ORIGINAL
CONSULTANT AGREEMENT
THIS AGREEMENT, entered into this 1st day of September, 2015, by and between CITY OF ALAMEDA, a municipal corporation (the "City"), and The Permanente Medical Group, Inc., a California Corporation, whose address is 1800 Harrison Street, 9"" Floor, Oakland, CA 94612 (the "Consultant"), is made with reference to the following:
RECITALS:
A. City is a municipal corporation duly organized and validly existing under the laws of the State of California with the power to carry on its business as it is now being conducted under the statutes of the State of California and the Charter of the City; and B. Consultant is specially trained, experienced and competent to perform the special services which will be required by this Agreement; and
C. Consultant possesses the skill, experience, ability, background, certification and knowledge to provide the services described in this Agreement on the terms and conditions described herein; and
D. City and Consultant desire to enter into an agreement for Occupational Medical Services for the City upon the terms and conditions herein.
NOW, THEREFORE, it is mutually agreed by and between the undersigned parties as follows:
1. TERM:
The term of this Agreement shall commence on the 1st day of September, 2015, and shall terminate on the 31st day of August, 2018, unless terminated earlier as set forth herein. This contract may be amended to add up to two additional three year terms, based upon satisfactory performance by the vendor and upon the discretion and agreement of both parties; provided, however, that with respect to any term beginning on or after July 2, 2018, Consultant may revise the billing rates set forth in Exhibit A with respect to any three-year renewal term. In such event, Consultant shall provide at least sixty (60) days prior written notice to the City of any such change in rates.
2. SERVICES TO BE PERFORMED:
Consultant shall perform as required, each and every service from that list of services set forth in Exhibit "A" which is attached hereto and incorporated herein by this reference, including all incidental services customarily furnished in accordance with generally accepted practice ("the Services"). City retains the right to modify requested services at any time. 38011 0000118196683.3
ЗАМІДІЯО
COMPENSATION TO CONSULTANT:
A. Consultant shall be compensated for the Services performed in accordance with this Agreement at the hourly rates set forth in Exhibit A. Payment under this contract shall not exceed $200,000 for the three year term. Payment shall be made by checks drawn on the treasury of the City.
B. Additional Services:
(1) City shall pay Consultant for authorized Additional Services in accordance with the schedule of fees attached hereto as Exhibit A. City shall pay only for Additional Services authorized by the City Manager or designee in writing or requested verbally by City and confirmed in writing by Consultant within five (5) working days. (2) Consultant and City shall agree upon an estimated not-to-exceed cost for any proposed Additional Services or, in the case of a verbal request, Consultant shall provide City with a written estimated not-to-exceed cost for such Additional Services at least one (1) working day prior to commencing the Additional Services. In no event shall City pay for Additional Services made necessary by Consultant's errors or oversights.
C. Consultant shall not stop or delay performance of Services under this Agreement on account of payment disputes with City, provided that City continues to make payment of undisputed amounts.
SCHEDULE FOR PERFORMANCE:
Time is of the essence regarding the performance of this Agreement. Consultant shall promptly commence performance of the Services upon execution of this Agreement, and shall diligently pursue performance of the Services until completion.
5. STANDARDS OF CARE AND SAFETY REQUIREMENTS:
Consultant agrees to perform all the Services in a manner at least equal to the prevailing standards of like professionals in the San Francisco Bay Area and agrees that the Services shall be performed by qualified and experienced personnel who are not employed by the City and have no contractual relationship with City.
B. Consultant shall not maintain, commit, or permit the maintenance or commission of any nuisance in connection with the performance of the Services under this Agreement.
The Services performed under this Agreement shall be performed in such a manner as to provide safety to the public and to meet or exceed the safety standards outlined by CAL-OSHA. City reserves the right to issue restraints or cease and desist orders to Consultant when unsafe or harmful acts or conditions are observed or documented relative to the performance of the Services.
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D. Consultant shall maintain the work sites free of hazards to persons and/or property resulting from his or her operations. Any hazardous condition noted by Consultant, which is not a result of his or her operations, shall immediately be documented to City.
6. INDEPENDENT PARTIES:
City and Consultant intend that the Consultant's status under this Agreement is that of an independent contractor as defined in Labor Code Section 3353. The manner and means of conducting the Services are under the control of Consultant, except to the extent they are limited by statute, rule or regulation and the express terms of this Agreement. No civil service status or other right of employment will be acquired by virtue of Consultant's services. None of the benefits provided by City to its employees, including but not limited to, unemployment insurance, workers' compensation plans, vacation and sick leave are available from City to Consultant, its employees or agents. Deductions shall not be made for any state or federal taxes, FICA payments, PERS payments, or other purposes normally associated with an employer- employee relationship from any fees due Consultant. Payments of the above items, if required, are the responsibility of Consultant.
7. IMMIGRATION REFORM AND CONTROL ACT (IRCA):
Consultant assumes any and all responsibility for verifying the identity and employment authorization of all of his/her employees performing work hereunder, pursuant to all applicable IRCA or other federal, or state rules and regulations. Consultant shall indemnify and hold City harmless from and against any loss, damage, liability, costs or expenses arising from any noncompliance of this provision by Consultant.
8. NON-DISCRIMINATION:
Consistent with City's policy that harassment and discrimination are unacceptable employer/employee conduct, Consultant agrees that harassment or discrimination directed toward a job applicant, a City employee, or a citizen by Consultant or Consultant's employee or subconsultant on the basis of race, religious creed, color, national origin, ancestry, handicap, disability, marital status, pregnancy, sex, age, or sexual orientation will not be tolerated.
Consultant agrees that any and all violations of this provision shall constitute a material breach of this Agreement.
9. LOCAL HIRE REQUIREMENTS:
Consultant acknowledges the City's local preference policies set forth in Alameda Municipal Code Sections 2-62.1-.6 (extending City contract award preferences to local businesses with fixed addresses in the City), and will comply with any local hiring requirements set forth by the funding source of the contract and/or all applicable law.
10. HOLD HARMLESS:
A. Consultant shall indemnify, defend, and hold harmless City, its City Council, boards, commissions, officials, employees, and volunteers ("Indemnitees") from and against any and all loss, damages, liability, claims, suits, costs and expenses whatsoever, including 38011.00001 18196683.3
reasonable attorneys' fees ("Claims"), arising out of negligent acts or willful misconduct of employment discrimination based on results of Consultant's services, a lawsuit by an employee of City alleging breach of an employment statute or regulation, etc.). If Claims are filed against Indemnities which allege negligence on behalf of the Consultant, Consultant shall have no right of reimbursement against Indemnities for the costs of defense even if negligence is not found on the part of Consultant.
B. Neither termination of this Agreement nor completion of the Services shall release Consultant from its obligations under this Section 10.
Consultant's compliance with the insurance requirements does not relieve Consultant from the obligations described in this Section 10, which shall apply whether or not such insurance policies are applicable to a claim or damages.
11. INSURANCE:
On or before the commencement of the term of this Agreement, Consultant shall furnish City with certificates showing the type, amount, class of operations covered, effective dates and dates of expiration of insurance coverage in compliance with paragraphs 11 A, B, C, D and E.
Such certificates, which do not limit Consultant's indemnification, shall also contain substantially the following statement: "Should any of the above insurance covered by this certificate be canceled or coverage reduced before the expiration date thereof, the insurer affording coverage shall provide thirty (30) days' advance written notice to the City of Alameda by certified mail, Attention: Risk Manager." It is agreed that Consultant shall maintain in force at all times during the performance of this Agreement all insurance required by this Agreement with an insurance company that is acceptable to City and licensed to do insurance business in the State of California. Endorsements naming the City as additional insured shall be submitted with the insurance certificates. Notwithstanding any other provision of this Agreement, including but not limited to those contained in this Paragraph 11, Consultant, in lieu of any insurance requirements contained herein, may fulfill such insurance obligations through its alternative risk management programs, including self-insurance, and City consents to such self-insurance and agrees that, in such case, Consultant cannot provide endorsements or report deductibles, or self- insured retentions, or other requirements that are inconsistent with a program of self-insurance.
