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HomeMy WebLinkAbout24I360 - Ailevon Pacific Aviation Consulting LLCCONTRACT ABSTRACT Contract/Amendment Name of Contract: Company Name: Company Contact: Email: Summary of Services: Contract Price: Contract Term: Public Integrity/ Business Disclosure Forms: Contract Administration Lead Department: Contract Administrator/ Ext: Contract Approvals Council/City Manager Approval Date: Agreement Number: Amendment Number: Contract Compliance Exhibits:Signatures: Insurance:Bonds: Business License: Sole Source Co-Op CoOp Agmt #:Sole Source Documents:CoOp Name: CoOp Pricing: By:Submitted on: Contract Abstract Form Rev  $XWKRUL]HG6LJQHUV 1DPH(PDLO &&RUSRUDWLRQVUHTXLUHVLJQDWXUHV Professional Services Agreement Ailevon Pacific Aviation Consulting LLC Brad Difiore brad.difiore@ailevonpacific.com Consulting Services to provide a passenger leakage study $21,500 November 19, 2024 - May 18, 2025 (6-Months) N/A Brad Difiore, brad.difiore@ailevonpacific.com Aviation Daniel Meier/ 3806 N/A 24I360 N/A Yes Yes Yes Yes N/A No N/A N/A N/A N/A 11/19/2024 Tanya Perez Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 1 of 65 CONSULTING SERVICES AGREEMENT NO. 24I360 PASSENGER LEAKAGE STUDY THIS AGREEMENT FOR CONSULTING SERVICES (“Agreement”) is made and entered into on November 19, 2024, by and between the City of Palm Springs, a California charter city and municipal corporation (“City”), and Ailevon Pacific Aviation Consulting LLC, a Limited Liability Company, (“Consultant”). City and Consultant are individually referred to as “Party” and are collectively referred to as the “Parties”. RECITALS A. City requires the services of a qualified consulting firm, to conduct and provide a passenger leakage study for the Palm Springs International Airport, (“Project”). B. Consultant has submitted to City a proposal to provide a passenger leakage study for the Palm Springs International Airport, to City under the terms of this Agreement. C. Based on its experience, education, training, and reputation, Consultant is qualified and desires to provide the necessary services to City for the Project. D. City desires to retain the services of Consultant for the Project. NOW, THEREFORE, in consideration of the promises and mutual obligations, covenants, and conditions contained herein, and other valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Parties agree as follows: AGREEMENT 1. CONSULTANT SERVICES 1.1 Scope of Services. In compliance with all terms and conditions of this Agreement, Consultant shall provide services to City as described in the Scope of Services/Work attached to this Agreement as Exhibit “A” and incorporated by reference (the “Services” or “Work”). Exhibit "A" includes the agreed upon schedule of performance and the schedule of fees. Consultant warrants that the Services shall be performed in a competent, professional, and satisfactory manner consistent with the level of care and skill ordinarily exercised by high quality, experienced, and well qualified members of the profession currently practicing under similar conditions. In the event of any inconsistency between the terms contained in the Scope of Services/Work and the terms set forth in this Agreement, the terms set forth in this Agreement shall govern. 1.2 Compliance with Law. Consultant shall comply with all applicable federal, state, and local laws, statutes and ordinances and all lawful orders, rules, and regulations when performing the Services. Consultant shall be liable for all violations of such laws and regulations in connection with the Services and this Agreement.         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 2 of 65 1.3 Licenses and Permits. Consultant shall obtain at its sole cost and expense such licenses, permits, and approvals as may be required by law for the performance of the Services required by this Agreement. 1.4 Familiarity with Work. By executing this Agreement, Consultant warrants that it has carefully considered how the Work should be performed and fully understands the facilities, difficulties, and restrictions attending performance of the Work under this Agreement. 2. TIME FOR COMPLETION The time for completion of the Services to be performed by Consultant is an essential condition of this Agreement. Consultant shall prosecute regularly and diligently the work of this Agreement according to the agreed upon schedule of performance set forth in Exhibit “A.” Neither Party shall be accountable for delays in performance caused by any condition beyond the reasonable control and without the fault or negligence of the non-performing Party. Delays shall not entitle Consultant to any additional compensation regardless of the Party responsible for the delay. 3. COMPENSATION OF CONSULTANT 3.1 Compensation of Consultant. Consultant shall be compensated and reimbursed for the services rendered under this Agreement in accordance with the schedule of fees set forth in Exhibit “A”. The total amount of Compensation shall not exceed $21,500. 3.2 Method of Payment. In any month in which Consultant wishes to receive payment, Consultant shall submit to City an invoice for Services rendered prior to the date of the invoice, no later than the first working day of such month, in the form approved by City’s finance director. Payments shall be based on the hourly rates set forth in Exhibit “A” for authorized services performed. City shall pay Consultant for all expenses stated in the invoice that are approved by City and consistent with this Agreement, within thirty (30) days of receipt of Consultant’s invoice. 3.3 Changes. In the event any change or changes in the Scope of Services/Work is requested by City, Parties shall execute a written amendment to this Agreement, specifying all proposed amendments, including, but not limited to, any additional fees. An amendment may be entered into: A. To provide for revisions or modifications to documents, work product, or Work, when required by the enactment or revision of any subsequent law; or B. To provide for additional services not included in this Agreement or not customarily furnished in accordance with generally accepted practice in Consultant’s profession. 3.4 Appropriations. This Agreement is subject to, and contingent upon, funds being appropriated by the City Council of City for each fiscal year. If such appropriations are not made, this Agreement shall automatically terminate without penalty to City.         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 3 of 65 4. PERFORMANCE SCHEDULE 4.1 Time of Essence. Time is of the essence in the performance of this Agreement. 4.2 Schedule of Performance. All Services rendered under this Agreement shall be performed under the agreed upon schedule of performance set forth in Exhibit “A.” Any time period extension must be approved in writing by the Contract Officer. 4.3 Force Majeure. The time for performance of Services to be rendered under this Agreement may be extended because of any delays due to a Force Majeure Event, if Consultant notifies the Contract Officer within ten (10) days of the commencement of the Force Majeure Event. A Force Majeure Event shall mean an event that materially affects the Consultant’s performance and is one or more of the following: (1) Acts of God or other natural disasters occurring at the project site; (2) terrorism or other acts of a public enemy; (3) orders of governmental authorities (including, without limitation, unreasonable and unforeseeable delay in the issuance of permits or approvals by governmental authorities that are required for the Work); and (4) pandemics, epidemics or quarantine restrictions. For purposes of this section, “orders of governmental authorities,” includes ordinances, emergency proclamations and orders, rules to protect the public health, welfare and safety, and other actions of the City in its capacity as a municipal authority. After Consultant notification, the Contract Officer shall investigate the facts and the extent of any necessary delay and extend the time for performing the Services for the period of the enforced delay when and if, in the Contract Officer’s judgment, such delay is justified. The Contract Officer’s determination shall be final and conclusive upon the Parties to this Agreement. The Consultant will not receive an adjustment to the contract price or any other compensation. Notwithstanding the foregoing, the City may still terminate this Agreement in accordance with the termination provisions of this Agreement. 4.4 Term. Unless earlier terminated in accordance with Section 4.5 of this Agreement, this Agreement shall continue in full force and effect for a period of 6-months, commencing on November 19, 2024, and ending on May 18, 2025, unless extended by mutual written agreement of the parties. 4.5 Termination Prior to Expiration of Term. City may terminate this Agreement at any time, with or without cause, upon thirty (30) days written notice to Consultant. Where termination is due to the fault of Consultant and constitutes an immediate danger to health, safety, and general welfare, the period of notice shall be such shorter time as may be determined by the City. Upon receipt of the notice of termination, Consultant shall immediately cease all Services except such as may be specifically approved by the Contract Officer. Consultant shall be entitled to compensation for all Services rendered prior to receipt of the notice of termination and for any Services authorized by the Contract Officer after such notice. City shall not be liable for any costs other than the charges or portions thereof which are specified herein. Consultant shall not be entitled to payment for unperformed Services and shall not be entitled to damages or compensation for termination of Work. If the termination is for cause, the City shall have the right to take whatever steps it deems necessary to correct Consultant's deficiencies and charge the cost thereof to Consultant, who shall be liable for the full cost of the City's corrective action. Consultant may not terminate this Agreement except for cause upon thirty (30) days written notice to City.         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 4 of 65 5. COORDINATION OF WORK 5.1 Representative of Consultant. The following principal of Consultant is designated as being the principal and representative of Consultant authorized to act and make all decisions in its behalf with respect to the specified Services and work: Brad Difiore, Managing Director. It is expressly understood that the experience, knowledge, education, capability, and reputation of the foregoing principal is a substantial inducement for City to enter into this Agreement. Therefore, the foregoing principal shall be responsible during the term of this Agreement for directing all activities of Consultant and devoting sufficient time to personally supervise the Services under this Agreement. The foregoing principal may not be changed by Consultant without prior written approval of the Contract Officer. 5.2 Contract Officer. The Contract Officer shall be the City Manager or his/her designee ("Contract Officer"). Consultant shall be responsible for keeping the Contract Officer fully informed of the progress of the performance of the Services. Consultant shall refer any decisions that must be made by City to the Contract Officer. Unless otherwise specified, any approval of City shall mean the approval of the Contract Officer. 5.3 Prohibition Against Subcontracting or Assignment. The experience, knowledge, education, capability, and reputation of Consultant, its principals and employees, were a substantial inducement for City to enter into this Agreement. Consultant shall not contract with any other individual or entity to perform any Services required under this Agreement without the City's express written approval. In addition, neither this Agreement nor any interest may be assigned or transferred, voluntarily or by operation of law, without the prior written approval of City. Subcontracts, if any, shall contain a provision making them subject to all provisions stipulated in this Agreement including without limitation the insurance and indemnification requirements. If Consultant is permitted to subcontract any part of this Agreement by City, Consultant shall be responsible to City for the acts and omissions of its subcontractor(s) in the same manner as it is for persons directly employed. Nothing contained in this Agreement shall create any contractual relationships between any subcontractor and City. 5.4 Independent Consultant. Neither City nor any of its employees shall have any control over the manner, mode, or means by which Consultant, its agents or employees, perform the Services required, except as otherwise specified. Consultant shall perform all required Services as an independent Consultant of City and shall not be an employee of City and shall remain at all times as to City a wholly independent Consultant with only such obligations as are consistent with that role; however, City shall have the right to review Consultant’s work product, result, and advice. Consultant shall not at any time or in any manner represent that it or any of its agents or employees are agents or employees of City. Consultant shall pay all wages, salaries, and other amounts due personnel in connection with their performance under this Agreement and as required by law. Consultant shall be responsible for all reports and obligations respecting such personnel, including, but not limited to: social security taxes, income tax withholding, unemployment insurance, and workers’ compensation insurance. Consultant shall not have any authority to bind City in any manner. 5.5 Personnel. Consultant agrees to assign the following individuals to perform the Services in this Agreement. Consultant shall not alter the assignment of the following personnel         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 5 of 65 without the prior written approval of the Contract Officer. Acting through the City Manager, the City shall have the unrestricted right to order the removal of any personnel assigned by Consultant by providing written notice to Consultant. Name: Title: Brad Difiore Managing Director 5.6 California Labor Code Requirements. A. Consultant is aware of the requirements of California Labor Code Sections 1720 et seq. and 1770 et seq., which require the payment of prevailing wage rates and the performance of other requirements on certain “public works” and “maintenance” projects (“Prevailing Wage Laws”). If the Services are being performed as part of an applicable “public works” or “maintenance” project, as defined by the Prevailing Wage Laws, and if the total compensation is $15,000 or more for maintenance or $25,000 or more for construction, alteration, demolition, installation, or repair, Consultant agrees to fully comply with such Prevailing Wage Laws. Consultant shall defend, indemnify and hold the City, its officials, officers, employees and agents free and harmless from any claims, liabilities, costs, penalties or interest arising out of any failure or alleged failure to comply with the Prevailing Wage Laws. It shall be mandatory upon the Consultant and all subcontractors to comply with all California Labor Code provisions, which include but are not limited to prevailing wages (Labor Code Sections 1771, 1774 and 1775), employment of apprentices (Labor Code Section 1777.5), certified payroll records (Labor Code Sections 1771.4 and 1776), hours of labor (Labor Code Sections 1813 and 1815) and debarment of contractors and subcontractors (Labor Code Section 1777.1). B. If the Services are being performed as part of an applicable “public works” or “maintenance” project and if the total compensation is $15,000 or more for maintenance or $25,000 or more for construction, alteration, demolition, installation, or repair, then pursuant to Labor Code Sections 1725.5 and 1771.1, the Consultant and all subcontractors performing such Services must be registered with the Department of Industrial Relations. Consultant shall maintain registration for the duration of the Project and require the same of any subcontractors, as applicable. This Agreement may also be subject to compliance monitoring and enforcement by the Department of Industrial Relations. It shall be Consultant’s sole responsibility to comply with all applicable registration and labor compliance requirements. 6. INSURANCE Consultant shall procure and maintain, at its sole cost and expense, policies of insurance as set forth in the attached Exhibit "B", incorporated herein by reference. 7. INDEMNIFICATION. 7.1 Indemnification. To the fullest extent permitted by law, Consultant shall defend (at Consultant’s sole cost and expense), indemnify, protect, and hold harmless City, its elected officials, officers, employees, agents, and volunteers (collectively the “Indemnified Parties”), from and against any and all liabilities, actions, suits, claims, demands, losses, costs,         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 6 of 65 judgments, arbitration awards, settlements, damages, demands, orders, penalties, and expenses including legal costs and attorney fees (collectively “Claims”), including but not limited to Claims arising from injuries to or death of persons (Consultant’s employees included), for damage to property, including property owned by City, for any violation of any federal, state, or local law or ordinance or in any manner arising out of, pertaining to, or incident to any acts, errors or omissions, or willful misconduct committed by Consultant, its officers, employees, representatives, and agents, that arise out of or relate to Consultant’s performance of Services or this Agreement. This indemnification clause excludes Claims arising from the sole negligence or willful misconduct of the Indemnified Parties. Under no circumstances shall the insurance requirements and limits set forth in this Agreement be construed to limit Consultant’s indemnification obligation or other liability under this Agreement. Consultant’s indemnification obligation shall survive the expiration or earlier termination of this Agreement until all actions against the Indemnified Parties for such matters indemnified are fully and finally barred by the applicable statute of limitations or, if an action is timely filed, until such action is final. 7.2 Design Professional Services Indemnification and Reimbursement. If Consultant’s obligation to defend, indemnify, and/or hold harmless arises out of Consultant’s performance as a “design professional” (as that term is defined under Civil Code section 2782.8), then, and only to the extent required by Civil Code section 2782.8, which is fully incorporated herein, Consultant’s indemnification obligation shall be limited to the extent which the Claims arise out of, pertain to, or relate to the negligence, recklessness, or willful misconduct of the Consultant in the performance of the Services or this Agreement, and, upon Consultant obtaining a final adjudication by a court of competent jurisdiction, Consultant’s liability for such claim, including the cost to defend, shall not exceed the Consultant’s proportionate percentage of fault. 8. RECORDS AND REPORTS 8.1 Reports. Consultant shall periodically prepare and submit to the Contract Officer reports concerning the performance of the Services required by this Agreement, or as the Contract Officer shall require. 8.2 Records. Consultant shall keep complete, accurate, and detailed accounts of all time, costs, expenses, and expenditures pertaining in any way to this Agreement. Consultant shall keep such books and records as shall be necessary to properly perform the Services required by this Agreement and enable the Contract Officer to evaluate the performance of such Services. The Contract Officer shall have full and free access to such books and records at all reasonable times, including the right to inspect, copy, audit, and make records and transcripts from such records. 8.3 Ownership of Documents. All drawings, specifications, reports, records, documents, and other materials prepared by Consultant in the performance of this Agreement shall be the property of City. Consultant shall deliver all above-referenced documents to City upon request of the Contract Officer or upon the termination of this Agreement. Consultant shall have no claim for further employment or additional compensation as a result of the exercise by City of its full rights or ownership of the documents and materials. Consultant may retain copies of such documents for Consultant's own use. Consultant shall have an unrestricted right to use the concepts embodied in such documents.         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 7 of 65 8.4 Release of Documents. All drawings, specifications, reports, records, documents, and other materials prepared by Consultant in the performance of Services under this Agreement shall not be released publicly without the prior written approval of the Contract Officer. 8.5 Audit and Inspection of Records. After receipt of reasonable notice and during the regular business hours of City, Consultant shall provide City, or other agents of City, such access to Consultant’s books, records, payroll documents, and facilities as City deems necessary to examine, copy, audit, and inspect all accounting books, records, work data, documents, and activities directly related to Consultant’s performance under this Agreement. Consultant shall maintain such books, records, data, and documents in accordance with generally accepted accounting principles and shall clearly identify and make such items readily accessible to such parties during the term of this Agreement and for a period of three (3) years from the date of final payment by City hereunder. 9. ENFORCEMENT OF AGREEMENT 9.1 California Law. This Agreement shall be construed and interpreted both as to validity and to performance of the parties in accordance with the laws of the State of California. Legal actions concerning any dispute, claim, or matter arising out of or in relation to this Agreement shall be instituted in the Superior Court of the County of Riverside, State of California, or any other appropriate court in such county, and Consultant covenants and agrees to submit to the personal jurisdiction of such court in the event of such action. 9.2 Interpretation. This Agreement shall be construed as a whole according to its fair language and common meaning to achieve the objectives and purposes of the Parties. The terms of this Agreement are contractual and the result of negotiation between the Parties. Accordingly, any rule of construction of contracts (including, without limitation, California Civil Code Section 1654) that ambiguities are to be construed against the drafting party, shall not be employed in the interpretation of this Agreement. The caption headings of the various sections and paragraphs of this Agreement are for convenience and identification purposes only and shall not be deemed to limit, expand, or define the contents of the respective sections or paragraphs. 9.3 Waiver. No delay or omission in the exercise of any right or remedy of a non- defaulting party on any default shall impair such right or remedy or be construed as a waiver. No consent or approval of City shall be deemed to waive or render unnecessary City’s consent to or approval of any subsequent act of Consultant. Any waiver by either party of any default must be in writing. No such waiver shall be a waiver of any other default concerning the same or any other provision of this Agreement. 9.4 Rights and Remedies are Cumulative. Except with respect to rights and remedies expressly declared to be exclusive in this Agreement, the rights and remedies of the parties are cumulative. The exercise by either Party of one or more of such rights or remedies shall not preclude the exercise by it, at the same or different times, of any other rights or remedies for the same default or any other default by the other Party.         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 8 of 65 9.5 Legal Action. In addition to any other rights or remedies, either Party may take legal action, in law or in equity, to cure, correct, or remedy any default, to recover damages for any default, to compel specific performance of this Agreement, to obtain injunctive relief, a declaratory judgment, or any other remedy consistent with the purposes of this Agreement. 9.6 Attorney Fees. In the event any dispute between the Parties with respect to this Agreement results in litigation or any non-judicial proceeding, the prevailing Party shall be entitled, in addition to such other relief as may be granted, to recover from the non-prevailing Party all reasonable costs and expenses. These include but are not limited to reasonable attorney fees, expert consultant fees, court costs and all fees, costs, and expenses incurred in any appeal or in collection of any judgment entered in such proceeding. 10. CITY OFFICERS AND EMPLOYEES: NON-DISCRIMINATION 10.1 Non-Liability of City Officers and Employees. No officer or employee of City shall be personally liable to the Consultant, or any successor-in-interest, in the event of any default or breach by City or for any amount which may become due to the Consultant or its successor, or for breach of any obligation of the terms of this Agreement. 10.2 Conflict of Interest. Consultant acknowledges that no officer or employee of the City has or shall have any direct or indirect financial interest in this Agreement, nor shall Consultant enter into any agreement of any kind with any such officer or employee during the term of this Agreement and for one (1) year thereafter. Consultant warrants that Consultant has not paid or given, and will not pay or give, any third party any money or other consideration in exchange for obtaining this Agreement. 10.3 Covenant Against Discrimination. In connection with its performance under this Agreement, Consultant shall not discriminate against any employee or applicant for employment because of actual or perceived race, religion, color, sex, age, marital status, ancestry, national origin ( i.e., place of origin, immigration status, cultural or linguistic characteristics, or ethnicity), sexual orientation, gender identity, gender expression, physical or mental disability, or medical condition (each a “prohibited basis”). Consultant shall ensure that applicants are employed, and that employees are treated during their employment, without regard to any prohibited basis. As a condition precedent to City’s lawful capacity to enter this Agreement, and in executing this Agreement, Consultant certifies that its actions and omissions hereunder shall not incorporate any discrimination arising from or related to any prohibited basis in any Consultant activity, including but not limited to the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship; and further, that Consultant is in full compliance with the provisions of Palm Springs Municipal Code Section 7.09.040, including without limitation the provision of benefits, relating to non- discrimination in city contracting. 11. MISCELLANEOUS PROVISIONS 11.1 Notice. Any notice, demand, request, consent, approval, or communication that either Party desires, or is required to give to the other Party or any other person shall be in         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 9 of 65 writing and either served personally or sent by pre-paid, first-class mail to the address set forth below. Notice shall be deemed communicated seventy-two (72) hours from the time of mailing if mailed as provided in this Section. Either Party may change its address by notifying the other Party of the change of address in writing. To City: City of Palm Springs Attention: City Manager/ City Clerk 3200 E. Tahquitz Canyon Way Palm Springs, California 92262 To Consultant: Ailevon Pacific Aviation Consulting LLC Attention: Brad DiFiore/ Managing Director 1100 Peachtree St. NE Suite 250 Atlanta, GA 30309 11.2 Integrated Agreement. This Agreement constitutes the entire understanding between the Parties and supersedes and cancels all prior negotiations, arrangements, agreements, representations, and understandings, if any, made by or among the Parties with respect to the subject matter in this Agreement. 11.3 Amendment. No amendments or other modifications of this Agreement shall be binding unless through written agreement by all Parties. 11.4 Severability. Whenever possible, each provision of this Agreement shall be interpreted in such a manner as to be effective and valid under applicable law. In the event that any one or more of the phrases, sentences, clauses, paragraphs, or sections contained in this Agreement shall be declared invalid or unenforceable by valid judgment or decree of a court of competent jurisdiction, such invalidity or unenforceability shall not affect any of the remaining phrases, sentences, clauses, paragraphs, or sections of this Agreement, which shall be interpreted to carry out the intent of the parties. 11.5 Successors in Interest. This Agreement shall be binding upon and inure to the benefit of the Parties’ successors and assignees. 11.6 Third Party Beneficiary. Except as may be expressly provided for in this Agreement, nothing contained in this Agreement is intended to confer, nor shall this Agreement be construed as conferring, any rights, including, without limitation, any rights as a third-party beneficiary or otherwise, upon any entity or person not a party to this Agreement. 11.7 Recitals. The above-referenced Recitals are hereby incorporated into the Agreement as though fully set forth in this Agreement and each Party acknowledges and agrees that such Party is bound, for purposes of this Agreement, by the same.         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 10 of 65 11.8 Authority. The persons executing this Agreement on behalf of the Parties warrant that they are duly authorized to execute this Agreement on behalf of Parties and that by so executing this Agreement the Parties are formally bound to the provisions of this Agreement. 11.9 Counterparts. This Agreement may be signed in counterparts, each of which shall constitute an original. 12. COMPLIANCE WITH ECONOMIC SANCTIONS IN RESPONSE TO RUSSIA'S ACTIONS IN UKRAINE. When funding for the services is provided, in whole or in part, by an agency controlled of the State of California, Consultant shall fully and adequately comply with California Executive Order N-6-22 (“Russian Sanctions Program”). As part of this compliance process, Consultant shall also certify compliance with the Russian Sanctions Program by completing the form located in Attachment “C” (Russian Sanctions Certification), attached hereto and incorporated herein by reference. Consultant shall also require any subconsultants to comply with the Russian Sanctions Program and certify compliance pursuant to this Section. 13. FEDERAL PROVISIONS Since funding for the Services is provided, in whole or in part, by the Federal Aviation Administration, Supplier shall also fully and adequately comply with the provisions included in Exhibit “D” attached hereto and incorporated herein by reference (“Federal Provisions”). With respect to any conflict between such Federal Provisions and the terms of this Agreement and/or the provisions of state law, the more stringent requirement shall control. [SIGNATURES ON NEXT PAGE]         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 11 of 65 SIGNATURE PAGE TO AGREEMENT BY AND BETWEEN THE CITY OF PALM SPRINGS AND AILEVON PACIFIC AVIATION CONSULTING LLC IN WITNESS WHEREOF, the Parties have executed this Agreement as of the dates stated below. CONTRACTOR: By: _____________________________________ By: _________________________________________ Signature Signature (2nd signature required for Corporations) Date: Date: CITY OF PALM SPRINGS: APPROVED BY CITY COUNCIL: Date: N/A Item No. N/A APPROVED AS TO FORM: ATTEST: By: ___________________________ By: _______________________________ City Attorney City Clerk APPROVED: By: _______________________________ Date: City Manager – over $50,000 Deputy/Assistant City Manager – up to $50,000 Director – up to $25,000 Manager – up to $5,000           Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE 11/19/2024 Page 12 of 65 EXHIBIT “A” SCOPE OF SERVICES/WORK Including, Schedule of Fees And Schedule of Performance         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 13 of 65 Service: Complete a U.S. (domestic) and Mexico market leakage study using ARC Market Locator, and Department of Transportation data for the Palm Springs International Airport (Airport) catchment area. Scope: 1. Market Leakage Study Report: o Catchment Area Definition: ƒ Consultant will define the Airport’s catchment area by dividing it into 4-7 distinct zones using relevant zip codes (e.g., Airports Primary, Airports Secondary, etc.) o Analysis Components: ƒ Airport Usage by Zip Code: ƒ Examination of the Airport’s primary catchment area and secondary/swing zones, analyzing Airport utilization in relation to competing Airports ƒ Carrier Usage by Zip Code: ƒ Analysis of the different carriers used by passengers in the defined catchment area ƒ Catchment Area Revenue Leakage: ƒ Assessment of revenue lost to other Airports ƒ Catchment Leakage by Market: ƒ Detailed breakdown of leakage by specific market segments ƒ Key Origin & Destination (O&D) Market Breakdown: ƒ Analysis of O&D markets by zip code ƒ Points of Origin for Passengers: ƒ Identification of where passengers traveling to the Airport originate. ƒ Point of Sale for Airport Passengers: ƒ Examination of where Airport passengers are purchasing their tickets ƒ Top Markets by Airport Usage: ƒ Identification of the top markets based on Airport usage statistics 2. Format of Delivery: o The study will be delivered in PowerPoint format (.ppt) and will include two packages: ƒ A full study ƒ An executive summary 3. Data Utilization: o The Consultant will utilize year-ending 2Q 2024 data to ensure relevance and accuracy in the findings Completion Term & Compensation: x Work will be completed on or before May 18, 2025. x Total $21,500 which includes any and all data costs.         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 14 of 65 EXHIBIT “B” INSURANCE PROVISIONS Including Verification of Coverage, Sufficiency of Insurers, Errors and Omissions Coverage, Minimum Scope of Insurance, Deductibles and Self-Insured Retentions, and Severability of Interests (Separation of Insureds)         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 15 of 65 INSURANCE 1. Procurement and Maintenance of Insurance. Consultant shall procure and maintain public liability and property damage insurance against all claims for injuries against persons or damages to property resulting from Consultant’s performance under this Agreement. Consultant shall procure and maintain all insurance at its sole cost and expense, in a form and content satisfactory to the City, and submit concurrently with its execution of this Agreement. Consultant shall also carry workers’ compensation insurance in accordance with California workers’ compensation laws. Such insurance shall be kept in full force and effect during the term of this Agreement, including any extensions. Such insurance shall not be cancelable without thirty (30) days advance written notice to City of any proposed cancellation. Certificates of insurance evidencing the foregoing and designating the City, its elected officials, officers, employees, agents, and volunteers as additional named insureds by original endorsement shall be delivered to and approved by City prior to commencement of Services. The procuring of such insurance and the delivery of policies, certificates, and endorsements evidencing the same shall not be construed as a limitation of Consultant’s obligation to indemnify City, its elected officials, officers, agents, employees, and volunteers. 2. Minimum Scope of Insurance. The minimum amount of insurance required under this Agreement shall be as follows: A. Comprehensive general liability and personal injury with limits of at least one million dollars ($1,000,000.00) combined single limit coverage per occurrence and two million dollars ($2,000,000) general aggregate; B. Automobile liability insurance with limits of at least one million dollars ($1,000,000.00) per occurrence; C. Professional liability (errors and omissions) insurance with limits of at least one million dollars ($1,000,000.00) per occurrence and two million dollars ($2,000,000) annual aggregate is: ___X_____ required _________ is not required; D. Workers’ Compensation insurance in the statutory amount as required by the State of California and Employer’s Liability Insurance with limits of at least one million dollars $1 million per occurrence. If Consultant has no employees, Consultant shall complete the City’s Request for Waiver of Workers’ Compensation Insurance Requirement form. 3. Primary Insurance. For any claims related to this Agreement, Consultant’s insurance coverage shall be primary with respect to the City and its respective elected officials, officers, employees, agents, and volunteers. Any insurance or self-insurance maintained by City and its respective elected officials, officers, employees, agents, and volunteers shall be in excess of Consultant’s insurance and shall not contribute with it. For Workers’ Compensation and Employer’s Liability Insurance only, the insurer shall waive all rights of subrogation and         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 16 of 65 contribution it may have against City, its elected officials, officers, employees, agents, and volunteers. 4. Errors and Omissions Coverage. If Errors & Omissions Insurance is required, and if Consultant provides claims made professional liability insurance, Consultant shall also agree in writing either (1) to purchase tail insurance in the amount required by this Agreement to cover claims made within three years of the completion of Consultant’s Services under this Agreement, or (2) to maintain professional liability insurance coverage with the same carrier in the amount required by this Agreement for at least three years after completion of Consultant’s Services under this Agreement. Consultant shall also be required to provide evidence to City of the purchase of the required tail insurance or continuation of the professional liability policy. 5. Sufficiency of Insurers. Insurance required in this Agreement shall be provided by authorized insurers in good standing with the State of California. Coverage shall be provided by insurers admitted in the State of California with an A.M. Best’s Key Rating of B++, Class VII, or better, unless otherwise acceptable to the City. 6. Verification of Coverage. Consultant shall furnish City with both certificates of insurance and endorsements, including additional insured endorsements, effecting all of the coverages required by this Agreement. The certificates and endorsements are to be signed by a person authorized by that insurer to bind coverage on its behalf. All proof of insurance is to be received and approved by the City before work commences. City reserves the right to require Consultant’s insurers to provide complete, certified copies of all required insurance policies at any time. Additional insured endorsements are not required for Errors and Omissions and Workers’ Compensation policies. Verification of Insurance coverage may be provided by: (1) an approved General and/or Auto Liability Endorsement Form for the City of Palm Springs or (2) an acceptable Certificate of Liability Insurance Coverage with an approved Additional Insured Endorsement with the following endorsements stated on the certificate: A. "The City of Palm Springs, its officials, employees, and agents are named as an additional insured…” ("as respects City of Palm Springs Contract No.___" or "for any and all work performed with the City" may be included in this statement). B. "This insurance is primary and non-contributory over any insurance or self- insurance the City may have..." ("as respects City of Palm Springs Contract No.___" or "for any and all work performed with the City" may be included in this statement). C. "Should any of the above described policies be canceled before the expiration date thereof, the issuing company will mail 30 days written notice to the Certificate Holder named." Language such as, “endeavor to” mail and "but failure to mail such notice shall impose no obligation or liability of any kind upon the company, its agents or representative" is not acceptable and must be crossed out.         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 17 of 65 D. Both the Workers’ Compensation and Employers' Liability policies shall contain the insurer's waiver of subrogation in favor of City, its elected officials, officers, employees, agents, and volunteers. In addition to the endorsements listed above, the City of Palm Springs shall be named the certificate holder on the policies. All certificates of insurance and endorsements are to be received and approved by the City before work commences. All certificates of insurance must be authorized by a person with authority to bind coverage, whether that is the authorized agent/broker or insurance underwriter. Failure to obtain the required documents prior to the commencement of work shall not waive the Consultant’s obligation to provide them. 7. Deductibles and Self-Insured Retentions. Any deductibles or self-insured retentions must be declared to and approved by the City prior to commencing any work or Services under this Agreement. At the option of the City, either (1) the insurer shall reduce or eliminate such deductibles or self-insured retentions with respect to the City, its elected officials, officers, employees, agents, and volunteers; or (2) Consultant shall procure a bond guaranteeing payment of losses and related investigations, claim administration, and defense expenses. Certificates of Insurance must include evidence of the amount of any deductible or self-insured retention under the policy. Consultant guarantees payment of all deductibles and self-insured retentions. 8. Severability of Interests (Separation of Insureds). This insurance applies separately to each insured against whom claim is made or suit is brought except with respect to the limits of the insurer’s liability.         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 18 of 65 EXHIBIT “C” EXECUTIVE ORDER N-6-22 CERTIFICATION Executive Order N-6-22 issued by Governor Gavin Newsom on March 4, 2022, directs all agencies and departments that are subject to the Governor’s authority to (a) terminate any contracts with any individuals or entities that are determined to be a target of economic sanctions against Russia and Russian entities and individuals; and (b) refrain from entering into any new contracts with such individuals or entities while the aforementioned sanctions are in effect. Executive Order N-6-22 also requires that any contractor that: (1) currently has a contract with the City of Palm Springs funded through grant funds provided by the State of California; and/or (2) submits a bid or proposal or otherwise proposes to or enter into or renew a contract with the City of Palm Springs with State of California grant funds, certify that the person is not the target of any economic sanctions against Russia and Russian entities and individuals. The contractor hereby certifies, SUBJECT TO PENALTY FOR PERJURY, that a) the contractor is not a target of any economic sanctions against Russian and Russian entities and individuals as discussed in Executive Order N-6-22 and b) the person signing below is duly authorized to legally bind the Contractor. This certification is made under the laws of the State of California. Signature: Printed Name: Title: Firm Name: Date:                  Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 19 of 65 Exhibit “D” FEDERAL AVIATION ADMINISTRATION FEDERAL PROVISIONS Provision Reference Provision Description Page No. FAA - 01 Access to Records and Reports 2 FAA - 02 Affirmative Action Requirement * 3 FAA – 03 Breach of Contract Terms 5 FAA – 04 Buy American Preference * 6 FAA – 05 Civil Rights General 7 FAA – 06 Civil Rights – Title VI Assurances * 8 FAA – 07 Clean Air and Water Pollution Control 11 FAA – 08 Contract Work Hours and Safety Standards Act Requirements 12 FAA – 09 Copeland Anti-Kickback Act 14 FAA – 10 Davis Bacon Requirements 15 FAA – 11 Debarment and Suspension * 22 FAA – 12 Disadvantaged Business Enterprise * 23 FAA – 13 Distracted Driving 25 FAA – 14 Prohibition on Certain Telecommunications and Video Surveillance Services or Equipment 26 FAA – 15 Drug Free Workplace Requirements (not applicable to Contractors) 27 FAA – 16 Equal Employment Opportunity 28 FAA – 17 Federal Fair Labor Standards Act * 36 FAA – 18 Lobbying and Influencing Federal Employees 37 FAA – 19 Prohibition of Segregated Facilities 38 FAA – 20 Occupational Safety and Health Act of 1970 39 FAA – 21 Procurement of Recovered Materials * 40 FAA – 22 Right to Inventions 41 FAA – 23 Seismic Safety 42 FAA – 24 Tax Delinquency and Felony Convictions* 43 FAA – 25 Termination of Contract 44 FAA – 26 Trade Restriction Certification (Foreign) * 45 FAA – 27 Veteran’s Preference 47 FAA – 28 Domestic Preferences for Procurements * 48 *Solicitation Clause also Updated 5.24.2023         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 20 of 65 FAA - 01 Access to Records and Reports APPLICABILITY – pertains to all contracts. The Contractor must maintain an acceptable cost accounting system. The Contractor agrees to provide the City, the Federal Aviation Administration and the Comptroller General of the United States or any of their duly authorized representatives access to any books, documents, papers and records of the Contractor which are directly pertinent to the specific contract for the purpose of making audit, examination, excerpts and transcriptions. The Contractor agrees to maintain all books, records and reports required under this contract for a period of not less than three years after final payment is made and all pending matters are closed. Reference: 2 CFR § 200.334, 2 CFR § 200.337, FAA Order 5100.38         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 21 of 65 FAA - 02 Affirmative Action Requirement NOTICE OF REQUIREMENT FOR AFFIRMATIVE ACTION TO ENSURE EQUAL EMPLOYMENT OPPORTUNITY APPLICABILITY – pertains to all contracts over $10,000 as follows: Construction – AIP funded construction work contracts and subcontracts that exceed $10,000. Construction work means construction, rehabilitation, alteration, conversion, extension, demolition or repair of buildings, highways or other changes or improvements to real property, including facilities providing utility services. The term also includes the supervision, inspection and other onsite functions incidental to the actual construction. Equipment – any equipment project exceeding $10,000 that involves installation of equipment onsite (e.g., electrical vault equipment). This provision does not apply to equipment acquisition projects where the manufacture of the equipment takes place offsite at a manufacturer’s plant (e.g., firefighting and snow removal vehicles). Professional Services – any professional service agreement if the professional services agreement includes tasks that meet the definition of construction work [as defined by the U.S. Department of Labor (DOL)] and exceeds $10,000. Examples include installation of monitoring systems (e.g., noise, environmental, etc.). Property/Land – any agreement associated with land acquisition if the agreement includes construction work (defined above) that exceeds $10,000. Examples include demolition of structures or installation of boundary fencing. REQUIREMENTS - 1. The Contractor’s attention is called to the “Equal Opportunity Clause” and the “Standard Federal Equal Employment Opportunity Construction Contract Specifications” set forth herein. 2. The goals and timetables for minority and female participation, expressed in percentage terms for the Contractor’s aggregate workforce in each trade on all construction work in the covered area, are as follows: Timetables Goals for minority participation for each trade: Does Not Apply Goals for female participation in each trade: 6.9% These goals are applicable to all of the Contractor’s construction work (whether or not it is Federal or federally assisted) performed in the covered area. If the Contractor performs construction work in a geographical area located outside of the covered area, it shall apply the goals established for such geographical area where the work is actually performed. With regard to this second area, the Contractor also is subject to the goals for both its federally involved and nonfederally involved construction. The Contractor’s compliance with the Executive Order and the regulations in 41 CFR Part 60 -4 shall be based on its implementation of the Equal Opportunity Clause, specific affirmative action obligations required by the specifications set forth in 41 CFR 60-4.3(a) and its efforts to meet the goals. The hours of minority and female employment and training must be         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 22 of 65 substantially uniform throughout the length of the contract, and in each trade, and the Contractor shall make a good faith effort to employ minorities and women evenly on each of its projects. The transfer of minority or female employees or trainees from Contractor to Contractor or from project to project for the sole purpose of meeting the Contractor’s goals shall be a violation of the contract, the Executive Order and the regulations in 41 CFR Part 60- 4. Compliance with the goals will be measured against the total work hours performed. 3. The Contractor shall provide written notification to the Director of the Office of Federal Contract Compliance Programs (OFCCP) within 10 working days of award of any construction subcontract in excess of $10,000 at any tier for construction work under the contract resulting from this solicitation. The notification shall list the name, address, and telephone number of the subcontractor; employer identification number of the subcontractor; estimated dollar amount of the subcontract; estimated starting and completion dates of the subcontract; and the geographical area in which the subcontract is to be performed. 4. As used in this notice and in the contract resulting from this solicitation, the “covered area” is California, Riverside County, Palm Springs. Reference: 41 CFR Part 60-4         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 23 of 65 FAA – 03 Breach of Contract APPLICABILITY – required for all contracts that exceed the simplified acquisition threshold as stated in 2 CFR Part 200, Appendix II (A). This threshold is occasionally adjusted for inflation and is $250,000. REQUIREMENT - See Section 4.5 of the Agreement. Reference: 2 CFR § 200 Appendix II(A)         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 24 of 65 FAA – 04 Buy American Preferences APPLICABILITY – required for contracts defined as follows: x Construction Projects involving the replacement, rehabilitation, reconstruction of airfield surfaces such as on runways, taxiways, taxilanes, aprons, roadways, parking lots, etc. – Insert the Certificate of compliance to FAA Buy American Preference based on Construction Projects. x Equipment and Buildings Projects involving and including the acquisition of equipment such as snow removal equipment, navigational aids, wind cones, and the construction of buildings such as hangars, terminal development, lighting vaults, aircraft rescue & firefighting buildings, etc. - Insert the Certificate of Compliance with FAA Buy American Preference Based on Equipment/Building Projects. REQUIREMENT - The Contractor certifies that all constructions materials, defined to mean an article, material, or supply other than an item of primarily iron or steel; a manufactured product; cement and cementitious materials; aggregates such as stone, sand, or gravel; or aggregate binding agents or additives that are or consist primarily of: non-ferrous metals; plastic and polymer-based products (including polyvinylchloride, composite building materials, and polymers used in fiber optic cables); glass (including optic glass); lumber; or drywall used in the project are manufactured in the U.S. Reference: Title 49 USC § 50101         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 25 of 65 FAA – 05 Civil Rights General APPLICABILITY – required for all contracts regardless of funding source. REQUIREMENT - In all its activities within the scope of its airport program, the Contractor agrees to comply with pertinent statutes, Executive Orders, and such rules as identified in Title VI List of Pertinent Nondiscrimination Acts and Authorities to ensure that no person shall, on the grounds of race, color, national origin (including limited English proficiency), creed, sex (including sexual orientation and gender identity), age, or disability be excluded from participating in any activity conducted with or benefiting from Federal assistance. The above provision binds the Contractor and subcontractors from the bid solicitation period through the completion of the contract. This provision is in addition to that required by Title VI of the Civil Rights Act of 1964. Reference: 49 USC § 47123         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 26 of 65 FAA – 06 Civil Rights – Title VI Assurances APPLICABILITY – required for all contracts. REQUIREMENT - Title VI List of Pertinent Nondiscrimination Acts and Authorities During the performance of this contract, the Contractor, for itself, its assignees, and successors in interest (hereinafter referred to as the “Contractor”) agrees to comply with the following non - discrimination statutes and authorities; including but not limited to: • Title VI of the Civil Rights Act of 1964 (42 USC § 2000d et seq., 78 stat. 252) (prohibits discrimination on the basis of race, color, national origin); • 49 CFR part 21 (Non-discrimination in Federally-Assisted programs of the Department of Transportation—Effectuation of Title VI of the Civil Rights Act of 1964); • The Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970, (42 USC § 4601) (prohibits unfair treatment of persons displaced or whose property has been acquired because of Federal or Federal-aid programs and projects); • Section 504 of the Rehabilitation Act of 1973 (29 USC § 794 et seq.), as amended (prohibits discrimination on the basis of disability); and 49 CFR part 27 (Nondiscrimination on the Basis of Disability in Programs or Activities Receiving Federal Financial Assistance); • The Age Discrimination Act of 1975, as amended (42 USC § 6101 et seq.) (prohibits discrimination on the basis of age); • Airport and Airway Improvement Act of 1982 (49 USC § 47123), as amended (prohibits discrimination based on race, creed, color, national origin, or sex); • The Civil Rights Restoration Act of 1987 (PL 100-259) (broadened the scope, coverage and applicability of Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975 and Section 504 of the Rehabilitation Act of 1973, by expanding the definition of the terms “programs or activities” to include all of the programs or activities of the Federal-aid recipients, sub-recipients and contractors, whether such programs or activities are Federally funded or not); • Titles II and III of the Americans with Disabilities Act of 1990 (42 USC § 12101, et seq) (prohibit discrimination on the basis of disability in the operation of public entities, public and private transportation systems, places of public accommodation, and certain testing entities) as implemented by U.S. Department of Transportation regulations at 49 CFR parts 37 and 38; • The Federal Aviation Administration’s Nondiscrimination statute (49 USC § 47123) (prohibits discrimination on the basis of race, color, national origin, and sex); • Executive Order 12898, Federal Actions to Address Environmental Justice in Minority Populations and Low-Income Populations (ensures nondiscrimination against minority populations by discouraging programs, policies, and activities with disproportionately high and adverse human health or environmental effects on minority and low-income populations);         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 27 of 65 • Executive Order 13166, Improving Access to Services for Persons with Limited English Proficiency, and resulting agency guidance, national origin discrimination includes discrimination because of limited English proficiency (LEP). To ensure compliance with Title VI, you must take reasonable steps to ensure that LEP persons have meaningful access to your programs [70 Fed. Reg. 74087 (2005)]; • Title IX of the Education Amendments of 1972, as amended, which prohibits you from discriminating because of sex in education programs or activities (20 USC § 1681, et seq). Compliance with Nondiscrimination Requirements: During the performance of this contract, the Contractor, for itself, its assignees, and successors in interest (hereinafter referred to as the “Contractor”), agrees as follows: 1. Compliance with Regulations: The Contractor (hereinafter includes consultants) will comply with the Title VI List of Pertinent Nondiscrimination Acts and Authorities, as they may be amended from time to time, which are herein incorporated by reference and made a part of this contract. 2. Nondiscrimination: The Contractor, with regard to the work performed by it during the contract, will not discriminate on the grounds of race, color, national origin (including limited English proficiency), creed, sex (including sexual orientation and gender identity), age, or disability in the selection and retention of subcontractors, including procurements of materials and leases of equipment. The Contractor will not participate directly or indirectly in the discrimination prohibited by the Nondiscrimination Acts and Authorities, including employment practices when the contract covers any activity, project, or program set forth in Appendix B of 49 CFR part 21. 3. Solicitations for Subcontracts, including Procurements of Materials and Equipment: In all solicitations, either by competitive bidding or negotiation made by the Contractor for work to be performed under a subcontract, including procurements of materials, or leases of equipment, each potential subcontractor or supplier will be notified by the Contractor of the Contractor’s obligations under this contract and the Nondiscrimination Acts and Authorities on the grounds of race, color, or national origin. 4. Information and Reports: The Contractor will provide all information and reports required by the Acts, the Regulations, and directives issued pursuant thereto and will permit access to its books, records, accounts, other sources of information, and its facilities as may be determined by the City or the Federal Aviation Administration to be pertinent to ascertain compliance with such Nondiscrimination Acts and Authorities and instructions. Where any information required of a Contractor is in the exclusive possession of another who fails or refuses to furnish the information, the Contractor will so certify to the City or the Federal Aviation Administration, as appropriate, and will set forth what efforts it has made to obtain the information. 5. Sanctions for Noncompliance: In the event of a Contractor’s noncompliance with the non-discrimination provisions of this contract, the City will impose such contract sanctions as it or the Federal Aviation Administration may determine to be appropriate, including, but not limited to:         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 28 of 65 a. Withholding payments to the Contractor under the contract until the Contractor complies; and/or b. Cancelling, terminating, or suspending a contract, in whole or in part. 6. Incorporation of Provisions: The Contractor will include the provisions of paragraphs one through six in every subcontract, including procurements of materials and leases of equipment, unless exempt by the Acts, the Regulations, and directives issued pursuant thereto. The Contractor will take action with respect to any subcontract or procurement as the City or the Federal Aviation Administration may direct as a means of enforcing such provisions including sanctions for noncompliance. Provided, that if the Contractor becomes involved in, or is threatened with litigation by a subcontractor, or supplier because of such direction, the Contractor may request the City to enter into any litigation to protect the interests of the City. In addition, the Contractor may request the United States to enter into the litigation to protect the interests of the United States. Reference: 49 USC § 47123, FAA Order 1400.11         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 29 of 65 FAA – 07 Clean Air/Water Pollution Control APPLICABILITY – This provision is required for all contracts and lower tier contracts that exceed $150,000. REQUIREMENT - If the Agreement exceeds $150,000, Contractor agrees to comply with all applicable standards, orders, and regulations issued pursuant to the Clean Air Act (42 USC § 7401-7671q) and the Federal Water Pollution Control Act as amended (33 USC § 1251-1387). The Contractor agrees to report any violation to the City immediately upon discovery. The City assumes responsibility for notifying the Environmental Protection Agency (EPA) and the Federal Aviation Administration. Contractor must include this requirement in all subcontracts that exceeds $150,000. Reference: 2 CFR § 200, Appendix II(G); 42 USC § 7401; 33 USC § 1251         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 30 of 65 FAA – 08 Contract Work Hours and Safety Standards APPLICABILITY – This provision is required for contracts as follows: Contract Work Hours and Safety Standards Act Requirements (CWHSSA) (40 USC §§ 3702 & 3704) requires contractors and subcontractors on covered contracts to pay laborers and mechanics employed in the performance of the contracts not less than one and one-half times their basic rate of pay for all hours worked over 40 in a workweek. CWHSSA prohibits unsanitary, hazardous, or dangerous working conditions on federally- assisted projects. The Wage and Hour Division (WHD) within the U.S. Department of Labor (DOL) enforces the compensation requirements of this Act, while DOL’s Occupational Safety and Health Administration (OSHA) enforces the safety and health requirements. Contract Types – Construction – This provision applies to all contracts and lower tier contracts that exceed $100,000, and employ laborers, mechanics, watchmen, and guards. Equipment – This provision applies to any equipment project exceeding $100,000 that involves installation of equipment onsite (e.g., electrical vault equipment). This provision does not apply to equipment acquisition projects where the manufacture of the equipment takes place offsite at the vendor plant (e.g., ARFF and SRE vehicles). Professional Services – This provision applies to professional service agreements that exceed $100,000 and employs laborers, mechanics, watchmen, and guards. This includes members of survey crews and exploratory drilling operations. Property – While most land transactions do not involve employment of laborers, mechanics, watchmen, and guards, under certain circumstances, a property acquisition project could require such employment. Examples include the installation of property fencing or testing for environmental contamination CONTRACT WORKHOURS AND SAFETY STANDARDS ACT REQUIREMENTS 1. Overtime Requirements. No contractor or subcontractor contracting for any part of the contract work which may require or involve the employment of laborers or mechanics shall require or permit any such laborer or mechanic, including watchmen and guards, in any workweek in which he or she is employed on such work to work in excess of forty hours in such workweek unless such laborer or mechanic receives compensation at a rate not less than one and one-half times the basic rate of pay for all hours worked in excess of forty hours in such workweek. 2. Violation; Liability for Unpaid Wages; Liquidated Damages. In the event of any violation of the clause set forth in paragraph (1) of this clause, the Contractor and any subcontractor responsible therefor shall be liable for the unpaid wages. In addition, such contractor and subcontractor shall be liable to the United States (in the case of work done under contract for the District of Columbia or a territory, to such District or to such territory), for liquidated damages. Such liquidated damages shall be computed with respect to each individual laborer or mechanic, including watchmen and guards, employed in violation of the clause set forth in paragraph (1) of this clause, in the sum of $29 for each calendar day on which such individual was required or permitted to work in excess of the standard workweek of forty hours without payment of the overtime wages required by the clause set forth in paragraph (1) of this clause.         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 31 of 65 3. Withholding for Unpaid Wages and Liquidated Damages. The Federal Aviation Administration (FAA) or the City shall upon its own action or upon written request of an authorized representative of the Department of Labor withhold or cause to be withheld, from any moneys payable on account of work performed by the Contractor or subcontractor under any such contract or any other Federal contract with the same prime Contractor, or any other federally-assisted contract subject to the Contract Work Hours and Safety Standards Act, which is held by the same prime Contractor, such sums as may be determined to be necessary to satisfy any liabilities of such Contractor or subcontractor for unpaid wages and liquidated damages as provided in the clause set forth in paragraph (2) of this clause. 4. Subcontractors. The Contractor or subcontractor shall insert in any subcontracts the clauses set forth in paragraphs (1) through (4) and also a clause requiring the subcontractor to include these clauses in any lower tier subcontracts. The prime contractor shall be responsible for compliance by any subcontractor or lower tier subcontractor with the clauses set forth in paragraphs (1) through (4) of this clause. Reference: 2 CFR Part 200, Appendix II(E); 2 CFR § 5.5(b); 40 USC § 3702; 40 USC § 3704         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 32 of 65 FAA – 09 Copeland Anti-Kickback APPLICABILITY - The Copeland (Anti-Kickback) Act (18 USC § 874 and 40 USC § 3145) makes it unlawful to induce by force, intimidation, threat of dismissal from employment, or by any other manner, any person employed in the construction or repair of public buildings or public works, financed in whole or in part by the United States, to give up any part of the compensation to which that person is entitled under a contract of employment. The Copeland Act also requires each contractor and subcontractor to furnish weekly a statement of compliance with respect to the wages paid each employee during the preceding week. Contract Types – Construction – This provision applies to all construction contracts and subcontracts financed under the AIP that exceed $2,000. Equipment – This provision applies to all equipment installation projects (e.g., electrical vault improvements) financed under the AIP that exceed $2,000. This provision does not apply to equipment acquisitions where the equipment is manufactured at the vendor’s plant (e.g., SRE and ARFF vehicles). Professional Services –The emergence of different project delivery methods has created situations where Professional Service Agreements (PSAs) include tasks that meet the definition of construction, alteration, or repair as defined in 29 CFR Part 5. If such tasks result in work that qualifies as construction, alteration, or repair and it exceeds $2,000, the PSA must incorporate the Copeland Anti-kickback provision. Property –Ordinarily, land acquisition projects would not involve employment of laborers or mechanics and thus the Copeland Anti-Kickback provision would not apply. However, land projects that involve installation of boundary fencing and demolition of structures would involve laborers and mechanics. The City must include this provision if the land acquisition project involves employment of laborers or mechanics for a contract exceeding $2,000. REQUIREMENT - Contractor must comply with the requirements of the Copeland “Anti-Kickback” Act (18 USC 874 and 40 USC 3145), as supplemented by Department of Labor regulation 29 CFR part 3. Contractor and subcontractors are prohibited from inducing, by any means, any person employed on the project to give up any part of the compensation to which the employee is entitled. The Contractor and each Subcontractor must submit to the City, a weekly statement on the wages paid to each employee performing on covered work during the prior week. City must report any violations of the Act to the Federal Aviation Administration. Reference: 2 CFR Part 200, Appendix II(D); 29 CFR Parts 3 and 5         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 33 of 65 FAA – 10 Davis Bacon Requirements APPLICABILITY - The Davis-Bacon Act (40 USC §§ 3141-3144, 3146, and 3147) ensures that laborers and mechanics employed under the contract receive pay no less than the locally prevailing wages and fringe benefits as determined by the Department of Labor. Contract Types – Construction –all construction contracts and subcontracts that exceed $2,000 and include funding from the AIP. Equipment – This provision applies to all equipment installation projects (e.g., electrical vault improvements) financed under the AIP that exceed $ 2,000. This provision does not apply to equipment acquisitions where the equipment is manufactured at the vendor’s plant (e.g., SRE and ARFF vehicles) Professional Services – The emergence of different project delivery methods has created situations where Professional Service Agreements (PSAs) includes tasks that meet the definition of construction, alteration, or repair as defined in 29 CFR Part 5. If such tasks result in work that qualifies as construction, alteration, or repair and it exceeds $2,000, the PSA must incorporate this clause. Property – Ordinarily, land acquisition projects would not involve employment of laborers or mechanics and thus the provision would not apply. However, land projects that involve installation of boundary fencing and demolition of structures would involve laborers and mechanics. The City must include this provision if the land acquisition project involves employment of laborers or mechanics for a contract exceeding $2,000. Fencing Projects – Fencing projects that exceed $2,000 must include this provision. DAVIS-BACON REQUIREMENTS 1. Minimum Wages. (i) All laborers and mechanics employed or working upon the site of the work will be paid unconditionally and not less often than once a week, and without subsequent deduction or rebate on any account (except such payroll deductions as are permitted by the Secretary of Labor under the Copeland Act (29 CFR Part 3)), the full amount of wages and bona fide fringe benefits (or cash equivalent thereof) due at time of payment computed at rates not less than those contained in the wage determination of the Secretary of Labor which is attached hereto and made a part hereof, regardless of any contractual relationship which may be alleged to exist between the Contractor and such laborers and mechanics. Contributions made or costs reasonably anticipated for bona fide fringe benefits under section 1(b)(2) of the Davis-Bacon Act on behalf of laborers or mechanics are considered wages paid to such laborers or mechanics, subject to the provisions of paragraph (1)(iv) of this section; also, regular contributions made or costs incurred for more than a weekly period (but not less often than quarterly) under plans, funds, or programs which cover the particular weekly period, are deemed to be constructively made or incurred during such weekly period. Such laborers and mechanics shall be paid the appropriate wage rate and fringe benefits on the wage         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 34 of 65 determination for the classification of work actually performed, without regard to skill, except as provided in 29 CFR § 5.5(a)(4). Laborers or mechanics performing work in more than one classification may be compensated at the rate specified for each classification for the time actually worked therein: Provided, that the employer’s payroll records accurately set forth the time spent in each classification in which work is performed. The wage determination (including any additional classification and wage rates conformed under (1)(ii) of this section) and the Davis-Bacon poster (WH-1321) shall be posted at all times by the Contractor and its subcontractors at the site of the work in a prominent and accessible place where it can easily be seen by the workers. (ii)(A) The contracting officer shall require that any class of laborers or mechanics, including helpers, which is not listed in the wage determination and which is to be employed under the contract shall be classified in conformance with the wage determination. The contracting officer shall approve an additional classification and wage rate and fringe benefits therefore only when the following criteria have been met: (1) The work to be performed by the classification requested is not performed by a classification in the wage determination; (2) The classification is utilized in the area by the construction industry; and (3) The proposed wage rate, including any bona fide fringe benefits, bears a reasonable relationship to the wage rates contained in the wage determination. (B) If the Contractor and the laborers and mechanics to be employed in the classification (if known), or their representatives, and the contracting officer agree on the classification and wage rate (including the amount designated for fringe benefits where appropriate), a report of the action taken shall be sent by the contracting officer to the Administrator of the Wage and Hour Division, U.S. Department of Labor, Washington, DC 20210. The Administrator, or an authorized representative, will approve, modify, or disapprove every additional classification action within 30 days of receipt and so advise the contracting officer or will notify the contracting officer within the 30-day period that additional time is necessary. (C) In the event the Contractor, the laborers, or mechanics to be employed in the classification, or their representatives, and the contracting officer do not agree on the proposed classification and wage rate (including the amount designated for fringe benefits, where appropriate), the contracting officer shall refer the questions, including the views of all interested parties and the recommendation of the contracting officer, to the Administrator for determination. The Administrator, or an authorized representative, will issue a determination within 30 days of receipt and so advise the contracting officer or will notify the contracting officer within the 30-day period that additional time is necessary. (D) The wage rate (including fringe benefits where appropriate) determined pursuant to subparagraphs (1)(ii) (B) or (C) of this paragraph, shall be paid to all workers performing work in the classification under this contract from the first day on which work is performed in the classification. (iii) Whenever the minimum wage rate prescribed in the contract for a class of laborers or mechanics includes a fringe benefit which is not expressed as an hourly rate, the contractor         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 35 of 65 shall either pay the benefit as stated in the wage determination or shall pay another bona fide fringe benefit or an hourly cash equivalent thereof. (iv) If the Contractor does not make payments to a trustee or other third person, the Contractor may consider as part of the wages of any laborer or mechanic the amount of any costs reasonably anticipated in providing bona fide fringe benefits under a plan or program, Provided, that the Secretary of Labor has found, upon the written request of the Contractor, that the applicable standards of the Davis-Bacon Act have been met. The Secretary of Labor may require the Contractor to set aside in a separate account assets for the meeting of obligations under the plan or program. 2. Withholding. The Federal Aviation Administration or the CIty shall upon its own action or upon written request of an authorized representative of the Department of Labor withhold or cause to be withheld from the Contractor under this contract or any other Federal contract with the same prime contractor, or any other federally-assisted contract subject to Davis-Bacon prevailing wage requirements, which is held by the same prime contractor, so much of the accrued payments or advances as may be considered necessary to pay laborers and mechanics, including apprentices, trainees, and helpers, employed by the Contractor or any subcontractor the full amount of wages required by the contract. In the event of failure to pay any laborer or mechanic, including any apprentice, trainee, or helper, employed or working on the site of the work, all or part of the wages required by the contract, the Federal Aviation Administration may, after written notice to the Contractor, City, Applicant, or Owner, take such action as may be necessary to cause the suspension of any further payment, advance, or guarantee of funds until such violations have ceased. 3. Payrolls and Basic Records. (i) Payrolls and basic records relating thereto shall be maintained by the Contractor during the course of the work and preserved for a period of three years thereafter for all laborers and mechanics working at the site of the work. Such records shall contain the name, address, and social security number of each such worker; his or her correct classification; hourly rates of wages paid (including rates of contributions or costs anticipated for bona fide fringe benefits or cash equivalents thereof of the types described in 1(b)(2)(B) of the Davis-Bacon Act); daily and weekly number of hours worked; deductions made; and actual wages paid. Whenever the Secretary of Labor has found under 29 CFR 5.5(a)(1)(iv) that the wages of any laborer or mechanic include the amount of any costs reasonably anticipated in providing benefits under a plan or program described in section 1(b)(2)(B) of the Davis-Bacon Act, the Contractor shall maintain records that show that the commitment to provide such benefits is enforceable, that the plan or program is financially responsible, and that the plan or program has been communicated in writing to the laborers or mechanics affected, and records which show the costs anticipated or the actual costs incurred in providing such benefits. Contractors employing apprentices or trainees under approved programs shall maintain written evidence of the registration of apprenticeship programs and certification of trainee programs, the registration of the apprentices and trainees, and the ratios and wage rates prescribed in the applicable programs. (ii)(A) The Contractor shall submit weekly for each week in which any contract work is performed a copy of all payrolls to the Federal Aviation Administration if the agency is a party to the contract, but if the agency is not such a party, the Contractor will submit the payrolls to the applicant, the City, or Owner, as the case may be, for transmission to the Federal Aviation         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 36 of 65 Administration. The payrolls submitted shall set out accurately and completely all of the information required to be maintained under 29 CFR § 5.5(a)(3)(i), except that full social security numbers and home addresses shall not be included on weekly transmittals. Instead the payrolls shall only need to include an individually identifying number for each employee (e.g., the last four digits of the employee’s social security number). The required weekly payroll information may be submitted in any form desired. Optional Form WH–347 is available for this purpose from the Wage and Hour Division Web site at https://www.dol.gov/agencies/whd/government- contracts/construction/payroll-certification or its successor site. The prime contractor is responsible for the submission of copies of payrolls by all subcontractors. Contractors and subcontractors shall maintain the full social security number and current address of each covered worker and shall provide them upon request to the Federal Aviation Administration if the agency is a party to the contract, but if the agency is not such a party, the Contractor will submit them to the applicant, the City, or Owner, as the case may be, for transmission to the Federal Aviation Administration, the Contractor, or the Wage and Hour Division of the Department of Labor for purposes of an investigation or audit of compliance with prevailing wage requirements. It is not a violation of this section for a prime contractor to require a subcontractor to provide addresses and social security numbers to the prime contractor for its own records, without weekly submission to the sponsoring government agency (or the applicant, City, or Owner). (B) Each payroll submitted shall be accompanied by a "Statement of Compliance," signed by the Contractor or subcontractor or his or her agent who pays or supervises the payment of the persons employed under the contract and shall certify the following: (1) That the payroll for the payroll period contains the information required to be provided under 29 CFR § 5.5(a)(3)(ii), the appropriate information is being maintained under 29 CFR § 5.5 (a)(3)(i), and that such information is correct and complete; (2) That each laborer and mechanic (including each helper, apprentice, and trainee) employed on the contract during the payroll period has been paid the full weekly wages earned, without rebate, either directly or indirectly, and that no deductions have been made either directly or indirectly from the full wages earned, other than permissible deductions as set forth in Regulations, 29 CFR Part 3; (3) That each laborer or mechanic has been paid not less than the applicable wage rates and fringe benefits or cash equivalents for the classification of work performed, as specified in the applicable wage determination incorporated into the contract. (C) The weekly submission of a properly executed certification set forth on the reverse side of Optional Form WH-347 shall satisfy the requirement for submission of the “Statement of Compliance” required by paragraph (3)(ii)(B) of this section. (D) The falsification of any of the above certifications may subject the Contractor or subcontractor to civil or criminal prosecution under Section 1001 of Title 18 and Section 231 of Title 31 of the United States Code. (iii) The Contractor or subcontractor shall make the records required under paragraph (3)(i) of this section available for inspection, copying, or transcription by authorized representatives of the City, the Federal Aviation Administration, or the Department of Labor and shall permit such representatives to interview employees during working hours on the job. If the Contractor or         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 37 of 65 subcontractor fails to submit the required records or to make them available, the Federal agency may, after written notice to the Contractor, the City, applicant, or Owner, take such action as may be necessary to cause the suspension of any further payment, advance, or guarantee of funds. Furthermore, failure to submit the required records upon request or to make such records available may be grounds for debarment action pursuant to 29 CFR § 5.12. 