Loading...
HomeMy WebLinkAboutCoastal Occupational Medical Group dba Akeso Occupational Health; 2022-10-17;OocuSign Envelope ID: C7C7C3O9-CC26-4DCA-8E2F-64B6O0873C4O AGREEMENT FOR OCCUPATIONAL HEALTH SERVICES COASTAL OCCUPATIONAL MEDICAL GROUP OBA AKESO OCCUPATIONAL HEALTH THIS AGREEMENT is made and entered into as of the \] tit'-" day of ~ C:\::'o\;)W , 20~ by and between the CITY OF CARLSBAD, a municipal corporation, ("City"), and Coastal Occupational Medical Group, a corporation dba Akeso Occupational Health, ("Contractor"). RECITALS A. City requires the professional services of a healthcare provider that is experienced in occupational medical services. B. Contractor has the necessary experience in providing professional services and advice related to occupational health programs. 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 (1) year from the date first above written. The City Manager may amend the Agreement to extend it for two (2) additional two (2) year periods 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 forty thousand dollars ($40,000). 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 forty thousand dollars ($40,000) 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". City Attorney Approved Ve rsion 8/2/2022 DocuSign Envelope ID: C7C7C3D9-CC26-4DCA-8E2F-64B6D0873C4D 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 City Attorney Approved Version 8/2/2022 2 DocuSign Envelope ID: C7C7C3D9-CC26-4DCA-8E2F-64B6D0873C4D 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 sep ··ately to this projecUlocation 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 or City). $2,000,000 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 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. City Attorney Approved Version 8/2/2022 3 DocuSign Envelope ID: C7C7C3O9-CC26-4DCA-8E2F-6486O0873C4O 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 Name Nathan Pearson Title Fire Division Chief Department Fire Department City of Carlsbad Address 2560 Orion Way Carlsbad, CA 92010 Phone No. 442-339-2141 For Contractor Name Lisa Fitting Title Director of Partner Relations Address 3142 Vista Way, Suite 401 Oceanside, CA 92056 Phone No. 760-415-6556 Email lisa@workpartnersohs.com 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. City Attorney Approved Version 8/2/2022 4 DocuSign Envelope ID: C7C7C3O9-CC26-4DCA-8E2F-64B6O0873C4D 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. YesD No [8] 17. GENERAL COMPLIANCE WITH LAWS Contractor will keep fully informed offederal, 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 Contractor's failure to prosecute, deliver, or perform the Services, City may terminate this Agreement for nonperformance by notifying Contractor by certified mail of the termination. If City decides to abandon or indefinitely postpone the work or services contemplated by this Agreement, City may terminate this Agreement upon written notice to Contractor. Upon notification of termination, Contractor has five (5) business days to 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. City may terminate this Agreement by tendering thirty (30) days written notice to Contractor. Contractor may terminate this Agreement by tendering thirty (30) days written notice to City. In City Attorney Approved Version 8/2/2022 5 OocuSign Envelope ID: C7C7C309-CC26-4DCA-8E2F-64B600873C40 the event of termination of this Agreement by either party and upon request of City, Contractor will assemble the work product and 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. City Attorney Approved Version 8/2/2022 6 DocuSign Envelope ID: C7C7C3O9-CC26-4DCA-8E2F-64B6O0873C4D 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 (sign here) Daniel Pencak -Chief Financial Officer (print name/title) By: [L.JJ.Ck_~ (sign here) Chuck Kruger -Chief Executive Officer (print name/title) CITY OF CARLSBAD, a municipal corporation of the State of California MICH CAL WO Fire hie ATTEST: ft-FAVIOLA MEDINA City Clerk Services 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: CINDIE K. McMAHON, City Attorney City Attorney Approved Version 8/2/2022 7 DocuSign Envelope ID: C7C7C3D9-CC26-4DCA-8E2F-64B6D0873C4D EXHIBIT "A" SCOPE OF SERVICES Akeso Occupational Health shall provide as-needed occupational health services to the