HomeMy WebLinkAbout2017-298-E Health - Wake Medical Laboratory Consultants, Inc. for lab services for family planning DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
[Departmental Use Only]
TITLE Wake Med Lab Service
FY 2017-18
NORTH CAROLINA
SERVICES AGREEMENT UNDER$90,000.00
NO RFP/RFQ
ORANGE COUNTY
This Services Agreement (hereinafter "Agreement"), made and entered into this 1st day of
July, 2017, ("Effective Date") by and between Orange County, North Carolina a political
subdivision of the State of North Carolina (hereinafter, the "County") and Wake Med Health and
Hospitals and Wake Medical Laboratory Consultants, (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): Laboratory Services
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 general professional standards of care in the
relevant community.
b. Standard of Care.
i) The Provider shall exercise reasonable care and diligence in performing services
under this Agreement in accordance with the generally accepted standards of this
type of Provider practice in the relevant community and in accordance with
applicable federal, state and local laws and regulations applicable to the
performance of these services. Provider is solely responsible for the professional
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DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
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) 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.
vi) 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): See Exhibit A "Scope of Services", which is
attached and hereby incorporated by reference into this Agreement.
4. Duration of Services
a. Term. The term of this Agreement shall be from July 1, 2017 to June 30, 2018.
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
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DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
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 July 1, 2017.
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.
The maximum amount payable for Basic Services shall not exceed Fifteen Thousand
Dollars ($15,000). 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.
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
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DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
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
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.
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DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
11. Additional Provisions
a. Limitation and Assignment; No Third-Party Beneficiaries. 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. Nothing contained herein,
express or implied, is intended to confer upon any person or entity other than the parties
hereto any rights or remedies under or by reason of this Agreement.
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. 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. 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.
c. Anti-Discrimination. 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 Anti-Discrimination Policy. 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.
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
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DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
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 1 A 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
certified or registered mail,return receipt requested to the following:
Orange County Provider's Name
Attention: Kimberlee Quatrone Wake Medical Laboratory
P.O. Box 8181 3000 New Bern Avenue
Hillsborough,NC 27278 Raleigh, NC 27610
[SIGNATURE PAGE TO FOLLOW]
Revised 6/17
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DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
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: Wake Med Health and Hospitals
DocuSigned by: '.,.y►' {^�,,1��\
7,—DocuSigned by: 7� E. 'VARA, ar W) ' JJ
By: bdln,in�t, N � 'I I, By: F1C22280AF22453...
—0�i37fl94��5�E UZ �I Grover Smith, Executive Director
County Manager Printed Name and Title
E,i
PRO bIE4aeW:ake Med Laboratory Consultants
Olt,l�t, (,a wLor
By: 3B65448B3D55479
John Lawlor, Chief Financial Officer
Printed Name and Title
Revised 6/17
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DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
Exhibit A REF: Scope of Services 00,111 mimm 1111111
RP Aki,
1 V. minim „HI
High Quality and Service
➢ A regional lab that is an alternative to the large commercial labs
➢ High quality processes
• reprocessing of unsats to keep rate low(currently 0.8%)
• rescreening of paps lacking endocervical cells
• rescreening of paps negative for SIL and with+HPV test
➢ Pathologist credentials—Ten MDs, many with subspecialty training as well as experience in
Gynecologic pathology and Cytopathology
➢ Pathologists available 24/7. Interactions to enhance quality patient care at every level
➢ Continuity of care(pap to biopsy to LEEP to hysterectomy)
➢ Turn-around time—2.5 days once received
➢ Samples retained at lab for 8-10 weeks for any additional testing
➢ Availability of high risk HPV 16/18 testing as add-on or reflex
➢ Dedicated Outreach number—no teleprompts to answer any questions
➢ Call center—available 24/7 for resulting or add-on testing
Competitive Cost
➢ Competitive pricing while maintaining highest quality
➢ All Inclusive pricing providing all supplies at no additional cost
o FedEx ground— 1 day delivery zone
o Collection kits
➢ Availability to be billed monthly
➢ Dedicated billing staff to correct and/or address any billing questions/concerns
Pap-$22.00* Biopsy Technical fee- $22.50*
Pap MD Interpretation- $18.00* Biopsy Professional Fee - $28.00*
HPV- $25.00* Genotyping 16/18 - $25.00/each*
GC/Chlamydia Testing- $20.00*
*All pricing is subject to adjustment based on changes to the applicable Medicare Fee
Schedules; provided, however, that any fee adjustments shall occur not more than once
per contract year, and any increases in fees for individual services shall be limited to not
more than the change in the healthcare CPI, which changes once per year. Contractor
shall provide at least 30 days prior written notice of any increase in fees.
Shipping
➢ Fedex ground— 1 day shipping
➢ WakeMed Pathology to provide shipping supplies and labels inclusive in cost
Revised 10/14
52949381.2
DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
➢ Simple re-order for supplies and shipping materials via fax
Ordering and Resulting
➢ Simple requisitions with only pertinent testing for ease in workflow
➢ Fax resulted and ability to e-fax
Revised 10/14
52949381.2
DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
oltsZ,`N
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Nictlical Milt tiai
M.E.',: ICAL PR C_TESSIONAL LIABILITY INSURANCE POLICY
DECLARATIONS PAGE
,
Raleigh Pathology Labo story A. ociates .11l'A Mr:idical Mutual Insurance Company Of.' orth Carolina
PO Box 14045 700 Spring Forest Rd. Suite 400
Raleigh,NC 27620 IIIIIIII7Raleigh, NC 27609
, .....
Nien..m.„.11 M Ilium insurance Company OC Nonth Carolina Policy Number: I ,..1 l i 4 6 1
700 Spring Forest Rd. Suite 400 E•,tective Date: August 1115,2016
Raleigh, NC 27609 Expiration Date: August 15,2017
411 dates-herein as of 12,01 A,M Standard Te. ,II the
of the above Named Insured
[-- S ,, '
_....,... j, cl:imeb11 abi ntars1 e Medical Rm dical Expenses:
C-)od a . S10,000 Maximum Reimbursable Amount
c10„0C - -eimbursable. mm it i
, 1
, .
mmem■ -- - =. - - -
Covc[ .:., - li-Medic a ..ractice Professional Lialliliiy
k'Lileip-1" f;drhol02.,.--1 .,iiiorory I 7 T---E1 '$8,000,000
1
Cu,,k'niti'-, A-Individual Profession .,I Liat,ih“
arke, MD 07/01/2016 $6,000,(i0048,000,000
Di L Dookhan, 1 it) 11 1 '42013 $6,000.000,48,000,000
..._
ll Mienaei t' , 1 , ' °' mr rY /20P", li'' r'09.000/S8,000,000
11 Matthew LLIty lLy1-1\Cl, tvii.■; I 'Uk......'j/20t' •••i:'• .11(.0,000/S8,000,000 .-
1 Shrim vas Raingo;.. ti, Ml) 03/15/19'' 1,, ..i, i i. )00:S8,000.000
_ __..
Ahren Charles Rittershaus, MD 07/11/2011 111 1:1 ) 000,58:000.000
[ Dawsi HI ,,, , rson Scarborough,Jr, MD 02/01/1976 2,0,nr.o0.(111',11, , ' ,:t10111.11111)r i
..., _ .._
Christ ' Ion Sinn, ,s, MD
With/ .1„111 , -"nyder, MD
Cheryl ',milt ..),.i..iak, MI) 01/03/1991 OW01/2010
07/18/2005
S6,000,000,'1,,'.(00,000
S6,0110,()0/, , inch poo
.:,,,,,6 ,0iin.
_
I Michael Iloward Weinstein, MD 07/01;2002 $6,000,0100/$K,000,000
I. Ming Yin„ MD 01/13/2014 $6,000,000/S8,000.000 1 .....
TOTAL PREMIUM:
,
\4
.1'...DICA I,MUTUAL INSURANCE COMPANY ':PR A MT
PIXY!(OM 6) OF NORTH CAROLINA IIN 5176c)I 77:>
Page 0 of;
, (
/
DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
Medical Mutual
ADDITIONAL INTEREST(Coverage B) ENDORSEMENT
THIS ENDORSEMENT CHANGES YOUR POLICY
PLEASE FILE WITH YOUR POLICY
Raleigh Pathology Laboratory Associates PA Policy Number: PG112061
PO Box 14045 Effective Date of Policy: August 15, 2016
Raleigh,NC 27620
Endorsement Effective Date: August 15,2016
Date Endorsement Issued: June 3,2016
All dates herein as of 12:01 AM. Standard Time at the
Principal Address of the above Named Insured
In consideration of the premium, it is agreed that in Section I. PROFESSIONAL LIABILITY COVERAGE,paragraph
(b)Coverage B. Medical Practice Professional Liability, is amended to include, as an Insured, the professional
corporation named below, except that the Limits of Liability shown in the Declarations for Coverage B are shared by the
Insured covered in Coverage B and the professional corporation named below:
Wake Medical Lab Consultants Inc
All other terms and conditions of the policy remain unchanged.
Signed By: *ate: Jane
Authorized C P any Representattc
MEDICAL MUTUAL INSURANCE COMPANY SPRA
PE39(OM 6) OF NORTH CAROLINA Page of 1
DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
This Declaration Page is attached to and forms part of certificate provisions (Form SLC-3).
Previous No. MMN10670 Authority Ref. No. B1216PRVV161818 Certificate No. MM1N ( 1 )£32
e-MDT"/MEDEFENSETM PLUS POLICY
THIS CERTIFICATE IS WRITTEN ON A CLAIMS-MADE AND REPORTED BASIS. EXCEPT AS OTHERWISE
PROVIDED HEREIN, THIS POLICY COVERS ONLY CLAIMS FIRST MADE DURING THE POLICY PERIOD OR ANY
EXTENDED REPORTING PERIOD, IF APPLICABLE, AND REPORTED TO THE UNDERWRITERS NO LATER THAN
SIXTY (60) DAYS AFTER THE CLAIM IS FIRST MADE. ALL CLAIMS ARE SUBJECT TO THE APPLiCABLE LIMITS
OF LIABILITY AND THE APPLICABLE RETENTION(S). PLEASE NOTE THAT THE LIMITS OF LIABILITY FOR
NAMED COVERAGES I., II., III. AND IX. INCLUDE CLAIM EXPENSES. PLEASE REVIEW THE COVERAGE
AFFORDED UNDER THIS INSURANCE POLICY CAREFULLY AND DISCUSS THE COVERAGE HEREUNDER WITH
YOUR INSURANCE AGENT OR BROKER.
Item 1. Named Insured: Raleigh Pathology laboratory Assocoates P.A.
Principal Address: P 0 Box 14045
RaPeogh NC 27620
Item 2. Policy Period: August 09,2016 to August 09,2017
both days at 12:01 a.m. standard time at the Principal Address stated in Item 1.
Item 3. Named Coverage(s) Purchased (ii):
You have purchased some or all of the following Named Coverages. Only those Named Coverage(s)
that specify a Limit of Liability in Item 4 have been purchased. If a Named Coverage has not been
purchased, that portion of this Policy does not apply.
I. Multimedia Liability
II. Security and Privacy Liability
INI' III. Privacy Regulatory Defense and Penalties
IV. Privacy Breach Response Costs, Notification Expenses, and Breach Support and Credit
Monitoring Expenses
V. BrandGuardTM
►1 VI. Network Asset Protection
VII. Cyber Extortion
VIII. Cyber Terrorism
IX. MEDEFENSETM Plus
Item 4. Limits of Liability
A. Limits of Liability for Named Coverage(s) Purchased:
Each Claim Aggregate
I. Multimedia Liability $1,000,000 $1„000„000
II. Security and Privacy Liability $1„000,000 $1,000„000
III. Privacy Regulatory Defense and Penalties $1,000,000 $1,000,000
IV. Privacy Breach Response Costs, Notification
Expenses, and Breach Support and Credit Monitoring
Expenses $1,000000 $1,000,00C)
Proactive Privacy Breach Response Costs Sublimit $25,000 $25,000
Voluntary Notification Expenses Sublimit $1,000,000 $1,000,000
V. BrandGuardTM $1,000,000 $1„000„000
VI. Network Asset Protection $1,000,000 $1„000,000
VII. Cyber Extortion $1,000,000 $1,000,000
VIII. Cyber Terrorism $1,000,000 $1,000,000
IX. MEDEFENSETM Plus $1,000„000 $5„000„000
Note: The Proactive Privacy Breach Response Costs Sublimit and the Voluntary Notification Expenses
Sublimit are part of,and not in addition to,the Limit of Liability for Named Coverage IV.
B. Maximum Policy Aggregate Limit of Liability: $5,000,000
D1818CE-0115 Page 1 of 3
DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
Item 5. Retention, Co-insurance, Waiting Period and Period of Indemnity:
I. Multimedia Liability $0 each Claim
H. Security and Privacy Liability $O each Claim
VII, Privacy Regulatory Defense and Penalties so each Claim
IV, Privacy Breach Response Costs,Notification Expenses, and
Breach Support and Credit Monitoring Expenses $0 each Claim
V. randGuardTM
Waiting Period 2 Weeks
Period of Indemnity: 6 Months
M. Network Asset Protection
A. Data Recovery
Digital Assets Loss So each Claim
Special Expenses 1.0 %co-insurance each
and every loss
B. Non-Physical Business Interruption and Extra Expense 8 hour Waiting Pehod
VII Cyber Extortion $o each Claim
VIII_ Cyber Terrorism 8 hour waiting period
Ix OVIEDEFENSIE"" Plus $0 each Claim
Item 6, Retroactive Date:
I. Multimedia Liability None. Full unknown Ow acts
II. Security and Privacy Liability None Full unknown error acts,
Pnivacy Regulatory Defense and Penalties None Full unknown prior acts.
IV. Privacy Breach Response Costs, Notification
Expenses, and Breach Support and Credit Monitoring
Expenses None, Full unknone prior acts,.
V. BrandGuard Tm None. Full unknown prior acts.
VI, Net,,,,,,,ork Asset Protection N/A
VII Cyber Extortion N/A
Cyber Terrorism N/A
IX, MEDEFENSE'm Plus None. Full onlkrtown prior acts.
Item 7. Premium:
Item 8. Endorsements: E1818N1E-0111, El 818CIEllllIP-01115, E181811„..t5.0315
Item 9. Notification under the Certificate shall be given to:
NAS Insurance Services, LLC
16501 Ventura Blvd., Su ite 200
Encino, CA 91436
(818) 382-2030
ID1818CE-0115 Page 2 of 3
DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
Item 10. Policy form PI8I8CE-0115 and Application dated mey31. 2016 are hereby attached and made a part of
this Policy. Wherever in any of the forms, clauses or conditions of this insurance the word "Policy"
appears, this shall be deemed to be "Certificate".
Insurance is effected with certain UNDERWRITERS ATLL0YD'S. LONDON (1Q00/0)
Item 11. Service of Suit:
FLWA Service Corp,
c/o Foley& LordnerLLP
555 California Street, Suite 1700
San Franciscc CA 94104-1520
Dated July 26, 2016 NAS INSURANCE SERVICES, LLC
By:
Correspondent
D1818CE'0115 Page 3of3
DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
This Endorsement changes the Policy. Please read it carefully
e-MDTM/MEDEFENSETM PLUS ENDORSEMENT
NAMED SUBSIDIARIES AMENDATORY — E1818CEBM-0814
In consideration of the premium charged, it is hereby agreed and understood that the
definition of Subsidiary, as provided in Section 7. Definitions of this Policy, includes
the following entity(ies):
Wake Medical Laboratory Consultants
This endorsement is to take effect on August 9, 2016.
Policy No: MMN11182
Name: Raleigh Pathology Laboratory Associates, P.A.
Policy Effective Date: August 9, 2016 Expiration: August 9, 2017
Endorsement No.: 4
All other terms and conditions of the Policy remain unchanged
El 818CEBM-0814 Page 1 of 1
DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB Polley Number
MY 1010647
Issued By: SELECTIVE INSURANCE COMPANY OF AMERICA
40 WANTAGE AVE, BRANCHVILLE, NJ 07890
PRIVATE COMPANY MANAGEMENT LIABILITY POLICY DECLARATIONS
THE LIABILITY COVERAGES ON THIS POLICY ARE WRITTEN ON A CLAIMS-MADE BASIS. COVERAGE
APPLIES TO CLAIMS FIRST MADE AGAINST INSUREDS DURING THE POLICY PERIOD OR EXTENDED
REPORTING PERIOD. THE LIMIT OF LIABILITY AVAILABLE TO PAY SETTLEMENTS OR JUDGMENTS WILL
BE REDUCED BY DEFENSE COSTS, AND DEFENSE COSTS WILL BE APPLIED AGAINST THE RETENTION.
REM 1. ITEM 2.
Na •d and Address: Policy Period
RALEIGH PATHOLOGY LABORATORY ASSOCIATES, PA / WAKE MEDICAL From: JUNE 15, 2017
LABORATORY CONSULTANTS, INC.
PO BOX 14045 To: JUNE 15, 2018
RALEIGH, NC 27620-4045 12:01 A.M Standard Time At
Named Entity Mailing Address.
Producer Number:
00-07265-00000
Produ..r: SENTINEL RISK ADVISORS, LLC
$ ITEM 3.
All Notices Of Claim Or Loss Must Be Sent To The Insurer: Pursuant To The Terms Of This Policy In Writing To:
SELECTIVE INSURANCE COMPANY OF AMERICA
40 WANTAGE AVE, BRANCHVILLE, NJ 07890
C vicenterlselectave.corn)
ITEM 4.
"X" Indicates Coverage Applies
® Part A—Private Company Directors, Officers And Entity Liability Premium
Part B—Employment Practices Liability Premium
0 Part C—Fiduciary Liability Premium
Part D—MLI ElitePac Premium
TOTAL PREMIUM
In return for pay nt of the premium, and subject to all to and conditions of policy, the Insurer agrees with the
Insured to provide the ins , .Ence Indicated In schedules of these declarations. Insurance Is only • •vlded for those
coverages when a specific limit is shown in the Declaration(s).
Date Issued: APRIL 7, 2017
Issuing Office: SOUTHERN REGION
A + •rized Representative:
Copyright, 2013 Selective Insurance Company of America. All rights reserved. MY 00 10 04 13
Page 1 of 2
INSURED'S COPY
DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
Policy Number
FIT 1010647
DEM 5. Coverage Applies Where A Limit Is Shown For - Cove raw
PART A—PRIVATE COMPANY DIRECTORS, OFFICERS AND ENTITY LIABILITY ---1
Limit of Liability: *1,000,000.00 All Claims In The Aggregate
Retention: $.00 Each Claim under Insuring Agreement A
*10„,On. 00 Each Claim under I . urine Aoreement B
*10,000.00 Each Claim under lining Agreement C ,
$.00 Each Claim under Insuring Agreement D
Prior or Pending Litigation Date: 06-05-2010
„.„ -___... .......
