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#18-7470 (Omega Care Services)
FIXED FEE PROFESSIONAL SERVICE AGREEMENT 18-7470 for Services for Seniors Program _ THIS AGREEMENT, made and entered into on this day of \�.]�,n(4 I `-k 20 by and between Omega Health Services, LLC d/b/a Omega Care Services authorized to do business in the State of Florida, whose business address is 5921 Washington Street#120, Hollywood, FL 33023 , (the "Contractor") and Collier County, a political subdivision of the State of Florida, (the "County"): WITNESSETH: 1. The Agreement shall be for a three (3 ) year period, commencing • upon the date of Board approval on and terminating on three (3 ) year(s) from that date or until all outstanding Purchase Order(s) issued prior to the expiration of the Agreement period have been completed or terminated. The County may, at its discretion and with the consent of the Contractor, renew the Agreement under all of the terms and conditions contained in this Agreement for three (3 ) additional one ( 1 ) year(s) periods. The County shall give the Contractor written notice of the County's intention to renew the Agreement term 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 one hundred and eighty (180) days. The County Manager, or his designee, shall give the Contractor written notice of the County's intention to extend the Agreement term prior to the end of the Agreement term then in effect. 2. COMMENCEMENT OF SERVICES. The Contractor shall commence the work upon issuance of a Purchase Order n Notice to proceed --der. 3. STATEMENT OF WORK. The Contractor shall provide services in accordance with the terms and conditions of ■ Request for Proposal (RFP) Invitation to Bid (ITB)- Other ( } # 18-7470 , including all Attachment(s), Exhibit(s) and Addenda and the Contractor's proposal referred to herein and made an integral part of this Agreement. ■ The Contractor shall also provide services in accordance with Exhibit A — Scope of Services attached hereto. Page 1 of 15 Fixed Price Professional Service Agreement#2017-001 (Ver.2) 0 3.1 This Agreement contains the entire understanding between the parties and any modifications to this Agreement shall be mutually agreed upon in writing by the Parties, in compliance with the County's Procurement Ordinance, as amended, and Procurement Procedures in effect at the time such services are authorized. 3.2 The execution of this Agreement shall not be a commitment to the Contractor to order any minimum or maximum amount. The County shall order items/services as required but makes no guarantee as to the quantity, number, type or distribution of items/services that will be ordered or required by this Agreement. 4. THE AGREEMENT SUM. The County shall pay the Contractor for the performance of this Agreement based on Exhibit B- Fee Schedule, attached hereto and the price methodology as defined in Section 4.1. Payment will be made upon receipt of a proper invoice and upon approval by the County's Contract Administrative Agent/Project Manager, and in compliance with Chapter 218, Fla. Stats., otherwise known as the "Local Government Prompt Payment Act". 4.1 Price Methodology (as selected below): ❑ ••.,e. _ _..U. :w. ".•..__ : A .._•• =e. e _ ,. e.•._ ••e e t..e•_._.; •_ _ _ •,, e ea. at: —. ._• • 41:: ••. e ; •.•. _ �„._•.•_.�__ e - •- ae •e_ e ••_.,t •.• e• _ s : _.• te, • • _ea.. -_.s ••_- ! ■e a•. e at t _ a.. at. ��•.. _ • e•=. ie. z a ••=a. e.. ■: •. =e price contract is authorized. 0■ Time and Materials: The County agrees to pay the contractor for the amount of labor time spent by the contractor's employees and subcontractors to perform the work (number of hours times hourly rate), and for materials and equipment used in the project (cost of materials plus the contractor's markup). This methodology is generally used in projects in which it is not possible to accurately estimate the size of the project, or when it is expected that the project requirements would most likely change. As a general business practice, these contracts include back-up documentation of costs; invoices would include number of hours worked and billing rate by position (and not company (or subcontractor) timekeeping or payroll records), material or equipment invoices, and other reimbursable documentation for the project. II • ma e • =e e - = _._.- •• • •• -se •• - -• •••-• a.. e •- _• a e _ ;e: e !! _ _ - e e - ••. e et ,a ,: :* e et e.. .. -et e , �, •- .•.. e _.:.....••_ _ ••-•_..1 •- _ • a__. :. W..•.• •_W. • _ •••- Via.__-__•.• _ e `ae ea • •• =• e• • e._. - •e• . Page 2 of 15 Fixed Price Professional Service Agreement#2017-001(Ver.2) 0 4.2 Any County agency may obtain services under this Agreement, provided sufficient funds are included in their budget(s). 4.3 Payments will be made for services furnished, delivered, and accepted, upon receipt and approval of invoices submitted on the date of services or within six (6) months after completion of the Agreement. Any untimely submission of invoices beyond the specified deadline period is subject to non-payment under the legal doctrine of "laches" as untimely submitted. Time shall be deemed of the essence with respect to the timely submission of invoices under this Agreement. 4.4 ❑ - • • r _. a w.,W.. • : ' - a - . �. �.. -.•e ��...u��.. -- e : a-. e: 9e e :e •. ..• ..__W.. • —me e . w... .. W .. ...:.. shall be reimbursed as per Section 112.061 Fla. Stats. •-'... W.•• • _ -• •e •- e e '.e - Mileage file Breakfast Lunch Dinner $19.00 A4ar-e Actual ticket cost limited to tourist or Rental car :a _ _e_ .. :e e _ease_ _ standard-size vehicles Lodging Actual cost of lodging at single occupancy rate with a cap of no more than $150.00 per night e A. ee •••e__.•: Actual cost of either taxi or airport limousine •-'... . s•• • .- •-.• - - .-• - •- .. '.•' -. e a- e e '•• _.e•}._- ••• e' . • _ - •___. •- . e:_, ••-_.a,,e e '... •_ e t_ ' .. ,,_ •_ • ... .._-.. '.:a._ e: e_., e• .-. •• e •_... • e '.-. '. aCW-Ft -- --. _ __.•e•- - 'e: -.._._.• e- -__ •.. e_.. fit- 5. SALES TAX. Contractor 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. Page 3 of 15 Fixed Price Professional Service Agreement#2017-001(Ver.2) 6. NOTICES. All notices from the County to the Contractor shall be deemed duly served if mailed or emailed to the Contractor at the following: Company Name: Omega Health Services, LLC d/b/a Omega Care Services Address: 5921 Washington Street#120 Hollywood, FL 33023 Authorized Agent: Agnes Saint Preux Attention Name & Title: Administrator Telephone: 786-304-8483 E-Mail(s): info@omegahealthservices.org All Notices from the Contractor to the County shall be deemed duly served if mailed or emailed to the County to: Board of County Commissioners for Collier County, Florida Division Director: Kristi Sonntag Division Name: Community and Human Services Division Address: 3339 East Tamiami Trail Building H, Room 211 Naples, Florida 34112 Administrative Agent/PM: Wendy Klopf, Grants Coordinator Telephone: 239-252-2901 E-Mail(s): wendy.klopf@colliercountyfl.gov The Contractor 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 Contractor or to constitute the Contractor 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 Contractor. The County will not be obligated to pay for any permits obtained by Subcontractors. 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 Contractor. The Contractor shall also be solely responsible for payment of any and all taxes levied on the Contractor. In addition, the Contractor 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 Contractor agrees to comply with all laws governing the responsibility of an employer with respect to persons employed by the Contractor. Page 4 of 15 Fixed Price Professional Service Agreement#2017-001(Ver.2) 0 9. NO IMPROPER USE. The Contractor 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 Contractor or if the County or its authorized representative shall deem any conduct on the part of the Contractor to be objectionable or improper, the County shall have the right to suspend the Agreement of the Contractor. Should the Contractor 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 Contractor further agrees not to commence operation during the suspension period until the violation has been corrected to the satisfaction of the County. 10. TERMINATION. Should the Contractor be found to have failed to perform his 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 the sole judge of non-performance. In the event that the County terminates this Agreement, Contractor's recovery against the County shall be limited to that portion of the Agreement Amount earned through the date of termination. The Contractor 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 Contractor agrees that there shall be no discrimination as to race, sex, color, creed or national origin. 12. INSURANCE. The Contractor shall provide insurance as follows: A. 0 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 Contractors; Products and Completed Operations and Contractual Liability. B. ❑■ Business Auto Liability: Coverage shall have minimum limits of $ 1,000,000 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. Page 5 of 15 Fixed Price Professional Service Agreement#2017-001(Ver.2) 0 The coverage must include Employers' Liability with a minimum limit of $ 1,000,000 for each accident. D. . Professional Liability: Shall be maintained by the Contractor to ensure its legal liability for claims arising out of the performance of professional services under this Agreement. Contractor waives its right of recovery against County as to any claims under this insurance. Such insurance shall have limits of not less than $ 1,000,000 each claim and aggregate. • _. _ •. . a y m e • a m_•• as occurrence. g n Tec nology-Errs-and--Qnlissions ver-age-sfaaft have-+mtnirnum- its-of $►— --per-occurrence„ G„ -pe -eccurrence- G- ! _!: -• •_ : •••• _•___•• '••• e per occurrence: {�-- n •- :_, }se .. se __... . , •. _...., a •.,...e _ ' • _ e : _. - -•- occurrence: L I - $ per occurrence. L. INC Crime/Employee Dishonesty (other): Coverage shall have minimum limits of$50,000 per occurrence. Special Requirements: Collier County Board of County Commissioners, OR, Board of County Commissioners in Collier County, OR, Collier County Government shall be listed as the Certificate Holder and included as an "Additional Insured" on the Insurance Certificate for Commercial General Liability where required. This insurance shall be primary and non-contributory with respect to any other insurance maintained by, or available for the benefit of, the Additional Insured and the Contractor's policy shall be