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Home My WebLink AboutU.S. HEALTHWORKS-2017C0MPLE-Tf------') INSURANCE D01 ON FILE DocuSign Envelope ID: 7673C3E1-928C-47BD-9506-868444A553C2 rK MAY �dV i _ PROCEED N-2016-070,001 �� C0) CLERK OF COUNCIL � C�W�l 030- DATE: FIRST" AMENDMENT TO CONSULTANT AGREEMENT WITH U.S.I= EALTHWORKS MEDICAL GROUP THIS FIRST AMENDMENT to the above -referenced agreement is entered into .tune 30, 2017 by and between U.S. HealthWorks Medical Group, Prof. Corp., a California Corporation, (hereinafter "Consultant"), and the City of Santa Ana, a charter city and municipal corporation organized and existing ender the Constitution and laws of the State of Califamia. (hereinafter "City"). RECITALS A. The parties entered into Agreement 9N-2016-070 dated April 29, 2016 ("Agreement"), by which Consultant agreed to provide medical services For job related injuries and illnesses. B. The agreement provided for a one year extension of the term of the Agreement from June 30, 2017 to June 30, 2018, The City desires to exercise this extension.. Now, therefore, in consideration of the mutual and respective; promises, and subject to the terms and conditions of said Agreement, except as herein modified, the parties agree as follows: 1. Section 3, Terin, is amended to change the termination date from June 30, 2017 to June 30, 2018. 2. Except as hereinabove modified, all terms and conditions of said Agreement shall remain in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this First Amendment to the Agreement on the date and year first written above. ATTEST: MARIA. D. RUIZAR Cleric of the Council APPROVED AS TO FORM SONIA R. CARVALHO City Attorney By: 4, ♦�r1 h'! A. I.aura A. Rossini Senior Assistant City Attorney RECOMMENDED FOR APPROVAL,: -m�� C-1-(1 ED RAYA Executive Director of Personnel Services Agency CITY OF SANTA ANA. Robert C. Cortez Deputy City Manager U.S. HealthWorks Medical Group, Prof. Corp. HKuM' ftned by, By. Jose Ez... President and Secretary AcIl �" P CERTIFICATE OF LIABILITY INSURANCE M DATE(MMIDOIYY ) 4r28�2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. TF IS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICI is BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rl hts to the certificate holder in lieu of such endorsement(s). PRODUCER Intel Insurance Services License #01301094EMAIL 222 Court Street CNAME:ONTACT Michelle Goodwin, CIC, CISR, CPSR PHONE 831-635-2247 FAx 6831-638-680 . mgoodwin@iwins.com INSUREII AFFORDING COVERAGE NAIC Woodland CA 95695 INSURERA:NORCAL Mutual Ins Company 33200 INSURED USHEA-1 INSURER B INSURER C U.S. Healthworks, Inc. 25124 Springfield Ct., Ste 200 Valencia CA 91355 INSURER D CLAIMS -MADE 7-1OCCURPREMISES INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 1536280575 REVISION NUMBER: I THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI b INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH, T IS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE. INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TER �S, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ID WVO POLICYNUMBER POLICY EFF MMIODIYYYY POLICY EXP MM1DDNYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE 7-1OCCURPREMISES I TO a cocuFr ence $ MED EXP (Any one person) $ PERSONAL & Al INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ❑ PRO JECT ❑ LOC PRODUCTS - COMPIOP AGG $ $ OTHER: AUTOMOBILE LIABILITY Ea COMBINED5 G F LI IT $ BODILY INJURY (Per person) $ ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ HIRED NON -OWNED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE $ Par eco€dent UMBRELLA LAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I I RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN STATUTE I I ER ANY PROPRIETORIPARTNERIEXECUTIVEElNIA E.L. EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L. DISEASE- EA EMPLOYEE $ (Mandatary In NHI If yes, descrlbs under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A A Medical Malpractice Professional Liabllityy $150,000 Ded ILICAJTXIFLIWA 729820E 721823N 51'[12017 5/1/2017 51112018 5/112018 Aggregate $3,000,000 Limit $1,000,000 Ded.-A{ Ctl States $100,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (ACORD 901, Additional Remarks Schodule, maybe attached ii morn space is required) Although multiple policies are shown above, the person or organization identified above as the Insured qualifies as an Insured under only one of those policies shown, and the coverages and limits of liability for such coverages of only one of those policies will apply to that Insured. Re: 1619 East Edinger, Santa Ana, CA 92705 CERTIFICATE HOLDER CANCELLATION 10 Days for Non Payment of Premium O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD �] ;l SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Santa Ana THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 20 Civic Center Plaza ACCORDANCE WITH THE POLICY PROVISIONS. Santa Ana CA 92701 AUTHORIZED REPRESENTATIVE f["vt: 0L. a ZQ .1 �cIbvi,o J O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD �] ;l