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WORKERS' COMPENSATION SERVICE AGREEMENT
This Agreement is entered into by and between City of South San Francisco ("Employer") and Athens Administrators ("Administrator") this 1st day of July 2019.
RECITALS
WHEREAS, Administrator provides claims administration services to California employers subject to the California Workers' Compensation Laws; and
WHEREAS, Employer desires to purchase Claims Administration Services from Administrator for existing open claims reported before the effective date of this agreement ("takeover claims") and new claims reported on or after the effective date of this agreement ("new claims"); NOW THEREFORE, it is agreed:
This Agreement is between the Employer and the Administrator to provide third party workers' compensation claim administration services for Employer in the State of California, including takeover claims and new claims, subject to the terms stated below:
I. TERM AND TERMINATION
1.01 Term:
The term of this agreement shall consist of three years from July 1, 2019 through June 30, 2022. At the Employer's option, this agreement may be extended for two additional one-year periods.
1.02 Termination:
a. Either party may terminate this Agreement, with or without cause and without penalty, upon ninety (90) days prior written notice.
b. Upon termination of this Agreement for any reason, a final accounting agreeable to both parties will be made of fees payable to Administrator and a final accounting of any funds belonging to Employer then in the possession of Administrator, and any balance due either party will be promptly paid over to the party entitled thereto.
c. All claim files, records, reports and other material pertaining to the employee claims subject to this Agreement shall be the property of Employer and shall be made available promptly to Employer upon termination of this Agreement.
d. Upon the effective date of any termination of this Agreement, all rights and obligations of the parties under this Agreement shall cease except with respect to rights and obligations, which have accrued or expressly survive termination.
e. In the event Employer terminates this contract but desires Administrator to handle the remaining claims to a conclusion, a service charge will be agreed upon between the parties for Administrator's 1 | Page
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handling of these claims. Employer agrees to provide Administrator with funds sufficient to pay all benefits and Allocated Loss Expenses on these remaining claims.
II. SERVICE FEES
2.01. Employer agrees to pay to Administrator Service Fees as follows:
PRICING OPTION - FLAT ANNUAL FEE FLAT ANNUAL FEE
Program Year 1 7/1/2019 6/30/2020 $196,052
Program Year 2 7/1/2020 6/30/2021 $201,933
Program Year 3 7/1/2021 6/30/2022 $207,991
TOTAL THREE YEAR COST $605,977
ONE YEAR PROGRAM EXTENSIONS FLAT ANNUAL FEE
Program Year 4 7/1/2022 6/30/2023 $214.231
Program Year 5 7/1/2023 6/30/2024 $220,658
Employer's fixed annual fee will be paid in twelve (12) equal installments and will be due and payable at the end of each month during the period this Agreement is in force.
2.02. Employer agrees to pay to Bill Review Service Fees as follows:
MEDICAL BILL REVIEW
T
Medical Fee Schedule Reduction (OMFS) $8.50 Per Bill
(Includes: Medical, Pharmacy and Supplies)
Hospital In and Out Patient Fee Schedule Reductions ' $650.00 Per Bill PPO Network & Specialty Bill Negotiations 23.00% of Savings Duplicate Bills No Charge
2.03. Employer agrees to pay an Annual Administration Fee of $5,000. This fee will be billed in full in the first installment, and at the start of every program year thereafter.
2.04. Employer agrees to pay a fee of 15% of all subrogation recoveries. This fee will be paid directly from the individual claim file as an allocated expense.
2.05. City shall pay fees for all other services as described in Administrator's pricing proposal dated April 24, 2019 (Exhibit A).
III. ADMINISTRATOR DUTIES AND SERVICES
3.01 Administrator agrees to meet on a regular basis with Employer to:
a. Develop procedures, forms, instructions, schedules and other materials related to claim management, including a procedure manual for Employer's use, within thirty (30) days of the effective date of this Agreement and update such materials as needed.
b. Provide claim reporting kits including, but not limited to, claim and accident report forms, required notices, and procedural instructions, for distribution by Employer to Employer's staff on or before the effective date of this Agreement, and as needed thereafter. c. Provide group education for Employer's management personnel regarding claim management as 2 | Page
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requested.
d. Assist Employer's personnel in the development of directives, notices, and other program communication to employees as requested.
e. Provide all forms and supplies necessary for the efficient operation of the Workers' Compensation insurance program, including customized benefit checks bearing Employer's name and logo, and to prepare all legally required forms and documents including but not limited to, 1099 reports to the I.R.S. and any and all other documents and reports now or in the future required by the state or federal government or any other agency associated with Employer's Workers' Compensation program.
3.02. Administrator agrees to administer all claims as follows:
a. Establish and maintain a claim file, with a diary date not to exceed thirty (30) days, on each active claim upon which indemnity benefits are being paid; A diary system not to exceed sixty (60) days on all other open, active Indemnity claims; and a supervisory review diary not to exceed one-hundred-twenty (120) days, or more often when needed.
b. Manage timely receipt of all pertinent claim information from Employer providers and other sources. c. Determine, on behalf of Employer for each reported employee injury or illness, those benefits, if any that should be paid or rendered under the California Workers' Compensation Laws. Such determination shall include an estimate of future claim payment. Retain outside services with prior approval of Employer, for the investigation and management of the claims. Outside services include but are not limited to:
• AOE/COE Investigators
• Activities Check/Sub-rosa Investigator;
• Medical Case Management and Rehabilitation Nurses/Consultants • Subrogation Investigators and Experts
d. Exhibit in each Indemnity claim file good faith efforts to contact all injured workers by telephone within at least twenty-four hours of receipt of claim, and in no event any later than forty-eight hours of receipt of claim, excluding weekends and holidays. Establish phone contact with appropriate Employer department for initial discussion of claims, as needed, within three (3) working days of receipt of claim. e. Initiate investigations, subject to approval by Employer, to determine compensability of reported and actual claim status. Employer shall have prior approval of the selection of any investigator used to investigate Employer's claims of industrial injury or illness. Take necessary statements and investigate facts of the case within thirty (30) days receipt of claim, when warranted. f. Prepare documentation of cases for litigation and continue to monitor legal counsel representing Employer in legal action(s) and assist counsel as necessary in preparation of litigation. Employer shall select and approve counsel prior to each referral. In addition, Administrator shall promptly provide Employer with copies of all correspondence generated on those claim files which are litigated and shall immediately notify Employer in writing and shall keep Employer closely informed on those claims involving allegations of Serious and Willful Misconduct or alleged violation(s) of California Labor Code Section 132(a). At time of case referral to defense counsel administrator shall prepare a letter of 3 | Page
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direction to defense counsel outlining work to be done, by whom, and in what time frame. All assignments, instructions and communication with defense counsel must be documented in the claim file and computer note pads. Administrator shall manage defense counsel on an ongoing basis and obtain status reports from defense counsel every sixty (60) days. Administrator shall actively manage litigated files and not perform functions and shall not require defense counsel to perform activities which can be accomplished effectively by claims staff. Examples of required examiner activity on litigated files include by are not limited to:
• Scheduling medical appointments
Writing cover letters to doctors
• Subpoenaing medical records
Answering applications
• Filing and serving requisite documents
Administrator shall obtain defense counsels' written evaluation within sixty (60) days of submission, including evaluation of liability, verdict potential, settlement value, and case strategy. g. Disburse payment on behalf of Employer out of the bank trust account funded by Employer, all "Allocated Loss Expenses", which is defined to include all costs incurred on behalf of Employer specifically related to an individual claim, including but not limited to, attorneys, independent adjusters or investigators, expert witnesses, copying records or transcripts, court costs or Appeals Board fees or other costs deemed proper and necessary to represent Employer. h. Examine on behalf of Employer all reports of industrial injury or illness relating to Employer's employees or former employees and reported to Administrator and to conduct investigations on such cases by Administrator's salaried employees as in Administrator's judgment is deemed necessary. i. Pay compensation, medical expense, "Allocated Loss Expense", ', and all other benefits as prescribed by law out of funds provided by Employer. Payments made by Administrator without Employer approval, where approval is required elsewhere in this Agreement, shall be the responsibility of the Administrator.
