HomeMy WebLinkAboutC16-242 Colorado Mountain College Go2WorkshopsAGREEMENT FOR PROFES SIONAL SERVICES
BETWEEN EAGLE COIINTY. COLORADO
AND
COLORADO MOUNTAIN LOCAL COLLEGE DISTRICT
'n
THIS AGREEMENT ("Agreement") is executed this L'l- day of Jv^t6 ,20l6and is effective
as of the I st day of July, 2016 by and between Colorado Mountain Local College District (hereinafter
"Consultant" or "Contractor") and Eagle County, Colorado, a body corporate and politic (hereinafter
"County").
RECITALS
WHEREAS, the County, through its Department of Human Services ("DHS") works to promote the
health, safety and welfare of County residents of all ages; and
WHEREAS, the County uses outside providers and professionals to enhance the ability of the County to
promote such health, safety and welfare; and
WHEREAS, County desires to hire the Consultant to conduct Go2Work workshops and to perform the
Services defined below in paragraph 1; and
WHEREAS, Consultant is authorized to do business in the State of Colorado and has the time, skill,
expertise, and experience necessary to provide the Services; and
WHEREAS, this Agreement shall govem the relationship between Consultant and County in connection
with the Services.
AGREEMENT
NOW, THEREFORE, in consideration of the foregoing and the following promises Consultant and
County agree as follows:
1. Services. Consultant agrees to diligently provide all services, labor, personnel and materials
necessary to perform and complete the services described in Exhibit A ("Services") which is attached
hereto and incorporated herein by reference. The Services shall be performed in accordance with the
provisions and conditions of this Agreement.
a. Consultant agrees to furnish the Services in accordance with the schedule established in
Exhibit A. If no completion date is specified in Exhibit A, then Consultant agrees to furnish the Services
in a timely and expeditious manner consistent with the applicable standard of care. By signing below
Consultant represents that it has the expertise and personnel necessary to properly and timely perform the
Services.
Eagl,a Cornty Ealtmlssioners' OfficeC16-242
b. In the event of any conflict or inconsistency between the terms and conditions set forth in
Exhibit A and the terms and conditions set forth in this Agreement, the terms and conditions set forth in
this Agreement shall prevail.
c. Consultant agrees that it will not enter into any consulting or other arrangements with
third parties that will conflict in any manner with the Services.
2. County's Representative. The Department of Human Services designee shall be Consultant's
contact with respect to this Agreement and performance of the Services.
3. Term of the Agreement. This Agreement shall commence upon the date first written above, and
subject to the provisions of paragraph 11 hereof, shall continue in full force and effect through the 30th
day ofJune,2017.
4. Extension or Modification. This Agreement may not be amended or supplemented, nor may any
obligations hereunder be waived, except by agreement signed by both parties. No additional services or
work performed by Consultant shall be the basis for additional compensation unless and until Consultant
has obtained written authorization and acknowledgement by County for such additional services in
accordance with County's internal policies. Accordingly, no course of conduct or dealings between the
parties, nor verbal change orders, express or implied acceptance ofalterations or additions to the Services,
and no claim that County has been unjustly enriched by any additional services, whether or not there is in
fact any such unjust enrichment, shall be the basis of any increase in the compensation payable hereunder.
In the event that written authorization and acknowledgment by County for such additional services is not
timely executed and issued in strict accordance with this Agreement, Consultant's rights with respect to
such additional services shall be deemed waived and such failure shall result in non-payment for such
additional services or work performed.
5. Compensation. County shall compensate Consultant for the performance of the Services in a sum
computed and payable as set forth in Exhibit A. The performance of the Services under this Agreement
shall not exceed $3.640. Consultant shall not be entitled to bill at overtime and/or double time rates for
work done outside of normal business hours unless specifically authorized in writing by County.
a. For reimbursement Consultant must submit invoices monthly. Invoices shall include a
description of Services performed. If County is not satisfied with the completeness of a submitted
invoice, County may request Consultant to either revise the invoice or provide additional information.
Payment will be made for Services satisfactorily performed within thirty (30) days of receipt of a proper
and accurate invoice. All invoices shall include detail regarding the hours spent, tasks performed, who
performed each task and such other detail as County may request.
All invoices must be mailed, delivered in-person, or via e-mail to the following address to ensure
proper payment.
Eagle County Department of Human Services
550 Broadwav
2
Eagle County HHS ProfServ Final 5/14
Post Office Box 660
Eagle, CO 81631
DHS Communications@eaglecounty. us
b. Any out-of-pocket expenses to be incurred by Consultant and reimbursed by County shall
be identified on Exhibit A. Out-of-pocket expenses will be reimbursed without any additional mark-up
thereon and are included in the not to exceed contract amount set forth above. Out-of-pocket expenses
shall not include any payment of salaries, bonuses or other compensation to personnel of Consultant.
Consultant shall not be reimbursed for expenses that are not set forth on Exhibit A unless specifically
approved in writing by County.
c. If, prior to payment of compensation or reimbursement for Services but after submission
to County of a request therefore by Consultant, County reasonably determines that payment as requested
would be improper because the Services were not performed as prescribed by the provisions of this
Agreement, the County shall have no obligation to make such payment. If, at any time after or during the
term or after termination or expiration of this Agreement, County reasonably determines that any payment
theretofore paid by County to Consultant was improper because the Services for which payment was
made were not performed as set forth in this Agreement, then upon written notice of such determination
and request for reimbursement from County, Consultant shall forthwith return such payment(s) to County.
Upon termination or expiration of this Agreement, unexpended funds advanced by County, if any, shall
forthwith be retumed to Countv.
d. All funds received by Consultant under this Agreement shall be or have been expended
solely for the purpose for which granted, and any funds not so expended, including funds lost or diverted
for other pulposes, shall be returned to County. Consultant shall provide the County with progress
reports upon County's request; or Consultant shall fumish progress reports as more specifically set forth
in the attached Exhibit A.
e. County will not withhold any taxes from monies paid to the Consultant hereunder and
Consultant agrees to be solely responsible for the accurate reporting and payment of any taxes related to
payments made pursuant to the terms of this Agreement.
f. Notwithstanding anything to the contrary contained in this Agreement, County shall have
no obligations under this Agreement after, nor shall any payments be made to Consultant in respect of any
period after December 31 of any year, without an appropriation therefor by County in accordance with a
budget adopted by the Board of County Commissioners in compliance with Article 25, title 30 of the
Colorado Revised Statutes, the Local Government Budget Law (C.R.S .29-I-l0l et. seq.) and the
TABOR Amendment (Colorado Constitution, Article X, Sec. 20).
6. Sub-consultants. Consultant acknowledges that County has entered into this Agreement in
reliance upon the particular reputation and expertise of Consultant. Consultant shall not enter into any
sub-consultant agreements for the performance of any of the Services or additional services without
County's prior written consent, which may be withheld in County's sole discretion. County shall have
the right in its reasonable discretion to approve all personnel assigned to the subject project during the
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Eagle County HHS Prof Serv Final 5/14
performance of this Agreement and no personnel to whom County has an objection, in its reasonable
discretion, shall be assigned to the project. Consultant shall require each sub-consultant, as approved by
County and to the extent of the Services to be performed by the sub-consultant, to be bound to Consultant
by the terms of this Agreement, and to assume toward Consultant all the obligations and responsibilities
which Consultant, by this Agreement, assumes toward County. County shall have the right (but not the
obligation) to enforce the provisions of this Agreement against any sub-consultant hired by Consultant
and Consultant shall cooperate in such process. The Consultant shall be responsible for the acts and
omissions of its agents, employees and sub-consultants or sub-contractors.
7. Insurance. Consultant agrees to provide and maintain at Consultant's sole cost and expense, the
following insurance coverage with limits of liability not less than those stated below:
a. Types oflnsurance.
Workers' Compensation insurance as required by law.
ll. Auto coverage with limits of liability not less than $1,000,000 each accident
combined bodily injury and property damage liability insurance, including coverage for owned, hired, and
non-owned vehicles.
iii. Commercial General Liability coverage to include premises and operations,
personaVadvertising injury, products/completed operations, broad form property damage with limits of
liability not less than $1,000,000 per occurrence and $2,000,000 aggregate limits.
lv.Intentionally Omitted.
b. Other Requirements.
i. The automobile and commercial general liability coverage shall be endorsed to
include Eagle County, its associated or affiliated entities, its successors and assigns, elected officials,
employees, agents and volunteers as additional insureds.
ii. Consultant's certificates of insurance shall include sub-consultants as additional
insureds under its policies or Consultant shall furnish to County separate certificates and endorsements for
each sub-consultant. All coverage(s) for sub-consultants shall be subject to the same minimum
requirements identified above. Consultant and sub-consultants, if any, shall maintain the foregoing
coverage in effect until the Services are completed. In addition, all such policies shall be kept in force by
Consultant and its sub-consultants until the applicable statute of limitations for the Services has expired.
iii. Insurance shall be placed with insurers duly licensed or authorized to do business
in the State of Colorado and with an "A.M. Best" ratins of not less than A-VIL
4
Eagle County HHS ProfServ Final 5/14
lv. Consultant's insurance coverage shall be primary and non-contributory with
respect to all other available sources. Consultant's policy shall contain a waiver of subrogation against
Eagle County.
v. All policies must contain an endorsement affording an unqualified thirty (30)
days notice of cancellation to County in the event of cancellation of coverage.
vi. All insurers must be licensed or approved to do business within the State of
Colorado and all policies must be written on a per occurence basis unless otherwise provided herein.
vii. Consultant's certificate of insurance evidencing all required coverage(s) is
attached hereto as Exhibit B. Upon request, Consultant shall provide a copy of the actual insurance
policy and/or required endorsements required under this Agreement within five (5) business days of a
written request from County, and hereby authorizes Consultant's broker, without further notice and
authorization by Consultant, to immediately comply with any written request of County for a complete
copy of the policy.
vlrl.
termination hereof.
The insurance provisions of this Agreement shall survive expiration or
. lx. The parties hereto understand and agree that the County is relying on, and does
not waive or intend to waive by any provision of this Agreement, the monetary limitations or rights,
immunities and protections provided by the Colorado Governmental Immunity Act, as from time to time
amended, or otherwise available to County, its affiliated entities, successors or assigns, its elected
officials, employees, agents and volunteers.
x. Consultant is not entitled to workers' compensation benefits except as
provided by the Consultant, nor to unemployment insurance benefits unless unemployment compensation
coverage is provided by Consultant or some other entity. The Consultant is obligated to pay all federal
and state income tax on any moneys paid pursuant to this Agreement.
8. Intentionally Omitted.
9. Ownership of Documents. All documents prepared by Consultant in connection with the Services
shall become property of County. Consultant shall execute written assignments to County of all rights
(including coflrmon law, statutory, and other rights, including copyrights) to the same as County shall
from time to time request. For purposes of this paragraph, the term "documents" shall mean and include
all reports, plans, studies, tape or other electronic recordings, drawings, sketches, estimates, data sheets,
maps and work sheets produced, or prepared by or for Consultant (including any employee or
subcontractor in connection with the performance of the Services and additional services under this
Agreement).
10. Notice. Any notice required by this Agreement shall be deemed properly delivered when (i)
personally delivered, or (ii) when mailed in the United States mail, first class postage prepaid, or (iii)
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Eagle County HHS Prof Serv Final 5/14
when delivered by FedEx or other comparable courier service, charges prepaid, to the parties at their
respective addresses listed below, or (iv) when sent via facsimile so long as the sendingparty can provide
facsimile machine or other confirmation showing the date, time and receiving facsimile number for the
transmission, or (v) when transmitted via e-mail with confirmation of receipt. Either party may change its
address for purposes of this paragraph by giving five (5) days prior written notice of such change to the
other party.
COUNTY:
Eagle County, Colorado
Attention: Megan Burch
500 Broadway
Post Office Box 850
Eagle, CO 8163 I
Telephone: 970-328-88 I 5
Facsimile: 1-855-846-075 1
E-Mail: DHSCommunications@eaglecounty.us
With a copy to:
Eagle County Attorney
500 Broadway
Post Office Box 850
Eagle, Co 81631
Telephone: 97 0-328-8685
Facsimile: 97 0-328-8699
E-Mail : atty @eaglecounty.us
CONSULTANT:
Colorado Mountain LOCAL Colleee District
Attn: Steve Boyd
801 Grand Avenue
Glenwood Springs, CO 81601
Telephone: 97 0 -9 47 -8402
1 l. Termination. County may terminate this Agreement, in whole or in part, at any time and for any
reason, with or without cause, and without penalty therefor with seven (7) calendar days' prior written
notice to the Consultant. Upon termination of this Agreement, Consultant shall immediately provide
County with all documents as defined in paragraph t hereof, in such format as County shall direct and
shall return all County owned materials and documents. County shall pay Consultant for Services
satisfactorily performed to the date of termination.
12. Venue. Jurisdiction and Applicable Law. Any and all claims, disputes or controversies related to
this Agreement, or breach thereof, shall be litigated in the District Court for Eagle County, Colorado,
which shall be the sole and exclusive forum for such litigation. This Agreement shall be construed and
interpreted under and shall be governed by the laws of the State of Colorado.
6
Eagle County HHS Prof Serv Final5ll4
13. Execution by Counterparts: Electronic Signatures. This Agreement may be executed in two or
more counterparts, each of which shall be deemed an original, but all of which shall constitute one and the
same instrument. The parties approve the use of electronic signatures for execution of this Agreement.
Only the following two forms of electronic signatures shall be permitted to bind the parties to this
Agreement: (i) Electronic or facsimile delivery of a fully executed copy of the signature page; (ii) the
image of the signature of an authorized signer inserted onto PDF format documents. All documents must
be properly notarized, if applicable. All use of electronic signatures shall be governed by the Uniform
Electronic Transactions Act, C.R.S .24-71.3-l0l to l2l.
t4.Other Contract Requirements.
a. In rendering the Services hereunder, Consultant shall comply with the highest standards
of customer service to the public. Consultant shall provide appropriate supervision of its employees to
ensure the maintenance of these high standards of customer service and professionalism are maintained.
The performance of such obligation shall be determined at the sole discretion of County. In the event
County finds these standards of customer service are not being met by Consultant, County may terminate
this Agreement, in whole or in part, upon seven (7) days' notice to Consultant.
b. Consultant shall be responsible for the completeness and accuracy of the Services,
including all supporting data or other documents prepared or compiled in performance of the Services,
and shall correct, at its sole expense, all significant errors and omissions therein. The fact that the County
has accepted or approved the Services shall not relieve Consultant ofany ofits responsibilities.
Consultant shall perform the Services in a skillful, professional and competent manner and in accordance
with the standard of care, skill and diligence applicable to Consultants performing similar services. This
paragraph shall survive termination of this Agreement.
c. Consultant represents and warrants that it has the expertise and personnel necessary to
properly perform the Services and covenants that its professional personnel are duly licensed to perform
the Services within Colorado.
d. Consultant agrees to work in an expeditious manner, within the sound exercise of its
judgment and professional standards, in the performance of this Agreement. Time is of the essence with
respect to this Agreement.
e. This Agreement constitutes an agreement for performance of the Services by Consultant
as an independent contractor and not as an employee of County. Nothing contained in this Agreement
shall be deemed to create a relationship of employer-employee, master-servant, partnership, joint venture
or any other relationship between County and Consultant except that of independent contractor.
Consultant shall have no authority to bind County.
f. Consultant represents and warrants that at all times in the performance of the Services,
Consultant shall comply with any and all applicable federal and state laws, codes, rules and regulations.
7
Eagle County HHS ProfServ Final 5/14
g. Consultant shall comply with the Civil Rights Act of 1964 and Section 504,
Rehabilitation Act of 1973, concerning discrimination on the basis of race, color, sex, age, religion,
political beliefs, national origin or handicap.
h. This Agreement contains the entire agreement between the parties with respect to the
subject matter hereof and supersedes all other agreements or understanding between the parties with
respect thereto.
i. Consultant shall not assign any portion of this Agreement without the prior written
consent of the County. Any attempt to assign this Agreement without such consent shall be void.
j This Agreement shall be binding upon and shall inure to the benefit of the parties hereto
and their respective permitted assigns and successors in interest. Enforcement of this Agreement and all
rights and obligations hereunder are reserved solely for the parties, and not to any thiid party.
k. No failure or delay by either party in the exercise of any right hereunder shall constitute a
waiver thereof. No waiver of any breach shall be deemed a waiver of any preceding or succeeding
breach.
l. The invalidity, illegality or unenforceability of any provision of this Agreement shall not
affect the validity or enforceability of any other provision hereof.
m. Consultant shall maintain for a minimum of three years, adequate financial and other
records for reporting to County. Consultant shall be subject to financial audit by federal, state or county
auditors or their designees. Consultant authorizes such audits and inspections of records during normal
business hours, upon 48 hours' notice to Consultant. Consultant shall fully cooperate during such audit or
inspections.
n. The signatories to this Agreement aver to their knowledge, no employee of the County
has any personal or beneficial interest whatsoever in the Services or Property described in this
Agreement. The Consultant has no beneficial interest, direct or indirect, that would conflict in any manner
or degree with the performance of the Services and Consultant shall not employ any person having such
known interests.
o. The Consultant, if a natural person eighteen (18) years of age or older, hereby swears and
affirms under penalty of perjury that he or she (i) is a citizen or otherwise lawfully present in the United
States pursuant to federal law, (ii) to the extent applicable shall comply with C.R.S. 24-76.5-103 prior to
the effective date of this Asreement.
