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HomeMy WebLinkAboutU.S. HEALTHWORKS (2)DocuSign Envelope ID: FF7F3462-A44C-4038-8086-1F64FF4E2441 A-2017-330 iNSURANCF NOT ON FILE 'WORK MAY Nff PROCEED CLERK OF COUNCIL & MEDICAL SERVICES AGREEMENT WITH DATE: DEC 19 2017 U.S. HEALTHWORKS MEDICAL GROUP THIS AGREEMENT is made and entered into on this 6th day of December, 2017, by and between U.S. HealthWorks Medical Group, Prof. Corp., a California professional corporation ("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 ("City"). boa ;y RECITALS v c c1 sk P-'t.p t.P, A -I. -S A. City and Consultant entered into Agreement #N-2016-070 on April 29, 2016, to provide medical services for job related injuries and illnesses including for workers exposed to communicable diseases. B. The parties entered into a First Amendment to the Agreement (#N-2016-070-001) to exercise the option to extend the agreement for one year from June 30, 2017 through June 30, 2018, The Agreement, by operation of the First Amendment, currently remains in effect. All funds allocated to this Agreement have been exhausted. C. On October 13, 2017, Governor Jerry Brown declared a state of emergency regarding an. outbreak of Hepatitis A. This outbreak had been also declared emergencies in neighboring Los Angeles and San Diego counties. The City began to offer Hepatitis A vaccinations which was met by an increased demand by Police and City staff requests for vaccinations against Hepatitis A. The vaccinations require multiple shots over a six month period and will benefit those City employees that work directly with or were exposed to the illness due to the clean-up of and City services related to the Civic Center area. D. City desires to retain the services of Consultant for the continuation of its current services, treatment for job related injuries and to include vaccinations for City workers that could be potentially exposed to communicable diseases, to include Hepatitis A. Consultant represents that Consultant is able and willing to provide such services to the City. E. Consultant was selected to provide these services based on its continuing work in. conjunction with the City's worker's compensation provider for industrial injuries and worker's compensation claims. F, "The parties agree that this Agreement supersedes all prior understandings, agreements and informal working arrangements between the parties and may not be amended orally, but only by a writing duly executed by the parties hereto. G. 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: Page 1 of 9 DocuSign Envelope ID: FF7F3462-A44C-4038-8086-1 F69FF4E2441 1. SCOPE OF SERVICES Consultant shall perform during the term of this Agreement, the tasks and obligations including all labor, materials, tools, equipment, and incidental customary work required to fully and adequately provide treatment to City employees suffering from an industrial injury. In addition, Consultant will also provide preventative medical services to City employees who may be exposed to communicable diseases per the attached Exhibit A, including vaccinations for Hepatitis A. 2. COMPENSATION a. City agrees to pay, and Consultant agrees to accept as total payment for its services for City, the rates and charges identified in Exhibit A. The total amount to be expended under this Agreement shall not exceed $150,000. b. Payment by City shall be made within 45 days (forty-five) 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 continue through June 30, 2019, unless terminated earlier in accordance with Section 14, 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 mamier 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. S. OWNERSHIP OF MATERIALS This Agreement creates a non-exclusive and perpetual license for City to copy, use, modify, reuse, or sublicense any and all copyrights, designs, and other intellectual property embodied in plans, specifications, studies, drawings, estimates, and other documents or works of authorship fixed in any tangible medium of expression, including but not limited to, physical drawings or data magnetically or otherwise recorded on computer diskettes, which are prepared or caused to be prepared by Consultant under this Agreement ("Documents & Data"). Consultant Page 2 of 9 DocuSign Envelope ID: FF7F3462-A44C-4038.8086-1F69FF4E2441 shall require all subcontractors to agree in writing that City is granted a non-exclusive and perpetual license for any Documents & Data the subcontractor prepares under this Agreement. Consultant represents and warrants that Consultant has the legal right to license any and all Documents & Data. Consultant makes no such representation and warranty in regard to Documents & Data which were provided to Consultant by the City. City shall not be limited in any way in its use of the Documents and Data at any time, provided that any such use not within the purposes intended by this Agreement shall be at City's sole risk. 6. 