Loading...
HomeMy WebLinkAboutWallace, Audra; 2023-08-03;City Attorney Approved Version 4/24/2023 1 AGREEMENT FOR CRITICAL INCIDENT STRESS MANAGEMENT AND PYSCHOLOGICAL COUNSELING SERVICES AUDRA WALLACE, LICENSED PROFESSIONAL CLINICAL COUNSELOR, INC. 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 Audra Wallace, Licensed Professional Clinical Counselor, a corporation, ("Contractor"). RECITALS A. City requires the professional services of a mental health service provider that is experienced in Critical Incident Stress Management and psychological counseling services. B. Contractor has the necessary experience in providing professional services and advice related to Critical Incident Stress Management and psychological counseling services. C. Contractor has submitted a proposal to City and has affirmed its willingness and ability to perform such work. NOW, THEREFORE, in consideration of these recitals and the mutual covenants contained herein, City and Contractor agree as follows: 1. SCOPE OF WORK City retains Contractor to perform, and Contractor agrees to render, those services (the "Services") that are defined in attached Exhibit "A", which is incorporated by this reference in accordance with this Agreement’s terms and conditions. 2. STANDARD OF PERFORMANCE While performing the Services, Contractor will exercise the reasonable professional care and skill customarily exercised by reputable members of Contractor's profession practicing in the Metropolitan Southern California Area, and will use reasonable diligence and best judgment while exercising its professional skill and expertise. 3. TERM The term of this Agreement will be effective for a period of one (1) year from the date first above written. The City Manager may amend the Agreement to extend it for four (4) additional one (1) 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 thirty-five thousand dollars ($35,000.00). 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 thirty-five thousand dollars ($35,000.00) 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". DocuSign Envelope ID: 8C3751C5-4426-464B-ACC6-6B0CFC832CCB 23 3rd August City Attorney Approved Version 4/24/2023 2 Incremental payments, if applicable, should be made as outlined in attached Exhibit "A". 6. STATUS OF CONTRACTOR Contractor will perform the Services in Contractor's own way as an independent contractor and in pursuit of Contractor's independent calling, and not as an employee of City. Contractor will be under control of City only as to the result to be accomplished but will consult with City as necessary. The persons used by Contractor to provide services under this Agreement will not be considered employees of City for any purposes. The payment made to Contractor pursuant to the Agreement will be the full and complete compensation to which Contractor is entitled. City will not make any federal or state tax withholdings on behalf of Contractor or its agents, employees or subcontractors. City will not be required to pay any workers' compensation insurance or unemployment contributions on behalf of Contractor or its employees or subcontractors. 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 attorney’s 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 DocuSign Envelope ID: 8C3751C5-4426-464B-ACC6-6B0CFC832CCB City Attorney Approved Version 4/24/2023 3 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 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). $2,000,000 combined single-limit per accident for bodily injury and property damage. 10.1.3 Workers' Compensation and Employer's Liability. Workers' Compensation limits as required by the California Labor Code. Workers' Compensation will not be required if Contractor has no employees and provides, to City's satisfaction, a declaration stating this. 10.1.4 Professional Liability. Errors and omissions liability appropriate to Contractor’s profession with limits of not less than $1,000,000 per claim. Coverage must be maintained for a period of five years following the date of completion of the work. 10.2 Additional Provisions. Contractor will ensure that the policies of insurance required under this Agreement contain, or are endorsed to contain, the following provisions: 10.2.1 The City will be named as an additional insured on Commercial General Liability which shall provide primary coverage to the City. 10.2.2 Contractor will obtain occurrence coverage, excluding Professional Liability, which will be written as claims-made coverage. 10.2.3 This insurance will be in force during the life of the Agreement and any extensions of it and will not be canceled without thirty (30) days prior written notice to City sent by certified mail pursuant to the Notice provisions of this Agreement. 10.3 Providing Certificates of Insurance and Endorsements. Prior to City's execution of this Agreement, Contractor will furnish certificates of insurance and endorsements to City. 10.4 Failure to Maintain Coverage. If Contractor fails to maintain any of these insurance coverages, then City will have the option to declare Contractor in breach or may purchase replacement insurance or pay the premiums that are due on existing policies in order to maintain the required coverages. Contractor is responsible for any payments made by City to obtain or DocuSign Envelope ID: 8C3751C5-4426-464B-ACC6-6B0CFC832CCB City Attorney Approved Version 4/24/2023 4 maintain insurance and City may collect these payments from Contractor or deduct the amount paid from any sums due Contractor under this Agreement. 10.5 Submission of Insurance Policies. City reserves the right to require, at 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 billing records with respect to costs incurred under this Agreement. All billing 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 billing records and any other documents created pursuant to this Agreement, which do not contain or reflect confidential communications between the patient and Contractor. 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. Nothing in this paragraph shall permit the City to review confidential patient records. 13. OWNERSHIP OF DOCUMENTS Reserved. 14. COPYRIGHTS Reserved. 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 Eric Kovanda Name Audra Wallace Title Lieutenant Title Owner/ Licensed Professional Clinical Counselor Department Police Address 2100 Palomar Airport Rd., Suite 214-6 City of Carlsbad Carlsbad, CA 92011 Address 2560 Orion Way Phone No. 760-571-9862 Carlsbad, CA 92010 Email audrawallace@audrawallace.org Phone No. 442-339-2146 Each party will notify the other immediately of any changes of address that would require any notice or delivery to be directed to another address. 16. CONFLICT OF INTEREST 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 as required in the City of Carlsbad Conflict of Interest Code. DocuSign Envelope ID: 8C3751C5-4426-464B-ACC6-6B0CFC832CCB □ ■ City Attorney Approved Version 4/24/2023 5 Yes No If yes, list the contact information below for all individuals required to file: Name Email Phone Number 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. DocuSign Envelope ID: 8C3751C5-4426-464B-ACC6-6B0CFC832CCB City Attorney Approved Version 4/24/2023 6 City may terminate this Agreement by tendering thirty (30) days written notice to Contractor. Contractor may terminate this Agreement by tendering 30 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. 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: 8C3751C5-4426-464B-ACC6-6B0CFC832CCB City Attorney Approved Version 4/24/2023 7 // // // // // // // // // // // // // // // // // DocuSign Envelope ID: 8C3751C5-4426-464B-ACC6-6B0CFC832CCB City Attorney Approved Version 4/24/2023 8 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) Police Chief Audra Wallace, LPCC/Owner (print name/title) ATTEST: By: (sign here) SHERRY FREISINGER 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: 8C3751C5-4426-464B-ACC6-6B0CFC832CCB City Attorney Approved Version 4/24/2023 9 EXHIBIT “A” SCOPE OF SERVICES This document shall constitute an agreement between Audra Wallace, Licensed Professional Clinical Counselor, Inc., and the City of Carlsbad to provide Critical Incident Stress Management Services (CISM) and Psychological Counseling Services to the sworn and non-sworn members of the Carlsbad Police Department. Counseling Services 1. Audra Wallace, Licensed Professional Clinical Counselor, Inc., will be available to receive direct referrals for routine counseling services for members of the Carlsbad Police Department at a flat rate of $150.00 per hour session. 2. Appointments will be offered within three working days, or at the discretion of the employee. 3. A maximum of six (6) sessions is authorized per issue, each calendar year. 4. Audra Wallace, Licensed Professional Clinical Counselor, Inc., assesses that between one and three more sessions will not successfully conclude the services, they will call for authorization. 5. Alternatively, Audra Wallace, Licensed Professional Clinical Counselor, Inc., will attempt to access the employee’s health insurance for reimbursement or negotiate a self-pay arrangement that will not exceed the departmental rate. The co-pay is the responsibility of the employee. 6. All collateral referrals for support (such as family therapy, child therapy, or any other specialized care) will be made by Audra Wallace, Licensed Professional Clinical Counselor, Inc., to ensure a smooth transition. 7. For any appointments that are missed by the employee without 24-hour notice of cancellation, the employee may be invoiced for the cost of the session ($150.00). Confidentiality and Exceptions to Confidentiality: 1. Contractor is required by law to abide by standard HIPAA regulations in the State of California. 2. All records will be maintained at the office, and all issues of client confidentiality will be protected. Records will not be released without signed employee authorization or legal proceedings that compel records such as a subpoena. 3. The Carlsbad Police Department will not be advised of names of employees who utilize the service, unless the employee gives a release of information. 4. Every attempt will be made to prevent overlap of employee appointments. 5. All issues of suicide, homicide, child abuse, elder abuse, and dependent adult abuse reporting will be made according to standard procedure to protect the client if a danger to self or others is assessed. This includes reports to the appropriate agency as required, including CPS, APS and 911. Debriefing Services: 1. If services for staff debriefing or critical incident debriefs are requested, the hourly rate of reimbursement will be $150.00 per hour per debrief. 2. No mileage will be invoiced. DocuSign Envelope ID: 8C3751C5-4426-464B-ACC6-6B0CFC832CCB City Attorney Approved Version 4/24/2023 10 Pro-bono Services: 1. No charges will be invoiced for services related to the support of the Peer Support Team of the Carlsbad Police Department. Carlsbad Police Departmental Updates 1. Audra Wallace, Licensed Professional Clinical Counselor, Inc., provide a yearly report of services rendered. This will include amount of contact hours, financial total, debriefing services, and extensions, if any, with no identifying information of employees utilizing these services. Billing: 1. If a monthly invoice approaches or exceeds $2,000.00 Audra Wallace, Licensed Professional Clinical Counselor, Inc., will call or email the Chief to note the increased use of services as soon as it becomes apparent that there is an unusual demand for services. 2. Billing will occur monthly, addressed to the attention of the police department’s Management Analyst or Office Specialist. 3. Dates of service will be provided, but the invoice will not indicate any client names of identifying information. 4. The total amount paid by the City of Carlsbad shall not exceed $35,000.00 Conflict of Interest: 1. As demand for services grows over time, it is possible that two or more employees may present for counseling and share a similar issue that may generate a conflict of interest for the employee, counselor and the department. In order to handle this in an ethical and professional manner, once the situation is realized a prompt referral will be made. 2. The employee will not be informed about any of the details of the conflict, in order to protect confidentiality, but they will be referred to other Mental Wellness resources. These alternatives will also be provided on a voicemail message for coverage during vacations, illness or other times during which the office is closed. DocuSign Envelope ID: 8C3751C5-4426-464B-ACC6-6B0CFC832CCB DocuSign Envelope ID: 1C94F94E-FF1E-459D-B605-CCC23E830D47 7/12/2023 DocuSign Envelope ID: 8C3751C5-4426-464B-ACC6-6B0CFC832CCB W AIYER REQUEST FORM FACTORS IN SUPPORT OF REQUEST TO MODIFY INSURANCE REQUIREMENT(S) Generally, a modification to the coverage requirement will be accepting a lower limit of coverage or waiving the requirement(s). Requested by: ~ G\ '1 d 0\ b C\ 'f:.e ( , f O \\ U \)e ~C\ ChY~ yyt- (Name and Department) (Date) Proposed modification(s) to the bL/ fwtO / WO\\c.(6ffifre~uirement(s) for f\\)(}.'