City also agrees that Consultant's fulfillment of the insurance requirements through alternative risk management programs shall not constitute a breach of this Agreement.
A. COVERAGE:
Consultant shall maintain the following insurance coverage:
Workers' Compensation and Employers' Liability: Statutory coverage as required by the State of California.
(2) General Liability: Commercial general liability coverage in the following minimum limits:
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Bodily Injury: $1,000,000 each occurrence
$2,000,000 aggregate
Property Damage: $1,000,000 each occurrence
$2,000,000 aggregate
If submitted, combined single limit policy with aggregate limits in the amounts of $2,000,000 will be considered equivalent to the required minimum limits shown above.
(3) Automotive: Comprehensive automotive liability coverage in the following minimum limits:
Bodily Injury: $1,000,000 each occurrence
Property Damage: $1,000,000 each occurrence
or
Combined Single Limit: $2,000,000 each occurrence
(4) Professional Liability: Professional liability insurance which includes coverage for the professional acts, errors and omissions of Consultant in the amount of at least $1,000,000.
B. SUBROGATION WAIVER: Consultant agrees that in the event of loss due to any of the perils for which he/she has agreed to provide comprehensive general and automotive liability insurance, Consultant shall look solely to his/her insurance for recovery. Consultant hereby grants to City, on behalf of itself and any insurer providing comprehensive general and automotive liability insurance to Consultant with respect to the services of Consultant herein, a waiver of any right to subrogation which any such insurer of Consultant may acquire against City by virtue of the payment of any loss under such insurance. should fail to secure or maintain the foregoing insurance, City shall be permitted to obtain such FAILURE TO SECURE: If Consultant at any time during the term hereof insurance in the Consultant's name or as an agent of the Consultant and shall be compensated by the Consultant for the costs of the insurance premiums at the maximum rate permitted by law and computed from the date written notice is received that the premiums have not been paid.
D. ADDITIONAL INSURED: City, its City Council, boards and commissions, officers, employees and volunteers shall be named as an additional insured by endorsement under all insurance coverages, except any professional liability insurance, required by this Agreement. The naming of an additional insured shall not affect any recovery to which such additional insured would be entitled under this policy if not named as such additional insured.
An additional insured named herein shall not be held liable for any premium, deductible portion of any loss, or expense of any nature on this policy or any extension thereof. Any other insurance held by an additional insured shall not be required to contribute anything toward any loss or expense covered by the insurance provided by this policy. 38011.0000118196683.3
SUFFICIENCY OF INSURANCE: The insurance limits required by City are not represented as being sufficient to protect Consultant. Consultant is advised to confer with Consultant's insurance broker to determine adequate coverage for Consultant.
12. CONFLICT OF INTEREST:
Consultant warrants that it is not a conflict of interest for Consultant to perform the Services required by this Agreement. Consultant may be required to fill out a conflict of interest form if the services provided under this Agreement require Consultant to make certain governmental decisions or serve in a staff capacity as defined in Title 2, Division 6, Section 18700 of the California Code of Regulations.
13. PROHIBITION AGAINST TRANSFERS:
A. Consultant shall not assign, sublease, hypothecate, or transfer this Agreement, or any interest therein, directly or indirectly, by operation of law or otherwise, without prior written consent of City. Any attempt to do so without said consent shall be null and void, and any assignee, sublessee, hypothecate or transferee shall acquire no right or interest by reason of such attempted assignment, hypothecation or transfer. However, claims for money by Consultant from City under this Agreement may be assigned to a bank, trust company or other financial institution without prior written consent. Written notice of such assignment shall be promptly furnished to City by Consultant.
B. The sale, assignment, transfer or other disposition of any of the issued and outstanding capital stock of Consultant, or of the interest of any general partner or joint venturer or syndicate member or cotenant, if Consultant is a partnership or joint venture or syndicate or cotenancy, which shall result in changing the control of Consultant, shall be construed as an assignment of this Agreement. Control means fifty percent (50%) or more of the voting power of the corporation.
14. SUBCONSULTANT APPROVAL:
A. Unless prior written consent from City is obtained, only those people and subconsultants whose names and resumes are attached to this Agreement as Exhibit D shall be used in the performance of this Agreement.
B. In the event that Consultant employs subconsultants, such subconsultants shall be required to furnish proof of workers' compensation insurance and shall also be required to carry general, automobile and professional liability insurance in reasonable conformity to the insurance carried by Consultant. In addition, any work or services subcontracted hereunder shall be subject to each provision of this Agreement.
15. PERMITS AND LICENSES:
Consultant, at his/her sole expense, shall obtain and maintain during the term of this Agreement, all appropriate permits, certificates and licenses including, but not limited to, a City Business License, that may be required in connection with the performance of Services hereunder.
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16. OWNERSHIP OF DOCUMENTS:
A. Each and every report, draft, work product, map, record and other document, hereinafter collectively referred to as "Document," reproduced, prepared or caused to be prepared by Consultant pursuant to or in connection with this Agreement, shall be the exclusive property of City. Consultant shall not copyright any Document required by this Agreement and shall execute appropriate documents to assign to City the copyright to Documents created pursuant to this Agreement. Any Document, information and data acquired or required by this Agreement shall become the property of City, and all publication rights are reserved to City.
Notwithstanding the foregoing, this Paragraph 16 shall not apply to medical records, and any medical record created or modified by Consultant in connection with its provision of services hereunder shall not be considered a Document or a work product reproduced, prepared or caused to be prepared by Consultant pursuant to or in connection with this Agreement. Consultant shall retain all rights and title to such medical records.
B. City's ownership interest in the Documents includes the following single, exclusive license from Consultant for the Project: Consultant, for itself, its employees, heirs, successors and assigns, hereby grants (and if any subsequent grant is necessary, agrees to grant) to City an irrevocable, perpetual, royalty-free, fully paid-up, sole and exclusive license and right to use and exercise any and all of the copyrights or other intellectual property rights that Consultant may author or create, alone or jointly with others, in or with respect to the Documents, including without limitation all drawings, designs and graphic representations.
City's license shall include the right to sublicense, shall be for all purposes with respect to each right of copyright, and shall be without restriction.
C. All Documents prepared by Consultant may be used by City in execution or implementation of:
(1) The original Project for which Consultant was hired; (2) Completion of the original Project by others;
(3) Subsequent additions to the original project; and/or (4) Other City projects as appropriate.
D. Consultant shall, at such time and in such form as City may require, furnish Documents concerning the status of services required under this Agreement.
E. All Documents required to be provided by this Agreement shall be printed on recycled paper. All Documents shall be copied on both sides of the paper except for one original, which shall be single sided.
F. All Documents, information, data, and exhibits prepared or assembled by Consultant in connection with the performance of its services pursuant to this Agreement are confidential until released by the City to the public, and the Consultant shall not make any of these documents or information available to any individual or organization not employed by the 38011.0000118196683.3
Consultant or the City without the written consent of the City before any such release, unless otherwise required by law.
17. RECORDS:
A. Consultant shall maintain complete and accurate records with respect to sales, costs, expenses, receipts and other such information required by City that relate to the performance of services under this Agreement.
B. Consultant shall maintain adequate records of the Services provided in sufficient detail to permit an evaluation of services. All such records shall be maintained in accordance with generally accepted accounting principles and shall be clearly identified and readily accessible. Consultant shall provide free access to such books and records to the representatives of City or its designees at all proper times, and gives City the right to examine and audit same, and to make transcripts therefrom as necessary, and to allow inspection of all work, data, documents, proceedings and activities related to this Agreement. Such records, together with supporting documents, shall be kept separate from other documents and records and shall be maintained for a period of three (3) years after receipt of final payment.
