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HomeMy WebLinkAbout2023-135 PO 20240123- Wellness 2000 Inc. FirAll CITY RECORDER Purchase Order ,aft Fiscal Year 2024 Page: 1 of: 1 IB City of Ashland _ == ATTN: Accounts Payable20 E. MPurchase L Ashlandaln OR 97520 Order# 20240123 T Phone: 541/552-2010 0 Email: payable@ashland.or.us • V H C/O Senior Center E WELLNESS 2000, INC I 1699 Homes Ave N 1175 E MAIN ST, SUITE 2F p Ashland, OR 97520 O MEDFORD, OR 97504 Phone: 541/488-5342 - RT Fax: 541/488-5314 a-fldQrhan u �r�fi time uj iia -� - —= F rGlatt Isleen 09/14/2023 1457 FOB ASHLAND OR/NET30 City Accounts Pa able AWN ' FORM #3CITY OF D , (� ASHLAND A request for of �jl,irc;haSO Ort ' � �/-D � � . REQUISiTION Date of request: 08/2812023 ' • . Required date for delivery: 10101/2023 - Vendor Name Wellness 2000, Inc. • • • Address,City,State,Zip 1175 E Main St#2F,Medford OR 97504 Contact Name&Telephone Number .Bea Berry,CEO,541-776.9167 . Email address • bberry@wellness2000.com • SOURCING METHOD • .0 Exempt from Competitive Bidding ❑ 'Invitation to Bid ❑ Emergency ❑ Reason for exemption: Date approved by Council: 0 Form#13,Written findings and Authorization ❑ 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 ❑ 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 it . ❑ VerbalNVritten bid(s)or:proposal(s) ❑ 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 ❑ Written quote or proposal attached Intergovernmental Agreement 0 (3)Written bids&solicitation attached 0 Form#4,Personal Services$5K to$75K Agency • 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 • ,II Less than$35,000,by direct appointment 0 Special Procurement• City Administrator.AMC 2.50.070(4) • ❑ (3)Written proposals&solicitation attached 0 Form(19,Request for Approval. ❑ Annual cost to City exceeds$25,000,Council ❑ Form#4,Personal Services$5K to$75K 0 Written quote or,proposal attached approval required.(Attach copy of council communication) • Date approved by Council: Valid until: (Date) • Description of SERVICES . . Provide flu and COVID-19 vaccinations bylicensed nurses and insurance billing for clinic. at T.oTA1.,C0"ST'• ' Ashland Senior Center.Not to exceed$10,000 per attached:contract . 1000:00 . Item# Quantity Unit- • Description of MATERIALS Unit Price Total Cost ' El Per attached quotelproposal • : 'TOTAL(.COST.. • $; • Project Number . ,Account Number 1 2 6 e 3 a.a 0 4 1 0 0 Account Number Account Number - • 'Expenditure must be charged to the appropriate account numbers for the financials to accurately reflect.the actual expenditures. 1T-Director in:collaboration with department to�approve all.hardwara and.software purchases: IT Director. Date Support-Yes/No . By signing this requisition form,I certify that the City's public contracting requirements have been satisfied. r s7,6,:,,e,,,..._. Employee: fDepartment ad: • (E ual ��=�-� �� to or greater than$5,000) Department ManagerlSupervisor: City Manager. . (Greater than$35,000) Funds appropriated for.current,flscal'year: YES /NO Finance Director-(Equal to orgreater,than$5,000)' Date Comments:. • . Form 43-Requisition . ..) . . • Kariann Olson From: Isleen Glatt Sent: Tuesday,August 29,2023 1:49 PM To: Kariann Olson Cc: Tara Kiewel Subject: Wellness 2000 purchase order request,W-9 Attachments: Form#3-Requisition_Wellness 2000 vaccination clinic with attachments.pdf;Wellness 2000 W-9.pdf Hello Kariann, • The first attachment is a'signed Form 3•with.signed personal services agreement (stamped by Legal), insurance certificate and W-9 attached. Note that Risk Management Committee approved 1,000,000 per occurrence for professional liability, as indicated in agreement. • • I am also attaching the W-9 separately as you requested for Finance. It is possible that Finance already has Wellness 2000 in the system as a payee, since they did flu vaccine clinics for our employees in the past, but , this is a new W-9. . . - Please let me know if you need anything else. I can separate parts of the .pdf if you need'me to. Thank you!' • • Isleen Isleen Glatt,Senior Services Superintendent(she/her) Ashland Parks& Recreation Commission,Senior Services Division 1699 Homes Avenue Ashland,QR 97520 Main:541-488-5342 Desk: 541-552-2481 Email: isleen.glatt@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)552-2481. • • • • • • • • ( 1. • PERSONAL SERVICES AGREEMENT(LESS THAN$35,000) CONSULTANT: Bea Berry, CEO,Wellness 2000, Inc. CITY OF '78t,S H LAN D ADDRESS: 1175 E Main St i Medford, OR 97504 20 East Main Street - . ZG(#/4) Ashland, Oregon 97520 TELEPHONE: (800)866-8344 or 541-776-9167 ? Senior Services Division EMAIL: bbeny@wellness2000.com Telephone: 541/488-5342 This Personal Services Agreement(hereinafter"Agreement")is entered into by and between the City of Ashland, an Oregon municipal corporation(hereinafter "City") and Wellness 2000, Inc., a domestic business corporation("hereinafter"Consultant"),to perform influenza and COVID immunization clinics at Ashland Senior Center for local senior residents and other qualifying individuals such as staff. 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 affirmative acceptance of Consultant's Work as complete and Consultant's acceptance of the City's final payment therefore,but not later than December 31,2023. 2. Scope of Work: Consultant will provide influenza and COVID immunizations as more fully set forth in"Exhibit A"which is attached hereto and incorporated herein by this reference. Consultant's services are collectively referred to herein as the"Work." 3. Supporting Documents/Exhibits; 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.• . 4. 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. j 5. Qualified Work: Consultant has represented,and by entering into this Agreement now represents,that all personnel assigned to the Work to be performed under this Agreement are fully qualified to perform • Page 1 of 6: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND WELLNESS 2000,INC. . r the service to which they will be assigned in a skilled and worker-like manner and, if required to be registered, licensed or bonded by the State of Oregon, are so registered,licensed and bonded, •6. Compensation: See Schedule A for details of compensation,billed to patients' health insurance if available or directly paid by individuals at time of service. The Senior Services Division will provide a subsidy for underinsured participants and a limited number of scholarships for uninsured participants,to be invoiced by Consultant after completion of the last scheduled day, as full compensation 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$10,000 (ten thousand 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. 7. Statutory Requirements: The following laws of the State of Oregon are hereby incorporated by reference into this Agreement: ORS•279B.220,279B.230 and 279B.235. 8. 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. 9. 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, actions, costs, or other • damages, caused solely by the gross negligence of City. 10. Termination: This Agreement may be terminated per the conditions set forth in Exhibit A. 11. Independent Contractor Status: Consultant is an independent contractor and not an employee of the City for any purpose. • Page 2 of 6: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY Of ASHLAND AND WELLNESS 2000,INC. • 12. 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. • 13. 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 under the Agreement; or attempts to assign rights in, or delegate duties under,this Agreement. 14. Insurance. Consultant shall,at its own expense,maintain the following insurance: a. Workers' Compensation. Consultant shall obtain and maintain Workers' Compensation insurance in compliance with ORS 656.017,which requires subject employers to provide Oregon Workers' Compensation coverage for its subject workers, unless such employers are exempt under ORS 656.126. If exempt under ORS 656.126, Consultant shall certify such exemption to the City. b. Professional Liability insurance with a combined single limit,or the equivalent, of not less than $1,000,000 (one million dollars)per occurrence. This is to cover any damages caused by error, omission or negligent acts related to the Work to be provided under this Agreement. 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 accident 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 and endorsements prior to commencing the Work under this Agreement. 15. 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 Page 3 of 6: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND WELLNESS 2000,INC. 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. 16. 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: (1)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 implement or 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; (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. 17. Governing Law; Jurisdiction: This Agreement shall be governed and construed in accordance with 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. • • 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 Senior Services Division Attn: Isleen Glatt 1699 Homes Ave Ashland, Oregon 97520 • With a copy to: Page 4 of 6: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND WELLNESS 2000,INC. • City of Ashland-Legal Department 20 East Main Street ' Ashland,Oregon 97520 • If to Consultant: Bea Berry 1175E Main St*re 2 Medford, OR 97504 ,i6) Medford, 541-776-9167 or 800-866-8344 bberry@wellness2000.com 19. Amendments. This Agreement may be amended only by written instrument executed by both parties with the same formalities as this Agreement. 