endorsed accordingly. Current, valid insurance policies meeting the requirement herein identified shall be maintained by Contractor during the duration of this Agreement. The Contractor shall provide County with certificates of insurance meeting the required insurance provisions. Renewal certificates shall be sent to the County thirty (30) days prior to any expiration date. Coverage afforded under the policies will not be canceled or allowed to expire until the greater of: thirty (30) days prior written notice, or in accordance with policy provisions. Contractor 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 Contractor from its insurer, and nothing contained herein shall relieve Contractor of this requirement to provide notice. Page 6 of 15 Fixed Price Professional Service Agreement#2017-001 (Ver.2) I0 Contractor shall ensure that all subcontractors comply with the same insurance requirements that the Contractor is required to meet. 13. INDEMNIFICATION. To the maximum extent permitted by Florida law, the Contractor shall defend, 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 Contractor, 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 Contractor or anyone employed or utilized by the Contractor 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 Contractor, 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 Contractor. Contractor'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. AGREEMENT ADMINISTRATION. This Agreement shall be administered on behalf of the County by the Community and Human Services Division 15. CONFLICT OF INTEREST. Contractor 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. Contractor further represents that no persons having any such interest shall be employed to perform those services. 16. COMPONENT PARTS OF THIS AGREEMENT. This Agreement consists of the following component parts, all of which are as fully a part of the Agreement as if herein set out verbatim: Contractor's Proposal, Insurance Certificate(s), IUI Exhibit A Scope of Services, Exhibit B Fee Schedule, IMI RFP/I I ITB/LI Other #18-7470 , including Exhibits, Attachments and Addenda/Addendum, ❑ subsequent quetes, and ■ Other Exhibit/Attachment: Grant Documents Page 7 of 15 Fixed Price Professional Service Agreement#2017-001 (Ver.2) 17. APPLICABILITY. Sections corresponding to any checked box (11111) will expressly apply to the terms of this Agreement. 18. 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. 19. 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 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 Agreement held by the individual and/or firm for cause. 20. COMPLIANCE WITH LAWS. By executing and entering into this Agreement, the Contractor 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)-(b) as stated as follows: IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN OF PUBLIC RECORDS AT: Communication and Customer Relations Division 3299 Tamiami Trail East, Suite 102 Naples, FL 34112-5746 Telephone: (239) 252-8383 The Contractor must specifically comply with the Florida Public Records Law to: 1. Keep and maintain public records required by the public agency to perform the service. Page 8 of 15 Fixed Price Professional Service Agreement#2017-001(Ver.2) 2. Upon request from the public agency's custodian of public records, provide the public agency with a copy of the requested records or allow the records to be inspected or copied within a reasonable time at a cost that does not exceed the cost provided in this chapter or as otherwise provided by law. 3. Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not disclosed except as authorized by law for the duration of the contract term and following completion of the contract if the Contractor does not transfer the records to the public agency. 4. Upon completion of the contract, transfer, at no cost, to the public agency all public records in possession of the Contractor or keep and maintain public records required by the public agency to perform the service. If the Contractor transfers all public records to the public agency upon completion of the contract, the Contractor shall destroy any duplicate public records that are exempt or confidential and exempt from public records disclosure requirements. If the Contractor keeps and maintains public records upon completion of the contract, the Contractor shall meet all applicable requirements for retaining public records. All records stored electronically must be provided to the public agency, upon request from the public agency's custodian of public records, in a format that is compatible with the information technology systems of the public agency. If Contractor observes that the Contract Documents are at variance therewith, it shall promptly notify the County in writing. Failure by the Contractor 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. 21. OFFER EXTENDED TO OTHER GOVERNMENTAL ENTITIES. Collier County encourages and agrees to the successful Contractor extending the pricing, terms and conditions of this solicitation or resultant Agreement to other governmental entities at the discretion of the successful Contractor. 22. 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. 23. ADDITIONAL ITEMS/SERVICES. Additional items and/or services may be added to this Agreement in compliance with the Procurement Ordinance, as amended, and Procurement Procedures. 24. 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 Contractor 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 Page 9 of 15 Fixed Price Professional Service Agreement#2017-001(Ver 2) 0 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 Contractor with full decision-making authority and by County's staff person who would make the presentation of any settlement reached at mediation to 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. 25. 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. 26. n - • ....... _.-. .._.... ._ . �_ •�.... ,,.e•• _.•• .. • e:..-.. e et • e e :__ _•_ et •,_. ..- • _ •n-tiel--areas of expertise. es • •_ • e ___ •e_ ._- •• •- et t.rrIerd—rleGessary to ensure that _.•••- -• ___•- .. ._ -• •. • et•e .. . -_.•.._ • • • __.•_-• . •_ _ .•. _ _ . _•_ _ _.....•.. •• • .-e• - .- - • w _.... .- - . -- e• •..- _e -• _. a. e_. •._ _ e• _._.�.. _•_. •• • •e_ z �- �••.e • •- a..e , ...AU_.' - eee_te _ a. _ _ _!_ _ • _ •_ __••_ • _!. _ •._..�.. �•___ a •- _ea _. •. •._.. .•_ . - e•.•._ - 1.1 AGREEMENT STAFFING. The Contractor's personnel and management to be utilized for this Agreement shall be knowledgeable in their areas of expertise. The County reserves the right to perform investigations as may be deemed necessary to ensure that competent persons will be utilized in the performance of the Agreement. The Contractor shall assign as many people as necessary to complete required services on a timely basis, and each person assigned shall be available for an amount of time adequate to meet required services. 27. l ORDER OF PRE-C-E-DE--A1C.€ to the event of any conflict between or among the. am_ e _.. e •_ _e. . _ !•__ .•..:.. • - •• e . • ' ' '.••. •._ e• • • •••.. ... _ .. a a_ • • ' w__. a _ .e. . . G? ••..._ •- e• - - • ORDER OF PRECEDENCE (Grant Funded). In the event of any conflict between or among the terms of any of the Contract Documents and/or the County's Board approved Executive Summary, the terms of the Agreement shall take precedence over the terms of all other Contract Documents, except the terms of any Supplemental Conditions shall take precedence over the Agreement. To the extent any conflict in the terms of the Contract Documents cannot be resolved by application of the Supplemental Conditions, if any, or the Agreement, the conflict shall be resolved by Page 10 of 15 Fixed Price Professional Service Agreement#2017-001 (Ver.2) imposing the more strict or costly obligation under the Contract Documents upon the Contractor at County's discretion. 28. ASSIGNMENT. Contractor 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 Contractor does, with approval, assign this Agreement or any part thereof, it shall require that its assignee be bound to it and to assume toward Contractor all of the obligations and responsibilities that Contractor has assumed toward the County. 29. SECURITY. The Contractor is required to comply with County Ordinance 2004-52, as amended. Background checks are valid for five (5) years and the Contractor shall be responsible for all associated costs. If required, Contractor shall be responsible for the costs of providing background checks by the Collier County Facilities Management Division for all employees that shall provide services to the County under this Agreement. This may include, but not be limited to, checking federal, state and local law enforcement records, including a state and FBI fingerprint check, credit reports, education, residence and employment verifications and other related records. Contractor shall be required to maintain records on each employee and make them available to the County for at least four (4) years. All of Contractor's employees and subcontractors must wear Collier County Government Identification badges at all times while performing services on County facilities and properties. Contractor ID badges are valid for one (1) year from the date of issuance and can be renewed each year at no cost to the Contractor during the time period in which their background check is valid, as discussed below. All technicians shall have on their shirts the name of the contractor's business. The Contractor shall immediately notify the Collier County Facilities Management Division via e-mail (DL-FMOPS@colliergov.net) whenever an employee assigned to Collier County separates from their employment. This notification is critical to ensure the continued security of Collier County facilities and systems. Failure to notify within four (4) hours of separation may result in a deduction of$500 per incident. (Intentionally left blank -signature page to follow) Page 11 of 15 Fixed Price Professional Service Agreement#2017-00I (Ver 2) IN WITNESS WHEREOF, the parties hereto, have each, respectively, by an authorized person or agent, have executed this Agreement on the date and year first written above. ATTEST: BOARD OF CO TY COMMISSI• ERS COLLIER CO 'NT LORID Crystal K. Kinzel, C erkc& Comptroller / • L,_ ® 4(1 AA A, V.olis, Esq. , Chairman Dated: t— .. 1y� trfdiS to Nionan s..� Contr$I9 4hesses: Omega Health Services, LLC d/b/a Omega Care Services Contractor L1 . 