Carlsbad Fire Department. Services will be billed according to the list below. Annual compensation shall not exceed forty thousand dollars ($40,000) per Agreement year. Annual Surveillance T-Spot/PPD Screenina $85.00 X-ray: Chest, 2v Frontal and Lateral $65.00 Respirator Questionnaire $30.00 TB PPD -(2 visits) $30.00 Titer TestinQ -MMR & Varicella Zoster Pan $70.00 MMRVaccine $110.00 Hepatitis B Booster Hepatitis B Vaccination Booster $90.00 • Schedule He atitis B Titer in 30 da s Hepatitis B Vaccine Series Hepatitis B Vaccine per Dose • U on Authorization Onl Onsite Orders T-S ot/PPD Screenin Flu Vaccine -Quadrivalent 8 $90.00 $85.00 $32.00 City Attorney Approved Version 8/2/2022 California Secretary of State Electronic Filing FILED Secretary of State State of California Corporation -Statement of Information Entity Name: COASTAL OCCUPATIONAL MEDICAL GROUP Entity (File) Number: C2763759 File Date: 03/08/2022 Entity Type: Corporation Jurisdiction: CALIFORNIA Document ID: H308214 Detailed Filing Information 1. Entity Name: 2. Business Addresses: a. Street Address of Principal Office in California: b. Mailing Address: c. Street Address of Principal Executive Office: 3. Officers: a. Chief Executive Officer: b. Secretary: COASTAL OCCUPATIONAL MEDICAL GROUP 7700 Irvine Center Drive, Ste. 870 Irvine, California 92618 United States of America 7700 Irvine Center Drive, Ste 870 Irvine, California 92618 United States of America 1901 Outlet Center Drive, Ste 100 Oxnard, California 93036 United States of America Charles Kruger 7700 Irvine Center Drive, Ste 870 Irvine, California 92618 United States of America Herbert Jennings 7700 Irvine Center Drive, Ste 870 Irvine, California 92618 United States of America Use bizfile.sos.ca.gov for online filings, searches, business records, and resources. "V ....... N co 0 ('I) I 0 +-' C (l) E ::J u 0 0 California Secretary of State Electronic Filing Officers (cont'd): c. Chief Financial Officer: 4. Director: Number of Vacancies on the Board of Directors: 5. Agent for Service of Process: 6. Type of Business: Daniel Pencak 7700 Irvine Center Drive, Ste 870 Irvine, California 92618 United States of America Herbert Jennings 7700 Irvine Center Drive, Ste 870 Irvine, California 92618 United States of America 0 Daniel Pencak 7700 Irvine Center Drive, Ste. 870 Irvine, California 92618 United States of America Occupational Medicine No Officer or Director of this Corporation has an outstanding final judgment issued by the Division of Labor Standards Enforcement or a court of law, for which no appeal therefrom is pending, for the violation of any wage order or provision of the Labor Code. By signing this document, I certify that the information is true and correct and that I am authorized by California law to sign. Electronic Signature: Daniel Pencak Use bizfile.sos.ca.gov for online filings, searches, business records, and resources. ',;t ...... N a:, 0 <"'> I 0 ...... C Q) E ::J u 0 0 Akeso July 1, 2022 Hello Valued Customer, Akeso Occupational Health is proud to announce a strategic pa11nership with Work.Partners Occupational Health Specialists ("WorkPartners"). Currently with thirteen facilities located throughout the state of Califomia, Akeso Occupational Health is focused on delivering high quality medical care to injured workers and superior customer service to employers. Akeso is focused on driving positive outcomes, reducing litigation, and assuring that patients are treated with respect. We look forward to expanding the WorkPartncrs offering as we appoint Dr. Gene Ma as our Chief Medical Officer across the Akeso organization. In addition, Dr. Kathleen Gray and Dr. Vicky Young will continue to support your needs in San Diego County. Lisa Fitting is still the primary contact as the Dirnctor of Partner Relations with our plan to provide better alternatives to the San Diego commw1ity going forward. As a result of this partnership, we will be transitioning the invoicing as follows: • Effective July 1, 2022 Work.Pa1tners will begin invoicing under the Akeso Occupational Health TIN (TIN: 71-0983832) for Employer Services and Workers' Compensation claims. • Our address for payment remittances will remain the same for employer services and is listed below for your reference: Akeso Occupational Health 3142 Vista Way, Suite 401 Oceanside, CA 92056 • The updated W-9 is also attached for your records. If you have questions about the acquisition, email Lisa Fitting at li::.a(<~w<1rk1?