Loading...
HomeMy WebLinkAboutAdminSure Inc. - Workers Comp Third Party Administration and Claims Review - Amendment No. 3 - 2020THIRD AMENDMENT TO THE AGREEMENT BY AND BETWEEN THE CITY OF NATIONAL CITY AND ADMINSURE, INC. THIS THIRD AMENDMENT TO THE AGREEMENT, is entered into this 1st day of July, 2020, by and between the CITY OF NATIONAL CITY, a municipal corporation (the "CITY"), and ADMINSURE, INC., a California corporation (the "CONSULTANT"). RECITALS WHEREAS, on June 21, 2016, the City Council adopted Resolution No. 2016-88 entering into a two-year Agreement with CONSULTANT wherein the CONSULTANT agreed to provide Workers' Compensation Third Party Administration and Claims Review. WHEREAS, the original Agreement, effective as of August 1, 2016, had a not -to -exceed amount of $173,262 and an expiration date of July 31, 2018 with the option to extend for three (3) additional one-year terms pursuant to the approval of the City Manager. WHEREAS, the parties signed a First Amendment extending the term of the Agreement for one (1) year, expiring June 30, 2019 for a not -to -exceed amount of $88,760 for administration fees. WHEREAS, the parties signed a Second Amendment extending the term of the Agreement for one (1) year, expiring June 30, 2020 for a not -to -exceed amount of $91,575 for administration fees. WHEREAS, the parties desire to amend the Agreement to extend the term for an additional year, expiring June 30, 2021, for the not -to -exceed amount of $94,470 for administration fees. NOW, THEREFORE, the parties hereto agree that the Agreement entered into on August 1, 2016 and extended by a Second Amendment to the Agreement to June 30, 2020 shall hereby be further amended as follows: 1. The term of the Agreement shall be extended for one (1) year, expiring on July 31, 2021, for the not -to -exceed amount of $94,470 for a total not -to -exceed amount of $353,597 for administration fees. -1- 2. The parties further agree that with the foregoing exceptions, each and every term and provision of the Agreement dated August 1, 2016, the First and Second Amendments dated respectively as July 2018 and June 2019 shall remain in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this Third Amendment to the Agreement on the date and year first above written. CITY OF NATIONAL CITY By: City Manager By: -2- ADMINSURE, INC. (signatures of two corporate officers t By: By: Alithia Vargas -Flo President/Director of Operations at Ashley Sills Corporate Secretary equired) %coRE,DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 12/30/2019 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). RODUCER DIton & Company 475 E. Foothill Blvd., Suite 100 isadena, CA 91107 SURED AdminSure, Inc. 3380 Shelby Street Ontario, CA 91764 CONTACT NAME:PHONE (A/C, No, Ext): (626) 799-7000 1 (AiC, No):(626) 441-3233 EAIL ADDRESS:propcasualty©boltonco.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Sentinel Insurance Co. 11000 INSURER B : Twin City Fire Insurance Co 29459 INSURER C : Evanston Insurance Company 35378 INSURER D: United States Fire Insurance Co. 21113 INSURER E : INSURER F : OVERAGES CERTIFICATE NUMBER: 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. 312 -R TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYYI POLICY EXP (MM/DD/YYYY1 LIMITS X COMMERCIAL GENERAL LIABILITY X 72SBAUV7737 10/05/2019 10/05/2020 EACH OCCURRENCE $ 2,000,00 DAMAGE TO RENTED PREMISES (Ea occurtencel 1,000,00 $ CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 10,00 PERSONAL & ADV INJURY $ 2,000,00 GENERAL AGGREGATE $ 4'000'00 GEN'L AGGREGATE POLICY OTHER: X LIMIT APPLIES PE - PER: LOC PRODUCTS - COMP/OP AGG $ 4,000,00 $ k AUTOMOBILE X LIABILITY ANY AUTO OWNED X _ SCHEDULED AUTOS NON -AWNED AUTOS ONLY 72SBAUV7737 10/05/2019 10/05/2020 CMBIED (Eaacccident) SINGLE LIMIT $ 1,000,00 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ ROPERTY DAMAGE (Per accident) $ $ k X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 72SBAUV7737 10/05/2019 10/05/2020 EACH OCCURRENCE $ 4,000,00 AGGREGATE $ 4,000,00 $ DED X RETENTION $ 10,000 3 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A X 72WECNG7400 01/01/2020 01/01/2021 X STATUTE ER E.L. EACH ACCIDENT $ 1'000'00 E.L. DISEASE - EA EMPLOYEE $ 1,000,00 E.L. DISEASE - POLICY LIMIT 1,000,00 $ ) Errors &Omissions Crime MKLV5PE0000052 6260373351 10/05/2019 10/13/2019 10/05/2020 10/13/2020 Ded. $25K Ded. $10,000 5,000,00 2,000,00 ESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) rber Liability - Policy #ES1031172638 - 7/1/2019-7/1/2020-Limits: $2,000,000-Ded: $10,000 _ Blanket Additional Insured per form IH12001185 attached, only if required by written contract/agreement. Primary & Non-contributory wording applies pe ;00080405. Workers Compensation waiver of subrogation applies per form WC040306 attached. Cancellation Conditions attached. iditional Insured: The City of National City, its officers, officials, employees, and volunteers ERTIFICATE HOLDER CANCELLATION City of National City 1243 National City Boulevard National City, CA 91950 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE R2e-6.6-c-e- CORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved BUSINESS