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2023-078 PO 20230350- 1582, LLC
Purchase Order ♦ CITY RECORDER Vaal � Fiscal Year 2023 Page: 1 of: 1 1 �dl � OCL �ILII ETA_ B City of Ashland I ATTN: Accounts Payable L 20 E. Main Purchase 20230350 Ashland, OR 97520 . Order# T Phone: 541/552-2010 0 Email: payable@ashland.or.us V H CIO Fire and Rescue Department E1582, LLC I 455 Siskiyou Blvd D 1855 N MCCARRON BLVD P Ashland, OR 97520 O SPARKS, NV 89431 Phone: 541/482-2770 T Fax: 541/488-5318 Marshall Rasor _ `'.a=:1EIa=1�`35Ise�11�=�I kf- i e-7a� _ l'1si riMi �1-1 'af 1 aI _ i_�.n �� J-ei'i=llfi =1._1i.[eia�— ttJ'06/29/2023 7773F_ 22 FOB ASHLAND OR/NET30 • Cit Accounts Payable a®lIQ3FI.- 3��2�v E4T-N 9l5��}'o5EY v _ 2 = - _f @- `Z' a 2 NFPA 1582 Health Screenings 1 NFPA 1582 Health and Cancer Screenings for Firefighters 1.0 $183,150.00 $183,150.00 Contract for NFPA Compliant Health and Cancer Screenings for Ashland Firefighters - completion date: August 1, 2024 Project Account: E-G00032-700 • - Project Account: E-G00032-999 ***************GL SUMMARY*************** 071200-606600 $183,150.00 \ • • • • 1�. Date: r I lL €_ =—_ — g Authorized Si nate=', I !` —�= �_a E===' $183 150.00 ,FORM #3 ' CITY OF rq Purchase *ASHLAND �2 req 'e t for Purchas Order clef _ REQUISITION . . �a r 0 Date-of request: c "lie Required date for delivery: l2- Vendor Name 1582 LLC - Address,City,State,Zip 1855 N McCarran BLVD, Sparks, NV 89431 Contact Name&Telephone Number Paul Granstrom (775) 846-3413 Email address paul@1582exam.com SOURCING METHOD ' ❑ Exempt from Competitive Bidding ❑ Invitation to Bid 0 Emergency ❑ Reason for exemption: Date approved by Council: '0 Form#13,Written findings and Authorization O AMC 2.50 (Attach copy of council communication) 0 Written quote or proposal attached ❑ Written quote or proposal attached (If council approval required,attach copy of CC) ❑ Small Procurement 0 Request for Proposal ' Cooperative Procurement . Not exceeding$5,000 Date approved by Council: 0 State of Oregon ❑ Direct Award _(Attach copy of council communication) Contract# , ❑ Verbal/Written bid(s)or proposal(s) 0 Request for Qualifications(Public Works) 0 State of Washington . Date approved by Council: Contract# ' _(Attach copy of council communication) 0 Other government agency contract •. Intermediate Procurement 0 Sole Source - Agency GOODS&SERVICES 0 Applicable Form(#5,6,7 or 8) Contract# Greater than$5,000 and less than$100,000 0 Written quote or proposal attached Intergovernmental Agreement ❑ (3)Written bids&solicitation attached- 0 Form#4,Personal Services$5K to$75K Agency 1, PERSONAL SERVICES Date approved by Council: 0 Annual cost to City does not exceed$25,000: Greater than$5,000 and less than$75,000 Valid until: Date Agreement approved by Legal and approved/signed by- ❑ Less than$35,000,by direct appointment El Special Procurement City Administrator.AMC 2.50.070(4) ❑ (3)Written proposals&solicitation attached 0 Form#9,Request for Approval 0 'Annual cost to City exceeds$25,000,Council ❑ Form#4,Personal Services$5K to$75K O. Written quote or proposal attached approval required.(Attach copy of council communication) Date approved by Council:05/16/2023 , Valid until: • (Date) Description of SERVICES NFPA 1582 Health and Cancer Screenings for Ashland Fire&Rescue,delivered on site for 2023 TOTAL.COST and 2024. $ 182,324.00. Item # Quantity Unit Description of MATERIALS . Unit Price Total Cost • ' 0 Per attached quote/proposal ----- 1441%%\ TOTAL ,COST Project Number _ Account Numb/err�0Zoe 00.404660 . ' _ ' . . . 16,c a ,frkt efrQ x e- � 4 5' ct ' ci.e�Q Account Number _ _._ _ _ . Ace6unt Number - *Expenditure must be charged to the appropriate account numbers for the financials to accurately reflect the actual expenditures. IT Director in collaborationrwith department to approve all hardware and software purchases: . , IT Director Date Support-Yes/No : :: s requisition form,I certify that the City's public contracting requirements have been satisfied.e: Department Head; � 44 • Equal to or greater than$5,000) Department Manager/Supervisor: City Manager: 1 (Greater than$35,000) Funds appropriated for current fiscal year: YES /NO \-1- 4. _ _ _ inance Director-(Equal t. •'Igreater than$5,000) �6a1 Comments: Form#3-Requisition ` Kariann Olson Frpm: ��and"xwamv� Sent: Wednesday,May 31,2023 2:15 PM ' To: Kariann Olson Cc: Todd Stubbs Subject RE:Account numbers Hi Kari, Thank you for Iettingme know. It doesn't go to a diffnantaccountnunmberbutit goes to separate project strings. Grants always have to have pject numbers. Otherwise,we can't run a report to submit to the grantor. -' Will you please m; :••9" . Will you please code Thank you for checknQ� . . Thanks, . Miranda . From: KahannOlson <keh,obon@ash|and.ocus> Sent:Wednesday, May 31, 2023 1:21 PM - To: Mirandairandakma ashtand.or | Cc: Kariann Olson<kari.olson@ashland.or.Us>;Todd Stubbs<todd.stubbs@ashland.or.us> Subject:Account numbers Hello Miranda, Fire Department has a contract forhealth and cancer screening rvices for firs. Grant portion$ City match 1O%portion$16,GSUl]O A/C#O712UU6O6GDO ' Does the grant portion go in a different A/C#? Please advise: Thank you. ' , Kariann • Kariann(Kari)Olson, • • 1 rV-4; 7 4 Aare(„ c :: 0 City of Ashland Purchasing Office 90 North Mountain Avenue,Ashland,Oregon 97520 541.488.5354 I TTY 800.735.2J0O : - Karii.olson ashland.or.us This email transmission is official business of the City of Ashland,and it is subject to Oregon Public Records Law for disclosure and retention.If you have received this message in error,please contact me at 541.488.5354.. 2 J !EACouncil Business Meeting May 16,2023 { Class Special Procurement Method Approval for Firefighter Health and Cancer �AgeriiaC ��� Screenings 'Front 33: ' � r Ralph Sartain Fire Chief -Cont.ct1 •`' ralph.sartaini ashland.or.us 541-552-2229 rpt • .y •Itemitype '" Requested by Council El Update I: Request for Approval 0 Presentation 1=1. a�, SUMMARY Approval is being requested for a Contract-specific Special Procurement. This Contract-specific Special Procurement will allow Ashland Fire&Rescue to directly award a contract to 1582,LLC for NFPA 1582 Health and Cancer Screening for Firefighters. The contractor will provide onsite NFPA 1582 Health and Cancer Screenings for the Ashland Firefighters in accordance with NFPA 1582 standards.The contract will begin on June 1,2023,and end on August 1,2024. POLICIES,PLANS&GOALS SUPPORTED BACKGROUND AND ADDITIONAL INFORMATION A Special Procurement (sourcing method) is used forthe purpose of seeking an exemption from the competitive bid process,custom designing a contracting approach,or the direct selection or award of a public contract or for a series of contracts.The attached Form #9 Special Procurement Request for Approval (written findings) is attached for your review and consideration. A formal solicitation (Request for Proposal/Competitive Sealed Proposal) was released on March 24,2023,and proposals were due on April 18,2023. It appears at least nine (9) firms or individuals accessed the RFP on the City's website. One proposal was received in the amount of$292,932.45,which substantially exceeded the available funding. The RFP was cancelled due to the proposed cost exceeding the available funding by more than $100,000.00. Due to the grant deadlines and lack of interest in the City's RFP,Ashland Fire&Rescue negotiated a contract directly with 1582, LLC to ensure the Ashland Firefighters would receive the NFPA 1582 Health and Cancer Screenings,the cost would not exceed the available funding and the grant requirements would be.satisfied. FISCAL IMPACTS Testing Schedule Quantity Cost per Firefighter Amount June 2023 37 $2,399.99 • .$88,763.00 July 2024 Up to 39 $2,399.00 $93,561.00 Estimated Total Cost $182,324.00 Amount of Grant $166,500.00 10%City Match $16,650.00 Page 1 of 2 . /A rasi Council Business Meeting Available Funding $183,150.00 DISCUSSION QUESTIONS SUGGESTED NEXT STEPS Staff recommends the Contract-specific Special Procurement be approved and the public contract be directly awarded to 1582,LLC. REFERENCES&ATTACHMENTS 1. Form#9 Special Procurement Request for Approval(Written Findings) 2. 1582,LLC. Proposal for Ashland Fire &Rescue Page 2 of 2 a+ IqA�p CtlC2%gcfr CITY OF FORM #9 ASHLAND S+PE�C�I�A QaI�J1R�E �E�NT QUoss Fro #A�R- aoy To: City Council, Local Contract Review Board From: Marshall Rasor, Deputy Fire Chief Date: May 16, 2023 Subject: REQUEST FOR APPROVAL OF A SPECIAL PROCUREMENT In accordance with ORS279B.085,this request for approval of a Special Procurement is being presented to the City Council for approval.This written request for approval describes the proposed contracting procedure and the goods or services or the class of goods or services to be acquired through the special procurement and the circumstances that justify the use of a special procurement under the standards set forth ORS 279B.085(4). 1. Requesting Department Name: Ashland Fire&Rescue 2. Department Contact Name: Marshall Rasor,Deputy Fire Chief 3. Type of Request: Class Special Procurement X Contract-specific Special Procurement 4. Time Period Requested: From June 1,2023 To: August 1,2024 5. Total Estimated Cost: Testing Schedule Quantity Cost per Firefighter Total Cost June 2023 37 $2,399.00 $88,763.00 July 2024 Up to 39. $2,399.00 93,561.00 Total Estimated Cost $182,324.00 Amount of Grant $166,500.00 10%City Match 16,650.00 Available Funding $183,150.00 6. Short title of the Procurement: NFPA 1582 Health and Cancer Screening for Firefighters Supplies and/or Services or class of Supplies and/or Services to be acquired: Overview of Periodic Physical Exam/Health Screening: The NFPA 1582 compliant,Physician-led laboratory blood and urine testing,Occupational Health testing, cardiopulmonary fitness evaluation,Physician Exam,multiple ultrasound screening panels including echocardiogram,strength/endurance/flexibility testing,infectious disease and immnni7ation titer testing,chest x- ray and quantitative fit test.Some of these tests can lead to the discovery of cancer markers. Overview of Cancer Screening Physical: The NFPA 1582 compliant cancer screening includes cancer specific tests and some of the general medical assessments that may lead to the discovery of cancer markers. Form#9-Special Procurement—Request for Approval,Page 1 of 3,5/12/2023 7.Background and Proposed Contracting Procedure: Provide a description of what has been done in the past and the proposed procedure. The Agency may,but is not required to,also include the following types of documents:Notice/Advertising, Solicitation(s),Bid/Proposal Forms(s), Contract Form(s),and any other documents or forms to be used in the proposed contracting procedure. Attach additional sheets as needed. ' .Background: A formal solicitation(Request for Proposal/Competitive Sealed Proposal)was released on March 24,2023,and proposals were due on April 18,2023. It appears at least nine(9)firms or individuals accessed the RFP on the City's website. One proposal was received in the amount of $292,932.45,which substantially exceeded the available funding. The RFP was cancelled due to the proposed cost exceeding the available funding by more than$100,000.00. Proposed procedure: This Contract-specific Special Procurement(sourcing method)is being processed to request approval to"directly award"a contract to 1582,LLC for onsite NFPA 1582 Health and Cancer Screenings for Firefighters. 8. Justification for use of Special Procurement: Describe the circumstances that justify the use of a Special Procurement. Attach relevant documentation. Due to the grant deadlines and lack of interest in the City's RFP,Ashland Fire&Rescue negotiated a contract directly with 1582,LLC to ensure the Ashland Firefighters would receive the NFPA 1582 - Health and Cancer Screenings,the cost would not exceed the available funding and the grant requirements would be satisfied. , 9. Findings to Satisfy the Required Standards: This proposed special procurement: X (a)will be unlikely to encourage favoritism in the awarding of public contracts or to substantially diminish competition for public contracts because: An RFP (formal solicitation)was processed,at least nine(9)firms or individuals accessed the RFP on the City's website and only one(1)proposal was received. The costs associated with the proposal that was received exceeded the available funding by$100K and the RFP was cancelled. (Please provide specific information that demonstrates how the proposed Special Procurement meets this requirement.);and X (b)(i)will result in substantial cost savings to the contracting agency or to the public because: The grant received by AF&R will fund 90%of the cost for these services with a 10%match by the City. (Please provide the total estimate cost savings to be gained and the rationale for determining the cost savings);or X (b)(ii)will otherwise substantially promote the public interest in a manner that could not practicably be realized by complying with the requirements of ORS 279B.055,279B.060,279B.065, or 279B.070,or any rules adopted thereunder because: An RFP(ORS 275B.060)was processed but was unsuccessful and cancelled due to reasons identified above. (Please provide specific information that demonstrates how the proposed Special Procurement meets this requirement.) Form#9-Special Procurement—Request for Approval,Page 2 of 3,5/12/2023 Public Notice: Pursuant to ORS.279B.085(5)and OAR 137-047-0285(2),a Contracting Agency shall give public notice of the Contract Review Authority's approval of a Special Procurement in the same manner as a • public notice of competitive sealed Bids under ORS 279B.055(4)and OAR 137-047-0300. The public . notice shall describe the Goods or Services or class of Goods or Services to be acquired through the- Special Procurement and shall give such public notice of the approval of a Special Procurement at least seven(7)Days before Award of the Contract. After the Special Procurement has been approved by the City Council,the following public notice will be posted on the City's website to allow for the seven(7)day protest period. Date Public Notice first appeared on www.ashland.or.us-[If approved May 17] • PUBLIC NOTICE Approval of a Special Procurement First date of publication:[If approved,May 17,2023] - A request for approval of a Special Procurement was presented to and approved by the City Council,acting as the Local Contract Review Board,on[If approved,May 16,2023]. • A formal solicitation(Request for ProposalCompetitive Sealed Proposal)was released on March 24,2023, and proposals were due on April 18,2023. It appears at least nine(9)firms or individuals accessed the RFP . on the City's website.One proposal was received in the amount of$292,932.45,which substantially • exceeded the available funding. The RFP was cancelled due to the proposed cost exceeding theevailable funding by more than$100,000.00. • Due to the grant deadlines and lack of interest in the City's RFP,Ashland Fire&Rescue negotiated a contract directly with 1582,LLC to ensure the Ashland Firefighters would receive the NFPA 1582 Health and Cancer Screenings,the cost would not exceed the available funding of$183,150.00,and the grant requirements would be satisfied.The grant received by AF&R will fund 90%of the cost for these services with a 10% match by the City. It has been determined based on written fmdings.that the Special Procurement will be unlikely to encourage favoritism in the awarding of public contracts or to substantially diminish competition for public contracts, and result in substantial cost savings or substantially promote the public interest in a manner that could not be realised by complying with the requirements that are applicable in ORS 279B.055,279B.060,279B.065,or 279B.070. • An affected person may protest the request for approval of a Special Procurement in accordance with ORS `279B A00 and OAR 137-047-0300. A written protest shall be delivered to the following address:City of Ashland,Kari Olson,Purchasing Specialist,90 N.Mountain,Ashland,OR 97520. The seven(7)protest period will expire at 5:00pm on[Ifposted May 17,2023,will expire May 24,2023] This public notice is being published on the City's Internet World Wide Web site at least seven days prior to • the award of a public contract resulting from this request for approval of a Special Procurement. • • • Form#9-Special Procurement-Request for Approval,Page 3 of 3,5112/2023 • NFPA 1582 Compliant Health and Cancer Screenings for Ashland Firefighters CONSULTANT: Gilbert Gaetke and Associates of Nevada,MD,LDT dba 1582,LLC CITY OF ASHLAND CONTACT: Paul Granstrom,President Ashland Fire and Rescue 20 East Main Street ADDRESS: 1855 N.McCarran Blvd. Ashland,Oregon 97520 . Sparks,NV 89431 : • Telephone: 541/482-2770 Fax: 541/488-5318 TELEPHONE: (775) 846-3413 • EMAIL:,paulQ 1582exain.com This Personal Services Agreement (hereinafter"Agreement") is entered into by and between the City of Ashland, an Oregon municipal' corporation (hereinafter "City") and Gilbert, Gaetke and Associates of Nevada, MD, LDT, dba •1582,.LLC ("hereinafter "Consultant"), for NFPA 1582 • Compliant Health and Cancer Screenings for Ashland Firefighters. NOW THEREFORE,in consideration of the mutual covenants contained herein, the City and Consultant hereby agree as follows: . • 1. Effective Date and Duration: This Agreement shall become effective on the date of execution on behalf of the City,as set forth below (the"Effective Date"),and unless sooner terminated as specifically provided herein, shall terminate upon the City's;affinnative acceptance of Consultant's Work as complete and Consultant's acceptance,of the City's final payment therefore, but not later than.August 1,2024. 2. Scope of Work: Consultant will provide NFPA 1582 Compliant Health and Cancer Screenings for Ashland Firefighters as more fully set forth in the Consultant's Proposal dated April 27,2023,which is,attached hereto as "Exhibit A"and incorporated herein by this reference. Consultant's services are collectively referred to in this Agreement as the"Work." 3. Compensation: City shall pay Consultant the sum of$2,399.00 per firefighter,two thousand three hundred ninety-nine dollars.for Consultant's performance of all Work under this Agreement. In no event shall Consultant's total of all compensation and reimbursement under this Agreement exceed the sum of$183,150.00(Grant$166,500.00 plus City's 10% match $16,650.00)one hundred eighty-three thousand one hundred fifty dollars,without the . express,written approval from the City official whose signature appears below,or such official's successor in office. Payments shall be made within thirty (30) days of the date of receipt by the City of Consultant's invoice. Should this Agreement be terminated prior to completion of all • Work,payments will be made for any phase of the Work completed and accepted as of the date of termination. • Page 1 of 7: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND 1582,LLC 4. Supporting Documents/Conflicting Provisions: This Agreement and any exhibits or other supporting documents"shall be construed to be mutually complementary and supplementary wherever possible. In the event of a conflict which cannot be so resolved, the provisions of this Agreement itself shall control over any conflicting provisions in any of the exhibits or supporting documents. • 5. All Costs Borne by Consultant: Consultant shall,at its own risk,"perform the Work described above and,unless otherwise specified in this Agreement, furnish all labor,equipment,and materials required for the proper performance of such Work. 6. Qualified Work: Consultant has represented,and by entering into this Agreementnow represents,that all personnel assigned to the Work to be performed under this Agreement are fully qualified to perform the services to which they will be assigned in a skilled manner and,if required to be registered, licensed,or bonded by the State of Oregon,are so registered,licensed, or bonded. 7. Ownership of Work/Documents: All Work,work product, or other documents produced in furtherance of this Agreement belong to the City,and any copyright,patent,trademark proprietary or any other protected intellectual property right shall vest in and is hereby assigned to the City. 8. Statutory Requirements: The following laws of the State of Oregon are hereby incorporated by reference into this Agreement: ORS279B.220, 27911230 and 279B.235. 9. Living Wage Requirements: If the amount of this Agreement is$24,050.68 or more, Consultant is required to comply with Chapter 3.12 of the Ashland Municipal Code by paying a • living wage,as defined in that chapter,to all employees performing Work under this Agreement and to any Subcontractor who performs 50%or more of the Work under this Agreement. Consultant is also required to•post the notice attached hereto as"Exhibit B"predominantly in areas where it will be seen by all employees. 10. Indemnification: Consultant hereby agrees to defend, indemnify,save,and hold City, its officers, employees, and agents harmless from any and all losses,claims, actions,costs, expenses,judgments,or other damages resulting from injury to any person(including injury resulting in death),or damage(including loss or destruction)to property,of whatsoever nature arising.out of or incident to the performance,of this Agreement by Consultant(including but not limited to,Consultant's employees,agents,and others designated by Consultant to perform Work or services attendant to this Agreement). However,Consultant shall not be held responsible for any losses,expenses,claims, costs,judgments,or other damages,caused solely by the gross negligence of City: 11. Termination: . a. Mutual Consent. This Agreement may be terminated at any time by the mutual consent of both parties. b. City's Convenience. This Agreement may be terminated by City at any time upon not less than thirty(30)days' prior written notice delivered by certified mail or in person. c. For Cause. City may terminate or modify this Agreement, in whole or in part,effective • Page 2 of 7: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND 1582,LLC upon delivery of written notice to Consultant,or at such later date as may be established by City under any of the following conditions: ' i. "If City funding from federal,state,county or other sources is not obtained and continued at levels sufficient to allow for the purchase of the indicated quantity of services; ii.` If federal or state regulations or guidelines are modified,changed,or interpreted in such a way that the services are no longer allowable or appropriate for purchase under this Agreement or are no longer eligible for the funding proposed for payments authorized by this Agreement; or • iii. If any license or certificate required by law or regulation to be held by Consultant to provide the services required by this Agreement is for any reason denied,revoked, suspended,or not renewed. d. For Default or Breach. i. Either City or Consultant may terminate this Agreement in the event of a breach of the Agreement by the other. Prior to such termination the party seeking termination shall give to the other party written notice of the breach and its intent to terminate. If the party committing the breach has not entirely cured the breach within fifteen(15) days of the date of the notice,or within such other period as the party giving the notice may authorize in writing,then the Agreement may be terminated at any time thereafter by a written notice of termination by the party giving notice. ii. Time is of the essence for Consultant's performance of each and every obligation and duty under this Agreement. City,by written notice to Consultant of default or breach, may at any time terminate the whole or any part of this Agreement if Consultant fails to provide the Work called for by this Agreement within the time specified herein or within any extension thereof. iii. The rights and remedies of City provided in this subsection(d)are not exclusive and are in addition to any other rights and remedies provided by law or under this Agreement. e, Obligation/Liability of Parties. Termination or modification of this Agreement pursuant to subsections a,b,or c above shall be without prejudice to any obligations or liabilities of either party already accrued prior to such termination or modification. However,upon receiving a notice of termination(regardless whether such notice is given pursuant to Subsection a,b,c,or d of this section,Consultant shall immediately cease all.activities under this Agreement,unless expressly directed otherwise by City in the notice of termination. Further,upon termination,Consultant shall deliver to City all documents, information,works-in-progress and other property that are or would be deliverables had the Agreement been completed. City shall pay Consultant for Work performed prior to the termination date if such Work was performed in accordance with this Agreement. 12. Independent Contractor Status: Consultant is an independent contractor and not an employee of the City for any purpose. Consultant shall have the complete responsibility for the Page 3 of 7:'PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND 1582.LLC performance of this Agreement. Consultant shall provide workers' compensation coverage as required in ORS Chapter 656 for all persons employed to perform Work pursuant to this Agreement. Consultant is a subject employer that will comply with ORS 656.017. 13. Assignment: Consultant shall not assign this Agreement or subcontract any portion of the Work without the written consent of City. Any attempted assignment or subcontract without written consent of City shall be void. Consultant shall be fully responsible for the acts or omissions of any assigns or subcontractors and of all persons employed by them, and the approval by City of any assignment or subcontract of the Work shall not create any contractual relation between'the assignee or subcontractor and City. 14. Default. The Consultant shall be in default of this Agreement if Consultant: commits any. material breach or default of any covenant,warranty, certification, or obligation under the Agreement; institutes an action for relief in bankruptcy or has instituted against it an action for insolvency; makes a general assignment for the benefit of creditors; or ceases doing business on a regular basis of the type identified in its obligations underthe Agreement; or attempts to assign • rights in,or delegate duties under,this Agreement. 15. Insurance. Consultant shall, at its own expense,maintain the following insurance: a. Worker's Compensation insurance in compliance with?RS 656.017, which requires subject employers to provide Oregon workers' compensation coverage for all their subject workers b. Professional Liability insurance with a combined single limit, or the equivalent,of not less than , o OO'( oo million ollars per occurre ce. T Ili, 'sato cover any damages caused ... 60 caa ' gt g `fid� .. i Agreement. byerror, om�ssio or ne I ec s I la a tote ork,to eprovided under this A reement. c. General Liability insurance with a combined single limit, or the equivalent, of not less than $2,000,000(two million dollars)per occurrence for Bodily Injury,Death,and Property Damage. d. Automobile Liability insurance with a combined single limit, or the equivalent,of not less than$1,000,000(one million dollars)for each accidenti for Bodily Injury and Property Damage, including coverage for owned,hired or non-owned vehicles,as applicable. e. Notice of cancellation or change. There shall be no cancellation,material change, reduction of limits or intent not to renew the insurance coverage(S)without thirty (30)days' prior written notice from the Consultant or its insurer(s)to the City. f. Additional Insured/Certificates of Insurance. Consultant shall name the'City of Ashland, Oregon, and its elected officials, officers and employees as Additional Insureds on any insurance policies, excluding Professional Liability and Workers' Compensation,required herein,but only with respect to,Consultant's services to be provided under this Agreement.The consultant's insurance is primary and non-contributory. As evidence of the insurance coverages required by this Agreement, the Consultant shall furnish acceptable insurance certificates prior to . commencing the Work under this Agreement. The ceztificate will specify all of the parties who are Additional Insureds. Insuring companies or entities are subject to the City's acceptance. If requested, complete copies of insurance policies;trust agreements,etc.shall Page 4 of 7: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND 1582.LLC be provided to the City. The Consultant shall be financially responsible for all pertinent deductibles,self-insured retentions,and/or self-insurance. 16. Nondiscrimination: Consultant agrees that no person shall,on the grounds of race,color, religion,creed,sex,marital status, familial status or domestic partnership,national origin,age, mental or physical disability,sexual orientation,gender identity or source of income, suffer discrimination in the performance of any Work under this Agreement when employed by Consultant. Consultant agrees to comply with all applicable requirements of federal and state civil rights and rehabilitation statutes,rules and regulations. Further;Consultant agrees not to discriminate against a disadvantaged business enterprise,minority-owned business,woman- owned business,a business that a service-disabled veteran owns or an emerging small business enterprise certified under ORS 200.055,in awarding subcontracts as required by ORS 279A.110. • 17. Consultant's Compliance with Tax Laws: • 17.1 Consultant represents and warrants to the City that: 17.1.1 Consultant shall,throughout the term of this Agreement, including any extensions hereof, comply with: (i)All tax laws of the State of Oregon, including but not limited to ORS 305.620 and • ORS Chapters 316,317,and 318; . (ii) Any tax provisions imposed by a political subdivision of the State of Oregon applicable to Consultant; and (iii) Any rules,regulations,charter provisions,or ordinances that implementor enforce any of the foregoing tax laws or provisions. 17.1.2 Consultant, for a period of no fewer than six (6)calendar years preceding the Effective . Date of this Agreement,has faithfully complied with: (i) All tax laws of the State of Oregon, including but not limited to ORS 305.620 and ORS Chapters 316,317,and 318; 0 (ii) Any tax provisions imposed by a political subdivision:of the State of Oregon applicable to Consultant;and (iii) Any rules,regulations,charter provisions,or ordinances that implement or enforce any of the foregoing tax laws or provisions. • 18. Notice. Whenever notice is required or permitted to be given under this Agreement,such notice shall be given in writing to the other party by personal delivery,by sending via a reputable commercial overnight courier,by mailing using registered or certified United States mail,return receipt requested,postage prepaid,or by electronically confirmed at the address or facsimile • number set forth below: • If to the City: Ashland Fire&Rescue Attention: Marshall Rasor,Deputy Chief-Operations • 455 Siskiyou Blvd. Ashland, Oregon 97520 Page 5 of 7: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND 1582,LLC Telephone: 541-482-2770 Marshall:rasor(a?ashland.or.us 1 With a copy to: City of Ashland Attention: Legal Department • 20 E. Main Street Ashland, Oregon 97520. . ' Telephone: 541-488-5350 If to Consultant: 1582; LLC Attention:Paul Granstrom,President 1855 N.McCarran Blvd., Sparks,NV 89431 ' Telephone: 775-846-3413' paul@t582exam.com • 19. Governing Law. This Agreement shall be governed by the laws of the State of Oregon without regard to conflict of laws principles. Exclusive venue for litigation of any action arising under this Agreement shall be in the Circuit Court of the State of Oregon for Jackson County unless exclusive jurisdiction is in federal court, in which case exclusive venue shall be in the federal district court for the district of Oregon: Each party expressly waives any and all rights to maintain an action under this Agreement in any other venue, and expressly consents that,upon motion of the other party,any case may be dismissed or its venue transferred,as appropriate;so as to effectuate this choice of venue. 20. Amendments. This Agreement may be amended only by written instrument executed by both parties with the same formalities as this Agreement. 21. Nonappropriations Clause. Funds Available and Authorized: City has sufficient funds currently available and authorized for expenditure to finance the costs of this Agreement within the City's-fiscal year budget. Consultant understands and agrees that City's payment of amounts under this Agreement attributable to Work performed after the last day of the current fiscal year is contingent on City appropriations,or other expenditure authority sufficient to allow City in the exercise of its reasonable administrative discretion,to continue to make payments under this Agreement. In the event City has insufficient appropriations, limitations or other expenditure authority,City may terminate this Agreement without penalty or liability to City,effective upon the delivery of written notice to Consultant,with no further liability to Consultant 22. THIS AGREEMENT AND THE ATTACHED EXHIBITS CONSTITUTE THE ENTIRE UNDERSTANDING AND AGREEMENT BETWEEN T E PARTIES. NO WAIVER, CONSENT, MODIFICATION OR CHANGE OF TERMS OF THIS AGREEMENT SHALL ,BIND EITHER PARTY UNLESS IN WRITING AND SIGNED BY.BOTH PARTIES. SUCH WAIVER, CONSENT, MODIFICATION OR CHANGE,i IF MADE, SHALL BE EFFECTIVE ONLY IN THE SPECIFIC INSTANCE AND FOR THE SPECIFIC PURPOSE GIVEN. • THERE ARE NO UNDERSTANDINGS,AGREEMENTS,OR REPRESENTATIONS, ORAL Page 6 of 7: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND.1582,LLC OR WRITTEN,NOT SPECIFIED HEREIN REGARDINGTHIS AGREEMENT. CONSULTANT, BY SIGNATURE OF ITS AUTHORIZED REPRESENTATIVE,HEREBY ACKNOWLEDGES THAT HE/SHE HAS READ THIS'AGREEMENT, UNDERSTANDS IT, AND.AGREES TO BE BOUND BY ITS TERMS AND CONDITIONS. 23. Certification. Consultant agrees to and shall sign the certification attached hereto as"Exhibit C"and incorporated herein by this reference. IN WITNESS WHEREOF the parties have caused this Agreement to be signed in their respective names by their duly authorizedrepresentatives as of the dates set forth below. • CITY OF A •I ,ND: . Gilbert,Gaetke and Associates of Nevada,MD,LT, • i/f .dba 1582,LLC Joseph L. Lessard, City Manager By: lJ Signature-7/1 Of 1/b9%; Date GC . Printed Name ceo .�2 �—O Title Purchase Order No. 11S(; 12023 te (W-9 is to bejsubmitted with this signed Agreement) • APPROVED AS TO FORM: City Attorney 177/0.5/2-S Date - Page 7 of 7: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND 1582,LLC EXHIBIT B CITY OF ASHLAND, OREGON City of Ashland • LiVING ALL employers described WAG E " below must comply with City of Ashland laws regulating •a ment of a livin• wa•e. $17.02 per hour, effective June 30, 2022. • 1111 The Living Wage is adjusted:annually,.every June 30 .by the Consumer Price index. Employees must be paid a portion of business of their 401K and IRS eligible . living wage- employer,if the employer has: cafeteria plans(including ten or more employees, and childcare)benefits to the has received financial amount of wages received by assistance for the project or the employee. y For all hours worked under a business from the City of service contract between their Ashland in excess of > Note: For temporary and employer and the City of $24,050.68. parttime employees,the • Ashland if the contract Living Wage does not apply exceeds$24,050.68 or more. > If their employer is the City of to the first 1040 hours worked Ashland,including the Parks . in any calendar year. For > For all hours worked in a and Recreation Department. more details,please see month if the employee spends Ashland Municipal Code 50%or more of the > In calculating the living wage, Section 3.12.020. employee's time in that month employers may add the value working on a project or of health care,retirement, For additional information: Call the Ashland City Administrator's office at 541-488-6002 or write to the:City Administrator, City Hall, 20 East Main Street,Ashland, Oregon 97520, or visit the City's website at www:ashland.or.us. Notice to Employers: This notice must be posted predominantly in areaswhere it can be - seen by all employees. CITY OF ASHLAND► Page 1 of 1: EXHIBIT B �I EXHIBIT C CERTIFICATIONS/REPRESENTATIONS: Consultant,by and through its authorized representative,under penalty of perjury,certifies,that(a)the number shown on the attached W-9 form is.its correct taxpayer ID (or is waiting for the number to he issued to it and(b) Consultant is not subject to backup withholding because: (i) it is exempt from backup withholding,or(ii)it has not been notified by the Internal Revenue Service(IRS)that it is subject to backup withholding as a result of a failure to report all interest or dividends, or(iii) the IRS has notified it that it is no longer subject to backup withholding. Consultant further represents and warrants to City that: (a) it has the power and authority to enter into this,Agreement and perform the Work, (b) the Agreement,when executed and delivered, shall by a valid and binding obligation of Consultant enforceable in accordance.with its terms, (c)the work under the Agreement shall be performed in accordance with the highest professional standards,and(d) Consultant is qualified,professionally competent, and duly licensed(if applicable)to perform the Work'. Consultant also certifies under penalty of perjury that its business is not in violation of any Oregon tax laws, it is an independent contractor as defined in the Agreement, it is authorized to do business in the State of Oregon, and Consultant has checked}four or more of the following criteria that apply to its business. . ✓ (1)Consultant carries out the work or services at a location separate from a private residence or is in a specific portion of a private residence,set aside as the location of business. ' L✓ (2)Commercial advertising or business cards or a trade association membership are purchased for the business. (3)Telephone listing is used for the business separate from the personal residence / listing. ✓ (4) Labor or services are performed only pursuant to written contracts. ✓� (5)Labor or services are performed for two or more differentpersons within a period of one year. (6)Consultant assumes financial responsibility for defective workmanship or for service not provided as evidenced by the ownershipof performance bonds, warranties,errors and omission (professional liability) insurance or liability insurance relating to the Work or services to be provided. . . Consultant's signature . Date . . • Page 1 of I: EXHIBIT C • EXHIBIT A 1582 April 27th, 2023 • • Ashland Fire Department 455 Siskiyou Boulevard • Ashland,OR 97520 • Attn: Chief Marshall Rasor RE: Professional ServicesContract for NFPA 1582 Compliant Exams and Cancer Screenings Chief, This "proposal is per your request to conduct NFPA 1582 Health and Cancer Screenings. for Firefighters from the RFP released by the City of Ashland on March 24th,2023. We are prepared to assist your group,if Ashland Fire desires. We understand that the City of Ashland has very few resources in the area.and will consider a professional services contract to provide the following very specialized services. 