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HomeMy WebLinkAbout2024-182-E-KKJ Forensic and Psychological Services-psychological servicesRevised 01/24 NORTH CAROLINA CONTRACT AMENDMENT ORANGE COUNTY THIS CONTRACT AMENDMENT (“Amendment”) is made and entered into this 1st day of March, 2024 by and between ORANGE COUNTY (hereinafter referred to as “County”) and KKJ Forensic and Psychological Services, PLLC. (hereinafter referred to as “Provider”). WITNESSETH: THAT WHEREAS, the County and Provider entered into a contract dated June 21, 2023, (hereinafter the “Original Agreement”), for the provision of services for psychological evaluations, parental competency evaluations, interpretive sessions, and/or court testimony; and WHEREAS, the County and Provider desire to amend the Original Agreement while keeping in effect all terms and conditions of the Original Agreement not inconsistent with the terms and conditions set forth below. NOW THEREFORE, for and in consideration of the mutual covenants and agreements made herein, the parties agree to amend the Original Agreement as follows: 1. Section 1(a)(i) is amended to add individual treatment and couples/family treatment to the Scope of Work. 2. Section 3(b) is amended to add “To provide individual treatment and/or couples/family treatment to referred Orange County Social Services clients” to Basic Services. 3. Section 3(c) is amended to add Individual treatment $185/hour and couple/family treatment $200/hour to Provider Rates. 4. Section 5(a) is amended to read “The maximum amount payable for Basic Services shall not exceed Eighteen Thousand Dollars ($18,000)”. 5. Except for the changes made herein, the Original Agreement shall remain in full force and effect to the extent it is not inconsistent with this Amendment. In the event there is a conflict between the terms of the Original Agreement and the terms of this Amendment, this Amendment shall control. IN TESTIMONY WHEREOF, this Amendment has been executed by the parties hereto, as of the date first above written. ORANGE COUNTY PROVIDER ______________________________ __________________________________ Bonnie Hammersley Katrina Kuzyszyn-Jones, Psy.D. County Manager Owner DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 Revised 01/24 ORANGE COUNTY—INTERNAL USE ONLY ______________________________________________________________________________ Finance Information Vendor Name: KKJ Forensic and Psychological Services, PLLC. Vendor Contact Person: Katrina Kuzyszyn-Jones Phone: 919-493- 1975 Address: 5317 Highgate Dr, Suite 213 City Durham State: NC Zip: 27713 Department: Social Services Amount: $18,000 Purpose: psychological services Budget Code(s): 10400220-761005/10405020-768000 Vendor # 61106 Vendor Status with NCSOS: Current-Active Vendor is a BOCC consultant: Yes No Contract Details Contract Type: New Amendment (Original Contract: 6/23/23) (Most Recent Amendment ) Effective Date 7/1/23 End Date 6/30/24 Notice Date (Notice Purpose ) Award Approved by Board (Agenda Date: ); Made or Administered by Nancy Coston Signature Authority - BOCC Express Delegation (Agenda Date: ) - Policy 9.4: Under $5,000; Service Under $90,000; Construction Under $250,000 - Budget Policy Section XV (Capital Improvement Project: ) Bidding Informal Bidding ($30k-$90k); Formal RFP ($90k+); Other (<$30k); Exception(# ) Department Affirmation 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. This agreement is approved as to technical form and content. Services related to this agreement have already begun or been completed. Description of the nature of the emergency condition that was addressed: Department Director’s Signature ________________________________________ Date: ________ Information Technologies This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer___________________________________ Date: ________ Inapplicable because no hardware/software purchases or related services 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 All Docusign contracts must be copied to the Clerk upon completion: occlerkdocs@orangecountync.gov The following signature block is for hard copies only and is not required for Docusign contracts: Received for record retention: Office of the Clerk to the Board __________________________________________Date:_________ DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 3/18/2024 3/25/2024 3/26/2024 3/26/2024 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 06/12/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Trust Risk Management Services, Inc. doing business in NC as Potomac Risk Management Services, Inc. 1791 Paysphere Circle Chicago, IL 60674 CONTACT NAME: Trust Risk Management Services, Inc PHONE (A/C, No, Ext): 877.637.9700 FAX (A/C, No): 877.251.5111 EMAIL ADDRESS: info@trustrms.