. As a company, we are committed to serving the fire departments of the greater Tucson area and
would appreciate the opportunity to serve Northwest Fire District.
The President of 1582, Paul Granstrom, as well as our Corporate Medical Director, Mark Gaetke, MD, will
not only be the initial point of contact, but will also oversee the entire operation to ensure that 1582 meets
your program objectives.
Should you have any questions or concerns regarding our response, please contact Paul Granstrom,
President of 1582, via phone at (775) 846-3413 or by email: paul@l582exam.com.
Cordially,
Pautror sns—
President
858 West Elliott Road, Tem pe, AZ 85284
PH: (775) 846-3413 • FAX: (775) 823-9025
EXECUTIVE SUMMARY
1582's medical staff is aware of how challenging it is to be a firefighter and the risks involved for these
"Industrial Athletics" performing their jobs. The NFPA Guidelines detail (over 775 times) that a Licensed
Physician should be conducting the NFPA 1582 Annual Exams. 1582 will provide a Licensed Physician
to conduct the Annual Exams—. rather than a mid-level practitioner, such as a Nurse Practitioner or
Physician Assistant Mid-level practitioners are NOT endorsed by NFPA at all in NFPA 1582 as being
authorized to conduct these exams. 1582 is prepared to meet, if not exceed, all the specifications listed in
RFP # 20-07-C24, Section IV: Group 1 — Annual Exam Services.
PROPOSED SOLUTION
This proposal will be based on providing the Annual Physiouls on-site within the premises of one or more
of the Northwest Fire District's stations. 1582 will provide, transport and set up "state of the art" medical
equipment and provide all clinical staffing to conduct the Annual Exams. Northwest Fire District will
provide up to four (4) separate rooms to conduct the exams. There will be no need to send your firefighters
to other locations or medical providers for any components of the Annual Exams.
COST OF SOLUTION
1582 is serious about wanting the Northwest Fire District to be our first client in the greater Tucson area.
Therefore, we are willing to offer the pricing structures listed below depending on which Methodology you
select. Furthermore, 1582 is willing to honor the prices listed in this proposal for the term of Agreement
agreed to by both parties.
Price per Annual Physical: $ 625 per exam
OPERATIONAL PLAN
•
1582 staff will work closely with Northwest Fire District to maximize efficiency regarding scheduling the
Annual Physicals based on your firefighters' various shifts to minimize any disruption of services to the
community. The Annual Physicals will be conducted in two phases. Phase I of the exams will include
blood draws, chest x-rays, Ultrasound Tests, Vision, Audiogram, and Pulmonary Function Test conducted
"On-site" over a period of approximately 15 - 20 working days. Phase II of the exams will be scheduled
approximately three (3) weeks later and will include the Resting EKG, Stress treadmill Exam, Fitness
Endurance exams, and the Physician exams. Phase 11 exams will be conducted over a period of
approximately 25 working days. Additional option: we would like to offer for consideration Quarterly
Visits to complete the exams serving 50 - 60 members per quarter.
Northwest Fire District will provide three (3) rooms and a waiting area for conducting the Blood Draws,
Audiograms, PFT Tests, Ultrasound Screenings and Mobile Chest x-rays (which will require an outside
wall.) Phase II of the exams will require: a minimum of three (3) separate rooms as well as a waiting area
for the stress treadmill testing, and the Physician exams and Fitness Endurance. Please note that we will
not be referring your Fire members to complete testing offsite like a Diagnostic Imaging Center (e.g Simon
Med) or a Laboratory Service Center (e.g. Quest or LabCorp) to complete the x-rays or labs. These tests
will be conducted on-site by I 582 's staff
1582 will meet with representatives of Northwest Fire District to discuss and approve all aspects of the
Annual Physirals including clinical protocols, reporting systems, medical recordkeeping, and billing. At
the time of their physical, all firefighters will receive their results. All medical information will be stored
and maintained by 1582 at its corporate office. Northwest Fire District will be notified immediately if any
of the firefighters fail to pass their physical based on pre-agreed protocols established by your organization.
All Fit for Duly Medical Clearance Reports will be delivered within fourteen (14) working days to
Northwest Fire District. Each firefighter will be provided a 1582 Report Card highlighting key elements
which will provide a trend analysis from year to year.
TAB 2
HISTORY OF 1582
Gilbert, Gaetke and Associates of Nevada, MD, LTD (Professional Corporation) dfb/a ARC Health &
Wellness Centers /1582 (hereinafter referred to as "1582") was formed in 2009 to specialize in conducting
NFPA 1582 Annual Heart & Lung Physicals for firefighters and police officers. Our first client was the
City of Sparks Fire Department located in Northern Nevada. Over the years, our book of business grew
rapidly to include all agencies with the State of Nevada as well as all major cities and counties in Nevada
including the Cities of Las Vegas and North Las Vegas. 1582 then expanded its services in the states of
Colorado, Arizona and California. As a result, 1582 has become the leading provider of NFPA 1582
compliant physical exams in the Western United States conducting approximately 8,500 annual exams per
year.
Currently we have a total of nine (9) offices in Nevada and as well as one (1) satellite office in Tempe, AZ
and one (1) satellite office in Monterey, CA. In addition, 1582 has a fleet of five (5) mobile medical units
to provide on-site services for our clients.
We have been serving various clients in Arizona for a number of years including Kingman Fire Department,
Bullhead City Fire Department, Rural Metro Fire Department, Casa Grande Fire Department and others in
the Arizona Market.
Tab 3
STA It J1MENT OF QUAMICATIONS
Conducting NFPA 1582 Compliant exams is not merely a product line for 1582, it is our primary business.
As indicated previously, 1582 has been providing the services solicited in this RFP since 2009. Very few
medical providers understand the complexities of conducting NFPA 1582 compliant exams. The
principals/key personnel of 1582 have collectively been conducting these examinations for over 40 years!
1582's dedicated clinical and management team has a depth of expertise which only comes from having
extensive working experience in the industry they serve. Our Occupational Health team of experts can help
you stay in compliance with all regulations pertaining to the services provided in this RFP.
It takes more than even the key personnel listed in this document to successfully deliver high quality
services to 1582's clients. The checks and balances that have been implemented as part of 1582's Quality
Assurance Program are unsurpassed. 1582's staff of certified x-ray technologists, certified ultrasound
technicians, certified phlebotomists, NIOSH certified pulmonary function technicians, CAOHC certified
hearing conservationists, and cardiovascular technicians, complement the physician and management team
and are critical to the success of 1582.
1582 currently has seven (7) licensed physicians who provide physical exams...and all are certified in
conducting stress treadmill tests. In the event of the death or disability of a clinical provider, 1582 has
sufficient physician staff to ensure that all services provided under this RFP will remain un-interrupted.
NFPA 1582 —2018 edition references that the examination will be conducted by a Department Physician,
this is referenced seven-hundred and fifty-five times (755) in the current edition. Unlike some of our
competitors, we DO NOT USE, Mid-Level Providers to complete this critical examination for your Fire
Members. NFPA 1582 does not reference the use of Mid-Level Practitioners such as Nurse Practitioners
or Physician Assistants_
Please see Appendix I: Statement of Qualifications for expanded details regarding 1582.
TAB 4
1582 SOLUTION: FIREFIGHTER ANNUAL PHYSICAL EXAMS
1582 will customire the services we provide to minimize any disruption to Northwest Fire District and the
community you serve. We recognize that conducting these physicals are time consuming for your
firefighters and we are prepared to conduct all services On-Site.
On-Site within the premises of one or more of the Northwest Fire District's stations. 1582 will
transport, set up all "state of the art" medical equipment and provide all clinical staffing to conduct all
components of the Annual Exams. There will be no need to send your firefighters to other locations for any
of the services, such as Lab Draws or X-Rays.
Additionally, if desired 1582 can deploy one of our Mobile Medical Units on-site at the location(s)
rather than within Northwest Fire District's premises to conduct the examinations. 1582 will drive its
Mobile Medical Unit to the location(s) designated by Northwest Fire District. All equipment required is
on-board the Mobile Medical Unit and it would not be necessary to utilize Northwest Fire District's
facilities or equipment. We would need additional testing space for Ultrasounds and Fitness Evaluations.
We understand that your current preference is to conduct the Annual Physicals during one defined time
period per year. If you wish to consider other options in the future, 1582 is willing to work with Northwest
Fire District and conduct the Annual Physicals on a Bi-annual or Quarterly basis depending on which
ever option is most convenient for your organizationeat no additional charge if you prefer.
Upon being awarded the contract, 1582 and Northwest Fire District will set up one or more meetings to
discuss all aspects of conducting the Annual Physicals including, but not limited to: scheduling, time
frames, components of the exams, all forms utilized in the Annual Physicals, clinical protocols, space
requirements, medical record system, and approval of the reporting system, etal.
The 1582 Scheduler will work closely with Northwest Fire District to schedule all firefighters based on
their various Battalion shifts within the specified time period. The staffing recommendations below will
be based on how many firefighters can be "freed up" daily to conduct the various components of the exam.
These recommendations can be adjusted as needed.
1582 is recommending that the Part I phase of the exam include, at a minimum, the blood draws, chest x-
rays, Audiograms, PFTs, ultrasound screenings, and miscellaneous additional testing. A minimum of three
(3) separate areas will be required to conduct the Part I exams: a blood draw area, a room to conduct the
audiograms and PFTs, a private room for ultrasound screenings and a room in which our staff can "shoot"
the mobile x-rays against an outside wall. 1582 will provide and set up all medical equipment including a
portable digital x-ray system. 1582 will deliver all blood specimens to LabCorp and electronically send the
x-ray images to SimonMed for the Radiologist Over-reads.
Since fasting is involved, it is preferable to conduct the blood draws during the first part of the day from
7am — Noon. 1582 will provide on-site staffing of a phlebotomist(s), ultrasound technician, and x-ray
technician over a period of approximately 15 working days (15 Phase 1 Exams/day). The Part I phase of the
exam should take no longer than 30 minutes per firefighter.
Approximately three weeks later, 1582 will conduct the components of Part 11 of the physical over a period
of twenty-five (25) working days which will include the stress treadmill exams, the Fitness Endurance
Exams and the Physician exams. Space requirements include: one private room for stress treadmill exams,
and one private room for the Physician exams and one private room for the Fitness Endurance exams. Part
II of the exams should take no longer than 3 hours per firefighter. 1582 projects conducting approximately
nine (9) physicals per day scheduling 3 firefighters at a time beginning at 7:30am, 10:30am, and 1:30pm.
The critical point is for the physician to have all Results, including Lab/X-Ray reports, and
Ultrasound results at the time of visit with the patient to maximize the quality of the examination.
O
•
The methodology used for all the physicals as well as the submission of reports and billing will be agreed
to in advance by Northwest Fire District and 1582.
As outlined in the RFP, other Departments may elect to use this contract for their services. We are prepared
to explore opening a Dedicated Office if other Fire Departments in the area wish to use our services
as well, in addition to continuing to provide on-site services.
"1582 is willing to set up a permanent, dedicated office which would serve the Northwest Fire District
firefighters and other fire departments in the area by appointment only."
•
•
TAB 5
NOT APPLICABLE S
TAB 6
APPENDIX I: STATEMENT OF QUALIFICATIONS
A. FIRM QUALIFICATIONS AND EXPERIENCE
General Overview and History of 1582
Gilbert, Gaetke and Associates of Nevada, MD, LTD d/b/a ARC Health & Wellness Centers was
formed as a Professional Medical Corporation in the State of Nevada in 2009 to provide
Occupational Medicine Services including Annual Heart & Lung Physicals for firefighters and
police officers.
ARC Health & Wellness Centers/1582 was formed as a Nevada Limited Liability Company. 1582
is the Management Services Organization (MSO) that provides all administrative services for the
professional medical corporation. Since our organizations were specializing in providing NFPA
1582 Compliant Annual Exams, our management team decided to name MSO company "1582."
1582's growth as a company has been quite remarkable. During the past twelve (12) years, 1582
has grown from conducting only several hundred Annual Physicals per year to over 8,500 Annual
Physicals per year. 1582 serves fire departments in Nevada, California, Colorado and Arizona.
Currently 1582 has eleven (11) offices including one office in Tempe, AZ and one in Monterey,
CA. In addition, 1582 owns and operates five (5) Mobile Medical Units which are transported by
CDL drivers throughout the State of Nevaila, California, Colorado and Arizona.
In addition, 1582 provides occupational medicine services for work-related injuries to over 1,500
clients in the State of Nevada.
Number of Employees
Currently 1582 employs approximately thirty-five (35) employees including seven (7) physicians.
Headquarter Location
1582's corporate headquarters are located at 1855 N. McCarron Blvd, Sparks, NV 89431.
Type of Business
Gilbert, Gaetke and Associates of Nevada, MD, LTD d/b/a ARC Health & Wellness Centers is a
Nevada Professional Medical Corporation. 1582 is a Nevada Limited Liability Company qualified
to do business in the State of Arizona. 1582 is the Management Services Organization for ARC
Health & Wellness Centers.
Office Serving Northwest Fire District
This proposal is based on 1582 providing on-site services for the Annual Physicals for firefighters
on the premises of Northwest Fire District. However, 1582 is prepared to open an exclusive office
in Tucson, AZ for Northwest Fire District and other Fire Departments if desired. In addition, 1582
is open to the idea of providing exclusive workers compensation services for the fire departments
in the greater Tucson area in the future.
•
•
B. QUALIFICATIONS OF KEY PERSONNEL
1) The key staff that will be assigned to this contract include:
A)Paul Gran.strom — President
B)Mark Gaetke, MD — Corporate Medical Director
C)Chris Pederson, MD — Medical Director
D)Triporah Richmond Ultrasound Technician
E)Mariah Mathis — Phlebotomist, Cardio-vascular Technician
F)Amanda Hickson — Phlebotomist/Medical Assistant
G)Danielle Garcia — Phlebotomist/Medical Assistant
0) Lisa Baysinger — Phlebotomist, X-ray Technician
I) Kristin Venters Phlebotomist, NIOSH/CAOHC
Resumes of each key staff member are included below.
2) The physicians that will be conducting the Physician Exams will be Drs. Mark Gaetke and
Chris Pederson. Their biographies are listed below.
3) Included above in #2 above.
4) The key staff and technicians biographies are listed below.
5) The staff member responsible for all Summary Reports will be Mariah Mathis under the
supervision of Paul Granstrom, President of 1582.
6) 1582 should NOT need to secure additional staffing for this RFP. The only subcontractors
utilized will be LabCorp for processing all lab specimens and SimonMed to perform the over-
reads of the Chest X-rays.
BIOGRAPHY OF PAUL GRANSTROM
PAUL GRANSTROM
PRESIDENT
1582, LLC
EDUCATION: Bethel College, Arden Hills, MN, 1999
Bachelor of Arts Degree
EXPERIENCE:
President/ Principal
ARC Health & Wellness Centers/1582: 2009 — Present
Served as President of 1582 for the past ten (10) years. He has successfully mimed ARC
Health & Wellness Centers/1582 in becoming the leading medical provider of NFPA 1582 and
NRS 617 Annual Examinations in the Western United States. Currently, ARC/1582 conduct
over 8,500 Annual Physical Exams per year in Nevada, Arizona, Colorado and California.
Executive Vice President/Principal
ARC MedCenters, LLC: 2004 - 2009
Managed operations of a network of medical facilities in Northern Nevada which provided
urgent care/family practice/occupational medicine services treating over 50,000 patients per year.
Successfully sold the various practices to two local hospital systems.
Executive
Textron Financial Group: 1998 — 2004
Textron Financial Group is a subsidiary of a Fortune 100 company, Textron, Inc. Served as
Recovery Specialist, Regional Sales Representative and Sr. Account Manager.
Certifications:
Intoidmeters Certified Instructor (Evidential Breath Tester/Breath Alcohol Technician)
Urine Specimen Collector Instructor - Department of Transportation (DOT)
•
S RifOGRAPHY OF MARK GAETKE, MD
MARK!. GArricE, MD
BOARD — CERTIFIED FAMILY PRACTICE
Medical School
Family Practice Residency
Corporate Medical Director / Principal
Loma Linda University, 1987
Loma Linda 1987-1990
ARC Health & Wellness Centers — 2010 — Present
Dr. Gaetke has served as Corporate Medical Director of ARC for the past nine (9) years. He is recognized
as one of the leading experts in the area in conducting NFPA 1582 and NRS 617 medical evaluations.
Past Positions: • Medical Director/Staff Physician
Concentra Medical Centers — Reno/Sparks/Carson City, NV 1996-2010
Dr. Gaetke held various staff physician and medical director positions during his 14-year
term of employment with Concentra Medical Centers. He gained extensive experience in
conducting heart and lung physical during his employment with Concentra.
Hyperbaric Medicine Specialist
US Naval Hospital — Guantanamo Bay, Cuba 1987 - 1990
Certification & Affiliations Medical:
Nevada Medical License - # 6893
California Medical License - #663790
Alabama Medical Licensure Commission - #MD3698A
American Board of Independent Medical Examiners — Certified 1997
Advanced Cardiac Life Support Re-Certification — May 2019
Certified: Stress ECG Testing
Medical Review Office Certification Council
BIOGRAPHY OF CHRIS PlEDERSON, MD
CHRISTOPHER PEDERSON, MD, MPH, DABPM
BOARD CERTIFIED - PREVENTATIVE MEDICINE
Medical School University of Nevada, Reno 1983
Preventative Medicine Fellowship City of Faith Medical Center 1984 - 1986
Family Medicine Residency City of Faith Medical Center 1983 - 1984
Master's of Public Health 1984 - 1986
Medical Director — Las Vegas
ARC Health & Wellness Centers — 2013 - Present
As Medical Director of ARC'S Las Vegas operations, Or. Pederson has conducted thousands of firefighter
and police annual medical exams.
Past Positions:
Physician Manaaer Onsite Corporate Medical Di partment (10 years)
Hughes Aircraft/Electronics Corporation - Los Angeles
California Corporate practice of Preventive Medicine in a large company with responsibilities
concentrated in the management, treatment and prevention of injuries/diseases, employee
health promotion/education, medical surveillance including cardiopulmonary fitness testing,
drug-free workplace programs, and pre-placement health evaluations; Design and
implementation of an on-site executive health evaluation program; Medical benefits analysis
and modification including a worldwide health enhancement initiative; FAA Aviation Medical
Examiner; Team leader for ACOEM Corporate Health Achievement competition - Winner
1997.
Certification & Affiliations Medical:
1995 — Present Nevada Medical License
1986 — Present California Medical License
1993 — Present American Board Certified in Preventive Medicine
2014 Present Active Physician Licenses: AZ, CO, FL, NM, NY, OR, PA
2014 — Present FMCSA DOT Certification (National Reg. # 5585030956) •
• Biography of Tziporah Richmond, RVS
Tziporah Richmond
Clinical Director, Ultrasound Imaging
EDUCATION:
2008 PCCTI, Chicago, IL
Certification in Sonography Science, PCCTI IT
& HealthCare
EXPERIENCE:
ARC Health & Wellness/1582
2018 Present: Clinical Director, Ultrasound Imaging
Tziporah serves as 1582's Clinical Director of Ultrasound Imaging on a part-time basis. She is responsible
for managing 1582's Ultrasound Program and conducts ultrasounds in 1582's offices and on our mobile
medical units. She performs Ultrasound Sonography: Echocardiograms, Small organs: Thyroid, Testicular,
Breast, and Prostate, Obstetrics and Gynecology, Abdominal: Liver, Pancreas, Spleen, Kidneys, Abdominal
Aorta, WC, Urinary bladder, Gall Bladder, and Biliary tree. Upper and lower Extremities. Vascular.2-D
Echocardiograms, as well as proper general and vascular exams.
Ultraclear Imaging
2016 — Present: Clinical Director
Responsible for hiring and training new technicians. Performs 2-D Echocardiograms, as well as proper
general and vascular exams.
Portasonix
2009 — 2016: Ultrasound Technician
Tziporah worked as an Ultrasound Technician performing vascular ultrasound and arterial Doppler, general
ultrasound of upper abdomen and pelvic, using 2-D, measurements and color flow; and 2-D
Echocardiograms including measurements, color flow and doppler.
CERTIFICATIONS:
Registered Vascular Specialist (RVS) - Cardiovascular Credentialing International
•
•
Biography of Mariah Mathis
Mariah Mathis
Certified Cardiographic Technician/Phlebotomist/EKG Technician
EDUCATION:
2014 East Valley Institute of Technology, Mesa, AZ
CMA/CPT/CEKGT
2015 Pima Community College
EMT
2016 Arizona Medical Training Institute
CCT
2017 Arizona State University
Bachelor's Degree
EXPERIENCE:
ARC Health & Wefiness/1582
2017— Present: Clinic Administrator/Phlebotomist/CYT
Mariah served as Clinic Administrator/Phlebotomist/CVT at ARC's office at 2500 W. Sahara in Las Vegas
from January of 2017 through the summer of 2019 at which time she was responsible for setting up our
new office in Tempe, AZ. She has excellent clinical and leadership skills, She has extensive experience
in conducting pulmonary function studies, audiograms and administering vaccines.
Cardiovascular Associates of Mesa
2016 — 2017: Cardiovascular Technician
Responsible for administering and monitoring stress tests, setting up holder/wireless monitors, performing
pulmonary function tests, ankle-brachial index tests and at home sleep studies. She was also responsible
for conducting blood draws, EKGs, etal
CERTIFICATIONS:
Certified Cardiographic Technician
Certified/Nationally Registered EMT-B
Certified Medical Assistant National Healthcare Association
Certified Phlebotomy Technician National Healthcare Association
Certified EKG Technician National Healthcare Association
ACLS & BCL,S Healthcare Provider CPR Certified •
BIOGRAPHY OF LISA BASINGER
USA BASINGER
Certified X-Ray Technician/Phlebotomist
EDUCATION
2008 Great Basin College (GBC); Elko, NV
AAS Radiology Technology; ARRT Certified
BAS Management Technology
EXPERIENCE
ARC Health & Wellness Centers/1582
2015 Present: Radiologic Technologist/Phlebotomist/Medical Assistant
Lisa served as a Certified X-ray Technician/Phlebotomist for ARC/1582 serving as an integral part of the team
conducting thousands of Annual Physicals in 1582 various offices and on its mobile medical units. She has extensive
experience in conducting audiogtams, pulmonary function studies and administering vaccines.
SUMMT HEALTHCARE OF ARIZONA
2010— 2015 Health Screener/Wellness Coach
Lisa was responsible for setting up the health screening sites, checking in participants, performing Biometrics on
patients, perfotming finger sticks using Cholestech machine for lipids panel and performing venipunctare_ As a
wellness coach she was responsible for coaching patients on glucose, lipids and biometric results with the goal of
helping patients achieve a healthy lifestyle.
