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HomeMy WebLinkAboutA4681 - COLEN LEE WORKERS COMPENSATION THIRD PARTY ADMINISTRATOR (ADMINSURE) Page 1 of 3 Revised: 2.9.22 AMENDMENT NO. 2 TO THE A4681 CONTRACT SERVICE AGREEMENT FOR THIRD PARTY ADMINISTRATION OF WORKERS COMPENSATION SERVICES BETWEEN THE CITY PALM SPRINGS AND COLEN & LEE INCORPORATED DBA ADMINSURE, INC 1. Parties and Date. This Amendment No. 2 to the agreement for Third Party Administration of Workers Compensation Services is made and entered into as of this first day of September 2007, by and between the City of Palm Springs (“City”) and Colen & Lee, Incorporated, dba Adminsure, Incorporated (Administrator) with its principal place of business at 3380 Shelby Street Ontario, CA 91764-5566, and Colen & Lee dba Adminsure are sometimes individually referred to as “Party” and collectively as “Parties.” 2. Recitals. 2.1 Agreement. The City and Colen & Lee have entered into an agreement entitled contract service agreement for third party administration of workers compensation services dated May 1, 2003 (“Agreement” or “Contract”) for the purpose of retaining the services of Colen & Lee to provide Third Party Administration of Workers Compensation Services. 2.2 Amendment. The City and Colen & Lee, Incorporated desire to amend the Agreement to dba Adminsure, Incorporated. The Parties have heretofore entered into Amendment No. 2 dated September 7, 2007. 2.3 Amendment Authority. This Amendment No. 2 is authorized pursuant to Section 29 of the Agreement. 3. Terms. 3.1 Page 1, Paragraph 1, lines 2 and 3. Section 2 of the Agreement is hereby amended in its entirety to read as follows: Page 1, Paragraph 1, lines 2 and 3: City of Palm Springs, hereinafter referred to as the “City” and Colen & Lee, Inc., a California Corporation, dba Adminsure, Inc, hereinafter referred to as “Administrator.” 3.2 Continuing Effect of Agreement. Except as amended by this Amendment No. 2 all other provisions of the Agreement remain in full force and effect and shall govern the actions of the parties under this Amendment No. 2. From and after the date of this Amendment No.2, whenever the term “Agreement” or “Contract” appears in the Agreement, it shall mean the Agreement as amended by this Amendment No.2. 3.3 Adequate Consideration. The Parties hereto irrevocably stipulate and agree that they DocuSign Envelope ID: 0C4960A6-850D-4C2A-8553-0179226100B5 Page 2 of 3 Revised: 2.9.22 have each received adequate and independent consideration for the performance of the obligations they have undertaken pursuant to this Amendment No. 2. 3.4 Severability. If any portion of this Amendment No. 2 is declared invalid, illegal, or otherwise unenforceable by a court of competent jurisdiction, the remaining provisions shall continue in full force and effect. 3.5 Counterparts. This Amendment No. 2 may be executed in duplicate originals, each of which is deemed to be an original, but when taken together shall constitute but one and the same instrument. [SIGNATURES ON FOLLOWING PAGE] DocuSign Envelope ID: 0C4960A6-850D-4C2A-8553-0179226100B5 Page 3 of 3 Revised: 2.9.22 SIGNATURE PAGE TO AGREEMENT BYAND BETWEEN THE CITY OF PALM SPRINGS AND COLEN & LEE, INCORPORATED dba ADMINSURE, INC. 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: _______ Item No. 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: 0C4960A6-850D-4C2A-8553-0179226100B5 9/12/2022 | 4:02 PM PDT 9/13/2022 | 6:59 AM PDT Colen 8 Lee Workers Comp Services FIRST AMENDMENT TO CONTRACT SERVICES AGR AGREEMENT #4681 Amend 1 FOR THIRD PARTY ADMINISTRATION OF M07411 , 11-19-03 THE WORKERS COMPENSATION SERVICES- This First Amendment to Contract Services Agreement for Third Party Administration of the Workers' Compensation Services (":First Amendment") is made and entered into on November 19, 2003, but effective as of May 1, 2003,by and between the City of Palm Springs, a California municipal corporation ("City") and Colen & Lee, Incorporated, a California Corporation ("Administrator"), amending that certain Agreement for Third Party Administration of the Workers' Compensation Services ("Original Agreement") dated May 1, 2003 between the City and Administrator. RECITALS A. On or. about May 1, 2003, City and Administrator entered into the Original Agreement for Third Party Administration of Workers' Compensation. Services pursuant to which Original Agreement Administrator agreed to administer the City's workers' compensation self-insurance program during the term of the Agreement. B. Pursuant to the Original Agreement, City agreed to compensate Administrator on a monthly basis for services rendered under the agreement C. As set forth in the Original Agreement, Administrator's monthly fee is based on the assumption that the City had 137 open claims during the first year, of the Agreement. D. Subsequent to the execution of the Original Agreement the parties discovered that the actual number of open claims, as reported on the City's Interim Annual Report to the State of California, was 167 claims E. City and Administrator now desire to amend the Original Agreement to adjust the total number of open claims from 137 to 167 to properly reflect the actual number of open claims turned over to Administrator upon execution of the agreement. NOW, THEREFORE, in consideration of the mutual covenants contained herein and intended to be bound, the parties agree as follows: 1003/002/26203,01 01/06/2004 TUE 10:50 [TX/RX No 01441 12002 -' 1. Section 19 of the Original Agreement are amended to read, in its entirety, as follows: "19. COMPENSATION. The City shall pay the Administrator $11,272.50 per month for services rendered under this Agreement, based on the assumption that the City has 167 open files, during the first year of this Agreement. There is also a one-time data conversion fee of $7,000, which shall be paid at the end of the first month of this Agreement. The monthly fee to be paid to Administrator will be adjusted up or down on the anniversary of this Agreement based on the average number of open files. The adjustment will be made on a direct percentage basis. The second year fees, based on 167 open files, will be $11,610.80 per month. The third year fees, based on 167 open files, will be $11,958.73 per month. The fourth year fees, based on 167 open files, will be $12,316.53 per month. The fifth year fees, based on 167 open files, will be $12,685.88 per month." 2. Except as modified by this First Amendment, all other terms and conditions of the Agreement are hereby ratified and confirmed by the parties. IN WITNESS WHEREOF, the parties hereto executed this First Amendment to be effective as of the date first written above. CITY OF PALM SPRINGS, a�muuni�cipaal corporation B -ram' ✓ City Manager ST' ity C APPROVED AS TO FORM: APPnokrED BY THEEr City Attorney COLEN &LEE ��II 44 By: 79 ���x, ana__ Name: Title: 1003/002/26303.01 A-2 • • ��. I I �I nLl•1 JI h11Y1'Ao rHllG UJI CIJ 1. Section. 19 of the Original Agreement are amended to read, in its entirety, as follows: "19. COMPENSATION. The City shall pay the Administrator S11,272.50 per month for services rendered under this Agreement, based on the assumption that the City has 167 open files, daring the first year of this Agreement, There is also a onetime data conversion fee of$7,000, which shall be paid at the end of the first month of this Agreement. The monthly fee to be paid to Administrator will be adjusted up or down on the anniversary of this Agreement based on the average number of open files. The adjustment will be made on a direct percentage basis. The second year fees, based on 167 open files, will be $11,610.80 per month. The third year fees, based on 167 open files, will be $I 1„958.73 per month.. The fourth year fees, based on 167 open files, will be $12,316,53 per month. The ,fifth year fees, based on 167 open files, will be$12,685.88 per month" 2. Except as modified by this First Amendment, all other terms and conditions of the Agreement are hereby ratified and confirmed by the parties. IN WITNESS WHEREOF, the parties hereto executed this First Amendment to be effective as of the date first written above. CTTY OF PALM SPRINGS, a municipal corporation By: City Manager ATTEST: City Clerk APPROVED AS TO FORM: rip City, orne COLEN&LEE By: 7&,4,,,e, �[7� Name: Title: 1003/002/26303.01 A-2 01/06/2004 TUE 10:50 [TK/RH NO 9144] ta003 Colen & Lee Third Party Administrator AGREEMENT #4681 M07284, 4-2-03 CITY OF PALM SPRINGS CONTRACT SERVICES AGREEMENT FOR THIRD PARTY ADMINISTRATION OF WORKERS COMPENSATION SERVICES THIS AGREEMENT is entered into this 15t day of May, 2003 between the CITY OF PALM SPRINGS, hereinafter referred to as the "City" and COLEN & LEE, INC., a California Corporation, hereinafter referred to as the "Administrator." WHEREAS, the City has undertaken to self-insure its Workers' Compensation obligation; and WHEREAS, the Administrator is engaged in the business of administering Workers' Compensation self-insurance programs; and WHEREAS, the City desires to retain the services of the Administrator to administer a Workers' Compensation self-insurance program, hereinafter referred to as the "Program," for the City; NOW, THEREFORE, the City hereby retains the services of the Administrator and the Administrator agrees to perform service for the City under the terms and conditions of this Agreement. The above-stated recitals are incorporated herein by this reference. 1. TERM: This Agreement shall become effective as of May 1, 2003, and shall continue in effect until terminated by the cancellation provision set forth herein. 2. PERIODIC MEETINGS: The Administrator shall meet with City staff periodically to: A. Assist the City in developing internal procedures. 23376v2 ORG aGNAL I39D 1 A DJO y AGREIE irp',v d' B. Provide orientation and training to City personnel involved in the administration of the Program. C. Discuss specific claims and general trends in the Program. 3. ADVISORY SERVICES: The Administrator shall provide written advisory bulletins to inform the City of the adoption, amendment or repeal of all statutes, rules and regulation, which directly affect the Program. 4. REPORTING OBLIGATIONS: Administrator will provide City with an annual report summarizing the City's claim history during that year, comparing the City's claims to past claims and claims made in other jurisdictions or in the State in general based on data available to Administrator and recommending improvements to be made in the City's claim administration. The evaluation shall include data helpful to evaluate the City's effectiveness in minimizing and managing claims, including factors to permit evaluation by nature of claims, number of employees, department, nature of expenses and similar criteria. The report shall make suggestions on cost containment and discuss and analyze whether the City's claims are unusual, with reference to the categories listed above. 5. LICENSES._PERMITS, FEES AND ASSESSMENTS: Administrator 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. Administrator shall have the sole obligation to pay for any fees, assessments and taxes, plus applicable penalties and interest which may be imposed by law and arise from or are necessary for the Administrator's 2337Gv2 2 performance of the services required by this Agreement, and shall indemnify, defend and hold harmless City against any such fees, assessments, taxes, penalties or interest levied, assessed or imposed against City hereunder. 6. REQUIRED FORMS: The Administrator shall provide the City with all forms required by the State in connection with the Program. 7. TIME OF ESSENCE: Time is of the essence in the performance of this Agreement. 8. COMPLIANCE WITH LAW: The Administrator shall administer the Program in full compliance with all laws, rules and regulations governing Workers' Compensation and self-insurance, as well as the ordinances, statutes, rules and resolutions of the City and any federal, state or local governmental agency having jurisdiction during Administrator's provision of services in connection with the Program. 9. CLAIMS ADMINISTRATION; The Administrator shall have the authority and responsibility to provide claims administration services, which include: A. Entering claim information on a log and establishing a claim file upon receipt of an injury report. B. Setting and updating reserves. C. Arranging for investigation. D. Determining compensability. E. Preparing and issuing benefit notices and pamphlets. 23376v2 3 F. Arranging for medical treatment from specialists, as necessary- G. Initiating and maintaining contact with employees or attorneys- H. Monitoring disability status by reviewing medical reports and calling doctors for updates. I. Auditing and paying medical bills. J. Paying mileage reimbursement to employees. K. Paying temporary disability compensation when appropriate to do so or advising the City of the need to adjust payroll records when salary continuation is applicable. L Arranging medical exams in conformance with State law to determine whether an employee's medical condition is permanent and stationary and what, if any, permanent disability exists. M. Paying permanent disability compensation in accordance with the law. N. Arranging for attorney representation of the City whenever the need arises, selecting attorneys from a list approved by the City, which shall also be coordinated with the Contract Officer and City Attorney. O. Monitoring attorneys and assisting them in preparing cases. P. Auditing and paying legal expenses. Q. Arranging for vocational rehabilitation services when appropriate. 23375v2 4 R. Monitoring vocational rehabilitation consultants and assisting them as necessary. S. Auditing and paying vocational rehabilitation expenses. T. Attending all hearings that are required by law. U. Preparing and issuing vocational rehabilitation notices- V. Preparing and issuing permanent disability compensation notices. W. Pursuing subrogation when there is a viable third party. X. Notifying the City's excess insurers of all claims, which exceed or may exceed the self-insurance retention, maintaining a liaison between the City and its excess insurers on matters affecting the handling of such claims and arranging for reimbursement to the City of losses in excess of its self-insurance retention. Y. Obtaining settlement authority and negotiating settlement on appropriate claims. Z. Closing claim files when appropriate to do so. AA. Updating City on the status of all open files on a monthly basis and in a form satisfactory to City. 10. OBLIGATIONS OF EMPLOYER: The City shall: A. Submit all reports of work injury to the Administrator within one (1) business day of the City's knowledge of the injury. B. Respond to Administrator requests for information and authority within five days of such requests. 23376v2 5 C. Provide information that is accurate and is in a form specified by the Administrator. D. Grant settlement authority to the Administrator in advance of vocational rehabilitation and legal hearings or be available by phone or in person during those hearings. 11. CHECKING ACCOUNT: The City and Administrator agree that: A. The City shall establish a checking account from which all Workers' Compensation benefits and expenses are to be paid. 6. The Administrator shall prepare checks and issue those checks directly to payees without delay. C. The Administrator shall sign checks manually or with a facsimile signature. D, The Administrator shall secure checks in a locked room accessible to a limited number of personnel. E. The City shall maintain an adequate balance in the checking account to meet all Workers' Compensation obligations without delay. F. The checking account may be used to pay civil penalties in which case the Administrator shall reimburse the City within fifteen days for any amount of the penalty, which the Administrator caused. Administrator shall maintain the standard of paying at least ninety-five percent of all of the claims without penalty. Administrator shall inform City in writing whenever penalties have been assessed, and whenever such penalties have been assessed on five (5) percent or more of the claims in 23376v2 6 any calendar year. The parties shall meet to determine why such penalties are occurring. If additional penalties are assessed on five (5) percent or more of such claims in the calendar year the Administrator will be required to pay City an additional penalty of $250 per additional occurrence. If the situation is not corrected, the parties shall meet to identify additional measures. 12. REPRESENTATIVE OF ADMINISTRATOR: The following principals of Administrator are hereby designated as being the principals and representatives of Administrator authorized to act in its behalf with respect to the work specified herein and make all decisions in connection therewith: Bernard Colen. It is expressly understood that the experience, knowledge, capability and reputation of the foregoing principals were a substantial inducement for City to enter into this Agreement. Therefore, the foregoing principals shall be responsible during the term of this Agreement for directing all activities of Administrator and devoting sufficient time to personally supervise the Program. For purposes of this Agreement, the foregoing principals may not be replaced nor may their responsibilities be substantially reduced by Administrator without the express written approval of City. 13. CONTRACT OFFICER: The Contract Officer shall be they City's Director of Human Resources. It shall be the Administrator's responsibility to assure that the Contract Officer is kept informed of the progress of the performance of the services and the Administrator shall refer any decisions which 23376v2 7 must be made by City to the Contract Officer. Unless otherwise specified herein, any approval of City required hereunder shall mean the approval of the Contract Officer. The Contract Officer shall have authority to sign all documents on behalf of the City required hereunder to carry out the terms of this Agreement. 14. PROHIBITION AGAINST SUBCONTRACTING OR ASSIGNMENT: The experience, knowledge, capability and reputation of Administrator, its principals and employees were a substantial inducement for the City to enter into this Agreement. Therefore, Administrator shall not contract with any other entity to perform in whole or in part the services required hereunder without the express written approval of the City. In addition, neither this Agreement nor any interest herein may be transferred, assigned, conveyed, hypothecated or encumbered voluntarily or by operation of law, whether for the benefit of creditors or otherwise, without the prior written approval of City. In the event of any such unapproved transfer, including any bankruptcy proceeding, this Agreement shall be void. No approved transfer shall release the Administrator or any surety of Administrator of any liability hereunder without the express consent of City. After obtaining approval as provided herein, Administrator may retain consultants, as contemplated in Section 20 below. 15. INDEPENDENT CONTRACTOR: Neither the City nor any of its employees shall have any control over the manner, mode or means by which Administrator, its agents or employees, perform the services required herein, except as otherwise set forth herein. City shall have no voice in the selection, discharge, supervision or control of Administrator's employees, servants, 23376v2 8 representatives or agents, or in fixing their number, compensation or hours of service. Administrator shall perform all services required herein as an independent contractor of City and shall remain at all times as to City a wholly independent contractor with only such obligations as are consistent with that role. Administrator 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. City shall not in any way or for any purpose become or be deemed to be a partner of Administrator in its business or otherwise or a joint venturer or a member of any joint enterprise with Administrator. 16. ELECTRONIC DATA PROCESSING: The Administrator shall provide the City with electronic data processing services that will allow for the production of loss experience and transaction reports within ten days following the close of each calendar month. The Administrator shall either print these reports or shall provide the City with electronic media containing the data needed to print such reports. 17. REGULATORY REPORTING: The Administrator shall prepare all reports required by State regulatory agencies in connection with the Program, including the Self-Insurer's Annual Report required by the Department of Self- Insurance Plans. 18. RECORDS: The Administrator shall establish and maintain claim files, claim logs, transaction documents and all other records associated with the Program. These records shall be the property of the City and shall be available, on five (5) days notice, for review or transfer to another custodian. Unless this 23376v2 9 Agreement is canceled, closed files shall be stored by the Administrator for five (5) years and shall thereafter become the responsibility of the City. Upon cancellation of this Agreement, the City shall be responsible for maintaining and storing all records. The Administrator shall not dispose of or destroy these records without the prior, written authorization of the City. 19. COMPENSATION: The City shall pay the Administrator $ 9,247.50 per month for services rendered under this Agreement, based on the assumption that the City has 137 open files, during the first year of this Agreement. There is also a one-time data conversion fee of $7,000, which shall be paid at the end of the first month of this Agreement. The monthly fee to be paid to Administrator will be adjusted up or down on the anniversary of this Agreement based on the average number of open files. The adjustment will be made on a direct percentage basis. The second year fees, based on 137 open files, will be $9,525 per month. The third year fees, based on 137 open files, will be $9,810.50 per month. The fourth year fees, based on 137 open files, will be $10,104 per month. The fifth year fees, based on 137 open files, will be $10,407 per month. 20. ALLOCATED EXPENSES: The City shall pay for field investigation, defense attorneys, legal costs, remote photocopy, engineering experts, accident reconstruction experts, process servers, messenger service, court reporters, vocational rehabilitation consultants, structured settlement consultants and translators. All consultants must be approved by the City in writing before City will be responsible for their expenses. 23376v2 10 21. PENALTIES: The Administrator shall be responsible for paying or appealing penalties that are caused by the Administrator. The Administrator shall not be responsible for penalties that are caused by the City or any third parties. 22. INDEMNIFICATION: Administrator 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 Administrator, its agents, employees, subcontractors, provided for herein, or arising from the negligent acts or omissions of Administrator hereunder, or arising from Administrator's negligent performance of or failure to perform any term, provision, covenant or condition of this Agreement, but excluding such claims, liabilities, damages or portions thereof arising from the negligence or willful misconduct of the City, its officers, agents or employees, who are directly responsible to the City, and in connection therewith, subject to the exclusion for the negligence or willful misconduct of the City. A. Administrator will defend any action or actions filed in connection with any of said claims or liabilities and will pay costs and expenses, including legal costs and attorneys' fees incurred in connection therewith; 23376v2 11 B. Administrator 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 Administrator hereunder, and Administrator 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 Administrator for such damages or other claims arising out of or in connection with the negligent performance of Administrator hereunder, Administrator 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, to the extent such costs, expenses and fees are attributable to the negligence of Administrator and not the City. 23. INSURANCE: The Administrator shall: A. Maintain in force at all times General Liability Insurance in the amount of One Million ($1,000,000) Dollars per occurrence, combined single limit- B. Maintain in force at all time Professional Liability Insurance in the amount of One Million ($1,000,000) Dollars per occurrence, combined single limit. 23376v2 12 C. Maintain in force at all times a Fidelity Bond in the amount of One Million ($1,000,000) Dollars- D. Maintain in force at all times Workers' Compensation Insurance for employees of the Administrator, as required by law. E. Notify the City, in writing, thirty days prior to any cancellation or reduction in the above coverage- F. Maintain evidence of the above coverage on file with the City throughout the term of this Agreement. G. All policies of insurance shall be maintained at Administrator's sole cost and expense during the entire term of this Agreement and shall name the City, its officers, employees and agents as additional insureds. All of these policies 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 Administrator shall, prior to the cancellation date, submit new evidence of insurance in conformance with this section to the Contract Officer. No work or services under this Agreement shall commence until Administrator has provided the City with certificates of insurance evidencing the above insurance coverage. 24. NOTICES: All notices, demands, requests, or approvals which are required under this Agreement, or which either the City or the Administrator may desire to serve upon the other, shall be in writing and shall be conclusively 23376v2 13 deemed served when delivered personally, or forty-eight (48) hours after the deposit thereof in the United States Mail with postage pre-paid. 25. CANCELLATION: This Agreement may be canceled by either party giving to the other, in writing, notice of its intention to cancel this Agreement at least one hundred twenty (120) days prior to the date of termination. Upon the date of termination of this Agreement, or the date on which records are transferred to another custodian, whichever occurs first, the Administrator shall no longer have the authority or responsibility to administer the City's claims. Notwithstanding the above, the City reserves the right to terminate this Agreement due to Administrator's default upon thirty (30) days' written notice to Administrator of the default and the opportunity to cure such default. Upon termination of this Agreement for any reason, Administrator shall have thirty (30) days to return all documents relating to the City's claims to the City and to provide the City with a report on the status of each open claim. 26. PARTIAL INVALIDITY: If any provision of this Agreement is held by a competent court to be invalid, void or unenforceable, the remaining provisions shall nevertheless continue in full force and effect. 27. GOVERNING LAW: The validity of this Agreement and of any of its terms and provisions shall be interpreted pursuant to 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. 23376v2 14 28. INTERPRETATION: The terms and conditions of this Agreement shall be construed pursuant to their plain, ordinary meaning and shall not be interpreted against the maker. 29. ASSIGNMENT: The Administrator shall not assign, sublet or transfer by operation of law or otherwise any or all of its rights, burdens, duties or obligations of this Agreement without the prior, written consent of the City. 30. RETENTION OF FUNDS: Administrator hereby authorizes City to deduct from any amount payable to Administrator arising out of this Agreement amounts which may be in dispute concerning the monthly amount of compensation due to Administrator pursuant to Section 19. 