HomeMy WebLinkAboutC17-221 Mary EzequelleAGREEMENT FOR PROFESSIONAL SERVICES
BETWEEN EAGLE COUNTY, COLORADO
AND
MARY EZEQUELLE, LCSW, PC
THIS AGREEMENT ("Agreement") is effective as of the 3e day of May, 2017 by and between Mary
Ezequelle, LCSW, P.C., (hereinafter "Consultant" or "Contractor") and Eagle County, Colorado, a body
corporate and politic (hereinafter "County").
RECITALS
WHEREAS, the County, through its Department of Health and Human Services ("HHS") 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 County to
promote such health, safety and welfare; and
WHEREAS, County desires to hire the Consultant 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 govern 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. The Services shall be delivered at designated offices,
clients' homes and other locations approved by the County's Representative.
a. Subject to the provisions of paragraph 11 hereof, Consultant agrees to furnish the
Services through May 31, 2019 and 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.
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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.
d. Consultant shall protect the confidentiality of all records and other materials containing
personally identifying information that are maintained in accordance with this Agreement pursuant to
applicable state and federal law and regulations. Except as provided by law, no information about any
individual in the possession of the Consultant shall be disclosed in any form. Client specific reports are
subject to the confidentiality provisions of Section 19-1-101, et seq. and 26-1-101, et seq., C.R.S. , as
amended; the federal Health Insurance Portability and Accountability Act of 1996; 42 U.S.C. Section 290
dd-2 regarding the confidentiality of alcohol and drug abuse patient records; and other applicable federal
and state law and regulation.
2. County's Representative. The Human Service Department's 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 31st
day of May, 2019.
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 of alterations 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. For the satisfactory performance of the Services, the Consultant shall be paid on
a fee-for-service basis in accordance with Exhibit A. The performance of the Services under this
Agreement shall not exceed $10,000 annually. Contractor 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. Contractor shall not charge or collect fees from clients for the Services provided hereunder.
a. Method of Compensation. Contractor shall be compensated for Services satisfactorily
performed in accordance with the statewide "Trails Users Fiscal Calendar" and by means of the Trails
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provider payroll system. Consultant shall submit an invoice to the County by the tenth (10) day of the
month for Services performed in the preceding month. Upon receipt of the invoice, the County will input
the Consultant's invoice into the Trails system Payment will be made by the State of Colorado through
the Trails provider payroll system. 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. 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 emailed to the following address to ensure proper payment:
dh s acetpay able @ eaglec ou my . u s
b. Billing Cut-off Date. Consultant shall not be reimbursed for billing received by the
County two (2) months or more after the date of Service.
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.
d. If, prior to payment of compensation or reimbursement for Services but after submission
to County of a request therefore by Contractor, 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 request payment through the Trails provider payroll
system. 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 to Contractor 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 for payment to the State of Colorado. Upon termination or
expiration of this Agreement, unexpended funds advanced by County, if any, shall forthwith be returned
to County.
d. All funds received by Contractor 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 purposes, shall be returned to the State of Colorado.
e. Contractor shall provide the County with progress reports as more specifically set forth in
the attached Exhibit A.
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.
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g. 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. 29-1-101 et. seq.) and the
TABOR Amendment (Colorado Constitution, Article X, Sec. 20).
b. 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
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 Contractor 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 of Insurance.
i. Workers' Compensation insurance as required by law.
ii. 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,
personal/advertising injury, productslcompleted operations, broad form property damage with limits of
liability not less than $1,000,000 per occurrence and $2,000,000 aggregate limits. This policy shall be
endorsed to include coverage for physical/sexual abuse and molestation.
iv. Professional liability insurance with prior acts coverage for all Services required
hereunder, in a form and with an insurer or insurers satisfactory to County, with limits of liability of not
less than $1,000,000 per claim and $2,000,000 in the aggregate. In the event the professional liability
insurance is on a claims -made basis, Consultant warrants that any retroactive date under the policy shall
precede the effective date of this Agreement. Continuous coverage will be maintained during any
applicable statute of limitations for the Services.
