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Gaetke Medical Corporation; 2023-04-20;
City Attorney Approved Version 12/28/2022 1 AGREEMENT FOR NFPA 1582 MEDICAL EXAMS GAETKE MEDICAL CORPORATION THIS AGREEMENT is made and entered into as of the ______________ day of _________________________, 20___, by and between the City of Carlsbad, California, a municipal corporation, ("City"), 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 two years from the date first above written. The City Manager may amend the Agreement to extend it for two additional one 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 one hundred thousand dollars ($100,000). 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 one hundred thousand dollars ($100,000) 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". DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F April 20th 23 City Attorney Approved Version 12/28/2022 2 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 DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F City Attorney Approved Version 12/28/2022 3 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 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. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F City Attorney Approved Version 12/28/2022 4 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 Sparks, NV 89431 Address 2560 Orion Way Phone No. 775-846-3413 Carlsbad, CA 92010 Email paul@1582exam.com Phone No. 442-339-2141 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. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F City Attorney Approved Version 12/28/2022 5 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 No 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 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 ninety (90) days written notice to City. In 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. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F □ City Attorney Approved Version 12/28/2022 6 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. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F City Attorney Approved Version 12/28/2022 7 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 OF CARLSBAD, a municipal corporation of the State of California By: By: (sign here) SCOTT CHADWICK City Manager Mark J. Gaetke, President (print name/title) ATTEST: By: (sign here) SHERRY FREISINGER Mark J. Gaetke, Secretary City Clerk (print name/title) If required by City, proper notarial acknowledgment of execution by contractor must be attached. If a corporation, Agreement must be signed by one corporate officer from each of the following two groups. Group A Group B Chairman, Secretary, President, or Assistant Secretary, Vice-President CFO or Assistant Treasurer Otherwise, the corporation must attach a resolution certified by the secretary or assistant secretary under corporate seal empowering the officer(s) signing to bind the corporation. APPROVED AS TO FORM: CINDIE K. McMAHON, City Attorney BY: _____________________________ Deputy / Assistant City Attorney DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F City Attorney Approved Version 12/28/2022 8 EXHIBIT “A” SCOPE OF SERVICES Gaetke Medical Corporation will provide specialized medical tests and physical exams compliant with National Fire Protection Association 1582 guidelines. All services shall be in accordance with Contractor’s response to RFP #20-07-C24 awarded by Northwest Fire District, including any and all amendments to the agreement, which is attached and incorporated herein by this reference as Exhibits B, C, and D. The Contractor will provide a mobile medical clinic to conduct all testing and examinations onsite with a licensed physician over various shifts and days. Station #1 – Comprehensive Ultrasound Screening Sonogram screening of carotid arteries, aortic aneurysm appearance, thyroid, kidneys, liver, spleen, pancreas, gallbladder, testicular, prostate for males, and transabdominal pelvic for women. Station #2 – Medical Assessment Additional testing such as audiogram, spirometry, vision, TB, and biometric Station #3 – Physical Fitness Assessment Cardiac stress test with physical fitness assessment involving pushups, plank, grip strength, flexibility Station #4 – Physician Examination Skin cancer screening, physical examination, and review of results Requires health history paperwork prior to examination: • 1582 Health History Questionnaire • Berlin Sleep Study • OSHA Respirator Questionnaire FEE SCHEDULE ITEM NO. UNIT DESCRIPTION PRICE 1 Per Participant Physical examination $625.00 2 Per Participant Ultrasound screening $150.00 3 Per Participant TB Test $20.00 Annual agreement compensation shall not exceed one hundred thousand dollars ($100,000) per Agreement year. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F Exhibit B DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • •• ,. November 12, 2019 Northwest Fire District S22S W. Massingale Road Tucson, Arimna 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 Organimtion) (hereinafter collectively referred to as 1 S82) are pleased to present to Northwest Fire District our proposal to provide Annual Physical Exams under Section N: 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 States serving fue deparbnents in Arizona, Nevada, Colorado and California. In accordance with the NFPA 1582 guidelines, 1582 only utilizl!s Licensed Physicians in conducting the Annual Physical Exams. 