1582, LLC (hereafter referred to as "1582"), ispleased,to present our submission to assist the Ashland Fire, Department by providing NFPA Compliant Firefighter Medical Examinations and Cancer Screenings. • 1582 specializes in serving Fire Departments and Fire Districts throughout the Western States by providing On-Site Medical Testing. 1582 is headquartered and located at 1855 N. McCarran Blvd., Sparks,NV 89431. , Primary contact with this submission will be Paul Granstrom President of 1582, can be reached via phone at (775) 846-3413 or by email: paul@1582exam.com. • Sincerely, • Paul Granstrom • • President (775) 846-3413 - Cell pauln,1582exam.com • 15482 PRIMARY CONTACT INFORMATION 1582,LLC 1855 N.McCarran Blvd. Sparks,NV 89431 • Contact: .Paul Granstrom Cell# (775) 846-3413 • Email: paul@l582exam.com Company Background: 1582, LLC (hereafter referred to as "1582") was formed for the purposes of providing NFPA 1582 compliant examinations ON-SITE for Fire Departments throughout the Western States. We believe the conducting of these examinations ON-SITE can save Fire Departments large sums of money,by eliminating down time,paid overtime and units and staff being out of service. Additionally,bringing the medical specialists to the Fire Department will provide the best possible experience for serving large groups of Firefighters. Mark Gaetke, MD is President of Gilbert, Gaetke and Associates of Nevada, MD, LTD d/b/a ARC Health & Wellness Centers (sister company to 1582) was formed in 2009 to specialize in conducting NFPA 1582 Examinations and Comprehensive Public Safety Examinations for Police officers and Firefighters. Over the years,the ARC Health &Wellness book of business grew rapidly • to include all agencies with the State of Nevada as well as•all major cities and counties in Nevada including Police and Fire Departments in the Cities of Reno, Sparks, Las Vegas, North Las Vegas, and Henderson. We've been proudly serving nearly every Fire Department in the State of Nevada for a period of 15 years, as Nevada put into law a Heart &Lung Bill mandate NRS / NAC 617 that closely follows NFPA 1582. Proudly Serving over 30 Nevada Fire Departments including(dates listed are the start dates): Sparks Fire Department(2007) Reno Fire Department(2008) Carson City Fire Department(2010) • Las Vegas Fire&Rescue(2011 -Fire Rescue Clinic) North Las Vegas Fire Department(2011) Henderson Fire Department(2014 WellTrac-sister company) Mesquite Fire Department(2019) Amentum(DOD Contractor-Nevada Test Site-2022) • 15.a .82 In 2017,we formed a Limited Liability Corporation,known as 1582,LLC- ("1582"for Short)as the . name is more synonymous with Firefighter Medical Examinations,we expanded services in the states of Colorado,Arizona,and California. As a result,1582 has become the leading provider of NFPA 1582 compliant physical exams in the Western United States conducting more than 11,000 annual exams per year. Currently, our organization has a total of(4) four medical facilities in Nevada (Las Vegas, Reno, Carson City and Sparks) and (1) one medical•facility in Tucson,Arizona. In addition, 1582 has a fleet of six(6)mobile medical units to provide on-site services for our clients. 1582 has been serving various Fire Department/District clients in California including: North.Lake Tahoe Fire Department(2019) Merced Fire Department(2019) - Clovis Fire Department(2019) Corona Fire Department(2020) • • •NASA Jet Propulsion Laboratory Fire Dept.'(2020) Carlsbad Fire Department(2021) Sonoma Valley Fire Protection District(2022) Sonoma County Fire District(2023) . Monterey Fire Department(2023) Monterey County Fire District(2023) . . Petaluma Fire Department(2023) South San Joaquin County Fire Authority(2023) 1582 has also been growing greatly in Arizona proudly serving Fire Departments/Districts including: Kingman Fire Department(2015) Bullhead City Fire Department(2016) • • Casa Grande Fire Department(2019) ' Northwest Fire District(2020) Golder Ranch Fire District(2020) Prescott Fire Department(2020) Buckeye Fire Department(2021) Yuma Fire Department(2021) . V • • Tucson Fire Department(2021) Lake Havasu City Fire Department(2022) . 1582 was awarded the contract to serve Northwest Fire District(the largest Fire District in Arizona) in 2019 and other departments have enacted the Mutual Use Clause of that contract to begin working with us;including Golder Ranch Fire District,Prescott Fire Department,and City of Buckeye Fire Department to name a few. • 15 82 In 2021, 1582 was awarded a multi-year contract to serve the State of Arizona's 2nd largest Fire Department(over 700 Annual Firefighters)in Arizona-Tucson Fire Department. Conducting NFPA 1582 Compliant Exams is not merely a product line for 1582, it is our primary business. As indicated previously, 1582 has been providing the services solicited in this RFP since 2009. Very few medical providers understand the complexities of conducting NFPA 1582 compliant physicals. The principals/key personnel of 1582 have collectively been conducting these exams for over 40 years! 1582's dedicated clinical and management team has a depth of expertise which only comes from having extensive working experience in the industry they serve. Our Occupational Health team of experts can help you stay in compliance with all regulations pertaining to the services provided in this RFP. Our Medical Director, Mark Gaetke, MD is one of the most experienced physicians in conducting Annual Police and Fire Exams in the country. He has been conducting these exams for the past 27 years...first as Medical Director of Concentra (one of the nation's largest Occupational Medicine Providers) and then as Corporate Medical Director of 1582/ARC Health&Wellness Centers. 1582 currently employs a total of approximately.35 team members including seven (7) licensed physicians who conduct physical exams...and all are trained and certified in conducting stress treadmill tests. In the event of the death or disability of a clinical provider, 1582 has sufficient physician staff to ensure that all services provided under this contract will remain un-interrupted. CONTINUED ON NEXT PAGE... 150` 82 , METHODOLOGY AND SCHEDULE 0 • We are prepared to'provide multiple solutions to complete the ONSITE Examinations and can conduct the examinations of different time frames. . Step#1-identify the best tune of year to complete the exams , Step#2-identify the best COUNTY LOCATIONS to conduct the testing Step#3-identify how many exams are to be completely weekly and how weeks are needed Step#4-identify if exams are completed ON DUTY/OFF DUTY and best scheduling frequency Step# 5-identify the options for completing the examinations(1 Visit vs 2 Visit) Step#6-rollout schedules and planning METHODOLOGY OPTIONS: Examinations will be conducted ONSITE ASHLAND FIRE PROPERTY for example a Training Center,Fire Station,City Hall, etc. We will bring our equipment to you facility and set up-for testing 1 at the desired city location most convenient for the Department. Enclosed are pictures of ONSITE Exams showing how we can setup virtually anywhere: Private Room/Area-Ultrasound Screenings . Area for Stress EKG Testing WI ,,' I - t .t: 7_ ' '. * ;: /' One Open Area for Audiogram 0 . Spirometry Blood Draw -1 - ' ` "' � P �® 4 PHYSICIAN EXAM ROOM: • • {y, i , j�` ,_.w`• -' B 5 1•r' 1 1 .--3 I ` Private room/Private office + . $ 1 . � . ii N' + m�� s for the Physician to conduct the ;.qtr- il. �-_I P t ,f `• '."*;? I- - Lt, examination and discuss all the i L . „ ,.-It- ,j`.; * c - . • - I} ' I results. This can be a Captain's °s a. n e a Office,private room or storage ' room. . 01 82 OPTION# 1 -TRADITIONAL TESTING METHODOLOGY DESCRIPTION Two separate visit event,Part 1 visit is for Diagnostic Testing that requires the results to be compiled before the Part 2 Visit. • Part 1 Visit- 10 Patients per Day scheduled every 30 Minutes (40 patients per week). Time needed per member is one(1)hour per member. • Blood Draw and Urinalysis • Biometric Screening • Spirometry r • Audiogram • Ultrasound • . Chest X-Ray,if medically indicated Part 2 Visit-10 Patients per Day scheduled every 30 Minutes. Time needed per member is one(1)hour per member. • Resting EKG • Cardiac Stress Test • Fitness Assessment • Physician Examination and Skin Cancer Screening Traditional Testing Methodology(2 Visit Event) Sample Schedule-40 patients per week Comments: If we plan on working\five day increments, we can target 3 different Battalion Shifts to maximize flexibility and rotate the weeks so that we can provide an equal number of days for Each Battalion Shift. • REINiE irilMEIFARIS MOI E SGM+E+tiME 154 82 ASHLAND FIRE-SAMPLE SCHEDULE Part 1(Blood Draws,Ultrasound,additional Testing-2 Techs) TJME141onday Tiuesday Wednesday LIli day • 8:00 8:30 9:00 ' 9:30 • 10:00 10:30 • 11:00 bEgal Brea• Mai Brea iLrueehTBreall PIRA Brea• 11:30 12:00 12:30 • 13:00 13:30 • 14:00 BREA-i 14:30 15:00 15:30 - • • 16:00 • 15 15 15 15 Part 2 at Ashland (Physician/ Exercise Tech) • • T1Iv1E Monday TtuesdayrM_day Tthursday 8:00 ' 8:30 • • 9:00 9:30 • 10:00 10:30 11:00 MARTA �iRrichTBr'eal gu_ricfflBrea11 hunch Brea . 11:30 . . 12:00 • • • 12:30 13:00 13:30 14:00BEA REQ • R A' R_EA 14:30 . 15:00 • 15:30 • 16:00 " 15 15 15 15 • 15 � 82 OPTION# 2 -EXAM ONE TESTING METHODOLOGY ****PREFFERED METHOD**** This method is least disruptive to the Department as the exam is compressed into ONE VISIT. We must get the labwork completed ahead of time at Ashland Fire. Open to discussion and finding the best solution. • Step # 1 - 1582 sends a phlebotomist to conduct ONSITE blood draw based on the schedule and frequency minimizing the total number of days to accomplish 300 blood draws. In this scenario, 1582.wi11 send an phlebotomist to the different stations to complete the blood and urine collections and coordinate shipping of samples to LabCorp or Quest via FedEx.. Step#2 -1582 sends a team of specialists to cdhduct examinations as listed below. EXAM ONE VISIT-15 Patients per Day scheduled every 30 Minutes. Time needed per member is two(2)hours per member.- SAMPLE ember.SAMPLE SCHEDULE FOR DAY: Patient.#1 Start time: 0700. Station #1 Ultrasound 30 Minutes 700 Station#2 Medical Assistant Testing 30 Minutes 730 Station#3 Cardiac Stress Test 30 Minutes 800 Station #4 Physician Exam 30 Minutes 830 SAMPLE SCHEDULE FOR DAY: Patient#'2 Start Time:0730 • Station#1 Ultrasound 30 Minutes 730 Station#2 Medical Assistant Testing 30 Minutes 800 Station#3 Cardiac Stress Test 30 Minutes 830 Station#4 . Physician Exam 30 Minutes 900 This is the PREFERRED scheduling option is we complete all testing in ONE VISIT. We must get the Labs completed ahead of time for the physician to be able to review the results with the member to determine any potential concerns or make a Fitness for Duty Determination. • • At the end of the visit,the member will receive a copy of the results to present to their primary care provider for treatment recommendations by 1582. All copies of results will be provided including Labs, Ultrasound Results,Stress EKG tracings and comments from the physician detailing areas of concern. . 14 82 EXAM ONE-Testing Methodology(2 Visit Event) Sample Schedule-40 patients per week Comments:.If we plan on working five-day increments, we can target 3 different Battalion Shifts to • maximize flexibility and rotate.the weeks so that we can provide an equal number of days for Each Battalion Shift. We'll.complete 40 patients weekly in this scenario. Ashland Fire • SAMPLE SCHEDULE-NFPA 1582 Exams, • A SHIFT B SHIFT B SHIFT C SHIFT MONDAY : TUESDAY _ WEDNESDAY THURSDAY. 700 730 800 . 