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V. Third party fidelity/crime coverage including coverage for theft and mysterious
disappearance. The policy shall include coverage for all directors, officers, agents and employees of the
Consultant. The policy shall name Eagle County and Eagle County's clients as loss payee as their
interests may appear. The policy shall not contain a condition requiring an arrest or conviction. Policies
shall be endorsed to provide coverage for computer crime/fraud.
b. Other Requirements.
L The automobile and commercial general liability coverage and such other
coverage as indicated above 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" rating of not less than A -VII.
iv. 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 occurrence 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.
viii. Consultant shall advise County in the event the general aggregate or other
aggregate limits are reduced below the required per occurrence limit. Consultant, at its own expense, will
reinstate the aggregate limits to comply with the minimum limits and shall furnish County a new
certificate of insurance showing such coverage.
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ix. If Consultant fails to secure and maintain the insurance required by this
Agreement and provide satisfactory evidence thereof to County, County shall be entitled to immediately
terminate this Agreement.
X. The insurance provisions of this Agreement shall survive expiration or
termination hereof.
xi. 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.
xii. 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.
S. Indemnification. The Consultant shall indemnify and hold harmless County, and any of its
officers, agents and employees against any losses, claims, damages or liabilities for which County may
become subject to insofar as any such losses, claims, damages or liabilities arise out of, directly or
indirectly, this Agreement, or are based upon any performance or nonperformance by Consultant or any
of its sub -consultants hereunder including claims for bodily injury or personal injury including death, or
loss or damage to tangible or intangible property; and Consultant shall reimburse County for reasonable
attorney fees and costs, legal and other expenses incurred by County in connection with investigating or
defending any such loss, claim, damage, liability or action. This indemnification shall not apply to claims
by third parties against the County to the extent that County is liable to such third party for such claims
without regard to the involvement of the Consultant. This paragraph shall survive expiration or
termination hereof.
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 common 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)
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 sending party can provide
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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: Kendra Kleinschmidt
551 Broadway
Post Office Box 660
Eagle, CO 81631
Telephone: 970-328-8827
Facsimile: 855-848-8826
E -Mail: Kendra.kleinschmidt@eaglecounty.us
With a copy to:
Eagle County Attorney
500 Broadway
Post Office Box 850
Eagle, Co 81631
Telephone: 970-328-8685
Facsimile: 970-328-8699
E -Mail: atty@eaglecounty.us
CONSULTANT:
Mary Ezequelle, LCSW, PC
PO Box 4066
Gypsum, CO 81637
970-948-2877
mary.eKNuette@centurylel.net
11. 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. County may also terminate this Agreement as set forth in paragraph 14 below.
Upon termination of this Agreement, Consultant shall immediately provide County with all documents as
defined in paragraph 9 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.
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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. 24-71.3-101 to 121.
14. Other Contract Requirements.
a. In rendering the Services hereunder, Contractor shall comply with the highest standards
of customer service to the public. Contractor 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 of any of its 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. Specifically, during the period of this Agreement, Consultant and its
professional personnel shall each be licensed as a professional counselor through the Colorado
Department of Regulatory Agencies ("DORA"), shall maintain such license in good standing and shall
adhere to all rules, standards, policies and laws applicable to such license, including, but not limited to,
any requirements for criminal background checks. Consultant shall immediately notify the County if any
state or local agency makes a substantiated finding of abuse, neglect or injurious environment against it or
any of its professional personnel during the period of this Agreement. In the event of a substantiated
finding as set forth herein, the County in its sole discretion may terminate this Agreement, in whole or in
part, upon seven (7) days' notice to Consultant.
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
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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.
g. Contractor 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 third 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.
1. 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 (1$) 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
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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 Agreement.