j. Maintain a claim file on each reported claim which shall be available to Employer at all times for inspection and to conduct, on a quarterly basis, claim file reviews with Employer at the City's Offices. k. Index Bureau System. On the Employer's behalf, Athens shall subscribe and report to the Index Bureau System related to each claim. The costs of such reports will be allocated to each individual claim file.
I. Create, reserve and enter required claim data into Administrator's computer system within five (5) working days of receipt of notice of claim from Employer. Enter all payments, reserved revisions, and file closings into the information system within three (3) working days. m. Review Employer's medical bills and other medical charges and treatment relating to Employer's claims of industrial injury or illness, for causal relationship to all claims of injuries/illness, and reasonableness of treatment prior to payment. Solicit all medical bills, medical reports and records, and documentation of alleged wage loss prior to settlement negotiations. n. Make all disability payments and send all notices in a timely manner, abiding by all applicable 4 l Page
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provisions of the California Labor Code and California Workers' Compensation Laws, Rules and Regulations.
o. Make payments of bills within thirty (30) days of receipt, and assure timely review and payment of all medical bills in accordance with statutory deadlines and requirements. p. Acknowledge to Employer all claims reported to Administrator within three (3) working days of receipt of the notice of claim and to notify Employer and injured workers within five (5) working days of the notice of claim to Employer, whether the claim has been accepted, delayed for further investigation, or denied. Administrator shall consult with Employer prior to accepting, delaying and/or denying a claim. q. Convert all Medical Only Claims to Indemnity Claims status when the paid amount reaches two- thousand-five-hundred ($2,500) dollars or when the claim remains open in excess of one (1) year. r. Recognize and where appropriate investigate all subrogation and/or contribution possibilities, preserving evidence and utilizing appropriate investigators and experts, as needed, after first obtaining Employers permission to engage such investigators/experts. As respects subrogation and contribution cases, any compromise settlements or lien reductions will be discussed with the Employer. s. Administrator may receive compensation in connection with outsourced services, either by retaining a portion of expenses charged to the Account, or by receiving fees from preferred providers. The amount that Administrator receives will vary depending upon the preferred provider, and may be calculated based on percentage of savings, percentage of revenue to the provider or Administrators mark-up of provider fees. The amounts retained or received by Administrator in connection with outsourced services are in addition to the basic fees, reimbursable expenses, additional service fees, and the taxes paid to Athens by Company.
t. MSA Allocations/SCHIP Reporting - Athens has contracted with third party Gould & Lamb, LLP for Medicare Set Aside allocations and State Children Health Insurance Program ("SCHIP") reporting efforts. Athens may exclusively utilize the services of Gould and Lamb, LLP for MSA allocations and SCHIP reporting requirements unless otherwise requested in writing by Employer. u. Inflation Protection Clause - In the event that the annual average All Items Consumer Price Index for All Urban Consumers (CPI-U) as published by the Bureau of Labor and Statistics is subject to an inflation rate of greater than 10% above the rate which is published as of the effective date of this agreement the Administrator has the ability to make reasonable adjustments to the fees which are detailed in Section II of this agreement so as to equitably share the effect of inflation between Administrator and Employer. Notice of fee adjustments will be in writing and must be delivered at least (30) days in advance of adjustment.
3.03 Administrator agrees to monitor relevancy of medical treatment by the following:
a. Maintain continual contact with medical practitioners in order to monitor claimant treatment process and a timely return to work. Administrator shall make a good faith effort to establish contact with attending physician within twenty-four (24) hours of receipt of injury report and shall make contact with attending physician's office within forty-eight (48) hours of receipt of injury report and shall document such contact in the claim file. In cases involving loss of time from work in excess of (10) ten calendar days, Administrator shall make contact with the attending physician's office on a biweekly 5 | Page
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basis during the continuation of temporary disability to assure disability payments are supported by medical opinion.
b. Review and discuss Vocational Rehabilitation Program(s) with Employer prior to its initiation for an individual claimant.
c. Monitor individual vocational rehabilitation programs to determine appropriateness and progress.
3.04. Administrator agrees to the following record keeping and reporting requirements:
a. Provide Employer with monthly reports consisting of:
(1) Check Registers including all claim disbursements made on behalf of Employer.
Computerized loss reports in an acceptable format as mutually agreed upon at the effective date of this Agreement, showing descriptive data, details of each month's payments, total payments, reserves and total experience and incurred loss values for each claim.
(3) Any and all other reports as required by Employer.
b. Provide oral claims reports on demand, special specific-focus loss run reports within twenty-four (24) hours and larger or major computer analysis reports within seven (7) working days, excluding weekends and holidays. It is further agreed and understood that should Employer require that Administrator prepare for Employer special reports, which require additional programming costs there may be an additional charge for said reports.
c. Maintain all records and statistical data on each employee claim of injury or illness, including, but not limited to, a record of each denial, delay, litigated claim and loss, which records and data shall be available upon request by Employer. Employer, at Employer's discretion, may audit all records maintained by Administrator including, but not limited to, all payments made on behalf of Employer.