830 900 930 Break Break [3013 DiG N 1000 1030 1100 • • 1130 1200 1230 Break Break T Break 1300 1330 1400 • 1430 1500 : • In this scenario,we start a little earlier to have the first Doctor's appointment at 0830,the physician will complete his last exam at 1700. . If we complete 40 patients per week,we can schedule 4 weeks to complete the entire department(300). We are open to spreading this out per the request the Department based on the two physical years. 15 �` 82 COST PROPOSAL COST PER FIREFIGHTER: $2,399.00 SCOPT OF WORK "ON-SITE" rates are: 1582 Compliant Examination-$750.00 1582 Ultrasound Screening Panel-$250.00 Grail Cancer Screening Panel-$699.00 Blood Draw and Coordination of Shipping-$200.00+$100.00 transport fee Chest X-Ray-$50.00 Infectious Disease Testing(HIV,HEP A.B,C/Quantiferon Gold)-$350.00 We are prepared to come out,to Ashalnd Fire.to serve your members. To accomplish this, we suggest Two (2) events of Four (4) Working Days for the Part 1 (Bloodwork, Ultrasound, Hearing, Spirometry, Chest X-Ray etc.) and an additional Four (4) Working Days for the Part 2 (Physician Exam and Maximal Stress EKG). We'll work around your Battalion Calendar to ensure all Shifts are covered. Essentially, it will take us 8 days to complete the 37 examinations for the department. Physical Examination and Evaluation will include all tests listed below listed as "INCLUDED", unless patient declines or opts out of components or if 'considered, not medically necessary based on NFPA 1582 Standards. Occupational Health Testing Audiogram-Occupational Hearing Exam INCLUDED Biometric Screening INCLUDED Spirometry(Pulmonary Function Test) INCLUDED Vision Screening INCLUDED Resting EKG INCLUDED Blood Pressure Monitoring INCLUDED Vital Signs INCLUDED • 15482 Physical Exam-NFPA 1582 Physical Examination as outlined in NFPA 1582 INCLUDED Medical History Review INCLUDED Skin Cancer Assessment . INCLUDED • Cardiac Risk Stratification. INCLUDED Sleep Disturbance Apnea Assessment INCLUDED Health Promotion Counseling-Review INCLUDED OSHA Respirator Questionnaire INCLUDED • Firefighter Medical Clearance- 1582 TIERS INCLUDED Laboratory Blood/Urine Testing " Complete Blood Count with Differential INCLUDED Comprehensive Metabolic Panel INCLUDED. Fasting Lipid Panel INCLUDED Urinalysis INCLUDED Diabetes Screening-Fasting Glucose-A1C Hemoglobin INCLUDED • C-Reactive Protein INCLUDED Prostate Specific Antigen INCLUDED Hemoccult Test INCLUDED CA-125 (female only) INCLUDED Thyroid Panel INCLUDED Hepatitis Profile Screening/HIV Quantiferon Gold TB Test INCLUDED GRAIL TEST CANCER SCREENING INCLUDED • Cardiac/Pulmonary/Ultrasound Assessment Stress EKG,WFI Protocol INCLUDED Aerobic Capacity INCLUDED Treadmill Stress EKG • INCLUDED Ultrasound Screening-Carotid and Aortic Aneurysm Screening INCLUDED Ultrasound Screening-Thyroid INCLUDED Ultrasound Screening-Pancreas,Liver,Gallbladder,Spleen and Kidney INCLUDED Ultrasound Screening-External Pelvic(Female Only) INCLUDED Ultrasound Screening-Prostate and Testicular(Male Only) INCLUDED 15482 Members will receive a copy of all results electronically online via Citrix Sharefile, all records will be scanned to a PDF document for easy retrieval and members encouraged to bring to their physician to review. 1582 only uses a LICENSED PHYSICIANS to conduct the NFPA 1582 Examination on-site, as per year. 15 824, H i Pkr # 1 a5 MARK J. GAETKE,MD r FAMILY PRACTICE ' , 1 Medical School Loma Linda University, 1987 , , Family Practice Residency Loma Linda 1987-1990 Corporate Medical Director/Principal ARC Health&Wellness Centers—2010—Present 1582—2018 -Present Dr: Gaetke has served as Corporate Medical Director of ARC for the past thirteen (13)years. He is recognized as one of the leading experts in the area in conducting NFPA 1582 and NRS 617 medical evaluations. Past Positions: Medical Director/Staff Physician Concentra Medical Centers—Reno/Sparks/Carson City,NV 1996-2010 Dr. Gaetke held various staff physician and medical director positions during his 14- year term of employment with Concentra Medical Centers. He gained extensive experience in conducting heart and lung physical during his employment with • Concentra. Hyperbaric Medicine Specialist US Naval Hospital—Guantanamo Bay, Cuba 1987- 1990 Certification &Affiliations Medical: Arizona Medical License-#51408 Nevada Medical License-#6893 • California Medical License-#G63790 Alabama Medical Licensure Commission-#MD36984 Oregon Medical License-#MD195696 American Board of Independent Medical Examiners—Certified 1997- Advanced Cardiac Life Support Re-Certification—May 2019 Certified: Stress ECG Testing Medical Review Office Certification Council 15 e 82 WILLIAM(MARK) ELLIOTT,II,MD FAMILY MEDICINE Medical School The Medical College of Virginia 1976—1980 Family Medicine Residency North Carolina Baptist Hospital 1981 - 1983 Wake Forest University Bowman Gray School of Medicine Staff Physician 1582-9/2021 -Present Dr. Elliott has worked full time as a physician-since 1983 in Family Practice and Emergency Medicine. He has successfully served many 1582 clients with raving reviews from our Firefighters about great attention to detail and very personable. • Past Positions: Adean Region Medical Center 6/20—9/21 Greenfield Area Medical Center 6/18—6/20 Stonewall Jackson Memorial Hospital 9/17—9/21 Pocahontas Memorial Hospital. 4/18—8/18 MEDICAL AFFILIATIONS The American College of Emergency Physicians Member since 1999 Fellow since 2007 . The American Medical Association Member since 1983 LICENSED TO PRACTICE: Nevada Arizona . California - S Oregon West Virginia Hawaii . • • 15 � 82 REFERENCES • ' • RENO FIRE DEPARTMENT . . . ANDY ANCHO • Division Chief/Emergency Manager (775)432-3805-Cell (775) 333-7774-Work - AnchoA(c Reno.Gov We provide NFPA 1582 Compliant Examinations for City of Reno Fire Department since 2008 with Mark Gaetke,MD as the•Medical Director of ARC Health&Wellness Centers, sister company to 1582,LLC. With a project date since 2008 over the last 15 years. • TUCSON FIRE DEPARTMENT - LEWIS M. HARRIS Assistant Chief-Administrative and Personnel Services Bureau (520) 406-9652 - Cell . (520) 837-7090 -Work • • Lewis.harris(atucsonaz.gov • We provide NFPA 1582 Compliant Examinations for City of Tucson Fire Department with a project date since 2021 with Mark Gaetke,MD as the Medical Director of 1582,LLC. BUCKEYE FIRE-MEDICAL-RESCUE Jake Rhoades Fire Chief (623) 271-2831- Cell. (623) 349-6723 -Work jrhoads@buckeyeaz.gov We provide ONSITE NFPA 1582 Compliant Examinations:for Buckeye Fire Department with a project date since 2021. S 15 482 SAMPLE PAPERWORK • WFI TESTING PROTOCOL FOR STRESS EKG • TIER RESULTS • ULTRASOUND RESULTS NFPA 1582-Wellness Fitness Initiative Protocol 82 Table C.2.1.3 Treadmill Assessment �,. J TIER 4- Physical Conditioning TIER 3- Prescibed Fitness ' . - L`?,o fr prove r ' Concern Program, Time. •METs MPH %Grade , Time METs MPH, % Grade Time METs MPH %Grade 3:00 3:4 4.5 0 6:50 8.0 5 . 4 8:30 10.0 5.5, Mall 3:10 3.6 4.5 0 7:00 , 8.2 °5.5 4 8:40 10.2. 5.5 ' NM 3:20 3.8 4.5. 0 7:10 8.4 ' 5.5 4. 8:50 10.4 '5.5 "MS 3:30 4.0 4.5 0 7:20 8.6 '5.5 4 9:00 10.6 6. ;" �6j 3:40 4.2 4.5 0 7:30 8.8 '5.5, ' 4 9:10 10.8 6 y=6I • 3:50 4.4 '4.5 0 7:40 9.0 5.5 „ 4 9:20 11.0 6 6, IllEll 4:00 4.6 4.5 2 7:50 9.2. -5.5 4 9:30 11.2 6,,,..,..;t6IN 4:10 4.8 4.5 2 8:00 9.4 5.5 . U 9:40 11.4 ._6` ' 11111 4:20 5.0 4.5 2 8:10 9.6 5.5 11111M0 9:50 11.6 -6 '..MIS 4:30 5.2 4.5 :: 2 8:20 9.8 ":5.5 . VIM 10:00 11.8 6 8 4:40 5.4 4.5 2 4:50 5.6 4.5 2 8.2.2.1.3 82.2.1.2* 5:00 5.8 5 2 At levels below 10 METs,participation in At levels below 12 METs,a firefighter 5:10 6.0 . 5: 2 a prescribed aerobic fitness program shall; shall be counseled to improve his/her 5:20 6.2 5 2 be required. fitness 5:30 6.4 5 2 5:40 6.6 5 2 s:so 6.8 5 2 TIER 1 -At or Above NFPA 1582 Fitness Level - 6:00 .7.0 5 4 6:10 7.2 5 4 6:20 7.4 5 4 ' Time METs MPH % Grade Time METs MPH %Grade 6:30 . '7.6 5 4 10:10 12.0 6._ 8 • 15:00 17.8 7.5 12 6:40 7.8 ' 5 4 / 10:20 12.2 6 8 15:10 18.0 7.5 12 10:30 12.4 6.. 8 .15:20 18,2 ° 7.5 12 8.2.2.1:4 10:40 12.6 6 - ; 8 15:30 18.4 . 7.5 12 At levels at or below 8 METs,a prescribed 10:50 12.8 r 6 8 15:40 18.6 7.5 12 aerobic fitness program shall be required, 11:00 13.0 ea 8 15:50 18.8 7.5 12 and the AHJ shall be advised to consider 11:10 13.2 8 16:00 19.0 . 7.5 14 restriction from essential job tasks 1,2,4, 5,6,7,8,9,and 13. 11:20 13.4 . 8 16:10 19.2 7.5 14 11:30. 13.6 C3 8 16:20 19.4 7.5 14 11:40 13.8 eta 8 16:30 19.6 7.5 14 11:50 14.0 C 5 8 16:40 19.8 '7.5 14 12:00 14.2 <6;5. i 0 ` 16:50 20.0 , 7.5 14 12:10 14.4 C 1 10 17:00 '20.2 8 14 12:20 14.6 (:3a 10 17:10 20.4 8 14 12:30 14.8 11[5.1S1. 10 17:20 . 20.6 8 14 12:40 . 15.0 a@ 1 10 17:30 20.8 8 14 12:50 15.2 10 17:40 . 21.0 8 14 13:00 15.4 E61-7 1 10 17:50 21.2 8 14 13:10 15.6 L•_7 , 10 ' 18:00 21.4 8 14 13:20 15.8E-7-7] 10 18:10 21.6 8 14 • 13:30 16.0 7-j 10 • 18:20 21.8 8 14 13:40 16.2 _. .... 10 18:30 22.0 8 14 13:50 16.4 F-1-:.7 1 10 18:40 22.2 8 14 14:00 16.6 E1- _1; 12 18:50 22.4 8 14 14:10 16.8 [-7 12 14:20 17.0 E_7: _.I 12 14:30 17.2 [_-_---77 a 12 . . • 15 82 NFPA 1582 Medical Standard Evaluation FIRE DEPARTMENT: Ashland Fire FIRE CONTACT: DEPT.`PHYSICL4N:• PHYSICIAN EMAIL: FIREFIGHTER: Chief, The following Firefighter has completed the Annual 1582 Medical Evaluation and has been • deemed as: Meets NFPA 1582 Medical Standards. Firefighter is at or above the Tier 1 recommended NFPA 1582 fitness level and is encouraged maintain their current fitness level. ❑ Tier 2 Meets NFPA 1582 Medical Standards.Firefighter is encouraged to improve current fitness level to comply with NFPA 1582 fitness standards. • n Tier 3 Meets NFPA 1582 Medical Standards.Participation in a prescribed fitness program is required to comply with NFPA 1582 fitness standards. • Tier 4 May require removal from firefighting duty due to fitness level Tier 5 May require removal from firefighting duty due to medical condition Comments: Mark Elliott,MD Date: Disclaimer: • Per NFPA 1582,it is up to each,department to decide who is or is not qualified. That is not a decision that we are making as the Medical Provider. Our objective is to idents if members are or are not meeting the NFPA 1582 standard In closure, the Fire department is required tb decide whether any particular standard in NFPA 1582 applies to their department, as well as that particular individual's essential job duties and position, • © 2022—1582, LLC 15 82 PATIENT NAME: DOB: DATE: (, Pancreas: head .4 Pancreas Results: I I The pancreas, located in the back I • of the abdomen,plays an essential [ ] Normal [ ] Normal Limited. q .e- —_...__ O.k act role in digestion. It also produces • _. • [ ] Echogenic insulin and uses it to regulate the °°°'°^^ glucose, ' or sugar, in our [ ] Enlarged bloodstream. Due to the pancreas's position, in the back of our body, below our stomach,it may be difficult to examine due to stomach gases. [ ] Unable to Visualize During the exam we will analyze the pancreas to determine if there are [ ] Follow up with your physician is, any abnormalities in size and texture. We will also be able to determine recommended in months. if there are any tumors or cysts. If any abnormalities are noted you should consult with your physician. Liver: The liver is the.largest organ in our body and Liver Ultrasound Scan: sits on the right side just under the rib.cage _ ` l liver [ ] Normal The liver is split into two sections,the right [ ] Enlarged and left lobes. The liver's primary functions common biledud [ ] Fatty Infiltration are to filter the blood from toxic substances, gallbladder aid in digestion, •and produce proteins - [ ] Cyst: cm important for our bodies. An abdominal ultrasound can detect many •liver conditions including cancer, cirrhosis, and fatty liver. It will also [ ] Mass: cm •1 determine the size,texture,and blood flow of the liver. - [ ] Follow up with your physician is recommended in months. if the liver is found.to be enlarged or have any other abnormalities, we will advise you to follow up with your doctor to evaluate if any furthertesting is necessary. Gallbladder: Ever • Gallblader Ultrasound Scan: The Gallbladder is a small pear-shaped gallbladder .V [ ] Normal organ located under the liver. Its gallstones L cV 'stomodn. [ ] Thickened Wall primary purpose is to collect and store b''ed°ct . rR' bile that is produced by the liver. It then intestine Y [ ] Contracted(due to normal digestion) squeezes the bile into the intestines via [ ] Possible Stone(s) a duct. The common bile duct creates a path for the bile to exit from the gallbladder into the intestinal tract. When we eat food, [ ] Possible Polyp(s) • the gallbladder works quickly to aid in digestion and contract [ ] possible Sludge therefore the ability to evaluate this organ will depend on when • the patient last ate. Ultrasound.imaging reveals if the gallbladder [ ] Gallblader Removed has polyps, sludge, or stones—which is a sand like material that [ ] Follow up with your physician is can irritate the GB walls. recommended in months. • • It is recommended to follow up with your doctor if stones,sludge,or any other abnormal findings are detected. PATIENT NAME: DOB: DATE: 15 00 82 • Kidneys: Weep • Kidney Results: bladderI.