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HomeMy WebLinkAboutConcerned Citizens, Amendment No. 2 - 052421 Contract Amendment#2 j: Between Concerned Citizens And ,' Jefferson County Public Health Developmental Disabilities Program WHEREAS, Concerned Citizens (Subcontractor) and Jefferson County (County) entered into an agreement on July 1, 2019 for Professional Services to be provided in connection with the provision of Community Inclusion Services to Persons with Intellectual/Developmental Disabilities in Jefferson County; as amended by Amendment 1 executed on November 20, 2020. WHEREAS,the parties desire to amend the terms of that agreement. IT IS AGREED BETWEEN BOTH PARTIES AS NAMED HEREIN AS FOLLOWS: 1. From March of 2021 to June of 2021; Subcontractor's unit of billable Community Inclusion Service will be $49.00. A unit is defined as one"hour"of direct service to one eligible client. 2. One unit of Community Inclusion Service is defined as one (1) "hour" of direct service or assigned service level to one eligible client. An"hour" is at least fifty(50) minutes of direct service; (partial hour to the quarter may be recorded); ten(10) minutes of every "hour" of direct service to one eligible client can be used for documentation and/or meeting times. 3. Subcontractor's contract will be decreased by $339.06 in funding for services rendered during the term of July 1, 2019 through June 30, 2021. Total compensation under this Agreement shall not exceed$8,900.94 without express written amendment signed by both parties. 4. Work performed between July 1, 2019 and the execution of this Agreement that is consistent with the provisions of this Agreement is hereby ratified. 5. All other terms and conditions of the agreement will remain the same. (SIGNATURES ON FOLLOWING PAGE) Dated this 2' ` day of -MC(.4 ,2021 By: K to Dean, Cha' Jefferson Board of County Commissioners By: I� inda Middl on, xecutive Director oncerned Citizens ATTEST: By: (.' �' �'` C-��4�Gt'zvca Carolyn Gall ay, Clerk of the Board APPROVEDRO AS TO FORM ONLY: By: V • G 'r/ 'j Av z � �j / Philip Hunsucker, Chief Civil Deputy Prosecuting Attorney A Concerned Citizens J ` Consolidated Insurance Recap )►. Effective 2021 to 2022 Callis & Associates Underwritten by Philadelphia Insurance Co. INSURANCE Property Perils Insured: Special Form (Subject to Policy Limitations & Exclusions) Includes Equipment Breakdown Deductible: $1,000 Valuation: Replacement Cost, 90% Coinsurance Penalty Schedule of Coverage: 945 S Forks Ave, Forks, WA Office& Daycare Building $281,048 Business Personal Property $40,950 73 Sportsman Club Rd, Forks, WA Adult Family Home Building $101,104 51 Chimacum Rd, Port Hadlock, WA Office Business Personal Property $7,390 87 Sportsman Club Rd, Forks, WA Administration Office Building $102,077 Business Personal Property $27,260 87 Sportsman Club Rd, Forks, WA Family Center Building $121,664 Business Personal Property $32,000 1601 E Front St, Ste 4, Port Angeles, WA Business Personal Property $6,000 1601 E Front St, Ste AB, Port Angeles, WA Business Personal Property $6,000 Extensions: Refer to Elite Property Enhancement: Human Services, Bell &Crisis Management endorsements ,"( r , T 7,. ''Pd i J , ../7eLc %:.9'ri;a.1, r..,):.ice .', '.C %'c'SC?iF'USP 7.'r7`,5.re ,,, Y',sz2- r✓;-'.L-',Ir.,, c3.' '; .I /," 0,'I iJ%,'': r. l"'S,, z r',0_`.if.(EYE. Si / , J1 i.(p,/67 3,'6' ' 'D.=i(!C. iesicr, ,,,, t'_ :_k , .. A Concerned Citizens Consolidated Insurance Recap Effective 2021 to 2022 Callis & Associates Underwritten by Philadelphia Insurance Co. INSUR ANCE General Liability Limits: $1,000,000 Per Occurrence $2,000,000 Annual Aggregate $2,000,000 Products/Completed Operations Aggregate $1,000,000 Personal and Advertising Injury $5,000 Premises Medical — Per Person $100,000 Rented to You Limit Policy Type: Occurrence Form — PKG Coverage: Premises, Operations, Products, Completed Operations Personal Injury (libel, slander, wrongful eviction, invasion of privacy) Bodily Injury and Property Damage Legal Liability Limited Contractual Liability Independent Contractors Personal Injury (libel, slander, wrongful eviction, invasion