1S82 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@1S82exam.com. Cordially, ~ President 858 West Elliott Road, Tempe, AZ 85284 PH: (775) 846-3413 • FAX: (775) 823-9025 DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • 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 Asstmuu. Mid-level practitionen 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 Physicals 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 frrefighters 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: S 625 per exam OPERATIONAL PLAN 1582 staff will work closely with Northwest Fire District to maximiz.e efficiency regarding scheduling the Annual Physicals based on your firefighters' various shifts to minimiz.e 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 1 S -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 II 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 Il 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 1582 's staff 1582 will meet with representatives of Northwest Fire District to discuss and approve all aspects of the Annual Physicals including clinical protocols, reporting systems, medical recordkeeping, and billing. At the time of their physical, all frrefighters 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 organi7.ation. 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. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • TAB2 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 fonned 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. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • Tab3 STATEMENT OF QUALmCATIONS 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 on-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 . DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • TAB4 1582 SOLUTION: FIREFIGHTER ANNUAL PHYSICAL EXAMS 1582 will customize 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 stafimg 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 Bl-annual or Quarterly basis depending on which ever option is most convenient for your organiz.ation . .at 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 utiJraed 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 Batta.Ilion 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 I 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 II 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. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • 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 Deparbnents 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 weU, in addition to continuing to provide on-site senices. "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." DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • TABS NOT APPLICABLE • • DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • TAB6 APPENDIX I: STATEMENT OF QUALIFICATIONS A. FIRM QUALIFICATIONS AND EXPERIENCE General Overview and History of 1582 Gilbert, Gaetke and Associates of Nevada, MD, LID 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 organimtions 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 COL 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 Gilbert, Gaetke and Associates of Nevada, MD, LID 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 Organimtion 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 . DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • B. QUALIFICATIONSOFKEYPERSONNEL l) The key staff that will be amigned to this contract include: A) Paul Granstrom -President 8) Mark Gaetke, MD -Corporate Medical Director C) Chris Pedenon, MD -Medical Director D) Tziporah Richmond -Ultrasound Technician E) Mariah MathJs -Phlebotomist, Canlio-vascular Techaiciaa F) Amaada BieDOll -Phlehotolllist/Medical Assistaat G) Daaielle Gareia-Phlebotomist/Medical AISistant H) Lisa Baysinger-Phlebotomist, X-ray Techaieian I) Kristia Venten-Phlebotomist, NIOSB/CAOHC Resumes of each key staff member are included below. 2) The physicians that wiJI be conducting the Physician Exams will be Ors. 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. S) The staff member responsible for all Summary Reports will be Mariah Mathis under the supervision of Paul Granstrom, President of 1S82. 6) 1582 should NOT need to secure additional staffing for this RFP. The only subcontractors utiliz.ed will be LabCorp for processing all lab specimens and SimonMed to perform the over- reads of the Chest X-rays . DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • PAUL GRANSTROM PRESIDENT 1582,LLC EDUCATION: EXPERIENCE: President/ Principal BIOGRAPHY OF PAUL GRANSTROM Bethel College, Arden Hills, MN, 1999 Bachelor of Arts Degree ARC Health & Wellness Centen/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 ofNFPA 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 MedCenten, 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) DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • BIOGRAPHY OF MARK GAETKE, MD MARKJ. GAETKE, 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 -#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 DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • BIOGRAPHY OF CHRIS PEDERSON, MD CHRISTOPHER PEDERSON, MD, MPH, DABPM BoARD CERTIFIED -PREVENTATIVE MEDICINE Medical School Preventative Medicine Fellowship Family Medicine Residency Master's of Public Health Medical Director -Las Vegas University of Nevada, Reno 1983 City of Faith Medical Center 1984 -1986 City of Faith Medical Center 1983 -1984 1984-1986 ARC Health & Wellness Centers -2013 -Present As Medical Director of ARC's Las Vegas operations, Dr. Pederson has conducted thousands of firefighter and police annual medical exams. Past Positions: Physician Manaqer-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. 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) DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • Biography of Tziporah Richmond, RVS Tziporah Richmond Clinical Director, Ultrasound Imaging EDUCATION: 2008 EXPERIENCE: ARC Health & Wellness/1582 2018 -Present: Clinical Director, Ultrasound Imaging PCCTI, Chicago, IL Certification in Sonography Science, PCCTI IT & HealthCare 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, NC, Urinary bladder, Gall Bladder, and Bilimy 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. Portasonh 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 Ecbocardiograms including measurements, color flow and doppler. CERTIFICATIONS: Registered Vascular Specialist (RVS) -Cardiovascular Credentialing International DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • Biography of Mariah Mathis Mariah Mathis Certified Cardiographic Technician/Phlebotomist/EKG Technician EDUCATION: 2014 2015 2016 2017 EXPERIENCE: ARC Health & Wellness/1582 East Valley Institute of Technology, Me~ A'Z CMA/CPT/CEKGT Pima Community College EMT Arizona Medical Training Institute CCT Arizona State University Bachelor's Degree 2017 -Present: Clinic Administrator/Phlebotomist/CVT 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, A'Z. 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 & BCLS Healthcare Provider CPR Certified DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • BIOGRAPHY OF LISA BASINGER LISA BASINGER Certified X-Ray Technician/Pblebotomist EDUCATION 2008 EXPERIENCE ARC Health & Wellness Centen/1582 Great Duin College (GBC); Elko, NV AAS Radiology Tec•notogy; ARRT Certified BAS Management Technology 2015 -Present: Radiologic Technologist/Phlebotomist/Medica/ Assistant Lisa served as a Certified X-ray Tedmician/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 bas extensive experience in conducting audiograms, pulmonary function studies and administering vaccines. SUMMIT HEALfflCARE 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. Nortben Nevada Health Center 2010-20/1: Radiology Technologist/Medical Assistant CERTIFICATIONS: Certified X-Ray Technician Certified Phlebotomist DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • BIOGRAPHY OF AMANDA mCKSON AMANDA WCKSON Certified Phlebotomist/Medical Assistant EDUCATION 2012 EXPERIENCE ARC Health & Wellness Centen/1582 Berkeley College Woodland Park Certified Clinical Medical Assistant Certified EKG Technician Certified Phlebotomy Technician 2013 -Present: Clinic Administrator/Phlebotomist/Medica/ 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 HEALfflCARE OF ARIZONA 2010-2015 Health Screener/Wellness Coach Lisa was responsible for setting up the health screening sites, checking in participants, perfmming Biometrics on patients, perfonning 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 20 JO -2011: Radiology Technologist/Medical Assistant CERTIFICATIONS: Certified X-Ray Technician Certified Phlebotomist DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • BIOGRAPHY OF DANIELLE GARCIA DANEILLE GARCIA Certified Phlebotomist/Medieal Assistant EDUCATION 2008 EXPERIENCE ARC Health & Wellness Centen/1582 KAPLAN COLLEGE, Las Vegas Certified Clinical Medical Assistant Certified EKG Technician Certified Phlebotomy Technician 2013 -Present: Clinic Administrator/Phlebotomist/Medical .Assistant Danielle bas 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, minalysis, patient wound caM, EKG testing, x-rays, etal. Delert 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 Pblebotomist DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • Kristin Venten Heart & Lung Technician EDUCATION: Current 2016 -2018 EXPERIENCE: ARC Health & Wellness/1582 Biography of Kristin Venten Arizona State University Forensic Psychology Truckee Community College Community Health January 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 DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • C. UNDERSTANDING OF REQUIRED SCOPE OF SERVICES 1) Uadentandiag and ability to provide the services required by tile 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 ofNFPA 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, 1S82 does not utilize mid-level providen 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 exams. There is no substitute for experience! Based on over ten (10) years of experience in working with Fire Deparbnents, 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, replations and requirements of NFP A, DOT, OSHA, BIPAA aad 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. I 582 guarantees that it bas 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 aad 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 I S82 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. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • However, 1582 is prepared to conduct the Annual Physicals even earlier in 2020 ifNorthwest Fire District so desires. 