Such audit may incorporate random sampling or other audit procedures suitable to Employer. d. Prepare and submit Federal Information Return (Form 1099) by statutory deadline for applicable payments made by Administrator on Employer's behalf, during the term of this Agreement and as specified under Section 1.02. (e) of this Agreement.
e. Prepare all other reports as necessary to remain in compliance with all Workers' Compensation Laws and other state and federal laws, rules and regulations. f. Provide report to Employer of all payments when made and any other information necessary for Employer to adequately fund the bank trust account. All such payments shall be supported with check payment detail and monthly summary report showing all payees, payment amounts and dates of payment.
g. Provide for Employer the ability to be on-line with Administrator's computer system. This system will provide Employer with all financial and statistical data relating to Employer's workers' compensation claims, together with narrative topical "notepad" reports, on each individual claim. This system will 6 Page
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also include electronic mail service between Administrator and Employer; the ability to electronically transmit 5020's (Employer's First Report of Industrial Injury/Illness); OSHA Log generation; and complete report generation capabilities.
h. Special reports, new reports and data feeds can also be requested. They are subject to a cost per quote at a rate per project or per hour once the scope has been agreed upon.
IV. EMPLOYER'S DUTIES
4.01. Employer agrees to perform as follows:
a. Promptly report to Administrator as they shall occur and become known to Employer, the employee claims of occupational injury, disease, illness, or death. b. Promptly forward to Administrator all applications, notices of claims, notices of hearings or other legal notices pertaining to claims against Employer for occupational injury, disease, illness, or death, and all other correspondence or information received by Employer which is or could be relevant to the efficient and proper handling of any reported claim of industrial injury, disease, illness, or death. c. Provide Administrator with all necessary data required for Administrator to perform under this Agreement and cooperate fully with Administrator in the performance of this Agreement. d. Make available to Administrator funds for the payment of benefits or services to or for occupational injury, disease, illness, death, or vocational rehabilitation and medical treatment of employees of Employer, or their dependents in the event of death, and "Allocated Loss Expense". Administrator shall administer said funds in accordance with the terms of this Agreement as Trustee of Employer. e. Pay promptly to Administrator the service fees as prescribed and included in this Agreement. The Service Fees are not included in and do not include "Allocated Loss Expenses" V. ELECTRONIC CLAIM FILES, STORAGE, AND TRANSFER OF FILES
5.01 Files
Administrator shall record and maintain an electronic file of all industrial injuries reported. Files may be maintained electronically, in hard copy, or in other media, at Administrator's discretion. Such files shall be made available to Employer or its designated representative for inspection upon request.
5.02 Transfer of Electronic Files
Upon termination of this Agreement pursuant to section 1.02 above, Administrator will arrange for the transfer of Employer's files to Employer, or an entity designated by Employer, within 30 business days of the agreed upon transfer date of the files to the new Administrator. Employer will reimburse Administrator all reasonable costs incurred in such transfer of the files to the Employer. The electronic files will be in the electronic form used by Administrator to provide the services to Employer under this Agreement. Employer may request that the files be provided in a different format or that the hard copies of the files be provided to it, provided that Employer pays Administrator for all costs associated with such request. Notwithstanding the foregoing, Administrator will not be obligated to transfer the files to Employer or an entity designated by Employer, unless Employer has paid Administrator for all amounts due for services rendered pursuant to Section 3 of this Agreement. Employer agrees to comply, and to 7 | Page
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require any recipient of the files designated by it to comply, with all applicable laws and regulations relating to the storage, transmission, use and confidentiality of the files and to hold Administrator harmless in relation thereto.
5.03 Copies of Files
Administrator may, at its discretion keep a copy of Employer's files if it deems it necessary to comply with or defend itself in relation to any obligation or rights that it has under this Agreement, applicable laws or regulations. Notwithstanding the foregoing, Employer may at any time request that any copies of Employer's files retained by Administrator be deleted destroyed and Administrator shall provide notice to Employer that such request has been complied with.
VI. FINES, PENALTIES AND STANDARDS
6.01. All services as described in this Agreement shall be performed in accordance with all applicable laws, rules and regulations of any and all governmental authorities and applicable standards, and specifically performed in accordance with all applicable Workers' Compensation Laws of the State of California.
6.02. Administrator and Employer acknowledge the obligations and penalties contained in the California Workers' Compensation Reform Act of 1989 that may be imposed on both Employers and claim administrators and agree to the following:
a. Penalties for errors or omissions caused by Employer's failure to act or timely report claims or issues to Administrator that create a delay in payment of benefits, incorrect payment of benefits, or administrative fine(s) or penalty(s) shall be the responsibility of Employer. Penalties for errors or omissions caused by Administrator's performance of services under this contract that create a delay in payment of benefits, incorrect payment of benefits, or administrative fine(s) or penalty(s) shall be the responsibility of Administrator.
b. Administrator shall provide Employer with a quarterly accounting of penalties paid by Administrator on behalf of Employer including a description and detailed listing of each penalty payment and the specific claim file to which the penalty payment was charged. Penalties, which are computed by Administrator, shall be paid out of Employer's benefit account and Administrator shall then reimburse Employer quarterly for those penalties, which are the responsibility of Administrator under the terms and conditions of this Agreement, with pro-rated interest at the prevailing prime interest rate. c. Without limiting the provisions set forth in the above two paragraphs it is agreed that upon receipt by Administrator of a notice of claim from Employer, upon which indemnity benefits shall be paid or notice given promptly to the employee in order to avoid late payment or notice of benefit penalties, Administrator shall have ten working days (excluding weekends and holidays) from the date of receipt of the claim from Employer, to investigate and pay the temporary disability or send the required wage continuation notice, and that failure on the part of Administrator to do so within this time frame shall be the financial responsibility of Administrator for any fine imposed for late notice or payment of benefits. Any fines or penalties for late payment or notice of benefits on claims, which are received from Employer by Administrator on or, after the ninth day following the date Employer knew or should have known about the claim(s) shall be the responsibility of Employer. d. Administrator will be responsible for any fines or penalties associated with questionable or controverted claims which Administrator denies without first consulting and obtaining approval by 8 | Page
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Employer for denial of the claim(s) Administrator will not be responsible for any fines or penalties levied by the Division of Workers' Compensation or any other judicial or quasi-judicial organization for improper denial of a claim (s) if, over the written objections of Administrator, Administrator has denied said claim(s) at the express written direction of Employer. e. Any controversy between the parties to this Agreement involving the construction or application of the terms, provisions, or conditions of this Agreement relating to the payment of penalties or fines shall be submitted to arbitration upon the written request of one party, after service of that request upon the other party.
f. Arbitration and controversies relating to the payment of penalties or fines under this Agreement shall comply with and be governed by the provisions of the California Arbitration Act, as set forth at sections 1280 et. seq. of the California Code of Civil Procedure. g. Failing informal efforts between the parties to this Agreement to resolve disputes regarding the payment of penalties or fines, each party shall appoint one person to hear and resolve the dispute.
