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#14-6358 (Physician Led Access Network of Collier County, Inc. (PLAN) AGREEMENT14-6358 for Physician Led Access Network (PLAN) THIS AGREEMENT, made and entered into on this a'lr'‘ day of ion/tar,/ 2015, by and between Physician Led Access Network of Collier County, Inc. (PLAN), authorized to do business in the State of Florida, whose business address is 501 Goodlette Road North Suite B- 300, Naples, FL 34102, hereinafter called the "Provider" or "PLAN" and Collier County, a political subdivision of the State of Florida, (the "County"): WITNESSETH: 1. COMMENCEMENT. The Provider shall commence the work on the date of January 1, 2015, provided a Purchase Order has been issued. 2. CONTRACT TERM. The contract shall be nine (9) months commencing on January 1, 2015, and terminating on September 30, 2015. The County may, at its discretion and with the consent of the Provider, renew the Agreement under all of the terms and conditions contained in this Agreement for two (2) additional twelve (12) month periods commencing October 1 and ending September 30. The County shall give the Provider written notice of the County's intention to renew the Agreement term not less than ten (10) days prior to the end of the Agreement term then in effect. The County Manager, or his designee, may, at his discretion, extend the Agreement under all of the terms and conditions contained in this Agreement for up to ninety (90) days. The County Manager, or his designee, shall give the Contractor written notice of the County's intention to extend the Agreement term not less than ten (10) days prior to the end of the Agreement term then in effect. 3. STATEMENT OF WORK. The Provider shall assist income eligible residents of Collier County with access to medical services provided by medical providers in PLAN's network. The network providers will accept PLAN approved eligible persons and provide no fewer than five hundred (500) services per quarter. Services are defined as each encounter with each patient to include but not limited to referral, enrollment, clinical and routine service, etc. Intakes will be completed and verified by the Patient Coordinator of PLAN who will obtain all necessary household documentation and determine eligibility for this program in accordance with PLAN's policy. PLAN will track performance measures and report them quarterly to Community and Human Services as part of the invoice process. All documentation supporting the performance measures will be stored and made presentable to Community and Human Services upon request for monitoring of this contract. This Agreement contains the entire understanding between the parties and any modifications to this Agreement shall be mutually agreed upon in writing by the Provider and the County Project Manager or Contract Manager or his designee, in Page 1 of 11 Cq compliance with the County Purchasing Ordinance and Purchasing Procedures in effect at the time such services are authorized. Provider's failure to perform any term or condition of this Agreement as a result of conditions beyond its control such as, but not limited to, war, strikes or lock-outs, fires, floods, epidemics, quarantine regulations, acts of nature, acts of government or of the County, shall not be deemed a breach of this Agreement. 4. COMPENSATION. The County shall pay the Provider for the performance of this Agreement and the total amount of fifty-thousand dollars and 00/100 ($50,000), based on the submission of the required quarterly report, attached hereto as Attachment A. Quarterly payments of twelve thousand five hundred dollars and 00/100 ($12,500) will be made upon receipt of a proper quarterly invoice and in compliance with Section 218.70 Florida Statues, otherwise known as the "Local Government Prompt Payment Act." Collier County reserves the right to withhold and/or reduce an appropriate amount of any payments for work not performed or for unsatisfactory performance of Contractual requirements. The Provider shall submit quarterly progress reports to the Community and Human Services Department on the 30th day of the month following the reporting quarter. The progress report format is outlined in Attachment A and the reporting schedule is cited below. Quarter Service Dates Report Due 1st Quarter January 1 - March 31 April 30th 2nd Quarter April 1 -June 30 July 30th 3rd Quarter July 1 - September 30 October 30th 4th Quarter October 1 - December 31 January 30th 5. SALES TAX. Provider shall pay all sales, consumer, use and other similar taxes associated with the Work or portions thereof, which are applicable during the performance of the Work. Collier County, Florida as a political subdivision of the State of Florida, is exempt from the payment of Florida sales tax to its vendors under Chapter 212, Florida Statutes, Certificate of Exemption # 85-8015966531C-2. 6. NOTICES. All notices from the County to the Provider shall be deemed duly served if mailed or faxed to the Provider at the following Address: Physician Led Access Network of Collier County, Inc. (PLAN) 501 Goodlette Road North Suite B-300 Naples, FL 34102 Dr. Bill Kuzbyt, Chair Phone: (239) 776-3016 Fax: (239) 435-1297 Page 2 of 11 CA All Notices from the Provider to the County shall be deemed duly served if mailed or faxed to the County to: Community and Human Services Department 3339 Tamiami Trail East, Suite 211 Naples, FL 34112-5361 Attention: Leslie Hayes, Grants Coordinator Phone: (239) 252-2903 The Provider and the County may change the above mailing address at any time upon giving the other party written notification. All notices under this Agreement must be in writing. 7. NO PARTNERSHIP. Nothing herein contained shall create or be construed as creating a partnership between the County and the Provider or to constitute the Provider as an agent of the County. 8. PERMITS: LICENSES: TAXES. In compliance with Section 218.80, F.S., all permits necessary for the prosecution of the Work shall be obtained by the Provider. The County will not be obligated to pay for any permits obtained by Subproviders/Subconsultants. Payment for all such permits issued by the County shall be processed internally by the County. All non-County permits necessary for the prosecution of the Work shall be procured and paid for by the Provider. The Provider shall also be solely responsible for payment of any and all taxes levied on the Provider. In addition, the Provider shall comply with all rules, regulations and laws of Collier County, the State of Florida, or the U. S. Government now in force or hereafter adopted. The Provider agrees to comply with all laws governing the responsibility of an employer with respect to persons employed by the Provider. 9. NO IMPROPER USE. The Provider will not use, nor suffer or permit any person to use in any manner whatsoever, County facilities for any improper, immoral or offensive purpose, or for any purpose in violation of any federal, state, county or municipal ordinance, rule, order or regulation, or of any governmental rule or regulation now in effect or hereafter enacted or adopted. In the event of such violation by the Provider or if the County or its authorized representative shall deem any conduct on the part of the Provider to be objectionable or improper, the County shall have the right to suspend the contract of the Provider. Should the Provider fail to correct any such violation, conduct, or practice to the satisfaction of the County within twenty-four (24) hours after receiving notice of such violation, conduct, or practice, such suspension to continue until the violation is cured. The Provider further agrees not to commence operation during the suspension period until the violation has been corrected to the satisfaction of the County. Page 3 of 11 10. TERMINATION. Should the Provider be found to have failed to perform the services in a manner satisfactory to the County as per this Agreement, the County may terminate said agreement for cause; further the County may terminate this Agreement for convenience with a thirty (30) day written notice. The County shall be sole judge of non- performance. In the event that the County terminates this Agreement, Provider's recovery against the County shall be limited to that portion of the Contract Amount earned through the date of termination. The Provider shall not be entitled to any other or further recovery against the County, including, but not limited to, any damages or any anticipated profit on portions of the services not performed. 11. NO DISCRIMINATION. The Provider agrees that there shall be no discrimination as to race, sex, color, creed or national origin. 12. INSURANCE. The Provider shall provide insurance as follows: A. Commercial General Liability: Coverage shall have minimum limits of$1,000,000 Per Occurrence, $2,000,000 aggregate for Bodily Injury Liability and Property Damage Liability. This shall include Premises and Operations; Independent Providers; Products and Completed Operations and Contractual Liability. B. Business Auto Liability: Coverage shall have minimum limits of $500,000 Per Occurrence, Combined Single Limit for Bodily Injury Liability and Property Damage Liability. This shall include: Owned Vehicles, Hired and Non-Owned Vehicles and Employee Non-Ownership. C. Workers' Compensation: Insurance covering all employees meeting Statutory Limits in compliance with the applicable state and federal laws. The coverage must include Employers' Liability with a minimum limit of $500,000 for each accident. Special Requirements: Collier County Government shall be listed as the Certificate Holder and included as an Additional Insured on the Comprehensive General Liability Policy. Current, valid insurance policies meeting the requirement herein identified shall be maintained by Provider during the duration of this Agreement. The Provider shall provide County with certificates of insurance meeting the required insurance provisions. Renewal certificates shall be sent to the County ten (10) days prior to any expiration date. Coverage afforded under the policies will not be canceled or allowed to expire until the greater of: ten (10) days prior written notice, or in accordance with policy provisions. Provider shall also notify County, in a like manner, within twenty- four (24) hours after receipt, of any notices of expiration, cancellation, non-renewal or material change in coverage or limits received by Consultant from its insurer, and nothing contained herein shall relieve Provider of this requirement to provide notice. Provider shall ensure that all