of privacy) Employees as Additional Insured's Host Liquor Liability Incidental Medical Malpractice Non-owned Watercraft (up to 26 feet) Auditable: No Rating Basis: $641,653 Payroll Extensions: Refer to General Liability Deluxe Endorsement Blanket Additional Employees &Volunteers; Funding Source; Medical Directors and Administrators; Insured's: Managers or Lessor of Premises; Lessor of Leased Equipment Major Exclusions: Adult care facility Medical payments coverage to day care enrollees Skateboarding at Teen Center Guardian trustee/ Power of Attorney program Common Exclusions: Special Events Limitation endorsement Liquor Liability Employment Law Violations Pollution and Asbestos Care, Custody and Control Data Breach/Cyber Liability Professional Liability Expected or Intended Actions Injury to Employees (Workers Compensation) r/ 7 r-,r e %P_�,SE'it -7 :f'-11,1 V^ 'tfc/ r << l If'✓ Or'1 a r r ,9! , 3l1 / ► Concerned Citizens 1 1 Consolidated Insurance Recap Effective 2021 to 2022 Canis & Associate's Underwritten by Philadelphia Insurance Co. INSURANCE II Abuse & Molestation Limits: $100,000 Per Occurrence $300,000 Annual Aggregate Coverage: Actual or threatened abuse or molestation to any person in the care, custody or control the insured Endorsements: Employee Defense Coverage tl c./0 ' t, r ,2ce,'Xic3 er,--11.. re{7/odC.4._C7✓J,C:3713S& 4ssoLpires, t t `'!" t sci(' ..mac-'of!ES_!1e,tS "f/erips. 3?Cd _?` r v t r3f', ,..7Yd117 CCL//); /7<-,7�C17t..tL`�C:E7�f/7 it (2,73iS_>t_)l75/L3 rl -^ /�Et3I}/ i ffr(77 fc?rl 0:2d1- L7 i:d/t 'I %l 7- r ,\7 977.t 3r e.. 3-x,/x .�r.�dr 'rs' ,St f ,.,orr .ford>r1 , %.1.a 7 7 s r r 4 1 > ;,i,. ! Concerned Citizens Consolidated Insurance Recap Effective 2021 to 2022 Callis & Associates Underwritten by Philadelphia Insurance Co. INSURANCE Professional Liability Limits: $1,000,000 Per Occurrence $2,000,000 Annual Aggregate Policy Type: Occurrence Form Coverage: Act, Error or Omission in the actual rendering of professional services to others, including counseling services, in your capacity as a human services organization. Professional services include the furnishing of food, beverages, medications or appliances in connection therewith. rt d/ y ! c/ 7 SE 1,lr 1 -3 ."t'P:/`7 .C31/; 7Ic..:4, 1 'l- ri P ?;`c' 1SF' Jrrt7 /f`r5, i1e}n?: r I:r<,� rts��'S C._ ;al,ii"I'c7/"£I?]t /. :01't.,/ k;r. n th t cre' 'I%S r b C,??utU`{. ",U �I'9�/ 17f037 .dt/ t_ 'at � ..,,,' A Concerned Citizens _. j 1 Consolidated Insurance Recap Effective 2021 to 2022 Callis & Associates Underwritten by Philadelphia Insurance Co. INSUR A NCE Business Auto Limits: $1,000,000 Liability -Combined Bodily Injury and Property Damage $1,000,000 Underinsured Motorists - Bodily Injury only $1,000,000 Employers Hired & Non-owned Auto Liability $1,000 Medical Payments— Per Person Deductibles: No Collision Coverage No Comprehensive Coverage Schedule of Vehicles: 1) 1995 Toyota Passenger Van 2) 1999 Ford E Super Duty RV 3) 1995 Buick LeSabre 4) 1995 Ford Windstar 5) 2002 Dodge Grand Caravan . I' (�U�cG Dr,"�.-?liy � Qy r r '�C /?'' h !�i"..�'z S / � lE-1 7; �[7 �I Irr ` / - 3 r/� ,rl�'4 1 r/C.V� 9 /7 fl J;r 7 �, +, f,7 I! ht5E- 'i�3r 71Ic rf /-i ru rr , '+(I i r. 3r a: , ,.7 ,. ., � � 4', tir r,. ,.1l?ram rt/"� �.t 7 � i +-,C"'' i.,�/_j.?5 C.r ',i�E'!� r� Ii: 4, ,I.Yf!. ,( • / ► Concerned Citizens Consolidated Insurance Recap Effective 2021 to 2022 Callis & Associates Underwritten by Philadelphia Insurance Co. INSURANCE Umbrella Liability Limits: $1,000,000 Per Occurrence $1,000,000 Annual Aggregate $1,000,000 Products Completed Operations Aggregate $1,000,000 Personal &Advertising Injury Retention: $10,000 Coverage: Excess above General Liability, Auto Liability, &Professional Liability Excludes Directors &Officers Liability A_ Concerned Citizens I N, Consolidated Insurance Recap Effective 2021 to 2022 Callas & Associates Underwritten by Philadelphia Insurance Co. INSURANCE Crime Coverage Limits: $422,687 Per Occurrence Deductible: $5,000 Coverage: Employee Theft— Loss Sustained form Includes Non-compensated officers as employees Endorsements: Social Security Administration is loss payable v rz