These arbitrators, one appointed by each party, shall be known for the purposes of this Agreement as "initial arbitrators". If the "initial arbitrators" are unable to agree on a resolution of the dispute they shall then choose a third independent and impartial arbitrator whose decision shall be final and conclusive on both parties.
h. If a dispute or arbitration under this Agreement is pending at a time when payment of the disputed penalty(s) or fine(s) is either statutorily mandated or when failure to effect payment will result in an increase in the fine or penalty, or an additional fine or penalty, each party shall bear liability for one- half of the penalty(s) or fine(s) in dispute until such time as the arbitration is concluded and liability for payment of the fine or penalty is finally determined. Once determined, the party adjudged to be liable for the penalty(s) or fine(s) shall reimburse the non-liable party for any portion of the penalty(s) or fine(s) the non-liable party may have paid during the pendency of the arbitration.
6.03 Excess Coverage or Other Insurance: Administrator, as a part of the regular claims administration process, shall comply with the reporting provisions, guidelines, and requirements imposed by the Employer's Excess Workers' Compensation Insurance Carrier(s) and other carriers that may be involved in the administration of the Employer's Workers' Compensation Program. However, Employer as policyholder shall continue to be liable for all the duties, requirements, obligations, and penalties imposed by Employer's Carrier(s).
VII. MATERIAL CHANGE
7.01. In the event of material change to Employer's operations, Section II, "Service Fees" , to this Agreement shall be subject to renegotiation. "Material Change" shall be defined as the acquisition, merger, or divestiture by Employer of or with another company or business entity, the creation of new business operations not directly related to Employer's current California operations, or the elimination of business operations within the State of California, which could result in a materially significant increase or decrease in employee population and workers' compensation claims filed in the State of California.
VIII. DEFINITION OF "MEDICAL ONLY" AND "INDEMNITY" CLAIM
8.01. The definition of an "Indemnity Claim" shall be:
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a. Any alleged work-related claim for which any of the following is claimed:
(1) Temporary Disability
(2) Permanent Disability
(3) Vocational Rehabilitation
(4) Life Pension
(5) Death
8.02. The definition of a "Medical Only" claim shall be:
Any alleged work-related injury or illness for which medical treatment is sought, the claimant is not hospitalized, temporary disability does not exceed the waiting period as defined by the Workers' Compensation Laws of California, and no other Indemnity benefits are claimed.
IX. INSURANCE
9.01. Prior to beginning the Work and continuing throughout the term of this Agreement, Administrator, at its sole cost and expense, furnish the City with certificates of insurance evidencing that Consultant has obtained and maintains insurance in the following amounts:
a. Workers' Compensation that satisfies the minimum statutory limits. b. Commercial General Liability and Property Damage Insurance in an amount not less than ONE MILLION DOLLARS ($1,000,000) combined single limit per occurrence, TWO MILLION DOLLARS ($2,000,000) annual aggregate, for bodily injury, property damage, products, completed operations and contractual liability coverage. The policy shall also include coverage for liability arising out of the use and operation of any City-owned or City-furnished equipment used or operated by the Administrator, its personnel, agents or subcontractors.
c. Comprehensive automobile insurance in an amount not less than ONE MILLION DOLLARS ($1,000,000) per occurrence for bodily injury and property damage including coverage for owned and non- owned vehicles.
d. Professional Liability Insurance in an amount not less than ONE MILLION DOLLARS ($1,000,000) covering the licensed professionals' errors and omissions.
X. GENERAL PROVISIONS
10.01 Administrator shall comply with all applicable local, state and federal laws, regulations and ordinances in the performance of this Agreement. Administrator shall not discriminate in the provision of service or in the employment of persons engaged in the performance of this Agreement on account of race, color, national origin, ancestry, religion, gender, marital status, sexual orientation, gender identity or gender expression, age, physical or mental disability in violation of any applicable local, state or federal laws or regulations.
10.02. Neither party shall assign this Agreement or any part hereof without the written consent of the other party.
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10.03. Each party agrees to indemnify, defend, and hold harmless the other against all actions, claims or demands, and against all costs, expenses and attorneys' fees, arising directly or indirectly out of an actual or alleged injury to a person or to property as an actual or alleged result of an act or omission of the party or any of its shareholders, directors, officers, employees, or agents and each party's obligation to so indemnify, defend and hold harmless the other shall survive the expiration or earlier termination of this Agreement.
10.04. All notices or other communications under this Agreement shall be sent to the parties at the addresses set forth below:
Employer: Administrator
City of South San Francisco Athens Administrators, Inc. 400 Grand Avenue P.O. Box 696
South San Francisco, CA 94080 Concord, CA 94522
Attn: Leah Lockhart, Human Resources Director Attn: James R. Jenkins, President
10.05. In the event either party hereto shall institute formal legal action, the prevailing party shall be entitled to its reasonable attorneys' fees.
10.06 This Agreement may be amended at any time by mutual agreement of the parties, but any such amendment must be in writing, dated, signed by the parties and attached hereto.
10.07. Any failure of a party to insist upon strict compliance with any term, undertaking or condition of this Agreement shall not be deemed to be a waiver of such term, undertaking, or condition. To be effective, a waiver must be in writing, and signed by the parties hereto.
10.08. This Agreement shall be governed by California law and any action arising out of it shall be instituted and prosecuted only in the municipal or superior court of San Mateo County, State of California.
10.09 This Agreement instrument constitutes the entire agreement between the parties. Any oral representations or modifications concerning this Agreement shall be of no force and effect.
IN WITNESS WHEREOF: The Parties have hereto caused this Agreement to be executed by their duly authorized representatives as of the day and year stated.
CITY OF SOUTH SAN FRANCISCO ATHENS ADMINISTRATORS
Mn
Signature Signature
Human Resounces Drectr President
Title Title
6/24/19 June 11, 2019
Dated Dated
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Dated
CITY OF SOUTH SAN FRANCISCO
By: _
City Manager
Approved as to Form:
ATTEST
Your thy leak
COUTH SAN FRAN City of South San Francisco
P.O. Box 711 (City Hall,
400 Grand Avenue)
South San Francisco, CA
City Council
CALIFORNIA
Resolution: RES 72-2019
File Number: 19-497 Enactment Number: RES 72-2019
RESOLUTION APPROVING AN AGREEMENT WITH ATHENS
ADMINISTRATORS FOR WORKER'S COMPENSATION CLAIMS
ADMINISTRATION SERVICES FOR A TOTAL AMOUNT OF
$620,977 FOR JULY 1, 2019 THROUGH JUNE 30, 2022.
WHEREAS, the City of South San Francisco is a self-insured employer for worker's compensation; WHEREAS, the City utilizes the services of a third-party administrator to administer worker's compensation claims;
WHEREAS, City staff conducted a request for proposals for third-party administrator services for the period of July 1, 2019 through June 30, 2022;
WHEREAS, Athens Administrators was selected as the proposer best meeting the needs of the City in a cost-effective manner.
WHEREAS, the City desires to enter a service agreement with Athens Administrators for worker's compensation claims administration services.