Subproviders/Subconsultants comply with the same insurance requirements that he is required to meet. Page 4 of 11 �A 13. INDEMNIFICATION. To the maximum extent permitted by Florida law, the Provider shall indemnify and hold harmless Collier County, its officers and employees from any and all liabilities, damages, losses and costs, including, but not limited to, reasonable attorneys' fees and paralegals' fees, whether resulting from any claimed breach of this Agreement by Provider, any statutory or regulatory violations, or from personal injury, property damage, direct or consequential damages, or economic loss, to the extent caused by the negligence, recklessness, or intentionally wrongful conduct of the Provider or anyone employed or utilized by the Provider in the performance of this Agreement. This indemnification obligation shall not be construed to negate, abridge or reduce any other rights or remedies which otherwise may be available to an indemnified party or person described in this paragraph. This section does not pertain to any incident arising from the sole negligence of Collier County. 13.1 The duty to defend under this Article 13 is independent and separate from the duty to indemnify, and the duty to defend exists regardless of any ultimate liability of the Provider, County and any indemnified party. The duty to defend arises immediately upon presentation of a claim by any party and written notice of such claim being provided to Provider. Provider's obligation to indemnify and defend under this Article 13 will survive the expiration or earlier termination of this Agreement until it is determined by final judgment that an action against the County or an indemnified party for the matter indemnified hereunder is fully and finally barred by the applicable statute of limitations. 14. CONTRACT ADMINISTRATION. This Agreement shall be administered on behalf of the County by the Community and Human Services Department. 15. CONFLICT OF INTEREST. Provider represents that it presently has no interest and shall acquire no interest, either direct or indirect, which would conflict in any manner with the performance of services required hereunder. Provider further represents that no persons having any such interest shall be employed to perform those services. 16. COMPONENT PARTS OF THIS CONTRACT. This Contract consists of the following component parts, all of which are as fully a part of the contract as if herein set out verbatim: Insurance Certificate(s), and Attachment A: Performance Measures Calendar Year. 17. SUBJECT TO APPROPRIATION. It is further understood and agreed by and between the parties herein that this agreement is subject to appropriation by the Board of County Commissioners. 18. PROHIBITION OF GIFTS TO COUNTY EMPLOYEES. No organization or individual shall offer or give, either directly or indirectly, any favor, gift, loan, fee, service or other item of value to any County employee, as set forth in Chapter 112, Part III, Florida Statutes, Collier County Ethics Ordinance No. 2004-05, as amended, and County Page 5 of 11 CA Administrative Procedure 5311. Violation of this provision may result in one or more of the following consequences: a. Prohibition by the individual, firm, and/or any employee of the firm from contact with County staff for a specified period of time; b. Prohibition by the individual and/or firm from doing business with the County for a specified period of time, including but not limited to: submitting bids, RFP, and/or quotes; and, c. immediate termination of any contract held by the individual and/or firm for cause. 19. COMPLIANCE WITH LAWS. By executing and entering into this agreement, the Provider is formally acknowledging without exception or stipulation that it agrees to comply, at its own expense, with all federal, state and local laws, codes, statutes, ordinances, rules, regulations and requirements applicable to this Agreement, including but not limited to those dealing with the Immigration Reform and Control Act of 1986 as located at 8 U.S.C. 1324, et seq. and regulations relating thereto, as either may be amended; taxation, workers' compensation, equal employment and safety (including, but not limited to, the Trench Safety Act, Chapter 553, Florida Statutes), and the Florida Public Records Law Chapter 119 (including specifically those contractual requirements at F.S. § 119.0701(2)(a)-(d) and (3))). If Provider observes that the Contract Documents are at variance therewith, it shall promptly notify the County in writing. Failure by the Provider to comply with the laws referenced herein shall constitute a breach of this agreement and the County shall have the discretion to unilaterally terminate this agreement immediately. 20. OFFER EXTENDED TO OTHER GOVERNMENTAL ENTITIES. Collier County encourages and agrees to the successful proposer extending the pricing, terms and conditions of this Agreement to other governmental entities at the discretion of the successful proposer. 21. AGREEMENT TERMS. If any portion of this Agreement is held to be void, invalid, or otherwise unenforceable, in whole or in part, the remaining portion of this Agreement shall remain in effect. 22. ADDITIONAL ITEMS/SERVICES. Additional items and/or services may be added to this contract in compliance with the Purchasing Ordinance and Purchasing Procedures. 23. DISPUTE RESOLUTION. Prior to the initiation of any action or proceeding permitted by this Agreement to resolve disputes between the parties, the parties shall make a good faith effort to resolve any such disputes by negotiation. The negotiation shall be attended by representatives of Provider with full decision-making authority and by County's staff person who would make the presentation of any settlement reached during negotiations to County for approval. Failing resolution, and prior to the commencement of depositions in any litigation between the parties arising out of this Agreement, the parties shall attempt to resolve the dispute through Mediation before an agreed-upon Circuit Court Mediator certified by the State of Florida. The mediation shall be attended by representatives of Provider with full decision-making authority and by County's staff person who would make the presentation of any settlement reached at mediation to Page 6 of 11 County's board for approval. Should either party fail to submit to mediation as required hereunder, the other party may obtain a court order requiring mediation under section 44.102, Fla. Stat. 24. VENUE. Any suit or action brought by either party to this Agreement against the other party relating to or arising out of this Agreement must be brought in the appropriate federal or state courts in Collier County, Florida, which courts have sole and exclusive jurisdiction on all such matters. 25. ORDER OF PRECEDENCE. In the event of any conflict between or among the terms of any of the Contract Documents, the terms of the Agreement shall take precedence over the terms of all other Contract Documents. 26. ASSIGNMENT. Provider shall not assign this Agreement or any part thereof, without the prior consent in writing of the County. Any attempt to assign or otherwise transfer this Agreement, or any part herein, without the County's consent, shall be void. If Provider does, with approval, assign this Agreement or any part thereof, it shall require that its assignee be bound to it and to assume toward Provider all of the obligations and responsibilities that Provider has assumed toward the County. 27. RECORDS AND DOCUMENTATION. The Provider shall maintain sufficient records to determine compliance with the requirements of this Agreement, and all other applicable laws and regulations. This documentation shall include, but not be limited to, the following: A. All records required by County regulations. B. Provider shall keep and maintain public records that ordinarily and necessarily would be required by County in order to perform the service. C. All reports, plans, surveys, information, documents, maps, books, records and other data procedures developed, prepared, assembled, or completed by the Provider for the purpose of this Agreement shall be made available to the County by the Provider at any time upon request by the County or Community and Human Services Department. Materials identified in the previous sentence shall be in accordance with generally accepted accounting principles (GAAP), procedures and practices, which sufficiently and properly reflect all revenues and expenditures of funds provided directly or indirectly by this Agreement, including matching funds and Program Income. These records shall be maintained to the extent of such detail as will properly reflect all net costs, direct and indirect labor, materials, equipment, supplies and services, and other costs and expenses of whatever nature for which reimbursement is claimed under the provisions of this Agreement. D. Upon completion of all work contemplated under this Agreement copies of all documents and records relating to this Agreement shall be surrendered to Community and Human Services Department if requested. In any event the Page 7 of 11 �pU Provider shall keep all documents and records in an orderly fashion in a readily accessible, permanent and secured location for three (3) years with the following exception: if any litigation, claim or audit is started before the expiration date of the three (3) year period, the records will be maintained until all litigation, claim or audit findings involving these records are resolved. The County shall be informed in writing if an agency ceases to exist after closeout of this Agreement of the address where the records are to be kept. Meet all requirements for retaining public records and transfer, at no cost, to County all public records in possession of the Provider upon termination of the contract and destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. All records stored electronically must be provided to the County in a format that is compatible with the information technology systems of the public agency. E. The Provider will be responsible for the creation and maintenance of income eligible files on clients served and documentation that all households are eligible under Income Guidelines. The Provider agrees that Community and Human Services Department shall be the final arbiter on the Provider's compliance. F. Provider shall provide the public with access to public records on the same terms and conditions that the public agency would provide the records and at a cost that does not exceed the cost provided in this chapter or as otherwise provided by law. Provider shall ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law. 28. MONITORING. During the term, Provider shall submit an annual audit report and monitoring report to the County no later than one hundred eighty (180) days after the Provider's fiscal year end. The County will conduct an annual financial and programmatic review. The Provider agrees that Community and Human Services Department will carry out no less than one (1) annual on-site monitoring visit and evaluation activities as determined necessary. At the County's discretion, a desk top review of the activities may be conducted in lieu of an on-site visit. The continuation of this Agreement is dependent upon satisfactory evaluations. The Provider shall, upon the request of Community and Human Services Department, submit information and status reports required by Community and Human Services Department to enable Community and Human Services Department to evaluate said progress and to allow for completion of reports required. The Provider shall allow Community and Human Services Department to monitor the Provider on site. Such site visits may be scheduled or unscheduled as determined by Community and Human Services Department. The County will monitor the performance of the Provider based on performance standards as stated with all other applicable federal, state and local laws, regulations, and policies governing the funds provided under this contract. Substandard performance as Page 8 of 11 1,,1\U determined by the County will constitute noncompliance with this Agreement. If corrective action is not taken by the Provider within a reasonable period of time after being notified by the County, contract suspension or termination procedures will be initiated. Provider agrees to provide the County's internal auditor(s) access to all records related to performance measures under this agreement. 29. CORRECTIVE ACTIONS. Corrective action plans may be required for noncompliance, nonperformance, or unacceptable performance under this contract. Penalties may be imposed for failures to implement or to make acceptable progress on such corrective action plans. (signature page to follow) Page 9 of 11 . ' IN WITNESS WHEREOF, the Provider and the County, have each, respectively, by an authorized person or agent, hereunder set their hands and seals on the date and year first above written. BOARD OF COUNTY COMMISSIONERS ATTEST: COLLIER COUNTY, FLORIDA Dwight E. Brock, Clerk of Courts �. _ �► By: / z: riEL T , Chairman Dated. \ N'ance_.. ,tt��;.4 a a - , �iit di s, sig re only. Provider: Physician Led Access Network of Collier County, Inc. Provider's First Witness: tc.L.ci E 6 -'d r By: `_ Signature it nat TType/print witness nameT Provider's Second Wi ness: al -02,0 D .W i 111 orvt by C 1'LCA i r o Signature Type/print signature and title (-1 COtteeA_ rtinX11 Ve_ TType/print witness nameT Approved as to form and legality: efe.k�. • As•►f taut ounty Attorney yC2. Pccin Print Name Page 9 of 10 Attachment A Physician Led Access Network of Collier County, Inc. (PLAN) Performance Measures Calendar Year(insert correct year) Performance 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Cumulative Measures Jan 1-Apr 30 May 1 —June 30 July 1 — Sep 30 Oct 1 —Dec 31 Total Number of patient Services: Value of donated services: Number of new medical providers enrolled in program: Signature & Date: *Services are defined as all encounters with each patient to include but not limited to Referral date, Enrolment date, Clinical service date, etc. Services do not include phone calls, and other routine customer service. Page 1 1 of 1 1 ACOREI CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 12/1/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONT PRODUCER NAMEACT Kristi Tulin Lutgert Insurance-Naples PHONE Fax PO Box 112500 (AICcNrk F,n)•239-280-3261 tac.Not:239 262-5360 Naples FL 34108 a DD ktulin @lutgertinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Old Dominion 40231 INSURED INSURER B: Physician Led Access Network INSURER C: of Collier County, Inc. 222 Industrial Boulevard, Suite#138 INSURER D: Naples FL 34104 INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER:297170688 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER (MMIDD/YYYY) (MM/DDIYYYY) A X COMMERCIAL GENERAL LIABILITY BPG0946A 12/1/2014 12/1/2015 EACH OCCURRENCE $1,000,000 DAMAGE CLAIMS-MADE X OCCUR PREMISES O(Ea occurrence) $500,000 MED EXP(Any one person) $5,000 _ PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY JECT LOC PRODUCTS-COMP/OP AGG $2,000,000 _ OTHER: $ A AUTOMOBILE LIABILITY BPG0946A - 12/1/2014 12/1/2015 COMBINED SINGLE LIMIT $ (Ea accident) 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED --'SCHEDULED BODILY INJURY(Per accident) $ X HIRED AUTOS )( NON-OWNED PROPERTY DAMAGE $ _ AUTOS (Per accident) UMBRELLA LIAB _ OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Collier County Board of County Commissioners as Additional Insured with regards to General Liaiblity. For any and all work on behalf of Collier County. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Collier County Board of County Commissioners ACCORDANCE WITH THE POLICY PROVISIONS. 3301 Tamiami Trail East Naples FL 34112 AUTHORIZED REPRESENTATIVE 2/Q24Lb ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Associated Industries Insurance Company, Inc. 6/9/2014 Physician Led Acess Network of Collier County Att: Deb Cecere 2500 Tamiami Tr. N. Suite 212 Naples FL 34103 RE: Workers' Compensation Coverage Effective Date: 7/20/2014 Policy Number: AWC1034704 Program Offered: Guaranteed Cost We are pleased to renew your workers' compensation coverage with Associated Industries Insurance Company, Inc., an AmTrust North America company. Depending on your pay plan, an invoice for the first installment may be enclosed. Enclosed with your policy are any premium credit applications, if applicable. Should you need to report a claim, please contact our Countrywide First Report Line at (866)272-9267 or our Florida First Report Line at(888)225-2442. Again, thank you for allowing Associated Industries Insurance Company, Inc. to service your workers' compensation needs. Sincerely, Michael R. Diamond Vice President, Underwriting cc: ProActive Insurance Management, LLC 5633 Strand Boulevard Suite 318 Naples FL 34110 [FILtrRenewBus] Associated Industries Insurance Company, Inc. PO Box 310704 Boca Raton, FL 33431-0704 WORKERS' COMPENSATION and EMPLOYERS' LIABILITY INSURANCE POLICY In Witness Whereof, we have caused this policy to be executed and attested, and, if required by state law, this policy shall not be valid unless countersigned by our authorized representative. n Stephen Ungar, Secretary Barry Dov Zyskind, President To obtain information,please contact your agent or Associated Industries Insurance Company, Inc. at 877-528-7878. You may also write Associated Industries Insurance Company, Inc. Consumer Relations at: 800 Superior Avenue East, 21st Floor Cleveland, OH 44114 we 00 00 00 FA AmTrust North America An AmTrust Financial Company Timely reporting of workers'compensation claims is essential so a complete and thorough investigation can be completed and determination of benefits made.Additionally, timely claim reporting supports our efforts to provide you and your employees the best possible medical and disability management. We urge you to please report the claim immediately upon notification. Claim Reporting Information To Report a Claim by Phone, Fax or Email For ALL States For Florida Only . Phone: (866) 272-9267 Florida Only: (888) 225-2442 Fax: (877) 669-9140 Fax: (561) 241-3257 Email: Amtrustclaims @qrm-inc.com Email: Amtrustclaims @qrm-inc.com Have a specific claim question? Contact the following service offices: States Office Mailing Address Physical Address Phone/Fax AL,AR,VA,NC, Atlanta Amtrust North America Amtrust North America 888-239-3909 SC,GA,MS,TN P.O.Box 740042 11330 Lakefield DR.,Bldg. II 678-258-8000 Atlanta,GA 30374-0042 Johns Creek,GA 30097 Fax 678-258-8399 AZ,LA,NM,OK, Dallas Amtrust North America Amtrust North America 214-360-8065 SD,TX,NE,UT, P.O.Box 650767 12790 Merit Drive 866-249-4298 CO,NV Dallas TX 75265-0767 Tower 9,3rd Floor Fax 678-258-8395 Dallas,TX 75251 Sub office in Missoula,MT MT Montana Amtrust North America The Talbot Agency Attn:Kay Martin 866-246-6891 P.O.Box 650767 2600 Garfield Street 678-258-8531 Dallas,TX 75265-0767 Missoula,MT 59806 Fax 214-382-2425 CT,DC,DE,MA, Princeton Amtrust North America Amtrust North America 888-239-3909 MD,ME,NH,NJ, P.O.Box 105010 300 Alexander Park,Suite 300 Fax 678-258-8399 NY,PA,RI,VT Atlanta,GA 30348-5010 Princeton, NJ 08540 IL,IN,KS, Chicago Amtrust North America Amtrust North America 888-239-3909 KY,MI,MO P.O.Box 105074 33 W.Monroe 312-781-0401 Atlanta,GA 30348-5074 Chicago,IL 60603 Fax 678-258-8399 IA Des Moines Amtrust North America Amtrust North America 888-239-3909 x8534 P.O.Box 105074 4201 Weston Parkway,Ste 214 678-258-8534 Atlanta,GA 30348-5074 West Des Moines,IA 50266 Fax 678-258-8399 MN,WI Milwaukee Amtrust North America Amtrust North America 888-239-3909 x 8538 P.O.Box 105074 400 S.Executive Dr.,Ste 150 262-641-0672 Atlanta,GA 30348-5074 Brookfield,WI 53005 Fax 678-258-8399 FL Florida AIIS,an AmTrust Group Company AIIS,an AmTrust Group Company 800-866-8600 P.O.Box 310719 901 NW 51st St. 561-994-9888 Boca Raton,FL 33431 Boca Raton,FL 33431 Fax 561-995-1004 Sub offices in Sunrise&Clearwater AIIS,an AmTrust Group Company AIIS,an AmTrust Group Company 800-866-8600 P.O.Box 310719 1551 Sawgrass Corporate Parkway 561-994-9888 Boca Raton,FL 33431 Suite 105 Fax 561-995-1004 Sunrise,FL 33323 AIIS,an AmTrust Group Company AIIS,an AmTrust Group Company 727-725-9900 P.O.Box 310719 2605 Enterprise Rd.East,Suite 290 888-250-7030 Boca Raton,FL 33431 Clearwater,FL 33759 Fax 727-725-7456 ACORD TM WORKERS COMPENSATION-FIRST REPORT OF INJURY OR ILLNESS EMPLOYER(NAME&ADDRESS INCL ZIP) CARRIER/ADMINISTRATOR CLAIM NUMBER REPORT PURPOSE CODE Physician Led Acess Network of Collier JURISDICTION JURISDICTION CLAIM NUMBER County 2500 Tamiami Tr.N. INSURED REPORT NUMBER Naples FL 34103 SIC CODE EMPLOYER FEIN EMPLOYER'S LOCATION ADDRESS(IF DIFFERENT) LOCATION# 200477556 PHONE# COUNTY CARRIER/CLAIMS ADMINISTRATOR CARRIER(NAME,ADDRESS&PHONE NO) POLICY PERIOD CLAIMS ADMINISTRATOR(NAME,ADDRESS&PHONE NO) Associated Industries Insurance Company, 7/20/2014 To Report a Claim By Phone: 1-866-272-9267 Inc. TO To Report a Claim By Fax: 1-877-669-9140 800 Superior Avenue East,21st Floor 7/20/2015 To Report a Claim My Email:amtrustclaims @qmi-inc.com Cleveland,OH 44114 CHECK IF APPROPRIATE 877-528-7878 ❑SELF INSURANCE CARRIER FEIN POLICY/SELF INSURED NUMBER ADMINISTRATOR FEIN 59-0714428 AWC1034704 AGENT NAME&CODE NUMBER ProActive Insurance Management,LLC-#20269 EMPLOYEE/WAGE NAME(LAST,FIRST,MIDDLE) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED STATE OF HIRE ADDRESS(INCL ZIP) SEX MARITAL STATUS OCCUPATION/JOB TITLE ❑MALE ❑UNMARRIED(SNGL/DIV) ❑FEMALE ❑MARRIED ❑UNKNOWN ❑SEPARATED ❑UNKNOWN EMPLOYMENT STATUS PHONE HOME #OF DEPENDENTS NCCI CLASS CODE WORK RATE PER: ❑DAY 0 MONTH #DAYS WORKED/WEEK FULL PAY FOR DAY OF INJURY? ❑YES ❑NO O WEEK ❑OTHER: DID SALARY CONTINUE ❑YES ❑NO OCCURRENCE/TREATMENT TIME EMPLOYEE BEGAN WORK DATE OF INJURY/ TIME OF LAST WORK DATE DATE EMPLOYER DATE DISABILITY BEGAN ILLNESS OCCURRENCE NOTIFIED CONTACT NAME/PHONE NUMBER TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED DID INJURY/ILLNESS EXPOSURE OCCUR ON EMPLOYER'S PREMISES? TYPE OF INJURY/ILLNESS CODE PART OF BODY AFFECTED ❑YES ❑NO DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED ALL EQUIPMENT,MATERIALS,OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLESS WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED EXPOSURE OCCURRED HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED.DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECT OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL CAUSE OF INJURY CODE DATE RETURN(ED)TO WORK IF FATAL GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? ❑YES ❑NO WERE THEY USED? ❑YES ❑NO HOSPITAL(NAME&ADDRESS) INITIAL TREATMENT ❑NO MEDICAL TREATMENT ❑MINOR BY EMPLOYER WITNESS(NAME&PHONE) ❑MINOR CLINIC/HOSP ❑EMERGENCY CARE ❑HOSPITALIZED>24 HRS ❑FUTURE MAJOR MED/LOST TIME ANTICIPATED DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER'S NAME&TITLE PHONE NUMBER WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Form 09-Notice (Ed. 1-14) FLORIDA NOTICE OF PENDING LAW CHANGE TO TERRORISM RISK INSURANCE PROGRAM REAUTHORIZATION ACT OF 2007 This notice is being sent to you with respect to your workers compensation and employers liability insurance policy. This notice does not replace the separate Florida Terrorism Risk Insurance Program Reauthorization Act Endorsement (WC 09 04 03 A) that is attached to your current policy and which remains in effect as applicable. The Terrorism Risk Insurance Act of 2002 (TRIA) as previously amended and extended by the Terrorism Risk Insurance Program Reauthorization Act of 2007 (TRIPRA), provides for a program under which the federal government will share in the payment of insured losses caused by certain acts of terrorism. In the absence of affirmative US Congressional action to extend, update, or otherwise reauthorize TRIPRA, in whole or in part, TRIPRA is scheduled to expire December 31, 2014. Since the timetable for any further Congressional action respecting TRIPRA is unknown at this time, and exposure to acts of terrorism remains, we are providing our policyholders with relevant information concerning their workers compensation policies in effect on or after January 1, 2014 in the event of TRIPRA's expiration. Your policy provides coverage for workers compensation losses caused by acts of terrorism or war, including workers compensation benefit obligations dictated by state law. Coverage for such losses is still subject to all terms, definitions, exclusions, and conditions in your policy. The premium charge for the coverage your policy provides for terrorism or war losses is shown in Item 4 of the Information Page or the Schedule in the Florida Terrorism Risk Insurance Program Reauthorization Act Endorsement (WC 09 04 03 A) that is attached to your policy, and this amount may continue or change for new, renewal, and in-force policies in effect on or after December 31, 2014 in the event of TRIPRA's expiration, subject to regulatory review in accordance with applicable state law. You need not do anything further at this time. Form 09-Notice (Ed.1-14) ©Copyright 2013 National Council on Compensation Insurance,Inc.All Rights Reserved Associated Industries Insurance Company, Inc. A Stock Insurance Company PO Box 310704 Boca Raton,FL 33431-0704 WORKERS COMPENSATION WC 00 00 01 A AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE 1. Insured: Policy Number: AWC1034704 Physician Led Acess Network of Collier County 2500 Tamiami Tr.N. Suite 212 Naples,FL 34103 Federal Tax ID: 200477556 Other workplaces not shown above: Board File Number: See Extension of Information Page Renewal Of: AWC1022898 Producer: Entity: Corporation AmTrust North America,Inc. Interim Adjustment: Annual c/o ProActive Insurance Management,LLC Ncci Code: 25372 5633 Strand Boulevard Suite 318 SIC Code: 7338 Naples,FL 34110 2. The policy period is from 7/20/2014 to 7/20/2015 12:01 a.m.at the insured's mailing address. 3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed here:Florida B. Employers Liability Insurance:Part Two of the policy applies to work in each stated listed in item 3.A.The limits of our liability under Part Two are: Bodily Injury by Accident $ 1,000,000 each accident Bodily Injury by Disease $ 1,000,000 policy limit Bodily Injury by Disease $ 1,000,000 each employee C. Other States Insurance:Part Three of the policy applies to the states, if any,listed here:All states except ND, OH,WA,WY and State(s)Designated in Item 3A. D. This policy includes these endorsements and schedules: See attached endorsement schedule. 