HomeMy WebLinkAboutCOUNSELING TEAM INTERNATIONAL, THE - 2014INSURANc;I ON ME
WORK MAY PROCEED
UNTIL INSURANCE EXPIRES 3(_
wn
GtERK O� GOUNGft.
DATE: 1-2-- t D —1
CONSI41LTANT AGREEMENT
A-2014-235
THIS AGREEMENT, made and entered into this 7th day of October, 2014 by and
between The Counseling Team International, (hereinafter "Consultant"), and the City of Santa
Ana, a charter city and municipal corporation organized and existing under the Constitution and
laws of the State of California (hereinafter "City").
RECITALS
A. The City desires to retain a consultant having special skill and knowledge in the field of
providing psychological evaluations.
I3, Consultant represents that Consultant is able and willing to provide such services to the
City.
C. In undertaking the performance of this Agreement, Consultant represents that it is
knowledgeable in its field and that any services performed by Consultant under this
Agreement will be performed in compliance with such standards as may reasonably be
expected from a professional consulting firm in the field.
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 those psychological evaluation services as set forth in Exhibit A
to this Agreement including pre-employment screening.
2. COMPENSATION
a. City agrees to pay, and Consultant agrees to accept as total payment for its services, the
rates and charges identified in Exhibit A. The total sum to be expended under this
Agreement shall not exceed $65,000.00 during the term of this Agreement.
b. Payment by City shall be made within thirty (30) days following receipt of proper
invoice evidencing work performed, subject to City accounting procedures. Payment
need not be made for work which fails to meet the standards of performance set forth in
the Recitals which may reasonably be expected by City.
3. TERM
This Agreement shall commence on the date first written above and terminate on September
30, 2017, unless terminated earlier in accordance with 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 allow the City to exercise discretion or control over the professional
marmer in which Consultant performs the services which are the subject matter of this
Agreement; however, the services to be provided by Consultant shall be provided in a
manner consistent with all applicable standards and regulations governing such 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
withholding taxes.
5. INSURANCE
Prior to undertaking performance of work under this Agreement, Consultant shall
maintain and shall require its subcontractors, if any, to obtain and maintain insurance as
described below:
a. Based on the nature of services provided commercial general liability insurance is not
required.
b. Worker's Compensation Insurance. In accordance with the provisions of Section 3300
of the Labor Code, Consultant, if Consultant has any employees, is required to be insured
against liability for worker's compensation or to undertake self-insurance. Prior to
commencing the performance of the work under this Agreement, Consultant agrees to
obtain and maintain any employer's liability insurance with limits not less than
$1,000,000 per accident.
c. Professional liability (errors and omissions) insurance, with a combined single limit of
not less than $1,000,000 per claim.
d. The following requirements apply to the insurance to be provided by Consultant
pursuant to this section:
(i) Consultant shall maintain all insurance required above in full force and
effect for the entire period covered by this Agreement.
(ii) Certificates of insurance shall be furnished to the City upon execution of
this Agreement and shall be approved in form by the City Attorney.
(iii) Certificates and policies shall 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.
e. If Consultant fails or refuses to produce or maintain the insurance required by this
section or fails or refuses to furnish the City with required proof that insurance has been
procured and is in force and paid for, the City shall have the right, at the City's election,
to forthwith terminate this Agreement. Such termination shall not affect Consultant's
right to be paid for its time and materials expended prior to notification of termination.
Consultant waives the right to receive compensation and agrees to indemnify the City for
any work performed prior to approval of insurance by the City.
6. INDEMNIFICATION
Consultant agrees to and shall indemnify and hold hannless the City, its officers, agents,
employees, consultants, special counsel, and representatives from liability for personal
injury, damages, just compensation, restitution, judicial or equitable relief arising out of
claims for personal injury, including health, and claims for property damage, which may
arise from the direct or indirect operations of the Consultant or its contractors,
subcontractors, agents, employees, or other persons acting on their behalf which relates to
the services described in section I of 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 effects, arising from this Agreement.
7. CONFIDENTIALITY
If Consultant receives from the City information which 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 of care it uses to protect its
own information of like importance, but in no event less than reasonable care.
"Confidential Information" shall include all nonpublic information. Confidential
information includes not only written information, 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 party is covered by this Agreement.
The foregoing obligations of non-use and nondisclosure shall not apply to any
information that (a) has been disclosed in publicly available sources; (b) is, through no
fault of the Consultant disclosed in a publicly available source; (c) is in rightful
possession of the Consultant without an obligation of confidentiality; (d) is required to be
disclosed by operation of law; or (e) is independently developed by the Consultant
without reference to information disclosed by the City. Consultant agrees to comply with
all applicable laws regarding the confidentiality of medical and psychological records
including but not limited to HIPPA.
8. CONFLICT OF INTEREST CLAUSE
Consultant covenants that it presently has no interests and shall not have interests, direct
or indirect, which would conflict in any manner with performance of services specified
under this Agreement.
9. NOTICE
Any notice, tender, demand, delivery, or other communication pursuant to this
Agreement shall be in writing and shall be deemed to be properly given if delivered in
person or mailed by first class or certified mail, postage prepaid, or sent by facsimile or
other telegraphic communication in the manner provided in this Section, to the
following persons:
To City: Clerk of the City Council
City of Santa Ana
20 Civic Center Plaza (M-30)
P.O. Box 1988
Santa Ana, CA 92702-1988
Facsimile (714) 647-6956
With courtesy copies to:
and
City of Santa Ana Police Department
Attention: Chief of Police
60 Civic Center Plaza (M-97)
P.O. Box 1981
Santa Ana, California 92702
Facsimile (714) 245-8090
City Attorney
City of Santa Ana
20 Civic Center Plaza (M-29)
P.O. Box 1988
Santa Ana, California 92702
Facsimile (714) 647-6515
To Consultant: Nancy K. Bohn Incorporated dba The Counseling Team International
1881 Business Center Drive, Suite I 1
San Bernardino, CA 92408
Facsimile (909) 384-0734
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
prepaid, and addressed as set forth above. If sent by facsimile, communication shall be
effective or deemed to 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 frames, weekends, federal, state,
County or City holidays shall be excluded.
10. EXCLUSIVITY AND AMENDMENT
This Agreement represents the complete and exclusive statement between the City and
Consultant, and supersedes any and all other agreements, oral or written, between the
parties. In the event of a conflict between the terms of this Agreement and any
attachments hereto, the terms of this Agreement shall prevail. This Agreement may not
be modified except 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 with, or in addition to, the terms
and conditions hereof, shall not bind or obligate Consultant nor the City. Each party to
this Agreement acknowledges that no representations, inducements, promises or
agreements, orally or otherwise, have been made by any party, or anyone acting on behalf
of any party, which is 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 of the City and any such assignment, transfer, delegation or
subcontract without the City's prior written consent 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 other
consultants retained by City.
12. TERMINATION
This Agreement may be terminated by the City with thirty (30) days written notice to
consultant. The City will pay all reasonable services incurred pursuant to the Agreement
up to the date of termination.
13. DISCRIMINATION
Consultant shall not discriminate because of race, color, creed, religion, sex, marital
status, sexual orientation, age, national origin, ancestry, or disability, as defined and
prohibited by 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 applicable federal, state and
local laws and regulations.
14. JURISDICTION - VENUE
This Agreement and all questions relating to its validity, interpretation, performance, and
enforcement shall be governed and construed in accordance with the laws of the State of
California. This Agreement has been executed and delivered in the State 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 of the State of California.
Both parties further agree that Orange County, California, shall be the venue for any
action or proceeding that may be brought or arise out of, in connection with or by reason
of this Agreement.
15. PROFESSIONAL LICENSES
Consultant shall, throughout the tern of this Agreement, maintain all necessary licenses,
permits, approvals, waivers, continuing education, and exemptions necessary for the
provision of the services hereunder and required by the laws and regulations of the
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, waivers, and exemptions. Said
inability shall be cause for termination of this Agreement.
16. MISCELLANEOUS PROVISIONS
a. Each undersigned represents and warrants that its signature hereinbelow has the power,
authority and right to bind their respective parties to each of the terms of this Agreement,
and shall indemnify City fully, including reasonable costs and attorney's fees, for any
injuries or damages to City in the event that such authority or power is not, in fact, held by
the signatory or is withdrawn.
b. All Exhibits referenced herein and attached hereto shall be incorporated as if fully set
forth in the body of this Agreement.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year
first above written.
ATTEST:
a f-�DpV
MARIA D. HUIZAR
Clerk of the Council
CITY OF SANTA ANA
DAVI CAVAZOS
City Manager
APPROVED AS TO FORM:
SONIA R. CARVALHO
City Attorney
s{; h
$y i.GvLUtG''y A. �t �3✓Vl.t
Laura Rossini
Senior Assistant City Attorney
RECOMMENDED FOR APPROVAL:
CARLOSROJAS
Chief of Police
CONSULTANT
EXHIBIT A
SCOPE OF SERVICES
Complete Pre-employment Psychological Evaluation
Consultant agrees to perform a complete pre-employment psychological evaluation for City's
Police Department applicants. Said psychological evaluation shall comply with the California
Peace Officer's Standards and Training (P.O.S.T.) Psychological Screening Manual, as well as
any additional psychological suitability criteria specified by City's Police Department and agreed
to by Consultant.
a. For the purpose of this Agreement, a complete pre-employment psychological evaluation
includes, but is not limited to a clinical interview, administration of necessary tests,
scoring of tests and preparing verbal and written recommendations for employment.
b. Consultant agrees to provide City's Police Department with verbal recommendation of
the candidate's psychological suitability for the classification of Police Officer as well as
other classifications within the Police Department within two (2) working days of said
candidate's clinical interview.
c. Consultant agrees to provide City's Police Department with a written report of the
candidate's psychological suitability for the classification of Police Officer as well as
other classifications within the Police Department within five (5) working days of the
candidate's clinical interview.
d. Consultant agrees to complete required continuing professional education (CPE)
requirement of six (6) hours by August 30, 2014 and complete twelve (12) hours of
POST approved CPE every two years beginning September 1, 2014 based on TCTI's
biennial license renewal cycle.
Complete Post -Traumatic Psychological Incident Evaluation
Consultant agrees to give City's Police Department Employees involved in violent incidents,
such as a life-threatening situation and/or serious injury or death to any person, complete post-
traumatic psychological evaluation.
a. A complete post-traumatic psychological incident evaluation includes, but is not
limited to, clinical interview and post-traumatic counseling.
b. Initial psychological service contact with involved officer(s) shall be made
immediately if possible, but no later than forty-eight (48) hours following the
incident.
C. A minimum of three (3) follow-up counseling sessions shall follow, if the Consultant
deems those sessions necessary. Such follow-up sessions shall, whenever possible
and practical, be scheduled by Consultant at Consultant's Orange County office
locations, unless otherwise agreed by involved officer(s).
d. If Consultant deems immediate follow-up counseling sessions are not indicated,
Consultant shall schedule one (l) follow-up session within a period of not less that
fourteen (14) days and not more than thirty (30) days following the traumatic incident
with the involved officer(s) to assess whether additional sessions shall be deemed
necessary. Such sessions shall, whenever possible and practical, be scheduled at
Consultant's Orange County office locations unless otherwise agreed by involved
officer(s). Following such sessions Consultant shall provide City's Police
Department with verbal recommendation as to the necessity of additional sessions
and an assessment of officer(s) recommended duty status within forty-eight (48)
hours. A written psychological assessment of the officer(s) evaluated shall be
submitted within five (5) calendar days to the City's Police Department upon
completion of such follow-up counseling session(s).
e. Consultant shall provide City's Police Department with a verbal recommendation for
return of said officer(s) involved in traumatic incidents to full or modified duty status
as soon as possible and in no case later than forty-eight (48) hours following the
incident.
f Consultant shall provide City's Police Department with a written psychological
assessment of officer(s) in question and a recommendation as to their suitability to
return to active duty, full or modified, and need for follow-up treatment within five
(5) days following the post-traumatic counseling session.
g. At the direction and with the consent of City's Police Department, Consultant shall
provide similar post traumatic incident counseling services to immediate family
members of involved officer(s) adversely impacted by the incident. The goal of such
services shall be to stabilize external factors which might otherwise affect officer(s)
return to duty or recovery and to determine if referral to other private service
providers is warranted. Verbal consultation with City's Police Department is
recommended but no written reports of family member counseling sessions are
required unless otherwise indicated or where the fitness for duty of the officer(s)
comes in doubt.
Crisis Interview Counseling
Consultant agrees to conduct crisis intervention counseling with authorization and approval of
City's Police Department when a Department employee(s) is believed to be gravely disabled as a
result of psychological disorder or emotional disturbance and unable to perform any or all of the
full range of duties of an employee's classification.
a. Consultant agrees to obtain authorization from City's Chief of Police or designate
prior to conducting crisis intervention counseling of City's Police Department
employee(s). Should intervention be requested by employee and not Department,
7
Consultant agrees to obtain authorization fiom City's Chief of Police or designate
prior to conducting crisis intervention counseling.
SWAT Consultation
Consultant agrees to be on-call and to respond to SWAT call -outs as requested.
a. Consultant will provide consulting with the SWAT commander regarding
psychological profiles and recommended approach to specific suspects.
b. Consultant will assist in interpreting intelligence data in reference to SWAT call -out
and/or suspect.
COMPENSATION
In consideration for Consultant services, City shall pay Consultant an hourly rate as follows:
1. For complete pre-employment psychological evaluation, City agrees to pay
Consultant three hundred dollars ($300.00) per applicant.
2. For complete post-traumatic psychological incident review, and crisis intervention,
City agrees to pay Consultant the hourly rate of one hundred seventy-five dollars
($175.00).
3. Initial consultation for post -trauma incidents will be billed at a rate of ninety-five
dollars ($95.00) per hour.
4. For SWAT consultation and training, City agrees to pay Consultant the hourly rate of
one hundred seventy -fifty dollars ($175.00).
The total sum to be expended pursuant to this Agreement shall not exceed sixty-five thousand
dollars ($65,000.00) during the term of this Agreement.
to
Certificate of Insurance (Proof of Coverage) Date Issued: 8/28/2014
THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.
THIS CER I'IW IC:.A`PE DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Insured Name and Mailing Address*
Program Administrator
Nancy K. Bohl Inc.
Administered By:
dba The Counseling Team
CPH and Associates
Nancy Bohl
711 S. Dearborn, Suite 205
1881 Business Center Dr. Stell
Chicago, IL 60605
San Bernardino, CA 92408
P.312-987-9823 F.312-987-0902
info@ephins.eom
'"Additional insurers locations are often requested by individual business
owners who have more than one office. Your coverage is portable,
Underwritten By:
meanirs;; that you are covered at any location./or practice under the
Philadelphia Indemnity Insurance Company
occupatiou(s) listed on your policy.