NOW THEREFORE BE IT RESOLVED, that the City Council of the City of South San Francisco hereby takes the following actions:
Approves the Agreement with Athens Administrators for claims administration services for the period of July 1, 2019 through June 30, 2022, attached hereto and incorporated herein as Exhibit 1.
Authorizes the City Manager to execute this agreement and to make any revisions, amendments, or modifications, deemed necessary to carry out the intent of this resolution which do not materially alter or increase the City's obligations thereunder, subject to approval as to form by the City Attorney. * * * * *
At a meeting of the Special City Council on 6/12/2019, a motion was made by Buenaflor Nicolas, seconded City of South San Francisco Page 1
File Number: 19-497 Enactment Number: RES 72-2019
Mark Nagales, that this Resolution be approved. The motion passed.
Yes: 5 Councilmember Nagales, Mayor Matsumoto, Councilmember Addiego, Councilmember Nicolas, and Vice Mayor Garbarino
Attest by
Rosa Govea Acosta
City of South San Francisco Page 2
EXHIBIT A ATHENS
Pricing Proposal People, Powered.
CITY OF SOUTH SAN FRANCISCO
Pricing Proposal - Claim Administration Services
Prepared by: Athens Administrators
PRICING OPTION 1 - FLAT ANNUAL FEE FLAT ANNUAL FEE
Program Year 1 7/1/2019 6/30/2020 $198,052
Program Year 2 7/1/2020 8/30/2021 $201,933
Program Year 3 7/1/2021 6/30/2022 $207,991
TOTAL THREE YEAR COST 5605,977
OPTIONAL ONE YEAR PROGRAM EXTENSIONS FLAT ANNUAL FEE
Program Year 4 7/1/2022 6/30/2023 $214,231
Program Year 5 7/1/2023 6/30/2024 $220,658
POSITION STAFFING
Supervisor 1 Designated
Senior Claim Examiner 1 Designated
Future Medical Claim Examiner Not Applicable
Assistant Claim Examiner 1 Designated
PRICING NOTES
1) Pricing contemolates Athens Administrators providing both claim administration and managed care services 2) Pricing assumes new claim volume of: Indemnity 44
Medical Only 30
3) Pricing contemplates the takeover of the following open historical claims.
Indemnity 129
Medical Only 5
Future Medical 21
ADDITIONAL SERVICES
Annual Administration Fee $5,000
Administration -includes mgmt. of (1) bank account, addli. accounts at $400 per month Included Data Management Included
Account Management Included
Claim Reporting (web, fax, telephonic) Incuded
Dash Board Risk Management Web Site Included
Web Site Access (2 Users) Included
Annual Stewardship Report Included
Electronic Delivery of Monthly Loss Runs Included
4/24/2019
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CITY OF SOUTH SAN FRANCISCO
Staffing Expense Model - Claim Administration Services
Prepared by: Athens Administrators
Job Title (Employee)
SENIOR CLAIM EXAMINER
FUTURE MEDICAL CLAIM EXAMINER
ASSISTANT CLAIM EXAMINER
Total Direct Compensation 5127.103
Indirect Allocated Compensation 515.252
Total Compensation 5142.355
Total Operational Expense & Profit $53,697
Total Proposed Claim Administration Fee $196,052
Indirect Allocated Compensation
Finance, Human Resources, Malroom, Information Technology, Executive, Account Management, Operational Support and Receptior *Total Operational Expense A Profit
Rent, Equip Leases, Insurance, Bottaare Expense, Battware Bupport, Telephones, Postage, Training, Education, Ottce Bupples, Consuling Fees, Legal Fees as wet as other Miscellaneous Expenses.
PRICING NOTES
1) Pricing contemplates Athens Administrators providing both claim administration and managed care services. 2) Pricing assumes new claim volume Indemnity 44
Medical Only 30
3) Pricing contemplates the takeover of the following open historical claims.
Indemnity 129
Medical Only
Future Medical 21
ADDITIONAL SERVICES
Annual Administration Fee $5,000
Administration - includes mgmt of (1) bank account, addi. accounts at $400 per month Included Data Management Included
Account Management Included
Claim Reporting (web, fax, telephonic) Included
Dash Board Risk Management Web Site Included
RMIS Claim System Web Based Acoess Included
Annual Stewardship Report Included
Electronic Delivery of Monthly Loss Runs Included
4/24/2019
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ATHENS
People, Powered
CITY OF SOUTH SAN FRANCISCO
Pricing Proposal - Managed Care Services
Prepared by: Athens Administrators
MEDICAL BILL REVIEW
Medical Fee Schedule Reduction (OMFS) $8.50 Per Bill
(Includes: Medical, Pharmacy and Supplies)
Hospital In and Out Patient Fee Schedule Reductions $850.00 Per Bill PPO Network & Specialty Bill Negotiations 23.00% of Savings Duplicate Bills No Charge
UTILIZATION REVIEW. CASE MANAGEMENT AND PHYSICIAN REVIEW Concurrent, Prospective and Retrospective review $145 Flat Fee UR appeals: Peer to Peer $300 Per Hour
Authorization Only $35 Flat Rate
Telephonic Nurse Case Management $118 Per Hour
Field Case Management $125 Per Hour + Travel and Mileage Catastrophic Case Management $140 Per Hour + Travel and Mileage Phyaician Peer Review $300 Flat Fee
Records Review $250 Per Hour
OTHER RELATED SERVICES
Investigations Typically, S97 Per Hour
Pharmacy Benefits Management (PBM) No Charge
Pharmacy Drug Review $125 Per Hour
Central Index Bureau & First and Subsequent Report of Incident Reporting $18 Per Claim Reporting Included
Predictive Modeling Included
Subrogation Recovery 15% of Gross Recovery
MPN (Blue Cross) $4.50 Per Bill
Nurse Triage (optional) $150 Per Claim
ATHENS
4/24/2019 son a Powered
14 | Page
ACORD® DATE (MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE
7/3/2019
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 endorsements).
PRODUCER CONTACT Rebecca Foster
NAME:
Edgewood Partners Insurance Center PHONE No, Ext): 916-576-1524 (AC, No): 916-583-7613 License #0B29370 (A/C,
E-MAIL
PO Box 13847 ADDRESS: Rebecca. [email protected]
Sacramento CA 95853 INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Travelers Prop Casualty Co of America 25674 INSURED ATHEINSU INSURER B: Travelers Indemnity Co of CT 25682 Athens Insurance Service, Inc.
INSURER C:
DBA: Athens Administrators
PO Box 696 INSURER D:
Concord CA 94522 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 949567402 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADDL SUBR POLICY EXP
TYPE OF INSURANCE POLICY NUMBER MM/DD/YYYY) |(MM/DD/YYYY LIMITS
LTR INSD WVD
COMMERCIAL GENERAL LIABILITY 630594M4320 1/1/2019 1/1/2020 EACH OCCURRENCE $1,000,000
DAMAGE TO RENTED
CLAIMS-MADE OCCUR PREMISES (Ea occurrence) $ 300,000
MED EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10,000,000 X POLICY PRO- PRODUCTS - COMP/OP AGG $ 2,000,000
JECT LOC
OTHER:
COMBINED SINGLE LIMIT $ 1,000,000
AUTOMOBILE LIABILITY BA8L572517 1/1/2019 1/1/2020 (Ea accident) X ANY AUTO BODILY INJURY (Per person)
OWNED SCHEDULED BODILY INJURY (Per accident)
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY Per accident)
$
UMBRELLA LIAB OCCUR EXOK045623 EACH OCCURRENCE $5,000,000 Approved as a formo
EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000
RETENTION $ $
DED
WORKERS COMPENSATION UB9J160807 Date: 11/2016 FATUTE
AND EMPLOYERS' LIABILITY YIN City Attorney 112020
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000 N/ A By:-
OFFICER/MEMBEREXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH)
res. describe und E.L. DISEASE -POLICY LIMIT$1,000,000
SCRIPTION OF OPERATIONS bel
Re: Al Contracts Witen Agreen even ice to caterer and cour dred more your raise When regained bye General Liabily, Automobile Liaisy and Workers Compensation, all peo Ge atached endorsements bile Liability and waiver of subrogation applies to
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
City Grand Avenu Francisco
AUTHORIZED REPRESENTATIVE
South San Francisco, CA 94080
© 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
COMMERCIAL GENERAL LIABILITY
POLICY NO.: 630594M4320
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED
(CONTRACTORS OPERATIONS)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
1. WHO IS AN INSURED - (Section II) is amended c) The insurance provided to the additional in- to include any person or organization that you sured does not apply to "bodily injury" or agree in a "written contract requiring insurance" "property damage" caused by "your work" to include as an additional insured on this Cover- and included in the "products-completed op- age Part, but: erations hazard"
a) Only with respect to liability for "bodily injury", 3. The insurance provided to the additional insured "property damage" or "personal injury"; and by this endorsement is excess over any valid and b) If, and only to the extent that, the injury or collectible "other insurance", whether primary, damage is caused by acts or omissions of excess, contingent or on any other basis, that is available to the additional insured for a loss we
you or your subcontractor in the performance
of "your work" to which the "written contract cover under this endorsement. However, if the requiring insurance" applies. The person or "written contract requiring insurance" specifically organization does not qualify as an additional requires that this insurance apply on a primary insured with respect to the independent acts basis or a primary and non-contributory basis, or omissions of such person or organization. this insurance is primary to "other insurance" available to the additional insured which covers
2. The insurance provided to the additional insured that person or organization as a named insured by this endorsement is limited as follows: for such loss, and we will not share with that a) In the event that the Limits of Insurance of "other insurance". But the insurance provided to this Coverage Part shown in the Declarations the additional insured by this endorsement still is exceed the limits of liability required by the excess over any valid and collectible "other in- "written contract requiring insurance" ", the in- surance", whether primary, excess, contingent or surance provided to the additional insured on any other basis, that is available to the addi- shall be limited to the limits of liability re- tional insured when that person or organization is an additional insured under such "other insur-
ance".
As a condition of coverage provided to the
Section III - Limits Of Insurance. additional insured by this endorsement:
b) The insurance provided to the additional in- a) The additional insured must give us written sured does not apply to "bodily injury", "prop- notice as soon as practicable of an "occur- erty damage" or "personal iniurv" arisina out rence" or an offense which may result in a of the rendering of, or failure to render, any claim. To the extent possible, such notice professional architectural, engineering or sur- should include:
veying services, including:
i. How, when and where the "occurrence"
i. The preparing, approving, or failing to or offense took place; prepare or approve, maps, shop draw-
ii. The names and addresses of any injured
ings, opinions, reports, surveys, field or-
ders or change orders, or the preparing, persons and witnesses; and approving, or failing to prepare or ap- iii. The nature and location of any injury or prove, drawings and specifications; and damage arising out of the "occurrence" or ii. Supervisory, inspection, architectural or offense.
engineering activities.
CG D2 48 08 05 © 2005 The St. Paul Travelers Companies, Inc. Page 1 of 2
COMMERCIAL GENERAL LIABILITY
b) If a claim is made or "suit" is brought against ance provided to the additional insured by the additional insured, the additional insured this endorsement is primary to "other insur- ance" available to the additional insured
which covers that person or organization as a
i. Immediately record the specifics of the named insured as described in paragraph 3. claim or "suit" and the date received; and
above.
ii. Notify us as soon as practicable. 5. The following definition is added to SECTION V.
The additional insured must see to it that we - DEFINITIONS:
receive written notice of the claim or "suit" as
"Written contract requiring insurance" means
soon as practicable.
that part of any written contract or agreement
c) The additional insured must immediately under which you are required to include a send us copies of all legal papers received in person or organization as an additional in- connection with the claim or "suit", cooperate sured on this Coverage Part, provided that with us in the investigation or settlement of the "bodily injury" and "property damage" oc- the claim or defense against the "suit", and curs and the "personal injury" is caused by an otherwise comply with all policy conditions. offense committed:
The additional insured must tender the de- a. After the signing and execution of the fense and indemnity of any claim or "suit" to contract or agreement by you; any provider of "other insurance" which would b. While that part of the contract or cover the additional insured for a loss we agreement is in effect; and cover under this endorsement. However, this
condition does not affect whether the insur- c. Before the end of the policy period.
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
OTHER INSURANCE - ADDITIONAL INSUREDS -
PRIMARY AND NON-CONTRIBUTORY WITH RESPECT TO
CERTAIN OTHER INSURANCE
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
The following is added to Paragraph 4. a., Primary (1) The "bodily injury" or "property damage" for which Insurance, of SECTION IV - COMMERCIAL GEN- coverage is sought is caused by an "occurrence" ERAL LIABILITY CONDITIONS: that takes place; and
However, if you specifically agree in a written contract (2) The "personal injury" or "advertising injury" for or agreement that the insurance afforded to an addi- which coverage is sought arises out of an offense tional insured under this Coverage Part must apply on that is committed; a primary basis, or a primary and non-contributory
basis, this insurance is primary to other insurance that subsequent to the signing and execution of that con- is available to such additional insured which covers tract or agreement by you. such additional insured as a named insured, and we
will not share with that other insurance, provided that:
CG D4 25 07 08 © 2008 The Travelers Companies, Inc. Page 1 of 1 Effective Date: 01/01/19
COMMERCIAL GENERAL LIABILITY
However, if this policy includes an endorse- cancellation or nonrenewal in accordance with ment that provides limited coverage for "bod- applicable insurance laws or regulations. ily injury" or "property damage" or pollution Q. BLANKET WAIVER OF SUBROGATION costs arising out of a discharge, release or
escape of "pollutants" which contains a re- The following is added to Paragraph 8., Transfer quirement that the discharge, release or es- Of Rights Of Recovery Against Others To Us, cape of "pollutants" must be reported to us of SECTION IV - COMMERCIAL GENERAL LI- within a specific number of days after its ABILITY CONDITIONS:
abrupt commencement, this Paragraph e. If the insured has agreed in a contract or agree- does not affect that requirement. ment to waive that insured's right of recovery P. UNINTENTIONAL OMISSION against any person or organization, we waive our right of recovery against such person or organiza-
The following is added to Paragraph 6., Repre- tion, but only for payments we make because of:
sentations, of SECTION IV - COMMERCIAL a. "Bodily injury" or "property damage" caused GENERAL LIABILITY CONDITIONS:
by an "occurrence" that takes place; or
The unintentional omission of, or unintentional
error in, any information provided by you which b. "Personal injury" or "advertising injury" we relied upon in issuing this policy will not preju- caused by an offense that is committed; dice your rights under this insurance. However, subsequent to the execution of the contract or this provision does not affect our right to collect agreement. additional premium or to exercise our rights of
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
Policy #BA8L572517
COMMERCIAL AUTO
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BUSINESS AUTO EXTENSION ENDORSEMENT
This endorsement modifies insurance provided under the following:
BUSINESS AUTO COVERAGE FORM
GENERAL DESCRIPTION OF COVERAGE - This endorsement broadens coverage. However, coverage for any njury, damage or medical expenses described in any of the provisions of this endorsement may be excluded o imited by another endorsement to the Coverage Part, and these coverage broadening provisions do not apply t the extent that coverage is excluded or limited by such an endorsement. The following listing is a general cover- age description only. Limitations and exclusions may apply to these coverages. Read all the provisions of this en- dorsement and the rest of your policy carefully to determine rights, duties, and what is and is not covered.
A. BROAD FORM NAMED INSURED H. HIRED AUTO PHYSICAL DAMAGE - LOSS OF
USE - INCREASED LIMIT
B. BLANKET ADDITIONAL INSURED
I. PHYSICAL DAMAGE - TRANSPORTATION
C. EMPLOYEE HIRED AUTO EXPENSES - INCREASED LIMIT
D. EMPLOYEES AS INSURED J. PERSONAL PROPERTY
E. SUPPLEMENTARY PAYMENTS - INCREASED K. AIRBAGS
LIMITS
L. NOTICE AND KNOWLEDGE OF ACCIDENT OR
F. HIRED AUTO - LIMITED WORLDWIDE COV- LOSS
ERAGE - INDEMNITY BASIS M. BLANKET WAIVER OF SUBROGATION G. WAIVER OF DEDUCTIBLE - GLASS N. UNINTENTIONAL ERRORS OR OMISSIONS
PROVISIONS
A. BROAD FORM NAMED INSURED this insurance applies and only to the extent that The following is added to Paragraph A.1., Who Is person or organization qualifies as an "insured" An Insured, of SECTION I - COVERED AUTOS under the Who Is An Insured provision contained LIABILITY COVERAGE: in Section II.
Any organization you newly acquire or form dur- C. EMPLOYEE HIRED AUTO ing the policy period over which you maintain 1. The following is added to Paragraph A.1., 50% or more ownership interest and that is not Who Is An Insured, of SECTION II - COV- separately insured for Business Auto Coverage. ERED AUTOS LIABILITY COVERAGE:
Coverage under this provision is afforded only un- An "employee" of yours is an "insured" while til the 180th day after you acquire or form the or- operating an "auto" hired or rented under a ganization or the end of the policy period, which- contract or agreement in an "employee's" ever is earlier. name, with your permission, while performing duties related to the conduct of your busi-
B. BLANKET ADDITIONAL INSURED ness.
The following is added to Paragraph c. in A.1., The following replaces Paragraph b. in B.5., Who Is An Insured, of SECTION II - COVERED Other Insurance, of SECTION IV - BUSI- AUTOS LIABILITY COVERAGE: NESS AUTO CONDITIONS:
Any person or organization who is required under b. For Hired Auto Physical Damage Cover- a written contract or agreement between you and age, the following are deemed to be cov- that person or organization, that is signed and ered "autos" you own:
executed by you before the "bodily injury" or (1) Any covered "auto" you lease, hire, "property damage" occurs and that is in effect rent or borrow; and during the policy period, to be named as an addi- (2) Any covered "auto" hired or rented by tional insured is an "insured" for Covered Autos your "employee" under a contract in Liability Coverage, but only for damages to which an "employee's" name, with your CA T3 53 02 15 © 2015 The Travelers Indemnity Company. All rights reserved. Page 1 of 4 Includes copyrighted material of Insurance Services Office, Inc. with its permission.
COMMERCIAL AUTO
permission, while performing duties (a) With respect to any claim made or "suit" related to the conduct of your busi- brought outside the United States of America, the territories and possessions
However, any "auto" that is leased, hired, of the United States of America, Puerto Rico and Canada:
rented or borrowed with a driver is not a
covered "auto". (i) You must arrange to defend the "in- D. EMPLOYEES AS INSURED sured" against, and investigate or set- tle any such claim or "suit" and keep
The following is added to Paragraph A.1., Who Is us advised of all proceedings and ac- An Insured, of SECTION II - COVERED AUTOS tions.
LIABILITY COVERAGE:
(ii) Neither you nor any other involved
Any "employee" of yours is an "insured" while us- "insured" will make any settlement ing a covered "auto" you don't own, hire or borrow without our consent. in your business or your personal affairs.
(iii) We may, at our discretion, participate
E. SUPPLEMENTARY PAYMENTS - INCREASED in defending the "insured" against, or LIMITS in the settlement of, any claim or
1. The following replaces Paragraph A.2.a.(2), "suit".
of SECTION II - COVERED AUTOS LIABIL- (iv) We will reimburse the "insured" for ITY COVERAGE: sums that the "insured" legally must
(2) Up to $3,000 for cost of bail bonds (in- pay as damages because of "bodily cluding bonds for related traffic law viola- injury" or "property damage" to which tions) required because of an "accident" this insurance applies, that the "in- we cover. We do not have to furnish sured" pays with our consent, but these bonds. only up to the limit described in Para-
graph C., Limits Of Insurance, of
2. The following replaces Paragraph A.2.a.(4), SECTION II - COVERED AUTOS of SECTION II - COVERED AUTOS LIABIL-
LIABILITY COVERAGE.
ITY COVERAGE:
(v) We will reimburse the "insured" for
(4) All reasonable expenses incurred by the
the reasonable expenses incurred
"insured" at our request, including actual
with our consent for your investiga-
loss of earnings up to $500 a day be-
tion of such claims and your defense
cause of time off from work.
of the "insured" against any such
F. HIRED AUTO - LIMITED WORLDWIDE COV- "suit", but only up to and included ERAGE - INDEMNITY BASIS within the limit described in Para- The following replaces Subparagraph (5) in Para- graph C., Limits Of Insurance, of graph B.7., Policy Period, Coverage Territory, SECTION II - COVERED AUTOS of SECTION IV - BUSINESS AUTO CONDI- LIABILITY COVERAGE, and not in addition to such limit. Our duty to
make such payments ends when we
(5) Anywhere in the world, except any country or
have used up the applicable limit of
jurisdiction while any trade sanction, em-
insurance in payments for damages,
bargo, or similar regulation imposed by the
settlements or defense expenses.
United States of America applies to and pro-
hibits the transaction of business with or (b) This insurance is excess over any valid within such country or jurisdiction, for Cov- and collectible other insurance available ered Autos Liability Coverage for any covered to the "insured" whether primary, excess, "auto" that you lease, hire, rent or borrow contingent or on any other basis. without a driver for a period of 30 days or less (c) This insurance is not a substitute for re- and that is not an "auto" you lease, hire, rent quired or compulsory insurance in any or borrow from any of your "employees", country outside the United States, its ter- partners (if you are a partnership), members ritories and possessions, Puerto Rico and a limited liability company or Canada.
members of their households.
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
COMMERCIAL AUTO
You agree to maintain all required or (2) In or on your covered "auto". compulsory insurance in any such coun- This coverage applies only in the event of a total try up to the minimum limits required by theft of your covered "auto". local law. Your failure to comply with
compulsory insurance requirements will No deductibles apply to this Personal Property coverage.
not invalidate the coverage afforded by
this policy, but we will only be liable to the K. AIRBAGS same extent we would have been liable The following is added to Paragraph B.3., Exclu- had you complied with the compulsory in- sions, of SECTION III - PHYSICAL DAMAGE COVERAGE:
(d) It is understood that we are not an admit- Exclusion 3.a. does not apply to "loss" to one or outside the more airbags in a covered "auto" you own that in- United States of America, its territories flate due to a cause other than a cause of "loss" and possessions, Puerto Rico and Can- set forth in Paragraphs A.1.b. and A.1.c., but ada. We assume no responsibility for the only:
furnishing of certificates of insurance, or a. If that "auto" is a covered "auto" for Compre- for compliance in any way with the laws hensive Coverage under this policy; of other countries relating to insurance b. The airbags are not covered under any war- G. WAIVER OF DEDUCTIBLE - GLASS ranty; and
The following is added to Paragraph D., Deducti- c. The airbags were not intentionally inflated. ble, of SECTION III - PHYSICAL DAMAGE We will pay up to a maximum of $1,000 for any COVERAGE: one "loss".
No deductible for a covered "auto" will apply to L. NOTICE AND KNOWLEDGE OF ACCIDENT OR glass damage if the glass is repaired rather than LOSS
replaced. The following is added to Paragraph A.2.a., of H. HIRED AUTO PHYSICAL DAMAGE - LOSS OF SECTION IV - BUSINESS AUTO CONDITIONS:
USE - INCREASED LIMIT Your duty to give us or our authorized representa- The following replaces the last sentence of Para- tive prompt notice of the "accident" or "loss" ap- graph A.4.b., Loss Of Use Expenses, of SEC- plies only when the "accident" or "loss" is known TION III - PHYSICAL DAMAGE COVERAGE: to:
However, the most we will pay for any expenses (a) You (if you are an individual); for loss of use is $65 per day, to a maximum of (b) A partner (if you are a partnership); $750 for any one "accident". (c) A member (if you are a limited liability com- PHYSICAL DAMAGE - TRANSPORTATION pany;
EXPENSES - INCREASED LIMIT
(d) An executive officer, director or insurance
The following replaces the first sentence in Para- manager (if you are a corporation or other or- graph A.4.a., Transportation Expenses, ganization); or
SECTION III - PHYSICAL DAMAGE COVER- (e) Any "employee" authorized by you to give no- tice of the "accident" or "loss".
We will pay up to $50 per day to a maximum of M. BLANKET WAIVER OF SUBROGATION $1,500 for temporary transportation expense in- The following replaces Paragraph A.5., Transfer curred by you because of the total theft of a cov- Of Rights Of Recovery Against Others To Us, ered "auto" of the private passenger type. of SECTION IV - BUSINESS AUTO CONDI- J. PERSONAL PROPERTY TIONS:
The following is added to Paragraph A.4., Cover- 5. Transfer Of Rights Of Recovery Against age Extensions, of SECTION III - PHYSICAL Others To Us
DAMAGE COVERAGE: We waive any right of recovery we may have Personal Property against any person or organization to the ex- tent required of you by a written contract
We will pay up to $400 for "loss" to wearing ap- signed and executed prior to any "accident" parel and other personal property which is: or "loss", provided that the "accident" or "loss" (1) Owned by an "insured"; and arises out of operations contemplated by CA T3 53 02 15 © 2015 The Travelers Indemnity Company. All rights reserved. Page 3 of 4 Includes copyrighted material of Insurance Services Office, Inc. with its permission.
COMMERCIAL AUTO
such contract. The waiver applies only to the The unintentional omission of, or unintentional person or organization designated in such error in, any information given by you shall not contract. prejudice your rights under this insurance. How- N. UNINTENTIONAL ERRORS OR OMISSIONS ever this provision does not affect our right to col- The following is added to Paragraph B.2., Con- lect additional premium or exercise our right of Or Fraud, of cancellation or non-renewal.
cealment, Misrepresentation,
SECTION IV - BUSINESS AUTO CONDITIONS:
© 2015 The Travelers Indemnity Company. All rights reserved. CA T3 53 02 15
Includes copyrighted material of Insurance Services Office, Inc. with its permission.
WORKERS COMPENSATION
TRAVELERSJ AND
ONE TOWER SQUARE EMPLOYERS LIABILITY POLICY
HARTFORD, CT 06183
ENDORSEMENT WC 99 03 76 (A) - 001
POLICY NUMBER: UB9J160807
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS
ENDORSEMENT - CALIFORNIA
(BLANKET WAIVER)
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.
The additional premium for this endorsement shall be 1.0 % of the California workers' compensation pre- mium.
Schedule
Person or Organization Job Description
ANY PERSON OR ORGANIZATION FOR WHICH
THE NAMED INSURED HAS AGREED BY
WRITTEN CONTRACT EXECUTED PRIOR TO LOSS
TO FURNISH THIS WAIVER.
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise (The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective 1/1/2019 Policy No. UB9J160807 Endorsement No.
Insured Athens Insurance Services, Inc. Premium
Insurance Company Travelers Property Casualty Countersigned by.
Company of America
DATE OF ISSUE: ST ASSIGN: Page 1 of 1