31. CONFLICT OF INTEREST: The Administrator agrees not to enter into any activity or business arrangement, which is likely to result in a conflict between the interests of the City and the interests of any third parties. 32. 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 to 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. 33. ENTIRE CONTRACT: This instrument contains the entire Agreement between the parties relating to the rights herein granted and 23376v2 15 obligations herein assumed. Any oral representations or modifications concerning this instrument shall be of no force or effect. Subsequent modifications shall be made in writing with the agreement of both parties. 34. 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 the breach of 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. Attorney's fees shall include attorney's fees on any appeal, and in addition a party entitled to attorney's fees shall be entitled to all other reasonable costs for investigating such action, taking depositions and discovery and all other necessary costs the court allows which are incurred in such litigation. All such fees shall be deemed to have accrued on commencement of such action and shall be enforceable whether or not such action is prosecuted to judgment. 35. NON-LIABILITY OF CITY OFFICERS AND EMPLOYEES: Except for intentional acts of willful misconduct, no officer or employee of the City shall be personally liable to the Administrator, 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 Administrator or to its successor, or for breach of any obligation of the terms of this Agreement. 36. COVENANT AGAINST DISCRIMINATION: Administrator 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 23376v2 16 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. Administrator shall take affirmative action to insure 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. 37. CORPORATE AUTHORITY: 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] 23376v2 17 EXECUTED at Palm Springs, California, on the date and year first above written. CITY OF PALM SPRINGS COLEN AND LEE INC. b — � Gct�. r�a�ac�ar by C EST: APPROVED AS TO FORM:by APPROVE AS TO �p1T� Agrecnient od cr(u $25,000 by Rcviewed acid approved by Procurement &a Contracting Date ,� 79S D3 P.O. Nu4nber 23376v2 18 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT 'r State of California 15 County o - c ss. f �yy ti I �� � �d. I��On 0 before me, Dale Narne �nA Tdle of Ofllcer(e B '��^�Doe Notary Public) personally appeared ICI Narre(e)of Sil r< personally known to me ❑ proved to me on the basis of satisfactory F evidence C i to be the person($) whose name($) is/are subscribed to the within instrument and ^' Nol1EINA tSA9AlAN acknowledged to me that he/she/they executed r CgmmTssign tk 1293750 �I Notary Public-CallWrnlQ the same in his/her/their authorized Los Angeles County capacity(ies), and that by his/her/their )I QWCornm.BpiresFeb1Q=! signature(s) on the instrument the person(s), or r'I the entity upon behalf of which the person(s) ' l�r acted, executed the instrument. WITNESS rfly hand and of icial seal. f�I hII, Place Notary Seal Above I�� Mary Pubic �`I I^ OPTIONAL � til Though the information below is not required by law, it may prove valuable to persons relying on the document �I and could prevent fraudulent removal and reattachment of this farm to another document. Ili Description of Attached D4cumpr t �I {( Title or Type of Document: _ o ,I r Document Date: MI a4° � FOCI �j _Number of Pages. -42z? � O j LPL CILoG�G•� Ilrl r Signer(s) Other Than Named Above: rl Capacity(lies) Claimed by Signer �I �I Signer's Name: -•- ❑ Individual Top of thumb here fi ❑ Corporate Officer—Title(s): I ❑ Partner—❑ Limited 1-- General � ❑ Attorney in Fact ( ❑ Trustee I F ❑ Guardian or Conservator ❑ Other. �II I II Signer Is Representing: _ r` .c.'�'w•=T. tic.c.-�.<,�z�ir.<,''.C,r�t;Cv.�.,:r^.rti'C:.:na�fcY<..., •^,-_a_r�;..��r�,r.�,rr;'i..=� .c;�w=C'+-2-c.�•-.,u. ..,..� 01999 Nal anal Notiry Assnaellon•8050Do,Sato Ava Po 9ox2402•Chut:wmth CA acity2a02•www nallona notary or0 Prod No 5901 Pnordnr Call Toll-Frno 1800 87e-ee27 1 1 1 1 1 Claims 1 Administration 1 Proposal 1 1 1 1 1 ORIGINAL 1 CITY OF PALM SPRINGS RTP 03-03 1 ' 1 COLEN AND LEE 1 1 *6L ' CO u�� L nt i V De LEE Diamond Bar,CA 91765 "telephone(909)861-0816 Risk Mnnngemenl Services INWAWNW-T ORIGINAL ' PROPOSAL for the ADMINISTRATION of a ' WORIaRS' COMPENSATION SELF-]NSURANCE PROGRAM ' for the CITY OF PALM SPRINGS ' REP 03-03 Presented By ' COLEN & LEE, INC. Submitted January 17, 2003 1 1 1 1 COLEN AND LEE 1470 South Valley Vitt,Drive,Suite 230,Diamond Bar,CA 91765 Telephone(909)861-0816 Rzek Management Services 116 ' January 17, 2003 ORIGINAL Harold E. Good, CPPO, Director of Procurement & Contracting PALM SPRINGS CITY HALL 3200 East Tahquitz Canyon Way Palm Springs, California 92262 RE: "Third Party Administrator (TPA) for the City's (Palm Springs) Self- Insured Workers' Compensation Program, RFP 03-03". Dear Mr. Good: Thank you for inviting us to present a proposal on behalf of the City of Palm Springs. We would be honored to administer a self-insured workers' compensation program on behalf of City. Over the years many organizations have come to rely upon self-insurance to handle their workers' compensation and liability risks. In doing so, they have found that their self-insurance programs work best when administered in a professional and diligent manner. Administering self-insurance programs is what Colen & Lee is all about. We have administered such programs for the public sector for almost twenty years. We offer a full-range of claims administration, accounting, management reporting, and consulting services. These services are both comprehensive and flexible, allowing us to serve your individual needs. Our people possess a combination of education; training and experience that makes them well qualified to administer self-insurance programs. Key staff members are properly licensed or State certified in accordance with State regulations. iThey are afforded every opportunity, through continuing programs of education and training, to sharpen their skills and upgrade their knowledge. This is important in a field such as ours where change is rapid. Moreover, realizing that your public and employee relations can be enhanced or ' harmed by our conduct, our people are instilled with a service-oriented attitude, which manifests itself in a courteous, responsive and business like demeanor. Claims administration is one of the most important aspects of a self-insurance program. After all, claim costs usually account for the single largest portion of a program's budget. i January 17, 2003 City of Palm Springs Page Two ' In administering workers' compensation claims, we provide services relating to: ' AOE/COE Determination ■ Benefit Delivery • Coordination of Benefits • Medical Management ' Disability Management • Vocational Rehabilitation ' Litigation Management • Cost Containment • Subrogation ' All of our activities are conducted with a clear purpose in mind; to see that claims ' are handled properly, quickly and economically. In workers' compensation the fundamental goal is to deliver benefits with ' accuracy and timeliness, as prescribed by State law. But there is more to it than that. For instance, we take the time to talk with your injured employees, to explain benefits to them and to answer any questions they may have. In this way, ' we avoid the kind of misunderstanding that often leads to costly litigation. At the same time, we fight abuse of the system. Not only exaggerated or ' fraudulent claims, but also overcharging by medical care providers and other vendors. ' We offer management reports that provide accountability and feedback. These are the reasons why management reports are necessary. Our management ' reports offer current activity as well as historical data. We take care to ensure that these reports are accurate, timely, easy-to-read and informative. We also offer on-line access to your data at no additional cost to you. ' In addition to claims administration and management reports, we provide services in the areas of: • Orientation & Training —for management groups and / or employees. • Banking — you choose from a variety of techniques, we take care of the ' details. • Accounting — We provide your accounting department with the information they need to monitor expenditures. 1 1 ' January 17, 2003 City of Palm Springs ' Page Three ' As administrators of workers' compensation and liability self-insurance programs, we at Colen & Lee take a straightforward, no nonsense approach in providing excellent service at a fair price. When you place your self-insured workers' compensation with us, you work with a team of Colen & Lee specialists who are permanently assigned to your account. They get to know your preferences, your needs and your problems. ' Furthermore, you are as involved with or removed from your program as you wish. You may retain almost total control or simply set guidelines and attend to other matters while we do the rest. ' Strong lines of communication ensure that there are no surprises. Your Colen & ' Lee representatives periodically meet with you to discuss individual cases, general procedures and trends in your program. ' Carefully designed systems provide the support our people need to do the job properly and efficiently. These systems, refined by years of experience, include quality control measures that ensure a consistently high level of service — day ' after day, year after year. If you believe as we do, that high quality service does make a difference, please consider us to provide your claims administration services. Respectfully submitted, 1 �l_ �Z✓iu ,cv- eG'. Bernard Colen Vice President ' BC/s 1 1 1 TABLE OF CONTENTS tPage 01 A. Company and Employee Profile: Page 01 (1) Finn is Regional (Cali(orrria) Page 01 (2) Firm Profile Page 01 (3) Location of Main Office Page 01 (4) List of Public Agency Clientele Page 01 (5) List of Fonner Clientele with Expired Contracts Page 01 (6) Fines - State Audit Page 01 (7) Financial Statement Page 01 B. Staffing and Qualifications of Personnel: Page 01 (1) Organizational Chart (Appendix A) Page 01 (2) Employees Assigned to the City's Account Page 01 (3) State Certification Page 01 (4) Number of Clients in a Unit ' Page 01 (5) Number of Employees in a Unit Page 02 (6) Qualifications and Experience of Personnel Page 02 (7) Pro Fessional Education of Personnel ' Page 02 (8) Work Hours and Accessibility of Assigncd Personnel Page 02 (9) Estimated Number and Composition of Staff Page 02 (10) Caseload of Staff Assigned ' Page 02 (11) Familiarity with ADA and PERS Page 03 C. Claims Management Philosophy: Page 03 (1) Philosophy/Approach to Claims Management Services ' Page 03 (2)Number and Level of Examiners Assigned Page 03 (3) MaXilllUiu Number of Claims for Examiner Control Page 03 (4) Level of Supervision and Management Review ' Page 03 (5) In-house File Reviews Page 03 (6) Criteria Used to Identify Subrogation Page 04 (7) Reserving Practices and Philosophy Page 04 (8) Criteria of Notifying Excess Carrier Page 04 (9) Claim Settlement Philosophy Page 04 (10) Handling of Questionable Claims ' Page 05 (11) Extent of Investigative Services Provided by Staff Page 05 (12) Finn's Philosophy on Utilizing AME vs. QME Page 05 (13) Protocol for Reviewing, Handling & Prooessiug DWCls and 5020s ' Page 05 (14) Philosophy on Delaying and Investigating a Claim Pagc 06 (15) Examiner Protocol for Diary, Reviewing and Updating Open Claims Page 06 (16) Recordkeeping Procedures for All Aspects of Claims Administration ' Page 06 (17) Initial and Follow-up Contact with Injured Employees Page 06 (18) Finn's Procedure for Advising Initial Treating Doctor/Modified Duty Page 07 (19) Sample Posters, Letters, Pamphlets, Forms that would be Provided ' Page 07 (20) Procedures for Contact with the City of Claim Status Page 07 (21) Automated Process for Reporting Employer First Report Page 07 (22) Vocational Rehabilitation Vendors Used 1 1 ' Page 07 (23) Preferences for Employer Management Involvement in Claims Page 07 (24) Sample Claims File/Claim File Organization Page 08 D. Litigation Management: Page 08 (1) Services Provided by Staff for Litigated and Subrogated Claims Page 08 (2) Number of Litigated Claims Handled by Examiner In-House ' Page 08 (3) Firm's Participation in Workers' Compensation Hearings Page 08 (4) Procedures Utilized in Determining Referral to Outside Legal Counsel Page 08 (5) Cases Handled Legal Counsel—Firm's Position in Handling Liens ' Page 09 (6) Procedures for Managing Quality and Cost of Work of Law Firms Page 09 (7) Law Firms Recommended for Handling Litigated Cases ' Page 09 (8) Hearing Representatives Page 09 E. Cost Control: Page 09 (1) Outside Firms for Investigation, Subrogation, Subrogation, etc. ' Page 09 (2) Outside Contracted or Services Provided In-House Page 09 (3) Fees for Charges (E-1) Page 09 (4) Innovative Cost Controls ' Page 10 (5) Safety and Loss Control Services Page 10 F. Managed Care: Page 10 (1) Managed Care/Medical Cost Conlairurient Program ' Page 10 (2) Charges/Fees for F1 Page 11 (3) Discuss Panel of Medical Experts Page 11 (4) Procedures for Auditing Prescriptions and Medical Costs ' Page 11 (5) Cases that Benefit from Case Management Page 11 GPayments/Funding: Page 11 (1) Company Interface with City's Payroll Departirrent Pagc 11 (2) Administering Payment of Benefits Page 11 H. Risk Management Information Systems (RMIS): Page I (1) Computer/Software Environment ' Page 11 (2) Back Up and Disaster Recovery Procedures Page 11 (3) Sample and Frequency of Reports Page 12 (4) Claims Files and Electronic Data Property of the City ' Page 12 (5) System Access for Data Review Page 12 (6) Data Conversion from City's RMIS to Firm's Page 12 (7) Updating City's RMIS System with Claims Information 1 Page 12 1. 1m Iementation: Page 12 (1) Describe Finn's Transition of Services Page 13 (2) Information/Assistance Required of City Staff During Transition ' Page 13 J. Other: Page 13 (1) Performance Measures to Evaluate TPA Performance Page 13 (2) Current or Pending Legal Action Page 13 (3) Copies of Contracts between TPA and Other Public Agencies Page 13 K. Cost Proposal: Page 13 (1) Cost Proposal for 3, 4 and 5 Year Contract Terms ' Page 13 (2) Methods, which can be Used to Reduce TPA Costs ! ! Page 14 Appendix A— Sample Organizational Chart Page 15 Appendix B — Staff Resmnes Page 18 Appendix C—Client List Page 21 Appendix D —Client Cont-acls Page 55 Appendix E— Sample Loss Experience Reports ! Page 83 Appendix F Sample Forms, Pamphlets, Poster i ! ! i i ! i ! 1 i 1 ' A. Company and Employee Profile: 1. Colen & Lee specializes in the administration of claims for California self-insured public entities. We have been in business since 1982 and in that time have developed a reputation for providing responsive, high quality service. t 2. Firm Profile: Colen & Lee, Inc. is a California Corporation. Gary Lee is the Chief Executive Officer and President. Bernard Colen is the Chief Financial Officer, Secretary and Vice President. 3. Location of Main Office: We have one office where all workers' compensation and general liability claims administration services are performed: 1470 South ' Valley Vista Drive, Suite 230, Diamond Bar, CA 91765, (909) 861-0816, Fax (909) 860-3995. 4. Please note Appendix C for a list of Public Agency clients. ' 5. We have had no clients whose contracts have expired in the last 2 years. 6. We have not been fined in the past 7 years due to a state audit- 7- If selected, we will provide our most current financial information. ' B. Staffing and Qualifications of Personnel: 1. Please see Appendix A for a Sample Organizational Chart. 2_ The City's claims would be haudled out of Colen and Lee's office located in Diamond Bar, California. Within that office, we have four separate claims touts. ' The City's account would be assigned to one of those units. The City's claims would be tinder the supervision of the Claim Unit Manager. All active indemnity claims would be assigned to one Workers' Compensation Claims Administrator. ' All medical only and resolved future medical claims would be assigned to one Medical Claims Administrator. In addition, each unit has a Clerical Claims Assistant and a File Clerk providing clerical support for all clients within that ' unit. 3. All Unit Claim Managers and all Workers' Compensation Claims Administrators are cord bed by the State of California as Self-Insurance Claims Administrators. ' In addition, many have completed the certification requirements through the Insurance Educational Association to obtain their designation as Workers' Compensation Claims Administrators (WCCA) or Workers' Compensation ' Claims Professionals (WCCP). Some of our Managers and Claims Administrators have obtained similar training and certification though recognized training programs offered by insurance companies. Medical Claims ' Administrators and Clerical Claims Assistants arc required to take the training classes through the Insurance Educational Association in order to prepare £or advancement to the position of Workers' Compensation Claims Administrator in ' our organization. 4. The number of clients assigned to each unit will vary depending on the volume of claims associated with each client. Currently each unit has between 8-13 clients. ' S. Currently each claim unit is comprised of: one Unit Manager, five Workers' Compensation Claims Administrators, two Medical Claims Administrators, one Clerical Claims Assistant and one File Clerk. In addition, the units have ' 1 ' additional support employees within the company to assist with clerical, data and administrative issues. ' 6. Qualifications and certifications were previously provided under Section B.3. Because Colen and Lee encourage training and promotion within our organization, we do not have specific experience requirements for our staff. We evaluate the level of an employee's training and the quality of their performance within the organization to determine where that employee should be placed within the company. As a result, we experience very low staff turnover and have a high ' level of experience. Currently, our level of experience is as follows: Unit Claims Managers: Average over 17 years experience and Average, More than 5 years managerial experience. Workers' Compensation Claims Administrators: Average more than 8 years experience. Jill-Marie Andreski would he assigned as the Workers' Compensation Manager to oversee the City's account. Please see ' Appendix B for her restage. The Workers' Compensation Administrator assigned to the City's account would be hired or placed from in-house staff. 7. Colen and Lee encourage all employees to continue their education. We pay for ' all classes and seminars through the Insurance Educational Association that are necessary to obtain or maintain professional accreditation. In addition, we regularly schedule "in-house" seminars on claims handling, medical and legal ' issues for our staff. 8. All employees work eight hours a day, Monday through Friday. Employees received every other Friday off, but the office is open and there is always somebody available to answer questions and provide medical authorization in the event the Claims Administrator is off work. The switchboard is open from 8:OOam until 430pm on Monday through Friday. The claims administrators and ' managerial staff are available through e-mail and direct dial phone numbers. 9. The City of Palm Springs would be assigned one Unit Claims Manager, one Workers' Compensation Claims Administrator and one Medical Claims ' Administrator. The Unit Claims Managers have no claims assigned to them for handling. They supervise a unit that contains approximately 1200-1300 open indemnity, future medical and medical only files. ' 10. The Workers' Compensation Claims Administrator will handle approximately 150 active indemnity files. The Medical Claims Administrator will handle 250- 300 medical only and future medical files. We currently do not have a Workers' Compensation Claims Administrator with the capacity to assume the City of Palm Springs; therefore, we anticipate hiring now staff. 11. Because of our extensive experience with handling the programs for public entities, all of our staff is very proficient in dealing with those issues associated with the coordination of workers' compensation benefits and the PERS disability retirement system. We are also very familiar with the Americans with Disabilities ' Act and the requirements of coordinating those activities with the workers' compensation requirements for providing benefits to an injured employee deemed to be a Qualified Injured Worker for vocational rehabilitation services. Our ' involvement in that process varies for each client and the level of our inclusion is detennined by the client. 1 2 C. Claims Management Philosophy: 1. Colen and Lee believe in flexibility and communication with our clients is essential in providing comprehensive claims management services. We are an "extension" of the City when administering benefits under this program. Our goal ' is to provide the proper level of benefits to those injured workers as quickly and efficiently as possible. We also believe that claims without merit should be resisted using all available defenses under California law. At all times, we keep in mind that our customer is the City of Palm Springs and we are to carry out the wishes of the City, within the parameters of the law. We will provide our recommendations and advise you as to the ramifications of the different possible courses of action, but the ultimate authority in this program rests with the City. We understand that there may be "issues" on a claim that extends beyond the ' workers' compensation claim itself. Because these may determine a course of action on the claim, it is important that all appropriate City personnel are involved in the claims process. Teamwork and communication are essential to the success of this program. 2. Colen and Lee have established our caseloads at 150 open indemnity claims per Workers' Compensation Claims Administrator and 300 open medical only and ' future medical claims per medical Claims Administrator. Theses caseloads arc monitored monthly and workloads are shifted as appropriate. 3. Workers' Compensation Claim Administrators (examiners) handle an average of 150 open indemnity files. Medical only claims and claims where future medical treatment has been awarded and there are no ongoing indemnity payments are not handled by the Workers' Compensation Claim Administrator. ' 4. Colen and Lee have divided the claims department into "Units". Each unit has a Unit Manager that does not cagy a claims caseload. The manager is responsible to supervise 5-6 Workers' Compensation Claim Administrators, 2 Medical Claim ' Administrators, and clerical support staff. The manager reviews all incoming mail, approves new claims set ups, all claim delays or denials, approves reserve changes, monitors subrogation and excess insurance claims, and is responsible for ' the training and the quality control within that unit. hi addition, the Director of Operations is responsible for the perl'ormance of the claims department. The Director works with the Managers in implementing procedures, audits files, t monitors workloads, identifies training issues and assists the managers in responding to specific client requests. 5. We do not have a formal program for in-house file reviews or round tables. Each manager schedules specific office hours with each member of their staff to review specific claims issues. If there are issues that require additional expertise, the Manager will involve other Unit Managers or the Director of Operations to bring the issue to resolution. In addition, there are weekly meetings with all Unit Managers where claims questions and issues are discussed. 6. Upon receipt of all new claims, both the Administrator and the Unit Manager ' review the claim for subrogation potential. They look for vehicle accidents, all injuries occurring off city premises, any accident caused by a non-city employee or any accident caused by machinery or equipment which may be owned or 1 1 3 1 maintained by someone other than the City. If subrogation is a possibility, we then contact the City to obtain any police, supervisors or internal investigation reports that may exist. Once we determine that a subrogation opportunity exists, we contact the City to obtain authorization to proceed with subrogation activities. If the value of the loss is small, we will attempt to recovery the claims costs. If ' the loss is significant, we will contact the City about filing in Small Claims Court or utilizing an attorney to File a Complaint. If the injured employee is pursuing legal action on their own, we will discuss the options of filing a lien or joining ' that complaint. We will not proceed without City approval. 7. We believe in reserving for the ultimate expected claim cost. As soon as we can identify that the claim may involve permanent disability, vocational rehabilitation, of lifetime medical expenditures, we estimate those costs and set the reserves as appropriate. Reserves are evaluated at each diary date, or upon receipt of any medical or legal correspondence. The file notes are documented to reflect that the reserves have been reviewed and any reason to change the reserves are fully explained. The unit manager approves reserve changes. If requested, the client can be.notified when a significant reserve change is being made. We do not believe in "stair-stepping"reserves. We believe it is important for our clients to have an accurate assessment of their financial exposure at the earliest possible ' time. 8. We maintain a complete history of the City's excess insurance coverage. It is our responsibility to know the reporting requirements for each carrier involved. The unit manager is responsible for making sure that infonuation is current and accurate, as well as ensuring that the claim administrator is aware of the reporting requirements. Twice a year the manager does a complete review of all claims that ' may require reporting to the excess carrier. The manager approves all initial and subsequent reports to the carrier. Once a claim is eligible for reimbursement from the excess carrier, a schedule is established for requesting periodic reimbursement ' From the carrier. This schedule is determined by current and ongoing case expenditures. 9. We normally do not have claim settlement authority from our clients. Therefore, we evaluate each case and develop a recommendation concerning the amount and type of any file settlement and then present the options to the City. If the settlement is to be a Compromise and Release, we make sure that all know issues and claims with the City are resolved. If we are concluding the claim with a Stipulated Findings and Award, we make sure the level of permanent disability is appropriate for the injury. We also make sure that any work restrictions are in line with the employee's job and that any job modifications or vocational rehabilitation issues have been addressed. The detennmation to settle a claim verses taking a claim to trial may involve other City issues that our staff may not ' be aware o F, therefore, the decision to try or settle a claim will be discussed with the appropriate people within the City. ]0. Each employer has different standards for those claims that they want accepted and those claims they want delayed and investigated. The unit manager and the claim administrator will meet with the City and establish a protocol for claims to be investigated. No claim will be delayed and investigated without the City's 1 4 authorization. If the City has an investigator they utilize, we will work with that investigator. If the City would like us to recommend and select the investigator, I we can do so. We will also work with the City on coordinating any employee, supervisor, or witness statements through the appropriate personnel at the City. The City can choose to coordinate those statements at work or we can arrange to ' contact those employees away from the job. The City will be able to make that decision. 