PART B—EMPLOYMENT PRAC ICES LIABILITY
Limit of Liability: $1,000,000.00 AU Claims In The Aggregate
Third Party Liability: 0
Applies
0 Does not apply
Retention: *10,000 .00 Each Claim
P -.r or Pending Litigation Date: 06-05-2010 Claims for Wronaful Acts
Claims for Third Party Wrongful Acts
— ,
PART C— FIDUCIARY LIABILITY
ILimit of Liability: All Claims In The A,, .regale
Voluntary Compile : Program All Claims In The Aggregate
SublImIt of Liability:
This amount induded in Fiduciary Liability Limit
Health Insurance Portabilky and
Aggregate
Accountability Act (HIPAA) Cover. All Claims In Th
age Sublimit of Liability: This amount induded In Fiduciary Liability Limit
Retention: Each Claim
I • *.r or Pending Litigation Date:
rrEm V.
Additional Defense Co sb Limit of
* 00
Liability: .
All Claims In The Aggregate Under All Liability
Coverage Parts
ITEM 7.
liability Coverages Single - A of NIA All Claims U . r All Liability Coverage Parts
Liability:
V a Single Limit of Liability is listed above, the insurer's maximum liability in one policy period for all Claims under
each purchased liability coverage shall not exceed this limit
SUPPLEMENTAL EXTENDED REPORTING PERIOD
1 Year: 75% 1
2 Years: 100%
3 Years: 125%
4 Years: 150%
5 Years: 165%
[6 Years: 175% I
Copyright, 2013 Selective Insurance Company of America. All rights reserved. MY 00 10 04 13
Page 2 of 2
INSURES COPY
. _ .
DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB n ,1A879CDB 'ra "- v-umPonY Policy Number
S 1940885
SELECTIVE INSURANCE COMPANY OF SOUTH CAROLINA
3426 TORINGDON WAY, CHARLOTTE, NC 28277
CO I RCIAL POLICY CO I ON DECLARATION
Named Insured and Address Policy Period
RALEIGH PATHOLOGY LABORATORY ASSOCIATES PA 8 WAKE MED From JUNE 7, 2017
L ABORAI ORY CORP To: JUNE 7, 2018
PO BOX 14045
RALEIGH, NC 27620-4045
1 t2:0$ A m Standard'lime At
Locabon of Des ated Premises. 2
Named insured is; Producer Number:
CORPORATION 00-07265-00000
Producer:
SENTINEL RISK ADVISORS, LLC
NORTH CAROLINA
Schedule of Coverage
BUSINESSOWNERS COVERAGE
COMMERCIAL UMBRELLA COVERAGII
0
•••■•
xxxowfm■
.1■1
..■-
■1•11111
PREMIUM INCLUDES TERRORISM — CERTIFIED ACTS
In return for pa nt of the premium, and subject to all the terms uf this policy, we a: with
you to provide the insurance indicated in the schedule above. Insurance is provided only fo those
coverages for which a ilk limit is shown on the at el covers:e deelaratiel4)-
PAYMENT METHOD T. Policy iun,
D/B — 4 (I his pr- slum y be subject ba adjustment.)
Date issued: APRIL 21, 2017
Issuing ce: SERVICE CENTER
Authorized Representative
IL-7025 (11/89)
INSURED'S COPY
Docu Sign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB as Policy Number Policy Number
$ 1940885
S 1940885
MERCHANTSPRO COVERAGE DECLARATIONS
Rilicy Effective Date: JUNE 7, 2017 Coverage Effective Date: JUNE 7, 2017
Named insured is CORPORATION
Business of Named_Insured: MEDICAL
DESCRIPTION OF PRE III ISES
Rain. Bldg. Location Occupancy
No. No.
t.1
Refer to "Schedule of Locations"
In return for payment of the premium and subject to all the wins of this policy, we as wi you to provide
insairance For those coveragm for whidi a weak Emit is drown in the following coverage schedule
COVERAGE SCHEDULE
Property Antomadc
Nero. Bldg. Menke Increase In
No. No. Coverage Limit of Insurance Insona Deductible Valuation linerarita
1 1 .INESS PE • AL PROPERTY 8302,351 EXCLUDED $5,000 RC N/A
2 1 315 SS PE PROPERTY $27, BLDG 8 BPP 05.40 RC WA
3 1 BUSINESS PE' AL PROPERTY $27,088 BLDG BPP $5,000 RC
4 1 BUS/NESS PERSONAL PROPERTY $2,70 BLOB 8 BPP $5,000 RC NIA
BUSINESS PERSONAL PROPERTY $27,088 BLOC & BPP $5,00 0 RC N/A
TOTAL BL- --ET !PP & BLEW $83,972
MOW.
