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HomeMy WebLinkAbout04993 - ADDICTION MEDICINE CONSULTANTS AMC DOT DRUG ALCOHOL TESTING DOCUMENT TRACKING Page: 1 Report: One Document Detail April 24, 2006 Condition: Document NumberA4993, Document# Description Approval Date Expiration Date Closed Date A4993 Drug And Alcohol Testing Program $10,000.001 11/16/2004 06/30/2005 Company Name: Addiction Medicine Consultants Inc Address: Service: In File xRef: HUMAN RESOURCES Ins. Status: No Certificate on file. Document Trackina Items, Due Comoleted Tracking Amount Amount Code Item Description Date Date Date Added Paid distrto HR 11/17/2004 to CM for sig 11/16/2004 under$25,000 CM may approve 11/16/2004 * " * * END OF REPORT ' * * ' s 6 ! Al 1-14)� Addiction Medicine Consultants D.O.T. Drug &Alcohol Testing AGREEMENT#4993 CM signed 11-16-04 CITY OF PALM SPRINGS -- - CONTRACT SERVICES AGREEMENT FOR D.O.T. Drug and Alcohol Testing Program THIQ CONTRACT„ SERVICES AGREEMENT (herein "Agreement") is made and entered into this * day of \�� , 2004, by and between the CITY OF PALM SPRINGS, a municipal corporation (herein "City") and Addiction Medicine Consultants, Inc., (herein "Contractor"). NOW, THEREFORE, the parties hereto agree as follows: 1.0 SERVICES OF CONTRACTOR 1.1 Scope of Services. In compliance with all of the terms and conditions of this Agreement, the Contractor shall perform the work or services set forth in the "Scope of Services" attached hereto as Exhibit "A" and incorporated herein by reference. Contractor warrants that all work and services set forth in the Scope of Services will be performed in a competent, professional and satisfactory manner. 1.2 Compliance With Law. All work and services rendered hereunder shall be provided in accordance with all ordinances, resolutions, statutes, rules, and regulations of the City and any Federal, State or local governmental agency of competent jurisdiction. 1.3 Licenses, Permits, Fees and Assessments. Contractor 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. 2.0 COMPENSATION 2.1 Contract Sum. For the services rendered pursuant to this Agreement, Contractor shall be compensated in accordance with the "Schedule of Compensation" attached hereto as Exhibit "B" and incorporated herein by this reference, but not exceeding the maximum contract amount of Ten Thousand Dollars ($10,000.00) ("Contract Sum"). 2.2 Method of Payment. Provided that Contractor is not in default under the terms of this Agreement, Contractor shall be paid as outlined Exhibit "B" Schedule of Compensation. 3.0 COORDINATION OF WORK 3.1 Representative of Contractor. David Herold, is hereby designated as being the principal and representative of Contractor authorized to act in its behalf with respect to the work and services specified herein and make all decisions in connection therewith. 3.2 Contract Officer. Sue Mills, PHR is hereby designated as being the representative the City authorized to act in its behalf with respect to the work and services specified herein and make all decisions in connection therewith ("Contract Officer"). The City C:ATEMP\Addiction Medicine Consultants.wpd -1- Manager of City shall have the right to designate another Contract Officer by providing written notice to Contractor. 3.3 Prohibition Against Subcontractinq or Assiqnment. Contractor shall not contract with any entity to perform in whole or in part the work or services required hereunder without the express written approval of the City. Neither this Agreement nor any interest herein may be assigned or transferred, voluntarily or by operation of law, without the prior written approval of City. Any such prohibited assignment or transfer shall be void. 3.4 Independent Contractor. Neither the City nor any of its employees shall have any control over the manner, mode or means by which Contractor, its agents or employees, perform the services required herein, except as otherwise set forth. Contractor shall perform all services required herein as an independent contractor of City and shall remain under only such obligations as are consistent with that role. Contractor 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. 4.0 INSURANCE AND INDEMNIFICATION 4.1 Insurance. The Contractor shall procure and maintain, at its sole cost and expense, in a form and content satisfactory to City, during the entire term of this Agreement including any extension thereof, the following policies of insurance: (a) Commercial General Liability Insurance. A policy of commercial general liability insurance written on a per occurrence basis with a combined single limit of a least $1,000,000 bodily injury and property damage including coverages for contractual liability, personal injury, independent contractors, broadform property damage, products and completed operations. The General Liability Policy shall name the City of Palm Springs, its officers, employees, and agents, as additional insured in accordance with standard ISO additional insured endorsement form CG2010(1185) or equivalent language. (b) Worker's Compensation Insurance. A policy of worker's compensation insurance in such amount as will fully comply with the laws of the State of California and which will include $1,000,000 employer's liability. (c) Business Automobile Insurance. A policy of business automobile liability insurance written on a per occurrence basis with a single limit liability in the amount of $1,000,000 bodily injury and property damage, Said policy shall include coverage for owned, non-owned, leased and hired cars. (d) Additional Insurance. Policies of such other insurance, including professional liability insurance in a minimal amount of $1,000,000 if contract has professional liability exposure, as may be required in Exhibit"C". All of the above policies of insurance shall be primary insurance. The insurer shall waive all rights of subrogation and contribution it may have against the City, its officers, employees and agents, and their respective insurers. In the event any of said policies of insurance are canceled, the Contractor shall, prior to the cancellation date, submit new evidence of insurance in conformance with this Section 4.1 to the Contract Officer. No work or services under this Agreement shall commence until the Contractor has provided the City with C:\Documents and Settings\DLR\Local Settings\Temp\Addiction Medicine Consultants.wpd -2- The contractor agrees that the provisions of this Section 4.1 shall not be construed as limiting in any way the extent to which the Contractor may be held responsible for the payment of damages to any persons or property resulting from the Contractor's activities or the activities of any person or person for which the Contractor is otherwise responsible. In the event the Contractor subcontracts any portion of the work in compliance with Section 3.3 of this Agreement the contract between the Contractor and such subcontractor shall require the subcontractor to maintain the same polices of insurance that the Contractor is required to maintain pursuant to this Section. 4.2 Indemnification. Contractor agrees to indemnify the City, its officers, agents and employees against, and will hold and save them and each of them harmless from, any and all actions, suits, claims, damages to persons or property, losses, costs, penalties, obligations, errors, omissions or liabilities, (herein "claims or liabilities") that may be asserted or claimed by any person, firm or entity arising out of or in connection with the negligent performance of the work, operations or activities of Contractor, its agents, employees, subcontractors, or invitees, provided for herein, or arising from the negligent acts or omissions of Contractor hereunder, or arising from Contractor's negligent performance of or failure to perform any term, provision, covenant or condition of this Agreement, whether or not there is concurrent passive or active negligence on the part of the City, its officers, agents or employees but excluding such claims or liabilities arising from the sole negligence or willful misconduct of the City, its officers, agents or employees, who are directly responsible to the City, and in connection therewith: (a) Contractor will defend any action or actions filed in connection with any of said claims or liabilities and will pay all costs and expenses, including legal costs and attorneys' fees incurred in connection therewith; (b) Contractor will promptly pay any judgment rendered against the City, its officers, agents or employees for any such claims or liabilities arising out of or in connection with the negligent performance of or failure to perform such work, operations or activities of Contractor hereunder; and Contractor agrees to save and hold the City, its officers, agents, and employees harmless therefrom; (c) In the event the City, its officers, agents or employees is made a party to any action or proceeding filed or prosecuted against Contractor for such damages or other claims arising out of or in connection with the negligent performance of or failure to perform the work, operation or activities of Contractor hereunder, Contractor agrees to pay to the City, its officers, agents or employees, any and all costs and expenses incurred by the City, its officers, agents or employees in such action or proceeding, including but not limited to, legal costs and attorneys'fees. 5.0 TERM 5.1 Term. Unless earlier terminated in accordance with Section 5.2 below, this Agreement shall continue in full force until June 30, 2005. 5.2 Termination Prior to Expiration of Term. Either party may terminate this Agreement at any time, with or without cause, upon thirty (30) days' written notice to the other party. Upon receipt of the notice of termination, the Contractor shall immediately cease all work or services hereunder except as may be specifically approved by the Contract Officer. In C:\Documents and Settings\DLR\Local Settings\Temp\Addiction Medicine Consultants.wpd -3- the event of termination by the City, Contractor shall be entitled to compensation for all services rendered prior to the effectiveness of the notice of termination and for such additional services specifically authorized by the Contract Officer and City shall be entitled to reimbursement for any compensation paid in excess of the services rendered. 6.0 MISCELLANEOUS 6.1 Covenant Against Discrimination. Contractor covenants that, by and for itself, its heirs, executors, assigns and all persons claiming under or through them, that there shall be no discrimination against or segregation of, any person or group of persons on account of race, color, creed, religion, sex, marital status, national origin, or ancestry in the performance of this Agreement. Contractor shall take affirmative action to ensure that applicants are employed and that employees are treated during employment without regard to their race, color, creed, religion, sex, marital status, national origin or ancestry. 6.2 Non-liability of City Officers and Employees. No officer or employee of the City shall be personally liable to the Contractor, or any successor in interest, in the event of any default or breach by the City or for any amount which may become due to the Contractor or to its successor, or for breach of any obligation of the terms of this Agreement. 6.3 Conflict of Interest. No officer or employee of the City shall have any financial interest, direct or indirect, in this Agreement nor shall any such officer or employee participate in any decision relating to the Agreement which effects his financial interest or the financial interest of any corporation, partnership or association in which he is, directly or indirectly, interested, in violation of any State statute or regulation. The Contractor warrants that it has not paid or given and will not pay or give any third party any money or other consideration for obtaining this Agreement. 6.4 Notice. Any notice, demand, request, document, consent, approval, or communication either party desires or is required to give to the other party or any other person shall be in writing and either served personally or sent by prepaid, first-class mail, in the case of the City, to the City Manager and to the attention of the Contract Officer, CITY OF PALM SPRINGS, P.O. Box 2743, Palm Springs, California 92263, and in the case of the Contractor, to the person at the address designated on the execution page of this Agreement. 6.5 Interpretation. The terms of this Agreement shall be construed in accordance with the meaning of the language used and shall not be construed for or against either party by reason of the authorship of this Agreement or any other rule of construction which might otherwise apply. 6.6 Integration; Amendment. It is understood that there are no oral agreements between the parties hereto affecting this Agreement and this Agreement supersedes and cancels any and all previous negotiations, arrangements, agreements and understandings, if any, between the parties, and none shall be used to interpret this Agreement. This Agreement may be amended at any time by the mutual consent of the parties by an instrument in writing. 6.7 Severability. In the event that part of this Agreement shall be declared invalid or unenforceable by a valid judgment or decree of a court of competent jurisdiction, such invalidity or unenforceability shall not affect any of the remaining portions of this Agreement which are hereby declared as severable and shall be interpreted to carry out the intent of the C:\Documents and Settings\DLR\Local Settings\Temp\Addiction Medicine Consultants.wpd parties hereunder unless the invalid provision is so material that its invalidity deprives either party of the basic benefit of their bargain or renders this Agreement meaningless. 6.8 Waiver. No delay or omission in the exercise of any right or remedy by a nondefaulting party on any default shall impair such right or remedy or be construed as a waiver. A party's consent to or approval of any act by the other party requiring the party's consent or approval shall not be deemed to waive or render unnecessary the other party's consent to or approval of any subsequent act. Any waiver by either party of any default must be in writing and shall not be a waiver of any other default concerning the same or any other provision of this Agreement. 6.9 Attorneys' Fees. If either party to this Agreement is required to initiate or defend or made a party to any action or proceeding in any way connected with this Agreement, the prevailing party in such action or proceeding, in addition to any other relief which may be granted, whether legal or equitable, shall be entitled to reasonable attorney's fees, whether or not the matter proceeds to judgment. 6.10 Corporate Authoritv. The persons executing this Agreement on behalf of the parties hereto warrant that (i) such party is duly organized and existing, (ii) they are duly authorized to execute and deliver this Agreement on behalf of said party, (iii) by so executing this Agreement, such party is formally bound to the provisions of this Agreement, and (iv) the entering into this Agreement does not violate any provision of any other Agreement to which said party is bound. SIGNATURES ON NEXT PAGE C:\Documents and Settings\DLR\Local Settings\Temp\Addiction Medicine Consultants.wpd IN WITNESS WHEREOF, the parties have executed and entered into this Agreement as of the date first written above. CITY OF PALM SPRINGS ATTEST: a municipal corporation BY: W� ByT7 ty Clerk City Manager /gyOVA' � 122 ewed Aa 0 x---� and ap roved by CONTRACTOR: Addiction Medicine Consultants Check one: I videal Partner, . orjoratioq P.O. Box 8878 rp &,,, racting Redlands, CA 92375 Corporations require two notarized signatures: One from each of the following: A. etrt Boa a any Vice President:AND B.Secretary,Assistant Secretary,Treasurer,Assistant Treasurer,or Chief Financial ice By.11 : C By:- A-4---e-4� Signature (notarized) Signature (notarized) Name'. lb�4,,,J.,'I Name: '�) - I� d- Title: Ct—', c Address: P Address: T State of I State of County of&AW4 County of )ss On—before me, personally appeared personally appeared personally known to me (or proved to me on the basis of personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) satisfactory evidence) to he the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by histher/their signature(s) authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of on the instrument the person(s), or the entity upon behalf of which the person(s)acted,executed the instrument. which the person(s)acted,executed the instrument. WITNESS my hand and official seal. WITNESS my hand and official seal. Notary Signature: � Notary Signature: Notary Seal: Notary Seal: Z'Z deS to0wWwoo AW /4UrVOO OUPJK)U DK"kWO-OWd AIC40N quqp-- 990119 10 UOIMWwoo — — — NUM N3A3LS — — — — — — — — CADocuments and Settings\DLR\Local Settings\Temp\Addiction Medicine Consultantsmiad "µf ,� e.C1WL,lAy72lOII Y,{ 1,1!�0 d2£rt4hY�',rtslr,i:K �� EXHIBIT `A' SCOPE OF SERVICES Contractor shall provide a complete D.O.T. drug and alcohol testing program for the City of Palm Springs which includes all random drug and alcohol testing, reports, and compliance on an as- needed basis to support the activities and policies of the City of Palm Springs Human Resources Department. The standard program services, as provided per covered driver (employee), include the following: Urine Drug Test (Emit Screen with GC/MS Confirmation) SAMHSA Certified Laboratory for all Urine Drug Tests Chain of Custody Forms and Collection Supplies Random Selection Generation for Random Testing Supervisor Training & Educational Materials Storage of Positive Specimens as Required by D.O.T. Collection Site Selection MRO Services for all Urine Drug Tests Transportation to SAMHSA Lab Alcohol Breath Testing as D.O.T. Requires Employee Record Administration Federal Reporting as Required Services provided beyond the standard specified random tests that are optional and offered at additional fees include the following: Program Cost Per Urine Requisition Processed Breath Alcohol Per Test Mobile, On Site, or at SBCL Site Supervisor's Training Program Employee's Training Program Substance Abuse Professional D/L Isomer Confirmation Test Split Specimen GC/MS Confirmation Test a EXHIBIT `B' SPECIAL REQUIREMENTS Section 4.1 ( c) 'Business Automobile Insurance" is waived. Section 4.1 (d ) "Additional Insurance"—A policy of Medical Professional Liability Insurance written on an occurrence or claims made basis with a minimum limit of$1,000,000 is required. b EXHIBIT `C' SCHEDULE OF COMPENSATION Total compensation for all services and expenses as described and provided hereunder shall not exceed $10,000.00 ITEMIZED FEE SCHEDULE: $70.00 Standard Services Per Covered Driver(each employee) as described in Exhibit "A", Scope of Services: FOR SERVICES BEYOND THE SPECIFIED STANDARD SERVICESTS, THE FEES ARE AS BELOW: Program Cost Per Urine Requisition $49.50 Processed Breath Alcohol Per Test Mobile, On Site, or $45.00 at SBCL Site Supervisor's Training Program $150 / hour Employee's Training Program $150 / hour Substance Abuse Professional $150 / session D/L Isomer Confirmation Test $65.00 Split Specimen GC/MS Confirmation Test *this test is to be paid by the donor $150.00 c EXHIBIT V SCHEDULE OF PERFORMANCE For the scope of services described, the schedule of performance shall be on an as-needed basis and shall be continue in full force during the Term of this Agreement as outlined in 5.0 Term. d 9/3 /200AC M. CERTIFICATE OF LIABILITY INSURANCE I DATED )4 /] 4 PRODUCER HHRT INS SVCS-CARROLLTON THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY 110 DIXIE STREET AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CARROLLTON, GA 30117 CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE (888)661-3938 COVERAGE AFFORDED BY THE POLICIES BELOW. ZW642 700 INSURERS AFFORDING COVERAGE WNR10 ADDICTION NEDICINB CONSULTANTS INSURER A: TYBVBIere Property CmueRy Company Of Amorloa INC. DSA AMC INSURER a' NYa Y 0 SOX 8878 INSURER C: NIB ..... RSDLANDS, CA 92375 INSURER D: We INSURER E: NIR COVERAGES .. .._. ., _. .. THE POLICIES OF INSURANCE LISTED BELOW HAVE BEBN 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 18 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYP80FINSURANCE POLOYMIMSER Ulln . rOUCYEFFECTIVE POLIFOXPMTCH �. . aATR(W1pMY1) DATEUMPoDNY) GEIERAL UAEILRY (580-2779B72A-04 08/01/2004 08/01/260S FAf.HOCCUPaNCE $ 1L000,000 AFJ3jiAI ! WUYJpRLL_..... ...$-30G'i0 •.