{z The kidneys, "rd" u • which are rte— - , �" q' Right: cm Left: " cm bean shaped, [ ] Possible Cyst(s): [ ] Possible Cyst(s): can be found SWIM on both the left and right side of the spine. ( ] Possible Mass(s): [ ] Possible Mass(s): The kidneys main function is to filter our [ ] Possible Stone(s): [ ] Possible Stone(s): blood stream and remove any-wastes, or [ ] Enlarged [ ] Enlarged toxins via our urine: Each kidney has a duct [ ] Atrophy. [ ] Atrophy known as a ureter which is used as a path [ ] Follow up with your physician is recommended in months. for the waste to exit into our bladder. Ultrasound imaging is used to evaluate the ` kidneys for size,cysts,tumors,stones,and texture. If a kidney is too small or•too large it may not be functioning properly. If any abnormal findings are detected,follow up with your physician is suggested. Spleen' ~� Spleen Results: • The spleen, • which is part of the - '.: e ��. ' [ ] Normal lymphatic,system, is located near the upper. left side of the abdomen below [ ] Enlarged [ Echogenic the diaphragm. The spleen helps to - - [ ] remove waste, maintain fluid balance,and is in involved in the [ ] Cysts(s) body's immune response. It stores red blood cells and produces white,blood cells to help the body fight infection. We [ ] Follow up with your physician is will examine the spleen with the ultrasound to evaluate the recommended in months. size of the spleen, if it is enlarged, or if there are any changes - in texture including cysts and tumors. . Follow up with your physician of any abnormal findings are detected. Aortic Aneurysm Appearance: Aortic Aneurysm Appearance The main artery in our body is called the [ ]Normal Appearance Size: cm . ' .mUtaneugsm Aorta. The Aorta extends from the heart and - [ ] Ectasia . Size: cm continues through the abdomen and (Dilation/distention of the abdominal aorta) supplies blood to all the abdominal organs. r I i [ ] Possible Aneurysm Size: • cm The ultrasound V examines the abdominal J. section of the aorta,from the breastbone to [ ] Fusiform [ ] Saccular the umbilicus. The Aorta should measure less then 3cm in diameter. If it.measures more then 3cm,then an abdominal aneurysm is suspected. Follow up with your physician will be recommended if an abdominal aortic aneurysm is detected. ) ( A PATIENT NAME: DOB: DATE: 15 82. Prostate: The prostate is a walnut sized,reproductive organ,with its main Prostate Results: purpose being to secrete fluid and protect sperm. The urethra [ ] Normal . travels through the center of the prostate gland which is located [ ] Enlarged(BPH) between the bladder and the rectum. It is helpful to have a full [ ] Calcified. bladder upon examination as this will ensure a good window to [ ] Nodule: see the prostate. An ultrasound of your prostate is useful to [ ] Mass: examine the gland for any abnormalities such as an enlarged prostate also known as benign prostatic hypertrophy (BPH), [ ] Follow up with your physician is cancer,or other prostate related conditions. recommended in months. If any abnormalities are revealed, we recommend consulting your physician for a follow up. Thyroid gland: • Thyroid Ultrasound Appearance: The thyroid is a butterfly shaped gland located at the RIGHT: LEFT: bottom of your neck. The gland has both a right and left lobe connected by a [ ] Normal Appearance [ ] Normal Appearance narrow band of tissue, cartilage ? "` • \ t > [ ] Heterogenous [ ] Heterogenous. called an isthmus.. x tY • Besides revealing if the thyroid . sai> � ' �,; [ ] Enlarged [ ] Enlarged gland is enlarged, an gland '� ,e,, >1,"!' • g [ ]. Possible Cyst [ ] Possible Cyst ultrasound of the ir'-r` thyroid will detect if twndppe) ' -.3.'0, [ ] Possible Nodule [ ] Possible Nodule there are any nodules, °"CYfeW Follow up with physician is recommended in months. cysts,or any changes in the texture of the thyroid tissue. Thyroid cysts are fluid filled and mostly benign. The majority of thyroid nodules do not require treatment. Only a small percentage of nodules maybe problematic and need further attention. If a cyst or nodule is identified,we recommend you consult your physician for a follow up. CAROTID ARTERIES: Carotid Artery Evaluation: �i oft t_ FAerrol tppda Carotid Arteries travel from o , the heart up both sides of '"*Y�4 �, ,q " a'°°" RIGHT CIMT: mm the neck.The carotid artery v� ( � -......4 h� will split into two arteries, �" ,/ '''+, . RIGHT STENOSIS: the Internal Carotid Artery `` -, ` % of Plaque: [ ] Mild [ }Moderate [ ]Severe (ICA), which supplies bloodEdell' .. - Z.•" ' flow to the brain, and the External Carotid Artery LEFT CIMT: . mm (ECA), which supplies blood flow to the neck and face. Carotid artery disease occurs when plaque builds up on the LEFT STENOSIS: artery walls. Too much plaque in the artery can cause a %of Plaque: [ ] Mild [ }Moderate [ ]Severe blockage,or stenosis. If plaque is found it will be reported as either mild (0-50%), moderate (51-70%) or severe (70% or greater). A mild amount of plaque is normal for adults as they age. If you have moderate or severe findings,we recommend you follow up with your doctor to determine if further evaluation is necessary. PATIENT NAME: DOB: DATE: 15 82. • Transabdominal (TA) Pelvic Transabdominal (TA) Pelvic Results: NOT APPLICABLE [ ] Transabdominal .Pelvic Ultrasound you will need a full bladder. Please drink 24-32oz 'an PELVIC/Uterus hour prior to ultrasound scan will help Normal Appearance [ technician view the pelvic region. Heterogeneous [ ] Possible fibroid , [ ] A pelvic ultrasound is a noninvasive exam that Possible fluid [ ] produces images that are used to assess organs and . Possible cyst [ ] structures within the female pelvis. It allows for Possible Mass• [ ] quick visualization of the uterus,cervix,ovaries and _ bladder. Ultrasound imaging is used to evaluate OVARIES uterus size,cysts,tumors and texture.. RIGHT LEFT Normal [ ] [ ] Possible Cyst [ ] [ ] Follow up with your'physician if any abnormal Possible Mass [ ] . [ ] findings are detected. Not visualized . [ ] [ ] ULTRASOUND SCREENING CONDUCTED BY: ULTRASOUND SCREENING REVIEWED BY: • Thank you for allowing 1582 to take part in your journey of pursuing a healthy lifestyle! We hope your ultrasound screening was a positive and educational experience.• Enclosed you will find information regarding each of your screening tests that were performed today. There is a section, after each exam description that explained your results in a simple manner. We may have detected pathology or an abnormal finding, in this situation we always recommend you_follow up with your • personal care physician. If your tests were normal—congratulations,we encourage you to share your results with your doctor at your next health visit. It is important to us that you understand your results. Please do not hesitate to ask if you have any questions or would like some more information regarding our service. 15 ` PATIENT NAME: DOB: DATE: �, 82 Testicles: The testicles(testes)are part of a man's Testes Results: reproductive system. The testicles Right • Left produce sperm and testosterone. [ ] Normal Appearance [ ] Normal Appearance During the ultrasound exam we will be [ ] Heterogenous [ ] Heterogenous evaluating both testes and the [ ] Enlarged [ ] Enlarged epididymis, which is a tube that [ ] Hydrocele(s) [ ] Hydrocele(s) ultimately connects the testicles to the [ ]Varicocle(s) [ ]Varicocle(s) urethra. A testicular ultrasound is the [ ]Spermatocele(epi cyst) [ ]Spermatocele. (epi cyst) primary imaging method used to [ ]Cyst or Nodule: [ ] Cyst or Nodule: observe and detect any abnormalities such as,cysts,tumors,size and texture. [ ] Follow up with your physician is recommended If any abnormalities are found,follow up with your doctor is suggested. ULTRASOUND SCREENING CONDUCTED BY: ULTRASOUND SCREENING REVIEWED BY: ' Thank you for allowing 1582 to take part in your journeyof pursuing a healthy lifestyle! We hope your ultrasound screening was a positive and educational experience. Enclosed you will find information regarding each of your screening tests that were performed today. There is a section, after each exam description that • explained your results in a simple manner. We may have detected pathology or an abnormal finding, in this situation we always'recommend you follow up with your personal care physician. If your tests were normal— congratulations, we encourage you to share your results with your doctor at your next health visit. It is important to us that you understand your results. Please do not hesitate to ask if you have any questions • or would like some more information regarding our service. ' • _. A��® DATE(MM/DD/YYYY) �� CERTIFICATE OF LIABILITY INSURANCE 05/27/2023 • THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS • CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A•CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED • REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. . - . IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies.may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER . CONTACT Ann Lehtinen _- NAME: Crestline Insurance Services LLC PHONE (702)596-5686 FAx (702)988-5355 (A/C,No,Ext: (AIC,No): 6955 N Durango Dr#1115-765 E-MAIL annl.crestline@gmail.com ADDRESS: • INSURER(S)AFFORDING COVERAGE NAIC# Las Vegas NV 89149 INSURERA: Transportation Insurance Company 20494 -INSURED INSURER B: Sentinel Insurance Company Gilbert,Gaetke&Associates of NV,MD,Ltd, INSURER c: National Fire&Marine Ins Co 20079 1582,'LLC INSURER D: _ 1855 N McCarran Blvd INSURER E Sparks NV 89431 INSURER F: . • COVERAGES CERTIFICATE NUMBER: GGA 1582 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. INSR• TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/OD/MY) LIMITS X COMMERCIAL GENERALLIABILITY EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED CLAIMS-MADE n OCCUR PREMISES(Ea o ccu ence) $ 1,000,000 MED EXP(Any one person) g 10,000 A Y 7013673051 12/22/2022 12/22/2023 .PERSONAL&ADV INJURY $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER: • GENERAL AGGREGATE $ 4,000,000 • 1 POLICY n JECT n LOC , ' PRODUCTS-COMP/OPAGG _ $ 4,000,000 OTHER: DEDUCTIBLE $ NONE AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT $ 2,000,000 ' (Ea accident) ANY AUTO BODILY INJURY(Per person) $ • A OWNED SCHEDULED 7013673051 • 12/22/2022 12/22/2023 BODILY INJURY(Per accident) $ , AUTOS ONLY AUTOS X .HIRED X NON-OWNED PROPERTY DAMAGE $ _ AUTOS ONLY _ AUTOS ONLY (Per accident) _ $ UMBRELLA LIAR' _OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE _ $ DED RETENTION•$ v $ WORKERS COMPENSATION /� STATUTE ERH AND EMPLOYERS'LIABILITY 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE Y!N E.L EACH ACCIDENT $ B OFFICER/MEMBER EXCLUDED? N� NIA 53WECACOM4Z 09/26/2022 09/26/2023 (Mandatory inNH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,C) °0 ,000 DESCRIPTION OF OPERATIONS below - . E.L DISEASE-POLICY LIMIT $ MEDICAL'PROFESSIONAL LIABILITY • EACH CLAIM $1,000,000 C CLAIMS MADE FORM ES053943 09/01/2022 09/01/2023 ANNUAL AGGREGATE $3,000,000 DEDUCTIBLE $ 5,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if mom space Is required) City of Ashland,Oregon,its officers,employees&agents,are additional insured with respect to General Liability only,per BlanketAdditional Insured Endorsement SB146932G attached. 30 day notice of cancellation will be provided with the exception of 10 day notice for non-payment of premium. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE • - •. THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Ashland ACCORDANCE WITH THE POLICY PROVISIONS. • 20 E Main St AUTHORIZED REPRESENTATIVE Ashland OR 97520 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD • • 4 f • SB14t6932G • CNA . (Ed.1.0,19) Gilbert, Gaetke&Associates of Nevada, MD, Ltd. • Policy No: 7013673051 BLANKET ADDITIONAL INSURED AND LIABILITY EXTENSION ENDORSEMENT • • - This endorsernent.mOdIfies insurance provided 9rider.thefellowing; • StiSI1'iESSOWN5AS:t..1ASILITY.pdVERGE FOIM • 13.U.SikEselyvNER§"d0MmoN•pciLicy:pcif4biTIONt TABLE OF CONTENTS I. Blanket Additional Insured PrOVISIons. • A, Additional Insur4—Ellanket Vendors_ B. NliscellaneOuSAdditionallinsureds C. Additional Provisions Pertinent to Additional Insured Coverage Primary.