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HomeMy WebLinkAbout2019-782-E Animal Svc - Amanda Chapman DVM veterinary services DocuSign Envelope ID: ED70ABD7-FFE4-4C25-B3D1-84A819C70CE2 [Departmental Use Only] TITLE Amanda Chapman, DVM FY 19-20 ORANGE COUNTY CONTRACT UNDER$5,000.00 NORTH CAROLINA THIS AGREEMENT, made and entered into this 19th day of June, 2019, ("Effective Date") by and between Orange County, North Carolina, a body politic and corporate organized under the laws of the State of North Carolina, (the "County"), party of the first part; and Amanda Chapman, DVM (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 and/or construction (hereinafter referred to collectively as "Services") to be furnished under this Agreement are as follows: To administer three year rabies vaccines and implant microchips for the community at the rabies and microchip clinics held by Orange County Animal Services. The term of this agreement rendered shall be from July 1,2019 to June 30,2020. 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 one thousand dollars, ($1,000 at a rate of$150 per three-hour clinic). 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 Revised 12/18 1 DocuSign Envelope ID: ED70ABD7-FFE4-4C25-B3D1-84A819C70CE2 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 be designated here Professional 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, 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 in carrying out Provider's duties and obligations related to the Services to be provided in this Agreement. 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 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. Modifications may be evidenced by telefacsimile signature. 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. Governing Law and Priority: Both parties agree that this Agreement shall be governed by the laws of the State of North Carolina and Orange County. 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.oran ec�ountync. og v/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 certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.58. By executing this Agreement Provider certifies that Provider has not been identified, and has not utilized the services of any agent or subcontractor identified, on the list created by the State Treasurer pursuant to G.S. 147-86.81. By executing this Agreement Provider affirms Provider is and shall remain in compliance with Article 2 of Chapter 64 of the North Carolina General Statutes. In determining the basic services to be provided, should any documents be referenced in or attached to this Agreement, the terms herein shall have priority in any conflict between the terms of referenced documents and the terms of this Agreement. 9. Dispute Resolution: Neither party may initiate binding arbitration. Any disputes shall be resolved by nonbinding mediation. If such mediation fails either party may initiate litigation to resolve the dispute. Should either party initiate litigation to settle any dispute involving the terms of this Agreement such litigation shall be initiated in the General Court of Justice of North Carolina seated in Orange County, North Carolina. Revised 12/18 2 DocuSign Envelope ID: ED70ABD7-FFE4-4C25-B3D1-84A819C70CE2 10. 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. IN WITNESS WHEREOF, Orange County and the Provider have signed this Agreement, effective as of the day first written above. ORANGE COUNTY PROVIDER oo��s,,. b,: oo��s�a�� ny C Rs By. :aasn:sa�nnann By. l�n.ns.tw Department Director Title: 200 S. Cameron St. Amanda Chapman, DVM P.O. Box 8181 104 Mullin Court Hillsborough,NC 27278 Chapel Hill,NC 27514 Revised 12/18 3 DocuSign Envelope ID: ED70ABD7-FFE4-4C25-B3D1-84A819C70CE2 AV M A I P L I T® Veterinary Professional Liability Protecting you through it all Insurance Policy Certificate of Insurance This policy provides occurrence coverage.Please review the policy carefully. Z U R I C H ITEM 1:Insured by the stock company below and hereinafter called the Company Zurich American Insurance Company U-VPL-103-A-CW(07/04) ITEM 2:Named Certificate Holder,member number,rating code and address Master Policy Number: Certificate Number: EOL 5241302-14 VETPR0069825 Amanda Leah Chapman,DVM FOR INFORMATION OR TO FILE A CLAIM 104 Mullin Court PLEASE CALL (800)228-7548 Chapel Hill,NC 27514 ITEM 3:Policy Period From: 01/01/2019 To: 01/01/2020 12:01 am Standard time at the address of the Named Certificate Holder as stated herein ITEM 4:Limits of Liability Member Name Member No. Rating Code Each claim $ 1,000,000 Amanda Chapman 265520 [IV]Small Animal Exclusive Aggregate $3,000,000 ITEM 5:Premium and coverage summary ITEM 6:Forms Attached at Issuance: Primary Professional Liability $248.00 U-VPL-100-A CW(07/04);U-VPL-103-A CW(07/04);U-GU-1191-A CW(03/15); Veterinary License Defense $94.00 U-VPL-128-A NC(10/04);U-VPL-I55-A NC(10/04);U-VPL-102-B CW(06/11); U-GU-319-F(01/09);U-GU-1194-A CW(08/15) ITEM 7: Schedule of Plan Numbers and location(s)for Professional Extension TOTAL DUE: $342.00 Endorsement(Animal Bailee)/Embryo and Semen Storage(if purchased): For additional locations,please see the attached page Location Number/Address Extension Plan Embryo Plan ITEM 8:Veterinary Professional Liability Regulatory Action License Defense Coverage endorsement(if purchased): This Certificate of Insurance is issued off the Master Policy held by the American Veterinary Medical Association(AVMA)Professional Liability Insurance Trust.By Limit: $25,000 acceptance of this policy the Named Certificate Holder agrees that the statements in the certificate and the application and any attachments hereto are the Named Authorized Signature Certificate Holder's agreements and representations and that this policy embodies all agreements existing between the Named Certificate holder&the Company or any s of its representatives relating to this insurance. Notice to the Company: Zurich American Insurance Company P.O.Box 968041 Neil R.Hughes,President Schaumburg,IL 60196-8041 HUB International Midwest Limited DocuSign Envelope ID: ED70ABD7-FFE4-4C25-B3D1-84A819C70CE2 SANCTIONS EXCLUSION Z U RI C H ENDORSEMENT THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY The following exclusion is added to the policy to which it is attached and supersedes any existing sanctions language in the policy, whether included in an Exclusion Section or otherwise: SANCTIONS EXCLUSION Notwithstanding any other terms under this policy, we shall not provide coverage nor will we make any payments or provide any service or benefit to any insured, beneficiary, or third party who may have any rights under this policy to the extent that such cover, payment, service, benefit, or any business or activity of the insured would violate any applicable trade or economic sanctions law or regulation. The term policy may be comprised of common policy terms and conditions, the declarations, notices, schedule, coverage parts, insuring agreement, application, enrollment form, and endorsements or riders, if any, for each coverage provided. Policy may also be referred to as contract or agreement. We may be referred to as insurer, underwriter, we, us, and our, or as otherwise defined in the policy, and shall mean the company providing the coverage. Insured may be referred to as policyholder, named insured, covered person, additional insured or claimant, or as otherwise defined in the policy, and shall mean the party, person or entity having defined rights under the policy. These definitions may be found in various parts of the policy and any applicable riders or endorsements. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED U-GU-1191-A CW (03/15) Page 1 of 1 DocuSign Envelope ID: ED70ABD7-FFE4-4C25-B3D1-84A819C70CE2 Endorsement 0 North Carolina Amendatory Endorsement Z U RI C H Certificate No. Eff.Date of Cert. Exp.Date of Cert. Eff.Date of End. Add'1 Prem. Return Prem. VETPR0069825 01/01/2019 01/01/2020 $342.00 $0.00 Named Certificate Holder and Mailing Address: Producer: HUB International Midwest Limited Amanda Leah Chapman,DVM 55 East Jackson Boulevard 104 Mullin Court Chicago,IL 60604-4187 Chapel Hill,NC 27514 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: Veterinary Professional Liability Insurance Policy It is agreed that Section IV—CONDITIONS,Paragraph D is deleted in its entirety and replaced with the following: 1. CANCELLATION a. This policy may be canceled by the Named Certificate Holder by surrender of the policy to the Company or by mailing written notice to the Company stating when such cancellation shall take effect. If canceled by the Named Certificate Holder,the Company shall retain the customary short-rate proportion of the premium. In no event may the requested date of cancellation be greater than ten(10)days prior to the date the request is received by the Company. b. If this policy has been in effect less than sixty (60) days, the Company may cancel this policy for any reason by mailing written notice by certified mail to the Named Certificate Holder at the address shown in the Certificate of Insurance, and mailing to the producer of record, if any. Such cancellation shall be no fewer than fifteen(15) days from the date the notice is mailed. Such notice shall state the reason for cancellation and if applicable be accompanied by a refund of unearned premium,except a premium that has been financed. c. If this policy is in effect sixty(60)days or more,the Company may cancel this policy for the following reasons: (1) Nonpayment of premium in accordance with the policy terms; (2) An act or omission by the Named Certificate Holder or his representative that constitutes material misrepresentation or nondisclosure of a material fact in obtaining the policy, continuing the policy, or presenting a Claim under the policy; (3) Increase hazard or material change in the risk assumed that could not have been reasonably contemplated by the parties at the time of assumption of the risk; (4) Substantial breach of contractual duties,conditions,or warranties that materially affects the insurability of the risk; (5) A fraudulent act against the company by the Named Certificate Holder or his representative that materially affects the insurability of the risk; (6) Willful failure by the Named Certificate Holder or his representative to institute reasonable loss control measures that materially affect the insurability of the risk after written notice by the company; (7) Loss of facultative reinsurance,or loss of or substantial changes in applicable reinsurance as provided in G.S.58-41-30; (8) Conviction of the Insured of a crime arising out of acts that materially affect the insurability of the risk;or (9) A determination by the commissioner that the continuation of the policy would place the Company in violation of the laws of the state of North Carolina. If the Company cancels subject to c(1) through c(9) above, the Company will mail by certified mail to the Named Certificate Holder at the address shown in the Certificate of Insurance,and mail to the producer of record,if any. Written notice of cancellation shall take effect fifteen(15)days from the date of mailing for the reasons set forth in c(1) through c(9)above. Any written notice of cancellation subject to c(1) through c(9) will state the reason for such cancellation and will be accompanied by a refund of unearned premium,except a premium that has been financed. d. If notice is mailed,proof of mailing will be sufficient proof of notice. e. The Company shall refund the unearned premium computed at customary short rates if the policy is terminated by the Named Certificate Holder. Under any other circumstances the refund shall be computed pro rata. U-VPL-128-A-NC(09/04) Page 1 of 2 DocuSign Envelope ID: ED70ABD7-FFE4-4C25-B3D1-84A819C70CE2 2. NONRENEWAL a. If the Company elects not to renew this policy,the Company shall mail by certified mail to the Named Certificate Holder at the address shown in the Certificate of Insurance, and mail to the producer of record, if any,written notice of nonrenewal. The Company may refuse to renew a policy that has been written for a Policy Period of one (1)year or less at the policy's expiration date by mailing written notice of nonrenewal to the Named Certificate Holder at the address shown in the Certificate of Insurance at least forty-five(45)days prior to the expiration date of the policy. The Company may refuse to renew a policy that has been written for a Policy Period of more than one (1)year at the policy anniversary date by mailing written notice of nonrenewal to the Named Certificate Holder at the address shown in the Certificate of Insurance at least forty-five(45)days prior to the anniversary date of the policy. b. The Company must file a plan with the commissioner at least fifteen(15) days before the issuance of a nonrenewal because of loss or reduction of reinsurance. c. If notice is mailed,proof of mailing will be sufficient proof of notice. d. If either one of the following occurs,the company is not required to provide written notice of nonrenewal: (1) The Named Certificate Holder has insurance elsewhere; (2) The Named Certificate Holder has obtained replacement coverage or agreed in writing to do so;or (3) The Named Certificate Holder has requested or agreed to nonrenewal. e. The policy may not be extended to meet nonrenewal notice requirements in a.above. d. The transfer of a policy between companies within the same insurance group or changes in premium, Limit of Liability or coverage are not refusals to renew. 3. CONDITIONAL RENEWAL a. If the Company elects to renew this policy and the renewal is subject to the following: (1) reduction in coverage; (2) impose any kind of surcharge;or (3) increase premium rate. b. If the policy being conditionally renewed was written for a Policy Period of one (1) year or less, the renewal terms and statement of premium due must be mailed at least forty-five (45) days before the expiration date of the policy. If the policy being conditionally renewed was written for a Policy Period of more than one (1) year, the renewal terms and statement of premium due must be mailed at least forty-five(45)days before the anniversary date of that policy. The Company shall mail or deliver by certified mail written notice of the changes to the Named Certificate Holder at the address shown in the Certificate of Insurance,and mailed to the producer of record,if any. c. If the Company fails to furnish the conditional renewal terms and statement of premium due in the manner required in b above, the Named Certificate Holder may cancel the renewal policy within the thirty (30) day period following receipt of the conditional renewal terms and statement of premium due. For refund purposes, earned premium for any period of coverage shall be calculated pro-rata upon the premium applicable to the policy being renewed instead of the renewal policy. d. If the Company fails to comply with the forty-five (45) day written notice requirement in b. above, the Named Certificate Holder is entitled to the option of coverage under the policy being renewed and at the same cost of that policy until forty-five (45)days have elapsed after the Company has provided the Named Certificate Holder with the notice. e. If a policy has been issued for a Policy Period longer than one(1)year,and for additional consideration a premium has been guaranteed for the entire Policy Period, it is unlawful for the Company to increase that premium or other policy or coverage provisions less favorable to the Named Certificate Holder during the term of the policy. All other terms,conditions and exclusions of this policy remain unchanged. Signed by: 10/18/2018 Date Authorized Representative U-VPL-128-A-NC(09/04) Page 2 of 2 DocuSign Envelope ID: ED70ABD7-FFE4-4C25-B3D1-84A819C70CE2 Endorsement 0 North Carolina Amendatory Endorsement Z U RI C H Certificate No. Eff.Date of Cert. Exp.Date of Cert. Eff.Date of End. Add'1 Prem. Return Prem. VETPR0069825 01/01/2019 01/01/2020 $342.00 $0.00 Named Certificate Holder and Mailing Address: Producer: HUB International Midwest Limited Amanda Leah Chapman,DVM 55 East Jackson Boulevard 104 Mullin Court Chicago,IL 60604-4187 Chapel Hill,NC 27514 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the: Veterinary Professional Liability Insurance Policy It is agreed that the Veterinary Professional Liability Bailee Extension Endorsement, U-VPL-101-A CW (07/04), Section IV— ADDITIONAL CONDITIONS,Paragraph I is deleted in its entirety and replaced with the following: I. SUIT No suit, action or proceeding for the recovery of any Claim under this endorsement shall be sustainable in any court of law or equity unless the same be commenced within three (3) years after discovery by the Insured of the event which gives rise to the Claim. The three(3)year period of time will be extended by the number of days between the date proof of loss was submitted and the date the Claim is denied in whole or in part. All other terms,conditions and exclusions of this policy remain unchanged. S Signed by: 10/18/2018 Date Authorized Representative U-VPL-155-A-NC(09/04) Page 1 of 1 DocuSign Envelope ID: ED70ABD7-FFE4-4C25-B3D1-84A819C70CE2 Fraud Warnings Disclosure Z U RI C H TO BE ATTACHED TO AND FORM PART OF THE APPLICATION. IF FRAUD WARNINGS ARE INCLUDED IN THE APPLICATION TO WHICH THIS IS ATTACHED, THIS DISCLOSURE REPLACES THOSE WARNINGS. Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. (Not applicable in AL, AR, CO, DC, FL, KS, KY, LA, MD, ME, NJ, NM, NY, OH, OK, OR, PA, PR, RI, TN, TX, VA, VT, WA, and WV.) In Arkansas, Louisiana, Rhode Island, or West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. In Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison, or any combination thereof. In Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. In District of Columbia: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. In Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. In Kansas: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to an insurer, purported insurer, or to or by a broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act and may be subject to criminal and/or civil fines or penalties. In Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. In Maine, Tennessee, Virginia, or Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. U-GU-1147-A (01/14) Page 1 of 2 DocuSign Envelope ID: ED70ABD7-FFE4-4C25-B3D1-84A819C70CE2 In Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. In New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. In New Mexico: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. In New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. In Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. In Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. In Oregon: Any person who knowingly and with intent to defraud any insurer or other person files an application for insurance or statement of claim containing any materially false information upon which an insurer relies, if such information was either material to the risk assumed by the insurer or the misinformation was provided fraudulently, may commit a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. In Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. In Puerto Rico: Any person who has committed fraud, as defined in the law, shall incur a felony, and if convicted, shall be sanctioned for each violation by a penalty of a fine of not less than five thousand dollars ($5,000), nor more than ten thousand dollars ($10,000), or a penalty of imprisonment for a fixed term of three (3)years, or both penalties. If there were aggravating circumstances, the fixed penalty thus established may be increased up to a maximum of five (5) years; if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. In addition to the penalties provided in this chapter, any person who, as a result of the fraud thus committed is benefited in any way to obtain insurance, or in the payment of a loss pursuant to an insurance contract, shall be imposed the payment of restitution of the amount of money resulting from the fraud. Every violation shall have a prescription term of(5)five years. In Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. In Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. The undersigned, on behalf of all Insureds, acknowledges that discovery of any fraud, intentional concealment, or misrepresentation of any material fact may render this policy, if issued, voidable at inception or otherwise cancelled. Applicant Applicant Name and Title: Amanda Leah Chapman, DVM Date: 01/01/2019 Applicant Signature: U-GU-1147-A (01/14) Page 2 of 2 DocuSign Envelope ID: ED70ABD7-FFE4-4C25-B3D1-84A819C70CE2 ZURICH Important Notice to Policyholders The address for the headquarters of Zurich North America will change after August 1, 2016 due to a relocation of our office in the same city. The new address is: Customer Inquiry Center Zurich North America 1299 Zurich Way Schaumburg, IL 60196 1-800-382-2150 For specific questions regarding your policy, please contact your agent or broker. For other questions, you may contact the Customer Inquiry Center of Zurich North America. Any references to post office boxes previously provided remain unchanged. U-GU-1194-A CW(08/15) Page 1 of 1