—. ._... OCCUR --. . �r M®Eommp"A $ 5,000 PEp$OWLA.OYNARY $ 1,000,000 GFNMAGGREGATE $ 2,000,000 GENLAGWEGATE UNIT APPLIES PER: PROUL"7L0JVOT 6W ko $ 21000,000 TPOLICY n PRO' 71LOC AuTDMoMLEL%zIUTY 680-2779B72A-04 08/01/2004 08/01/2005 COMeINDswGLEUMT A _ANVAUTO xv W0440) $ 11000,000 _ALL OWNED AUTOS BODO INJIMY _KflED&EDAUT0S (PerrasPN $ X HREDAUT06 SOdLYINNMY X NON-MNEDAUTOS 1pRm N $ PROPERTYDAMAOE DAMGRUAKRY .. AUTO ONLY•EAACCIDENT s . ANYAUTO OTHERTHAN FAACC $ AUT00NLY: AGE $ EXCESS UAMTV EAOHOCCIIRRENOE $ . �OCCTIR �CLNMSMADE AGGREGATE $ �DEDUCTISLE _ $ - RETENTION T $ ._ - ..,..wnRIERS CONPENUT"AIL-.' ..._ ._ -_"-.� _ - _.__� .,� __rR .._..,� WAOYERS Wa,ITY ELEICHAOMM $ EL.DISEASE•EADV OYES $ EL,dSE45E.POLICYLMT $ ONIA $ DESCRIPTION OF 6PERATIONSILOCATIONSIVEHICLE9IEXCLUSIDNB ADDED by ENDORSEMENT/SPECIAL PROVIAONR CERTIFICATE HOLDER IS ADDED AS AN ADDITIONAL INSURED, DURING THE POLICY PERIOD, AS PER CG D2 52 CERTIFICATE HOLDER XI-ItIONALINaURED;INSURER LETTER:A CANCELLATION SHOULD ANY OP TIE ABOVE DESCRIBED POLIOIES RE CANCELLED BEFORE THE CITY OF PALN SPRILYGS EXPIRATION DATE THEREOF,THEMSU1NG INSURERWILL ENDEAVOR TO MAIL 10DAYS 3200 EA 9T PAHQUI'TZ CANYON WAL WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,SLIT FAILURE TO PALM SPRINGS, CA 92,262 DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATIVES, AUTHORIZED REPREDENTATRIE /J d ACORD 254(7197) ACORD CORPORATION 1988 RightFax Hartford 9/30/2004 2 : 13 PAGE 003/003 Fax Server IMPORTANT lithe oerUflcate holder Is an ADDITIONAL INSURED, the policy(ies)must be endorsed, A st'ternent on this certlicate does not confer rights to the certlIcate holder In lou of such endorsemengs). If SUBROGATION IS WAIVED, subOct to the tarms and condlf]CM Of the policy, certain polloles may requlre an endorsement A statement on this cerdAcate does not confer rights to the certtiGate holder In lieu of such endorsament s), DISCLAIMER The Certificate of Insurance on the reverse Side of this form does not constitute a contract between the issufng Insurer(s), authorized represontative or producer, and the certllcate holder, nor does It a%imatively or negatively amend,extend oraiterthe coverage afforded by the policies listed thereon, ACORD 2"(747) Travelers One Tower Square, Hartford, Connecticut 06183 BUSINESSOWNERS COVERAGE PART DECLARATIONS OFFICE PAC POLICYNO.: I-GSO-2779B72A-TIL-04 DELUXE PLAN ISSUE DATE: 07-27-04 INSURING COMPANY: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA DECLARATIONS PERIOD: From 08-01 -04 to 08-01 -05 12:01 A.M. Standard Time at your mailing address. FORM OF BUSINESS: CORPORATION COVERAGES AND LIMITS OF INSURANCE: Insurance applies only to an item for which a "limit' or the word "INCLUDED" is shown. BUSINESSOWNERS PROPERTY COVERAGE: PREM. BLDG. PREM. BLDG. NO. NO. NO. NO. 01 01 02 01 BUILDINGS: Limit of Insurance: $ $ Loss Adjustment Basis Inflation Guard: Exterior Building Glass Deductible: $ $ BUSINESS PERSONAL PROPERTY: Limit of Insurance: $ 10,000 $ 5,000 Loss Adjustment Basis: Inflation Guard: Exterior Building Glass: Exterior Building Glass Deductible $ $ BUSINESS INCOME: Limit-Actual loss up to 12 Consecutive Months DEDUCTIBLE AMOUNT: Businessowners Property Coverage: $ 500 Per Occurrence. COMMERCIAL GENERAL LIABILITY COVERAGE- OCCURRENCE FORM LIMITS OF INSURANCE General Aggregate (except Products-Completed Operations) Limit $ 2,000,000 Products-Completed Operations Aggregate Limit $ 2,000,000 Personal and Advertising Injury Limit $ 1 ,000,000 Each Occurrence Limit $ 1 ,000,000 Damage To Premises Rented To You $ 300,000 Medical Payments Limit (any one person) $ 5,000 MORTGAGE HOLDER-BUILDING COVERAGE ONLY: SPECIAL PROVISIONS: COMMERCIAL GENERAL LIABILITY COVERAGE IS SUBJECT TO A GENERAL AGGREGATE LIMIT MP TO 01 11 03 (Page 1 of 01) 1701 I avelers One Tower Square, Hartford, Connecticut 06183 COMMON POLICY DECLARATIONS POLICY NO.: I-680-2779B72A-TIL-04 OFFICE PAC ISSUE DATE: 07-27-04 14 BUSINESS:PHYSICIAN INSURING COMPANY: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA 1. NAMED INSURED AND MAILING ADDRESS: ADDICTION MEDICINE CONSULTANTS INC. DBA AMC P 0 BOX 8878 REDLANDS CA 92375 2. POLICY PERIOD: From 08-01 -04 to 08-01 -05 12:01 A.M. Standard Time at your mailing address. 3. LOCATIONS: ADDRESS PREM. NO. BLDG. NO. OCCUPANCY (same as Mailing Address unless specified otherwise) 01 01 PHYSICIAN 101 EAST REDLANDS REDLANDS CA 92373 02 01 PHYSICIAN 108 ORANGE ST. #5 REDLANDS CA 92375 4. COVERAGE PARTS AND SUPPLEMENTS FORMING PART OF THIS POLICY AND INSURING COMPANIES COVERAGE PARTS and SUPPLEMENTS INSURING COMPANY Businessowners Coverage Part TIL o= 5. The COMPLETE POLICY consists of this declarations and all other declarations, and the forms and endorse- ments for which symbol numbers are attached on a separate listing. 6. SUPPLEMENTAL POLICIES: Each of the following is a separate policy containing its complete provisions. POLICY POLICY NUMBER INSURING COMPANY DIRECT BILL 7. PREMIUM SUMMARY: o= Provisional Premium $ 750.00 Due at Inception $ a Due at Each $ NAME AND ADDRESS OF AGENT OR BROKER COUNTERSIGNED BY: i„fir + BB&T INS SVCS-CARROLLTON XW642 110 DIXIE STREET Authorized Representative CARROLLTON GA 30117 IL To 19 08 01 (Page 1 of 01 ) DATE: Office: ELMIRA NY SRV CTR DOWN 011700 . -�,i .. -!;'. I Client#: 780833 63ADDICMED ACORD,. CERTIFICATE OF LIABILITY INSURANCE 08/26104D"Y"') PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION BB&T Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 110 Dixie Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Carrollton, GA 30117 770 214-1991 INSURERS AFFORDING COVERAGE NAIL# INSURED INSURER A. Markel Ins (StringerWare) 38970 _ Addiction Medicine Consultants Inc. dba INSURER B' AMC; INSURER C P.O. Box 8878 INSURER Redlands, CA 92375 INSURER E' COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS T99R-ADD'L POLICYEFFECTIVE POUCYEXPIRATION LIMITS LTR INSRC TYPE OF INSURANCE POLICY NUMBER DATE(MM/DDIYY) DATE(MMIDD/YY) _ GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES(Ea occurrence) CLAIMS MADE ❑OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ _ GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ _ POLICY n JGCT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ _ANY AUTO (Ea acadenl) _ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ _ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Peracadenl) $ PROPERTY DAMAGE $ (Peracadent) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EAACC S AUTO ONLY: AGO $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ _ $ DEDUCTIBLE $ RETENTION $ $ WC STATU-WORKERS COMPENSATION AND I TORY LIMITS I DER _ EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNERIEXECUTIVE _ OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT $ A OTHER Professional 3CD3301304 09/08/04 09/08/05 $1,000,000 Occurrence $3,000,000 Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS Claims Made; Retro Date 09/08/03; Deductible: $1,000 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REP" AU�O IZEDTIEPRES�NTATIVE C�,� ACORD 25(2001/08) 1 of 2 #M1288233 R rL/l//1 jC/ PDW © ACORD CORPORATION 1988 �� � � ir ,� �i ', i,'( I c' :� �.i�1 r -,� i � ci S ����! J I„ i -, ; ACORDM CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 1/12/2004 PRODUCER (909)748-0074 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Steven Parker Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 108 Orange St., Suite 5 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. BOX 8684 Redlands CA 92375 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:S'tate Compensation Fund Addiction Medicine Consultants, Inc. INSURER B' 108 Orange St., Suite 5 INSURER INSURER D: Redlands CA 92373 INSURERS COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS INSR AOD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE(MM/DD(YY) DATE(MM/DDIYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ TO COMMERCIAL GENERAL LIABILITY DAMAGES( RENTED PREMISES(Ea occurrence) $ CLAIMS MADE ❑OCCUR MED EXP(Any one person) S PERSONAL&ADV INJURY S GENERAL AGGREGATE $ _ GEN'L AGGREGATE LIMIT APPLIES PER: _PRODUCTS-COMPIOP AGG S -1 POLICY JEC I T LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) _ ANY AUTO _ ALL OWNED AUTOS BODILY INJURY $ _ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY S (Per accldeol) NON-OWNED AUTOS - PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY _AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHERTHAN EAACC S AUTO ONLY AEG S EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE S 7 OCCUR CLAIMS MADE AGGREGATE S DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION AND TORV LIMITS OER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE C.L.EACH ACCIDENT $ 11000,000 OFFICER/MEMBER EXCLUDED? 1603927-04 1/1/2004 1/1/2005 EL DISEASE-EA EMPLOYEEI$ 1,000,000 If yes,descube under SPECIAL PROVISIONS below EL DISEASE-POLICY LIMIT S 11000,000 OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS Evidence of Workers Compensation CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Insured File Copy EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED PRESENTATIVE f A{yCORD 25(2001108) `( O ArdORD CORPORATION 1988 Win. INS025(010B).05 ELECTRONIC LASER FORMS,INC.-(000)327-0545 Peg.1 o(2 - t� C`��j7,lsv'o,, Vehicle Schedule Alk MERCURY CASUALTY COMPANY Policy Number Policy Period Producer Name and Code From 12:01 A M To 12:01 AM AC 11020341 10/12/2003 10/12/2004 CALDWELL & MORELAND INS.SV 4092 Named Insured: ADDICTION MEDICINE CONSULTANTS INC Description of Vehicles Vjhj Yr Make Body Type /Tonnage Model r w Serial Number Cost or Value "u ote__ New 1 1999-NIMN 1/2 T VAN L 4N2XN11TRXD807059 16,000 ' 07/1999 U Veh Garaging Address ("Same" means kept at mailing address) 1 1549 CAMBRIDGE AVE REDLANDS CA 92374 I, V#eh LP/AI Names and Addresses of Loss Payees(LP), Additional Interests(Al) and Registered Owners(RO) COVERAGES _ PREMIUMS Liability Veh # 1 Veh # Veh# Veh # Veh # Veh # BI $ ,000 each person S ,000 each accident PD $ ,000 each accident or 664 $ 1,000 ,000 Combined Single Limit Uninsured Motorist - BI $ ,000 Combined Single Limit 19 $ 30 ,000 each person S 60,000 each accident Uninsured Motorist - PD $ Maximum - Collision Deductible Waiver 4 Excess Medical Expense Providing For Reimbursement to Company 24 —� $ 5000 each person ..--1 No Excess, No Reimbursement Comprehensive-Deductible(sl Veh V.h. Vs.' Veh Vah Veh 120 1 S 250 $ 5 $ 5 S Collision-Deductible(s) Veh l $ 500 Veh Veh Veh Veh Veh 247 $ S $ $ $ Towing and Labor-Amount Per Disablement Veh Vah Veh Veh Veh Veh S 5 5 S 5 5 Rental Car Benefit ` $ each day $ Maximum _ 11 Premiums Per Vehicle 1078 L UC-3B 7/1996 Date Mailed: 1 1/05/2003 Search Results -Page- -AM Best Online Ratings and Analysis Page I of 2 October 5,2004 Fu BEST i am6estcram analysis C reinsurers wo: • Ra gs SAnbPshos • Mews Punicaticnr. r Products&Ser%ices e Insurance R—auoe- s Albert A.Poi Elect Search Results Page 1 of 2 1 Rating 29 Rated or Unrated companies found, results sorted by Company Name(ascending) s E A rs e n� Criteria Used: Company Name: Company names starting with Travelers To refine your search, please use our Advanced Search or view our_Online Help for more it G- Ratings (• Company lmum icn View results starting with: A B C D E F G H I J K L M N 0 P Q R S T U V W X Y Z Besfs Enter Co pony Mamie ® AMB# ® Industry ® Company Name ® Rating Domicile cr A tt.Bee[Muniber Find 86988 P Travelers_(eermude) Limited Bermuda ------------- -- ----------- -- More search Cpti=.n=. 02001 P Travelers Casualty and Surety At United States: Col Company CONTACT US 03609 P Travelers.Casual and Surety_of A+ United States: Col America Where 86921 P Travelers Casualty& Surety Co of A+ Canada: Ontario .�, in the Canada �,,"r world is ryr� h.M.tiE'S'i'1 ___ .- _ __ __ 87376 P Travelers Cas and Su_r Co Europe At United Kingdom Find our locations Ltd wnatda 11024 P Travelers Casual Company of CT A+ United States: Col yo�tnPnk„4 04465 P Travelers Casualty Insurance Co of A+ United States: Cot Lend um,pour comments Amer 11767 P Travelers Commercial Casualty A+ United States: Col Accessing the pages Company_ on ambest.com — — constitutes the user's 11025 P Travelers Commercial Insurance A+ United States: Col agreement to our Company terms„of Pam; information collected 00241 P Travelers-Excess..and Surplus_L nes A+ United States: Col site is via this Web site is CO protected by our ___.__---------.- -- Cn_mme is or one 11302 P Travelers Home and Marine Ins Co A+ United States: Col Comments or concerns should he directed to —__—__"--^� `- -------- -- -- ourcustomerservice 02520 P Travelers Indemnity Company A+ United States: Cot group;For other 86423 P Travelers Indemnity Com any CAB A+ — Canada Ontario matters refer to our cont-act us page. - -____ 04003 P Travelers Indemnity Co of America A+ United States:Col 02517 P _ Travelers Indemnity_Company of CT A+ United States: Col 07330 L� Travelers Insurance Company A++ United States: Cot 69351 L Travelers Insurance Company CAB A++ Canada: Ontario 08429 L Travelers Life and Annuity A++ United States: Col Company --- — -- — -- 03297 P -- Trayelers_Uo ds Insurance A+_ United States:Ter —Conn—parry 01743 P Travelers.Lloyds of Texas Insurance A+ United States:Ter http://www3.ambest.com/ratings/RatingsSearch.asp 10/5/2004 Search Results - Page - -AM Best Online Ratings and Analysis Page 2 of 2 Co *Ratings as of 1010512004 04:19 PM E.S.T. Industry: P= Property/Casualty(non-life) L = Life/Health View the Guide to Best's Financial StrengthRatings for an in-depth explanation of Best': System and Procedures. Page 2 Jump to Page: 12 Important Notice: Best's Ratings reflect our opinion based on a comprehensive qualitative evaluation of a company's balance sheet strength, operating performance and These ratings are not a warranty of an insurer's current or future ability to meet its contra, View our entire notice for a complete details. Companies interested in placing a Best's Security Icons on their web site to promo' strength may register online. Customer Service I_Product Support I Careers I Contact Info I About A.M_Be: Site Map I Privacy_Pollcy I Secures I Terms of Use I Legal &_Licensing Copyright©2004 by A.M. Best Company,_Inc. ALL RIGHTS RESERVED No part of this report may be distributed in any electronic form or by any means,or stored in a database or retrieval cyst written permission of the A M.Best Company.Refer to our terms of use for additional details. http://www3.ambest.com/ratings/RatingsSearch.asp 10/5/2004 Search Results - Page - -AM Best Online Ratings and Analysis Page 1 of 1 October 5,2004 ambest.com CSea3'ch. 'Confim A t;e,;&Publicaticns Prcducrs 8'oervion Insumnca Resources F.4bcur..0..M Best Search Results Page 1 of 1 2 Rated or Unrated companies found, results sorted by Company Name (ascending) SEARCH Rating �,,p, Criteria Used: Company Name: Company names starting with Markel Insurance C To refine your search, please use our Advanced Search or view our Online Help for more it rO. Ratings (- ccmpanglmormaticn View results starting with: ABCDEFGHIJKLMNOPQRSTUVWXYZ Best's Enrercompanp Nome ® AMB# Industry ® Company Name ® Rating ® Domicile or R.61.6esr Nunmer Find 02699 P Markel Insurance Company A United States: Illin r,mre search o.d� E, 85767 P Markel Insurance Company of A- Canada:Ontario p Canada CONTACT US Where .. ; in the 'fi'6dd IS 61ES7fi Find our lucncons *Ratings as of 1010512004 04:19 PM E.S.T. Whatdo you u co r tom m r m ma n a Send us your Industry: P = Property/Casualty(non-life) L= Life/Health View the Guide to Best's Financial Strength Ratings for an in-depth explanation of Best'E Accessing the pages System and Procedures. on ambest corn constitutes the user's agreement to our terms of.use; ___.