(ctl V\J Ot \ \ Ol( e LP(,(, (Type of insurance) (Name of contract) D Reduce coverage to the amount of: ~$ ______ _ ~ Waive coverage D Other: _____________________________ _ FACTOR(S) IN SUPPORT OF MODIFICATION(S) (check those th«t appl;j □Significance of Contractor: Contractor has previous experience with the City that is important to the efficiency of completing the scope of work and the quality of the work-product. [expl«in} ______ _ □Significance of Contractor: Contractor has unique skills and there are·few if any alternatives. [explain: incluie number of candidates RFP sent to and number responded if applicable} □Contract Amount/Term of Contract: $ ______ . Work will be completed over a period of __ _ □Professional Liability coverage is not available to this contractor or would increase the cost of the contract by $ [explain]. ___________________________ _ [A]Other (e.g. explain why exposures are minimal, how exposures are covered in another policy, exposure control mech~nis,ms, and any othe,r i~onnation pertinent to your request): CO \J Y\ ~€. hY1 \:e ~--ey v ,·ce S bC1'1t roH\\'(Y\O\\ 1,·v\w \\\Tij <iw,o\ cavn1-e \o rr cto not tr~Ntl twf{,vi Approved by Risk Manager for this contract only: (Signature) (Date) DocuSign Envelope ID: 8C3751C5-4426-464B-ACC6-6B0CFC832CCB CNA HEALTHCARE PROVIDERS SERVICE ORGANIZATION PURCHASING GROUP IIHPSO Qtertf ficate of 11" ngurance OCCURRENCE PROFESSIONAL LIABILITY POLICY FORM Print Date: 6/02/2023 The application for the Policy and any and allsupplementary information, materials, and statements submitted therewith shall be maintained on file by us or our Program Administrator and will be deemed attached to and incorporated into the Policy as if physically attached. PRODUCER BRANCH PREFIX POLICY NUMBER POLICY PERIOD 018098 970 HPG 0740567530 Named Insured and Address: From: 06/01/23 to 06/01/24 at 12:01 AM Standard Time Program Administered by: Audra Wallace Suite 214 - 6 2100 Palomar Airport Rd Carlsbad, CA 92011-4402 Medical Specialty: Code: Healthcare Providers Service Organization 1100 Virginia Drive, Suite 250 Fort Washington, PA 19034 1-800-982-9491 www.hpso.com Insurance Provided by: Mental Health Counselor Excludes Cosmetic Procedures 80723 American Casualty Company of Reading, Pennsylvania 151 N. Franklin Street Chicago, IL 60606 Professional Liability $ 1 000 000 each claim $ 5 000 000 aggregate Your professional liability limits shown above include the following: * Good Samaritan Liability * Malplacement Liability * Personal Injury Liability * Sexual Misconduct Included in the PL limit shown above subject to $ 25,000 aggregate sublimit Coverage Extensions License Protection $25,000 per proceeding $25,000 aggregate Defendant Expense Benefit $1,000 per day limit $25,000 aggregate Deposition Representation $10,000 per deposition $10,000 aggregate Assault $25,000 per incident $25,000 aggregate Includes Workplace Violence Counseling Medical Payments $25,000 per person $100,000 aggregate First Aid $10,000 per incident $10,000 aggregate Damage to Property of others $10,000 per incident $10,000 aggregate Information Privacy (HIPAA) Fines and Penalties $25,000 per incident $25,000 aggregate Media Expense $ 25,000 per incident $25,000 aggregate Workplace Liability Workplace Liability Included in Professional Liability Limit shown above Fire & Water Legal Liability Personal Liability Included in the PL limit shown above subject to $150,000 aggregate sublimit $1,000,000aggregate Total$ 266.00 Base Premium $266.00 Premium reflects Self Employed , Full Time Policy Forms and Endorsements (Please see attached list of policy forms and endorsements) Secretary Keep this Certificate of Insurance in a safe place. It and proof of payment are your proof of coverage. There is no coverage in force unless the premium is paid in full. To activate your coverage, please remit premium in full by the effective date of this Certificate of Insurance. Coverage Change Date: Endorsement Date: Master Policy: 188711433 CNA93692 (11-2018) © Copyright CNA All Rights Reserved. DocuSign Envelope ID: 8C3751C5-4426-464B-ACC6-6B0CFC832CCB POLICY FORMS & ENDORSEMENTS The following are the policy forms and endorsements that apply to your current professional liability policy. COMMON POLICY FORMS & ENDORSEMENTS FORM# G-121500-D (04-08) G-121503-C (07-01) G-121501-C1 (07-01) CNA96097 (06-19) CNA94164 (11-18) G-145184-A (06-03) G-147292-A (03-04) GSL 15563 (02-10) GSL 15564 (10-09) GSL 15565 (03-10) GSL17101 (02-10) GSL 13424 (05-09) CNA80051 (09-14) CNA80052 (09-14) G-123846-D04 (07-01) CNA81753 (03-15) CNA81758 (01-21) CNA82011 (04-15) CNA89027 (10-17) CNA79575 (07-14) CNA89026 (05-17) FORM NAME Common Policy Conditions Workplace Liability Form Occurrence Policy Form -California Amended Definition of Policy Period Endorsement Amendment Definition of Claim Endorsement Policyholder Notice -OFAC Compliance Notice Policyholder Notice -Silica, Mold & Asbestos Disclosure Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion Healthcare Providers Professional Liability Assault Coverage Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies Services to Animals Amended Definition of Personal Injury Endorsement Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement California Cancellation and Non-Renewal Coverage & Cap on Losses from Certified Acts Terrorism Notice -Offer of Terrorism Coverage & Disclosure of Premium Related Claims Endorsement Entity Exclusion Endorsement Exclusion of Cosmetic Procedures Media Expense Coverage PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC TO YOUR STATE AND YOUR POLICY PERIOD. For NJ residents: The PUGA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance Guaranty Association. For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement Foundation Program Fund and the Local Tax is the KY Local Government Premium Tax. As required by 806 Ky. Admin Regs. 2:100, this Notice is to advise you that a surcharge has been applied to your insurance premium and is separately itemized on the Declarations page or billing instrument attached to your policy, as required KRS. §136.392. For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge. For FL residents: The FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association -2022 Regular Assessment. Form #: CNA93692 (11-2018) Master Policy#: 188711433 Named Insured: Audra Wallace Policy#: 0740567530 © Copyright CNA All Rights Reserved. INVOICE (00124434) City of Carlsbad 1635 Faraday Avenue Carlsbad, CA 92008-7314 (442) 339-2495 business.license@carlsbadca.gov AUDRA WALLACE LPCC AUDRA WALLACE 2100 PALOMAR AIRPORT RD 214-6 CARLSBAD, CA 92011-4405 INVOICE NUMBER INVOICE DATE INVOICE DUE DATE INVOICE STATUS INVOICE DESCRIPTION UPON RECEIPT DUE BUSINESS LICENSE FEES0012443406/22/2023 REFERENCE NUMBER FEE NAME TOTAL BLNR013944-06-2023 $50.00 08.160 $4.00 SB1186 2100 PALOMAR AIRPORT RD 214-6 CARLSBAD, CA 92011-4405 $54.00 TOTAL ▌ ▌█▌█▌▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌▌ █▌▌█▌▌▌ █▌█▌▌▌▌ █▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌█▌▌▌ █▌▌█▌▌▌ █▌▌█▌█▌█▌ ▌▌▌▌▌ █▌▌█▌▌ ▌█▌█▌▌▌ ▌█▌█▌▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌▌ █▌▌█▌▌▌ █▌█▌▌▌▌ █▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌█▌▌▌ █▌▌█▌▌▌ █▌▌█▌█▌█▌ ▌▌▌▌▌ █▌▌█▌▌ ▌█▌█▌▌▌ ▌█▌█▌▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌▌ █▌▌█▌▌▌ █▌█▌▌▌▌ █▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌█▌▌▌ █▌▌█▌▌▌ █▌▌█▌█▌█▌ ▌▌▌▌▌ █▌▌█▌▌ ▌█▌█▌▌▌ ▌█▌█▌▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌▌ █▌▌█▌▌▌ █▌█▌▌▌▌ █▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌█▌▌▌ █▌▌█▌▌▌ █▌▌█▌█▌█▌ ▌▌▌▌▌ █▌▌█▌▌ ▌█▌█▌▌▌ ▌█▌█▌▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌▌ █▌▌█▌▌▌ █▌█▌▌▌▌ █▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌█▌▌▌ █▌▌█▌▌▌ █▌▌█▌█▌█▌ ▌▌▌▌▌ █▌▌█▌▌ ▌█▌█▌▌▌ ▌█▌█▌▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌▌ █▌▌█▌▌▌ █▌█▌▌▌▌ █▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌█▌▌▌ █▌▌█▌▌▌ █▌▌█▌█▌█▌ ▌▌▌▌▌ █▌▌█▌▌ ▌█▌█▌▌▌ ▌█▌█▌▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌▌ █▌▌█▌▌▌ █▌█▌▌▌▌ █▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌█▌▌▌ █▌▌█▌▌▌ █▌▌█▌█▌█▌ ▌▌▌▌▌ █▌▌█▌▌ ▌█▌█▌▌▌ ▌█▌█▌▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌▌ █▌▌█▌▌▌ █▌█▌▌▌▌ █▌█▌▌█▌▌ ▌▌█▌▌█▌ ▌▌█▌▌▌ █▌▌█▌▌▌ █▌▌█▌█▌█▌ ▌▌▌▌▌ █▌▌█▌▌ ▌█▌█▌▌ Online Account Payment PortalOnline Registration Please pay this invoice in full to ensure processing. Partial payments may result in process delays. Pay options: Online Payments Option 1 Log into your online account and open your dashboard. Open ‘My Invoices’, select fee to pay and complete payment. Not registered for online account? Register your email for portal access. Once you receive confirmation email, log in to access online licensing/permitting. Option 2 Pay as a guest by visiting the payment portal. No log-in needed for this option. Insert invoice #, select your payment option and complete payment. In-person Payments Bring this invoice and form of payment to the cashier station located at 1635 Faraday Ave, Carlsbad CA 92008. Refer to city’s website for office hours. DocuSign Envelope ID: 8C3751C5-4426-464B-ACC6-6B0CFC832CCB ('city of Carlsbad DocuSign Envelope ID: 8C3751C5-4426-464B-ACC6-6B0CFC832CCB IG Right-click or tap and hokl here to do.Ynloa-d pictures, To help protect your privacy, Outlook prevented automatic download of this picture from the internet. MyGovPay · Empowered by Tyler T,--1,.,.,.,1,.,,.:,._ Carlsbad, CA Payment Confirmation Line Items Payment Date Order Number Thursday, June 22, 2023 24372 Invoice# Item Description Quantity Unit Price Total Price 00124434 NONE Item Total Order Total I Thank you for your payment, Carlsbad, CA $54.00 $54.00 $54.00 $54.00