HomeMy WebLinkAbout2020-446-E Animal Svc-Mikaela Archambeault vet servicesRev 5/19
TITLE Mikaela Archambeault, DVM
FY 2020-21
NORTH CAROLINA
ORANGE COUNTY
AN AGREEMENT FOR THE PROVISION OF CONSULTING VETERINARY
SERVICES AND THE PERFORMANCE OF SPAY/NEUTER SERVICES
This Agreement is between the County of Orange (“County”) through the Animal Services
Department (“Department”) and Mikaela Archambeault, DVM, (“Veterinarian”) whose address is
836 Ember Drive, Durham NC 27703, for the provision of spay/neuter surgery services and back
up consulting veterinary services
WITNESSETH
WHEREAS, the County has a need for the services of a veterinarian with whom to consult in
regard to practices and procedures regarding animal health and to provide in -house spay/neuter
surgery services for animals adopted from or available to be adopted from the Department; and
WHEREAS, Mikaela Archambeault, DVM, a licensed veterinarian in the State of North Carolina
desires to provide consultation and surgical services to Orange County through the Animal
Services Department.
NOW, THEREFORE, in consideration of the promises and of the mutual covenants hereinafter set
forth, Orange County and Veterinarian agree to the following terms and conditions:
A. The Veterinarian agrees to the following:
1. Work with the Principal DVM, as required by the Veterinary Health Care Manager,
to provide up to 8.5 hours per week of services including, but not limited to,
procedures for sterilization, examination and treatment in accordance with the
Department’s standard operating guidelines; and
a. Surgical services shall be provide for up to 8.5 hours per week, unless the
veterinarian is providing back up coverage in absence of the other
contracted veterinarian or otherwise approved by the Veterinary Health
Care Manager (up to an additional 8.5 hours per week). The surgical
services shall be scheduled during the time period Monday through Friday,
8:00 am to 3:00 pm (unless otherwise approved by the Veterinary Health
Care Manager); and
b. Perform sterilization surgery services on select animals by performing a
complete ovariohysterectomy for female animals and castration for male
animals; and
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c. Conduct a pre-surgical physical examination of the animal to determine the
animal’s suitability for surgery. Any medical and physical abnormalities
that present upon examination will be documented in the animal’s medical
record and communicated to the Veterinary Health Care Manager or
designee. The Veterinarian shall consult with the Veterinary Health Care
Manager or appropriate designee prior to and concerning decisions to
disqualify an animal for surgery; and
d. Document the physical examination, any abnormalities, treatments and/or
surgical procedures performed for each animal in the animal’s medical
record; and
2. When needed as back up, provide consultation services to the Department,
including telephone consultation and on-site veterinary services in absence of the
other contracted veterinarian or as otherwise approved by the Veterinary Health
Care Manager. Consultation services to occur Monday through Sunday, and to be
available as needed to provide additional back-up coverage during a given week;
Veterinary services include, but are not limited to, animal health and husbandry;
disease outbreak and managing the care of individual animals with infirmities;
supervision of any staff implementing electronic identification devises
(“microchips”) into animals within the care of the Animal Services Department;
and
3.. Maintain a license to practice veterinary medicine, that is current and in good
standing, in the state of North Carolina as well as the level of expertise and
education necessary to keep abreast of current industry standards and practices; and
4. Maintain professional liability insurance coverage with coverage of at least $1
million, per occurrence, $1 million aggregate while providing services to the
Department, proof of such insurance shall be submitted annually to the Department;
and
5. Be a member in good standing of the American Veterinary Medical Association;
and
6. The Veterinarian agrees to defend, indemnify, and hold harmless the County, its
elected officials, employees or volunteers for all loss, liability, claims or expense
(including reasonable attorney's fees) 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 section
to require Provider to indemnify the County to the extent permitted under North
Carolina law; and
7. Comply with all applicable federal, State, and local laws, including non-
discrimination laws as may be applicable in fulfilling this agreement; and
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8. The Veterinarian shall submit an invoice for services rendered to the Department
on a monthly basis.
B. The County agrees to:
1. Payment. Orange County shall reimburse the Veterinarian for an amount not to
exceed Twenty Thousand Dollars ($20,000) for services rendered from July 1, 2019
to June 30, 2021, and as provided herein.
C. The Parties Agree to:
1. Term. The term of this Agreement shall be from July 1, 2020 through June 30,
2021, unless terminated sooner.
2. Terms of Payment.
a. The County shall pay the Veterinarian for consultation and surgical services
at a rate of Forty-Two Dollars ($42.00) per hour; and
b. Upon submission of an invoice, the County shall reimburse the Veterinarian
in an amount up to Five Hundred Dollars ($500) for any expenses related to
performance of this Agreement.
c. The Department shall pay the Veterinarian for services rendered within
thirty (30) days of an invoice properly submitted.
3. Termination of Prior Agreements and Amendments. This agreement supersedes
and nullifies any and all prior agreements or any amendments to the Agreements
between the County and Veterinarian.
4. Termination. This Agreement may be terminated at any time without penalty by
either party, with or without cause, upon delivery of written notice of termination
furnished to the other party at least thirty days prior to termination of the
Agreement. In the event of such termination, any payment due shall be prorated to
the date of termination.
5. Waiver. The payment of any sums by the County under this Agreement or the
failure of the County to require compliance by the Veterinarian 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 other required compliance with this Agreement.
6. Suspension. County may suspend the services to be rendered under this Agreement
and this Agreement at any time for County’s convenience and without penalty to
County upon three (3) days’ notice to Veterinarian. Upon any suspension by
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County, Veterinarian will discontinue work on the services and shall not resume
the services until notified to proceed by County.
7. Notice. Notice shall be provided to and sent as follows:
a. For Orange County: Robert A. Marotto, Animal Services Director, Orange
County, Animal Services Center, 1601 Eubanks Road, Chapel Hill, North
Carolina 27516.
b. For Mikaela Archambeault: Mikaela Archambeault, DVM, whose address is 836
Ember Drive, Durham NC 27703.
8. OSHA Compliance. Orange County controls the facilities where the Veterinarian
works. It is agreed Orange County is primarily responsible for compliance with the
Occupational Safety and Health Act (OSHA) and comparable state laws and
regulations to the extent those laws apply to the Veterinarian.
9. Workers Compensation. Veterinarian is responsible for her own workers’
compensation.
10. Independent Contractor. The services which Veterinarian shall render under this
Agreement shall be as an independent contractor with respect to Orange County.
Nothing contained in this Agreement shall be construed to create the relationship
of principal and agent, or employer and employee, between Veterinarian and
Orange County.
11. Limitation and Assignment. The County and Veterinarian each bind themselves,
their successors, assigns, and legal representatives to the terms of this Agreement.
Neither the County nor the Veterinarian shall assign or transfer its interest in this
Agreement without the written consent of the other.
12. Non-Appropriation. No provision of this Agreement shall be construed or
interpreted as creating a pledge of the faith and credit of the Orange County within
the meaning of any constitutional debt limitation. No provision of this Agreement
shall be construed or interpreted as creating a delegation neither of go vernmental
powers nor as a donation by a lending of the credit of Orange County within the
meaning of the Constitution of the State of North Carolina. This Agreement shall
and does not directly or indirectly or contingently obligate the Orange County to
make any payments beyond those appropriated in the sole discretion of Orange
County for any fiscal year in which this Agreement shall be in effect. No deficiency
judgment may be rendered against Orange County in any action for breach of a
contractual obligation under this Agreement and the taxing power of Orange
County is not and may not be pledged directly or indirectly or contingently to secure
any monies due under this Agreement.
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13. Entire Agreement. This Agreement contains the entire understanding of the parties
and shall not be altered, amended or modified except by an agreement in writing
executed by the duly authorized officials of both parties.
14. 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.
15. Ownership of Work Product. Should Veterinarian’s performance of this Agreement
generate documents, items or things that are specific to the services rendered to the
County such documents, items, or things shall become property of the County and
may be used on any other project without additional compensation to the
Veterinarian. The use of the documents, items, or things by the County or by any
person or entity for any purpose other than the services rendered to the County as
set forth in this Agreement shall be at the full risk of the County.
16. 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 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.
17. Non-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 non-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 refer ence and may be
viewed at
http://www.orangecountync.gov/departments/purchasing_division/contracts.php).
Any violation of the Orange County Non-Discrimination Policy 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.
18. 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
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agree to nonbinding mediation of any dispute prior to the bringing of such suit or
action.
19. 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 11A and Article 40 of North Carolina
General Statute Chapter 66.
IN WITNESS WHEREOF, the parties have hereunto signed this Agreement on the day and year
listed below.
FOR Mikaela Archambeault, DVM
____________________________________________ __________________________
Mikaela Archambeault, DVM Date
FOR AND ON BEHALF OF ORANGE COUNTY
_________________________________________ ______________________________
Bonnie Hammersley, Manager Date
DocuSign Envelope ID: C45900A9-8459-476D-8E28-F48F22DEF55B
7/1/2020
7/2/2020
Rev 5/19
ORANGE COUNTY—DEPARTMENT USE ONLY
______________________________________________________________________________
Party/Vendor Name: Mikaela Archambeault, DVM Party/Vendor Contact Person: Mikaela Archambeault Contact
Phone: 919-434-9725 Party/Vendor Address: 836 Ember Drive City Durham State: NC Zip: 27703 Department:
Animal Services Amount: Up to $10,000 Purpose: Veterinary Services Budget Code(s): 10215020 629010 and
629004 Vendor # 65325 (N/A if new vendor) Vendor is a BOCC consultant? Yes No Contract Type:
(Check one) New Renewal Amendment Effective Date Approved by Board Yes No
Agenda Date:
This agreement is approved as to technical form and content and I as Department Director affirmatively state work on
this project has not been initiated prior to execution of the agreement:
Department Director’s Signature ________________________________________ Date: ________
Agreements for emergency services or repair are not subject to the above affirmation. If services related to this
agreement have already begun or been completed please briefly describe the nature of the emergency condition that
was addressed:
Information Technologies
(Applicable only to hardware/software purchases or related services) This agreement has been reviewed and is
approved as to information technology content and specifications:
Office of the Chief Information Officer___________________________________ Date: ________
Risk Management
This agreement is approved for sufficiency of insurance standards, specifications, and requirements:
Office of the Risk Management Officer___________________________________ Date: _________
Financial Services
This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act:
Office of the Chief Financial Officer ____________________________________ Date: _________
Legal Services
This agreement is approved as to legal form and sufficiency:
Office of the County Attorney __________________________________________Date: ________
Clerk to the Board
Received for record retention:
All Docusign contracts must be copied to Sherri Ingersoll upon completion: singersoll@orangecountync.gov
The following signature block is for hard copies only and is not required for Docusign contracts:
Office of the Clerk to the Board __________________________________________Date:_________
DocuSign Envelope ID: C45900A9-8459-476D-8E28-F48F22DEF55B
7/1/2020
7/2/2020
7/2/2020
7/2/2020
Veterinary Professional Liability
Insurance Policy
Certificate of Insurance
This policy provides occurrence coverage. Please review the policy carefully.
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 -15 VETPRO154151
FOR INFORMATION OR TO FILE A CLAIM
PLEASE CALL (800) 228-7548
ITEM 3: Policy Period
From:01/01/2020
To:01/01/2021
12:01 am Standard time at the address of the Named Certificate Holder
as stated herein
Mikaela P Archambeault, DVM
836 Ember Drive
Durham, NC 27703
ITEM 4: Limits of Liability
Member Name Member No.Rating Code Each claim $ 1,000,000
Mikaela Archambeault 275855 [IV] Small Animal Exclusive Aggregate $ 3,000,000
ITEM 5:Premium and coverage summary ITEM 6: Forms Attached at Issuance:
U-VPL-100-A CW (07/04); U-VPL-103-A CW (07/04); U-GU-1191-A CW (03/15);
U-VPL-128-A NC (10/04); U-VPL-155-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
Endorsement (Animal Bailee) / Embryo and Semen Storage (if purchased):
For additional locations, please see the attached page
Primary Professional Liability
Veterinary License Defense
TOTAL DUE:
$248.00
$120.00
$368.00
Location Number/Address Extension Plan Embryo Plan
ITEM 8:Veterinary Professional Liability Regulatory Action License Defense
Coverage endorsement (if purchased):
Limit:$ 50,000
Authorized Signature
Neil R. Hughes, President
HUB International Midwest Limited
This Certificate of Insurance is issued off the Master Policy held by the American
Veterinary Medical Association (AVMA) Professional Liability Insurance Trust. By
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
Certificate Holder’s agreements and representations and that this policy embodies all
agreements existing between the Named Certificate holder & the Company or any
of its representatives relating to this insurance.
Notice to the Company: Zurich American Insurance Company
P.O. Box 968041
Schaumburg, IL 60196-8041
DocuSign Envelope ID: C45900A9-8459-476D-8E28-F48F22DEF55B
SANCTIONS EXCLUSION
ENDORSEMENT
U-GU-1191-A CW (03/15)
Page 1 of 1
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
DocuSign Envelope ID: C45900A9-8459-476D-8E28-F48F22DEF55B
Endorsement
North Carolina Amendatory Endorsement
U-VPL-128-A-NC (09 / 04)
Page 1 of 2
Title of form must not be placed above the logo
↑ Top Margin 3/4"
Certificate No.Eff. Date of Cert.Exp. Date of Cert.Eff. Date of End.Add’l Prem.Return Prem.
VETPRO154151 01/01/2020 01/01/2021 $368.00 $0.00
Named Certificate Holder and Mailing Address:
Mikaela P Archambeault, DVM
836 Ember Drive
Durham, NC 27703
Producer:
HUB International Midwest Limited
55 East Jackson Boulevard
Chicago, IL 60604-4187
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.
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U-VPL-128-A-NC (09 / 04)
Page 2 of 2
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.
10/16/2019Signed by:
Date
Authorized Representative
DocuSign Envelope ID: C45900A9-8459-476D-8E28-F48F22DEF55B
Endorsement
North Carolina Amendatory Endorsement
U-VPL-155-A-NC (09 / 04)
Page 1 of 1
Title of form must not be placed above the logo
↑ Top Margin 3/4"
Certificate No.Eff. Date of Cert.Exp. Date of Cert.Eff. Date of End.Add’l Prem.Return Prem.
VETPRO154151 01/01/2020 01/01/2021 $368.00 $0.00
Named Certificate Holder and Mailing Address:
Mikaela P Archambeault, DVM
836 Ember Drive
Durham, NC 27703
Producer:
HUB International Midwest Limited
55 East Jackson Boulevard
Chicago, IL 60604-4187
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.
10/16/2019Signed by:
Date
Authorized Representative
DocuSign Envelope ID: C45900A9-8459-476D-8E28-F48F22DEF55B
U-GU-1147-A (01/14)
Page 1 of 2
Fraud Warnings Disclosure
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.
DocuSign Envelope ID: C45900A9-8459-476D-8E28-F48F22DEF55B
U-GU-1147-A (01/14)
Page 2 of 2
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:Mikaela P Archambeault, DVM Date:01/01/2020
Applicant Signature:
DocuSign Envelope ID: C45900A9-8459-476D-8E28-F48F22DEF55B
Important Notice to Policyholders
U-GU-1194-A CW (08/15)
Page 1 of 1
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.
FORMAT IS A SAMPLE OF A BLANK FORM
DocuSign Envelope ID: C45900A9-8459-476D-8E28-F48F22DEF55B