4. Apprentices and Trainees. (i) Apprentices. Apprentices will be permitted to work at less than the predetermined rate for the work they performed when they are employed pursuant to and individually registered in a bona fide apprenticeship program registered with the U.S. Department of Labor, Employment and Training Administration, Office of Apprenticeship Training, Employer and Labor Services, or with a State Apprenticeship Agency recognized by the Office, or if a person is employed in his or her first 90 days of probationary employment as an apprentice in such an apprenticeship program, who is not individually registered in the program, but who has been certified by the Office of Apprenticeship Training, Employer and Labor Services or a State Apprenticeship Agency (where appropriate) to be eligible for probationary employment as an apprentice. The allowable ratio of apprentices to journeymen on the job site in any craft classification shall not be greater than the ratio permitted to the contractor as to the entire work force under the registered program. Any worker listed on a payroll at an apprentice wage rate, who is not registered or otherwise employed as stated above, shall be paid not less than the applicable wage rate on the wage determination for the classification of work actually performed. In addition, any apprentice performing work on the job site in excess of the ratio permitted under the registered program shall be paid not less than the applicable wage rate on the wage determination for the work actually performed. Where a contractor is performing construction on a project in a locality other than that in which its program is registered, the ratios and wage rates (expressed in percentages of the journeyman’s hourly rate) specified in the Contractor’s or subcontractor’s registered program shall be observed. Every apprentice must be paid at not less than the rate specified in the registered program for the apprentice’s level of progress, expressed as a percentage of the journeymen hourly rate specified in the applicable wage determination. Apprentices shall be paid fringe benefits in accordance with the provisions of the apprenticeship program. If the apprenticeship program does not specify fringe benefits, apprentices must be paid the full amount of fringe benefits listed on the wage determination for the applicable classification. If the Administrator determines that a different practice prevails for the applicable apprentice classification, fringes shall be paid in accordance with that determination. In the event the Office of Apprenticeship Training, Employer and Labor Services, or a State Apprenticeship Agency recognized by the Office, withdraws approval of an apprenticeship program, the Contractor will no longer be permitted to utilize apprentices at less than the applicable predetermined rate for the work performed until an acceptable program is approved. (ii) Trainees. Except as provided in 29 CFR § 5.16, trainees will not be permitted to work at less than the predetermined rate for the work performed unless they are employed pursuant to and individually registered in a program which has received prior approval, evidenced by formal certification by the U.S. Department of Labor, Employment and Training Administration. The ratio of trainees to journeymen on the job site shall not be greater than permitted under the plan approved by the Employment and Training Administration. Every trainee must be paid at not less than the rate specified in the approved program for the trainee’s level of progress, expressed as a percentage of the journeyman hourly rate specified in the applicable wage         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 38 of 65 determination. Trainees shall be paid fringe benefits in accordance with the provisions of the trainee program. If the trainee program does not mention fringe benefits, trainees shall be paid the full amount of fringe benefits listed on the wage determination unless the Administrator of the Wage and Hour Division determines that there is an apprenticeship program associated with the corresponding journeyman wage rate on the wage determination that provides for less than full fringe benefits for apprentices. Any employee listed on the payroll at a trainee rate that is not registered and participating in a training plan approved by the Employment and Training Administration shall be paid not less than the applicable wage rate on the wage determination for the classification of work actually performed. In addition, any trainee performing work on the job site in excess of the ratio permitted under the registered program shall be paid not less than the applicable wage rate on the wage determination for the work actually performed. In the event the Employment and Training Administration withdraws approval of a training program, the Contractor will no longer be permitted to utilize trainees at less than the applicable predetermined rate for the work performed until an acceptable program is approved. (iii) Equal Employment Opportunity. The utilization of apprentices, trainees, and journeymen under this part shall be in conformity with the equal employment opportunity requirements of Executive Order 11246, as amended, and 29 CFR Part 30. 5. Compliance with Copeland Act Requirements. The Contractor shall comply with the requirements of 29 CFR Part 3, which are incorporated by reference in this contract. 6. Subcontracts. The Contractor or subcontractor shall insert in any subcontracts the clauses contained in 29 CFR §§ 5.5(a)(1) through (10) and such other clauses as the Federal Aviation Administration may by appropriate instructions require, and also a clause requiring the subcontractors to include these clauses in any lower tier subcontracts. The prime contractor shall be responsible for the compliance by any subcontractor or lower tier subcontractor with all the contract clauses in 29 CFR § 5.5. 7. Contract Termination: Debarment. A breach of the contract clauses in paragraph 1 through 10 of this section may be grounds for termination of the contract, and for debarment as a contractor and a subcontractor as provided in 29 CFR § 5.12. 8. Compliance with Davis-Bacon and Related Act Requirements. All rulings and interpretations of the Davis-Bacon and Related Acts contained in 29 CFR Parts 1, 3, and 5 are herein incorporated by reference in this contract. 9. Disputes Concerning Labor Standards. Disputes arising out of the labor standards provisions of this contract shall not be subject to the general disputes clause of this contract. Such disputes shall be resolved in accordance with the procedures of the Department of Labor set forth in 29 CFR Parts 5, 6, and 7. Disputes within the meaning of this clause include disputes between the Contractor (or any of its subcontractors) and the contracting agency, the U.S. Department of Labor, or the employees or their representatives.         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 39 of 65 10. Certification of Eligibility. (i) By entering into this contract, the Contractor certifies that neither it (nor he or she) nor any person or firm who has an interest in the Contractor’s firm is a person or firm ineligible to be awarded Government contracts by virtue of section 3(a) of the Davis-Bacon Act or 29 CFR § 5.12(a)(1). (ii) No part of this contract shall be subcontracted to any person or firm ineligible for award of a Government contract by virtue of section 3(a) of the Davis-Bacon Act or 29 CFR § 5.12(a)(1). (iii) The penalty for making false statements is prescribed in the U.S. Criminal Code, 18 USC § 1001. Reference: 2 CFR Part 200, Appendix II(D); 29 CFR Part 5; 49 USC § 47112(b); 40 USC §§ 3141-3144, 3146, and 3147         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 40 of 65 FAA – 11 Debarment and Suspension APPLICABILITY - This requirement applies to covered transactions, which are defined in 2 CFR part 180 (Subpart B). AIP funded contracts are non-procurement transactions, as defined by 2 CFR § 180.970. Covered transactions include any AIP-funded contract, regardless of tier, that is awarded by a contractor, subcontractor, supplier, consultant, or its agent or representative in any transaction, if the amount of the contract is expected to equal or exceed $25,000. This includes contracts associated with land acquisition projects. REQUIREMENT - A11.3.1 Bidder or Offeror Certification By submitting a bid/proposal under the solicitation for this contract, the Contractor must have certified that neither it nor its principals are presently debarred or suspended by any Federal department or agency from participation in this transaction. A11.3.2 Lower Tier Contract Certification CERTIFICATION OF LOWER TIER CONTRACTORS REGARDING DEBARMENT The Contractor, by administering each lower tier subcontract that exceeds $25,000 as a “covered transaction”, must verify each lower tier participant of a “covered transaction” under the project is not presently debarred or otherwise disqualified from participation in this federally assisted project. The Contractor will accomplish this by: 1. Checking the System for Award Management at website: http://www.sam.gov. 2. Collecting a certification statement similar to the Certification of Offerer /Bidder Regarding Debarment, above. 3. Inserting a clause or condition in the covered transaction with the lower tier contract. If the Federal Aviation Administration later determines that a lower tier participant failed to disclose to a higher tier participant that it was excluded or disqualified at the time it entered the covered transaction, the FAA may pursue any available remedies, including suspension and debarment of the non-compliant participant. Reference: 2 CFR part 180 (Subpart B), 2 CFR part 200 Appendix II(H), 2 CFR Part 1200, DOT Order 4200.5; Executive Orders 12549 and 12689         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 41 of 65 FAA – 12 Disadvantaged Business Enterprise APPLICABILITY – all contracts with Airports that have a DBE program on file with the FAA. Contract Assurance (§ 26.13) – The Contractor or subcontractor shall not discriminate on the basis of race, color, national origin, or sex in the performance of this contract. The Contractor shall carry out applicable requirements of 49 CFR part 26 in the award and administration of Department of Transportation-assisted contracts. Failure by the Contractor to carry out these requirements is a material breach of this contract, which may result in the termination of this contract or such other remedy as the City deems appropriate, which may include, but is not limited to: 1) Withholding monthly progress payments; 2) Assessing sanctions; 3) Liquidated damages; and/or 4) Disqualifying the Contractor from future bidding as non-responsible. Prompt Payment (§26.29) – The prime contractor agrees to pay each subcontractor under this prime contract for satisfactory performance of its contract no later than [10 days] days from the receipt of each payment the prime contractor receives from [the City]. The prime contractor agrees further to return retainage payments to each subcontractor within [30 days] days after the subcontractor’s work is satisfactorily completed. Any delay or postponement of payment from the above referenced time frame may occur only for good cause following written approval of the [City]. This clause applies to both DBE and non-DBE subcontractors. Termination of DBE Subcontracts (49 CFR § 26.53(f)) – The prime Contractor must not terminate a DBE subcontractor listed in response to the solicitation (or an approved substitute DBE firm) without prior written consent of the City. This includes, but is not limited to, instances in which the prime contractor seeks to perform work originally designated for a DBE subcontractor with its own forces or those of an affiliate, a non- DBE firm, or with another DBE firm. The prime Contractor shall utilize the specific DBEs listed to perform the work and supply the materials for which each is listed unless the Contractor obtains written consent of the City. Unless City consent is provided, the prime Contractor shall not be entitled to any payment for work or material unless it is performed or supplied by the listed DBE. The City may provide such written consent only if the City agrees, for reasons stated in the concurrence document, that the prime Contractor has good cause to terminate the DBE firm. For purposes of this paragraph, good cause includes the circumstances listed in 49 CFR §26.53. Before transmitting to the City its request to terminate and/or substitute a DBE subcontractor, the prime Contractor must give notice in writing to the DBE subcontractor, with a copy to the City, of its intent to request to terminate and/or substitute, and the reason for the request. The prime contractor must give the DBE five days to respond to the prime contractor's notice and advise the City and the Contractor of the reasons, if any, why it objects to the proposed         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 42 of 65 termination of its subcontract and why the City should not approve the prime Contractor's action. If required in a particular case as a matter of public necessity (e.g., safety), the City may provide a response period shorter than five days. In addition to post-award terminations, the provisions of this section apply to preaward deletions of or substitutions for DBE firms put forward by offerors in negotiated procurements. Reference: 49 CFR part 26         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 43 of 65 FAA – 13 Distracted Driving APPLICABILITY - contracts that exceed the micro-purchase threshold of 2 CFR § 200.320 (currently set at $10,000). REQUIREMENT - TEXTING WHEN DRIVING In accordance with Executive Order 13513, “Federal Leadership on Reducing Text Messaging While Driving”, (10/1/2009) and DOT Order 3902.10, “Text Messaging While Driving”, (12/30/2009), the Federal Aviation Administration encourages recipients of Federal grant funds to adopt and enforce safety policies that decrease crashes by distracted drivers, including policies to ban text messaging while driving when performing work related to a grant or subgrant. In support of this initiative, the City encourages the Contractor to promote policies and initiatives for its employees and other work personnel that decrease crashes by distracted drivers, including policies that ban text messaging while driving motor vehicles while performing work activities associated with the project. The Contractor must include the substance of this clause in all sub-tier contracts exceeding $10,000 that involve driving a motor vehicle in performance of work activities associated with the project. Reference: Executive Order 13513, DOT Order 3902.10         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 44 of 65 FAA – 14 Prohibition on Certain Telecommunications and Video Surveillance Services and Equipment APPLICABILITY - all AIP funded contracts and lower-tier contracts. REQUIREMENT - Contractor and Subcontractor agree to comply with mandatory standards and policies relating to use and procurement of certain telecommunications and video surveillance services or equipment in compliance with the National Defense Authorization Act [Public Law 115-232 § 889(f)(1)]. Reference: 2 CFR § 200, Appendix II(K); 2 CFR § 200.216         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 45 of 65 FAA – 15 Drug Free Workplace Requirements APPLICABILITY - This provision applies to all AIP funded projects, but not to the contracts between the City and a contractor, subcontractors, suppliers, or subgrantees. The Drug-Free Workplace Act of 1988 requires some Federal contractors and all Federal grantees to agree that they will provide drug-free workplaces as a condition of receiving a contract or grant from a Federal agency. The Act does not apply to contractors, subcontractors, or subgrantees, although the Federal grantees workplace may be where the contractors, subcontractors, or subgrantees are working. Reference: 49 CFR part 32, Drug-Free Workplace Act of 1988 (41 U.S.C. 701 et seq., as amended)         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 46 of 65 FAA – 16 Equal Employment Opportunity APPLICABILITY – The purpose of this provision is to provide equal opportunity for all persons, without regard to race, color, religion, sex, or national origin who are employed or seeking employment with contractors performing under a federally-assisted construction contract. There are two provisions ― a construction clause and a specification clause. The equal opportunity contract clause applies to any contract or subcontract when the amount exceeds $10,000. Once the equal opportunity clause is determined to be applicable, the contract or subcontract must include the clause for the remainder of the year, regardless of the amount or the contract. Contract Types – Construction – all construction contracts and subcontracts as required above. Equipment – all equipment contracts as required above that involves installation of equipment onsite (e.g., electrical vault equipment). This provision does not apply to equipment acquisition projects where the manufacture of the equipment takes place offsite at the vendor plant (e.g., ARFF and SRE vehicles). Professional Services – all professional service agreements as required above. Property – all land acquisition projects that include work that qualifies as construction work as defined by 41 CFR part 60 as required above. An example is installation of boundary fencing. REQUIREMENT - A16.3.1 EEO Contract Clause During the performance of this contract, the Contractor agrees as follows: (1) The Contractor will not discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, or national origin. The Contractor will take affirmative action to ensure that applicants are employed, and that employees are treated during employment, without regard to their race, color, religion, sex, sexual orientation, gender identify, or national origin. Such action shall include, but not be limited to, the following: employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff, or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The Contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided setting forth the provisions of this nondiscrimination clause. (2) The Contractor will, in all solicitations or advertisements for employees placed by or on behalf of the Contractor, state that all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin. (3) The contractor will not discharge or in any other manner discriminate against any employee or applicant for employment because such employee or applicant has inquired about, discussed, or disclosed the compensation of the employee or applicant or another employee or applicant. This provision shall not apply to instances in which an employee who has         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 47 of 65 access to the compensation information of other employees or applicants as a part of such employee's essential job functions discloses the compensation of such other employees or applicants to individuals who do not otherwise have access to such information, unless such disclosure is in response to a formal complaint or charge, in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or is consistent with the contractor's legal duty to furnish information. (4) The Contractor will send to each labor union or representative of workers with which it has a collective bargaining agreement or other contract or understanding, a notice to be provided by the agency contracting officer, advising the labor union or workers’ representative of the Contractor’s commitments under this section 202 of Executive Order 11246 of September 24, 1965, and shall post copies of the notice in conspicuous places available to employees and applicants for employment. (5) The Contractor will comply with all provisions of Executive Order 11246 of September 24, 1965, and of the rules, regulations, and relevant orders of the Secretary of Labor. (6) The Contractor will furnish all information and reports required by Executive Order 11246 of September 24, 1965, and by the rules, regulations, and orders of the Secretary of Labor, or pursuant thereto, and will permit access to his books, records, and accounts by the contracting agency and the Secretary of Labor for purposes of investigation to ascertain compliance with such rules, regulations, and orders. (7) In the event of the Contractor’s noncompliance with the nondiscrimination clauses of this contract or with any such rules, regulations, or orders, this contract may be canceled, terminated, or suspended in whole or in part and the Contractor may be declared ineligible for further Government contracts in accordance with procedures authorized in Executive Order 11246 of September 24, 1965, and such other sanctions may be imposed and remedies invoked as provided in Executive Order 11246 of September 24, 1965, or by rule, regulation, or order of the Secretary of Labor, or as otherwise provided by law. (8) The Contractor will include the provisions of paragraphs (1) through (8) in every subcontract or purchase order unless exempted by rules, regulations, or orders of the Secretary of Labor issued pursuant to section 204 of Executive Order 11246 of September 24, 1965, so that such provisions will be binding upon each subcontractor or vendor. The Contractor will take such action with respect to any subcontract or purchase order as may be directed by the Secretary of Labor as a means of enforcing such provisions, including sanctions for noncompliance: Provided, however, that in the event the contractor becomes involved in, or is threatened with, litigation with a subcontractor or vendor as a result of such direction, the Contractor may request the United States to enter into such litigation to protect the interests of the United States. A16.3.2 EEO Specification STANDARD FEDERAL EQUAL EMPLOYMENT OPPORTUNITY CONSTRUCTION CONTRACT SPECIFICATIONS a. “Covered area” means the geographical area described in the solicitation from which this contract resulted;         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 48 of 65 b. “Director” means Director, Office of Federal Contract Compliance Programs (OFCCP), U.S. Department of Labor, or any person to whom the Director delegates authority; c. “Employer identification number” means the Federal social security number used on the Employer’s Quarterly Federal Tax Return, U.S. Treasury Department Form 941; d. “Minority” includes: (1) Black (all persons having origins in any of the Black African racial groups not of Hispanic origin); (2) Hispanic (all persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race); (3) Asian and Pacific Islander (all persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands); and (4) American Indian or Alaskan native (all persons having origins in any of the original peoples of North America and maintaining identifiable tribal affiliations through membership and participation or community identification). 2. Whenever the Contractor, or any subcontractor at any tier, subcontracts a portion of the work involving any construction trade, it shall physically include in each subcontract in excess of $10,000 the provisions of these specifications and the Notice which contains the applicable goals for minority and female participation and which is set forth in the solicitations from which this contract resulted. 3. If the Contractor is participating (pursuant to 41 CFR part 60-4.5) in a Hometown Plan approved by the U.S. Department of Labor in the covered area either individually or through an association, its affirmative action obligations on all work in the Plan area (including goals and timetables) shall be in accordance with that Plan for those trades which have unions participating in the Plan. Contractors must be able to demonstrate their participation in and compliance with the provisions of any such Hometown Plan. Each contractor or subcontractor participating in an approved plan is individually required to comply with its obligations under the EEO clause and to make a good faith effort to achieve each goal under the Plan in each trade in which it has employees. The overall good faith performance by other contractors or subcontractors toward a goal in an approved Plan does not excuse any covered contractor’s or subcontractor’s failure to take good faith efforts to achieve the Plan goals and timetables. 4. The Contractor shall implement the specific affirmative action standards provided in paragraphs 7a through 7p of these specifications. The goals set forth in the solicitation from which this contract resulted are expressed as percentages of the total hours of employment and training of minority and female utilization the Contractor should reasonably be able to achieve in each construction trade in which it has employees in the covered area. Covered construction contractors performing construction work in a geographical areas where they do not have a Federal or federally assisted construction contract shall apply the minority and female goals established for the geographical area where the work is being performed. Goals are published periodically in the Federal Register in notice form, and such notices may be obtained from any Office of Federal Contract Compliance Programs office or from Federal procurement contracting officers.         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 49 of 65 The Contractor is expected to make substantially uniform progress in meeting its goals in each craft during the period specified. 5. Neither the provisions of any collective bargaining agreement, nor the failure by a union with whom the Contractor has a collective bargaining agreement, to refer either minorities or women shall excuse the Contractor’s obligations under these specifications, Executive Order 11246, or the regulations promulgated pursuant thereto. 6. In order for the nonworking training hours of apprentices and trainees to be counted in meeting the goals, such apprentices and trainees must be employed by the Contractor during the training period, and the Contractor must have made a commitment to employ the apprentices and trainees at the completion of their training, subject to the availability of employment opportunities. Trainees must be trained pursuant to training programs approved by the U.S. Department of Labor. 7. The Contractor shall take specific affirmative actions to ensure equal employment opportunity. The evaluation of the Contractor’s compliance with these specifications shall be based upon its effort to achieve maximum results from its actions. The Contractor shall document these efforts fully, and shall implement affirmative action steps at least as extensive as the following: a. Ensure and maintain a working environment free of harassment, intimidation, and coercion at all sites, and in all facilities at which the Contractor’s employees are assigned to work. The Contractor, where possible, will assign two or more women to each construction project. The Contractor shall specifically ensure that all foremen, superintendents, and other onsite supervisory personnel are aware of and carry out the Contractor’s obligation to maintain such a working environment, with specific attention to minority or female individuals working at such sites or in such facilities. b. Establish and maintain a current list of minority and female recruitment sources, provide written notification to minority and female recruitment sources and to community organizations when the Contractor or its unions have employment opportunities available, and maintain a record of the organizations’ responses. c. Maintain a current file of the names, addresses, and telephone numbers of each minority and female off-the-street applicant and minority or female referral from a union, a recruitment source, or community organization and of what action was taken with respect to each such individual. If such individual was sent to the union hiring hall for referral and was not referred back to the Contractor by the union or, if referred, not employed by the Contractor, this shall be documented in the file with the reason therefor, along with whatever additional actions the Contractor may have taken. d. Provide immediate written notification to the Director when the union or unions with which the Contractor has a collective bargaining agreement has not referred to the Contractor a minority person or woman sent by the Contractor, or when the Contractor has other information that the union referral process has impeded the Contractor’s efforts to meet its obligations. e. Develop on-the-job training opportunities and/or participate in training programs for the area which expressly include minorities and women, including upgrading programs         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 50 of 65 and apprenticeship and trainee programs relevant to the Contractor’s employment needs, especially those programs funded or approved by the Department of Labor. The Contractor shall provide notice of these programs to the sources compiled under 7b above. f. Disseminate the Contractor’s EEO policy by providing notice of the policy to unions and training programs and requesting their cooperation in assisting the Contractor in meeting its EEO obligations; by including it in any policy manual and collective bargaining agreement; by publicizing it in the company newspaper, annual report, etc.; by specific review of the policy with all management personnel and with all minority and female employees at least once a year; and by posting the company EEO policy on bulletin boards accessible to all employees at each location where construction work is performed. g. Review, at least annually, the company’s EEO policy and affirmative action obligations under these specifications with all employees having any responsibility for hiring, assignment, layoff, termination, or other employment decisions including specific review of these items with onsite supervisory personnel such superintendents, general foremen, etc., prior to the initiation of construction work at any job site. A written record shall be made and maintained identifying the time and place of these meetings, persons attending, subject matter discussed, and disposition of the subject matter. h. Disseminate the Contractor’s EEO policy externally by including it in any advertising in the news media, specifically including minority and female news media, and providing written notification to and discussing the Contractor’s EEO policy with other contractors and subcontractors with whom the Contractor does or anticipates doing business. i. Direct its recruitment efforts, both oral and written, to minority, female, and community organizations, to schools with minority and female students and to minority and female recruitment and training organizations serving the Contractor’s recruitment area and employment needs. Not later than one month prior to the date for the acceptance of applications for apprenticeship or other training by any recruitment source, the Contractor shall send written notification to organizations such as the above, describing the openings, screening procedures, and tests to be used in the selection process. j. Encourage present minority and female employees to recruit other minority persons and women and, where reasonable, provide after school, summer, and vacation employment to minority and female youth both on the site and in other areas of a contractor’s work force. k. Validate all tests and other selection requirements where there is an obligation to do so under 41 CFR part 60-3. l. Conduct, at least annually, an inventory and evaluation at least of all minority and female personnel, for promotional opportunities and encourage these employees to seek or to prepare for, through appropriate training, etc., such opportunities. m. Ensure that seniority practices, job classifications, work assignments, and other personnel practices do not have a discriminatory effect by continually monitoring all         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 51 of 65 personnel and employment related activities to ensure that the EEO policy and the Contractor’s obligations under these specifications are being carried out. n. Ensure that all facilities and company activities are nonsegregated except that separate or single-user toilet and necessary changing facilities shall be provided to assure privacy between the sexes. o. Document and maintain a record of all solicitations of offers for subcontracts from minority and female construction contractors and suppliers, including circulation of solicitations to minority and female contractor associations and other business associations. p. Conduct a review, at least annually, of all supervisor’s adherence to and performance under the Contractor’s EEO policies and affirmative action obligations. 8. Contractors are encouraged to participate in voluntary associations, which assist in fulfilling one or more of their affirmative action obligations (7a through 7p). The efforts of a contractor association, joint contractor-union, contractor-community, or other similar group of which the Contractor is a member and participant may be asserted as fulfilling any one or more of its obligations under 7a through 7p of these specifications provided that the Contractor actively participates in the group, makes every effort to assure that the group has a positive impact on the employment of minorities and women in the industry, ensures that the concrete benefits of the program are reflected in the Contractor’s minority and female workforce participation, makes a good faith effort to meet its individual goals and timetables, and can provide access to documentation which demonstrates the effectiveness of actions taken on behalf of the Contractor. The obligation to comply, however, is the Contractor’s and failure of such a group to fulfill an obligation shall not be a defense for the Contractor’s noncompliance. 9. A single goal for minorities and a separate single goal for women have been established. The Contractor, however, is required to provide equal employment opportunity and to take affirmative action for all minority groups, both male and female, and all women, both minority and non-minority. Consequently, the Contractor may be in violation of the Executive Order if a particular group is employed in a substantially disparate manner (for example, even though the Contractor has achieved its goals for women generally, the Contractor may be in violation of the Executive Order if a specific minority group of women is underutilized). 10. The Contractor shall not use the goals and timetables or affirmative action standards to discriminate against any person because of race, color, religion, sex, sexual orientation, gender identity, or national origin. 11. The Contractor shall not enter into any subcontract with any person or firm debarred from Government contracts pursuant to Executive Order 11246. 12. The Contractor shall carry out such sanctions and penalties for violation of these specifications and of the Equal Opportunity Clause, including suspension, termination, and cancellation of existing subcontracts as may be imposed or ordered pursuant to Executive Order 11246, as amended, and its implementing regulations, by the Office of Federal Contract Compliance Programs. Any contractor who fails to carry out such sanctions and         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 52 of 65 penalties shall be in violation of these specifications and Executive Order 11246, as amended. 13. The Contractor, in fulfilling its obligations under these specifications, shall implement specific affirmative action steps, at least as extensive as those standards prescribed in paragraph 7 of these specifications, so as to achieve maximum results from its efforts to ensure equal employment opportunity. If the Contractor fails to comply with the requirements of the Executive Order, the implementing regulations, or these specifications, the Director shall proceed in accordance with 41 CFR part 60-4.8. 14. The Contractor shall designate a responsible official to monitor all employment related activity to ensure that the company EEO policy is being carried out, to submit reports relating to the provisions hereof as may be required by the Government, and to keep records. Records shall at least include for each employee, the name, address, telephone numbers, construction trade, union affiliation if any, employee identification number when assigned, social security number, race, sex, status (e.g., mechanic, apprentice, trainee, helper, or laborer), dates of changes in status, hours worked per week in the indicated trade, rate of pay, and locations at which the work was performed. Records shall be maintained in an easily understandable and retrievable form; however, to the degree that existing records satisfy this requirement, contractors shall not be required to maintain separate records. 15. Nothing herein provided shall be construed as a limitation upon the application of other laws which establish different standards of compliance or upon the application of requirements for the hiring of local or other area residents (e.g. those under the Public Works Employment Act of 1977 and the Community Development Block Grant Program). Reference: 2 CFR 200, Appendix II(C), 41 CFR § 60-1.4, 41 CFR § 60-4.3, Executive Order 11246         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 53 of 65 FAA – 17 Federal Fair Labor Standards Act APPLICABILITY – Contract Types – Per the Department of Labor, all employees of certain enterprises having workers engaged in interstate commerce; producing goods for interstate commerce; or handling, selling, or otherwise working on goods or materials that have been moved in or produced for such commerce by any person are covered by the FLSA. All consultants, sub-consultants, contractors, and subcontractors employed under this federally assisted project must comply with the FLSA. Professional Services – 29 CFR § 213 exempts employees in a bona fide executive, administrative or professional capacity. Because professional firms employ individuals that are not covered by this exemption, the agreement with a professional services firm must include the FLSA provision. REQUIREMENT - The provisions of 29 CFR part 201, the Federal Fair Labor Standards Act (FLSA), are incorporated by reference with the same force and effect as if given in full text. The FLSA sets minimum wage, overtime pay, recordkeeping, and child labor standards for full and part-time workers. The Contractor has full responsibility to monitor compliance to the referenced statute or regulation. The Contractor must address any claims or disputes that arise from this requirement directly with the U.S. Department of Labor – Wage and Hour Division. Reference: 29 USC § 201, et seq; 2 CFR § 200.430         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 54 of 65 FAA – 18 Lobbying and Influencing Federal Employees APPLICABILITY- all contracts exceeding $100,000. REQUIREMENT - Consultants and contractors that apply or bid for an award of $100,000 or more must have certified that it will not and has not used Federal appropriated funds to pay any person or organization for influencing or attempting to influence an officer or employee of any agency, a member of Congress, officer or employee of Congress, or an employee of a member of Congress in connection with obtaining any Federal contract, grant, or another award covered by 31 USC §1352. Each tier must also disclose any lobbying with non-Federal funds that takes place in connection with obtaining any Federal award. For an award over $100,00, the bidder or offeror certifies by signing and submitting this bid or proposal, to the best of his or her knowledge and belief, that: (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the bidder or offeror, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. (2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts under grants, loans, and cooperative agreements) and that all sub-recipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure. Reference: 31 USC § 1352 – Byrd Anti-Lobbying Amendment, 2 CFR part 200, Appendix II(I), 49 CFR part 20, Appendix A         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 55 of 65 FAA – 19 Prohibition of Segregated Facilities APPLICABILITY - The Contractor must comply with the requirements of the EEO clause by ensuring that facilities they provide for employees are free of segregation on the basis of race, color, religion, sex, sexual orientation, gender identity, or national origin. This clause must be included in all contracts that include the equal opportunity clause, regardless of the amount of the contract. Contract Types – any contract containing the Equal Employment Opportunity clause of 41 CFR § 60-1.4. This obligation flows down to subcontract and sub-tier purchase orders containing the Equal Employment Opportunity clause. Construction – Construction work means construction, rehabilitation, alteration, conversion, extension, demolition or repair of buildings, highways, or other changes or improvements to real property, including facilities providing utility services. The term also includes the supervision, inspection, and other onsite functions incidental to the actual construction. Equipment – On site installation of equipment such as airfield lighting control equipment meets the definition of construction and thus this provision would apply. This provision does not apply to equipment projects involving manufacture of the item at a vendor’s manufacturing plant. An example would be the manufacture of a SRE or ARFF vehicle. Professional Services – Professional services that include tasks that qualify as construction work as defined by 41 CFR part 60-1. Examples include the installation of noise monitoring equipment. Property/Land – Land acquisition contracts that include tasks that qualify as construction work as defined by 41 CFR part 60-1. Examples include demolition of structures or installation of boundary fencing. REQUIREMENT - (a) The Contractor agrees that it does not and will not maintain or provide for its employees any segregated facilities at any of its establishments, and that it does not and will not permit its employees to perform their services at any location under its control where segregated facilities are maintained. The Contractor agrees that a breach of this clause is a violation of the Equal Employment Opportunity clause in this contract. (b) “Segregated facilities,” as used in this clause, means any waiting rooms, work areas, rest rooms and wash rooms, restaurants and other eating areas, time clocks, locker rooms and other storage or dressing areas, parking lots, drinking fountains, recreation or entertainment areas, transportation, and housing facilities provided for employees that are segregated by explicit directive or are in fact segregated on the basis of race, color, religion, sex, sexual orientation, gender identity, or national origin because of written or oral policies or employee custom. The term does not include separate or single-user rest rooms or necessary dressing or sleeping areas provided to assure privacy between the sexes. (c) The Contractor shall include this clause in every subcontract and purchase order that is subject to the Equal Employment Opportunity clause of this contract. Reference: 2 CFR Part 200, Appendix II (C); 41 CFR Part 60-1         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 56 of 65 FAA – 20 Occupational Safety and Health Act APPLICABILITY – Contract Types – All contracts and subcontracts must comply with the Occupational Safety and Health Act of 1970 (OSH). The U.S. Department of Labor Occupational Safety and Health Administration (OSHA) oversees the workplace health and safety standards wage provisions from OSH. REQUIREMENT - All contracts and subcontracts that result from this solicitation incorporate by reference the requirements of 29 CFR Part 1910 with the same force and effect as if given in full text. The employer must provide a work environment that is free from recognized hazards that may cause death or serious physical harm to the employee. The employer retains full responsibility to monitor its compliance and their subcontractor’s compliance with the applicable requirements of the Occupational Safety and Health Act of 1970 (29 CFR Part 1910). The employer must address any claims or disputes that pertain to a referenced requirement directly with the U.S. Department of Labor – Occupational Safety and Health Administration. Reference: 29 CFR part 1910         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 57 of 65 FAA – 21 Procurement of Recovered Materials APPLICABILITY – Contract Types – This provision applies to any contracts that include procurement of products designated in subpart B of 40 CFR part 247 where the purchase price of the item exceeds $10,000 or the value of the quantity acquired by the preceding fiscal year exceeded $10,000. Construction and Equipment – all construction and equipment projects. Professional Services and Property – if the agreement includes procurement of a product that exceeds $10,000. REQUIREMENT - Contractor and subcontractor agree to comply with Section 6002 of the Solid Waste Disposal Act, as amended by the Resource Conservation and Recovery Act, and the regulatory provisions of 40 CFR Part 247. In the performance of this contract and to the extent practicable, the Contractor and subcontractors are to use products containing the highest percentage of recovered materials for items designated by the Environmental Protection Agency (EPA) under 40 CFR Part 247 whenever: 1) The contract requires procurement of $10,000 or more of a designated item during the fiscal year; or 2) The contractor has procured $10,000 or more of a designated item using Federal funding during the previous fiscal year. The list of EPA-designated items is available at www.epa.gov/smm/comprehensive- procurement-guidelines-construction-products. Section 6002(c) establishes exceptions to the preference for recovery of EPA-designated products if the contractor can demonstrate the item is: a) Not reasonably available within a timeframe providing for compliance with the contract performance schedule; b) Fails to meet reasonable contract performance requirements; or c) Is only available at an unreasonable price. Reference: 2 CFR § 200.323, 2 CFR Part 200, Appendix II (J); 40 CFR part 247, 42 USC § 6901, et seq (Resource Conservation and Recovery Act)         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 58 of 65 FAA – 22 Rights to Inventions APPLICABILITY – Contract Types – This provision applies to all contracts and subcontracts with small business firms or nonprofit organizations that include performance of experimental, developmental, or research work. This clause is not applicable to construction, equipment, or professional service contracts unless the contract includes experimental, developmental, or research work. REQUIREMENT - Contracts or agreements that include the performance of experimental, developmental, or research work must provide for the rights of the Federal Government and the City in any resulting invention as established by 37 CFR part 401, Rights to Inventions Made by Non-profit Organizations and Small Business Firms under Government Grants, Contracts, and Cooperative Agreements. This contract incorporates by reference the patent and inventions rights as specified within 37 CFR §401.14. Contractor must include this requirement in all sub- tier contracts involving experimental, developmental, or research work. Reference: 2 CFR § 200, Appendix II(F), 37 CFR 401         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 59 of 65 FAA - 23 Seismic Safety APPLICABILITY – Contract Types – This provision applies to construction of new buildings and additions to existing buildings financed in whole or in part through the Airport Improvement Program. Professional Services– any contract involved in the construction of new buildings or structural addition to existing buildings. Construction – any contract involved in the construction of new buildings or structural addition to existing buildings. Equipment – if the project involves construction or structural addition to a building such as an electrical vault project to accommodate or install equipment. Land – This provision will not typically apply to a property/land project. REQUIREMENT - A23.3.1 Professional Service Agreements for Design SEISMIC SAFETY In the performance of design services, the Consultant agrees to furnish a building design and associated construction specification that conform to a building code standard that provides a level of seismic safety substantially equivalent to standards as established by the National Earthquake Hazards Reduction Program (NEHRP). Local building codes that model their building code after the current version of the International Building Code (IBC) meet the NEHRP equivalency level for seismic safety. At the conclusion of the design services, the Consultant agrees to furnish the Owner a “certification of compliance” that attests conformance of the building design and the construction specifications with the seismic standards of NEHRP or an equivalent building code. A23.3.2 Construction Contracts SEISMIC SAFETY The Contractor agrees to ensure that all work performed under this contract, including work performed by subcontractors, conforms to a building code standard that provides a level of seismic safety substantially equivalent to standards established by the National Earthquake Hazards Reduction Program (NEHRP). Local building codes that model their code after the current version of the International Building Code (IBC) meet the NEHRP equivalency level for seismic safety. Reference: 49 CFR Part 41         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 60 of 65 FAA – 24 Tax Delinquency and Felony Conviction APPLICABILITY – This provision applies to all contracts funded in whole or part with AIP. REQUIREMENT - The Contractor must have certified under the procurement process that resulted in the award of this contract that: • Contractor has not been convicted of a Federal felony within the last 24 months; or • Contractor does not have any outstanding tax liability for which all judicial and administrative remedies have lapsed or been exhausted. Reference: Sections 8113 of the Consolidated Appropriations Act, 2022 (Public Law 117-103), and similar provisions in subsequent appropriations acts. DOT Order 4200.6 – Appropriations Act Requirements for Procurement and Non-Procurement Regarding Tax Delinquency and Felony Convictions         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 61 of 65 FAA – 25 Termination of Contract APPLICABILITY – All contracts and subcontracts in excess of $10,000. REQUIREMENT - See Section 4.5 of the Agreement. Reference: 2 CFR § 200 Appendix II(B), FAA Advisory Circular 150/5370-10, Section 80-09         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 62 of 65 FAA – 26 Foreign Trade Restriction APPLICABILITY – all AIP funded projects. REQUIREMENT - TRADE RESTRICTION CERTIFICATION By accepting this contract the Contractor certifies the following statements are true – 1) is not owned or controlled by one or more citizens of a foreign country included in the list of countries that discriminate against U.S. firms as published by the Office of the United States Trade Representative (USTR); 2) has not knowingly entered into any contract or subcontract for this project with a person that is a citizen or national of a foreign country included on the list of countries that discriminate against U.S. firms as published by the USTR; and 3) has not entered into any subcontract for any product to be used on the Federal project that is produced in a foreign country included on the list of countries that discriminate against U.S. firms published by the USTR. This certification concerns a matter within the jurisdiction of an agency of the United States of America and the making of a false, fictitious, or fraudulent certification may render the maker subject to prosecution under Title 18 USC Section 1001. The Contractor must provide immediate written notice to the City if the Contractor learns that its certification or that of a subcontractor was erroneous when submitted or has become erroneous by reason of changed circumstances. The Contractor must require subcontractors provide immediate written notice to the Contractor if at any time it learns that its certification was erroneous by reason of changed circumstances. Unless the restrictions of this clause are waived by the Secretary of Transportation in accordance with 49 CFR 30.17, no contract shall be awarded to an Offeror or subcontractor: 1) who is owned or controlled by one or more citizens or nationals of a foreign country included on the list of countries that discriminate against U.S. firms published by the USTR or 2) whose subcontractors are owned or controlled by one or more citizens or nationals of a foreign country on such USTR list or 3) who incorporates in the public works project any product of a foreign country on such USTR list. Nothing contained in the foregoing shall be construed to require establishment of a system of records in order to render, in good faith, the certification required by this provision. The knowledge and information of a contractor is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings. The Contractor agrees it will incorporate this provision for certification without modification in all lower tier subcontracts. The Contractor may rely on the certification of a prospective subcontractor that it is not a firm from a foreign country included on the list of countries that         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 63 of 65 discriminate against U.S. firms as published by USTR, unless the Contractor has knowledge that the certification is erroneous. This certification is a material representation of fact upon which reliance was placed when making an award. If it is later determined that the Contractor or subcontractor knowingly rendered an erroneous certification, the Federal Aviation Administration (FAA) may direct through the City cancellation of the contract or subcontract for default at no cost to the City or the FAA. Reference: 49 USC § 50104, 49 CFR part 30         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 64 of 65 FAA – 27 Veteran’s Preference APPLICABILITY – This provision applies to all AIP funded projects that involve labor to carry out the project. This preference, which excludes executive, administrative, and supervisory positions, applies to covered veterans [as defined under § 47112(c)] only when they are readily available and qualified to accomplish the work required by the project. REQUIREMENT - In the employment of labor (excluding executive, administrative, and supervisory positions), the Contractor and all sub-tier contractors must give preference to covered veterans as defined within Title 49 United States Code Section 47112. Covered veterans include Vietnam-era veterans, Persian Gulf veterans, Afghanistan-Iraq war veterans, disabled veterans, and small business concerns (as defined by 15 USC 632) owned and controlled by disabled veterans. This preference only applies when there are covered veterans readily available and qualified to perform the work to which the employment relates. Reference: 49 USC § 47112(c)         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Page 65 of 65 FAA – 28 Domestic Preferences for Procurements APPLICABILITY – all contracts and Purchase orders for work or products under the grant. REQUIREMENT - The Contractor certifies by signing and submitting its bid or proposal that, to the greatest extent practicable, the Contractor has provided a preference for the purchase, acquisition, or use of goods, products, or materials produced in the United States (including, but not limited to, iron, aluminum, steel, cement, and other manufactured products) in compliance with 2 CFR § 200.322. Reference: 2 CFR § 200.322; 2 CFR Part 200, Appendix II(L)         Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE November 7, 2024 PstgNtcLtr AILEVON PACIFIC AVIATION CONSULTING LLC 1382 MARION WALK SE ATLANTA, GA 30315-4450 Policy Number: 84 WEC BJ5256 Dear Policyholder, This packet includes the posting notices available for your Workers’Compensation policy from The Hartford.If any posting notices are attached below please print and post them in your workplace. We recommend that you keep these documents posted in your workplace, following your state’s requirements. Thank you, The Hartford Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE DWC 7 (1/1/2016) Form WC 88 04 00 I Printed in U.S.A. ESTADO DE CALIFORNIA - DEPARTAMENTO DE RELACIONES INDUSTRIALES División de Compensación de Trabajadores Aviso a los Empleados - Lesiones Causadas por el Trabajo Es posible que usted tenga derecho a beneficios de compensación de trabajadores si usted se lesiona o se enferma a causa de su trabajo.La compensación de trabajadores cubre la mayoría de las lesiones y enfermedades físicas o mentales relacionadas con el trabajo.Una lesión o enfermedad puede ser causada por un evento (como por ejemplo lastimarse la espalda en una caída)o por acciones repetidas (como por ejemplo lastimarse la muñeca por hacer el mismo movimiento una y otra vez). Beneficios.Los beneficios de compensación de trabajadores incluyen: o Atención Médica:Consultas médicas,servicios de hospital,terapia física,análisis de laboratorio,radiografías,medicinas,equipo médico y costos de viajar que son razonablemente necesarias para tratar su lesión.Usted nunca deberá ver un cobro.Hay límites para visitas quiroprácticas, de terapia física y de terapia ocupacional. o Beneficios por Incapacidad Temporal (TD):Pagos si usted pierde sueldo mientras se recupera.Para la mayoría de las lesiones,beneficios de TD no se pagarán por más de 104 semanas dentro de cinco años después de la fecha de la lesión. o Beneficios por Incapacidad Permanente (PD):Pagos si usted no se recupera completamente y si su lesión le causa una pérdida permanente de su función física o mental que un médico puede medir. o Beneficio Suplementario por Desplazamiento de Trabajo:Un vale no-transferible si su lesión surge en o después del 1/1/04,y su lesión le ocasiona una incapacidad permanente, y su empleador no le ofrece a usted un trabajo regular, modificado o alternativo. o Beneficios por Muerte:Pagados a sus dependientes si usted muere a causa de una lesión o enfermedad relacionada con el trabajo. Designación de su Propio Médico Antes de una Lesión o Enfermedad (Designación previa).Es posible que usted pueda elegir al médico que le atenderá en una lesión o enfermedad relacionada con el trabajo.Si elegible,usted debe informarle al empleador,por escrito,el nombre y la dirección de su médico personal o grupo médico,antes de que usted se lesione.Usted debe de ponerse de acuerdo con su médico para que atienda la lesión causada por el trabajo.Para instrucciones,vea la información escrita sobre la compensación de trabajadores que se le exige a su empleador darle a los empleados nuevos. Si Usted se Lastima: 1.Obtenga Atención Médica.Si usted necesita atención de emergencia,llame al 911 para ayuda inmediata de un hospital,una ambulancia,el departamento de bomberos o departamento de policía.Si usted necesita primeros auxilios, comuníquese con su empleador. 