1 _iti By.: (?A4(3 C•ntractor's First Witnessii Signatur 'nec % cull7-t" 04---LA,\<- O. l.X' \' TT pe/print signature and titleT TType/print witness natheT / - _ Contractor's Second Witness TType/print witness nameT 'pro ed as or and Legality: 111. ' ' -e--•: L ! -a,4, County Attorney �S'uit R—A-_,,,c_ Print Name Page 12 of 15 Fixed Price Professional Service Agreement#2017-001(Ver.2) V Exhibit A Scope of Services ❑■ following this page (pages 1 through 3 ) ❑ this exhibit is not applicable Page 13 of 15 Fixed Price Professional Service Agreement#2017-001 (Ver.2) 18-7470 Services for Seniors SCOPE OF SERVICES The Contractors ("Service providers" or"Vendors") providing the services detailed in this scope must adhere to all requirements in the Request for Proposal (RFP), in addition to maintaining adherence with the guidelines set forth by the current DOEA Handbook. Lack of knowledge of all requirements of a service listed in the proposal SHALL NOT relieve the provider of liability and obligations under the agreement. Collier County Community & Human Services (CHS) shall lead all service authorization and coordination. In an effort to comply with the requirements of the OAA, ADI, CCE and HCE Programs, clients entering the service system will be assessed and prioritized by CHS. Upon determination of the service level to be provided, the CHS will offer the client a listing of service vendors for the specific service(s) outlined within their care plan. The client will be encouraged to pick a service provider of their choice and have the option of interviewing potential service providers. Should the dient not have a preference, CHS will select a service provider from the centralized provider list, using a rotation basis (rotating to the next vendor on the list). In this manner, all service providers will be equally treated unless the client has a preference. CHS shall not endorse one service provider over another. Upon the determination of the service, the service levels, and the selected vendor, CHS will contact the vendor agency, and authorize the service, number of hours, and frequency. In keeping with the state policy of client choice of service providers, Collier County does not guarantee a minimum or maximum number of clients that will be referred, nor a minimum or maximum number of service hours that will be requested during the contract period. Should a client later indicate dissatisfaction with the chosen service provider, they will again be offered their choice of provider. CHS shall send the agreed-upon Service Authorization to the chosen provider. These "service authorizations" or"service orders" must contain necessary client information, such as street address, telephone number, and services or items needed, as well as the name and telephone number of the CHS case manager authorizing the service. In order to meet client needs, some services may be required outside of normal office hours(8:00 AM to 5:00 PM, Monday- Friday). CHS reserves the right to request adding additional service providers throughout the resultant agreement period. The County may do so through a competitive and publidy announced selection process, which shall be coordinated through the County's Procurement Department. Services shall be provided in the manner described in the most current DOEA manual and outlined herein. Should funding for additional Senior Services be identified the County reserves the right to add to the resultant agreements the services, descriptions, rates, etc. by way of a contract addendum. Services covered by this agreement include, but are not limited to: 1. Adult Day Care: A program of therapeutic social and health activities and services provided to adults who have functional impairments, in a protective environment that provides as non-institutional an environment as possible. 2. Chore: Performance of routine house or yard tasks including such jobs as seasonal cleaning, yard work, lifting and moving furniture, appliances, or heavy objects, household repairs which do not require a permit or specialist, and household maintenance. 3. Enhanced Chore: This service is beyond the scope of chore due to the level of service needed.The service includes a more intensified, thorough cleaning to address more demanding circumstances. 4. Homemaking: Specific home management duties including housekeeping, laundry, cleaning refrigerators, clothing repair, minor home repairs, assistance with budgeting and paying bills, client 6 C_ Page 1 of 3 transportation, meal planning and preparation, shopping assistance, and routine house-hold activities by a trained homemaker. 5. Personal Care: Assistance with eating, dressing, personal hygiene and other activities of daily living. This service may include assistance with meal preparation, housekeeping chores such as bed making, dusting, and vacuuming incidental to the care furnished or essential to the health and welfare of the individual. Personal care can include accompanying the client to clinics, physician office visits, or trips for the purpose of health care provided that the client does not require special medical transportation. Personal care can also include shopping assistance to purchase food, clothing, and other items needed for the client's personal care needs. 6. In Home Respite: Relief or rest for a primary caregiver from the constant/continued supervision, companionship, therapeutic and/or personal care, of a functionally impaired older person for a specified period of time. 7. Skilled Nursing: Part-time or intermittent nursing care administered to an individual by a licensed practical nurse, registered nurse, or advanced registered nurse practitioner, in the client's place of residence, pursuant to a care plan approved by a licensed physician. 8. Emergency Alert Response Services: Emergency alert/response service is defined as a community based electronic surveillance service which monitors the frail homebound elder by means of an electronic communication link with a response center. 9. Specialized Medical Equipment, Services, and Supplies: Adaptive devices, controls, appliances, or services, which enable individuab to increase their ability to perform activities of daily living and repair of such services which may include: dentures, walkers, reaching devices, bedside commodes, telephone amplifiers, touch lamps, adaptive eating equipment, glasses, hearing aids, and other mechanical or non- mechanical, electronic, and non-electronic adaptive devices. Supplies may include such things as adult briefs, bed pads, oxygen or nutritional supplements. 10. Facility Respite: 24-hour care in a State of Florida Licensed Nursing home. 11. Establish protocols for contacting CHS Case Managers in emergency or unusual circumstances and include the documentation requirements (oral and written) in the Service Provider Application. 12. Provide disaster response protocols, plans and services: In the event of a natural disaster (hurricane, tropical storm, tornado, flood, heat wave, etc.), the provider will have staff available to serve those clients in critical need of services, as designated by the CHS Case Managers. 13. Establish a client grievance process: Each service provider agency must have a policy addressing client grievances and/or complaints. 14. Establish and provide staff training: All services provided with funding from DOEA require service delivery personnel to have general pre-service orientation and training specific to the service being provided. Lead Agencies are responsible for provision of the pre-service training (on program and billing requirements, in particular) for all paid staff, volunteer staff and assigned staff of service providers. Pre-service orientation also must include: • An overview of the aging process • An overview of the aging network • Communication techniques with the elderly • Observation of abuse, neglect, exploitation and incident reporting • Local agency service procedures and protocol • Client confidentiality. NOTE: All "hands-on" service personnel must receive training emphasizing the necessity of Universal Precautions. Home Health Aides must have documentation of successful completion of 40 hours required training, and CNAs must have on file a copy of their State of Florida certification. In-service training hours Page 2 of 3 CGS and topics are to be provided at the discretion of the service provider agency and shall meet state requirements. 15. Compile and report program service delivery statistics and other data as identified by CHS. This may be required to be provided in an electronic format at the choosing of CHS. These are reported to the Area Agency on Aging and Department of Elder Affairs in accordance with the reporting requirements developed by the Department. Lead agencies are responsible for entry of data in the Client Information and Registration Tracking System (CIRTS), which generates payment to the service provider agency. Therefore, service provider agencies are required to provide Lead Agencies with correct and timely service data to comply with these requirements. Timely submission is no later than noon on Wednesday of the week following the week services are performed (service week defined as Monday through Sunday). 