If supplemental examination or audit of the records is necessary due to concerns raised by City's preliminary examination or audit of records, and the City's supplemental examination or audit of the records discloses a failure to adhere to appropriate internal financial controls, or other breach of contract or failure to act in good faith, then Consultant shall reimburse City for all reasonable costs and expenses associated with the supplemental examination or audit.
D. Pursuant to California Government Code Section 8546.7, the parties to this Agreement shall be subject to the examination and audit of representative of the Auditor General of the State of California for a period of three (3) years after final payment under the Agreement.
The examination and audit shall be confined to those matters connected with the performance of this Agreement including, but not limited to, the cost of administering the Agreement.
18. NOTICES:
All notices, demands, requests or approvals to be given under this Agreement shall be given in writing, addressed as hereinafter provided.
All notices, demands, requests, or approvals from Consultant to City shall be addressed to City at:
City of Alameda
2263 Santa Clara Avenue
Alameda CA 94501
Attention:Human Resources Analyst cc: City Attorney's Office All notices, demands, requests, or approvals from City to Consultant shall be addressed to Consultant at:
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Kaiser Permanente
Occupational Health, Sales Mgr.
1800 Harrison Street, 9th Floor
Oakland, CA 94612
The parties must designate, in writing, any change in the individual to who notice is to be addressed. Notices shall be deemed to be received upon personal delivery to the addresses above; if sent by overnight delivery, upon delivery as shown by delivery service records; if sent by facsimile, upon receipt as confirmed by the sending facsimile equipment; if by United States Postal Service, five days after deposit in the mail.
19. SUSPENSION AND TERMINATION:
A. The City may suspend this Agreement and Consultant's performance of the Services, wholly or in part, for such period as it deems necessary due to unfavorable conditions or to the failure on the part of the Consultant to perform any provision of this Agreement.
Consultant will be paid for satisfactory services performed through the date of temporary suspension. In the event that Consultant's services hereunder are delayed for a period in excess of six (6) months due to causes beyond Consultant's reasonable control, Consultant's compensation shall be subject to renegotiation.
B. If Consultant at any time refuses or neglects to prosecute its Services in a timely fashion or in accordance with the Project schedule, or is adjudicated a bankrupt, or commits any act of insolvency, or makes an assignment for the benefit of creditors without City's consent, or fails to make prompt payment to persons furnishing labor, equipment, materials or services, or fails in any respect to properly and diligently prosecute its services, or otherwise fails to perform fully any and all of the agreements herein contained, Consultant shall be in default.
C. If Consultant fails to cure the default within seven (7) days after written notice thereof, City may, at its sole option, take possession of any Documents (as defined in Section 16) or other materials (in paper and electronic form) prepared or used by Consultant in connection with the Project and (1) provide any such work, labor, materials or services as may be necessary to overcome the default and deduct the cost thereof from any money then due or thereafter to become due to Consultant under this Agreement; or (2) terminate Consultant's right to proceed with this Agreement.
D. In the event City elects to terminate, City shall have the right to immediate possession of all Documents and work in progress prepared by Consultant, whether located at the Project, at Consultant's place of business, or at the offices of a subconsultant, and may employ any other person or persons to finish the Services and provide the materials therefor. In case of such default termination, Consultant shall not be entitled to receive any further payment under this Agreement until the Services are complete. At that time, if the expenses incurred by City in obtaining Services for the Project exceed such unpaid balance, then Consultant shall promptly pay to City the amount by which such expense exceeds the unpaid balance of the Not-to-Exceed Amount. The expense referred to in the previous sentence shall include expenses incurred by City in causing the services called for under this Agreement to be provided by others, for 38011.00001\8196683.3
attorneys' fees, and for any costs or damages sustained by City by reason of Consultant's default or defective work.
E. In addition to the foregoing right to terminate for default, City reserves the absolute right to terminate this Agreement without cause, upon 72-hours' written notice to Consultant. Consultant shall have the option, at its sole discretion and without cause, of terminating this Agreement by giving sixty (60) days' prior written notice to City as provided herein. In the event of termination without cause, Consultant shall be entitled to payment which shall be calculated as follows: (1) Payment for Basic Services then satisfactorily completed and accepted by City, such acceptance not to be unreasonably withheld, plus (2) Payment for Additional Services satisfactorily completed and accepted by City, such acceptance not to be unreasonably withheld, plus (3) Reimbursable Expenses actually incurred by Consultant, as approved by City. In no event will Consultant be paid more than the Not to Exceed Amount.
The amount of any payment made to Consultant prior to the date of termination of this Agreement shall be deducted from the amounts described in (1), (2) and (3) above. Consultant shall not be entitled to any claim or lien against City or the Project for any additional compensation or damages in the event of such termination and payment. In addition, the City's right to withhold funds under Section 3 shall be applicable in the event of a termination for convenience.
If this Agreement is terminated by City for default and it is later determined that the default termination was wrongful, such termination automatically shall be converted to and treated as a termination for convenience under this Section, paragraph E and Consultant shall be entitled to receive only the amounts payable hereunder in the event of a termination for convenience.
20. COMPLIANCE WITH LAW:
Consultant shall comply with all state or federal laws and regulations as well as all ordinances, rules and regulations enacted or issued by City (collectively, "Applicable Laws").
21. CONFLICT OF LAW:
A. This Agreement shall be interpreted under, and enforced by the laws of the State of California excepting any choice of law rules which may direct the application of laws of another jurisdiction. The Agreement and obligations of the parties are subject to all valid laws, orders, rules, and regulations of the authorities having jurisdiction over this Agreement (or the successors of those authorities.)
B. Any suits brought pursuant to this Agreement shall be filed with the courts of the County of Alameda, State of California.
22. ADVERTISEMENT:
Consultant shall not post, exhibit, display or allow to be posted, exhibited, displayed any signs, advertising, show bills, lithographs, posters or cards of any kind pertaining to the services performed under this Agreement unless prior written approval has been secured from City to do otherwise.
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23. WAIVER:
A waiver by City of any breach of any term, covenant, or condition contained herein shall not be deemed to be a waiver of any subsequent breach of the same or any other term, covenant, or condition contained herein, whether of the same or a different character.
24. INTEGRATED CONTRACT:
This Agreement, including exhibits, represents the full and complete understanding of every kind or nature whatsoever between the parties hereto with regard to the Services, and all preliminary negotiations and agreements of whatsoever kind or nature are merged herein. No verbal agreement or implied covenant shall be held to vary the provisions hereof. Any modification of this Agreement will be effective only by written execution signed by both City and Consultant.
TABLE OF EXHIBITS
Exhibit A Scope of Services/ Compensation
25. INSERTED PROVISIONS:
Each provision and clause required by law to be inserted into the Agreement shall b leemed to be enacted herein, and the Agreement shall be read and enforced as though each wer included herein. If through mistake or otherwise, any such provision is not inserted or is not correctly inserted, the Agreement shall be amended to make such insertion on application by
26. CAPTIONS:
The captions in this Agreement are for convenience only, are not a part of the Agreement and in no way affect, limit or amplify the terms or provisions of this Agreement.
IN WITNESS WHEREOF, the parties have caused the Agreement to be executed on the day and year first above written.
The Permanente Medical Group, Inc., CITY OF ALAMEDA,
a California Corporation, a Municipal Corporation
hull
Chris Palkowski, M.D. Elizabeth Warmerdam
Interim City Manager
Gerard Bajada
Chief Financial Officer
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APPROVED AS TO FORM:
Michault Roush /n
Janet C. Kern
City Attorney
RECOMMENDED FOR APPROVAL:
8785
Stephanie Garrabrant-Sierra
Administrative Services Director
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SNI KAISER PERMANENTE.
Exhibit A
OCCUPATIONAL HEALTH INJURY AND ILLNESS CARE TO BE PROVIDED TO City of Alameda
Services will be provided to City of Alameda as follows:
The Permanente Medical Group (TPMG) will provide Occupational Health Injury and Illness care to City of Alameda employees. TPMG will facilitate care and meet all medical reporting requirements in accordance with the rules and regulations promulgated by the California Division of Workers' Compensation.
TPMG will work collaboratively with your Third Party Administrator to ensure that appropriate medical treatment is provided to injured workers and medical reports are submitted in accordance with DWC requirements.
TPMG will work with your Third Party Administrator to identify your utilization review service requirements and implement processes in accordance with the agreements.
TPMG or its designee accepts reimbursement at the California Official Medical Fee Schedule rate.
We will cooperate with your Third Party Administrator to provide the necessary billing invoices and medical documentation to support billing and reimbursement.
OCCUPATIONAL HEALTH AND SAFETY SERVICES TO BE PROVIDED TO City of Alameda Services will be provided to City of Alameda as follows:
Billing Code Description of Services Cost of
Services
PREPLACEMENT EXAM (P)
300388 Preplacement Physical Exam $65.00
FITNESS FOR DUTY/RETURN TO WORK (FFD/RTW)
300397 Fitness for Duty Physical Exam, initial $95.00
As Clinically Indicated:
300408 Physician Consultation; each additional 15 minutes $60.00
PREPLACEMENT EXAM (POSTPP)
300399 POST Physical Exam $95.00
92552 Audiogram, screening $30.00
94010 Spirometry $35.00
93000 EKG, resting $50.00
93015 Cardiac Stress Test with Treadmill $230.00
86580 RP HiP merers ent and one reading (no charge to curent $20.00
Kaiser On-the-Job'
SİNi KAISER PERMANENTE.
85025 CBC with automated differential $15.00
80053 Chem Comprehensive Panel $35.00
86704 Titer: Hepatitis B Core Antibody, HBcAb $31.00
86803 Titer: Hepatitis C $45.00
36415 Venipuncture $15.00
As Clinically Indicated:
90746 Vaccine: Hepatitis B (series of 3 injections)(no charge to $94.00/injection current KP HP members)
90707 Vaccine: MMR injection (series of 2 injections, if indicated) $76.00/injection 90716 Vaccine: Varivax (chickenpox)(series of 2 injections if $132.00/injection indicated)
81001 Urinalysis with microscopic (if abnormal UA dipstick) $15.00 71010 Chest X-Ray for positive PPD (1 view) $55.00
71020 Chest X-Ray for positive PPD + symptoms (2 views) $65.00 90658 Vaccine: Influenza; flu (when seasonally available)(no charge $20.00 to current KP HP members)
90715 Vaccine: Tdap (tetanus, diphtheria, pertussis) $63.00
FIREFIGHTER PREPLACEMENT EXAM (FFPP)
300398 Firefighter Physical Exam $95.00
92552 Audiogram, screening $30.00
94010 Spirometry $35.00
300422 PPD, 2 step, 2 placements and readings (no charge to $30.00 urrent KP HP members
71020 Chest X-Ray, 2 views (baseline $65.00
85025 CBC with automated differential $15.00
80053 Chem Comprehensive Panel $35.00
86704 Titer: Hepatitis B Core Antibody, HBcAb $31.00
86803 Titer: Hepatitis C $45.00
36415 Venipuncture $15.00
93000 EKG, resting -and- $50.00
93015 Cardiac Stress Test with Treadmill $230.00
As Clinically Indicated:
90746 Vaccine: Hepatitis B (series of 3 injections) (no charge to $94.00/injection current KP HP members)
90632 Vaccine: Hepatitis A (series of 2 injections) $96.00/injection 90707 Vaccine: MMR injection (series of 2 injections, if indicated) $76.00/injection 90716 Vaccine: Varivax (chickenpox)(series of 2 injections if $132.00/injection indicated)
90658 Vaccine: Influenza; flu (when seasonally available)(no charge $20.00 to current KP HP members)
Kaiser On-the-Job®
I KAISER PERMANENTE®
90715 Vaccine: Tdap (tetanus, diphtheria, pertussis) $63.00 90713 Vaccine: Polio (eiPV) if no prior vaccination $40.00 86580 PPD, one placement and one reading (no charge to current $20.00 (PHP members)
81001 Jrinalysis with microscopic (if abnormal UA dipstick $15.00
DRUG SCREEN (DRUG
99000 Collection for Drug Screen Billed by
Preferred Alliance
Kaiser On-the-Job is collection site only.
Collection only during clinic business hours.
As Indicated:
82075 Breathalyzer, alcohol screen $30.00
300421 Breathalyzer, alcohol confirmatory test (positive screen test) $30.00
VACCINATION ONLY
90746 Vaccine: Hepatitis B (series of 3 injections) (no charge to $94.00/injection current KP HP members)
ANNUAL PPD, PLACEMENT AND READING Only
86580 PPD, one placement and one reading (no charge to current $20.00 KP HP members)
As Clinically Indicated:
71010 Chest X-Ray for positive PPD (1 view) $55.00
71020 Chest X-Ray for positive PPD + symptoms (2 views) $65.00 300422 PPD, 2 step, 2 placements and readings (no charge to $30.00 current KP HP members)
99211 Brief encounter with non-MD Provider (PPD-Review Of $20.00
DMV/DOT EXAM (DMV)
300390 DMV/DOT Physical Exam $115.00
RESPIRATOR MEDICAL EVALUATION- BASELINE/ ANNUAL (RESP)
(with RESP Fit testing)
300415 Review of Respirator Questionnaire by MD/NP/RN $35.00 300410 Respirator Fit Test, qualitative $35.00
As Clinically Indicated:
71020 Chest X-Ray (2 views) $65.00
Kaiser On-the-Job®
i KAISER PERMANENTE.
300391 Respirator Physical Exam $60.00
93015 Cardiac Stress Test with Treadmill $230.00
94010 Spirometry $35.00
ONSITE SERVICES NURSING
300418 Site: Nursing Onsite each 15 min. (minimum one hour) $30.00 300412 Administrative Activity $60.00
Services will be determined prior to scheduling
If City of Alameda is requesting a health screening/physical examination of a job applicant/employee, City of Alameda will provide to TPMG detailed information concerning the hysical requirements for performing the job at issue. This information should include a written jo escription, including physical and mental requirements and environmental conditions. Tr examination and any medical conclusions will be based on the information furnished by City of Alameda and the physician's general understanding of the requirements of the jobs of similar nature. TPMG conducts such examinations with City of Alameda's assurances that the examination and City of Alameda's medical inquiries are job-related and consistent with the business needs of City of Alameda, and otherwise comply with all applicable legal obligations.
Based on its health screening/physical examination of a job applicant/employee, TPMG will advise City of Alameda of the following: a) the applicant/employee's physical limitations, if any, and the specific job tasks that cannot be performed and/or environmental conditions, if any, that are related to any risk to health and safety, and b) changes that may be made to permit the job tasks to be performed and/or eliminate/reduce the risk. TPMG will make no determination of whether job tasks are essential to the position in question. Any changes that are recommended are advisory only, based on the physician's general understanding of the job and environment in question, and are not intended to supplant the right of City of Alameda to determine what modifications are available and reasonable.
To the extent that other conditions are identified, TPMG will also: a) notify the employee/applicant of any medical condition, identified during the limited medical evaluation that City of Alameda requested, that TPMG believes requires further attention, and recommend that the employee/applicant seek care from his or her personal provider, thereby encouraging health and wellness, leading to a more productive workforce, and b) upon authorization of the employee/applicant, TPMG will inform his or her personal medical provider by transmitting copies of the medical records created during the visit.
TPMG will maintain a medical record, for each individual that will contain records of employer requested services, in addition to past, present and future services requested by the employee/applicant.
