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HomeMy WebLinkAboutC15-030 Rocky Mountain Counseling, IncAGREEMENT FOR PROFESSIONAL SERVICES BETWEEN EAGLE COUNTY, COLORADO AND ROCKY MOUNTAIN COUNSELING, LLC e—day ��A THIS AGREEMENT ("Agreement") is effective as of the, of , 2Q-) , by and between Rocky Mountain Counseling, LLC a Colorado limited liability company (he nafter "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 l; 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. a. Consultant agrees to furnish the Services no later than May 31, 2015 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. 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 Children, Family and Adult Services Department's designee shall be Consultant's contact with respect to this Agreement and performance of the Services. 3. Term of the AUeement. 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 31g` day of May, 2015. 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. 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 $10,000. 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. a. For reimbursement Contractor 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 Contractor 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 or delivered in-person to the following address to ensure proper payment. Invoices sent by fax or e-mail will not be accepted. Eagle County Health and Human Services Business Office 2 Eagle County HHS Prof Sery Final 5/14 550 Broadway Post Office Box 660 Eagle, CO 81631 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 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 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 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. 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 County. Contractor shall provide the County with progress reports upon County's request; or Contractor shall furnish 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. 29-1-101 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 3 Eagle County HHS Prof Sery 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 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. Consultant shall maintain personal auto coverage in compliance with Colorado law. Consultant will not be operating a motor vehicle in connection with the Services. iii. Commercial General Liability coverage to include premises and operations, personal/advertising 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. 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. V. Intentionally Omitted b. Other Requirements. i. 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. 4 Eagle County HHS Prof Sery Final 5/14 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. 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. 5 Eagle County HHS Prof Sery Final 5/14 8. 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 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. CK91INWA Eagle County, Colorado Attention: Toni Rozanski 500 Broadway Post Office Box 660 Eagle, CO 81631 Telephone: 970-328-8852 Facsimile: 1-855-848-8826 E -Mail: toni.rozasnld@eaglecounty.us With a copy to: Eagle County Attorney 500 Broadway Post Office Box 850 6 Eagle County HHS Prof Sery Final 5/14 Eagle, Co 81631 Telephone: 970-328-8685 Facsimile: 970-328-8699 E -Mail: atty@eaglecounty.us CONSULTANT: Rocky Mountain Counseling, LLC Dena L. Southerlan 407 Broadway Suite 2, Eagle, CO 81631 PO Box 7612, Avon, CO 81620 Phone and Fax: 970-445-2700 dsoutherlan@aol.com 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. 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. 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 Contractor, County may terminate this Agreement, in whole or in part, upon seven (7) days' notice to Contractor. 7 Eagle County HHS Prof Sery Final 5/14 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. 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. L 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. s Eagle County HHS Prof Sery Final 5/14 1. The invalidity, illegality or unenforceability of any provision of this Agreement shall not affect the validity or enforceability of any other provision hereof. in. 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 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 conium 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 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: 9 Eagle County HHS Prof Sery Final 5/14 http://www.dhs.gov/x/xprevprot/programs/gc 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 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). 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. 10 Eagle County HHS Prof Sery Final 5/14 COUNTY OF EAGLE, STATE OF COLORADO, By and Through Its COUNTY MANAGER By: Rachel Oys, Acting Coun Manager CONSULTANT: Rocky Mountain Counseling, LLC By: 44A c�' U_ Print Name: U t'& L . , O -y-A e Title: p✓ -2S/ 4AJ- 1111 Eagle County HHS Prof Sery Final 5/14 EXHIBIT A SCOPE OF SERVICES, SCHEDULE, FEES Deserintion of Services: Provide substance abuse treatment services and supervised visitation services for families and children involved in Eagle County Children, Family and Adult Services Prevention and Intervention programs. This includes: families involved with Child Welfare, Wayfinder, Colorado Community Response, or Program Area 3. The goal of prevention programs is to prevent child abuse or neglect and/or youth delinquency. The goal of Child Welfare intervention services is 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 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. 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 nopayment for services provided without prior authorization for such services by the Countv. Such authorization shall include the level of services to be provided, the nature and tvpe of services provided and the time frames in which these services are to be provided. 3. Mandatory Reporting. Contractor shall notify HHS immediately of all reports of suspected child abuse or neglect involving Contractor, including, but not limited to, employees, volunteers and clients. HHS contractors are considered to be mandatory reporters for suspected child abuse and neglect and are to make those reports directly to HHS Youth and Family Services Child Abuse and Neglect Hotline - (970) 328-7720. Payment and Fee Schedule: County will compensate Contractor for performance of services as follows: (1) Face to face contact with clients for individual outpatient services -$80 per hour for In- Office services, (2) Face to face contact with clients for group outpatient services -$45 per hour for In Office services (3) Face to face contact for supervised visitation services- $30 per hour for on- site/ office services, $40 per hour for off-site community services (4) Case management services -$35 per hour to perform services or participate in case conferences. The maximum contract amount is not to exceed $10,000- 12 Eagle County HHS Prof Sery Final 5114 EXHIBIT B Insurance Certificate 13 Eagle County HHS Prof Sery Final 5114 HEALTHCARE PROVIDERS SERVICE ORGANIZATION PURCHASING GROUP CNA Cerrifuate of .1murmte OCCURRENCE POLICY FORM PRODUCER I BRANCH PREFIX I POLICY NUMBER 018098 1 970 HPG 0615454855-8 Named Insured _ Dena Southerlan PO Box 7612 Avon, CO 81620-7612 Medical Specialty Code Social Worker, Clinical 80723 HPSO Policy Period: From 10/09/14 to 10/09/15 at 12:01 AM Standard Time Program Administered b Healthcare Providers Service Organization 159 E. County Line Road Hatboro, PA 19040-1218 1-800-982-9491 www.hpso.com Insurance is provided by: American Casualty Company of Reading, Pennsylvania 333 South Wabash Avenue Chicago, Illinois 60604 Profesalorml uablriby $1,000,000 each claim $5,000,000 aggregate Your professional liability limits shown above include the following: Good Samaritan Liability • Malplacement Liability • Personal Injury Liability • Sexual Misconduct included in the PL Limit shown above subject to $25,000 aggregate sublimit Coverage Extensions License Protection $ 25,000 per proceeding $ 25,000 aggregate Defendant Expense Benefit $ 1,000 per day limit $ 25,000 aggregate Deposition Representation $ 10,000 per deposition $ 10,000 aggregate Assault $ 25,000 per incident $ 25,000 aggregate Includes Workplace Violence Counseling Medical Payments $ 25,000 per person $ 100,000 aggregate First Aid $ 10,000 per incident $ 10,000 aggregate Damage to Property of Others $ 10,000 per incident $ 10,000 aggregate Information Privacy (HIPAA) Fines & Penalties $ 25,000 per incident $ 25,000 aggregate Workplace Liability Workplace Liability Included in Professional Liability Limit shown above Fire and Water Legal Liability Included in the PL limit above subject to $150,000 aggregate sublimit Personal Liability $1,000,000 aggregate Total: $151.00 Premium reflects self-employed, part-time rate. Policy Forms & Endorsements (Please see attached list for a general description of many common policy forms and endorsements.) G -121500-D G -121501-C G -121503-C G -145184-A G -147292-A GSL3886 GSL3908 GSL13424 GSL15563 GSL15564 GSL15565 GSL17101 G-123846-005 q4wv� 4C A;C�- Chairman of the Board Secretary Keep this Certificate of Insurance in a safe place. This Certificate of Insurance and proof of payment are your proof of coverage. There is no coverage in force unless the premium is paid in full. In order to activate your coverage, please remit premium in full by the effective date of this Certificate of Insurance. Form #: G -141241-B (3/2010) Master Policy: 188711433 .4v HEALTHCARE PROVIDERS SERVICE MHPSO CNA ORGANIZATION PURCHASING GROUP (!Certificate of 1n5urance HLddwmPrnri&rsSemetOrpaimtion- OCCURENCE POLICY FORM Print Date: 1/15/2015 Producer Branch Prefix Policy Number Policy Period 018098 970 HPG 0617363694 from 01/13/15to 01/13/16at 12:01 AM Standard Time Named Insured and Address: Rocky Mountain Counseling, LLC 407 Broadway, Suite 2 Eagle, CO 81631 Medical Specialty: Mental Health Counselor Firm Excludes Cosmetic Procedures Program Administered by: Healthcare Providers Service Organization 159 E. County Line Road Hatboro, PA 19040-1218 1-888-288-3534 www.hpso.com Code: Insurance is provided by: 80723 American Casualty Company of Reading, Pennsylvania 333 S. Wabash Avenue, Chicago, IL 60604 Professional Liability $1,000,000 each claim $ 5,000,000 aggregate Your professional liability limits shown above include the following: • Good Samaritan Liability ` Malplacement Liability Personal Injury Liability • Sexual Misconduct Included in the PL limit shown above subject to $ 25,000 aggregate sublimit Coverage Extensions License Protection $ 25,000 per proceeding $ 25,000 aggregate Defendant Expense Benefit $ 1,000 per day limit $ 25,000 aggregate Deposition