11. Colen and Lee can accomplish most investigations internally, either by talking to the injured worker, talking with the supervisor or obtaining internal investigation reports from the City. There are a small number of claims that require the use of I outside investigators to obtain signed statements, take photographs obtain records or complete a court search. Those investigations will be assigned to an outside investigator and the charges will be billed to the file as all allocated loss expense. I We can either utilize an investigator with which the City has an established relationship, or we can select an investigator from our panel of investigators. Under no circumstances will we assign an investigator without first obtaining I approval from the City. 12. Our obligation is to resolve the claim at the lowest overall cost. Towards that goal, an AME is often a useful tool in avoiding delays and multiple medical/legal I examinations. If the claim administrator believes that the assessment of permanent disability or the need for ongoing medical treatment established by the treating physician, it may be appropriate to approach the injured worker's attorney I about utilization of an AME, rather that incur the cost of an applicant's and defense QME. If there is a dispute concerning the industrial causation of an injury, often times an AME is a more cost effective way to resolve the dispute. I Each claim has to be evaluated on its own merits concerning the use of an AME_ If the claim is a denied claim and the basis of the denial is not medical, the value of an AME may be limited. I 13. All Employer's Reports and DWC — I's, regardless of how they are received are given to the Unit Manager for review. If it is a medical only claim, the form is given to the medical claim administrator. If it is a lost time claim, a claim where I lost time can't be determined, or a claim that looks like it may require delay and investigation, it is given to the workers' compensation administrator. The claim handler then reviews the report makes the appropriate telephone calls to the I employer, the doctor or the injured worker. Once all the information is gathered, the claim handler then enters the claim into the computer system, sets reserves, determines any benefits that may be due and develops a plan of action. The claim I is then returned to the unit manager in order to approve the reserves, the plan of action, and the payment of benefits and make any additional file reconunendations. This is to be accomplished within one business day from the I receipt of the employers report. 14. Our experience has taught us that certain types of claims may benefit need to be delayed and further investigation completed. Those claim that are typically I delayed are: claims reported late and un-witnessed, continuous trauma claims, claims involving employees with performance issues, claims for harassment and claims where the complaints seem out of line with the injury suffered. In some i I 5 cases, the City may not want to delay and investigate these claims. Often times, there are other issues at the City that make it appropriate to accept the claim ' without delay or investigation. For this reason, no claim will be delayed and no investigation will be undertaken without first discussing the claim and obtaining authorization from the City. t 15. The claim administrator is required to keep every open file on diary for review and action. On new and active claims the diary may be every 2-4 weeks in order to pay benefits or to obtain information concerning medical treatment. If no ' disability benefits are currently being provided, but active medical treatment continues, the diary will be 30 days. For claims no longer receiving active ' medical treatment,but the worker is not yet permanent and stationary or if the rite is litigated and the level of claim activity is dependent on upcoming medical appointments, depositions or hearing dates, the diary may be up to 90 days. ' Claims open for future medical care only may have a diary period up to 6 months, depending on the level of medical care being provided. The claim administrator is responsible for reviewing the file at each diary date or when a new piece of ' medical or legal correspondence is received. At that time the file notes in the computer system must be updated. 16. The proprietary software utilized by Colen and Lee captures and tracks all data ' necessary to meet all record-keeping requirements for self-insurance clangs administration. 17. The claim administrator contacts all injured workers, who arc missing lime from ' work, in 24 hours from receipt of the claim, unless an attorney represents the employee. At that time, they are given the basic information about workers' compensation, the benefits are explained and they are given the naive and telephone number of the person handling their claim. This is followed up with a claim acceptance letter, and any benefit notice and information necessary for compliance with state statutes. In most cases, follow up calls will be made at the ' time additional benefit checks are mailed. On severe cases involving hospitalization or complex medical issues; initial phone contact will be more frequent until the medical condition stabilizes. The number and frequency of telephone contact will very on the type of claim, length of disability and whether the claim is subject to additional investigation. We currently do not provide an 800-telephone number for the use of injured workers. ' 18. An aggressive modified duty program is effective in controlling claim costs. We recommend that all initial treating medical facilities utilized by the City be made aware of the modified duty available through the City. This can be done through ' a series of meeting involving the medical facility, the claim administrator and the City. Those facilities regularly used by the City for treatment of workers' compensation claims should be provided copies of job descriptions and physical requirements for the City's jobs. In addition, our claim administrators are trained to ask the medical facility about modified work when calling for disability information. When a referral is made to a medical specialist, the claim administrator will call the doctor prior to the exam and explain the City's modified duty program. Uthe doctor indicates the worker is temporarily disabled, the claim administrator will request specific work restrictions and clarification ' 6 1 1 concerning the activities with in the worker's restrictions. Once the extent and duration of the restrictions are known, the claim administrator will contact the ' City and together they will determine if the City can accommodate the restrictions. The City can then contact the injured worker and let them know they have work available with in the restrictions and when they should report to work. ' If the City cannot accommodate the restrictions, the claim administrator will continue to stay in contact with the doctor to monitor any change in the restrictions. 19. Enclosed are copies of the statutory forms, pamphlets and posters that will be supplied to the City at no additional charge. 20. We will work with the City to establish protocols for providing claim status ' information. As part of our service, the City will have electronic access to our claims data and files notes. That will allow the City to obtain the status of any claim 24 hours a day. We will also agree to file reviews on a quarterly basis to be done at the City or in our office. We suggest that the first file review be scheduled 90 days after the takeover of the files. This allows us to convert the t electronic data to our system, complete the review of all open files and develop recommendations to bring the claim to resolution. After the initial review, file reviews can be scheduled to review litigated files, files with a high dollar value or ' a specific group of files of concern to the City. 21. We do have the ability to submission of the Employer's First Report electronically. This is available at no additional charge. 22. If the City has vocational rehabilitation vendors who are familiar with the City and the City feels the work has been good, we will continue to utilize those vendors, whenever possible. If the City has been unhappy with the vendors being ' used, we can reconnnend several vendors that work in the Palm Springs area. All vocational rehabilitations services are contracted out. Colen and Lee do not receive any commissions or other compensation from any vendors we use. ' 23. Colen and Lee are used to establishing a"partnership"with our clients. As such, we are used to a high level of involvement from the employer. Employer involvement makes it easier to obtain the information necessary to handle the ' claims and obtain the best program results. Some employers do provide us with more decision-making authority and some level of settlement authority. Some employers do not require claims status reports or file reviews and rely on our ' expertise in the administration of the program. We can operate effectively under either program model, as long as the rules are established and communicated at the inception of the program. We do believe the most successful programs are t those where the employer maintains a high level of involvement in the program. 24. We can provide a sample copy of a claims file if you decide to consider us to be your administrator. Our claims files are organized into different sections. We maintain separate sections for: Medical Reports, Legal Correspondence, Vocational Rehabilitation, Subrogation, and Excess Insurance Correspondence. On the inside left cover of our files, we keep all payment and reserve information. On the inside right cover, we keep the employers report, employee claim for, supervisors report and any general File correspondence. 7 1 A Litigation Management: ' 1. Our level of involvement on litigated files depends on the preference of our clients. Some clients have as refer a file to an attorney as soon as Application for Adjudication of claim is received. Other clients prefer that we handle the file up ' until it is necessary for a deposition or trial. We believe that on those cases where the only issue is the extent of permanent disability, the claim administrator can handle the file to conclusion. If the claim involves a disputed injury,multiple legal issues, requires a deposition or will result in a trial, it is best to involve an attorney early in the proceedings. Regardless of whether an attorney is assigned ' to the file, the claim administrator maintains responsibility for all file issues and is responsible for all "non-legal" activities on the file. On claims involving subrogation, involvement of an attorney depends on the size of the potential recovery and whether the City will proceed on a"lien"basis or whether it needs ' to initiate legal proceedings against the third party. No attorney will be assigned to the claim with first obtaining client approval. ' 2. We currently have no maximum nunrber of litigated files the administrator handles in house. For those clients that allow us to handle litigate claims in- house, we have historically handled about 25% of the legal claims without assigning them to defense legal counsel. 3. Our claim administrators are familiar with the procedures at the WCAB. On those claims not assigned to legal counsel, the administrator will appear at conferences and hearings. If the case will require a trial, it will then be assigned to an attorney. On occasion, the claim administrator may be required to appear and testify at the WCAB, this will be done at no additional fee. ' 4. On claims where the issue involves more that the extent of permanent disability, we believe the City's interests are best served by retaining outside legal counsel. Claims involving disputed industrial injuries or body parts, denied claims, claims ' of mental stress brought on by harassment or personnel actions, claims of discrimination and allegations of serious and will ful misconduct should all be referred to outside counsel immediately. Any claim where the City is involved in ' civil litigation, as well as a workers' compensation claim, should be immediately referred to outside counsel because of the coordination necessary to obtain a "global settlement" of all issues. In general, claims that will require a deposition, or involve discovery issues that are subject to statutory time limitations, should be assigned to outside legal counsel as soon as possible. 5. Handling of lien claims depends on a number o f issues, including the amount of the lien, the status of the claim and the other issues to be resolved. In many cases, the claim administrator is able to negotiate resolution of a lien without the aide of legal counsel. This typically occurs on claims that were initially delayed or ' denied and later became an accepted claim. The administrator can usually resolve medical liens for treatment during the period of dispute. Claims that usually involve an attorney are those claims where injury is in dispute and the claim is ' settled at the WCAB. Many times the lien claimants are present at court and the attorney will attempt to resolve the liens at that time. There are rare cases when the lien claimant will not agree settle the lien and will proceed to trial after the rest 1 R 1 of the claim has been settled. Appearance by outside counsel may be necessary on those claims. 6. The best way to manage the quality of the work is to utilize only attorneys with whom you have a proven track record of performance and quality work The claim administrator must then make sure that only work that cannot be done ' internally is assigned to the attorney. As an example, once an attorney has identified the records to be obtained, the claim administrator should obtain those records, not the attorney. Except in special circumstances, the administrator ' should set all medical exams. The administrator must authorize all activities, such as taking depositions, meeting with witnesses, etc. The administrator, not the attorney, should assign any investigation. The proper selection of an attorney and the administrator maintaining total control of the file will ensure that the City receives the best legal representation at a reasonable cost. 7. If the City were satisfied with the present legal representation, then we would be comfortable continuing working with those firms. Should the City be interested in a change in their legal representation, we recommend the following fans that ' we have found to provide excellent legal representation before the Workers' Compensation Appeals Board in Riverside or San Bernardino: Law Offices of Mary J. Orban, Redlands, California ' Wilson, Pesota, and Pichardo, Palm Desert, California Law Offices of John B. Tharp, Santa Ana, California S. We do not provide bearing representatives. ' E. Cost Control: 1. We utilize the following fines for Investigation: Wilm's Investigative Services, Tom Romero Investigations, Paul Chance Investigations, Henry Barker Investigations, Krout & Schneider Investigations; for Subrogation: Law Offices of ' John B. Tharp, Law Offices of Jolm Larson, Law Offices of Glen Larson; for Sub- Rosa: Winn's Investigative Services, Tom Romero Investigations, Paul Chance Investigations, Henry Barker Investigations, Krout & Schneider Investigations; ' for Voc Rehab: Cannon Vocational Services, Rehab West. Return to Work (RTW), MCS Rehabilitation Services. 2. We assign the services referenced in E-1 to outside contractors only with the prior approval of the City. We do not receive any commissions for the assignment of claims to the above referenced companies- 3- The charge for investigators and sub-rosa services ranges from $50-$60 per hour ' plus costs. Subrogation attorneys charge an average of S 125.00 per hour. The Law Office of John Larson charges his fee based on a contingency. Vocational Rehabilitation charges are set by the State. 4. We have saved clients costs by handling some subrogation claims without the assistance of legal.counsel. We save clients money by photocopying files for legal referral at our cost and not assigning the job to a photocopy owned by us. With regard to fraud, we have submitted three claims to the Department of hisurance and District Attorney. One claimant has been arrested and is currently waiting for his case to come to trial. Two other cases have been reviewed but,to 1 9 idate, have not been prosecuted. California legislation (specifically the Presley Bill) mandates that employers and insurance companies investigate and prosecute I fraud. Unfortunately, the law does not fully or clearly explain how to proceed or what steps to take in seckmg legitimate, lawful assistance. The burden of proving fraud is on the employer, insurance company/third party administrator. The I California Insurance Code, which defines Workers' Compensation fraud, discusses material representation of facts (provable misrepresentation). Fraud investigation is performed using a multi-tiered approach; by the Claims I Administrator, Unit Manager, City, defense attorney, outside investigators to disprove claims made by claimants, physicians or other parties to the workers' I compensation claim. There are many types of fraud situations in the Workers' Compensation. The most prevalent arc employee and medical provider fraud. Frequently, information provided by the employer is the bans of a fraud I investigation. Some employee fraud red flags are: A short period employment, an un-witnessed injury, an injury that is not reported timely, a good faith personnel action, an internal affairs investigation, an involvement in off work sporting activities, faking or obvious exaggeration, a past history of filing claims, an employee malcontent, a history of prior claims filed with the same or other employers, multiple family members receiving compensation benefits. Fraud I claims are identified by thorough investigation of the claim. Investigation can be performed in a number of ways. The Claims Administrator may perform a check of the Index System for prior claim flhng(s); obtain employee health records, I subpoena prior medical and employment records, if available. Outside investigation would consist of an assets check, activities check, surveillance films, deposition or statements made by the inj erred employee, co-employcrs, spouse, I ex-spouse or neighbors. If medical provider fraud is uncovered, for example, billing to a group health carrier, auto carrier and a workers' compensation administrator,with payment being received from each, we would submit this I information to the Department of Insurance, the District Attorney, the Industrial Medical Council and the appropriate licensing agency of the medical provider, Suspected fraud claims are turned over to the Department of Insurance and the I District Attorney for prosecution but will only be done with the prior consent of the City. 5. We do not offer loss control services. IF. Managed Care: I 1. We offer managed care/medical cost-containment programs. We have 4 PPO networks. We offer case management services as well as utilization review and bill review services. Colen tic Lee owns MedReview, Inc., a bill review I company, which is a wholly owned subsidiary. 2. The fees for bill review are as follows: OMFS = 14% of savings—if no savings, no charge, PPO =24% of savings—if no savings, no charge. The fee I For utilization review is $90.00. The charge For Nurse Case Management is $90.00 per hour. I I 10 ' 3. It is our understanding that the City permits employees to treat with their own doctor from the inception of a claim. If the City desires to maintain this format, we would adhere to this. If are chosen as the City's administrator, we would recommend a panel of physicians primarily located in the Palm Springs area. We recommend physicians such as Dr. Kalfus or medical facilities such as Eisenhower Medical Center. Medical bills that are challenged would be submitted to Physicians Authorization Review or other such service for review. 4. Prescriptions, brand name and generic,would be filled through MSC for a discount. MSC guarantees that generic prescriptions would be filled at 20% below fee schedule. Medical costs contaim-nent for durable goods, etc, would be performed to ensure that medical durable goods and supplies are provided at the lowest possible cost. We contract with medical facilities, MRi/CT scan companies to provide discounts below the Official Medical Fee Schedule (OMFS). S. Severe cases and cases where there is a lengthy period of lost time would ' benefit most from medical case management (nurse case management). A claims examiner should medical case management on each and every case that is assigned to them. A case manager, if desired, would attend medical ' evaluations, discuss the medical treatment plan of the injured employee and provide periodic reports about the employee's progress. ' G. Pavrnents/Fundine: 1. We would issue an adjustment metro advising the City to adjust its records reflecting the amount of temporary disability or full-salary due Pursuant to Labor Code Section 4850. When to start or stop the adjustment memo would be accomplished through close communication with the ' City. We have used this mechanism successfully with our City clientele for many years. If the City desired we could issue a check to the City or employee. 2. We recommend that the City set up a trust account for its workers' compensation liabilities. The account could be an impress account. The account could be a zero balance account, a fixed or pegged balance account. We do not set up accounts and co-mingle funds to draw interest off of the client's funds. H. Risk Management information Systems: I. We utilize a proprietary data processing system developed in-house. Gary ' Lee, co-owner and co-founder of the firm developed the system. He has over 27 years ofprogramming/claims experience. 2. Computer activities are backed up onto a tape and arc stored in a fire proof ' safe. 3. Please see Appendix E for sample reports. Reports arc produced monthly. Information for ad hoc reports can be provided to clients in a printed t it 1 format or via email in Excel, Lotus, ASCII or DBF format. We would provide the following reports as part of out base service fee: Detail Report ' (Monthly) - A list of all claims segregated by policy year. Excess insurers usually require this type of report. For each claim, it shows the policy year, case number(we assign), claimant's name, cause of loss description, ' date of loss. allocation code (yours), status (i.e. litigated), losses paid-to- date, expenses paid-to-date, reserves, and total incurred- Allocation Report (Quarterly) - A list of all claims segregated by allocation code. This report ' shows the same information as above. You can distribute it to your department heads and/or use it to allocate self-insurance costs to their budgets. This will often motivate them to become more interested in your risk management goals. Summary Report (Monthly) - A summary for each year by type of loss. This report is useful when shopping for excess t insurance. Check Register (Monthly) - a list of all transactions made during the month. This report is useful to the City Finance Department in reconciling the trust account- Tt shows the check number, check date, amount, payee, type of payment (i-e- attorney fees), policy year, case number, allocationi code and claimant. Claims Opened During the_Month (Monthly') - An alphabetical listing. Claims Closed During the Month ' (Mostthly) - An alphabetical listing. In addition, the City could purchase specialized reports. which would be charged at $125.00 per hour for programuung costs. Furthermore, we have the capability ofprovidinb data on mabnetic rn:dsa for direct use in spreadsheet, database and word processing programs. �. All claim files, eleciron:c data processing/management information system ' records would be the property of the City. 5, The City could access real time date 2-1- hours a day through moda1n. File notes, payment ledgers, check the City could print rep5ters- ' 6. Upon being chosen as the third party »dministrator,we would irnutediately contact the Citv's lnfi)inmation 'Tcch-nology department to obtain a�i advance taps so thai we can begin the conversion process to our compu.cr ' format. We anticipate that the total conversion will be finished between 6 — S wceks from the date of the data transfer- 7. On a monthly basis we could provide the Cily's Infornarion Technology ' department data in an Excel. Lotus, DBF or other format for uploading to the City's I,MIS Sysle:n- 1._ImDlementation: 1. Upon ei:ecutinb a contract For ciaims administration with the Cit,, we t would immediatcly coordinate with the City's Human Resources/Risk Management aepartrnent in notifying all involved in the self-insurance program of the change from ism-house claims administration tc a third party ' claims administrator. 'iVe would notify, in writing, all involved in the orobram of(lie change in claims adnnimstration. So nothing falls through the cracks. we would meet with the City's Human Resources department 1 ' T2 ' to review files prior to the actual takeover of claims to determine what claims need immediate action and to make certain that benefit payments to ' employees continues with no intetxuption. 2. We would require computerized data from the City's Information Technology deparUnent as well as the assistance from City staff referenced ' in T-1. J. Other: ' 1. Our clients measure our performance in raany ways. One way is through ' review of the monthly loss experience reports. Another method is through client meetings. The level of complaints received(or lack thereof) is a measure to the client hour well we are getting the job done. We provide ' medical cost reduction information that shows the amount of money we are saving each client through medical bill review and medical case management. Low staff turnover is an indication of how well we are ' doing. Feedback from our client s employee is a mcasttre of how well we are doing. 2. There is no cu»-etrt or pending ir_gal action against our company- 3 Please sec Appendix D for 2 client contracts. We recommend and prefer that our standard service agreement be used. ' K. Cost Proposal: 1. Our fee for administering the City's program is based on the proposal stating there are 137 open files. If it is determined there are more or less open files, our fee would be adjusted appropnately on a percentage basis. The fees quoted below are good for 90 days from the date of this proposal. ' Our fee for claims administration would be as follows: Year 1 Fee =$110,970.00 or S 9,247,50 per month Year 2 Fee= $114,300,00 or$ 9,525.00 per month ' Year 3 Fee= S L17,726.00 or$ 9.810.50 per month Year 4 Fee— $121,248.00 nr $10,104.00 per month Ycar 5 L ee= $124,884.00 or $10,407.00 per month There would be a one-time data conversion fee of$7.000.00. 2. The cost o1 TPA services can be reduced by reducing the number of incurred and perdiT+g claims. This may be achieved by active safety ' training program to reduce the murber aM severity of injuries. 1 1 ' 1� APPENDIX A ORGANIZATIONAL CHART MANAGEMENT STRUCTURE ' PRESICENT VICE PRESIDENT Receptionist Admimstrative ' Assistant LABILTY ' Undt M niager U�M nOgoP UORnit M Manager DORM nog P UORM nogeP i TYPICAL CLAIMS UNIT ' Unrc Manager Medical Claims Clams Claims Claims Claims Medical Claims Administrator Administrator Administrator Adminlstrator Administrator Administrator ' Clerical Clerical Assistant Assistant ' File Clerk 1 14 i 1 1 iAPPENDIX B STAFF RESUMES i i 1 i i 1 i 1 i 1 i i 1 1 1 1 15 1 1 Calen&Lee Inc Phono(909)861.0$16 1470 South Valley Viste Drive Fax(909)860-3995 Sulfa 230 E-mail: Diamond Bar CA 01765 BMIIIer@ColenandLee.com 1 Bruce Miller 1 Professional 2000 -Present Colen & Lee, Inc., Diamond Bar, California 1 Experience Director of operations Primarily responsible for internal operations of the Workers' Compensation and General Liability Operations. Manages the Workers' 1 Compensation and General Liability Unit Managers. Randomly audits Claims Administrators and Unit Managers work. Responsible for staff development and training. 