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
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:
i. Knowingly employ or contract with an undocumented individual to perform
Services under this Agreement; or
H. 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-
htlp://www.dhs. ovlxprevprot/programslgc _1185221678150.shtm
C. Consultant shall not use either the E -verify program or other Department Program
procedures to undertake pre-employment screening of job 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
H. 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
la
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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).
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 hrough,Its COUNTY MANAGER
Bryan Treu, Interim County Manager
CONSULTANT:
By:
Print Name: Mary B Ezequelle
Title: Owner
ii
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EXIMIT A
SCOPE OF SERVICES, PAYMENT & FEE SCHEDULE
Description of Services: Provide individual, family counseling and other therapeutic services for clients
(children, youth and families) of the Department of Human Services to prevent unnecessary placement of
children and youth in out -of --home care, support family preservation, and assist in family reunification.
Additional Provisions:
1. Assessments and Planning. Contractor shall provide the County with an assessment and plan
within thirty (30) days of enrollment or participation in services by a family or child. This plan shall
include the treatment plan for the child's family, including specific goals, objectives and target dates for
accomplishment. Such plan shall be subject to review and approval by County. Thereafter, at monthly
intervals, Contractor shall submit reports that include progress and barriers in achieving the goals and
provisions of the treatment plan via e-mail. Reimbursement for services relating to the plan is subject to
the timely receipt of written assessment, plan, and reports.
2. Eligibility. County is responsible for determining the eligibility of each individual family for
services under this agreement. County shall advise Contractor in writing of the authorized service plan
within three (3) working days of receipt of the certification and service plan. There shall be no payment
for services provided without prior authorization for such services by the County. Such authorization shall
include the level of services to be provided, the nature and type of services provided and the time frames
in which these services are to be provided.
3. Mandatory Repoing. Contractor shall notify the state-wide hotline of all reports of suspected
child abuse or neglect involving Contractor, including, but not limited to, employees, volunteers and
clients. DHS contractors are considered to be mandatory reporters for suspected child abuse and neglect
and are to make those reports directly to the Hotline at 1 -844 -CO -4 -KIDS (844-264-5437).
Payment and Fee Schedule: County will compensate Contractor for performance of services as follows:
(1) Face to face contact for individual therapy with clients - $85 per hour for In Office Services and $95
per hour for In Home/ Off Site Services; (2) Group Therapy Services for clients -$45 per hour (3) Case
management services (report writing) - $35 per hour; (4) Attendance at Family Engagement Meetings
(also called Individual Service & Support Team meetings) - $45 per hour. The maximum contract amount
is not to exceed $10,000.
12
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EXIIIBIT B
INSURANCE CERTIFICATE
13
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r[lo N ASW
Insurance Company, RRG
Customer ID.
Policy Number:
Effective Date:
Expiration Date:
1HGLDWZLVE
G-3TFSTPHTIL-00
06/01/2017
06/01/2018
OCEURRENCE GENERAL LIABILITY POLIEY DECLARATIONS
Named Insured:
Address:
Mary B Ezequelie, LCSW, PC
262 Cedar Dr
P.O. Box 4066
Gypsum, CO 81637
Per Claim $1,000,000.00 $309.00
Aggregate $3,000,000.00
TOTAL PREMIUM FOR THIS COVERAGE PART- $309.00
THIS 15 AN OCCURRENCE POLICY, COVERAGE IS EFFECTIVE UPON RECEIPT 0FYOU R FIRST PREMIUM PAYMENT FOR THIS OCCU RRENCE G E N ERAL LIABILITY POLICY.
COVERAGE 0NLYAPP UES TO PROPERTY DAMAGE, BODILY INJURY, PER50NAL INJURY, ADVERTISING INJURY, AND FIRE LEGAL LIAB ILITY STATED IN THE
AFORESTATED POLICY FORM THAT ACTUALLY OCCUR AND ARE DISCOVERED ON OR AFTER THE DATE OF RECEIPT OF YOUR FIRST PREMIUM PAYMENT FOR THIS
SPECIFIC POLICY COVERAGE„ AND PRIOR TO THE TERMINATION DATE OF THIS SPECIFIC POLICY COVERAGE. TO BE COVERED UNDER THIS POLICY YOU MUST BE
INSURED UNDER A PROFES5IDNAL LIABILITY INSURANCE POLICY ISSUED BY THE NASW RISK RETENTION GROUP, INC.