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, Commercial General Liability Insurance. Consultant shall maintain commercial general liability insurance naming the City, its officers, employees, agents, volunteers and representatives as additional insured(s) and shall include, but not be limited to protection against claims arising from bodily and personal injury, including death resulting therefrom and damage to property, resulting from any act or occurrence arising out of Consultant's operations in the performance of this Agreement, including, without limitation, acts involving vehicles. The amounts of insurance shall be not less than the following: single limit coverage applying to bodily and personal injury, including death resulting therefrom, and property damage, in the total amount of $1,000,000 per occurrence, with $2,000,000 in the aggregate. Such insurance shall (a) name the City, its officers, employees, agents, and representatives as additional insured(s); (b) be primary and not contributory with respect to insurance or self-insurance programs maintained by the City; and (c) contain standard separation of insureds provisions. b, Business automobile liability insurance, or equivalent form, with a combined single limit of not less than $1,000,000 per occurrence. Such insurance shall include coverage for owned, hired and non -owned automobiles. C. Worker's Compensation Insurance. In accordance with the provisions of Section 3700 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. d. Professional liability (errors and omissions) insurance, with a combined single limit of not less than $1,000,000 per claim with $2,000,000 in the aggregate. C. 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 by the City. iii. Certificates and policies shall state that the policies shall not be canceled or Page 3 of 9 DocuSign Envelope ID: FF7F3462-A44C-4038-8086-1F69FF4E2441 reduced in coverage or changed in any other material aspect without thirty (30) days prior written notice to the City. iv. Consultant shall supply City with a fully executed additional insured endorsement. 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. 7. INDEMNIFICATION Consultant agrees to defend, and shall indemnify and hold harmless the City, its officers, agents, employees, contractors, special counsel, and representatives from liability; (1) for personal injury, damages, just compensation, restitution, judicial or equitable relief arising out of claims for personal injury, including death, and claims for property damage, which may arise from the negligent operations of the Consultant, its subcontractors, agents, employees, or other persons acting on its behalf which relates to the services described in section 1 of this Agreement; and (2) from any claim that personal injury, damages, just compensation, restitution, judicial or equitable relief is due by reason of the terns of or effects 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 effects, arising from this Agreement. The Consultant further agrees to indemnify, hold harmless, and pay all costs for the defense of the City, including fees and costs for special counsel to be selected by the City, regarding any action by a third party challenging the validity of this Agreement, or asserting that personal injury, damages, just compensation, restitution, judicial or equitable relief due to personal or property rights arises by reason of the terms of, or effects arising from this Agreement. City may make all reasonable decisions with respect to its representation in any legal proceeding. Notwithstanding the foregoing, to the extent Consultant's services are subject to Civil Code Section 2782.8, the above indemnity shall be limited, to the extent required by Civil Code Section 2782.8, to claims that arise out of, pertain to, or relate to the negligence, recklessness, or willful misconduct of the Consultant. 8. RECORDS Consultant shall keep records and invoices in connection with the work to be performed under this Agreement. Consultant shall maintain complete and accurate records with respect to the costs incurred under this Agreement and any services, expenditures, and disbursements charged to the City for a minimum period of three (3) years, or for any longer period required by law, from the date of final payment to Consultant under this Agreement. All such records and invoices shall be clearly identifiable. Consultant shall allow a representative of the City to examine, audit, and make transcripts or copies of such records and any other documents created pursuant to this Agreement during regular business hours. Consultant shall allow inspection of all Page 4 of 9 DocuSign Envelope ID: FF7F3462-A44C-4038-8086-1F69FF4E2441 work, data, documents, proceedings, and activities related to this Agreement for a period of three (3) years from the date of final payment to Consultant under this Agreement. 9. 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. Pursuant to this Agreement, confidential medical information may be disclosed by City's employees to Consultant. Consultant shall comply with all federal, state and local laws regarding the privacy of medical information including but not limited to the Health Information Portability and Accountability Act ("HIPAN). 10. 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. 11. 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. 12. 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 Page 5 of 9 DocuSign Envelope ID: FF7F3462-A44C-4038-8086-1F69FF4E2441 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 or 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. 13. 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. 14. TERMINATION This Agreement may be terminated by the City upon thirty (30) days written notice of termination. In such event, Consultant shall be entitled to receive and the City shall pay Consultant compensation for all services performed by Consultant prior to receipt of such notice of termination, subject to the following conditions: a. As a condition of such payment, the Executive Director of Personnel Services may require Consultant to deliver to the City all work product(s) completed as of such date, and in such case such work product shall be the property of the City unless prohibited by law, and Consultant consents to the City's use thereof for such purposes as the City deems appropriate. b. Payment need not be made for work which fails to meet the standard of performance specified in the Recitals of this Agreement. 15. WAIVER No waiver of breach, failure of any condition, or any right or remedy contained in or granted by the provisions of this Agreement shall be effective unless it is in writing and signed by the party waiving the breach, failure, right or remedy. No waiver of any breach, failure or right, or remedy shall be deemed a waiver of any other breach, failure, right or remedy, whether or not similar, nor shall any waiver constitute a continuing waiver unless the writing so specifies. 16. JURISDICTION - VENUE 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, Page 6 of 9 DocuSign Envelope ID: FF7F3462-A44C-4038-8086-1F69FF4E2441 17. PROFESSIONAL LICENSES Consultant shall, throughout the tern of this Agreement, maintain all necessary licenses, permits, approvals, waivers, 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 its inability to obtain or maintain such permits, licenses, approvals, waivers, and exemptions. Said inability shall be cause for termination of this Agreement. 18. MISCELLANEOUS PROVISIONS a. Each undersigned represents and warrants that its signature herein below has the power, authority and right to bind their respective parties to each of the terms of this Agreement, and sball 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. 19. 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 fax 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 Fax: 714- 647-6956 With courtesy copies to: Executive Director, Sonia R. Carvalho Personnel Services Agency City Attorney City of Santa Ana City of Santa Ana 20 Civic Center Plaza (M-24) 20 Civic Center Plaza (M-29) P.O. Box 1988 P.O. Box 1988 Santa Ana, California 92702 Santa Ana, California 92702 Fax: 714-647-5311 Fax: 714-647-6515 Page 7 of 9 DocuSign Envelope ID: FF7F3462-A44C-4038-8086-1F69FF4E2441 To Consultant: U.S. Healthworks — East Edinger Attn: Michelle Harrison, Clinic Supervisor 1619 E. Edinger Ave. Santa Ana, CA 92705 Fax: 714-541-5313 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 fax, 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. IN WITNESS WHEREOF, the parties hereto have executed this Agreement the date and year first above written. SONIA R. CARVALHO City Attorney By:�li,,V)V Laura A. Rossini Senior Assistant City Attorney RECOMMENDED FOR APPROVAL: _ i ED RAYA Executive Director Personnel Services Agency CITY OF SANTA ANA Raul Godinez II City Manager U.S. HEALTIIWORKS MEDICAL GROUP: OocuSigned by: Name: Joseph T. Mallas Title: usHW President & secretary to Medical Group Tax ID# 95-4643269 Pagc 8 of 9 DocuSign Envelope ID: FF7F3462-A44C-4038-8086-1F69FF4E2441 EXHIBIT A SERVICES and FEE SCHEDULE DocuSign Envelope ID: FF7F3462-A44C-4038-8086-1F69FF4E2441 DocuSign