HomeMy WebLinkAbout2020-485-E Health-Triangle Urology vasectomy servicesRevised 6/20
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[Departmental Use Only]
TITLE Triangle Urology-Sterilization
FY 2020-2021
NORTH CAROLINA
SERVICES AGREEMENT NO RFP/RFQ
ORANGE COUNTY
This Services Agreement (hereinafter “Agreement”), made and entered into this first day of
July, 2020, (“Effective Date”) by and between Orange County, North Carolina a political
subdivision of the State of North Carolina (hereinafter, the "County") and Triangle Urology
Associates, P.A, (hereinafter, the "Provider").
WITNESSETH:
That the County and Provider, for the consideration herein named, do hereby agree as
follows:
1. Services
a. Scope of Work.
i) This Agreement is for services to be rendered by Provider to County with respect
to (insert type of project): Medical Services
ii) By executing this Agreement, the Provider represents and agrees that Provider is
qualified to perform and fully capable of performing and providing the services
required or necessary under this Agreement in a fully competent, professional and
timely manner.
iii) Time is of the essence with respect to this Agreement.
iv) The services to be performed under this Agreement consist of Basic Services, as
described and designated in Section 3 hereof. Compensation to the Provider for
Basic Services under this Agreement shall be as set forth herein.
2. Responsibilities of the Provider
a. Services to be provided. The Provider shall provide the County with all services
required in Section 3 to satisfactorily complete the Project within the time limitations set
forth herein and in accordance with the highest professional standards.
b. Standard of Care.
i) The Provider shall exercise reasonable care and diligence in performing services
under this Agreement in accordance with the highest generally accepted standards
of this type of Provider practice throughout the United States and in accordance
with applicable federal, state and local laws and regulations applicable to the
performance of these services. Provider is solely responsible for the professional
DocuSign Envelope ID: F746D5BF-EF42-497A-9B83-D263FC4E623D
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quality, accuracy and timely completion and/or submission of all work related to
the Basic Services.
ii) Provider shall be responsible for all errors or omissions of its agents, contractors,
employees, or assigns in the performance of the Agreement. Provider shall
correct any and all errors, omissions, discrepancies, ambiguities, mistakes or
conflicts at no additional cost to the County.
iii) The Provider shall not, except as otherwise provided for in this Agreement,
subcontract the performance of any work under this Agreement without prior
written permission of the County. No permission for subcontracting shall create,
between the County and the subcontractor, any contract or any other relationship.
iv) Provider is an independent contractor of County. Any and all employees of the
Provider engaged by the Provider in the performance of any work or services
required of the Provider under this Agreement, shall be considered employees or
agents of the Provider only and not of the County, and any and all claims that may
or might arise under any workers compensation or other law or contract on behalf
of said employees while so engaged shall be the sole obligation and responsibility
of the Provider.
v) If activities related to the performance of this Agreement require specific licenses,
certifications, or related credentials Provider represents that it and/or its
employees, agents and subcontractors engaged in such activities possess such
licenses, certifications, or credentials and that such licenses certifications, or
credentials are current, active, and not in a state of suspension or revocation.
vi) In determining the Basic Services to be provided, should any documents be
referenced in this Agreement, the terms of this Agreement shall have priority in
any conflict between the terms of referenced documents and the terms of this
Agreement.
vii) Should this Agreement involve project designs, the construction or creation of
which is to be bid out and/or fulfilled by other contractors, and bidding or
negotiation with contractors produce prices which, when added to the other
elements of the approved total project cost, produce a cost that is in excess of the
approved total project cost, the Provider shall participate with the County in
negotiation and design adjustments to the extent such are necessary to obtain
prices within the approved total project cost. All activity of the Provider with
respect to these matters shall constitute Basic Services and shall be performed by
the Provider without additional compensation. If negotiation and design
adjustments fail to bring costs within the total project cost the County may reject
all bids and Provider will redesign and/or reduce portions of the project in an
effort to reduce the bid prices to within the total project cost and rebid the project.
One such redesign is included within Basic Services. If thi s second letting for
bids does not produce bids that are within the approved total project cost initially
or after negotiations with the contractor the cost is not reduced to an amount
within the total project cost, the Provider is not obligated to engage in further
redesign.
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3. Basic Services
a. Basic Services. The Services to be rendered pursuant to this Agreement are as follows
(fully describe services to be provided): Perform vasectomy and post-procedure semen
analysis to uninsured males referred by Orange County Health Department. OCHD will
pay Provider $900 per procedure performed inclusive of the post-precedure semen
analysis.
4. Duration of Services
a. Term. The term of this Agreement shall be from July 1, 2020 to June 30, 2021.
b. Scheduling of Services.
i) The Provider shall schedule and perform its activities in a timely manner.
ii) Should the County determine that the Provider is behind schedule, it may require
the Provider to expedite and accelerate its efforts, including providing additional
resources and working overtime, as necessary, to perform its services in
accordance with the approved project schedule at no additional cost to the
County.
iii) The Commencement Date for the Provider's Basic Services shall be July 1, 2020.
5. Compensation
a. Compensation for Basic Services. Compensation for Basic Services shall include all
compensation due the Provider from the County for all services satisfactorily (as
determined by the County) performed pursuant to this Agreement. The maximum
amount payable for Basic Services shall not exceed Nine Thousand Nine Hundred
Dollars ($9,900). Payment for satisfactorily performed Basic Services shall become due
and payable within thirty (30) days of Provider properly invoicing County. Payment
shall be subject to provisions of Section 5(b).
b. Disputes. In the event the amount stated on an invoice is disputed by the County, the
County may withhold payment of all or a portion of the amount stated on an invoice
until the parties resolve the dispute. Should Provider fail to perform its duties under the
terms of this Agreement, County may, without fault or penalty, withhold any payment
associated with the work to be performed until such time as said work is completed.
c. Additional Services. County shall not be responsible for costs related to any services in
addition to the Basic Services performed by Provider unless County requests such
additional services in writing and such additional services are evidenced by a written
amendment to this Agreement.
6. Responsibilities of the County
a. Cooperation and Coordination. The County has designated (Pam McCall) to act as the
County's representative with respect to the Project and shall have the authority to render
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decisions within guidelines established by the County Manager and/or the County Board
of Commissioners and shall be available during working hours as often as may be
reasonably required to render decisions and to furnish information.
7. Insurance
a. General Requirements. Provider shall obtain, at its sole expense, Commercial General
Liability Insurance, Automobile Insurance, Workers’ Compensation Insurance, and any
additional insurance as may be required by County’s Risk Manager as such insurance
requirements are described in the Orange County Risk Transfer Policy and Orange
County Minimum Insurance Coverage Requirements (each document is incorporated
herein by reference and may be viewed at
http://www.orangecountync.gov/departments/purchasing_division/contracts.php). If
County’s Risk Manager determines additional insurance coverage is required such
additional insurance shall consist of N/A (if no additional insurance required mark N/A
as being not applicable). Provider shall not commence work until such insurance is in
effect and certification thereof has been received by the County's Risk Manager.
8. Indemnity
a. Indemnity. To the extent authorized by North Carolina law the Provider agrees, without
limitation, to defend, indemnify and hold harmless the County from all loss, liability,
claims or expense, including attorney's fees, arising out of or related to the Project and
arising from property damage or bodily injury including death to any person or persons
caused in whole or in part by the negligence or misconduct of the Provider except to the
extent same are caused by the negligence or willful misconduct of the County. It is the
intent of this provision to require the Provider to indemnify the County to the fullest
extent permitted under North Carolina law.
9. Amendments to the Agreement
a. Changes in Basic Services. Changes in the Basic Services and entitlement to additional
compensation or a change in duration of this Agreement shall be made by a written
Amendment to this Agreement executed by the County and the Provider. The Provider
shall proceed to perform the Services required by the Amendment only after receiving a
fully executed Amendment from the County.
10. Termination
a. Termination for Convenience of the County. This Agreement may be terminated without
cause by the County and for its convenience upon seven (7) days’ prior written notice to
the Provider.
b. Other Termination. The Provider may terminate this Agreement based upon the County's
material breach of this Agreement; provided, the County has not taken all reasonable
actions to remedy the breach. The Provider shall give the County seven (7) days' prior
written notice of its intent to terminate this Agreement for cause.
c. Compensation After Termination.
DocuSign Envelope ID: F746D5BF-EF42-497A-9B83-D263FC4E623D
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i) In the event of termination, the Provider shall be paid that portion of the fees and
expenses that it has earned to the date of termination, less any costs or expenses
incurred or anticipated to be incurred by the County due to errors or omissions of
the Provider.
ii) Should this Agreement be terminated, the Provider shall deliver to the County
within seven (7) days, at no additional cost, all deliverables including any
electronic data or files relating to the Project.
d. Waiver. The payment of any sums by the County under this Agreement or the failure of
the County to require compliance by the Provider with any provisions of this Agreement
or the waiver by the County of any breach of this Agreement shall not constitute a
waiver of any claim for damages by the County for any breach of this Agreement or a
waiver of any other required compliance with this Agreement.
e. Suspension. County may suspend the Basic Services and this Agreement at any time for
County’s convenience and without penalty to County upon three (3) days’ notice to
Provider. Upon any suspension by County, Provider shall discontinue work on the Basic
Services and shall not resume the Basic Services until notified to proceed by County.
11. Additional Provisions
a. Limitation and Assignment. The County and the Provider each bind themselves, their
successors, assigns and legal representatives to the terms of this Agreement. Neither the
County nor the Provider shall assign or transfer its interest in this Agreement without the
written consent of the other.
b. Governing Law. This Agreement and the duties, responsibilities, obligations and rights
of respective parties hereunder shall be governed by the laws of the State of North
Carolina. By executing this Agreement Provider affirms that Provider and any
subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter
64 of the North Carolina General Statutes. By executing this Agreement Provider
certifies that Provider has not been identified, and has not utilized the services of any
agent or subcontractor 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.
c. 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 reference 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.
DocuSign Envelope ID: F746D5BF-EF42-497A-9B83-D263FC4E623D
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d. Dispute Resolution. Any and all suits or actions to enforce, interpret or seek damages
with respect to any provision of, or the performance or non-performance of, this
Agreement shall be brought in the General Court of Justice of North Carolina sitting in
Orange County, North Carolina. It is agreed by the parties that no other court shall have
jurisdiction or venue with respect to such suits or actions. Binding arbitration may not
be initiated by either Party, however, the Parties may agree to nonbinding mediation of
any dispute prior to the bringing of such suit or action.
e. Entire Agreement. This Agreement represents the entire and integrated agreement
between the County and the Provider and supersedes all prior negotiations,
representations or agreements, either written or oral. This Agreement may be amended
only by written instrument signed by both parties. Modifications may be evidenced by
facsimile signatures.
f. Severability. If any provision of this Agreement is held as a matter of law to be
unenforceable, the remainder of this Agreement shall be valid and binding upon the
Parties.
g. Ownership of Work Product. Should Provider’s performance of this Agreement generate
documents, items or things that are specific to this Project such documents, items or
things shall become the property of the County and may be used on any other project
without additional compensation to the Provider. The use of the documents, items or
things by the County or by any person or entity for any purpose other than the Project as
set forth in this Agreement shall be at the full risk of the County.
h. Non-Appropriation. Provider acknowledges that County is a governmental entity, and
the validity of this Agreement is based upon the availability of public funding under the
authority of its statutory mandate.
In the event that public funds are unavailable and not appropriated for the performance of
County’s obligations under this Agreement, then this Agreement shall automatically
expire without penalty to County immediately upon written notice to Provider of the
unavailability and non-appropriation of public funds. It is expressly agreed that County
shall not activate this non-appropriation provision for its convenience or to circumvent
the requirements of this Agreement, but only as an emergency fiscal measure during a
substantial fiscal crisis.
In the event of a change in the County’s statutory authority, mandate and/or mandated
functions, by state and/or federal legislative or regulatory action, which adversely affects
County’s authority to continue its obligations under this Agreement, then this Agreement
shall automatically terminate without penalty to County upon written notice to Provider
of such limitation or change in County’s legal authority.
i. Signatures. This Agreement together with any amendments or modifications may be
executed electronically. All electronic signatures affixed hereto evidence the 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.
DocuSign Envelope ID: F746D5BF-EF42-497A-9B83-D263FC4E623D
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j. Notices. Any notice required by this Agreement shall be in writing and delivered by
certified or registered mail, return receipt requested to the following:
Orange County Provider’s Name
Attention:Kimberlee Quatrone Triangle Urology Associates, P.A.
P.O. Box 8181 205 Frasier Street
Hillsborough, NC 27278 Durham, NC 27704
[SIGNATURE PAGE TO FOLLOW]
DocuSign Envelope ID: F746D5BF-EF42-497A-9B83-D263FC4E623D
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IN WITNESS WHEREOF, the Parties, by and through their authorized agents, have
hereunder set their hands and seal, all as of the day and year first above written.
ORANGE COUNTY: PROVIDER:
By: _________________________________
Bonnie Hammersley, County Manager
By: __________________________________
Davin Brown, Chief Financial Officer
Printed Name and Title
DocuSign Envelope ID: F746D5BF-EF42-497A-9B83-D263FC4E623D
Revised 6/20
9
ORANGE COUNTY—DEPARTMENT USE ONLY
______________________________________________________________________________
Party/Vendor Name: Triangle Urology Associates, P.A. Party/Vendor Contact Person: Kimberly Lowery Contact
Phone: 919-313-3662 Party/Vendor Address: 205 Frasier Street City Durham State: NC Zip: 27707 Department:
Health Amount: $9,900 Purpose: Provide vasectomy services to OCHD referred males. Budget Code(s):
10414020-630000-71400 Vendor # 63847 (N/A if new vendor) Vendor is a BOCC consultant? Yes No
Contract Type: (Check one) New Renewal Amendment Effective Date 7-1-20 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 sufficie ncy 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 Allen Coleman upon completion: acoleman@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: F746D5BF-EF42-497A-9B83-D263FC4E623D
7/7/2020
7/7/2020
7/8/2020
7/8/2020
Policy Number Policy Period
From To
Coverage is Provided in the Agency Code
Named Insured and Address Agent
Policy Period:Beginning and Ending at 12:01 a.m.Standard Time at the Location of the Described Premises.
Business Type:
Mortgagee/Loss Payable:
Business of the Named Insured:
In consideration of the premium,insurance is provided the Named Insured with respect to those premises described in the
Schedule below and with respect to those coverages and kinds of property for which a specific Limit of Insurance is shown,
subject to all of the terms of this policy including forms and endorsements made a part hereof:
LOCATION SCHEDULE
Described Premises:
SECTION I - PROPERTY LIMITS OF INSURANCE
Loc No Bldg No Loc No Bldg No Loc No Bldg No
Deductible Amount $$$
Building Amount
Valuation
Business Personal
Property Valuation
Business Income
Business Income
Waiting Period
Excluded /None /24 hours /48 hours /72 hours
SECTION II - LIABILITY
Liability and Medical Expenses Limit $Per Occurrence $Aggregate
Medical Expenses $Each Person
Damage to Premises Rented to You $
Date Issued:Payment Type:
LIMITS OF INSURANCE
All Perils
391-1002 08 16 Page 1 of 2
4.
Liability and Medical Expenses Limits of Insurance:
Except for Damage to Premises Rented to You, each paid claim for the following coverages reduce the Amount of Insurance we
provide during the applicable annual period. Please refer to SECTION II - LIABILITY, D. LIABILITY AND MEDICAL EXPENSES
LIMITS OF INSURANCE, paragraph. of the Businessowners Coverage Form.
AVENUES BUSINESSOWNERS DECLARATION
BUSINESSOWNERS RENEWAL DECLARATIONS
32
RENEWAL OF OD6 A005679
OD6-A005679-07 06/25/2020 06/25/2021 MASSACHUSETTS BAY INSURANCE COMPANY 190282000
TRIANGLE UROLOGY ASSOCIATES,
ATTN: DAVIN
205 FRASIER ST.
DURHAM, NC 27704
919-781-0200
ASSUREDPARTNERS OF NC LLC
CL HANOVER CSC/STE 350
4505 FALLS OF NEUSE RD
RALEIGH, NC 27609
CORPORATION (SINGLE).
SEE ADDITIONAL INTEREST SCHEDULE
OFFICE, SERVICE.
NO. 001 001 205 FRASIER ST., DURHAM, NC 27704
NO. 002 001 10321 LUMLEY RD. # 201, RALEIGH, NC 27617
NO. 003 001 101 CONNER DRIVER, SUITE 201, CHAPEL HILL, NC 27514
(SEE FORM 391-1013 FOR ADDITIONAL PREMISES.)
001 001 002 001 003 001
1,000 1,000 1,000
NOT COVERED
NOT COVERED
NOT COVERED
596,176
RC
143,082
RC
208,372
RC
ACTUAL BUSINESS LOSS SUSTAINED NOT EXCEEDING 12 CONSECUTIVE MONTHS
48 HOURS
1,000,000 2,000,000
10,000
500,000
04/21/2020 ORIGINAL/INSURED DIRECT BILL
$$$
DocuSign Envelope ID: F746D5BF-EF42-497A-9B83-D263FC4E623D
OD6 A005679 1902820
SCHEDULE A -SCHEDULE OF UNDERLYING POLICIES
Insured:
Effective on and after:,12:01 AM Standard Time
This schedule is part of Policy Number:
CARRIER,POLICY NUMBER &PERIOD TYPE OF POLICY APPLICABLE LIMITS OR
AMOUNT OF INSURANCE
(a)Carrier:
Policy Number:
Policy Period:
Commercial
General Liability
Non-owned &
Hired Autos
$Each Occurrence
$General Aggregate
$Product/Compl eted
Operations
Aggregate
(b)Carrier:
Policy Number:
Policy Period:
Comprehensive
Automobile Liability
Bodily Injury and Property
Damage Liability Combined
$Each Accident
Bodily Injury
$Each Person
$Each Accident
Property Damage
$Each Accident
(c)Carrier:
Policy Number:
Policy Period:
Standard Workers
Compensation &
Employers Liability
Please Note:The
Umbrella Coverage
for Workers
Compensation and
Employers Liability
is not applicable in
situations where an
employee is subject
to the New York
Workers
Compensation Law.
Coverage B -Employers Liability
Bodily Injury by Accident
$Each Accident
Bodily Injury by Disease
$Aggregate
$Each Employee
(d)Carrier:
Policy Number:
Policy Period:
Liquor Liability $Limit of Liability
(e)Carrier:
Policy Number:
Policy Period:
Professional
Liability
$Limit of Liability
An "X"marked in the box provided indicates these broadening or optional coverages are provided in the
Underlying Insurance
(f)Carrier:
Policy Number:
Policy Period:
Directors &Officers
Liability
$Limit of Liability
(g)Carrier:
Policy Number:
Policy Period:
Employee Benefits
Liability
$Limit of Liability
Countersigned By:
Date:
Authorized Representative of the Company
473-1103 (11/08)
TRIANGLE UROLOGY ASSOCIATES,
06/25/2020
OD6-A005679-07
MASSACHUSETTS BAY INSURANCE COMPANY
OD6-A005679-07
X
06/25/2020 TO 06/25/2021
CITIZENS INSURANCE COMPANY OF AMERICA
WB6A00428807
06/25/2020 TO 06/25/2021
1,000,000
2,000,000
2,000,000
500,000
500,000
500,000
DocuSign Envelope ID: F746D5BF-EF42-497A-9B83-D263FC4E623D
WC000001B
04/06/2020 ORIGINAL/INSURED DIRECT BILL
WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY
32 WORKERS COMPENSATION RENEWAL INFORMATION PAGE
RENEWAL OF WZ6-A004288-06
CARRIER CODE NO.11002
WB6-A004288-07 06/25/2020 06/25/2021 CITIZENS INSURANCE COMPANY OF AMERICA 1902820
919-781-0200
TRIANGLE UROLOGY ASSOCIATES PA
ATTN:DAVIN BROWN
205 FRASIER ST
DURHAM,NC 27704
ASSUREDPARTNERS OF NC LLC
CL HANOVER CSC/STE 350
4505 FALLS OF NEUSE RD
RALEIGH,NC 27609
561205950
SEE ATTACHED SCHEDULE OF ADDITIONAL LOCATIONS FOR OTHER
WORKPLACES NOT SHOWN ABOVE.
IF APPLICABLE SEE CONTINUATION OF NAMED INSURED SCHEDULE.
ENTITY OF INSURED - CORPORATION
ITEM 2. POLICY PERIOD- 06/25/20 TO 06/25/21 12:01 AM STANDARD TIME AT
THE ADDRESS OF THE INSURED AS STATED HEREIN.
----------------------------------------------------------------------------------
ITEM 3A. PART ONE OF THIS POLICY APPLIES TO THE WORKERS' COMPENSATION LAW AND
ANY OCCUPATIONAL DISEASE LAW OF EACH OF THE FOLLOWING STATES-
NC.
--------------------------------------------------------------------
B. PART TWO OF THIS POLICY APPLIES TO EMPLOYERS' LIABILITY INSURANCE FOR
WORK IN EACH STATE LISTED IN ITEM 3A:
BODILY INJURY BY ACCIDENT $500,000 EACH ACCIDENT
BODILY INJURY BY DISEASE $500,000 EACH EMPLOYEE
BODILY INJURY BY DISEASE $500,000 POLICY LIMIT
--------------------------------------------------------------------
C. PART THREE OF THIS POLICY APPLIES TO OTHER STATES INSURANCE FOR THE FOL-
LOWING STATES- ALL STATES EXCEPT ND,OH,WA,WY,
AND THOSE STATES SPECIFICALLY NAMED IN ITEM 3A.
--------------------------------------------------------------------
D. SEE ATTACHED SCHEDULE FOR LIST OF ENDORSEMENTS AND SCHEDULES FORMING
PART OF THIS POLICY.
----------------------------------------------------------------------------------
ITEM 4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUALS OF RULES,
CLASSIFICATIONS, RATES, AND RATING PLANS. ALL INFORMATION REQUIRED BELOW
IS SUBJECT TO VERIFICATION AND CHANGE BY AUDIT.
ADJUSTMENT OF PREMIUM SHALL BE MADE ANNUALLY.
---------------------------------------------------------------------------
CLASSIFICATION OF OPERATIONS | EST
| ANNUAL
| PREMIUM
SEE ATTACHED SCHEDULE OF OPERATIONS |
|
|
MINIMUM PREMIUM $EXPENSE CONSTANT|
PREMIUM FOR TERRORISM |$
PREMIUM FOR CATASTROPHE |$
TOTAL ESTIMATED ANNUAL PREMIUM | $
DEPOSIT PREMIUM| $
COUNTERSIGNED THIS DAY OF ,- - - - - - - - - - - - - - -
AUTHORIZED REPRESENTATIVE
BRANCH OFFICE:13840 BALLANTYNE CORP PL SUITE 100 CHARLOTTE NC 28277
IF THE BILL FOR YOUR POLICY IS NOT ENCLOSED, IT WILL BE SENT TO YOU SEPARATELY.
Form 331-0226 (9-03)
Date Issued:Payment Type:
WCDEC1
Policy Number Policy Period
From To
Coverage is Provided in the Agency Code
ITEM 1.Named Insured and Address Agent Telephone:
Federal ID No.
DocuSign Envelope ID: F746D5BF-EF42-497A-9B83-D263FC4E623D
WC000001B
04/06/2020 ORIGINAL/INSURED DIRECT BILL
WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY
32 EXTENSION OF INFORMATION PAGE
RENEWAL OF WZ6-A004288-06
CARRIER CODE NO.11002
WB6-A004288-07 06/25/2020 06/25/2021 CITIZENS INSURANCE COMPANY OF AMERICA 1902820
919-781-0200
TRIANGLE UROLOGY ASSOCIATES PA
ATTN:DAVIN BROWN
205 FRASIER ST
DURHAM,NC 27704
ASSUREDPARTNERS OF NC LLC
CL HANOVER CSC/STE 350
4505 FALLS OF NEUSE RD
RALEIGH,NC 27609
561205950
POLICY **A D D I T I O N A L L O C A T I O N S **SCHEDULE
PAGE 2 PAGE 1
LOCATION ADDRESS
NUMBER
--------------------------------------------------------------------
001 205 FRASIER STREET
DURHAM NC
27704
--------------------------------------------------------------------
Form 331-0226 (9-03)
Date Issued:Payment Type:
WCDEC1
Policy Number Policy Period
From To
Coverage is Provided in the Agency Code
ITEM 1.Named Insured and Address Agent Telephone:
Federal ID No.
DocuSign Envelope ID: F746D5BF-EF42-497A-9B83-D263FC4E623D
WC000001B
04/06/2020 ORIGINAL/INSURED DIRECT BILL
WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY
32 EXTENSION OF INFORMATION PAGE
RENEWAL OF WZ6-A004288-06
CARRIER CODE NO.11002
WB6-A004288-07 06/25/2020 06/25/2021 CITIZENS INSURANCE COMPANY OF AMERICA 1902820
919-781-0200
TRIANGLE UROLOGY ASSOCIATES PA
ATTN:DAVIN BROWN
205 FRASIER ST
DURHAM,NC 27704
ASSUREDPARTNERS OF NC LLC
CL HANOVER CSC/STE 350
4505 FALLS OF NEUSE RD
RALEIGH,NC 27609
561205950
POLICY ** S C H E D U L E O F O P E R A T I O N S **SCHEDULE
PAGE 3 PAGE 1
ITEM 4.CLASSIFICATION OF OPERATIONS EST RATE EST
ST LOCT CODE TYP TOT-ANN PER$100 ANNUAL
Y NO RSK REMUNERATION PREMIUM
----------------------------------------------------------------------------------
|| |
NC 001 8832 H PHYSICIAN & CLERICAL | 734,200||
|| |
PREMIUM SUBJECT TO MODIFICATION || |
--------------------------------------------------------------|------|------------
0930 PREMIUM FOR WAIVER OF SUBROGATION ||
9807 PREMIUM FOR INCREASED COV B LIMITS ||
9848 BALANCE TO MINIMUM FOR COV B LIMITS | |
9887 NC SCHEDULE MODIFICATION ||
0032 LOSS CONSTANT | |
| |
TOTAL FOR NORTH CAROLINA |
---------------------------------------------------------------------|------------
|
TOTAL SCHEDULE OF |
OPERATIONS PREMIUM | $
9740 TERRORISM|
9741 CATASTROPHE (OTHER THAN TERRORISM)|
----------------------------------------------------------------------------------
Form 331-0226 (9-03)
Date Issued:Payment Type:
WCDEC1
Policy Number Policy Period
From To
Coverage is Provided in the Agency Code
ITEM 1.Named Insured and Address Agent Telephone:
Federal ID No.
DocuSign Envelope ID: F746D5BF-EF42-497A-9B83-D263FC4E623D
WC000001B
04/06/2020 ORIGINAL/INSURED DIRECT BILL
WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY
32 EXTENSION OF INFORMATION PAGE
RENEWAL OF WZ6-A004288-06
CARRIER CODE NO.11002
WB6-A004288-07 06/25/2020 06/25/2021 CITIZENS INSURANCE COMPANY OF AMERICA 1902820
919-781-0200
TRIANGLE UROLOGY ASSOCIATES PA
ATTN:DAVIN BROWN
205 FRASIER ST
DURHAM,NC 27704
ASSUREDPARTNERS OF NC LLC
CL HANOVER CSC/STE 350
4505 FALLS OF NEUSE RD
RALEIGH,NC 27609
561205950
POLICY **E N D O R S E M E N T /F O R M S C H E D U L E **SCHEDULE
PAGE 4 PAGE 1
STATE NUMBER EFFECTIVE
DATE
----------------------------------------------------------------------------------
NC *000308 0484 PARTNERS,OFFICERS AND OTHERS EXCLUSION END.06/25/20
NC *000313 0484 WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS 06/25/20
NC *000424 0117 AUDIT NONCOMPLIANCE CHARGE ENDORSEMENT 06/25/20
NC *320301D0718 NORTH CAROLINA AMENDED COVERAGE ENDORSEMENT 06/25/20
NC *000414A0119 NOTIFICATION OF CHANGE IN OWNERSHIP ENDORSEMENT 06/25/20
NC *000419 0101 PREMIUM DUE DATE ENDORSEMENT 06/25/20
NC *000422B0115 TRIPRA DISCLOSURE ENDORSEMENT 06/25/20
NC *990612 0216 TRADE OR ECONOMIC SANCTIONS ENDT 06/25/20
NC *000311A0891 VOLUNTARY COMP.&EMPL.LIAB.COV.END.06/25/20
NC *000115 0120 NOTIFICATION ENDT OF PENDING LAW CHANGE TO TRIPRA 06/25/20
NC *000000C0115 WORKERS COMP AND EMPLOYERS LIABILITY INS POLICY 06/25/20
NC *000404 0484 PENDING RATE CHANGE END.06/25/20
Form 331-0226 (9-03)
Date Issued:Payment Type:
WCDEC1
Policy Number Policy Period
From To
Coverage is Provided in the Agency Code
ITEM 1.Named Insured and Address Agent Telephone:
Federal ID No.
DocuSign Envelope ID: F746D5BF-EF42-497A-9B83-D263FC4E623D
WC000001B
04/06/2020 ORIGINAL/INSURED DIRECT BILL
WORKERS COMPENSATION AND EMPLOYER'S LIABILITY INSURANCE POLICY
32 EXTENSION OF INFORMATION PAGE
RENEWAL OF WZ6-A004288-06
CARRIER CODE NO.11002
WB6-A004288-07 06/25/2020 06/25/2021 CITIZENS INSURANCE COMPANY OF AMERICA 1902820
919-781-0200
TRIANGLE UROLOGY ASSOCIATES PA
ATTN:DAVIN BROWN
205 FRASIER ST
DURHAM,NC 27704
ASSUREDPARTNERS OF NC LLC
CL HANOVER CSC/STE 350
4505 FALLS OF NEUSE RD
RALEIGH,NC 27609
561205950
POLICY **E N D O R S E M E N T /F O R M S C H E D U L E **SCHEDULE
PAGE 5 PAGE 2
STATE NUMBER EFFECTIVE
DATE
NC *000421D0115 CATASTROPHE (NON-TERRORISM)PREMIUM ENDT 06/25/20
----------------------------------------------------------------------------------
Form 331-0226 (9-03)
Date Issued:Payment Type:
WCDEC1
Policy Number Policy Period
From To
Coverage is Provided in the Agency Code
ITEM 1.Named Insured and Address Agent Telephone:
Federal ID No.
DocuSign Envelope ID: F746D5BF-EF42-497A-9B83-D263FC4E623D