Coverage
Policy #: PFICP02.5826
Effective Date: 08/31/2014
Expiration Date: 08/31/2015
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
NOTWITHS' ANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BF ISSUED D OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE
TERMS, ERCG.IiSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Limits of Liability
Coverage Part
EACH OCCURRENCE
AGGREGATE
(Per individual claim)
(Total amount perpodiey year)
$1 million
$5 million
Professional Liability
Commercial General Liability
N/A
N/A
Includes: General Liability, Fire & Water
Legal Liability, and Personal Liability
NIA
N/A
Property Coverage
$1 Dt -Mort
$5 million
Supplemental Liability
Unlimited
Unlimited
Defense Expense Coverage
$3�.LOd
$35,000
State Licensing Board Investigation
Defense Coverage
$ n5'C,00
$15,000
Assault Coverage
$10,000
$35,000
Deposition Expense Benefit
115,06E/person
$50,000
Medical Expense Coverage
$ l E,000
$15,000
First Aid Coverage
DescriptioolSpecial Provisions:
Certificate holder
Cancellation
Should any of the above described policy be cancelled before the expiration date
thereof, the issuing insurer will endeavor to mail 30 days written notice to the
certificate holder named to the left, but failure to do so shall impose no obligation
PROOF O- COV EIt.0. E or liability of any kind upon the insurer, its agents or representatives.
Holder has also nee:. added to the policy as an additional insured:*
Authorized Representative
_Yes/XNo
**If the certific.ite hn' ler is an ADDITIONAL INSURED, the policy(ies) must
-
be endorsed. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
C. Philip Hodson
DISCI,.ALi-ISR:.I iie Cert am r o" 1 !wn alice does not coustitute a contract between the issuing insurer(s), authorized representative or producer, and the
certificate bolder, nor does it affirmatively or negatively amend, extend, or alter the coverage afforded by the policies listed thereon.
CERTHOLDER COPY
SP
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 10-30-2014
SANTA ANA POLICY DEPARTMENT
ATTN: TAYLOR GEIL-CHIEFS OFFICE M-97
60 CIVIC CENTER PLZ
SANTA ANA CA 92701-4060
SP
GROUP:
POLICY NUMBER: 0702761-2014
CERTIFICATE ID: 38
CERTIFICATE EXPIRES: 08-12-2015
08-12-2014/08-12-2015
This is to certify that we have issued a valid Workers' Compensation insurance policy In a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer,
We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration,
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein Is subject to all the terms, exclusions, and conditions, of such policy.
��..Y"^."'r' / u✓'� ''ic�v///cT..-�r.^ .)ren-«-�..,
Authorized Representative/ President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT #0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2014-10-30 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED:
SANTA ANA POLICY DEPARTMENT
ENDORSEMENT #1600 - NANCY K. BOHL PRES,SEC,TRES - EXCLUDED.
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-12-2011 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
NANCY K BOHL INC DBA: THE COUNSELING TEAM SP
INTERNATIONAL
1881 BUS CTR DR STE 11
SAN BERNADINO CA 92408
[PJP,CS[
IREV.7-20141 PRINTED : 10-30-2014
DATE (61HIDDAYI^!)
01/0512016
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. - - t
{MPO RTANT: If 4he certificate holder is ah ADOl7lONAt 1N5URED, the policy(iesj musT 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 cart'rficate does not confer rights to the
carffficate holder in lieu of such enel rseErpi ft(3). ----- ----
ONTACT
PRODUCER NAME:_......_.._;..«....:
THIS IS TQ CERTIFY 1nAT THE POLICIES OF INSURANCE Lf5"I=D BELC!N! HAVESEEN ISSUED TO THE INSURED NAIViEU ABOVE FC1ft THE r.. t, -
INDICATED, NOTAITHSTANDiNG ANY REQUIREMENT, TERN? OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT T4' WHICH rHVf
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT 1'0 ALL THE TERAS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHO1AN MA.Y' HAVE SEEN REDUCED BY PAID CLAIMS. µ
T4 •._.� iCl+pg �f+0'l.0 EFF E%P LIMfrS
TYPEOF!NSURANCE IN `MO POOLICY NG r1 ER I NtNI+D
A l COMMERCIAL GENERAL TI IASILITY � C � BUSMESS OFFRCE POLICY EACR OCCURRENCE S i LLD h.;
r,Ln. „Inez=, MX .�.,. R' 4 82f.61*4269 07112720'18 07I12t2015 P s ar D „„
X HIREDrAUTO
I 97YLQE220 onlarzolC, 07712016 �eFnFIP(Art or e rnssnl
-
Edl 13CR4( itti'rA tfr `Iii � � i .---
-,,r � ttRGA T Pt'4 tICT�:S
TidEh I a
4111 UE NL
B 11Uio nalt,._Tlne.ury I +3414787F2475 12!2412095 [ 06124/2010
T ! IIIIII B DIV!ILR"
I
AN AU r �^+;�
- !)rr P 4 `€� E b4 l LED I # 1� a n .Y .uaY
AL ".:v ,4X N'ON O 4! I, :.R h'E.nPY DA!
I F'OA S 1 _3 A 4 ?iS�'aL'(R,it
pC:JUR
EXCESS UAa
EMPLOYERS '
WIN
o' JQ RIRTION CP OPERA 'OMS; LOCATIONS i VELItC GS ACORD 109
SuELL Ea3 Office Proper: f Locations:
1891 Buaineso Center Dr, San Bernardino, CA 97,403
1543 Aoacepa Rd Ste 7C Victcnlli 11e. CA 52392
444 Camino Del Ric Sr, 2^'i5,San Diego, CA 92108
4290 Bob Hope Dr Sta 110, Rancho Mirage, CA 32:d7C
428W Harr:„.an Ste 101, Claremont, CA 91711
r lonal R -marks FCF^Dviz, may Yx aaa¢hod Ir netts xipz� Is rayldredj ;
39755 klub reale Hot Springs Rd. Sta D 1*4?fi la: 2553
135 S State College Blvd Ste 2GU, Brea, CA 9232
5
s
$ IG SOLI
IT'7
'SO '00
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE ENFIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
ACORD 25 (2014101) The AIDORD name Ono 1090 are te915;arod marks of ACORD v 1001426 132849.9 172-04--2011
Skala Insurance Agency Inc
HONE?}; 90e-sa3-8861
ter: r
Gene Skala, Agent
4214 N Sierra VVay, San Bernardino, CA 92407
wsatmiRlSk
{1011
tNBUt{ERA;State Farm General
LF R=o
N NCY K S HU NC
INSURE, rMaata Farm Mulnel I
DBA THE COUNSELING TEAM
IN&URMCI
INTERNATIONAL AND DSA THE.
ORGANIZATIONAL NETVVVORh
rs sun v _
THIS IS TQ CERTIFY 1nAT THE POLICIES OF INSURANCE Lf5"I=D BELC!N! HAVESEEN ISSUED TO THE INSURED NAIViEU ABOVE FC1ft THE r.. t, -
INDICATED, NOTAITHSTANDiNG ANY REQUIREMENT, TERN? OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WTH RESPECT T4' WHICH rHVf
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT 1'0 ALL THE TERAS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHO1AN MA.Y' HAVE SEEN REDUCED BY PAID CLAIMS. µ
T4 •._.� iCl+pg �f+0'l.0 EFF E%P LIMfrS
TYPEOF!NSURANCE IN `MO POOLICY NG r1 ER I NtNI+D
A l COMMERCIAL GENERAL TI IASILITY � C � BUSMESS OFFRCE POLICY EACR OCCURRENCE S i LLD h.;
r,Ln. „Inez=, MX .�.,. R' 4 82f.61*4269 07112720'18 07I12t2015 P s ar D „„
X HIREDrAUTO
I 97YLQE220 onlarzolC, 07712016 �eFnFIP(Art or e rnssnl
-
Edl 13CR4( itti'rA tfr `Iii � � i .---
-,,r � ttRGA T Pt'4 tICT�:S
TidEh I a
4111 UE NL
B 11Uio nalt,._Tlne.ury I +3414787F2475 12!2412095 [ 06124/2010
T ! IIIIII B DIV!ILR"
I
AN AU r �^+;�
- !)rr P 4 `€� E b4 l LED I # 1� a n .Y .uaY
AL ".:v ,4X N'ON O 4! I, :.R h'E.nPY DA!
I F'OA S 1 _3 A 4 ?iS�'aL'(R,it
pC:JUR
EXCESS UAa
EMPLOYERS '
WIN
o' JQ RIRTION CP OPERA 'OMS; LOCATIONS i VELItC GS ACORD 109
SuELL Ea3 Office Proper: f Locations:
1891 Buaineso Center Dr, San Bernardino, CA 97,403
1543 Aoacepa Rd Ste 7C Victcnlli 11e. CA 52392
444 Camino Del Ric Sr, 2^'i5,San Diego, CA 92108
4290 Bob Hope Dr Sta 110, Rancho Mirage, CA 32:d7C
428W Harr:„.an Ste 101, Claremont, CA 91711
r lonal R -marks FCF^Dviz, may Yx aaa¢hod Ir netts xipz� Is rayldredj ;
39755 klub reale Hot Springs Rd. Sta D 1*4?fi la: 2553
135 S State College Blvd Ste 2GU, Brea, CA 9232
5
s
$ IG SOLI
IT'7
'SO '00
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE ENFIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
ACORD 25 (2014101) The AIDORD name Ono 1090 are te915;arod marks of ACORD v 1001426 132849.9 172-04--2011
POLICYHOLDER COPY
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
ISSUE DATE: 08-12-2015 GROUP:
POLICY NUMBER: 0702761-2015
CERTIFICATE ID: 25
CERTIFICATE EXPIRES: 08-12-2016 ✓
08-12-2016/08-12-2018
da
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer.
we will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not arrend, extend or atter the coverage afforded
by the policy fisted herein. Notwithstanding any requirement, term or condition of any contrabt or other document
with respect to which this certificate of insurance may be issued or to which It may pertain, the insurance
afforded by the policy described- herein is subject to all the Germs, exclusions and Conditions, of such policy.
Authorized Representative President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT #1500 - NANCY K. SOHL, PRES,SEC,TRES - EXCLUDED.