Northern Nevada Health Center
2010 — 2011: Radiology Technologist/Medical Assistant
CERTIFICATIONS:
Certified X-Ray Technician
Certified Phlebotomist
•
•
• BIOGRAPHY OF AMANDA DICKSON
AMANDA DICKSON
Certified Phlebotomist/Medical Assistant
EDUCATION
2012 Berkeley College Woodland Park
Certified Clinical Medical Assistant
Certified EKG Technician
Certified Phlebotomy Technician
EXPERIENCE
ARC Health & Wellness Centers/I582
2013 - Present: Clinic Administrator/PhlebotomiseMetitcal Assistant
Amanda has served as Clinic Achninistrator/Phlebotomist/IVIedical Assistant for ARC/1582 serving as an integral part
of the team conducting thousands of Annual Physicals in 1582's various offices and on its mobile medical units. She
has extensive experience in conducting audiograms, pulmonary function studies and administering vaccines.
SUMMIT HEALTHCARE OF ARIZONA
2010— 2015 Health Screener/Wellness Coach
Lisa was responsible for setting up the health screening sites, checking in participants, performing Biometrics on
patients, performing finger sticks using Cholestech machine for lipids panel and performing yew' tincture. As a
wellness coach she was responsible for coaching patients on glucose, lipids and biometric results with the goal of
helping patients achieve a healthy lifestyle.
Northern Nevada Health Center
2010 - 2011: Radiology Technologist/Medical Assistant
CERTIFICATIONS:
Certified X-Ray Technician
Certified Phlebotomist
•
BIOGRAPHY OF DANIELLE GARCIA
DANEILLE GARCIA
Certified Phlebotomist/Medical Assistant
EDUCATION
2008 ICAPIAN COLLEGE, Las Vegas
Certified Clinical Medical Assistant
Certified EKG Technician
Certified Phlebotomy Technician
EXPERIENCE
ARC Health & Wellness Centers/1582
2013 — Present: Clinic Administrator/Phlebototnist/Medical Assistcrnt
Danielle has served as Clinic Administrator/Phlebotomist/Medical Assistant for ARC/1582 serving as an integral part
of the team conducting thousands of Annual Physicals in 1582's various offices and on its mobile medical units. She
has extensive experience in conducting audiograms, pulmonary function studies and administering vaccines.
DESERT INN MEDICAL CENTER
2011— 2013 Medical Assistant
Danielle functioned as a Medical Assistant collecting and processing specimens, venipunctures/injections, capillary
sticks, urinalysis, patient wound care, EKG testing, x-rays, etal.
Desert Family Practice
2008 — 2011: Medical Assistant
Danielle served as a Medical Assistant primarily in the front office answering the phones, scheduling, performing
insurance verification, chart preparation, and data entry.
CERTIFICATIONS:
Certified Medical Assistant
Certified Phlebotomist
•
•
•
Biography of Kristin Venters
Kristin Venters
Heart & Lung Technician
EDUCATION:
Current Arizona State University
Forensic Psychology
2016 - 2018 Truckee Community College
Community Health
EXPERIENCE:
ARC Health & Wellness/1582
Janurny 2019— Present: Heart & Lung Technician
Serves as Heart & Lung Technician at the ARC/1582 Medical Centers and on the Mobile Medical Units.
Kristin is certified by NIOSH, CAOHC, and as a Breath Alcohol Technician.
The Rock Church/Pebbles Preschool & Kindergarden
2016 — 2019:
Teacher/First Aid Director
Washoe County Sheriff's Office
2017 —2018
Emergency Medical Technician
CERTIFICATIONS:
Emergency Medical Technician
Office Laboratory Assistant
NIOSH
CAOHC
BAT
CPR
S
o
S
C. UNDERSTANDING OF REQUIRED SCOPE OF SERVICES
1)Understanding and ability to provide the services required by the RFP
Please be advised that we completely understand the services required by the RFP and are
confident of, and guarantee 1582's ability to provide the services. As the leading medical provider
of NFPA 1582 physicals exams in the Western United States conducting in excess of 8,500 Annual
Physicals per year, we are confident of our ability to not only provide, but exceed, the services
stipulated in RFP# 20-07-C24. We strongly encourage Northwest Fire District to not only check
on the references listed in this document, but also check with any of our clients! 1582 excels in
customer service and take pride in our stellar reputation.
As stipulated previously, 1582 does not utilize mid-level providers to conduct these exams. As
required by NFPA 1582 (an organization with which we work closely with), 1582 only uses
experienced licensed physicians to conduct these exams. Our entire clinical team not only
possess the necessary credentials, but also have extensive experience in conducting NFPA 1582
There is no substitute for experience! Based on over ten (10) years of experience in working with
Fire Departments, 1582's clinical and administrative staff understand the complexities of the
firefighters' work specifications and the risk factors associated with these industrial athletes
performing their jobs.
1582's President and Corporate Medical Director will work closely with Northwest Fire District to
ensure the following: 1) Mutual agreement of the clinical protocols utilized in determining risk
factors and what constitutes being "Fit for Duty" versus "Non Fit for Duty" based on the NFPA
1582 Guidelines AND the goals and objectives of the Northwest Fire District.
2)Policies and procedures for complying with all rules, regulations and requirements of NFPA,
DOT, OSHA, HIPAA and GINA.
1582 has policies and procedures, as well as training programs in place, as standard practice
regarding the above rules and regulations and requirements. This is obviously a requirement of all
of our high profile government clients. ARC/1582 also has a network/privacy insurance policy of
$2,000,000.
3)Ability to comply with the Protocol and Procedures for services that the firm is responding
to as detailed in this RFP.
1582 guarantees that it has the ability to perform all of the specifications required as part of this
RFP.
4)Firm's capacity to conduct 225 or more annual physicals and fitness tests.
1582 guarantees its ability to conduct this number of physicals within the time frame outlined in
this RFP. It is not unusual for 1582 to conduct this number of physicals for our various clients.
5)Describe the firms' ability and action plan to undertake this work immediately after award
of contract.
It is our understanding that the Annual Physical Component of this RFP is requiring the physicals
to begin in June of 2020. 1582 is certainly capable of complying with this requirement.
•
•
However, 1582 is prepared to conduct the Annual Physicals even earlier in 2020 if Northwest Fire
District so desires.
1582's Action Plan is as follows:
1. 1582's President and Corporate Medical Director will set up a meeting with
representatives of the Northwest Fire District to accomplish the following:
A)Establish the various program goals and objectives and requirements of
Northwest Fire District
B)Discuss time frames, space requirements, staffing, scheduling, clinical
protocols, etal.
C)Agree on the all facets of both Phase I and Phase II of the Annual Physicals
described in this response to your RFP including discussion of all testing; and
D)Agree on all procedures regarding reporting of results.
2. Finalize scheduling of the Annual Physicals well in advance of the actual dates of
conducting Phase I and Phase II or the Physical.
Phase I: Blood Draws, Chest X-rays, Vision, Audiograrns, PFT's scheduled over
a period of fifteen (15) working days on the premises of Northwest Fire
District.., approximately three (3) weeks prior to conducting Phase II of
the physical. This time frame would require an average of fifteen (15)
firefighter Phase I exams per day. Since the blood tests stipulated in this
RFP require fasting, our technicians would be available early in the
morning to begin this process.
1582 is open to exactly how Northwest Fire District would prefer to
schedule the Part 1 - blood draws, chest x-rays and other testing. 1582
will provide a minimum of one (1) phlebotomist, one (1) medical assistant
and one (1) x-ray technician to accomplish this schedule.
Phase II: Stress Treadmill Tests, Fitness Tests and Physician exams Scheduled
over a period of twenty-five (25) working days on the premises of
Northwest Fire District.., approximately three (3) weeks after Phase I of
the physical has been completed. 1582 is recommending that nine (9)
firefighters per day be scheduled for these exams. The preferable time
frames would be three (3) firefighters at 7:00 AM; three (3) firefighters at
10:00 AM; and three (3) firefighters at 1:00 PM.
At a minimum, 1582 will provide the following staff members for the
Phase II: Physician, Cardiovascular Technician, Ultrasound Technician,
and a Certified Medical Assistant.
3. Reporting of Results
Please be advised that we are open to any requests from Northwest Fire
District as to reporting of results. Typically, on the day of Phase 11 of the
physical, 1582 provide all firefighters with copies of their lab results,
ultrasound images, Stress Treadmill results, and patient education
handouts.
Since 1582 has a Physician conducting the exam, Northwest Fire District
will be provided "real time" the results of any firefighter exam that is "Not
Fit for Duty" scenarios.
Within fifteen (15) working days, 1582 will provide Northwest Fire
District with the HT for DUTY Medical Clearance forms. Also within
thirty (30) working days, 1582 will provide to Northwest Fire District in a
Tamper Proof Box marked "Private & Confidential" the complete results
for the firefighters including a dictated Physician Report.
D.Billing and Record Keeping
1582's record keeping process consists of scanning all results of the examinations
into 1582's Electronic Health Information System which, of course, is HtPAA
compliant. 1582 retains all documents in accordance with state and federal
guidelines. However, we are open to any requests from Northwest Fire District as
to their policy for retaining the documents.
1582 will bill Northwest Fire District within thirty (30) days of completion of
Phase II of the Annual Physical.
It is not anticipated that there will be any FMLA paperwork or ADA
accommodations that would be needed to bill to Northwest Fire District.
E.Cost of Services: See Attachment
F.References: See Appendix Reference Form
RFP# 20-07-C24
APPENDIX II: COST SUMMARY —ANNUAL PHYSICAL EXAM SERVICES
Annual Physical Exams Price Page
Firefighter and Prevention Personnel Requirements
Based on the response to the Questions involving Page 28 # D7 and Page 33 we propose the following
components is what Northwest Fire actually desires for Annual Physical Exam Services.
REQUIRED: COST:
1 - Medical History and Physician Examination (NFPA 1582 Compliant Exam) Included
2 - Ultrasound of Heart (Echocardiogram with Cardiology overread) Included
3 - Vital Signs Included
3 - Audiogram Included
4 - Vision Included
5 - Pulmonary Function Test Included
6 - EKG 12-Lead Included
7 - OCR (Baseline Year 1 or medically indicated, with Radiology Overread) Included
8 - Respirator Questionnaire (OSHA) Included
9 - Hemet Questionnaire Included
10 - Flexibility/Core Strength Testing Included
11 - TB skin test Included
12 - Treadmill — submaximal (WFI Protocol as per NFPA 1582) Included
13 - Treadmill maximal treadmill test (WFI Protocol as per NFPA 1582) Included
15 PSA — over 40 (Males only — (On-Site Venipuncture) Included
17 - AlC (On-Site Venipuncture) Included
19 - Chest X-Ray with Overread (Duplication from # 7) Included
20 - Maximal Treadmill based on Risk (Duplication from # 13) Included
21 - Hepatitis B Quantitative Lab Draw (this test included below 7H — Hep. Profile) Included
23 - Cancer screening (Skin Cancer) Included
24 - Sleep & Stress Questionnaires (Mental Health and Sleep Assessment) Included
25 - Cancer & Cardio Disease Risk Reduction Included
Interpreted as a Full Body Ultrasound Screening: Carotid Artery,
Aortic Aneurysm, Thyroid, Liver, Gall Bladder, Spleen, Kidney, Bladder,
External Pelvic (women), Prostate / Testicular (Men)
27 - 12 mets or 42 VO2 max (WFI Protocol as per NFPA 1582)
28 - Alternative to flexibility (not sure what is meant, compared to # 10?)
