#09-5343 (Quest Diagnostics)
QUEST DIAGNOSTICS INCORPORATED
LETTER OF AGREEMENT
FOR BLUEPRINT FOR WELLNESSTM SERVICES
QUEST DIAGNOSTICS INCORPORATED, ("QUEST DIAGNOSTICS")
agrees to provide Blueprint for Wellness 1M Services to:
Customer Name Collier County Government
cOrDorate name)
N/A
Subcontract name
Customer ContactlTitle Karen Eastman, Wellness Programs Mgr, OR
Jeff Walker, Risk Manacement Director
Customer Contact Information Collier County Government
IStreet Address 3301 East Tamiami Trail, Bldg. D
City Naples
State, Zip FL 34112
Phone Number Karen Eastman 239-252-8906 OR Jeff Walker 239-252-6092
Email Address kareneastmanlBlcollieroov.net OR JeffWalkerallcollieraov. net
Program Name/Account #(s) "INVEST IN YOUR HEALTH"
Total # of Participants Eligible and Number of Participants eligible: _Based on age eligible criteria, and
employees> 50 years of age
Estimated % DartlciDatlon EXDected % ParticiDation: 80 %
Requested Date(s) and Locatlon(s) ~ List of locations for CCG is attached.
Iof Event ~ Primary location (same address as above, with -1,000
(Date(s) to be confirmed by BFW participants would like to begin BFW events on 1/20/09 for 2
Staff. weeks, then complete all locations by March 31't
List each individual location and # of
!eligible participants at each).
Note than an "Event" is considered a
health fair/screening at one location
or a fixed, uninterrupted period of
ime.
Event Staffing Commitment .: ~ Three (3) weeks before each Event
Wellness Specialist will confirm with
he customer the number of ..Staffing Commitments finalized less than three (3) weeks require
participants, event hours and prior approval and will be assessed additional charges as set forth in
~chedule event staffing three weeks Section 1 of the Terms of Service, below.
IDrior to each event date.
2009: Health-Plan-eligible employees of CCG total - 2,200
Eligibility Criteria for Participation 2010: Age-based, Health-Plan-eligible employees of CCG -1,200
(e.g., employees only, spouses, etc.) 2011: Age-based, Health-Plan-eligible employees of CCG + eligible,
active spouses -2,200
2012: Final events take Dlace Jan-March, 2012
Iservlces Requested Personal Laboratory Report Solution
Itprooram modules & Dricina. below)
BFW LOA rev. 11/07
I
Laboratory Tests Included: Heart: Total cholesterol, HDL, calculated LDL, triglycerides,
calculated cholesterol/HDL ratio (Note: no cardio-CRP as requested)
Thyroid: TSH-Thyroid Stimulating Hormone, and Free T4
Kidneys: BUN, creatinine, BUN/creatinine ratio
Bone: Calcium
Liver: Albumin, total protein, globulin, A1G ratio, Alkaline
Phosphatase, AL T, AST, total & direct bilirubin, and GGT
Pancreas: Glucose
!whole Body: Chloride, potassium, sodium
Pancreas: Hemoglobin A1c
Blood: CBC Hemogram
Lunas: Cotinine (blood sam ole)
PSA (Males> or = 40) (Yes or No) NO
sDecify if other than Males> or = 40\
HRA (on-line, paper or both) HRA - Both
Specimen Collection: On-site Events & Remote PSC Collection Kits
(On-site Events, Remote/PSCs,
other)
Medical Authority (PWN Physician Quest Diagnostics will provide medical authority via PWN-
or Customer-supplied) Physician's Wellness Network.
Biometric Measurement Data Height, Weight, BMI, Blood/Pressure, Waist, Hip, Waist/Hip Ratio
Requested:
Describe Customer reauirement)
Participation in BFW-PWR is a key "qualifying step" for health-plan-
Participant Incentive eligible employees to increase coverage from "Basic' to "Select" or
"Premium" without increasing their contribution to the health plan.
