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Home My WebLink About2017-399-E Health - Triangle Urology Associates, P.A. to provide vasectomy services to OCHD referred males DocuSign Envelope ID: 111672FC-E5A1-4E39-A023-8AC8C18839C7 [Departmental Use Only] TITLE TriangleUrology-Steriliz. FY 2017-2018 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 Triangle Urology Associates,P.A. (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: Provider will perform vasectomy and post-procedure semen analysis to uninsured males referred by Orange County Health Department. OCHD will pay Provider $850 per procedure performed inclusive of the post-precedure semen analysis. 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 Eight Thousand Dollars, ($8,000). 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 Revised 2/17 1 DocuSign Envelope ID: 111672FC-E5A1-4E39-A023-8AC8C18839C7 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. 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 Revised 2/17 2 DocuSign Envelope ID: 111672FC-E5A1-4E39-A023-8AC8C18839C7 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. [SIGNATURE PAGE TO FOLLOW] Revised 2/17 3 DocuSign Envelope ID: 111672FC-E5A1-4E39-A023-8AC8C18839C7 IN WITNESS WHEREOF,County and the Provider have signed this Agreement, effective as of the day first written above. O• ,,Es M NTY PRA FSB&ed by: bblAAA,lt, tkeumMwte-rStui Vawtv, fxbWIA, By: ---0637094B755E477... BY:'--ct 8A8247EA216o. County Manager Title: 200 S. Cameron St. Triangle Urology Associates,P.A. P.O. Box 8181 205 Frasier Street Hillsborough,NC 27278 Durham, NC 27704 Revised 2/17 4 DocuSi•n Envelope ID: 111672FC-E5A1-4E39-A023-8AC8C18839C7 Hanover Insurance Group.. WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY WORKERS COMPENSATION RENEWAL INFORMATION PAGE RENEWAL OF WZ6-A004288-03 CARRIER CODE NO. 30937 Policy Number Policy Period Coverage is Provided in the Agency Code From To WZ6-A004288-04 06/25/2017 06/25/2018 _ THE HANOVER AMERICAN INSURANCE COMPANY 1902820 ITEM 1. Named Insured and Address Agent Telephone: 866-635-9736 TRIANGLE UROLOGY ASSOCIATES PA MOORE &JOHNSON AGENCY ATTN: DAVIN BROWN CL HANOVER CSC/STE 350 205 FRASIER ST 4505 FALLS OF NEUSE RD DURHAM, NC 27704 RALEIGH, NC 27609 Federal ID No. 561205950 SEE ATTACHED SCHEDULE OF ADDITIONAL LOCATIONS FOR OTHER WORKPLACES NOT SHOWN ABOVE. IF APPLICABLE SEE CONTINUATION OF NAMED INSURED SCHEDULE. ENTITY OF INSURED - CORPORATION ITEM 2. POLICY PERIOD- 06/25/17 TO 06/25/18 12:01 AM STANDARD TIME AT THE ADDRESS OF THE INSURED AS STATED HEREIN. ITEM 3A. PART ONE OF THIS POLICY APPLIES TO THE WORKERS' COMPENSATION LAW AND ANY OCCUPATIONAL DISEASE LAW OF EACH OF THE FOLLOWING STATES- NC. B. PART TWO OF THIS POLICY APPLIES TO EMPLOYERS' LIABILITY INSURANCE FOR WORK IN EACH STATE LISTED IN ITEM 3A: BODILY INJURY BY ACCIDENT $500,000 EACH ACCIDENT BODILY INJURY BY DISEASE $500,000 EACH EMPLOYEE BODILY INJURY BY DISEASE $500,000 POLICY LIMIT C. PART THREE OF THIS POLICY APPLIES TO OTHER STATES INSURANCE FOR THE FOL- LOWING STATES- ALL STATES EXCEPT ND,OH,WA,WY, AND THOSE STATES SPECIFICALLY NAMED IN ITEM 3A. D. SEE ATTACHED SCHEDULE FOR LIST OF ENDORSEMENTS AND SCHEDULES FORMING PART OF THIS POLICY. ITEM 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. ADJUSTMENT OF PREMIUM SHALL BE MADE ANNUALLY. CLASSIFICATION OF OPERATIONS EST ANNUAL PREMIUM SEE ATTACHED SCHEDULE OF OPERATIONS 2,330 MINIMUM PREMIUM $274 EXPENSE CONSTANT 210 PREMIUM FOR TERRORISM $73 PREMIUM FOR CATASTROPHE $73 TOTAL ESTIMATED ANNUAL PREMIUM $2,686 DEPOSIT PREMIUM $2,686 COUNTERSIGNED THIS DAY OF AUTHORIZED REPRESENTATIVE BRANCH OFFICE:13840 BALLANTYNE CORP PL SUITE 100 CHARLOTTE NC 28277 IF THE BILL FOR YOUR POLICY IS NOT ENCLOSED, IT WILL BE SENT TO YOU SEPARATELY. 00053 orm 331-0226 (9-03) WC000001B iDate Issued; 04/26/2017 ORIGINAL/INSURED Payment Type: CUST SERV CTR-DIRECT BILL onnuS• 111672Fo-E5A1 1oonecr 4Hanover n° Insurance Group. WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY EXTENSION OF INFORMATION PAGE RENEWAL OF WZ6-A004288-03 CARRIER CODE NO. 30937 Policy Number Policy Period Coverage is Provided in the Agency Code From To VYZ6`A004288'04 06/25/2017 06/25K2018 THE HANOVER AMERICAN INSURANCE COMPANY 1902820 ITEM 1. Named |nowredo and n Address Agent Telephone: 866-635'3736 TRIANGLE UROLOGY ASSOCIATES PA MOORE &JOHNSON AGENCY ATTN: DAVIN BROWN CL HANOVER CSC/STE 350 205 FRASIER ST 4505 FALLS OF NEUSE RD DURHAM, NC 27704 RALE|GH, NC 27809 Federal ID No. 561205850 POLICY ** A D D I T I O N A L L O C A T I O N S ** SCHEDULE PAGE 2 PAGE 1 LOCATION ADDRESS NUMBER 001 205 FRASIER STREET DURHAM NC 27704 -------------------------------------------------------------------- Q�Q — 331-0226 VVCU00081B --Deta Issued: 04/26/2017 ORIGINAL/INSURED Payment Type: CUST SERV CTR-DIRECT BILL "~"~'' DOOuSign Envelope ID: 111672FC-E5A1-4E39-A023-8AC8C18839C7 , 4n° Hanover Insurance Group. OD6 A005679 1902820 '`' I" SCHEDULE A - SCHEDULE OF UNDERLYING POLICIES 11 Insured: TRIANGLE UROLOGY ASSOCIATES, ,,i/ Effective on and after: 06/25/2017 , 12:01 AM Standard Time 1:, This schedule is part of Policy Number: OD6-A005679-04 CARRIER, POLICY NUMBER & PERIOD TYPE OF POLICY APPLICABLE LIMITS OR AMOUNT OF INSURANCE (a)Carrier: Commercial 1.000'000 Each Occurrence MASSACHUSETTS BAY INSURANCE COMPANY czcneral Liability $ 2, General Aggregat Policy Number: ODG��OO587g-O4 L�UNon-owned & $ 2.000.000 Product/Complete Po|i�yP�riod� � Hired Autos Operations 06/25/2017 TO 06/25/2018 Aggregate (b) Carrier:� Comprehennive Bodily Injury and Property Automobile Liability Damage Liability Combined Policy Number: $ Each Accident Policy Period: Bodily Injury $ Each Person $ Each Accident Property Damage $ Each Accident (c)Carrier:� Sbandard Workers Coverage B - Employers Liability Compensation & Bodily Injury t ALLNER|CAHNANOALBEN|F|TS /NSURANCECDWPANy Employers Liability $ 500. Each Accident cident Po|icyNumber' y2GAOD428OU4 Please Note: The Bodily Injury by Disease Period: 06/25/2017 TO 06/25/2018 Umbrella Coverage $ 500,000 Aggregate for W or k -- ero $ 500,000 Each Employee Compensation d Employers Liability is not applicable in situations where an employee is subject to the New York Workers Compensation Law. 1 (d)Carrier: Liquor Liability $ Limit of Liability Policy Number: Policy Period: (e)Carrier: Professional $ Limit of Liability Liability Policy Number: Policy Period: An "X" marked in the box provided indicates these broadening uroptiond coverages are provided in the Underlying Insurance (D Carrier: Directors & Officers $ Limit of Liability Liability Policy Number: Policy Period: (g)Carrier: Employee Benefits $ Limit of Liability_ Liability Policy Number: Policy Period: ~--ItewsJ�medB� 0 -- : — . orized Representative of the Company 001344 473-1103 (11/08)