—Koppontributory proviSion 1.11. Definition of"Written contract" .2‘ Additional Insured—Extended Coverage. II. Liability Extension Coverages • A. .Bodily Injury: Expanded Definition • B. Broad KnoWledge sof Occurrence . • • Estates i Legal Representatives and Spouses D. Fellow Employee First Aid E. Legal Liability—Daniageto Premises F. Personal and Advertising Injury—Discrimination or Humiliation O.. Personal and Advertising Injury—.Broadened Eviction H. Waiver of Subrogation—Blanket. • I. BLANKET ADDITIONAL INSURED PROVISIONS • A. ADDITIONAL INSURED—BLANKET VENDORS • . . Who Is An Insured is attended to include-at an-additional insured any,oerSon or organization.(referred to below as vendor) with whom*you.agreed under a "Writtencontract" to provide insurance, but.only with respect to "bodily injury"or uOroperty damage"arising.out of"your products"which are distributed or sold in the.regular epursed•the vendors business,subjedtOthe following additionalexclusions:. 1. The inSUranCe•afforded the vendor doesnOtapply to; a. "Bodily injury"or"propetly.dernage"for whic.h the vendor is obligated to.pay damages by reason of the asstoptign f liability in a.contreot or agreement This exclusion does not apply to liability for damages thatthe.vendpr would:hove in the absence of the,oontraCt or agreement; .b. Any expressWartanty unauthorized by you; Any.physic*or chpraiqa1...chapge in..theproduet made intentionally by-the vendor; d. Repackaging,ekcept When unpacked-solely for the OUrpbte Of intpeCtion, demonstration,..testing, or:the • substitution :Of parts 'under instructions tern the •Martufacturer, .and•therr.repackaged in the btiginal container; e. Any'failuee to make such inspections, atijOstrriente,:tests Or serVicingaS the Vendor has agreed to.make or nbrfnallytindertakes tOrriake iri.the usual bourse of business,in connection with the distribution ot.sale Orthe"products;• DernonstratiPo, servicing or..repair.operations, except such :operations performed at the •Vendor's premises in 001010 With.the.,:sale Of the product; • • g. Products whith, after'distribUtiOrtOt sale by you,have been labeled or relabeled or used'ea a t or:Miner,. part or ingredleOtotany other thing orsubstance:by or ter the vendor;or SE3146932G 0-19y Pagel 07 • .copyriotit;:cNA Ai!Kim ROeNlati. • • . • . . • , . . . .. . . . 8B1409.820 . . ,.. . .. * (._ •d..1049) • . . h. "Bodily Injury"or!'prbpartY.damage"4iisipg."6ut of...(l* olo negligence of tite"... encipt-fer its own acts or . omissions or those of employees 0 ehyohe'eleesetinaen:its,.heheik.146WeVeyi titijkl*cliiWo.i.c does not el5p1V. • • • • • (1) The exceptions pentained•in Sphparpgrapt0.4,or fi;or , 12)• subh insectionk adjuStiriaritS; tet S or SerViding.es'the *.andOr Orbe0:10 000 or nerinally • undertakeS to Make in the usual.ooutse.of:Wait-less,in tennedien•with the:diStributiOh brale ate -...• • .... - • 1. •Thi s Insurance does.not apply to any insured person or 06j4r4z4tioil,..fet4n WhonvytiP haVe. acquired such produOteriiany itigradi09!,•POrt•Or ooritaih0,.entering:464..00000.ylP4 Or OntAin0:.0:00h.pr§cipti&. ...- - -: • • 4'. This.provision ?..does not:apply'to any vendor Included i As::.arlInaureds:Oy an endorsement issued by us and madee part of this.POliqy. •. . • , . 4. :This...preVition .1..lees hot:apply if-"bodily'inibir?Or.IltOparty darifage ihdlOded:sivithirt the "products;-.. boropteiad.otietatiobs.hatard"la kOlUdab:Sithar.by the prOVISibho riftha Polity or by endOitenierit. B. MISCELLANEOUS A0B1TIONAONBLiftg04 . . . . , . 1. .Who Is. An Insured IS enierided:te inblude!es #e •theiked l'any porSerf or erbenizetier,t .(ealled additional insured) described in paragraphs Ae.•thrOugh. 31 below whom you are required to:eat:es.an-.additional •Ineured.:•Ph this:.00POy•ohdar a 1.1-wr)tteri•oontract.!' . 2,. However, subject always'to the terms and COhOitiOh .efsthiS,:pelleirt:iiipitiOihg the limits of insurance, we'will ... . . riot pipitOpe'the•egtiehel insured With; , . .., .a. A hipharlitnit.ofinsuranoeithanTequired bysuchNrri.tten oontroct! . b. Coverage broader than required Watch"Written Poritf#trqpg.OAP*OMOte4teflhOn thpt•40.0Prib0 . , . . • .by the apOlidablo.paraOrabh,:a..1hrou0h k.below;Or . • .,. c. Coverage for "bodily Km!! .or :!'property dampge. ir!pludect .within fhp. .'"Orocinct$-pprnPle.t04 • operations ti4z04.".But this paragraph c, does not Apply to the Otent coverage fpr such liability is • • .p.rovido.d by 14•orogOlibm,below. • . . . . • .. .. . Any ooveraoe.qranwd by this endorsement shell appiyonlylo'the•extent permitted by law, . 3.: 9.nly:thetollowinapersongoorgarilzatiOns oah•quaiit 0. 400itjonroi iiiioro.O .pnctOr t*onoo,otnont. . . • a. Controlling Interest •' . .E - •. . • Any'pOiont Or OrgenilatiOnS wifh:a•*introllingrintereatin yt.).0.Wtonfr*ifty.f0004flollioir lieei14.ailSing . .4, 00tiit . . •C. . •• • '0 (l) speh.pemoror organization%linanoial.00ntrOlOtyoo;.or • g, A- (2) PretniSewsitch...PersOn or organization owns, maintains Of'100010*.bil0:.*j...,lege-or.b000py trI60 ••,, • pterhisek • • • provided that the oovarago.Qranted4o..4uth Pciditiorigil inswgds. dOesi:notapply:lo structural alterations; novtoqnstrAtion or.dernOtitionOporations performed 141Y pr tgrwck0.4ditiOnAl ins.urO, b. CO-Oviberiof lasufOO Premises • ........ • - •-• • - = A co-owner 0.0>prOmises.:cqqowboq by you arid coveregiunder this;:ineyranoeShut only with rqwe6t•to the ' co-owners for"bodily injury11 "property damage"• bi'!peribbOl.abil advertising injury"4.4 bo- . •.• , •• :..••:• • ,._ -. •. . .. ... • . .. • . . •.. •. ..• .„ ..., . ., .„..•... !!! !! Oysfrior of SOchfirOthiSpc, . . 1•Nimr ...... ..,. • .. • 'P. Grantor of Frarrcbioo • • -....,...= Any person or organization that .orrito.a#40040*to.you, of only with•respect IO such•person or. . = . . organizations liability for"bodily.injury,"veopeetyilathatfk!'.iir'Tiefsisnial:.*id advertising injury"as ...... .4raritOt tif.a fratithitelet yOu.. orksatur , • L , . ...mom . . • . ' ,S014032q.00-101 • • Ng.,''l 2 of 7 • • Copittiot„CNA Al RjOtitCibUitsitfit ' . • . • • SB146932G (Ed. 10-19) d. Lessor of Equipment Any person or organization.from whom you lease equipment, but only with respect to liability for"bodily injury," "property damage" or "personal and advertising injury" caused in whole or in part by your . maintenance, operation or use of such equipment, provided that the "occurrence" giving rise to such "bodily injury" or "property damage" or the offense giving rise to such "personal and advertising injury"takes place prior to the termination of such lease. • e. Lessor of Land Any person or organization from whom you lease land, but only with respect to liability for"bodily injury," • "property damage" or"personal and advertising injury" arising out of the ownership, maintenance or use of that specific part of the-land leased to you, provided that the "occurrence" giving rise to such • "bodily injury" or "property damage" or the offense giving rise to such "personal and advertising injury,"takes place prior to the termination of such lease.The insurance hereby afforded to the additional insured does not apply to structural alterations, new construction or demolition operations performed by, on behalf of or for such additional insured. f. Lessor of Premises An owner or lessor of premises leased to you, or such owner or lessor's real estate manager, but only with respect to liability for "bodily injury," "property damage" or "personal and advertising injury" arising out of the ownership, maintenance or use of suchpart,of the premises leased to you, and ' provided that the "occurrence" giving rise to such "bodily injury" or"property damage" or the offense giving rise to such"personal and advertising injury,"takes place prior to the termination of such lease. The insurance hereby afforded to the additional insured does not apply to structural alterations, new construction or demolition operations performed by, on behalf of or for such additional insured. g. Mortgagee,Assignee or Receiver A mortgagee, assignee or receiver of premises but only with respect to such mortgagee, assignee, or . receiver's liability for "bodily injury," "property damage" or "personal and advertising injury" arising out of the ownership, maintenance,or use of a premises by you. This insurance does not apply to structural alterations, new construction or demolition operations performed by,on behalf of or for such additional insured. h. State or Political Subdivisions' • A state or government agency or subdivision or political subdivision that has issued a permit.or authorization, but only with respect to such government agency or subdivision or political subdivision's J liability for"bodily injury,""property damage"or"personal and advertising injury"arising out of: (1) The following hazards in connection with premises you own, rent, or control and to which this insurance applies: ' • (a) The existence, maintenance, repair, construction, erectiori, or removal of advertising signs, • awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoistaway openings,sidewalk vaults;street banners, or decorations and similar exposures;or (b) The construction, erection,or removal of elevators; or • (c) The ownership, maintenance or use of any elevators covered by this insurance;or (2) The permitted or authorized operations performed by you or on your behalf. But the coverage granted by this paragraph does not apply to: (a) "Bodily injury", "property damage" or "personal and advertising injury" arising out of operations performed for the state or government agency or subdivision or political subdivision; or • (b) "Bodily injury" or "property damage" included within the "products-completed operations hazard." With respect to this provision's requirement that additional insured status must be requested under a "written contract,"we will treat as a"written contract"any governmental permit that requires you to add the governmental entity as an additional insured. SB146932G (10-19) • Page 3 of 7 Copyright,CNA All Rights Reserved. • .. . - • . . . - . . • • . , . . . •• S1632p. . . • • . . (td,.1(09.) .. . . . . . . , • . • . i. -Trado.,4how,Event*Lessor Wsmipthh,rpeeepi.se.porift.O01:}.tOofugrqpriaizrt4itoioip:fai,o. thi.aibnil.laty.tr:i,e,bssohdowoy7116,inutrya; ,phr•i4ophriiotyisteis:r•o.,01:dasg-9,017r,grortiptleisrp.olo'anyeli and • 'person.or organization whom yog.ara,Teguired.to.include as.go additional,inscired,OUtorily.with respect to . . advertising injury"caused by: • a. .Your acteoromieelonsi dr • . . . , • b. AOta or..ornISSiOnottoseActing on your 9.11.ak . . . • • • . in the'performance.of your ongoing operations at thatrade shOw.Vitemigeeduring the trade show eVerit.. j, Other P.erwror Organization . • • • • . Any...perSbri•or erganiZatiOn.who is nbt On additiOnainsuiadunder!.paragraphs a...thrOggli L••abeVe..Suen • Additional instead. is-an.insured solely •for "bally Injury,"• HOOPO4 tlarri400. or "personal .and advertising injury' tor which'such additiOnal..insured is ii6b1O:ttgoUScifyrair acts•orontistione.. • . The coverage granted by this pargraph does nOtapPli:tO•Onyofon....or oroo*..0* . . (A) For•"bodily injury" "property damage," or !iparponal ana..Aakert(ottly-:inji.try"•arising out of the . 1. rendering tir failgre.to•Terider any profassiOna1•ServioeS;-• • . • . • (2). For "bO411k. injury" Or "PrOort.Y. '.4ainage" ineittded In- the "giodtiOta,tonigleted 'operations • . • • hazard."But this:prOvision(2)does ndtapplytoeughtiodilir injury"Or."property:•damage"if...• . • . . (a) it is entirely due to your••n•egligence and specifically results from your work Arta•additional • insured which isthe•subjeot tate rN!.,,rrittOrt-C91itrOct.grid . • . , (b) The"written,00ntr•act"requiresydg to Make•the person grorganizatton.an additional,haired for• . ' . such'"1).0(14'injury"or'properti)damage`?;•or . .. . , (3) WhOl.§affOrded additional insured•Osie:rage..under•anothetandOr§ernent attached to this policy - • Co. _,.. •• • • .C. ADDITIONAL PROviStONS;PEOKENT.:TO*•AtiiiITOIAL.INSURED vkit'Ade - . . - • 1..• With respect on1Sflo.additidnal insured coverage provided'under Opra0-aphsA,..and:p.:al:ip.v*• • • • . . a. tha.••Ei01144$.SOWNEfl •COMMON POLICY CONtlitit)A are amended to 0.W the following:V.:the' . 'Condition:entitled Other.Insuranca: . . • This ingLifatide .ta-exOSS• of gil other'itiWgnoe.gvailable.to an gdditional •tired Whether tirithar ; . •,,, ekets,.bantitigeritor.bo.gy other basis. FidweVer,if a"Writt•ert don'traetqatioiees,that this ihStignae be :.,. F. . . either primary Or primary and noncontributing, then thia•insuratiod'Will be;primary and horkOntributory . • • .. . •„... relative:solely to'insuranoe.on whlOh.the additional irtautediSO harried.insured.. . .. . • -,. •:. . . bi uncfor:..P*Ifty and Medical Expense DefinitiOnsl,the:tolloWing definition is .'