HomeMy WebLinkAbout2008-049 Contract - Health Future
ADDRESS: 777 Murphy Road, Medford, OR 97504
TELEPHONE: (541) 772-3062
DATE AGREEMENT PREPARED: March 18,2008 FAX: (541) 772-0221
BEGINNING DATE: April 1 ,2008 COMPLETION DATE: March 31,2011
COMPENSATION: Per the attached Administrative Fee Schedule.
CITY Of
ASHLAND
20 East Main Street
Ashland, Oregon 97520
Telephone: 541/488-6002
Fax: 541/488-5311
CONSULTANT: Health Future, LLC
CONTACT: Mary Kay Chess, Ph.D.
SERVICES TO BE PROVIDED: Third Party Administrative Services for Workers' Compensation, Per the
scope of services in the RFP released January 21 , 2008, and proposal submitted by Health Future.
ADDITIONAL TERMS:
FINDINGS:
Pursuant to AMC 2.52.040E and AMC 2.52.060, after reasonable inquiry and evaluation, the undersigned Department
Head finds and determines that: (1) the services to be acquired are personal services; (2) the City does not have
adequate personnel nor resources to perform the services; (3) the statement of work represents the department's plan for
utilization of such personal services; (4) the undersigned consultant has specialized experience, education, training and
capability sufficient to perform the quality, quantity and type of work requested in the scope of work within the time and
financial constraints provided; (5) the consultant's proposal will best serve the needs of the City; and (6) the
compensation negotiated herein is fair and reasonable.
NOW THEREFORE, in consideration of the mutual covenants contained herein the CITY AND CONSULTANT AGREE as
follows:
1. Findings I Recitations. The findings and recitations set forth above are true and correct and are incorporated herein
by this reference.
2. All Costs by Consultant: Consultant shall, at its own risk and expense, perform the personal services described
above and, unless otherwise specified, furnish all labor, equipment and materials required for the proper performance
of such service.
3. Qualified Work: Consultant has represented, and by entering into this contract now represents, that all personnel
assigned to the work required under this contract are fully qualified to perform 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.
4. Completion Date: Consultant shall start performing the service under this contract by the beginning date indicated
above and complete the service by the completion date indicated above.
5. Compensation: City shall pay Consultant for service performed, including costs and expenses, the sum specified
above. Once work commences, invoices shall be prepared and submitted by the tenth of the month for work
completed in the prior month. Payments shall be made within 30 days of the date of the invoice. Should the contract
be prematurely terminated, payments will be made for work completed and accepted to date of termination.
6. Ownership of Documents: All documents prepared by Consultant pursuant to this contract shall be the property of
City.
7. Statutory Requirements: ORS 279C.505, 279C.515, 279C.520 and 279C.530 are made part of this contract.
8. Living Wage Requirements: If the amount of this contract is $17,342 or more, Consultant is required to comply with
chapter 3.12 of the Ashland Municipal Code by paying a living wage, as defined in this chapter, to all employees
performing work under this contract and to any Subcontractor who performs 50% or more of the service work under
this contract. 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 agrees to defend, indemnify and save City, its officers, employees and agents harmless
from any and all losses, claims, actions, costs, expenses, judgments, subrogations, 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 contract by Consultant (including but not
limited to, Consultant's employees, agents, and others designated by Consultant to perform work or services
attendant to this contract). Consultant shall not be held responsible for any losses, expenses, claims, subrogations,
actions, costs, judgments, or other damages, directly, solely, and proximately caused by the negligence of City.
10. Termination:
Contract for Personal Services, Revised by Legal 01/14/2008, Page 1 of 9
a. Mutual Consent. This contract may be terminated at any time by mutual consent of both parties.
b. City's Convenience. This contract may be terminated at any time by City upon 30 days' notice in writing
and delivered by certified mail or in person.
c. For Cause. City may terminate or modify this contract, in whole or in part, effective 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 contract or are
no longer eligible for the funding proposed for payments authorized by this contract; or
iii. If any license or certificate required by law or regulation to be held by Consultant to provide the
services required by this contract is for any reason denied, revoked, suspended, or not renewed.
d. For Default or Breach.
i. Either City or Consultant may terminate this contract in the event of a breach of the contract by
the other. Prior to such termination the party seeking termination shall give to the other party
written notice of the breach and intent to terminate. If the party committing the breach has not
entirely cured the breach within 15 days of the date of the notice, or within such other period as
the party giving the notice may authorize or require, then the contract 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 contract. City by written notice to Consultant of default or breach may at any time terminate
the whole or any part of this contract if Consultant fails to provide services called for by this
contract within the time specified herein or in 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 contract.
e. Obliqation/Liability of Parties. Termination or modification of this contract 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 subsections a, b, c or d of this section, Consultant shall immediately cease all activities under
this contract, unless expressly directed otherwise by City in the notice of termination. Further, upon termination,
Consultant shall deliver to City all contract documents, information, works-in-progress and other property that are
or would be deliverables had the contract been completed. City shall pay Consultant for work performed prior to
the termination date if such work was performed in accordance with the Contract.
11. Independent Contractor Status: Consultant is an independent contractor and not an employee of the City.
Consultant shall have the complete responsibility for the performance of this contract. Consultant shall provide
workers' compensation coverage as required in ORS Ch 656 for all persons employed to perform work pursuant to
this contract. Consultant is a subject employer that will comply with ORS 656.017.
12. Assignment and Subcontracts: Consultant shall not assign this contract 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 shall not create any
contractual relation between the assignee or subcontractor and City.
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 it owes under the Contract; its ORF status pursuant to the ORF
Rules or loses any license, certificate or certification that is required to perform the Services or to qualify as a ORF if
consultant has qualified as a ORF for this 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 Contract; or attempts to assign rights in, or
delegate duties under, the Contract.
14. Insurance. Consultant shall at its own expense provide the following insurance:
a. Worker's Compensation insurance in compliance with ORS 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
$1,000,000 for each claim, incident or occurrence. This is to cover damages caused by error, omission or
negligent acts related to the professional services to be provided under this contract.
c. General Liability insurance with a combined single limit, or the equivalent, of not less than $1,000,000 for
each occurrence for Bodily Injury and Property Damage. It shall include contractual liability coverage for the
indemnity provided under this contract.
d. Automobile Liability insurance with a combined single limit, or the equivalent, of not less than $1,000,000
for each accident for Bodily Injury and Property Damage, including coverage for owned, hired or non-owned
I vehicles, as applicable.
Contract for Personal Services, Revised by Legal 01/14/2008, Page 2 of 9
. ~. I
e. Notice of cancellation or chanqe. There shall be no cancellation, material change, reduction of limits or
intent not to renew the insurance coverage(s) without 30 days' 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 required herein but only
with respect to Consultant's services to be provided under this Contract. As evidence of the insurance coverages
required by this Contract, the Consultant shall furnish acceptable insurance certificates prior to commencing work
under this contract. The certificate 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 be provided to the City. The Consultant shall be financially responsible for all pertinent
deductibles, self-insured retentions and/or self-insurance.
15. Governing Law; Jurisdiction; Venue: This contract shall be governed and construed in accordance with the laws
of the State of Oregon without resort to any jurisdiction's conflict of laws, rules or doctrines. Any claim, action, suit or
proceeding (collectively, "the claim") between the City (and/or any other or department of the State of Oregon) and
the Consultant that arises from or relates to this contract shall be brought and conducted solely and exclusively within
the Circuit Court of Jackson County for the State of Oregon. If, however, the claim must be brought in a federal
forum, then it shall be brought and conducted solely and exclusively within the United States District Court for the
District of Oregon filed in Jackson County, Oregon. Consultant, by the signature herein of its authorized
representative, hereby consents to the in personam jurisdiction of said courts. In no event shall this section be
construed as a waiver by City of any form of defense or immunity, based on the Eleventh Amendment to the United
States Constitution, or otherwise, from any claim or from the jurisdiction.
16. THIS CONTRACT AND ATTACHED EXHIBITS CONSTITUTE THE ENTIRE AGREEMENT BETWEEN THE
PARTIES. NO WAIVER, CONSENT, MODIFICATION OR CHANGE OF TERMS OF THIS CONTRACT SHALL
BIND EITHER PARTY UNLESS IN WRITING AND SIGNED BY BOTH PARTIES. SUCH WAIVER, CONSENT,
MODIFICATION OR CHANGE, IF MADE, SHALL BE EFFECTIVE ONLY IN THE SPECIFIC INSTANCE AND FOR
THE SPECIFIC PURPOSE GIVEN. THERE ARE NO UNDERSTANDINGS, AGREEMENTS, OR
REPRESENTATIONS, ORAL OR WRITTEN, NOT SPECIFIED HEREIN REGARDING THIS CONTRACT.
CONSULTANT, BY SIGNATURE OF ITS AUTHORIZED REPRESENTATIVE, HEREBY ACKNOWLEDGES THAT
HE/SHE HAS READ THIS CONTRACT, UNDERSTANDS IT, AND AGREES TO BE BOUND BY ITS TERMS AND
CONDITIONS.
17. Nonappropriations Clause. Funds Available and Authorized: City has sufficient funds currently available and
authorized for expenditure to finance the costs of this contract within the City's fiscal year budget. Consultant
understands and agrees that City's payment of amounts under this contract 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 contract. In
the event City has insufficient appropriations, limitations or other expenditure authority, City may terminate this
contract without penalty or liability to City, effective upon the delivery of written notice to Consultant, with no further
liability to Consultant.
Certification. Consultant shall si n the certification attached hereto as Exhibit A and herein incorporated by reference.
CONSULTANT CITY OF ASHLAND:
BY
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CONTRACT AWARD AND FINDINGS DETERMINED BY:
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Federal 10#
ACCOUNT #
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(For City purposes only)
'Completed W9 form must be submitted with contract
PURCHASE ORDER #
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Contract for Personal Services, Revised by Legal 01/14/2008, Page 3 of 9
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EXHIBIT A
CERTIFICATIONS/REPRESENTATIONS: Contractor, 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) Contractor 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. Contractor further represents and
warrants to City that (a) it has the power and authority to enter into and perform the work, (b) the
Contract, when executed and delivered, shall be a valid and binding obligation of Contractor
enforceable in accordance with its terms, (c) the work under the Contract shall be performed in
accordance with the highest professional standards, and (d) Contractor is qualified, professionally
competent and duly licensed to perform the work. Contractor also certifies under penalty of perjury
that its business is not in violation of any Oregon tax laws, and it is a corporation authorized to act on
behalf of the entity designated above and authorized to do business in Oregon or is an independent
Contractor as defined in the contract documents, and has checked four or more of the following
criteria:
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(1) I carry out the labor or services at a location separate from my residence or is in a
specific portion of my residence, set aside as the location of the business.
(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 different persons within a period of one
year.
(6) I assume financial responsibility for defective workmanship or for service not provided
as evidenced by the ownership of performance bonds, warranties, errors and omission
insurance or liability insurance relating to the labor or services to be provided.
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Contract for Personal Services, Revised by Legal 01/14/2008, Page 4 of 9
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Health Future, LLC
Workers Compensation Fee Schedule
prepared for
City of Ashland
EST TOTAL CLAIMS HANDLING COST
Minimum 2008 Fee
$ 11,950.00
$ 12,500.00
SUPPLEMENTAL CLAIMS SUPPORT OPTIONS
Included
$ 90.00 Hour
$ 90.00 Hour
$ 300.00 Hour
Included
Included
$ 75.00 Hour
Included
Note: Medical Claims Exceeding $5,000
will be classified as Indemnity for billing
4/1/2008
3:28 PM
Form W-g
Request for Taxpayer
Identification Number and Certification
Give form to the
requester. Do not
send to the IRS.
(Rev. November 2005)
Department or the Treasury
lnt..-nal Revenue SeNjce
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Name (as shown on your income tax return)
Health Future LLC
Business name, if different from above
o IndlviduaV
Check appropriate box: Sole proprietor
Address (number. street, and apt. or suite no.)