16. Maintain complete and accurate records: Service delivery logs, at a minimum, must be legible and contain the name of client, type/s of services and date/s and hour/s of delivery. The client/caregiver must sign the log at the time of each service visit. The service worker must sign and date the log upon completion, and submit it to the service provider agency. Provide complete, clear and accurate invoices: Weekly invoices, which may be required to be provided electronically in a system provided by CHS, must be submitted by noon on the Wednesday following the week that the service was provided and shall include service provided. The service week is defined as Monday through Sunday. Monthly reporting requirements for CIRTS dictate that all client and service data for the previous month to be entered into CIRTS by the 10th day of the month. Collier County "Services for Seniors" will coordinate with vendors to determine due dates for invoices. This will insure compliance with DOEA reporting requirements. Failure to record or report units of service will result in nonpayment (or delayed payment)for such services. Data required on weekly invoices and weekly timesheets include: • Vendor name • Vendor address • Vendor telephone number • Client name • Service Provider employee who delivered the service(s) • Services ordered and services delivered date • Number of service hours, cost per hour and total cost • Person preparing the report and the date it was prepared •Weekly timesheets signed and dated by the client and Service Provider employee •Additional information as determined by CHS 17. Prepare for annual on-site compliance audits by CHS or members of the Collier County staff as directed by the CHS or grant requirements Page 3 of 3 Exhibit B Fee Schedule following this page (pages 1 through 1 ) Page 14 of 15 Fixed Price Professional Service Agreement#2017-001 (Ver.2) EXHIBIT B- FEE SCHEDULE Reimburseme Cost Per Service In-kind 10% nt Rate Per Unit(Cost your Match(Grant Unit(Amount Item ServicesGrant company charges Amount your the County Service Unit for the service) company will be will reimburse paying) your company for a given service) 1. Skilled CCE Per Hour $40.00 $4.00 $36.00 Nursing 2. Enhance Chore ADI,CCE, Per Hour $40.00 $4.00 $36.00 OAA 3. Respite (In-Home) ADI,CCE, Per Hour $24.11 $2.41 $21.70 OAA 4. Respite (Facility Based) ADI,CCE, Daily Rate $200.00 0 $200.00 OAA 5. Personal Care ADI,CCE, Per Hour $24.11 $2.41 $21.70 OAA 6. Chore ADI,CCE, Per Hour $24.00 $2.40 $21.60 OAA 7. Homemaking ADI,CCE, Per Hour $23.33 $2.33 $21.00 OAA 8. Adult Day Care ADI,CCE, Per Hour $13.89 $1.39 $12.50 OAA 9. Emergency Alert ADI,CCE, Per Day $1.09 $0.11 $0.98 Response OAA U Other Exhibit/Attachment Description: Grant Documents ■following this page p this exhibit is not applicable Page 15 of 15 Fixed Price Professional Service Agreement#2017-001 (Ver.2) 0 EXHIBIT I.A FEDERAL CONTRACT PROVISIONS FEDERAL UNITED STATE DEPARTMENT OF AGING AND FLORIDA DEPARTMENT OF ELDER AFFAIRS The supplemental conditions contained in this section are intended to cooperate with, to supplement,and to modify the general conditions and other specifications. In cases of disagreement with any other section of this contract,the Supplemental Conditions shall govern. Contractor means an entity that receives a contract. The services performed by the awarded Contractor shall be in compliance with the provisions of 45 Code of Federal Regulations(CFR)75 and/or 45 CFR Part 92,2 CFR Part 200 and other applicable regulations. It shall be the awarded Contractor's responsibility to acquire and utilize the necessary manuals and guidelines that apply to the work required to complete this project.In general, 1)The contractor(including all subcontractors)must insert these contract provisions in each lower tier contracts(e.g.subcontract or sub-agreement); 2)The contractor(or subcontractor)must incorporate the applicable requirements of these contract provisions by reference for work done under any purchase orders,rental agreements and other agreements for supplies or services; 3) The prime contractor is responsible for compliance with these contract provisions by any subcontractor,lower-tier subcontractor or service provider, FCP-I EXHIBIT LA FEDERAL CONTRACT PROVISIONS FEDERAL CONTRACT PROVISIONS Administrative,contractual,or legal remedies(Ref.41 U.S.C. 1908,2 CFR§200 Appendix II (A) Unless otherwise provided in this contract, all claims, counter-claims, disputes and other matters in question between the local government and the contractor,arising out of or relating to this contract,or the breach of it, will be decided by arbitration, if the parties mutually agree, or in a Florida court of competent jurisdiction. Access to Records and Reports(Reference: 2 CFR§200.333,2 CFR§200.336) The contractor/vendor agrees to maintain all books, records, accounts and reports required under this contract for a period of not less than three years after the date of termination or expiration of this contract, except in the event of litigation or settlement of claims arising from the performance of this contract,in which case the Contractor agrees to maintain same until the Purchaser,the Grantor Administrator,the Comptroller General,or any of their duly authorized representatives,have disposed of all such litigation,appeals,claims or exceptions related thereto. Furthermore,the County shall maintain written policies and procedures for computer system backup and recovery and shall have the same requirement of its Contractors. No Government Obligation to Third Parties-The Federal Government is not a party to this contract and is not subject to any obligations or liabilities to the non-Federal entity, contractor, or any other party pertaining to any matter resulting from the contract." Program Fraud and False or Fraudulent Statements of Related Acts The contractor acknowledges that 31 U.S.C.Chap.38(Administrative.Remedies for False Claims and Statements)applies to the contractor's actions pertaining to this contract." Clean Air and Federal Water Pollution Control Acts(Reference: 2 CFR§200 Appendix II(G)) Contracts and subgrants of amounts in excess of $150,000 shall contain a provision that requires the Contractor or recipient to comply with all applicable standards, orders, or requirements issued pursuant to the Clean Air Act (42 U.S.C. 7401-7671q) and the Federal Water Pollution Control Act as amended (33 U.S.C. 1251-1387). Violations must be reported to the Federal awarding agency and the Regional Office of the Environmental Protection Agency(EPA). Energy Policy and Conservation Act-(Reference 2 CFR§200 Appendix II (H) The contractor shall comply with any mandatory standards and policies relating to energy efficiency which are contained in the Florida state energy conservation plan issued in compliance with the Energy Policy and Conservation Act(Pub. L. 94-163,89 Stat. 871,42 U.S.0 Section 6201) Debarment and Suspension(Reference 2 CFR§200 Appendix II (I) Contract awards that exceed the small purchase threshold and certain other contract awards shall not be made to parties listed on the government wide Excluded Parties List System in the System for Award Management(SAM),in accordance with the OMB guidelines at 2 CFR 180 that implement Executive Orders 12549 (3 CFR Part 1986 Comp., p. 189) and 12689 (3 CFR Part 1989 Comp., p. 235), "Debarment and Suspension." The Excluded Parties List System in SAM contains the names of parties debarred, suspended, or otherwise excluded by agencies, as well as parties declared ineligible under statutory or regulatory authority other than Executive Order 12549. The successful bidder,by administering each lower tier subcontract that exceeds$25,000 as a"covered transaction", must verify each lower tier participant of a "covered transaction" under the project is not presently debarred or otherwise disqualified from participation in this federally assisted project. Byrd Anti-Lobbying Amendment(31 U.S.C. 1352)(Reference 2 CFR§200 Appendix II (J) Vendors must certify it will not and has not used Federal appropriated funds have been paid or will be paid, by or to any person or organization for influencing or attempting to influence an officer or employee of an agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the FCP-2 EXHIBIT I.A FEDERAL CONTRACT PROVISIONS making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan, or cooperative agreement. The certification includes any lobbying with non-Federal funds that takes place in connection with obtaining any Federal award. Procurement of Recovered Materials(Reference 2 CFR§200.322) Contractor and subcontractor agree to comply with Section 6002 of the Solid Waste Disposal Act, as amended by the Resource Conservation and Recovery Act, and the regulatory provisions of 40 CFR Part 247. (1)In the performance of this contract,the Contractor shall make maximum use of products containing recovered materials that are EPA designated items unless the product cannot be acquired(i)Competitively within a timeframe providing for compliance with the contract performance schedule; (ii) Meeting contract performance requirements;or (iii)At a reasonable price. (2)Information about this requirement is available at EPA's Comprehensive Procurement Guidelines web site,http://www.epa.gov/.The list of EPA-designate items is available at https://www.epa.gov/smm/comprehensive-procurement-guideline-cpg-program. Diversity(Reference 2 CFR§200.321) The County is dedicated to fostering the continued development and economic growth of small, minority-, women-, and service-disabled veteran business enterprises. All contracting and subcontracting opportunities afforded by this solicitation/contract are strongly encouraged to contribute as both Contractors and Sub-Contractors. Firms may be required to submit documentation addressing diversity and describing the efforts being made to encourage the participation of small, minority-, women-, and service-disabled veteran business enterprises. Information on Certified Minority Business Enterprises(CMBE)and Certified Service-Disabled Veteran Business Enterprises(CSDVBE)is available from the Office of Supplier Diversity at: http://dms.mvflorida.com/other programs/office of supplier diversity osd/ Termination for Cause and Convenience See County's Standard Terms and Conditions. Nondiscrimination-Civil Rights Compliance The Contractor will 1.not discriminate against any person in the provision of services or benefits under this contract or in employment because of age, race, religion, color, disability, national origin, marital status or sex in compliance with state and federal law and regulations. 2.Assumes others with whom it arranges to provide services or benefits in connection with any of its programs and activities are not discriminating against clients or employees because of age, race, religion, color, disability, national origin, marital status or sex. And 3. Assures others with whom it arranges to provide services or benefits to participants or employees in connection with any of its programs and activities are not discriminating against those participants or employees in violation of the above statutes,regulations, guidelines,and standards. Computer Use and Social Media Policy The Florida Department of Elder Affairs has implemented a Social Media Policy,in addition to its Computer Use Policy, which applies to all employees, contracted employees, consultants, OPS and volunteers, including all personnel affiliated with third parties, such as, but not limited to, contractors and subcontractors. Any entity that uses the Department's computer resource systems must comply with the Department's policy regarding social media. Social Media includes, but is not limited to blogs, podcasts, discussion forums,Wikis, RSS feeds,video sharing,social networks like MySpace, Facebook and Twitter, as well as content sharing networks such as flickr and YouTube.This policy is available on the Department's website at:http://elderaffairs.state.fl.us/doea/financial.php STATE CONTRACT PROVISIONS Discriminatory Vendors List In accordance with Section 287.134, Florida Statutes, an entity or affiliate who has been placed on the discriminatory vendor list may not submit a bid on a contract to provide any goods or services to a public FCP-3 EXHIBIT I.A FEDERAL CONTRACT PROVISIONS entity,may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to a public entity, may not be awarded or perform work as a contractor, supplier,subcontractor, or consultant under a contract with any public entity, and may not transact business with any public entity. Inspector General Cooperation The Parties agree to comply with Section 20.055(5), Florida Statutes, for the inspector general to have access to any records, data and other information deemed necessary to carry out his or her duties and incorporate into all subcontracts the obligation to comply with Section 20.055(5), Florida Statutes. Equal Employment Opportunity The Contractor shall not discriminate against any employee or applicant for employment because of race, age, creed, color, sex or national origin. The Agency will take affirmative action to ensure that applicants are employed,and that employees are treated during employment,without regard to their race,age,creed, color, sex, or national origin. Such action shall include, but not be limited to, the following: Employment upgrading,demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation;and selection for training,including apprenticeship.Contractors must insert a similar provision in all subcontracts, except subcontracts for standard commercial supplies or raw materials. Interest of Members of Congress No member of or delegate to the Congress of the United States shall be admitted to any share or part of this contract or to any benefit arising therefrom. Interest of Public Officials No member, officer, or employee of the public body or of a local public body during his tenure or for two years thereafter shall have any interest, direct or indirect, in this contract or the proceeds thereof. For purposes of this provision,public body shall include municipalities and other political subdivisions of States; and public corporations,boards,and commissions established under the laws of any State. Interest of Public Officials No member, officer, or employee of the MPO or of a local public body during his tenure or for two years thereafter shall have any interest,direct or indirect,in this contract or the proceeds thereof. Lobbying No funds received pursuant to this Agreement may be expended for lobbying the Legislature, the judicial branch or a state agency. EVerify Vendors/Contractors/Subcontractors: 1. shall utilize the U.S. Department of Homeland Security's E-Verify system to verity the employment eligibility of all new employees hired by the Vendor/Contractor during the term of the contract;and 2.shall expressly require any subcontractors performing work or providing services pursuant to the state contract to likewise utilize the U.S.Department of Homeland Security's E-Verify system to verify the employment eligibility of all new employees hired by the subcontractor during the contract term. FCP-4 J EXHIBIT I.B GRANT CERTIFICATIONS AND ASSURANCES GRANT CERTIFICATIONS AND ASSURANCES THE FOLLOWING DOCUMENTS NEED TO BE RETURNED WITH SOLICIATION DOCUMENTS BY DEADLINE TO BE CONSIDERED RESPONSIVE 1. Certification Regarding Debarment, Suspension, and Other Responsibility Matters - Primary Covered Transactions 2. Certification regarding Lobbying 3. Conflict of Interest 4. Anticipated DBE,M/WBE or VETERAN Participation Statement 5. Opportunity List for Commodities and Contractual Services and Professional Consultant Services 6. Acknowledgement of Grant Terms and Conditions 7. Scrutinized Companies Certification GCA- 1 EXHIBIT I.B GRANT CERTIFICATIONS AND ASSURANCES COLLIER COUNTY Certification Regarding Debarment,Suspension,and Other Responsibility Matters Primary Covered Transactions (1) The prospective primary participant certifies to the best of its knowledge and belief,that it and its principals: (a) Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency; (b) Have not within a three-year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction;violation of Federal or State antitrust statutes or commission of embezzlement,theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (c) Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (1)(b) of this certification;and (d) Have not within a three-year period preceding this application/proposal had one or more public transactions(Federal, State or local)terminated for cause or default. (2) Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal. 91nds Sain+ Fre,u,K S (V1Q S % 9Thrs Name Project Name Pam nI Tcc-1z,r r$-1 x10 Title Project Number Crne3c, tkt-1 v►ees 752.-527 Li k¢10 Firm Tax ID Number II ( ?33G52— DUNS 33G5tiDUNS Number 1(36 W McNCib Toy-rirac, FL-1 3332-( Stre d es , State,Zip Signature GCA-2 EXHIBIT LB GRANT CERTIFICATIONS AND ASSURANCES COLLIER COUNTY Certification Regarding Lobbying The undersigned certifies,to the best of his or her knowledge,that: (1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of an agency, a Member of Congress,an officer or employee of Congress,or an employee of a Member of Congress in connection with the awarding of any Federal contract,the making of any Federal grant, the making of any Federal loan,the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract,grant, loan,or cooperative agreement. (2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant,loan, or cooperative agreement,the undersigned shall complete and submit Standard Form- LLL,"Disclosure Form to Report Lobbying,"in accordance with its instructions. (3) The undersigned shall require that the language of this certification be included in the award documents for all subawards at all tiers (including subcontracts, subgrants, and contracts under grants, loans, and cooperative agreements)and that all subrecipients shall certify and disclose accordingly. This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31, U.S.C. § 1352 (as amended by the Lobbying Disclosure Act of 1995). Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than$100,000 for each such failure. The Contractor,(Sfl O HCI::44 Sery1CZ3 (A,C,, certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Contractor understands and agrees that the provisions of 31 U.S.C. § 3801 et seq.,apply to this certification and disclosure,if any. In addition, the Contractor understands and agrees that the provisions of 11.062, Florida Statutes., apply to this certific.tio,an. . ll6 osure,if any. Agge....-4, Signature of Contractor's Authorized Official " S4frt. PCLIV ildrYliflithvbIclame of Authorized Official and Title 1 (i 69 I ( ,R Date GCA-3 EXHIBIT I.B GRANT CERTIFICATIONS AND ASSURANCES COLLIER COUNTY Conflict of Interest Certification Collier County Solicitation No. I, naS1 RCJLXX , hereby certify that to the best of my knowledge, neither I nor my spouse, dependent child, general partner, or any organization for which I am serving as an officer, director,trustee,general partner or employee,or any person or organization with whom I am negotiating or have an arrangement concerning prospective employment has a financial interest in this matter. I further certify to the best of my knowledge that this matter will not affect the financial interests of any member of my household. Also, to the best of my knowledge, no member of my household; no relative with whom I have a close relationship; no one with whom my spouse, parent or dependent child has or seeks employment; and no organization with which I am seeking a business relationship nor which I now serve actively or have served within the last year are parties or represent a party to the matter. I also acknowledge my responsibility to disclose the acquisition of any financial or personal interest as described above that would be affected by the matter, and to disclose any interest I, or anyone noted above, has in any person or organization that does become involved in,or is affected at a later date by,the conduct of this matter. 4r-S. sct.... ptit....x4se (Ike Name Signature Firnint"s- -rthu 11/(0/( 3 Position Date Privacy Act Statement Title I of the Ethics in Government Act of 1978 (5 U.S.C. App.), Executive Order 12674 and 5 CFR Part 2634, Subpart I require the reporting of this information. The primary use of the information on this form is for review by officials of The Justice Department to determine compliance with applicable federal conflict of interest laws and regulations. Additional disclosures of the information on this report may be made: (1)to a federal, state or local law enforcement agency if the Justice Department becomes aware of a violation or potential violation of law or regulations; (2)to a court or party in a court or federal administrative proceeding if the government is a party or in order to comply with a judge-issued subpoena; (3)to a source when necessary to obtain information relevant to a conflict of interest investigation or decision; (4) to the National Archives and Records Administration or the General Services Administration in records management inspections; (5)to the Office of Management and Budget during legislative coordination on private relief legislation; and (6) in response to a request for discovery or for the appearance of a witness in a judicial or administrative proceeding, if the information is relevant to the subject matter. This confidential certification will not be disclosed to any requesting person unless authorized by law. See also the OGE/GOVT-2 executive branch-wide Privacy Act system of records. GCA-4 � '. EXHIBIT I.B GRANT CERTIFICATIONS AND ASSURANCES COLLIER COUNTY ANTICIPATED DISADVANTAGED,MINORITY,WOMEN OR VETERAN PARTICIPATION STATEMENT status will be verified. Uawerdabie statuses will require the PRIME { 1to either proivde a revised statement or provide sowce documentation that validates a Status. { E ihy t�otiei ykiitbwION `v PRIME NAME PRIME FED NUMBER CONTRACT DOLLAR AMOUNT tl iljth Sar Vi'Ca, LAX, 13€L- 52 z 4y'1 o IS THE PR EA FLORIDA•CERTIFIEDDISADVANTAGED, VETERAN Y N TSTHE ACFIVITYOFTHIS CONTRACT._ MINORITY OR WOMEN BUSINESS ENTERPRISE? DBE? Y N CONSTRUCTION? Y (DBE!MSFIWBE)OR HAVE ASMALL DISADVA.TAGED (-1-t BUS7NESSaACERTIFICATION FROM THE SMALL BUSINESS MBE? N CONSULTATION? /Y'� W ADMINISTRATION? A SERVICE DISABLED VETERAN? BE? Y N. OTHER? /rJl N SDB HA?' Y ,,,---N, l/ IS THIS SUBMISSION A REVISION? Y ( I 1F YES REVISION NUMBER ` DBE M/WBE SUBCONTRACTOR ORSUPPUER. TYPE OF WORK OR ETHNICfYCODE SUB/SUPPLIER PERCENT OF CON1IEACT VETERAN NAME SPECIALTY (See Below) DOLLAR AMOUNT DOLLARS TOTALS: ..