20. THIS AGREEMENT AND THE ATTACHED EXHIBITS CONSTITUTE THE ENTIRE UNDERSTANDING BETWEEN THE PARTIES. THERE ARE NO UNDERSTANDINGS, AGREEMENTS, OR REPRESENTATIONS,EITHER ORAL OR WRITTEN,NOT SPECIFIED HEREIN REGARDING THIS 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. 21. Certification, Consultant shall execute 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 authorized representatives as of the dates set forth below. • Page 5 of 6: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND WELLNESS 2000,INC. • • CITY OF HLAND:. WELLNESS 2000,INC. (CONSULTANT): B 7� .4 By: Lefeer Signature Signatur Leslie Eldridge Bea Berry Printed•Name Printed Name Interim Parks Director CEO Title Title . • Z? , 23 2f gD 23. Date G% Date • Purchase Order No. (�' -9 and certificates of insurance are to be submitted with this signed Agreement) • Cannel Zahran,Assistant City Attorney. Approved as to form/ • 8.24:23 • a • • Page 6 of 6: PERSONAL SERVICES AGREEMENT BETWEEN THE CITY OF ASHLAND AND WELLNESS 2000,INC. EXHIBIT A: Scope of Work 1) Clinic Dates: The Senior Services Division of Ashland Parks and Recreation Commission. (SSD)and Wellness 2000,Inc.,will reserve the following dates at Ashland Senior Center. Wellness 2000, Inc., will provide at least one nurse on each day,with administrative staff as needed for check-in and billing,and additional staff if pre-registration numbers are high. Staff provided by Wellness 2000 are to arrive early to set up and be ready to see the first patient at 1:00pm for the following days: • Friday, October 13, 1:00-5:00pm • • Friday, October 27, 1:00-5:OOpm • Additional date(s) may be agreed upon by both parties if demand exceeds . expectations . 2) Coordination Services provided,by a Wellness 2000,Inc.,Account Manager 3) Immunizations offered and fees:The fee for influenza immunizations is as follows,with the COVID vaccine fee to be determined by market rate when announced by the manufacturers and confirmed prior to September 30,2023. IMMUNIZATIONS PARTICIPANT AGE FEE,including administration OFFERED • Administration of Influenza— Participants under age 65 years $39 Quadrivalent 2023-24 Vaccine • Formula Administration of Influenza Participants age 65 years and $78 Quadrivalent Senior 2023-34 older who desire the higher . Vaccine Formula dose vaccine Administration of Participants age 18 and older Wholesale vaccine cost+$25 COVID-19 2023 Monovalent / administration fee Vaccine booster • 4) Participants must provide the following documents before receiving a vaccination: a. The Wellness 2000,Inc., Informed Consent for Flu and/or COVID-19 Vaccination b. A copy of any and all Medical Insurance Cards,or if no medical insurance, a copy of personal identification(State Driver License or Identification Card, or Passport) Wellness 2000,Inc.,will supply copies of the consent forms and will bring a portable copy machine to take copies of insurance and identification cards. 5) Site Fee: SSD will pay Wellness 2000 a site fee of$275 per clinic day (4 to 7 hours) for one nurse and one intake/paperwork staff person, and an additional fee of$125 for each additional nurse scheduled. Wellness 2000, Inc., will invoice the site fee with other agreed • fees after completion of the clinics. 6) Minimum number of immunizations and low-turnout fee: Wellness 2000, Inc.,will provide • up to twenty (20)vaccinations per hour per nurse,with a required minimum of twelve (12) • vaccinations per hour per nurse. If one Participant gets both flu and COVID vaccinations, that counts as two (2) vaccinations, If participation is below twelve (12) vaccinations per hour (eg: forty-eight (48) vaccinations per four-hour clinic), SSD will pay a low-turnout .fee of$39 per each unused appointment below the minimum requirement,averaged over the • two clinic dates.,Fee is based on the regular flu vaccination,'the lowest price of the three vaccines. Wellness.2000,Inc., will invoice the low-turnout fee along with other agreed fees after completion of the clinics. • 7) If SSD cancels the event or reschedules with less than 30 days.advance written notice to Wellness 2000, Inc., SSD agrees to pay Wellness 2000,Inc.,a cancellation fee of$350. 8) SSD will promote the clinic, manage patient scheduling and reminders, and provide staff and volunteers on the day of the event to.help with patient flow and hand out paperwork. SSD will fill the earlier dates and times first. With 48 hours advance notice,hours may be • reduced to two or three hours if not filled to the minimum of 12 shots per hour. Similarly,if appointments fill quickly, SSD may request additional hours and nurses on one or more days, subject to Wellness 2000,Inc.'s availability. • 9) For individuals covered by a health insurance medical plan, immunizations will be provided at no cost to Participants.:Wellness 2000,Inc.,will collect insurance information and bill the patients' insurance. a. Medicaid insurance (Oregon Health Plan, Jackson Care Connect, and AllCare) will be accepted. • . b. Wellness 2000,Inc.,is unable to accept United Health Care insurance.Full payment is required from Participant,who may submit to their insurer for reimbursement. 