HomeMy WebLinkAbout*AGMT - Colen & Lee Inc. City of Seal Beach
FILE REFERENCE FORM
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SELF - INSURANCE
• SERVICE AGREEMENT
THIS AGREEMENT is entered into this day o' Za,_ ed_,
1997 between the CITY OF SEAL BEACH, hereinafter referr ' to as the 1ty and
COLEN & LEE, INC., a California Corporation, hereinafter referred to as the
Administrator.
WHEREAS, the City has undertaken to self- insure its Workers'
Compensation obligation; and
WHEREAS, the Administrator is engaged in the business of administering
. Workers' Compensation self- insurance programs; and
WHEREAS, the City desires to retain the services of the Administrator to
administer a Workers' Compensation self- insurance program, hereinafter
• referred to as the "Program," for the City;
NOW, THEREFORE, the City hereby retains the services of the
Administrator and the Administrator agrees to perform services for the
City under the terms and conditions of this Agreement.
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1. TERM: This Agreement shall become effective as of r. _ ii_ d ¢ /197
and shall continue in effect until terminated by the cancellation provisio /et forth
herein.
2. PERIODIC MEETINGS: The Administrator shall meet with City staff four
times per year and as needed, to:
A. Assist the City in developing internal procedures.
B. Provide orientation and training to City personnel involved in
the administration of the Program.
C. Discuss specific claims and general trends in the Program.
3. ADVISORY SERVICES: The Administrator shall provide written advisory
bulletins to inform the City of the adoption, amendment or repeal of all statutes, rules
and regulations which directly affect the Program.
4. REQUIRED FORMS: The Administrator shall provide the City with all
forms required by the State in connection with the Program.
5. COMPLIANCE WITH LAW: The Administrator shall administer the
Program in full compliance with all laws, rules and regulations governing
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Workers' Compensation and self- insurance.
6. CLAIMS ADMINISTRATION: The Administrator shall have the
authority and responsibility to provide claims administration services which
include:
A. Entering claim information on a log and establishing a claim
file upon receipt of an injury report.
B. Setting and updating reserves.
C. Arranging for investigation.
D. Determining compensability.
E. Preparing and issuing benefit notices and pamphlets.
F. Arranging for medical treatment from specialists, as necessary.
G. Initiating and maintaining contact with employees or their
attorneys.
H. Monitoring disability status by reviewing medical reports and
calling doctors for updates.
Auditing and paying medical bills.
J. Paying mileage reimbursement to employees.
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K. Paying temporary disability compensation when appropriate to do
so or advising the City of the need to adjust payroll records when
salary continuation is applicable.
L. Arranging medical exams in conformance with State law to
determine whether an employee's medical condition is permanent
and stationary and what, if any, permanent disability exists.
M. Paying permanent disability compensation in accordance with the
law.
N. Arranging for attorney representation of the City whenever the
need arises, selecting attorneys from a list approved by the City.
Q. Monitoring attorneys and assisting them in preparing cases.
P. Auditing and paying legal expenses.
Q. Arranging for vocational rehabilitation services when appropriate.
R. Monitoring vocational rehabilitation consultants and assisting
them as necessary.
S. Auditing and paying vocational rehabilitation expenses.
T. Attending all hearings that are required by law.
U. Preparing and issuing vocational rehabilitation notices.
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V. Preparing and issuing permanent disability compensation notices.
W. Pursuing subrogation when there is a viable third party.
X. Notifying the City's excess insurers of all claims which exceed or
may exceed the City's self- insurance retention, maintaining liaison
between the City and its excess insurers on matters affecting the
handling of such claims and arranging for reimbursement to the City
of losses in excess of its self- insurance retention.
Y. Obtaining settlement authority and negotiating settlement on
appropriate claims.
Z. Closing claim files when appropriate to do so.
7. OBLIGATIONS OF EMPLOYER: The City shall:
A. Submit all reports of work injury to the Administrator within
one day of the City's knowledge of the injury.
B. Respond to Administrator requests for information and authority
within five days of such requests.
C. Provide information that is accurate and is in a form specified by the
Administrator. -
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D. Grant settlement authority to the Administrator in advance of
vocational rehabilitation and legal hearings or be available by phone
or in person during those hearings.
8. CHECKING ACCOUNT: The City and Administrator agree that:
A. The City shall establish a checking account from which all Workers'
Compensation benefits and expenses are to be paid.
B. The Administrator shall prepare checks and issue those checks
directly to payees without delay.
C. The Administrator shall sign checks with a facsimile signature.
D. The Administrator shall secure both checks and check signer in a
• locked room accessible to a limited number of personnel.
E. The City shall maintain an adequate balance in the checking
account to meet all Workers' Compensation obligations without
delay.
F. The checking account may be used to pay civil penalties in which
case the Administrator shall reimburse the City within fifteen days
for any amount of the penalty which the Administrator caused.
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9. STATISTICAL REPORTS: The Administrator shall provide monthly
statistical reports to assist City management in monitoring the Program.
These reports shall include, at a minimum:
A. A monthly loss experience report, on or before the tenth (10) day of
each calendar month, for the preceding month, containing the
following information: employee's name, injury date, closing date,
department, location, cause of injury, type of injury, days lost from
work, OSHA coding, reserves and payments.
B. A monthly transaction report, on or before the tenth (10) day of each
calendar month for the preceding month, containing the following
information: check number, transaction date, amount, payee, name
of employee and claim number.
10. REGULATORY REPORTING: The Administrator shall prepare all
reports required by State regulatory agencies in connection with the Program,
including the Self- Insurer's Annual Report required by the Department of Self-
Insurance Plans.
11. RECORDS: The Administrator shall establish and maintain claim
files, claim logs, transaction documents and all other records associated with the
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Program. These records shall be the property of the City and shall be available,
on five (5) days notice, for review or for transfer to another custodian. Unless this
Agreement is canceled, closed files shall be'stored by the Administrator for five
(5) years and shall thereafter become the responsibility of the City. Upon
cancellation of this Agreement, the City shall be responsible for maintaining and
storing all records. The Administrator shall not dispose of or destroy these
records without the prior, written authorization of the City.
12. CONSIDERATION: The City shall pay the Administrator $1,400.00
per month for services rendered under this Agreement. Once a year after the first
year of this Agreement, the Administrator may increase or decrease the service
fee by giving written notice of the change to the City at least sixty (60) days prior
to the change.
13. ALLOCATED EXPENSES: The City shall pay for field investigation,
defense attorneys, legal costs, remote photocopy, engineering experts, accident
reconstruction experts, process service, messenger service, court reporters,
vocational rehabilitation consultants, structured settlement consultants and
translators.
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14. PENALTIES: The Administrator shall be responsible for paying or
appealing penalties unless the penalty results from the City's failure to:
A. Provide an Employee Claim Form to an injured employee within 24
hours of knowledge of the injury.
B. Date stamp the returned Employee Claim Form.
C. Provide an Employer's First Report of Work Injury to the
Administrator within five days from the date of knowledge of an
injury.
D. Provide a wage statement within ten days from the date of
knowledge of an injury where the employee is entitled to less than
the maximum temporary disability rate.
E. Provide information requested by the Administrator within a timely
manner.
F. Provide accurate information to the Administrator.
G. Follow a written recommendation of the Administrator.
15. INDEMNIFICATION: The Administrator shall indemnify, hold harmless,
and defend the City from all claims, legal actions, losses, expenses, injuries or
damages arising out of the Administrator's or alleged negligence or
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intentional wrongdoing incident to the'performance of this Agreement except
when such claims, legal actions, losses, expenses, injuries or damages are due to
the sole negligence of the City, its officers, agents or employees.
16. INSURANCE: The Administrator shall:
A. Maintain in force at all times General Liability and Errors and
Omissions Insurance in the amount of One Million ($1,000,000)
Dollars per occurrence, combined single limit.
B. Maintain in force at all times a Fidelity Bond in the amount of Five
Hundred Thousand ($500,000) Dollars.
C. Maintain in force at all times Workers' Compensation Insurance
for employees of the Administrator, as required by law.
D. Notify the City, in writing, thirty (30) days prior to any cancellation or
reduction in the above coverages.
E. Maintain evidence of the above coverages on file with the City
throughout the term of this Agreement.
17. NOTICES: All notices, demands, requests, or approvals which are
required under this Agreement, or which either the City or the Administrator may
desire to serve upon the other, shall be in writing and shall be conclusively
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deemed served when delivered personally, or forty-eight (48) hours after the
deposit thereof in the United States Mail with postage pre -paid.
18. CANCELLATION: This Agreement may be canceled by either party
giving to the other, in writing, notice of its intention to cancel this Agreement at
least sixty (60) days prior to the date of termination. Upon the date of termination
of this Agreement, or the date on which records are transferred to another
custodian, whichever occurs first, the Administrator shall no longer be responsible
for administration of the City's claims.
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• 19. PARTIAL INVALIDITY: If any provision of this Agreement is held by a
competent court to be invalid, void or unenforceable, the remaining provisions
shall nevertheless continue in full force and effect.
20. GOVERNING LAW: The validity of this Agreement and of any of its
terms and provisions shall be interpreted pursuant to the Laws of the State of
California.
21. INTERPRETATION: The terms and conditions of this Agreement shall
be construed pursuant to their plain, ordinary meaning and shall not be
interpreted against the maker.
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22. ATTORNEY FEES: If any action at law or equity, including an action
for declaratory relief, is brought to enforce or interpret the provisions of this
Agreement, the prevailing party shall be entitled to reasonable attorney fees in
addition to any other relief to which it may be entitled.
23. ASSIGNMENT: The Administrator shall not assign, sublet or transfer
by operation of law or otherwise any or all of its rights, burdens, duties or
obligations of this Agreement without the prior, written consent of the City.
24. CONFLICT OF INTEREST: The Administrator agrees not to accept
any employment during the term of this Agreement from any other person, firm or
corporation if that employment is likely to result in a conflict between the interests
of the City and the interests of any third parties.
25. ENTIRE CONTRACT: This instrument contains the entire Agreement
between the parties relating to the rights herein granted and obligations herein
assumed. Any oral representations or modifications concerning this instrument
shall be of no force or effect. Subsequent modifications shall be made in writing
with the agreement of both parties.
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EXECUTED at Seal Beach, California, on the date and year first above written.
CITY OF SEAL BEACH COLEN & LEE, INC.
by _,1d u.IOla+rev by 2s.e..., �t� �--
ATTEST: APPROVED AS TO FORM:
b ), _./ by
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' A1DI11:11e CERTIFICATE INSURANCE B9 ° E °2TE /9�Y"
PRODUCER _ J THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
BOltOn /RGV Insurance Brokers DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
1100 El Centro
South Pasadena, CA 91101 COMPANIES AFFORDING COVERAGE
.
COMPANY I
LETTER A F idelity and Deposit Company of Maryland
COMPANY B
INSURED LETTER
Colen & Lee, Inc. ETTER
Attention: Gayle Cook
1470 S. Valley Vista Drive, No. 230 LETTER D
Diamond Bar, CA 91765 -- — — • - --
COMPANY E
LETTER
COVERAGES _ ._ . —_.._ =5 ` ..� � x._._` • r. ,' Xd. '`%.t °s._ _ a •3'A,InJ > __—
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
CO POLICY EFFECTIVE POLICY EXPIRATION
LTR TYPE OF INSURANCE POLICY NUMBER DATE (MM /DD /YY) DATE (MM /DO /VY) LIMITS
GENERAL LIABILITY / f r. GENERAL AGGREGATE S
COMMERCIAL GENERAL LIABILITY PRODUCTS-COMP /OP AGG. 1 S
CLAIMS MADE .00CUR. m',` PERSONAL & ADV INJURY 1 S
OWNER'S 8 CONTRACTOR'S PROT. �fL EACH OCCURRENCE S
FIRE DAMAGE (Any one fire) - S
—... MED. EXPENSE (Any one person) S
AUTOMOBILE LIABILITY - I'
_... COMBINED SINGLE
ANY AUTO LIMIT $
ALL OWNED AUTOS
BODILY INJURY S
SCHEDULED AUTOS I (Per person)
HIRED AUTOS
. BODILY INJURY
NON-OWNED AUTOS � (Per accitlant)
GARAGE LIABILITY - - - -'— _ -)
PROPERTY DAMAGE S
EXCESS LIABILITY EACH OCCURRENCE '
UMBRELLA FORM ■ AGGREGATE
•—
OTHER THAN UMBRELLA FORM ^_
STATUTORY LIMITS _ .I
WORKER'S COMPENSATION 1.____.._.__,____..___._i. —_. • EACH ACCIDENT S
AND -- .__ _.-
DISEASE — POLICY LIMIT S
EMPLOYERS' LIABILITY —_.._ .- ___ _____ ..._..___.._._._._.__._—. _.
DISEASE —EACH EMPLOYEE S
OTHER
A Fidelity Bond 06106351 10 -13 -96 10 -13 -97 $1,000,000
DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES /SPECIAL ITEMS
CERTIFICATE HOLDER . ^ - ,'CANCELLATION ^ "/ ;, :q '
; SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
City of Seal Beach EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
Attention: Ginger Bennington MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
211 8th Street ' LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
Seal Beach, CA 90740 LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESE TATIVE
MARY SMITH
ACORD 25 -S (7/90) - - CORPORATION 1990
02/14/97 FRI 10:20 FAX 888 487 7788 E &0 PROFESSIONAL 2003
PROFESSIONALS ° • •
" CERTIFICATE OF INSURANCE .. .
This is to certify that the policy of Insurance listed below has been Issued to the Named insured. This certificate is
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 policy listed below. Limits shown may have been reducedby
paid claims:
Named Insured and Mailing Address:
. Calen and Lee
1470 South 'Valley "Vieta Drive, Suite 230 '
Diamond Bar, CA 91765
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Company affording coverage: Gulf Insurance Company
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Type of insurance: Professional Liability and General- Liability Policy . •
Policy No,: . IG6501619 • • .
Policy period: Effective date October 5. 1996 • Expiration date October 5. 1997
. 12:01 A.M., Standard Time at the Mailing Address stated above.
limits of Liability for ISPP Errors and Omissions Liability:
' Each Wrongful Act $1.000, "000.
Policy Aggregate • • $1,000.,000 000., 000 . •
. Limits of Liability for ISPP.General Liability: .
General Aggregate Limit $1,000;000
Products- Completed Operations Aggregate Limit $1,000,000
. Advertising Injury Limit • $1,000,000
Each Occurrence Limit $1,000,000
Fire Damage Limit • . $50,000 .
Retroactive Data: • October . 5, 1985 • •
Schedule of Professional Services insured: • . •
• Insurance claims administration services. •
• . .. Certificate Holder Name and Address: .
•
City of Seal Beach
.211 - Sth. Street • .
Seal Beach, California 90740 ' •
Attn: Ginger Bennington - . • .
ng
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'NOTE: If the Named Insured is the same as the above named Certificate Holder, written Notice of Cancellation will be
provided to the Named Insured in accordance with the provisions of the policy and any applicable state law.
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CANCELLATION: Should the above described policy be cancelled before the expiration date thereof, the issuing
Company will endeavor to mail 30 days written notice to the above named Certificate Holder but
failure to mail such notice shall impose NO 'obligation or liability of any. kind upon the•Company.
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Date Certificate Issued: February 13, 1997 •
"CLAIMS MADE AND REPORTED POLICY°
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