_a1 llll.'.1:mh s.1.,;0111 . For billing inquires, you may contact Jesus at (760) 681 -5222, ext. J 15 or email invoiccs(c~J,vo, kp:utncrsohs.com. Best Regards, Akeso Occupational Health Office of the CEO Fom, W-9 Request for Taxpayer Give Form to the (Rev. October 2018) Identification Number and Certification requester. Do not Department of lhe Treasury send to the IRS. lnlomal Rovonuo Service ► Go to www.irs.gov/FonnW9 for Instructions and the latest information. 1 Nnmo (as shown on your Income tax return). Name is rcctulrud on !Ills hno, do not leave lhl$ llno blank. COASTAL OCCUPATIONAL MEDICAL GROUP 2 Business name/disregarded en lit)• name, 1f dilforonl from i>bo\-e AKESO OCCUPATIONAL HEAL TH C'i 3 Check appropriate box for federal lax classification of the person whose name Is enlered on line 1 Check only one of the 4 Exemptions (codes apply only lo 11) g> following seven boxes. certain en1ilies. not individuals; see a. ,nstruclions on page 3): C 0 lndividuaVsole proprietor or 0 C Corporallon 0 S Corporation 0 Partnership 0 Trust/esta1e 0 . "' single-member LLC Exempt payee code {if any) ii □ Limited liability company. Enter the lax classlflcation (C=C corporation, S=S corporation, P=Partnership) ► .... ::, Note: Check lho appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting 0 ~ ., 1ii LLC if the LLC is classllled as a single-member LLC that is disregarded from the owner unless the owner of lhe LLC Is code (If any) .g .E another LLC that Is not disregarded from lhe owner for U S. federal tax purposes. Otherwise, a slnglo-mamber LLC that a. () is disregarded from the owner should check the appropriate box for lhe tax classification of rts owner. ~ () 0 Other (see lnslnJ<:IIOO$) ► ~ppte~ tc .Jcc:utlf'•ls n:.:nrt.MlCO QIA.$IO& lhe U.SJ Q) Q. 5 Address (11urnl)er, street, and apt or suite no.) See Instructions Requester's name and address (ot)tlonat) II) Q) 3142 Vista Wav. Suite 401 Q) (/) 6 City, slate, and ZIP codo Oceanside CA 92056 7 List account number{s) here (optional) •·.J:T --Taxpayer Identification Number (TIN) I Soclol security number I Enter your TIN in the appropriate box. :he TIN provided must match t~e name given on line 1 to avoid backup withholding. For Individuals, this Is generally your social secunty number (SSN). However, for a ITO DJ I I I I I resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other -- entities, it is your employer identification number (EIN). If you do not have a number, see How to get a . . . _ _ TIN, later. ,.;;o_r ____________ - Note: If the account is In more than one name. see the Instructions for line 1. Also see What Name and I Employer identification number Number To Give the Requester for guidelines on whose number to enter. 71-0983832 Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me): and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service ORS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below): and 4. The FATCA code(s) entered on this form Of any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. Fot mortgage interest paid, acquisition or abando11menl of secured property, cancellation of debt, contributions to an individual retirement arrangement ORA), and generally, payments other than interest and diviJe,,·,Js, you arE: not , ,;qui••~d '.o sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later. Sign Here Slgnnlure of D, · ,? fJ / U.S. person ► ~ /""~ General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www irs.gov!FormW9. Purpose of Form An individual or entily (Form W-9 requester) who is required to file an information return wi1h the IRS must obtain your correct taxpayer identification number (Tl N) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid) Cal No 1023 IX Date ► 7/1/2022 • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or grass proceeds) • Form 1099-B (stock or mutual fund sales and certain other lransactlons by brokers) • Form 1099-S (proceeds flom real estate transactions) • Form 1099-K (merchant card and third party netwurk transactions) • Form 1096 (home mortgage interest). 