� ;t pp r..ft ;,t* :�yrA..... it �D�Y� try.. Hq m tMrM4t0PW ++ ` . u.. NAME OF SUBMITTER DATE. TITLE OF SUBMITTER ors i'rrf- I f h l rni�rS 4 v EMAIL ADDRESS OF PRIME{SUBMITTERI LE ONE NUMBER FAX NUMBER ill off ahtal V I CCs•(1 -75X0304 3'4'33 NOTE:This information is used to track and report anticipated OBE or MBE participation in federally-funded contracts.The anticipated DBE or MBE amount is voluntary and will not become part of the contractual terms.This form mast be submitted at time of response to a solicitation. If and when awarded a County contract,the prime curl@ be asked to update the information for the grant compliance files. wtlladtArraeacanLBTI. IfspanicAmerican HA ;NatweAnseriidn - , NA Subcont.Asian American SAA NA P+aficAma Tan . APA Non-Minority Women NMW Otf ac notat any other&'o i lli�ssted a .o..���y{; : {.{�=y tr;f.iF 1 k 4 Aty1. nN h{k'. .S 1R- lOBEWMP� Y'�� .},.trt {::rR..ra.tinv�,.,� 4 },: DEPARTMENT NAME COLLIER CONTRACTU(IFB/RFP or PO!REOl GRANT PROGRAM/CONTRACT ACCEPTED BY: DATE GCA-5 cl°I3 EXHIBIT I,B GRANT CERTIFICATIONS AND ASSURANCES COLLIER CGUr re GfLdItTCOMPLIANCE FORt. PID OPPORTUNITY UST FOR COMMODITIES AND CONTRACTUAL SERVICES AND PROFESSIONAL CONSULTANT SERVICES a is the poffcy of collier County that disadvantaged businesses and minority vendor,as defnted in the Code of Federal Regulations(CFR)or Florida statutes(F51,most have the opportunity to partktdate on contracts with federal enxd/cr state grant assistance. Prime Contractor/Primeconsultant () flt , ( }YV( 2er jc U"' I O Care &r\licits Address and Phone Number 1+3V W PC,N1 J1l3 5e1 } e""`"-`-l.._ iL.i 3332.1 J 1! -i/LV83 Procurement Number/AdvertisementNuanber: t7S 147 The list below u intended to be a listing of firms that are,or attempting to,participate on the project numbered above.The fist must include the firm bidding or quoting as prime,as well as subs and suppliers quoting for participation Prime contractors and consultants must provide information far Numbers 1,2,3,and 4;and,should provide any information they have for Numbers 5,6,7,and B.This form must be submitted with the bid package 1-Federal raxIDNumber; j --5',4S-441-C) ,6086 n-Annual GGrossReceipts : 2.Firm 111.11 -•Name: .11-.• • w l ate$ Non-C•BE V Less than$1 mtliarl 3.Phone Number: s Between$1-5 trillion 4.Address jik .,; !eBetween$5-10 million EinleArelt 1 Fly. 34y2.1 7. SabcoMractur .Between$1015 million baonsrr}tant: � More than$15 milion 5.Year Firm Established: 6 irrlarils 1. Federal Tax ID Number. 6.1--1 DBE 6.Annual Gross Receipts 2. Firm Name: Non-DBE Mess than 51 milion 3. Phone Number: Between 51.3 million 4.Address Between$5-10 million 7, Subcontractor Between$10.15 million EEI Subconsultant More than$15 million 5.Year Firm Established: 1. Federal Tax ID Number: 6. DISE 11.'Annual Gross Receipts 2, Firm Name: Nan-OBE , less than$1 milion 3.Phone Number. 5etween S1-5 million 4-Address Between$5-10 million 7. a r'` Between 510-15 million 8 ` SubconsultMt More than$15 milion 5.Year Firm Established: 1.Federal Tax ID Number: 6. OBE 8.Annual Gross Receipts 2_Finn Name: Noes-DBE less than$1 milion 3-Phone Number: Between 51-s million 4.Address tt—�--�� Between$5-to million 7.1 1 Subcontractor Between$10-15 million 1{L��III ____. Subcorts iltant —.....more than$15 Million 5 Year Firm Established: GCA-6ID EXHIBIT I.B GRANT CERTIFICATIONS AND ASSURANCES COLLIER COUNTY Acknowledgement of Terms,Conditions and Grant Clauses Flow Down of Terms and Conditions from the Grant Agreement Subcontracts: If the vendor subcontracts any of the work required under this Agreement, a copy of the signed subcontract must be available to the Department for review and approval. The vendor agrees to include in the subcontract that (1) the subcontractor is bound by the teens of this Agreement, (ii) the subcontractor is bound by all applicable state and federal laws and regulations, and (iii) the subcontractor shall hold the Department and Recipient harmless against all claims of whatever nature arising out of the subcontractor's performance of work under this Agreement, to the extent allowed and required by law. The recipient shall document in the quarterly report the subcontractor's progress in performing its work under this agreement. For each subcontract,the Recipient shall provide a written statement to the Department as to whether the subcontractor is a minority vendor as defined in Section 288.703,Fla. Stat. Certification On behalf of my firm, I acknowledge, and agree to perform all of the specifications and grant requirements identified in this solicitation document(s). Vendor/Contractor Name ()mesa {-H-eOJ' ) ScCos Date I I( /i7 Authorized Signaturei2g-1(1) Address 1130 lAJ It-1 ickb /tel', 10araG FL 3a)D-/ Solicitation/Contract# /?~ /q U GCA-7 o.` EXHIBIT I,B GRANT CERTIFICATIONS AND ASSURANCES COLLIER COUNTY Scrutinized Companies Certification The undersigned 46 •,"t 11 Ser _ ' Vendor/ Contractor) certifies, to the best of his or her knowledge and belief,that it is not listed on the • Scrutinized Companies with Activities in Sudan List, • Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List,and/or • Scrutinized Companies with Activities in Israel List (eff. 10.1.2016), pursuant to Section 215.473, F.S. The subcontractor further agrees the. County may immediately terminate this contract for cause if the vendor/contractor is found to have submitted a false certification or is placed on the Scrutinized Companies list during the term of the contract. F4irs a( ' 'fr€ Name of Authorized Official TG�YYII�1 l� Title Signature of Vendor/Contractor's Authorized Official HI0 /7 Date GCA-8 ACc CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDYYYY) `.,.� 12/03/2018 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 have ADDITIONAL INSURED provisions or 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). PRODUCER CONTACT Ashley Hemphill NAME: InsuranceHub Agency,LLC PHONE (770)497-1200 FAX (770)814-7187 (A/C,No,Ext): (A/C,No): 1720 Lakes Parkway E-MAIL ahemphill@insurancehub.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Lawrenceville GA 30043INSURERA: Certain Underwriters at Lloyds of London INSURED Progressive Express Ins Co 10193 INSURER B: g p Omega Health Services INSURER C: 5921 Washington St INSURER D: INSURER E: Hollywood FL 33321 INSURER F: COVERAGES CERTIFICATE NUMBER: CL1812310068 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 AUUL SUlilt POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD wVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR DAMAGE TO RENTED 50,000 PREMISES(Ea occurrence) $ MED EXP(Any one person) $ 10,000 A Y GAH-32882-181130 11/30/2018 11/30/2019 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 PRO X 0,000POLICY JECT LOCPRODUCTS-COMP/OP AGG $ 2,00 OTHER: Employee Benefits $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ B OWNED v SCHEDULED 08418054-0 11/30/2018 11/30/2019 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS _ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY _ AUTOS ONLY (Per accident) Underinsured motorist $ 1,000,000 UMBRELLA LIAB • ""RA"'E""• _ OCCUR EACHACH OCCURRENCE ENCE _ $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Per Claim $1,000,000 Professional Liability A GAH-32882-181130 11/30/2018 11/30/2019 Aggregate $3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Collier County Board of County Commissioners,OR,Board of County Commissioners in Collier County,OR,Collier County Government,OR,Collier County included as an additional insured under the captioned Commercial General Liability and Automobile Liability Policies on a primary and non-contributory basis if and to the extent requred by written contract. 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. 3295 Tamiami Trail E. AUTHORIZED REPRESENTATIVE Naples FL 34112 I 'it I t 4 ' I bay ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGES Ref# Description Coverage Code Form No. Edition Date PIP-Basic PIP Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 10,000 Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium OFADTLCV Copyright 2001,AMS Services,Inc. HISCOX A Guide To Your General Liability Policy The following is a guide to your General Liability policy.We have identified several kev coverage items along with the limits and deductibles you have selected.To make it easier,we have also added a brief explanation of those items. We want you to feel confident about your new policy.If any of the information below is incorrect or if you have any questions, please contact one of our advisors at 888-202-3007(Mon-Fri.8am-10pm EST)or send us an e-mail at contact@hiscox.com. Your business details Name: Agnes Sair: Business Name: Omega Heald'. ervoies Address: 7130 McNati Rd City: Tamarac State: FL Zip code: Occupation: Home hea Id-.aide Telephone number: 796-304-9433 Email address: info2orregahealthservices.crg Your General Liability Policy Policy number: LIDC-2'38752 -CGL-18 Policy effective dates: From: October 15.2018 This detemiines the time period during which your coverage applies. To October 15,2019 Form of business: This identifies the legal structure of your business and determines who is Limbed Lability Company insured under your policy. Business Property and Equipment Coverage: Rejected Optional terrorism coverage: Excluded Total cost of policy: g 711511,0 *HiSSOX Inc,2010 Page 1 Your coverage and limits Each occurrence limit $ 1,00C.350 The most we will pay for all damages due to bodily injury and property damage,and medical expenses that arise out of any one occurrence. Defense costs we incur,in the defense of a lawsuit filed against you. will not reduce this General aggregate limit S 2,000.030 The most we will pay for all damages and medical expenses for the entire policy.Defense costs we incur,in the defense of a lawsuit filed against you,will not reduce this limit. Damage to premises rented to you 5 100.007 any one premises The most we will pay for damages,for which you are liable,to any one premises that is rented to you.This may include office space,conference rooms or training facilities,but does not include your primary residence if you are a home-based business. Medical expenses S 5.00C any one person The most we will pay for all medical expenses sustained by any one person. Personal and advertising injury limit S 1,000.030 arty one person The most we will pay for all personal and advertising injury or organizatort (e.g.,libel,slander'sustained by any one person or organization. Deductible for General Liability Coverage No deductible Other policy information 14 day full refund Be confident that you have made the right choice.We give you 14 days to review your policy.If you