1582's Action Plan is as follows: I. 1582's President and Corporate Medical Director wiII 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, Audiograms, 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 II of the physical, 1582 provide all firefighters with copies of their lab results, ultrasound images, Stress Treadmill results, and patient education handouts . DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • 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 FIT 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 HIPAA 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 ill: Reference Form DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • RFP# 20-07-C24 APPENDIX D: COST SUMMARY -ANNUAL PHYSICAL EXAM SERVICES Annual Physical Eums Price Page Firefighter and Prevention Penonnel 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: 1-Medial llbtory and Physician Eumination (NFPA 1582 Compliant Exam) 2 -Ultrasound of Heart (Echocardiogram with Cardiology overread) 3 -Vital Signs 3 -Audiogram 4-Vision S -Pulmonary Function Test 6 -EKG 12-Lead 7 -CXR (Baseline Year I or medically indicated, with Radiology Overread) 8 -Respirator Questionnaire (OSHA) 9 -1187.mat Questionnaire 10 -Flexibility/Core Strength Testing 11 -TB skin test 12 -Treadmill -submuimal (WFI Protocol as per NFPA 1582) 13 -Treadmill-mubnal treadmill test (WFI Protocol as per NFPA 1582) 15 -PSA-over 40 (Males only -(On-Site Venipuncture) 17 -AlC (On-Site Venipuncture) 19 -Chest X-Ray with Overread (Duplication from # 7) 20-Maximal Treadmill based on Risk (Duplication from# 13) 21 -Hepatitis B Quantitative Lab Draw (this test included below 7H -Hep. Profile) 23 -Cancer screening (Skin Cancer) 24-Sleep & Stress Questionnaires (Mental Health and Sleep Assessment) 25 -Cancer & Cardio Disease Risk Reduction 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 V02 mu (WFI Protocol as per NFPA 1582) 28 -Alternative to flexibility (not sure what is meant, compared to # 1 O?) REQUIRED: Page 28 -Annual Exam (pot referenced above) 04-Lipid Profile-LDL, HDL, TC, Trig, TC/BDL Ratio On-Site Venipuncture D5 -Body Fat Analysis (Calipen / BMI) 7 A -Urinalysis 7B -Comprehensive Metabolic Panel 7C-T4 and TSH Thyroid Panel 7D -BladderChek NMP22 On-Site Collection On-Site Venipuncture On-Site Venipuncture 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 Immuo.) On-Site Venipuncture Total Annual Exam Price (all services conducted on-site) COST: Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included Included $625.00 ***Pricing will remain fixed for term contract with NO annual increases*** DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • Optiogal 18 -Offer HIV (also known as # 29 Exposure to HIV Testing) 16 -Blood Lead -if needed 22 -Heavy Metal screening (Blood Lead} (Duplication of 16) 14 -No Show/Cancellation of physical (Physician Visit Only) Fitnep JYllp•tiogl Unclear if this is done in addition to ru: instead of the Stress Treadmill Test 26 WFI Submuimal Step Mill test (if substituted for Stress Treadmill) 26 WFI Submaximal Step Mill test (If in addition to Stress Treadmill) Sppplepaeptan: Ic,tiPR I Seryias Respirator Fit Testing (Quantitative via PortaCount) Tetanus Vaeeinatioa Hepatitis A Vaccination (each dose) Hepatitis B Vaccination (each dose) TwinRb: Vaccination (each dose) Commercial Driver License Exam (conducted with Annual Exam) Coronary Calcium Score Baseline (on-site CT with interpretation) END OF APPENDIX Il $+43.65 $ + 75.00 $+75.00 $+100.00 Included $+30.00 $+30.00 $+41.25 $+72.25 $+58.20 $+ 100.88 $+45.00 $+ 150.00 DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • TABS WE ELECT TO NOT PARTICIPATE IN THE OCCUPATIONAL HEALTH SERVICES COMPONENT OF THIS RFP AT THIS TIME DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • RFP# 20-07-C24 APPENDIX IV: MINIMUM QUALIFICATIONS VERIFICATION FORM OFFEROR NAME: ARC HEALTH & WELLNESS CENTERS/1582 Proposals not meeting the minimum qualifications will be deemed NON RESPONSIVE and will not be considered for further evaluation. If defined in this solicitation, provide documented and verifiable evidence that your firm satisfies the Minimum Requirements, and indicate what/if attachments are submitted. 1 2 3 Minimum qualifications of the offeror's company Minimum qualifications of the proposed key personnel Provide copies of license, certifications, accreditation, etc. Will provide upon award of Contract Contract Contract ---------------------------------------- 4 Additional MQ if any. ~ Will provide upon award of END OF APPENDIX IV Page 37 of42 DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • RFP# 20-07-C24 EXHIBIT A PAST PERFORMANCE VERIFICATION EVALUATION SUBMITTAL$ LIST OF THOSE AGENCIES OR FIRMS WHO WILL BE SUBMITTING EVALUATIONS TO NWFD Please list the agency or finn name, address, phone number and contact infonnation for the finns that will be providing the Past Perfonnance Verification Form. It is the !'IIPADflbJllty pf Sbe firm to ensure that NWFD receives all of the Past Performance Verification Forms prior to the submittal deadlne. Failure to provide evaluations by date and time specified will result In no score for that specific evaluation. 