Kaiser On-the-Job"
-
POLICY NUMBER: GL 4048017 COMMERCIAL GENERAL LIABILITY
CG 20 26 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(3) Or Organization(s):
is required by written contract or agreement when such written contract or greement is executed prior to an occurrence, offense or loss to which thi Limits cf Liability provided by this policy, whichever is less. scheduled additional insureds shall not be construed to override nor negate this blanket additional insured.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations. include as an additional insured the person(s) or
organization(s) shown in the Schedule, but only
with respect to liability for "bodily injury", "property If coverage provided to the additional insured is damage" or "personal and advertising injury" required by a contract or agreement, the most we caused, in whole or in part, by your acts or
omissions or the acts or omissions of those acting amount or nuran of the aditional insured is the on your behalf:
1. Required by the contract or agreement; or
1. In the performance of your ongoing operations;
or 2. Available under the applicable Limits of
Insurance shown in the Declarations;
2. In connection with your premises owned by or
rented to you. whichever is less.
However. This endorsement shall not increase the
applicable Limits of Insurance shown in the
1. The insurance afforded to such additional Declarations.
Law, ad only applies to the extent permited by
2. If coverage provided to the additional insured is
agreement, the
the contract or agreement to
provide for such additional insured.
CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2
DATE (MMIDDMY)
ACORD CERTIFICATE OF LIABILITY INSURANCE 03/18/2015
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 INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate halder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements).
CONTACT
PRODUCER NAME:
MARSH RISK & INSURANCE SERVICES PHONE TAC. NoX:
345 CALIFORNIA STREET, SUITE 1300
CALIFORNIA LICENSE NO. 0437153
ADDRESS:
SAN FRANCISCO. CA 94104
INSURERS) AFFORDING COVERAGE 1150 MAN 9
10171 - TPMG-CAS-2016 GLALW CA INSURER A: Safety Nabonal Casuatty Corp.
INSURER B: Lexington Insurance Company 19437
INSURED
KAISER FOUNDATION HEALTH PLAN, INC.
KAISER FOUNDATION HOSPITALS INSURER C:
ONE KAISER PLAZA, 253 INSURER D:
OAKLAND. CA 94612
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: SEA-002602465-01 REVISION NUMBER: 7
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
INSA ADDL SUBR OLICY EF POLICY EXP LIMITS
LTF TYPE OF INSURANCE INSR /WYD POLICY NUMBER
GENERAL LIABILITY GL4048017 01/01/2015 01/01/2016 EACH OCCURRENCE 1,000.000 DAMAGE TO RENTED 1.000.000
COMMERCIAL GENERAL LIABILITY PREMISES (EA OccuTence)
10.000
CLAIMS MADE OCCUR MED EXP (Arty one person)
PERSONAL & ADV INJURY 1.000.000
GENERAL AGGREGATE 2,000,000
GENL AGGREGATE LIMIT APPLIES PER PRODUCTS • COMP/OP AGG 1.000.000
POLICY LOC
COMBINED SINGLE LIMIT
AUTOMOBILE LIABILITY (Es aco cont)
ANY AUTO BODILY INJURY (Per person)
ALL OWNED SCHEDULED BODILY INJURY (Por acodeni)
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE
HIRED AUTOS AUTOS (Per ascooni)...
UMBRELLA LIAB OCCUR EACH OCCURRENCE
EXCESS LIAB AGGREGATE
CLAIMS-MADE
DED I RETENTIONS S
WORKERS COMPENSATION (SP4052403 01/01/2015 T01/012017
AND EMPLOYERS LIABILITY 5.000.000
YIN S..R. S5.000,000
NY PROPRIETOR/PARTNER/EXECUTIVI EL. EACH ACCIDENT
IFFICER/MEMBER EXCLUDED N NIA
EL DISEASE • EA EMPLOYEE S 5.000.000
(Mandatory in NH)
yes. descrioo una 5.000.000
ESCRIPTION OF OPERATIONS bok EL DISEASE • POLICY LIMIT İ S 8 EXCESS AUTOMCBILE LIABILITY 048683338 /01.012015 101.01/2016 EACH OCCURRENCE 1,000.000 SI.R. $1.000.000 AGGREGATE 1.000.000
DESCRIPTON OF OPERATIONS / LOCATIONS / VEHICLES (Atach ACORD 101, Additional Remerka Schedude, It moro space is raquired) THE CITY OF ALAMEDA, ITS COUNCIL. OFFICERS, EMPLOYEES. VOLUNTEERS, BOARD, AND COMMISSIONS ARE ADDITICNAL INSUREDS UNDER THE GENERAL LIABILITY POLICY SOLELY AS RESPECTS WORK PERFORMED BY OR FOR THE NAMED INSURED IN CONNECTION WITH THE CONTRACT AGREEMENT.
CERTIFICATE HOLDER CANCELLATION
CITY OF ALAMEDA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 2263 SANTA CLARA AVENUE, ROOM 190 THE EXPIRATION DATE THEREOF, , NOTICE WILL BE DELIVERED IN ALAMEDA. CA 94501 ACCORDANCE WITH THE POLICY PROVISIONS.
Myrna Lee some Lu
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
ISSUE DATE (MM/DDAY)
EVIDENCE OF COVERAGE - CREDENTIALING 3/19/15
SPONSOR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE Kaiston: Corporate Risk Managemen SET FORTH BELOVE TEND OR ALTER THE COVERAGE ARRANGEMENTS Attention
One Kaiser Plaza, 25E
Oakland, CA 94612
Telephone: 510-271-2617 COVERAGE AFFORDED
Email: [email protected]
CODE PPL SUB-CODE PL LETTER A
Sett-insured
COVERED ENTITIES
Kaiser Foundation Health Plan, Inc.
Kaiser Foundation Hospitals
COVERAGES
co TYPE OF COVERAGE DESCRIPTION EFFECTIVE DATE EXPIRATION LIMITS LIR (MM/DDY) DATE (KM/DOrY
A Hospital/Physician/Professional Liability Self-Insured 01/01/15 01/01/16 Each Occurrence S5.00.000 Annual Aggregate
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/SPECIAL ITEMS This certicate provides evidence of professional labity coverage for the above named entities. The Permanente Medical Group is an indemied
CERTIFICATE HOLDER CANCELLATION
NOT APPLICABLE
City of Alameda AUTHORIZED REPRESENTATIVE
2263 Santa Clara Avenue, Room 190
Alameda, CA 94501
Janice Murphy
KPCRMEOC (2014 11 17)
-
Fom W-g Request for Taxpayer Give Form to the
requester. Do not
(Rev. December 2011) Identification Number and Certification send to the IRS. ema Revere Stree
Name fas shown on your income tax retum)
The Permanente Medical Group, Inc.
Business name/disregarded entity name, if different from above Check appropriate box for federal tax classification:
• Individual/solo proprietor EZ C Corporation •s Corporation • Partnership Trustestate • Exempt payee
Print or type , Specific Instructions on page 2. • Limited habitty company. Enter the tax classification (C=G corporation, corporation. corporation. Paparnership • Other (sae instructions) *
Address (number, street, and apt. or suite no.) Requester's name and address (optional) File 50016
Cry, state, and ZiP code
/Los Angeles, CA 90074-0016
List account number(s) here (optional)
Part l Taxpayer Identification Number (TIN)
Soclal security number
Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose Employer idantification number number to enter.
94-27 2 84 8
Part I! Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b)I have not been notified by the internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax retum. For real estate transactions. item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally. payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 4.
Sign Signaturo of
Here U.S. person • Coun Dator le5.15
General Instructions Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester's form if it is substantially similar Section references are to the Intemal Revenue Code unless otherwise to this Form W-9. noted.