1 1999-1999 Colen & Lee, Inc., Diamond Bar, California 1 Senior Workers'Compensation Claims Administrator • Performing broad range of claims services including, communication with injured workers, medical providers and coordination to ensure 1 effective and timely delivery of benefits, investigation of questionable claims, timely employer/attorney interface,when required, representation at various WCAB and Rehabilitation Unit Conferences. 1 1980 -1998 Cambridge Integrated, Pasadena, California Director of Operations • Primarily responsible for internal operations of the Workers' 1 Compensation and General Liability Operations. Manages the Workers' Compensation and General Liability Unit Managers. Randomly audits Claims Administrators and Unit Managers work. Responsible for staff 1 development and training. • Completed Workers' Compensation certification programs from the IEA 1 Education for the WCCA,which include basic and advanced workers'compensation, permanent disability rating and medical management. • Graduated from Arizona State University with a Bachelor's Degree in Business Administration. 1 State Certified Workers'Compensation Administrator. 1 References Will be provided upon request. 1 1 1 1 1 i Colen&Lae,Inc. Phone(909)861-0516 1 d70 South Valley Vista Cave Fax(909)980-3995 Suite p30 r-mail Diamond Bar,CA 91765 AndreskiCColonandLee com i i Jill-Marie Andreski 1 iProfessional 1998 - Present Colen & Lee, Inc., Diamond Bar, California Experience Workers'Compensation Unit Manager 10 Manage a Workers' Compensation unit consisting of 4-5 Claims Administrators including various support staff. Primarily responsible for quality control and client relations. Other responsibilities include recruiting,training, supervising and evaluating personnel. i 1990-1998 Colen 8 Lee, Inc., Diamond Bar, California 1 Workers'Compensation Claims Administrator Performing broad range of claims services including, communication with injured workers, medical providers and coordination to ensure i effective and timely delivery of benefits, investigation of questionable claims, timely employer/attorney interface, when required, representation at various WCAB and Rehabilitation Unit Conferences. 1 1988 -1990 Colen & Lee, Inc. , Diamond gar, California Workers'Compensation Claims Assistant 1 • Performing a number of tasks to assist the Workers' Compensation Administrator. Those services include: administering medical only claims, monitoring medical treatment on lifetime medical awards, verification of disability status, arranging medical examinations and new claim set ups. i • 1994 Completed IEA Courses to obtain the Workers' Compensation Education Claims Professional designation(WCCP). i 1993 Certificate in Supervisory Management, Insurance Institute of America. • 1989 Completed Workers' Compensation certification programs from the i [EA for the WCCA, which included basic and advanced workers' compensation, permanent disability rating and medical management. • 1990 State Certified Workers'Compensation Administrator. 1 References Will be provided upon request. 1 1 1 APPENDIX C WORKERS' COMPENSATION ' CLIENT LIST CITY OF ARCADIA 240 West Huntington Drive Since August 1, 1985 Arcadia, California 91006 Dave Bell ' (626) 574-5400 Assistant Personnel Director CITY OF BALDWIN PARK 14403 East Pacific Avenue Since September 1, 1982 Baldwin Park, California 91706 Michelle Alves (626) 960-4011 Personnel Technician ' CITY OF BELL 6330 Pine Street Since March 1, 1996 Bell, California 90201 Robert Rizzo (323) 588-6211 City Manager ' CITY OF BEVERLY HILLS 455 North Rexford Drive Since October 1 , 1982 ' Beverly Hills, California 90210 David Holmquist (310) 285-1065 Risk Manager CITY OF BREA 1 Civic Center Circle September 1, 2002 Brea, California 92821 Mary Tebbetts ' (714) 671-4486 Risk Management Analyst CITY OF BUENA PARK ' 6650 Beach Boulevard August 1 , 1999 Buena Park, California 9062 David Serrano (714) 562-3520 Risk Manager ' CITY OF CULVER CITY ' 9770 Culver Boulevard Since July 1, 1985 Culver City, California 90230 Mike Hodge (310) 202-5742 Risk Manager ' CITY OF CYPRESS 5275 Orange Avenue Since August 1, 2002 ' Cypress, California 90230 Kelly Barker (714) 229-6687 Personnel Manager ' 18 CITY OF DOWNEY 11111 Brookshire Avenue Since September 1, 1982 Downey, California 90241 Christopher Birch (562) 869-7331 Personnel Director CITY OF DESERT HOT SPRINGS 65950 Pierson Boulevard Since September 1 , 1999 Desert Hot Springs, California 92240 Roy Hill (760) 329-6411 Personnel Director CITY OF EL MONTE 11133 Valley Boulevard Since July 1, 1990 El Monte, California 90731 Eric Berry (626) 580-2040 Personnel Manager CITY OF FULLERTON 303 West Commonwealth Avenue July 1, 2001 Fullerton, California 92626 Pamela Mackie (714) 741-5008 Risk Management Analyst CITY OF GARDEN GROVE 11222 Acacia Parkway Since October 1, 1988 Garden Grove, California 92642 Steve Larson (714) 741-5008 Director of Personnel ' CITY OF MONTCLAIR 6111 Benito Street Since November 1, 1987 Montclair, California 91763 Christine Hayes (909) 626-8571 Personnel Officer ' CITY OF MONTEBELLO 1600 Beverly Boulevard Since July 1, 1994 Montebello, California 90640 Ron Chan (323) 887-1434 Risk Manager CITY OF MORENO VALLEY 14177 Frederick Street Since September 1, 1994 Moreno Valley, California 92552 Gary Baugh (909) 243-3044 Assistant City Manager CITY OF POMONA 505 South Garey Avenue Since January 1, 1985 Pomona, California 91769 Julie Theirl (909) 620-2296 Risk Manager 19 CITY OF REDONDO BEACH 415 Diamond Street Since April 1, 1983 Redondo Beach, California 90277 Jill Buchholz (310) 372-1171 Risk Manager ' CITY OF SAN MARINO 2200 Huntington Drive Since July 1 , 1992 San Marino, California 91108 Rob Wishner (626) 300-0700 Acting City Manager CITY OF UPLAND 415 North Euclid Avenue Since August 1, 2000 Upland, California 91786 Jane Fleenor (909) 931-4174 Director of Personnel/Risk Management CITY OF VERNON ' 4305 Santa Fe Avenue Since October 1, 1986 Vernon, California 90058 Joan Francone (213) 583-8811 Risk Manager COMMUNITY DEVELOPMENT COMMISSION OF LOS ANGELES COUNTY 2 Coral Circle Since November 1, 1986 Monterey Park, California 91755 Becky Yee (323) 890-7014 Risk Manager COUNTY SANITATION DISTRICTS OF LOS ANGELES COUNTY 1955 South Workman Mill Road Since July 1, 1999 Whittier, California 90601 Kathe Vasquez (562) 699-7411 Workers' Compensation Analyst PUBLIC ENTITY RISK MANAGEMENT AUTHORITY (PERMA) 77-670 Springfield Lane Since September 1, 1994 Palm Desert, California 92211 Scott Ellerbrock (760) 360-4966 General Manager TRI-CITY MENTAL HEALTH CENTER Since July 1, 2001 3201 Temple Avenue Jeffry Allred Pomona, California 91768 Deputy Executive Director (909) 594-5400 WHITTIER UNION HIGH SCHOOL DISTRICT 9401 South Painter Avenue Since September 15, 1986 Whittier, California 90605 Bonnie Schulz (562) 698-8121 Administrative Secretary ! ' 20 APPENDIX D SAMPLE WORKERS' COMPENSATION SELF-INSURANCE SERVICE. AGREEMENT ' THIS AGREEMENT is entered into this day of 2003 between the ' CITY OF PALM SPRINGS, hereinafter referred to as the "City" and COZEN & LEE, INC., a California Corporation, hereinafter referred to as the "Administrator." WHEREAS, the City has undertaken to self-insure its Workers' Compensation obligation; and ' WHEREAS, the Administrator is engaged in the business of administering Workers' Compensation self-insurance programs; and WHEREAS, the City desires to retain the services of the Administrator to administer a Workers' Compensation self-insurance program, hereinafter referred to as the "Program," for the City; ' NOW, THEREFORE, the City hereby retains the services of the Administrator and the Administrator agrees to perform service for the City under the terms and conditions of this Agreement. 1. TERM: This Agreement shall become effective as of and shall continue in effect until terminated by the cancellation provision set forth herein. 2. PERIODIC MEETINGS: The Administrator shall meet with City staff periodically to: ' A. Assist the City in developing internal procedures. ' 21 1 ' B. Provide orientation and training to City personnel involved in the ' administration of the Program. C. Discuss specific claims and general trends in the Program. ' 3. ADVISORY SERVICES: The Administrator shall provide written advisory bulletins to inform the City of the adoption, amendment or repeal of all 1 statutes, rules and regulation, which directly affect the Program. ' 4. REQUIRED FORMS: The Administrator shall provide the City with all forms required by the State in connection with the Program. 1 5. COMPLIANCE WITH LAW: The Administrator shall administer the Program in full compliance with all laws, rules and regulations governing Workers' Compensation and self-insurance. 6. CLAIMS ADMINISTRATION: The Administrator shall have the ' authority and responsibility to provide claims administration services, which ' include: A. Entering claim information on a log and establishing a claim file upon receipt of an injury report. ' B. Setting and updating reserves- C. Arranging for investigation. ' D. Determining compensability. ' 22 1 E. Preparing and issuing benefit notices and pamphlets. ' F. Arranging for medical treatment from specialists, as necessary. G. Initiating and maintaining contact with employees or attorneys. H. Monitoring disability status by reviewing medical reports and ' calling doctors for updates. ' I. Auditing and paying medical bills. J. Paying mileage reimbursement to employees. ' K. Paying temporary disability compensation when appropriate to do ' so or advising the City of the need to adjust payroll records when salary continuation is applicable. L. Arranging medical exams in conformance with State law to ' determine whether an employee's medical condition is permanent and stationary and what, if any, permanent disability exists. M. Paying permanent disability compensation in accordance with the law. N. Arranging for attorney representation of the City whenever the need arises, selecting attorneys from a list approved by the City. 0. Monitoring attorneys and assisting them in preparing cases. P. Auditing and paying legal expenses. 1 Q. Arranging for vocational rehabilitation services when appropriate. R. Monitoring vocational rehabilitation consultants and assisting them as necessary. ' S. Auditing and paying vocational rehabilitation expenses. ' 23 1 T. Attending all hearings that are required by law. ' U. Preparing and issuing vocational rehabilitation notices. V. Preparing and issuing permanent disability compensation notices. ' W. Pursuing subrogation when there is a viable third party. X. Notifying the City's excess insurers of all claims, which exceed or may exceed the self-insurance retention, maintaining a liaison ' between the City and its excess insurers on matters affecting the ' handling of such claims and arranging for reimbursement to the ' City of losses in excess of its self-insurance retention. Y. Obtaining settlement authority and negotiating settlement on appropriate claims. Z. Closing claim files when appropriate to do so. ' 7. OBLIGATIONS OF EMPLOYER: The City shall: ' A. Submit all reports of work injury to the Administrator within one business day of the City's knowledge of the injury. ' B. Respond to Administrator requests for information and authority ' within five days of such requests. C. Provide information that is accurate and is in a form specified by the Administrator. D. Grant settlement authority to the Administrator in advance of vocational rehabilitation and legal hearings or be available by ' phone or in person during those hearings. 1 ' 24 8. CHECKING ACCOUNT: The City and Administrator agree that: A. The City shall establish a checking account from which all Workers' Compensation benefits and expenses are to be paid. B. The Administrator shall prepare checks and issue those checks ' directly to payees without delay. C. The Administrator shall sign checks manually or with a facsimile ' signature. D. The Administrator shall secure checks in a locked room accessible to a limited number of personnel. ' E. The City shall maintain an adequate balance in the checking ' account to meet all Workers' Compensation obligations without delay. ' F. The checking account may be used to pay civil penalties in which case the Administrator shall reimburse the City within fifteen days for any amount of the penalty, which the Administrator caused. 1 ' 9. ELECTRONIC DATA PROCESSING: The Administrator shall provide the City with electronic data processing services that will allow for the production of loss experience and transaction reports within ten days following the close of each calendar month. The Administrator shall either print these reports or shall provide the City with electronic media containing the data needed to print such ' reports. 1 ' 25 ' 10. REGULATORY REPORTING: The Administrator shall prepare all reports required by State regulatory agencies in connection with the Program, ' including the Self-Insurer's Annual Report required by the Department of Self- Insurance Plans. ' 11. RECORDS: The Administrator shall establish and maintain claim ' files, claim logs, transaction documents and all other records associated with the 1 Program. These records shall be the property of the City and shall be available, on five (5) days notice, for review or transfer to another custodian. Unless this ' Agreement is canceled, closed files shall be stored by the Administrator for five (5) years and shall thereafter become the responsibility of the City. Upon cancellation of this Agreement, the City shall be responsible for maintaining and ' storing all records. The Administrator shall not dispose of or destroy these records without the prior, written authorization of the City. 12. CONSIDERATION: The City shall pay the Administrator $ per month for services rendered under this Agreement. Once a year after the first year of this Agreement, the Administrator may increase or decrease the service 1 fee by giving written notice of the change to the City at least thirty days prior to the change. 26 13. ALLOCATED EXPENSES: The City shall pay for field investigation, defense attorneys, legal costs, remote photocopy, engineering experts, accident reconstruction experts, process servers, messenger service, court reporters, vocational rehabilitation consultants, structured settlement consultants and translators. ' 14. PENALTIES: The Administrator shall be responsible for paying or appealing penalties that are caused by the Administrator. The Administrator shall not be responsible for penalties that are caused by the City or any third parties. 1 15. INDEMNIFICATION: The Administrator shall indemnify, hold harmless, and defend the City from all claims, legal actions, losses, expenses, injuries or damages arising out of the Administrator's negligence or intentional wrongdoing incident to the performance of this Agreement. 16. INSURANCE: The Administrator shall: A. Maintain in force at all times General Liability Insurance in the amount of One Million ($1,000,000) Dollars per occurrence, combined single limit. B. Maintain in force at all time Professional Liability Insurance in the amount of One Million ($1,000,000) Dollars per occurrence, combined single limit. 1 27 1 C. Maintain in force at all times a Fidelity Bond in the amount of One Million ($1,000,000) Dollars. D. Maintain in force at all times Workers' Compensation Insurance for employees of the Administrator, as required by law. ' E. Notify the City, in writing, thirty days prior to any cancellation or reduction in the above coverage. F. Maintain evidence of the above coverage on file with the City ' throughout the term of this Agreement. ' 17. NOTICES: All notices, demands, requests, or approvals which are ' required under this Agreement, or which either the City or the Administrator may desire to serve upon the other, shall be in writing and shall be conclusively deemed served when delivered personally, or forty-eight (48) hours after the deposit thereof in the United States Mail with postage pre-paid. 1 18. CANCELLATION: This Agreement may be canceled by either party giving to the other, in writing, notice of its intention to cancel this Agreement at least sixty (60) days prior to the date of termination. Upon the date of termination of this Agreement, or the date on which records are transferred to another custodian, whichever occurs first, the Administrator shall no longer have the ' authority or responsibility to administer the City's claims. 1 1 28 ' 19. PARTIAL INVALIDITY: If any provision of this Agreement is held by a ' competent court to be invalid, void or unenforceable, the remaining provisions shall nevertheless continue in full force and effect. 1 20. GOVERNING LAW: The validity of this Agreement and of any of its ' terms and provisions shall be interpreted pursuant to the Laws of the State of California. 1 t21. INTERPRETATION: The terms and conditions of this Agreement shall be construed pursuant to their plain, ordinary meaning and shall not be interpreted against the maker. 1 22. ASSIGNMENT: The Administrator shall not assign, sublet or transfer ' by operation of law or otherwise any or all of its rights, burdens, duties or ' obligations of this Agreement without the prior, written consent of the City. 23. CONFLICT OF INTEREST: The Administrator agrees not to enter ' into any activity or business arrangement, which is likely to result in a conflict between the interests of the City and the interests of any third parties. 1 ' 24. ENTIRE CONTRACT: This instrument contains the entire Agreement between the parties relating to the rights herein granted and obligations herein assumed. Any oral representations or modifications ' 29 tconcerning this instrument shall be of no force or effect. Subsequent ' modifications shall be made in writing with the agreement of both parties. ' EXECUTED at Palm Springs, California, on the date and year first above ' written. CITY OF PALM SPRINGS COLEN AND LEE INC. ' by by ' ATTEST: APPROVED AS TO FORM: by by by by 1 1 1 1 1 ' 30 WORKERS' COMPENSATION CONTRACT/AGREEMENT This Agreement is made and entered into this 91h day of September, 2002, by and between the Community Development Commission of the County of Los Angeles, hereinafter referred to as "Commission", and Colen & Lee, hereinafter referred to as "Contractor." RECITAL ' 1. PURPOSE Contractor is in the business of providing Workers' Compensation Third Party Administration. On July 8, 1999, in response to the Commission's Request for Bids, Contractor submitted a bid to furnish the hereinafter-described Workers' Compensation Claims Management services to the Commission. TERMS AND CONDITIONS 2. TERM This Agreement shall commence as of the day and year first above written and shall ' remain in full force and effect for two months until November 8, 2002 unless sooner terminated as provided herein. ' 3. CONTRACTOR'S RESPONSIBILITIES Contractor agrees to perform in a good workmanlike manner, to the satisfaction of the Commission's Executive ❑irector. 1 4. COMPENSATION ' The Contractor will[ submit to the Commission a Commission-approved invoice for services rendered on a monthly schedule and the Commission will pay to the Contractor, upon receipt of the invoice, payments not to exceed Six Thousand Five ' Hundred Dollars ($6,500). 5. SOURCES AND APPROPRIATION OF FUNDS The Commission's obligation is payable only and solely from funds appropriated through the U.S. Department of Housing and Urban Development (HUD) and, for the purpose of this Agreement. All funds are appropriated every fiscal year beginning July 1. In the event this Agreement extends into succeeding fiscal years and funds have not been appropriated, this Agreement will automatically terminate as of June 30 of the current fiscal year. The Commission will endeavor to notify the Contractor in writing within ten (10) days of receipt of non-appropriation notice. 1 6. TERMINATION FOR IMPROPER CONSIDERATION The Commission may, by written notice to the Contractor, immediately terminate the right of the Contractor to proceed under this Agreement, if it is found that consideration, in any form, was offered or given by Contractor, either directly or through an intermediary, to any County office, employee or agent with the intent of securing this Agreement or securing favorable treatment with respect to the award, amendment or extension of this Agreement of the making of any determinations with respect to the Contractor's performance pursuant to this Agreement. In the event of such termination, the Commission shall be entitled to pursue the same remedies against the Contractor ias it could pursue in the event of default by the Contractor. The Contractor shall immediately report any attempt by a Commission officer or employee to solicit such improper consideration. The report shall be made either to the Commission's Executive Director or to the County Auditor-Controller's Employee Fraud Hotline at (800) 544-6861. ' Among other items, such improper consideration may take the form of cash, discounts, service,the provision of travel or entertainment, or tangible gifts. 7. SUCCESSOR AND ASSIGNMENT This Agreement may not be assigned by the Contractor except with prior written ' consent of the Executive Director of the Commission, or his designee. However, the Commission reserves the right to assign this Agreement to another public agency without the consent of the Contractor. 8. CONFIDENTIALITY OF REPORTS The Contractor shall keep confidential all reports, information and data received, ' prepared or assembled pursuant to performance hereunder. Such information shall not be made available to any person, firm, corporation or entity without the prior written consent of the Commission. i9. SUBCONTRACTING The Contractor may subcontract only those specific portions of work allowed in the original specifications covered by this Agreement with prior written approval by the Commission. The Contractor shall not subcontract any part of the work covered by this Agreement or permit subcontracted work to be further subcontracted without prior written approval by the Commission. 10. INSURANCE Contractor shall procure and maintain at Contractors expense for the duration of this Agreement the following insurance against claims for injuries to persons or damage to property, which may arise from or in connection with the performance of the work by the Contractor, its agents, representatives, employees or subcontractors, y ' A. GENERAL LIABILITY INSURANCE (written on ISO policy form CS 00 01 or its equivalent) with limits of not less than the following: 1 General Aggregate $2,000,000 Products/Completed Operations Aggregate $1,000,000 Personal and Advertising Injury $1,000,000 Each Occurrence $1,000,000 ' The Community Development Commission of the County of Los Angeles ("Commission"), the Housing Authority of the County of Los Angeles ("Housing Authority"), the County of Los Angeles ("County"), and their officials and employees, ' shall be covered as insureds with respect to: liability arising out of activities performed by or on behalf of the Contractor; products and completed operations of the Contractor; premises owned, leased or used by the Contractor. ' B. AUTOMOBILE LIABILITY INSURANCE (written on ISO policy form CA 00 01 or its equivalent) with a limit of liability of not less than $1 million for each incident. Such insurance shall include coverage of all "awned", "hired" and "non-owned" vehicles, ' or coverage for"any auto". C. WORKERS' COMPENSATION and EMPLOYER'S LIABILITY insurance providing ' worker's compensation benefits, as required by the Labor Code of the State of California. In all cases, the above insurance also shall include Employer's Liability coverage with limits of not less than the following: Each Accident $1,000,000 Disease-policy limit $1,000,000 Disease-each employee $1,000,000 Any self-insurance program and self-insured retention must be separately approved by the Commission. ' Each insurance policy shall be endorsed to state that coverage shall not be canceled by either party, reduced in coverage or in limits except after thirty (30) days' prior written notice has been given to the Commission. ' Acceptable insurance coverage shall be placed with carriers admitted to write insurance in California or carriers with a rating of or equivalent to A: VI I] by A.M. Best& Company. ' Any deviation from this rule shall require specific approval in writing by the Commission. All coverage for subcontractors shall be subject to the requirements stated herein and shall be maintained at no expense to the Commission. Contractor shall furnish the Commission with certificates of insurance and with original endorsements affecting coverage as required above. The certificates and endorsements for each insurance policy are to be signed by a person authorized by that insurer to bind coverage on its behalf. ' 3 ' Failure on the part of the Contractor to procure or maintain insurance required by this Agreement shall constitute a material breach of contract upon which the Commission ' may immediately terminate this Agreement. 11. INDEMNIFICATION Contractor shall indemnify, defend and hold harmless the Commission, the Housing Authority of the County of Los Angeles ("Housing Authority"), the County of Los ' Angeles ("County"), and their elected and appointed officers, employees, and agents from and against any and all liability, including but not limited to demands, claims, actions, fees, costs, and expenses (including attorney and expert witness fees), ' arising from or connected with Contractor's acts and/or omissions arising from and/or relating to this Agreement. 12. COMMISSION'S QUALITY ASSURANCE PLAN ' The Commission will evaluate Contractors performance under this Agreement on not less than an annual basis. Such evaluation will include assessing Contractors compliance with all contract terms and performance standards. Contractor deficiencies which Commission determines are severe or continuing and that may place performance of the Agreement in jeopardy, if not corrected, will be reported to the ' Board of Commissioners. The report will include improvement/corrective action measures taken by the Commission and Contractor. If improvement does not occur consistent with the corrective measure, the Commission may terminate this Agreement, ' pursuant to Paragraph 13 or 14, or impose other remedies as specified in this Agreement. ' 13. TERMINATION FOR CONVENIENCE The Commission reserves the right to cancel this Agreement for any reason at all upon ten (10) days prior written notice to Contractor. In the event of such termination, Contractor shall be entitled to a prorated portion paid for all satisfactory work unless such termination is made for cause, in which event, compensation if any, shall be adjusted in such termination. 