Loading...
HomeMy WebLinkAbout2016-147-E Health - Family Centered Healthcare, PA to provide primary care for uninsured males in OC DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 [Departmental Use Only] TITLE FCH - Primary Care FY 15-16 NORTH CAROLINA SERVICES AGREEMENT UNDER$90,000.00 NO RFP/RFQ ORANGE COUNTY This Services Agreement (hereinafter "Agreement"), made and entered into this first day of February, 2016, ("Effective Date") by and between Orange County, North Carolina a political subdivision of the State of North Carolina (hereinafter, the "County") and Family Centered Healthcare, PA, (hereinafter, the "Provider"). WITNESSETH: That the County and Provider, for the consideration herein named, do hereby agree as follows: 1. Services a. Scope of Work. i) This Agreement is for services to be rendered by Provider to County with respect to (insert type of project): Primary Care Services for uninsured, male, Orange County residents, including the professional "Medical Services" identified in Section 3, Basic Services, below. ii) By executing this Agreement, the Provider represents and agrees that Provider is qualified to perform and fully capable of performing and providing the services required or necessary under this Agreement in a fully competent, professional and timely manner. iii) Time is of the essence with respect to this Agreement. iv) The services to be performed under this Agreement consist of Basic Services, as described and designated in Section 3 hereof. Compensation to the Provider for Basic Services under this Agreement shall be as set forth herein. 2. Responsibilities of the Provider a. Services to be provided. The Provider shall provide the County with all services required in Section 3 to satisfactorily complete the Project within the time limitations set forth herein and in accordance with the highest professional standards. b. Standard of Care. i) The Provider shall exercise reasonable care and diligence in performing services under this Agreement in accordance with the highest generally accepted standards of this type of Provider practice throughout the United States and in accordance with applicable federal, state and local laws and regulations applicable to the DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 performance of these services. Provider is solely responsible for the professional quality, accuracy and timely completion and/or submission of all work related to the Basic Services. ii) Provider shall be responsible for all errors or omissions of its agents, contractors, employees, or assigns in the performance of the Agreement. Provider shall correct any and all errors, omissions, discrepancies, ambiguities, mistakes or conflicts at no additional cost to the County. iii) The Provider shall not, except as otherwise provided for in this Agreement, subcontract the performance of any work under this Agreement without prior written permission of the County. No permission for subcontracting shall create, between the County and the subcontractor, any contract or any other relationship. iv) Provider is an independent contractor of County. Any and all employees of the Provider engaged by the Provider in the performance of any work or services required of the Provider under this Agreement, shall be considered employees or agents of the Provider only and not of the County, and any and all claims that may or might arise under any workers compensation or other law or contract on behalf of said employees while so engaged shall be the sole obligation and responsibility of the Provider. v) Provider agrees that Provider, its employees, agents and its subcontractors, if any, shall be required to comply with all federal, state and local antidiscrimination laws, regulations and policies that relate to the performance of Provider's services under this Agreement. vi) If activities related to the performance of this Agreement require specific licenses, certifications, or related credentials Provider represents that it and/or its employees, agents and subcontractors engaged in such activities possess such licenses, certifications, or credentials and that such licenses certifications, or credentials are current, active, and not in a state of suspension or revocation. vii) In determining the basic services to be provided, should any documents be referenced in this Agreement, the terms of this Agreement shall have priority in any conflict between the terms of referenced documents and the terms of this Agreement. Should a request for proposals and a proposal be referenced the terms of the request for proposals shall have priority over the terms of any proposal. 