REQUIRED: Pane 28 — Annual Exam (net referenced abovel
D4 - Lipid Profile — LDL, HDL, TC, Trig, TC/HDL Ratio On-Site Venipuncture
D5 - Body Fat Analysis (Calipers / BM)
7A - Urinalysis On-Site Collection
7B Comprehensive Metabolic Panel On-Site Venipuncture
7C - T4 and TSH Thyroid Panel On-Site Venipuncture
7D - BladderChek NMP22 On-Site Collection
7E - C-Reactive Protein On-Site Venipuncture
7F - Stool Hemoccult (age 40 and older) On-Site Collection
7H - Hep. Profile (Hep A/B/C Infection, Hep A/B Immun.) On-Site Venipuncture
Total Annual Exam Price (all services conducted on-site)
***Pricing will remain fixed for term contract with NO annual increases***
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
Included
$625.00
OntiouJ
18 - Offer HIV (also known as # 29 Exposure to 111V Testing)
16 - Blood Lead — if needed
22 - Heavy Metal screening (Blood Lead) (Duplication of 16)
14 - No Show/Cancellation of physical (Physician Visit Only)
$ + 43.65
S+ 75.00
$ + 75.00
+100.00
Fipess &abolitions
Unclear if this is done in addition to or instead of the Stress Treadmill Test
26 WF1 Submaximal Step Mill test (if substituted for Stress Treadmill) Included
26 WFI Submaxlmal Step Mill test (if in addition to Stress Treadmill) $ + 30.00
Supplementary Testing / Services
Respirator Fit Testing (Quantitative via PortaCount)
Tetanus Vaccination
Hepatitis A Vaccination (each dose)
Hepatitis B Vaccination (each dose)
Twinitir Vaccination (each dose)
Commercial Driver License Exam (conducted with Annual Exam)
Coronary Calcium Score Baseline (on-site CT with interpretation)
END OF APPENDIX 11
+30.00
+ 41.25
$ + 72.25
+ 58.20
$ + 100.88
5+ 45.00
+ 150.00
e TAB 8
WE ELECT TO NOT PARTICIPATE IN THE OCCUPATIONAL HEALTH SERVICES
COMPONENT OF THIS REP AT THIS TIME
e
co
RFP# 20-07-C24
APPENDIX IV: MINIMUM QUAUFICATIONS VERIFICATION FORM
OFFEROR NAME: ARC HEALTH & WELLNESS CENTERS/1582
Proposals not meeting the minimum qualifications will be deemed NON RESPONSIVE and will not be considered for further
evaluation.
If defined in this solicitation, provide documented and verifiable evidence that your firm satisfies the Minimum Requirements,
and indicate what/if attachments are submitted.
•
1 Minimum qualifications of the offeror's company i ---4o
Will provide upon award of
Contract
2 Minimum qualifications of the proposed key personnel 1..,,lo
Will provide upon award of
Contract
3 Provide copies of license, certifications, accreditation,
etc. (C.:
Will provide upoil dWdf d or
Contract
4 Additional MQ if any.
_
Will provide upon award of
Contract
es/No
Submitted by (Printed Name and Title): FL.. Initial: Date: i\-2
END OF APPENDIX IV
Page 37 of 42
RFP# 20-07-C24
EXHIBIT A
PAST PERFORMANCE VERIFICATION EVALUATION SUBMITTALS
LIST OF THOSE AGENCIES OR FIRMS WHO WILL BE SUBMITTING EVALUATIONS TO NWFD
Please list the agency or firm name, address, phone number and contact information for the firms that will be providing the
Past Performance Verification Form. It is the responglbjIlly of the tint.% to ensure that NWFD receives all of the Past
Performance Verification Forms prior to the submittal deadline. Failure to provide evaluations by date and time specified will
resuit in no score for that specific evaluation.
1.Reno Fire Department
1 E. 1st Street, 4th Floor
Reno, NV 89501
Division Chief - Bob Leighton / 775-333-7774
2.Rural Metro Fire
8465 N. Pima Rd.
Scottsdale, AZ 85258
Fire Chief Ted Beam / 602-489-6540
3.Kingman Fire Department
412 E. Oak St.
Kingman, AZ 86401
Fire Chief Jake Rhoades / 928-753-2891
4.Casa Grande Fire Department
377 W. Val Vista Blvd.
Casa Grande, AZ 85122
Fire Chief Scott Miller / 620-421-8777
END OF, APPENDIX V
Page 40 of 42
REP# 20-07-C24
The following section will be used as an evaluation tool for award. Please complete the checklist to ensure
your compliance to requested needs.
VENDOR INFORMATIONISERVICE: All offerors must demonstrate the willingness and capability of providing
substantial local service which may require the availability of an on-site sales representative and local stocking
facility as may be determined in the District's best interest All out-of-town vendors must be willing to accept collect
telephone calls or provide a toll-free number.
Address and/or E-mail to which purchase orders are to be sent.
paul@l582exam.00m
COMPLIANCE TO SCOPE OF WORK
Is Descriptive literature enclosed? Yes 2 No 0
Is Offer and Acceptance Page properly signed? Proposals submitted without an
original, signed Offer and Acceptance Page may be deemed nonresponsive. Yes La No 0
Are addendums signed and attached?
http://www.northwestfire.org/notices/purchasinq
Yes 2 No II
PRICE $625.00
Please Indicate number of days that prices are firm. Term of contract .
Are prices indicated by unit and totals?
Yes w No 0
Page 41 of 42
RFP# 20-07-C24
OFFER AND _ACCEPTANCE
RESPONDENT SHALL COMPLETE THE FOLLOWING INFORMATION IN INK AND SUBMIT WITH THEIR BID
Print or type in ink the requested information. TYPEWRITTEN RESPONSES ARE PREFERRED.
OFFER
TO THE NORTHWEST FIRE DISTRICT
The Undersigned hereby offers and agrees to furnish the material or service in compliance With all terms, conditions, specifications, and amendments in
the Invitation for Bid and any written exceptions in the offer. Signature also certifies understanding and compliance with paragraph (1) of the Northwest
Fire District Standani Terms and Conditions.
For clarification of this offer, contact:
Gilbert, Gaetke and Associates of Nevada, MD, LTD.
d/b/a ARC Neagh and Wellness Centers and 1582
Company Name
858 W. Elliot, Suite # 105
Address
Tempe. AZ 85284
State Me
Paul Granstrom
775-846-3413
602-581-3030
paul@1582exam.com
Name:
Phone:
Faic
E-mail: City
Paul Granstrom
Printed Name
President / CEO
Title
CERTIFICATION
By signature in the Offer Section above, the bidder certifies:
1.The submission of the offer did not involve collusion or other anti-competitive practices.
2.The bidder has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gift, loan,
gratuity, special discount trip, favor or service to a public servant in connection with the submitted offer.
Failure to provide a valid signature affirming the stipulations required by these clauses shall result in relectien of the offer. Signing the offer with a false
statement shall void the offer, any resulting contract and may be subject to legal remedies provided by law.
ACCEPTANCE OF OFFER
The Offer is hereby accepted.
The Contractor Is now bound to sed the materials or services fisted by the attached contract and based upon the Request For Proposal, Inc:hiding all terms,
conditions, specification, amendments, etc. and the Contractor's Offer as accepted by the District
This contract shaft henceforth be referred to as Contract No. 20-07-C24. The Contractor has been cautioned not to commence any billable work or to
provide any material or service under this contract until Contractor receives purchase order.
NORTHWEST FIRE DISTRICT, a political subdivision
Approved as to form this day of , 2019. Awarded this
day of , 2019.
Norman K Brad Bradley III George Carter
As Northwest Fire District Fire Chief and not personally As Northwest Fire District Chair and not personally
•Thomas A. BenairideZ
Page 42 of 42
RFP# 20-07-C24 Ark?,
ATA.
NORTHWEST FIRE DISTRICT NOTICE OF REQUEST FOR PROPOOALS (RFP)
RFP Number: 20-01-C24 Title: Annual Physica€ Exams and Occupational Health Services
DUE IN: FRIDAY, NOVEMBER 15, 2019 AT 11:00 A,M. AZ TIME
OPENING: SAME DAY AT 11:00 A.M. AZ TIME
Submit Proposal to:
Northwest Fire District Administration
5225 W. Massingale Road
Tucson, Arizona 85743
Pm-Proposal Conference: MONDAY, NOVEMBER 4,2019 at 11:00 A.M. AZ TIME
Northwest Fire District Administration
5225 W. Massingale Road
Tucson, Arizona 85743
SOLICITATION: Northwest Fire District (NWFD) is soliciting proposals from Offerors qualified, responsible and willing to
provide the following Goods and/or Services in compliance with all solicitation specifications and requirements contained
or referenced herein.
GENERAL DESCRIPTION: To provide the Northwest Fire District with Annual Physical Exam and Occupational Health
Services per specifications called for herein.
Prospective Offerors may pick up a copy of the RFP packet, Monday through Friday, 8 am to 5 pm MST, at the address
listed above.
A Pre-Proposal Conference will be held for the purpose of clarifying requirements and answering prospective offeror
questions. It is the responsibility of prospective offeror to familiarize themselves with all requirements of the solicitation
and to identify any issues at the conference. Attendance is optional and encouraged.
Proposals must be submitted as defined in the I Instructions to Offerors, in accordance with the Standard Terms and
Conditions, and Special Terms and Conditions. Failure to do so may be cause for rejection as non-responsive.
Offerors must complete and return all documents required in the section titled PROPOSAL SUBMITTAL".
Proposals may not be withdrawn for 60 days after opening.
OFFERORS ARE REQUIRED TO READ THE ENTIRE SOLICITATION INCLUDING ALL REFERENCED DOCUMENTS,
ASSURE THEY CAN AND ARE WILLING TO COMPLY, AND INCORPORATE ALL ASSOCIATED COSTS IN THEIR
PROPOSALS.
THIS PROPOSAL IS OFFERED BY:
Firm/Person Gibed, Gaetke and Associates of Nevada, MI:), LTD. cUbla ARC Health and Waftwass Centers and 1582
Address 858 W. Elliot, Suite # 105
City Tempe State AZ Zip 85284
signature Phone Number 775-846-3413
Title President / CEO
Publish: Daily Territorial: 10/29/2019, 10/30/2019, 10/31/2019, and 11/01/2019
Page 1 of 42
ISO CLASS I * INTERNATIONALLY ACCREDITED
6225 W. Ma-ssingale Rd. I Tucson, AZ 85743
(520) 887-9010 I wrAv.NorthwestFire.org
Ca@NorthwestFire Igl/NorthwestFireDistrict
November 6, 2019
ADDENDUM NO.1
REQUEST FOR PROPOSALS NO. 20-07-C24
ANNUAL PHYSICAL EXAMS AND OCCUPATIONAL HEALTH SERVICES
This Addendum No. 1 is hereby made a part of the Request for Proposals and shall be included with all
documentation. Offeror shall acknowledge receipt of this Addendum No. 1 by including this Addendum with all
proposals, signing and dating the following statement:
Addendum No. 1 acknowledged by
Date 11/12/19
• Name/Title Paul Granstrom / President / CEO
(Typed or printed)
Gilbert, Gaetke and Associates of Nevada, MD, LTD./ DBA
ARC Health and Wellness Centers / 1582 Name of firm
1.The RFP due date and time remains unchanged from: Friday, November 15, 2019 11:00 AM Local Time.
2.The following questions were received:
a. Page 28, #D7 — Identifies specific laboratory testing or other tests that is not included in the pricing
sheet on Page # 33 - Appendix II Cost Summary — Annual Physical Exam Services, such as:
Required:
T4 Free and TSH non-dialysis thyroid test
NMP22 Bladder Cancer Check
CRP High Sensitivity Test
Hepatitis A ab, Hepatitis B Surface ab and ag, Hepatitis C ab Screening
Ultrasound (please specify which tests)
Skin Cancer Screening
Digital Rectal Exams
Optional based on age / gender / history
Hemoccult Slide
CA-125 (optional for Females Only, correct?)
Tetanus Immunization?