14. TERMINATION FOR CAUSE This Agreement may be terminated by the Commission upon written notice to the Contractor for just cause (failure to perform satisfactorily) with no penalties incurred by the Commission upon termination or upon the occurrence of any of the following events in A, B, C or D: A. Should the Contractor fail to perform all or any portion of the work required to be ' performed hereunder in a timely and good workmanlike manner or properly carry out the provisions of this Agreement in their true intent and meaning, then in such case, notice thereof in writing will be served upon the Contractor, and should the ' Contractor neglect or refuse to provide a means for satisfactory compliance with this Agreement and with the direction of the Commission within the time specified in such notice, the Commission shall have the power to suspend or terminate the operations of the Contractor in whole or in part. ' 4 1 ' B. Should the Contractor fail within five (5) days to perform in a satisfactory manner, in accordance with the provisions of this Agreement, or if the work to be done under ' this Agreement is abandoned for more than three days by the Contractor, then notice of deficiency thereof in writing will be served upon Contractor by the Commission. Should the Contractor fail to comply with the terms of this Agreement ' within five (5) days, upon receipt of said written notice of deficiency, the Executive Director of Commission shall have the power to suspend or terminate the operations of the Contractor in whole or in part. ' C. In the event that a petition of bankruptcy shall be filed by or against the Contractor. D. If, through any cause, the Contractor shall fail to fulfill, in a timely and proper manner, the obligations under this Agreement, or if the Contractor shall violate any of the covenants, agreements, or stipulations of this Agreement, the Commission shall thereupon have the right to terminate this Agreement by giving written notice ' to the Contractor of such termination and specifying the effective date thereof, at least five days before the effective date of such termination. In such event, all finished or unfinished documents, data, studies, surveys, drawings, maps, models, photographs and reports prepared by the Contractor under this Agreement shall, at the option of the Commission become its property and the Contractor shall be entitled to receive just and equitable compensation for any work satisfactorily ' completed. 15. CONTRACTOR'S WARRANTY OF ADHERENCE TO COUNTY'S CHILD SUPPORT COMPLIANCE PROGRAM Contractor acknowledges that the County of Los Angeles, hereinafter referred to as ' "County", has established a go5lafemuring that all 1F&vialialswho benefit financially from County or Commission through contract, are in Compliance with their court-ordered child, family and spousal support obligations in order to mitigate the economic burden otherwise imposed upon County and its taxpayers. ' As required by County's Child Support Compliance Program (County Code Chapter 2.200) and without limiting Contractor's duty under this Agreement to comply with all ' applicable provisions of law, Contractor warrants that it is now in compliance and shall during the term of this Agreement maintain compliance with employment and wage reporting requirements as required by the Federal Social Security Act (42 USC ' Section 653a) and California Unemployment Insurance Code Section 1088.5, and shall implement all lawfully served Wage and Earnings Withholding Orders or District Attorney Notices of Wage and Earnings Assignment for Child or Spousal Support, pursuant to Code of Civil Procedure Section 706.031 and Family Code Section 5246(b). ' 16. TERMINATION FOR BREACH OF WARRANTY TO COMPLY WITH COUNTY'S CHILD SUPPORT COMPLIANCE PROGRAM ' Failure of Contractor to maintain compliance with the requirements set forth in Paragraph 15, "Contractor's Warranty of Adherence to County's Child Support Compliance Program" shall constitute a default by Contractor under this Agreement. Without limiting the rights and remedies available to County or Commission under any other provision of this Agreement, failure to cure such default within ninety (90) days of notice by the Los Angeles County Child Support Services Department ' S (CSSD) shall be grounds upon which the Commission Board of Commissioners may terminate this Agreement pursuant to Paragrapn 14, "Termination For Cause". ' 17. POST MOST WANTED DELINQUENT PARENTS LIST Contractor acknowledges that the County places a high priority on the enforcement of child support laws and the apprehension of child support evaders. Contractor understands that it is County's and Commission's policy to voluntarily post an entitled "L.A.'s Most Wanted: Delinquent Parents" poster in a prominent position at ContractOr's place of business. The Child Support Services Department (CSSD) will supply Contractor with the poster to be used. 18. INDEPENDENT CONTRACTOR ' This Agreement does not, is not intended to, nor shall it be construed to create the relationship of agent, employee or joint venture between the Commission and the Contractor. 19. EMPLOYEES OF CONTRACTOR Workers'Compensation: Contractor understands and agrees that all persons furnishing ' services to the Commission pursuant to this Agreement are, for the purposes of Workers' Compensation liability, employees solely of the Contractor. Contractor shall bear sole responsibility and liability for providing Workers' Compensation benefits to ' any person for injuries arising from an accident connected with services provided to the Commission under this Agreement. ' Professional Conduct: The Commission does not and will not condone any acts, gestures, comments or conduct from the Contractors employees, agents or subcontractors which may be construed as sexual harassment or any other type of activities or behavior that might be construed as harassment. The Commission will properly investigate all charges of harassment by residents, employees or agents of the Commission against any and all Contractors employees, agents or subcontractors providing services for the Commission. The Contractor assumes all liability for the ' actions of the Contractors employees, agents or subcontractors and is responsible for taking appropriate action after reports of harassment are received by the Contractor. 20. DRUG-FREE WORKPLACE ACT OF THE STATE OF CALIFORNIA Contractor certifies under penalty of perjury under the laws of the State of California that the Contractor will comply with the requirements of the Drug-Free Workplace Act of 1990. ' 21. SAFETY STANDARDS AND ACCIDENT PREVENTION ' The Contractor shall comply with all applicable federal, state and local laws governing safety, health and sanitation. The Contractor shall provide all safeguards, safety devices and protective equipment and take any other needed actions, as its own ' responsibility, reasonably necessary to protect the life and health of employees on the job and the safety of the public and to protect property in connection with the performance of this Agreement. ' 6 i i 22. COMPLIANCE WITH LAWS The Contractor agrees to be bound by applicable federal, state and local laws, regulations, and directives as they pertain to the performance of this Agreement. This Agreement is subject to and incorporates the terms of the Housing and Community Development Act of 1974, as amended by the Cranston-Gonzalez National Affordable Housing Act, 1990, and the 24 CFR Part 85. If the compensation under this Agreement is in excess of $100,000 then Contractor shall comply with applicable standards, orders, or requirements issued under section 306 of the Clean Air Act (42 U.S,C. 18579h)), section 508 of the Clean Water Act (33 U.S.C. 1368), Executive Order 11738, and Environmental Protection Agency Regulations (40 CFR part 15). The Contractor must obtain and present all relevant state and local insurance, training ' and licensing pursuant to services required within this Agreement. Contractor shall comply with the following laws in Sections 23-32, inclusive. ' 23. CIVIL, RIGHTS ACT OF 1964, TITLE VI (NON-DISCRIMINATION IN FEDERALLY- ASSISTED PROGRAMS) Contractor shall comply with the Civil Rights Act of 1964 Title VI which provides that no person shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance. 24. SECTION 109 OF THE HOUSING AND COMMUNITY DEVELOPMENT ACT OF 1974 Contractor shall comply with Section 109 of the Housing and Community Development Act of 1974 which states that no person in the United States shall, on the grounds of race, color, national origin, or sex be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity funded in whole or in part with funds made available under this title. 25. AGE DISCRIMINATION ACT OF 1975 AND SECTION 504 OF THE REHABILITATION ACT OF 1973 Contractor shall comply with the Age Discrimination Act of 1975 and section 504 of the Rehabilitation Act of 1973, which require that no person in the United States shall be excluded from participating in, denied the benefits of, or subject to discrimination under this Agreement on the basis of age or with respect to an otherwise qualified disabled individual. i26. EXECUTIVE ORDER 11246 AND 11375,EQUAL OPPORTUNITY IN EMPLOYMENT (NON-DISCRIMINATION IN EMPLOYMENT BY GOVERNMENT CONTRACTORS AND SUBCONTRACTORS) Contractor shall comply with Executive Order 11246 and 11375, Equal Opportunity in Employment, which requires that during the performance of this Agreement, the Contractor will not discriminate against any employee or applicant for employment because of race, color, religion, sex or national origin. The Contractor will take 7 1 affirmative action to ensure that applicants are employed, and that employees are treated fairly during employment, without regard to their race, color, religion, sex 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 by the contracting officer setting forth the provisions of the non-discrimination clause. ' 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 or national origin. The Contractor will send to each labor union or representative of workers with which he has a collective bargaining Agreement or other contract or understanding, a notice to ' be provided by the agency of the Contractor's commitments under Section 202 of Executive Order No. 11246 of September 24, 1965, and shall post copies of the notice in conspicuous places available to employees and applicants for employment. The ' Contractor will comply with all provisions of Executive Order No. 11246 of September 24, 1965, and of the rules, regulations and relevant orders of the Secretary of Labor. The Contractor will furnish all information and reports required by the Executive Order and by the rules, regulations and orders of the Secretary of Labor, or pursuant thereto, and will permit access to its books, records, and accounts by the Commission and the ' Secretary of Labor for purposes of inves[igation to ascertain compliance with such rules, regulations and orders. In the event of Contractor's noncompliance with the non-discrimination clauses of this Agreement or with any of such rules, regulations or orders, this Agreement 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 the Executive Orders and such other Sanctions may be imposed and remedies invoked as provided in the Executive Order or by rule, regulation or order of the Secretary of Labor, or as otherwise provided by law. ' The Contractor will include the provisions of these paragraphs in every subcontract or purchase order unless exempted by rules, regulations, or orders of the Secretary of ' Labor issued pursuant to Section 204 of the Executive Order No. 11246 of September 24, 1965, that such provisions will be binding upon each subcontractor or vendor. The Contractor will take such actions with respect to any subcontract or purchase order as ' the Commission may direct 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 by a subcontractor or vendor as a result of such direction by the Commission, the Contractor may request the United States to enter into such litigation to protect the interests of the United States. 27. SECTION 3 OF THE HOUSING AND COMMUNITY DEVELOPMENT ACT OF 1968, ' AS AMENDED A. The work to be performed under this Agreement is subject to the requirements of Section 3 of the Housing and Urban Development Act of 1968, as amended, 12 U.S.C. 1701 u (Section 3). The purpose of Section 3 is to ensure that 1 employment and other economic opportunities generated by HUD assistance or HUD-assisted projects covered by Section 3, shall, to the greatest extent ' feasible, be directed to low-and very low-income persons, particularly persons who are recipients of HUD assistance for housing. ' B. The parties to this Agreement agree to comply with HUD's regulations in 24 CFR Part 135, which implement Section 3. As evidenced by their execution of this Agreement, the parties to this Agreement certify that they are under no contractual or other impediment that would prevent them from complying with the Part 135 regulations. C. The Contractor agrees to send to each labor organization or representative of ' workers with which the Contractor has a collective bargaining Agreement or other understanding, if any, a notice advising the labor organization or workers' representative of the Contractor's commitments under this Section 3 clause, and ' will post copies of the notice in conspicuous places at the work site where both employees and applicants for training and employment positions can see the notice. The notice shall describe the Section 3 preference, shall set forth ' minimum number and job titles subject to hire, availability of apprenticeship and training positions, the qualifications for each; and the name and location of the person(s) taking applications for each of the positions; and the anticipated date the work shall begin. D. The Contractor agrees to include this Section 3 clause in every subcontract ' subject to compliance with regulations in 24 CFR Part 135, and agrees to take appropriate action, as provided in an applicable provision of the subcontract or in this Section 3 clause, upon a finding that the subcontractor is in violation of the regulations in 24 CFR Part 135. The Contractor will not subcontract with any ' subcontractor where the Contractor has notice or knowledge that the subcontractor has been found in violation of the regulations in 24 CFR Part 135. E. The Contractor will certify that any vacant employment positions, Including training positions, that are filled (1) after the Contractor is selected but before the Agreement is executed, and (2) with persons other than those to whom the ' regulations of 24 CFR part 135 require employment opportunities to be directed, were not filled to circumvent the Contractor's obligations under 24 CFR Part 135. F. Noncompliance with HUD's regulations in 24 CFR Part 135 may result in sanctions, termination of this Agreement for default, and debarment or suspension from future HUD assisted contracts. G. With respect to work performed in connection with Section 3 covered Indian housing assistance, section 7(b) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450e) also applies to the work to be performed under ' this Agreement. Section 7(b) requires that to the greatest extent feasible (i) preference and opportunities for training and employment shall be given to Indians, and (ii) preference in the award of contracts and subcontracts shall be ' given to Indian organizations and Indian-owned Economic Enterprises. Parties to this Agreement that are subject to the provisions of Section 3 and section 7(b) agree to comply with Section 3 to the maximum extent feasible, but not in ' derogation of compliance with section 7(b). 1 9 28. LOBBYIST ORDINANCES ' A. County Lobbyist Ordinance: Contractor and each County Lobbyist or County lobbyist firm, as defined in Los Angeles County Code Chapter 2.160 (County Ordinance 93-0031), retained by the Contractor, shall fully comply with the ' requirements as set forth in said County Code. The Contractor must also certify in writing on the County Lobbyist Certification form that they are familiar with the Los Angeles County Code Chapter 2.160 and that all persons acting on behalf of the Contractor will comply with the County Code. Failure on the part of the Contractor and or Lobbyist to fully comply with the County ' Lobbyist requirements shall constitute a material breach of this Agreement upon which the Commission may immediately terminate this Agreement and the Contractor may be subject to civil liability pursuant to Los Angeles County Code Chapter 2.160 (County Ordinance 93-0031). B. Federal Lobbyist Requirements: The Contractor is prohibited by the Department of Interior and Related Agencies Appropriations Act, known as the Byrd Amendments, and HUD's 24 CFR Part 87, from using federally appropriated funds for the purpose of 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 the awarding of any Federal contract, the making of any Federal grant, loan or cooperative Agreement, and any extension, continuation, renewal, amendment or modification of said documents. ' The Contractor must certify in writing on the Federal Lobbyist Requirements Certification form that they are familiar with the Federal Lobbyist Requirements and ' that all persons and/or subcontractors acting on behalf of the Contractor will comply with the Lobbyist Requirements. Failure on the part of the Contractor or persons/subcontractors acting on behalf of ' the Contractor to fully comply with the Federal Lobbyist Requirements may be subject to civil penalties. ' 29. NOTICE TO EMPLOYEES REGARDING THE FEDERAL EARNED INCOME CREDIT Contractor shall notify its employees, and shall require each subcontractor to notify its employees, that they may be eligible for the Federal Earned Income Credit under the federal income tax laws. Such notice shall be provided in accordance with the requirements set forth in Internal Revenue Service Notice 1015. ' 30. USE OF RECYCLED-CONTENT PAPER PRODUCTS Consistent with the Board of Supervisors' policy to reduce the amount of solid waste deposited at the County landfills, the Contractor agrees to use recycled-content paper to the maximum extent possible in relation to its provision of services hereunder. 31. CONTRACTOR RESPONSIBILITY AND DEBARMENT A. A responsible contractor is a contractor who has demonstrated the attribute of ' trustworthiness, as well as quality, fitness, capacity and experience to ' 10 satisfactorily perform the contract. It is the policy of the County, the Commission and the Housing Authority to conduct business only with responsible contractors. ' B_ The Contractor is hereby notified that, in accordance with Chapter 2.202 of the County Code, if the County, which, as defined under Section 2.202.020, includes ' the Commission and the Housing Authority, acquires information concerning the performance of the Contractor on this or other contracts which indicates that the Contractor is not responsible, the County may, in addition to other remedies provided in the contract, debar the Contractor from bidding on County, Commission or Housing Authority contracts for a specified period of time not to exceed 3 years, and terminate any or all existing contracts the Contractor may have with the County, the Commission or the Housing Authority. C. The Commission or the Housing Authority may debar a contractor if the Board of ' Commissioners finds, in its discretion, that the contractor has done any of the following: (1) violated any term of a contract with the County, the Commission or the Housing Authority, (2) committed any act or omission which negatively reflects on the contractor's quality, fitness or capacity to perform a contract with the County, the Commission or the Housing Authority or any other public entity, or engaged in a pattern or practice which negatively reflects on some, (3) committed an act or offense which indicates a lack of business integrity or ' business honesty, or (4) made or submitted a false claim against the County, the Commission or the Housing Authority or any other public entity. D. If there is evidence that the Contractor may be subject to debarment, the Commission or the Housing Authority (specify identifying entity) will notify the Contractor in writing of the evidence which is the basis for the proposed ' debarment and will advise the Contractor of the scheduled date for a debarment hearing before the Contractor Hearing Board. E, The Contractor Hearing Board will conduct a hearing where evidence on the proposed debarment is presented. The Contractor and/or the Contractor's representative shall be given an opportunity to submit evidence at that hearing. After the hearing, the Contractor Hearing Board shall prepare a proposed ' decision, which shall contain a recommendation regarding whether the Contractor should be debarred, and, if so, the appropriate length of time of the debarment. If the Contractor fails to avail itself of the opportunity to submit evidence to the Contractor Hearing Board, the Contractor may be deemed to have waived all rights of appeal. ' F. A record of the hearing, the proposed decision and any other recommendation of the Contractor Hearing Board shall be presented to the Board of Commissioners. The Board of Commissioners shall have the right to modify, deny or adopt the ' proposed decision and recommendation of the Contractor Hearing Board. G. These terms shall also apply to subcontractors/subconsultants of County, Commission or Housing Authority contractors. 1 ' 11 32. COMPLIANCE WITH JURY SERVICE PROGRAM A. Jury Service Program. This Contract is subject to the provisions of the County's ordinance entitled ' Contractor Employee Jury Service ("Jury Service Program") as codified in Sections 2.203.010 through 2.203.090 of the Los Angeles County Code. 13. Written Employee Jury Service Policy. 1. Unless Contractor has demonstrated to the County's satisfaction either that 1 Contractor is not a "Contractor" as defined under the Jury Service Program (Section 2.203.020 of the County Code) or that Contractor qualifies for an exception to the Jury Service Program (Section 2.203.070 of the County Code), Contractor shall have and adhere to a written policy that provides that its Employees shall receive from the Contractor, on an annual basis, no less than five days of regular pay for actual jury service. The policy may provide that Employees deposit any fees received for such jury service with the Contractor or that the Contractor deduct from the Employee's regular pay the fees received for jury service. 2. For purposes of this Section, "Contractor" means a person, partnership, corporation or other entity which has a contract with the County or a subcontract with a County contractor and has received or will receive an aggregate sum of $50,000 or more in any 12-month period under one or more County contracts or subcontracts. "Employee" means any California resident who is a full time employee of Contractor. "Full time" means 40 hours or more worked per week, or a lesser number of hours if: 1) the lesser number is a recognized industry ' standard as determined by the County, or 2) Contractor has a long-standing practice that defines the lesser number of hours as full-time. Full-time employees providing short-term, temporary services of 90 days or less within a 12-month period are not considered full-time for purposes of the Jury Service Program. If Contractor uses any subcontractor to perform services for the County under the Contract, the subcontractor shall also be subject to the provisions of this Section. The provisions of this Section shall be inserted into any such subcontract agreement and a copy of the Jury Service Program shall be attached to the agreement. ' 3. If Contractor is not required to comply with the Jury Service Program when the Contract commences, Contractor shall have a continuing obligation to review the applicability of its "exception status" from the Jury Service Program, and Contractor shall immediately notify County if Contractor at any time either comes within the Jury Service Program's definition of "Contractor" or if Contractor no longer qualifies for an exception to the Program. In either event, Contractor shall immediately implement a written policy consistent with the Jury Service Program. The County may also require, at any time during the Contract and at its sole discretion, that Contractor demonstrate to the County's satisfaction that Contractor either continues to remain outside of the Jury Service Program's definition of "Contractor" and/or that Contractor continues to qualify for an exception to the Program. i12 4. Contractor's violation of this Section of the contract may constitute a material breach of the Contract. In the event of such material breach, County may, in its ' sole discretion, terminate the Contract and/or bar Contractor from the award of future County contracts for a period of time consistent with the seriousness of the breach. 33. ACCESS AND RETENTION OF RECORDS Contractor shall provide access to the Commission, the Federal Grantor agency, the Comptroller General of the United States, or any of their duly authorized representatives to any books, documents, papers and records of the Contractor which are directly pertinent to this Agreement for the purpose of making audits, examinations, excerpts and transcriptions. The Contractor is required to retain the aforementioned records for a period of five years after the Commission pays final payment and other pending matters are closed under this Agreement. 33. CONFLICT OF INTEREST The Contractor represents, warrants and agrees that to the best of its knowledge, it does not presently have, nor will it acquire during the term of this Agreement, any interest direct or indirect, by contract, employment or otherwise, or as a partner, joint venture or shareholder (other than as a shareholder holding a one (1%) percent or less ' interest in publicly traded companies) or affiliate with any business or business entity that has entered into any contract, subcontract or arrangement with the Commission, Upon execution of this Agreement and during its term, as appropriate, the Contractor shall, disclose in writing to the Commission any other contract or employment during the term of this Agreement by any other persons, business or corporation in which employment will or may likely develop a conflict of interest between the Commission's interest and the interests of the third parties. ' 34. SEVERABILITY In the event that any provision herein contained is held to be invalid, void, or illegal by any court of competent jurisdiction, the same shall be deemed severable from the remainder of this Agreement and shall in no way affect, impair or invalidate any other ' provision contained herein_ If any such provision shall be deemed invalid due to its scope or breadth, such provision shall be deemed valid to the extent of the scope or breadth permitted by law. 35. INTERPRETATION ' No provision of this Agreement is to be interpreted for or against either party because that party or that party's legal representative drafted such provision, but this Agreement is to be construed as if drafted by both parties hereto. 36. WAIVER No breach of any provision hereof can be waived unless in writing. Waiver of any one ' breach of any provision shall not be deemed to be a waiver of any breach of the same or any other provision hereof. 13 1 37. PATENT RIGHTS ' The Commission will hold all the patent rights with respect to any discovery or invention which arises or is developed in the course of, or under this Agreement. ' 38. COPYRIGHT No report, maps, or other documents produced in whole or in part under this Agreement shall be the subject of an application for copyright by or on behalf of the Contractor. All such documents become the properly of the Commission and the Commission holds all the rights to said data. 39. NOTICES Commission shall provide Contractor with notice of any injury or damage arising from or connected with services rendered pursuant to this Agreement to the extent that Commission has actual knowledge of such injury or damage. Commission shall ' provide such notice within ten (10) days of receiving actual knowledge of such injury or damage. ' Notices provided for in this Agreement shall be in writing and shall be addressed to the person intended to receive the same, at the following address: ' The Commission: Robert Fujisaki Human Resources Manager Community Development Commission ' County of Los Angeles 2 Coral Circle Monterey Park, CA 91755 t The Contractor: Bernie Colen Gary Lee Colen & Lee ' 1470 S. Valley Vista Drive Diamond Bar, CA 91765 Notices addressed as above provided shall be deemed delivered three (3) business days after mailed by U.S. Mail or when delivered in person with written acknowledgement of the receipt thereof. The Contractor and the Commission may ' designate a different address or addresses for notices to be sent by giving written notice of such change of address to all other parties entitled to receive notice. 40. ENTIRE AGREEMENT ' This Agreement with attachments constitutes the entire understanding and agreement of the parties. This Agreement includes the following attachments: 1 A. Specifications B. Internal Revenue Service's Notice 1015 ' 14 1 SIGNATURES 1 IN WITNESS WHEREOF, the Contractor and the Commission have executed this Agreement through their duly authorized officers this 91h day of September, 2002. ' COMMUNITY DEVELOPMENT COMMISSION OF THE C NTY OF LOS ANGELES 6y xecutive Direc r COLEN D LEE ' 7 BY Title APPROVED AS TO FORM: ' LLOYD W. PELLMAN County Counsel 9 /-7( BY eputy 1 1 1 1 ' 15 ' VENAOR°S EQUAL EMPLOYlYMNT OPPORTUNITY CERTIFICATION clel,i �' L.,2-,—, r,✓c , ' Vendor's Name L4 Address 1 215 - _3 7755 /f ' Internal Revenue Service Employer Identification Number GENERAL The Contractor certifies and agrees that all persons employed by such firm, its affiliates, ' subsidiaries, or holding companies are and will be treated equally by the firm without regard to or because of race, religion, ancestry, national origin, or sex and in compliance with all anti-discrimination laws of the United States of America, the State of California, ' and all local ordinances- The Contractor further certifies that all subcontractors, suppliers, vendors and distributors with whore the Contractor has a contractual relationship are also in compliance with all applicable ,Federal, state and local anti- discriminatory laws. VENDOR'S CERTIFICATION ' 1. The vendor has a written policy statement prohibiting discrimination in all phases Of employment. 2. The vendor periodically conducts a self analysis or utilization analysis of its work ' force. 3. The vendor has a system for determining if its employment practices are ' discriminatory against protected groups. 4. Where problem areas are identified in employment practices, the vendor has a system for taking reasonable corrective action, to include establishment of goals of timetables. ' Name and Title of Signer: p+'"y'rtCCrd �o�Evr x �liC[ , ' Signature: COUNTY LOBBYIST CODE CHAPTER 2.160 COUNTY ORDINANCE NO. 93-0031 CERTIFICATION Name of Firm: 1 �7� C, /en L(J/l J ,Si/c . Date: 5/�- GAG _fl 7 S7� � Oey //lS Di, ��au� C�%FIm�%irk .�Address: / ?f State: r14 _ Zip Code: Phone No.: iActing on behalf of the above named firm, as its Authorized Official, I make the following Certification to the County of Los Angeles and the Community Development Commission, County of Los Angeles: 1) It is understood that each person/entity/£um who applies for a Community Development Commission contract, and as part of that process, shall certify that they are familiar with the requirements of the Los Angeles County Code Chapter 2.160,(Los Angeles County Ordinance 93-0031)and; 2) That all persons/entities/firms acting on behalf of the above named firm have and will comply with the County Code,and; 3) That any person/entity/firm who seeks a contract with the Community Development Commissiou shall be disqualified therefrom and denied the contract and, shall be liable in civil action, if any lobbyist, lobbying firm, lobbyist employer or any other person or entity acting on behalf of the above named firm fails to comply with the provisions of the County Code. ' 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 contract with the Los Angeles County and the ' Community Development Commission, County of Los Angeles. Authorized Official: /� Name: 7 e"'I'Larci CIr (eiA Title: AC,5 /' -;Si< &IJ 7 Signature: Date: 1 ' FEDERAL ]LOBBYIST RFQUIREM1NTS CERTIFICATION Name of Firm: Cr7le,/'7 /G� 'Z Vr . Date: ' Address: State: C.a Zip Code: G/ 7H, Pbone No- Acting on behalf of the above named firm, as its Authorized Official, I make the ' followitag Certification to tbs Department of IIousing and Urban Development (HUD) and the Community Development Commission, County of Los Angeles: ' 1) No Federal appropriated funds have been paid, by or on behalf of the above named firm to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or cmployec of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the malting of and Federal grant, loan or ' cooperative agreement, and any extension, continuation, renewal, amendment, or modification thereof,and; ' 2) If any funds other than Federal appropriated funds have paid or will be paid to any person for influencing or attempting to influence an officer or employee or 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 above named firm shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying", in accordance with its instructions,and: ' 3) The above name firm shall require that the language of this cenification be included in the award documents for all sub-awards at all tiers (including subcontracts, sub-grants, and contracts tinder grants, loans, and cooperative agreement) 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 the 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 S10,000 and not more than 5100,000 for each such failure. ' Authorized Official: ' Name: q g/,-f2QY� L r loll Title; _ zhr .& Signature: �iU i �{ .� Date: 1 Item 14 For. W-9 Request for Taxpayer .Give foram to the ' (Rov,°w°"'""11116) Identification Number and Certification requester:too NOT Dmr, .a d uric mr.b.y send to the IRs. w.,r iMwvr S• Name Of a joint arcrxrnt a y-o/u Changed Your narne,ten Specific lrt.trut� W page 2,j ' Gil a / �z /V,( e. Su name,If diaery at tmm r rxo ^(.,ee SpadGc Irtitructinm on page 7J 0 a Q--k art mp ab.b= © tdrvi6uolF.,oia pmpdemr [ cwpcmticn ❑ Perm-.* © Other ■ --- -------------------- = odd,/m/ sa(rauhahr,aaeaL apt or w�h�im ro�� y - Requestero rum and address(opti / 1 VIES I/,� ��1'. �G� atom,aro ZIP code ' n leln r)lGl & , G.q Taxpayer identification Number uat S:co d mffrb is)hero(cpbrri Eater your TIN in the appropriate box.-For ' individuals,this Is your social security number So W"oft rwrnbw ISSM.However,If you are a resident alien OR a soh proprietor,see Me instructions on page 2. 1117 For other ettibes,it is your employer DR For Paym s Exempt From Backup - kdenti5catim number(FJM, if you do not have a Wiftickhm(Sea the Instructions number,sea Now To Get a TIN on page Note:N the account Is fir Inoue than one name, 6apwrnr k leniffiMtlm manhnr on page 2.) see iharhart on page 2 for guidelines an whose Sit '7 number to enter. Certification Under penalties of perjury,I certify thac t. The number shown on M fort is my correct taxpayer Identification number(or I am waiting for a number to be issued to me).and ' 2. I am not subject to backup Withholding because: (a) I am exempt from backup withholding,or(b)I have not been nodfiad by the Internal Revenue Service(IRS)that I am subject to bacMea withhak fang as a result of a failure to report all interest or dividends,or(c)the IRS has notified me that I am no longer su4(ect to backup Withholding. Cartlffradon Insbuetlorq.—You mart Inns oue Item 2 above 11 you have been notified by the IRS that you are currently subject to backup w h nkdrhg because you have felled to report all armrest and dividends on your tax rub+ For real estate tra'rsadiorcy item 2 does not apply. For mortgage Interest pakd,aMulsiann or abandonment of secured propertyw canoallalm of debt.Contributions to an Individual radma ant arangefnent pwq,and generally,paymens other than interest and dividends,you are not r%gL*W to Sign erne Certification.but you must probe your correct TIN.(see the instntc5ans on page 2.) Here Slgnatun ■ C&)16L,._ Latta . -it. oorb Purpose of Fort.--A parson who is trnduds interest.dividends,broker and 5.You do not certify your TIN when required to file an Information return with barter excnwW transactions,rents, required.See the Part III instructions on the IRS must got your correct taxpayer royalties, nonernployee pay.and certain page 2 for details Idmdfication number MM to report.for payments from fishing boat operators. Real Certain payees and payments tare -at®tnple, income paid to you.reW estate estate transactions are not subject to exempt from backup withholding. See the bmitsactions,mortgage irrtarest you paid, backup withholding. Pan II atshictions and the separate acqui itibn or abandonment of secured If you give the requester your correct Iastrucidm for the Requester of Farm pngtarty,cancellation of debt,or TIN, make the proper certificatiau,and W-9. conbtx dim you made to an IRA. report as your taxable Interest and Use Form W-9 to give your coned TIN dividends on your tax realm, payments Penalties lo the person requesting it(the requester) you receive will not be subject to badanp Failure To Fimtah TIm+ v you fail to arc,when applicable,to: withholding.Payments you recolve will be subject to bertk up withholding if: furnish your correct TIN to a requester,you i_Certify,the TIN you are giving is are subject to a penalty of$W for each correct(or you we waiting for a number to i_You do not furnish your TIN to the such failure unless your failure is due to be isstt . requester•.or reasonable cause mW not to hnMM neglect. 2. Certify you are not subject to backup 2.The IRS tells the requester that you Civil Penalty for False hdonena With withholdng,or furnished an incorrect TIN, or Respect to W ifhhokdng.—If you make a S Clam ecenhption from backup 3.The IRS tells you that you are subject false statement with no reeconabie basis withholding kl you are an exempt payee: to backup withholding because you did not that results in no backup wthhwlding.you Now If a requesmr gives you a form vow report all your interest and dividends on are subject to a$500 penalty. Own a W-9 to request yew TIN,you must your tax ream(tor reportable interest and Crimkmal Penalty for Fahkfyig ttsa fie requssfW s fi rrri if it is subsmntially dividends only],or Information—Wdlfully faWfymg Easier to phis Form W-9. 4.You do not certify to the requester certlucations;or affimuitions may subject What Is gawp Wdrthiiotding7—Parsons that you are not subject to backup you to criminal penalties incyiding fines wahhnidind under 2 above(for reportable and/or imprisonment. COUNTY OF LOS ANGLES CONTRACTOR EMPLOYEE JURY SERVICE PROGRAM APPLICATION FOR EXCEPTION AND CERTIFICATION FORM ' The County's solicitation for this contractipurchase order (Request for Proposal or Invitation for Bid) is subject to the County of Los Angeles Contractor Employee Jury Service Program (Program) (Los Angeles County Code, Chapter 2.203). All bidders or ❑r000sers, whether a contractor or subcontractor. must complete this form to either 1) request an exception from the Program reouirements or 2) certify compliance. Upon review of the submitted form, the County department will determine, in its sole discretion,whether the bidder or proposer is excepted from the Program. ' Company Name: Gnu 'I ' Company Address: /T 7C ViS& Dl /lvz 1 city. JrC State: c;4 Zip Code: Telephone Number: C CCI61 tSolicitation For(Type of Goods or Services): if you believe the Jury Service Program does not apply to your business, check the appropriate box in Part I(attach documentation to support your claim), or, complete Part 11 to certify compliance with the Program. Whether you complete Part I or Part 11, please sign and date this form below. ' Part I: Jury Service Proaram Is Not Applicable to My Business ❑ My business does not meet the definition of "contractor," as defined in the Program as it has not received an aggregate sum of$50,000 or more in any 12-month period under one or more County contracts or subcontracts (this exception is not available if the contract/purchase order itself will exceed $50,000). 1 understand that the exception will be lost and I must comply with the Program if my revenues from the County exceed an aggregate sum of $50,000 in any 12-month period. ❑ My business is a small business as defined in the Program It 1) as tenor fewer employees; and, 2) has annual gross revenues in the preceding twelve months which, i ed to the annual amount of this contract, are ' $500,000 or less; and, 3) is not an affiliate or subsidiary of a.business dominant in its field of operation, as defined below. I understand that the exemption will be lost and I must comply with the Program if the number of employees in my business and my gross annual revenues exceed the above limits. ' "Dominant in its field of operation" means having more than ten employees, including full-time and part-time employees, and annual gross revenues in the preceding twelve months, which, if added to the annual amount of the contract awarded, exceed $500,000. ' "Affiliate or subsidiary of a business dominant in its field of operation" means a business which is at least 20 percent owned by a business dominant in its field of operation, or by partners, officers, directors, majority stockholders, or their equivalent, of a business dominant in that field of operation. ' ❑ My business is subject to a Collective Bargaining Agreement (attach agreement) that expressly provides that it supersedes all provisions of the Program. OR ' Part II -Certification of Compliance My business has and adheres to a written policy that provides, an an annual basis, no less than five days of regular pay for actual jury service for full-time employees of the business who are also California residents, or my company will have and adhere to such a policy prior to award of the contract. I declare under penalty of perjury under the laws of the State of California that the information stated above is true and correct. Print Name: Title: ' Signature: Date: 1 CODY to: Child Support Services Department Special Projects ' P. O. Box 911009 Las Angeles, CA 90091-1099 FAX: (323) 869-0634 Telephone: (323) 832-7277 or (323) 832- 7276 1 (CHILD SUPP CERT PRO CERT) ' Romed QV02101 ' CONFIRMATION OF CONTRACTOR COMPLIANCE (Check appropriate boXes) ' [ ] To [ ] From Child Support Services Department Special Projects FAX: (323) 869-0634 Telephone. (323) 832-7277 or (323) 832-7276 ' [ d] From [ I To Department Contact: Tracey Curry Department Name: Caumxg.ty Devel.oument Commission FAX: (323) 890-8588 Telephone: (323) 890-7010 [ s ] Departmental Request bate: ' Please confirm receipt of the Principal Owner information Form from the following contractor as certified in the Child Support Compliance Program Certification: Contractor Name as Shown on the Bid or Proposal: c01.EN & IXE, 111C. Contractor Address: 1470 South Valley Vista Drive, Suite 230 Diamond liar, C6 91765 Phone'No.: (909) 861-0816 FAX: (909) 860-3995 Name of Person Certifying Submission: Bernard Col_en Date of Contractor Certification: 09-12-2002 [ Child Suoport Services Denartment Resnonse The Principal Owner Information Form: [ ] Has been received and approved. [ ] Has not been received. Contractor cannot document timely submission. Contractor may be deemed non- responsible. Signature of Person Completing this Confirmation: Print Name: Phone Number: Revood 071=001 ' CHILD SUPPORT COMPLIANCE PROGRAM CERTIFICATION os Angeles County Code Chapter 2.200 establishes the Los Angeles County Child Support Compliance ' Program. This Program requires the County to provide certain information to the Child Support Services Department(CSSD) concerning its employees and business licensees. It further requires that bidders or proposers for County contracts submit certifications of Program compliance to the soliciting County ' department along with their bids or proposals. (In an emergency procurement, as determined by the soliciting County department, these certifications may be provided immediately following the procurement.) ' IN ORDER TO COMPLY WITH THIS REQUIREMENT, COMPLETE THIS FORM AND SUBMIT IT DIRECTLY TO THE SOLICITING COUNTY DEPARTMENT ALONG WITH YOUR BID OR PROPOSAL. IN ADDITION, PROVIDE A COPY TO THE CHILL) SUPPORT SERVICES DEPARTMENT AT THE ' ADDRESS OR FAX NUMBER SHOWN BELOW. SOLE PRACTITIONER MEMBERS OF AN ASSOCIATION MUST COMPLETE AND SUBMIT INDIVIDUAL FORMS. I, (print name as shown in bid or proposal ) COLEH & I=• , INC. ' hereby submit this certification to the (County Department), pursuant to the provisions of County Code Section 2.200.060 and hereby certify that (contractor name as shown in bid or proposal), an independently-owned or franchiser-owned business (circle one), located at (contractor or, if an association, associated member address) 1470 South yalleg Vista Drive. Suite 230, Diamond Bar. CA 91765 is in compliance with Los Angeles County's Child Support Compliance Program and has met the following requirements; 1) Submitted a completed Principal Owner Information Form to the Child Support Services ' Department; 2) Fully complied with employment and wage reporting requirements as required by the Federal Social Security Act (42 USC Section 653a) and/or California Unemployment Insurance Code Section 1088.5 and will continue to comply with such reporting requirements; 3) Fully complied with all lawfully served Wages and Earnings Withholding Orders or Notices of Wage and Earnings Assignment, pursuant to Code of Civil Procedure Section 706.031 and Family Code Section 5246(b) or pursuant to applicable provisions of the Uniform Interstate Family Support Act, and will continue to comply with such Orders or Notices. f declare under penalty of perjury that the foregoing is true and correct. Executed this 12th. day of Septemner 2002 ' (Month and Year) at; Diamond Bar, California (City/State) (Telephone No.) by: Bernard Colen (909) 861-0816 (Signature of a Principal Owner, an officer or manager responsible for submission of the bid or proposal to the County) 1 (POI FORM)REVISED 07 PRINCIPAL OWNER INFORMATION FORM Los Angeles County Code Chapter 2.200 establishes the Los Angeles County Child Support Compliance Program. This Program requires the County to provide certain information to the Child Support Services Department(CSSD) concerning its employees and business licensees. It further requires that bidders or proposers for County contracts provide directly to the Child Support Services Department information concerning their"Principal Owners," that is, those natural persons who own an interest of 10 percent or more in the Contractor. For each "Principal Owner," the information which must be provided to the Child Support Services Department is: 1) the Principal Owner's name, 2) his or her title, and 3)whether or not the Contractor has made a payment of any sort to the Principal Owner. IN ORDER TO COMPLY WITH THIS REQUIREMENT, COMPLETE THIS FORM AND SUBMIT IT DIRECTLY TO THE CHILD SUPPORT SERVICES DEPARTMENT AT THE ADDRESS OR FAX NUMBER SHOWN BELOW ON OR ' BEFORE THE DATE YOU SUBMIT A BID OR PROPOSAL TO A COUNTY DEPARTMENT. MAINTAIN DOCUMENTATION OF SUBMISSION. SOLE PRACTITIONER MEMBERS OF AN ASSOCIATION MUST COMPLETE AND SUBMIT INDIVIDUAL FORMS. In addition, bidders or proposers must certify to the soliciting County department that they are in full compliance with the Program requirements by submitting the Child Support Compliance Program Certification along with the bid or proposal. ' To: Child Support Services Department Special Projects P.O. Box 911009 Los Angeles, CA 90091-1009 1 FAX: (323) 869.0634 Telephone: (323) 832-7277 or (323) 832-7276 Contractor or Association Name as Shown on Bid or proposal: cOIZN s LEE, INC_ Contractor or Associated Member Name, if Contractor is an Association: Contractor or Associated Member Address: 1470 south valley Vista Drive, suite 230 Diamond Bar, CA 91765 Telephone: (909) 861-0816 FAX: (909) 860-3995 ' County Department Receiving Bid or Proposal: Crn,mixaxry Development Commission E 090302 Type of Goods or Services To Be Provided: Claims Administration ' Contract or Purchase Order No. (if applicable): BFP am- ER090302 Principal Owners: Please check appropriate box. If box I is checked, no further information is required. Please sign and date the form below. ' I. [ ) No natural person owns an interest of 10 percent or more in this Contractor. II. [g ] Required principal owner information is provided below. (Else a separate sheet i ' necessary.) Name of Principal Owner Title Pavment Received From Contractor ' 1. Gary M. Lee President IrRm [NO] 2. Bernard Colen Vice President [ ] [NO] ' 3. [YES] [NO) 1 declare under penalty of perjury that the foregoing information is true and correct. By: -( &-V - Date: september 1,2, 2002 (Signature of a principal owner, an officer, or manager responsible for submission of the bid or proposal to the County.) Bernard Colen Vice President (Print Name) (Title/Position) 1 ' APPENDIX E SAMPLE LOSS EXPERTENCE REPORTS 1 1 1 1 1 ' 55 w w w w w w w w w w w w w w w w w w w CITY OF PALM SPRINGS WORKERS COMPENSATION CLAIMS LMNAGEMENT REPORTS AS OF DECEMBER 31, 2002 for Sue mills aL Cicy of Palm Springs N■11 � � � i �1 r � � 1■11 i r � r � � � � � DECEMBER 31, 2002 PAGE 1 PREPARED BY COLE7! & LEE CITY OF PALM SPRIFlGS WORKERS COMPENSATION CLAIMS f•1ANAGFMEpi REPNRTS TABLE OF COi9TENIS Table of Contents 1 General Information 2 Summary by Year 3 Allocation Report 7 Voucher/Check Register g Transaction Report 10 Claims Opened this Month lq Claims Closed this Month 16 Active Claims Listed by Allocation iS DECEMBER 31, 2002 PREPARED BY PAGE 2 COLEM & LEE CITY OF PALM SPRINGS WORKERS COMPENSATION CLAIMS MANAGEMENT REPORTS GENERAL INFORMATION DISTRIBD110N LIST 1. Sue Y.ills, City Of Palm Springs, 3200 East Tahquitz Canyon Way, Palm Springs, CA 92262 2 Zara Mac Mullen, City of Palm Springs, 3200 East Tahquitz Canyon Way, Palm Springs, CA 92262 KEY TU ABBREVIATIONS MED = Medical TO = Temporary Disability ATTY = Attorney D = Denied 1§ = Life Medical IND = Indemnity PD = Permanent Disability INV = Investigation E = Excess P = Police Officer ESP = Expense VR = Voc Rehab OTH = Other F = Fire Fighter S = Subrogated MI = Mileage VRTD = Voc Rehab TD L = Litigated R = Rehab INFORMATION CONTACT Jill-Mane Andreski c/o Colen & Lee, 1470 South Valley Vista Drive, Suite 230, Dianond Bar, California 91765, Telephone (909) 861-OB16 DECEMBER 31, 2002 PREPARED BY PAGE 3 COLEN S LEE CITY OF PALM SPRINGS WORKERS COMPENSATI➢N CLAIMS SUMMARY BY YEAR MED/.M/YR TDIPDIVRTD AIWIIIVIDTHER RED/INOIEXP SUB40 RECOYERYI POLICY YEAR PERIOD OPEN CASES TOTAL CASES DAYS LOST BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED PAID-TO-DAIE PAID-TD-DATE PAID-TO-BAIE LIABILITY 07/01/74 THRU 06/30/75 1 2 161 8,291.99 2,720 00 1.544.09 22,858 01 -8,452.26 8.40 30,836.77 0.00 0 D0 59,663.55 0.00 0.00 1,856.55 0.00 07/01/75 THRU 06/30/76 0 1 0 32,999.19 1,794.OG 0.00 0.00 Q.00 0.00 5,545.42 0.00 0.00 41,991 63 0 00 0.00 1,653.02 0 00 07/01/76 THRU 06/30/77 0 3 58 56,474.20 1,973.65 3,193 80 0.00 0.00 0.00 15,934.70 0.00 0 00 82,115.00 0 00 0.00 4,538.57 0 00 07/01/77 THRU 06/30/78 0 2 0 3,4B1.20 0.00 613.50 0.00 0.00 126.G1 525 40 0.00 0 00 4,786.87 0.00 0 00 60.16 0 00 07/01/78 THRU 06/30/79 0 4 155 20.9B7 16 9,52d.73 9,547 66 0.00 0.00 1,057.35 11,297.50 1,390 77 0.00 72,232.43 7,967.51 6,776.00 3,6B3.75 0.00 07/01/79 THRU 06/30/80 0 2 40 8,325.95 880,00 1,076.80 0.00 0.00 0.00 472.50 O.DD 0 00 10,859.33 0.00 0.00 104.08 0 00 07/01/80 THIRD 06/30/81 0 5 40 15.929.59 943,00 28,382.52 0 00 0.00 4.20 22,905.72 2,284.29 0 00 74.266.36 1,934.75 0.00 1,902.29 0.00 07/01/81 TNRU OS/30182 0 3 28 7,039.55 1,050.00 7,483.75 0,00 0.00 46.20 11,001 64 826.86 0.00 27,948.60 0.00 0 00 500.60 0.00 07/01/82 THRU 06/30/03 0 2 0 9,517.29 350.00 7,392 66 0.00 0.00 46.20 35,012.33 3,599 15 0.00 58,342.90 D.DO 0.00 2,425.27 0.00 07/01/83 THRU 06/30/84 0 4 50 10,845.4H 1,380.02 900 OD 0.00 -4,500.00 120.00 5,330,00 0.00 0 00 14,075.50 0.00 0.00 0.00 0.00 DECEMBER 31, 2002 PREPARED BY PAGE 4 COLEN & LEE CITY OF PALM SPRINGS WORKERS COMPENSATION CLAIMS SHk ARY BY YEAR MED/MI/VR TD/PD/VRTD ATTY/INVIOTHER MED/IND/EXP SHBRO RECOVERY/ POLICY YEAR PERIOD OPEN CASES TOTAL CASES DAYS LOST BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED PAID-TO-DATE PAID-ID-DATE PAID-TO-DATE LIABILITY 07/01/84 THRU 06/30/85 1 42 616 136,150.10 12,987.31 25,969.73 30,429.28 -8.500.00 407.06 61,052.10 4,851.35 0.00 304,148.67 10,705.95 6,384.OD 3,711.79 D.00 07/01/85 THRU 06/30/86 0 41 607 71,772.80 19,088.00 9,927.44 0.00 -1,483 40 427.59 128,738.12 1,299.45 0.00 239,061.04 5,973 43 0.00 3,317.61 0.00 07/01/86 THRU 06/30/87 D 34 34 32,297.95 1,088.00 6,187.05 0.00 -10,783.9E 110.70 33.935.79 329.50 0.00 63.771.81 0 00 0.00 606.80 0.00 07/01/87 THRU 06/30/98 D 45 119 25,986.24 3,808.00 755.50 0.00 -30 00 262.34 27,875.D0 2,931.00 0.00 61,B24.32 0.00 0.00 236.24 0.00 07/01/88 THRU 06/30/89 0 56 109 56,707 90 3,719.6U 11,155.36 0.00 -4,196 75 164.48 41,072.00 106.00 0.00 110,932 29 234.00 0.00 1,969.70 0.00 07/01/89 THRU 06/30/90 0 45 889 43,617.23 25,037.36 8,779,30 0.00 -656.90 1,300.17 22,630.00 3,106.73 0.00 130,290-.95 14,541.84 11,420.50 424.72 0.00 0710119D TRRU O6/30/9t 0 58 1.617 108,334.93 64,607.00 38,091.31 0.00 -13,162.51 4,219.12 80,016.60 1,940.,05 0.00 321,572.80 20,374.53 12,383.78 4,767.99 0,00 07/01/91 THRU 06/30/92 0 43 555 39,342.6E 29,370.58 20,806.17 0,00 -3,328.00 442.9B 89,180.00 3,427.20 0,00 220,770.63 28,529.17 10,015.75 2,984.10 0,00 07/01/92 THRU O6/30/93 0 60 361 62,7BB 01 34,412.00 8,753.30 0.,00 0.00 065 2B 78,863 00 0.00 0.,00 208,533.16 23,914.44 0.00 1,137.13 0.00 07/O1/93 THRU 06/30/94 1 79 2,026 217,961 67 95,899 B2 28,967.50 10.366.58 -2,980 40 4,500.38 133,445.00 410.00 0.00 553,066.33 49,644.32 10,577.95 4,156.86 116.65 DECEMBER 31, 2002 PREPARED BY PACE 5 COLEN & LEE CITY OF PALM SPRINGS WORKERS COMPENSATION CLAIMS SUMMARY BY YEAR MED/r4I/VR TO/PD/VRTD ATTY/INWOTHER MED/IND/EXP SUER RECOVERY/ POLICY YEAR PERIOD OPEN CASES TOTAL CASES DAYS LOST BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED PAID-TO-DATE PAID-TO-DATE PAID-TO-DAME LIABILITY 07/01/94 TURD 06/30/95 0 57 252 51,74D B5 20,892.70 11,580 31 0 00 0.00 642.22 85,720.00 150 DO 0.00 199,496 42 14,281.71 0.0U 4,488 63 0.00 07/01/95 THRU OG/30/96 1 57 2,098 107,465 44 114,847.37 37,097.62 100.00 -6,402.47 1,774 52 91,397.IB 735 6O 100 00 392,5B9 16 28,235.06 1,081.95 10,055 91 100.00 0710119G THRU O6/30/97 1 82 2.035 140,991 42 2B9,B90.20 4B4O61.27 179,46B.15 0.00 4,643.35 190,618.99 269 20 0 00 919,904 29 58,082.81 0.00 7,878 90 0.00 07/01/97 THRU 06/30/98 3 BO 1,064 98,994.17 142,020.60 31,648.48 76,792 93 0.00 1,438 35 82,790.B7 0.00 37,393 96 502,085.56 21,227.42 0.00 9,778 78 0 00 07/01/98 THRU 0613D199 5 72 2.228 1B9,524.74 320,374 27 53,250.37 175,652 77 -229.04 5,149.58 241,332.73 1,481.87 305,478 OB 1,362,604.04 53,837.33 806.52 B,120.17 7,824 65 07/01/99 THRU O6/30100 4 73 1,641 111,121.78 205,380.39 35,181.n 36,533 56 O.UO 4,550.38 137,41D.93 2,476.90 8,361 98 574.901.18 20,210.52 D.00 6,406.25 7,267 25 07/01/00 THRU O6/301U1 7 73 973 130,149.26 150,415.52 26,02B.90 67,956 43 0.00 2,072.45 77,724.9E 525.50 150,859.94 623,948.70 1,549.50 4,615.57 3,445.14 8,8U5.51 07/01/01 THRU 06/30/02 5 67 14B 78,948.99 19,760.90 11,1B0.50 58,26U 38 -24,000.00 385.78 16,651.09 0.00 79,414 19 251,705.39 669.50 O.DO 2,035 74 7,598.32 07/01/02 THRU 06/30/03 22 46 lOB 12,777.02 8,260 50 0.00 37,647.55 0.00 174.08 131.50 0.00 12,944.48 79.135.13 0.00 0.00 0.00 7,200.00 �1 � �1 ■■1 ■1■ !� � � � � ■■1 1� � �1 � �1 � � !