HomeMy WebLinkAboutCOLUCCI, DENNIS A.-2006
iNSURANCE ON ALE
,'/OPK MAY PROCEED N-2006-116
UNTIL INSURANCE EXPIRES
$-'-07
Cl.ERl(OfCOONCll CONSULT A"IT AGREEMENT
IlA1t IZ./"f-O'
0: \'8"""".\(2.')
THIS AGREEMENT, made and entered into this 10'" day of October, 2006, hy and
bct\-\'een Dennis A. Colucci (hereinafter "Collsullant"), and the City of Santa Ana. a charter citv
and municipal corporation organized and existing under the Constitution and laws of the Slate of
California (hereinafter "City"),
RECITALS
A, The City desires to retain a consultant having special skill and knowledge in the field or
audiology. to perform hearing evaluation and diagnostic testing of City employees.
R. Consultant represents that Consultant is able and willing to provide SLI(.:h services to the
City,
C. In undertaking the performance of this Agreement. Consulta11l represents that it is
knowledgeable in its lield and that any services performed by Consultant under this
Agreement \vill be pcrfonm:J in compliance \\"ith such standards as may reasonably be
expected from a professional consulling firm in tne f1cld.
NOW THEREFORE. in consideration of the mutual and respective promises, and subject to the
terms and conditions hereinafter set forth, the parties agree as follows:
1. SCOPE OF SERVICES
Consultant shall perform audiology services as set forth in Exhihit A to this Agreement
2, COMPE;'</SATION
a. City agrees to pay', and Consultant agrees to ac<.:ept as totol payment for its services,
the rates and charges identitied in Exhibit A. The total sum to be expended under this
Agreement shall not exceed $10,000.00 during the term ofthis Agreement.
h. Payment hy City shall he made within thirty (10) days following receipt of proper
invoi<.:c evidencing work pcrformed, subject to City a(.;<.:ounting procedures. Payment need not
be madt.: J()J" \vork \\.-hich t~lils to meet the standards of periurmance set forth in the Recitals
which may reasonahly be expected hy City.
3, TERM
This Agreement shall commence on the date first wrillen above and terminate on
expenditure ofallm;ated funds, unless terminated earlier in aecordam;e \vith Section 12, below.
4. INDEPENDENT CONTRACTOR
Consultant shall. during the entire term of this Agreement. be construed to be an
independent contractor and not an employee of the City. This Agreement is not intended nor
shall it be construed to create an employer-employee relationship, a joint venture relationship, or
to aHow the City to exen:isc discretion or control over the professional manner in which
Consultant performs the services which arc the subject matter of this Agreement; ho\vever, the
services to bc provided by Consultant sball be provided in a manner consistent witb all
applicable standards and regulations governing sllch services. Consultant shall pay all salaries and
wages, employer's social security taxes. unemployment insurance and similar taxes relating to
employees and shall be responsible for all applicable witbbolding taxes.
5. INSURANCE
Prior to undertaking performance of work under this Agreement. Consultant shall
maintain ano shall require its subcontractors. if any, to ohtain and maintain insuranl:e as
described below:
a. Professional liability (errors and omissions) insurance, with a comhined single limit
of not less than $1,OOO.IJIJIJ per elaim.
b. The following requirements apply to the insurance to be provided by Consultant
pursuant to this section:
(i) Consultant shall maintain all insurance reqnired above in ledl force and
effect for the entire period covered by this Agreement.
(ii) Certiticatcs of insurance shall be furnished to thc City upon execution of
this Agreement and shall be approved in lorm by the City Attorney.
(iii) Certitlcates and policies sball state that the policies shall not be canceled
or reduced in coverage or changed in any other material aspect without
thirty (30) days prior written notice to the City.
c. If Consultanl l'ails or refuses to produce or maintain the insurance required by this
section or fails or refuses to furnish the City \-vith required proof that insurance has heen procured
and is in force and paid for. the City shall have tbe rigbt, at the City's election. to forthwitb
terminate tbis Agreement. Such termination shall not effect Consultant's right to be paid for its
time and materials expended prior to notification ot" termination. Consultant waives tht: right to
rccei \it: compensation and agrees to indemnify the City tor any \vork per1~}rmcd prior to approval
of insurance by the Cily.