Incentive Criteria BFW-Personal Wellness Report to include HRA
On Line Registration Key CCG
lWellness Program Participant 101 CCG Employee ID # - this change occurred 10/2/08
~hen spouses are added in 2011 they will use the employee 10 + S
Participant 10: Define unique or Spouse.
Participant 10 requested as it will
appear in the Customer eligibility
lIe(emDlovee 10, SSN, Etc~)
DIsclosure of Partlciaant Data In }> Do not send PWR data to Meritain (health plan) at this time.
Identifiable Format (i.e., disclosure }> CCG identified data should go to CHP-Community Health
of data other than the aggregate de- Partners weekly.
identified statistical report provided to }> CCG request that all printed BFW-PLR printed reports be made
Customer): available to CHP so the CHP Health Advocates can review lab
and HRA results with each participant during their one-on-one
Define Customer requested Result counseling sessions.
Reporting to participant or other 3rd }> All mailed PWRs should ship in bulk to:
parties. Attn: Sandy Theobald
(e.g., third party disease Community Health Partners
management or wellness provider) 851 5th Ave. North, Suite 201
Disclosure of identifiable participant Naples, FL 34102
:lata requires a written directive from }> CCG prefers no participant results be available on-line at any
he Customer containing specific time.
elements, and must be received prior
o any release of PHI to anyone other
han the Dartic/Dant.
BFW LOA rev. 11/07
2
-~-~""'--' --,,--.-,--_...._._-~~._,-,..~~._".._,---,,'-----~.."_._~----"." ..-.
De-Identified - Aggregate
Reporting:
Define requirements for De-Identified ..
aggregate reporting breakout and
parties to receive the reporti ng.
Eligibility File of Participants:
Define contact that will provide the
ligibility file and target date for
delivery
n eligibility file is required where
BFW scheduling and/or an HRA
omponent is provided.
Note: Will participation be allowed if
mployee and/or spouse is not
included in the eligibility file?
Program estimated start date(s)
Program estimated end date(s)
BFW LOA rev. 1lI07
.. Exact Reporting TBD - includes program aggregate report and
weekly participation reports.
CCG would like the standard Aggregate Report following the
events (predicted to last through March 31, 2009, and about 1
month to allow some ees to visit a Quest Diagnostics PSC. After
that time, additional BFW registrations should be new
employees.
.. They would like to get weekly Participant participation reports
showing those employees that have had BFW collected. CCG
will sort by Dep1. or Cost Center to determine where they need
more communication to encourage participation.
.. In subsequent years they want cohort reports that demonstrate
chan es over rior ear, stratified b De 1. or Cost Ctr.
Eligibility File to be Provided By:
lice Toppe 239-252-8966 and James(Jim) Young of Collier County
Government
.. Only names in the eligibility file are allowed to participate in
Blueprint for Wellness. CCG will send updated eligibility file
(monthly) for the 39 months of the program.
.. First eligibility file is due about Nov. 1, 2008. Beginning in 2011
spouses will be included.
arget Date for Year 2 Eligibility File: TBD
.. Events Jan 1 - Mar 31, 2009, then as needed for new ees
throughout the year until Dec.31, 2009
.. Events in 2010 will be limited to an age-based group, followed by
new employees.
.. Events in 2011 will be limited to an age-based group and
spouses, and will be followed by new employees.
.. Events in 2012 will include employees, spouses and may be age
based.
.. Client reserves the right to adjust dates and scope of services by
year with ample advance notice to BFW.
Program will end annually on Dec. 31s" and the complete
r ram will end on March 31, 2012
3
BFW Pro ram Module sand Pricin
erm of the Letter of Agreement:
(mm-dd-yy - mm-dd-yy)
Copies of electric invoices (as a convenience only) to:
).> Keith Wilson: keith.wilson@meritain.com
).> Victoria Krenik: victoria.krenik meritain.com
nnually - through March 31, 2012 (39 months)
[ ] One Year [] One-time Event (check one box)
X 39 Months - Jan 1,2008 - March 31,2012.
Other comments or requirements:
Customer BUlin Account # s :
Invoices should be sent to CCG (email preferred but not required) for
Billing Arrangements: payment:
If other than bill to "Customer" please).> Alice Toppe: 239-252-8966 or alicetoppe@collieraov.net
etail and provide billing contact ).> Claire Wilson: 239-252-6120 or c1airewilson@collieroov.net
Alice Toppe OR Claire Wilson
Collier County Government
3301 Tamiami Trail, Bldg D
Naples, FL 34112
Monthl :39 months
R an Van Horn
NO
NO
PROGRAMS OR COMPONENTS
ro ram details and s cial re uirements should be noted
).> Participant Registration and Scheduling, online and by phone
).> Physician Oversight provided throughout program
).> BFW Specialist assigned as key contact throughout program
).> On-Site Collection Events.
).> Remote Collection Kits provided to employees unable to attend events
).> Bio-Metric Measures (Height, Weight, B/P, BMI, Waist & Hip circumference)
).> Personal Wellness Report for every participant
).> Health Management Data Feed provided to vendors you select.
).> Heart: Total chol, HDL, calc LDL, triglycerides, calc chol/HDL ratio (NO CRP)
).> Thyroid: TSH-Thyroid Stimulating Hormone, and Free T4
).> Kidneys: BUN, creatinine, BUN/creatinine ratio
).> Bone: Calcium
).> Liver: Alb, total protein, globulin, AlG ratio, Alk Phos, AL T, AST, total &
direct bilirubin, and GGT
).> Pancreas: Glucose
).> Whole Body: Chloride, K, Na++
).> Pancreas: Hemoglobin A 1 c
).> Blood: CBC Hemogram
).> Lun s: Cotinine blood sam Ie
aist circumference, Hip circumference, Waist/Hip Ratio
TOTAL Price/Participant
Note: This price is for 2010 Program. The 3rd and 4th year (Jan. 2011 & Jan-
Mar 2012 ma be sub.ect to a rice increase u to but not exceed in 4%.
SPECIAL PROGRAMS OR EVENT ARRANGEMENTS
(program details and special requirements should be noted)
All lab tests Included
Included
129.50
PRICE PER PROGRAM
OR EVENT
BFW LOA rev. 11107
4
In the event Collier County Government requests additional services not set forth
bove, the arties shall mutuall a ree u on services and ricin.
BLUEPRINT FOR WELLNESS CUSTOM PROGRAMS
FULLY DETAIL
Send invoices to: Alice Toppe and Claire Wilson at CCG
)> Alice Toppe: 239-252-8966 or alicetoppe@collieraov.net
)> Claire Wilson: 239-252-6120 or c1airewilson@collieraov.net
)> Addresses listed above
PRICE PER PROGRAM
OR EVENT
Included
BFW LOA rev. 11/07
5
Terms of Service:
1. BFW SERVICES: In accordance with the program-specific details listed above, Quest Diagnostics agrees to
provide the Blueprint For Wellness™ ("BFW) Services as further set forth herein. The BFW Services
provided by Quest Diagnostics are as follows:
a. Registration and Scheduling of participants (if selected by Customer): offered via online access or by
calling a toll-free wellness scheduling number.
b. Provision of all supplies and test kits necessary to provide BFW Services.
c. Collection Services to obtain/collect all specimens from participants at an "Event". Additional charges will
apply when:
(i) Paramedical examiner is required to collect specimens between the hours of 9:00 PM and 6:00 AM
Monday-Saturday and between the hours of 6:00 PM Saturday and 6:00 AM Monday (additional
charge of $30 per hour, per examiner applies).
(i1) Staffing of the Event is requested less than three (3) weeks prior to the Event (additional $7 per-
participant charge).
(iii) Staffing is requested in advance for Events with fewer than 20 participants (a "Small Group Event"):
. Home or office visit to collect specimens from one participant: $95** per visit
. Small Group Events with 10 or fewer participants (based upon a 1-2 hour event, with one
examiner): $140**
. Small Group Events with 11-19 participants (based upon a 1-2 hour event, with one or two
examiners as determined by Quest Diagnostics)): $240**
. **the surcharges specified above are added in addition to BFW per-participant charges for
BFW Services. If additional staffing is requested for a Small Group Event, an additional $60
per hour/per examiner charge will be assessed.
. Depending on the number of Actual Participants who participate in the Small Group Event,
Customer will be assessed either the Small Group surcharges listed above, or the per-
participant charges for at least 20 Participants, whichever amount is lower.
(iv) Paramedical examiner is required to travel more than fifty (50) miles each way to/from the Event from
the ExamOne office where the paramedical examiner is based (additional $.47/mile over 50 miles
to/from Event). If an overnight stay is required, Customer will be billed actual lodging/food expenses.
d. Based upon the specific Program components selected by Customer, includes collection of biometric data,
shipment of specimens to the testing laboratory, and testing of laboratory specimens.
e. Release of test results to an Authorized Provider and if authorized, directly to participants. Customer will
also receive a report detailing aggregate de-identified statistics. Additional or reprinted reports may be
provided for an additional charge.
1. THIRD PARTY WELLNESS/DISEASE MANAGEMENT PROVIDER
COMMUNITY HEALTH PARTNERS (CHP)
2. WELL SOURCE - Wellness Provider
Customer has directed Quest Diagnostics to release participant test results or other identifiable health
information to third party disease management or wellness providers. Customer represents and warrants
that (i) it has provided the appropriate notice to participants in its HIPAA Notice of Privacy Practices to
allow such a disclosure, (ii) the provision of identifiable participant data is consistent with the Notice (i1i)
access to identifiable participant data will be limited to only those employees who require access to the
data for the proper performance of their duties on behalf of Customer's third party disease management or
wellness provider receiving the data on its behalf is acting in its capacity as a "Business Associate" of
Customer.
2. PAYMENT TERMS: Customer agrees to pay Quest Diagnostics for services as set forth herein within thirty
(30) days of date of invoice, and Customer agrees not to submit (or request Quest Diagnostics to submit) any
claim, bill or other request for reimbursement to any insurer, Managed Care Organization, Govemment health
program, fund, or to any other person or entity. Quest Diagnostics reserves the right to add a charge of the
lesser of one and one-half percent (1 %%) per month, or the maximum rate the law permits, on all amounts
thirty (30) or more days past due.
BFW LOA rev. tlI07
6
3. MEDICAL AUTHORITY: Customer acknowledges and agrees that only a person who is authorized under
applicable state/federal law to order those clinical laboratory tests included in the Blueprint For Wellness 1M
product ("Testing") shall order all Testing (such person shall be referred to as an "Authorized Provider").
a. In the event Customer provides such Authorized Provider themselves, Customer represents and warrants
that the Authorized Provider meets all state/federal laws applicable to the ordering of Testing. Alternately,
in the event Customer elects to have Quest Diagnostics arrange for an Authorized Provider, Quest
Diagnostics shall represent and warrant that this Authorized Provider meets all state/federal laws
applicable to the ordering of Testing.
b. Quest Diagnostics shall report laboratory results only to such Authorized Provider, unless such Authorized
Provider gives permission for Quest Diagnostics to release the lab results to such employee participants
as desired. If Customer is providing such Authorized Provider, the requirement to allow release of results
directly to the participant must be included in Customer's contract with such Authorized Provider.
c. The Authorized Provider is responsible for contacting participants in the event of alert, critical, and
significantly out-of-normal range laboratory results.
d. While the Authorized Provider may set hislher own alert values, critical ranges are not modifiable.
e. The Authorized Provider may be required to forward test results to the participant's personal physician.
4. NO-SHOW, MINIMUM, AND CANCELLATION CHARGES:
At least three (3) weeks prior to an Event, Customer and Quest Diagnostics will finalize a Staffing Commitment
("Staffing Commitment") which allows Quest Diagnostics to schedule staffing for the Event based upon the
number of expected participants and length of the Event. At the point the Staffing Commitment is finalized,
Customer will be responsible for paying no-show, minimum, and cancellation charges
a. No-Show Charges: No-Show Charges will not apply if at least 90% of the Expected Participants
participate in the Event ("Actual Participation Rate"). The term "Expected Participants" means the
number of participants that were expected to participate at the time the Staffing Commitment is
finalized (including scheduled participants and expected walk-in participants). For all Events where the
Actual Participation Rate is less than 90%, Customer will be charged a No-Show Charge of $20 per
participant until the Actual Participation Rate is equivalent to 90%.
For example: If an Event is held for 100 Expected Participants and there are 80 Actual Participants,
Customer will be charged a No-Show Charge of $20 for 10 Participants. [100 Expected Participants x
90% No-Show Threshold] = 90 . and [90 minimum required participants - 80 Actual Participants] x $20
= $200 No-Show Penalty.
b. Minimum Event Participation and Hourly Participant Flow: Unless a Small Group Event is arranged in
advance, Quest Diagnostics will only schedule and staff Events with a minimum of 20 Expected
Participants and where at least 10 participants per hour can be processed by a specimen collector For
purposes of this section, "Event" means one wellness screening/health fair held at a single location. For
an Event that is expected to have less than 20 Expected Participants, Customer may make arrangements
in advance for Quest Diagnostics to staff for a Small Group Event. Small Group Event charges are further
described in Section 1 and are assessed to Customer to equip, staff and manage the Small Group Event.
c. Cancellation Charges: If an Event is cancelled after the Staffing Commitment has been finalized,
Customer shall be responsible for paying $20.00 for each Expected Participant. Postponement of an
Event is equivalent to a Cancellation.
5. LEGISLATIVE/REGULATORY CHANGE: In the event federal or state legislative and/or regulatory changes
impact Quest Diagnostics' clinical reference laboratory business, Quest Diagnostics will retain the right, upon
prior written notice to Customer, to immediately amend this agreement to fully comply with any legislative or
regulatory changes. All other modifications or amendments to this agreement will not be binding unless
reduced to writing and signed by the parties hereto.
6. TERMINATION: This agreement will take effect on the date it is fully executed by both parties and may be
renewed on an annual basis upon mutual agreement of the parties for two additional one (1) year periods.
Customer will provide Quest Diagnostics with sixty (60) days advanced written notice of its intent to renew.
BFW LOA rev. 11107
7
7. INDEMNIFICATION: Not to exceed the maximum extent permitted by Florida law, Quest Diagnostics shall
indemnify and hold harmless Collier County, its officers and employees from any and all liabilities,
damages, losses and costs, including, but not limited to, reasonable attorneys' fees and paralegals' fees, to
the extent caused by the negligence, recklessness, or intentionally wrongful conduct of Quest Diagnostics
or anyone employed or utilized by the Quest Diagnostics 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. The
provisions of this paragraph shall survive termination of this Agreement. This section does not pertain to
any incident arising from the sole negligence of Collier County.
8. INSURANCE: Quest Diagnostics shall agree to maintain the following insurance coverage during the
course of this agreement. Quest Diagnostics may utilize a program of self insurance for all or any portion
of the minimum limits required to be carried.
TYPE LIMITS (Checkl
X Workers' Compensation Statutory Limits of Florida Statutes 440 and Federal Government Statutory Limits
and Reauirements
X Emolover's Liabilitv X $500,000 $1,000,000
X Commercial General $500,000 per occurrence X $1,000,000 per occurrence bodily injury and
Liability (Occurrence Form) bodily injury and property property damage
patterned after the current damage
ISO form with no limiting
endorsements.
X Professional Liability X $1 ,000,000 per occurrence $2,000,000 per occurrence
Insurance $1,000,000 aaareaate $2,000,000 aaareaate
Collier County Board of County Commissioners shall be named as the Certificate Holder. NOTE-- The "Certificate
Holder" should read as follows:
Collier County
Board of County Commissioners
Naples, Florida
No County Division, Department, or individual name should appear on the Certificate. No other format will be
accentanle. Thirty (30) Days Cancellation Notice required on Agreements exceeding 6 months. The contract name and number
shall be included on the certificate of insurance.
Collier County must be named as "ADDITIONAL INSURED" on the Insurance Certificate for Commercial General
Liabilitv.
9. ENTIRE AGREEMENT: This Agreement constitutes the entire understanding between the parties regarding
the subject matter hereof and supersedes all prior understandings, arrangements and agreements relating to
the subject matter hereof. .
10. INDEPENDENT CONTRACTORS: It is expressly understood and agreed by the parties hereto that Quest
Diagnostics and Customer will at all times be and act as independent contractors.
t I. TRADEMARKS: Neither party shall use the trademark, trade name, or service mark of the other party for any
purpose without the prior written consent of the other party, however, Customer authorizes the use of its name
and/or logo as a participant in the Blueprint for Wellness program.
BFW LOA rev. 1 1107
8
IN WITNESS WHEREOF. Quest Diagnostics Incorporated and Collier County have each, respectively, by an
authorized person or agent, hereunder set their hands and seals on the date and year first written above.
"; .
\c
~ --------'
. ,--~~
Witnes~~ -
/. ~/ o/~
?~- Yet{ .~. ..
Witness Signature '
Assial",,\ County At r ey
D.l"..../
S ""it a< -r~e.L.
Print Name
BFW LOA rev, 11/07
BOARD OF CO)::1NTY COMMISSIONERS
COLLIER C~TY, FL
I. ;'
/ i / ,
By: \, ;../t""-r~)"1A," <::;.;"!' ,; ([~,."/tf
Donna Fiala, Chairman
A"....
?f:~ laS
Item # lfo~;1
9
A@' _ . ~~_R....IFICA TE OF LIABILITY INSUR~NCE
[ PROOUCER
MARSH USA INC.
ATTN: JANET T. NORMAN
b. 1166 AVENUE OF THE AMERICAS
NEW YORK, NY 10036
37986 -MAl N -09-10 xxx
, INSURED
QUEST DIAGNOSTICS INCORPORATED AND
ITS WHOLLY OWNED SUBSIDIARIES
3 GIRALDA FARMS
MADISON, NJ 07940
INSURERS AFFORDING COVERAGE
--- DATE (M~/-;;O~
01/05/2010
THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
--tl NAIC# 1
---"'-- -....
--
25674
N/A
~~ 19437
~..
COVEIlA~_ . .' __ ___ _____ _________ -----------
~E 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. .
INSRADD'L ------.--- --- ----- -----.poLICyEF"ECTIVE -POLICY EXPlRATlON--
LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE {MMfDDfYYYY) DATE (MMIDDIYYYY)
GENERAL LIABILITY
I~COMMERCIAL GENERAL :IABILlTY
I CLAIMS MADE l I OCCUR
---- --
- --
GENERAL AGGREGATE LIMIT APPLIES PER
~ PRO-
POLICY JECT LOC
AUTOMOBILE L.IABllITY I
INSURER A: Quest Diagnostics Incorporated
~N~U~ER ~: -Traveler~--pr~~~-_?as~~~-co.__?TAmerica
INSURER C N/A
- -------- ---
_________ ____n__ _______ _____
INSURER D: Lexington Insurance Company
r-INSUR~---- ---- ---- _m_
-I
LIMITS
A
1"$2,000,000 SELF INSURED
'RETENTION'"
12/31/2009
12/31/2010
EACH OCCURRENCE
DAMAGE to RENTED
PREMIS_~~{E:.~ occurrence)
MED EXP (Anyone person)
PERSONAL & ADV INJURY
2 000 OOQ
i GENERAL AGGREGATE
I .
1$
$
$
$
PRODUCTS - COMP/OP AG
-I
'-I ANY AUTO
__ ALL O~ED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
,
COM.BINED SING.L.E=+-L1MIT '$
(Eaaccldent)
BODILY INJURY- - $--
~ (Per person)
I BODILY INJURY $
, 1- NON-OWNED AUTOS i (Per accident) I
- --
PROPERTY DAMAGE
- - -- ----- (Per accident} $
GARAGE LIABILITY AUTO ONLY -- EA ACCIDENT $
-- $ I
I ANY AUTO OTHER THAN EA ACC 5:;;00001
, AUTO ONLY ,$
AGG
'D EXCESS I UMBREL.LA LIABILITY 8124655 12/31/2009 12/31/2010 EACH OCCURRENCE $
_J I~ -----
, OCCUR CLAIMS MADE AGGREGATE $
- - - -
-, 1..----- $
DEDUCTIBLE - -
--- i - $ --
RETENTION $ i .
B WORKERS COMPENSATION AND TC2JUB.266T3523-TIL-09 (DED) 12/31/2009 12/3t/2010 :x 1 we STATU- IOJ~ I
,B EMPLOYERS' LIABILITY TRJU B-266T3535- TIL-09 RETRO) 12/31/2009 12/31/2010 ~ TORY UMITe::' , -- -
ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N !
i OFFICER/MEMBER EXCLUDED? L_~l '
i (Mandatory In NH) If yes, describe under
! SPECIAL PROVISIONS below
$
EO_L DISEASE - EA EMPLOYE $
$
L_ DISEASE - POLICY LIMIT
2,000,000,
2,000.000
2,000,000,
1
I
i
E.L. EACH ACCIDENT
I OTHER
A PROFESSIONAL L1AB.
, CLAIMS MAOE
ISELF-INSUREO RETENTION
I
I
112/31/2009
12/31/2010
$5,000,000 (SIR)
rESCRIPTION OF OPERATIONSJLOCATlONSNEHICLES/EXCLUSIONS ADDEO BY ENDORSEMENT/SPECIAL PROVISIONS
RE BLUEPRlNT FOR WELLNESS SERVICES - CONTRACT #00000105
COLLIER COUNTY BOARD OF COUNTY COMMlSSIONERS IS INCLUDED AS AN ADOITIONAL INSUREO
--
CERTIFICATE HOLDER
1-
NYC-003942183-26
- --
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POL.ICIES BE CANCELL.ED BEFORE THE
COLLIER COUNTY BOARD OF COUNTY
COMMISSIONERS
3301 TAMIAMI TRAIL EAST
BOARD OF COUNTY COMMISSIONERS
NAPLES, FL 34112
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE L.EFT,
BUT FAILURE TO DO SO SHAL.L.IMPOSE NO OBLIGATION OR LIABILITY OF ANY KINO
UPON THE INSURER,
A~ltli'i~i,EBgiPrn~~ENTATlVE
Marla Nicholson
ITS AGENTS
-u(~
OR REPRESENTATIVES.
..~
--- ----
ACORD 25 (2009/01)
@ 1998-2009 ACORD CORPORATION. All Rights Reserved
The ACORD name and logo are registered marks of ACORD
IMPORT ANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized
representative or producer, and the certificate holder, nor does it affirmatively or negatively amend,
extend or alter the coverage afforded by the policies listed thereon.
Acord 25 (2009/01)
~ ()IH.St
""""- ...,..
~ Diagnostics
CERTIFICATE OF SECRETARY
I, William J. O'Shaughnessy, Jr., Secretary of Quest Diagnostics Incorporated, a
corporation organized under the laws of the State of Delaware (the "Company") do
hereby certify the individual whose name appears below is authorized in the name and on
behalf of the Company to enter into Blueprint for Wellness Agreements, and to execute
and deliver such documents in connection therewith:
NAME
TITLE
Steven L. Burton
Vice President, Health and Wellness Services
IN WITNESS WHEREOF, I have hereunto set my hand this 20th day of
November, 2009.
tJ~
William
Secretary
State of New Jersey
County of Morris
}
Subscribed and sworn to before me this 20th day of November, 2009
By:
/
-_ WIW
.... NIle
......... ...,
., em . .1Ia.... lip 12. .13
RLS# D1-!Jt2t- /)1 '101
CHECKLIST FOR REVIEWING CONTRACTS
Entity Name: rPUb7 b III G-fJOSTIC. S INt:OA-fJC!~1'r nc.
Insurance
Insurance Certificate attached?
Insured registered in Florida?
Contract # &/or Project referenced on Certificate?
Certificate Holder name correct (BCC)?
Commercial General Liability
General Aggregate Required $ I "'" L.
Products/CompVOp Required $
Personal & Advert Required $
Each Occurrence Required $
FirelProp Damage Required $
Automobile Liability
Bodily Inj & Prop Required $
Workers Compensation
Each accident Required $ tjl, -r
Disease Aggregate Required $ 5 " ,t C.
Disease Each Empl Required $ ...,
Umbrella Liability
Each Occurrence Provided $ S tlA.l L
Aggregate Provided $ , ,
Does Umbrella sufficiently cover any underinsured portion?
Professional Liability
Each Occurrence Required $ I 'IV\. l L
Per Aggregate Required $ M' l-
Other Insurance
Each Occur Type: ".....h"', ~ IS
. ~,A.
County required to be named as additional insured?
County named as additional insured?
Entity name correct on contract?
Entity registered with FL Sec. of State"
f ,\ \'T
\
Exp. Dale <lilI
Exp. Date ___.____
Exp_ Date
Exp. Date 12-/3/ i to
Exp_ Date
./ Yes
__.,:,::Yes
V Yes
-,-",-Yes
_LYes
_~Yes
Provided $___
Provided $
Provided $
Provided $ ~ t L-
Provided $__
Provided $~
Exp Date
Provided $
Provided $
Provided $
ZMlL
Exp Date
Exp Date
Exp Date
"
t'
Exp Date _~_
Exp Date v
,V Yes
No
No
No
No
No
No
1 "-!3'!1O
"
"
No
Provided $ ., ^" \ L
Provided $ ____~._,__
Exp. Date rz.13'{/0
Exp. Date \ '
Required $ .5'11(2) ._0
Provided $
Indemnification
Does indemnification meet County standards?
Is County indemnifying other party?
Performance Bond
Bond requirement referenced in contract?
If attached, expiration date of bond
Does dollar amount match contract?
Agent registered in Florida?
_ .,/ Yes
_~Yes
--->L:: Yes
_~~Yes
Yes
Signature Blocks
Correct executor name in signature block?
Correct title of executor?
Executor authorized to sign for entity?
Proper number of witnesses/notary?
Authorization for executor to sign, if necessary:
Chairman's signature block?
Clerk's attestation signature block?
County Attorney's signature block?
Attachments
Are all required attachments included?
Yes
Yes
/lJO-rA/'LlZ't.b
('UflFt6ll"i.
_,,".,Yes
-"",,-Yes
~Yes
v Yes
OF S E~R f """-i
__-'LYes
_ ..........-Yes
vYes
~Yes
Exp Date_
No
No
No
~No
No
No
No
No
No
No
No
No
No
No
No \-~
Reviewer Imtials: ~_
Date: l/h ~ID
04,COA-O [03 /222