EMPLOYER
NANCY K BOHL INC DBA: THE COUNSELING TEAM SP
INTERNATIONAL DBA: THE ORGANIZATIONAL NETWORK
1881 BUS CTR DR STE 11
SAN BERNAOINO CA 82408
M0410
PRINTED : 07-17-2015
M
Certificate of Insurance (Proof of Coverage) 08/19/2915
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER,
THIS CERTIFICATE DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
_orad NaAddress*
am_Aa_LXAA
? (Includes: General Liability, Fire & i
Nancy X Bahl Inc.___._
Administered By:
'Nancy Bahl
CPH and Associates
1881 Business Center Drive, Suite 71
711 S. Dearborn, Suite 205
'San Bernardino, CA 92408
Chicago, IT, 60605
—------
t P. 312-987.9823 F. 312.987.0902
*Additional insured locations are often requested by individual business owners who
iltfn r eplibas.nonu
'have more than one office, Your coverage is portable, meaning that you are covered at
Underwritten By:
any location forpractice finder the occupatlon(s) listed on your policy.
' ] hltnti}e blu Sptterc[rtfty Insu ance COm)
Coverage
_
Pa1teY#:025826 'Effective Date: 08/31/2015
LL)ExpfrattonDate 08/3U2016
iiH-..-„_._...,-.._._�.____..._..-___T ___._
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
fiNDICATED. 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'rHE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
_._
EACH OCCURRENCE ' AGGREGATE Coverage Part
(Per individual clams) (Total amornnt per policy year)
�I 000 000 _ - _ 4,000,000 � Prutexsmnul Lmb�,�..,r�: .
DISCLAIMER: The Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and
the certificate holder, nor does it affirmatively or negatively amend, extend, or alter the coverage afforded by the policies listed thereon.
90 ®1A#O1j
? (Includes: General Liability, Fire & i
N/A
N/A = Water Legal Liability, and Personal
_fra6ltPtP)
--_$5,000,000__—.–mentulLla6i_liiy
Unlimited
Unlimited i _ Defense EXense Coveragce
$35,000
$35,000 State Licensing Board Investigation
Defense Coverage
Assuul[Caverag_e :__.......--,,
$10000 _ .
- --- i35,000 .. _. _ _ ._i.___ - Deposfttan Fxpensa Baaefft
Medncaf Evpens Cbv®rn9! ---,.
$15,000
- $15„000 i first Aid Coverit
}3esattpEEonlSpe, a#n11'�av3gCOns, -
_ - _`__.....,._„. ....W__
Certificate holder
Cancellation
,Should any of the above described policy be cancelled before the expiration date thereof,
,,the issuing insurer will endeavor to mail 30 days written notice to the certificate holder
,tamed to the left, but failure to do so shall impose no obligation or liability of any kind
PROOF OF COVERAGE
upon the insurer, Its agents a€rgpKesankatives.,
Holder has also been added to the policy
as an additional insured **
Yes/XNoi
71,Ge,19ay
**If the certificate holder is an ADDITIONAL
s
INSURED, the policyAuthorized Representative
ties) must be endorsed. A statement on
this certificate does not C, Philip Hodson
confer rights to the cerkiftcah, holder in lieu of such endorsement ,
DISCLAIMER: The Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and
the certificate holder, nor does it affirmatively or negatively amend, extend, or alter the coverage afforded by the policies listed thereon.
90 ®1A#O1j
IN REPLY REFER TO:
JANUARY 7, 2016
SANTA ANA POLICY DEPARTMENT
ATTN: TAYLOR GEIL—CHIEFS OFFICE M-97
60 CIVIC CENTER PLZ
SANTA ANA CA 92701-4060
Bs `j lL4 CERTIFICATE OF WORKERS'
-----------------------
COMPENSATION INSURANCE
----------------------
CANCELLATION WITHDRAWAL NOTICE
------------------------------
RE: CERTIFICATE DATED AUGUST 12, 2015
THE CANCELLATION HAS BEEN WITHDRAWN FOR THE WORKERS' COMPENSATION
INSURANCE POLICY FOR THE EMPLOYER NAMED BELOW. THIS LETTER
THE NOTICE OF CANCELLATION SENT TO YOU ON JANUARY 6, 2016.
THIS EMPLOYER'S WORKERS' COMPENSATION INSURANCE COVERAGE CONTINUED
UNINTERRUPTED.
EMPLOYER:
NANCY K BOHL INC
1881 BUS CTR DR STE 11
SAN BERNADINO, CA 92408
POLICY 0702761-15
CUSTOMER SERVICE REPRESENTATIVE
CUSTOMER SERVICE CENTER
(888) 782-8338
5860 Owens Or Pleasanton, CA 94588-3900
Mailing Address: P.O. Box 8192 - Pleasanton, CA 94588-9682
SCIF 19102
IN REPLY REFER TO:
JANUARY 6, 2016
SANTA ANA POLICY DEPARTMENT
ATTN: TAYLOR GEIL-CHIEFS OFFICE M-97
60 CIVIC CENTER PL2
SANTA ANA CA 92701-4060
CERTIFICATE OF WORKERS'
-----------------------
COMPENSATION INSURANCE
----------------------
CANCELLATION NOTICE
RE: CERTIFICATE DATED AUGUST 12, 2015
THE WORKERS' COMPENSATION INSURANCE POLICY FOR THE EMPLOYER
NAMED BELOW WILL BE CANCELLED EFFECTIVE FEBRUARY 11, 2016 AT
12:01 A.M.
IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE
CONTACT THE EMPLOYER NAMED BELOW
EMPLOYER:
NANCY K BOHL INC
1881 BUS CTR DR STE 11
SAN BERNADINO, CA 92408
POLICY 0702761-15
CUSTOMER SERVICE REPRESENTATIVE
CUSTOMER SERVICE CENTER
(888) 782-8338
5860 Owens Dr Pleasanton, CA 94588-3900
Mailing Address: P.O. Box 8192 • Pleasanton, CA 94588-9682
SCIF 19102
Certificate of Insurance (Proof of Coverage), Date Issued: 9/13/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE
CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
Insured Name and Mailing Address*
Coverage
Program Administrator
Nancy K. Bohl Inc. dba'I'he Counseling
Effective Date: 08/31/2016
Administered By:
Team international
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER
CPH and Associates
Nancy Bold A — �01-t+
THE INSURANCE AFFORDED BY THE POLICIES
711 S. Dearborn, Suite 205
1881 Business Center Dr. #11
POLICIES. AGGREGATE LIMITS SHOWN MAY
Chicago, IL 60605
San Bernardino, CA 92408
(Coverage Part
P. 312-987-9823 F. 312-987-0902
*Additional insured locations are often requested by individual
(Per individual clahn)
info�,cphins.com
business owners who have more than one office. Your coverage
$1 Million
Underwritten By:
is portable, ineaning that you are covered at any locationfir
Philadelphia Indemnity Insurance Company
practice under the occupation (s) listed on your policy.
N/A
N/A
DISCLAIMER: The Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer,
and the certificate holder, nor does it affirmatively or negatively amend, extend, or alter the coverage afforded by the policies listed thereon
Coverage
Policy #: 0,25826
Effective Date: 08/31/2016
Expiration Date: 08/31/2017
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. AGGREGATE LIMITS SHOWN MAY
HAVE BEEN REDUCED BY PAID CLAIMS.
Limits of Liability
(Coverage Part
EACH OCCURRENCE
AGGREGATE
(Per individual clahn)
(Total amount per policy year)
$1 Million
$5 Million
Professional Liability
Commercial General Liability
N/A
N/A
Includes: General Liability, Fire & Water
Legal Liability, and Personal Liability
N/A
N/A
Property Coverage
$1 Million
$5 Million
Supplemental Liability
Unlimited
Unlimited
Defense Expense Coverage
$35,000
$35,000
State Licensing Board Investigation Defense
Coverage
$15,000
$15,000
Assault Coverage
$10,000
$35,000
Deposition Expense Benefit
$5,000/person
$50,000
Medical Expense Coverage
$15,000
$15,000
First Aid Coverage
Description/Special Provisions:
Certificate Holder
Santa Ana Policy Department
SHOULD ANY OF'rHE ABOVE DESCRIBED POLICIES BE CANCELLED
60 Civic Center Plaza
BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
Santa Ana, CA 92702
IN ACCORDANCE WITH THE POLICY
PROVISIONS.
Holder has also been added to the
Authorized Representative
policy as an additional insured:**
[EYES El NO
**If the certificate holder is an
ADDITIONAL INSURED, the policy(ies)
Cl. Philip Hodson
must be endorsed. A statement on this
certificate does not confer rights to the
certificate holder in lieu of such
endorsement(s).
DISCLAIMER: The Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer,
and the certificate holder, nor does it affirmatively or negatively amend, extend, or alter the coverage afforded by the policies listed thereon
ISSUE DATE: 08-12-2016
POLICYHOLDER COPY
CERTIFICATE OF WORKERS' COMPENSATION' INSURANCE
SANTA ANA POLICY DEPARTMENT SIP
ATTN: TAYLOR GEIL-CHIEFS OFFICE M-97
60 CIVIC CENTER PLZ
SANTA ANA CA 92701-4050
GROUP:
POLICY NUMBER: 0702761-2016
CERTIFICATE 10: 38
CERTIFICATE EXPIRES: 08-12-2017
08-12-2016/08-12-2017
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the employer named below for the policy period indicated.
This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer.
We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
Authorized Representative President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS: $1,000,000 PER OCCURRENCE.
ENDORSEMENT 1#0015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2015-08-12 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY. NAME OF ADDITIONAL INSURED:
SANTA ANA POLICY DEPARTMENT
ENDORSEMENT #1600 - NANCY K. BOHL, PRESI,SEC,TRES - EXCLUDED.
ENDORSEMENT #2065 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-12-2011 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
EMPLOYER
NANCY K BOHL INC DBA;
INTERNATIONAL
1881 BUS CTR DR STE 11
SAN BERNADINO CA 92408
THE COUNSELING TEAM SIP
M0410
PRINTED : 07-16-2016
(REV. 7- 2'0141
-M
Certificate of Insurance (,Proof ol'Coverage) Date Issued:: 08/21/2017
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPONTHE CERTIFICATE HOLDER.
TIAs CERTIFICATE DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BYTUE POLICIES BELOW.
Insured Name and Mailing Address*
Program Administrator
jVac iey K. Bohl Inc. Ciba The Coienseling Team infernration!
Administered By:
Naricy K Boh'l
1881 Business Center Drive 911 w
CPH and Associates
711 S. Dearborn, Suite 205
Scan Bernardino, C21 92408
Chicago, IL 60605
P. 312-987-9823 F. 3.12-987.0902
*Additional insured locations are afteu requested by imfividiml business owners who have rraore than one
infokiahins.com
office. Your coverage is portable, meaning thatyon are cowered at any location fcrr practice ander the
Underwritten By:
occupations) listed on yourpolicy.