__ Information collected Important Notice: Best's Ratings reflect our opinion based on a comprehensive via this web site is qualitative evaluation of a company's balance sheet strength, operating performance and protected by at our These ratings are not a warrant of an insurer's current or future ability to meet its contra, privacy statement; g y y Comments or concerns View our entire notice for a complete details. should be directed to our customer service group;For other Companies interested in placing a Best's Security Icons on their web site to promo matters refer to our strength may register online. contact us page. 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Best Company, Inc.ALL RIGHTS RESERVED No part of this report may be distributed in any electronic form or by any means,or stored in a database or retrieval syst written permission of the A.M.Best Company.Refer to our terms,of use for additional details. littp://www3.ambest.com/ratings/RatingsSearch.asp 10/5/2004 Contract Agreement Palm Springs, City of o and il - ADDICTION MEDICINE CONSULTANTS (AMC) .r Administrated Program Services and Fee Schedule r- Program Services Include: Urn e Drug Test(Emit Screen with GCIMS Confirmation) Collection Site Selection SM UBA Certified Laboratory for all Urine Drug Tests MRO Services for all Urine Drag Tests Cha n of Custody Forms and Collection Supplies Transportation to SAMHSA Lab Ran loin Selection Generation for Random Testing Alcohol Breath Testing as D.O.T.Requires Sup,avisor Training&Educational Materials Employee Record Administration Stor tge of Positive Specimen as Required by D.O.T. Federal Reporting as Required Effective From January 4 2003 until December 31,2003 AMC will provide a complete D.O.T. drug and alcohol testing program for Palm Springs, City of. The fee charged is $70.00 per covered driver for inclusion into the random testing pool. This includes all random drug and alcohol testing,reports, and compliance. Services beyond the random testing will be charged at the end of -ach calendar quarter by the fee schedule listed below, except for split specimen :esting which is paid for by donor. AMC's Itemized Fee Schedule (For services beyond the specified random tests for covered drivers) Pro€ram Cost Per Urine Requisition Processed $49.50 Bret th Alcohol Per Test Mobile, On Site, or at SBCL Site S40.00 Suporvisor's Training Program per hour $150.00 EmI loyee's Training Program per hour $150.00 Sub,tance Abuse Professional per session $150.00 D/L Isomer Confirmation Test $65,00 Spli Specimen GC/MS Confirmation Test $150.00 President Addiction Medicine Consultants, Inc. Date T�Qa� November 27, 2002 Contract Agreement c_ Palm Springs, City of � . T, and u ADDICTION MEDICINE CONSULTANTS(AMC) o Administrated Program Services and Fee Schedule - IT" Program Services Include: Urine Drug Test(Emit Screen with GC/MS Confirmation) Collection Site Selection SAMHSA Certified Laboratory for all Urine Drug Tests MRO Services for all Urine Drug Tests Chain of Custody Forms and Collection Supplies Transportation to SAMHSA Lab Random Selection Generation for Random Testing Alcohol Breath Testing as D.O.T. Requires Supervisor Training&Educational Materials Employee Record Administration Storage of Positive Specimen as Required by D.O.T. Federal Reporting as Required Effective From January 1, 2003 until December 31, 2003 AMC will provide a complete D.O.T. drug and alcohol testing program for Palm Springs, City of. The fee charged is $70.00 per covered driver for inclusion into the random testing pool. This includes all random drug and alcohol testing, reports, and compliance. Services beyond the random testing will be charged at the end of each calendar quarter by the fee schedule listed below, except for split specimen testing which is paid for by donor. AMC's Itemized Fee Schedule (For services beyond the specified random tests for covered drivers) Program Cost Per Urine Requisition Processed $42.50 Breath Alcohol Per Test Mobile, On Site, or at SBCL Site 4S 0 A Supervisor's Training Program per hour $150.00 Employee's Training Program per hour $150,00 Substance Abuse Professional per session $150.00 D/L Isomer Confirmation Test $65 0 Split Specimen GC/MS Confirmation Test (� (] $150.00 President Addiction Medicine Consultants, Inc. Date November 27, 2002 CONTRACT ABSTRACT Contract :` ; Company Name: Addiction Medicine Consultants %°> Company Contact: David Herold (Dq &2-0 p "IF-CEWED r Summary of Services: D.O.T. Drug and Alcohol Testing Contract Price: $24 9b®'00 Funding Source: 5903/5904 Contract Term: 7/1/04 - 6/30/05 i V Contract Administration \A Lead Department: Human Resources 11h� Contract Administrator: Dana Rascon �\ v �v Contract Approvals rX Council/ Community Redevelopment Agency Approval Date: Minute Order/ Resolution Number: ✓11l-6; \ Agreement No: Contract Compliance Exhibits: Signatures: Insurance: t Bonds: Cc��/✓Gt���. Contract prepared by: /Z4i21 Submitted on: 1015/04 By: Dana Rascon