■11 DECEMBER 31, 2002 PREPARED BY PAGE 6 COLEN & LEE CITY OF PALM SPRINGS WORKERS CDISPENSATION CLAIMS SUMMARY BY YEAR MEDIMIM TDJPD/VRTO AT TV I INVIOTH ER I.IEDIIND/EXP SUBRO RECOVERY/ POLICY YEAR PERIOD OPEN CASES TOTAL CASES DAYS LDS! BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED PAID-TO-DATE PAID-TO-0ATE PAID-TO-DATE LIABILITY TOTALS FOR ALL YEARS 51 1,13B 18,012 1,890,544.86 1,582,475.52 471.556.15 696,065.62 -BB,705.71 35,029.77 1,785,247.84 32,122.42 534,352.63 7.556.624.04 361,313.79 64,062.02 93,046 75 3B,912.38 DECEMBER 31, 2002 PREPARED BY PAGE 7 COLEN & LEE CITY OF PALM SPRINGS WORKERS COMPENSATION CLAIMS ALLOCATIONi REPORT ALLOCATION SUB-ALLOCATION PAID THIS MONTH PAID YEAR-TO-SATE 0001 - CITY COUNCIL & CITY TREASURER 0.00 0.00 0002 - CITY CLERK 0010 - ADMINISTRATION 0.00 O.OB 0011 - CODE ENFORCEMENT 192.42 517.20 0003 - ADMINISTRATIVE SERVICES 0012 - AOM I NI S!RAI ION 0 00 -472.601 0014 - FINANCE 0.00 0.00 0015 - INfORMAI(DN SERVICES 0.00 0.00 0016 - SUPPORT SERVICES 0.00 0.00 0017 - PERSONNEL 0.00 0.00 0018 - HOUSING 0.00 1,58S.49 0019 - GRANTS 0.00 0.00 0020 - ECO NON IC DEVELOPMENT 0.00 O OD 0004 - POLICE 0021 - ADM I N I S!RAI IDN 1,309.50 51,757.70 0022 - FIELD SERVICES 15,225.71 131,850.99 0023 - INVEST[GATIOIIS Mo.00 12,084.84 0024 - OISPAICR 134.86 305.18 0005 - PUBLIC WORKS 0024 - AOMINISIRAIION 0.00 0.00 0025 - ENGINEERING 0.00 0.00 0026 - PUBLIC WORKS 1,868.04 12,888.20 0027 - BUILDING 0.00 52.02 0028 - PLANNING 0.00 0.00 OOOS - RECREATION SERVICES 0029 - ADMINISIRA3ION 0.OD 0.00 0030 - RECREATION 417.19 1,227.53 0031 - COMMUNITY SERVICES 0.00 0.00 0007 - CITY VOLUNTEERS 1000 - ALL LOCATIONS 0.00 0.00 TOTAL 19,827.72 211,797.55 DECEMBER 31, 2002 PREPARED BY PAGE 8 COLEN & LEE CITY OF PALM SPRINGS WORKERS COMPENSATION CLAIMS VOUCHER/CHECK REGISTER NUMBER DATE AMOUNT PAYEE DESCRIPTION CLAMANT CODE CASE NO. 12/04/02 990.00 GEORGE MARTINEZ SALARY CONTINUATION P-u7RTINEZ, GEORGE 0005 02-0026 1211B102 280.00 GEORGE MARTINEZ SALARY CONTINUATION M0TINEZ, GEORGE 0005 02-0026 12/19/02 -24,000.00 INTER NATIONAL BANK SUBROGATION RECOVERY F0.2D, fiICHAEL 0004 01-0006 12/23/02 3,454.60 JOHN PANIQUE SALARY CONTINUATION PANIQUE, JOHN 0004 02-0039 014447 12/03/02 340.00 HERBERT CRANTON PERMANENT DISABILITY CRANTON, HERBERT 0004 98-0059 01444E 12/03/02 3 97 I.IEDREVIE'W INC. MEDICAL BILL REVIEW RDDRIGUEZ, ENRIQUE 0004 02-0025 014449 12/03/02 97.48 IRWLNDALE INDUSTRIAL MEDICAL CLINIC MEDICAL TREATMENT RODRIGUEZ, ENRIQUE 0004 02-0025 014450 12/04/02 569.50 OONALD FRENCH PERMANENT DISABILITY FRENCH, QDNALD 0004 98-0052 014451 12/04/02 2BO.00 HECTOR GARAY PERMANENT DISABILITY GARAY, RECTOR 0004 01-0034 014452 12/05/02 340 00 R08ERT CURTIS PERMANENT DISABILITY CURTIS, ROBERT 0004 98-0064 014453 12/05/02 103.96 WORKING RA MEDICAL PRESCRIPTION BENNETT, MICHAEL 0004 97-0060 014454 12/09/02 9B.31 IRWINDALE INDUSTRIAL MEDICAL CLINIC MEDICAL TREATMENT HARPER, RICHARD 0004 02-0027 D14455 121G9102 3 34 I.IEOREVIEW INC. MEDICAL BILL REVIEW HARPER, RICHARD 0004 02-0027 014456 12/10/02 320 00 RICHARD LEGARRA PERMANENT DISABILITY LEGARRA, RICHARD 0004 01-0033 014457 12/11/02 340.00 MA%II.IIANO GARCIA PERMANENT DISABILITY GARCIA, NA%IMIANO 0004 00-0021 D1445B 12/12/02 B5.68 IRWINDALE INDUSTRIAL MEDICAL CLINIC MEDICAL TREATMENT BISHOP, GAIL 0002 02-0019 014459 12/12/02 2 28 I.IEOREVIEW INC. MEDICAL BILL REVIEW BISHOP, GA[L 0002 02-0019 014460 12/12/02 LB4 44 WORKING RA MEDICAL PRESCRIPTION -SPANTO, TED 0004 97-0038 014461 12/12/02 4 62 I.IEDREVIEW INC. MEDICAL BILL REVIEW ESPARTO, TED 0004 97-0038 014462 12/12/02 400.00 POMONA SURGICAL SUPPLY COMPANY MEDICAL TREATMENT ESPANTO, TED 0004 97-0038 014463 12/12/02 346.10 WORKING RX MEDICAL PRESCRIPTIONI ESPANTO, TED 0004 97-0038 014464 12/12/02 120.03 ROBERT MC CAULEY, I.I.D. MEDICAL TREATMENT ESPARTO, TED 0004 97-0038 014465 12/12/02 3.94 MEDREVIEW INC. MEDICAL BILL REVIEW ESPARTO, TED 0004 91-0038 014466 12/16/112 18 02 MEDREVIEW INC. MEDICAL BILL REVIEW ORTIZ, GILBERT 0006 02-0032 U14467 12/16/02 399 17 IRWINDALE INDUSTRIAL MEDICAL CLINIC MEDICAL TREATMENT ORTIZ, GILBERT 0006 02-0032 U1446B 12/16/02 88.70 APOLLO ENTERPRISES MEDICAL PRESCRIPTION FRENCH, DONALD 0004 9B-0052 D14469 12/16/02 42.84 IRWINDALE INDUSTRIAL MEDICAL CLINIC MEDICAL TREATMENT NUNEZ, JESUS 0005 02-0011 014470 12/16/02 222 49 IRWINDALE INDUSTRIAL MED[CAL CLINIC ,E DI CAL TREATMENT RODRIGUEZ, RICHARD 0005 02-OOIB 014471 12/16/02 7.88 MEDREVIEW INC. MEDICAL BILL REVIEW RODRIGUEZ, RICHARD 0005 D2-0018 014,02 12/16/02 55 83 SANDSTONE PHYSICAL THERAPY MEDICAL TREATMENT RODRIGUEZ, RICHARD 0005 02-0018 014473 12/16/02 15 9B MICHAEL HEMENWAY MEDICAL MILEAGE HEMENWAY, RICHAEL 0004 01-0055 014F74 12/16/02 48 83 MEDREVIEW INC. MEDICAL BILL REVIEW HEMENWAY, MICHAEL 0004 01-0055 014A75 12/16/02 72 25 CALIFORNIA EM-1 I•IED SERVICES, DEPT. Q58 RE DI CAL TREATMENT HEMENWAY, MICHAEL 0004 01-0055 014476 12/16/02 103.37 IRWINDALE INDUSTRIAL MEDICAL CLINIC MEDICAL TREATMENT NCCAULEY, SCDTT ODDS 02-0034 D14477 12/16/02 9.D3 MEDREVIEW INC. ;E DI CAL BILL REVIEW MCCAULEY, SCDTT OD05 02-0034 014478 12/16/02 131.05 IRWINDALE INDUSTRIAL MEDICAL CLINIC MEDICAL TREATMENT VARELA, KARINA 0004 02-0035 014479 12/16/02 3 81 MEDREVIEW INC. MEDICAL BILL REVIEW VARELA, KARIMA 0004 02-0035 014480 12/17/02 340.00 HERBERT CRANTON PERMANENT DISABILITY CRANTOa, HERBERT 0004 98-0059 014481 12/18/02 280.00 HECTOR GARAY PERMANENT DISABILITY GARAY, HECTOR 0004 01-0034 014482 12/18/02 569.50 DONALD FRENCH PERMANENT DISABILITY FRENCH, DUTALD OD04 9B-0052 014483 12/18/02 166.60 GEORGE MARTINEZ MEDICAL S[LEAGE MARTINE2, GEORGE OD05 02-0026 DECEMBER 31, 2002 PREPARED BY PAGE 9 COLEN & LEE CITY OF PALS SPRINGS WORKERS CaNIPENSATI0N CLAIMS VOOCHERICHECK REGISTER NUMBER DATE MIOBNI PAYEE DESCRIPTION CLAIMANT CODE CASE NO. 014484 12/18/02 138.89 WDRKING RA MEDICAL PRESCRIPTION SYRJA, RANDEL 0004 96-0065 014485 12/18/02 84 55 CHARLES SADLER. M.D. MEDICAL TREATMENT FDRD, MICHAEL 0004 01-0006 014486 12/18/02 31 70 FEDREVIEW INC. RED€CAL BILL REVIEW ECRU, MICHAEL 0004 01-0006 014487 12/19/02 340.00 RDBERT CURTIS PERMANENT DISABILITY CURIIS, RDBERT 0004 98-0064 014488 12/19/02 1,340.DD JDHN MONTGOMERY PERMANENT DISABILITY MDNIGCMERY, JOHN 0004 99-0070 014489 12/19/02 1,200 00 LEWIS, NARENSTEIN, WICKE G SHERWIli APPLICANT ATTORNEY FEE [PD] LDNIGDMERY, JOHN 0004 99-0070 014490 12/19/02 878 25 LAW OFFICE OF JOHN B. THARP DEFENSE ATTORNEY EXPENSE ADNTCDMERY, JOHN 0004 99-0070 014491 12/20/02 430 50 WORKING RA REDFCAL PRESCRIPTION CURTIS, RDBERT 0004 9R-0064 014492 12/23/02 2.52 MEDREVIEW INC. REDFCAL BILL REVIEW AYALA, SUZIE 0002 02-0022 D144D 12/23/02 94 45 IRWIN'DALE INDUSTRIAL MEDICAL CLINIC MEDICAL TREATMENT AYALA, SU71E 0002 02-0022 014494 12/23/02 32D 00 RICHARD LEGARRA PERMANENT DISABILITY LEGARRA, RICHARD 0004 01-0033 014495 12/24/02 7.48 PETER LIM MEDICAL MILEAGE LIM, PETER 0002 02-0023 014496 12/24/02 340.00 MAXIMIANO GARCIA PERAIIENT DISABILITY GARCIA, MAXIMIANO 0004 00-0021 014497 12/24/02 25,177 00 SAINT MARYS REGIONAL MEDICAL REDICAL RBSPITALIZATIDN BROWN, RICHARD 0004 84-0022 014498 12/26/02 146 77 JOHN A GIDDINGS, M.D. REDFCAL TREATMENT SYRdA, RANDEL 0004 96-0065 014499 12/26/02 41 05 MEDREVIEW INC. RED,CAL BILL REVIEW SYRJA, RANDEL 0004 96-0065 014500 12/30/02 318.50 LIEBMAN & ASSOCIATES REHAB COUNSELOR FEE LEGARRA, RICHARD 0004 01-0033 014501 12/30/02 351.OD LIEBMAN & ASSOCIATES REHAB COUNSELOR FEE LEGARRA, RICHARD 0004 01-0033 014502 12/31/02 28G 00 HECTOR GARAY PERMANENT DISABILITY GARAY, HECTOR 0004 01-0034 014503 12/31/02 569 50 DONALD FRENCH PERMANENI DISABILITY FRENCH, DONALD 0004 98-0052 014504 12/31/02 340 00 HERBERT CRANTON PERMNENI DISA.BILIIY CRANTON, HERBERT 0004 98-0059 014505 12/31/02 280.42 WDRKING RA RED€CAL PRESCRIPTION SYRJA, RANDEL 0004 96-0065 014506 12/31/02 181.53 WDRKING RA MEDICAL PRESCRIPTION BENNETT, MICHAEL 0004 97-0060 TOTAL 19,827.72 DECEMBER 31, 2002 PREPARED BY PAGE 10 COLEM & LEE CITY OF PALM SPRINGS WORKERS COMPENSATION CLAIMS TRANSACTION REPORT NUMBER DATE AMOUNT PAYEE FROM THRU DAYS LOST CLAIMANT CODE CASE MD. APPLICANT ATTORNEY FEE {PO] 014489 12/19/02 1,2UO.U9 LEWIS, MAP,ENSIEIM, WICKE & SHERWIN 12/19/02 12/19/02 MONTGOMERY, JOHN 0004 99—D070 SUBTOTAL 1,200.00 DEFENSE ATTORNEY EXPENSE 014490 12/19/02 878.25 LAW OFFICE OF JOHN B. THARP 09112102 12/11/02 MONTGOMERY, JOHN D004 99—DO70 SUBTOTAL 878 25 MEDICAL BILL REVIEW 014448 12/03/02 3.97 MEDREVIEW INC 11113102 11/13/02 R00RIGUEZ, ENRIRUE D004 02-0025 U14455 12/09/02 3.34 MEDREVIEW IMC. 11/11/02 11/11/02 HARPER, R[CHARD 0004 02-0027 U14459 12/12/02 2.28 MEDREVIEW IMC. 12/02/02 12/02/02 BISHOP, GAIL 0002 02—OOL9 014461 12/12/02 4.62 MEDREVIEW INC. 11/25/02 11/25/02 ESPANTO, TED 0004 97—D038 014465 12/12/02 3 94 Id E DR EVI EW INC. 12/05/02 12/05/02 ESPANTO, TED 0004 97-0038 014466 12/16/02 18.02 MEDREVIEW INC. 12/03/02 12/03/02 ORTIZ, GILBERT 0006 02-0032 014471 12/16/02 7.88 MEDREVIEW [MC, 11/21/02 11121102 RODRIGUEZ, RICHARD 0005 02-0018 014474 12/16/02 48.83 MEDREVf EW [MC, 11/13/02 11/13/02 HEMENWAY, MICHAEL 0004 01-0055 (114477 12/16/02 9.03 MEDREL'l EW IMC 12/03/02 12/03/02 I.ICCAULEY, SCOTT 0005 02-0034 U14479 12/16/02 3.81 MEDREVIEW INC. 121031D2 12/03/02 VARELA, KARINA 0004 02-0035 U14486 12/18/02 31.70 MEDREL'IEW IMC. 10/30/02 10/30/02 FORD, MICHAEL 0004 01—D000 U14492 12/23/02 2.52 MEDREVIEW INC. 12/05/02 12/05/02 AYALA, SOZIE 0002 02-0022 D14499 12/26/02 41.05 MEDR EV IEW IMC. 12/11/02 12/11/02 SYRJA, RANDEL 0004 96-0065 SUBTOTAL 180.99 MEDICAL HOSPITALIZATION 014497 12/24/02 25,177.00 SAINT MARYS REGIONAL M_DICAL 06/16/02 06/20/02 BROWN, RICHARD 0004 B4-0022 SUBTOTAL 25,177 00 DECEMBER 31. Z002 PREPARED BY PAGE 11 COLEN G LEE CITY OF PALM SPRINGS 1,'DRKERS COMPENSATION CLAIMS TRANSACTION REPDRT NUMBER DATE AMOUNT PAYEE FROM THRU DAYS LOST CLAIMANT CODE CASE NO MEDICAL MILEAGE 014473 12/16/02 15.98 MICHAEL HEMENW,4Y 01/08/03 01/08/03 HEMENWAY, MICHAEL 0004 O1-0055 014483 12/18/02 166.60 GEDRGE MARTINEZ 10/30/02 1Z/04/02 MARTINEZ, GEORGE 0005 02-0026 014495 12/24/02 7.48 PETER LIM 09/12/02 09/12/02 LIM, PETER 0002 02-0023 SUBTOTAL 190.06 MEDICAL PRESCRIPTION 014453 12/05/02 103.96 WORKING RA 10/29/02 10/29/02 BENNETT, MICHAEL 0004 97-0060 014460 12/12/02 184.44 WORKING RA 11/06/02 11/06/02 ESPANTO, TED 0004 97-0038 014463 12/12/02 346.10 WORKING RX ll/1B102 11/18/02 ESPANTO, IED U04 97-0038 0144H 12/16/02 88.70 APOLLO ENTERPRISES 11/11/02 11/11/02 FRENCH, DONALD 0004 98-0052 014484 12/18/02 138.89 'WORKING RA 11/02/02 11/02/02 SYRJA, RANDEL 0004 96-DUBS 014491 12/20/02 430.50 WORKING RA ll/18/02 11/18/02 CURTIS, ROBERT 0004 98-0064 014505 12/31/02 280.42 WORKING RX 11/21/02 12/04/02 SYRJA, RANDEL 0004 96-0065 014HB 12/31/02 181.53 'WORKING RX 11/25/02 12/02/02 BENiNETT, 4ICHAEL 0004 97-0060 SUBTOTAL 1,754 54 MEDICAL TREATMENT D14449 12/03/02 97.48 1R'WINDALE INDUSTRIAL MEDICAL CLINIC 10/14/02 10/14/02 RODRIGUEZ, ENRIQUE 0004 02-0025 014454 12/09/02 98.31 IRWINDALE INDUSTRIAL MEDICAL CLINIC 10/05/02 10/05/02 HARPER, RICHARD OD04 02-0027 014458 12/12/02 85.6E IRWINDALE INDUSTRIAL MEDICAL CLINIC 10/21/02 10/23/02 BISHOP, GAIL 0002 02-0019 014462 12/12/02 400.00 POMONA SURGICAL SUPPLY COMPANY 11/12/02 11/12/02 ESPANTO, TED D004 97-003B 014464 12/12/02 120.03 ROBERT N.0 CAULEY, N.0 11/15/02 11/15/02 ESPANTO, TED 0004 97-003B 014487 12/16/02 39917 IRWINDALE INDUSTRIAL 8EDICAL CLINIC 10/29/02 11/04/02 ORT12, GILBERT 0006 02-0032 D144B9 12/16/02 42.84 IRWINDALE INDUSTRIAL 8EDICAL CLINIC 10108102 10/08/02 NUNEZ, JESUS 0005 02-0017 D14470 12/16/02 222.49 IRWINDALE INDUSTRIAL MEDICAL CLINIC 10/10/02 10/10/02 RODRIGUEZ, RICHARD 0005 02-0018 D14472 12/16/02 55.B3 SANDSTONE PHYSICAL THERAPY 10/10/02 10/14/02 RODRIGUEZ, RICHARD 0005 02-0018 014475 12/16/02 72 25 CALIFDRMIA EM-1 RED SERVICES, DEPT. Q58 04/14/02 04/14/02 HENENWAY, MICHAEL 0004 01-0055 014476 12/16/02 103.37 IRWINDALE INDUSTRIAL MEDICAL CLINIC 10/30/02 10/30/02 MCCAULEY, SCOTT 0005 02-0034 01447E 12/16/02 131.05 IRWINDALE INDUSTRIAL MEDICAL CLINIC 10/31/02 10/31/02 VARELA, KARINA 0004 02-0035 0144B5 12/18/02 84 55 CHARLES SADLER, M.D. 08/02/01 OB102101 FORD, MICHAEL 0004 a1-0006 014493 12/23/02 94.46 IRW'INDALE INDUSTRIAL MEDICAL CLINIC 10/23/02 10/26/02 AYALA, SUZIE 0002 02-0022 014498 12/26/02 146.77 JOHN A. GIDDINGS, bI.D. 11/13/02 11/13/02 SYRJA, RANDEL 0004 96-0065 DECEMBER 31, 2002 PREPARED BY PAGE 12 COLEN 9, LEE CITY OF PALM SPRINGS WORKERS COMPENSATION CLAIMS TRANSACTION REPORT NUMBER DATE AMOUNT PAYEE FROM THRU DAYS LOST CLAI4AIIT CODE CASE NO MEDICAL TREATMENT SUBTOTAL 2,154.28 PERMANENT DISABILITY 014447 12/03/02 340.00 HERBERT CRANTON 11/20/02 12/03/02 CRANTON, HERBERT 0004 98-0059 014450 12/04/02 569 50 DONALD FRENCH 11/Z1102 12/04/02 FRENCH, DONALD 0004 98-0052 014451 12/04/02 280.00 HECTOR GARAY IlIZI102 12/04/02 GARAY, HECTOR D004 01-0034 014452 12/05/02 340.00 ROBERT CURTIS 11/22/02 12/05/02 CURTIS, ROBERT D004 98-0064 014456 12/10/02 320 00 RICHARD LEGARRA 11/27/02 12/10/02 LFGARRA, RICHARO D004 01-0033 014457 12/11/02 340 00 E.AXI?4i ANO GARCIA 11128IO2 12/11/02 GARCIA, MAXIMIANO 0004 00-0021 0144B0 12/17/02 340.00 HERBERT CRANTON 12/04/02 12/17/02 CRANTON, HERBERT D004 98-0059 014491 12/18/02 280.00 HECTOR GARAY 12/05/02 12/18/02 GARAY, HECTOR D004 01-OD34 014482 12/18/02 569 50 DONALD FRENCH 12/05/02 1211B102 FRENCH, DONALD D004 98-0052 014487 12/19/02 340 00 RUDER! CURTIS 12/06/02 12/19/02 CURTIS, ROBERT D004 98-0064 0144BU 12/19/02 1,340.00 JOHN F:ONTGDI•IERY 12/19/02 12/19/02 MONTG0MERY, JOHN 0004 99-0070 014494 12/23/02 320.00 RICHA4D LEGARRA 12/11/02 12/24/02 LEGARRA, RICHARD D004 01-0033 014496 12/24/02 340.00 PA%IMIANO GARCIA 12/12/02 12/25/02 GARCIA, MAXIMIANO D004 00-0021 014502 12/31/02 280.00 HECTOR GARAY 12/19/02 01/01/03 GARAY, HECTOR D004 01-0034 014503 12/31/02 569.5D DONALD FRENCH 12/19/02 01/01/03 FRENCH, DONALD D004 98-0052 014504 12/31/02 340.0D HERBERT CRANTON 12/18/02 12/31/02 CRANTON, HERBERT D004 98-0059 SUBTOTAL 6,908.5D REHAB IWNSELOR FEE 014500 12/30/02 318.50 LIEBHAN & ASSOCIATES 10/03/02 10/30/02 LEGARRA, RICHARD D004 01-0033 014501 12/30/02 351 DO LIEBPAN & ASSOCIATES 11/01/02 11/29/02 LEGARRA, RICHARD D004 01-0033 SUBTOTAL 669.50 SALARY CONTINUATION 12/04/02 980.00 GEORGE MARTINEZ 11/21/02 12/04/02 14 MARTINEZ, GEORGE 0005 02-0026 12/18/02 280.00 GEORGE MARTINEZ 12/05/02 12/08/02 4 MARTINE7, GEORGE D005 02-0026 12/23/02 3,454.60 JOHN PANIQUE 11/25/02 12/17/02 23 PANIQUE, JOHN 0004 02-0039 D€CEMBER 31, 2002 PREPARED BY PAGE 13 CDLEN & LEE CITY OF PALM SPRINGS WORKERS COMPENSATION CLAIMS TRANSACTION REPORT NUMBER DATE AMOUNT PAYEE FROM THRU DAYS LOST CLAIMANT CODE CASE NO. SALARY CONTINUATION SUBTOTAL 4,714.60 41 SUBRDGAYION RECOVERY 12/19/02 -24,OD0.00 INTER NAYIDNAL BANK 1 1 1 1 FORD, MICHAEL 0004 01-0006 SUBYOTA`=_ -24,000.A0 TOTAL 19,827.72 41 DECEMBER 31, 2002 PREPARED BY PAGE 14 COLEN & LEE CITY OF PALM SPRINGS WORKERS COMPENSATION CLAIMS OPENED THIS P.DNTH EMPLOYEE'S NAME YEAR DEPARTMENT INJURY DATE MEO/HI/VR TD/PD/VRTD ATTY/INV/OTHER MEO/IND/EXP SUBRO RECOVERY/ CAUSE OF INJURY CASE NO LOCATION CLOSING DATE BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED DESCRIPTION OF INJURY STATUS DSHA CODE DAYS LOST PAID-TO-DATE PAID-TO-GATE PAID-TO-DATE LIABILITY CAMARGO, DIANA 02/03 0004 12/11/02 0 00 O.DO 0.00 500.00 0.00 RIFLE TRAINING 0044 0023 0 00 0.00 0.00 O.Do 500.00 LEFT FOREARM NUMBNESS P 0010 0 0 00 0.00 0.00 0.00 CAMPA, DAVID 02/03 0004 12/09/02 0.00 0 00 0.00 250.00 0.00 TRAINING POLICE K-9 0041 0022 0 00 0 00 0.00 0 00 250.00 RIGHT ARM DOG BITE P 0010 0 0 00 0.00 0.00 O.OD CARRILLO, MITZUH 02/03 0004 12/09/02 0 00 D GO 0.00 100.00 0 00 FIRE RANGE TRAINING 0045 0023 0 00 0.00 0.00 0 00 100.00 LEFT EYE INSECT BITE P OOLO 0 0 oD 0.00 0.00 0.00 FAJARDO, MICHAEL 02/03 0004 12/09/02 0 00 0.00 0.00 I,D00.00 0 00 TAKING SUSPECT INTD CUSTD 0040 0022 0.00 0 00 0.00 0 00 1,000.00 RIGHT SHOULDER CDNTUS1ON P 0010 0 0 oD 0.00 0.00 0 00 FLORES, MATTHEW 02/03 0004 11/19/02 0 DO 0.00 0.00 1,000.00 0 00 TRIPPED ON DBJECT AND FEL 0038 0022 0 00 D.00 0.00 0.00 1,000 00 MULTIPLE P 0010 0 0.00 0.00 0.00 0 ON HERNANDEZ, WILLIAP, 02/03 0005 12/07/02 0.00 0.00 0.00 800 OD 0.00 STACKING BALES OF HAY 0042 0026 0.00 0.00 0.00 0 OD 800.00 RIGHT HAND INSECT DiTE 0010 0 D.00 0.00 0.00 0 00 KOLBACH, JAMES 02/03 0004 11/17/02 0.00 0.00 0.00 6,500 00 0.00 GETTING INTO POLICE VEHIC 0043 0023 O.DO 0.00 0.00 4,415 80 14,415.80 LOW BACK STRAIN P 0010 0 0.00 0.00 0.00 3,500 OD MEISTER, JOSEPH 02/03 0004 11/11/02 0.00 0 00 0.00 500 00 0.00 BIT BY DOG 0037 0022 0.00 0.00 0.00 0 00 500.00 RIGHT HAND PUNCTURE P 0010 0 0.00 0.00 0.00 0 00 PAN14UE, JOHN 02/03 0004 11/24/02 D 00 3.454.60 0.00 6,000.00 0 00 ALTERCATION WITH FELDIIY S 0039 0022 0.00 0.00 0.00 2,853.68 12,40B.2B RIGHT HAND FRACTURE P OD10 23 O.DD 0.00 0.00 100 00 RODRIGUEZ. ENRIQUE 02/03 0004 12/06/02 0 00 0.00 0.00 5,000.00 0.00 KEULAR VEST 0036 OD22 0.00 0.00 0.00 4,415 BB 12,915.00 ENTIRE BODY FUNGAL RASH P 0026 0 O.oO 0.00 0.00 3,500.00 DECEI.IBER 31, 2002 PREPARED BY PAGE 15 CDLEN 8 LEE CITY OF PALM SPRINGS WORKERS COMPENSATION CLAIMS OPENED THIS VDNTH EMPLOYEE'S NA4E YEAR DEPARTMENT INJURY DATE MEDIMIJVR TDIPDIVRTD ATTYIINVIOTF.ER f•1ED/INDIEXP SUBRO RECOVERY/ CAUSE OF INJURY CASE ND. LOCATION CLOSING DATE BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED DESCRIPTION OF INJURY STATUS OSHA CODE DAYS LOST PAID-TO-DATE PAID-TD-DATE PAID-TO-DATE LIABILITY RODRIGUEZ, RICHARD 02103 0005 10/10/02 0.00 0.00 0.00 2,500.00 0.00 PULLING BUT BROKEN TREE S 0046 0026 0 00 0 00 0 00 0.00 2,50D.OG LDW BACK SPRAIN 0010 0 0 00 0.00 0.00 0.00 TOTALS FOR CLAIMS OPENED THIS MONTH 23 0.00 3,454.50 0.00 24.150.00 0.00 NUMBER OF CLAIMS = 11 0.00 0.00 0.00 11,684.48 45,389.06 0 00 0 00 0.00 7,100.00 DECEMBER 31, 2002 PREPARED BY PAGE 16 COLEN & LEE CITY OF PALM SPRINGS WORKERS COMPENSATION CLAIMS CLOSED THIS MONTH EMPLOYEE'S NAME YEAR DEPARTMENT INJURY DATE MED/MI/YR TDIPDIVRTD ATTY/IMV10THER MED/IND/EXP SUBRO RECOVERY/ CAUSE OF INJURY CASE NO LOCATION CLOSING DATE BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED DESCRIPTION OF INJURY STATUS DSHA CODE GAYS LOST PAID-TO-DATE PAID-TO-DATE PAID-TO-DATE LIABILITY ACWtlA, GREGORY 96197 0004 02/19/97 22,687.02 61,355 46 8.178.96 0 00 0.00 TRAFFIC COLLISION 0052 0022 12/30/02 66.40 15,000 00 0 00 0.00 123,654.94 RIGHT SHOULDER PAIN LRP 0010 544 15,189.7E 0 00 1,177.32 0.00 BISHOP, GAIL 02103 0002 09/10/02 210.50 0.00 0.00 0.00 0.00 EXPOSED TO PERSON WITH TB 0019 0011 12/24/02 0.00 0.00 0 00 0.00 210.50 TEL EXPOSURE OD29 0 0.,00 0 00 O.DO 0.00 COLEY, GREG 02/03 0004 11/04/02 0.00 0.00 0.00 0 O0 0.00 STUGGLE WITH 01•fBA11YE SO 0033 0022 12/24/02 0.00 0.00 0 00 0.00 0.00 RIGHT HARD/KMEE LACERAIIO P 0010 O 0.00 0 00 0.00 0.D0 COLLASO, ERNEST 01/02 0004 09/07/01 3,489 71 0.00 0 00 0 D0 O 00 LIFTING A DUTY BAG 0027 0022 12/30/02 G.00 0.00 0 00 O 00 3,489.71 LUMBOSACRAL SPINE STRAIN P 0010 0 0.00 0.00 0 00 0.00 HARPER, RICHARD 02103 0004 10/05/02 101 65 0.00 0 00 0 00 0 00 ARRESTING COMBATIVE SUSPE 0027 0022 12/31/02 0 00 0.00 0 00 0 00 101 65 RT. WRIST/LEFT HAND CONTU P 0010 0 0.00 0.00 0 00 0 00 LIM, PETER 02/03 0002 09/10/02 122.54 O.AO 0 00 0 00 0.00 EXPOSED TO A PERSON WITH 0023 0011 12/24/02 7.4B O.OD 0 00 0.00 130.02 TB EXPOSURE 0029 0 0.00 0.00 0 00 0.00 MCCAULEY, SCDTT 02103 00115 10/30/02 112.40 0.00 0 00 0.00 0.00 STEPPED ON OBJECT 0034 0026 12/24/02 0.00 0.00 0 00 0.00 112.40 LEFT FDDT FOREIGN BODY 0010 0 0.00 U.00 0.00 0.00 NUNEZ, JESUS 02/03 0005 OB112/02 842.42 1,206.98 0 00 0.00 0.00 FAINTED DUE TO CHEUICAL U 0017 0026 12/27/02 0.,00 120.70 O 00 0.DO 2,170.10 LEFT LEGIANKLE CELLULITIS 0010 29 0.,00 0.00 0.00 0.00 ORTIZ, GILBERT 02I03 0006 10/29/02 417.19 0.00 0.00 0.00 0.00 FOOTBALL PRACTICE 0032 0030 12/24/02 0 00 0.00 0 D0 0 00 417.19 UPPER LIP LACERATION 0010 0 0 00 0.00 0 00 0.00 SYED, MADEEM 94/95 0005 07/18/94 12r764.7' 464.00 2,1B3 95 0 00 0.00 FELL DOWN STAIRS OOOB 0025 12/24/02 105.12 6,335.00 0.00 0 00 22,040.21 LOW BACK STRAIN L'S 0010 B 0.00 O.,DO 1B7.40 0.00 DECEMBER 31, 2002 PREPARED BY PAGE 17 COLEM & LEE CITY OF PALM SPRINGS WORKERS COMPENSATION CLAIMS CLOSED THIS MONTH EMPLOYEE'S NAME YEAR DEPARTMENT INJURY DATE MED/MI/VR TD/PD/VRTD ATTY/i N'710THER MED/IN07EXP SUBRO RECOVERY/ CAUSE OF INJURY CASE MD. LOCATION CLOSING DATE BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED DESCRIPTION OF INJURY STATUS DSHA CODE DAYS LOST PAID-TO-DATE PAID-TO-DATE PAID-TO-DATE LIABILITY ZABALA, MICHAEL 02/03 0005 09/26/02 52.02 0.00 0.00 0 00 0.00 RAN INTO METAL POLE 0030 0027 12/24/02 0.00 0.00 0.00 0.00 52_02 LEFT ORBITAL RIM CONTUSIO 0010 0 0.00 0.00 0.00 0.00 TOTALS FOR CLAIMS CLOSED THIS MDMTH 5B1 40,800.19 63,026.44 10,362.91 0 00 0 00 NUMBER OF CLAIMS = 11 179.00 21,455.70 0.00 0 00 152,378.74 15,189.78 0.00 1,364.72 0 00 DECEMBER 31, 2002 PREPARED BY PAGE 18 COLEN & LEE CITY DF PALM SPRINGS WORKERS COMPENSATION ACTIVE CLAIMS LISTED BY ALLOCATION EMPLOYEE'S :LAME YEAR DEPARTMENT INJURY DATE MED/MI/YR TDIPD/VRID ATTY/INVIOTRER MBE DI I ND/EXP SUBRO RECOVERY/ CAUSE OF INJURY CASE MD. LOCATION CLOSING DATE BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED DESCRIPTION OF INJURY STATUS OSHA CODE DAYS LDST PAID—TO—DATE PAID-10—DATE PAID—ID—DATE LIABILITY DEPARTMENT — CITY CLERK AYALA, SUZIE 02/03 0002 09I10/02 176.68 U.00 0.00 2,323.32 0.00 EXPOSED TO PERSON WITH TB 0022 0011 0 00 0 00 0 00 0.00 2,500.00 TB EXPOSURE 0029 0 0 00 0 00 0 00 0.00 TOTALS FOR THIS DEPARTMENT 0 176.68 0.00 0 00 2,323 32 0 00 NUIdBER OF CLAIMS = 1 0.00 0 00 0 DO 0.00 2.500.00 0 00 0 00 0 00 0.00 DECENBER 31, 2002 PREPARED BY PAGE 19 COL€N & LEE CITY DF PALM SPRINGS WORKERS COMPENSATION ACTIVE CLAIMS LISTED BY ALLDCATIOR EMPLOYEE'S NAME YEAR DEPARTMENT INJURY DATE MEDIMIIVR TDIPDIVRTD ATTVINV/OTHER f•IEDIINDIEXP SUBRO RECOVERY/ CAUSE OF INJURY CASE HD LDCATIDR CLOSING DATE BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED DESCRIPTI➢N OF INJURY STATUS OSHA CODE DAYS LOST PAID—TO—DATE PAID—TD—DATE PAID—TO—GATE LIABILITY DEPARTMENT — ADMINISTRATIVE SERVICES GUZMAN, PATRICIA 97/98 0003 03/03/97 11,575.27 4,379.10 0 00 14,253.78 0_00 UNKNOWN 0053 0018 70.95 2,100.00 0.00 15,600.90 48,292.22 Pd UTIPLE BODY PARTS 0026 DO 0 00 0 OD 312.22 0.00 STEWART, THELMA 74/75 0003 02/05/75 7,141 99 0.00 0.00 22,858 OL —B,452.26 CUP,ULATIVE TRAURAISTRESS 8003 0012 0.00 17,204 27 0 00 0.00 40,315.39 HEART PROBLEMS LM 0026 0 0.00 0 00 1,563.38 0.00 TOTALS FOR THIS DEPARTMENT 80 18,717.26 4,379 10 O.OD 37.111 79 —8,452.26 NUMBER DF CLAIMS = 2 70.95 19,304 27 0.00 15,600 90 W.6'J7.61 0.00 0 DO 1,875.60 0.00 ■w w■ w w w w ■w w w w w w w w w w w a■� w DECEMBER 31, 2002 PREPARED BY PAGE 20 COLEN & LEE CITY OF PALM SPRINGS WORKERS COMPENSATION ACTIVE CLAIMS LISTED BY ALLOCATION EMPtOYEE'S NAME YEAR DEPARTAENT INJURY DATE MED/MI/VR TD/PD/VRTD ATTY/Ifi V/OTHER MEDIUIDIEXP SUBRD RECOVERY/ CAUSE OF INJURY CASE NO. LOCATION CLOSING DATE BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED DESCRIPTION OF INJURY STATUS OSHA CODE DAYS LOST PAID-TO-DATE PAID-TO-DATE PAID-TD-DATE L€ABILITY OEPA4TNENT - POLICE AGDRCIA, DRALIA 99100 0004 06/2B/99 23,080.26 18.034.18 2,250.50 11,390.88 0.00 REPETITIVE MOTION 0003 0021 528.86 8,040.00 0.00 0.00 63,763.42 BILATERAL WRISTS LM 0026 276 344.50 0 00 94 24 0 00 BENNETT. MICHAEL 97/98 0004 OB/01/97 13,916.75 59,310.9E 5,751.15 32,922.88 0.00 CONTINUOUS STRESSISTRAL`! 0060 0022 176.70 27,063 5& D 00 0.00 150,373.32 HYPERTENSIOWLUMBAR SPINE LMERP 0026 365 10,251.21 0 00 920 15 0 0O BLACKBURN, S9AW4 02/03 0004 07/15/02 270.88 0.00 0.00 29.12 0 00 STRUGGLE WITH A SUSPECT 0010 0022 0.00 0.00 0 00 O.OD 300.00 RIGHT HAND/1EFT FOOTILOWE P 0010 0 0.00 G 00 0 00 0 OD BROWN, RICHARD 84185 0004 11/03/84 94,567.78 2,36B.00 1,421 76 30,429.28 0 00 CARDIOVASCULAR 0022 0022 2.94 20,154.93 0.00 0.00 150,449 46 HEART AND CIRCULATORY SYS LMRP 0026 74 931.65 0.00 573.12 0 00 CAMARGO, DIANA 02/03 0004 12/11/02 0.00 0 00 0 00 500 00 0 00 RIFLE TRAINING 0064 0023 0 00 0.00 0.00 0 00 SOO 00 LEFT FOREARil NUMBNESS P 0010 0 0 00 0.00 0.00 0 00 CAMPA, DAVID 02/03 0004 12/09/02 0.00 0.00 D.00 250 00 0.00 TRAINING POLICE K-9 0041 0022 0.00 0.00 0.00 0.00 250.00 RIGHT ARM DOG BITE P 0010 0 0 00 0.00 0.00 0.00 CARRILLO, M1TZUH 02/03 0004 121DBID2 0 00 0.00 0.00 100.00 0.00 FIRE RANGE TRAINING 0045 0023 0 00 0.00 0.00 0.00 100.00 LEFT EYE INSECT BITE P 0910 0 0 00 0.00 0.00 0.00 COLEY, GREG 02/03 0004 OB/24/02 174 01 0.00 0_00 325.99 0.00 CONTACT WITH CO-POLICE OF 0020 0022 0.00 0.00 0.00 0.00 500.00 LEFT MIDDLE FINGER CONTUS P 0010 0 0.00 0.00 0.00 0.00 CRANTON, HERBERT 98/99 0004 03/13/99 38,012.92 57,516.90 5,691.49 10,191.25 0.00 RESTRAINING SUSPECT 0059 0022 0.00 23,867.37 0.00 9,BB7.85 163.707.98 LEFT KNEE LMERP 0010 450 16,425.17 806.52 0,00 1,308.51 DECEMBER 31, 2002 PREPARED BY PAGE 21 C(ILEN & LEE CITY OF PALM SPRINGS WORKERS COMPEINSATION! ACTIVE CLAIMS LISTED BY ALLOCATION EMPLOYEE'S NAME YEAR DEPARTMENT INJURY DATE MED/NIIVR TD/PDIVRTO ATTYIIMVIOTHER MEO/INDIEXP SUBRO RECOVERY/ CAUSE OF INJURY CASE NO. LOCATION CLOSING DATE BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED DESCRIPTION OF INJURY STATUS OSHA CODE DAYS LOST PAID-TO-DATE PAID-TO-DATE PAID-TD-DATE LIABILITY DEPARTMENT - POLICE CURTIS, ROBERT 96199 0004 03/17/99 27,974 51 66,767.97 4,383,87 22,103.52 0 00 CONTINUOUS TRAU4A 0064 0022 229 41 30,485.18 0.00 22,795.41 193,300 00 HEART LMERP 0026 375 15,944.00 0.00 1,317.05 1,299.08 ESPANTO, TED 37/98 0004 10/22/97 20,374 43 3,206 94 0.00 29,616 27 0 00 INHALED SMOKE 0038 0022 9 30 0.00 0.00 21,793 06 75,000 00 RESPIRATORY MP 0023 22 0.00 0.00 0.00 0.00 FA,)ARDO, MICHAEL 02/03 DOD4 12/09/02 0 00 0 00 0 DO 1,000.00 0 00 TAKING SUSPECT INTD CUSTO 0040 0022 0 00 0 00 0.00 0.00 1,000.00 RIGHT SHOULDER CONTUSION P 0010 0 0.00 0.00 0.00 0.00 FLORES, MATTHEW 02/03 0004 11/19/02 0.00 0 00 0 Do- 1,000.00 0 DO TRIPPED ON OBJECT AND FEL 0038 0022 0 00 0 00 0 00 0.00 1,000 DO MULTIPLE ? 