6. IlIIDEMlIIIFICATION
Consultant agrees to and shall indemnify and hold harmless the City, its officers, agents,
employecs, consultants. special counsel. and representatives from liability: (1) for personal
injury, damages, just compensation, restitution, judicial or equitable reliet" arising out of claims
for personal injury. including health. and claims for property damage. \vhich may arise from the
2
direct or indirect operations of the Consultant or its contractors, subcontractors. agents,
cmployees. or other persons acting on their bchalf v./hich relates to the services described in
section 1 of this Agreement; and (2) from any elaim that personal injury, damages, just
compensation, restitution, judicial or equitahle relief is due hy reason of the terms or or eflects
arising from this Agreement. This indemnity and hold harmless agreement applies to all claims
for damages, just compensation, restitution. judicial or equitable relief suffered, or alleged to
have been suffered, by reason of the events referred to in this Section or by reason of the terms
of, or efleets, arising !i'om this Agreement. The Consultant further agrees to indemnify, hold
harmless, and pay all costs for thc defense of the City, including fees and costs for special
counsel to he selected hy the City, regarding any action by a third party challenging the validity
of this Agreement, or asserting that pl:rsonal injury, uamages,jusl compensation, restitution.
judicial or equitable relief due to personal or property rights arises by reason of the terms ot~ or
effects arising from this Agreement. City may make all reasonable decisions \vith respect to its
representation in any legal proceeding.
7. CONFIDENTIALITY
If Consultant receives from the City information \vhich due to the nature of such
information is reasonably understood to be confidential and/or proprietary, Consultant agrees
that it shall not use or disclose such information except in the performance of this Agreement,
and further agrees to exercise the same degree or care it uses to proted its O\\'n information of
likl,; importance, but in no event less than reasonable care. "Confidential Information" shall
include all nonpublie informatiou, Conlidential information includes not only wrilten
infiJrmation, but also information transferred orally, visually, electronically, or by other means.
Confidential information disclosed to either party by any subsidiary and/or agent of the other
pany is covered hy this Agreement. The foregoing obligations of nOll-use anLl nondisclosure
shall not apply to aoy ioformation that (a) has been disclosed in publicly available sources; (b) is,
through no t~,ull of the Consultant disclosed in a publicly available source; (c) is in rightful
possession orthe Consultant without an obligation of confidentiality; (d) is required to be
disclosed by operation of law; or (e) is independently developed by the Consulllmt withom
reference to information disclosed by the City.
S. CONFLICT OF INTEREST CLAUSE
Consultant covenants that it presently has no interests and shall not have interests, direct
or indirect, \:vhich would conflict in any manner \\-'ith performance of services specified under
this Agreement.
9. NOTICE
Any notice, tender, demand, delivery, or other communication pursuant to this
Agreement shall he in writing and shall be deemed to be properly given if delivered in person or
mailed by lirst class or certilled mail, postage prepaid, or sent by telefacsimile or otber
telt:graphic communication in the manner provided in this Section, to the following persons:
To City:
Clerk of the Citv Council
City! of Santa Ana
20 Civic Center Pln,n (M-30)
P.O. Box 1988
Snntn Ann. CA 92702-1988
te1efacsimile (714) 647-6956
\\lith courtesy copies to:
Risk Manager
City or Santa Ana
20 Civic Center Plaza (M-28)
P.O. Box 1988
Santa Ana, California 92701
telefnesimilc (714) 647-5317
and
City Attorney
City of Santa Ana
20 Civic Center Plnza (M-29)
P.O. Box 1988
Santa Ana, California 92702
telelaesimile (714) 647-6515
To Consultant:
Dennis A. Colucci, M.A." r AAA
24902 Moulton Parkway
Laguna Woods, Californin 92653
A party. may change its address by giving notice in writing to the other party. Thereafter,
any communication shall be addressed and transmitted to the new address. If sent by maiL
communication shall be effective or deemed to have been given three (3) days after it has been
deposited in the United States mail, duly registered or certified, with postage prepnid, and
aJun:ssl'U as st:t furth above. If sent by telefacsirnile, communication shall be e1Tet:1ive or
deemed 10 have been given twenty-four (24) hours after the time set forth on the transmission
report issued by the transmitting facsimile machine, addressed as set forth above. For purposes
of calculating these time rrames, weekends, federal, state, County or Cit), holidays shall be
excluded.
10. EXCLlJSIVlTY AND AMICNDMENT
This Agreement represents the complete and exclusive statement bet\veen the City and
Consultant, and supersedes any and all other agreements, oral or written, between the parties. Tn
the event of a conflict hetween the terms of this Agreement and any attachments hereto, the
terms of this Agr~~m~nl shall prevail. This Agreement may nut be modifieu CXL:Cpt by written
instrument signed by the City and by an authorized representative of Consultant. The parties
agree that any terms or conditions of any purchase order or other instrument that are inconsistent
\vith, or in addition to, the terms and conditions hereof. shall not bind or obligate Consultant nor
the City. I'acn party to this Agreement acknowledges that no representations, inducements,
4
promises or agreements, orally' or othenvisc, have been made by any' party, or anyone acting on
behalf of any parly. which arc not embodied herein.
11. ASSIGNMENT
Inasmuch as this Agreement is intended to secure the specialized services of Consultant,
Consultant may not assign, transfer, delegate, or subcontract any interest herein without the prior
written consent or the City and any such assignment. transfer, delegation or suhcontract without
the City's prior written cunsent shall be considered null and void. Nothing in this Agreement
shall be construed to limit the City's ability to have any of the services which are the subject to
this Agreement performed by City personnel or by uther consultants retained by City.
12. TERMINATION
This Agreemeut may be terminated by the City upon thirty (30) days written nutiee of
termination. In such event, Consultant shall be entitled to receive and the City shall pay Consultant
compensation fiJr all services performed by Consultant prior to receipt of slIch notice of termination,
subject to the following conditions:
a. As a condition of such payment, the Executive Director may require Consultant to deliver
to the City a1l work product completed as o['such date, and in s\leh case such work product shall be
the property of the City unless prohibited by law, ruld CU\lsultant consents to the City's use thereof
Itlf sllch purposes as the City deems appropriate.
b. Payment need not be made for work which fails to meet the standard of perforrnam.:e
spccified in the Recitals of this Agreement.
13. DISCRIMINA T10N
Consultant shall not discriminale because of race, color, creed, religion. sex, marital
status, sexual orientation, age, national origin, ancestry, or disahility, as defined and prohibited
hy applicable law, in the recruitment, selection. training, utilization, promotion, termination or
other employment related activities. Consultant affirms that it is an equal opportunity employer
and shall comply with all applicahle federaL state and local laws and regulations.
14. JURISDICTION - VENUfo:
This Agreement and all questions relating to its validity, interpretation, performance, and
enlorcement shall be governed and construed in accordance with the laws ofthe State uf
Calilornia. This Agrcement has been executed and delivered in the Stale of California and the
validity, interpretation, performance, and enforcement of any of the clauses of this Agreement
shall be determined and governed by the laws orthe State of California. Both parties further
agree that Orange County, California, shall be the venue for any action or proceeding that ma.y
be brought or arise out of, in connection with or by reason of this i\greemt:nt.
,
15. PROFESSIONAL LICENSES
Consultant shall. throughout the term of this Agreement, maintain all necessary licenses.
permits, approvals, waivers, and exemptions necessary forrhc provision of the services
hereunder and required by the laws and regulalions ofthe United States, the State of California.
the City of Santa Ana and all other governmental agencies. Consultant shall notify the City
immediately and in writing of her inability to obtain or maintain such permits, licenses,
approvals, \\/aivers, and exemptions. Said inability shall be canse for termination of this
Agreement.
16. MISCELLANEOUS PROVISIONS
a. Each undersigned represents and warrants that its signature hereinbelow has the power,
aUlhority and right to bind their respective parties to each ofthc terms of this Agreement, and shall
indenmify City fully, induding reasonable costs and attorney's fees, for any injuries or damages to
City in the event that such authority or power is not. in hlct, held by the signatory or is withdrmvn.
h. All Exhibits referenced herein and anached hereto shall be incorporated as iffltlly set
I(lfth in the body of this Agreement.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year
first above \vritten.
