HomeMy WebLinkAbout2019-597-E Human Resources - Select Physical Therapy work fitness testing DocuSign Envelope ID:00D05599-14C3-451E-84B4-EDC8CADBDAFD
AGREEMENT
THIS AGREEMENT, made and entered into this 8th day of August, 2019, ("Effective Date") by and
between Select Physical Therapy Holdings, Inc. and RehabClinics,Inc., a Delaware Corporation located at
4716 Gettysburg Rd, Mechanicsburg PA 17055 for and on behalf of its subsidiaries and affiliates,
("Provider"), WorkSTEPSO, Inc., a Texas corporation located at University Business Park, 3019 Alvin
Devane, Suite 150, Austin, Texas, 78741 ("WorIcSTEPS"), and Orange County, a local political
subdivision of the State of North Carolina, located at 200 South Cameron Street, Post Office Box 8181,
Hillsborough,North Carolina {°'COMPANY"),collectively(°'THE PARTIES").
WHEREAS: COMPANY is desirous of implementing a functional employment testing program as a part
of its work injury and disability management program, to, among other reasons, effectuate a reduction of
on-the-job injuries by trying to determine if an applicant or employee can safely perform the essential
functions of the job.
WHEREAS: WorkSTEPS has developed functional employment testing protocols and procedures that
COMPANY desires to utilize for its functional employment testing program,and
WHEREAS: WorkSTEPS desires to assist COMPANY in implementing the WorkSTEPS functional
employment-testing program,
THEREFORE THE PARTIES HERETO DO HEREBY AGREE AS FOLLOWS:
1. Scope of Services, The services and/or materials(hereinafter referred to collectively as"Services")to
be furnished under this Agreement are as follows: [functional employment testing of job descriptions
identified by Company, as further described in Attachment A, Description of Services, which is
attached hereto and incorporated by reference herein, except as to those parts that conflict with this
Agreement.
Job Analyses is the foundation of the COMPANY'S functional employment testing program. A job
analyses is a measurement of the physical demands and requirements of the essential functions of a
specific job. Accurate and current job analyses are the COMPANY'S responsibility. Job Specific
Authorization Forms that document essential function requirements must be executed by
COMPANY'S representative and provided to WorkSTEPS before testing can begin. COMPANY
managers should use professionals experienced in assisting with job analyses or other trained and
certified ergonomic assessment specialists to assist in the preparation of job analyses and
documentation of essential functions.The job analyses should be based on a close,careful examination
of the specific job by an individual trained and competent in making the physical measurements of the
essential functions of the specific job. The job analyses provides specific job content validity to
COMPANY's functional employment testing program, which seeks to simulate the specific physical
demands necessary to perform essential job functions. Accurate and up-to-date job analyses help
ensure that employment decisions are based on objective, sound, individual, and job specific
information, Likewise,accurate and up-to-date job analyses helps ensure that no individual or group of
individuals is discriminated against. COMPANY agrees to enter into an agreement in the form
attached hereto as Exhibit "1" with the provider that will perform the job analysis, which is attached
and incorporated by reference into this Agreement, except as to those parts that conflict with this
Agreement.
If there is any conflict between the Exhibits and the all other documents and this Agreement, this
Agreement shall take precedence over any other document.
2. Compensation for Services. Company agrees to pay at the rates specified for satisfactorily performed
in accord with this Agreement. The amount to be paid by the Company shall not exceed Fifteen
thousand dollars, ($15,000). Payment shall be made within thirty (30) days of an invoice properly
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submitted to the Company. Should Provider fail to perform the duties under the terms of this
Agreement,Company may,without fault or penalty,withhold any payment associated with the work to
be performed until such time as said work is completed. Based on the functional employment test(s)
and services that have been identified below the price for the test(s)and services shall be:
+ Comprehensive Post Offer Functional Employment Test $125.00
+ Comprehensive Fit for Duty Test per employee $125.00
+ Partial Test $75.00
+ No Show Fee(24 hour cancellation required) $75.00
+ Job Analysis(per hour-maximum of 6 hours per job analyzed} $150.00
+ POET creation per job title' $500.00
+ Validation of POET per hour $150.00
+ Work Conditioning initial 2 hours $150.00
+ Work Conditioning-each additional hour $75.00
2. Terms. The term of this Agreement shall be for a term of one (I)year, from the effective date of this
Agreement july 1,2019 until June 30,2020.
3. Termination. This Agreement may be terminated by either Party hereto. The termination shall be
effective five (5) business days after receipt of notice thereof. Receipt shall be deemed effective upon
actual delivery to the noticed Party. Upon termination, COMPANY shall be responsible to pay for any
employment tests that have actually been performed prior to the termination.
4. Ownership. All data and information generated by the WorkSTEPS Functional Employment Testing
Program for Company shall be the property of WorkSTEPS and Company. WorkSTEPS shall use best
efforts to keep such data or information in a legally compliant manner pursuant to all state or federal laws
affecting such data or information. COMPANY may keep copies of data or information for use in its
normal course of business, but COMPANY hereby agrees that should it have possession of any
WorkSTEPS materials, forms,procedures,protocols, or information,that such shall be deemed proprietary
and confidential and kept strictly confidential. COMPANY shall use best efforts to see that such is not
utilized for any purpose that would reasonably be deemed in competition with WorkSTEPS.
5. Confidentiality. WorkSTEPS shall keep all information or materials received by COMPANY strictly
confidential,and shall not divulge any such information or materials without the express written consent of
COMPANY.
d. Third Party Claims. In the event of any third party claims associated with the services provided under
this Agreement, the arty receiving notice of the claim shall immediately inform the other party of such
claim. WorkSTEPS and COMPANY shall timely make available to each other such information and
assistance as reasonably requested in connection with the defense of any potential claim or action.
7. Release of Data. Notwithstanding any prohibition contained within this Section, WorkSTEPS or
COMPANY may release data or information as contemplated herein should a state or federal court of law
require it. WorkSTEPS may also release data or information received from the testing of COMPANY's
employees for any legitimate business purpose, provided that (i) any personal information is kept
confidential,and(ii)that all state and federal laws regarding such data or information are strictly followed.
8. Proprietary Marks. COMPANY acknowledges that is has been advised that WorkSTEPS believes the
WorkSTEPS name, and its marks and proprietary software, protocols and testing process are federally
trademarked and copyrighted. COMPANY agrees that WorkSTEPS proprietary software, protocols,
processes, procedures, including modifications thereto, are, and shall be considered "proprietary" and
"confidential information." WorkSTEPS confidential and proprietary information will be provided to
COMPANY for the sole purpose of having the WorkSTEPS Provider provide functional employment
testing services to the COMPANY. COMPANY acknowledges, agrees and confirms that COMPANY's
disclosure or misappropriation of WorkSTEPS proprietary information could cause irreparable injury to
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WorkSTEPS, and COMPANY hereby expressly agrees that it will not use the confidential and proprietary
information provided to COMPANY,except for the express purposes described in this Agreement.
9. Protected Health Information. WorkSTEPS may receive from Company health information that is
protected under applicable state and/or federal law, including without limitation, protected health
information("PHI")as defined in the regulations at 45 C.F.R. Parts 160 and 164(the"Privacy Standards")
promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996
("HIPAA"), WorkSTEPS agrees not to use or disclose(or permit the use or disclosure of)PHI in a manner
that would violate the requirements of the Privacy Standards if the PHI were used or disclosed by Company
in the same manner. WorkSTEPS shall use appropriate safeguards to prevent the use or disclosure of PHI
other than as expressly permitted under this Agreement.
Use of PHI. WorkSTEPS will use PHI solely for Company's benefit and only (i) for the purpose of
performing services for Company and (ii) as necessary for the proper management and administration of
the Company or to carry out its legal responsibilities, provided that such uses are permitted under federal
and state law.Company shall retain all rights in the PHI not granted herein,
Disclosure of PHI. WorkSTEPS may disclose PHI as necessary to perform its obligations under this
Agreement and as permitted by law, provided that WorkSTEPS shall in such case: (a) obtain reasonable
assurances from any person to whom the information is disclosed that it will be held confidential and
further used and disclosed only as required by law or for the purpose for which it was disclosed to the
person or entity;(b)agree to immediately notify Company of any instances of which it is aware that PHI is
being used or disclosed for a purpose that is not otherwise provided for in this Agreement or for a purpose
not expressly permitted by the Privacy Standards; and (c)ensure that all disclosures of PHI are subject to
the principle of"minimum and necessary use and disclosure," i.e.,only the minimum PHI that is necessary
to accomplish the intended purpose may be disclosed. If WorkSTEPS discloses PHI received from
Company, or created or received by WorkSTEPS on behalf of Company, to agents, including a
subcontractor (collectively, "Recipients"), WorkSTEPS shall require Recipients to agree in writing to the
same restrictions and conditions that apply to the WorkSTEPS under this Agreement.
10. Remedies, THE PARTIES agree that (i) the covenants and restrictions contained herein are of
material consideration to this Agreement and are reasonable and necessary to protect and preserve the
interest of both PARTIES; (ii) irreparable loss and damage will result from any breach hereof; (iii)
monetary damages will not be sufficient to compensate a PARTY for any such default or breach by the
other party; and (iv) in addition to all other remedies provided at law or in equity, a PARTY shall be
entitled to seek and obtain temporary, preliminary and permanent injunctive relief in a court of law to
prevent and restrain any breach or contemplated or threatened breach of and to specifically enforce the
provisions of this Section, and neither PARTY will be obligated to post a bond or other security in seeking
such relief or to provide proof of irreparable harm. Such remedies shall be in addition to and not in
limitation of any injunctive relief or other rights or remedies to which a PARTY is or may be entitled at law
or in equity or under this Agreement,
11. Exclusivity and Performance of Test. For as long as this Agreement is in effect, COMPANY shall
not acquire the same or similar functional testing services from anyone other than WorkSTEPS or its' duly
licensed providers. COMPANY acknowledges and understands that the tests are to be performed by
medical providers that are independent contractors that have been licensed by WorkSTEPS to perform the
tests identified.
12. Non-Solicitation of Employees and Use of Proprietary Network. COMPANY acknowledges that
WorkSTEPS has invested considerable time and financial resource in the training, education, and
certification of the professional staff necessary to deliver the services set forth on Attachment A to this
Agreement. During the term of this Agreement, and for a period of one year after its termination,
COMPANY agrees that it shall not actively or knowingly solicit or make an offer of employment to any of
WorkSTEPS employees or WorkSTEPS licensed Providers associated with the delivery of these services to
COMPANY nor shall COMPANY utilize the proprietary WorkSTEPS Network to perform any other
competitive product to the WorkSTEPS Testing Program.
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13. Use of Information after Termination. Without limiting the generality of this Section, THE
PARTIES agree that after the termination or expiration of this Agreement,such PARTIES will not use the
proprietary, confidential information of the other PARTY to provide the same or similar services to any
person (unless and until such information ceases to be proprietary and confidential through no fault of the
PARTY seeking to use the same),however, nothing in this Section shall prohibit Company or its affiliates,
after termination of this Agreement, from providing a service to COMPANY similar to the services
provided by Provider hereunder as long as neither COMPANY nor its affiliates uses the proprietary,
confidential information of WorkSTEPS in so doing.
14. Employment Decision, COMPANY acknowledges and understands that this Agreement contemplates
the functional employment testing of prospective employees and/or actual employees of COMPANY. That
COMPANY, as employer of the individuals tested have a significant role, both before and after the test,
including, but not limited to, selection of the essential functions of the applicable job, the writing of job
descriptions, if any, in communicating with the individuals to be tested in a consistent manner, in making
appropriate employment decisions based on test results and in properly processing and advising those
individuals tested.
15.Independent Contractor.The Provider and WorkSTEPS shall operate as independent Contractors,and
the Company shall not be responsible for any of their acts or omissions. Neither the Provider nor
WorkSTEPS shall be treated as an employee with respect to the Services performed hereunder for either
federal or state tax or unemployment or workers' compensation purposes. The Provider and WorkSTEPS
understand that neither federal,state, or payroll tax of any kind shalt be withheld or paid by the Company
on behalf of the Provider or WorkSTEPS,or their employees.
16. WorkSTEPS and Provider represents and agrees that they are qualified to perform and are 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 Company. WorkSTEPS and Provider shall be
responsible for all its' errors or omissions, in the performance of the Agreement. WorkSTEPS and
Provider shall correct any and all its' errors, omissions, discrepancies,ambiguities, mistakes or conflicts at
no additional cost to the Company. WorkSTEPS and Provider agree that they will 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 Company
17. Insurance. The Provider and WorkSTEPS shall obtain, at its sole expense, all insurance needed to
adequately insure itself during the performance of these services as required by the Company's Risk
Management Policy.
18. Indemnity. The Provider and WorkSTEPS agrees, without limitation, 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 or WorkSTEPS.
19.' Adherence to Laws. COMPANY agrees to follow state and federal employment laws, regulations
and practices including,but not limited to,appropriate procedures related to employment testing as set forth
in the Americans' With Disabilities Act and any and all applicable laws.COMPANY further acknowledges
that the Company, not the Provider or WorkSTEPS, is responsible for making employment decisions
concerning any post employment candidates' or current employees' suitability for employment or
continued employment and for making decisions concerning reasonable accommodations,
20. North Carolina Public Records Act. Provider and WorkSTEPS acknowledge that this Agreement,
the Confidential Information and any documents, memorandum, data, reports, analyses, compilations,
records, pricing and evaluation of all or any portion of the transactions contemplated by this Agreement
may be deemed public records and subject to disclosure,in whole or in part,pursuant to the North Carolina
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Public Records Law. Company will provide WorkSTEPS with prompt notice of any intended disclosures
or requests for disclosure pursuant to the North Carolina Public Records Law and an appropriate
opportunity to seek protection of the Confidential Information consistent with all applicable laws and
regulations. Should a public records request be made for information WorkSTEPS claims is proprietary in
nature, Company will, within a reasonable time, notify WorkSTEPS of such public records request.
WorkSTEPS shall, within five(5)business days of said notification provide notice that it does or does not
object to the Company disclosing the requested information pursuant to the subject public records request.
If WorkSTEPS objects to the disclosure of the requested information, WorkSTEPS agrees that it shall be
solely responsible for the defense of and the cost of defending any claim or complaint against the Company
for its refusal to disclose Confidential Information. WorkSTEPS agrees that if any such complaint or
claim is filed it will indemnify Company and will reimburse Company for any and all damages awarded
against Company its refusal to disclose the requested information. WorkSTEPS agrees that it releases
Company from all loss,liability,claims or expense,including attorney's fees,arising out of or related to the
release or disclosure or failure by the Company to release or disclose Confidential Information.
WorkSTEPS further agrees that it waives the right to file any court action for any such release, disclosure,
or failure to release or disclose Confidential Information.
21. 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 intent of the Parties to comply with Article 11 A and Article 40 of North
Carolina General Statute Chapter 66.
22. 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, 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
b=://www,orajigecoujitync.gov/departments/purchasingdiyision_Icontrac#s.plip}. Any violation of this
requirement is a breach of this Agreement and Company may immediately terminate this Agreement
without further obligation on the part of the Company. This paragraph is not intended to limit the
definition of breach to discrimination. 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. Where applicable, failure to maintain compliance with the requirements of
Article 2 of Chapter 64 of the General Statutes constitutes Provider's breach of this Agreement. By
executing this Agreement Provider affirms Provider is 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 Iran divestment list
created by the State Treasurer pursuant to G.S. 147-86.58 and the Israel boycott list created pursuant to
G.S. 147-86.81.
23. 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 and it is agreed by the
parties that no other court shall have jurisdiction or venue with respect to such suits or actions. The Parties
may agree to nonbinding mediation of any dispute prior to the bringing of such suit or action. Under no
circumstances shall any dispute be addressed through binding arbitration.
24. Non-Appropriation. Provider and WorkSTEPS acknowledge that Company 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 Company's obligations under this Agreement, then this Agreement shall automatically expire without
penalty to Company immediately upon written notice to Provider of the unavailability and non-
appropriation of public funds.
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DocuSign Envelope ID:OOD05599-14C3-451 E-84B4-EDC8CADBDAFD
IN WITNESS WHEREOF,Orange County, WorkSTEPS and the Provider have signed this Agreement on
the Effective Date as the day first written above.
yK3T1, thxty. gC
1�aUAV jOWAAt, tya*MtV b By '
President County Manager
Title Title
Peter Gallaher Bonnie Hammersley
Printed Signature Printed Signature
-d by:
't€4E-4�55€07�€43A..
By
VP National Contracting
Title
David Engelhardt
Printed Signature
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DocuSign Envelope ID:00D05599-14C3-451 E-84B4-EDC8CADBDAFD
Exhibit"1"
Contract for Services
For
Job Analysis Bid Proposal
Orange County, NC. ("Company") understands that a job analysis must be completed in order to meet
requirements for the Americans with Disabilities Act(ADA)so that Select Physical Therapy Holdings,Inc.
and RehabClinics, Inc. for and on behalf of its subsidiaries and affiliates ("Provider") may perform post-
offer and post employment testing pursuant to WorkSTEPS employment testing protocols, While the ADA
does not require that a formal job analysis be conducted to determine the essential functions of a specific
job position, the ADA does require an employer to prove that any exclusionary criteria obtained from a
medical examination used to withdraw an offer of employment or terminate employment are "job related
and justified by business necessity."(EEOC ADA Technical Assistance Manual II at 19 and Vl at 2).Thus,
the Provider must conduct a job analysis of the positions for which employment tests are performed to
ensure that the employment test is measuring the candidate's or employee's ability to perform essential job
functions. It is imperative that the Company provides accurate information to the Provider regarding the
essential job functions for specific job positions. The EEOC provides a discussion relating to the
identification of essential job functions in its Technical Assistance Manual. (EEOC ADA Technical
Assistance Manual II at 13-22). The Company acknowledges that the Company is responsible for
familiarizing itself with this section of the ADA Technical Assistance Manual and providing the Provider
accurate information concerning essential job functions.
A separate job analysis must be performed for each position for which the Company desires to utilize
employment testing. The job analysis may include filming, weighing, and measuring tasks for the selected
major job positions for the Company.
The Company understands that the evaluation usually takes between one (1) and six(b) hours to complete
for each position and is billed at$150 per hour. The Company hereby authorizes Provider to provide said
job analysis for each job position for which the Company will be requesting employment testing at the
above referenced rate.
DocuSigned by:
f jbin,IML f Aa*KAUIS�, 9/3/2019
L!
no e resentative/Title Date
�GWU� 41
8/27/2019
Prellropresen#ative/Title Date
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DocuSign Envelope ID:00D05599-14C3-451E-84B4-EDC8CADBDAFD
"Attachment All
Description of Services
Post Offer Testing to Include:
Medical History—The job candidate is asked to complete a comprehensive medical history administered
by an occupational healthcare professional that has been trained and certified in the WorkSTEPS Program.
This history includes information gathering on previous injuries and/or surgeries, previous physical
therapy/chiropractor visits, etc. The employee also signs a statement that falsification of the information
he/she has provided could result in the withdrawal of the conditional job offer,
Musculoskeletal Examination — A WorkSTEPS certified clinician completes this portion of the exam.
The exam looks at all major joints and muscle groups.Thirty(30)baseline measurements are documented.
The muscle groups are checked for strength as well as any atrophy. The shoulders, elbows, wrists, back,
ankles, knees and hips are checked for signs of crepitus as well as ligament stability. In addition, the
lumbar and the cervical spine is also checked. Flexion, extension, side bending and twisting are all
measured. Visual inspection of the spine for signs of surgery is performed. Deep tendon reflexes of the
biceps, triceps, patellar tendon and Achilles tendon are performed to further check for spinal cord
problems. Shoulder range of motion is checked and measured as well for movement in the internal and
external rational planes. The rotator cuff is also thoroughly checked.
Static Grip-This portion of the tests measures grip strength and gathers baseline strength readings on the
employee.
Dynamic Lifting - This portion of the test gathers baseline, full motion, and strength readings. The
employee is asked to lift a NIOSH box from 4 different positions. These 4 positions are lifting the box
from floor to knuckle height, 12 inches off the floor to knuckle height, knuckle height to shoulder and
shoulder to overhead. With each of these lifts,the employee is asked to lift the box. After the lift,they are
asked if they can safely handle more weight. The employee is asked at the beginning to try and lift their
maximum safe lift. The employee is shown and instructed on the proper lifting techniques for each of these
lifting positions.
Job Specific Tasks - This portion tests assesses the job candidate's ability to perform the essential
functions of the job he/she is applying for. The essential functions for a job description are created through
job analysis that is performed by a qualified vendor of the employer's choosing (this can be the
WorkSTEPS Provider who will be providing testing service but is not required).The employer is obligated
to participate in the job analysis process by approving and verifying that the essenflai functions have been
properly identified and are accurate.
Fit For Duty Testing As Part Of A Return To Work("RTW")Program To Include:
WorkSTEPS will be conducting Fit-far-Duty(Post-Injury RTW)Tests on existing employees to include the
following:
• Any reported injury,illness,or condition that gives the employer reasonable belief that the
employee's ability to perform essential job functions will be impaired or create a direct threat to
health and safety.
■ This category may also include testing at the request of the employer because,although there has
been no formal injury or medical condition reported,the employer has observed current
performance problems or has received reliable reports of performance problems indicating that the
employee may not be able to perform essential job functions,or may pose a direct threat to the
health and safety of the employee or others.
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DocuSign Envelope ID:00D05599-14C3-451 E-84B4-EDC8CADBDAFD
■ Even if the employee has fully"recovered"from injury or illness and no longer considers him or
herself"injured",for documentation purposes the test should be identified as a"post-injury"fit for
duty,or an injured worker,because that was the trigger for the test.
• When testing an employee post-injury or illness the provider will:
o Use the WorkSTEPS Fit for Duty Physical Capacity Consent Form
o Use the WorkSTEPS Post Injury Fit for Duty Medical History Interview
a Not perform"routine"medical measures,including heart rate and blood pressure,that are
not related to the injury or condition for which the employee is being seen,or that are not
contributing to a job related functional deficit.
v Not perform the standard"baseline"tests such as step test,Sorenson's or grip if they are
not related to the injured area.
o Perform only the dynamic lift postures that are considered qualifying criteria.
o Perform any and all standard job specific tasks for the position,and expand to include
any additional essential function tasks that could be impacted by their injury or condition.
DocuSigned by:
f jbin,ln.lt, �gw�w�t,yS�t� 9/3/2019
ampan resentativelTitle Date
Docu'S"igned by:
8/27/2019
Wor epresentative(Title Date
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DocuSign Envelope ID:00D05599-14C3-451 E-84B4-EDC8CADBDAFD
ACCIIJ?" CERTIFICATE OF LIABILITY INSURANCE PAT /28/2DIYYYY]
3
1z81zo1s
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(tes)must have ADDITIONAL INSURED provisions or be endorsed.
if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder In lieu of such endorsement($).
PRODUCER CNAMIACT 5electMed Unit
The Graham Company PHONE FAx
The Graham Building a MAIL Ext):215-567-6300 Arc Nos 215-405-2711
1 Penn Square West ADDRESS: SELECTME❑ UNIT@grahamco.com
Philadelphia PA 19102- INSURERS AFFORDING COVERAGE NAIC#
INSURER A.Columbia Casualty Company 31127
INSURED SELEMED-01 INSURER a:American Guarantee&Liability Ins.Co. 26247
SELECT PHYSICAL THERAPY HOLDINGS, INC. INSURERC:Allied World Assurance Company,Ltd. DOMICILED
c/o Select Medical Corporation
4716 Old Gettysburg Road INSURER D:Liberty Mutual Fire ins.Co. 23035
Mechanicsburg PA 17055 INSURER E:Li be rty Insurance Cor oration 42404
INSURER F:
COVERAGES CERTIFICATE N UMBER:788083230 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD SUBR POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE JNSD I WVD POLICYNUMBER 4MMIDDlYYYY M
M1ODrYYY
COM M ERCIAL GEN E RA L LIABILITY EACH OCCURRENCE S
DAMAUE TO RENTED
CLAIMS-MADE 7OCCUR PREMISES Ea occurrence $
MEd EXP Any oneperson) $
PERSONAL&ADV INJURY $
GEN'L AG G REGATE LI MIT APPLIES PER: GENERAL AGGREGATE $
POLICY PRO JECT LOC PRODUCTS-COMPIOP AGG $
OTHER: $
D AUTOMOBILE LIABILITY A82-631-509047-039 4/1/2019 41112020 COMBINED SINGLE LIMIT $2,000,ODD
Ea accident
X ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY ALTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
C UMBRELLA LIAR X OCCUR C001445-017 12J3112018 12/31/2019 EACH OCCURRENCE $25,000,000
X EXCESS LIAR CLAIMS-MADE AGGREGATE $25,000.00D
DED I RETENTIONS $
E WORKERS COMP ENSATiON WA7-630-509047-019 4/1/2019 4/1/2020 X STEAARTUTE ERN-
E AND EMPLOYERS•L"ILITY Yr N WC5-632-509047.029 41112019 4/1/2020
ANY PROPRIETORIPARTNERIEXECUTIVE ❑ N rA E,L,EACH ACCIDENT $1,000,000
OFF ICERIMEMB E R EXC LU DED7
(Mandatory in NH) L.DISEASE-EA EMPLOYEE $1,DDD,OOD
if s,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
A Excess General+Pra[esslonal Llab, HMU2066248465-15 12/3112018 12J3112019 see Below
B Property ZMD5917837-13 12/3112018 12/31/2019 See Below
IT
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required)
EXCESS COMMERCIAL GENERAL LIABILITY COVERAGE(CGL)-$10M Each Occurrencel$10M Aggregate Limit Excess of$2M Self-Insured Retention;
EXCESS PROFESSIONAL LIABILITY COVERAGE(PL)-$7M Each Claiml$71V Aggregate Limit Excess of$5M Self-Insured Retention;Both Coverages are
subject to a$10M Policy Aggregate Limit.
PROPERTY COVERAGE: $6,000,000 Limit for Unnamed/Unscheduled Locations; Specified Limits for Scheduled Locations.
Coverage is provided for all medlcaI professionals currently or previously employed or contracted by the above Named Insured,but only for professional
services performed for or on behalf of the above Named Insured.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Select Physical Therapy Holdings, Inc, ACCORDANCE WITH THE POLICY PROVISIONS.
dba Select Physical Therapy
c/o Select Medical Corporation AUTHOR IZED RE P R ES ENTATIVE
4716 Old Gettysburg Road
Mechanicsburg PA 17055
D 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD