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HomeMy WebLinkAboutA9011 - COVID CLINIC INC.City Clerk Form Updated 7/21/2021 CONTRACT ABSTRACT Contract prepared by: ____________________________________________________ Submitted on: __________________ By: __________________________________ Note: _________________________________________________________________ Contract Compliance Exhibits: Yes No Signatures: Yes No Insurance: Yes No Bonds: Yes No Contract Approvals Council/ Community Redevelopment Agency Approval Date: __________________________ Agenda Item No./ Resolution No.: _______________________________________________ Agreement No: _____________________________________________________________ Contract Administration Lead Department: ___________________________________________________________ Contract Administrator: _______________________________________________________ Contract Company Name: __________________________________________________________ Company Contact: _________________________________________________________ Summary of Services: ______________________________________________________ Contract Price: ____________________________________________________________ Funding Source: ___________________________________________________________ Contract Term: ____________________________________________________________ Munis Contract Number: _____________________________________________________ Covid Clinic Inc. Wendy Dahl Non-Exclusive Operating and Space Lease Agreement $12,392.40/Monthly Revenue 1/1/2022 - 12/31/2022 Customer No. 35 Aviation Victoria Carpenter/Nadia Seery N/A N/A A9011 Nadia Seery 2/1/22 4 4 4 4 4 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD6122/3/2022 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME: CONTACT (A/C, No): FAX E-MAIL ADDRESS: PRODUCER (A/C, No, Ext): PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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 rights to the certificate holder in lieu of such endorsement(s). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT ER OTH- STATUTE PER LIMITS(MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) POLICY EFF POLICY NUMBERTYPE OF INSURANCELTR INSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 92262CAPalm Springs 3400 E Tahquitz Canyon Way, Suite 1 City of Palm Springs, Its Officials, Employees and Agents The City of Palm Springs, It's officials, employees and agents are listed as Additional Insured. Primary and noncontributory wording does apply to the general liability policy and commercial auto policy. Should any of the policies be cancelled before the expiration date thereof, the issuing company will mail 30 days written notice to the certificate holder named. 2,000,000Aggregate08/04/202208/04/2021LHM843914X Professional Liability D \ 5,000,000 5,000,000 12/15/202212/15/2021PLM-CB-SVUCFS8KVX 8 88 C 1,000,000 12/10/202212/10/202172APB005114X 8 8 8 8 B 2,000,000Cyber (Ea Occurrence) 3,000,000 1,000,000 10,000 50,000 1,000,000 11/14/202211/14/20210100132898-1X 8 Cyber Liability8 8 8 A 33138Landmark American Insurance Company 15792Underwriters at Lloyd's, London 68102National Fire & Marine Insurance Company 38920Kinsale Insurance Company 92648CAHUNTINGTON BEACH 18800 DELAWARE ST Covid Clinic casey.paulson@insideinsurance.net (866) 672-9668 EZ Insurance 84003UTAmerican Fork 915 South 500 East #210 Inside Insurance 01/06/2022 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 The ACORD name and logo are registered marks of ACORD CERTIFICATE HOLDER © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) AUTHORIZED REPRESENTATIVE CANCELLATION DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE LOCJECTPRO-POLICY GEN'L AGGREGATE LIMIT APPLIES PER: OCCURCLAIMS-MADE COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence)$DAMAGE TO RENTED EACH OCCURRENCE $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $RETENTIONDED CLAIMS-MADE OCCUR $ AGGREGATE $ EACH OCCURRENCE $ UMBRELLA LIAB EXCESS LIAB DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) INSRLTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)LIMITS PERSTATUTE OTH-ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ $ $ ANY PROPRIETOR/PARTNER/EXECUTIVE If yes, describe under DESCRIPTION OF OPERATIONS below (Mandatory in NH) OFFICER/MEMBER EXCLUDED? WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED HIRED AUTOS NON-OWNEDAUTOSAUTOS AUTOS COMBINED SINGLE LIMIT BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE $ $ $ $ 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. INSD ADDL WVD SUBR N / A $ $ (Ea accident) (Per accident) OTHER: 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 policy(ies) 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 certificate does not confer rights to the certificate holder in lieu of such endorsement(s). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: INSURED PHONE(A/C, No, Ext): PRODUCER ADDRESS:E-MAIL FAX(A/C, No): CONTACTNAME: NAIC # INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : INSURER(S) AFFORDING COVERAGE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 2/1/2022 PCF Insurance Services of the West LLC 21300 Victory Blvd Ste 700 Woodland Hills CA 91367 Candace Valentino 747.234.3179 818.703.0935 cvalentino@pcfoy.com State Compensation Insurance Fund 35076 COVICLI-01 Covid Clinic Inc. 18800 Delaware Street,Suite 800 Huntington Beach CA 92648 879184914 A Y 9274784-2021 4/20/2021 4/20/2022 X 1,000,000 1,000,000 1,000,000 Waiver of Subrogation Applies *30 Days notice of cancellation/10 days notice for non-payment of premium applies* The City of Palm Springs 3200 E.Tahquitz Canyon Way Palm Springs CA 92262 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612 DocuSign Envelope ID: 6DE8327A-5CB1-4A2A-90BC-4BE41DFCD612