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans. All information required below is subject to verification and change by audit. See Extension of Information Page TOTAL ESTIMATED ANNUAL PREMIUM 989 STATE ASSESSMENT 0 TOTAL ESTIMATED COST 989 Minimum Premium 342 Deposit Premium 989 Issue Date: 6/9/2014 Countersigned By: Authorized Representative A STOCK COMPANY MARKEL® MARKEL AMERICAN INSURANCE COMPANY 4521 Highwoods Parkway Glen Allen, VA 23060 (804) 527-2700 INSURANCE POLICY Coverage afforded by this policy is provided by the Company(Insurer)and named in the Declarations. In Witness Whereof,the company(insurer) has caused this policy to be executed and attested and countersigned by a duly authorized representative of the company(insurer) identified in the Declarations. /2.,LihilZ_ /Q4 _ _ _ C46.1,, Secretary President 1000 06 10 Page 1 of 1 MARKEL AMERICAN INSURANCE COMPANY IIII MAM NOT-FOR-PROFIT MANAGEMENT LIABILITY POLICY DECLARATIONS Claims Made Coverage: The coverage afforded by this policy only applies to Claims that are first made against the Insured during the Policy Period or the Extended Reporting Period, if exercised. Notice: If purchased pursuant to Item 5 below, the Insurer shall have the duty to defend covered Claims. Claims Expenses shall reduce the Limit of Liability and any applicable Retention under this policy, unless otherwise stated in an endorsement to this policy. Pleas751 the policy carefully. POLICY NUMBER: ML-811844 RENEWAL OF POLICY: ML-805635 IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, THE INSURER AGREES WITH THE PARENT ORGANIZATION TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. Item 1. Parent Organization and Address (No., Street, Town or City,State,Zip Code) PHYSICIAN LED ACCESS NETWORK OF COLLIER COUNTY, INC. 2500TAMIAMI TRAIL NORTH NAPLES, FL 34103 Item 2. Policy Period Fr January 13, 2014 tauary 13, 2015, at 12:01 A.M. Standard Time at the address shown above. Item 3. Extended Reporting Period A. Additional Premium: B. Additional Period: (Percent of Annualized Premium Stated in Item 4 below) 75% 1 Year 100% 3 Years 125% 6 Years Item 4. Policy Premium \/$5,500.00 Payable at inception 1.3% FL Hurricane Catastrophe Fund 71.50 \lK. Producer Number, Name and Address 25437 ATLANTIC SPECIALTY LINES OF FLORIDA, INC 380 Park Place Blvd Suite 175 Clearwater, FL 33759 MDML 1001 01 11 Page 1 of 3 Item 5. Coverage Schedule This policy includes only those Coverage Parts designated below by"X"as purchased. If a Coverage Part is not expressly designated as purchased, this policy does not include such Coverage Part. Coverage Coverage Coverage Part Coverage Coverage Part Part Coverage Part Part Pending or Part Duty Purchased Limit of Liability Retention ' � Prior Date to Defend A. Directors and Officers and Yes [X] k 1,000,000 Yes[X] Organization Liability No [ ] Aggregate Limit of No [ ] Liability 1. Insuring Agreement A: $0 V /13/2006 Insured Person Liability Each Claim 2. Insuring Agreement B: ✓$`25,000 1/13/2006 Organization Each Claim Reimbursement 3. Insuring Agreement C: $25,000 1/13/2006 Organization Liability Each Claim B. Employment Practices and Yes [X] $1,000,000 025,000 1/13/2006 Yes[X] Third Party Discrimination No [ ] Aggregate Limit of Each No [ ] Liability Liability Employment Practices Claim Third Party ✓$25,000 1/13/2006 Discrimination Each Third Liability Sublimit: Party $1,000,000 Discrimina- All Claims tion Claim Wage and Hour Claims Sublimit: $0 All Claims C. Fiduciary Liability Yes [ I Yes[ ] No [X1 Aggregate Limit of Each Claim No [ ] Liability Voluntary Settlement Programs Sublimit: No Retention shall apply to Non-Indemnifiable Loss incurred by Insured Persons under any Coverage Part, except as required by state law. Item 6. Coverage Parts Which Share a Limit of Liability [ ] A. Directors and Officers and Organization Liability [ ] B. Employment Practices and Third Party Discrimination Liability [ ] C. Fiduciary Liability [X] D. None Item 7. Combined Aggregate Limit of Liability $2,000,000 All Loss (including Claim Expenses) under all purchased Coverage Parts, combined. MDML10010111 Page 2of3 Item 8. Forms and Endorsements Forms and Endorsements applying to the Coverage Part(s) made part of this policy at time of issue: MML 1004 01 11 General Terms and Conditions MML 1005 01 11 Directors and Officers and Organization Liability Coverage Part MML 1006 01 11 Employment Practices and Third Party Discrimination Liability Coverage Part ✓ 1. MPML 1000 05 10 Notices to Insurer 2. MML 1223 05 10 Certified Acts of Terrorism Coverage 3. MPIL 1007 04 10 Privacy Notice 4. MPML 1003 01 11 Confirmation of Certified Acts of Terrorism Coverage 5. MIC-PN-FL 08 07 Florida Policyholder Notice 6. MML 1434-FL 01 11 Florida Amendatory Endorsement 7. MPML 1002 09 10 Policyholder Notice-Claim Expenses 8. MPML 1009-FL 01 11 Florida Loss Control Policyholder Notice 9. MML 1314 01 11 Healthcare Professional Liability E fusion✓ 10. MML 1315 01 11 Sexual Misconduct Exclusion These declarations, together with the General Terms and Conditions and Coverage Part(s) and any Endorsements(s), complete the above numbered policy. February 10, 2014 Countersignature Date Authorized Representative MDML 1001 01 11 Page 3 of 3