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: ACE American Insurance Company 22667 INSURED Katrina Kuzyszyn-Jones 5317 Highgate Dr Ste 213 Durham, NC 27713 6622 INSURER B: INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY)LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ ___________________________________MED EXP (Any one person)$ ___________________________________PERSONAL & ADV INJURY $ GEN’L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS–COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY (Per Person)$ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Per accident)$ HIRED AUTOS NON-OWNED AUTOS PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION $$ WORKERS COMPENSATION AND EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A PER STATUTE OTH- ER $ E.L.EACH ACCIDENT $ E.L. DISEASE-EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A Psychologist's Professional Liability Retroactive Date: 05/02/2007 Y 78G27815467 05/02/2023 05/02/2024 Each Incident Annual Aggregate $1,000,000 $3,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required): CERTIFICATE HOLDER CANCELLATION Additional Insured Orange County Government P.O. Box 8181 Hillsborough, NC, 27278 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03)©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 815Ren (2011) June 12, 2023 Katrina Kuzyszyn-Jones 5317 Highgate Dr Ste 213 Durham, NC 27713 6622 RE: Your Trust Sponsored Professional Liability Insurance Policy # 78G27815467 Dear Katrina Kuzyszyn-Jones Thank you for your continued participation in the Trust Sponsored Professional Liability Program. Enclosed is your Trust Sponsored Professional Liability Insurance Renewal. In an effort to conserve resources and "go green"with your renewal,we have not included a copy of your insurance policy form as part of this renewal packet. The insurance policy form was provided to you previously,and the enclosed endorsements included in this renewal packet will reflect changes to your coverage, if any. If you would like a copy of the policy form, you are able to request it by accessing your account at the Online Service Center at www.trustinsurance.com or by contacting our Customer Service Center. We urge you to read this renewal packet and notify us if you believe any changes are necessary. At the first notice of claim, lawsuit or incident, please contact our Customer Service Center immediately at 1.877.637.9700. We will assist you in providing the necessary information to get your claims process started. Our claims staff is dedicated to listening, understanding,and taking action to route your claim to the appropriate experts working on your behalf. If you have not already done so, be sure to access your Online Service Center account at www.trustinsurance.com. Your account is available 24 hours a day, 7 days a week, with anytime access to your professional liability insurance form. You can request additional Memorandums of Insurance, view all of your account transactions, submit requests for changes, update your personal information and (if eligible) renew your policy. For your convenience we have provided your user name at the bottom of this letter. If you wish to change your customer information, simply log into the Online Service Center and click on Customer Service. Should you have any questions regarding this correspondence, or for additional information regarding further membership benefits and other membership insurance options, please be sure to contact us at 1.877.637.9700. Our professional staff is available to assist you Monday-Friday 8:30am-6:00pm (est)or visit our website at www.trustinsurance.com. You may also email us your questions at info@trustrms.com. Sincerely, Jana N. Martin, Ph.D., President Trust Risk Management Services, Inc. doing business in NC as Potomac Risk Management Services, Inc. Licensed Producer - Sheila LeBeau, CA #OF77147, FL #PO99941. Principal Place of Business - Maryland. Insurance provided by ACE American Insurance Company, Philadelphia, PA and its U.S.