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Home My WebLink About2017-286-E Aging - Janice Galloway for wellness instructor DocuSign Envelope ID:AEC896C7-7694-4887-A4FE-8A80ADE254E5 [Departmental Use Only] TITLE Wellness Instructor FY 2017-18 ORANGE COUNTY CONTRACT UNDER $15,000.00 NORTH CAROLINA THIS AGREEMENT, made and entered into this first day of July, 2017, ("Effective Date")by and between Orange County, North Carolina, a political subdivision of the State of North Carolina, (the "County"),party of the first part; and Janice Galloway,R.N. (the "Provider"),party of the second part; WITNESSETH: For the purpose and subject to the terms and conditions hereinafter set forth, the County hereby contracts for the services of the Provider, and the Provider agrees to provide the following services to the County in accordance with the terms of this Agreement, time being of the essence: The services and/or materials (hereinafter referred to collectively as "Services") to be furnished under this Agreement are as follows: Fit Feet Clinic services at each senior center weekly The term of this agreement rendered shall be from July 1, 2017 to June 30, 2018. 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 to the satisfaction of the County. Provider shall be responsible for all errors or omissions, 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. Provider agrees that Provider shall not sub-contract any of the services to be provided in this Agreement, nor shall Provider assign any right or responsibility granted or required by this Agreement, without the prior written approval of the County. SPECIFIC TERMS 1. Payment: The County agrees to pay at the rates specified for Services satisfactorily performed in accord with this Agreement. The amount to be paid by the County shall not exceed the lesser of $22.50 per hour or six-thousand dollars, ($6,000). Payment shall be made within thirty (30) days of an invoice properly submitted to County. 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. 2. Non—waiver: Failure by County at any time to require the performance by Provider of any of the provisions hereof shall in no way waive or affect the County's right hereunder to enforce the same, nor shall any waiver by the County of any breach be held to be a waiver of any succeeding breach or a waiver of this Non-Waiver Clause. 3. Independent Contractor: The Provider shall operate as an independent contractor and the County shall not be responsible for any of the Provider's acts or omissions. The Provider shall not be treated as an employee with respect to the Services performed hereunder for federal or state tax, unemployment or workers' compensation purposes. The Provider understands that neither federal, nor state, nor payroll tax of any kind shall be withheld or paid by the County on behalf of the Provider or the employees of the Provider. 4. Insurance: 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 Revised 2/17 1 DocuSign Envelope ID:AEC896C7-7694-4887-A4FE-8A80ADE254E5 http://www.orangecountync.gov/departments/purchasing division/contra cts.php). if County's Risk Manager determines additional insurance coverage is required such additional insurance shall consist of personal liability insurance (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. 5. Indemnity: The Provider agrees to defend, indemnify, and hold harmless Orange County from all losses, liabilities, claims, demands, suits, costs, damages or expenses (including reasonable attorney's fees) arising from bodily injury, including death, to any person or persons or damage to or destruction of any property caused in whole or in part by any negligent or intentional act or omission on the part of the Provider, its agents, or assigns directly or indirectly related to the Services to be performed pursuant to this Agreement on the part of the Provider. 6. Termination: This Agreement may be terminated at any time by mutual written agreement of the parties or by the County upon written notice to the Provider. County may suspend this Agreement upon reasonable notice to the Provider. 7. Entire Agreement and Signatures: The parties have read this Agreement and agree to be bound by all of its terms, and further agree that it constitutes the complete and exclusive statement of the Agreement between the parties unless and until modified in writing and signed by the parties. This Agreement together with any amendments or modifications may be executed electronically. All electronic signatures affixed hereto evidence the consent of the Parties to utilize electronic signatures and the intent of the Parties to comply with Article 11A and Article 40 of North Carolina General Statute Chapter 66. 8. Priority: In determining the basic services to be provided, should any documents be referenced in or attached to 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. 9. Governing Law: Both parties agree that this Agreement shall be governed by the laws of the State of North Carolina. 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 state and federal anti-discrimination laws, policies, rules, and regulations and the Orange County Non-Discrimination Policy and Orange County Living Wage Policy (each policy is incorporated herein by reference and may be viewed at http://www.orangecountync.gov/departments/purchasing_division/contracts.php.). Any violation of this requirement is a breach of this Agreement and County may immediately terminate this Agreement without further obligation on the part of the County. This paragraph is not intended to limit and does not limit the definition of breach to discrimination. By executing this Agreement Provider affirms that Provider is and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-86.58. 10. 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. 11. 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 Revised 2/17 2 DocuSign Envelope ID:AEC896C7-7694-4887-A4FE-8A80ADE254E5 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. [SIGNATURE PAGE TO FOLLOW] Revised 2/17 3 DocuSign Envelope ID:AEC896C7-7694-4887-A4FE-8A80ADE254E5 IN WITNESS WHEREOF,County and the Provider have signed this Agreement, effective as of the day first written above. ORANGE COUNTY PROVIDER DocuSigned by: � DocuSigned by: By: fX A)A,it, NIKK WSLUi By: ,61,1AAu, Attbwa� C ty a.1 t.. Title'-3EC638897BA1467... 200 S. Cameron St. Janice Galloway,R.N. P.O. Box 8181 6615 Glen Forest Drive Hillsborough,NC 27278 Chapel Hill, NC 27517 Revised 2/17 4 DocuSign Envelope ID:AEC896C7-7694-41387-A4FE-8A80ADE254E5 111HPSO c nso Healthcare Providers Service Organization- nurses service organization'" 159 East County Line Road • Hatboro,PA 19040-1218 1.800.982-9491 •Fax 1-800-739-8818 •www.hpso.com FACSIMILE COVER FORM PLEASE DELIVER THE FOLLOWING PAGES TO: I NAME: Janice Galloway COMPANY: DATE: 06/28/17 FACSIMILE NUMBER: 919-732 -2239 FROM: Administration TELEPHONE: 800-982-9491 * IF YOU DO NOT RECEIVE ALL OF THE PAGES, OR HAVE ANY OTHER TRANSMISSION PROBLEMS, PLEASE CALL IMMEDIATELY. ; MESSAGE: NOTICE:The information contained in this message is proprietary information belonging to Affinity Insurance Services,Inc.and is intended for the personal and confidential use of the addressee. If you are not the addressee or an agent of the addressee,you are hereby notified that you have received this message in error and that any review,dissemination,distribution or copying of this message is strictly prohibited. If you have received this message in error,please notify Affinity Insurance Services immediately by telephone and return the original by mail. Dedicated To Serving The Insurance Needs of Healthcare Providers Healthcare Providers Service Organization is a division of Affinity Insurance Services,Inc.;in NY and NH,AIS Affinity Insurance Agency; in MN and OK,AIS Affinity Insurance Agency,Inc.;and in CA,AIS Affinity Insurance Agency,Inc.dba Aun Direct Insurance Administrators License#0795465. DocuSign Envelope ID:AEC896C7-7694-4887-A4FE-8A80ADE254E5 II ry cii159 East County Line Road •Hatboro,P.A.19040-1218 nurses service organization: 1-800-247-1500 • Fax 1-800-739-8818 • www.nso.com 06/28/'17 Janice Galloway 6615 Glen Forrest Dr Chapel Hill, NC 27517-8631 1 i I`. Dear Janice Galloway: Enclosed is the replacement certificate of insurance that you requested. If you have any questions or need assistance, please call us toll free at 1-800-247-1500. Our Customer Service Representatives are available weekdays from 8:00 a.m. to 6:00 p.m., EST. Sincerely, Customer Service i ;` '111 I, Enclosure Q035 f?3 ■ Dedicated To Serving The Insurance Needs of Nurses Nurses Service Organization is a registered-trade name of Affinity Insurance Services,Inc.;in NY and NH,AIS Affinity Insurance Agency; in MN and OK,AID Affinity Insurance Agency,Inc.;and in CA,AIS Affinity Insurance Agency,Inc.dba Aon Direct Insurance Administrators License#0795465. DocuSign Envelope ID:AEC896C7-7694-4887-A4FE-8A80ADE254E5 HEALTHCARE PROVIDERS SERVICE 4 tiVA ORGANIZATION PURCHASING GROUP eetttft to of 3ti urante onso nurses service organization- OCCURRENCE POLICY FORM Print Date: 6/28/2017 Producer Branch Prefix Policy Number Policy Period 018098 970 HPG 0312115639 from 03/27/17 to 03/27/18 at 12:01 AM Standard Time Named Insured and Address: Program Administered by: Janice Galloway Nurses Service Organization 6615 Glen Forrest Dr 159 E. County Line Road Chapel Hill, NC 27517-8631 Hatboro, PA 19040-1218 1-800-247-1500 www.nso.com Medical Specialty: Code: Insurance is provided by: Registered Nurse 80964 American Casualty Company of Reading, Pennsylvania 333 S.Wabash Avenue, Chicago, IL 60604 Professional Liability $1,000,000 each claim $6,000,000 aggregate Your professional liability limits shown above include the following: * Good Samaritan Liability * Malplacement Liability * Personal Injury Liability * Sexual Misconduct Included in the PL limit shown above subject to$25,000 aggregate sublimit Coverage Extensions License Protection $ 25,000 per proceeding $25,000 aggregate Defendant Expense Benefit $ 1,000 per day limit $25,000 aggregate Deposition Representation $ 10,000 per deposition $ 10,000 aggregate Assault $ 25,000 per incident $25,000 aggregate Includes Workplace Violence Counseling Medical Payments $ 25,000 per person $ 100,000 aggregate First Aid $ 10,000 per incident $ 10,000 aggregate Damage to Property of Others $ 10,000 per incident $ 10,000 aggregate 25 000 per incident 25 000 aggregate Information Privacy(HIPAA) Fines and Penalties $ p $ Workplace Liability Workplace Liability Included in Professional Liability Limit shown above Fire&Water Legal Liability Included in the PL limit shown above subject to $150,000 aggregate sublimit Personal Liability $1,000,000 aggregate Total: $ 106.00 Base Premium $106.00 Premium reflects Employed , Full Time Policy Forms& Endorsements(Please see attached list for a general description of many common policy forms and endorsements.) G-121500-D GSL10546NC G-121503-C G-121501-C G-145184-A G-147292-A GSL15563 GSL15564 GSL15565 GSL17101 GSL13424 CNA80051 CNA80052 G-123846-C32 CNA81753 CNA81758 CNA82011 Keep this document in a safe place.tt , C641/41/2 �1„V v l f and proof of payment are your proof of coverage. There is no coverage in force unless the premium is paid in ful.In order Chairman of the Board Secretary to activate your coverage,please remit premium in full by the effective date of this Certificate of Insurance. Master Policy#188711433 G-141241-B(03/2010) Coverage Change Date: Endorsement Change Date: DocuSign Envelope ID:AEC896C7-7694-4887-A4FE-8A80ADE254E5 POLICY FORMS &ENDORSEMENTS The following are the policy forms and endorsements that apply to your current professional liability insurance policy. COMMON POLICY FORMS& ENDORSEMENTS FORM# DESCRIPTION G-121500-D Common Policy Conditions GSL10546NC North Carolina Amendatory Endorsement 0-121503-C Workplace Liability Form G-121501-C Occurrence Policy Form 0-145184-A Policyholder Notice-OFAC Compliance Notice G-147292-A Policyholder Notice-Silica, Mold &Asbestos Disclosure GSL15563 Information Privacy Coverage Endorsement HIPAA Fines, Penalties& Notification Costs GSL15564 Sexual Misconduct Sublimits of Liability Professional Liability&Sexual Misconduct Exclusion GSL15565 Healthcare Providers Professional Liability Assault Coverage GSL17101 Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies GSL13424 Services to Animals CNA80051 Amended Definition of Personal Injury Endorsement CNA80052 Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement G-123846-C32 North Carolina Cancellation and Non-Renewal CNA81753 Coverage&Cap on Losses from Certified Acts Terrorism CNA81758 Notice-Offer of Terrorism Coverage&Disclosure of Premium CNA82011 Related Claims Endorsement PLEASE REFER TO YOUR CERTIFICATE OF INSURANCE FOR THE POLICY FORMS &ENDORSEMENTS SPECIFIC TO YOUR STATE AND YOUR POLICY PERIOD. For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property&Liability Insurance Guaranty Association. For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement Foundation Program Fund and the KY LGPT is the KY Local Government Premium Tax which includes charges at a municipality and/or county level. For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge. For FL residents: The FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty Association -2012 Regular Assessment. Form#:G-141241-B(03/2010) Named Insured:Janice Galloway Master Policy#:188711433 Policy#: 0312115639 DocuSign Envelope ID:AEC896C7-7694-41387-A4FE-8A80ADE254E5 111HPSO nso !t. Healthcare Providers Service Organization nurses service organization 159 East County Line Road • Hatboro,PA 19040.1218 1.800.982-9491 •Fax 1-800-739-8818 •www.bpso.cotn FACSIMILE COVER FORM PLEASE DELIVER THE FOLLOWING PAGES TO: NAME: Janice Galloway COMPANY: DATE:06/28/17 FACSIMILE NUMBER: 919 -732 -2239 FROM: Adminis tration TELEPHONE: 800-982-9491 * IF YOU DO NOT RECEIVE ALL OF THE PAGES, OR HAVE ANY OTHER TRANSMISSION PROBLEMS, PLEASE CALL IMMEDIATELY. MESSAGE: NOTICE:The information contained in this message is proprietary information belonging to Affinity Insurance Services,Inc.and is intended for the personal and confidential use of the addressee. If you are not the addressee or an agent of the addressee,you are hereby notified that you have received this message in error and that any review,dissemination,distribution or copying of this message is strictly prohibited. If you have received this message in error,please notify Affinity Insurance Services immediately by telephone and return the original by mail. Dedicated To Serving The Insurance Needs of Healthcare Providers Healthcare Providers Service Organization is a division of Affinity Insurance Services,Inc.;in NY and NH,AIS Affinity Insurance Agency; in MN and OK,AIS Affinity Insurance Agency,Inc.;and in CA,AIS Affinity Insurance Agency,Inc.dba Aon Direct Insurance Administrators License#0795465. DocuSign Envelope ID:AEC896C7-7694-4887-A4FE-8A80ADE254E5 "Ins° 159 East County Line Road •Hatboro,PA 19040-1218 nurses service organization 1-800-247-1500 • Fax 1-800-739-8818 • wtivw,nso.com 06/28/17 Janice Galloway 6615 Glen Forrest Dr Chapel Hill, NC 27517-8631 Dear Janice Galloway: Enclosed is the replacement certificate of insurance that you requested. If you have any questions or need assistance, please call us toll free at 1-800-247-1500. Our Customer Service Representatives are available weekdays from 8:00 a.m. to 6:00 p.m., EST. Sincerely, Customer Service Enclosure Q035 Dedicated To Serving The Insurance Needs of Nurses Nurses Service Organization is a registered trade name of Affinity Insurance Services,Inc.;in NY and NH,AIS Affinity Insurance Agency; in MN and OK,AIS Affinity Insurance Agency,Inc.;and in CA,AIS Affinity Insurance Agency,Inc.dba Aon Direct Insurance Administrators License#0795465. DocuSign Envelope ID:AEC896C7-7694-4887-A4FE-8A80ADE254E5 HEALTHCARE PROVIDERS SERVICE CNA ORGANIZATION PURCHASING GROUP €ettifitate >of Intatrante mins° nurses service organization" OCCURRENCE POLICY FORM Print Date: 6/28/2017 Producer Branch Prefix Policy Number Policy Period 018098 970 HPG 0312115639 from 03/27/17 to 03/27/18 at 12:01 AM Standard Time Named Insured and Address: Program Administered by: Janice Galloway Nurses Service Organization 6615 Glen Forrest Dr 159 E. County Line Road Chapel Hill, NC 27517-8631 Hatboro, PA 19040-1218 1-800-247-1500 www.nso.com Medical Specialty: Code: Insurance is provided by: Registered Nurse 80964 American Casualty Company of Reading, Pennsylvania 333 S. Wabash Avenue, Chicago, IL 60604 Professional Liability $1,000,000 each claim $6,000,000 aggregate Your professional liability limits shown above include the following: * Good Samaritan Liability * Malplacement Liability * Personal Injury Liability * Sexual Misconduct Included in the PL limit shown above subject to$25,000 aggregate sublimit Coverage Extensions License Protection $ 25,000 per proceeding $25,000 aggregate Defendant Expense Benefit $ 1,000 per day limit $25,000 aggregate Deposition Representation $ 10,000 per deposition $ 10,000 aggregate Assault $ 25,000 per incident $25,000 aggregate Includes Workplace Violence Counseling Medical Payments $25,000 per person $ 100,000 aggregate First Aid $ 10,000 per incident $ 10,000 aggregate Damage to Property of Others $ 10,000 per incident $10,000 aggregate Information Privacy(HIPAA) Fines and Penalties $25,000 per incident $25,000 aggregate Workplace Liability Workplace Liability Included in Professional Liability Limit shown above Fire&Water Legal Liability Included in the PL limit shown above subject to $150,000 aggregate sublimit Personal Liability $1,000,000 aggregate Total: $ 106.00 Base Premium $106.00 Premium reflects Employed , Full Time Policy Forms& Endorsements(Please see attached list for a general description of many common policy forms and endorsements.) G-121500-D GSL10546NC G-121503-C G-121501-C G-145184-A G-147292-A GSL15563 GSL15564 GSL15565 GSL17101 GSL13424 CNA80051 CNA80052 G-123846-C32 CNA81753 CNA81758 CNA82011 Keep this document in a safe place.it A.1`, _ and proof of payment are your proof of I\1i-* coverage. There is no coverage in force unless the premium is paid in full In order to activate your coverage,please remit Chairman of the Board Secretary premium in full by the effective date of this Certificate of Insurance. Master Policy#188711433 G-141241-B(03/2010) Coverage Change Date: Endorsement Change Date: DocuSign Envelope ID:AEC896C7-7694-4887-A4FE-8A80ADE254E5 i POLICY FORMS &ENDORSEMENTS The following are the policy forms and endorsements that apply to your current professional liability insurance COMMON POLICY FORMS& ENDORSEMENTS pollCy. FORM# DESCRIPTION G-121500-D Common Policy Conditions GSL10546NC North Carolina Amendatory Endorsement G-121503-C Workplace Liability Form G-121501-0 Occurrence Policy Form G-145184-A Policyholder Notice-OFAC Compliance Notice G-147292-A Policyholder Notice-Silica, Mold &Asbestos Disclosure GSL15563 Information Privacy Coverage Endorsement HIPAA Fines, Penalties& Notification Costs GSL15564 Sexual Misconduct Sublimits of Liability Professional Liability&Sexual Misconduct Exclusion GSL15565 Healthcare Providers Professional Liability Assault Coverage GSL17101 Exclusion of Specified Activities Reuse of Parenteral Devices and Supplies GSL13424 Services to Animals CNA80051 Amended Definition of Personal Injury Endorsement CNA80052 Distribution or Recording of Material or Information in Violation of Law Exclusion Endorsement G-123846-032 North Carolina Cancellation and Non-Renewal CNA81753 Coverage&Cap on Losses from Certified Acts Terrorism CNA81758 Notice-Offer of Terrorism Coverage&Disclosure of Premium CNA82011 Related Claims Endorsement PLEASE REFER TO YOUR CERTIFICATE OF INSLRANCE FOR THE POLICY FORMS &ENDORSEMENT TO YOUR STATE AND YOUR POLICY PERIOD. ENDORSEMENTS SPECIFIC For NJ residents: The PLIGA surcharge shown on the Certificate of Insurance is the NJ Property& Guaranty Association. Liability Insurance rance For KY residents: The Surcharge shown on the Certificate of Insurance is the KY Firefighters and Law Enforcement Foundation Program Fund and the KY LGPT is the KY Local Government Premium Tax which includes charges at a municipality and/or county level. For WV residents: The surcharge shown on the Certificate of Insurance is the WV Premium Surcharge. For FL residents: The FIGA Assessment shown on the Certificate of Insurance is the FL Insurance Guaranty -2012 Regular Assessment. my Association Form*G-141241-B(03/2010) Master Policy#:188711433 Named Insured:Janice Galloway Policy#:0312115639