777 Murphy Rd
City, state, and ZIP code
Medford, OR 97504
LIst account number(s) here (opliona~
o CorpOration
IN
o Partnership III Other ~
LLC
D Exempt from backup
w~hholding
Requester's name and address (optional)
Enter your TIN In the appropriate box. The TIN provided must match the name given on Une 1 to avoid
backup withholding. For Individuals. this is your social security number (SSN). However, for a resident
alien, sole proprietor, or disregarded entity. see the Part I instructions on page 3. For other entities. it Is
your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose
number to enter.
I Social security number
I I iLl: I
or
Under penalties of perjury. I certify that:
,. The number shown on this form is my correct taxpayer Identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien).
Certification Instnuctions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.
For mortgage interest paid. acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement
arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must
provide your correct TI~:'(~ee the Instructions on page 4.)
S. -,
19n Signature of [~^ 11 .\ L' I
Here u.s. person ~ LM-LL-Y\.. V.V .1" I j
Purpose of Form ::.-\.
A person who is required to file an information retWwlth the
IRS, must obtain your correct taxpayer identification number
(TIN) to report, for example. income paid to you. real estate
transactions, mortgage interest you paid, acquisition or
abandonment of secured property, cancellatIon of debt, or
contributions you made to an IRA.
U.S. person. Use Form W-9 only if you are a U.S. person
(including a resident alien), to provide your correct TIN to the
person requesting it (the requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are
waiting for a number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a
U.S. exempt payee.
In 3 above, if applicable, you are also certifying that as a
U.S. person, your allocable share of any partnership Income
from a U.S. trade or business Is not subject to the .
withholding tax on foreign partners' share of effectively
connected income.
Note. If a requester gives you a form other than Form W-9 to
request your TIN, you must use the requester's form it it is
substantially similar to this Form W-9.
For federal tax purposes, you are considered a person if you
are:
Certification
Date ~
rp~!
~2-oD CO
. An individual who is a citizen or resident of the United
States,
. A partnership, corporation, company, or association
created or organized In the United States or under the laws
of the United States, or
. Any estate (other than a foreign estate) or trust. See
Regulations sections 301. 7701-6(a) and 7(a) for additional
information.
Special rules for partnerships. Partnerships that conduct a
trade or business in the United States are generally required
to pay a withholding tax on any foreign partners' share of
income from such business. Further, in certain cases where a
Form W-9 has not been received, a partnership Is required to
presume that a partner is a foreign person, and pay the
withholding tax. Therefore, if you are a U.S. person that is a
partner in a partnership conducting a trade or business in the
United States, provide Form W-9 to the partnership to
establish your U.S. status and avoid withholding on your
share of partnership Income.
The person who gives Form W-9 to the partnership for
purposes of establishing its U.S. status and avoiding
withholding on its allocable share of net income from the
partnership condUcting a trade or business in the United
States is in the following cases:
. The U.S. owner of a disregarded entity and not the entity,
Cat. No. 10231X
Form W-9 (Rev. 11-2005}
CERTIFICATE NUMBER
SEA-001066727-01
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE
POLICY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE
AFFORDED BY THE POLICIES DESCRIBED HEREIN.
CE
PRODUCER
MARSH USA INC.
111 S.w. COLUMBIA
FIFTH FLOOR
PORTLAND, OR 97201
COMPANIES AFFORDING COVERAGE
02317---07/08
COMPANY
A AMERICAN STATES INS. CO. (SAFECO)
INSURED
Health Future LLC
777 Murphy Road
Medford, OR 97501
COMPANY
B
COMPANY
C
COMPANY
o
noted below.
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS AND EXCLUSIONS OF SUCH POLICIES. AGGREGATE
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MMIDDNY) DATE (MMIDDNY)
A AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
01CH0740382
05/31/07
05/31/08
LIMITS
GENERAL AGGREGATE $ 2,000,000
PRODUCTS - COMPIOP AGG $ 2,000,000
-~
PERSONAL & ADV INJURY $ 1,000,000
EACH OCCURRENCE $ 1,000,000
FIRE DAMAGE (Anxoneflre) $ 200,000
MED EXP (Anyone person) $ 10,000
COMBINED SINGLE LIMIT $ 1,000,000
BODILY INJURY $
(Per person)
BODILY INJURY $
(Per aCCident)
PROPERTY DAMAGE 1$
AUTO ONLY - EA ACCIDENT $
OTHER THAN AUTO ONLY
A GEN ERAL LIABILITY
01CH0740382
05/31/07
05/31/08
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE [K] OCCUR
OWNER'S & CONTRACTOR'S PROT :
x
X
NON-OWNED AUTOS
GARAGE LIABILITY
ANY AUTO
EXCESS LIABILITY
.!C_ACH ACCIDENT $
AGGREGATE $
EACH OCCURRENCE $
AGGREGATE $
$
H-
ER
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
$
EL DISEASE-POLICY LIMIT $
EL DISEASE-EACH EMPLOYEE $
THE PROPRIETOR!
PARTNERS/EXECUTIVE
OFFICERS ARE
OTHER
INCL
EXCL
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESISPECIAL ITEMS
The City of Ashland, Oregon, and its elected officials, officers and employees are included as Additional Insureds regarding Third Party Administrator services
contract.
City of Ashland
20 East Main Street
Ashland, OR 97520
SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION OATE THEREOF.
THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL -----.3.0 DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE, ITS AGENTS OR REPRESENTATIVES. OR THE
ISSUER OF THIS CERTIFICATE
AUTHORIZED REPRESENTATIVE
Marsh USA Inc.
BY: Lorie Larsen-Denning
i(~~.~t(
MM1(3102)
VALID AS OF:03/25/08
RSH
SEA-001066557-01
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS
NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE
POLICY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE
AFFORDED BY THE POLICIES DESCRIBED HEREIN.
RANCE
CERTIFICATE NUMBER
PRODUCER
MARSH USA INC.
111 SW. COLUMBIA
FIFTH FLOOR
PORTLAND, OR 97201
COMPANIES AFFORDING COVERAGE
02317 ---08-09
COMPANY
A HOUSTON CASUALTY COMPANY
INSURED
Health Future LLC
777 Murphy Road
Medford, OR 97501
COMPANY
I--~~---
COMPANY
C
COVERAGES noted below. 3
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS AND EXCLUSIONS OF SUCH POLICIES AGGREGATE
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER
LTR
GEN ERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
_ CLAIMS MADE D OCCUR
OWNER'S & CONTRACTOR'S PROT
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON.OWNED AUTOS
--~
GARAGE LIABILITY
__~ ANY AUTO
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
i THE PROPRIETOR! INCL
PARTNERS/EXECUTIVE
OFFICERS ARE EXCL
OTHER
A Professional Liability H70811458
POLICY EFFECTIVE I POLICY EXPIRATION
DATE (MM/DDNYI I DATE (MM/DDNYI
LIMITS
GENERAL AGGREGATE $
PRODUCTS - COMP/OP AGG $
PERSONAL & ADV INJURY $
EACH OCCURRENCE $
FIRE DAMAGE (Anyone fire) $
MED EXP (Anyone person) $
COMBINED SINGLE LIMIT $
BODILY INJURY
(Per person)
$
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE
$
AUTO ONLY - EA ACCIDENT
OTHER THAN AUTO ONLY:
EACH ACCIDENT
AGGREGATE
EACH OCCURRENCE
AGGREGATE
$
$
$
$
$
--_.~_._----
$
TH
ER
$
EL DISEASE-POLICY LIMIT $
EL DISEASE-EACH EMPLOYEE $
,03/13/08
I
03/13/09
1$1,000,000 Limit
$25,000 Deductible
I
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
The City of Ashland, Oregon, and its elected officials, officers and employees are included as Additional Insureds regarding Third Party Administrator services
contract.
City of Ashland
20 East Main Street
Ashland, OR 97520
SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF
THE INSURER AFFORDING COVERAGE WlLL ENDEAVOR TO MAIL -30 DAYS WRITTEN NOTICE TO THE
CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE, ITS AGENTS OR REPRESENTATIVES. OR THE
ISSUER OF THIS CERTIFICATE.
AUTHORIZED REPRESENTATIVE
Marsh USA Inc.
BY: Lorie Larsen-Denning
i(~~.~~
VALID AS OF:03/25/08
MAR, 25. 2008 9: 46AM
SA! F PORTLAND
NO. 6253 P. 1
OREGON WORKERS' COMPENSATION
CERTIFICATE OF INSURANCE
.!!,;!
MAIL TO:
CERTIFICATE HOLDER:
HEALTH FUTURE lLC
777 MURPHY ROAD
MEDFORD, OR 97504
CITY OF ASHLAND
90 N MOUNT AVE.
ASHLAND, OR 97520
The policy of insurance listed below has been Issued to the insured named below for the policy period indicated. The
insurance afforded by the policy described herein Is subject to all the terms, exclusions and conditions of such policy.
POLICY NO.
901471
POUCY PERIOD
10/01/2007 TO 10/01/2008
ISSUE DATE
03/25/2008
INSURED:
HEALTH FUTURE LLC
777 MURPHY ROAD
MEDFORD, OR 97504
BROKER OF REcORD:
ASHLAND INS (ASHLAND)
PO BOX 880
ASHLAND, OR 97520
LIMITS OF LIABILITY:
Bodily Injury by Accident $500,OOOeach accident
Bodily Injury by Disease $500,OOOeach employee
Bodily Injury by Disease $500,OOOpolicy limit
DESCRIPTION OF OPERAnONS/LOCATIONS/SPECIAL IT!MS:
ALL OPERATIONS
IMPORTANT:
The coverage described above is j n effect as of the issue date of this certificate. It is subject to change at any time in the
future.
....'.. '
ThiS certificate is issued as a matter of information only and confers no rights to the certificate holder. This
certificate does not amend, extend or alter the coverage afforded by the policies above.
CANC~LLATJON:
SHOULD ANY O~ THE ABOVE DESCRIBED POUCIES BE CANCELED BEFORE THE EXPIRATION DATE THEREOF,
THE ISSUING COMPANY WILL MAIL 30 DAYS' WRITTEN NOTICE TO THE ABOVE NAMED CERTIFICATE HOLDER.
AUTHORIZED REPRESENTATIVE
~r---
tJ S^IF CORPORATION I 400 High St SE I Salem, OR 97312 I P: 800.285.8525 I www.saif.com
r6'
CITY RECORDER
CITY OF
ASHLAND
20 E MAIN ST.
ASHLAND, OR 97520
(541) 488-5300
Page 1 / 1
DATE
4/4/2008
PO NUMBER
08203
VENDOR: 013125
HEALTH FUTURE LLC
777 MURPHY ROAD
MEDFORD, OR 97504
SHIP TO: City of Ashland
(541) 488-6002
20 E MAIN STREET
ASHLAND, OR 97520
FOB Point:
Terms: Net
Req. Del. Date:
Speciallnst:
Req. No.:
Dept.: ADMINISTRATIVE SERVICES
Contact: Lee TuneberQ, Tina Gray
Confirming? No
Quantity Unit Description Unit Price Ext. Price
Third Party Administrative Services for 7,000.00
Workers' Compensation, Per attached fee
schedule
Estimate for balance of current fiscal
year
Approximately $4,000 for claims
handlinQ, plus $3,000 for the cost of
conversion
Contract for TPA Services
BeQinninQ date: April 1, 2008
Completion date: March 31,2011
Insurance required/On file
SUBTOTAL 7 000.00
BILL TO: Account Payable TAX 0.00
20 EAST MAIN ST FREIGHT 0.00
541-552-2028 TOTAL 7,000.00
ASHLAND, OR 97520
ACC()untNumber Project Number Amount Account Number ProjectNumber Amount
E 720.03.00.00.60416( 7.000.00
-7/7 -
/A< ~edSian~ r
VENDOR COPY