2.Reporte su Lesión.Reporte la lesión inmediatamente a su supervisor(a)o a un representante del empleador.No se demore.Hay límites de tiempo.Si usted espera demasiado,es posible que usted pierda su derecho a beneficios.Su empleador está obligado a proporcionarle un formulario de reclamo dentro de un día laboral después de saber de su lesión.Dentro de un día después de que usted presente un formulario de reclamo,el empleador o administrador de reclamos debe autorizar todo tratamiento médico,hasta diez mil dólares,de acuerdo con las pautas de tratamiento aplicables a su presunta lesión, hasta que el reclamo sea aceptado o rechazado. 3.Consulte al Médico que le está Atendiendo (PTP).Este es el médico con la responsabilidad total de tratar su lesión o enfermedad. o Si usted designó previamente a su médico personal o grupo médico,usted puede consultar a su médico personal o grupo médico después de lesionarse. o Si su empleador está utilizando una Red de Proveedores Médicos (MPN)o una Organización de Cuidado Médico (HCO),en la mayoría de los casos usted será tratado dentro de la MPN o la HCO a menos que usted designó previamente un médico personal o grupo médico.Una MPN es un grupo de médicos y proveedores de atención médica que proporcionan tratamiento a trabajadores lesionados en el trabajo. Usted debe recibir información de su empleador si está cubierto por una HCO o una MPN.Hable con su empleador para más información. o Si su empleador no está utilizando una MPN o HCO,en la mayoría de los casos el administrador de reclamos puede escoger el médico que lo atiende primero, cuando usted se lesiona, a menos que usted designó previamente a un médico personal o grupo médico. 4.Red de Proveedores Médicos (MPN):Es posible que su empleador use una MPN,lo cual es un grupo de proveedores de asistencia médica designados para dar tratamiento a los trabajadores lesionados en el trabajo.Si usted ha hecho una designación previa de un médico personal antes de lesionarse en el trabajo,entonces usted puede recibir tratamiento de su médico previamente designado.Si usted está recibiendo tratamiento de parte de un médico que no pertenece a la MPN para una lesión existente,puede requerirse que usted se cambie a un médico dentro de la MPN.Para más información, vea la siguiente información de contacto de la MPN: Página web de la MPN: Fecha de vigencia de la MPN:Número de identificación de la MPN: Si usted necesita ayuda en localizar un médico de una MPN, llame a su asistente de acceso de la MPN al: Si usted tiene preguntas sobre la MPN o quiere presentar una queja en contra de la MPN, llame a la Persona de Contacto de la MPN al: Discriminación:Es ilegal que su empleador le castigue o despida por sufrir una lesión o enfermedad en el trabajo,por presentar un reclamo o por testificar en el caso de compensación de trabajadores de otra persona.De ser probado,usted puede recibir pagos por pérdida de sueldos,reposición del trabajo,aumento de beneficios y gastos hasta los límites establecidos por el estado. ¿Preguntas?Aprenda más sobre la compensación de trabajadores leyendo la información que se requiere que su empleador le dé cuando es contratado.Si usted tiene preguntas,vea a su empleador o al administrador de reclamos (que se encarga de los reclamos de compensación de trabajadores de su empleador): Administrador de Reclamos Hartford Casualty Insurance Company Teléfono (800) 327-3636 Asegurador del Seguro de Compensación de trabajador Hartford Casualty Insurance Company (Anote "autoasegurado" si es apropiado) Usted también puede obtener información gratuita de un Oficial de Información y Asistencia de la División Estatal de Compensación de Trabajadores. El Oficial de Información y Asistencia más cercano se localiza en: o llamando al número gratuito (800)736-7401.Usted puede obtener más información sobre la compensación del trabajador en el Internet en: www.dwc.ca.gov y acceder a una guía útil "Compensación del Trabajador de California Una Guía para Trabajadores Lesionados." Los reclamos falsos y rechazos falsos del reclamo.Cualquier persona que haga o que ocasione que se haga una declaración o una representación material intencionalmente falsa o fraudulenta,con el fin de obtener o negar beneficios o pagos de compensación de trabajadores,es culpable de un delito grave y puede ser multado y encarcelado. Es posible que su empleador no sea responsable por el pago de beneficios de compensación de trabajadores para ninguna lesión que proviene de su participación voluntaria en cualquier actividad fuera del trabajo, recreativa, social, o atlética que no sea parte de sus deberes laborales. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE DWC 7 (6/10) Form WC 88 04 01 I Printed in U.S.A. STATE OF CALIFORNIA - DEPARTMENT OF INDUSTRIAL RELATIONS Division of Workers’ Compensation Notice to Employees - Injuries Caused By Work You may be entitled to workers’compensation benefits if you are injured or become ill because of your job.Workers’compensation covers most work- related physical or mental injuries and illnesses.An injury or illness can be caused by one event (such as hurting your back in a fall)or by repeated exposures (such as hurting your wrist from doing the same motion over and over). Benefits.Workers’ compensation benefits include: o Medical Care:Doctor visits,hospital services,physical therapy,lab tests,x-rays,medicines,medical equipment and travel costs that are reasonably necessary to treat your injury.You should never see a bill.There are limits on chiropractic,physical therapy and occupational therapy visits. o Temporary Disability (TD)Benefits:Payments if you lose wages while recovering.For most injuries,TD benefits may not be paid for more than 104 weeks within five years from the date of injury. o Permanent Disability (PD)Benefits:Payments if you do not recover completely and your injury causes a permanent loss of physical or mental function that a doctor can measure. o Supplemental Job Displacement Benefit:A nontransferable voucher,if you are injured on or after 1/1/2004,your injury causes permanent disability, and your employer does not offer you regular, modified, or alternative work. o Death Benefits:Paid to your dependents if you die from a work-related injury or illness. Naming Your Own Physician Before Injury or Illness (Predesignation).You may be able to choose the doctor who will treat you for a job injury or illness.If eligible,you must tell your employer,in writing,the name and address of your personal physician or medical group before you are injured. You must obtain their agreement to treat you for your work injury.For instructions,see the written information about workers’compensation that your employer is required to give to new employees. If You Get Hurt: 1.Get Medical Care.If you need emergency care,call 911 for help immediately from the hospital,ambulance,fire department or police department.If you need first aid, contact your employer. 2.Report Your Injury.Report the injury immediately to your supervisor or to an employer representative.Don’t delay.There are time limits.If you wait too long,you may lose your right to benefits.Your employer is required to provide you with a claim form within one working day after learning about your injury.Within one working day after you file a claim form,your employer or claims administrator must authorize the provision of all treatment,up to ten thousand dollars,consistent with the applicable treatment guidelines,for your alleged injury until the claim is accepted or rejected. 3.See Your Primary Treating Physician (PTP).This is the doctor with overall responsibility for treating your injury or illness. o If you predesignated your personal physician or a medical group,you may see your personal physician or the medical group after you are injured. o If your employer is using a medical provider network (MPN)or a health care organization (HCO),in most cases you will be treated within the MPN or HCO unless you predesignated a personal physician or medical group An MPN is a group of physicians and health care providers who provide treatment to workers injured on the job.You should receive information from your employer if you are covered by an HCO or a MPN.Contact your employer for more information. o If your employer is not using an MPN or HCO,in most cases the claims administrator can choose the doctor who first treats you when you are injured, unless you predesignated a personal physician or medical group. 4.Medical Provider Networks.Your employer may be using an MPN,which is a group of health care providers designated to provide treatment to workers injured on the job.If you have predesignated a personal physician or medical group prior to your work injury,then you may go there to receive treatment from your predesignated doctor.If you are treating with a non-MPN doctor for an existing injury,you may be required to change to a doctor within the MPN.For more information, see the MPN contact information below: MPN website: MPN Effective Date:MPN Identification number: If you need help locating an MPN physician, call your MPN access assistant at: If you have questions about the MPN or want to file a complaint against the MPN, call the MPN Contact Person at: Discrimination.It is illegal for your employer to punish or fire you for having a work injury or illness,for filing a claim,or testifying in another person’s workers’compensation case.If proven,you may receive lost wages,job reinstatement,increased benefits,and costs and expenses up to limits set by the state. Questions?Learn more about workers’compensation by reading the information that you employer is required to give you at time of hire.If you have questions, see your employer or the claims administrator (who handles workers’ compensation claims for your employer): Claims Administrator Hartford Casualty Insurance Company Phone (800) 327-3636 Workers’ compensation insurer Hartford Casualty Insurance Company (Enter "self-insured" if appropriate) You can also get free information from a State Division of Workers’Compensation Information (DWC)&Assistance Officer.The nearest Information & Assistance Officer can be found at location:or by calling toll-free (800)736-7401.Learn more information about workers’compensation online:www.dwc.ca.gov and access a useful booklet “Workers’ Compensation in California:A Guidebook for Injured Workers.” False claims and false denials.Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers’compensation benefits or payments is guilty of a felony and may be fined and imprisoned. Your employer may not be liable for the payment of workers’ compensation benefits for any injury that arises from your voluntary participation in any off-duty, recreational, social, or athletic activity that is not part of your work-related duties. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Form WC 88 04 05 D Printed in U.S.A.Page 1 of 4 WORKERS’ COMPENSATION - WRITTEN NOTICE TO NEW EMPLOYEES This notice includes some of your rights,benefits and obligations under the workers’ compensation law. EVENTS,INJURIES AND ILLNESSES COVERED BY WORKERS’ COMPENSATION You may be entitled to workers’compensation benefits if you are injured or become ill because of your job. Workers’compensation covers most work related physical or mental injuries and illnesses.An injury or illness can be caused by one event (such as hurting your back in a fall)or by repeated exposures (such as hurting your wrist from doing the same motion over and over). You may not be entitled to workers’compensation benefits for any injury that arises from your voluntary participation in any off-duty,recreational,social or athletic activity that is not part of your work-related duties. RIGHTS AND BENEFITS You may have the right to the following: o Medical Care Benefits which include:Doctor visits,hospital services,physical therapy,lab tests,x-rays,and medicines as reasonably necessary to treat your injury. o Temporary Disability (TD)Benefits:Payments if you lose wages while recovering.For most injuries that occur on or after Jan 1,2008, temporary disability (TD)benefits may not extend for more than 104 compensable weeks within five years from the date of injury.For a few long term injuries,such as severe burns or chronic lung disease,benefits may not extend for more than 240 weeks within five years from the date of injury. Filing a timely Employment Development Department claim may result in additional state disability benefits when TD benefits terminate. o Permanent Disability (PD)Benefits:Payments if your injury causes a permanent disability. o Supplemental Job Displacement Benefits:A nontransferable voucher payable to a state approved school if you are injured on or after 1/1/04,the injury results in a permanent disability, you don’t return to work within 60 days after TD ends,and your employer does not offer modified or alternative work. o Death Benefits:Paid to dependents of a worker who dies from a work-related injury or illness. Temporary disability,permanent disability,vocational rehabilitation maintenance allowance and death benefits are all payable based on 2/3 of your average weekly wage subject to state minimum and maximum rates in effect on your date of injury.Your benefits are paid every two weeks while you are eligible. CHOOSING YOUR OWN DOCTOR You may be able to choose the doctor who will treat you for a job injury or illness during the first 30 days after the injury.If eligible,you must tell your employer,in writing, the name and address of your personal physician before you are injured.You may be treated for such injury or illness by your personal medical doctor (M.D.),doctor of osteopathic medicine (D.O.) or medical group if: o your employer offers group health coverage; o the doctor is your regular physician,who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician,obstetrician-gynecologist,or family practitioner,and has previously directed your medical treatment,and retains your medical records; o your "personal physician"may be a medical group if it is a single corporation or partnership composed of licensed doctors of medicine or osteopathy,which operates an integrated multispecialty medical group providing comprehensive medical services predominantly for nonoccupational illnesses and injuries; o prior to the injury your doctor agrees to treat you for work injuries or illnesses; o prior to the injury you provided your employer the following in writing:(1)notice that you want your personal doctor to treat you for a work-related injury or illness,and (2)your personal doctor’s name and business address. Pages 3 and 4 of this notice are forms which can be used for this purpose. If you do not choose a doctor,your employer has the right to select the physician who will treat you for the first 30 days.You may be able to switch to a doctor of your choice after 30 days,which may include your personal chiropractor or personal acupuncturist.Special rules apply if your employer offers a Health Care Organization (HCO)or after 1/1/05,has a medical provider network (MPN). Contact your employer for more information. ROLE OF THE PRIMARY TREATING PHYSICIAN Your Primary Treating Physician will decide what type of medical care you will receive for your injury or illness, determine when you can return to work,help identify the kinds of work you can do safely while recovering,refer you to specialists,if necessary,and write medical reports that will affect the benefits you receive.It is important to get good medical care to help you recover.You should be treated Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Form WC 88 04 05 D Printed in U.S.A.Page 2 of 4 by a doctor who understands your particular type of injury or illness.Tell the doctor about your symptoms and the events at work that you believe caused them.Also, describe your job and your work environment. IF YOU GET HURT –GET MEDICAL CARE.If you need first aid,contact your employer.If you need emergency medical treatment,call 911 or one of the numbers listed below.Tell the health care provide who treats you that your injury or illness is job related. Ambulance Fire Dept. Police Doctor Hospital REPORT YOUR INJURY OR ILLNESS Report the injury immediately to your supervisor or to: Employer Representative Phone Number Tell your supervisor right away.If your injury or illness developed gradually,report it as soon as you learn it was caused by your job.Reporting promptly helps prevent problems and delays in receiving benefits,including medical care you may need to avoid further injury.If your employer does not learn of your injury within 30 days,you could lose your right to receive workers’compensation benefits. Your employer is required to provide you a claim form within one working day after learning about your injury. Within one working day after an employee files a claim form,the employer shall authorize the provision of all treatment,consistent with the applicable treating guidelines,for the alleged injury and shall continue to provide treatment until the date that liability for the claim is accepted or rejected.Until the date the claim is accepted or rejected,liability for medical treatment shall be limited to ten thousand dollars ($10,000). ADDITIONAL INFORMATION You can get free information from a State of Workers’ Compensation Information &Assistance Officer.To hear recorded information including a list of local offices,call toll-free (800)736-7401.Learn more online: http://www.dir.ca.gov The nearest Information & Assistance Officer is at: Address City Phone Your employer’s compensation carrier at the time of your hire is: Hartford Casualty Insurance Company DISCRIMINATION It is illegal for your employer to punish or fire you for having a work injury or illness,for filing a claim,or testifying in another person’s workers’compensation case. If proven,you may receive lost wages,job reinstatement, increased benefits,and costs and expenses up to the limits set by the state. MEDICAL PROVIDER NETWORKS Your employer may be using an MPN,which is a selected network of health care providers to provide treatment to workers injured on the job.If you have pre-designated a personal physician prior to your work injury,then you may receive treatment from your pre-designated doctor.If you have not pre-designated and your employer is using a MPN,you are free to choose an appropriate provider from the MPN list after the first medical visit directed by your employer.If you are treating with a non-MPN doctor for an existing injury,you may be required to change to a doctor within the MPN.Contact your employer for more information. False Claims and False Denials.Any person who makes or causes to be made any knowingly false of fraudulent material statement or material representation for the purpose of obtaining or denying workers’compensation benefits or payment is guilty of a felony and may be fined and imprisoned. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE (Optional DWC Form 9783 March 1, 2007) Form WC 88 04 05 D Printed in U.S.A.Page 3 of 4 PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment,you may be treated for such injury or illness by your personal medical doctor (M.D.) or doctor of osteopathic medicine (D.O.) or medical group if: o your employer offers group health coverage; o the doctor is your regular physician,who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist,pediatrician,obstetrician- gynecologist,or family practitioner,and has previously directed your medical treatment,and retains your medical records; o your "personal physician"may be a medical group if it is a single corporation or partnership composed of licensed doctors of medicine or osteopathy,which operates an integrated multispecialty medical group providing comprehensive medical services predominantly for nonoccupational illnesses and injuries; o prior to the injury your doctor agrees to treat you for work injuries or illnesses; o prior to the injury you provided your employer the following in writing:(1)notice that you want your personal doctor to treat you for a work-related in injury or illness,and (2)your personal doctor’s name and business address. You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work – related injury or illness and the above requirements are met. NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee:Complete this section. To:(name of employer).If I have a work-related injury or illness, I choose to be treated by: (name of doctor)(M.D., D.O., or medical group) (street address, city, state, zip) (telephone number) Employee Name (please print): Employee’s Address: Employee’s Signature Date: Physician:I agree to this Predesignation: Signature:Date: (Physician or Designated Employee of the Physician or Medical Group) The physician is not required to sign this form,however,if the physician or designated employee of the physician or medical group does not sign,other documentation of the physician’s agreement to be predesignated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3). Title 8, California Code of Regulations, section 9783. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE DWC FORM 9783.1 (March 14 2006) Form WC 88 04 05 D Printed in U.S.A.Page 4 of 4 NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST If your employer or your employer’s insurer does not have a Medical Provider Network,you may be able to change your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness.In order to be eligible to make this change,you must give your employer the name and business address of a personal chiropractor or acupuncturist in writing prior to the injury or illness.Your claims administrator generally has the right to select your treating physician within first 30 days after your employer knows of your injury or illness.After your claims administrator has initiated your treatment with another doctor during this period,you may then,upon request,have your treatment transferred to your personal chiropractor or acupuncturist. You may use this form to notify your employer of your personal chiropractor or acupuncturist. Your Chiropractor or Acupuncturist’s Information: (name of chiropractor or acupuncturist) (street address, city, state, zip code) (telephone number) Employee Name (Please Print): Employee’s address: Employee’s Signature Date: Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Form WC 88 04 06 D Impreso en los EE. UU.Página 1 de 4 SEGURO CONTRA ACCIDENTES LABORALES - NOTIFICACIÓN ESCRITA PARA NUEVOS EMPLEADOS Esta notificación incluye algunos de sus derechos, beneficios y obligaciones según la ley del seguro contra accidentes laborales. EVENTOS,LESIONES Y ENFERMEDADES CUBIERTOS POR EL SEGURO CONTRA ACCIDENTES LABORALES Usted tendrá derecho a los beneficios del seguro contra accidentes laborales en caso de sufrir una lesión o contraer una enfermedad relacionada con su trabajo.El seguro contra accidentes laborales cubre gran parte de las enfermedades y lesiones físicas o mentales relacionadas con el trabajo.La lesión o enfermedad puede ser causada por un solo evento (como lesionarse la espalda en una caída)o por exposición reiterada (como lesionarse la muñeca por realizar un mismo movimiento repetidas veces).Usted no tendrá derecho a los beneficios del seguro contra accidentes laborales por una lesión que surja de la participación voluntaria en cualquier actividad fuera del trabajo,recreativa,social o deportiva,que no forme parte de sus obligaciones laborales. DERECHOS Y BENEFICIOS Usted podrá tener derecho a lo siguiente: o Beneficios de atención médica que incluyen: consultas a médicos,servicios hospitalarios, fisioterapia,pruebas de laboratorio,radiografías y medicamentos que sean razonablemente necesarios para tratar la lesión. o Beneficios por incapacidad temporal (TD):pagos en caso de perder el salario durante la recuperación.En la mayoría de las lesiones producidas después del 1 de enero de 2008 inclusive,los beneficios por incapacidad temporal (temporary disability,TD)no podrán extenderse por más de 104 semanas compensables en un plazo de cinco años a partir de la fecha de la lesión.Para algunas lesiones de largo plazo,tales como quemaduras graves o enfermedad pulmonar crónica,los beneficios no podrán extenderse por más de 240 semanas en un plazo de cinco años a partir de la fecha de la lesión. Cuando los beneficios por TD terminan,puede obtener beneficios por incapacidad adicionales del estado si presenta en forma oportuna una reclamación ante el Departamento de Desarrollo del Empleo. o Beneficios por incapacidad permanente (PD): pagos cuando la lesión causa una incapacidad permanente. o Beneficios complementarios por desplazamiento del trabajo:vale no transferible pagadero a una escuela autorizada por el estado por una lesión ocurrida después del 1/1/04 inclusive,cuando lesión causa una incapacidad permanente,usted no regresa al trabajo en el plazo de 60 días luego de finalizar la TD y su empleador no le ofrece un puesto de trabajo modificado o alternativo. o Beneficios por fallecimiento:se pagan a los dependientes de un empleado que fallece a causa de una enfermedad o lesión relacionada con el trabajo. Los beneficios por incapacidad temporal,incapacidad permanente,rehabilitación profesional,pensión alimenticia y fallecimiento se pagan sobre la base de 2/3 de su salario promedio semanal,sujeto a tasas máximas y mínimas,vigentes a la fecha de la lesión.Los beneficios se pagan cada dos semanas mientras usted sea elegible. ELECCIÓN DEL MÉDICO PERSONAL Usted podrá elegir el médico que tratará su enfermedad o lesión laboral durante los primeros 30 días posteriores a la lesión.Si es elegible,deberá informar por escrito el nombre y la dirección del médico personal a su empleador,antes de sufrir la lesión.Podrá ser tratado por dicha lesión o enfermedad por su médico personal (M.D.), osteópata (D.O.) o grupo médico si: o su empleador ofrece cobertura médica colectiva; o el médico es su médico habitual,quien deberá ser médico general o médico de familia,ginecólogo obstetra,pediatra o internista elegible por la junta médica o certificado por dicha junta,y que haya coordinado su tratamiento médico con anterioridad y conserve sus registros médicos; o su "médico personal"puede ser un grupo médico si se trata de una única sociedad o asociación formada por médicos u osteópatas con licencia, que opera como un grupo médico integrado con múltiples especialidades,que brinda servicios médicos amplios,especialmente para lesiones y enfermedades no ocupacionales; o antes de la lesión,el médico acepta tratarlo por enfermedades o lesiones laborales; o antes de la lesión,usted suministra a su empleador lo siguiente por escrito:(1)notificación del deseo de que su médico personal lo trate por enfermedades o lesiones relacionadas con el trabajo,y (2)el nombre y la dirección comercial de su médico personal. Para tal fin,puede utilizar los formularios de las páginas 3 y 4 de esta notificación. Si no elige un médico,el empleador tendrá derecho a seleccionar el médico que lo tratará durante los primeros 30 días.Después de 30 días,usted podrá cambiar de médico según desee;este cambio podrá incluir a su Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Form WC 88 04 06 D Impreso en los EE. UU.Página 2 de 4 quiropráctico o acupunturista personal.Si su empleador ofrece una Organización de Atención Médica (Health Care Organization,HCO)o a partir del 1/1/05 tiene una red de proveedores de atención médica (medical provider network, MPN), se aplicarán normas especiales. Contacte a su empleador para obtener más información. FUNCIÓN DEL MÉDICO DE ATENCIÓN PRIMARIA El médico de atención primaria decidirá qué tipo de atención médica recibirá usted para su lesión o enfermedad,determinará cuándo podrá regresar a trabajar,contribuirá a identificar el tipo de tareas que puede realizar en forma segura durante la recuperación, lo referirá a especialistas,si es necesario,y escribirá informes médicos que afectarán los beneficios que usted reciba.Es importante obtener una buena atención médica para poder recuperarse.El médico que lo trate deberá conocer el tipo de lesión o enfermedad específica.Informe al médico sobre los síntomas y los eventos laborales que usted cree que los ocasionaron. También describa su trabajo y entorno laboral. SI SE LESIONA,OBTENGA ATENCIÓN MÉDICA.Si necesita primeros auxilios,contacte a su empleador.Si necesita tratamiento médico de emergencia,llame al 911 o a uno de los números indicados debajo.Informe al proveedor de atención médica que la lesión o enfermedad está relacionada con su trabajo. Ambulancia Bomberos Policía Médico Hospital INFORMAR SOBRE LA LESIÓN O ENFERMEDAD Informe de inmediato sobre la lesión a su supervisor o: Representante del empleador Número de teléfono Hable con su supervisor de inmediato.Si la lesión o enfermedad se desarrolló en forma gradual,informe sobre esta tan pronto advierta que fue causada por su trabajo.Si se comunica de inmediato,evitará problemas y retrasos en la recepción de beneficios,incluida la atención médica necesaria para evitar lesiones mayores. Si el empleador no toma conocimiento de su lesión en un plazo de 30 días,usted puede perder el derecho a recibir los beneficios del seguro contra accidentes laborales. El empleador deberá proporcionarle un formulario de reclamación en el plazo de un día laboral después de enterarse de la lesión.En el plazo de un día laboral tras la presentación del formulario de reclamación por parte del empleado,el empleador deberá autorizar la prestación del tratamiento, conforme a las pautas de tratamiento aplicables,para la supuesta lesión, y deberá continuar suministrando tratamiento hasta la fecha en que se acepte o rechace la responsabilidad por la reclamación.Hasta la fecha de rechazo o aceptación de la reclamación,la responsabilidad por el tratamiento médico se limitará a diez mil dólares ($10,000). INFORMACIÓN ADICIONAL Podrá obtener información gratuita a través de un Funcionario Estatal de Asistencia e Información sobre el Seguro contra Accidentes Laborales.Para escuchar información grabada,incluida una lista de oficinas locales, llame sin cargo al 1 (800)736-7401.Información en línea: http://www.dir.ca.gov Funcionario de Asistencia e Información más cercano se encuentra en: Dirección Ciudad Teléfono Compañía aseguradora contra accidentes laborales de su empleador al momento de su contratación: Hartford Casualty Insurance Company DISCRIMINACIÓN La sanción o despido por sufrir una enfermedad o lesión laboral,presentar una reclamación o testificar en un caso de seguro contra accidentes laborales de otra persona, constituye un acto ilegal por parte del empleador.Si esto se demuestra,usted podrá recibir salarios perdidos, reincorporación al trabajo,aumento en los beneficios,más costos y gastos hasta el límite establecido por el estado. RED DE PROVEEDORES MÉDICOS (MPN) Es posible que su empleador use una MPN,lo cual es una red de proveedores de asistencia médica seleccionados para dar tratamiento a los trabajadores lesionados en el trabajo.Si su empleador usa una MPN, una notificación hablando al número de la MPN debajo descrito.Si usted ha hecho una designación previa de un médico personal antes de leionarse en el trabajo, entonces usted puede recibir tratamiento de su medico previamente designado.Si usted no ha hecho una designación previa y su empleador está usando una MPN, usted puede esoger un proveedor apropiado de la lista de la MPN después de la primera visita médica dirigida por su empleador.Si usted está recibiendo tratamiento de parte de un médico que no pertenece a la MPN para una lesión existente,puede requerirse que usted se cambie a un médico dentro de la MPN.Contacte a su empleador para obtener más informatión. Reclamaciones y negaciones falsas.Toda persona que realice o motive una declaración o manifestación sustancial falsa o fraudulenta en forma intencional,con el fin de obtener o negar el pago o los beneficios del seguro contra accidentes laborales, será culpable de delito grave y quedará sujeta a la pena de multa o prisión. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE (Formulario DWC opcional 9783 1 de marzo de 2007) Form WC 88 04 06 D Impreso en los EE. UU.Página 3 de 4 DESIGNACIÓN PREVIA DE MÉDICO PERSONAL En caso de sufrir una lesión o enfermedad relacionada con su trabajo,podrá ser tratado para dicha lesión o enfermedad por su médico personal (M.D.), osteópata (D.O.) o grupo médico si: o su empleador ofrece cobertura médica colectiva; o el médico es su médico habitual,quien deberá ser médico general o médico de familia,ginecólogo obstetra, pediatra o internista elegible por la junta médica o certificado por dicha junta,y que haya coordinado su tratamiento médico con anterioridad y conserve sus registros médicos; o su "médico personal"puede ser un grupo médico si se trata de una única sociedad o asociación formada por médicos u osteópatas con licencia,que opera como un grupo médico integrado con múltiples especialidades, que brinda servicios médicos amplios, especialmente para lesiones y enfermedades no ocupacionales; o antes de la lesión, el médico acepta tratarlo por enfermedades o lesiones laborales; o antes de la lesión,usted suministra al empleador lo siguiente por escrito:(1)notificación del deseo de que su médico personal lo trate por enfermedades o lesiones relacionadas con el trabajo,y (2)el nombre y la dirección comercial de su médico personal. Si cumple con los requisitos anteriores y desea que su médico u osteópata personal lo trate por una lesión o enfermedad relacionada con el trabajo, podrá usar el siguiente formulario para notificar a su empleador. NOTIFICACIÓN DE DESIGNACIÓN PREVIA DE MÉDICO PERSONAL Empleado: complete esta sección. Para:(nombre del empleador). Si sufro una lesión o enfermedad relacionada con mi trabajo, elijo ser tratado por: (nombre del médico) (M.D., D.O. o grupo médico) (dirección, ciudad, estado, código postal) (número de teléfono) Nombre del empleado (en letra de imprenta): Dirección del empleado: Firma del empleado Fecha: Médico: acepto esta designación previa: Firma:Fecha: (Médico o empleado designado del médico o grupo médico) No es obligatorio que el médico firme este formulario;no obstante,si el médico o empleado designado del médico o el grupo médico no lo firma,se exigirá otra documentación en la que conste la aceptación del médico a ser designado previamente conforme al Título 8 del Código de Reglamentaciones de California, sección 9780.1(a)(3). Título 8 del Código de Reglamentaciones de California, sección 9783. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE FORMULARIO DWC 9783.1 (14 de marzo de 2006) Form WC 88 04 06 D Impreso en los EE. UU.Página 4 de 4 NOTIFICACIÓN DE QUIROPRÁCTICO O ACUPUNTURISTA PERSONAL Si su empleador o la compañía aseguradora de su empleador no tienen una Red de Proveedores de Atención Médica, usted podrá cambiar el médico que lo trata por su quiropráctico o acupunturista personal tras una lesión o enfermedad relacionada con el trabajo.A fin de ser elegible para realizar este cambio,deberá informar por escrito a su empleador el nombre y la dirección comercial del quiropráctico o acupunturista personal,antes de la lesión o enfermedad.Por lo general,el administrador de reclamaciones tiene derecho a seleccionar el médico que lo trata durante los primeros 30 días después de que el empleador se entere de la lesión o enfermedad.Después de que el administrador de reclamaciones inicie el tratamiento con otro médico durante dicho período,usted podrá solicitar que el tratamiento se transfiera a su quiropráctico o acupunturista personal. Para notificar al empleador sobre su quiropráctico o acupunturista personal, puede usar el siguiente formulario. Información del quiropráctico o acupunturista: (nombre del quiropráctico o acupunturista) (dirección, ciudad, estado, código postal) (número de teléfono) Nombre del empleado (en letra de imprenta): Dirección del empleado: Firma del empleado Fecha: Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Form WC 88 04 07 D Printed in U.S.A.Page 1 of 11 Important Information about Medical Care if you have a Work-Related Injury or Illness Complete Written MPN Employee Notification (Title 8, California Code of Regulations, section 9767.12) California law requires your employer to provide and pay for medical treatment if you are injured at work.Your employer has chosen to provide this medical care by using a Workers’Compensation physician network called a Medical Provider Network (“MPN").The claims for this MPN are administered by Hartford Fire Insurance Company.This notification tells you what you need to know about the MPN program and describes your rights in choosing medical care for work-related injuries and illnesses. o What happens if I get injured at work? In case of an emergency, you should call 911 or go to the closet emergency room. If you are injured at work,notify your employer as soon as possible.Your employer will provide you with a claim form. When you notify your employer that you have had a work-related injury,your employer or insurer will make an initial appointment with a doctor in the MPN. o What is a MPN? A Medical Provider Network (MPN)is a group of health care providers (physicians and other medical providers)used by your employer to treat workers injured on the job.Each MPN must include a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine. MPNs must allow employees to have a choice of provider(s). o What MPN is used by my employer? You must refer to the MPN name and the MPN identification number whenever you have questions or requests about the MPN.Your employer is using The Hartford Select Network MPN with the MPN identification number 3044. General information regarding the MPN can also be found at the following website:The MPN informational website address is:https://www.thehartford.com/ca-workers-compensation. o How do I find out which doctors are in my MPN? First,you could access the Provider Directory as set out below.Alternative resources are available as follows:by calling your Claim Handler,the Network Referral Unit,or the Medical Access Assistant also set out below under Provider Directories.A roster of all treating physicians in the MPN is available at http://www.thehartfordselectnetworkmpn.com/. The MPN contact listed in this notification will be able to answer your questions about the MPN and will help you obtain a regional list of all MPN doctors in your area.At minimum,the regional listing must include a list of all MPN providers within fifteen (15)miles of your workplace and/or residence or a list of all MPN providers within the county where you live and/or work.You may choose which list you wish to receive. You can get the list of MPN providers by calling the MPN Contact.Or,you may contact The Hartford to locate a participating provider or obtain a regional listing as follows: Provider Directories: On-line Directories –if you have internet access,you may obtain a regional directory or locate a participating provider near you by visiting http://www.thehartfordselectnetworkmpn.com/. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Form WC 88 04 07 D Printed in U.S.A.Page 2 of 11 If you do not have internet access,you may request assistance in locating an MPN provider or obtaining a regional listing by calling: o Your Claim Handler @ 866.401.9222, or o The Network Referral Unit at 1.800.327.3636, prompt 4, or The Medical Access Assistant @ 866-758-7256. Statewide Treating Provider List: You also have the right to a complete listing of all of the MPN providers upon request.You may generate the list yourself via the internet, go to http://www.thehartfordselectnetworkmpn.com/. If you need assistance with finding an available MPN provider,or would like help in scheduling and confirming provider appointments,our MPN Medical Access Assistant can be reached,toll free,at 866-758-7256,7 am –8 pm Pacific Time (Monday –Saturday)(excluding Sundays and holidays);by fax at 916-293-5025;or by email at thehartfordmaa@primehealthservices.com.At least one MPN Medical Access Assistant is available to respond at all required times,with the ability for callers to leave a voice message.Medical Access Assistants will respond to calls,faxes or messages by the next day,excluding Sundays and holidays.Medical Access Assistants work in coordination with the MPN Contact and the Claim Handler(s)to ensure timely and appropriate medical treatment is available to you,the injured worker.Assistance provided by the Medical Access Assistants is available in English and Spanish. o How do I choose a provider? Your employer or the insurer for your employer will arrange the initial medical evaluation with a MPN physician.After the first medical visit,you may continue to be treated by that doctor,or you may choose another doctor from the MPN.You may continue to choose doctors within the MPN for all of your medical care for this injury. If appropriate,you may choose a specialist or ask your treating doctor for a referral to a specialist.Some specialists will only accept appointments with a referral from the treating doctor.Such specialist might be listed as “by referral only”in your MPN directory. If you need help in finding a doctor or scheduling a medical appointment, you may call the Medical Access Assistant. o Can I change providers? Yes.You can change providers within the MPN for any reason,but the providers you choose should be appropriate to treat your injury.Contact your MPN Contact or your Claim Handler if you want to change your treating physician. o What standards does the MPN have to meet? The MPN has providers for the entire state of California. The MPN must give you a regional list of providers that includes at least three available physicians of each specialty to treat common injuries based on your occupation or industry.The MPN must have at least three available primary treating physicians and a hospital or emergency healthcare service provider within fifteen (15)miles or thirty (30)minutes of your residence or workplace.The MPN must have providers of occupational health services and specialists within thirty (30) miles or sixty (60) minutes of your residence or workplace. The MPN must provide initial treatment within three (3)days.You must receive specialist treatment within twenty (20) business days of your request for an appointment through an MPN Medical Access Assistant.If an MPN Medical Access Assistant is unable to schedule a timely medical appointment (i.e.scheduled within twenty (20)business days)with an appropriate specialist within ten (10)business days of an employee’s request,the employer shall permit the employee to obtain necessary treatment with an appropriate specialist outside of the MPN.If you have trouble getting an appointment, contact the Medical Access Assistant. If there are no MPN providers in the appropriate specialty available to treat your injury within the distance and timeframe requirements, then you will be allowed to seek the necessary treatment outside of the MPN. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Form WC 88 04 07 D Printed in U.S.A.Page 3 of 11 o What if there are no MPN providers where I am located? If you are a current employee: o living in a rural area or temporarily working or living outside the MPN service area, or o you are a former employee permanently living outside the MPN service area, or o you are an injured worker who decides to temporarily reside outside the MPN service area during recovery, Your Claim Handler,the MPN,or your treating doctor will give you a list of at least three physicians who can treat you. Your Claim Handler may also allow you to choose your own doctor outside of the MPN network. o What if I need a specialist not in the MPN? If you need to see a type of specialist that is not available in the MPN,you have the right to see a specialist outside of the MPN. o What if I disagree with my doctor about medical treatment? If you disagree with your doctor or wish to change your doctor for any reason,you may choose another doctor within the MPN. If you disagree with either the diagnosis or treatment prescribed by your doctor,you may ask for a second opinion from another doctor within the MPN.If you want a second opinion,you must contact the MPN Contact or your Claim Handler and tell them you want a second opinion.The MPN should give you at least a regional MPN provider list from which you can choose a second opinion doctor.To get a second opinion,you must choose a doctor from the MPN list and make an appointment within sixty (60)days.You must tell your Claim Handler of your appointment date,and your Claim Handler will send the doctor a copy of your medical records.You can request a copy of your medical records that will be sent to the doctor. If you do not make an appointment within sixty (60)days of receiving the regional provider list,you will not be allowed to have a second or third opinion with regard to this disputed diagnosis or treatment of this treating physician. If the second opinion doctor feels that your injury is outside of the type of injury he or she normally treats,the doctor’s office will notify your employer or insurer and you.You will get another list of MPN doctors or specialists so you can make another selection. If you disagree with the second opinion,you may ask for a third opinion.If you request a third opinion,you will go through the same process you went through for the second opinion. Remember that if you do not make an appointment within sixty (60)days of obtaining another MPN provider list,then you will not be allowed to have a third opinion with regard to this disputed diagnosis or treatment of this treating physician. If you disagree with the third opinion doctor,you may ask for an MPN Independent Medical Review (IMR).Your employer or MPN contact person will give you information on requesting an Independent Medical Review and a form at the time you request a third opinion. If either the second or third opinion doctor agrees with your need for a treatment or test,you will be allowed to receive that medical service from a provider inside the MPN,or if the MPN does not contain a physician who can provide the recommended treatment, you may choose a physician outside the MPN within a reasonable geographic area. If the Independent Medical Reviewer supports your need for a treatment or test you may receive that care from a doctor inside or outside of the MPN. o What if I am already being treated for a work-related injury before the MPN begins? Your employer or insurer has a "Transfer of Care"policy which will determine if you can continue being temporarily treated for an existing work-related injury by a physician outside of the MPN before your care is transferred into the MPN. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Form WC 88 04 07 D Printed in U.S.A.Page 4 of 11 If you have properly pre-designated a primary treating physician,you cannot be transferred into the MPN.(If you have questions about pre-designation,ask your supervisor.)If your current doctor is not or does not become a member of the MPN, then you may be required to see a MPN physician. If your employer decides to transfer you into the MPN,you and your primary treating physician must receive a letter notifying you of the transfer. If you meet certain conditions,you may qualify to continue treating with a non-MPN physician for up to a year before you are transferred into the MPN.The qualifying conditions to postpone the transfer of your care into the MPN are in the box below. Can I Continue Being Treated By My Doctor? You may qualify for continuing treatment with your non-MPN provider (through transfer of care or continuity of care)for up to a year if your injury or illness meets any of the following conditions: o (Acute) The treatment for your injury or illness will be completed in less than 90 days; o (Serious or chronic)Your injury or illness is one that is serious and continues for at least 90 days without full cure or worsens and requires ongoing treatment.You may be allowed to be treated by your current treating doctor for up to one year, until a safe transfer of care can be made. o (Terminal)You have an incurable illness or irreversible condition that is likely to cause death within one year or less. o (Pending Surgery)You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN effective date,or the termination of contract date between the MPN and your doctor. You can disagree with your employer’s decision to transfer your care into the MPN.If you don’t want to be transferred into the MPN,ask your primary treating physician for a medical report on whether you have one of the four conditions stated above to qualify for a postponement of your transfer into the MPN. Your primary treating physician has twenty (20)days from the date of your request to give you a copy of his/her report on your condition.If your primary treating physician does not give you the report within twenty (20)days of your request,the employer can transfer your care into the MPN and you will be required to use a MPN physician. You will need to give a copy of the report to your employer if you wish to postpone the transfer of your care.If you or your employer disagrees with your doctor’s report on your condition,you or your employer can dispute it.See the complete transfer of care policy for more details on the dispute resolution process. For a copy of the entire transfer of care policy in either English or Spanish, ask your MPN Contact. o What if I am being treated by a MPN doctor who decides to leave the MPN? Your employer or insurer has a written "Continuity of Care"policy that will determine whether you can temporarily continue treatment for an existing work injury with your doctor if your doctor is no longer participating in the MPN. If your employer decides that you do not qualify to continuing your care with the non-MPN provider,you and your primary treating physician must receive a letter notifying you of this decision. If you meet certain conditions,you may qualify to continue treating with this doctor for up to a year before you must switch to MPN physicians.These conditions are set forth in the box above,"Can I Continue Being Treated By My Doctor?" You can disagree with your employer’s decision to deny you Continuity of Care with the terminated MPN provider.If you want to continue treating with the terminated doctor,ask your primary treating physician for a medical report on whether you have one of the four conditions stated in the box above to see if you qualify to continue treating with your current doctor temporarily. Your primary treating physician has twenty (20)days from the date of your request to give you a copy of his/her medical report on your condition.If your primary treating physician does not give you the report within twenty (20)days of your request,your employer’s decision to deny you Continuity of Care with your doctor who is no longer participating in the MPN will apply, and you will be required to choose a MPN physician. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Form WC 88 04 07 D Printed in U.S.A.Page 5 of 11 You will need to give a copy of the report to your employer or Claim Handler if you wish to postpone the selection of another MPN doctor for your continued treatment.If you or your employer disagrees with your doctor’s report on your condition,you or your employer can dispute it.See the complete Continuity of Care policy for more details on the dispute resolution process. For a copy of the entire Continuity of Care policy in either English or Spanish, ask your MPN Contact. o Who do I contact if I have questions about my MPN? o MPN Contact:You may always contact the MPN Contact or Claim Handler assigned to your case,if you need help or an explanation about your medical treatment for your work-related injury or illness at: P.O. Box 14475, Lexington, KY 40512 Toll-free Telephone Number for Claim Handler:866.401.9222 Toll-free Telephone Number of MPN Contact:866.401.9222, x2304195 Toll-free Telephone Number of Network Referral Unit for a list of MPN providers and/or MPN Pharmacies:1.800.327.3636, prompt 4 E-Mailbox:CAMPN.Claim@thehartford.com If you have questions concerning your: 1)medical prescriptions, or 2)physical therapy,occupational therapy,work hardening or chiropractic services need for your work- related injury or illness, please contact your Claim Handler at 866.401.9222. If you have a complaint about the MPN, please contact your MPN Contact. o MPN Medical Access Assistant (MAAs): If you need assistance with finding an available MPN provider,or would like help in scheduling and confirming provider appointments,our Medical Provider Network Medical Access Assistants can be reached,toll free,at 866-758-7256,7 am –8 pm Pacific Time (Monday –Saturday)(excluding Sundays and holidays);by fax at 916-293-5025; or by email at: TheHartfordMAA@Primehealthservices.com.At least one MPN Medical Access Assistant is available to respond at all required times,with the ability for callers to leave a voice message.Medical Access Assistants will respond to calls,faxes or messages by the next day,excluding Sundays and holidays.Medical Access Assistants work in coordination with the MPN Contact and the Claim Handler(s)to ensure timely and appropriate medical treatment is available to you,the injured worker.Assistance provided by the Medical Access Assistants is available in English and Spanish. Division of Workers’Compensation (DWC):If you have concerns,complaints or questions regarding the MPN,the notification process,or your medical treatment after a work-related injury or illness,you can call DWC’s Information and Assistance at 1.800.736.7401.You can also go to DWC’s website at www.dir.ca.gov/dwc and click on "medical provider networks" for more o information about MPNs. o Independent Medical Review:If you have questions about the Independent Medical Review process contact the Division of Workers’ Compensation’s Medical Unit at: DWC Medical Unit P.O. Box 71010 Oakland, CA 94612 510.286.3700 or 800.794.6900 Keep this information in case you have a work-related injury or illness. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Form WC 88 04 07 D Printed in U.S.A.Page 6 of 11 (Español) Información Importante sobre Cuidado Médico si tiene una Lesión o Enfermedad de Trabajo. Notificación Completa Escrita del Empleado sobre la Red de Proveedores Médicos (Título 8, Código de Regulaciones de California, sección 9767.12) La ley de California requiere que su empleador le proporcione y pague el tratamiento médico si se lesiona en el trabajo. Su empleador ha elegido a proveer este cuidado médico utilizando una red de médicos de Compensación de Trabajadores llamada Red de Proveedores Médicos o MPN (Medical Provider Network).Esta MPN está administrada por Hartford Fire Insurance Company.Esta notificación le informará lo que necesita saber sobre el programa de la MPN y le describirá sus derechos en elegir cuidado médico para sus lesiones o enfermedades de trabajo. o ¿Qué pasa si me lastimo en el trabajo? En caso de emergencia, debe llamar al 911 o ir a la sala de emergencias más cercana. Si se lesiona en el trabajo,notifique a su empleador lo más pronto posible.Su empleador le proporcionará un formulario de reclamo.Cuando le notifique a su empleador que ha sufrido una lesión de trabajo,su empleador hará la cita inicial con el médico de la MPN. o ¿Qué es una MPN? Una Red de Proveedores Médicos o MPN es un grupo de proveedores de asistencia médica (médicos y otros proveedores médicos)utilizados por su empleador para atender a trabajadores que se lesionan en el trabajo.Cada MPN debe incluir una combinación de médicos que se especializan en lesiones de trabajo y médicos expertos en áreas de medicina general. Las MPN deben permitir que los empleados tengan una selección de proveedor(es). o ¿Qué MPN utiliza mi empleador? Debe consultar el nombre de la MPN y el número de identificación de la MPN siempre que desee realizar preguntas o solicitudes relacionadas con la MPN.Su empleador utiliza la MPN The Hartford Select Network y el número de identification #3044. Para obtener información general relacionada con la MPN,también puede visitar la siguiente página web:La dirección de la página web informativa de la MPN es:https://www.thehartford.com/ca-workers-compensation. o ¿Cómo puedo averiguar cuáles médicos pertenecen a mi MPN? En primer lugar,puede acceder a los Directorios de Proveedores tal como se explica debajo.Los siguientes son recursos alternativos:llamar a su gestor de reclamo,a la Unidad de Referencia de la R o al Asistente de Acceso Médico,también indicado debajo bajo los Directorios de proveedores.Una lista de todos los médicos tratante de la MPN está disponible en http://www.thehartfordselectnetworkmpn.com/y haga clic en la lista de la MPN de CA de la ficha de tratamiento los médicos. El contacto de la MPN indicado en esta notificación podrá contestarle sus preguntas sobre la MPN y le ayudará a obtener una lista regional de los médicos de la MPN en su área.Como mínimo,la lista regional debe incluir una lista de todos los proveedores de la MPN dentro de quince (15)millas de su lugar de trabajo y/o residencia o una lista de todos los proveedores de la MPN dentro del condado donde usted vive y/o trabaja.Usted puede elegir cual lista quiere recibir. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Form WC 88 04 07 D Printed in U.S.A.Page 7 of 11 Puede obtener la lista de los proveedores de la MPN llamando al contacto de la MPN.Para ubicar a un proveedor participante u obtener un directorio regional. Directorios de proveedores médicos: o Directorios en línea.Si tiene acceso a Internet puede obtender un directorio regional o localizar a un proveedor participante cerca de usted, visitando http://www.thehartfordselectnetworkmpn.com/. o Si no dispone de acceso a Internet,puede pedir asistencia para localizar un proveedor de MPN u obtender un listado regional llamando a: o su Gestor de reclamos al 866.401.9222, o la Unidad de la Red de Referencia al 1.800.327.3636, selección 4, o bien o Su Asistente de Acceso Médico al 866-758-7256. Lista de proveedores de todo el estado: Usted también tiene derecho a recibir un listado completo de todos los proveedores de la red de proveedores de atención médica (Medical Provider List Network,MPN)a solicitud.Podrá generar la lista usted mismo a través de internet de la siguiente manera. Vaya a http://www.thehartfordselectnetwork.mpn.com/. También tiene derecho a una lista completa de todos los proveedores de la MPN,si la pide.Si necesita asistencia para encontrar a un proveedor MPN disponible,o desea obtener ayuda para obtener una cita,puede contactar a nuestro Asistente de Acceso Médico sin cargo al 866-758-7256 de 7 a.m.a 8 p.m.Pacifico (lunes a sábado)(excepto domingos y feriados);por fax al 916-293-5025;o por correo electrónico a thehartfordmaa@primehealthservices.com.Al menos un Asistente de Acceso Médico está disponible para responder en todos los momentos solicitados,pudiendo las personas que llaman dejar un mensaje de voz.Los Asistentes de Acceso Médico responderán los llamados,faxes o mensajes antes del día siguiente,excepto domingos y feriados.Los Asistentes de Acceso Médico trabajan en conjunto con el Contacto MPN y el(los)Gestor(es)de reclamos para asegurarse de que usted,el trabajador lesionado,tenga tratamiento médico adecuado a tiempo.Asistencia prestada por los médicos asistentes de acceso está disponible en inglés y español. Errores en listados de proveedores Los errores en cualquier dato de proveedores pueden informarse a las redes médicas directamente utilizando la función Notification (Notificación)en la página de resultados o enviando un correo electrónico a la siguiente dirección de correo electrónico de The Hartford:CAMPN.Claim@thehartford.com; o bien, llamando al número gratuito 866.401.9222. Pasos de la función Notification (Notificación): o En el encabezado Notification (Notificación), o Haga clic en Notify Provider Status Change (Notificar cambio de estado de proveedor), o Aparece la pantalla Provider Letter (Carta de proveedor), o Complete con la información correspondiente, o Haga clic en el botón Create Request (Crear solicitud) en la parte inferior de la pantalla. o ¿Cómo escojo un proveedor? Después de la primera visita médica,puede continuar ser atendido por este médico o puede elegir otro médico dentro de la MPN.Puede continuar eligiendo médicos de la MPN para todo su cuidado médico para esta lesión.Si es apropiado, puede escoger un especialista o puede pedirle al médico que lo está atendiendo que lo refiera a un especialista.Si necesita ayuda para eligir un médico puede llamar al Asistente de Acceso Médico arriba descrito.Puede haber limitaciones con respecto a los quiroprácticos seleccionados como médicos tratantes,tales como límite de veinte y cuatro (24) visitas, a menos que el empleador o la aseguradora autoricen lo contrario. o ¿Puedo cambiar de proveedor? Sí.Usted puede cambiar de proveedores dentro de la MPN por cualquier razón,pero los proveedores que elija deben ser apropiados para tratar su lesión. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Form WC 88 04 07 D Printed in U.S.A.Page 8 of 11 o ¿Qué requisitos debe tener la MPN? La MPN tiene proveedores para todo el estado de California. La MPN tiene que proporcionarle una lista regional de proveedores que incluya por lo menos tres médicos disponibles en cada especialidad usualmente utilizada para tratar lesiones/enfermedades en su industria u ocupación.La MPN debe tener al menos tres médicos tratantes primarios y un hospital o proveedor de servicios de emergencia dentro de las quince (15)millas o treinta (30)minutos de su residencia o lugar de trabajo.La MPN debe tener proveedores de servicios de medicina laboral y especialistas dentro de las treinta (30)millas o sesenta (60)minutos de su residencia o lugar de trabajo. La MPN debe proporcionarle tratamiento inicial dentro de tres (3)días.Debe recibir tratamiento del especialista dentro de veinte (20)días hábiles de su petición de una cita a través del Asistente de Acceso Médico de la MPN.Si un Asistente de Acceso Médico no puede programar una cita médica a tiempo (es decir,programada dentro de los veinte (20)días hábiles)con un especialista adecuado dentro de los diez (10)días hábiles desde la solcitud del empleador,el empleador permitirá al empleado obtener el tratamiento necesario con un especialista adecuado por fuera de la MPN.Si tiene algún problema en obtener una cita, póngase en contacto con el Asistente de Acceso Médico. Si no hay proveedores de la MPN de la especialidad apropiada disponible para tartar su lesión dentro de los requisitos de distancia y tiempo, entonces podrá buscar el necesario tratamiento fuera del MPN. o ¿Qué tal si no hay proveedores de la MPN donde estoy localizado? Si es un empleado actual: o que vive en un área rural, o temporalmente está trabajando o viviendo fuera del área de servicio de la MPN, o o es un ex empleado viviendo permanentemente fuera del área de servicio de la MPN, o o es un trabajador lesionado que decide residir temporalmente fuera del área de servico de la MPN durante su recuperación,su gestor de reclamos,la MPN o el médico que lo está atendiendo le dará una lista de por lo menos tres médicos que lo puedan atender.Su Gestor de reclamos también puede permitirle elegir su propio médico fuera de la red de la MPN. o ¿Qué tal si necesito un especialista que no está dentro de la MPN? Si necesita ver un especialista que no está disponible dentro de la MPN,usted tiene derecho a ver un especialista fuera de la MPN. o ¿Qué tal si no estoy de acuerdo con mi médico sobre tratamiento médico? Si usted no está de acuerdo con su médico o desea cambiar de médico por cualquier razón,usted puede escoger otro médico dentro de la MPN. Si usted no está de acuerdo con el diagnóstico o tratamiento recetado por su médico,usted puede pedir una segunda opinión de un médico dentro de la MPN.Si quiere una segunda opinión,debe ponerse en contacto con la MPN o el su Gestor de reclamos y decirles que quiere una segunda opinión.La MPN debe proporcionarle por lo menos una lista regional de proveedores de la MPN para elegirlo.Para obtener una segunda opinión,debe elegir un médico dentro de la lista de la MPN y hacer una cita dentro de sesenta (60)días.Usted debe decirle a su Gestor de reclamos la fecha de su cita y su Gestor de reclamos le mandará al médico una copia de su expediente médico.Usted puede pedir una copia de su expediente médico que se le enviará al médico. Si no hace una cita dentro de sesenta (60)días a partir de que recibe la lista regional de proveedores,no le será permitido tener una segunda o tercera opinión sobre el diagnóstico o tratamiento disputado recomendado por el médico que lo está atendiendo. Si el médico de la segunda opinión siente que su lesión está fuera del tipo de lesión que él o ella normalmente trata,la oficina del médico le notificará a su empleador o compañía de seguros y a usted.Además obtendrá otra lista de médicos o especialistas de la MPN para que pueda hacer otra selección. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Form WC 88 04 07 D Printed in U.S.A.Page 9 of 11 Si usted no está de acuerdo con la segunda opinión,puede pedir por una tercera opinión.Si usted pide una tercera opinión, usted pasará por el mismo proceso que pasó para la segunda opinión. Recuerde que si no hace una cita dentro de sesenta (60)días a partir de recibir la otra lista de proveedores de la MPN, entonces no le será permitido tener una tercera opinión sobre el diagnóstico o tratamiento disputado recomendado por el médico que lo está atendiendo. Si usted no está de acuerdo con el médico de la tercera opinión,usted puede pedir una Revisión Médica Independiente o IMR (Independent Medical Review).Su empleador o la persona de contacto de la MPN le darán información sobre cómo pedir la Revisión Médica Independiente y un formulario cuando usted pida la tercera opinión. Si el médico de la segunda o tercera opinión está de acuerdo que usted necesita algún tratamiento o análisis,le será permitido recibir el servicio médico de un proveedor dentro de la MPN,o si la MPN no incluye un médico que pueda proporcionarle el tratamiento recomendado,usted puede elegir a un médico fuera de la MPN dentro de un área geográfica razonable. Si el médico que hace la Revisión Médica Independiente corrobora su necesidad para algún tratamiento o análisis,usted podrá recibir ese cuidado de un médico dentro o fuera de la MPN. o ¿Qué tal si ya estoy siendo atendido por una lesión de trabajo antes de que empiece la MPN? Su empleador o la compañía de seguros tienen un plan de "Transferencia de Cuidado"que determinará si usted puede continuar siendo temporalmente atendido por una lesión de trabajo existente por un médico fuera de la MPN antes de que su cuidado sea transferido a la MPN. Si usted ha designado previamente un médico para atenderlo de manera apropiada,usted no puede ser transferido a la MPN.(Si tiene preguntas acerca de la designación previa,pregúntele a su supervisor.)Si su médico actual no es o no se convierte en un miembro de la MPN, entonces podrá ser obligado ver a un médico de la MPN. Si su empleador decide tranferirlo a la MPN,usted y su médico que lo está atendiendo deben recibir una carta notificándoles de la tranferencia. Si usted cumple con ciertos requistos,pueda que califique a continuar ser atendido por un médico fuera de la MPN hasta por un año antes de que sea transferido a la MPN.Los requisitos para posponer la tranferencia de su cuidado a la MPN están en el recuadro debajo. ¿Puedo continuar siendo tratado por mi médico? Usted puede calificar para tratamiento continuo con su proveedor que no está dentro de la MPN (por tranferencia de cuidado o continuidad de cuidado)hasta por un año si su lesión o enfermedad cumple con cualquiera de las siguentes condiciones: o (Agudo) El tratamiento para su lesión o enfermedad será completado en menos de 90 días; o (Grave o crónico)Su lesión o enfermedad es una que es grave y continúa por lo menos 90 días sin una cura total o empeora y requiere de tratamiento continuo.Se le podrá permitir ser tratado por su médico actual hasta por un año, hasta que una tranferencia de cuidado segura pueda ser hecha. o (Terminal)Tiene una enfermedad incurable o condición irreversible que probablemente cause la muerte dentro de un año o menos. o (Cirugía pendiente)Ya tiene una cirugía u otro procedimiento que ha sido autorizado por su empleador o compañía de seguros y que se realizará dentro de 180 días a partir de la fecha efectiva de la MPN o la fecha de la terminación del contrato entre la MPN y su médico. Usted puede no estar de acuerdo con la decisión de su empleador sobre transferir su cuidado a la MPN.Si no quiere ser transferido a la MPN,pídale a su médico de atención primaria un informe médico que indique si tiene una de las cuatro condiciones indicadas arriba para poder posponer su transferencia a la MPN. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Form WC 88 04 07 D Printed in U.S.A.Page 10 of 11 El médico que lo está atendiendo tiene veinte (20)días a partir de la fecha de su petición para darle una copia del informe sobre su condición.Si el médico que lo está atendiendo no le da el informe dentro de los veinte (20)días a partir de la fecha de su petición,el empleador podrá transferir su cuidado a la MPN y estará obligado a utilizar un médico de la MPN. Tendrá que darle una copia del informe a su empleador si desea posponer la transferencia de su cuidado.Si usted o su empleador no está de acuerdo con el informe de su médico sobre su condición,usted o su empleador puede disputarlo. Vea el plan de transferencia de cuidado para más detalles sobre el proceso de resolución de disputa. Para una copia del plan entero sobre la transferencia de cuidado en Inglés o Español,pregúntele a su contacto de la MPN. o ¿Qué tal si estoy bajo tratamiento con un médico de la MPN que decide dejar la MPN? Su empleador o compañía de seguros tiene un plan de "Continuidad de Cuidado"por escrito que determinará si es que podrá continuar temporalmente su tratamiento por su lesión de trabajo actual con su médico si su médico ya no está participando en la MPN. Si su empleador decide que usted no califica para continuar su tratamiento con el médico que no es un proveedor dentro de la MPN, usted y el médico que lo está atendiendo deberán recibir una carta para notificarle sobre esta desisión. Si usted cumple con ciertos requisitos,tal vez podrá calificar para continuar su tratamiento con este médico hasta por un año antes de que tenga que cambiar a un médico de la MPN.Estos requisitos están expuestos en el recuadro descrito arriba,"¿Puedo continuar siendo tratado por mi médico?" Usted puede no estar de acuerdo con la decisión de su empleador de negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN.Si quiere continuar su tratamiento con este médico,pidale al médico que lo está atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su médico actual. El médico que lo está atendiendo tiene viente (20)días a partir de la fecha de su petición para darle una copia del informe sobre su condición.Si el médico que lo está atendiendo no le da el informe dentro de los viente (20)días a partir de la fecha de su petición,se aplicará la decisión de su empleador de negarle la Continuidad de Cuidado con su médico que ya no participa en la MPN, y se le pedirá que elija a un médico de la MPN. Tendrá que darle una copia del informe a su empleador o a su Gestor de reclamos si desea posponer la selección de otro médico de la MPN para su tratamiento continuo.Si usted o su empleador no está de acuerdo con el informe de su médico sobre su condición,usted o su empleador puede disputarlo.Vea el plan de Continuidad de Cuidado para más detalles sobre el proceso de resolución de disputa. Para una copia del plan de la Continuidad de Cuidado entero en Inglés o Español, pregúntele a su Contacto de la MPN. o ¿Qué tal si tengo preguntas o necesito ayuda? o El Contacto de la MPN:Usted siempre puede ponerse en contacto con el Contacto de la MPN o el Gestor de reclamos si necesita ayuda o una explicación sobre su tratamiento médico para su lesión o enfermedad de trabajo a: P.O. Box 14475, Lexington, KY 40512 Número de teléfono gratuito para el Gestor de reclamos:866.401.9222 Número de teléfono gratuito para el contacto de la MPN:866.401.9222, x2304195 Número de teléfono gratuito para la Unidad de la Red de Referencias para recibir una lista de los proveedores de la MPN y/o Farmacias de la MPN: 1.800.327.3636, selección 4 E-Mail de la MPN:CAMPN.Claim@thehartford.com Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE Form WC 88 04 07 D Printed in U.S.A.Page 11 of 11 Si usted tiene preguntas referentes a sus necesidades de: 1)prescripciones médicas, 2)de proveedores de servicio de fisioterapia,terapia ocupacional,endurecimiento por trabajo o servicios de quiropráctico en relación su lesión o enfermedad debido al trabajo,por favor contacte a su Gestor de reclamos al 866.401.9222. Si tiene alguna queja de la MPN, póngase en contacto con su Contacto de la MPN. Si necesita ayuda para encontrar a un proveedor de la MPN disponible,o quiere asistencia para programar y confirmer citas con los proveedores,puede contactar a nuestros Asistentes de Acceso Médico sin cargo al 866-758-7256,de 7 a.m.a 8 p.m.Pacifico (lunes a sábado)(excepto domingos y feriados);por fax al 916-293- 5025 o por correo electrónico a thehartfordmaa@primehealthservices.com.Al menos un Asistente de Acceso Médico está disponible para responder en todos los momentos solicitados,pudiendo las personas que llaman dejar un mensaje de voz.Los Asistentes de Acceso Médico responderán los llamados,faxes o mensajes antes del día siguiente,excepto domingos y feriados.Los Asistentes de Acceso Médico trabajan en conjunto con el Contacto MPN y el (los)Gestor(es)de reclamos para asegurarse de que usted,el trabajador lesionado,tenga tratamiento médico adecuado a tiempo.Asistencia prestada por los médicos asistentes de acceso está disponible en inglés y español. o La División de Compensación de Trabajadores (DWC):Si tiene alguna preocupación,queja o pregunta sobre la MPN,el proceso de notificación,o su tratamiento médico después de una lesión o enfermedad de trabajo,puede llamar a la Oficina de Información y Asistencia de la DWC al 1.800.736.7401.También puede consultar con la página web de la DWC en el www.dir.ca.gov/dwc y hacer clic en "red de proveedores médicos" [medical provider networks] para más información sobre las MPN. o Revisión Médica Independiente:Si usted tiene preguntas sobre el proceso de la Revisión Médica Independiente póngase en contacto con la Unidad Médica de la División de Compensación de Trabajadores en: DWC Medical Unit P.O. Box 71010 Oakland, CA 94612 510.286.3700 o 800.794.6900 Guarde esta información en caso que tenga una lesión o enfermedad de trabajo. Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? INSR ADDL SUBR LTR INSD WVD PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE EACH OCCURRENCE $ DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence) MED EXP (Any one person)$ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ PRO-POLICY LOC PRODUCTS - COMP/OP AGGJECT OTHER:$ COMBINED SINGLE LIMIT $(Ea accident) ANY AUTO BODILY INJURY (Per person)$ OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $AUTOS ONLY AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE CLAIMS-MADE AGGREGATE $ DED RETENTION $ PER OTH- STATUTE ER E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMITDESCRIPTION OF OPERATIONS below INSURER(S) AFFORDING COVERAGE NAIC # COMMERCIAL GENERAL LIABILITY Y / N N / A (Mandatory in NH) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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 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). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved.ACORD 25 (2016/03) CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) $ $ $ $ $ The ACORD name and logo are registered marks of ACORD 11/14/2024 (636) 537-5000 (636) 537-5009 11000 Ailevon Pacific Aviation Consulting LLC 1382 Marion Walk SE Atlanta, GA 30315 19682 24319 A 2,000,000 X 84SBAPD3029SA 12/28/2023 12/28/2024 1,000,000 10,000 2,000,000 4,000,000 4,000,000 2,000,000A X 84SBAPD3029SA 12/28/2023 12/28/2024 3,000,000A 84SBAPD3029SA 12/28/2023 12/28/2024 3,000,000 10,000 B X 84WECBJ5256 12/28/2023 12/28/2024 1,000,000 1,000,000 1,000,000 C Misc Prof/E&O 03091939 12/28/2023 2,000,000 The City of Palm Springs, it’s officials, employees and agents are included as Additional Insureds with regard to the General and Auto Liability coverages. Primary and Non-Contributory wording applies. Waiver of Subrogation applies to the workers compensation coverage. City of Palm Springs 3200 E Tahquitz Canyon Way Palm Springs, CA 92262 AILELLC-01 TLEECH Concannon Insurance Agency Inc Charles L. Crane Agency Co. 400 Chesterfield Ctr, Ste 100 Chesterfield, MO 63017 Sentinel Insurance Co., Ltd. Hartford Fire Insurance Co. Allied World Surplus Lines Insurance Company 12/28/2024 X X X X X X X X Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 99 00 06 A (1)Printed in U.S.A.Page 1 Process Date:11/07/24 Policy Expiration Date:12/28/24 CHANGE IN INFORMATION PAGE INSURER:See Attached Endorsement NCCI Company Number:10456 Audit Period:ANNUAL Policy Effective Date:12/28/23 Policy Expiration Date:12/28/24 Policy Number:84 WEC BJ5256 Endorsement Number:006 Effective Date:10/10/24 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:AILEVON PACIFIC AVIATION CONSULTING LLC 1382 MARION WALK SE ATLANTA GA 30315 FEIN Number:46-3685068 Producer Name:CHARLES L CRANE AGENCY COMPANY Producer Code:84530483 It is agreed that the policy is amended as follows: This is NOT a bill. However, any changes in your premium will be reflected in your next billing statement. You will receive a separate bill from The Hartford.If you are enrolled in repetitive EFT draws from your bank account, changes in premium will change future draw amounts. In consideration of an additional premium of $68, it is agreed that: Policy is amended to add the following location(s): CA, Schedule Number 01-04-18 3200 E TAHQUITZ CANYON WAY PALM SPRINGS California 92262 Policy is amended to add the following condition(s): Waiver of Our Right to Recover from Others Endorsement Policy is amended to add the following Endorsement Forms reflecting the changes made to your policy. WC000421E WC040306 Policy is amended to revise the following Endorsement Forms reflecting the changes made to your policy. WC880405D Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE CHANGE IN INFORMATION PAGE (Continued) Policy Number: 84 WEC BJ5256 Form WC 99 00 06 A (1)Printed in U.S.A.Page 2 Process Date:11/07/24 Policy Expiration Date:12/28/24 WC880401I WC990006A(.2) WC990006A(.1P) WC880400I WC990005 WC000406 WC880407D WC880406D Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE CHANGE IN INFORMATION PAGE (Continued) Policy Number: 84 WEC BJ5256 SCHEDULE IT IS AGREED THAT THE POLICY IS AMENDED AS FOLLOWS: CLASS CODE NUMBER AND DESCRIPTION ESTIMATED TOTAL ANNUAL REMUNERATION RATES PER 100 OF REMUNERATION ESTIMATED ANNUAL PREMIUMS Form WC 99 00 06 A (1)Printed in U.S.A.Page 3 Process Date:11/07/24 Policy Expiration Date:12/28/24 CA - Location 2 Rating Period: 12/28/2023-04/08/2024 8742 SALESPERSONS - OUTSIDE 41,664.00 0.560000 233 Rating Period: 04/08/2024-10/10/2024 8742 SALESPERSONS - OUTSIDE 75,567.00 0.560000 423 Rating Period: 10/10/2024-12/28/2024 8742 SALESPERSONS - OUTSIDE 32,269.00 0.560000 181 Rating Period: 12/28/2023-12/28/2024 8742 SALESPERSONS - OUTSIDE 149,500.00 0.560000 -837 Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE SCHEDULE OF OPERATIONS This Schedule of Operations forms a part of the policy effective on the inception date of the policy unless another date is indicated below: INSURER:HARTFORD CASUALTY INSURANCE COMPANY Company Code:3 Policy Number:84 WEC BJ5256 Schedule Number:01-04-18 Effective Date:10/10/24 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Location Address of operations covered by this schedule: AILEVON PACIFIC AVIATION CONSULTING LLC 3200 E TAHQUITZ CANYON WAY PALM SPRINGS CA 92262 NAICS: 541611 FEIN:46-3685068 SIC: 8742 NO. OF EMPL: 1 4.The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans.All information required below is subject to verification and change by audit. Classifications Code Number and Description Premium Basis Total Estimated Annual Remuneration Rates Per $100 of Remuneration Estimated Annual Premium Countersigned by Authorized Representative Form WC 99 00 05 (1) Printed in U.S.A. Process Date:11/07/24 Policy Expiration Date:12/28/24 Rating Period: 10/10/2024-12/28/2024 8742 SALESPERSONS - OUTSIDE 3,248.00 0.560000 18 Total State Summary Total Class Premium 18 CA Territorial Differential 0.00 0.707000 -5 Waiver charge 0.00 54 Premium discount 0.00 0.001000 1 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement 3,248.00 0.020000 0 CA User Fund 0.00 2.520800 1 CA Fraud 0.00 0.467900 0 CA Uninsured Employers Benefit Trust Fund 0.00 0.137200 -1 CA Subsequent Injuries Benefit Trust Fund Assessments 0.00 1.370300 0 CA Occupational Safety & Health Fund 0.00 0.657200 0 CA Labor Enforcement & Compliance Fund 0.00 0.701100 0 California Total Cost 68 Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 00 04 06 Printed in U.S.A. Process Date:11/07/24 Policy Expiration Date:12/28/24 PREMIUM DISCOUNT ENDORSEMENT Policy Number:84 WEC BJ5256 Endorsement Number:006 Effective Date:10/10/24 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:AILEVON PACIFIC AVIATION CONSULTING LLC 1382 MARION WALK SE ATLANTA GA 30315 The premium for this policy and the policies,if any,listed in Item 3 of the Schedule may be eligible for a discount.This endorsement shows your estimated discount in Item 1 or 2 of the Schedule.The final calculation of premium discount will be determined by our manuals and your premium basis as determined by audit.Premium subject to retrospective rating is not subject to premium discount. SCHEDULE 1.Table of States Georgia Oklahoma or any other State that has approved the premium discount plan applicable to the total policy premium on an interstate basis at the effective date of the policy. 2.Average percentage discount: 0.10 % 3.Other policies: 4.If there are no entries in Items 1,2 and 3 of the Schedule,see the Premium Discount Endorsement attached to your policy number: Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Form WC 00 04 21 E Printed in U.S.A. Process Date:11/07/24 Policy Expiration Date:12/28/24 CATASTROPHE (OTHER THAN CERTIFIED ACTS OF TERRORISM) PREMIUM ENDORSEMENT Policy Number:84 WEC BJ5256 Endorsement Number:006 Effective Date:10/10/24 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:AILEVON PACIFIC AVIATION CONSULTING LLC 1382 MARION WALK SE ATLANTA GA 30315 This endorsement is notification that your insurance carrier is charging premium to cover the losses that may occur in the event of a Catastrophe (Other Than Certified Acts of Terrorism)as that term is defined below.Your policy provides coverage for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism).This premium charge does not provide funding for Certified Acts of Terrorism contemplated under the Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement (WC 00 04 22 C), attached to this policy. For purposes of this endorsement,the following definitions apply: o Catastrophe (Other Than Certified Acts of Terrorism):Any single event,resulting from an Earthquake,Noncertified Act of Terrorism,or Catastrophic Industrial Accident,which results in aggregate workers compensation losses in excess of $50 million. o Earthquake:The shaking and vibration at the surface of the earth resulting from underground movement along a fault plane or from volcanic activity. o Noncertified Act of Terrorism:An event that is not certified as an Act of Terrorism by the Secretary of the Treasury pursuant to the Terrorism Risk Insurance Act of 2002 (as amended)but that meets all of the following criteria: a.It is an act that is violent or dangerous to human life, property, or infrastructure; b.The act results in damage within the United States,or outside of the United States in the case of the premises of United States missions or air carriers or vessels as those terms are defined in the Terrorism Risk Insurance Act of 2002 (as amended); and c.It is an act that has been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. o Catastrophic Industrial Accident:A chemical release, large explosion,or small blast that is localized in nature and affects workers in a small perimeter the size of a building. The premium charge for the coverage your policy provides for workers compensation losses caused by a Catastrophe (Other Than Certified Acts of Terrorism)is shown in Item 4 of the Information Page or in the Schedule below. Schedule State Rate Premium See Attached Schedule Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE THIS ENDORSEMENT CHANGES THE POLICY.PLEASE READ IT CAREFULLY. Countersigned by Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. Process Date:11/07/24 Policy Expiration Date:12/28/24 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number:84 WEC BJ5256 Endorsement Number:006 Effective Date:10/10/24 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address:AILEVON PACIFIC AVIATION CONSULTING LLC 1382 MARION WALK SE ATLANTA GA 30315 We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce our right against the person or organization named in the Schedule.(This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 5 %of the California workers'compensation premium otherwise due on such remuneration. SCHEDULE Person or Organization Job Description City of Palm Springs, 3200 E TAHQUITZ CANYON WAY, PALM SPRINGS, CA, 92262 4 Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE CITY OF PALM SPRINGS 3200 E TAHQUITZ CANYON WAY, PALM SPRINGS, CA 92262 (760) 322-8328 BUSINESS LICENSE CERTIFICATE Fees Paid:$174.00 ISSUANCE OF THIS LICENSE DOES NOT ENTITLE THE LICENSEE TO OPERATE OR MAINTAIN A BUSINESS IN VIOLATION OF ANY OTHER LAW OR ORDINANCE. THIS IS NOT AN ENDORSEMENT OF THE ACTIVITY NOR OF THE APPLICANT'S QUALIFICATIONS. Business Name:Ailevon Pacific Aviation Consulting DBA: Owner:Ailevon Pacific Aviation Consulting Mailing Address:1382 SE MARION WALK ATLANTA, GA 30315 License Number:OC-007478-2024 Expiration Date:10/31/2025 PLEASE NOTE THAT IT IS YOUR RESPONSIBILITY TO RENEW AND UPDATE THIS LICENSE ANNUALLY. Business Location:1100 Peachtree NE PEACHTREE ST 250, ATLANTA, GA 30309 Business Description:BUSINESS CONSULTING SERVICES TO BE POSTED IN A CONSPICUOUS PLACE Docusign Envelope ID: 6753D260-D6CE-4179-A66F-011217458FCE