1. Reno Fire Department 1 E. 1st Street, 4th Floor Reno, NV 89501 Division Chief -Bob Leighton / 775-333-777 4 Rural Metro Fire 2. ----------------- 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/ 520-421-8777 END OF APPENDIX V Page40 of 42 DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F RFP# 20-07-C24 • The following section wlll be used as an evaluation tool for award. Please complete the checklist to ensure your compliance to requested needs. VENDOR INFORMATION/SERVICE: All offerers 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 detennined 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@1582exam.com COMPLIANCE TO SCOPE OF WORK Is Descriptive Uterature enclosed? Yes OI Non Is Offer and Acceptance Page properly signed? Proposals submitted without an oriainal, sianed Offer and Acceptance Paae mav be deemed nonresoonsive. Yes 01 Non Are addendums signed and attached? htt~://www.northwestfire.org/notices/~urchasing Yes~ Non PRICE $625.00 • Please Indicate number of davs that Prices are finn. Term of contract Are prices indicated bv unit and totals? Yes~ Non • Page41 of 42 DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F 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 NORTMWEST FIRE DISTRICT The Undersigned hereby offers and agrees to furnish the material or service In compliance With all terms, eonditlons, specifications, and amendments tn the Invitation for Bid and any written exceptions in the offer. Signature also certifies understanding and compliance with paragraph (1) of the Northwest Fira Dlslrict Standard Terms and Condlllons. GIibert, Gaetke and Associate& of Nevada, MD, LTD. d/b/a ARC Health and Wellneaa c.itws and 1582 Company Name 858 W. Elliot. Suite # 105 City CERTIFICATION Addrass Tempe, AZ. 85284 State By algnature in the Offer Section above, the bidder c:ertlftes: Zip Name: Phone: Fax: E-mail: For darlficatlon of this offer, c:ontact: Paul Granstrom 775-846-3413 602-581-3030 paul@1582exam.com ?~,. .... Paul Granstrom Printed Name President / CEO Tille 1. The aubmission of the offer did not involve colluaion or olher anti-competitive prac:tices. 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, bip, favor or service to a public servant in connection with the submitted offer. Fallin ID provide a valid signabn affinnlng the stipulalions requlrad by these clauses shall rasull in rejection of the offer. Signing the offer with a false statement shaH void the offer, any resulting contract and may be subject to legal remedies provided by law. AC(cEPT ANCE QF OFFER The Offer is hereby accepted. The Contractor Is now bound to sell the materials or services listed by the attached contract and based upon the Request For Proposal, including all terms, conditions, speclllcatloli, amendments, etc. and the Conlractol's Offer as accepted by the District This contract shall henceforth be referred to• 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 pollllcal subdivision Approved as to form this ___ dayc:A ________ , 2019. Awarded this ___ day of _______ __, 2019. Norman K. Brad Bradley Ill George Carter As Northwest Fire Disbict Fire Chief and not personally As Northwest Fire District Chair and not personally • Thomas A. Benavidez Page42 of42 DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • RFP# 20-07-C24 submit Proposal to: NORTHWEST FIRE DISTRICT NOTICE OF REQUEST FOR PROPOSALS (RFP) RFP Number: 20-07-C24 Title: Annual Physical Exams and Occupational Health Services ~ FRIDAY, NOVEMBER 15, 2019 AT 11 :00 A.M. AZ. TIME OPENING: SAME DAY AT 11:00A.M. AZ TIME Northwest Fire District Administration 5225 W. Massingale Road Pm-Proposal Conference: MONDAY, NOVEMBER 4, 2019 at 11:00 A.M. AZ. TIME Northwest Fire District Administration 5225 W. Massingale Road Tucson, Arizona 857 43 Tucson, Arizona 857 43 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 offerer 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. • • I 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: Finn/Person Gilbert, Gaetke and Associates of Nevada, MD, L TO. d/b/a ARC Health and Welness Centers and 1582 Address 858 W. Elliot, Suite# 105 City Tempe ------State AZ ----Zip 85284 Phone Number 775-846-3413 Signature Title Publish: Daily Territorial: 10/29/2019, 10/30/2019, 10/31/2019, and 11/01/2019 7 President I CEO Page 1 of42 DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • NORTHWEST ..... FIRE DISTRICT ADDENDUM NO. 1 ISO CLASS 1 * INTERNATIONALLY ACCREDITED 5225 W. Massingale Rd. I Tucson, AZ 85743 (520) 887-1010 I www.NorthwestFire.org l:l@NorthwestFire I II /NorthwestFireDistrict November 6, 2019 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. Offerer shall acknowledge receipt of this Addendum No. 1 by including this Addendum with all proposals, signing and dating the following statement: -m No. 1 acknowledged by ~ Date 11/12/19 /:: (Signature) Name/Title Paul Granstrom / President / CEO (Typed or printed) Gilbert, Gaetke and Associates of Nevada, MD, LTD./ OBA Name of firm ARC Health and Wellness Centers / 1582 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, #07 -Identifies specific laboratory testing or other tests that is not included in the pricing sheet on Page # 33 -Appendix 11 -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 DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F • • • NORTHWEST ...-..FIRE DISTRICT ISO CLASS 1 * INTERNATIONALLY ACCREDITED 5225 W. Massingale Rd. I Tucson, AZ. 85743 (520) 887-1010 I www.NorthwestFire.org rJ@NorthwestFire I ■ INorthwestFireDistrict 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 indude 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://www.northwestfire.org/notices/purchasing. Raymond Thibault Procurement and Contract Specialist NORTHWEST FIRE DISTRICT ISO CLASS 1 INTERNATIONALLY ACCREDITED 5225 W. Massingale Rd. | Tucson, AZ 85743 (520) 887-1010 | www.NorthwestFire.org @NorthwestFire | /NorthwestFireDistrict CONTRACT CHANGE ORDER Contract Change Order: #1 Bid/Contract # 20-07-C24 Bid/Contract Name: Annual Physical Exam and Occupational Health Services Effective Date: March 25, 2020 The contract term is amended to: CONTRACT PERIOD: It is the intent of the District to award a multi-term contract for the specified services beginning on the first day of the month following date of award and shall continue for a period of three (3) years thereafter, unless terminated, cancelled or extended as otherwise provided herein. If this is a multi- term contract and assuming funds are appropriated to support continuation of services for succeeding periods, the original contract may be renewed extended for supplemental periods of up to a maximum of two (2) years. If all contract extensions were to be exercised, the total term of this contract would be five (5) years. Renewal shall be a mutual agreement between the awarded firm and the Northwest Fire District. However, no contract exists unless and until a purchase order is issued. Conditions for renewal of the contract shall include, but not be limited to, satisfactory performance of services during the preceding contract term, ability to continue to provide satisfactory services, continued adherence to the requirements of the proposal documents, and continued competitive prices for the services and/or products provided under the original contract. The contract is amended to add the following optional items: Exhibit CDocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F, ...... NOR HWEST * ~ FIRE DISTRICT NORTHWEST FIRE DISTRICT DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F C.vi. Cancer Prevention b. C. Doe to the rare natnre or most die tests bi!lnc requested In sKtton VI. canar Prewndon and ordered by 1582, we offer any of these tests listed at 1S82 Labt'orp r.ost Price or wtth a?, at ow-COST pins al 5" af1mlnfstratlon • to cover various upe lndudl Draw fee, Pn>c: Inc, Pbystdan Time to review, lntrepert and explain the results to the Fire ter eaw etc... 67.60 2 • 2-4.00 93.50 36.-40 12.50 108.00 NORTHWEST FIRE DISTRICT Signature of the Contractor and Owner indicates agreement herewith, to waive all future claims against each other for work associated with this Change Order for direct and/or indirect damages. All other terms and conditions of the contract remain unchanged. Contractor: Name & Position Address Signature Date Northwest Fire District: Raymond Thibault, Procurement and Contract Specialist Name & Position Signature Date 1855 N. McCarran Blvd, Sparks, NV 89431 Paul Granstrom - President 1582, LLC 4/6/2020 04/06/2020 DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F 4 HormoneBal.mcr: C. d. Cortisol, am and pm (blood) or multiple points (saliva Thyroid panel -TSH, FT4, "3, TJ'3, RT3, Thyroid antibodies Hstro eo rofile a. Methylation SN1'S: MTHFR, a>M'f, CBS, MTR, MTRR mocysteinr, RBW, MMA, Comprehrnsive ~ 7 85.50 20.80 119.60 1 ,2~~ RFP# 20-07-C24 Page 8 of 42 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 Exhibit DDocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F Business Name/DBA G M BUSINESS INTERIORS GREG CONSULTING INC G SCOTT ASPHALT INC G SQUARED COMPUTING LLC G10 LAW A PROFESSIONAL LAW CORPORATION GABBY'S BABRBER SHOP GABRIEL CARINI HEATING AND AIR CONDITIOING GABRIEL NATHANAEL DESIGNS GABRIELLA MCFARLAND -HAIRSTYLIST GAETKE MEDICAL CORPORATION GAFCON INC GAIAGELATO GALEN BIO INC GALLANT ELECTRIC INC GALLUS GAMEDAY HEALTH MANAGEMENT GAMEDAY MEN'S HEALTH GAMMILL ELECTRIC INC GAP KIDS OUTLET NO 1670 GAP OUTLET NO 7780 GARCIA AND BIRGE APC GARCIA'S BARBERSHOP GARCIAS CUSTOM PAINTING GARCIA'S LANDSCAPING SERVICE GARCILASO CONSTRUCTION GARDEN STATE BAGELS -6020 GARDEN STATE BAGELS -755 GARDNER OUTDOOR AND POOL REMODELING GARRISON TROOPS LLC GARTNER INC GARY AND MARY WEST MANAGEMENT CO INC GARY FAITH CONSTRUCTION INC GASLAMP INSURANCE SERVICES LLC GATEWAY DENTAL GROUP GATZKE DILLON AND BALLANCE LLP GAYTAN FAMILY FARM GBC CONCRETE AND MASONRY CONSTRUCTION INC Page 65 of 180 ACTIVE BUSINESSES AS OF February 01, 2023 NOTE: Home-based businesses are not available to search. To validate the license status of a home-based business, please contact Business License at (760) 602-2495. Owner Name GOFORTH AND MARTI GREG CONSULTING INC G SCOTT ASPHALT INC G SQUARED COMPUTING LLC G10 LAW A PROFESSIONAL LAW CORPORATION GABRIELA RAMIREZ GABRIEL CARINI HEATING AND AIR CONDITIOING GABRIEL NATHANAEL GABRIELLA MCFARLAND GAETKE MEDICAL CORPORATION GAFCON INC GAIA ITALY GROUP INC GALEN BIO INC GALLANT ELECTRIC INC GALLUS GAMEDAY HEALTH MANAGEMENT GAMEDAY MEN'S HEALTH GAMMILL ELECTRIC INC THE GAP INC THE GAP INC GARCIAAND BIRGEAPC ABEL GARCIA PAUL GARCIA BELTRAN GARCIA GRANT GARCILASO ROYAL BIALY LLC ROYAL BIALY LLC GARDNER POOL COMPANY INC GARRISON TROOPS LLC GARTNER INC GARY AND MARY WEST MANAGEMENT CO INC GARY FAITH CONSTRUCTION INC SIS SPECIALTY HOLDINGS LLC GATEWAY DENTAL GROUP GATZKE DILLON AND BALLANCE LLP GAYTAN FAMILY FARM INC GBC CONCRETE AND MASONRY CONSTRUCTION INC Business Address 110WASTSTE 140SAN DIEGO, CA92101-3701 2888 LOKER AVE E STE 101 CARLSBAD, CA 92010-6683 358 TROUSDALE DR CHULA VISTA, CA 91910-1045 13200 KIRKHAM WAY STE 107 POWAY, CA 92064-7126 2792 GATEWAY RD STE 102 CARLSBAD, CA92009-1749 2960 STATE ST CARLSBAD, CA 92008-2336 3388 CHANNEL WAY SAN DIEGO, CA 92110-5101 2558 ROOSEVELT ST STE 200 CARLSBAD, CA 92008-1673 7188 AVENIDA ENCINAS STE 110 CARLSBAD, CA 92011-4602 2540 ORION WAY CARLSBAD, CA 92010-7240 10301 MEANLEY DR STE 225 SAN DIEGO, CA 92131-3011-SAN DIEGO 300 CARLSBAD VILLAGE DR STE 104 CARLSBAD, CA 92008-2990 1949 KELLOGG AVE CARLSBAD, CA 92008-6582 1735 IVY RD OCEANSIDE, CA 92054-5640-SAN DIEGO 5205 AVENI DA ENCINAS STE A CARLSBAD, CA 92008-4366 2753 JEFFERSON ST STE 204 CARLSBAD, CA 92008-1704 2753 JEFFERSON ST STE 204 CARLSBAD, CA 92008-1704 16224 ARROW HWY IRWINDALE, CA 91706-2015-LOS ANGELES 5620 PASEO DEL NORTE CARLSBAD, CA 92008-4461 5620 PASEO DEL NORTE CARLSBAD, CA 92008-4461 2173 SALK AVE STE 250 CARLSBAD, CA 92008-7383 2960 STATE ST CARLSBAD, CA 92008-2336 1850 MANZANITA CT VISTA, CA 92083-7719 3818 COMMODORE DR SAN MARCOS, CA 92078-2339 2577 JOANN DR OCEANSIDE, CA 92056-3428 6020 PASEO DEL NORTE STE D CARLSBAD, CA 92011-1146 755 CARLSBAD VILLAGE DR CARLSBAD, CA 92008-2317 801 GABLE WAY EL CAJON, CA92020-1910 701 PALOMAR AIRPORT RD STE 300 CARLSBAD, CA 92011-1028 56 TOP GALLANT RD STAMFORD, CT 06902-7747 5800 ARMADA DR STE 100 CARLSBAD, CA 92008-4611 7313 CARROLL RD STEC SAN DIEGO, CA92121-2319-SAN DIEGO 1811 ASTON AVE STE 200 CARLSBAD, CA 92008-7396 2635 GATEWAY RD STE 101 CARLSBAD, CA92009-1753 2762 GATEWAY RD CARLSBAD, CA 92009-1730 5665 RIDGEVIEW AVE JURUPA VALLEY, CA 91752-2223 561 BIRCH ST LAKE ELSINORE, CA 92530-2732 EXP Date 09/30/2023 08/31/2023 06/30/2023 08/31/2023 04/30/2023 03/31/2023 09/30/2023 04/30/2023 08/31/2023 02/29/2024 09/30/2023 01/31/2024 05/31/2023 01/31/2024 10/31/2023 02/29/2024 02/29/2024 10/31/2023 06/30/2023 09/30/2023 06/30/2023 12/31/2023 08/31/2023 02/28/2023 09/30/2023 02/28/2023 02/28/2023 01/31/2024 02/28/2023 11/30/2023 12/31/2023 03/31/2023 04/30/2023 05/31/2023 12/31/2023 08/31/2023 04/30/2023 08/26/2022 Crestline Insurance Services LLC 6955 N Durango Dr #1115-765 Las Vegas NV 89149 Ann Lehtinen, CLU/CPCU (702) 596-5686 (702) 988-5355 annl.crestline@gmail.com 1582 LLC & ARC Health & Wellness Centers, LLC Gaetke Medical Corp, A CA Professional Corp 1855 N McCarran Blvd Sparks NV 89431 Transportation Insurance Company 20494 Hartford National Fire & Marine Ins Co 20079 22-23 1582 ARC A Y 4034592085 12/22/2022 12/22/2023 2,000,000 1,000,000 10,000 2,000,000 4,000,000 4,000,000 DEDUCTIBLE NONE B N 53WECAS8FFW 06/02/2022 06/02/2023 1,000,000 1,000,000 1,000,000 C MEDICAL PROFESSIONAL LIABILITY CLAIMS MADE POLICY ES053943 09/01/2022 09/01/2023 EACH CLAIM $1,000,000 ANNUAL AGGREGATE $3,000,000 DEDUCTIBLE $ 5,000 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 OperationsAdditional Insured Form SB146968C. Primary/Non-Contributory Wording Form CNA80103XX. Work Comp Waiver Form WC990302B. 30 day notice of cancellation will be provided with the exception of 10 day notice for non-payment of premium. City of Carlsbad Nathan Pearson, Div Fire Chief 2560 Orion Way Carlsbad CA 92010 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED?(Mandatory in NH) DESCRIPTION OF OPERATIONS belowIf yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCEDAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIREDAUTOS ONLY DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F ACORD® I ~ I X I [81 - - ~ □ [81 - -- -- -- -H I I XI I I □ rL ✓.--71'~·._ I -/ DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F eNA SB146932G (Ed. 10-19) Gilbert, Gaetke & Associates of Nevada, MD, Ltd. Policy No: 4034592085 BLANKET ADDITIONAL INSURED AND LIABILITY EXTENSION ENDORSEMENT This endorsement modifies insurance provided under the following: I. II. BUSINESSOWNERS LIABILITY COVERAGE FORM BUSINESSOWNERS COMMON POLICY CONDITIONS TABLE OF CONTENTS 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 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; g. 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 of7 Copyright, CNA All Rights Reserved. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F ~ i "' "' ... "' 0 ... "' "' 0 0 ~ 0 ~ iiiiiiii = -= -- iiiiiiii -- SB146932G (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 . S8146932G (10-19) Page 2 of7 Copyright, CNA All Rights Reserved. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F d. Lessor of Equipment 58146932G (Ed. 10-19) 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 lessor's 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. 58146932G (10-19) Page 3 of7 Copyright, CNA All Rights Reserved. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F :g i "' "' ... "' 0 ... "' "' 0 0 ~ 0 ~ iiiiiiii --= -- iiiiiiii -- i. Trade Show Event Lessor SB146932G (Ed . 10-19) 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; S8146932G (10-19) Page 4 of7 Copyright, CNA All Rights Reserved. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F 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; 58146932G (Ed. 10-19) 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 lnsured's business. 58146932G (10-19) Page 5 of7 Copyright, CNA All Rights Reserved. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F :g i "' "' ... "' 0 ... "' "' 0 0 ~ 0 ~ iiiiiiii -iiiiiiii -= -- iiiiiiii -- D. Fellow Employee First Aid Coverage In the section entitled Who Is An Insured, paragraph 2.a.1. is amended to add the following: SB146932G (Ed . 10-19) 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. S8146932G (10-19) Page 6 of7 Copyright, CNA All Rights Reserved. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F 58146932G (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. 58146932G (10-19) Page 7 of? Copyright, CNA All Rights Reserved. Gilbert, Gaetke & Associates of Nevada, MD, Ltd. Policy No: 4034592085 DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F 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 of3 Copyright, CNA All Rights Reserved. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F 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. j E. Additional Insured -Extended Coverage "' "' i:;i 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: 0 ~ If the additional insured is: ~ iiiiiiii -= -- iiiiiiii -- 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; S8146968C (Ed. 10-19) Page 2 of 3 Copyright, CNA All Rights Reserved. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F 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 of3 Copyright, CNA All Rights Reserved. DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT Policy Number: 53 WEC AB6IDK Endorsement Number: Effective Date: 05/29/22 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: ARC WorkPlace Services LLC 1855 N MCCARRAN BL VD SPARKS NV 89431 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. SCHEDULE Any person or organization for whom you are required by contract or agreement to obtain this waiver from us. Endorsement is not applicable in KY, NH, NJ or for any MO construction risk Form WC 00 03 13 Printed in U.S.A. Process Date: 04/19/22 Countersigned by ~ Authorized Representative Policy Expiration Date: 05/29/23 Gilbert, Gaetke & Associates of Nevada, MD, Ltd. Policy No: 4034592085 DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F t::; i "' "' ... "' 0 ... "' "' 0 0 ~ 0 ~ iiiiiiii !!!!!!!!! -- iiiiiiii -- 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 1582 LLC & ARC Health & Wellness Centers, LLCCrestline Insurance Services LLC 25 Certificate of Liability Insurance: Notes Covered Physicians:Mark Gaetke MD, Retroactive Date 1-5-2000 Warren Gilbert MD, Retroactive Date 1-5-2000 Brian Kuhn MD, Retroactive Date 4-15-2019Troy Ross MD, Retroactive Date 9-1-2022 Robert P K Keller MD, Retroactive Date 10-15-2019 William Elliott II, MD, Retroactive Date 11-15-2021 Juk L Ting, DO, Retroactive Date 1-3-2022 Daniel R Dobbe, MD, Retroactive Date 1-24-22 Timothy Durkin DO, Retroactive Date 10-15-2019 Covered Locations: 1855 N McCarran Blvd, Sparks, NV 89431 2500 W Sahara Ave, Las Vegas, NV 89102 3337 W Washington Ave, Las Vegas, NV 89107 844 W Nye Lane, Carson City, NV 89703 1925 W Orange Grove, Tucson, AZ 85704 5546 Longley Ln, #A, Reno, NV 89511 ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F I DocuSign Envelope ID: 9FB59934-B795-4DFA-B2B8-C67D3371961F ~ ACORD® CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DD/YYYY) ~ 01/24/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer riahts to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT JOHN RAKER NAME: State Farm JOHN RAKER INSURANCE AGENCY INC rA~gNJ. ~~,. 775-782-7107 I FAX IA/C Nol: A . 1701 COUNTY RD SUITE G E-MAIL ADDRESS: ---MINDEN, NV 89423 INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: State Farm Mutual Automobile Insurance Company 25178 INSURED INSURERS : 1582, LLC and Gaetke Medical Corporation INSURERC: --1855 N MCCARRAN BLVD INSURERD: SPARKS, NV 89431 ~~ERE: INSURERF : 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 ADDL ISUBR ·--1,~g~%YvW-, l,~~'t,%~, LTR TYPE OF INSURANCE '····-, ... ,_ POLICY NUMBER LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ ......_ □ CLAIMS-MADE □ OCCUR ioAMAGTTO"'Rl:Nit=u PREMISE=$ <Ea occurrence\ $ ......_ MED EXP (Anv one person) $ ~ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ R □PRO-□ PRODUCTS -COMP/OP AGG $ POLICY JECT LOC OTHER: $ AUTOMOBILE LIABILITY y YE~~~~~~~t?NGLE LIMIT s 1,000,000 ......_ ANY AUTO 163 2592-E06-28 1 '1/06/2022 1 ·1 /06/2023 BODILY INJURY (Per person) $ ......_ -A .X OWNED X SCHEDULED BODILY INJURY (Per accident) $ AUTOS ONLY AUTOS HIRED .X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY /Per accident\ >-- $ UMBRELLA LtAB H OCCUR EACH OCCURRENCE $ >-- EXCESS LIAB CLAIMS-MADE I AGGREGATE $ DED I I RETENTION $ I $ WORKERS COMPENSATION I ~ffTuTE I i OTH-AND EMPLOYERS' LIABILITY ER Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE □ NIA E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L. DISEASE -EA EMPLOYEE $ ~ft~~ftfr8~ ~:~PERATIONS below I E.L. DISEASE· POLICY LIMIT $ DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES (ACORD 101, Addltlonal Remarks Schedule, may be attached if more space is required) City of Carlsbad: IS LISTED AS NAMED ADDITIONAL INSURED CERTIFICATE HOLDER City of Carlsbad Attn: Nathan Pearson -Division Fire Chief 2560 Orion Way Carlsbad, CA 92010 CA NC ELLA TION 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 ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD 1001486 132849.13 04-22-2020