Definition of a U.S. person. For federal tax purposes, you are Purpose of Form considered a U.S. person if you are
A person who is required to file an information return with the IRS must • An individual who is a U.S. citizen or U.S. resident alien. obtain your correct taxpayer identification number (TIN) to report, for • A partnership, corporation, company, or association created or example, income paid to you, real estate transactions, mortgage interest organized in the United States or under the laws of the United States. you paid, acquisition or abandonment of secured property, cancellation • An estate (other than a foreign estate). or of debt. or contributions you made to an IRA. • A domestic trust (as defined in Regulations section 301.7701-7).
Use Form W-9 only if you are a U.S. person (including a resident Special rules for partnerships. Partnerships that conduct a trade or alien), to provide your correct TIN to the person requesting it (the business in the United States are generally required to pay a withholding requester) and, when applicable, to:
tax on any foreign partners' share of income from such business.
1. Certify that the TIN you are giving is correct (or you are waiting for a Further, in certain cases where a Form W-9 has not been received, a number to be issued). partnership is required to presume that a partner is a foreign person.
2. Certify that you are not subject to backup withholding.or and pay the withholding tax. Therefore, if you are a U.S. person that is a
3. Claim exemption from backup withholding if you are a U.S. exempt partner in a partnership conducting a trade or business in the United payee. If applicable, you are also certifying that as a U.S. person, your States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. allocable share of any partnership income from a U.S. trade or business is not subject to the withholding fax on foreign partners share of effectively connected income.
Cat. No. 10231X Form W-9 (Rov. 12-2011)
Form W-9 (Rov. 12-2011) Page 2
The person who gives Form W-9 to the partnership for purposes of Certain payees and payments are exempt from backup withholding. establishing its U.S. status and avoiding withholding on its allocable See the instructions below and the separate instructions for the share of net income from the partnership conducting a trade or business Requester of Form W-9. in the United States is in the following cases: Also see Special rules for partnerships on page 1. • The U.S. owner of a disregarded entity and not the entity.
Updating Your Information
• The U.S. grantor or other owner of a grantor trust and not the trust. and You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee • The U.S. trust (other than a grantor trust) and not the beneficiaries of and anticipate receiving reportable payments in the future from this the trust. person. For example. you may need to provide updated information if you are a C corporation that elects to be an s corporation, or if you no Instead, use the appropriate Form W-8 (see Publication 515. longer are tax exempt. In addition, you must furnish a new Form W-9 if Withholding of Tax on Nonresident Aliens and Foreign Entities). the name or TIN changes for the account, for example, if the grantor of a grantor trust dies.
nonresident alien individual may use the terms of a tax treaty to reduce Penalties treaties contain a provision known as a "saving clause." Exceptions Failure to furnish TIN. If you fail to furnish your correct TIN to a specified in the saving clause may permit an exemption from tax to requester, you are subject to a penalty of S50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. become a U.S. resident alien for tax purposes. Civil penalty for false information with respect to withholding, If you If you are a U.S. resident alien who is relying on an exception make a false statement with no reasonable basis that results in no contained in the saving clause of a tax treaty to claim an exemption backup withholding, you are subject to a S500 penalty. from U.S. tax on certain types of income, you must attach a statement Criminal penalty for falsifying information. Willfully falsifying to Form W-9 that specifies the following five items: certifications or affirmations may subject you to criminal penalties
1. The treaty country. Generally, this must be the same treaty under including fines and/or imprisonment. which you claimed exemption from tax as a nonresident alien. Misuse of TINs. If the requester discloses or uses TINs in violation of
2. The treaty article addressing the income. federal law, the requester may be subject to civil and criminal penalties.
3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. Specific Instructions
4. The type and amount of income that qualities for the exemption Name from tax.
5. Sufficient facts to justify the exemption from tax under the terms of If you are an individual, you must generally enter the name shown on your income tax return. However, if you have changed your last name. the treaty article.
for instance, due to marriage without informing the Social Security Example. Article 20 of the U.S.-China income tax treaty allows an Administration of the name change, enter your first name, the last name exemption from tax for scholarship income received by a Chinese shown on your social security card, and your new last name. student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in if the account is in joint names. list first, and then circle, the name of the United States exceeds 5 calendar years. However, paragraph 2 of the person or entity whose number you entered in Part I of the form. the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows Sole proprietor. Enter your individual name as shown on your income the provisions of Article 20 to continue to apply even after the Chinese tax return on the "Name" line. You may enter your business, trade, or student becomes a resident alien of the United States. A Chinese "doing business as (DBA)" name on the "Business name/disregarded student who qualifies for this exception (under paragraph 2 of the first entity name" line. protocol) and is relying on this exception to claim an exemption from tax Partnership, C Corporation, or S Corporation. Enter the entity's name on his or her scholarship or fellowship income would attach to Form on the "Name" line and any business, trade, Or "doing business as W-9 a statement that includes the information descrbed above to (DBA) name" on the "Business name/disregarded entity name" line. support that exemption.
Disregarded entity. Enter the owner's name on the "Name" line. The If you are a nonresident alien or a foreign entity not subject to backup name of the entity entered on the "Name" line should never be a withholding, give the requester the appropriate completed Form W-8. disregarded entity. The name on the "Name" line must be the name What is backup withholding? Persons making certain payments to you shown on the income tax retum on which the income will be reported. must under certain conditions withhold and pay to the IRS a percentage For example, if a foreign LLC that is treated as a disregarded entity for of such payments. This is called "backup withholding." Payments that U.S. federal tax purposes has a domestic owner, the domestic owner's may be subject to backup withholding include interest, tax-exempt name is required to be provided on the "Name" line. If the direct owner interest, dividends, broker and barter exchange transactions, rents. of the entity is also a disregarded entity, enter the first owner that is not royalties, nonemployee pay, and certain payments from fishing boat disregarded for federal tax purposes. Enter the disregarded entity's operators. Real estate transactions are not subject to backup name on the "Business name/disregarded entity name" line. If the owner withholding. of the disregarded entity is a foreign person, you must complete an You will not be subject to backup withholding on payments you appropriate Form W-8. receive if you give the requester your correct TIN, make the proper Note. Check the appropriate box for the federal tax classification of the certifications, and report all your taxable interest and dividends on your person whose name is entered on the "Name" line (Individual/sole tax return. proprietor, Partnership, C Corporation, S Corporation, Trust/estate).
Payments you receive will be subject to backup Limited Liability Company (LLC). If the person identified on the withholding if: "Name" line is an LLC. check the "Limited liability company" box only and enter the appropriate code for the tax classification in the space
1. You do not furnish your TIN to the requester. provided. If you are an LLC that is treated as a partnership for federal
2. You do not certify your TIN when required (see the Part Il tax purposes, enter "p" for partnership. If you are an LLC that has filed a instructions on page 3 for details). Form 8832 or a Form 2553 to be taxed as a corporation, enter "C" for
3. The IRS tells the requester that you furnished an incorrect TIN. C corporation or "S" for S corporation. If you are an LLC that is disregarded as an entity separate from its owner under Regulation
4. The IRS tells you that you are subject to backup withholding section 301.7701-3 (except for employment and excise tax). do not because you did not report all your interest and dividends on your tax check the LLC box unless the owner of the LLC (required to be retur (for reportable interest and dividends only). or identified on the "Name" line) is another LL that is not disregarded for
5. You do not certify to the requester that you are not subject to federal tax purposes. If the LLC is disregarded as an entity separate backup withholding under 4 above (for reportable interest and dividend from its owner, enter the appropriate tax classification of the owner accounts opened after 1983 only). identified on the "Name" line.
Form W-9 (Rev. 12-2011) Page 3
Other entities. Enter your business name as shown on required federal Part I. Taxpayer Identification Number (TIN) tax documents on the "Name" line. This name should match the name shown on the charter or other legal document creating the entity. You Enter your TIN in the appropriate box. If you are a resident alien and may enter any business, trade, or DBA name on the "Business name/ you do not have and are not eligible to get an SSN, your TIN is your IRS disregarded entity name" line. individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN Exempt Payee below.