are not satisfied and have not had any claims or losses,you can cancel your policy back to its start date and receive a full refund. Notice of claim if you have a claim,please call us at 866-424-8509.You may also e-mail us at reportaclaim@hiscox.com . _ What does my General Liability Policy cover? For a summary showing examples of what you are and are not covered for, please read the Coverage Summary document. This guide does not modify.the terms and conditions of your policy,which are contained in your policy documents, nor does it imply any claim is covered or not covered.We recommend that you read your policy documents to learn the details of your coverage. Hiscox Ira,2010 Page HISCOX Reinventing Small Business insurance' General Liability Insurance Home Health Aide and Personal Care Aide Professionals We want you to understand the Hiscox General Liability coverage.This summary explains the main areas of coverage and exclusions. If you have any questions about your coverage,please contact one of our advisors at 888-202-3007(Mon- Fri,8am-10pm EST)or Manage Your Policy online by visiting httas_IM^raw_hisoox_com/manacle-your-policvL This policy does cover Bodily injury or property damage To the extent you are legally liable,we cover damages or claims expenses if you injure a third-party or damage someone else's property(including damage due to a fire at a premise you rent,unless you work from home). However,such damage must not be as a result of your professional services.Bodily injury that occurs to a third- party as a result of your professional services may be covered by our Professional Liability potty. Medical payments iNe will make medical payments as a result of bodily injury that occurs in the course of your business operations, regardless of fault Defense costs If you're sued,even if you're not at fault we will appoint an attorney to defend you.even if the lawsuit is groundless.We will pay these defense costs on your behalf. Personal and advertising injury We cover claims of libel and sl once-that are not part of your professional services.We also protect you if your advertisement unintentiona'ly uses a third-part's advertising idea or infringes upon another's copyright. Worldwide insurance coverage We cover damage that occurs in the United States,its temtories and Canada.We also offer some coverage for instances outside these areas while you're away on short periods of travel. Employees,temporary staff or volunteers Hiscox tyro cover claims arising from actions of your employees,temporary staff,or volunteers if they were performed on behalf of your business. Supplemental payments Your H;sco.*.policy covers the following expenses,should they be incurred,without reducing your limit of liability. • a l expenses we incur,including the defense of lawsuits • up to S250 a day for reasonable expenses(including loss of earnings)you incur as a result of assisting us in the defense of a claim or lawsuit • interest on damage awards. ( ( 1 ( GO This policy does not cover Intent to injure We won't cover you for any act that occurs with the intent to injure.This includes personal and advertising injuries if you knew your actions were false or violated the rights of others_ Outside the policy period We won't cover clams for bodily injury,property damage,or personal and advertising injury that do not occur durkng the policy period. Known claims and circumstances 'We wont cover your business for any claim or circumstance that could result in a claim you knew about prior to the start of your first Hisoox policy. Personally identifiable information t,41e won't cover your failure to protect any personally identifiable information that is in your care.These types of risks may be covered or a I'mited basis as part of our Professional Liability Policy. Professional services Vt'e won't cover any professional services performed by you.These types of risks may be covered as part of our Professional Liability Policy. Vehicles and boats 'We won't cover any claims arising out of the ownership or use of an automobile or a watercraft. Workers'compensation '0,e won't cover any obligation you may have under a workers compensation claim or similar law. Your property 'Ae wont cover claims for damage to property you own or have in your care. Bodily injury During an appointment at a clients home you step away to answer your phone.When you return you see that your client has tripped over your bag and injured his hip and is unable to get up.We will cover the subsequent claim and related medical expenses up to your Punts of liability. Property damage You spil coffee on a client`s rug causing a permanent stain.We will cover the subsequent claim up to your limits of Lability Personal injury One of your employees is gossiping with a long standing client.She talks about one of your new clients in a false and unflattering way.The client learns of this discussion and sues for slander.We will cover the subsequent claim.up to your limits of liability,and pay for an attorney to defend you if necessary'. Coverage summaries.descriptions,and claims examples are provided for illustrative purposes only and are subject to the applicable policy limits.deductibles,exclusions.terms,and conditions.Not all insurance products and services are available in all states_I-tiscox recommends you read the policy documents to learn the full details of coverage. Ur erwrtten try Hisccx Insurance Campa^y Inc.,1 4 Scut Mic^van Aeenr,Suite 600,Cl>caao,IL 60603,M administered by Hisccx Inc, a'censed ins-rand&p'cuider in all states and DC. f. Pollution (d) At or from any premises, site or location (1) "Bodily injury" or "property damage" arising on which any insured or any contractors out of the actual, alleged or threatened dis- or subcontractors working directly or in- charge, dispersal, seepage, migration, re- lease or escape of"pollutants": forming operations if the "pollutants" are brought on or to the premises, site or lo- (a) At or from any premises, site or location cation in connection with such opera- which is or was at any time owned or tions by such insured, contractor or sub- occupied by, or rented or loaned to, any contractor. However, this subparagraph insured. However, this subparagraph does not apply to: does not apply to: (i) "Bodilyinjury" "property or " ro damage" (i) "Bodily injury" if sustained within a i y p p y arising out of the escape of fuels, lu- building and caused by smoke, bricants or other operating fluids fumes, vapor or soot produced by or which are needed to perform the originating from equipment that is normal electrical, hydraulic or me- used to heat, cool or dehumidify the chanical functions necessary for the building, or equipment that is used to operation of "mobile equipment" or heat water for personal use, by the its parts, if such fuels, lubricants or building's occupants or their guests; other operating fluids escape from a (ii) "Bodily injury" or "property damage" vehicle part designed to hold, store for which you may be held liable, if or receive them. This exception does you are a contractor and the owner not apply if the "bodily injury" or or lessee of such premises, site or "property damage" arises out of the location has been added to your pol- intentional discharge, dispersal or re- icy as an additional insured with re- lease of the fuels, lubricants or other spect to your ongoing operations operating fluids, or if such fuels, lu- performed for that additional insured bricants or other operating fluids are at that premises, site or location and brought on or to the premises, site or such premises, site or location is not location with the intent that they be and never was owned or occupied discharged, dispersed or released as by, or rented or loaned to, any in- part of the operations being per- sured, other than that additional in- formed by such insured, contractor sured;or or subcontractor; (iii) "Bodily injury" or "property damage" (ii) "Bodily injury" or "property damage" arising out of heat, smoke or fumes sustained within a building and from a"hostile fire"; caused by the release of gases, (b) At or from any premises, site or location fumes or vapors from materials which is or was at any time used by or brought into that building in connec for any insured or others for the han tion with operations being performed dling, storage, disposal, processing or by you or on your behalf by a con treatment of waste; tractor or subcontractor;or (c) Which are or were at any time trans- (iii) "Bodily injury" or "property damage" ported, handled, stored, treated, dis arising out of heat, smoke or fumes posed of, or processed as waste by or from a"hostile fire". for: (e) At or from any premises, site or location (i) Any insured;or on which any insured or any contractors or subcontractors working directly or in- (ii) Any person or organization for whom directly on any insured's behalf are per- you may be legally responsible;or forming operations if the operations are to test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the ef- fects of, "pollutants". CG 00 01 12 07 ©ISO Properties, Inc., 2006 Page 3 of 16 o CNA SURETY1-800-331-6053 Fax 1-605-335-0357 www.cnasuretv.com PO Box 5077 Sioux Falls SD 57117-5077 Email: uwservicesacnasuretv.com DATE: December 3, 2018 AGENT CODE: 32 17950 TO: Insurancehub Agency, L L C 1720 Lakes Parkway Fax: 770/814-7187 Lawrenceville, GA 30043-0000 ATTENTION: Angie Cooper NUMBER OF PAGES: 1 FROM: Underwriting Services, Business Services RE: Bond#64438611 - Omega Health Services LLC $50,000.00 - Dishonesty B Medical Services &Home Care Company Code: 601 - Western Surety Company We received the information you submitted electronically. Thank you for thinking of CNA Surety. We are pleased to handle your request. Your client can expect to receive the bond in the mail soon. The bond is being written through CNA Solution, Inc., our in-house agency, and is being billed directly to your client. They should send their check for the gross amount due, made payable to CNA Surety,to the address listed on their billing invoice. CNA Solution, Inc.,will pay you a referral fee of $5 for notary bonds and purchased Notary E&O, $15 for other commercial bonds, $150 for contract bonds other than bid bonds in excess of$10,000, and$50 for contract bonds other than bid bonds which are less than $10,000. The annual premium assigned to this risk is $257.00. If you have any questions,please contact our office. Consider making your payment through CNA Surety ePay. Pay for your bond/policy premium online using your own credit/debit card or ACH at your convenience 24 hours a day. Simply go