/
,
_~:l~T;:~;~_( C C~: ~/ / -e;
PATRICIA I: HE-A"~ U
Clerk of the Council
mYO'I1~
U~ 'f/; {2~~
DA VlD N. REAM
City Manager
APPROVED AS TO FORM:
. . JO~'E~ll'\V(FiEfdHER
City Attorney
RECOMMENDED FOR APPROVAL:
CONSULTANT
,-
,.b-
'C/},..,;
Enriyue Al a. /
Executive lrectltr..p;' the
Personnel Agency
Tax lD#
6
EXHIBIT A
SCOPE OF SERVICES
Consultant shall perform audiological services as requested by Risk Management to evaluate
\\:'orkers Compensation claims. Said services shall be performed at the rates set forth in
Attachment 1. hereto.
The audiological reporls and a copy oCthe exam results shall be sent to:
Risk Manager
20 Civic Center Plaza. M-28
Santa Ana, California 92701
Alln: Loss Control Analyst
7
Dennis A. Colucci, Au.D., M.A. FAAA
Auditory Disorders and Balance Labo11Jtory
Board Cerlif1ed In Audiology
Patient:
Date:
23961 Calle De La Magdalena, Suite 355
Laguna Hills, Ca 92653
949 830.5770 949 830.2324 FAX
l.icenses AU 348 I HA 1026
SSN:
Physician
DaB:
M.D. UPIN:
Lie.
0 314,Q AD!) - AUe:ntion Deficit Uisorder
0 314.01 ADHD. AI1e-otion Deficit Hyperactivity Disorder
0 7&4.3 Aphasia
0 299,0 Autism
0 389.14 Central Hearing l,Oss
0 315.39 Delayed Speech Development
0 38Q.4\ Ear wax
0 382.9 OtitisM:dia
CHARGES
0 JR9.12 Sensorineural Hearing loss! Neural
0 AMOUNT PAID
389.tl Sensorinerual Hearing Loss! Sensory
0 Other RALANCE DUE
CPT Code Description No Fee
Pediatric Testing
0 92582 Pediatric Evaluation 80.00
0 925R3 Picture Selection Test 58.00
0 92506 Auditory Perception Evuhmtion 110.00
0 92507 Auditory Therapy Number of Units - --
0 92579 Visual RcinforccJIlt"nt Audiometry 125,00
0 92557 Comprehenslve Hearing Evaluation 17500
0 92552 Air Conduction Test 29.00
0 9255J Air and Bone Conductiol.t Te:;ts 58,00
0 92562 ABLB 27.00
0 92563 Tone Decay Tests 25,00
0 92565 Strnger, Pure Tone 26.00
0 92571 Speecn Stenger 47.00
0 92567 Tympanometry 45.00
U 91568 Acoustic Reflexes 35.00
0 92569 Acoustic Reflex Decay 35.00
0 92584 Ekcuocochleograplly 200.00
0 92586 Al.ldilory Brailt.'ltcm Evoked Potentials (Limited) 250.00
0 91585 Al.ldilory Brainstem f:vGk~d Potentials tComplex) 300.00
0
DiagnosIs Code Descnptlon
CPT Code Description No Fee
Central Auditory Procl!ssing Te.<ih
0 92700 Childrens's Auditory Perfonnancc Scale 45,()()
0 92700 Pcdiatric Development Scalc 45.00
0 99243 COll~\.Iltil.li\ll1, Hx, Exam, Decision, Calculations
0 92572 Staggered Spondaic Wurd Test (SSW) 75.00
0 9257(; Synthetic Sentence Identificatiol\ Test (SSI)
0 92511 PiheJcu Word Test 45.00
0 92700 Competing Word Test 45.00
[J 92700 Competing Sentence Test 45.00
0 92700 Auditory rigure Ground 45.00
0 92700 Pitch Pattcrn Perceplion Test 45,UU
0 92700 Timc Compressed Speech 55.00
0 92700 HINT Quiet 45,00
0 92700 HiNT Noise Front 45.00
0 92700 HINT Noise Right 45,00
0 92700 HINT Noise Left 45.00
0 92700 Dichotic Digit~ Single Pair~ 45.00
0 92700 Dichotic Digits Doubk Pairs 50.00
0 92700 Random Gap Detection 50.00
0 92700 Masking Levcl DiflCrence 45.00
0 92700 WIP[ Word ldentiflCation (Noise) 65.00
0
NOTES
Dennis A. Colucci, Au.D., M.A., FAAA
Audllory Disorders .rld Balance LaboJlltory
Board Certified In Audiology
Patient:
Date:
23961 Calle De La Magdalena, Suite 355
Laguna Hills, Ca 92653
949 830-5770 949830-2324 FAX
Licenses Au 3481 HA 1026
SSN:
DOB:
Physician
M.D. UPIN:
Lie.
0 92557 Comprehensive Hearing Evaluation 175,00 0 92582 Pediatric Evaluation 80,00
0 92552 Air Conduction Test 29,00 0 9251U Picture Selection Test 58,00
0 92553 Air and Rone Conduction Tests 58.00 0 92620 Central Auditory Processing Evaluation 150.00
0 92562 ABLB 27.00 0 92621 Central Auditory Processing Eva!. Number of Units
- -
0 92563 Tone Decay Tests 25.00 0 92579 Visual Reinforcement Audiometry 125.00
0 92565 Stenger, Pure Tone 26.00 0 92596 Far Protection Attenuator Measures 39.00
0 92517 Speech Stenger 47.00 0 92625 k>sessment of Tinnitus 45.00
[J 92567 Tympanomctry 45.00 [] 92700 Hearing in Noise Test (HINT) 4 180.00
0 92568 ^coustic Reflexes 35.00 0 6921(l Cerumen Management procedure $45 I $55
0 92569 Acoustic Reflex Decay 35.00 0 99243 Consultation, Hx, Exam, Decision, Calculations
0 92584 F.1ectrocochleography 250.00 0 92590 Hearing Aid Evaluation, Monaural 75.00
0 92586 Auditory Drainstem Evoked Potentials (Limited) 250.00 0 92591 Ht:aring Aid Evaluation, Bimtural 150.00
[J 92585 Auditory Rrainslcm Evoked Pott:ntials (Complex) 350.00 0 92592 Hearing Aid Confonnity Evaluation, Monaural 75_00
0 92531 Recorded Fistula Test 90.00 0 92593 Hearing Aid Conionnity Evaluation. Binaural 150.00
0 92541 Sponlaneous Nystagmus Tests 91.00 0 92594 Electro-Acullstic or Probe Mic. Testing, Monaural 50.00
0 92542 Positional Nystagmus Tests 92.00 0 92595 Electro-Acoustic or Probe Mic. Testing, Billaural 100.00
0 92543 Bithennal Calories 4 180.00 0 V5011 1 learing Aid Cleaning Monaural 45.00
0 92S44 OplokineticTcsts 15.00 0 VSOII Hearing Aid Cleaning Binaural 90.00
[] 9254S oscillating Tracking Tests 69.00 0 VS264 Eannold Monaurnl or Binaural $ISU/$300
0 92546 Sinusoidal Vt:rtical/Tlorirontal Axis Rorntioll Tests 6 330.00 U V5110 Dispt:ming Fee 200 / 3001 4001 5001 600
0 92547 0 99202 New patknt Office Visit 70.00
0 99212 Kepeat Office Visit 40.00
0 V50t4 In-I louse Repair $25 I $351 $45 I $SS I $100
0 225.1 Acoustic Neuroma 0 V5014 Factory Repair $200 I $250 I $30U ! $350
0 386.02 Active Menierc'sDisease 0
VS266 Balterie& 10 312 13 615 x
0 388.43 Auditory Discrimnation Defel:il
0 99002 Product Dispensing ~
0 389.14 Central Dt:afiless
0 389.0 Conductive Hearing Loss 0 V509<l Dispensing
0 812.8 Ear Trauma 0 92588 Otoacoustic Emissiuns 150.00
0 381.81 Eu&tachian Tuhe Dysfunction 0 92100
0 388.41 Hyperacusis 0
92700
U 38004 Impacted Cerumen
0 389.2 Mixed Hearing Loss 0 92700
0 389.12 Neural Hearing Loss NOTES
0 380.1 Otitis Externa
U 382.9 OtilisMedia
0 387.2 Otosclerosis
0 384.2 Perforalt:d Tympanic Membrane
0 389.11 Sensory Hearing Loss C1IARGES
U 389.10 Sensory Hearing Loss _Unspcciticd
0 388.31 Subjective Tinnitus AMOUNT PAID - -
0 388.2 Sudden Sensorineural Hearing Loss BALANCE DUE
0 7S004 Verti oIDise uilibrium
:0!03/20~b 1&:51
'34'::1 830232..
DENNIS COLUCCI MA
PAGl J3
Prlnl Dot.. 10/03/06
C'NA
HEALTHCAI{E PROVIDI;R8
8EI{VICE OI{GANIZAnON
PU~CHA8ING OROUP
CEII11FICII n, Of INSUItANCE
OCCUIlIlENCE POLICY FOIlM
Denni. A COl"cci
23961 Calle de la
J. 355
aguna !fill 9 . CA
, OOleal SpeC/oily:
I AudtoIOglst
Magdalena
92653
Code. 80714
Amorieon Casuolly Ce. of Rea<llng, PA
CNA Plaza 28$ Chicavo, IL 60685
A. PROFE:S8IONAL I.JJ\IlILfTY
l-~~ - - -~- ~::~r
$-'0;000 -. ... . 0011- -ole-
'-'-:M/j-----"-- -~-.-
. iin-- _.__._."l!Grego~_
.-- _J~__ _ __..__~ggr~!.....
. _2,500 . .agg~at~_
S 10,000
C, WOl{l<PlI\CE UABllITY
- 'J\fonipi8caL.:i8iiIIi~:-
F"... & Water L~.lliaDlI
-JIOr.on-ill'obilrty -
. '-
eo.....,. PI" c. Worllplaoe LiNlI....dooI noIIlWtvIl'COww.,. j:llu1C. ee.,.rw .....11""',. "".~otuW.poIlcy
0, OENEAAL lIA.BIUTV
included in A. Pllimn3hO;n -8OOV8-'--- -----_ n._._,._._ _ __'_ __.
1nc:I.if8ci in A.Pllmit .hoWnob""G sub ed to $150,000 s.I>-Jjm~
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eo......" D. Geo'lll'lll UllbMr lID-. ~0II1flP" I ClJI'_"" PwI C w~ LillI.IV" h'lad. ~ Of',,", 1IOI1ew.
-Ge;';;:Q,-ua~ity (Gl)'-----' -- ---"""iKU.--e ----- - ------ '__
Rima AUlo"l"Non Ov<<ied AuW . _-.~. ~-~-~fuf___,_. __._
.-. i~Tre_&!Nater leQiILlabmiy~- none
_..~e~~l!?!~blliiy ~_~--=
none
- _._,_..~ - - ..--... - - -,,- -,- "-
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G-121503-C G-121501-C1 G-145184
G 144872-A G'12]846-004
· 124,00 PREMIUM fO.OO CIGA SURCHARGE
Ms5ter Polic.y *188111433 J
K-.rpIhlllClOOutl'l-nlIn a:..r.p'Iee. ll""pn'JOl'OI""",".r&~OfI'tlUrIM~OOlI~
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COverage C~.noe Dille:
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Endomment Change Oats;
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~4~-~jI1LjL4
DENNIS COLUCCI MA
PAGE 04
"
"
~NA
HEAL THCARE PROVIDERS
SERVICE ORGANIZATION
PURCHASING GROUP
CERTIFICATE OF INSURANCE
OCCURRENCE POLICY FORM
Print Dale: 05/16/08
IV, D2()Ob- // b
Dennis A Colucci
23961 Calle De La
Laguna HillS, CA
Medical SpeCialty:
AudiologIst
Magdalena St
92653-3679
Code: 80716
A. PROFESSIONAL LIABILITY
"
..__._--_._-_..._.._._...._._--~.. --_._--~----
profeSSio. nal Liability (PL) '.. $ 1,000,000 each claim
'-GOod Samaritan UiillilffY--"- ..-..-- includ-ed 'a60Ve-~--'
persorialTnjiiry-[lability ..-- ------includedabove-.
rJlaIpllieememIlaOlilty-------. --Included above'::
-----...._~_.__.,"___ ~___......____.._,i...._
$"s,oOO,OOO -"aggre!gate-"
B. COVERAGE EXTENSIONS:
license Protection
Defendant ExpenseBenefit
DeP~~uon ~epresent!l.!~o.!'''::._ .
Assault
- MedTCarr>a~m~.lI.ts-:...__..:__......_
First Aid ...___ .
.._ Da~a~_~~.!"~oper:t.Y. of O~~':"~.._.___.____.__.____.._. pe~~cict:,!lt
"'25':000 --aiig regate ..
10,000 aggregate
5,000 aggregete
-25;OOO----.~......ii{lgregate -.
100 000 .._:.~:=:__aggi-'eQal~:::::
2 500 ._.___.1!gg[~.t.e..__
_~9flOO _____._~ggregat~_
C. WORKPLACE LIABILITY
Coverage part C, WOfkpt;;.Oe: L.IQblllt)' ~ not IilIpp~ if C~e part D. Genel'8111ablllty la made part of tills policy.
~ WorkPlaceuabiiiti.--..~_."-.=... included in},. F:q~ shoWn above "-. .. .=--===.:::-.::::::
._ Fire ..!..vv~!g,~egaT[la6!1!!>'...._ included in A. PC"[lmit shown abOVE! sub'ect t~J150,000..~ub-1iffi'1l ____._
_..!"ers~na, ~~aDilitr.... _. ",1,000,000 . . aggregate
D. GENERAL UABILITY
Covereg9 part D. General Liability does not~ly If CoY$rage part C. Workpiece Usblllty IE!; made pan cf thIs policy.
o;;.-.r"."",,(.c;--~.~
Hired Aufii'&l\J'Oriowneo Aulo---:=:-: ......I:l~~ ======_ ~
J:~~~!~~~~==~=_ . none ~~..-===.==:======~~~=::.:
I Total Premium: $
G-121500-C G-121503-C G-121501-C1 G~145184-A
G-147292-A G-144872-A G-123846-D04
" ,~ ~}d
~~
,"
Master Policy # 188711433
1("1' this document In <".l $af'E1 place. It and proof-of paymenl a~ evider'lce of your Insurance coverage.
~./B::;- rl-( ~r~JIv ~
G.141241-A (07/2001)
Coverage Change Date:
Endorsement Change Date:
08/18/2008
949-8302324
10:34
Det1l1is A. Colucci, Au.D., MA., FAAA
AudltOty Di$Dtders lIl1C' BafClnce J,..abaratory
Soard C.rtJfted In AudiolOgy
23981 Calle De La Magdalena, Suite 355
Laguna Hills, Ca 92853
949 830-5710 949 830-2324 FAX
Licenses Au 348 { HA 1028
PAGE
03
DENNIS COLUCCI MA
Patient:
Date:
21~.OO
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30"00
l:;O:m
20S.~1l
'24(l.~C1
;240,00
150.00
120,00
11-0,00
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160.00
90.00
25('1,00
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336.01
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3$9,14
3&';1,0
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3$5."4
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:180.1
38:2.9
387.2
3084.2
319.11
~IW.16
3$9.1~
389.1B
389.10
3M1.31
J88.n
:I.BB.l
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386.2
\172:.19
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AC1in M~iere'$ Di~9$t!
Auditory DiW'im:lzticlIl O...fel;it. lmo&irnd Di~trimin:stiGI1
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StnP>rlrlneurel HiM.-::nl! LOOI~ Combined. Bi]c~ellll
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Tiflnltui,SubJrilC'li~
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Physician
M.D. UPIN:
Lie.
0 n~,7 Comprelll,"~iv" f'll'llri"1l. e:valu~lQf)
0 nS52 AlrC()l'od...<<>(tnT~
0 onm A.irlndBolll!Car.du-.tionTIl!lU
" 92361 ABLB, L.ouc!!\m' JhIMl;~
" 9'25~~ TIlIlt Oll;l:~~ ,~;
" 92555 SlO1l\Btf,P\lI'll'f'O".e.
" 512H7 Speeah$l~
D 92561 "TymplUlOlnctl')' S9ClI SJ:25
0 92S68- Acou~i,,'R(lre:'<<ls
0 92569 Ac.oU:5tI"P.o~01tD~"
0 92584 E]ClCtr\XOc;~IOO8t'.P")'
C 92583- OlA!l1Q~ll" OI~()I'li~ PrQd. Otocmustic; E.miS5ions
0 51;l5!:l AB2P rComp:ex) s:J50/~SSO
" 92,.., 'I'irtulaTaji
" 92:141 SPOmMCoQIl; Ny;tllBr.v..t~ 1'1!:$l.s
" 92~ Positil:llll! Nyl'tISJ'!Il1~Te;:,(6xS40.00}
" "'" Bithermd CIIQri~ (4x $60.00)
:J "'" (~WftII:l"Odoric.s(2lc:~go,OO)
D .',., Op1<)ldn~lc'r~3(4K)O,M)
" 92545 05cilll.ting Tl'WOking T~SI~
" ,.",. Sim~idal V~rtiCll!llioti7,(lnlal Allie 1t.o!Mio", Ttets
" 'jI2S47 SUppI4l1'1.eI\IQIEftClrl:l(lt1'<<l(Vel1~X'$40,C:o)
D 92700 A~ndinli-~d;ll!! OQpe....a1u.tinn
q 92:700 PC$UIl:?lllfonr.'EVIIlllf..lion
4~.OO
r;J 92582
C ns~3
90.00
C 92(i2O
C 92al
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45,00
4500
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o 9~@;i
o 92627
o 92519
j5.oo
CJ 92~'16
(J 92625
3~.QO
o 92100
o ml0
o 9l}443
P 91700
o 92700
o 92590
o oml
o 91$92
o 9m3
o 92594
o n59S
::J V501!
:;I VSOII
o Y5:yj4
C<l~Play A'Jdiom~
30,00
:p1Cl,l,II'l:Sel~ionTM1
80.00
Cent1'ftl A.uditl:lry'P~ins e.valuatim. Fn'~ Hwr
HO.OO
Ctmral Aw:llull'Y l'r~ing 'EVil!. Num::'M" of Uniu
F.vA1UIltiOll of Auditory Roh$b,!i~tJo)n SUU'J!. rim l40ur
)51;\.00
E~h.:.a(lQn of A.udilory Reh&bililltiQn StlUe9, NUtl'Iber (lf1Jn,ll$
YiMIl ~$Inf(lr~tnl AudiC)tllctry
IH.on
Ear PTot.c~liOIl Attt'll'lulll('ll' MU~Ll(rea
90.00
Aneume:rrl ofTjnrtit~~
1;2~.OO
RurilllJ in NoiH Teat (HTNT)
(:IT\Jfllen Man.;semllnt JITo.;:edul'll s~s I $55
225.00
c.:mNhl~i()n, !b:, aum, Dl!:tli~o", CaJ.ctJllIlioM
FO~$iC~ytJuat!Q"I)IU1JlIPOrt
D1lpo,itiOC!(lr'Cour1Apl.learenee
Hearing Aid ~]n;tion Ewlllar:iOl:\, MOlliural
\75.00
HwI~ Aid selection eyalulclon. alr1m....1
350.00
allllnns Aid Confi:mnity EVllh:.WQn. MDllBUI'!II
4COOO
Htulna:AidCoDfur/YtltyBVQIuatIOll,13I(tII,L.'l.1
gCiOOu
E1k1ro-Al:lOLl.G1ie or Prob(! Mle. TCSlin$. M():r$llral
~Q,OO
EIO!Ctro.AooLl..'Itic orPn:Jbe Mil:. TMting, Sinlural
180,00
HflnIl8,1l.ltlC1Q.1111lgMOIlI1,lrtl
$4"!$~~I$6~!S7:'
HClnllg Aid ClRni,,!! Bin=l
S90Ii;10/S130/SI50
EllfITIold MofltlJral or e.h\9:Uft\!
SI:;!S IS2~O
o V$:IO Di!;p~ingF~ ~OI:l{)C1/4COIS[}CI~OO
:J 9m2 Li:nitedOffi.:.cVisil
75.00
o 9~13 Limited Pol[ow..UpOreceViail
"'~.co
o VW104 In.l-lOO4,,,,~lt $2Sf $3SI $4$f SS~ilS1OO
D V50]4 Fatmn'Rlllpllir 52001 $250' S300 1S3~OI400
o V5266 Batlerie~ lC 3t2 13 (,75
D 9900:2 PrMIJe1. OilPt.nstll~
o VS090 Oi;peruing
D YS257 HMtil'llj: Aid Ate=lary
C V,5275 Impre:l$iQ~ Mq"l/.Ul"llllBln~\lrftl $'00/$:<00
D
D 92700
CHARGES
AMOUNT PAlO
BALANCE DUE