0010 0 0.00 0.00 0 00 0.00 FORD, MICHAEL 01102 000, 06/20/01 10,121.99 11,314.26 2,51E.35 14,643.51 -24,000.00 TRAFFIC COLLISION 0006 0022 234.50 5,910.24 D.DO 10,775.50 32,450.00 THORACOLUMSAR SPINE LMESP 0010 75 0.00 0.00 325.05 550.60 FRENCH, DONALD 98/99 0004 12/29/97 10,619.03 0.00 7,8D4.19 118,827.00 0.00 CUMULATIVE STRESS 0052 0022 553.97 86,440.18 0.00 268,559.82 500,000 00 STROKE / HYAERTLNSION LMEDP 0026 0 0.00 0.00 1,978.75 5,217.06 GARAY, HECTOR 95196 0004 11/04/95 488.47 1,138.77 0.00 100.00 0 DD DOG BITE 0020 0022 0.00 0.00 0.00 100.00 1,927 24 RIGHT FOREARM PUNCTURES LP 0010 9 0.00 0.00 0.00 100.00 GARAY, HECTOR 01102 0004 05/21/01 0.00 0.00 2,420.55 6,000.00 0 00 BURNED BY SHELL CASING 0005 0022 0.00 0.00 0.00 5,000.00 16,000 00 NECK SCAR LP 0010 0 0 00 O.00 179.30 1,791.15 GARAY, HECTOR 01102 0004 O6/25/01 2,755.73 U.00 795.85 22,200.27 0 00 CONTINUOUS TRAUlkA 0034 0022 44 Do- 3,100.00 0.00 26,900.00 60,000.00 RIGHT CARPAL TUNNEL SYMDR LDP 0026 0 0 00 0.00 0.00 4,204.15 DECERBER 31, 2002 PREPARED BY PAGE 22 CDLEN & LEE CI!Y DF PALM SPRINGS WORKERS COMPENSATION ACTIVE CLAIMS LISTED BY ALLOCATION EV.PLOYEE'S NAME YEAR DEPARTMENT INJURY DATE MED1 Nil NR TDIPDIVRTD ATTY/INVIOTHER MED/UdD/EXP SUBRO RECOVERY/ CAUSE OF INJURY CASE IIO LOCATION CLOSING DATE BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED DESCRIPTION OF INNJURY STATUS OSHA CODE DAYS LOST PAID-iD-DATE PAID-TO-DATE PAID-10-DATE LIABILITY DEPARTMENT - POLICE GARCIA, MAXIMIANO GGIDt 0004 10/05/00 18,005.29 57,440.77 8.525.60 21,329.93 0.00 PULLING SUITCASE OFF BUNK G021 0023 1.539.78 13,251.69 0.00 49,379.97 1B1,875 00 LOW BACK STRAIiN LMERP 0010 487 312.00 4,615.57 229.72 1,244.68 HART, KENNETN GGIDI G004 12/22/00 7,825.75 583,68 2.1B8.60 13,127.75 0.00 EXPOSURE 0037 G022 46.50 3,361.00 0.00 890.32 32,935 00 LUNGS/ RESPIRATORY SYSTEM. LP.P 0023 3 0.00 0.00 882.39 3,929.01 HA4T, KENNETH GG/Dt 0004 03/21/01 38,443.64 10,506.18 3.524.20 9,056.36 0.00 0,4ULATIVE TRAUMA 0065 0022 0.00 8,670.37 0.00 25,B23.45 97,500 00 HYPERTENSION (UMBILICAL H L40P D026 54 0.00 0_00 0.00 1,475.80 HEMENWAY, MICHAEL G1102 0004 04/14/02 552.14 1,709.1'0 0.00 5,931.88 0.00 ARRESTING A COMBATIVE SUS G055 0022 15.98 0.00 0.00 3,729.04 12,038 20 MULTIPLE BODY PARTS P DO10 11 0.00 0.00 0.00 100.00 HOLGUIN, EDWARO G2103 0004 09/22/02 816.12 0.00 0.00 4,183 88 D DO 1AKING A SUSPECT INTO CUS G024 0022 0.00 0.00 0.00 0 00 5,000.00 LEFT RING :INGER INJURED P 0010 0 0.00 0.00 0.00 0 00 KOLBACH, JAMES 02/03 0004 11/17/02 0.00 0.00 0.00 6,500.00 0.00 GETTING LtlTO POLICE VEH1C D043 0023 0.00 0.00 0.00 4,415.80 14,415.60 LOW BACK STRAIN P 0010 0 0.00 0.00 0.00 3,500 00 LECARRA, RICHARD 01102 0004 07/01/01 40,464.28 0.00 5,380.75 9,4B4 72 0.00 CONTINUOUS TRAUMA 0033 0021 51.00 7,640.85 0.00 33,009 65 99,320.00 HEART DISEASE / GERD (GAS LN,ERP 0026 0 669.54) 0.00 1,666.83 952 42 LE'VESQUE, CR[STINA 93194 0004 09/09/93 18,733.05 5,044.85 0.00 10,366.58 0 00 UNKNOWN 0020 0021 900.37 1,050.00 0.00 0.00 37,706 97 RIGHT HAND/WRIST LM 0010 108 612.12 0.00 983.35 116.65 LE4ESQUE, CRIST[NA 00/01 0004 05/02/01 9,286.51 0.00 6,473.50 10,625.30 0.00 COHIINUOUS TRAU4A 0066 0021 88.19 0.00 0.,00 70,000.00 99,000 00 MULTIPLE LD 0026 0 0.00 0.00 1,370.38 1,156.02 DECEMBER 31, 20OZ PREPARED BY PAGE 23 COLEII 9, LEE CITY OF PALM SPRINGS WORKERS COMPEIlSATIDN ACTIVE CLAIMS LISTED BY ALLOCATION EMPLOYEE'S NAME YEAR DEPARTMENT INJURY DATE MED/MI/NR TD/PD/VRTD ATTY/INV/OTHER MED/IND/EXP SUBRO RECDVERY/ CAUSE DF INJURY CASE ND. LOCATION CLOSING DATE BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED DESCRIPTION OF INJURY STATUS OSHA CODE DAYS LOST PAID-TO-DAIS PAID-TD-DATE PAID-TO-DATE LIABILITY DEPARTMENT - POLICE LEVESQUE, CRISTINA 00/01 0004 04/19/01 0 00 0.00 0 00 985.12 0 00 UNKRDWN DO67 0021 14 BB 0.00 0.00 1,000 00 3,000.00 LEFT WRIST PAIR LD 0010 D o 00 0.00 0.00 1,000.4)0 LOPEZ. ARMANDO 02/03 0004 09/23/02 702 52 0 00 0 Do 297.48 0 00 BIT BY DOG 0031 0022 O.OD 0.00 0 00 0 DO 1,000.00 LEFT FOREARM LACERATIDN P 0010 0 0 00 0.00 0.00 0.00 MARSHALL, CHRISTOPHER 00/01 0004 09/02/00 6,092 12 12,474 7H 1,36D IO 3.656.78 0 00 ALTERCATION WITH SUSPECT 0016 11022 251 10 1,680.00 0 DO 0 UD 25.BB5.3B RIGHT THUMB FRACTURE LMP 0010 8B 370.50 0.00 o.D0 0.00 MEISTER, JOSEPH 02/03 0004 111W02 0 00 0 00 0 00 500.00 0 00 BIT BY DOG 0037 0022 0 00 0 00 0 00 0.00 500.00 RIGHT HANG PUNCTURE P 0010 0 0.00 D.00 0.00 0 00 MONTGOMERY, JOHN 99/00 0004 06/10/00 17,314.07 43,720.02 4,14B.45 13,006.14 0 00 FELL PULLING OUT FENCE 0070 0022 860.BB B,Oto 00 0.00 8,127.98 99,36H 09 MULTIPLE STRAINS LMERP 0010 290 299.00 0.00 0.00 3,851.55 PAN14UE, JOHN 02/03 0004 IIJ24102 0 00 3,454.60 0.00 6,00B.00 0.00 ALTERCATION WITH FELONY S 0039 0022 0.00 0.00 0.00 2,853.6E 12,40H.28 RIGHT HAND FRACTURE P 0010 23 0.00 0.00 0.00 100.00 REYNOSO, DAVID 98/99 DD04 09/15/98 13.741.94 0.00 0.00 10,258.06 0.00 STRIKING BAG WITH BATON 0028 D022 0.00 0.00 0.00 0.00 24,000.00 RIGHT SHOULDER/UPPER EXTR MP DO10 0 0.00 0.00 0.00 0.00 REYNO50, DAVID 99/00 0004 09/14/99 7,851.68 7,970.16 3,436.63 7,133.75 0.00 CONTINUOUS STRAIN OF JOB 0019 0022 14.57 1,6BO.00 0.00 U.00 29,783.01 ULCERAI[4E COLITIS LMOP 0026 88 O.00 0.00 1,696.22 0.00 RODRIGUEZ, ENRIQUE 02/83 0004 10/13/02 ID1.45 0.00 0.00 2,398.55 0.00 BITTEN BY SUSPECT 0025 0022 0.00 0.00 0.00 0.00 2,500.00 RIGHT LITTLE FINGER BITTE A 0010 0 0.00 O.UO 0.00 0.00 DECEMBER 31, 2D02 PREPARED BY PAGE 24 COLEN & LEE CITY OF PALM SPRINGS WORKERS COMPENSATION ACTIVE CLAIMS LISTED BY ALLOCATION EMPLOYEE'S NAME YEAR DEPARTMENT INJURY DATE MED/M[I VR TD/PD/VRTD ATTY/IN@/OTHER MEDIIND/EXP SUBRO RECOVERY/ CAUSE DF INJURY CASE NO. LDCATIDN CLOSING DATE BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED DESCRIPTION OF INJURY STATUS OSHA CODE DAYS LOST PAID—TO—DATE PAID—TO—DATE PAID—TO—OATS LIABILITY DEPARTMENT — POLICE RDDRIGUE2, ENRIQUE 02/03 0004 12/06/02 O 00 0.00 D DO 5,000.00 0.00 KEULAR VEST 0036 0022 O.OD D DO 0.00 4.415.00 12,915 00 ENTIRE BODY FUNGAL RASH P 0026 0 ().OD 0 00 0.00 3,500.00 SAPIEN, RENT 02103 0004 07/21102 92 50 0 DO 0.00 407.50 0.00 RITTEN BY COMBATIVE ARRES 0006 0022 D.00 0 00 0.00 0.00 50D 00 RIGHT HAND SUPERFICIAL BI P 0010 0 D.00 0 00 0.00 0.00 SVRJA, RANDEL 96197 0004 04/D8197 40,483 65 50,096 25 9,853 31 179,468.15 0.00 UNKNflWN 0065 D022 1,610 14 27,028 84 0.00 0.00 319,834 44 PSYCHE, HYPERTENSIONINEAD LhfERP D026 365 9,406.49 0 00 1,827.61 0.00 VARELA, KARINA 02103 OD04 10/31/02 134.86 D DD 0.00 165.14 O.00 FINGER CAUGHT IN DOOR 0035 OG24 0 00 0.00 0.41D 0.00 300.00 LEFT IdIODLE FINGER CRUSH 0010 0 0 00 0 00 0.00 0.00 TOTALS FOR THIS DEPARTMENT 3,163 462,998.33 422,718 41 77,993.95 627,513.04 —24,000.00 NUMBER OF CLAIMS = 40 7,233.07 277,464 19 0.00 569,456.53 2,532,306.59 55,566.14 5,422 09 14.544.16 35,396.68 DECEMBER 31, 2002 PREPARED BY PAGE 25 COLEN & LEE CITY OF AALi5 SPRINGS WORKERS COMPENSATION ACTIVE CLANS SS LISTED BY ALLOCATION EHPLOYEE'S NAME YEAR DEPARTMENT INJURY DATE MEDIMIAR TDIPDIVRTD AIIYIINVIOTHER f4EDIINDIEXP SUBRO RECOVERY/ CAUSE OF INJURY CASE NO LOCATION CLOSING DATE BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED DESCRIPTION OF INJURY STATUS OSHA CODE BAYS LOST PAID-TO-DATE PAID-TO-DATE PAID-TO-DATE LIABILITY DEPARTMENT - PUBLIC WORKS CARRIZALES, DAVID 99100 0005 02116100 1,997.23 280.80 1,584.30 5,002 77 0.00 AUTO COLLISION OD48 0026 0.00 7,806.00 0.00 234.00 20,300.B0 NECK AND BACK STRAIN LAS 0010 4 0 00 0 ON 0.00 3,415.70 HERNANDEZ, WILLIAM 02103 0005 12/07/02 0.00 O.00 0.DO EGO 00 0.00 STACKING BALES OF HAY 0042 0026 0.00 O.00 O.Do 0.00 BOO.00 RIGHT HAND INSECT BITE 0010 0 0.00 0 HN 0.00 0.00 AARTINEZ, GEORGE 02103 0005 10/15/02 4,917.05 2,730.00 0.DO 2,416 35 0.00 LIFTING TIRE ASSEMBLY 0026 0026 166.60 0 00 B.DO 1,19o.00 11,520.00 HERNIA 0010 39 0.00 0 00 0.DO 10o.00 RODRIGUEZ, RICHARD 02103 0005 08129102 1,049.7E 700 00 0.00 150.22 0.00 LIFTING 1 GALLON BLEACH B 0019 0026 0.00 O.00 0.00 70 00 2.270.00 LUMBOSACRAL STRAIN 0010 10 0.00 0 O0 0.00 0.00 RODRIGUEZ, RICHARD 02103 DODS 10/10/02 0.00 U 00 0.00 2,500.00 0.00 PULLING OUT BROKEN TREE S 0046 0026 0.00 0 DO 0.00 0.00 2.500.00 LOW BACK SPRAIN 0010 0 0.00 0 DO O.OB 0.00 THOMPSON, TY 00/01 0005 10/24/00 4.149.94 7,753 40 0 00 3,175.19 0.00 USING JACKHAMMER 0038 0026 0.00 840 00 0.00 3,566.20 20,422.73 RT ELBOW LATERAL EPICONDY M 0010 122 338.00 0 00 0 00 0.00 2ABALA, MICHAEL 02/03 0005 09/10/02 0.00 0.00 0.00 500.00 0.00 CONDUCTING INSPECTION 0029 0027 0.00 0 00 0.00 0.00 500.00 TB EXPOSURE 0029 0 0.00 0.00 0 00 0.00 TOTALS FOR THIS DEPARTMENT 175 12,714_00 ll,�44.20 1,584 30 14,B44.53 0.00 NUMBER OF CLAIMS = 7 166.60 8,646.00 0.00 5,060.20 58,313.53 338.00 0.00 0.00 3,515.70 DECEMBER 31, 2002 PREPARED BY PAGE 26 COLEN & LEE CITY OF PALM SPRINGS WORKERS COMPENSATION ACTIVE CLAWMS L€STED BY ALLOCATIDN EMPLOYEE'S IJAME YEAR DEPARTMENT INJURY DATE NEDIMIIVR TDIPDJVRTU ATTY/1RV/OTHER MEDIINDIEXP SUBRO RECOVERY/ CAUSE OF INJURY CASE NO. LOCATION CLOSING DATE BENEFITS BENEFITS EXPENSES FUTURE TOTAL INCURRED DESCRIPTION OF IrMURY STATUS OSHA CODE DAYS LOST PAID-TO-DATE PAID-TO-GATE PAID-TO-DATE LIABILITY DEPARTMENT - RECREATION SERVICES BELTRAN, EMILY 98799 DG06 OB110798 5,555.82 0.00 0.00 14,272.94 0.00 TRIPPED AND FELL 0025 0030 171.24 0.00 0.00 A,235 00 24,269.00 MULTIPLE BODY PARTS M 0010 0 0.00 0.00 34.00 0.00 TOTALS FOR THIS DEPARTMENT O 5,555 82 0.00 0 00 14,272.94 0 00 NUMBER OF CLAWMS = 1 17I 24 O.DD 0.00 4,235 DO 24,269.DO 0.00 0.00 3t 00 0.00 1 ' APPENDrx F SAMPLE FORMS, PAMHPLETS, POSTER 1 1 1 1 1 1 1 1 1 1 1 1 1 83 54a4e of OaVifmpnia Please complete in trlp,cale(typo,II possible) Mad two copies to EMPLOYER'S REPORT CO LEN AND LEE case NO. OF OCCUPATIONAL 1470 South Valley Vista Drive Suite 230 Diamond Bar CA 91765 INJURY OR ILLNESS Hlsk Management Se,v,ces (909)661-0816 ❑ Fatality NOTICE California law requires employers to report within five days of knowledge every occupational Injury or Illness 111 C`1'/TYe jr1 which results in lost lime beyond the date of the Incident OR requires medical treatment beyond first aid.If an employee ;a11 subsequently dies as a result of a previously reported injury or Illness, the employer must file within five days of knowledge an amended report indicating death In addition, every senous injury/Illness or death must be reported I'z'xijYw • n ' immediately by telephone or telegraph to the nuarost Office of the California Division of Occupational Safety and Health , H mrrlrl, t FIRM NAME 1A.POLICY NUMBER DO NOT USE THIS COLUMN 2 MAILING ADDRESS(Number and Street City ZIP) 2A PHONE NUMBER Case No IP e 2 LOCATION IF DIFFERENT FROM MAILING ADDRESS(Number and S1mm City ZIP) 3A LOCATION CODE Ownership I © Y 4 NA URE OF BUSINESS 19 pnmlm9 mntrador wh.16,Aa grocer sawmill hotel,etc S STATE UNEMPLOYMENT INSURANCE ACCT NO Industry C R G TYPE OF EMPLOYER rr I Occupation III El PRIVATE ❑ STATE ❑ CITY ❑ COUNTY ❑ SCHOOL DIST u OTHER GOVERNMENT•SPECIFY EMPLOYEE NAME a SOCIAI-SECURITY NUMBER 9 DATE OF BIRTH(mm/tld/yy) Szx G 10 HOME ADDRESS(Number and Street.City ZIP) IDA.PHONE NUMBER A, P n SEX 12 OCCUPATION(Regular lob 011e—rv0,nnnlr ibbrev,vhons or number) 13 DA(E OF HIRE(min/tld/yy) Daily hours © ❑ MALE ❑ FEMALE Y 14 EMPLOYEE USUALLY WORKS 14A EMPLOYMENT STATUS(chrck applicable slaws at time of Injury) 14B Under what class code o1 your Days per week E hour: days total I rcgubv rotor win wigt,. G —per day —per week wcckly hour.. lull-lime —part-lime Icmpomry .. ..Owl 1e GROSS WAGF,S/SALARY t6 OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY fe g.,lips meals,lodging Weekly hours $ per mmi-imn benu•ae•: me)' [I YES,S per ❑ NO I S rRbSS W�6FS/SALARY Is 7 DATE OF INJURY OR ONSET OF ILLNESS 1S TIME INJURY/ILLNESS OCCURRED 1U TIME EMPLOYEE BEGAN WORK 20.IF EMPLOYEE DIED DATE OF DEATH Weekly wage (mm dd,W) Am P.M —AM PM (mm/dd/yy) 21 UNABLE TO WORK FOR AT LEAST ONE FULL DAY 22 DATE LAST WORKED(mm/dd/yy) 23 DATE RETURNED TO WORK 24 IF STILL OFF WORK Ceunly AFTER DATE OF INJURY' ❑ YES ❑ NO (mnVddlyy) CHECK THIS 80X ❑ 25 PAID FULL WAGES FOR DAY OF INJURY OR 26 SALARY BEING CONTINUED? 27 DATE OF EMPLOYER SKNOWLEDGE/NOTICE 26 DA(E EMPLOYEE WAS PROVIDED Nature pl injury LAST DAY WORKED Of INJURYiILLNE66 EMPLOYEE CLAIM FORM YES ❑ NO ❑ YES ❑ NO (mm/ddlyy) (mmldilm) 20 SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS II avallable so second ocgrac burn: os ow lea on right arm iendon, at IOh elbd pouonm9. 1 Par1 of body C 30 LOCATION WHERE EVENT OR EXPOSURE OCCURRED(Numb-,Stroll City) 30A COUNTY WT 30B ON EMPI OYER S PREMISES' Suureu t ❑ YES ❑ NO R 31 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED e q shipping department mnchim-shop 32 OTHER WORKERS INJURED/ILLIN Fvonl Y PHIS EVENT' ❑ YES ❑ NO © 33 EQUIPMENT,MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR ERPOSURP OCCURRED O g. en.•tylon0 welding larch farm traclor scaffold Sec Source R 31 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED e g welding scams of metal forms loading bp cp onto trunk Exmnt of mryry C L 35 HOW INJURYIILLNESS OCCURRED DESCRIBE SEOUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNFSS cq worker.Xippod hock N to Inspect work and slipped on scrap m,ler,al Ae he fell he crushed agO,ns1 hL h weld and burned right hand USE SEPARATE SHEET IF NECESSARY e s s 36 NAME AND ADDRESS OF PHYSICIAN(Number and Street City ZIP) 35A PHONE NUMBER � 37 IF HOSPITALIZED AS AN INPATIENT NAME AND ADDRESS OF HOSPITAL(Number and S1ren1 City ZIP) fµ 37A PHONE NUMBER Complele0 by hype or prIntl S,gn,Wm Tgc Date FORM 5020(9EV.6) 1492 FILING OF THIS REPORT 15 NOT AN ADMISSION OF LIABILITY State of California OPETICION Estado de California Department of Industrial Relations Departamanto de Relaciones lndustdales DIVISION OF WORKERS'COMPENSATION DIVlsioNDECOMPENSAWNAL TRAEmADOR EMPLOYEE'S CLAIM FOR DEL EMPLEADO PARA BENEFICIOS WORKERS' COMPENSATION BENEFITS DE COAiPENSACON DEL TRABAJADOR If you are injured or become ill because of your job, you may be Si Ud. se ha lesionado o se ha enfermado a causa de su trabajo, Ud. liens entitled to workers' compensation benefits. derecho a recibir beneficios de compensaci6n at lraballador. Complete the "Employed' section and give the form to your Complete la secci6n "Empleado" y eraregue to forma a sit empleador. employer. Keep the copy marked "Employee's Temporary Quesdese can la copia designada "Recibo Temporal del Empleado" Receipt" until you receive the dated copy from your employer. harla que Ud. reciba la copia fechada de su empleador. Si Ud. necesita You may call the Division of Workers' Compensation at ayuda Para completar esin forma o para obtener sus beneficios, Ud.puede 1-g00.736-7401 if you need help in Calling out this form or in hablar can la Division de Compensaci6n a1 Trabajador llamando al obtaining your benefits. An explanation of workers 1-900-736-7401- En la parle de arr6s de esta forma se encuentra una compensation benefits is included on the back of this form. etplicaci&de los beneficios de compensaci6n of trabajador. You should also have received a pamphlet from your employer Ud. tambidn deberfa haber recibido de su empleador un follelo describiendo describing workers' compensation benefits and the procedures to los beneficios de compensaci6n at trabajador lesionado y Ins obtain them. procedimiemas para obtenerlos. IOWA I benefits or payments is guilty of a felony, trabajadores lesionadus es culpable de un crimen mayor leloniall- Employer. Empleado: 1. Name.Nombre- Today's Date.Fecha de Noy. 2. Home Address.Direcci6n Residential. 3. City.Ciudad. State. Eslado. Zip. C6digo Postal. 4. Date of Injury.Fecha de la lesi6n(accidenle). Time of Injury.Nora en que ocurri6. a.m- in. 5. Address and description of where injury happened.Direcci6nllugar d6nde occuri6 el accidence. 6. Describe injury and part of body affected.Describa to lesi6n y parte del cuerpo afectada. 7. Social Security Number.Nibnero de Seguro Social del Empleado. 8. Signature of employee. Firma del empleado. Employer—complete this section and give the employee a copy immediately as a receipt. Empleador—complete esta secci6n y dfle inmedialamente ana copia al empleado canto recibo. 9. Name of employer,Nombre del empleador. 10,Address-Direcci6n. 11.Date employer first knew of injury.Fecha en que el empleador supo por primera vez de 1a lesi6n o accidents. 12.Date claim form was provided to employee. Fecha en que se le eritreg6 al empleado la petici6n. 13.Date employer received claim form- Fecha en que el empleado devolvi6 la petici6n al empleador. 14.Name and address of insurance carrier or adjusting agency.Nombre y direcci6n de In compmlla de seguros o agencia administradora de seguros. Colon and Lee a 1470 South Valley Vista Drive, Suite 230, Diamond Bar, California 91765 15.Insurance Policy Number.El nfimero de la p6liza del Seguro. 16-Signature of employer representative.Firma del represenlanle del empleador. 17.Title. Titulo. 18. Telephone. Telffono. Employer: You are required to date this form and provide copies to Empleador: Se requiere que Ud. feche esta forma y que provia your insurer or claims administrator and to the employee,dependent copfas a sit eompatlfa de seguros, administrador de reclamos, o or representative who filed the claim within one workior day of dependienteirepresenlanle de reclamos y at empleado que hayan receipt of the form from the employee. presentado esta petici6n dentro del plazo de an dfa kdbi1 desde el SIGNING THIS FORM IS NOT AN ADMISSION OF LiABMXJ Y momanto de haber silo recibida In forma del empleado. EL FiRMAR ESTA FORMA NO SIGNiFiCA ADMISION DE RESPONSABILIDAD Original (Employer's Copy) Original(Copia del Empleador) DWC Form I (REV. 1194) DWC Forma I (REV. 1194) COLEN AND LEE Supervisor's Report of Injury or Illness (Complete for All Employee Reported Injuries) Employer: Nature of Business: Department: Division/Location: Name of Injured Employee: Occupation: Date of Injury or Illness: lime: AM PM Was medical treatment offered? —Yes No Was treatment refused? —Yes—No Was employee given a claim form?—Yes No Employee's Signature: What type of medical treatment was given? ,First Aid —Paramedics Emergency Room Hospitalization Clinic _Authorized Predesignated Physician's Name: (attach form) Was employee required to leave work due to this injury or illness? —Yes No Date Last Worked: Has employee returned to work? Yes, Date Returned: —No, Still Off Work Name of person injury or illness was reported to! Timeliness of Reporting: If the accident was not reported immediately, why not? Location where accident or exposure occurred: Was the injury or exposure witnessed? _Yes—No WITNESS INFORMATION Name: Name: Address: Address: City/State/Zip: City/State/Zip: Telephone: Telephone: List property damage, if any: (continued on reverse) Body Part Injured (check all that apply, indicate left and/or right): Head —Upper Back Finger(which?) Ankle Face _Lower Back —Upper Leg Foot Eye —Arm _Lower Leg —Toe (which?) Neck —Wrist —Knee _Other Nature of Injury/Illness: Scrape Burn Fracture Cold Related Problem Cut Sprain/Strain Skin Problem —Loss of Consciousness Puncture Foreign Body —Chemical Related Problem —Respiratory Problem Bruise Poisoning Heat Related Problem `Other What was employee doing at the time of injury or exposure? Person, object or substance that directly injured employee: Check any of the fallowing unsafe actions which apply: Haste/Unsafe Speed Improper Procedure —Unsafe Lifting Not Authorized Unsafe Equipment Usage —Unsafe Position —Disregard of Instructions Defective Equipment/Tools —Running/Jumping Lack of Knowledge Skill/Training Inattention _Poor Housekeeping Failure to Use Proper Equipment Assault —Act of Other Inadequate Protective Gear Horseplay Physical Handicap Carelessness —Alcohol/Drugs Other know the injury occurred on duty. I have no specific knowledge the injury occurred on duty. What steps have been taken or recommended to prevent recurrence? Comments: Supervisor's Signature, Date: E[MMMWfM) A�P CERTIFICATE OF LIABILITY INSURANCE OPID CAT05/12/03 FIDRL 2 05 1Z 03 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 1301wn A C®wpLay ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Cv LiOsnae 4000030 9 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 24S a. T'os IY+blogI Ave, Ste 105 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, PiamuderrAAL CPL A1111 vb=e:626 7997D00 Fax:626441-3233 INSURERS AFFORDING COVERAGE NAIC9 INSuRW — INSURER!, Fidlait Bit CD Of MO INSURER E. l ann (1 IC100 1 locca.� s INSURERC' DL 7 1 �(l{ EIaIC�C 9E7 5 Dr #230on INsuRERo: LNSURERE' COVERAGES POLICIES OF DZUF4NC_USTEO SE40W HAVE BEEN ISSUED TO THE INSURED IJAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERMCR CONDITION OF.NlY CONTRACT OR OTHER DOCUMENT WIH RESPECT TO WHICH THIS CERTIFlCATE MAY BE ISSUED OR MAY PERTAIN,ME INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS MWECTTO ALL THE TERMS,EXCWSIONS AND CONDHONS OF SUCHPLICIES.AGGREGATE LIMR•S SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS[7101rE T2 N9Rd TYP2 of INSURANCE POLICY NDMOER DA DP DA ID uNR6 B ENERAL LLkSlUTY EACH OCCURRENCE $ ( COMMERCIAL 03fRAL LIABILITY PREMISES aeecLrencE S CLNMSMADE OCCUR MWW(A,ry pv ) 5 G PERSONAL 6 ADV INJURY S A GENERALAGGREGATE $ t VEN'L AGGREGATE LIMIT ARMIES PER PRODUCTS-COMPIOPAGG S rrrr nl POLICY F7 jffr D LOC { f AGTOMOBILE LIAEILRY COMBINED SINGLE LIMIT $ ANY AUTO (FneWMn1) ALLOWNEDAUTOS BODILY INJURY SCHEDULED/JIGS (Pw PERw) S HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Pfraawwi) $ PROPERTYDAMAGE $ (peTeeclnont) GARAGE LIABILITt AUTO ONLY-EAACCIDENT $ ANYeL-0 OTHERTHAN EAACC S AUTO ONLY: ACC S EXCESSIUMDRELLA_UABIIm EACH OCCURRENCE $ m�OCCUR _]CVIIMS MACE AGGREGATE $ S DEDUCI)C E $ RETENTION S $ ADRICmi COIAPE'I'ATON AND TORT UMTTS ER EMPLOYERTLIALILITY ANY PROPRIETORIPFJiTNEIUEXECIJNVE F%L,EACH ACCIDENT $ OFFICERIiMEMBER EXCLUDED? ELDISEASE-EAEMPIA $ tfTa5 dwmneuridv S�EOIN-PRGVISIoNSww E.LDISEASE-POLICYLDAN S Try OTHER V 21. rida3.it1 ftrd 6106351 10/13/02 10/13/03 1,000,000 i Cui Rl"Ium OF 0F8RATWHO I LOCA71ONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS L. —� CERTIFICATE HOLDER CANCELLATION OD00000 SHGUW ANY OF THE ABOVE DESCRIBED EOUCDSBE CANCELLED BBFORE THE ExPBUTIO City of PuLm Springs DATE•HEREOF,THE RISUING INSURERWILLENDEAVONTO MAIL 3D DAY$WRITTEN Sua Mil L D NOTICETO THE CFRTFICATE HOLDER NAM$D TO THE LEFT,BUT FAILURE TO Do SO$HALL Director of BumiLn aaslources IMPOSE NO OBLIGATION ORUABILITYOF ANY MWUPONTHEINSURER,ITS AGENTS OR P.O. Boa 2743 Palm Springs CI1 92263 2743 REPRESENTATR'ES, AUTHORIZED REPFE$ENT BolWn G an ACORO 23(200T19o) OACORD CORPORATION 1988 Z00 in oNOS/NolloH IPTZC92999 %Vd 9£.CT INd 90/9T/S0 03/08/03 12:34 FAX 6618a54Soo _ ILIA INSITRANCE Opt ACORD CERTIFICATE OF LIABILITY INSURANCE °"'i°"'"°°""r asfol?,/�oa� PeanucER C661)835-4542 FAR (661)835-4500 T SCERTIFICATEI�ISSUED A3AFIIATT2K-oF I1Ji-ORPdATOR KTA Insurance Associates, Inc. ONLY ANDCONFERSNORIGHTSuPOf.ITHECE:RTIPICATI- HOLDER THIS CERTIFICATE DOES NOT ANIEND,EXTEND CR License * 0415101 ALTER THE COVEkACYEA\FFORDEDBY THE POLICILSEIEJ)w- 1601 New Stine Road, Suite 23D I Bakersfield, CA 93309 INSURERS AFFORDING CCVERAGE I'NAU,;# WsuRE2 Co en And Lee Inc. INsuRERA• FrernonY Ccmpehsatian Insurance^ 1470 So. Valley Vista Dr. ;R230 INSURvRB. Diamond Bar, CA 91765 INSURERC. INSURERO INSURER E' COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUE.O TO THE INSURED NAMED ABOVE FOR THE FOLICY PERIOD Ir 1UICv,FC.rIO'IWITHST N[IIDI ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MA`EE ISSUI?C CR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I$SUBJECT-0 ALL THE TERMS,EXCLUSIONS AND CCIDID TION3 OF SU UI•I POLICIES.AGGREGATL LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS" LTR NSR TYPE OF INSURANCE POLICY NUMBOR PATE MMMP Pok I DATE fMMMOTYYI r' GENEHALLIABILITY EACH OCOURREME COMMERCIAL GENERAL LIASILF''I T-AaX.=�'T N 0 T 5 PFZEMISEELr 6[1renC i CLAIMS MADE +OCCUR MED EXP(AnY ore pec arl 5 __ J u PERSONAL LAD I INJURY 5-T GENE¢AL ACOR:GATE f 5 ._- DEW AGGREGATE LIMIT APPLIES PER' PROD ICTS•CO,IFIOP/GG POLICY JEECT LOC AUTOMOBILE LIABILITY COMB WED SINGE LII41"" NYAUTO (ES sc,Jdenq ALL OWNED AUTOS BODILY INJURY SCJHEDULEO AUTOS (Per pareonl HIRED AUTOS BODILY INJURY NONQWNEDAUTOS (Pera:C,dfm3 t PROPERTY DAM IGE (PersdcldonU GARAGE LIABILITY AUTO ONLY-EA ACCIDI NT ,S ANYAUTG AV EA NCC'- S-- ^---' O _ A=IITD ONLY --1cc 5 —^�-••— "OFSSIUNBRELLA UA&LTTT FACHOCCL'RFE•ICE S OCCUR ❑CLAIMS MADE AGGREGATE S F! —_f s DEDUCTIBLE s I RETENTION 5 15 WORI5ERs GOMPENSATIONAND 518 0 01-0 3 10 9 3 2 O-L 01/2003 01/01/T.004'• X ��D EMPLOYCRE'LIABILITY / IORY_L�MtT�� F-,__ A ANY PRO PRIETORARTNERIEXECUTNE G.LEAC14A-Cff1ENT OFFICERIMEMEER EXCLUDED? EL CISEM15'_-E1EMI�LDYFEI& 11 vee.Oeson under SPECIAL PROVISIONS OPIDW 54 CISEASE•PDLIC•'IIMT7 5 I-06a('116" OTHtl DESCRIPTION ON OPER\TOHe I LOCATIONS/VENICLtS/ LLU310N:.ADDED By CNDQRSEMP14T1SPEC IAL PROVISIONS — CERTIFICATE HOLDER CANCELLATI9N _ 5H0'JLO ANY OF TREASOVE DESCRIDED POLICILS 3E CIMCELL:x FFFOIi E TFE EXPIRATION UATETHEREOF.THE ISSUING INSUREF WILL,E NDI'AHOP TO MAIL City of Palm Springs -JAL-DAYS WRnTFN NOTIDETO THE CERTIFICA E HCUIER nARIED TFTHE'.E'T, Attn: Sue Mills BUT PARURE TO MAILSUCH NOTICE 5HALI INPOSE NO CIE LIGATICH OR UAWATY P.O. Box 2743 OF ANT HIND UPON THE INSURER,nS AC ENTS OR FI SENl AT1VF$. Palm Springs, CA 92263-2743 nvrnawzsDREPRes �—'�"j .� A) 1 ACORD 25(2001108) FAX„ (760)323-8287 4ACORDC-GRPOF TIOII•Id6 PROFESSIONALS' CERTIFICATE OF INSURANCE This is to certify that the policy of insurance listed below has been issued to the Named Insured. This certificate is issued as a matter of information only and confers no rights upon the Certificate Holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed below. Limits shown may have been reduced by paid claims. Named Insured and Mailing Address: c G ca Colen and Lee, Inc . 1470 South Valley Vista Drive Suite 230 7C Diamond Bar, California 91765 C rn Company affording coverage: Gulf Insurance Company m a cr Type of insurance: Professional Liability and General Liability Policy Policy No. IG0646150 Policy Period: Effective date October 5, 2002 Expiration date October 5, 2003 12 01 A.M., Standard Time at the Mailing Address stated above. Limits of Liability for ISPP Errors and Omissions Liability: Each Wrongful Act $2,000,000 Policy Aggregate $2, 000, 000 Limits of Liability for ISPP-General Liability: General Aggregate Limit $2, 000, 000 Products-Completed Operations Aggregate Limit $2, 000,000 Advertising Injury Limit $2, 000,000 Each Occurrence Limit $2,000, 000 Fire Damage Limit $50, 000 Retroactive Date: October 5, 19$5 Schedule of Professional Services insured: Insurance claims administration services . Certificate Holder Name and Address: City of Palm Springs P.O. Sox 2743 Palm Springs, CA 92263-2743 Attn: Sue Mills, Director of Human Resources NOTE: IF the Named Insured is the same as the above named Certificate Holder, written Notice of Cancellation will he provided to the Named Insured in accordance with the provisions of the policy and any applicable state law. CANCELLATION: Should the above described policy be cancelled before the expiration date thereof, the issuing Company will endeavor to mail 30 days written notice to the above named Certificate Holder but failure to mail such notice shall impose NO obligation or liability of any kind upon the Company. Date Certificate Issued- May 9, 2003 "CLAIMS MADE, AND REPORTED POLICY" FILE No.738 05/13 '03 11:55 ID: FAX; PAGE 2i Flo PROFESSIONALS CERTIFICATE OF INSURANCE This is to certify that the policy of insurance listed below has been issued to the Named Insured This certificate is issued as a matter of information only and confers no rights upon the Certificate Holder. This certificate does not amend, extend or alter the coverage afforded by the policy listed below. Limits shown may have been reduced by Paid claims. Named Insured and Mailing Address: Colen and Lee, Inc . 1470 south Valley vista Drive Suite 230 Diamond Bar, California 91765 Company affording coverage- Gulf Insurance Company Type of insurance; Professional Liability and General Liability Policy Policy No.' IG0646150 Policy Period: Effective date October 5. 2002 _ Expiration date October 5, 2003 12:01 A.M., Standard Time at the Mailing Address stated above Limits of Liability for ISPP Errors and Omissions Liability. Cach Wrongful Act $2,000,000 Policy Aggregate $2,000, 000 Lirrins of Liability for ISPP-General Liability: General Aggregate Limit $2, 000, 000 Products-Completed Operations Aggregate Limit $2,000, 000 Advertising Injury Limit $2,000, 000 Each Ocourrerce Limit $2, 000, 000 Fire Damage Limit $50, 000 Retroactive pate: October 5, 1985 Schedule of Professional Servires insured: Insurance claims administration services. Certificate Holder Name and Address. City of Palm springs P.O. Box 2743 Palm Springs, CA 9226'3-2743 At=: Bruce Johnson NOTE: If the Named Insured is the same as the above named Certificate Holder, written Notice of Cancellation will be provided to the Named Insured in accordance with the provisions of the policy and any applicable state law. CANCELLATION: Should the above described policy be cancelled before the expiration date thereof, the issuing Company will endeavor to mail 30 days written notice to the above named Certificate Holder but failure to mail such notice shall impose NO obligation or liability of any kind upon the Company, Cercifica'te Holder is named as an Additional Insured Date Certificate Issued: May 13, 2003 "CLAIMS MADE AND REPORTED POLICY" FILE No.738 05/13 '03 11:55 I➢: FAX: PAGE 3i 3 Gulf Insurance Company 125 Broad Street, New York, New York 10004 (888) 467-7767 Named Insured and Mailing Address; Colen and Lee. Inc. 1470 South Valley Vista Drive Suite 230 Diamond Bar, California 91765 Effective May 9, 2002 _ 12 01 a.m., at the Named Insured's address as shown on the Meclaretions Page, this Endorsement No. 4 is part of Policy No IG01546150 .ADDITIONAL INSURED ENDORSEMENT In consideration of the premium charged, it is hereby understood and agreed that the person(s) or entity(ies) listed below is added as an Additional Insured, but only for liability arising solely out of Wrongful Acts of the Named Insured in the performance of Professional Services: City of Palm Springs P.O. Sox 2743 Palm Springs , C„y 92263-2743 It is also understood and agreed that the Policy does not apply to any Claim: (1) by an Additional Insured against any other Insured; (2) which includes allegations or facts indicating actual or alleged independent or direct liability on the part of an Additional Insured_ Except as stated above, this endorsement does not change any other provisions of the policy. It the Company issued this endorsement to be part of the policy on the Effective Date, then the countersignature on the Declarations Page also applies to the endorsement If this endorsement is effective after the Effectiva Date of the policy, ilia Company's authorized representative must countersign in the space below to validate the endorsement FORM: ISP-45061 Countersigned by _ _ A thoriz d Representative