HomeMy WebLinkAboutCC Resolution 11529 (Workers Comp. Claims Administration Services)RESOLUTION NO. 11529
RESOLUTION OF THE CITY COUNCIL OF THE CITY OF SAN RAFAEL
AUTHORIZING THE SIGNING OF AN AGREEMENT WITH
REDWOOD EMPIRE MUNICIPAL INSURANCE SERVICES FOR
WORKERS' COMPENSATION CLAIMS ADMINISTRATION SERVICES
(Initial term of three years from 7/1/04 to 6/30/07,
with automatic yearly renewal thereafter unless terminated)
THE CITY COUNCIL OF THE CITY OF SAN RAFAEL RESOLVES as follows:
The MAYOR is authorized to execute, on behalf of the City of San Rafael, an Agreement
with Redwood Empire Municipal Insurance Services for Workers' Compensation Claims
Administration Services from July 1, 2004 to June 30, 2007.
I, JEANNE M. LEONCINI, Clerk of the City of San Rafael, hereby certify that the
foregoing resolution was duly and regularly introduced and adopted at a regular meeting of the
City Council of said City on Monday, the 19" day of April, 2004, by the following vote, to wit:
AYES: COUNCILMEMBERS: Cohen, Heller, Hiller, Phillips & Mayor Boro
NOES: COUNCILMEMBERS: gone
ABSENT: COUNCILMEMBERS: gone
JEANW M. LEONCINI, City Cleric
AGREEMENT BETWEEN CITY OF SAN RAFAEL AND
REDWOOD EMPIRE MUNICIPAL INSURANCE FUND FOR
WORKERS' COMPENSATION CLAIMS ADMINISTRATION SERVICES
This Agreement is made and entered into this 19th day of April, 2004, by and between the CITY
OF SAN RAFAEL (hereinafter "CITY"), and Redwood Empire Municipal Insurance Fund
(hereinafter "R.E.M.I.F.").
RECITALS
WHEREAS, CITY desires comprehensive Workers' Compensation Claims Administration
Services; and
WHEREAS, R.E.M.I.F. is licensed in California to provide management and independent
adjusting services for workers' compensation claims and represents that it has the experience,
expertise and the ability to provide said services.
AGREEMENT
NOW, THEREFORE, the parties hereby agree as follows:
1. PROJECT COORDINATION
A. CITY. The City Manager, or designee, shall be the representative of the CITY for all
purposes under this Agreement. The Risk Manager 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. R.E.M.I.F. R.E.M.I.F. shall assign a single PROJECT DIRECTOR to have overall
responsibility for the progress and execution of this Agreement for R.E.M.I.F. Mr. Mark
Ferguson is hereby designated as the PROJECT DIRECTOR for R.E.M.I.F. Should
circumstances or conditions subsequent to the execution of this Agreement require a
substitute PROJECT DIRECTOR for any reason, R.E.M.I.F. shall notify the CITY within
ten (10) business days of the substitution.
2. DUTIES OF R.E.M.I.F
R.E.M.I.F. agrees to provide the following workers' compensation claims management
services for the CITY:
A. Examine, on behalf of CITY, all reports of injury as defined by Labor Code Section 3208
and 3208.1 and make contact with the injured employee within two days after notice of lost
time injury is received.
B. Conduct such investigation as in its judgment is deemed necessary and determine, on behalf
of CITY, for each reported injury those benefits, if any, that should be paid or rendered
under the California Workers' Compensation Laws.
C. Engage persons or firms outside the R.E.M.I.F. organization, including attorneys, for
services in connection with investigations and adjustments of claims at the CITY's expense,
hereinafter referred to as "Allocated Loss Expense".
D. Consult with and receive permission from CITY before engaging any legal representation of
the CITY, including those cases where an employee of the CITY files an Application with
the California Workers' Compensation Appeals Board. It is understood that even when an
Application has been filed, a substantial effort will be made by R.E.M.I.F. to settle the claim
without assigning it to legal counsel.
E. Assign the work involved in its performance of its obligations under this agreement to
persons outside of R.E.M.I.F.'s staff, who, in the opinion of R.E.M.I.F., are capable,
competent, and experienced.
F. R.E.M.I.F. will endeavor to assign claims examiners with at least 5 years of experience in
handling California workers' compensation claims.
G. Determine and pay on behalf of CITY from funds provided by CITY, those sums that
should reasonably be paid under the California Workers' Compensation Laws for each
reported claim for compensation, medical expense and Allocated Loss Expense.
H. Advise CITY when it is necessary for an interactive process to be initiated pursuant to state
or federal law in the case of an injured worker who may not be able to return to his or her
normal occupation. The CITY, and not R.E.M.I.F., will conduct the interactive process.
R.E.M.I.F. will provide the medical documentation that sets forth the work
restrictions/limitations that preclude the injured employee from returning to his usual and
customary work.
I. Establish and maintain an orderly claims file on each reported claim. Each file shall be
available to CITY or its designee for inspection, upon three working days notice to
R.E.M.I.F.
J. Maintain a reserve of the total cost of all reasonably foreseeable benefits and related
expenses on each case. Each cost shall be recorded separately in the following categories:
1. Medical
2. Temporary Disability
3. Permanent Disability
4. Rehabilitation
5. Allocated Expense
6. 4850 (Labor Code) Benefits
K. Provide all forms necessary for the efficient operation of the workers' compensation self-
insured program and to prepare and file on behalf of CITY all legally required forms with
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the appropriate agency.
L. Proceed against responsible persons, agencies and/or their agent in subrogation actions in
order to recover losses suffered by CITY.
M. Provide a computerized loss analysis and summary each month covering activity of
claims reported to R.E.M.I.F. to include cumulative loss information to date.
N. R.E.M.I.F. will monitor all aspects of the injured worker's medical treatment. This will
include bill review, utilization review, case management, and referral to medical
treatment facilities. The cost of these services will be borne by the CITY.
O. R.E.M.I.F. will provide training sessions for CITY's management, supervisors and line
staff regarding the handling of workers' compensation claims by R.E.M.I.F.
P. On a periodic basis, R.E.M.I.F. will meet with properly designated staff of CITY to
discuss the progress of each injured worker's case that is active at the time of the
discussion. Such discussions will be conducted in accordance with the confidentiality
laws applicable to workers' compensation claims.
Q. R.E.M.I.F. will endeavor to consult with and advise the CITY on any matter arising in
connection with the business of the CITY which involves the subject matter of this
contract and shall fully cooperate with all audit requests by CITY or other authorized
agencies.
R. R.E.M.I.F., not CITY, shall be responsible for all penalties or fees assessed whether state
mandated, self-imposed or imposed by a state audit, that are the result of handling errors
of the CITY's claim files by R.E.M.I.F.
S. This contract excludes services of a safety consultant, training performed by non-
R.E.M.I.F. staff or administrative services not described herein.
T. R.E.M.I.F. agrees to abide by the Performance Standards in Exhibit "A", attached.
3. DUTIES OF CITY
CITY agrees to the following:
A. To make funds available upon which R.E.M.I.F. may draw at any time and from time to
time for claims or loss payments, including approved settlements, medical expenses,
temporary and permanent disability payments, rehabilitation expenses and for all
Allocated Loss Expenses.
B. To pay to R.E.M.I.F. the service fees as prescribed in this contract. The service fee is not
included in Allocated Loss Expense. "Allocated Loss Expense" shall include all non-
medical services that are rendered to adjust a workers' compensation claim. This
includes, but is not limited to, all court costs, attorneys fees, investigation costs (other
than that performed by R.E.M.I.F. staff), transcripts, medical reports, deposition costs,
and other costs associated with the investigation, adjustment and any appeal of the claim.
C. R.E.M.I.F. shall have full authority and control in all matters pertaining to the adjustment,
handling, investigation, and administration of claims and losses, including entering into
any stipulations which are required by law or are ordered by the court, which in its
judgment R.E.M.I.F. deems proper except that the final settlement of any claim by
R.E.M.I.F. shall only be made following consultation with and approval by CITY.
D. R.E.M.I.F. shall maintain all records and statistical data on losses arising from employee
injuries in accordance with the requirements of the applicable laws of the State of
California.
E. CITY, not R.E.M.I.F., shall be responsible for all penalties or fees assessed whether state
mandated, self-imposed or imposed by a state audit, that are the responsibility of CITY,
including, but not limited to,
Failure by CITY to provide an Employee Claim Form within twenty-four (24) hours
upon request of the injured worker or his/her agent. Failure of employer to complete
DWC-1 as required by the Labor Code, even when DWC-1 is submitted to employer
by an attorney.
2 . Failure by CITY to provide R.E.M.I.F. with an Employer's First Report within seven
(7) days of the date of injury.
3. Failure by CITY to advise R.E.M.I.F. of subsequent periods of disability after a
worker returns to work.
4. Failure by CITY to advise R.E.M.I.F. of the conclusion of salary continuation.
5. Any penalties for late payment of any required payment if late payment is due to
failure by Self -Insurer to make funds available for such required payment.
6. Any penalties or sanctions ordered by the court in a litigated case unless R.E.M.I.F.
litigated the case without obtaining permission from CITY.
4. TERM OF AGREEMENT
This Agreement shall be in effect for an initial term of three years, commencing on July 1, 2004
and ending on June 30, 2007, and shall be automatically renewed each year thereafter unless
terminated pursuant to paragraph 6 herein.
For the purpose of maintaining the continuity of claims administration for CITY upon the
termination of this Agreement, R.E.M.I.F. may continue to perform services as outlined in
the Agreement on a month-to-month basis, at the rates then in effect.
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5. COMPENSATION
For the full performance of the services described herein by R.E.M.I.F., City agrees to pay
R.E.M.I.F. a one-time fee of $895 per claim at the time the claim is opened. The $895 fee will
be in effect from July 1, 2004 through June 30, 2005, and will apply whether the claim is for
medical treatment only or is an indemnity claim. Provided that City is given written notice no
later than April 15, R.E.M.I.F. may adjust the fee, up to a maximum of 5%, for the following
fiscal year. The fiscal year shall run from July 1 through the following June 30.
The minimum guaranteed number of claims per fiscal year is 110. Self -Insurer shall pay a
minimum annual fee equal to the then minimum guaranteed number of claims per fiscal year
times the claim cost rate in effect for that fiscal year. Any claims over the guaranteed
minimum will be billed at the then current claim cost. In the event there is a continuing trend
of more than 110 claims per year, the parties may, by agreement, increase the minimum
guaranteed number of claims to be billed on an annual basis in subsequent years.
The above described claim fees will be billed and become due and payable three times per
year: the billing in June (payable in July) will be for one-half of the guaranteed minimum
number of claims for the following fiscal year; the billing in December (payable in January)
will be for the second half of the guaranteed minimum number of claims for that fiscal year;
there will be a billing by July 15th for the number of open claims that exceeded the agreed
upon guaranteed minimum for the prior year.
CITY agrees to pay R.E.M.I.F. a one-time startup fee of $30,000 in a lump sum payment
prior to the effective date of this agreement. This start up fee is in addition to any individual
claims fees and is for the purpose of taking over the existing files. The fee is to pay for
computer programming, file storage, clerical supplies, checks, forms and other expenses
incurred in effecting the transfer of responsibility for administering workers' compensation
claims from the City's current third party administrator to R.E.M.I.F.
6. TERMINATION
Either party hereto shall have the right to terminate this Agreement upon giving the other party
hereto written notice of intent not to renew at least sixty (60) calendar days prior to the
anniversary of the contract's effective date. In the event such notice is given, the contract
shall terminate on the anniversary date of its effective date or, if the parties mutually agree in
writing, on a date after the anniversary date of its effective date.
In the event the CITY purchases Workers' Compensation Insurance (excluding excess) or its
"Certificate of Consent to Self -Insure" is rescinded, this contract automatically and
immediately is terminated and canceled.
Upon termination of the contract, a final accounting will be made of the service fees and
Allocated Loss Expense, if any, owed to R.E.M.I.F. and of any funds belonging to the CITY
in possession of R.E.M.I.F. and any balance due shall be promptly paid.
At the time of termination of this contract, all handling and adjusting of pending claims by
R.E.M.I.F. will cease and become the responsibility of the CITY. A final accounting as to
amounts owed with respect to such pending claim(s) shall be made when responsibility for
the outstanding claim(s) is transferred to the CITY.
7. PROJECT DOCUMENTS: OWNERSHIP
All claims files, records, reports, computer tapes, and other documents and material
pertaining to CITY's claims shall be the property of CITY and shall be delivered to the
CITY or its designee, at the CITY's expense, upon termination of this Agreement.
8. 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.
9. INSURANCE
A. During the term of this Agreement, R.E.M.I.F. shall maintain, at no expense to CITY, the
following insurance policies:
A comprehensive general liability insurance policy in the minimum amount of one
million ($1,000,000) dollars per occurrence for death, bodily injury, personal injury, or
property damage;
2. An automobile liability (owned, non -owned, and hired vehicles) insurance policy in the
minimum amount of one million ($1,000,000) dollars per occurrence;
3. If any licensed professional performs any of the services required to be performed under
this Agreement, a professional liability insurance policy in the minimum amount of one
million ($1,000,000) dollars to cover any claims arising out of the R.E.M.I.F.'s
performance of services under this Agreement.
B. The insurance coverage required of the R.E.M.I.F. by section 10. A., shall also meet the
following requirements:
1. 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;
2. Except for professional liability insurance, the insurance policies shall be endorsed for
contractual liability and personal injury;
3. Except for professional liability insurance, the insurance policies shall be specifically
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endorsed to include the CITY, its officers, agents, and employees as additionally named
insureds under the policies;
4. R.E.M.I.F. shall provide to PROJECT MANAGER (a) Certificates of Insurance
evidencing the insurance coverage required herein, and (b) specific endorsements
naming CITY, its officers, agents and employees, as additional insureds under the
policies;
5. 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
thirty (30) days written notice to CITY's PROJECT MANAGER;
6. 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;
7. The insurance policies shall provide for a retroactive date of placement coinciding with
the effective date of this Agreement;
8. The insurance shall be approved as to form and sufficiency by PROJECT MANAGER
and the City Attorney.
C. If it employs any person, R.E.M.I.F. 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 R.E.M.I.F. and CITY against all liability for
injuries to R.E.M.I.F.'s officers and employees.
D. Any deductibles or self-insured retentions in R.E.M.I.F.'s insurance policies must be
declared to and approved by the PROJECT 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 R.E.M.I.F. shall procure a bond guaranteeing payment
of losses and related investigations, claims administration, attorney fees and defense
expenses.
10. INDEMNIFICATION
R.E.M.I.F. 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 from any acts or omissions,
intentional or negligent, of R.E.M.I.F. or R.E.M.I.F.'s officers, agents and employees in the
performance of their duties and obligations under this Agreement.
CITY shall indemnify, release, defend and hold harmless R.E.M.I.F., 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 from any acts or omissions,
intentional or negligent, of CITY or City's officers, agents and employees in the performance of
their duties and obligations under this Agreement.
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11. NONDISCRIMINATION
R.E.M.I.F. 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.
12. COMPLIANCE WITH ALL LAWS
R.E.M.I.F. 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. R.E.M.I.F. shall perform all services under this Agreement in accordance with
these laws, ordinances, codes and regulations. R.E.M.I.F. 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.
13. NO THIRD PARTY BENEFICIARIES
CITY and R.E.M.I.F. 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.
14. NOTICES
All notices and other communications required or permitted 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: Sharon E. Andrus
Risk Manager
City of San Rafael
P.O. Box 151560
San Rafael, CA 94915-1560
TO R.E.M.I.F.: Jeffrey J. Davis
General Manager
Redwood Empire Municipal Insurance Fund.
POB 885
Sonoma, CA 95476
15. INDEPENDENT CONTRACTOR
For the purposes, and for the duration, of this Agreement, R.E.M.I.F., its officers, agents and
employees shall act in the capacity of an Independent Contractor, and not as employees of the
CITY. R.E.M.I.F. and CITY expressly intend and agree that the status of R.E.M.I.F., its
officers, agents and employees be that of an Independent Contractor and not that of an
employee of CITY.
16. 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 R.E.M.I.F. 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 R.E.M.I.F. 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.
17. WAIVERS
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 term, 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.
18. COSTS AND ATTORNEY 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 fees expended in connection with such
action.
19. APPLICABLE LAW.
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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
ALBERT J.IBO, Mayor
ATTEST:
Ni
JNNE M. LEONC%, City Clerk
APPROVED A TO FORM:
Yl' lk
VARY T. RAO TI, C��y Attorney
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R.E.M.I.F.
JE FER MURRAY�-r sident
EXHIBIT "A"
PERFORMANCE STANDARDS
Contact with the Injured Worker
• The injured worker will receive a personalized letter introducing the TPA and explaining
the interaction/accountability of the TPA, the City and the injured worker.
• The injured worker will be provided with the Claims Examiner's name.
• Two or three point contact will be made within twenty-four hours.
Diary Systems
Files will be reviewed every 30 days.
Critical claims will be maintained on a separate diary by the Claims Manager or
Supervisor.
Documentation
• Each file will contain a brief summary of the claim.
• Every conversation will be documented in the claims database or written in the file.
• Major activities (e.g. ratings, medical reports, legal analysis) will be analyzed and
documented.
Excess Claim Identification & Handling
The Self Insured Retention level will be identified in the claim notes.
• Reimbursement requests will be made on a regular basis, at least every 6 months.
• Copies of recovery checks will be maintained in the claim file.
Investigation
• Questionable claims will be identified and investigated.
• Referrals to outside investigation firms require approval of the City and should take place
within 10 days from receipt of the claim.
Housekeeping: File Organization & Maintenance
Files will be neat and organized.
Packets of information will be labeled for identification.
Information on separate injuries for the same person is to be maintained in separate files.
Litigation
• Referral to legal counsel requires approval from the City. Upon receipt of City's
approval, file will be copied and sent to legal counsel within 48 hours.
• Claims staff will require initial legal analysis within 30 days of referral.
• Claims staff will obtain status reports from legal counsel at least every sixty days.
• Settlements will address all known outstanding issues, to the extent possible by law.
Medical Direction and Control
• Claims staff will ensure that quality medical care is provided to injured workers.
• Claims staff will direct City employees who have not pre -designated a physician to one
of the City's designated facilities for medical control in the time frame allowed by law.
• Claims staff will contact the physician's office during the continuation of temporary
disability to assure that treatment is related to a compensable injury or illness and that
payment of benefits is justified.
• Claims staff will contact the physician's office as needed to get the medical restrictions
whenever a City employee is taken off work. Whenever a physician repeatedly fails to
respond to the request for medical restrictions, claims staff will take the appropriate
action which may include a referral to legal counsel so the physician's deposition can be
scheduled in a timely manner.
Permanent disability
Permanent disability advances will be made in a timely manner.
In the event of overpayment of any indemnity benefit, the amount of the overpayment
will be recorded in the database and written in the claim file.
• Claims staff will pursue repayment of all overpayments.
Planning & Direction
• Every file will have a plan of action.
• The plan will be labeled in the claim notes.
• Plans will be updated whenever a significant event occurs.
Reserves
Reserves will reflect the total probable cost of the claim, consistent with State regulation.
Future medical claims will be reserved based on the injured worker's life expectancy and
past usage of the medical Award.
Reserves will be reviewed every 90 days and such review will be documented in the
claim file.
Subrogation
Misc.
Files involving subrogation will be kept on a separate diary by the Claims Manager or
Supervisor.
The City will be copied on all correspondence pertaining to subrogation.
Claims staff will evaluate claims for Compromise & Release potential at least annually
and will document their attempt to "buy out" claims involving only future medical care
for the City's ex-employees.
Claims staff will meet with the City at least once per quarter for file reviews, training, or
injury prevention review.
rlrR ci-Cuu4 iuc. u4-ui rl'I KNIIV NiA NU, IUI UJb UJ14 F. U1/03
Yo: Jeanne Leoncini, City Clerk
Fax; 415-485-3133
Phone.
Rec REMIF Insurance Certificates
From Jeff Davis
Pages: 3
Datec April 27, 2004
CC:
❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle
Attached are the General Liability and Workers' Compensation insurance certificates you requested.
Please feel free to give me a call with any questions. Thank you.
Redwood Empire Municipal Insurance Fund • P.O. Box 885 • Sonoma, CA 95476 - 707.938.2388 • Fax 707.938.0374
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P. N. 5
Sonoma, `CA 95476
CERTIFICATE OF COVERAGE
CERTIFICATE HOLDER:
THIS CERTIFIES THAT THE
COVERAGE DESCRIBED
HEREIN HAS BEEN ISSUED
TO:
City of San Rafael
P.O. Box 151560
San Rafael, CA 94915
Attn: Ms. Sharon Andrus
Redwood Empire Municipal Insurance Fund
414 W. Napa Street
Sonoma, CA 95476
DESCRIPTION OF ACTIVITY: Workers' Compensation Claims Handling Services
POLICIES LIMITS
Continental Statutory xs
Casualty 51,000,000 SIR
$2,000,000
Employers'
Liability
POLICY NUMBER EXPIR. DATE
W128587841 06-30-2004
The following Workers' Compensation coverage is in effect and is provided through self insurance and
Purchase of excess coverage through the above named company or companies. The policy and the
Memorandum of Coverage are on file with the entity and will be made available upon request.
The coverage being provided is subject to all the terms, conditions and exclusions of the REMIF
Memorandum of Coverage and the insurance policy provided by the above named company or
companies.
Coverage Is in effect at this time and will not be cancelled, limited or allowed to expire at a date other
than that indicated herein except upon 30 d=GE
lder.
c ?
1) E.
JEFFER
THIS CERTIFICATE DOES NOT PROVIDE COVERAGE TO THE CERTIFICATE HOLDER
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4 f /LV V4U It7 �ua rrin u U,tlor rbj (115Ub r CJPfth1A + REMIf 002/002
0! CALIFORMA JOINT TOWERS RISK MANAGEMENT AU'WORITX
Certificate Holder and
Additlokxmil Covered Party.
CERTIFICATE OF CO GE
City of San Rafael
P. 0. Box 151560
San Rafael, CA 94915
Attention: Ms, Sharon Andrus
This certifies that the coverage
Described herein has been Issued to: REMIF - REMIF
Description of Activity: Provision of Workers' Compensation Claims Administration Services.
Dates) of Activity: July 1, 2004 - June 30, 2007
Location of Activity! 40 W, Napa Street, Sonoma, CA 95476
Certificate
Entity Providinp Coverage Excess Coverage Expiration Date
Cali Fornia Joint Powers Risk Management Authority S 500,000 6/30/2005
excess of
$ 500,000 —_ –
The following coverage is in effect and is provided through participation in a risk sharing joint powers authority: comprehensive
general liability, automobile liability, and public officials errors and omissions, as defined in the Memorandum of Coverage on file
with the entity and which will be made available upon request.
'Cha coverage being provided is limited to the activity and the time period indicated herein and Is subject to all the terms, conditions
and exclusions of the Memorandum of Coverage of the California Joint Powers Risk Management Authority.
Pursuant to Section 11, subsection 8, relating to the definition of x covered parry, the certificate holder named herein is only ori
additional covered party for covered claims arising out of the activity described herein and Is subject to the limits stated herein.
Covcrace is In effect at this tune and will not be cancelled, limited or allowed to expire at a date other than that indicated heroin except
upon 30 days written notice to the cordficate. holder.
4/27/2004
IDnte
Form C- Revised 0910911003
Robert J.-Germp4 General Mannuer
Name and Title (Print or type)
2333 San Ramon Valley Blvd, 6 Suite 250 + San Ramon, CA 9458311456 0 phone (923) 837-0667 # FAX (925) 837-5067