1098-E (student loan interest), 1096-T (tuition) • Form 1099-C (canceled debt) • Form 1099-A (acquisition or abandonment or secured property) Use Form W-9 only if you arc a ll.8. person (including a resident alien}. to provide your correct TIN. If you do not return rorm W-9 to the requester with a TIN, you might be subject to backup withholding See What is backup withholding, later. ronn W-9 (Rev tO 2018) Client#· 704042 AKESO ACORD™ CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDIYYYY) 7/06/2022 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer any rights to the certificate holder in lieu of such endorsement(s). PRODUCER NA1le'.'" Teresa Darlene Corder Marsh & Mclennan Agency llC r1J8Ntro Extl: I 1Ai~ Nol: Marsh & Mclennan Ins. Agency llC ~~~bs, OCCerts@MarshMMA.com 1 Polaris Way #300 INSURER(S) AFFORDING COVERAGE NAIC# Aliso Viejo, CA 92656 INSURER A: Continental Casualty Company 20443 INSURED INSURER B: Hartford Accident and Indemnity Company 22357 Kain Akeso Medical Holdings, llC INSURER c : Employers Preferred Insurance Company 999999 7700 Irvine Center Drive, Suite 870 INSURER D: Transportation Insurance Company 20494 Irvine, CA 92618 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL ~UBR 1,&S/cl5~, ,&Skl5~i LIMITS LTR 1.,,,., WVD POLICY NUMBER A ~ COMMERCIAL GENERAL LIABILITY 7013598464 ~6/01/2022 06/01/202:l EACH OCCURRENCE s1,000,000 D CLAIMS-MADE ~ OCCUR ~~r~~H9~~r?..ncei s1 000.000 1--MED EXP (Any one person) s10 000 PERSONAL & ADV INJURY s1,000,000 -GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,000,000 Pi □PRO-□Loe s2,000,000 POLICY JECT PRODUCTS -COMP/OP AGG OTHER: s D AUTOMOBILE LIABILITY BUA7018734715 06/01/2022 06/01/202:l fe~~~;~llNGLE LIMIT s1,000,000 -X ANYAUTO BODILY INJURY (Per person) $ -OWNED -SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ --HIRED NON-OWNED ;p~?~&fd~i?AMAGE X AUTOS ONLY X AUTOS ONLY $ --$ A ~ UMBRELLA LIAB ~ OCCUR 7013598478 06/01/2022 06/01/202:l EACH OCCURRENCE s3.000.000 EXCESS LIAB CLAIMS-MADE AGGREGATE s3.000.000 oED I xi RETENT10Ns$10 ooo $ B WORKERS COMPENSATION 72WECAP6RHA 02/19/2022 02/19/2023 X l~i~TIITI' I IgJH- C AND EMPLOYERS' LIABILITY y / N EIG478049000 07/02/2022 07/02/202~ s1 000 000 ANY PROPRIETOR/PARTNER/EXECUTIVE~ E.L. EACH ACCIDENT OFFICER/MEMBER EXCLUDED? N N/A (Mandatory In NH) E.L. DISEASE • EA EMPLOYEE s1 000 000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE • POLICY LIMIT s1000000 A Blkt BPP/BI 7013598464 06/01/2022 06/01/202~ BPP $1,649,326 Special/RC Oed $1,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remar1<s Schedule, may be attached If more space Is required) RE: 3142 Vista Way, Suite 401, Oceanside, CA 92056 3156 Vista Way, Suite 100, Oceanside, CA 92056 3156 Vista Way, Suite 150, Oceanside, CA 92056 2361-2365 S Melrose Dr, Vista, CA 92081 (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Evidence of Coverage 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 I 1)~ ~ © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) 1 of 2 The ACORD name and logo are registered marks of ACORD #S11085267/M11002574 WOPZB DESCRIPTIONS (Continued from Page 1) 7485 Mission Valley Rd, San Diego, CA 92108 1510 Sweetwater Rd, #B-D, National City, CA 91950 Evidence of coverage. SAGITTA 25.3 (2016/03) 2 of 2 #S 11085267 /M 1100257 4 SCHEDULE OF NAMED INSUREDS NAMED INSURED AND MAILING ADDRESS KAIN AKESO MEDICAL HOLDINGS, LLC 7700 Irvine Center Dr Suite 870 Irvine, CA 92618 SCHEDULE OF NAMED INSUREDS Coastal Occupational Medical Group dba Akeso Occupational Health Cheshire Medical Corporation OBA ProCare Work Center Injury KAIN AKESO MEDICAL HOLDINGS, LLC AM Best Rating Services Continental Casualty Company I BestL,nk 8 I AMB #: 002128 NAIC #: 20443 FEIN#: 362114545 Domiciliary Address 151 North Franklin Street Chicago, Illinois 60606 united States Web: www.cna com Phone: 312-822-5000 AM Best Rating Unit: AMB #: 018313 -CNA Insurance Com~ Assigned to insurance companies that have. in our opinion. an excellent ability to meet their ongoing insurance obligations. View additional news, reports and ~ for this company. Based on AM Best"s analysis. 050177 -Loews CorpQration is the AMB Ultimate Parent and identifies the topmost entity of the corporate structure. View a list of o~g insurance entjtjes in this structure. Best's Credit Ratings Financial Strength View Definition Rating (Rating Category): Outlook (or lmpllcatlon): Action: Effective Date: lnltlal Rating Date: A (Excellent) Stable Affirmed August 04. 2022 June 30, 1922 Long-Term Issuer Credit View Definition Rating (Rating Category): Outlook (or Implication): Action: Effective Date: Initial Rating Date: a+ (Excellent) Stable Affirmed August 04, 2022 June 21, 2005 Financial Size Category View Definition Financial Size Category: X:V ($2 Billion or greater) u Denotes Under Review Best's Rating Rating History AM Best has provided ratings & analysis on this company since 1922. Financial Strength Rating Effective Date Rating Best"s Credit Rating Analyst Rating Office: A.M. Best Rating Services, Inc. Senior Financial Analyst: Elizabeth Blamble Associate Director : Alan Murray Note: See the Disclosure information Form or Press Release below for the office and analyst at the time of the rating event. Disclosure Information Disclosure Information Form View AM Best's Rating Disclosure Form Press Release AM Best Affirms Credit Ratings of CNA Eioaocial .GQ.rnoration and Its Subsidiaries August 04, 2022 View AM Best"s Rating Review Form Long-Term Issuer Credit Rating Effective Date Rating 1/3 9/19/22, 12:44 PM Company Profile Reset Company Profile Search Company Complaints Company Performance Enforcement Actions & Comparison Data Workers' Compensation Workers' Compensation Complaint & Requests for Action/Appeals Cont act Information Additional Information View Financial Disclaimer Company Profile Search Lines of Insurance Sea rch Company Profile Company Detail Consumer Complaint Study Other Insurance Ent ities CONTINENTAL CASUALTY COMPANY 333 S Wabash Ave, Chi cago, IL 60604-4107 800-588-7400 https://interactive. web.insurance.ca .gov/apex_ extprd/f?p= 144:6:8950094546456:: NO: RP,6:P6 _ COMPANY _ID :264 7 1/4 9/19/22, 12:44 PM Company Detail Show All Name History Agent for Service Reference Information Lines of Business Financial Sta Name History Legal Name CONTINENTAL CASUALTY COMPANY Agent for Service Full Name Vivian Imperial Effective From Date 11/18/2015 08:00AM Reference Information Identification CA# NAIC NAIC Group 0048-9 20443 218 Name Status Effective Date Current Full Address 818 W 7th St Ste 930, Los Angeles, CA 90017- 3476 NAIC Group Name CNA INS GRP Classification https://interactive.web.insurance.ca.gov/apex_extprd/f?p=144:6:8950094546456::NO:RP,6:P6_COMPANY _ID:2647 Contact Phone 916-497-0656 2/4 9/19/22, 12:44 PM Category Category Type Status License Category Location State Name Origin Country Form Lines of Business Insurer Property & Casualty Unlimited-Normal Admitted Illinois Foreign Stock Company Detail The company is authorized to transact business within these lines of insurance. For an explanation of any of these terms, please refer to the glossary. Lines of Business Aircraft Automobile Boiler And Machinery Burglary Common Carrier Liability Credit Disability Fire Liability Marine Miscellaneous https://interactive. web. insurance.ca .gov/apex_ extprd/f?p=144:6:8950094546456:: NO: RP,6: P6 _COMPANY _ID:264 7 3/4 9/19/22, 12:44 PM Lines of Business Plate Glass Sprinkler Surety Team And Vehicle Financial Statements * Year California Department of Insurance Disclaimer Company Detail The Annual and Quarterly Financial Stat ements are submitted to the California Department of Insurance ("CDI") pursuant to Ca lifornia Insurance Code Sections 900 and 931 and Ca lifornia Code of Regulations Section 2308.1. The information is furnished to the CDI by California admitted insurers and is provided to t he public "AS IS" pursuant to California Insurance Code Section 12921.2. The CDI does not guarantee the truth, accuracy, adequacy or completeness of the data contained in the insurers' Annual and Quarterly Financial Statements and expressly disclaims any liability for any errors, omissions, or the result obtained from the use of such data. Individuals who are unable to access the Annual and Quarterly Financial Statements may contact the CDI at CustodianofRecords@insurance.ca.gov for additional information. Privacy Policy ADA Compliance Site Map Employment Opportunities Internships Free Document Readers Scheduled Site Maintenance Copyright 'tJ California Department of Insurance https:l/interactive.web.insurance.ca.gov/apex_extprd/f?p=144:6:8950094546456::NO:RP,6:P6_COMPANY _ID:2647 4/4