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HR Dependent Eligibility Audit ServicesAGREEMENT FOR DEPENDENT ELIGIBILITY AUDIT SERVICES A - This Agreement is made and entered into this S, day of _, 2012, by and between the CITY OF SAN RAFAEL (hereinafter "CITY"), and BMI Audit Services, LLC (hereinafter "CONTRACTOR"). AGREEMENT NOW, THEREFORE, the parties hereby agree as follows: PROJECT COORDINATION. A. CITY. The City Manager shall be the representative of the CITY for all purposes under this Agreement. The Human Resources Director is hereby designated the PROJECT MANAGER for the CITY, and said PROJECT MANAGER shall supervise all aspects of the progress and execution of this Agreement. B. CONTRACTOR. CONTRACTOR shall assign a single PROJECT DIRECTOR to have overall responsibility for the progress and execution of this Agreement for CONTRACTOR. Chad Gallaher is hereby designated as the PROJECT DIRECTOR for CONTRACTOR. Should circumstances or conditions subsequent to the execution of this Agreement require a substitute PROJECT DIRECTOR for any reason, the CONTRACTOR shall notify the CITY within ten (10) business days of the substitution. 2. DUTIES OF CONTRACTOR. CONTRACTOR shall perform the duties and/or provide services as further provided in the proposal attached hereto as Exhibit -A-. including: a. Perforin a training session between the PROJECT MANAGER and all designated staff. b. Review all dependent eligibility criteria established in benefit documents provided by the CITY. c. Communicate with employees regarding dependent eligibility requirements and request documentation as required to determine eligibility. d. Provide regular reports to PROJECT MANAGER. including a -Final Detail Report - and a -Final Executive Summary Report-. 3. DUTIES OF CITY. CITY shall pay the compensation as provided in Paragraph 4. and perform the duties as described in Exhibit A attached hereto and incorporated herein. CITY staff shall provide cooperation and information as reasonably required to assist CONTRACTOR perform the services and duties required under this agreement. version 2-15-11 4. BUSINESS ASSOCIATE To the extent that CONTRACTOR is the recipient under this Agreement of "protected health information" as that term is defined in the health Insurance Portability and Accountability Act ("HIPAA") as amended by the Ilealth Information Technology for Economic and Clinical Health Act ("HITECH"), CONTRACTOR shall be deemed a "Business Associate" and CITY shall be deemed a "Covered Entity", and the parties agree to comply with the HIPAA and HITECH Privacy Regulations as provided in Exhibit B attached hereto. 5. COMPENSATION. For the full performance of the services described herein by CONTRACTOR, CITY shall pay CONTRACTOR as follows: Professional Fees. Fees are based upon Services stated in above Scope of Services. CITY will pay CONTRACTOR fees in the amount of $7500 due within 30 days of fully executing this Agreement. Note: Fees stated above are hased upon the count of up to 190 enzploi'ees with one or more dependents. If this count paries more than +201o, CONTRACTOR reserivs the right to increase or decrease.fees at the rate of'$37.50 per each addedideducted cniplQyee cohering one or more dependents. Expenses. All postage, travel, phone and other incidental expenses will be the responsibility of CONTRACTOR. Payment will be made monthly upon receipt by PROJECT MANAGER of itemized invoices submitted by CONTRACTOR. 6. TERM OF AGREEMENT. The term of this Agreement shall be from the execution of this Agreement until CONTRACTOR's completion of performance of all duties and services under this Agreement, or December 31, 2012, whichever is earlier. The City Manager may extend the contract term, as needed, but no more than an additional calendar year. 7. TERMINATION. A. Diseretiona",. Either party may terminate this Agreement without cause upon thirty (30) days written notice mailed or personally delivered to the other party. B. Cause. Either party may terminate this Agreement for cause upon fifteen (15) days written notice mailed or personally delivered to the other party, and the notified party's failure to cure or correct the cause of the termination, to the reasonable satisfaction of the party giving such notice, within such fifteen (15) day time period. C. Effect of Termination. Upon receipt of notice of termination, neither party shall 2 incur additional obligations under any provision of this Agreement without the prior written consent of the other. D. Return of Documents. Upon termination, any and all CITY documents or materials provided to CONTRACTOR and any and all of CONTRACTOR's documents and materials prepared for or relating to the performance of its duties under this Agreement, shall be delivered to CITY as soon as possible, but not later than thirty (30) days after termination. 8. OWNERSHIP OF DOCUMENTS. The written documents and materials prepared by the CONTRACTOR in connection with the performance of its duties under this Agreement, shall be the sole property of CITY. CITY may use said property for any purpose, including projects not contemplated by this Agreement. 9. INSPECTION AND AUDIT. Upon reasonable notice, CONTRACTOR shall make available to CITY, or its agent, for inspection and audit, all documents and materials maintained by CONTRACTOR in connection with its performance of its duties under this Agreement. CONTRACTOR shall fully cooperate with CITY or its agent in any such audit or inspection. 10. ASSIGNABILITY. The parties agree that they shall not assign or transfer any interest in this Agreement nor the performance of any of their respective obligations hereunder, without the prior written consent of the other party, and any attempt to so assign this Agreement or any rights, duties or obligations arising hereunder shall be void and of no effect. 11. INSURANCE. A. During the tenn of this Agreement, CONTRACTOR shall maintain, at no expense to CITY, the following insurance policies: 1. A commercial general liability insurance policy in the minimum amount of one million (S 1,000,000) dollars per occurrence for death, bodily injury, personal injury, or property damage. 2. If any licensed professional performs any of the services required to be performed under this Agreement, a professional liability insurance polies in the minimum amount of one million 51,000,000) dollars to cover any claims arising out of the CONTRACTOR's performance of services under this Agreement. B. The insurance coverage required of the CONTRACTOR in Subparagraph A above, shall also meet the following requirements: Except for professional liability insurance, the insurance policies shall be 3 endorsed for contractual liability and personal injury. 2. Except for professional liability insurance, the insurance policies shall provide in their text or shall be specifically endorsed to name the CITY, its officers, agents, employees, and volunteers, as additionally named insureds under the policies, and to provide that the insurance shall be primary with respect to any insurance or coverage maintained by CITY and shall not call upon CITY's insurance or coverage for any contribution. 3. CONTRACTOR shall provide to City"s Project Manager, (a) Certificates of Insurance evidencing the insurance coverage required herein, and (b) text from the insurance policies or the endorsements as specified in Subparagraph B(2). 4. The insurance policies shall provide that the insurance carrier shall not cancel, terminate or otherwise modify the terms and conditions of said insurance policies except upon ten (10) days written notice to City*s Project Manager. 5. If the insurance is written on a Claims Made Form, then, following termination of this Agreement, said insurance coverage shall survive for a period of not less than five years. 6. The insurance policies shall provide for a retroactive date of placement coinciding with the effective date of this Agreement. 7. The insurance shall be approved as to form and sufficiency by PROJECT MANAGER and the City Attorney. C. If it employs any person, CONTRACTOR shall maintain worker's compensation and employer's liability insurance, as required by the State Labor Code and other applicable laws and regulations, and as necessary to protect both CONTRACTOR and CITY against all liability for injuries to CONTRACTOR's officers and employees. D. Any deductibles or self-insured retentions in CONTRACTOR's insurance policies must be declared to and approved by the City's Risk Manager and the City Attorney. At CITY's option, the deductibles or self-insured retentions with respect to CITY shall be reduced or eliminated to CITY's satisfaction, or CONTRACTOR shall procure a bond guaranteeing payment of losses and related investigations, claims administration, attorney's fees and defense expenses. I,?. INDEMNIFICATION. A. Except as provided in Subparagraph B., CONTRACTOR shall indemnify, release, defend and hold harmless CITY, its officers, and employees, against any claim, demand, suit, judgment, loss, liability or expense of any kind. including attorney's fees, arising out of or resulting in any way, in whole or in part, from any acts or omissions, intentional or negligent. of CONTRACTOR or CONTRACTOR's officers. agents and employees in the performance of their duties and obligations under this Agreement. 