Authorized Representative: Brokered and Administered by: To Verify Claims History Contact:
Western litigation, Inc.
rj N A J l A, ' N°QA�°� c/o Aima Garcia
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Pmda1200E6fm KII-61 9821 Katy Freeway, Suite 600
Amdt Heightr, iL 5161ir5318
Tony Benedetto Insurance Company, RRG u�M CAN ar7sars,Aec 1322 Houston, Tx 77024
Atma_Ga rcia @westemiltigation.com
Fax: 713-935-2479
Policy Forms & Endorsements: GL D01 [March 12, 2016};
For addhionof Information and onJf m epp7kattuns: NASSHnsule.com
the RUW Ahk Refm[hn Gmews A—V Mkpelkr wM6 YPa ve end o.M end Wrpdkr k—k—d wM a.^Ladm
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Insurance Company, RRG
Customer ID:
Policy Number:
Effective Date:
Expiration Date:
SOCIAL WORKERS PROFESSIONAL AND SUPPLEMENTAL
LIABILITY INSURANCE POLICY DECLARATIONS -CLAIMS MADE
1HGLDWZLVE Named Insured.
P -G RO1I(XH1G9RUVT-01 Address:
06/01/2017
06/01/2018
Mary B Ezequelle, LCSW, PC
262 Cedar Dr
P.O. Box 4066
Gypsum, CO 81637
Retroactive Date: 08/01/1999
NOTICE: A LOWER LIMIT OF LIABILITY APPLIES TO JUDGEMENTS OR SETTLEMENTS WHEN THERE ARE ALLEGATIONS OF SEXUAL MISCONDUCT
(SEE POLICY FOR DETAILS).
Professional Liability Per Claim Limit $1,000,000.00 $237.00
Professional Llabllity Aggregate Limit $3,000,0D0.00
Professional Liability Per Claim Limit $1,000,000,00
Professional I -I a b i I ity Algreg ate Limit $1,000,000.00
y&.. APPOW"..
Deposition Expense
$5,000 per deposition/$35,000 per policy period
Subpoena Expense
$400.DO
State License Board Investigation Defense
$35,000.00
Emergency First Aid
$15,000.00
Health Information - H1PAA
$25,000.00
First Party Assault
$15,000.00
Medical Payments
$5,000 per incident/$50,000 per policy period
Wage Loss and Expense
$1,000 per day/$35,000 per policy period
TOTAL PREMIUM FOR THIS COVERAGE PART: $237.00
IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THIS INSURANCE AS STATED IN
THIS POLICY.
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED, THIS PREMIUM MAY BE SUM ECT TO ADJUSTMENT.
THIS POLICY 15 ISSUED BY YOUR RISK RETENTION GROUP. YOUR RISK RETENTION GROUP MAY NOT BE SUBJECT TO ALL OF THE INSURANCE LAWS AND
REGULATIONS OF YOUR STATE. STATE INSURANCE INSOLVENCY GUARANTY FUNDS ARE NOT AVAILABLE FOR YOUR RISK RETENTION GROUP.
Authorized Representative; Brokered and Administered Cry; To Verity Claims History Contact:
Western Litigation, Inc.
N A S W 1R� p r eia Alma Garcia
1200 EWmAvenue
F"di Height% it 61616,5348 9821 Katy Freeway, Suite 600
Tony Benedetto Insurance Company, RRG Lk-- CAR OF WG. AU 1322 Houston, TX 77024
Alma Garcia@westemlitigation.com
Fax: 713-935-2479
Po$icy Forms & Endorsements: RRG PLI-1130 [May 9, 20161:
For additf mwi In/ormatfon and online appA dons: AASINMsure. com
Thank you for renewing your policy.