Representation $ 10,000 per deposition $10,000 aggregate Assault $ 25,000 per incident $ 25,000 aggregate Includes Workplace Violence Counseling Medical Payments $ 25,000 per person $100;000 aggregate First Aid $ 10,000 per incident $ 10,000 aggregate Damage to Property of Others $ 10,000 per incident $ 10,000 aggregate Information Privacy (HIPAA) Fines and Penalties $ 25,000 per incident $ 25,000 aggregate General Liability General Liability $1,000,000 each claim / $5,000,000 aggregate Fire & Water Legal Liability Included in the GL limit shown above subject to $250,000 aggregate sublimit Total: $ 700.00 Base Premium $700.00 Policy Forms & Endorsements(Please see attached list for a general description of many common policy forms and endorsements.) G -121500-D G -121501-C G -145184-A G-1 47292-A GSL15563 GSL15564 GSL15565 GSL17101 GSL13424 GSL13425 G-123846-005 GSL3886 GSL3908 G -121504-C CNA79575 Keep this document in a safe place.ft and proof of payment are your proof of coverage. There is no coverage in force T / V 1►► �_ "--- unless the premium is paid in full. In order Chairman of the Board Secretary to activate your coverage, please remit premium in fv# by the effective date of this Certificate of Insurance. Master Policy # 188711433 G -141241-B (03/2010) Coverage Change Date: Endorsement Change Date: POLICY FORMS & ENDORSEMENTS The list below contains general descriptions of the policy forms and endorsements that may or may not apply to your professional liability insurance policy. Please refer to your Certificate of Insurance for the policy forms & endorsements specific to your state and your policy period. Coverages, rates and limits may differ or may not be available in all states. All products and services are subject to change without notice. Think Green —expanded definitions and copies of these policy forms and endorsements are available online at www.hpso.com/policyforms COMMON POLICY FORMS & ENDORSEMENTS FORM # DESCRIPTION G -121500-D Common Policy Conditions G -121501-C Occurrence Policy Form G -145184-A Policyholder Notice - OFAC Compliance Notice G -147292-A Policyholder Notice - Silica, Mold & Asbestos Disclosure GSL15563 Information Privacy Coverage Endorsement HIPAA Fines, Penalties & Notification Costs GSL15564 Sexual Misconduct Sublimits of Liability Professional Liability & Sexual Misconduct Exclusion GSL15565 Healthcare Providers Professional Liability Assault Coverage GSL17101 Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies GSL13424 Services to Animals GSL13425 Business Owner Coverage Extension Endorsement G-123846-005 Colorado Cancellation and Non -Renewal GSL3886 Coverage & Cap on Losses from Certified Acts Terrorism GSL3908 Notice - Offer of Terrorism Coverage & Disclosure of Premium CNA79575 Exclusion of Cosmetic Procedures OPTIONAL ENDORSEMENTS FORM # DESCRIPTION G -121504-C General Liability Form CNA79575 Exclusion of Cosmetic Procedures PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS & ENDORSEMENTS SPECIFIC TO YOUR STATE AND YOUR POLICY PERIOD. For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property & Liability Insurance Guaranty Association. For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement Foundation Program Fund and the KY LGPT is the KY Local Government Premium Tax which includes charges at a municipality and/or county level. For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge. For FL residents: The FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association - 2012 Regular Assessment. Form#: G -141241-B (03/2010) Named Insured: Rocky Mountain Couns Master Policy#: 188711433 Policy#: 0617363694 HEALTHCARE PROVIDERS GENERAL LIABILITY COVERAGE PART ENDORSEMENT Additional Insured — General Liability In consideration of the premium paid, and subject to the General Liability limit of liability shown on the certificate of insurance, it is agreed that the GENERAL LIABILITY COVERAGE PART is amended as follows: The person or entity named below (the "additional insured") is an insured under this Coverage Part but only as respects its liability arising out of named insured's operations, or premises owned by or rented by the named insured and solely to the extent that: 1. a general liability claim is made against the named insured and the additional insured; and 2. in any ensuing litigation arising out of such claim, the named insured and the additional insured remain as co-defendants. In no event is there any coverage provided under this policy for an occurrence that is the direct liability of the additional insured. Additional Insured: Eagle County 500 Broadway Eagle, CO 81631 This endorsement is a part of your policy and takes effect on the effective date of your policy, unless another effective date is shown below. All other provisions of the policy remain unchanged. Complete Only When This Endorsement Is Not Prepared with the Policy Or Is Not to be Effective with the Policy ISSUED TO ENDORSEMENT EFFECTIVE DATE Rocky Mountain Counseling, 01/13/2015 LLC G -123827-B (07/2001) Page 1 of 1 AMERICAN CASUALTY COMPANY OF READING, Pa Must Be Completed ENDT. NO. POLICY NO. 1 617363694 Complete Only When This Endorsement Is Not Prepared with the Policy Or Is Not to be Effective with the Policy ISSUED TO ENDORSEMENT EFFECTIVE DATE Rocky Mountain Counseling, 01/13/2015 LLC G -123827-B (07/2001) Page 1 of 1 AMERICAN CASUALTY COMPANY OF READING, Pa