15. Prohibitions on Government Contracts.
As used in this Section 15, the term undocumented individual will refer to those individuals from foreign
countries not legally within the United States as set forth in C.R.S. 8-17.5-101, et. seq. If Consultant has
any employees or subcontractors, Consultant shall comply with C.R.S. 8-17.5-101, et. seq., and this
Agreement. By execution of this Agreement, Consultant certifies that it does not knowingly employ or
8
Eagle County HHS Prof Serv Final 5/14
contract with an undocumented individual who will perform under this Agreement and that Consultant
will participate in the E-verify Program or other Department of Labor and Employment program
("Department Program") in order to confirm the eligibility of all employees who are newly hired for
employment to perform Services under this Agreement.
a. Consultant shall not:
Knowingly employ or contract with an undocumented individual to perform
Services under this Agreement; or
ii. Enter into a subcontract that fails to certify to Consultant that the subcontractor
shall not knowingly employ or contract with an undocumented individual to perform work under the
public contract for services.
b. Consultant has confirmed the employment eligibility of all employees who are newly
hired for employment to perform Services under this Agreement through participation in the E-Verify
Program or Department Program, as administered by the United States Department of Homeland
Security. Information on applying for the E-verify program can be found at:
http://www.dhs.eov/xprevprot/proerams/sc_l 1 8522 I 678 1 50.shtm
c. Consultant shall not use either the E-verify program or other Department Program
procedures to undertake pre-employment screening ofjob applicants while the public contract for services
is being performed.
d. If Consultant obtains actual knowledge that a subcontractor performing work under the
public contract for services knowingly employs or contracts with an undocumented individual, Consultant
shall be required to:
i. Notify the subcontractor and County within three (3) days that Consultant has
actual knowledge that the subcontractor is employing or contracting with an undocumented individual;
and
ii. Terminate the subcontract with the subcontractor if within three days of receiving
the notice required pursuant to subparagraph (i) of the paragraph (d) the subcontractor does not stop
employing or contracting with the undocumented individual; except that Consultant shall not terminate
the contract with the subcontractor if during such three (3) days the subcontractor provides information to
establish that the subcontractor has not knowingly employed or contracted with an undocumented
individual.
e. Consultant shall comply with any reasonable request by the Department of Labor and
Employment made in the course of an investigation that the department is undertaking pursuant to its
authority established in C.R.S. 8-17 .5 -102(5).
9
Eagle County HHS Prof Serv Final 5/14
f. If Consultant violates these prohibitions, County may terminate the Agreement for breach
of contract. If the Agreement is so terminated specifically for breach of this provision of this Agreement,
Consultant shall be liable for actual and consequential damages to County as required by law.
g. County will notify the Colorado Secretary of State if Consultant violates this provision
of this Agreement and County terminates the Agreement for such breach.
IN WITNESS WHEREOF, the parties have executed this Agreement the day and year first set forth
above.
COUNTY OF EAGLE, STATE OF COLORADO,
By and Through Its COIINTY MANAGER
By:
CONSULTANT:
COLORADO MOUNTAIN COLLEGE LOCAL
COLLEGE DISTRICT
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Ftrr. >teve b oycl ::x&:*,?[:i.11]:i1".:;11,:xt:.*.Dl. t
Print Name:
Title: Purchasins & Contracts Manaser
10
Eagle County HHS Prof Serv Final5/14
Brent McFall.
EXHIBIT A
SCOPE OF SERVICES, PAYMENT & FEE SCHEDULE
Description of Services:
From July 7,20L6 to June 30,2017, Colorado Mountain College will provide Go2Work workshops
delivered at the Eagle County Building in Eagle, CO.
Workshops will be provided to Temporary Aid to Needy Families (TANF)-eligible individuals (see
eligibility requirements listed below). Colorado Mountain College must require Workshop participants
to complete and sign Exhibit "C" incorporated herein by this reference which includes:
1. Affirmation of lawful presence,
2. Declaration of annual household income of below 575,000, and
3. Declaration of being the caretaker for a child.
Contractor should explain to participants that they may be eligible for food assistance, Medicaid or
other potential benefits and refer them to the Eagle County Department of Human Services for more
information on application for benefits.
These workshops will include some or all of the following services based on individual needs of
workshop participants as assessed by TANF case worker and Workshop facilitator:
The Workshop will be instructor-led with the opportunity for participants to "work ahead" with self-
guided resources while the instructor provides individual assistance where needed. Workshops last
approximately two hours and consist of a structured skills progression based on participants' initial skills
and abilities as outlined by progression flow chart (attached). Workshop participants are provided with
the tools they need to access all the resources covered during the workshop on their own. Participants
will be given USB flash drives to save their work completed during the workshop: drafted resumes, skills
assessment certifications, completed applications, contacts and resources, etc.
t7
Eagle County HHS Prof Serv Final 5/14
Purpose and Expected Outcomes:
The Go2Workshops are intended to provide participants with support and tools to aid job readiness and
job search skills. The workshop facilitator will administer a pre-survey and post-survey to workshop
participants to assess expectations and results of training. Contractor will follow up with workshop
participants within six months of participation to survey workshop impacts by capturing changes in
participants' rating of themselves on job search skills, job retention skills, self-confldence, etc. The
survey results will be provided to the County to be analyzed and used to structure ongoing workshop
content.
Pavment and Fee Schedule:
The total cost of the program in Eagle County is:
Instructor Salaries 24 workshops x 2 hours (including set up) x 540/hr
lnstructor Fringe 22.O%
( PERA, Workman's Comp, Medicare, U nemployment)
Instructor Mileage: 24 trips x 62 miles x 50.57
Marketing including information cards and posters
Supplies-USB flash drives 25 x 58.00
Resume Paper
TOTAL:
s1e20
5 422
S s+s
s 2oo
s 2oo
5so
$3,6a0
It is anticipated that approximately 25 individuals will participate in the Workshops and that 100% will
be TANF-eligible.
The maximum amount of reimbursement under this contract shall not exceed 53,540
!2
Eagle County HHS Prof Serv Final 5/14
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EXHIBIT B
Insurance Certificate
See Attached
13
Eagle County HHS Prof Serv Final 5/14
--,5rt>pffAC(}fit CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY)
03/28/20L6
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
GERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE GOVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTTTUTE A CONTRACT BETWEEN THE ISSU|NG INSURER(S), AUTHORTZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
lMPoRTANT:|fthecertificateholderisanADD|T|oNAL|NsURED,thepo|icy(ies)mustb
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rightsto the
certificate holder in lieu of such endorsement(s).
PRoDUCER 1-303-534-4567
IMA, Inc, - Colorado Division
1705 17th Street
Suite 100
Denver, CO 8O2O2
UUN IAU I
NAME:
PHONE , FAX(A/C- No- Extl: I larc Ndl.
iilffiL5"", denaccounttechsGimacorp.com
INSURER(SI AFFORDING COVERAGE NAIC #
;N5URERA: CITIZENS INS CO OF AI{ER(Hanover Ins Co)31534
INSURED
Colorado Mountain Colleae
802 Grand Avenue
Glenwood Sprinqs, CO 81601
;N5URERB. ALLMERICA FIN BENEFIT fNS CO(Ilanove! In 41840
tNsURERc. IIANOVER INS CO 22292
;N5URERD. PINNACOL ASSUR 41190
INSURER E :
INSURER F :
COVERAGES CERT|FICATE NUMBER: 464L1 6s4 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSUMNCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. 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.
NSR
LTR TYPE OF INSURANCE lNsn WN POLICY NUMBER
POLICY EFF(MM/DD/YYYY}POLICY EXP(MM/DDTYYYYI LIMITS
A x
l $mencnl e ENERAL LlABlLlrY
cLAIMS-MADElx]occuR
LB4989526004 04/oL/L6 04/ot/L1 EACH OCCURRENCE s 1,000,000
UAMAUE IU KtsNIEU
PRFMISFS lFa decrrrrr s 1,000,000
MED EXP (Any one person)g 15,000
PERSONAL & ADV INJURY 1,000,000
GEI i,L AGGREGATE LIMIT APPLIES PER:
I
-^-^I eolrcv L l 55""t lx I roc
GENERAL AGGREGATE 6 2,000,000
PRODUCTS - COMP/OP AGG $ INCLUDED
B AU'.OMOBILE LI,ABILITY
ANY AUTO
ALLOWNED f__l SCHeOUrroAUTOS I I AUTOS[J ruon-owrueoHIREDAUTOS | ^ AUT6Sn
AW4 98 9525803 04/ot/L6 o4/01/17 COMBINED SINGLE LIIVIT(Ea accidentl $ 1,000,000
x BODILY INJURY (Per person)$
BODILY INJURY (Per accident)
x PROPERTY DAMAGE(Per accidenl)
$
c x UMBRELLA LIAB
EXCESS LIAB
x I occuR_.l
"ro,r.-"oo,
un4 989525903 o4/oL/16 o4/oL/L1 EACH OCCURRENCE s 10,000,000
g 10,000,000
oeo lX lnprpnrroruso
D WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETORYPARTNER/EXECUTIVE
OFFICERYMEI\4BER EXCLUDED?
(Mandatory in NH)
lf yes, describe under
DESCRIPTION OF OPEMTIONS below
tr N/A
4 0454 03 01 /0L/t5 01 /ot/L6 Xl[Ff;,,,,, I lSJn-
E,L. EACH ACCIDENT g 1,000,000
E.L. DISEASE - EA EMPLOYEI $ 1,000,000
E.L. DISEASE. POLICY LIMIT s 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 1 01, Additional Remarks Schedule, may be attached if more space ts required)
Eagle County, Colorado its associated or affiliated entities, its successols and assigns, elected officials, employees,agents and volunteels aare included as Additional Insureds on the General, Automobile, and Urnbrella Liability policies
if requi:red by written contract or agreement subject to the policy terms and conditions. This Insurance is primary and
Non-Contlibutory on the GeneraL Liability Policy subject to the policy terms and conditions. A Waive:r of Subrogation isprovided in favor of Additional Insureds on the General, Automobile, Umbrella Liability and tforkets CompensationPolicies if required by t',litten cotrtract or agreement subject to the policy terms and conditions.
Eagle County, Colorado
!4egan Burch
500 Broadway, PO Box 850
Eagle, CO 81631-0000
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
/fuA EXHIBIT
t\rtr<IJ
ACORD 25 (2014t01)
ashmcclain
@ 1988-2014 ACORD
registered marks of ACORDThe ACORD name and logo are
EXHIBIT C
SELF-DECLARATION FORM
t4
Eagle County HHS ProfServ Final 5/14
t,
SELF-DECLARATION FORM
My household's income is less than S75,000/year.
I am a caretaker for a child.
AFFIDAVIT OF LAWFUL PRESENCE (to comply with HB 1023)
swear or affirm under the penalty of perjury under the laws of the State of
Colorado that (check one):
I am a United States Citizen
I am a Permanent Resident of the United States, or
I am lawfully present in the United States pursuant to Federal law.
I understand that this sworn statement is required by law because I have applied for a public benefit. I
understand that state law requires me to provide proof that lam lawfully present in the United States priorto
receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or
representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the
second degree under Colorado Revised Statute 5 18-8-503 and it shall constitute a separate criminal offense
each time a public benefit is fraudulently received.
Signature Date
I NTERAGENCY RELEASE FORM
Interagency consent to release confidential information:
Name:Date of Birth:
Social Security #:
I hereby initialfor authorization the following agencies to release & exchange information:
_Colorado Workforce Center
-Department
of Human Services
_Mental Health Agency
Other
_Department of Vocational Rehabilitation
_Probati on/ P arole / Juven ile Division
_Com m un ity Corrections
Consent:
This outhorization is voluntary ond remoins in effect (up to one yeor), unless specificolly revoked by written notice to the agency or
person. A photocopy of this releose is os effective as the originol. By signing this release, I understand and approve the informotion
requested will be provided to eqch qgency checked.
Signature Date
**This information has been disclosed to you from records whose confidentiality is protected by the Federal Law. Federal Regulations (34-CFR Part 361) prohibit you
from making any further disclosure of this information without the specified written consent of the person to whom it pertains, or as otherwise permitted by such
regulations. A general authorization for release of information is NOT sufficient for this purpose.
EXHte|T!c06/rs