. :..g . • . "Written contract" means -e iwritten• oraraot or agreement thau•raotilree::.you to make a person or 1 • . orgaration.an additional Insured on tht§polioy,OroVided.the•gontroot Orogreement . . , (1).. 10 torr0Otly*Off6Ot Or becomes effective 441000010r*of#1100011PY;.004. . . • , Was . • • M W ' executed priori& . . . , • . ....... (a) The"bodily injury"or"PeoPattrden149*"or - • • . . = . . . . . • (b):The•olieng0 ttiatoaOsed.theY'PerePinAl.anct'advertising injury.% '--, .• PM • . . • for Wiji0h#16,a.d01.0:001.105000.s..o0P001:eir40,Eb. . • -=--.: • . .2 With...resoe6t.to.any additional insured added by-it-.11$.endor4.ome.rit or by:any,,gther endorsement attached to this Coverage'.Part,the section entitie.d Whole•Arl.Insurecils,amprOpa to rnaKe2ihelciilowing natural'persons = . = . • :IriSigeriS, • iMINEINIII • - , 11.... .414. • If the additional.insured ist . . . • = • • , a.. An individual;thenfilirpr her spouse.JO an! surd; • . . . . . . • .. — . :SR:14932G clo-ip). • . ., • . . . Pd.''p 4-cif 7 • . . . • . • • • . . . Copy-riot.QNA •All ii.iptifiiiW . . . . . . . . • • . . .- . • • . . • . • a SB146932G (Ed. 10-19) b. •A partnership or joint venture,then its partners, members and their spouses are insureds;. c. A limited liability company,then its members and managers are insureds; d. An organization other than a partnership, joint venture or limited liability company, then its executive officers,directors and shareholders are insureds;or e. Any type of entity,then its employees are insureds; • but only.with respect to locations and,operations covered by the additional insured endorsement's provisions, and only with respect to their respective roles within their organizations. Furthermore, employees of additional insureds are not insureds with respect to liability arising out of: (1) "Bodily injury" or"personal and advertising injury"-to any fellow employee or to any natural person listed in paragraphs a.through d.above; {2) "Property damage"to property owned,occupiedorused by their employer or by any fellow employee;or (3) Providing or failing to provide professional health care services. • Il.( LIABILITY EXTENSION COVERAGES - ' It is understood and agreed that this endorsement amends the Businessowners Liability Coverage Form. If any other endorsement attached to this policy amends any provision also amendedby this endorsement, then that other endorsement controls with respect to such provision,and the changes made by this endorsement to such provision do not apply. A. Bodily injury—Expanded Definition Under Liability\and Medical Expenses Definitions,the definition of"Bodily injury" is deleted and replaced by the following: "Bodily injury" means physical injury, sickness or disease sustained by a person, including death, humiliation, • • shock,mental anguish or mental injury by that person at any time which results as a consequence of the physical, injury,sickness or disease. . • B. Broad Knowledge of Occurrence ' ' Under Businessowners Liability Conditions, the Condition entitled Duties In The Event of Occurrence, Offense, Claim or Suit is amended to add the following: ' Paragraphs a. and b. above apply to you or to any additional insured only when 'such "occurrence," offense, claim or"suit"is known to: (1) You or any additional insured that is•an individual; . • (2) Any partner, if you or an additional insured is a partnership; • ' (3) Any manager, if you or an additional insured is a limited liability company; (4) Any"executive officer"or insurance manager, if you or an additional insured is a corporation; (5) Any trustee, if you or an additional insured is a trust;or (6) Any elected or appointed official, if you or an additional insured is a political subdivision or public entity. This paragraph applies separately to you and any additional insured. • C. Estates,Legal Representatives and Spouses t • • The estates, heirs, legal representatives and spouses of any natural person insured shall also be insured under this policy; provided, however,coverage is afforded to such estates, heirs, legal representatives and spouses only for claims arising solely out of their capacity as such and, in the case of a spouse, where such claim seeks damages from marital common property, jointly held property, or property transferred from'such natural person insured -to such spouse. No coverage is provided for any act, error or omission of an estate, heir, legal representative or spouse outside the scope of such person's capacity as such, provided however that the spouse r of a natural person Named Insured and the spouses of members or partners of joint venture or partnership Named Insureds are insureds with respect to such spouses'acts,errors or omissions in the conduct Of the Named Insured's business. SB146932G(10-19) Page 5 of 7 Copyright,CNA All Rights Reserved: . . . . . , . . , ... . . . . , SB1469.32Q. (0d, io.A.0) ' • • , . . . , . . . . . D. .Fellow s EniploYea.FiretAid:Coverage. • . - - In the section entitied.WhO.ts An Inaured,..paragraph 2.0.IS emended-1C add itterilotleviring: . . .. . . . . .. .. ThetirOtationa.4eeCriPed in StibparagraptIS.Za4.(0), (b.):;.atiff.(c).qo nOta.01y.to:yOtit••'!empibyeag" for "bodily injury"that fozi41%..frdrri.prbviding..Carditipuirrionery'reateOttatidri or other trot'01.40.r0000•:4•00onlp1o0a"or . - "volunteer worker"that OO•c;Onio's"10060ty*hWyo(ir"employee"•is PetiOrthing.duties in tha',0Ontltiabf your buginass";.. Your Hemployees"are hereby Insureds far SIICh servites.. But the insured status conferred V this provision does riOt,:applsf to,"atnployeOsn•WhOSO•dutieS in your bUsitiesazarelb provide professional health care services.or health:examinations.: E., Legal Lialglity–Damage To Premises .. . : . . .. . . . ... . .. . . 1.• .Under I.k Exclusions,1-.ApOlicable to Business Liability poveraga,...E)dtidon iii:Damageto Property,is . • replaced by-theleiliowing: . . ••• • , It. Damage To•Property.- . . - • • Troperty•damage!!to:- . • . . .. 1.. Property-you tvitn, rent or bccuPyi inolUdingl ai..iy.cots Or Oflatiaetti itiCulted15Y•ypoj or•atty'other person, orgentzatidti or.e.tititii for repair, replacernerit,..enhanCebent; restoration de niaintehanoe of suchproperty.•for any reason, Including Oravention of Injury to a.lieraott or damage to another's prOpertp. , • Z. PreiniSee you i.rsall,.0e away or Ot.?andCtii ifthe:.."PfOpetty d:a0d.ge.arisaS:00 of any part of thOS0 . premises; . . • .3;. Property loaned to•yok.4* • . . . • . . 4',. POrsObal:11r0000.k.161110:611*4100y"Or•Ontr91":Of the • . . . .. • 5. That particular part of any real property on which you crAlly.00dttadtors.dr:sobcontractors•working directly or indirectly In your•banalfero performing operations, if to"property damage's arises out of those operations;or . . - • . 6.. That partictIlar paitOtanyptopbtly themustte restored,:repaired or replaced beoausej!youtwork!' • was ificorrectly.perfdtmed On it . • • • Paragraph 2 does If#1q.0..rqrtliPP§."1YOU'r*Prie.and:Were;neyer.O.C.cuplee, rented or held*rental.hyyOui• . . . . ., . Paragraphs 14.4-,and 4,of this exclusion do not apply to'property damage" than•dornage.15y Jiro E :pry:0%1m)to premises: . . ... – w • (1). rented•toyOu: . ,. ,..-. . ,.: .(0. temporarily opp.tvidd:by•:.g you.With•ttAt•pennipginn ordwownp.r,•cir. -... (3) Id the contents of.Ordm' iids"..ranted toy-6111%e period of 7 orleite Cortedo.titiVe.::dayS: . •• , - • • • • - ... • *seoarate.litnit of insurance applies I()Damage To Premises Rentqd TreYatkoe..desOribadirt. e.ctibri b*-- LialillityancIVOdicgil.PxOgnses Litnits•Prin.410.nce., • ---- Paragraphs 3,4,5,and 6 of this egaloSibri•dts not Apply to liability asWited."uticte . idetrabk agreement IIMINIIM1 i..* Paragraph if. of this exclusion.;does . to "property damage" included in the fipraducts-• . . .. ... .. .... . .. . not. .apply ... ... • •• • • • - - • • •• •• • -• - • • • :coaiplated.OperattiOne•*id: .. „ ....„ ,. , ... . ... . . •Immir 2. :Underfi..Exelusitfils,I.Applicable to Business'Liability Coverage,Al i011Owinpparagraph-leadded;and — . ,, ..., .. , .rePiacas the similar paragraph paragraph; If any beneath paragraph (14)•.4.•ilia...ex.dolor, entitled Personal and Advertising Injury:. . . . - _ . . - . • • • Eielusione'o..1,git.6;•.hf I,it., t, mi-kat-leo;do tibtaiJdly 10 darda§.0 by fiiW dtdrhitdS.Whildloritod to yoti ,....... ' or temporarily occupied by you with permission of the OWneir PrtO.the.edntent6V.prernieda rented tO yOV.for:.:a _- . period.'0.'7'of•fewer consecutive days A:separate limit ttifihsoanoo'applios to this coverage as described in Section D.Liability And Medical eicponoes.Limits Of Insurance. --"_:......."-- — • ,....— . ..,. . . . . . . . . Si31409U0(10-19): • • :NO.0:Of.''i. , • . - copooht,,CIM All R.lotitkliiiftnieicl. • , . • . . . • SB146932G (Ed. 10-1.9) 3. The first Paragraph under item 5. Damage To Premises Rented To You Limit of the section entitled Liability And Medical Expenses Limits Of Insurance is replaced by the following: The most we will pay under Business Liability for damages because of "property damage" to any one premises, while rented to you.or temporarily occupied by you with-the permission of the owner, including contents of such premises rented to you for a period of 7 or fewer consecutive days, is the Damage to • Premises Rented to You Limit. The Damage to Premises Rented to You Limit is the greater of: a.. $1,000,000;or b. The Damage to Premises Rented to You Limit shown in the Declarations. F. Personal and Advertising Injury—Discrimination or Humiliation 1. Under Liability and Medical Expenses Definitions, the definition of"personal and advertising injury" is amended to add the following: h. Discrimination or humiliation that results in injury to the feelings or reputation of a natural person, but only if such discrimination or humiliation is: (1) Not done intentionally by or at the direction of: (a) The insured;or (b) Any"executive officer,"director, stockholder, partner, member or manager(if you are a limited liability company)of the insured; and (2) Not directly or indirectly related to the employment, prospective employment,.past employment or . termination of employment of any person or person by any insured. 2. Under B. Exclusions, 1.Applicable to Business Liability Coverage, the exclusion entitled Personal and Advertising Injury is amended to add the following additional exclusions: (15)Discrimination Relating to Room, Dwelling or Premises Caused by discrimination directly or indirectly related to the sale,rental,lease or sub-lease or prospective sale, rental, lease or sub-lease of any room,dwelling or premises by or at the direction of any.insured. • (16)Employment Related Discrimination Discrimination or humiliation directly or indirectly related to the employment, prospective employment, past employment or termination of employment of any person by any insured. (17)Fines or Penalties . Fines or penalties levied or imposed by a governmental entity because of discrimination. • 3. This provision (Personal and Advertising Injury — Discrimination or Humiliation) does not apply if Personal and Advertising Injury Liability is excluded either by the provisions of the Policy or by endorsement. G. Personal and Advertising Injury-Broadened Eviction Under Liability and Medical Expenses Definitions, the definition of "Personal and advertising injury" is amended to delete Paragraph c.and replace it with the following: c. The wrongful eviction from, wtongful entry into, or invasion of the right of private occupancy of a room dwelling or premises that a person or organization occupies committed by or on behalf of its owner, landlord or lessor. . H. Waiver of Subrogation—Blanket We waive any right of recovery we may have against: • a. Any person or organization with whom you have a written contract that requires such a waiver. All other terms and conditions of the Policy remain unchanged. SB146932G(10-19) Page 7 of 7 • Copyright,CNA All Rights Reserved. • AGENCY.CUSTOMER ID: 00001256 LOC#: ' � ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED ' Crestline Insurance Services LLC Gilbert,Gaetke&Associates of NV,MD,Ltd,DBA:&ARC Health&Wellness Centers • POLICY NUMBER • CARRIER • NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS - THIS ADDITIONAL REMARKS FORM ISA SCHEDULE TO ACORD FORM, • FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance:Notes Covered Physicians: • Mark Gaetke MD,Retroactive Date 1-5-2000 Warren Gilbert MD,Retroactive Date 1-5-2000 Brian Kuhn MD,Retroactive Date 4-15-2019' Troy Ross MD,Retroactive Date 9-1-2022 Robert P K Keller MD,Retroactive Date 10-15-2019 William Elliott II,MD,Retroactive Date 11-15-2021 Cherie Lin DO,Retroactive Date 1-21-22 Daniel R Dobbe,MD,Retroactive Date 1-24-22 Timothy Durkin DO,Retroactive Date 10-15-2019 • • • • • • • • • • ACORD 101(2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD