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Agenda 09/28/2021 Item #16F 3 (Annual COPCN for Ambitrans Medical Transport, Inc.))09/28/2021 EXECUTIVE SUMMARY Recommendation to renew the annual Certificate of Public Convenience and Necessity (COPCN) for Ambitrans Medical Transport, Inc. to provide Class 2 Advanced Life Support (ALS) inter- facility transport ambulance service for a period of one year. OBJECTIVE: To recommend the renewal of Ambitrans Class 2 ALS inter -facility transport services in Collier County by a private provider. CONSIDERATIONS: A COPCN may be approved routinely by the Board as provided by Section 50- 60 of the Collier County Code of Laws and Ordinances governing medical transportation services. Ambitrans inter-facility transport was granted a Certificate of Public Convenience and Necessity on October 25, 2011, by the Board. Staff has deemed Ambitrans renewal application as complete and recommends that the COPCN be renewed for one year. A Class 2 operator provides post-hospital inter- facility medical transfer services, both within and outside the County. Section 50-60 of the Code of Laws and Ordinances provides: Each certificate holder shall file within 90 days of expiration, an application for renewal of his certificate. Renewals shall be based upon the same standards, as the granting of the original certificate along with such other factors as may be relevant. The renewal application shall be accompanied by a $250.00 renewal fee. The renewal certificate may be approved routinely by the board, upon advice of the administrator, or the board may hold a hearing on same. These requirements have been met and the administrator recommends renewal. The Emergency Medical Authority reviewed the application on August 11, 2021, and unanimously recommended to the Board that the Certificate be renewed. FISCAL IMPACT: There is no fiscal impact to the Board for the granting of this certificate. The Board is requested to accept and recognize as revenue in Fund (001) the $250.00 application fee with the corresponding application. GROWTH MANAGEMENT IMPACT: There are no Growth Management Impacts associated with this action. LEGAL CONSIDERATIONS: A hearing is not required for renewal. If a hearing is held, the Board must find that the standards set forth in Section 50-57 of the Code of Laws and Ordinances have been satisfied based on competent evidence as follows: (1) That there is a public necessity for the service. In making such determination, the Board of County Commissioners shall consider, as a minimum, the following factors: a. The extent to which the proposed service is needed to improve the overall emergency medical services (EMS) capabilities of the County. b. The effect of the proposed service on existing services with respect to quality of service and cost of service. 16.F.3 Packet Pg. 1325 09/28/2021 c. The effect of the proposed service on the overall cost of EMS service in the county. d. The effect of the proposed service on existing hospitals and other health care facilities. e. The effect of the proposed service on personnel of existing services and the availability of sufficient qualified personnel in the local area to adequately staff all existing services. (2) That the applicant has sufficient knowledge and experience to properly operate the proposed service. (3) That, if applicable, there is an adequate revenue base for the proposed service. (4) That the proposed service will have sufficient personnel and equipment to adequately cover the proposed service area. This item is approved as to form and legality and requires a majority vote for approval. JAB RECOMMENDATION: That the Board awards a Class 2 Certificate of Public Convenience and Necessity to Ambitrans Medical Transport, Inc., for a period of one year. Prepared by: Dan E. Summers, Director, Bureau of Emergency Services ATTACHMENT(S) 1. Ambitrans 2021 Collier County COPCN Application (PDF) 2. CAO approved Permit (PDF) 3. VIN List 2021 (PDF) 4. CAO approved Certificate (PDF) 16.F.3 Packet Pg. 1326 09/28/2021 COLLIER COUNTY Board of County Commissioners Item Number: 16.F.3 Doc ID: 17843 Item Summary: Recommendation to renew the annual Certificate of Public Convenience and Necessity (COPCN) for Ambitrans Medical Transport, Inc. to provide Class 2 Advanced Life Support (ALS) inter-facility transport ambulance service for a period of one year. Meeting Date: 09/28/2021 Prepared by: Title: Executive Secretary – Emergency Management Name: Kathy Heinrichsberg 08/23/2021 2:42 PM Submitted by: Title: Division Director - Bureau of Emer Svc – Emergency Management Name: Daniel Summers 08/23/2021 2:42 PM Approved By: Review: Agenda Clerk Preview Michael Cox Agenda Item Preview Completed 08/23/2021 3:09 PM Emergency Management Daniel Summers Director Review Completed 08/30/2021 11:59 AM County Attorney's Office Jennifer Belpedio Level 2 Attorney of Record Review Completed 09/01/2021 11:03 AM Office of Management and Budget Debra Windsor Level 3 OMB Gatekeeper Review Completed 09/01/2021 12:07 PM County Attorney's Office Jeffrey A. Klatzkow Level 3 County Attorney's Office Review Completed 09/01/2021 3:06 PM Office of Management and Budget Laura Wells Additional Reviewer Completed 09/02/2021 10:24 AM County Manager's Office Sean Callahan Level 4 County Manager Review Completed 09/20/2021 5:41 PM Board of County Commissioners Geoffrey Willig Meeting Pending 09/28/2021 9:00 AM 16.F.3 Packet Pg. 1327 AMBITRANS MEDICAL TRANSPORT, INC. 2021 COPCN Renewal Application Collier County, Florida Ambitrans Medical Transport, Inc., submits its 2021 Application for Renewal of its Certificate of Public Convenience and Necessity in and for Collier County, Florida. 16.F.3.a Packet Pg. 1328 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application Sec. 50-55 Procedure for obtaining certificate. An applicant for a certificate shall obtain forms from the department to be completed and returned to the division administrator. Each application shall contain: (1) The name, age and address of the owner of the ambulance or ALS provider, or if the owner is a corporation, then of the directors of the corporation and of all of the stoc kholders holding more than 25 percent of the outstanding shares. For governmental units, this information shall be supplied for members of the governing body. Corporate Officers/Directors Michael J. Grant, 71, 4351 Pinnacle Street, Charlotte Harbor, FL 33980 50% Lorraine B. Grant, 66, 4351 Pinnacle Street, Charlotte Harbor, FL 33980 50% Alan J. Skavroneck, 56, 4351 Pinnacle Street, Charlotte Harbor, FL 33980 0% Vanessa Grant Oliver, 40, 4351 Pinnacle Street, Charlotte Harbor, FL 33980 0% (2) The boundaries of the territory desired to be served. Collier County, Florida (3) The number and brief description of the ambulances or other vehicles the applicant will have available. Ambitrans currently has thirty-five licensed ambulances available to its fleet. These units are dually permitted with the Florida Department of Health - Bureau of EMS as Advanced Life Support and Basic Life Support vehicles. Through the use of the company’s computer aided dispatch software, Zoll Data RescueNet Dispatch-Billing™, management is able to staff according to anticipated demand. Staffing levels and patterns are determined using historical data and other internal statistics. Vehicles are posted in accordance with direction from our communications center personnel to specified areas to aid in proper deployment and call response. In the event of increased call volume, Ambitrans has the ability to schedule additional labor and resources to meet any unforeseen increase in market demand. A spreadsheet listing each ambulance in our fleet is attached hereto as Exhibit “A.” 16.F.3.a Packet Pg. 1329 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application (4) The address of the intended headquarters and any substations. Ambitrans corporate office is located at: 4351 Pinnacle Street, Port Charlotte, FL 33980 Our Collier County substation is located at: 1120 Turtle Creek Drive, Unit 625, Naples, FL 34110 Our auxiliary substation to back up the Collier County operation is located at: 935 N.E. 7th Terrace, Cape Coral, FL 33909 16.F.3.a Packet Pg. 1330 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application (5) The training and experience of the applicant. Ambitrans Medical Transport, Inc. was incorporated in 1983 to provide Paratransit services to the residents of Charlotte County. In 1988, ownership of the company transferred to its current principals. In 1995, Ambitrans commenced its ambulance operations. Today, Ambitrans operates in Charlotte, Collier, Lee, Sarasota and Manatee counties. Ambitrans is committed to maintaining compliance with all federal, state and local laws and regulations. We are compliant with Florida Statute 401 and Florida Administrative Code 64J in accordance with standards set forth by the Bureau of EMS and Department of Health. Our state license is valid through June 19, 2023. A copy of our state license is attached hereto as Exhibit “B.” Ambitrans is a licensed Medicare and Medicaid provider and we have contracts in place with many national third-party payors, which enable us to serve all citizens of Collier County. Further, we employ a national law firm specializing in Medicare issues related to the ambulance industry to ensure we remain compliant with all federal laws, rules and regulations relating to Medicare, as well as our CEO, who is also a Florida Bar Board Certified Health Law attorney, to ensure our facility contracts and daily operations conform with all federal, state and local regulations. The management team at Ambitrans collectively has over 200 years of experience in the EMS industry. Our Training and Quality Assurance Department reviews patient care reports for quality assurance and adherence to our medical protocols and standards of care. Our education team is also responsible for our in-house training, which includes CPR, Advanced Cardiac Life Support, Pediatric Advanced Life Support, Emergency Vehicles Operators Course and on-going continuing education units needed for bi-annual certification renewal. Our local, in-house billing department is knowledgeable and responsive and available Monday through Friday to answer any questions our customers may have. 16.F.3.a Packet Pg. 1331 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application Our personnel and managers have diverse experiences that take them well outside of Southwest Florida. Michael Grant, our co-owner, is the Representative for District 75 in the Florida House, where he serves as Majority Leader. Our Chief Operating Officer, Alan Skavroneck, served as President for the Florida Ambulance Association and recently completed his term as State Surgeon General appointee to the Emergency Medical Services Advisory Council. Vanessa Oliver, our Chief Executive Officer, was elected to the Charlotte County Airport Authority, where she oversees the Punta Gorda Airport, one of the fastest growing airports in the nation. She is also a past gubernatorial appointee to the State Board of Funeral, Cemetery and Consumer Services. Dr. Daniel V. O’Leary serves as our medical director of record as mandated under Florida Statute 401.265. This is in addition to his normal day-to-day duties as an emergency room physician at Bayfront Health Port Charlotte as well as serving as the Medical Director for Charlotte County Fire and EMS. (6) The name and addresses of three Collier County residents who will act as references for the applicant. Patricia Davis 212 Napa Ridge Road East Naples, FL 34119 State Senator Garrett Richter 2320 Harrier Run Naples, FL 34105 Jay Crandall, CCIM Managing Broker Crandall Commercial Group LLC 27499 Riverview Center Blvd. Suite 127 Naples, FL 34134 16.F.3.a Packet Pg. 1332 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application (7) A schedule of rates which the service intends to charge. Code Service Description Rate A0428 Basic Life Support Base Rate $425.00 A0429 Basic Life Support Base Rate $455.00 A0426 Advanced Life Support Base Rate $470.00 A0427 Advanced Life Support Base Rate $575.00 A0433 Advanced Life Support Base Rate – Level 2 $725.00 A0434 Specialty Care Transport Base Rate $950.00 A0425 Per Loaded Mile $11.00 Wait Time (BLS or ALS) $200 per hour Wait Time (Critical Care) $350 per hour Extra Ambulance for Lift Assistance $200 per hour 16.F.3.a Packet Pg. 1333 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application (8) Such other pertinent information as the administrator may require. No additional information was requested by the administrator at the time of submission. However, for your convenience, Ambitrans has attached hereto a copy of its Certificate of Insurance as Exhibit “C” and its Certificate of Worker’s Compensation Insurance as Exhibit “D.” Dr. O’Leary’s DEA license and Department of Health license information is attached hereto as composite Exhibit “E.” (9) An application or renewal fee of $250.00. (Exception Collier County EMS). Ambitrans’ check in the amount of $250.00 is enclosed with this Renewal Application. (10) Financial data including assets and liabilities of the operator. A schedule of all debts encumbering any equipment shall be included. Ambitrans’ financial data is attached hereto as Exhibit “F.” 16.F.3.a Packet Pg. 1334 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) Ambitrans Medical Transport, Inc. - Collier County COPCN Renewal Application Schedule of Exhibits Exhibit “A” List of Ambulances in Fleet Exhibit “B” State License Exhibit “C” Certificate of Insurance Exhibit “D” Certificate of Worker’s Compensation Insurance Exhibit “E” Medical Director Certifications Exhibit “F” Financial Data 16.F.3.a Packet Pg. 1335 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) Ambitrans Medical Transport, Inc. 2021 Licensed Ambulance List Vehicle Identification Number License Type License Number Effective Date 1FDSS3ES0DDA41561 VEHICLE PERMIT (ALS)20888 8/24/2017 1FDSS3ES0DDA41561 VEHICLE PERMITS (BLS)4956 2/18/2016 1FDSS3ES1BDB27801 VEHICLE PERMIT (ALS)17027 12/8/2011 1FDSS3ES1BDB27801 VEHICLE PERMITS (BLS)5212 8/24/2017 1FDSS3ES3CDA18371 VEHICLE PERMIT (ALS)20885 8/24/2017 1FDSS3ES3CDA18371 VEHICLE PERMITS (BLS)4832 4/8/2015 1FDSS3ES4BDA26137 VEHICLE PERMIT (ALS)20882 8/24/2017 1FDSS3ES4BDA26137 VEHICLE PERMITS (BLS)4775 7/31/2014 1FDSS3ES5CDA18372 VEHICLE PERMIT (ALS)20886 8/24/2017 1FDSS3ES5CDA18372 VEHICLE PERMITS (BLS)4954 2/18/2016 1FDSS3ES6ADA31208 VEHICLE PERMIT (ALS)20880 8/24/2017 1FDSS3ES6ADA31208 VEHICLE PERMITS (BLS)4678 8/1/2013 1FDSS3ES6BDB36820 VEHICLE PERMIT (ALS)22521 10/1/2019 1FDSS3ES6BDB36820 VEHICLE PERMITS (BLS)5940 10/1/2019 1FDSS3ES7BDB27799 VEHICLE PERMIT (ALS)20883 8/24/2017 1FDSS3ES7BDB27799 VEHICLE PERMITS (BLS)4777 7/31/2014 1FDSS3ES7BDB27804 VEHICLE PERMIT (ALS)17026 12/8/2011 1FDSS3ES7BDB27804 VEHICLE PERMITS (BLS)5213 8/24/2017 1FDSS3ES8DDB02266 VEHICLE PERMIT (ALS)20889 8/24/2017 1FDSS3ES8DDB02266 VEHICLE PERMITS (BLS)4776 7/31/2014 1FDSS3ES9EDA22265 VEHICLE PERMIT (ALS)20890 8/24/2017 1FDSS3ES9EDA22265 VEHICLE PERMITS (BLS)4823 3/10/2015 1FDWE3FD7ADA20886 VEHICLE PERMITS (BLS)5121 3/8/2017 1FDWE3FS4ADA62447 VEHICLE PERMIT (ALS)20891 8/24/2017 1FDWE3FS4ADA62447 VEHICLE PERMITS (BLS)5119 3/8/2017 1FDWE3FS5ADA20885 VEHICLE PERMIT (ALS)20892 8/24/2017 1FDWE3FS5ADA20885 VEHICLE PERMITS (BLS)5120 3/8/2017 1FDWE3FS6BDA87027 VEHICLE PERMIT (ALS)20896 8/24/2017 1FDWE3FS6BDA87027 VEHICLE PERMITS (BLS)4821 3/10/2015 1FDWE3FS7ADA20886 VEHICLE PERMIT (ALS)20893 8/24/2017 1FDWE3FS7ADA69148 VEHICLE PERMIT (ALS)18535 7/31/2014 1FDWE3FS7ADA69148 VEHICLE PERMITS (BLS)5216 8/24/2017 1FDWE3FS88DA01958 VEHICLE PERMIT (ALS)21048 10/25/2017 1FDWE3FS88DA01958 VEHICLE PERMITS (BLS)5368 10/25/2017 1FDWE3FS8BDA09607 VEHICLE PERMIT (ALS)18896 3/10/2015 1FDWE3FS8BDA09607 VEHICLE PERMITS (BLS)5218 8/24/2017 1FDWE3FS9ADA34661 VEHICLE PERMIT (ALS)19943 6/6/2016 1FDWE3FS9ADA34661 VEHICLE PERMITS (BLS)5224 8/24/2017 1FDWE3FSXDDA26427 VEHICLE PERMIT (ALS)23547 3/2/2021 1FDWE3FSXDDA26427 VEHICLE PERMITS (BLS)6317 3/2/2021 1FDXE4FS0EDA55897 VEHICLE PERMIT (ALS)22001 1/18/2019 1FDXE4FS0EDA55897 VEHICLE PERMITS (BLS)5692 1/18/2019 1FDXE4FS0GDC00665 VEHICLE PERMIT (ALS)22759 2/3/2020 1FDXE4FS0GDC00665 VEHICLE PERMITS (BLS)6007 2/3/2020 1FDXE4FS2BDB29932 VEHICLE PERMIT (ALS)19699 1/19/2016 1FDXE4FS2BDB29932 VEHICLE PERMITS (BLS)5220 8/24/2017 Exhibit "A" 16.F.3.a Packet Pg. 1336 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) Ambitrans Medical Transport, Inc. 2021 Licensed Ambulance List 1FDXE4FS2EDA12033 VEHICLE PERMIT (ALS)23784 7/8/2021 1FDXE4FS2EDA12033 VEHICLE PERMITS (BLS)6385 7/8/2021 1FDXE4FS2EDA55898 VEHICLE PERMIT (ALS)22002 1/18/2019 1FDXE4FS2EDA55898 VEHICLE PERMITS (BLS)5693 1/18/2019 1FDXE4FS2GDC00666 VEHICLE PERMIT (ALS)22760 2/3/2020 1FDXE4FS2GDC00666 VEHICLE PERMITS (BLS)6008 2/3/2020 1FDXE4FS3BDB29941 VEHICLE PERMIT (ALS)19758 2/18/2016 1FDXE4FS3BDB29941 VEHICLE PERMITS (BLS)5222 8/24/2017 1FDXE4FS3BDB35786 VEHICLE PERMIT (ALS)19759 2/18/2016 1FDXE4FS3BDB35786 VEHICLE PERMITS (BLS)5223 8/24/2017 1FDXE4FS4BDB35781 VEHICLE PERMIT (ALS)19757 2/18/2016 1FDXE4FS4BDB35781 VEHICLE PERMITS (BLS)5221 8/24/2017 1FDXE4FS5EDA77930 VEHICLE PERMIT (ALS)23534 2/23/2021 1FDXE4FS5EDA77930 VEHICLE PERMITS (BLS)6312 2/23/2021 1FDXE4FS6CDA90604 VEHICLE PERMIT (ALS)19956 6/20/2016 1FDXE4FS6CDA90604 VEHICLE PERMITS (BLS)5225 8/24/2017 1FDXE4FS8BDB35783 VEHICLE PERMIT (ALS)19957 6/20/2016 1FDXE4FS8BDB35783 VEHICLE PERMITS (BLS)5226 8/24/2017 1FDXE4FS8GDC04320 VEHICLE PERMIT (ALS)23009 6/5/2020 1FDXE4FS8GDC04320 VEHICLE PERMITS (BLS)6112 6/5/2020 1FDXE4FSDDA34901 VEHICLE PERMIT (ALS)23548 3/2/2021 1FDXE4FSDDA34901 VEHICLE PERMITS (BLS)6318 3/2/2021 1FDXE4FSXGDC04321 VEHICLE PERMIT (ALS)23010 6/5/2020 1FDXE4FSXGDC04321 VEHICLE PERMITS (BLS)6113 6/5/2020 16.F.3.a Packet Pg. 1337 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) STATE OF FLORIDA DEPARTMENT OF HEALTH BUREAU OF EMERGENCY MEDICAL OVERSIGHT ADVANCED LIFE SUPPORT SERVICE LICENSE This is to certify that: AMBITRANS MEDICAL TRANSPORT, INC. Provider Number # 804 Name of Provider 4351 PINNACLE STREET, PORT CHARLOTTE, FLORIDA 33980 Address has complied with Chapter 401, Florida Statutes, and Chapter 64J-1, Florida Administrative Code, and is authorized to operate as an Advanced Life Support Service subject to any and all limitations specified in the applicable Certificate(s) of Public Convenience and Necessity and/or Mutual Aid Agreements for the County(s) listed below: CHARLOTTE; COLLIER; LEE; MANATEE & SARASOTA County (s) Steve A. McCoy Emergency Medical Services Administrator Florida Department of Health THIS CERTIFICATE EXPIRES ON: 06/19/2023 This certificate shall be posted in the above mentioned establishment Exhibit "B" 16.F.3.a Packet Pg. 1338 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) INSR ADDLSUBR LTR INSR WVD DATE (MM/DD/YYYY) PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE INSURER(S) AFFORDING COVERAGE NAIC # Y / N N / A (Mandatory in NH) ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? EACH OCCURRENCE $ DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ $ PRO- OTHER: LOCJECT COMBINED SINGLE LIMIT $(Ea accident) BODILY INJURY (Per person) $ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS AUTOS ONLY HIRED PROPERTY DAMAGE $AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE $ CLAIMS-MADE AGGREGATE $ DED RETENTION $$ PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below POLICY NON-OWNED SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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 any rights to the certificate holder in lieu of such endorsement(s). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03) ACORDTM CERTIFICATE OF LIABILITY INSURANCE Arch Insurance Company Arch Specialty Insurance Company 6/29/2021 Marsh & McLennan Agency Bouchard Region 5310 Clark Rd Sarasota, FL 34233 727 447-6481 clcerts@bouchardinsurance.com Grant Medical Transportation, Inc. 4351 Pinnacle Street Charlotte Harbor, FL 33980 11150 21199 A X X X 3rd Party PD Incl. X MAPK08386906 07/01/2021 07/01/2022 1,000,000 100,000 10,000 1,000,000 3,000,000 3,000,000 A X X X MAPK08386906 07/01/2021 07/01/2022 1,000,000 A X X X 0 MAUM08509606 07/01/2021 07/01/2022 2,000,000 2,000,000 B Professional Liab MAPL20015500 07/01/2021 07/01/2022 $1M Occ/$3M Agg ** Supplemental Name ** First Supplemental Name applies to all policies - Grant Medical Transportation, Inc. Policy# MAPK08386906 - : Ambulance Management Services, LLC Policy# MAPK08386906 - : Ambitrans Medical Transport, Inc. Policy# MAPK08386906 - : Venice Ambulance Service, Inc. (See Attached Descriptions) FL Dept. of Health, Bureau of Emergency Medical Services 4052 Bald Cypress Way MB C-18 Tallahassee, FL 32399-1738 1 of 2 #S8438855/M8437288 GRANTMEDIC1Client#: 707514 RCMXC 1 of 2 #S8438855/M8437288 Exhibit "C" 16.F.3.a Packet Pg. 1339 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) SAGITTA 25.3 (2016/03) DESCRIPTIONS (Continued from Page 1) Policy# MAUM08509606 - : Ambulance Management Services, LLC Policy# MAUM08509606 - : Ambitrans Medical Transport, Inc. Policy# MAUM08509606 - : Venice Ambulance Service, Inc. Policy# MAPL20015500 - : Ambulance Management Services, LLC Policy# MAPL20015500 - : Ambitrans Medical Transport, Inc. Policy# MAPL20015500 - : Venice Ambulance Service, Inc. 2 of 2 #S8438855/M8437288 16.F.3.a Packet Pg. 1340 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) INSR ADDLSUBR LTR INSR WVD DATE (MM/DD/YYYY) PRODUCER CONTACT NAME: FAXPHONE (A/C, No):(A/C, No, Ext): E-MAIL ADDRESS: INSURER A : INSURED INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY AUTOMOBILE LIABILITY UMBRELLA LIAB EXCESS LIAB WORKERS COMPENSATION AND EMPLOYERS' LIABILITY DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) AUTHORIZED REPRESENTATIVE INSURER(S) AFFORDING COVERAGE NAIC # Y / N N / A (Mandatory in NH) ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? EACH OCCURRENCE $ DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ $ PRO- OTHER: LOCJECT COMBINED SINGLE LIMIT $(Ea accident) BODILY INJURY (Per person) $ANY AUTO OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS ONLY AUTOS AUTOS ONLY HIRED PROPERTY DAMAGE $AUTOS ONLY (Per accident) $ OCCUR EACH OCCURRENCE $ CLAIMS-MADE AGGREGATE $ DED RETENTION $$ PER OTH- STATUTE ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below POLICY NON-OWNED SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 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. 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 any rights to the certificate holder in lieu of such endorsement(s). COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: CERTIFICATE HOLDER CANCELLATION © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORDACORD 25 (2016/03) ACORDTM CERTIFICATE OF LIABILITY INSURANCE Benchmark Insurance Company 5/14/2021 Marsh & McLennan (SAR) 5310 Clark Road, Suite 1 Sarasota, FL 34233 941 922-0245 Bouchard Insurance 941 922-0245 941 923-4126 clcerts@bouchardinsurance.com Ambitrans Medical Transport, Inc. 4351 Pinnacle Street Punta Gorda, FL 33980 41394 A N FPD20129000 12/27/2020 12/27/2021 X 1,000,000 1,000,000 1,000,000 For Informational Purposes Only For Informational Purposes Only 1 of 1 #S8295719/M7056730 AMBITMEDICClient#: 711402 RCMXC 1 of 1 #S8295719/M7056730 Exhibit "D" 16.F.3.a Packet Pg. 1341 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) Exhibit "E" 16.F.3.a Packet Pg. 1342 