3. Basic Services a. Basic Services. The Services to be rendered pursuant to this Agreement are as follows (fully describe services to be provided): General Medical Services as follows. b. 1. Provide approved Primary Care Services to uninsured, male Orange County residents referred to the Provider by the Orange County Health Department in accordance with appropriate medical standards, accepted methods and procedures, and State and Federal guidelines. c. 2. Refer patients covered under this program to receive laboratory services from providers other than the Orange County Health Department. The Provider will inform DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 these patients of their options and potential costs as the patients will be responsible for any laboratory charges. d. 3. Referred patients shall be responsible for a minimum of$20 co-pay if income eligible, and a percentage of the charges as indicated by where their income falls on the DHHS Sliding Fee Schedule, to be provided to the Provider. Referred patients are also responsible for charges as a result of laboratory services provided by the Provider. e. 4. The Provider shall invoice Orange County Health Department on a monthly basis for services rendered in the prior month. Monthly reimbusement shall be based on reports detailing actual procedures provided to referred patients during the reimbursement period. Approved procedures will be reimbursed at the current Local Health Department (LHD) Medicaid rate, to be furnished to the Provider as updated by the NC State Department of Medical Assistance (DMA.) Monthly reports shall detail date of service, Patient ID number, CPT code, and diagnosis code for each procedure provided to an eligible, referred patient. f. 5. The Provider shall provide current regisration and licensure for all physicians, Family Nurse Practitioners, and Physician Assistants in the practice as appendices to this contract. 4. Duration of Services a. Term. The term of this Agreement shall be from February 1, 2016 to June 30, 2016. b. Scheduling of Services. i) The Provider shall schedule and perform its activities in a timely manner. ii) Should the County determine that the Provider is behind schedule, it may require the Provider to expedite and accelerate its efforts, including providing additional resources and working overtime, as necessary, to perform its services in accordance with the approved project schedule at no additional cost to the County. iii) The Commencement Date for the Provider's Basic Services shall be February 1, 2016. 5. Compensation a. Compensation for Basic Services. Compensation for Basic Services shall include all compensation due the Provider from the County for all services under this Agreement except for any authorized Reimbursable Expenses which are defined herein. The maximum amount payable for Basic Services shall not exceed Thirty Thousand Dollars ($30,000). Payment for Basic Services shall become due and payable within thirty (30) days of Provider properly invoicing County. Payment shall be subject to provisions of Section 5(b). b. Disputes. In the event the amount stated on an invoice is disputed by the County, the County may withhold payment of all or a portion of the amount stated on an invoice until the parties resolve the dispute. Should Provider fail to perform its duties under the terms of this Agreement, County may, without fault or penalty, withhold any payment associated with the work to be performed until such time as said work is completed. DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 c. Additional Services. County shall not be responsible for costs related to any services in addition to the Basic Services performed by Provider unless County requests such additional services in writing and such additional services are evidenced by a written amendment to this Agreement. 6. Responsibilities of the County a. Cooperation and Coordination. The County has designated (Pam McCall) to act as the County's representative with respect to the Project and shall have the authority to render decisions within guidelines established by the County Manager and/or the County Board of Commissioners and shall be available during working hours as often as may be reasonably required to render decisions and to furnish information. 