HomeMy WebLinkAboutHR 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