LIABILITY COVERAGE FORM (b) Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by you, any of your "employees", "volunteer workers", any partner or member (if you are a partnership or joint venture), or any member (if you are a limited Liability company). b. Real Estate Manager Any person (other than your "employee" or "volunteer worker"), or any organization while acting as your real estate manager. c. Temporary Custodians Of Your Property Any person or organization having proper temporary custody of your property if you die, but only: (1) With respect to liability arising out of the maintenance or use of that property; and (2) Until your legal representative has been appointed. d. Legal Representative If You Die Your legal representative if you die, but only with respect to duties as such. That representative will have all your rights and duties under this insurance. e. Unnamed Subsidiary Any subsidiary and subsidiary thereof, of yours which is a legally incorporated entity of which you own a financial interest of more than 50% of the voting stock on the effective date of this Coverage Part. The insurance afforded herein for any subsidiary not shown in the Declarations as a named insured does not apply to injury or damage with respect to which an insured under this insurance is also an insured under another policy or would be an insured under such policy but for its termination or upon the exhaustion of its limits of insurance. 3. Newly Acquired Or Formed Organization Any organization you newly acquire or form, other than a partnership, joint venture or limited liability company, and over which you maintain financial interest of more than 50% of the voting stock, will qualify as a Named Insured if there is no other similar insurance available to that organization. However: a. Coverage under this provision is afforded only until the 180th day after you acquire or form the organization or the end of the policy period, whichever is earlier; and b. Coverage under this provision does not apply to: (1) "Bodily injury" or "property damage" that occurred; or (2) "Personal and advertising injury" arising out of an offense committed before you acquired or formed the organization. 4. Operator Of Mobile Equipment Wrth respect to "mobile equipment" registered in your name under any motor vehicle registration law, any person is an insured while driving such equipment along a public highway with your permission. Any other person or organization responsible for the conduct of such person is also an insured, but only with respect to liability arising out of the operation of the equipment, and only if no other insurance of any kind is available to that person or organization for this liability. However, no person or organization is an insured with respect to: a. "Bodily injury" to a co -"employee" of the person driving the equipment; or b. "Property damage" to property owned by, rented to, in the charge of or occupied by you or the employer of any person who is an insured under this provision. 5. Operator of Nonowned Watercraft With respect to watercraft you do not own that is less than 51 feet long and is not being used to carry persons for a charge, any person is an insured while operating such watercraft with your permission. Any other person or organization responsible for the conduct of such person is also an insured, but only with respect to liability arising out of the operation of the watercraft, and only if no other insurance of any kind is available to that person or organization for this liability. However, no person or organization is an insured with respect to: a. "Bodily injury" to a co -"employee" of the person operating the watercraft; or b. "Property damage" to property owned by, rented to, in the charge of or occupied by you or the employer of any person who is an insured under this provision. 6. Additional Insureds When Required By Written Contract, Written Agreement Or Permit The person(s) or organization(s) identified in Paragraphs a. through f. below are additional insureds when you have agreed, in a written Form SS 00 08 04 05 Page 11 of 24 BUSINESS LIABILITY COVERAGE FORM contract, written agreement or because of a permit issued by a state or political subdivision, that such person or organization be added as an additional insured on your policy, provided the injury or damage occurs subsequent to the execution of the contract or agreement, or the issuance of the permit. A person or organization is insured under this provision period of time required by agreement or permit. However, no such person or organization is an additional insured under this provision if such person or organization is included as an additional insured by an endorsement issued by us and made a part of this Coverage Part, including all persons or organizations added as additional insureds under the specific additional insured coverage grants in Section F. — Optional Additional Insured Coverages. a. Vendors Any person(s) or organization(s) (referred to below as vendor), but only with respect to "bodily injury" or "property damage" arising out of "your products" which are distributed or sold in the regular course of the