If you are exempt from backup withholding, enter your name as If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. However, the IRS prefers that you use your SSN. described above and check the appropriate box for your status, then check the "Exempt payee" box in the line following the "Business name/ If you are a single-member LL that is disregarded as an entity disregarded entity name." sign and date the form. separate from its owner (see Limited Liability Company (LLC) on page 2).
Generally, individuals (including sole proprietors) are not exempt from enter the owner's SSN (or EIN, if the owner has one). Do not enter the disregarded entity's EIN. If the LLC is classified as a corporation or backup withholding. Corporations are exempt from backup withholding for certain payments, such as interest and dividends. partnership, enter the entity's EIN.
Note. See the chart on page 4 for further clarification of name and TIN Note. If you are exempt from backup withholding, you should still combinations.
complete this form to avoid possible erroneous backup withholding.
The following payees are exempt from backup withholding: How to get a TIN. If you do not have a TIN, apply for one immediately.
To apply for an SSN. get Form SS-5. Application for a Social Security
1. An organization exempt from tax under section 501(a), any IRA, or a Card, from your local Social Security Administration office or get this custodial account under section 403(b)(7) if the account satisfies the form online at www.ssa.gov. You may also get this form by calling requirements of section 401(0(2), 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer
2. The United States or any of its agencies or instrumentalities. Identification Number, to apply for an ITIN, or Form SS-4, Application for
3. A state. the District of Columbia, a possession of the United States. Employer Identification Number, to apply for an EIN. You can apply for or any of their political subdivisions or instrumentalities. an EIN ontine by accessing the IRS website at www.irs.gov/businesses and clicking on Employer Identification Number (EIN) under Starting a
4. A foreign government or any of its political subdivisions, agencies. Business. You can get Forms W-7 and SS-4 from the IRS by visiting or instrumentalities, or IRS.gov or by calling 1-800-TAX-FORM (1-800-829-3676).
5. An international organization or any of its agencies or If you are asked to complete Form W-9 but do not have a TIN, write instrumentalities. "Applied For" in the space for the TIN, sign and date the farm, and give Other payees that may be exempt from backup withholding include: it to the requester. For interest and dividend payments, and certain
6. A corporation, payments made with respect to readily tradable instruments. generally you will have 60 days to get a TIN and give it to the requester before you
7. A foreign central bank of issue, are subject to backup withholding on payments. The 60-day rule does
8. A dealer in securities or commodities required to register in the not apply to other types of payments. You will be subject to backup United States, the District of Columbia, or a possession of the United withholding on all such payments until you provide your TIN to the States. requester.
9. A futures commission merchant registered with the Commodity Note. Entering "Applied For" means that you have already applied for a Futures Trading Commission. TIN or that you intend to apply for one soon.
10. A real estate investment trust. Caution: A disregarded domestic entity that has a foreign owner must
11. An entity registered at all times during the tax year under the use the appropriate Form W-8.
Investment Company Act of 194D, Part II. Certification
12. A common trust fund operated by a bank under section 584(a). To establish 1o the withholding agent that you are a U.S. person, or
13. A financial institution, resident alien, sign Form W-g. You may be requested to sign by the
14. A middleman known in the investment community as a nominee or withholding agent even if item 1, below, and items 4 and 5 on page 4 custodian, or indicate otherwise.
15. A trust exempt from tax under section 664 or described in section For a joint account, only the person whose TIN is shown in Part I 4947. should sign (when required). In the case of a disregarded entity, the person identified on the "Name" line must sign. Exempt payees, see The following chart shows types of payments that may be exempt Exempt Payee on page 3. from backup withholding. The chart applies to the exempt payees listed above. 1 through 15. Stams 1 trug 3. Deto, comes and itr pas a indicated in IF the payment is for... THEN the payment is exempt
for...
Interest and dividend payments for exempt payees except Broker transactions Enough 13. Also, C corporations
Barton an hang rare in and Exempt payees 1 through 5
1 through 7: Cross out let 2 rane celiai onu must sign the cenication, You may Form W-9 (Rov. 12-2011) Page 4
4. Other payments. You must give your correct TIN, but you do not Note. If no name is circled when more than one name is listed. the have to sign the certification unless you have been notified that you number will be considered to be that of the first name listed. have previously given an incorrect TIN. "Other payments" include payments made in the course of the requester's trade or business for Secure Your Tax Records from Identity Theft rents, royalties, goods (other than bills for merchandise), medical and Identity theft occurs when someone uses your personal information health care services (including payments to corporations), payments to such as your name, social security number (SSN), Or other identifying a nonemployee for services, payments to certain fishing boat crew information, without your permission, to commit fraud or other crimes. members and fishermen, and gross proceeds paid to attorneys An identity thief may use your SSN to get a job or may file a tax return (including payments to corporations). using your SSN to receive a refund.
5. Mortgage interest paid by you, acquisition or abandonment of To reduce your risk:
secured property, cancellation of debt, qualifled tuition program • Protect your SSN. payments (under section 528), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You • Ensure your employer is protecting your SSN, and must give your correct TIN, but you do not have to sign the certification. • Be careful when choosing a tax preparer.
If your tax records are affected by identity theft and you receive a What Name and Number To Give the Requester notice from the IRS, respond right away to the name and phone number Give name and SSN of: printed on the IRS notice or letter.
For this type of account:
If your tax records are not currently affected by identity theft but you
1. Individual The individual think you are at risk due to a lost or stolen purse or wallet, questionable
2. Two or more individuals (joint The actual owner of the account or. credit card activity or credit report, contact the IRS Identity Theft Hotline account) if combined funds, the first at 1-800-908-4490 or submit Form 14039. individual on the account
For more information, see Publication 4535. Identity Theft Prevention
3. Custodian account of a minor The minor'
and Victim Assistance.
(Uniform Gift to Minors Act)
4. a The usual revocable savings The grantor-trustee Victims of identity theft who are experiencing economic harm or a trust (grantor is also trustee) system problem, or are seeking help in resolving tax problems that have b. So-called trust account that is The actual owner not been resolved through normal channels, may be eligible for not a legal or valld trust under Taxpayer Advocate Service (TAS) assistance. You can reach TAS by stato law calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD
5. Sola proprietorship or disregardod Tho owner' 1-800-829-4059. entity owned by an individual
Protact yourself from suspicious emails or phishing schemes.
G. Grantor trust fling under Optional The grantor' Phishing is the creation and use of email and websites designed to Form 1099 Filing Method 1 (soe mimic legitimate business emails and websites. The most common act Regulation section 1.671-4(bX2)(XA))
is sending an email to a user falsely claiming to be an established For this type of account: Give name and EIN of:
legitimate enterprise in an attempt to scam the user into surrendering
7. Disregarded entity not owned by an The owner private information that will be used for identity theft. individual
The IRS does not initiate contacts with taxpayers via emails. Also, the
8. A valid trust, estate, or pension trust Legal entity' IRS does not request personal detailed information through emal or ask
9. Corporation or LLC electing The corporation taxpayers for the PIN numbers, passwords, or similar secret access corporato status on Form 8832 or
information for their credit card, bank, or other financial accounts.
Form 2553
10. Association, ctub, religious. The organization If you receive an unsolicited email claiming to be from the IRS. chartable, educational, or other forward this message to phishing®irs.gov. You may also report misuse tax-oxempt organization of the IRS name. logo, or other IRS property to the Treasury Inspector
11. Partnership or multi-member LLC The partnerstup General for Tax Administration at 1-800-366-4484. You can forward
12. A broker or registered nominco The broker or nominee suspicious emails to the Federal Trade Commission at: [email protected] or contact them at www.ftc.govlidtheft or 1-877-IDTHEFT
13. Account with the Department of The public entity
(1-877-438-4338).
Agriculture in the name of a public
entity (such as a state or local Visit IRS.gov to learn more about identity theft and how to reduce government, school district, or your risk.
prison that receives agricultural
program payments
1-4. Grantor trust filing under the Form The trust
1041 Filing Method or the Optional
Form 1099 Filing Method 2 (seo
Regulation section 1.671-4(b)2)(XB))
"List first and orcle the name of the person whose number you furnish if only one personon a jont account has an SSN. that Derson's rumber must be furnisnod 'Cucie the minor's name and furnish the minor's SSN
'You must snow your indondual name and you may aiso enter your business or 'DBA" name an ine -Business name/disregarded entity" name ine. You may use atner your SSN or EIN (if you nave one). Dut the IRS encourages you to use your SSN
Personal opresentate or rete unles a legal priy so is of eat tate the co int titio.) Also soo Special rules for partnerships on page 1 "Noto. Grantor also must provido a Form W.9 to trusted of trust Privacy Act Notice
Section 6109 of the Internal Revanue Code requires you to provide your correct TIN lo persons (including federal agoncies) who are required to file information relums with TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.
DATE (MM/DDMAY)
ACORD® CERTIFICATE OF LIABILITY INSURANCE 03/18/2015
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 INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER
MPORTANT: If the certificato holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject t he terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to th certificate holder in lieu of such endorsements).
PRODUCER CONTACT
NAME:
MARSH RISK & INSURANCE SERVICES
PHONE TAC, No):
345 CALIFORNIA STREET. SUITE 1300 JA/S. No. Ext):
CALIFORNIA LICENSE NO. C437153 E-MAIL
ADDRESS:
SAN FRANCISCO. CA 94104
INSURER(5) AFFORDING COVERAGE
10171 - TPMG-CAS-2016 GLALW CA INSURER A : Safety Natonal Casualty Corp INSURED INSURER B: Lexington Insurance Company 19437
KAISER FOUNDATION HEALTH PLAN, INC.
KAISER FOUNDATION HOSPITALS INSURER C:
ONE KAISER PLAZA, 253 INSURER D:
OAKLAND, CA 94612
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: SEA-002602465-01 REVISION NUMBER:7
IS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI INDICATED TWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TH
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 ADDL SUBR POLICY
LTR TYPE OF INSURANCE INSRWYD! POLICY NUMBER LIMITS
GENERAL LIABILITY GL4048017 01.01/2015 01:01/2016 EACH OCCURRENCE 1.000,000 DAMAGE TO RENTED 1.000,000
COMMERCIAL GENERAL LIABILITY PREMISES (Ea occumence)
CLAIMS-MADE OCCUR MED EXP (Any one person) 10.000
PERSONAL & ADV INJURY 1.000.000
GENERAL AGGREGATE 2,000,000
GENL AGGREGATE LIMIT APPLIES PER PRODUCTS • COMP/OP AGG 1,000,000
POLICY PROT LOC CITY OF ALAMEDA
AUTOMOBILE LIABILITY COMBINED SINGLE LIMI
a acciden
Risk Management
ANY AUTO BODILY INJURY (Per person)
ALL OWNED SCHEDULED BODILY INJURY (Per accident)
AUTOS
1-8-15
NON-OWNED PROPERTY DAMAGE
HIRED AUTOS AUTOS _ Date (Per accident)
Lucretia Akil, . City Risk Manager
UMBRELLA LIAB OCCUR EACH OCCURRENCE
EXCESS LIAB CLAIMS-MADE AGGREGATE
DED RETENTION S
WORKERS COMPENSATION SP4052403 01.01/2015 101.01.2017 IC STATI (OTH- AND EMPLOYERS' LIABILITY TORY LIMITS LER.
YIN SIR. $5.000.000 5.CCC.0C0
ANY PROPRIETOR PARTNER/EXECUTIVE EL. EACH ACCIDENT
OFFICER MEMBER EXCLUDED? IN/ A
(Mandatory in NH) EL DISEASE • EA EMPLOYEE S 5,000.000
yes. deserte under 5.C00.000
PTION OF OPERATIONS beca EL DISEASE • POLICY LIMIT S
• EXCESS AUTOMOBILE LIABILITY 048863338 (01.01.2015 01.01.2016 EACH OCCURRENCE :.030.050 SIR $1.000.000 AGGREGATE 1.000.000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If moro space is required) THE CITY OF ALAMEDA, ITS COUNCIL. OFFICERS, EMPLOYEES, VOLUNTEERS. BOARD, AND COMMISSIONS ARE ADDITICNAL INSUREDS UNDER THE GENERAL LIABILITY POLICY SOLELY AS
RESPECTS WORK PERFORMED BY OR FOR THE NAMED INSURED IN CONNECTION WITH THE CONTRACT AGREEMENT
CERTIFICATE HOLDER CANCELLATION
CITY OF ALAMEDA SHE EXARATON DATE THERE, NOTE ELSE DELIVERED IN 2253 SANTA CLARA AVENUE, ROOM 190 THE EXPIRATION THEREOF, ALAMEDA, CA 94501 ACCORDANCE WITH THE POLICY PROVISIONS.
Myrna Lee some Lu
© 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
ISSUE DATE (MM/DDAY)
EVIDENCE OF COVERAGE - CREDENTIALING 3/19/15
SPONSOR
aiser Foundation Health Plan, In DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE ARRANGEMENTS ttention: Corporate Risk Managemer
One Kaiser Plaza, 25E
Dakland, CA 94612
elephone: 510-271-26 COVERAGE AFFORDED
mail: [email protected]
CODE PPL SUB-CODE PL LETTER A
Self-insured
COVERED ENTITIES
aiser Foundation Health Plan. Ir
aiser Foundation Hospita
COVERAGES
co TYPE OF COVERAGE DESCRIPTION ERECTE DATE LIMITS
LIR
A Hospital/Physician/Professional Liability Self-Insured 01/01/15 01/01/16 $5.000.000 None
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS This certicate provides evidence of professional labily coverage for the above named entities. The Permanente Medical Group is an indemnified
CERTIFICATE HOLDER CANCELLATION
NOT APPLICABLE
City of Alameda AUTHORIZED REPRESENTATIVE
2263 Santa Clara Avenue, Room 190
Alameda, CA 94501
Janice Murphy
CITY OF ALAMEDA
nagemen
KPRMEOC (2014 1: 17)
Lucretia Akil, City Risk Manager 2ml 1-115
POLICY NUMBER: GL 4048017 COMMERCIAL GENERAL LIABILITY
CG 20 26 04 13
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED
PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s) Or Organization(s):
required by written contract or agreement when such written contract or is executed prior to an occurrence, offense or loss to which this endorsement applies, but only for the limits agreed to in such contract or the of liability provided by this policy, whichever is less. Any individually scheduled additional insureds shall not be construed to override nor negate this blanket additional insured.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II - Who Is An Insured is amended to B. With respect to the insurance afforded to these include as an additional insured the person(s) or additional insureds, the following is added to organization(s) shown in the Schedule, but only Section III - Limits Of Insurance:
with respect to liability for "bodily injury". "property If coverage provided to the additional insured is damage" or "personal and advertising injury"
required by a contract or agreement, the most we
caused, in whole or in part, by your acts
omissions or the acts or omissions of those acting will pay on behalf of the additional insured is the amount of insurance:
on your behalf:
1. Required by the contract or agreement; or
1. in the performance of your ongoing operations;
or 2. Available under the applicable Limits of
Insurance shown in the Declarations;
2. In connection with your premises owned by or
rented to you whichever is less.
However: This endorsement shall not increase the
applicable Limits of Insurance shown in the
1. The insurance afforded to such additional Declarations. insured only applies to the extent permitted by
law; and
2. If coverage provided to the additional insured is CITY OF ALAMEDA required by a contract or agreement, the
insurance afforded to such additional insured Risk Management will not be broader than that which you are 7-815
required by the contract or agreement to
provide for such additional insured -Date -
Lucretia Akil, City Risk Manager
CG 20 26 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 2