Al*
===
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1.11.01.
.1110=
1111111110111
■orses
===
MMM
LIABILITY AND MEDICAL PAYMENTS
Liability and Medical Expenses. Limit $1,0 01 ,0 0 0 General A: egate Limn $3,000,000
Medical Expenses Limit - Per Person $iO p D00 Product Aggregate Limit DE 000,000
Forms and Endorse -/As: u s unt
Refer to "Cumme 'al Policy Po ,Is and Endorsui ent Mole"
BP-7119 (04/10)
INSURED'S COPY
DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB
Previous Policy ts umber Policy Number
S 1940885 S 1940885
- -
SELECTIVE INSURANCE COMPANY OF SOUTH CAROLINA
3426 To it 1NCi DON WAY, ARLOTI°E,NC 28277
DECLARATIONS - COMMERCIAL UMBRELLA LIABILITY COVERAGE
imm-One -Name of Insured & Mailing Address Policy Parket
From: JUNE 7, 2017
SEE COMMERCIAL POLICY COMMON DECLARATION: IL-7025
.2 JUNI 7, 2010
12°01 AMStndardTimeAtThc
irrourer2 s M 41 Ad I I est.
Producer: Producer Number:
, SEE COMMERCIAL POLICY CO t DWLAPATION: IL-7025 00-07265-C,0000
ed Insured is: CORPORATION
Business of the Named Insured: MEDICAL
Limits Of lam cc
Occurrence Limit $1,000,000.00 Aggregate LiMit $1,000, 000.00
Self Retained Limit: .00
ScImdite of Underlying Insurance and 1.; t'ts
Standard EmOrsy Liability or Stopi4 4 • Policy No. W7227674
• - Li •••ity Pidicy
C pony SELECTIVE INS CO OF AMERY
Policy Period Eu ployers liability Each Accident $100,000
JUNE 7, 2017 Disease Each Employee $100,110i
To: JUNE 7, 2018 Di Each Policy 8500,000
CommerciaJ G "ty Pa&y Piiey No.
mm=
111.111111.1
C MEW
,VEM
Policy Period General Agate
ME7 F • Products-Completed •- aliens
=111.01111m '10: 1VE:0 al and Advertising Injury Limit
nn=
plampo Each S urrence limit
===
Automobile Liability Policy Pdicy No.
Compny
Policy Pesiixt Bodily [Maly Pro,
F . : • .1. Combined 4 Ii Act.; t
To:
P s i
Estimated Exposure Bose Rate Rate Per Annual Minimum Pr ium Estimated Premium Due
ht the event of cancellanon by the Named insured we will receive and retain not less than
as the Policy Minimum • 'urn.
Fo 5 and Endorsements: ritunated Total PICIAIIMI
SEE FORMS AND ENDORSEMENT SCHEDULE: IL-7035
APRIL 21, 2017 SERVICE CENTER
Issue Dale Issuing Office Authorized Representative
C7X-0003 (01/99) INSURED'S COPY
DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB Effective Date Policy Number
JUNE 7, 2017 5 1940885
DECLARATIONS - COMMERCIAL UMBRELLA LIAB IL ITY COVE ' . GE
SCHEDULE OF UNDERLYING INSURANCE AND LIMITS EXTENSION
BOP
Policy No, S 194088507
Co mny SELECTIVE INS CO OF SOUTH EACH OCCURENCE LIMIT: 01,000,000
GENERAL AGGREGATE LIMIT: 03,000,000
Policy Pera! PRODUCT AGGREGATE LIMIT $3,000,000
Fr. : JUNE 7, 2017
To: JUNE 7, 2018 e
- 8
Dellovee
Benefits
INiity No. S 194088507
C• pany SELECTIVE INS CO OF SOUTH AGGREGATE LIMIT: 03,000,000
PER CLAIM LIMIT?. 01,000,000
Policy Period 1
From: JUNE 7, 2017
To: JUNE 7, 2018
A:
ir, 1
Policy No.
E el larlY
g
m 1
Policy Period
nom:
To:
, .-..
Piracy No.
---=-,
—
=.... C* PRY
-.=
---
----. I
Policy Period
From:
E"..- To:
...
Policy No.
e.,
'' ' w y 1
Pdiey Period
Fr i :
To:
Policy No
1
r
....' PanY
Policy Period
From:
To:
CX-0004 (0499)
INSUREDS COPY
DocuSign Envelope ID:3DAF2DFC-999B-4C15-9AAF-83B41A879CDB ;urance Company WC 00 00 01 A
POLICY NUMBER PREVIOUS POLICY NUMBER
MC 7227674 WC 7227674
SELECTIVE INSURANCE COMPANY OF SOUTH CAROLINA
3426 TORIMGDON NAY, CHARLOTTE, NC 28277
.. t
INFORMATION PAGE NCCI COMPANY NO. 23937
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
p l�iL.M In NAME OF INSURED & MAILING ADDRESS �� PItODUCEtt'S NAME AND MAILING ADDRESS
RALEIGH PATHOLOGY LABORATORY ASSOCIATES SENT It r L ADVISORS, LLC
PA& WAKE MED LABORATORY CORP 4700 SIX FORKS RD STE 200
PO BOX 14045 RALEIGH, NC 27609-5244
RA I.F'IGH,NC 27, 1-4045
INSURED Is: CORPORATION I FED ID NO 561230477 AGENT NUMBER: 31-00-07265-00000
ITEM Z. POLICY PERIOD The Policy Period Is from JUNE 7, 2017 TO JUNE 7, 2018
12:01 A.M.,otondnrd!Imo at the Insured's mailing address.
polio applies to Workers Compensation law of the states
ITEM 3. CO Di AGE A. Wo Compensation 1 ce'Part One of the
policy pp p listed here:
NC
B. Employers Liability Insurance: Part Two of the policy applies to worK in each stated listed In item 3.A.
limits of our liability under Part'iWo are: Bodily Injury By Accident $100.000 each accident
Bodily Injury By Disease $100,000 each employee
r,.,.ily Injury By Di ..se $500,000 policy limit
C. Other States Insurance: Part Three of the policy applies to the states,it any,listed here:
ALL STATES EXCEPT NO,OH,NA 8 KY.
ITEM 4. PR IUM: The premium for this policy will Le determined by our manuals of rules,classifications,rates and rating plans. All
Information required bend° is subject to verification and change by audit.
Code Premium Basis Rate Per Estimated
CLASSIFICATION No. Total Estimated $1013 of Annual
Annual Remuneration Remuneration Premium
SEE ATTACHED SCHEDULES)
EXPENSE CONSTANT 0900
TERRORISM - NC $.010 9740
CATASTROPHE - NC $.010 9741
IIII
Minimum Premium NORTH CAROLINA Total._Estimated Cost
If Indicated below, interim adjusI :nts of premium shall be made:
Semi- ualiy [1:1 Quarterly [] Monthly De• ;,it Premium
This policy includes the:: endorsements and schedules: REFER TO NC-52
D/B - 4 - 7706552991
Issue Date: APRIL 22, 2017 issuing office: SERVICE CENTER, 23225-0325
Authorized Representative
Form-64 (07/08) Copyright 1987 National Council on Compensation insurance,
INSURED'S COPY