a Concerned Citizens Consolidated Insurance Recap Effective 2021 to 2022 Callis & Associates Underwritten by Philadelphia Insurance Co. INSUR A NCE Premium Breakdown: Annual Premium Property $3,104 General Liability $3,258 Auto $4,470 Professional Liability $5,760 Crime $792 Sexual/Physical Abuse $954 Umbrella $1,884 Total $20,222 / Concerned Citizens Consolidated Insurance Recap � Effective 2021 to 2022 Callis & Associates Underwritten by Philadelphia Insurance Co. INSUR ANCE Reminder: This policy may contain an annual audit provision requiring you to report either one or more of the following items to the insurance company after each subsequent policy year: 1) Gross sales; 2) Employee payroll; 3) Amount paid to subcontractors; 4) Number of units sold; 5) Number of participants; 6) Number of volunteers. Disclosure: This is a brief recap of coverages and does not amend, bind or alter coverage. It is intended for review purposes only and inherently may contain inaccuracies of actual coverage and limits. All coverages are subject to policy conditions, limitations, endorsements and exclusions. We recommend that you review your policy documents for actual policy limits and coverages and call us with any questions. Recommended Optional Coverages: • Higher Liability Limits including abuse • Earthquake, Flood & Landslide • Money Coverage • Cyber Liability/Data Compromise • Business Income & Extra Expense • Accident Medical for Volunteers • Accident Medical for day care enrollees • Adult family home coverage • WA State Stop Gap •7 Sr;7Li::2 ..P, IJdu �C _`'i '3��,k 4 S0,idl'S, 1 ';'.?r,.,r, 5 l'.-,_Sr i ri.' , r l�'7 � C`rr� ' I7 3 ._ r{ _.I._3, ,(', ;r'T; '`!'•� C?,'?.a_,'!%r7 F 1.�'F/'d__ a1.Sr__ .r "fir 3 , :.aC1k`,'"?r7'_ l..l'r=- �ri _r,,,}tr :,:31 .`� -�sS(. �,...5: 9" Aco CERTI: ;ATE OF LIABILITY INSURAI E DATE(MM/DD/YYYY) 5/13/2020 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CLRTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Derek Floor NAME: CALLIS & ASSOCIATES, INC. / C NNo,Ext): (360)452-2314 jA/C,No): (360)452-1701 802 East First Street, Suite 3 E-MAIL ADDRESS: derek@callisinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# Port Angeles WA 98362 INSURER A:Philadelphia Insurance Company 18058 INSURED INSURER B Concerned Citizens for Special Children INSURERC: PO Box 1787 INSURER D: INSURER E: Forks WA 98331 INSURERF: COVERAGES CERTIFICATE NUMBER:CL2051305866 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRLT TYPE OF INSURANCE AINSD WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MMIDD/YYYY) (MMIDDIYYYY) X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X OCCUR DAMAGETO RENTED PREMISES (Ea occurrence) $ X PHPK2120808 5/26/2020 5/26/2021 MED EXP(Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO POLICY X JECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 X OTHER: Abuse & Molestation Per Occurrence/Annual Aggregate $ 100,000/300,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED PHPK2120808 5/26/2020 5/26/2021 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE X HIRED AUTOS % AUTOS (Per accident) x UMBRELLALIAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAR CLAIMS-MADE AGGREGATE $ 1,000,000 DED X RETENTION $ 10,000 PHUB672382 5/26/2020 5/26/2021 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Professional Liability PHPK2120808 5/26/2020 5/26/2021 Each occ/Ann Aggregate $lm/$2m Crime/Employee Dishonesty PHPK2120808 5/26/2020 5/26/2021 $5,00 Deductible $422,687 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Certificate holder is additional insured when required by written contract. Refer to policy(s) for all applicable terms, conditions, exclusions, and endorsements. Evidence Only. Contract: B-3- Early Intervention CERTIFICATE HOLDER CANCELLATION AMcEnery@co.je£ferson.wa.us SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Jefferson County THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Developmental Disabilities Program ACCORDANCE WITH THE POLICY PROVISIONS. 615 Sheridan Port Townsend, WA 98368 AUTHORIZED REPRESENTATIVE QQ� Andy Callis/KAYLA � CgA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401)