vendor's business and only if this Coverage Part provides coverage for "bodily injury" or "property damage" included within the "products -completed operations hazard". (1) The insurance afforded to the vendor is subject to the following additional exclusions: This insurance does not apply to: (a) "Bodily injury" or "property damage" for which the vendor is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages that the vendor would have in the absence of the contract or agreement; (b) Any express warranty unauthorized by you; (c) Any physical or chemical change in the product made intentionally by the vendor; (d) Repackaging, except when unpacked solely for the purpose of inspection, demonstration, testing, or the substitution of parts under instructions from the manufacturer, and then repackaged in the original container; an additional only for that the contract, (e) Any failure to make such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products; (f) Demonstration, installation, servicing or repair operations, except such operations performed at the vendor's premises in connection with the sale of the product; (g) Products which, after distribution or sale by you, have been labeled or relabeled or used as a container, part or ingredient of any other thing or substance by or for the vendor; or (h) "Bodily injury" or "property damage" arising out of the sole negligence of the vendor for its own acts or omissions or those of its employees or anyone else acting on its behalf. However, this exclusion does not apply to: (i) The exceptions contained in Subparagraphs (d) or (f); or (ii) Such inspections, adjustments, tests or servicing as the vendor has agreed to make or normally undertakes to make in the usual course of business, in connection with the distribution or sale of the products. (2) This insurance does not apply to any insured person or organization from whom you have acquired such products, or any ingredient, part or container, entering into, accompanying or containing such products. b. Lessors Of Equipment (1) Any person or organization from whom you lease equipment; but only with respect to their liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your maintenance, operation or use of equipment leased to you by such person or organization. Page 12 of 24 Form SS 00 08 04 05 (6) When You Are Added As An Additional Insured To Other Insurance That is other insurance available to you covering liability for damages arising out of the premises or operations, or products and completed operations, for which you have been added as an additional insured by that insurance; or When You Add Others As An Additional Insured To This Insurance That is other insurance available to an additional insured. However, the following provisions apply to other insurance available to any person or organization who is an additional insured under this Coverage Part: (a) Primary Insurance When Required By Contract This insurance is primary if you have agreed in a written contract, written agreement or permit that this insurance be primary. If other insurance is also primary, we will share with all that other insurance by the method described in c. below. (b) Primary And Non -Contributory To Other Insurance When Required By Contract If you have agreed in a written contract, written agreement or permit that this insurance is primary and non-contributory with the additional insured's own insurance, this insurance is primary and we will not seek contribution from that other insurance. Paragraphs (a) and (b) do not apply to other insurance to which the additional insured has been added as an additional insured. When this insurance is excess, we will have no duty under this Coverage Part to defend the insured against any "suit" if any other insurer has a duty to defend the insured against that "suit". If no other insurer defends, we will undertake to do so, but we wit be entitled to the insured's rights against all those other insurers. (7) BUSINESS LIABILITY COVERAGE FORM When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of: (1) The total amount that all such other insurance would pay for the loss in the absence of this insurance; and (2) The total of all deductible and self - insured amounts under all that other insurance. We will share the remaining loss, if any, with any other insurance that is not described in this Excess Insurance provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Declarations of this Coverage Part. c. Method Of Sharing If all the other insurance permits contribution by equal shares, we will follow this method also. Under this approach, each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share is based on the ratio of its applicable limit of insurance to the total applicable limits of insurance of all insurers. 8. Transfer Of Rights Of Recovery Against Others To Us a. Transfer Of Rights Of Recovery If the insured has rights to recover all or part of any payment, including Supplementary Payments, we have made under this Coverage Part, those rights are transferred to us. The insured must do nothing after loss to impair them. At our request, the insured will bring "suit" or transfer those rights to us and help us enforce them. This condition does not apply to Medical Expenses Coverage. b. Waiver Of Rights Of Recovery (Waiver Of Subrogation) If the insured has waived any rights of recovery against any person or organization for all or part of any payment, including Supplementary Payments, we have made under this Coverage Part, we also waive that right, provided the insured waived their rights of recovery against such person or organization in a contract, agreement or permit that was executed prior to the injury or damage. Form SS 00 08 04 05 Page 17 of 24 *2100272UV77370113 ..r -,s NEE COMMON POLICY CONDITIONS All coverages of this policy are subject to the following conditions. A. Cancellation 1. The first Named Insured shown in the Declarations may cancel this policy by mailing or delivering to us advance written notice of cancellation. 2. We may cancel this policy by mailing or delivering to the first Named Insured written notice of cancellation at least: a. 5 days before the effective date of cancellation if any one of the following conditions exists at any building that is Covered Property in this policy: (1) The building has been vacant or unoccupied 60 or more consecutive days. This does not apply to: (a) Seasonal unoccupancy; or (b) Buildings in the course of construction, renovation or addition. Buiklings with 65% or more of the rental units or floor area vacant or unoccupied are considered unoccupied under this provision. (2) After damage by a Covered Cause of Loss, permanent repairs to the building: (a) Have not started; and (b) Have not been contracted for, within 30 days of initial payment of loss. (3) The building has: (a) An outstanding order to vacate; (b) An outstanding demolition order; or (c) Been declared unsafe by governmental authority. (4) Fixed and salvageable items have been or are being removed from the building and are not being replaced. This does not apply to such removal that is necessary or incidental to any renovation or remodeling. (5) Failure to: (a) Furnish necessary heat, water, sewer service or electricity for 30 consecutive days or more, except during a period of seasonal unoccupancy; or (b) Pay property taxes that are owing and have been outstanding for more than one year following the date due, except that this provision will not apply where you are in a bona fide dispute with the taxing authority regarding payment of such taxes. b. 10 days before the effective date of cancellation if we cancel for nonpayment of premium. c. 30 days before the effective date of cancellation if we cancel for any other reason. 3. We will mail or deliver our notice to the first Named Insured's last mailing address known to us. 4. Notice of cancellation will state the effective date of cancellation. The policy period will end on that date. 5. If this policy is canceled, we will send the first Named Insured any premium refund due. Such refund will be pro rata. The cancellation will be effective even if we have not made or offered a refund. 6. It notice is mailed, proof of mailing will be sufficient proof of notice. 7. If the first Named Insured cancels this policy, we will retain no less than 5100 of the premium. B. Changes This policy contains ail the agreements between you and us conceming the insurance afforded. The first Named Insured shown in the Declarations is authorized to make changes in the terms of this policy with our consent This policy's terms can be amended or waived only by endorsement issued by us and made a part of this policy. Form SS 00 05 12 06 Page 1 of 3 © 2006, The Hartford POLICY NUMBER: 72 SBA UV7737 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - PERSON -ORGANIZATION The City of National City, Its Elected Officials, Officers, Agents and Employees 1243 National City Boulevard National City, CA 91950 Form IH 12 00 11 85 T SEQ. NO. 002 Printed in U.S.A. Page 002 (CONTINUED ON NEXT PAGE) n.. 1°1, a... (1'7 / 1 0 /'1 0 c....;..,.;..., n..4..,.. 1 n / n; /? n THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT - CALIFORNIA Policy Number: 72 WEC NG7400 Endorsement Number: Effective Date: 01/01/20 Effective hour is the same as stated on the Information Page of the policy. Named Insured and Address: ADMINSURE, INC. 3380 SHELBY ST ONTARIO CA 91764 We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the work described in the Schedule. The additional premium for this endorsement shall be 2 % of the California workers' compensation premium otherwise due on such remuneration. SCHEDULE Person or Organization Job Description Any person or organization from whom you are required by written contract or agreement to obtain this waiver of rights from us Countersigned by Authorized Representative Form WC 04 03 06 (1) Printed in U.S.A. CONTRACT TRANSMITTAL FORM (Attach as Cover Sheet to Documents dropped off to City Clerk's Office) Date: 06/10/2020 From (Dept.): Human Resources Submitted by (First & Last Name): Lizza Rojas Vendor: Adminsure, Inc Resolution: YES / NO 0 C, Resolution No. (if applicable): 1 2 3 4 Originals Provided to City Clerk (Select Quantity) 0000 Department has Copy / Duplicate Original Vendor has Copy / Duplicate Original