11 B. Where the services to be provided by CONTRACTOR under this Agreement are design professional services to be performed by a design professional as that term is defined under Civil Code Section 2782.8, CONTRACTOR shall, to the fullest extent permitted by law, indemnify, release, defend and hold harmless CITY, its officers, and employees, against any claim, demand, suit, judgment, loss, liability or expense of any kind, including attorney's fees, that arises out of, pertains to, or relates to the negligence, recklessness, or willful misconduct of CONTRACTOR in the performance of its duties and obligations under this Agreement. 13. NONDISCRIMINATION. CONTRACTOR shall not discriminate, in any way, against any person on the basis of age, sex, race, color, religion, ancestry, national origin or disability in connection with or related to the performance of its duties and obligations under this Agreement. 14. COMPLIANCE WITH ALL LAWS. CONTRACTOR shall observe and comply with all applicable federal, state and local laws, ordinances, codes and regulations, in the performance of its duties and obligations under this Agreement. CONTRACTOR shall perform all services under this Agreement in accordance with these laws, ordinances, codes and regulations. CONTRACTOR shall release, defend, indemnify and hold harmless CITY, its officers, agents and employees from any and all damages, liabilities, penalties, fines and all other consequences from any noncompliance or violation of any laws, ordinances, codes or regulations. 15. NO THIRD PARTY BENEFICIARIES. CITY and CONTRACTOR do not intend, by any provision of this Agreement, to create in any third party, any benefit or right owed by one party, under the terms and conditions of this Agreement, to the other party. 16. NOTICES. All notices and other communications required or pennitted to be given under this Agreement, including any notice of change of address, shall be in writing and given by personal delivery, or deposited with the United States Postal Service, postage prepaid, addressed to the parties intended to be notified. Notice shall be deemed given as of the date of personal delivery, or if mailed, upon the date of deposit with the United States Postal Service. Notice shall be given as follows: TO CITY: Anil Comelo, Human Resources Director City of San Rafael 1400 Fifth Ave., Room 210 San Rafael, CA 94915-1560 TO CONTRACTOR: Jeff Hart, Member BMI Audit Services, LLC 220 W. Colfax Ave., Suite 700 South Bend, Indiana 46601 17. INDEPENDENT CONTRACTOR. For the purposes, and for the duration, of this Agreement, CONTRACTOR, its officers, agents and employees shall act in the capacity of an Independent Contractor, and not as employees of the CITY. CONTRACTOR and CITY expressly intend and agree that the status of CONTRACTOR, its officers, agents and employees be that of an Independent Contractor and not that of an employee of CITY. 18. ENTIRE AGREEMENT -- AMENDMENTS. A. The terms and conditions of this Agreement, all exhibits attached, and all documents expressly incorporated by reference, represent the entire Agreement of the parties with respect to the subject matter of this Agreement. B. This written Agreement shall supersede any and all prior agreements, oral or written, regarding the subject matter between the CONTRACTOR and the CITY. C. No other agreement, promise or statement, written or oral, relating to the subject matter of this Agreement, shall be valid or binding, except by way of a written amendment to this Agreement. D. The terms and conditions of this Agreement shall not be altered or modified except by a written amendment to this Agreement signed by the CONTRACTOR and the CITY. E. If any conflicts arise between the terms and conditions of this Agreement, and the terms and conditions of the attached exhibits or the documents expressly incorporated by reference, the terms and conditions of this Agreement shall control. 19. SET-OFF AGAINST DEBTS. CONTRACTOR agrees that CITY may deduct from any payment due to CONTRACTOR under this Agreement, any monies which CONTRACTOR owes CITY under any ordinance, agreement, contract or resolution for any unpaid taxes, fees, licenses, assessments, unpaid checks or other amounts. 20. WAITERS. The waiver by either party of any breach or violation of any term. covenant or condition of this Agreement, or of any ordinance, law or regulation, shall not be deemed to be a waiver of any other tend, covenant, condition. ordinance. law or regulation, or of any subsequent breach or violation of the same or other term, covenant, condition, ordinance. law or regulation. The subsequent acceptance by either party of any fee, performance, or other consideration which may become due or owing under this Agreement, shall not be deemed to be a waiver of any preceding breach or violation by the other party of any term, condition, covenant of this Agreement or any applicable law, ordinance or regulation. 21. COSTS AND ATTORNEY'S FEES. The prevailing party in any action brought to enforce the terms and conditions of this Agreement, or arising out of the performance of this Agreement, may recover its reasonable costs (including claims administration) and attorney's fees expended in connection with such action. 22. CITY BUSINESS LICENSE / OTHER TAXES. CONTRACTOR is exempt from the business license requirement of the San Rafael Municipal Code because CONTRACTOR is based outside of and will conduct business outlined in Exhibit A outside of San Rafael city limits. CONTRACTOR shall pay any and all state and federal taxes and any other applicable taxes. CITY shall not be required to pay for any work perfonned under this Agreement, until CONTRACTOR has provided CITY with a completed Internal Revenue Service Form W-9 (Request for Taxpayer Identification Number and Certification). 23. APPLICABLE LAW. The laws of the State of California shall govern this Agreement. IN WITNESS WHEREOF, the parties have executed this Agreement as of the day, month and year first above written. CITY OF SAN RAFAEL V NANCY MACKLE, City Manager' ATTEST: ESTHER C. BEIRNE. City Clerk APPROVED AS TO FORM: ROBERT F. EPSTEIN. City Attorney 7 CONTRACTOR T JEFF H T. Member �LL LLC BMI Audit Services, 1 1. Scope of Services. Specific to this Agreement, Auditor will provide the following Services for Client. • Auditor will perform a training session between the Project Manager and all staff dedicated for that particular audit. The session will review Client's industry and geographic makeup, the plan's eligibility criteria, the timeline of expected mailings, and any additional Client concerns. • Client will provide Auditor with one electronic file of data for pian members to be included in the audit (such as names, addresses, unique employee identification numbers, relationship codes, locations, dates of birth, and coverage election) per the enrollment file layout provided by the Auditor. Auditor will accept the file either from Client and/or administrator(s) responsible for administering the medical, dental, vision and/or prescription drug pians. • Client will provide Auditor with all current published plan documentation including Summary Plan Description(s) (SPD(s), plan amendments, and any other correspondence or directives prepared for the purpose of interpreting and/or clarifying plan eligibility. Auditor will review all dependent eligibility criteria established in Client's benefits documents. Initial Mailinz (Phase 1) • Auditor will produce a Verification Mailing, consisting of an "Audit Letter" and "Dependent Verification Form", to be approved by Client that will be mailed to all employees who have enrolled at least one dependent. The audit mailing will advise employee of eligibility requirements for the plan(s), advise of an audit close date, ask questions about the plan(s) requirements, and request documentation specific to each dependent. The mailing will also include Helpful Information to assist the employee in understanding document requirements, and in obtaining replacements documents if needed. The employee will be asked to either fax the required information to Auditor via a secure fax line, mail the required information to Auditor utilizing the included postage -paid return envelope addressed to Auditor's designated P.O. Box, or upload the required information via Auditor's secure Internet data transfer capabilities. Second Mailinv, ( Phase 2 ) • Five business days after the end of Phase 1, Auditor will produce an "Extension Letter". to be approved by Client, and to be mailed to all employees who have not responded or have at least one dependent who is incomplete. The mailing will include a copy of a "Dependent Verification Form" and/or a member specific "Incomplete Letter" requesting all documentation specific to each dependent that is necessary for Auditor to complete its verification review. The employee will be asked to either fax the required information to Auditor via a secure fax line, mail to Auditor's designated P.O. Box or securely upload through Auditors web portal. `ts Cr LLC Third Mailinv, (Phase 3 ) BMI Audit Services, • Five business days after the end of Phase 2, Auditor will produce a "Drop Benefit Letter", to be approved by Client, and to be mailed to all employees who have not responded or have at least one dependent who is incomplete. Each letter will advise the employee that the deadline has passed and that unless they take immediate action by a specified extension date, benefits for their dependents will be dropped on a stated date/time. The mailing will include a copy of a "Dependent Verification Form" and/or a member specific "Incomplete Letter" requesting all documentation specific to each dependent that is necessary for Auditor to complete its verification review. The employee will be asked to either fax the required information to Auditor via a secure fax line, mail to Auditor's designated P.O. Box or securely upload through Auditor's web portal. Auditor will continue to post all responses through the end of this drop benefit period. Secure Web Portals • Auditor will provide to Client a secure web portal that will contain an area for its sole access and use. Specified users, with permission levels set by Client, can log in to view and download up-to- date summaries and detailed information about the status of the audit, the project timeline, samples of audit communications, and documentation of the verification process. In addition, Client can upload revisions to audit communication documents where applicable. • Auditor will provide to employees of Client secure web portal that will allow employees to upload their dependent eligibility verification documents to the Auditor dependent eligibility processing center. This web upload process is 100% secure and private for the employee and only authorized Auditor personnel will have access to the documents once they have been uploaded. • Auditor will provide to employees of Client a secure web portal where employees can find out the overall status of their audit, returned mail instruction and explanations of each status along with instructions and guidance on how to complete their audit if their status is "Incomplete" or "No Response". Employees also can view dates that forms and correspondence from Auditor were sent to the individual, access FAQs and privacy and security policies. Verification, Call Center & Document Processin! • All mailings and all follow-up correspondence will reference a toll-free phone number for additional support and guidance. This phone line will be staffed during normal business hours and supported with 24/7 voice messaging. Auditor will track all in -bound and out -bound messaging and return any missed calls within 1 business day. All identified calls will be logged by date. time, and call -center team initials. • All incoming secure faxes, secure web portal uploads, and emails will be electronically scanned into our system. In addition, documents received that contain a Auditor unique family barcode will automatically be assigned to the corresponding family record in AUDiT iQTM while also providing real-time document receipt status on our secure web portal. BMI"� V LLC BMI Audit Services, • Documentation submitted by employees will be reviewed by our team to determine completeness of the submission. We will not assume any responsibility or liability associated with the receipt of falsified or misleading documents. Documentation supplied by employees will be presumed to be valid. If a question as to an item's validity is raised by one of our staff members, it will be forwarded to Client for a determination. • If documentation is sufficient, a confirming "Thank You" postcard will be sent to the employee, advising that all information required to complete the audit has been received. • If documentation is not sufficient, Auditor will send hard copy follow-up requests, "Incomplete Letter", indicating the member specific missing or incomplete documentation and deadline for submission. • If the employee does not respond by the mid -point of the audit, a "No Response Reminder Letter" will be mailed. Periodic summary updates will be provided to Client. • Auditor will provide Client with the collected hard copy documentation for its records or Auditor will securely shred all collected documentation after six (6) months from the close of audit date. However, Client may request an alternate disposition for their collected documentation 30 days prior to the shredding process. All necessary postage required to mail the collected hard copy documentation will be the responsibility of Client. Reporting • At any point throughout the process, a summary of findings can be generated with "real-time" results. Typically results are provided to Client after each major milestone, on a regular weekly basis, or as often as requested. After each mailing/phase, Auditor will provide a "Detail Report" containing a status summary as well as details of no responses, incompletes, failed members, mail returns, and members suspended from audit. • After the Third Mailing (Phase 3) is reached, Auditor will provide a "Final Detail Report" and "Final Executive Summary Report containing narratives, tables and graphs to Client. The report will also summarize those employees who satisfactorily complied, detail those employees who did not respond at all, and detail those employees who responded with documentation. yet it did not sufficiently support eligibility, far which Client will make the final determination and/or action. Auditor will also provide teleconference support to discuss the results in order to ensure Client receives optimal benefit from our services. [The remainder of this page is intentionally left blank.] 08/01/12 15:02 FAX 1 574 232 2991 Ae(OWbr CERTIFICATE OF PROOUMR ROCKSM11 INSURANCE MWCY IWC 333 N Lafayette Blvd South Bond, IN 46601-1208 f5741233 -5I36 INSURED BW AUDIT SERVICES LLC ROCKSTROR INSURANCE =5 LIABILITY INSURANCE 1 7?25/2012 1 THIS CERTIFICATE 16 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY 'THE POLICIES BELOW. INSURERS AFFORDING COVERAGE I NAICS I INSMR A Hastings Mutual IneUranCe I I INSURRR & AlitoPimers Insurance I PO BOIL 4666 I *MuRER C SOUTH BE=, IN 46634 INSURER D. INSURER 1*1 COVERACM THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED To THE iNsvRED 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 PtfdHC�S. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED By PAID CLAIMS, TYPEOF104SURANrE POUCY"M joeACOW ULM GENERAL LMILTTY EACH OCCURRENCE 4 2.000.0001 L~taft V _P2rIMERCLAL GENERAL LLMILITY I PREMISES IM4 I is 5Q.&OO CLAIMSMADE FX7 OCCUR. I MED EXP (My one parmn) Is 5.000 SO 9345120 2-3-12 2-3-3.3 1 PERSON&&ADVINJURY It 2.00 ^Ad% I GENERAL AGGREGATE 13 4. dao nAft A*AA GEWL AGGREGATE LIMIT APPLIES PIE�, PRODUCTS - com-OP AW 1 1, 4,000,000, x I POLICY " 2, F1 LOG ArOMOBILE LIABILITY COMBINED SINGLE LIMIT 11000,000 AMYAUTO (Ea 90"M) ALL OWK13 AUTOS KW&Y INJURY SCHEDQL%O AUTOS (per PeW) A HIRED AUTOS ACV 9821554 2-3-12 2-3-13 powLy wuw hON-OWNWAMS (P- *Cddwo) PROPERTY DAMAGE S (per ftddeft) GARAGE LIABILITY AUTO ONLY -EA ACCIDENT 3 ANYAUTO 1i OTHER THAN EAACC I ALITOONLY; AGG S UCESS IL REUA LIABILITY I 1 EACH OCCURRENCE 1 2.000.0001 OCCUR 5L-1 CLAIMS MAN i AGGREGATE 5 2 '000,0001 ULC 9456643 6-10-13 I S A DEDUCTIBLE 16-10-19 faMCHTION S WORKERS COMPENSATION AND EMPLOYERS'LWIUTY SIA;% CTW ER ANY PROPRVORMARTNEII&MMMV& OFFMa"WAMM CxCUJMD? vim E] WC 9345I21 C 2-3-12 2-3-13 HEL EACHACCIDENT $ 1.000.0001 A Pbndftq In I" Indiana EL DISEASE - EA EMPLOM S 1.000 OQP K dewLnw SXE"1be 6(AL PROVISIONS bW. E.L. DISEASE - POLICY Limm: s 1 000 OTHER B Crime 09358870-10 3-23-12 13-23-13 1,000,000 DESCRIPTION Of OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENCORZEMENT I SPECIAL PROVISIONS Additional Insured on General Liability: City of San Rafael Basting MUtual's policy is primary coverage for SHI Audit Services. CERTIFICATE HOLDER CANCELLATION City of San Rafael $HOMI) ANY OF TM Aboft I)IMMIM0 FOLIC" BE CAMMIM RTK WMT= C/O Wells Fargo InSUrance Service DAIZ TWLMOF, 749 *SUM M3URM %Vjj- EMWAVM To MAIL 2-0 DAYS wFurm 1039—A N. McDowell Blvd. NOTIM TO THE eLVWCAT5 HOLM NAM ft TIC LEFT, OW FMLMW To no so EWA" Petaluma, CA 94954 WME NO OMMATION OR LAVILM OF ANY K1W UPON TW MURM M Aa&m as REPRE39ffAT7YM. AMORIZED REPRESENTATIVE Attn,.%Iena Baptista Baptista- - 1 511' ll 1—e-- ACCIR00021!01) T7@ —19M2009 ACORD CORPORATION. All rights reserved. The ACORD, name and I*go are registered maft Df ACORD os/ol/12 15:02 FAX 1 574 232 2991 ROCKSTROH INSURANCE 16003 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modffies insurance provided under the following- BUSINESSOWNERS; COVERAGE FORM Name Of AddPJonal Insured Person(s) Or Organizaeon(s)* City of San Rafael Information required to complete this Schedule, 4 not shown abm, will be shown in the Declarations The folloWWg is added to Paragraph C. VWho Is An Insured in Section N - Liabilay. 3. Any person(s) or orgar&ation(s) show in the Schedule is also an insured, but only with respect to liabilky fbr "bodily injury", "Property damage!', or "personal and adverbs" injury" caused, in whole or In pen't by your acts or omissions or the acts or omissions of those acting on your behalf in performance of your ongoing operations or in connection with your premises owned by or rented to you. BP 04 48 0106 0 ISO ftperfts, Inc., 2004 Page 1 of I