7. Insurance a. General Requirements. Provider shall obtain, at its sole expense, Commercial General Liability Insurance, Automobile Insurance, Workers' Compensation Insurance, and any additional insurance as may be required by County's Risk Manager as such insurance requirements are described in the Orange County Risk Transfer Policy and Orange County Minimum Insurance Coverage Requirements (each document is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing division/contracts.php). If County's Risk Manager determines additional insurance coverage is required such additional insurance shall consist of N/A (if no additional insurance required mark N/A as being not applicable). Provider shall not commence work until such insurance is in effect and certification thereof has been received by the County's Risk Manager. 8. Indemnity a. Indemnity. The Provider agrees to defend, indemnify and hold harmless the County from all loss, liability, claims or expense, including attorney's fees, arising out of or related to the Project and arising from bodily injury including death or property damage to any person or persons caused in whole or in part by the negligence or misconduct of the Provider except to the extent same are caused by the negligence or willful misconduct of the County. It is the intent of this provision to require the Provider to indemnify the County to the fullest extent permitted under North Carolina law. 9. Amendments to the Agreement a. Changes in Basic Services. Changes in the Basic Services and entitlement to additional compensation or a change in duration of this Agreement shall be made by a written Amendment to this Agreement executed by the County and the Provider. The Provider shall proceed to perform the Services required by the Amendment only after receiving a fully executed Amendment from the County. 10. Termination DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 a. Termination for Convenience of the County. This Agreement may be terminated without cause by the County and for its convenience upon seven (7) days' prior written notice to the Provider. b. Other Termination. The Provider may terminate this Agreement based upon the County's material breach of this Agreement; provided, the County has not taken all reasonable actions to remedy the breach. The Provider shall give the County seven (7) days' prior written notice of its intent to terminate this Agreement for cause. c. Compensation After Termination. i) In the event of termination, the Provider shall be paid that portion of the fees and expenses that it has earned to the date of termination, less any costs or expenses incurred or anticipated to be incurred by the County due to errors or omissions of the Provider. ii) Should this Agreement be terminated, the Provider shall deliver to the County within seven (7) days, at no additional cost, all deliverables including any electronic data or files relating to the Project. d. Waiver. The payment of any sums by the County under this Agreement or the failure of the County to require compliance by the Provider with any provisions of this Agreement or the waiver by the County of any breach of this Agreement shall not constitute a waiver of any claim for damages by the County for any breach of this Agreement or a waiver of any other required compliance with this Agreement. e. Suspension. County may suspend the Basic Services and this Agreement at any time for County's convenience and without penalty to County upon three (3) days' notice to Provider. Upon any suspension by County, Provider shall discontinue work on the Basic Services and shall not resume the Basic Services until notified to proceed by County. 11. Additional Provisions a. Limitation and Assignment._ The County and the Provider each bind themselves, their successors, assigns and legal representatives to the terms of this Agreement. Neither the County nor the Provider shall assign or transfer its interest in this Agreement without the written consent of the other. b. Governing Law. This Agreement and the duties, responsibilities, obligations and rights of respective parties hereunder shall be governed by the laws of the State of North Carolina. c. Compliance with Laws. Provider shall at all times remain in compliance with all applicable local, state, and federal laws, rules, and regulations including but not limited to all anti-discrimination laws. By executing this Agreement Provider affirms that Provider and any subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 d. Dispute Resolution. Any and all suits or actions to enforce, interpret or seek damages with respect to any provision of, or the performance or non-performance of, this Agreement shall be brought in the General Court of Justice of North Carolina sitting in Orange County, North Carolina. It is agreed by the parties that no other court shall have jurisdiction or venue with respect to such suits or actions. Binding arbitration may not be initiated by either Party, however, the Parties may agree to nonbinding mediation of any dispute prior to the bringing of such suit or action. e. Entire Agreement. This Agreement represents the entire and integrated agreement between the County and the Provider and supersedes all prior negotiations, representations or agreements, either written or oral. This Agreement may be amended only by written instrument signed by both parties. Modifications may be evidenced by facsimile signatures. f. Severability. If any provision of this Agreement is held as a matter of law to be unenforceable, the remainder of this Agreement shall be valid and binding upon the Parties. g. Ownership of Work Product. Should Provider's performance of this Agreement generate documents, items or things that are specific to this Project such documents, items or things shall become the property of the County and may be used on any other project without additional compensation to the Provider. The use of the documents, items or things by the County or by any person or entity for any purpose other than the Project as set forth in this Agreement shall be at the full risk of the County. h. Non-Appropriation. Provider acknowledges that County is a governmental entity, and the validity of this Agreement is based upon the availability of public funding under the authority of its statutory mandate. In the event that public funds are unavailable and not appropriated for the performance of County's obligations under this Agreement, then this Agreement shall automatically expire without penalty to County immediately upon written notice to Provider of the unavailability and non-appropriation of public funds. It is expressly agreed that County shall not activate this non-appropriation provision for its convenience or to circumvent the requirements of this Agreement, but only as an emergency fiscal measure during a substantial fiscal crisis. In the event of a change in the County's statutory authority, mandate and/or mandated functions, by state and/or federal legislative or regulatory action, which adversely affects County's authority to continue its obligations under this Agreement, then this Agreement shall automatically terminate without penalty to County upon written notice to Provider of such limitation or change in County's legal authority. i. Signatures. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the intent of the Parties to comply with Article 1 I and Article 40 of North Carolina General Statute Chapter 66. j. Notices. Any notice required by this Agreement shall be in writing and delivered by DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 certified or registered mail, return receipt requested to the following: Orange County Provider's Name Attention: Kimberlee Quatrone Family Centered Healthcare P.O. Box 8181 400 Millstone Dr. Ste. 100 Hillsborough,NC 27278 Hillsborough,NC 27278 [SIGNATURE PAGE TO FOLLOW] DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 IN WITNESS WHEREOF, the Parties, by and through their authorized agents, have hereunder set their hands and seal, all as of the day and year first above written. ORANGE COUNTY: PROVIDER: E� �,DocuSigned by: DocuSigned bye: r VUVWt, RA.w KA V'Sbt �AAIiL �Iyt t St �l By F¢� P7 SgPA77 By EoFunan5'iwmB4... County Manager Dain E. Vines, MD, owner Printed Name and Title DocurSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 PREMIER BUSINESSOWNERS POLICY irk PREMIER OFFICE PROPERTY DECLARATIONS Policy Period: Policy Number: ACP BPOK2273711151 From 11-04-15 To 11-0415 Description of Premises Number: 002 Building Number: 001 Construction: FRAME Premises Address 400 MILLSTONE DR STE 100 HILLSBOROUGH NC 27273-9007 Occupancy T Classification: PHYSICIANS & SURGEONS Described as: MEDICAL CLINIC WE PROVIDE INSURANCE ONLY FOR THOSE COVERAGES INDICATED BY A LIMIT- OR BY "INCLUDED". The Property Coverage provided at this premises is subject to a $ 500 Deductible, unless otherwise stated. COVERAGES LIMITS OF INSURANCE Building - NOT PROVIDED Business Personal Property - Replacement cost $153,600 ADDITIONAL COVERAGES -the Coverage Form Includes other Additional Coverages not shown. Business Income-ALS- 12 Months- NO Hour Waiting Period-60 Day Ordinary Payroll Limit INCLUDED Extra Expense - Actual Loss Sustained (ALS) - 12 Months - NOHour Waiting Period INCLUDED Equipment Breakdown INCLUDED Automatic Increase in Insurance - Building NOT PROVIDED Automatic Increase in Insurance - Business Personal Property 2®9% Back Up of Sewer and Drain Water (limit shown per Building; subject to $25;000 policy aggregate) $5,000 OPTIONAL INCREASED LIMITS Included Limit Additional Limit Account Receivable $25,000 $25,000 Valuable Papers and Records (At the Described Premises) $25,000 $25,000 Forgery and Alteration $10,000 $10,000 Money and Securities - Inside the Premises $10,000 $10,000 Outside the Premises (Limited) *10,000 $10,000 Outdoor Signs *2,500 $21500 Outdoor Trees, Shrubs, Plants and Lawns *10,000 $10,000 Business Personal Property Away From Premises $15,000 $15,000 Business Personal Property Away From Premises - Transit 515,000 $15,000 Electronic Data 510,000 $10,000 Interruption of Computer Operations $10,000 $10,000 Building Property of Others $10,000 $10,000 OPTIONAL COVERAGES ® Other frequently purchased coverage options. Employee Dishonesty $5,000 Policy Occurrence INCLUDED Ordinance or Law - 1 - Loss to Undamaged Portion NOT PROVIDED 2 - Demolition Cost and Broadened Increased Cost of Construction NOT PROVIDED Ordinance or Law Broadened NOT PROVIDED PROTECTIVE SAFEGUARDS This premise has Protective Safeguards identified by symbols below. insurance for Fire or Burglary and Robbery at this premise will be excluded if you do not notify us immediately if any of these safeguards are impaired. See PB 04 30 for a description of each symbol. APPLICABLE SYMBOLS: P-2/ P®73 PB 81 01 ( 4-11) NATIONWIDE PROPERTY & CASUALTY INS CO Page 1 of 2 DIRECT BILL MACH MAC INSURED COPY UID 63 22 33006 DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 PREMIER BUSINESSOWNERS POLICY PREMIER OFFICE LIABILITY DECLARATIONS Policy Period: Policy Number: ACP BPOK2273711151 From 11-04-1 To 11-04-1 LIMITS OF INSURANCE Each Occurrence Limit of Insurance Per Occurrence $2,000,000 Medical Payments Coverage Sub Limit Per Person $5,000 Tenants Property Damage Legal Liability Sub Limit Per Covered Loss $300,000 Personal and Advertising Injury Per Person Or Organization $2,000,000 Products—Completed Operations Aggregate All Occurrences $4,000,000 General Aggregate All Occurrences $4,000,000 (Other than Products—Completed Operations) AUTOMATIC ADDITIONAL INSUREDS STATUS The following persons or organizations are automat caily insureds when you and they have agreed in a written contract or agreement that such person or organizatior4 be added as an additional insured on your policy. Go-Owners of Insured Premises Controlling Interest Grantor of Franchise or License Lessors of Leased Equipment Managers or Lessors of Leased Premises Mortgagee,Assignee or Receiver Owners or Other Interest from Whom Land has been Leased State or Political Subdivisions- Permits Relating to Premises PROPERTY DAMAGE DEDUCTIBLE TONE OPTIONAL COVERAGES NONE PROVIDED PR 81 03(06-12) NATIONWIDE PROPERTY & CASUALTY ISIS CO Page 1 of DIRECT BILL MACH MAC INSURED COPY UID 63 22 33008 000uSign Envelope ID:uraou400'ons5-44 oFosos CERTIFICATE OF INSURANCE MAG Mutual Insurance Company Certificate issued to: Durham Regional Hospital Attn: Medical Staff Office 3G43 North Roxboro Rd Durham N(} 277O4-27O3 Name and mailing address of insured: Doin E. Vines, M.D. 400 Millstone Dr. Ste. 100 Hillsborough, North C8n]hOa 27278 This into certify that K4AG Mutual Insurance Company has issued a Medical Professional Liability Policy tnthe insured listed above, subject to the provisions to the current policy contract and any endorsements. Policy Number: Effective Date: Expiration Date: P8L 1701979 08 February 1, 2018 February 1' 2017 Limits Each loss/Aq91ftg&e linfit Retroactive Date: 1,008,000/3'000'000 04/00/2002 TOTAL LIMITS 1,000'000/3'000.000 This document is issued as a matter ofinformation only and confers no rights upon the document holder. This document does not amend, axtend, or alter the oovenaga, herme, oxo|usione, conditiona, or other provisions afforded by the policies referenced herein. 9|oaae inquire directly with the insured for individual restrictive endorsements that may apply. In the event ofcancellation of the described policy, MAG Mutual will make reasonable effort to notify the party at vvhnne request this certificate was issued, but K8A8 Mutual shall not be liable in any way for failure to give such notice. W4AG Mutual Insurance Company P(] Box 52979 Atlanta, GA30355-097S Page 1 of CINS Ed.01/14 12/22/2U15 000uSign Envelope ID:uraou400'ons5-44 oFosos CERTIFICATE OF INSURANCE MAG Mutual Insurance Company Certificate issued to: Blue Cross/Blue Shield - North Carolina Attn: CredenUa|ing P.{}. Box 2281 Durham NC27703 Name and mailing address of insured: Family Centered Healthcare, PA 4OO Millstone Dr. Ste. 100 Hillsborough, North Carolina 27270 This is to certify that K4AG Mutual Insurance Company has issued a Medical Professional Liability Policy bothe insured listed above, subject to the provisions to the current policy contract and any endorsements. Policy Number: Effective Date: Expiration Date: PSL170187S08 February 1, 201M February 1. 2O17 Limits Each loss/Aggregate limit Retroactive Date:: 1.000,000/3.000'000 02/01/2009 TOTAL L|Q8ll[S $1.000'000/$3.000'000 This document is issued as matter ofinformation only and confers no rights upon the document holder. This document does not amend, extend, or alter the coverage, terms, exo|usinne, oondiiiona, or other provisions afforded by the policies referenced herein. Please inquire directly with the insured for individual restrictive endorsements that may apply. In the event ofcancellation of the described policy, N1AG Mutual will make reasonable effort to notify the party at whose request this certificate was issued, but PWAG Mutual shall not be liable in any way for failure to give such notice. K4A{S K4UtU@| Insurance Company P[] Box 52Q7S Atlanta, GA3O355-007& Page I of CINS Ed.01/14 12/22/2015 000uSign Envelope ID:uraou400'ons5-44 oFosos CERTIFICATE OF INSURANCE MAG Mutual U Compay Certificate issued to: University Of North Carolina Hospital Attn: Medical Staff Office 101 Manning Drive Chapel Hill NC27514-4335 Name and mailing address of insured: [>ain E Vines, M.D. 4OU Millstone Dr. Ste. 100 Hillsborough, North Carolina 27278 This into certify that K8A8 Mutual Insurance Company has issued e Medical Professional Liability Policy tothe insured listed above, subject to the provisions to the current policy contract and any endorsements. Policy Number: Effective Date: Expiration Date: PSL170197& O8 February 1' 2O18 February 1. 2U17 Limits Each loss/Aggregate limit Retroactive Date: 1.000.000/3.000.000 04/08/2002 TOTAL LIMITS 1,000.000/3.000.000 This document is issued as a matter ofinformation only and confers no rights upon the document holder. This document does not amend, extend, or alter the coverage, terms, exo|uoione, oonditinna, ur other provisions afforded by the policies referenced herein. Please inquire directly with the insured for individual restrictive endorsements that may apply. In the event of cancellation of the described policy, K4AG Mutual will make reasonable effort to notify the party at whose request this certificate was isaued, but yWAG Mutual shall not be |iob|o in any way for failure to give such notice. MAG Mutual Insurance Company PO Box 5297S Atlanta, GA30355'OH79 Page I of CINS Ed.01/14 12/22/2015 000uSign Envelope ID:uraou400'ons5-44 oFosos CERTIFICATE OF INSURANCE MAG Mutual Insurance Company Certificate issued to: Blue Cross/Blue Shield ' North Carolina Attn: Credentia|ing P.O. Box 2291 Durham NC277O2 Name and mailing address of insured: Dm\D E. Vines, M.D. 40O Millstone Dr. Ste. 100 Hillsborough, North Carolina 27278 This is to certify that K4AG Mutual Insurance Company has issued a Medical Professional Liability Policy tothe insured listed above, subject to the provisions to the current policy contract and any endorsements. Policy Number: Effective Date: Expiration Date: PSL 1701979 08 February 1' 2010 February 1, 2017 Limits Each loss/Ag,gregate limit Retroactive Date: 1'080'000/3'000'000 04/09/2002 TOTAL L|Q8|l[S 1'000'000/3'000'000 This document iaissued as matter ofinformation only and confers nu rights upon the document holder. This document does not amend, extend, or alter the coverage, terma, exclusions, oondiUone, or other provisions afforded by the policies referenced herein. Please inquire directly with the insured for individual restrictive endorsements that may apply. In the event ofcancellation of the described policy, MAS Mutual will make reasonable effort to notify the party at whose request this certificate was issued, but MAG PWuiuo| shall not be liable in any way for failure to give such notice. K4AG Mutual Insurance Company P[> Box 52S78 Atlanta, GA30355'0Q7S Page 1v(1 12/22/2015 C|NS Ed.O1/14 000uSign Envelope ID:uraou400'ons5-44 oFosos CERTIFICATE OF INSURANCE MAG Mutual Y Company Certificate issued to: Duke University Hospital Cnedentia|ing Services Office Box 3251 Durham NC 27710 Name and mailing address of insured: C>aiO E. Vines, M.D. 4O0 Millstone Dr. Ste. 100 Hillsborough, North Carolina 27278 This is to certify that MAG Mutual Insurance Company has issued a Medical Professional Liability Policy bothe insured listed above, subject to the provisions to the current policy contract and any endorsements. Policy Number: Effective Date: Expiration Date: PSL17O107Q08 February 1. 2O10 February 1' 2017 Limits Each loss/Aggregate limi Retroactive Date: 1,000.000/3.000'000 04/09/2002 TOTAL LIMITS 1'000,000/3'000.000 This document is issued as n matter nfinformation only and confers no rights upon the document holder. This document does not amend, exbsnd, or alter the ooveraQe, harmo, oxo|usione, oondibona, or other provisions afforded by the policies referenced herein. Please inquire directly with the insured for individual restrictive endorsements that may apply. In the event ofcancellation of the described policy, MAG Mutual will make reasonable effort to notify the party atwhose request this certificate was issued, but MAG Mutual shall not be liable in any way for failure to give such notice. Authorized F�6presentative K4AG Mutual Insurance Company PD Box 52979 Atlanta, GA3O355-0079 Page of CINS Ed.01/14 12/22/2015 DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 CERTIFICATE OF INSURANCE MAG Mutual Insurance Company Certificate issued to: Name and mailing address of insured: Family Centered Healthcare, PA 400 Millstone Drive Suite 100 Hillsborough, North Carolina 27278 This is to certify that MAG Mutual Insurance Company has issued a blanket employee endorsement under the physicians and surgeons claims-made professional liability insurance policy to the insured listed above, subject to the provisions of the current policy contract. Policy Number: Effective Date: Expiration Date: PSL 1701979 07 2/01/2015 2/01/2016 Shared Limits of Coverage: $1,000,000 Each loss limit $3,000,000 Aggregate limit Covered Employee(s): Heather Fayhee, FNP This document is issued as a matter of information only and confers no rights upon the document holder. This document does not amend, extend, or alter the coverage, terms, exclusions, conditions, or other provisions afforded by the policies referenced herein. Please inquire directly with the insured for individual restrictive endorsements that may apply. In the event of cancellation of the described policy, MAG Mutual will make reasonable effort to notify the party at whose request this certificate was issued, but MAG Mutual shall not be liable in any way for failure to give such notice. Lisa Coppolino Authorized Representative January 26, 2015 MAG Mutual Insurance Company P.O. Box 52979 CI-ESPB Ed. 2/11 Atlanta, GA 30355-0979 DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 89 06 00 B (Ed 7-01) POLICY INFORMATION PAGE ENDORSEMENT The following item(s) Insured's Name(WC 89 06 01) Item 3.13. Limits (WC 89 06 12) Policy Number(WC 89 06 02) Item 3.C. States (WC 89 06 13) Effective Date(WC 89 06 03) Item 3.D. Endorsement Numbers (WC 89 06 14) Expiration Date(WC 89 06 04) Item 4. Class, Rate, Other(WC 89 04 15) X Insured's Mailing Address (WC 89 06 05) Interim Adjustment of Premium(WC 89 04 16) Experience Modification(WC 89 04 06) Carrier Servicing Office(WC 89 06 17) Producer's Name(WC 89 06 07) Interstate/Intrastate Risk ID Number(WC 89 06 18) Change in Workplace of Insured(WC 89 06 08) Carrier Number(WC 89 06 19) Insured's Legal Status (WC 89 06 10) Issuing Agency/Producer Office Address (WC 89 06 25) Item 3.A. States (WC 89 06 11) is changed as follows: Action Type Previous Value New Value Change Mailing Address:400 Millstone Dr Address:PO Box 1119 Address Ste 100 City:Hillsborough City:Hillsborough State:NC State:NC Postal Code:27278-1119 Postal Code:27278-9006 Phone#:919-619-3018 Phone#:9196193018 Total Estimated Annual Premium $1,288.00 Premium Adjustment $0.00 Minimum Premium $ 304.00 Deposit Premium $210.00 All other terms and conditions of this policy remain unchanged. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 11/17/2015 Policy No. MWC0071930-02 Endorsement No. Insured: Family Centered Healthcare INC Premium(See Attached) Insurance Company: Markel Insurance Company Countersigned by WC890600B Ed.7-01 ©2001 National Council on Compensation Insurance,Inc. 111111111111111111111111111111111111111111111111111111111111111111111111111111111 1 of 6 005274-011459-36588592-11112015 MWC0071930-02 DocuSign Envelope ID:273B24CC-D965-44DO-A589-37C63CDFC6B6 M11 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Original Printing Issued November 9,2015 WC000001A INFORMATION PAGE Insurer. '""""" '"" aaaaaaaallllllllllllllllaaallliiissso;,, ,,,, //, ���,� � iii ... iiiiiiiiiiiiii,,,. % �� �/,. Markel Insurance Company "`""/ // / Ten Parkway North Deerfield, IL 60015-2526 800-431-1270 1. The Insured: Individual Partnership Family Centered Healthcare INC Corporation or X Corporation Mailing address: PO Box 1119 Hillsborough, NC 27278-1119 Other workplaces not shown above: See attached Location Schedule 2. The policy period is from 11/17/2015 to 11/17/2016 at the insured's mailing address 3. A. Worker Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: NORTH CAROLINA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3 A.The limits of our liability under Part Two are: Bodily Injury by Accident $100,000 each accident Bodily Injury by Disease $500,000 policy limit Bodily Injury by Disease $100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except those listed in Item 3A of the Information Page and the following states or territories: AZ, District of Columbia, ID, ME,MA, MT,NJ, NY, ND,OH, OR,WA,WY, Puerto Rico and US Virgin Islands. D. This policy includes these endorsements and schedules:MJWC1000, MPIL 1007,WCOOOOOOC,WC000308, WC000404,WC000406,WC000414,WC000419,WC000421D,WC000422B,WC320301C,WC890600B, WC990601,WC990602,WC990603 4. The premium for this policy will be determined by our Manuals of Rules,Classifications, Rates and Rating Plans.All information required below is subject to verification and change by audit Code Premium Basis Rate Per Estimated Classifications No Total Estimated $100 of Annual Annual Remuneration Remuneration Premium Total Estimated Annual Premium:$1,288.00 Minimum Premium:$304.00 Expense Constant$210.00 Countersigned by WC000001A ©1987 National Council on Compensation Insurance 2of6 DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 WC 99 06 01 EXTENSION OF INFORMATION PAGE Worker's Compensation and Employer's Liability Policy Schedule Of Premium Information Policy Number: MWC0071930-02 Issued to: Family Centered Healthcare INC Effective Date: 11/17/2015 - 11/17/2016 Coverage Provided By: Markel Insurance Company Carrier Code: 22616 Period of Operation: 11/17/2015 - 11/17/2016 State of Operation: NC Premium Basis Total Rate Per Estimated Estimated Annual $100 of Annual Code Classification Remuneration Remuneration Premium Class code Description 8832 Physician $268,000.00 0.510 $1,367.00 Manual Premium $1,367.00 Total Manual Premium $1,367.00 Subject Premium $1,367.00 Total Subject Premium $1,367.00 Modified Premium $1,367.00 9887 Schedule Rating -0.270 ($369.00) Standard Premium $998.00 0900 Expense Constant $210.00 9740 Terrorism 0.015 $40.00 9741 Catastrophe(other than 0.015 $40.00 Certified Acts of Terrorism) Estimated Annual Premium $1,288.00 Total Amount Due $1,288.00 ©1991 National Council on Compensation Insurance. 3 of 6 DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 04 14 (Ed.7-90) NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT Experience rating is mandatory for all eligible insureds. The experience rating modification factor, if any, applicable to this policy, may change if there is a change in your ownership or in that of one or more of the entities eligible to be combined with you for experience rating purposes. Change in ownership includes sales, purchases, other transfers, mergers, consolidations, dissolutions, formations of a new entity and other changes provided for in the applicable experience rating plan manual. You must report any change in ownership to us in writing within 90 days of such change. Failure to report such changes within this period may result in revision of the experience rating modification factor used to determine your premium. This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated. (The information below is required only when this endorsement is issued subsequent to preparation of the policy.) Endorsement Effective 11/17/2015 Policy No. MWC0071930-02 Endorsement No. Insured: Family Centered Healthcare INC Premium(See Attached) Insurance Company: Markel Insurance Company Countersigned by WC000414 Ed.7-90 ©1990 National Council on Compensation Insurance. 4of6 DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 WC 99 06 02 EXTENSION OF INFORMATION PAGE Worker's Compensation and Employer's Liability Policy LOCATION SCHEDULE Policy Number: MWC0071930-02 Issued to: Family Centered Healthcare INC Effective Date: 11/17/2015 to 11/17/2016 Coverage Provided By: Markel Insurance Company Carrier Code 22616 Other workplaces not shown above: Location FEIN PHONE CODE ENTITY TYPE 1 400 Millstone Dr Ste 100 800240291 919-619-3018 8011 Corporation Hillsborough, NC 27278-9007 ©1991 National Council on Compensation Insurance. 5 of 6 DocuSign Envelope ID:273B24CC-D965-44D0-A589-37C63CDFC6B6 WC 99 06 03 Worker's Compensation and Employer's Liability Policy Payment Schedule Policy Number: MWC0071930-02 Issued to: Family Centered Healthcare INC Effective Date: 11/17/2015 Month Payment 11/17/2015 $210.00 If you elect a payment plan,then you will be subject to installment fees for each payment ranging from$3-$10 depending on the state. If you elect electronic funds transfer,these fees will not apply. ©1991 National Council on Compensation Insurance. 6 of 6