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) INDEPENDENT ACCOUNTANTS’ COMPILATION REPORT To the Board of Directors Ambitrans Medical Transport, Inc. Charlotte Harbor, Florida We have compiled the accompanying statement of assets and liabilities of the ambulance transportation operations of Ambitrans Medical Transport, Inc. and subsidiaries as of April 30, 2021. This financial statement has been prepared on the income basis of accounting utilized by the Company for federal income tax reporting purposes. We have not audited or reviewed the accompanying financial statement and, accordingly, do not express an opinion or provide any assurance about whether the financial statement is in accordance with the income tax basis of accounting. Management is responsible for the preparation and fair presentation of the financial statement in accordance with the income tax basis of accounting and for designing, implementing, and maintaining internal control relevant to the preparation and fair presentation of the financial statement. Our responsibility is to conduct the compilation in accordance with Statements on Standards for Accounting and Review Services issued by the American Institute of Certified Public Accountants. The objective of a compilation is to assist management in presenting financial information in the form of a financial statement without undertaking to obtain or provide any assurance that there are no material modifications that should be made to the financial statement. The accompanying statement was prepared for the purpose of presenting the assets and liabilities of the ambulance transportation operations of Ambitrans Medical Transport, Inc. and subsidiaries, and is not intended to be a complete presentation of Ambitrans Medical Transport, Inc. and subsidiaries consolidated assets and liabilities. Accordingly, this report and related financial statement is restricted for use only by known third parties with knowledge of these restrictions and should not be used for any other purpose. July 21, 2021 Port Charlotte, Florida E X C E L L E N C E S I N C E 1 9 8 4 BRIAN W. CROSLAND, CPA, PL CERTIFIED PUBLIC ACCOUNTING & CONSULTING 2200 KINGS HIGHWAY #3L242 PORT CHARLOTTE, FL 33980 PHONE: 941.676.8900 FACSIMILE: 941.347.4275 AMERICAN INSTITUTE OF CERTIFIED PUBLIC ACCOUNTANTS FLORIDA INSTITUTE OF CERTIFIED PUBLIC ACCOUNTANTS MEDICAL GROUP MANAGEMENT ASSOCIATION COMMUNITY ASSOCIATIONS INSTITUTE KRISTI L. SCOTT SHAWN M. COOLEY, CPA Exhibit "F" 16.F.3.a Packet Pg. 1343 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) Assets Current Assets: Cash available for ambulance transportation operations 695,000$ Property and Equipment: Office equipment and computers 172,336 Machinery and equipment 824,028 Medical transportation vehicles 1,831,986 2,828,350 Less accumulated depreciation (2,761,506) Property and Equipment, net 66,844 Total Assets 761,844$ Liabilities Current Liabilities: Accrued profit sharing 85,645$ Other liabilities 37,500 Notes payable to banks 226,615 349,760 Long Term Liabilities: Notes payable to banks 344,648 Less current portion above (226,615) 118,033 Total liabilities 467,793 Net Assets Over Liabilities, income tax basis 294,051$ Ambitrans Medical Transport, Inc. and Subsidiaries Statement of Assets and Liabilities of the Ambulance Transportation Operations Income Tax Basis of Accounting April 30, 2021 (Unaudited) Read Independent Accountants' Compilation Report 16.F.3.a Packet Pg. 1344 Attachment: Ambitrans 2021 Collier County COPCN Application (17843 : 2021 Ambitrans Annual CoPCN) 16.F.3.b Packet Pg. 1345 Attachment: CAO approved Permit (17843 : 2021 Ambitrans Annual CoPCN) 16.F.3.c Packet Pg. 1346 Attachment: VIN List 2021 (17843 : 2021 Ambitrans Annual CoPCN) 16.F.3.c Packet Pg. 1347 Attachment: VIN List 2021 (17843 : 2021 Ambitrans Annual CoPCN) 16.F.3.d Packet Pg. 1348 Attachment: CAO approved Certificate (17843 : 2021 Ambitrans Annual CoPCN)