For a complete explanation of your coverage, please refer to your auto insurance policy_
Questions on Your Polices Call The Hartford at 1 -800 -423 -UM.
INSURED:
Jonathan A Ezequelle
P O Box 4158
Gypsum, CO 81637-4158
POLICY INFORMATION:
Your Policv Number.
6A;j201t''U1K3
Aft hwumnce
Program imm
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Policy Effective/Expiration Dates: 0310112017, 12:01AM to 0310112018, 12:01AM
Standard Time at the Address of the Named Insured
Homeowner: Yes .�.
Billi'nq Account Number. 88879509
Coverage by Policy Premium: $_1_53.06
Coverage by Vehicle Premium: $1,902.09
I Total Policy Premium: $2.055.15
DRIVERS ON YOUR POLICY:
Jonathan A Ezequelle Mary B Ezequelle
VEHICLES COVERED:
Vehicle:
Vehicle ID Number (VIN):
Premium:
2007 Volks EOS 2.OT Sport _
WVWCA71 F67V043826
$463.18
2001_13od.ge Ram 2500
1 B7KF236X1 J241790 -__-
--
_- - - $301.1
?008 Jeep Wrangler U!!IW R
U!!IW
1J4GA69138L6#1908
$27325
2016 Toyot Prius
_
JTDKARFU6G3502721
-....... _..
$864.51
Twin City Fre Insurance Company, One Hartford Plaza, Hartford, CT 06155
This Continuation Page, with Policy Jacket Farm 8505 and farms and endorsements listed, continues your personal
automobile policy package_ RIZ{�+�d'�
COUNTERSIGNED BY AITHGED AGENT: CJ or
A-9800-0 (Ed_ 02116) Page 1 of 5
2008 Jeep Wrangler Unitd R
VIN: 1 J4GA6913BL611106
Territory: 069
Use: Pleasure
Class: 800000
Garaging Address: 262 Cedar Dr
Gympsum, CO B1637
Elf+it&I
DEDUCTIBLE: PREMIUM:
Bodily Injury Liability:
$500,000 each person
$60.66
$500,000 each accident
Property Damage Liability►: _ _ ._._._
$500,000 each accident___
T _�........ - .... ___�__ $38.51
Medical Payments^W-_ -- _ _ _$5,000
each person_ - -
--- __ $19.93
Comprehensive (Other Than Collision):
ACV'
$1,000 $85.39-______
Includin Full Window Glass
-----_._____r�.___---------------
._._.._._-..._ included
Collision:
AC11=
�1,U00 $68.78
Total Premium:
$27325
2016 Toyot Prius
VIN: JTDKARFU6G3502721
Territory: 069
Use: Pleasure
Class: 820000
Garaging Address: 262 Cedar Dr
Gypsum, CO 81637
Lender: Toyota Motor Cred
PO Bax 3025
Coraopolis, PA 15108
LIMITS:
DEDUCTIBLE: PREMIUM:
Bodily Injury Liability: $500,000 each person $170.05
$500,000 each accident
------------
._--------------- _--------___-__-__----------
! pert�r Damage Liabilityr� _ - $500,000 each accident--__._____ —_-______ $64.90 _--------
AAedical PaXments: __ ___ __ _ $5,0_00 each person----------- ------- $34.46
Comprehensive {Other Than Collision}: - ACV �--- - $1,000 $242.99 -
Inciudino Full Window Glass Included
Collision_.ACV _ _ __ $1,000 �-_ __- 352_11
Total Premium ne Applies}: $864.51
DRIVERS ON YOUR POLICY:
Driver. Jonathan A Ezequelle
DOB: 05/23/1938
Gender. Male
Driver: Mary B Ezequelle
DDB: 01/0611947
Gender. Female
*ACV = Actual Cash Value ROR = Repair or Replace
Marital Status: Married
occupation: Retired
Marital Status: Married
Occupation: Employed
A-9804-0 (Ed. 02116) Page 3 of 5
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