Answer: Please provide pricing for the NFPA 1582 required and optional. •
NORTHWEST FIRE DISTRICT
NORTHWEST
FIRE DISTRICT
ISO CLASS 1 * INTERNATIONALLY ACCREDITED
5225 W. Massingale Rd. Tucson, AZ 85743
(520) 887-1010 I www.NorthwastFire.org
ju@NorthwestFire I in/Nori.hwestFireDistrict
b.Page 28, #2 — The Scope of Services references Ultrasounds but does not specify what specific
Ultrasounds are required - which Ultrasounds are required?
Answer: Per NFPA 1582, The ultrasound we would be referring to would be echocardiograms. These
would be administered following a determination by the FD physician due to a member's particular risk
assessment. Used in conjunction with an EST (exercise stress test), read by a cardiologist and reviewed
by the FD physician. The scope would be to determine the member's ability to perform any and all of the
Essential Tasks required for firefighters. Use screening and/or diagnostic.
Optional preference by the District - please include in the cardiac assessment: carotid arteries ultrasound
and aortic aneurysm ultrasound. Also, the District would like to have as another option for cancer and
disease assessment: thyroid ultrasound, liver, pancreas, gall bladder, spleen & kidney ultrasounds,
bladder ultrasound, pelvic ultrasound for women (external), and testicular ultrasound for men.
c.Page 28, # 2 — Are the Ultrasounds considered Diagnostic (requiring an overread for all or some) or
simply Screenings?
Answer: Based on our response to page 28, #2, please make a recommendation. •
d.Page 28, #B — Annual Fire Department Evaluations was listed 632 in number of NWFD, yet Appendix
I on page 31, # C4 states 225. What is the correct number of exams?
Answer: To date, it is 225.
3.The following documents are now on the NWFD website.
Minutes of the Pre-Proposal Conference November 4, 2019
4. All other terms and conditions remain unchanged.
The revised documents can be downloaded from our website at
http://ww.v.northwesffire.ore/notices/purchasine.
Raymond Thibault
Procurement and Contract Specialist
NORTHWEST FIRE DISTRICT
.--- 7 ® AccoREP CERTIFICATE OF LIABILITY INSURANCE ‘....------ DATE (MM/DD/YYYY) 03/11/2021
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 po icy, 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
Crestline Insurance Services LLC
6955 N Durango Dr #1115-765
Las Vegas NV 89149
ONTACT N Ann Lehtinen AME:
PHONE No. Ext): (702) 596-5686 FAX No): (702) 988-5355 (A/C. (A/C,
E-MAIL ADDRESS: info@crestlineins.com
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A: Transportation Insurance Company 20494
INSURED
1582, LLC
Gaetke Medical Corporation
82 E Glendale Ave
Sparks NV 89431
INSURERS: Sentinel Insurance Company
INSURER C: National Fire & Marine Ins Co 20079
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 20-21 Corona 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 VVHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLIC ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR LTR TYPE OF INSURANCE AUDI
INSD
SUB
INVD POLICY NUMBER POLICY EFF (MMIDD/YYYY) POLICY EXP (MMIDDNYYY) LIMITS
A
X COMMERCIAL GENERAL LJABILITY
4034592085 12/22/2020 12/22/2021
EACH OCCURRENCE •2 000 000 S ,
CLAIMS-MADE X OCCUR DAMAGE I 0 REM ED PREMISES (Ea occurrence) $ 1 00C1 000
MED EXP (Any one person) 1 00 S 0,0
PERSONAL 8. ADV INJURY S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES
PRO- POLICY JECT
OTHER:
N.,,,, ..,..
PER:
LOC.
GENERAL AGGREGATE 4 000.000 S , •
PRODUCTS - COMP/OP AGG . S 4,00 0.000
DEDUCTIBLE s NONE
-
,_,
AUTOMOBILE LIABILITY
ANY AUTO
OWNED AUTOS ONLY HIRED AUTOS ONLY
- SCHEDULED AUTOS NON-OWNED AUTOS ONLY
COMBINED SINGLE LIMIT (Ea accident) s
BODILY INJURY (Per person) S
BODILY INJURY (Per accident) S
PROPERTY DAMAGE (Per accident) $
S
— UMBRELLA LIAB
EXCESS LIAB
_ OCCUR
CLAIMS-MADE
EACH OCCURRENCE s
AGGREGATE S
DED
RETENTION S
$
0 .
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH)
If yes, describe under DESCRIPTION OF OPERATIONS below
YIN
N N /A
53VVECACOM4Z 09/26/2020 09/26/2021
N./ PER I 0TH-
eN STATUTE I ER
EL. EACH ACCIDENT S • 1.000 . 000
EL. DISEASE - EA EMPLOYEE S 1,000'000
EL. DISEASE - POLICY LIMIT S 1 0 0
C
MEDICAL PROFESSIONAL LIABILITY
CLAIMS MADE POLICY
ES053943 09/01/2020 09/01/2021.
EACH CLAIM
ANNUAL AGGREGATE
DEDUCTIBLE
$1,000,000
$3,000,000
NONE
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
The City of Carlsbad its directors, officials, officers, employees, agents and volunteers are additional insured with respect to General Liability only.
Additional forms attached: General Liability Blanket Additional Insured including Waiver of Subrogation Form SB146932G & Blanket Completed Operations
Additional Insured Form SB146968B. Primary/Non-Contributory Wording Form CNA80103XX. Work Comp Waiver Form WC990301C.
30 day notice of cancellation will be provided with the exception of 10 day notice for non-payment of premium.
CERTIFICATE HOLDER CANCELLATION
City of Carlsbad
Nathan Pearson, Div Fire Chief
2560 Orion Way
Carlsbad
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
CA 92010
0 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: 00001256
LOC #: •
ACCIRD ADDITIONAL REMARKS SCHEDULE Page of
AGENCY
Crestline Insurance Services LLC
NAMED INSURED
Gilbert, Gaetke & Associates of NV, MD, Ltd, DBA: &ARC Health & Wellness Centers
POLICY NUMBER
CARRIER NAIC CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance: Notes
Named Insured:
Gilbert, Gaetka &Associates of Nevada MD Ltd dba:
ARC Health & Wellness Centers
ARC Health & Wellness Centers LLC
ARC WorkPlace Services LLC
ARC National WorkPlace Services LLC
WorkPlace Medical Services LLC
1582 LLC
Gaetke Medical Corporation, A California Professional Corporation
Covered Physicians:
Warren Gilbert, MD, Retroactive date 1-5-2000
Mark Gaetke, MD, Retroactive date 1-5-2000
Troy Ross, MD, Retroactive date 9-29-2016
Christopher Pederson, MD, Retroactive date 9-29-2015
Brian J Kuhn, MD, Retroactive date 4-15-2019
Covered Locations:
1:2205 GlendaleAve, Sparks, NV 89431
2:82 Glendale Ave, Sparks, NV 89431
4:2500 W Sahara Ave, Las Vegas, NV 89102
5:333 No Rancho Dr #540, Las Vegas, NV 89106
7: 2510 Wigwam Pkwy, Henderson, NV 89074
9: 3920 East Idaho Street, Suite 2D, Elko, NV 89801
11:1855 N McCarran Blvd, Sparks, NV 89431
12:2332 Las Vegas Blvd North, North Las Vegas 89030
13:844 W Nye Lane, Carson City, NV 89703
14:858 West Elliot Road, Tempe, Arizona 85284
15:950 Cass Si, Monterey, CA 93940
ACORD 101 (2008101) 0 2008 ACORD CORPORATION. All rights reserved,
The ACORD name and logo are registered marks of ACORD
CNA SB146932G
(Ed. 10-19)
BLANKET ADDITIONAL INSURED AND LIABILITY EXTENSION ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS LIABILITY COVERAGE FORM
BUSINESSOWNERS COMMON POLICY CONDITIONS
TABLE OF CONTENTS
I. Blanket Additional Insured Provisions
A. Additional Insured — Blanket Vendors
B. Miscellaneous Additional Insureds
C. Additional Provisions Pertinent to Additional Insured Coverage
1.a.Primary — Noncontributory provision
1.b.Definition of "written contract"
2. Additional Insured — Extended Coverage
II. Liability Extension Coverages
A. Bodily Injury — Expanded Definition
B. Broad Knowledge of Occurrence
C. Estates, Legal Representatives and Spouses
D. Fellow Employee First Aid
E. Legal Liability — Damage to Premises
F. Personal and Advertising Injury — Discrimination or Humiliation
G. Personal and Advertising Injury — Broadened Eviction
H. Waiver of Subrogation — Blanket
I.BLANKET ADDITIONAL INSURED PROVISIONS
A. ADDITIONAL INSURED — BLANKET VENDORS
Who Is An Insured is amended to include as an additional insured any person or organization (referred to below
as vendor) with whom you agreed under a "written contract" to provide insurance, but only with respect to
"bodily injury" or "property damage" arising out of "your products" which are distributed or sold in the regular
course of the vendor's business, subject to the following additional exclusions:
1. The insurance afforded the vendor does not apply to:
a."Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the
assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages
that the vendor would have in the absence of the contract or agreement;
b.Any express warranty unauthorized by you;
c.Any physical or chemical change in the product made intentionally by the vendor;
d.Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the
substitution of parts under instructions from the manufacturer, and then repackaged in the original
container;
e.Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make
or normally undertakes to make in the usual course of business, in connection with the distribution or sale
of the products;
f.Demonstration, installation, servicing or repair operations, except such operations performed at the
vendor's premises in connection with the sale of the product;
9. Products which, after distribution or sale by you, have been labeled or relabeled or used as a container,
part or ingredient of any other thing or substance by or for the vendor; or
SB146932G (10-19) Page 1 of 7
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(Ed. 10-19)
h. "Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or
omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not
apply to:
(1)The exceptions contained in Subparagraphs d. or f.; or
(2)Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally
undertakes to make in the usual course of business, in connection with the distribution or sale of the
products.
2.This insurance does not apply to any insured person or organization, from whom you have acquired such
products, or any ingredient, part or container, entering into, accompanying or containing such products.
3.This provision 2. does not apply to any vendor included as an insured by an endorsement issued by us and
made a part of this Policy.
4.This provision 2. does not apply if "bodily injury" or "property damage" included within the "products-
completed operations hazard" is excluded either by the provisions of the Policy or by endorsement.
B. MISCELLANEOUS ADDITIONAL INSUREDS
1. Who Is An Insured is amended to include as an insured any person or organization (called additional
insured) described in paragraphs 3.a. through 3.j. below whom you are required to add as an additional
insured on this policy under a "written contract."
2. However, subject always to the terms and conditions of this policy, including the limits of insurance, we will
not provide the additional insured with:
a.A higher limit of insurance than required by such "written contract"
b.Coverage broader than required by such "written contract" and in no event greater than that described
by the applicable paragraph a. through k. below; or
C. Coverage for "bodily injury" or "property damage" included within the "products-completed
operations hazard." But this paragraph c. does not apply to the extent coverage for such liability is
provided by paragraph 3.j. below.
Any coverage granted by this endorsement shall apply only to the extent permitted by law.
3. Only the following persons or organizations can qualify as additional insureds under this endorsement:
a. Controlling Interest
Any persons or organizations with a controlling interest in you but only with respect to their liability arising
out of:
(1)such person or organization's financial control of you; or
(2)Premises such person or organization owns, maintains or controls while you lease or occupy these
premises;
provided that the coverage granted to such additional insureds does not apply to structural alterations,
new construction or demolition operations performed by or for such additional insured.
b. Co-owner of Insured Premises
A co-owner of a premises co-owned by you and covered under this insurance but only with respect to the
co-owners liability for "bodily injury," "property damage" or "personal and advertising injury" as co-
owner of such premises.
c. Grantor of Franchise
Any person or organization that has granted a franchise to you, but only with respect to such person or
organization's liability for "bodily injury," "property damage," or "personal and advertising injury" as
grantor of a franchise to you.
SB146932G (10-19) Page 2 of 7 20020008540345920857464 Copyright, CNA All Rights Reserved.
SB146932G
(Ed. 10-19)
d.Lessor of Equipment
Any person or organization from whom you lease equipment, but only with respect to liability for "bodily
injury," "property damage" or "personal and advertising injury" caused in whole or in part by your
maintenance, operation or use of such equipment, provided that the "occurrence" giving rise to such
"bodily injury" or "property damage" or the offense giving rise to such "personal and advertising
injury" takes place prior to the termination of such lease.
e.Lessor of Land
Any person or organization from whom you lease land, but only with respect to liability for "bodily injury,"
"property damage" or "personal and advertising injury" arising out of the ownership, maintenance or
use of that specific part of the land leased to you, provided that the "occurrence" giving rise to such
"bodily injury" or "property damage" or the offense giving rise to such "personal and advertising
injury," takes place prior to the termination of such lease. The insurance hereby afforded to the additional
insured does not apply to structural alterations, new construction or demolition operations performed by,
on behalf of or for such additional insured.
f.Lessor of Premises
An owner or lessor of premises leased to you, or such owner or lessors real estate manager, but only
with respect to liability for "bodily injury," "property damage" or "personal and advertising injury"
arising out of the ownership, maintenance or use of such part of the premises leased to you, and
provided that the "occurrence" giving rise to such "bodily injury" or "property damage" or the offense
giving rise to such "personal and advertising injury," takes place prior to the termination of such lease.
The insurance hereby afforded to the additional insured does not apply to structural alterations, new
construction or demolition operations performed by, on behalf of or for such additional insured.
g.Mortgagee, Assignee or Receiver
A mortgagee, assignee or receiver of premises but only with respect to such mortgagee, assignee, or
receiver's liability for "bodily injury," "property damage" or "personal and advertising injury" arising
out of the ownership, maintenance, or use of a premises by you.
This insurance does not apply to structural alterations, new construction or demolition operations
performed by, on behalf of or for such additional insured.
h.State or Political Subdivisions
A state or government agency or subdivision or political subdivision that has issued a permit or
authorization, but only with respect to such government agency or subdivision or political subdivision's
liability for "bodily injury," "property damage" or "personal and advertising injury" arising out of:
(1) The following hazards in connection with premises you own, rent, or control and to which this
insurance applies:
(a)The existence, maintenance, repair, construction, erection, or removal of advertising signs,
awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoistaway
openings, sidewalk vaults, street banners, or decorations and similar exposures; or
(b)The construction, erection, or removal of elevators; or
(c)The ownership, maintenance or use of any elevators covered by this insurance; or
(2) The permitted or authorized operations performed by you or on your behalf. But the coverage granted
by this paragraph does not apply to:
(a)"Bodily injury", "property damage" or "personal and advertising injury" arising out of
operations performed for the state or government agency or subdivision or political subdivision;
or
(b)"Bodily injury" or "property damage" included within the "products-completed operations
hazard."
With respect to this provision's requirement that additional insured status must be requested under a
"written contract," we will treat as a "written contract" any governmental permit that requires you to add
the governmental entity as an additional insured.
SB146932G (10-19) Page 3 of 7
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SB146932G
(Ed. 10-19)
i. Trade Show Event Lessor
With respect to your participation in a trade show event as an exhibitor, presenter or displayer, any
person or organization whom you are required to include as an additional insured, but only with respect to
such person or organization's liability for "bodily injury," "property damage," or "personal and
advertising injury" caused by:
a.Your acts or omissions; or
b.Acts or omissions of those acting on your behalf;
in the performance of your ongoing operations at the trade show premises during the trade show event.
j. Other Person or Organization
Any person or organization who is not an additional insured under paragraphs a. through i. above. Such
additional insured is an insured solely for "bodily injury," "property damage" or "personal and
advertising injury" for which such additional insured is liable because of your acts or omissions.
The coverage granted by this paragraph does not apply to any person or organization:
(1) For "bodily injury," "property damage," or "personal and advertising injury" arising out of the
rendering or failure to render any professional services;
(2) For "bodily injury" or "property damage" included in the "products-completed operations
hazard." But this provision (2) does not apply to such "bodily injury" or "property damage" if:
(a)It is entirely due to your negligence and specifically results from your work for the additional
insured which is the subject to the "written contract"; and
(b)The "written contract" requires you to make the person or organization an additional insured for
such "bodily injury" or "property damage"; or
(3) Who is afforded additional insured coverage under another endorsement attached to this policy.
C. ADDITIONAL PROVISIONS PERTINENT TO ADDITIONAL INSURED COVERAGE
1. With respect only to additional insured coverage provided under paragraphs A. and B. above:
a.The BUSINESSOWNERS COMMON POLICY CONDITIONS are amended to add the following to the
Condition entitled Other Insurance:
This insurance is excess of all other insurance available to an additional insured whether primary,
excess, contingent or on any other basis. However, if a "written contract" requires that this insurance be
either primary or primary and noncontributing, then this insurance will be primary and non-contributory
relative solely to insurance on which the additional insured is a named insured.
b.Under Liability and Medical Expense Definitions, the following definition is added:
"Written contract" means a written contract or agreement that requires you to make a person or
organization an additional insured on this policy, provided the contract or agreement:
(1)Is currently in effect or becomes effective during the term of this policy; and
(2)Was executed prior to:
(a)The "bodily injury" or "property damage;" or
(b)The offense that caused the "personal and advertising injury";
for which the additional insured seeks coverage.
2. With respect to any additional insured added by this endorsement or by any other endorsement attached to
this Coverage Part, the section entitled Who Is An Insured is amended to make the following natural persons
insureds.
If the additional insured is:
a. An individual, then his or her spouse is an insured;
SB146932G (10-19) Page 4 of 7 20020008540345920857465 Copyright, CNA All Rights Reserved.
SB146932G
(Ed. 10-19)
b.A partnership or joint venture, then its partners, members and their spouses are insureds;
c.A limited liability company, then its members and managers are insureds;
d.An organization other than a partnership, joint venture or limited liability company, then its executive
officers, directors and shareholders are insureds; or
e.Any type of entity, then its employees are insureds;
but only with respect to locations and operations covered by the additional insured endorsement's provisions,
and only with respect to their respective roles within their organizations. Furthermore, employees of
additional insureds are not insureds with respect to liability arising out of:
(1)"Bodily injury" or "personal and advertising injury" to any fellow employee or to any natural person
listed in paragraphs a. through d. above;
(2)"Property damage" to property owned, occupied or used by their employer or by any fellow employee; or
(3)Providing or failing to provide professional health care services.
II. LIABILITY EXTENSION COVERAGES
It is understood and agreed that this endorsement amends the Businessowners Liability Coverage Form. If any
other endorsement attached to this policy amends any provision also amended by this endorsement, then that other
endorsement controls with respect to such provision, and the changes made by this endorsement to such provision do
not apply.
A. Bodily injury — Expanded Definition
Under Liability and Medical Expenses Definitions, the definition of "Bodily injury" is deleted and replaced by
the following:
"Bodily injury" means physical injury, sickness or disease sustained by a person, including death, humiliation,
shock, mental anguish or mental injury by that person at any time which results as a consequence of the physical
injury, sickness or disease.
B. Broad Knowledge of Occurrence
Under Businessowners Liability Conditions, the Condition entitled Duties In The Event of Occurrence, Offense,
Claim or Suit is amended to add the following:
Paragraphs a. and b. above apply to you or to any additional insured only when such "occurrence," offense,
claim or "suit" is known to:
(1)You or any additional insured that is an individual;
(2)Any partner, if you or an additional insured is a partnership;
(3)Any manager, if you or an additional insured is a limited liability company;
(4)Any "executive officer" or insurance manager, if you or an additional insured is a corporation;
(5)Any trustee, if you or an additional insured is a trust; or
(6)Any elected or appointed official, if you or an additional insured is a political subdivision or public entity.
This paragraph applies separately to you and any additional insured.
C. Estates, Legal Representatives and Spouses
The estates, heirs, legal representatives and spouses of any natural person insured shall also be insured under
this policy; provided, however, coverage is afforded to such estates, heirs, legal representatives and spouses only
for claims arising solely out of their capacity as such and, in the case of a spouse, where such claim seeks
damages from marital common property, jointly held property, or property transferred from such natural person
insured to such spouse. No coverage is provided for any act, error or omission of an estate, heir, legal
representative or spouse outside the scope of such person's capacity as such, provided however that the spouse
of a natural person Named Insured and the spouses of members or partners of joint venture or partnership
Named Insureds are insureds with respect to such spouses' acts, errors or omissions in the conduct of the Named
Insured's business.
SB146932G (10-19) Page 5 of 7
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SB146932G
(Ed. 10-19)
D.Fellow Employee First Aid Coverage
In the section entitled Who Is An Insured, paragraph 2.a.1. is amended to add the following:
The limitations described in subparagraphs 2.a.1.(a), (b) and (c) do not apply to your "employees" for "bodily
injury" that results from providing cardiopulmonary resuscitation or other first aid services to a co-"employee" or
"volunteer worker" that becomes necessary while your "employee" is performing duties in the conduct of your
business. Your "employees" are hereby insureds for such services. But the insured status conferred by this
provision does not apply to "employees" whose duties in your business are to provide professional health care
services or health examinations.
E.Legal Liability — Damage To Premises
1. Under B. Exclusions, 1. Applicable to Business Liability Coverage, Exclusion k. Damage To Property, is
replaced by the following:
k. Damage To Property
"Property damage" to:
1.Property you own, rent or occupy, including any costs or expenses incurred by you, or any other
person, organization or entity, for repair, replacement, enhancement, restoration or maintenance of
such property for any reason, including prevention of injury to a person or damage to another's
property;
2.Premises you sell, give away or abandon, if the "property damage" arises out of any part of those
premises;
3.Property loaned to you;
4.Personal property in the care, custody or control of the insured;
5.That particular part of any real property on which you or any contractors or subcontractors working
directly or indirectly in your behalf are performing operations, if the "property damage" arises out of
those operations; or
6.That particular part of any property that must be restored, repaired or replaced because "your work"
was incorrectly performed on it.
Paragraph 2 of this exclusion does not apply if the premises are "your work" and were never occupied,
rented or held for rental by you.
Paragraphs 1, 3, and 4, of this exclusion do not apply to "property damage" (other than damage by fire
or explosion) to premises:
(1)rented to you:
(2)temporarily occupied by you with the permission of the owner, or
(3)to the contents of premises rented to you for a period of 7 or fewer consecutive days.
A separate limit of insurance applies to Damage To Premises Rented To You as described in Section D —
Liability and Medical Expenses Limits of Insurance. •
Paragraphs 3, 4, 5, and 6 of this exclusion do not apply to liability assumed under a sidetrack agreement.
Paragraph 6 of this exclusion does not apply to "property damage" included in the "products,
completed operations hazard."
2. Under B. Exclusions, 1. Applicable to Business Liability Coverage, the following paragraph is added, and
replaces the similar paragraph, if any, beneath paragraph (14) of the exclusion entitled Personal and
Advertising Injury:
Exclusions c, d, e, f, g, h, I, k, I, m, n, and o, do not apply to damage by fire to premises while rented to you
or temporarily occupied by you with permission of the owner or to the contents of premises rented to you for a
period of 7 or fewer consecutive days. A separate limit of insurance applies to this coverage as described in
Section D. Liability And Medical Expenses Limits Of Insurance.
SB146932G (10-19) Page 6 of 7 20020008540345920857466 Copyright, CNA All Rights Reserved.
SB146932G
(Ed. 10-19)
3. The first Paragraph under item 5. Damage To Premises Rented To You Limit of the section entitled
Liability And Medical Expenses Limits Of Insurance is replaced by the following:
The most we will pay under Business Liability for damages because of "property damage" to any one
premises, while rented to you or temporarily occupied by you with the permission of the owner, including
contents of such premises rented to you for a period of 7 or fewer consecutive days, is the Damage to
Premises Rented to You Limit. The Damage to Premises Rented to You Limit is the greater of:
a. $1,000,000; or
b. The Damage to Premises Rented to You Limit shown in the Declarations.
F. Personal and Advertising Injury — Discrimination or Humiliation
1. Under Liability and Medical Expenses Definitions, the definition of "personal and advertising injury" is
amended to add the following:
h. Discrimination or humiliation that results in injury to the feelings or reputation of a natural person, but only
if such discrimination or humiliation is:
(1) Not done intentionally by or at the direction of:
(a)The insured; or
(b)Any "executive officer," director, stockholder, partner, member or manager (if you are a limited
liability company) of the insured; and
(2) Not directly or indirectly related to the employment, prospective employment, past employment or
termination of employment of any person or person by any insured.
2. Under B. Exclusions, 1. Applicable to Business Liability Coverage, the exclusion entitled Personal and
Advertising Injury is amended to add the following additional exclusions:
(15)Discrimination Relating to Room, Dwelling or Premises
Caused by discrimination directly or indirectly related to the sale, rental, lease or sub-lease or prospective
sale, rental, lease or sub-lease of any room, dwelling or premises by or at the direction of any insured.
(16)Employment Related Discrimination
Discrimination or humiliation directly or indirectly related to the employment, prospective employment,
past employment or termination of employment of any person by any insured.
(17)Fines or Penalties
Fines or penalties levied or imposed by a governmental entity because of discrimination.
3. This provision (Personal and Advertising Injury — Discrimination or Humiliation) does not apply if
Personal and Advertising Injury Liability is excluded either by the provisions of the Policy or by
endorsement.
G. Personal and Advertising Injury - Broadened Eviction
Under Liability and Medical Expenses Definitions, the definition of "Personal and advertising injury" is
amended to delete Paragraph c. and replace it with the following:
c. The wrongful eviction from, wrongful entry into, or invasion of the right of private occupancy of a room
dwelling or premises that a person or organization occupies committed by or on behalf of its owner, landlord
or lessor.
H. Waiver of Subrogation — Blanket
We waive any right of recovery we may have against:
a. Any person or organization with whom you have a written contract that requires such a waiver.
All other terms and conditions of the Policy remain unchanged.
SB146932G (10-19) Page 7 of 7
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CNA SB146968C
(Ed. 10-19)
IMPORTANT: THIS ENDORSEMENT CONTAINS DUTIES THAT APPLY TO THE ADDITIONAL
INSURED IN THE EVENT OF OCCURRENCE, OFFENSE, CLAIM OR SUIT. SEE PARAGRAPH
C., OF THIS ENDORSEMENT FOR THESE DUTIES.
BLANKET ADDITIONAL INSURED ENDORSEMENT
WITH PRODUCTS-COMPLETED OPERATIONS COVERAGE AND
BLANKET WAIVER OF SUBROGATION
Architects, Engineers and Surveyors
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS LIABILITY COVERAGE FORM
BUSINESSOWNERS COMMON POLICY CONDITIONS
A. Who Is An Insured is amended to include as an insured any person or organization whom you are required to add as
an additional insured on this policy under a written contract or written agreement; but the written contract or written
agreement must be:
1.Crrently in effect or becoming effective during the term of this policy; and
2.Executed prior to the:
a."Bodily injury" or "property damage"; or
b.Offense that caused the "personal and advertising injury";
for which the additional insured seeks coverage
B. The insurance provided to the additional insured is limited as follows:
1. The person or organization is an additional insured only with respect to liability for "bodily injury," "property
damage" or "personal and advertising injury" caused in whole or in part by:
a.Your acts or omissions; or
b.The acts or omissions of those acting on your behalf,
in the performance of your ongoing operations specified in the written contract or written agreement; or
c."Your work" that is specified in the written contract or written agreement, but only for "bodily injury" or
"property damage" included in the "products-completed operations hazard," and only if:
(1)The written contract or written agreement requires you to provide the additional insured such coverage;
and
(2)This Coverage Part provides such coverage.
2. The Limits of Insurance applicable to the additional insured are those specified in the written contract or written
agreement or in the Declarations of this policy, whichever is less. These Limits of Insurance are inclusive of, and
not in addition to, the Limits of Insurance shown in the Declarations.
3. The insurance provided to the additional insured does not apply to "bodily injury," "property damage" or
"personal and advertising injury" arising out of an architect's, engineer's, or surveyor's rendering of or failure to
render any professional services including:
a.The preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports, surveys,
field orders, change orders or drawings and specifications by any architect, engineer or surveyor performing
services on a project of which you serve as construction manager; or
b.Inspection, supervision, quality control, engineering or architectural services done by you on a project of
which you serve as construction manager.
4. The insurance provided to the additional insured does not apply to "bodily injury," "property damage" or
"personal and advertising injury" arising out of construction or demolition work while you are acting as a
construction or demolition contractor.
SB146968C (Ed. 10-19) Page 1 of 3
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SB146968C
(Ed. 10-19)
C. Under Businessowners Liability Conditions, the condition entitled Duties In The Event of Occurrence, Offense,
Claim or Suit is amended to add the following:
An additional insured under this endorsement will as soon as practicable:
1.Give written notice of an occurrence or an offense to us which may result in a claim or "suit" under this insurance;
2.Tender the defense and indemnity of any claim or "suit" to us for a loss we cover under this Coverage Part;
3.Except as provided for in paragraph D.2. below:
a.Tender the defense and indemnity of any claim or "suit" to any other insurer which also has insurance for a
loss we cover under this Coverage Part; and
b.Agree to make available any other insurance which the additional insured has for a loss we cover under this
Coverage Part.
We have no duty to defend or indemnify an additional insured under this endorsement until we receive written notice
of a claim or "suit" from the additional insured.
D. With respect only to the insurance provided by this endorsement, the condition entitled Other Insurance of the
BUSINESSOWNERS COMMON POLICY CONDITIONS is amended to delete paragraphs 2. and 3. and replace them
with the following:
2.This insurance is excess over any other insurance available to the additional insured, whether primary, excess,
contingent or on any other basis, But if required by the written contract or written agreement, this insurance will be
primary and noncontributory relative to insurance on which the additional insured is a Named Insured.
3.When this insurance is excess, we will have no duty under Business Liability insurance to defend the additional
insured against any "suit" if any other insurer has a duty to defend the additional insured against that "suit" If no
other insurer defends, we will undertake to do so, but we will be entitled to the additional insured's rights against
all those other insurers.
When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any,
that exceeds the sum of:
(a)The total amount that all such other insurance would pay for the loss in the absence of this insurance; and
(b)The total of all deductible and self-insured amounts under all that other insurance.
We will share the remaining loss, if any, with any other insurance that is not described in this Excess Insurance
provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Declarations
of this Coverage Part.
E. Additional Insured — Extended Coverage
When an additional insured is added by this or any other endorsement attached to this Coverage Part, the section
entitled Who Is An Insured is amended to make the following natural persons insureds:
If the additional insured is:
1.An individual, then his or her spouse is an insured;
2.A partnership or joint venture, then its partners, members and their spouses are insureds;
3.A limited liability company, then its members and managers are insureds;
4.An organization other than a partnership, joint venture or limited liability company, then its executive officers,
directors and shareholders are insureds; or
5.Any type of entity, then its employees are insureds;
but only with respect to locations and operations covered by the additional insured endorsement's provisions, and only
with respect to their respective roles within their organizations. Furthermore, employees of additional insureds are not
insureds with respect to liability arising out of:
(1) "Bodily injury" or "personal and advertising injury" to any fellow employee or to any natural person listed in
paragraphs 1. through 4. above;
SB146968C (Ed. 10-19) Page 2 of 3 20020008540345920857468 Copyright, CNA All Rights Reserved.
SB146968C
(Ed. 10-19)
(2)"Property damage" to property owned, occupied or used by their employer or by any fellow employee; or
(3)Providing or failing to provide professional health care services.
F. The condition entitled Transfer of Rights of Recovery Against Others to Us of the BUSINESSOWNERS COMMON
POLICY CONDITIONS is amended to deleted paragraph 2. and replace it with the following:
2. We waive any right of recovery we may have against any person or organization with whom you have agreed to
waive such right of recovery in a written contract or agreement because of payments we make for injury or
damage arising out of your ongoing operations or "your work" done under a contract with that person or
organization and included within the "products-completed operations hazard."
All other terms and conditions of the Policy remain unchanged.
SB146968C (Ed. 10-19) Page 3 of 3
Copyright, CNA All Rights Reserved.
CNA CNA80103XX
(09-14)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY AND NONCONTRIBUTORY-
OTHER INSURANCE CONDITION
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS COMMON POLICY CONDITIONS
The following is added to Paragraph H. Other Insurance and supersedes any provision to the contrary:
Primary And Noncontributory Insurance
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
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.
All other terms and conditions of the Policy remain unchanged.
CNA80103XX (09-14)
Page 1 of 1
Copyright, CNA All Rights Reserved. Includes copyrighted material of Insurance Services Office, Inc., with its permission 20020008540345920857427
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WORKERS' COMPENSATION BROAD FORM ENDORSEMENT
EXTENDED OPTIONS
Policy Number: 53 WEC ACOM4Z Endorsement Number:
Effective Date: 09/26/20 Effective hour is the same as stated on the Information Page of the policy.
Named Insured and Address: Gilbert, Gaetke & Associates of Nevada MD Ltd
82 E GLENDALE AVE
SPARKS NV 89431
Section I of this endorsement expands coverage provided under WC 00 00 00.
Section ll of this endorsement provides additional coverage usually only provided by endorsement.
Section III of this endorsement is a Schedule of Covered States.
You may use the index to locate these coverage features quickly:
INDEX
SUBJECT PAGE SUBJECT PAGE
SECTION I 2 B. Part One Does Not Apply 3
PARTS ONE and TWO 2 C. Application of Coverage 3
01 We Will Also Pay 2 D. Additional Exclusions 3
PART - THREE 2 E. West Virginia 3
02 How This Insurance Works 2 EXTENDED OPTIONS 4
PART-SIX 2 01 Employers' Liability Insurance 4
03 Transfer of Your Rights and Duties 2 02 Unintentional Failure to Disclose 4
04 Liberalization 2 Hazards
SECTION II 2 03 Waiver of Our Right to Recover from 4
VOLUNTARY COMPENSATION 2 Others
INSURANCE
04 Foreign Voluntary Compensation 4
05 Voluntary Compensation Insurance 2 A. How This Reimbursement Applies 4
A. How This Insurance Applies 2 B. We Will Reimburse 4
B. We Will Pay 3 C. Exclusions 4
C. Exclusions 3 D. Before We Pay 5
D. Before We Pay 3 E. Recovery From Others 5
E. Recovery From Others 3 F. Reimbursement For Actual Loss 5
F. Employers' Liability Insurance 3 Sustained
EMPLOYERS' LIABILITY STOP GAP 3 G. Repatriation 5
ENDORSEMENT
H. Endemic Disease 5
06 Employers' Liability Stop Gap 3 05 Longshore and Harbor Workers' 5
Coverage
Compensation Act Coverage
A. Stop Gap Coverage Limited to 3 Endorsement
Montana, North Dakota, Ohio,
SECTION III 6
Washington, West Virginia and
01 Schedule of Covered States 6
Wyoming
Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 1 of 6
Process Date: 08/17/20 Policy Expiration Date: 09/26/21
2000, The Hartford
SECTION I
PARTS ONE and TWO
1. WE WILL ALSO PAY
D.We Will Also Pay of Part One (WORKERS'
COMPENSATION INSURANCE); and
E.We Will Also Pay of Part Two
(EMPLOYERS' LIABILITY INSURANCE) is
replaced by the following:
We Will Also Pay
We will also pay these costs, in addition to
other amounts payable under this insurance,
as part of any claim, proceeding, or suit we
defend:
1.reasonable expenses incurred at our
request, INCLUDING loss of earnings;
2.premiums for bonds to release
attachments and for appeal bonds in
bond amounts up to the limit of our
liability under this insurance;
3.litigation costs taxed against you;
4.interest on a judgment as required by law
until we offer the amount due under this
law; and
5.expenses we incur.
PART THREE
2.How This Insurance Applies
Paragraph 4. of A. How This Insurance Applies of
Part 3 (Other States Insurance) is replaced by the
following:
4. If you have work on the effective date of this
policy in any state not listed in Item 3.A. of the
Information Page, coverage will not be afforded
for that state unless we are notified within sixty
days.
PART SIX
3.Transfer Of Your Rights and Duties
C. Transfer Of Your Rights and Duties of Part 6
(Conditions) is replaced by the following:
Your rights or duties under this policy may not be
transferred without our written consent.
If you die and we receive notice within sixty days
after your death, we will cover your legal
representative as insured.
4.Liberalization
If we adopt a change in this form that would broaden
the coverage of this form without extra charge, the
broader coverage will apply to this policy. It will apply
when the change becomes effective in your state.
SECTION II
3.The bodily injury must occur in the United
States of America, its territories or
possessions, or Canada, and may occur
elsewhere if the employee is a United States
or Canadian citizen, or otherwise legal
resident, and legally employed, in the United
States or Canada and temporarily away from
those places.
4.Bodily injury by accident must occur during
the policy period.
5.Bodily injury by disease must be caused or
aggravated by the conditions of the
VOLUNTARY COMPENSATION ANDEMPLOYERS'
LIABILITY COVERAGE
5. Voluntary Compensation Insurance
A. How This Insurance Applies
This insurance applies to bodily injury by
accident or bodily injury by disease. Bodily
injury includes resulting death.
1.The bodily injury must be sustained by
any officer or employee not subject to the
workers' compensation law of any state
shown in Item 3.A. of the Information
Page.
2.The bodily injury must arise out of and in
the course of employment or incidental to
work in a state shown in Item 3.A. of the
Information Page.
Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 2 of 6
officer's or employee's employment. The
officer's or employee's last day of last
exposure to the conditions causing or
aggravating such bodily injury by disease
must occur during the policy period.
B. We Will Pay
We will pay an amount equal to the benefits
that would be required of you as if you and
your employees were subject to the workers'
compensation law of any state shown in Item
3.A. of the Information Page. We will pay
those amounts to the persons who would be
entitled to them under the law.
C. Exclusion
This insurance does not cover:
1.any obligation imposed by workers'
compensation or occupational disease
law or any similar law.
2.bodily injury intentionally caused or
aggravated by you.
3.officers or employees who have elected
not to be subject to the state workers'
compensation law.
4.partners or sole proprietors not covered
under the Standard Sole Proprietors,
Partners, Officers and Others Coverage
Endorsement.
D. Before We Pay
Before we pay benefits to the persons
entitled to them, they must:
1.Release you and us, in writing, of all
responsibility for the injury or death.
2.Transfer to us their right to recover from
others who may be responsible for the
injury or death.
3.Cooperate with us and do everything
necessary to enable us to enforce the
right to recover from others.
If the persons entitled to the benefits of this
insurance fail to do those things, our duty to
pay ends at once. If they claim damages
from you or from us for the injury or death,
our duty to pay ends at once.
E. Recovery From Others
If we make a recovery from others, we will
keep an amount equal to our expenses of
recovery and the benefits we paid. We will
pay the balance to the persons entitled to it.
If the persons entitled to the benefits of this
insurance make a recovery from others, they
must reimburse us for the benefits we paid them.
F. Employers' Liability Insurance
Part Two (Employers' Liability Insurance) applies
to bodily injury covered by this endorsement as
though the State of Employment was shown in
Item 3.A. of the Information Page.
This provision 5. does not apply in New Jersey or
Wisconsin.
EMPLOYERS' LIABILITY STOP GAP COVERAGE
6. Employers' Liability Stop Gap Coverage
A. This coverage only applies in Montana, North
Dakota, Ohio, Washington, West Virginia and
Wyoming.
B. Part One (Workers' Compensation Insurance)
does not apply to work in states shown in
Paragraph A above.
C. Part Two (Employers' Liability Insurance) applies
in the states, shown in Paragraph A., as though
they were shown in Item 3.A. of the Information
Page.
D. Part Two, Section C. Exclusions is changed by
adding these exclusions.
This insurance does not cover;
5. bodily injury intentionally caused or
aggravated by you or in Ohio bodily injury
resulting from an act which is determined by
an Ohio court of law to have been committed
by you with the belief than an injury is
substantially certain to occur. However, the
cost of defending such claims or suits in Ohio
is covered.
13.bodily injury sustained by any member of the
flying crew of any aircraft.
14.any claim for bodily injury with respect to
which you are deprived of any defense or
defenses or are otherwise subject to penalty
because of default in premium under the
provisions of the workers' compensation law
or laws of a state shown in Paragraph A.
E. This insurance applies to damages for which you
are liable under West Virginia Code Annot. S 23-
4-2.
Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 3 of 6
EXTENDED OPTIONS
1. Employers' Liability Insurance
Item 3.B. of the Information Page is replaced by
the following:
B. Employers' Liability Insurance:
1.Part Two of the policy applies to work in
each state listed in Item 3.A.
The Limits of Liability under Part Two are
the higher of:
Bodily Injury
by Accident $500,000 Each Accident
Bodily Injury
by Disease $500,000 Policy Limit
Bodily Injury
by Disease $500,000 Each Employee
OR
2.The amount shown in the Information
Page.
This provision 1 of EXTENDED OPTIONS does
not apply in New York because the Limits Of Our
Liability are unlimited.
In this provision the limits are changed from
$500,000 to $1,000,000 in California.
2. Unintentional Failure to Disclose Hazards
If you unintentionally should fail to disclose all
existing hazards at the inception date of your
policy, we shall not deny coverage under this
policy because of such failure.
3. Waiver of Our Right To Recover From Others
A.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 any person or organization for whom
you perform work under a written contract
that requires you to obtain this agreement
from us.
This agreement shall not operate directly or
indirectly to benefit anyone not named in the
agreement.
B.This provision 3. does not apply in the states
of Pennsylvania and Utah.
4.Foreign Voluntary Compensation and Employers'
Liability Reimbursement
A. How This Reimbursement Applies
This reimbursement provision applies to bodily
injury by accident or bodily injury by disease.
Bodily injury includes resulting death.
1.The bodily injury must be sustained by an
officer or employee.
2.The bodily injury must occur in the course of
employment necessary or incidental to work
in a country not listed in Exclusion C.1. of this
provision.
3.Bodily injury by accident must occur during
the policy period.
4.Bodily injury by disease must be caused or
aggravated by the conditions of your
employment. The officer or employee's last
exposure to those conditions of your
employment must occur during the policy
period.
B. We Will Reimburse
We will reimburse you for all amounts paid by
you whether such amounts are:
1.voluntary payments for the benefits that
would be required of you if you and your
officers or employees were subject to any
workers' compensation law of the state of
hire of the individual employee.
2.sums to which Part Two (Employers' Liability
Insurance) would apply if the Country of
Employment were shown in Item 3.A. of the
Information Page.
C. Exclusions
This insurance does not cover:
1.any occurrences in the United States,
Canada, and any country or jurisdiction
which is the subject of trade or economic
sanctions imposed by the laws or regulations
of the United States of America in effect as of
the inception date of this policy.
2.any obligation imposed by a workers'
compensation or occupational disease law,
or similar law.
3.bodily injury intentionally caused or
aggravated by you.
Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 4 of 6
4. liability for any consequence, whether
direct or indirect, of war, invasion, act of
Foreign enemy, hostilities (whether war
be declared or not), civil war, rebellion,
revolution, insurrection or military or
usurped power. No endorsement now or
subsequently attached to this policy shall
be construed as overriding or waiving
this limitation unless specific reference is
made thereto.
D. Before We Pay
Before we reimburse you for the benefits to
the persons entitled to them, you must have
them:
1. release you and us, in writing, of all
responsibility for the injury or death,
2. transfer to us their right to recover from
others who may be responsible for their
injury or death,
3. cooperate with us and do everything
necessary to enable us to enforce the
right to recover from others.
If the persons entitled to the benefits paid fail
to do these things, our duty to reimburse
ends at once. If they claim damages from us
for the injury or death, our duty to reimburse
ends at once:
E. Recovery From Others
If we make a recovery from others, we will
keep an amount equal to our expenses of
recovery and the benefits we reimbursed.
We will pay the balance to the persons
entitled to it. If persons entitled to the
benefits make a recovery from others, they
must repay us for the amounts that we have
reimbursed you.
F. Reimbursement for Actual Loss
Sustained
This endorsement provides only for
reimbursement for the loss you actually
sustain. In order for you to recover loss or
expenses under this reimbursement you
must:
1.actually sustain and pay the loss or
expense in money after trial, or
2.secure our consent for the payment of
the loss or expense.
G. Repatriation
Our reimbursement includes the additional
expenses of repatriation to the United States
of America necessarily incurred as a direct result
of bodily injury.
Our reimbursement shall be limited as follows:
1.to the amount by which such expenses
exceed the normal cost of returning the
officer or employee if in good health, or
2.in the event of death, to the amount by which
such expenses exceed the normal cost of
returning the officer or employee if alive and
in good health.
In. no event shall our reimbursement exceed the
bodily injury by accident limit shown in Item 3.B.
of the Information Page as respects any one
such officer or employee whether dead or alive.
H. Endemic Disease
The word "disease" includes any endemic
diseases.
The coverage applies as if endemic diseases
were included in the provisions of the workers'
compensation law.
5. Longshore and Harbor Workers' Compensation
Act Coverage
General Section C. Workers' Compensation Law
is replaced by the following:
C. Workers' Compensation Law
Workers' Compensation Law means the workers
or workers' compensation law and occupational
disease law of each state or territory named in
Item 3.A. of the Information Page and the
Longshore and Harbor Workers' Compensation
Act (33 USC Sections 901-950). It includes any
amendments to those laws that are in effect
during the policy period. It does not include any
other federal workers or workers' compensation
law, other federal occupational disease law or the
provisions of any law that provide
nonoccupational disability benefits.
Part Two (Employers' Liability Insurance), C.
Exclusions, exclusion 8, does not apply to work
subject to the Longshore and Harbor Workers'
Compensation Act.
This coverage does not apply to work subject to
the Defense Base Act, the Outer Continental
Shelf Lands Act, or the Nonappropriated Fund
Instrumentalities Act.
Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 5 of 6
SECTION III
1. SCHEDULE OF COVERED STATES
A. This endorsement only applies in the states
listed in this Schedule of Covered States.
C. Schedule of Covered States:
NV
B. If a state, shown in Item 3.A. of the Information
Page, approves this endorsement after the
effective date of this policy, this endorsement will
apply to this policy. The coverage will apply in
the new state on the effective date of the state
approval
Countersigned by
Authorized Representative
Form WC 99 03 03 B Printed in U.S.A. (Ed. 8/00) Page 6 of 6