10) Additional feesfor insured Participants. For the following four(4) insurers who do not • reimburse adequately, SSD will provide a subsidy to cover the gap,to be invoiced by Wellness 2000,Inc.,with other agreed fees after completion of the clinics. a. Regular Flu immunization: Wellness 2000, Inc., is in negotiation with Moda and Cigna insurance companies for influenza reimbursement rates.A charge to SSD,not to exceed$20 per vaccination,may be negotiated if reimbursement rate is too low. b. . Senior Flu immunization: i. Participant with Jackson Care Connect insurance—$4.00 per vaccination' ii. Participants with Providence insurance—$8.00 per vaccination c. COVID-19 immunization: A subsidy for'Moda,Cigna,Jackson Care Connect,and Providence may be negotiated between Wellness 2000, Inc., and SSD when wholesale cost of COVID-19 vaccine and insurer reimbursement rates are known. 11) For individuals NOT covered by health insurance, vaccinations will be the financial responsibility of the Participant and must be paid directly to Wellness 2000,Inc.,at the point of service,unless they are identified on the sign-up list as receiving a scholarship from SSD. SSD will provide a limited number of scholarships for uninsured patients,to be invoiced by Wellness 2000, Inc., with other agreed fees after completion of the clinics. Fees for uninsured scholarship recipients: SSD will pay a fee per vaccination as defined previously in item 3)above: a. Regular Flu immunization: $39.00 per shot. b. Senior Flu immunization: $78.00 per shot. c. COVID-19 vaccine: Wholesale cost of vaccine+$25 administration fee per shot. 12) Work Environment: SSD will provide a clean and properly maintained workspace for Wellness 2000, Inc.,to conduct the Clinic in a setting that will enable Wellness 2000,Inc., to safely provide Services to Participants seeking such service. SSD will provide furniture at its sole risk to include, but not limited to, tables and chairs. Wellness 2000 will provide room dividers as needed to create a private vaccination space for each nurse.Wellness 2000, Inc., will be responsible for the proper maintenance of any property supplied by SSD, including but not limited to tables, chairs and physical space provided to Wellness 2000, Inc., and Participants. Wellness 2000,Inc.,will assume no responsibility or liability for crowd control and security at Clinics. 13) Patient/Customer Information: Neither party nor its employees shall disclose any financial or medical information regarding patients/customers treated hereunder to any third-party, except where permitted or required by law or where such disclosure is expressly approved by SSD, Wellness 2000, Inc., and patient/customer in writing. Further, each party and its employees shall comply with the other party's rules, regulations and policies regarding the confidentiality of such information as well as all federal and state laws and regulations including, without limitation, the Health Insurance Portability and Accountability Act of 1996("HrPAA")and the Health Information Technology for Economic and Clinical Health Act("HITECH"). 14) Invoice and Payment: Ashland Parks and Recreation Commission agrees to the designated fees for services rendered. Upon completion of the second clinic date. Wellness 2000 will invoice all agreed fees in one bill to: Ashland Senior Services Division, Attention: Isleen Glatt, isleen.glatt a,ashland.or.us Payment for services is due upon receipt of invoice and no later than thirty(30) days of receipt of invoice. • • EXHIBIT B : • • • •a. CITY O F AS H L A N D, O R E G.ON :: 1 o 's an. • LIVING ALL employers described. below must comply with City WAGE • of Ashland laws regulating • ..y 1• . . 'ig, , ..•. .. $17.02 per hour,, effective June 30, 2022. The Living Wage is adjusted annually every June 30 by the Consumer Price Index. Employees must be paid a business of their the value of health care, living wage: employer,if the employer retirement,401K and IRS • has ten or more eligible cafeteria plans • • • • employees, and has (including childcare) D For all hours worked received financial benefits to the amount of under a service contract • assistance for the project wages received by the between their employer or business from the.City employee, and the City of Ashland if of Ashland in excess of the contract exceeds $24,050.68. > Note: For temporary and $24,050.68 or more. part-time employees,the D If their employer is the , Living Wage does not D For all hours worked in a City of Ashland, apply to the first 1040 • month if the employee including the Parks and hours worked in any spends 50%or more of Recreation Department. • calendar year. For more • the employee's time in details,please see that month working on a ➢ In calculating the living Ashland Municipal Code project or portion of wage,employers may add Section 3.12.020. 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,OR 97520, or visit the City's website at www.ashland.or;us. \Notice to Employers: This notice must be posted predominantly in areas where it can be seen by all employees. • • • CITY OF ASHLAND • 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 be 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 be 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 the business. 1i" (2)Commercial advertising or business cards or a trade association membership are purchased for the business. ✓ (3)Telephone Iisting is used for the business separate from the personal residence listing. - s� (4)Labor or services are performed only pursuant to written contracts. s/' (5)Labor or services are performed for two or more different persons within a period of one year. ✓ (6)Consultant assumesfinancial responsibility for defective workmanship or for service not provided as evidenced by the ownership of performance bonds, warranties,errors and omission(professional liability)insurance or liability insurance relating to the Work or services to-be provided. • Pf Consultant's sign.iure # 914 4 1. Wit .27 2Dz 3 Date/• • Page 1 of 1: EXHIBIT C • DATE(MMIDD/YYYY) ARE? CERTIFICATE OF LIABILITY INSURANCE 06/10/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMEND,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(les)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 Ileu of such endorsement(s), PRODUCER CONTACT Julie Asher NAME: Ashland Insurance Inc (AHic No,Exn. (541)482-0831. bac,No): (541)488-5851 585 A Street Suite 1 EMAIL jasher@ashiandlnsurance,com ADDRESS: P.O.Box 880 INSURER(S)AFFORDING COVERAGE NAICM Ashland • OR 97520 INSURER A: Travelers Indemnity Co of Conn. INSURED INSURER a: Certain Underwriters at Lloyd's of London • Wellness 2000 Inc INSURER c: BCS Insurance Company 1175 E Main Street,Suite 2C INSURER D: INSURER E: Medford OR 97504 INSURER F COVERAGES CERTIFICATE NUMBER: 23-24 Ceti 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 RESPECTTO 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. LTR TYPE OF INSURANCE AUDI.bUBR POLICY EFF POLICY EXP INSD WVD POLICY NUMBER (MMIDD/YI'YY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY , 2,000,000 EACH OCCURRENCE ; RENTED CLAIMS-MADE X OCCUR • PREM SESO(Ea occurrence) $ 30(Ea MED EXP(Any one person) $ 5.000 A. Y 680-6419B85A-23.42 01/20/2023 01/20/2024 PERSONAL&ADV INJURY $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE ; 4.000,000 PRO• F X POLICY n (, I�( PRODUCTS-COMP/OPAGG 5 4.000,000 JECT LOC OTHER: AUTOMOBILE LIABILITY • COMBINED SINGLE LIMIT $ 1,000,000 (Eaacddenn ANYAUTO BODILY INJURY(Per person} S A OWNED SCHEDULED Y 680.64191365A-23742 01/20/2023 01/20/2024 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE S AUTOS ONLY AUTOS ONLY O'er accident) UMBRELIALIAB OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE • AGGREGATE _S DED RETENTION S 5 WORKERS COMPENSATION I PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA (Mendeloy Is NH) EL DISEASE-EA EMPLOYEE $ II yes,describe under DESCRIPTION OF OPERATIONS below E.LDISEASE-POLICY LUJIT $ PROFESSIONAL LIABILITY EACH OCCURRENCE $1,000,000 B Y GAH-78934-220923 09/23/2022 09/23/2023 GENERALAGGREGATE $3,000,000 DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES(ACORD 101,Addlltonal Remarks Schedule,may be attached If more space Is required)- The City of Ashland,Oregon,and its elected officials,officers,and employees are Included as Additional Insureds for General Liability and Auto Liability coverages with written contract. This Insurance is primary and non-contributory. This form Is subject to policy terms,conditions and exclusions. 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,Oregon ACCORDANCE WITH THE POLICY PROVISIONS. 20 East Main Street AUTHORIZED REPRESENTATIVE //[[��� Ashland OR 97520 /� 7`�OJt"�L ©1988-2015ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD • ADDITIONAL COVERAGES Ref# Description Policy Number RPS-P-1136248M Coverage Code Form No. Edition Date C CYBER LIABILITY Eff 5-16-2023 to 5-16-2024 Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Occ$1,000,000 Agg$1,000,000 Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type. Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium• Ref# Description Coverage Code Form No. Edition Date Limit f Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 - Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type . Premium i Ref if Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No, Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date . Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium OFADTLCV • Copyright 2001,ANIS Services,Inc.