Philadelphia Indemnity Insurance Company'
Coverage
Policy #: 025826 iEffective Date: 08/3.11301.7
lExViration Date: 08/31/2018
THE POLICIES OF INSURANCE LISTED BELOW IIAVE BEEN ISSUED TO THE INSURED
NAMED ABOVE FORTHE POLICY PERIOD
INDICATED. NOT" vW'1THSTANDNG ANY R.EQUIREMENT, TERM OR CONTIiTTON
OF ANY CONTRACTOR OTHER DOCLTM NTWITTI
RES['kiCT BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE: TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCMS,
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Limits of Liability
E"ACtiOCCURl2ENCE At G'REGATE
coverage Part
(Per inefividual claim) (Total amount per policP;vear)
51,000,000 55,000,000
Professional Liability
Commercial General Liability
N)
N/A
Includes: General Liability, fire &'4Water Legal Liability
and Personal Liability
N/A
N/A
Proalertycovera e
$1,000.000
55,0001000,
Supplemental Liability
Unlimited
Unlimited
Defense Expense Coverage
$35,000
$35,000
State Licensing Board Iirvesti ation Defense Coverage
5,15,000
$15,001)
Assault Covera&e
510,000
$35,000
De osition Emense Benefit
5'5,0001 erson
550,000
Medical Expense Coverage
$15,000
;515,000
First Aid Coverage
Desariotion/Soecial Provisions
Certificate Bolder Cancellation
Santa Ana Police department
60 Civic Center Plaza SHOULD ANY OF TIIE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
Santa Ana, CA 92702 1 XPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
Holder has also been ndded to the policy as an additional insureds**
[ X Yes/No 1
**If the certificate holder is an ADDITIONAL INSURED, the poliey(ics) must be °
endorsed. A statement on this certificate does not confer rights to the certificate hulder in Authorized Representative
lieu of such endorsement(s)' C. Phill,aHodson
DISCLAI1yIER:The Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and
the certificate holder, nor does it affirmatively or negatively amend, extend, or alter the coverage afforded by the policies listed thereon.
THIS EN
Additional Insured Endorsement
This endorsement modifies insurance provided under the following:
ALLIED HEALTHCARE PROVIDERS PROFESSIONAL
AND SUPPLEMENTAL LIABILITY POLICY
In consideration of the premium paid, this policy is amended as follows:
Santa Ana Police Department is hereby added as an Additional Insured, solely for Damages arising out
of a Professional Incident covered under this policy. The Professional Incident must arise out of
services provided by the Insured, under contract with Santa Ana Police Department.
Additional Insured Name and Mailing Address:
Santa Ana Police Department
60 Civic Center Plaza
Santa Ana, CA 92702
All other terms and conditions, of this policy remain unchanged. This endorsement is part of your policy and
takes effect on the effective date of your Policy, unless another effective date is shown below.
Policy: 025826
Effective on and after: 08131/2017
Issued to: Nancy K. Bohl Inc. dba The Counseling Team International
Expiration date: 08/3,1/2018
PI-PHCP-05 (03/01)
By: Robert O'Leary, Authorized Representative
ISSUE DATE: 08-12-2017
CERTHOLDER COPY
P.O. BOX 8192, PLEASANTON, CA 94588
CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
SANTA ANA POLICY DEPARTMENT SP
ATTN: TAYLOR GEIL-CHIEFS OFFICE M-97
60 CIVIC CENTER PLZ
SANTA ANA CA 92701-4060
GROUP:
POLICY NUMBER: 0702761-2017
CERTIFICATE ID: 38
CERTIFICATE EXPIRES: 08-12-2018
08-12-2017/08-12-2018
This is to certify that we have issued a valid Workers' Compensation insurance policy in a form approved by the
California Insurance Commissioner to the emplover named below for the oolicy neriod indicntp.d
This policy is not subject to cancellation by the Fund except upon 30 days advance written notice to the employer.
We will also give you 30 days advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded
by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document
with respect to which this certificate of insurance may be issued or to which it may pertain, the insurance
afforded by the policy described herein is subject to all the terms, exclusions, and conditions, of such policy.
Authorized Representative President and CEO
EMPLOYER'S LIABILITY LIMIT INCLUDING DEFENSE COSTS. $11,000,000 PER OCCURRENCE.
ENDORSEMENT 110015 ENTITLED ADDITIONAL INSURED EMPLOYER EFFECTIVE 2015-08-12 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY, NAME OF ADDITIONAL INSURED:
SANTA ANA POLICY DEPARTMENT
ENDORSEMENT #201135 ENTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 08-112-2011 IS
ATTACHED TO AND FORMS A PART OF THIS POLICY.
Ap e,(ZOVZ)4.'
EMPLOYER
NANCY K BOHL INC DBA: THE COUNSELING TEAM SP
INTERNATIONAL
1881 BUS CTR DR STE III
SAN BERNADINO CA 92408
M0408
(REV.7- 2014) PRINTED : 07-17-2017
�U-