to: onlinepay.cnasurety.com and follow the easy-to-use prompts. You can pay your bill in minutes, saving you time and money. IMPORTANT NOTICE The information contained in this communication may contain confidential and/or privileged information and is intended for the sole use of the intended recipient. If you are not the intended recipient,you are hereby notified that any unauthorized use,disclosure,distribution or copying of this communication is strictly prohibited and that you will be held responsible for any such unauthorized activity,including liability for any resulting damages. As appropriate,such incident(s)may also be reported to law enforcement. If you received this communication in error,please reply to the sender and destroy or delete this communication including any attachments. Thank you. GAH-32882-181130 - Omega Health Services LLC From: Chelsea Felder<cfelder@bassuw.com> Received: 12/4/2018 10:49:26 AM To: 'rparks@insurancehub.com'<rparks@insurancehub.com> Attachments:Attachment.pdf Hello, Please see the attached binder and corresponding invoice for your records. If you have any questions please contact your underwriting team. In regards to the attached invoice,please note that if the Due Date is highlighted, this carrier may require payment before you receive your statement! Thank you for your business! et; (EJBASS 4-1 UNDERWRITERS 3355 Annandale Lane Suwanee, GA 30024 Ph:(954) 473-3788 Fax: (954) 316-3123 Date: December 4, 2018 To: Rachel Parks - InsuranceHub Agency, LLC Fax: (770) 497-8721 From: Robert Collier Phone: 770-510-1609 Email: rcollier@bassuw.com Fax: (954) 316-3113 Re: Insured: Omega Health Services LLC Effective Date: 11/30/2018 This transmission is intended to be delivered only to the named addressee(s) and may contain information that is confidential, proprietary or privileged. If this information is received by anyone other than the named addressee(s), the recipient should immediately notify the sender by e-mail and by telephone 770-510-1609 and obtain instructions as to the disposal of the transmitted material. In no event shall this material be read, used, copied, reproduced, stored or retained by anyone other than the named addressee(s), except with the express consent of the sender or the named addressee(s). Thank you. Reference#:2323402B Bass Underwriters, Inc. INSURANCE BINDER THE TERMS AND CONDITIONS OF THIS CONFIRMATION OF INSURANCE MAY NOT COMPLY WITH THE SPECIFICATIONS SUBMITTED FOR CONSIDERATION. PLEASE READ THIS CONFIRMATION CAREFULLY AND COMPARE IT WITH ANY QUOTE AND SUBMISSION DOCUMENTS AND REVIEW THE POLICY FORMS FOR THE ACTUAL COVERAGES PROVIDED. N ACCORDANCE WITH YOUR INSTRUCTIONS, AND IN RELIANCE UPON THE STATEMENTS MADE BY THE RETAIL BROKER IN THE NSURED'S APPLICATION/SUBMISSION,WE HAVE OBTAINED INSURANCE AT YOUR REQUEST AS FOLLOWS: DATE ISSUED: December 4, 2018 PRODUCER: InsuranceHub Agency, LLC 1720 Lakes Pkwy., Lawrenceville, GA 30043 INSURED MAILING Omega Health Services LLC ADDRESS: 5921 Washington St Hollywood, FL 33321 POLICY NO.: GAH-32882-181130 INSURER: Lloyd's of London Non-Admitted A(Excellent) AM Best Rating COVERAGE: Professional Liability- Medical-Claims Made-Greenhill POLICY PERIOD: 11/30/2018 TO 11/30/2019 RENEWAL OF: 12:01 A.M. STANDARD TIME AT THE LOCATION ADDRESS OF THE NAMED INSURED. THIS INSURANCE BINDER WILL BE TERMINATED AND SUPERSEDED UPON DELIVERY OF THE FORMAL POLICY(IES) ISSUED TO REPLACE IT. BINDER AS PER QUOTE: 2323402B LIMITS: See attached. PREMIUM: $1,357.00 TRIA: NOT APPLICABLE FEES: Policy Fee $35.00 SURPLUS LINES TAX: $69.60 SERVICE OFFICE FEE: $1.39 MISC STATE TAX: FHCF: (Florida) CPIE: (Florida) TOTAL: $1,462.99 TERMS/CONDITIONS: (a)25% MINIMUM EARNED PREMIUM AT INCEPTION -See attached. ALL FEES ARE FULLY EARNED AND NON-REFUNDABLE. PREMIUM FOR ADDITIONAL INSURED'S ARE FULLY EARNED AND NON-REFUNDABLE. (b)SUBJECT TO: Please see attached for Terms and Conditions. (c) ENDORSEMENTS: Please see attached for Endorsements and Exclusions. (d) ALL OTHER TERMS AND CONDITIONS APPLY PER FORM CANCELLATION: THIS POLICY IS SUBJECT TO THE CANCELLATION PROVISIONS AS FOUND IN THE POLICY(IES)OR CERTIFICATE(S) CURRENTLY IN USE BY THE INSURER. THE INSURANCE EFFECTED UNDER THE INSURER'S BINDER CAN BE CANCELLED BY THE INSURER(SUBJECT TO STATUTORY REGULATIONS)BY MAILING,TO THE INSURED AT THE ADDRESS STATED ON THE FACE OF THIS CONFIRMATION OF INSURANCE, WRITTEN NOTICE STATING WHEN SUCH CANCELLATION SHALL BE EFFECTIVE. IN THE EVENT OP CANCELLATION BY THE INSURED,THE EARNED PREMIUM WOULD BE SUBJECT TO THE MINIMUM PREMIUM IF APPLICABLE. THIS CONFIRMATION OF INSURANCE IS ISSUED BASED UPON THE INSURER'S AGREEMENT TO BIND AND IS ISSUED BY THE UNDERSIGNED WITHOUT ANY LIABILITY WHATSOEVER AS AN INSURER. INSURED: ,Omega Health Services LLC DATE ISSUED: December 4,2018 Account Executive: Robert Collier Team: Atlanta Reference#:2323402B GREENHILL BINDER Date of Binder December 04, 2018 INSURANCE SERVICES Policy Number GAH-32882-181130 New Insured Omega Health Services LLC Producer Robert Collier 5921 Washington St Hollywood, FL 33321 Brokerage Bass Underwriters -GA Business/ Home Health Agency Profession Policy November 30, 2018 to Period November 30, 2019 Carrier Certain Underwriters at Lloyd's of London Professional Liability Claims Made General Liability Claims Made Per Claim $1,000,000 Per Claim $1,000,000 Aggregate $3,000,000 Aggregate* $3,000,000 Per Claim Deductible $1,000 *Products/Completed Operations included Retroactive Date November 30, 2018 Personal/Advertising Injury $1,000,000 Fire Damage $100,000 Policy Premium $1,357.00 Medical Expense $5,000 Policy Fee $0.00 Per Claim Deductible $1,000 TOTAL $1,357.00 Retroactive Date November 30, 2018 *Bass Underwriters-GA will file and pay the taxes. Additional Coverages Employee Benefit Liability $1,000,000/$1,000,000 Physical & Sexual Abuse $200,000/$600,000 Al Primary Liability -GL Retro: November 30, 2018 All premiums are 25%earned upon inception.All policy fees are 100%earned upon inception.Any pricing,terms,or conditionals of the final policy at variance with this binder shall supersede this quotation. GREENHILL BINDER INSURANCE SERVICES Endorsements We require the following items: GH300-FL FL Cancellation Clause N/A GHA025 Minimum Earned Premium GHA120 Financial Exclusion GHA126 Limits of Liability-Limitation of Notes Endorsement GHA133 GH Medical Expense Additional Insured: GHA207 Medical Payments Exclusion- Patients Collier County Board of County Commissioners GHA302 Exclusion -Total Mold, Mildew or Other 3295 Tamiami Trail E Fungi Naples, FL 34112. GHA303 War, Terrorism and Bio-Terrorism Exclusion GHA305 Incident Trigger Endorsement GHA020b-Blanket Additional Insured Endorsement provides Vicarious Liability only. If other than Vicarious GHA306 Separate Limits of Liability Liability required, provide full contracts for consideration GHA308 Pending or Prior Litigation Exclusion GHA601 Cyber Exclusion GHA602 Exclusion— Dissociative Disorder LMA3100 Sanction Limitation & Excl Clause LMA5020 Service of Suit clause usa LMA5218 TRIA Election LSW1001 Several Liability Notice NMA1256 Nuclear Incident excl NMA1331 Cancellation clause NMA1477 Radioactive Contamination Excl NMA464 War and Civil War SL1 Syndicate List GHA006 Apnea Monitor Exclusion GHA013 Specified Professional Exclusion GHA020 Additional Insured GHA020b Blanket Additional Insured GHA020p Al Primary Liability GHA021 Employee Benefit Liability GHA128 Physical &Sexual Abuse All premiums are 25%earned upon inception.All policy fees are 100%earned upon inception.Any pricing,terms,or conditionals of the final policy at variance with this binder shall supersede this quotation. State of Florida Surplus Lines Binder Stamp "This insurance is issued pursuant to the Florida Surplus Lines Law. Persons insured by surplus lines carriers do not have the protection of the Florida Insurance Guaranty Act to the extent of any right of recovery for the obligation of an insolvent insurer." "SURPLUS LINES INSURERS' POLICY RATES AND FORMS ARE NOT APPROVED BY ANY REGULATORY AGENCY." Bass Underwriters, Inc. PAY ONLINE REMIT TO: PO Box 741753 Atlanta, GA 30374-1753 Click the link below: Phone: 1-888-422-7715 https://portal.bassuw.com Bill To: AGT13463 Insured: 20751385 Agent: AGT13463 CSR: rcollier Acct Exc: rcollier InsuranceHub Agency, LLC Attn: Rachel Parks 1720 Lakes Pkwy. Submission No: 2323402 Lawrenceville, GA 30043 INVOICE Invoice Date: Invoice Number: Page: 12/04/2018 1579156 1 Insured: Omega Health Services LLC INVOICE PAYMENT DBA: Payment Due On: 12/07/2018 Insurance Company: Policy Number: Effective: Expires: Lloyd's of London GAH-32882-181130 11/30/2018 11/30/2019 Type of Transaction Comp ID Amount Comm($) Net Due Professional Liability-Medical M0252 $1,357.00 $135.70 $1,221.30 Policy Fee INC $35.00 $0.00 $35.00 SL Tax T0006 $69.60 $0.00 $69.60 Svc Off Fee T0001 $1.39 $0.00 $1.39 Amount Invoiced: Comm % Commission Invoice Amount $ 1,462.99 10.00 $ 135.70 $1,327.29 Note: Agency Bill cfelder � . JIMMY PATRONIS CHIEF FINANICAL OFFICER STATE OF FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION ** CERTIFICATE OF ELECTION TO BE EXEMPT FROM FLORIDA WORKERS' COMPENSATION LAW* * NON-CONSTRUCTION INDUSTRY EXEMPTION This certifies that the individual listed below has elected to be exempt from Florida Workers' Compensation law. EFFECTIVE DATE: 11/29/2018 EXPIRATION DATE: 11/28/2020 PERSON: MIRLINE OMEGA EMAIL: INFO@OMEGAHEALTHSERVICES.ORG FEIN: 825284470 BUSINESS NAME AND ADDRESS: OMEGA HEALTH SERVICES LLC OMEGA CARE SERVICES 5921 WASHINGTON ST, 120 HOLLYWOOD, FL 33023 SCOPE OF BUSINESS OR TRADE: Home,Public and Traveling Healthcare-All Employees IMPORTANT:Pursuant to Chapter 440.05(14), F.S.,an officer of a corporation who elects exemption from this chapter by filing a certificate of election under this section may not recover benefits or compensation under this chapter. Pursuant to Chapter 440.05(12),F.S.,Certificates of election to be exempt...apply only within the scope of the business or trade listed on the notice of election to be exempt.Pursuant to Chapter 440.05(13),F.S.,Notices of election to be exempt and certificates of election to be exempt shall be subject to revocation if,at any time after the filing of the notice or the issuance of the certificate,the person named on the notice or certificate no longer meets the requirements of this section for issuance of a certificate.The department shall revoke a certificate at any time for failure of the person named on the certificate to meet the requirements of this section. DFS-F2-DWC-252 CERTIFICATE OF ELECTION TO BE EXEMPT REVISED 08-13 QUESTIONS?(850)413-1609