Envelope IDI E63EEB40-6DE4.48E1-A808-30ACB3F24B10 gELE SCHELIULH TYPE OF MEDICAL PROCEDURE M9llf]:B:ii#'S➢ AUDIOGRAM $ 25.00 BACK X-RAY $ 72.00 BLOOD LEAD LEVEL ZZP $ 61,00 BLOOD SCREENS -7 panel drug screen $ 86.00 CHESTX-RAY $ 55,00 CORE EXAM* $ 80.00 DMV $ 99,00 HEP A BLOOD SCREEN $ 50.00 HEP B 4000 SCREEN $ 5$.OD HEP B BOOSTER $ 100.00 MEP 8 TITER $ 55,00 HERB VACCINE $ 100,00 HEP AVACCINE $ 132,00 HEP $ 55.00 HIV BLOOD SCREEN $ 45,00 PULMONARY FUNCTION TEST $ 70.W RESPIRATOR FITTEST $ 50,00 RESPIRATOR PHYSICAL (requires Pufnionary Function Test) $ 80.00 RESPIRATOROLIESTIONIAREIP PX IS NOTREQUIR£0 W/CLEARANCE $ 28.00 TB $ 28,00 URINALYSIS $ 15.00 URINE COLLECYION FEE $ 28.00 *Care exams are basic physicals: Include vital signs, vision testing, physical exam, and urinalysis. 8 ACt'7)R®® CERTIFICATE OF LIABILITY INSURANCE UA 12/1612EtMMOD YYY) 01 7 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, Certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement s . PRODUCER InterWast Insurance Services License #0601094 222 Court Street CUNT NAmaAc' Michelle Goodwin CIC, CISR, CPSR PHONE FAx , 831-635-2247 tac Nal, 831-638-6801 EMAIL -, m9oodv4n@)iwins.cam Woodland CA 95695 INSURERS AFFORDING COVERAGE NAIC# INBURERA: LIbertV Mutual Fire Ins Co. 23035 EACH OCCURRENCE $1000,000 INSURED USHEA-i Inc. U,S.4Spri Springfield 25124 Springfield Ct., Ste 200 INSURERS: Liberty Insurance Corporation 42404 INSURER C: Safe National CasualtyCorp15106 INSURER Valencia CA 91355 INSURER E PRODUCTS -COMPIOPA09 P2,000,000 NSURER F: A COVERAGES CERTIFICATE NUMBER: 1957039178 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN POLICYNUMSER PMDD EFF MMUO EXP LIMITS A X COMMERCIAL GENERALLIASILITY CLAIMS -MADE M OCCUR Y T02091450294W 911/2017 9/12016 EACH OCCURRENCE $1000,000 _ AMA _ 6 $1,000,990 MED EXP(Amt one p.m.n) $10,000 PERSONAL&ADV INJURY $1000,000 GII AGGREGATE LIMIT APPLIES PER: POLICY ❑ JECLIjj T 1171 LOC OTHER: GENERAL AGGREGATE GENERAGGREGATE $2,000,000 PRODUCTS -COMPIOPA09 P2,000,000 $ A AUTOMOBILELIASILITY X X ANYAUTO OWNED SCHEDULED AUTOS ONLY AUTOS HIRED X NON -OWNED AUTOS ONLY AUTOS ONLY A$M91450294W7 9/1/2017 9/1/2018 COMBINED SINGLE LIMIT (Eae dd.M $ 1,000,00 BODILY INJURY(P., p®rs n)u $ BODILY INJURY Per.mtlent �$ ( ) PROPERTYOAMAGE $ era B X UMBRELLA LIAS EXCESS LIAR X OCCUR CWIM$-MADE TH7691460294D67 9/112017 9/1/2018 EACH OCCURRENCE $25000000 AGGREGATE $25000.000 DED X RETENTION$ io opp $ C WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN ANOFFIOMMEMBEREXCLUDED? YPROPRIETORfPARTNEWEXECUTNE ❑NIA (Mmdatary In NH) Hyx, tlaccdbe under DESCRIPTION OFOPERATION balow LDC4042721 9/1r2017 9/1@016 H- X P ?TR T TE E.L EACH ACCIDENT $20W009 E.L. DISEASE -EA EMPLOYEE $2,000,W0 E.L. DISEASE -POLICY LIMIT $2,EW 000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, A881tional Remarks Sch.d.le, may be etEchml Nmore."..Is q.].d) Re: 1619 East Edinger, Santa Ana, CA 02705 CERTIFICATE HOLDER CANCELLATION 110 dava notice for non Davment O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD s �r�e t SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Santa Ana 20 Civic Center Plaza Santa Ana CA 92701 ORIZ pI1THOR¢EOREPRE9EMATNE 'd {N^4a,7f4lL W.0 O 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD s �r�e t COMMERCIAL GENERAL LIABILITY CG 20 10 07 04 Policy Number: TB2691450294037 Effective Date: 09/01/17 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Location(s) Of Covered Operations ANY ENTITY FOR WHOM YOU ARE PERFORMING ALL COVERED PROJECTS ONGOING OPERATIONS, BUT ONLY IF REQUIRED BY WRITTEN CONTRACT PRIOR TO AN "OCCURRENCE" OR LOSS Information required to complete this Schedule if not shown above, will be shown in the Declarations. A. Section 11 — Who is An Insured is amended to include as an additional insured the person(s) or organizations(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by: 1. Your acts or omissions; or 2. The acts or omissions of those acting on your behalf; In the performance of your ongoing operations for the additional insured(s) at the locations(s) designated above. B. With respect to the Insurance afforded to these additional insureds, the following additional exclusions apply: This insurance CG 2010 07 04 does not apply to "bodily injury" or "property damage" occurring after: 1.AII work, including materials, parts or equipment furnished in connection with such work, on the project (other than service, maintenance or repairs) to be performed by or on behalf of the additional Insured(s) at the location of the covered operations has been completed; or 2.That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or organization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. © ISO Properties, Inc., 2004 Page 1 of 1 b rA