-based Chubb underwriting company affiliates. Program Administered by Trust Risk Management Services, Inc. OSC User Name: drkatrina@kkjpsych.com DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 PF-15215a (04/07)© 2007 The Trust Psychologists’ Professional Liability Claims Made Insurance Policy Declarations ACE American Insurance Company PRODUCER NUMBER 273865 DATE OF ISSUE June 12, 2023 PSYCHOLOGISTS’ PROFESSIONAL LIABILITY CLAIMS MADE INSURANCE POLICY NOTICE: THIS IS A CLAIMS MADE POLICY, PLEASE READ THE POLICY CAREFULLY THIS POLICY/CERTIFICATE IS ISSUED IN ASSOCIATION WITH THE PSYCHOLOGISTS PURCHASING GROUP ASSOCIATION Item POLICY/CERTIFICATE NUMBER: 78G27815467 1. Named Insured:Katrina Kuzyszyn-Jones Address:5317 Highgate Dr Ste 213 City, State & Zip Code:Durham, NC 27713 6622 2.Policy Period: 12:01 A.M. local time at the address shown in Item 1. From:05/02/2023 To:05/02/2024 3.COVERAGE LIMITS OF LIABILITY PREMIUM Professional Liability Wrongful Employment Practices $1,000,000 Each Incident $3,000,000 $5,000 Aggregate Aggregate $1,581.00 REIMBURSEMENTS Licensing Board Defense Other Governmental Regulatory Body Defense Deposition Expense Premises Medical Payment Assault and/or Battery Loss of Earnings $100,000 $15,000 $5,000 $2,500 $500 per Proceeding per Proceeding per Insured per Person per Day, per Insured $75,000 $1,000 $15,000 Aggregate Aggregate Aggregate Per Incident $75.00 Surcharge(s) Total Premium $1,656.00 4.Retroactive Date 05/02/2007 5.This policy is made and accepted subject to the printed conditions in this policy together with the provisions, stipulations and agreements contained in the following form(s) or endorsement(s). PF15215a, PF33748 , PF15217a (05/07), CC-1K11k (04/22), PF15245a, PF15234a, PF15224a, PF15235a, PF22543, PF15282b, PF17914 (02/05), 6.Notice of claim should be sent to: Trust Risk Management Services, Inc. 111 Rockville Pike Ste 700 Rockville MD 20850 All other correspondence should be sent to: Trust Risk Management Services, Inc. 1791 Paysphere Circle Chicago, IL 60674 DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 PF-15215a (04/07)© 2007 The Trust 7.REPRESENTATIVE:Agent or broker: Trust Risk Management Services, Inc. doing business in NC as Potomac Risk Management Services, Inc. Office address:1791 Paysphere Circle City, State, Zip Chicago, IL 60674 Website:www.trustinsurance.com Phone:1.877.637.9700 DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 PF-33748 (04/11) Renewal Notice IMPORTANT INFORMATION TO ALL POLICYHOLDERS AS PART OF OUR EFFORT TO REDUCE OUR USE OF PRINTED PAPER, PLEASE BE ADVISED THAT THE ENCLOSED POLICY DOES NOT INCLUDE A COPY OF THE FOLLOWING FORM: PF15217a Psychologist CM Policy (05/07)WE HAVE NOT INCLUDED THIS FORM BECAUSE SUCH FORM WAS PREVIOUSLY PROVIDED TO YOU AND SINCE THAT TIME, THERE HAVE BEEN NO MATERIAL CHANGES TO THE FORM. IF YOU WOULD LIKE TO OBTAIN COPIES OF THE FORM(S) PLEASE CONTACT US AT: TRUST RISK MANAGEMENT SERVICES, INC. doing business in NC as Potomac Risk Management Services, Inc. 1791 Paysphere Circle Chicago, IL 60674 OR Phone: 1.877.637.9700 Fax: 1.877.251.5111 info@trustrms.com www.trustinsurance.com DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 CC-1K11k (04/22) SIGNATURES Named Insured Katrina Kuzyszyn-Jones Endorsement Number Policy Symbol CRL Policy Number 78G27815467 Policy Period 05/02/2023 to 05/02/2024 Effective Date 05/02/2023 Issued By (Name of Insurance Company) ACE American Insurance Company THE ONLY COMPANY APPLICABLE TO THIS POLICY IS THE COMPANY NAMED ON THE FIRST PAGE OF THE DECLARATIONS. By signing and delivering the policy to you, we state that it is a valid contract. INDEMNITY INSURANCE COMPANY OF NORTH AMERICA(A stock company) BANKERS STANDARD INSURANCE COMPANY(A stock company) ACE AMERICAN INSURANCE COMPANY(A stock company) ACE PROPERTY AND CASUALTY INSURANCE COMPANY(A stock company) INSURANCE COMPANY OF NORTH AMERICA(A stock company) PACIFIC EMPLOYERS INSURANCE COMPANY(A stock company) ACE FIRE UNDERWRITERS INSURANCE COMPANY(A stock company) WESTCHESTER FIRE INSURANCE COMPANY(A stock company) 436 Walnut Street, P.O. Box 1000, Philadelphia, Pennsylvania 19106-3703 __ BRANDON PEENE, Secretary JOHN J. LUPICA,President _________________________________ Authorized Representative DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 PF-15245a (05/07)© 2007 The Trust Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured Katrina Kuzyszyn-Jones Endorsement Number Policy Symbol CRL Policy Number 78G27815467 Policy Period 05/02/2023 to 05/02/2024 Effective Date 05/02/2023 Issued By (Name of Insurance Company) ACE American Insurance Company Retroactive Date(s) Designated Individual(s) or Entity(ies) It is agreed that, in consideration of the premium charged, and solely with respect to the following designated individual(s) or entity(ies), Item 4. of the Declarations, Retroactive Date, is deleted with respect to such designated individual(s) or entity(ies) and replaced with the Retroactive Date for such designated individual(s) or entity(ies) listed in below. Designated Individual(s) or Entity(ies)Retroactive Date(s) Katrina Kuzyszyn-Jones 05/02/2007 Katrina Kuzyszyn-Jones 05/02/2007 Mackenzie Howard 07/01/2021 Julianne Ludlam 06/01/2022 Kaytie Mero 06/01/2022 Lisa Foss 06/01/2022 The premium for this endorsement is included in the premium shown on the Declarations unless a specific amount is shown here: Additional Premium: Return Premium: All other terms and conditions of this policy remain unchanged. ________________________ Authorized Agent DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 PF-15234a (05/07)© 2007 The Trust Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured Katrina Kuzyszyn-Jones Endorsement Number Policy Symbol CRL Policy Number 78G27815467 Policy Period 05/02/2023 to 05/02/2024 Effective Date 05/02/2023 Issued By (Name of Insurance Company) ACE American Insurance Company Vicarious Liability Extension for the Named Insured for Excluded Individual(s) or Entity(ies) It is agreed that Section VII. DEFINITIONS, is amended at the definition of Insured,by adding the following: The individual(s) or entity(ies) listed in the Schedule below is/are not (an) Insured(s)under this policy and shall not qualify as (an) Insured(s)under Section III. PERSONS INSURED. Schedule of Individual(s) or Entity(ies) Michelle Chase 05/02/2023 Whitney Wall 05/02/2017 Stephanie Skibba 09/19/2022 The premium for this endorsement is included in the premium shown on the Declarations unless a specific amount is shown here: Additional Premium: Return Premium: All other terms and conditions of this policy remain unchanged. ________________________ Authorized Agent DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 PF-15224a (05/07)© 2007 The Trust Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured Katrina Kuzyszyn-Jones Endorsement Number Policy Symbol CRL Policy Number 78G27815467 Policy Period 05/02/2023 to 05/02/2024 Effective Date 05/02/2023 Issued By (Name of Insurance Company) ACE American Insurance Company Additional Named Insured(s) It is agreed that: 1. The Named Insured shown in Item 1 of the Declarations of this policy is amended to include the following entity(ies) and if a Retroactive Date is listed opposite any entity(ies’) name, the Retroactive Date set forth in the Declarations is deleted with respect to such entity(ies) and replaced with the Retroactive Date listed below: Additional Named Insured(s):Retroactive Date KKJ Forensic and Psychological Services, PLLC 03/23/2012 The Purpose Center 05/02/2023 2. The following is hereby added to the CONDITIONS section of the policy. Authorization: By acceptance of this policy the first Named Insured set forth in the Declarations, or in any Named Insured Amended endorsement, agrees to act on behalf of all other Insureds, including any Insured listed on this endorsement, with respect to the giving and receiving of all notices to the Company as may be required by the terms of this policy, any right of cancellation and in the receiving of any return premiums that may become due hereunder. All Insureds agree that the first Named Insured listed in the Declarations or in any Named Insured Amended endorsement, is hereby designated to so act on their behalf. All other terms and conditions of this policy remain unchanged. ________________________ Authorized Agent DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 PF-15235a (05/07)© 2007 The Trust Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured Katrina Kuzyszyn-Jones Endorsement Number Policy Symbol CRL Policy Number 78G27815467 Policy Period 05/02/2023 to 05/02/2024 Effective Date 05/02/2023 Issued By (Name of Insurance Company) ACE American Insurance Company Additional Insured It is agreed that in consideration of the premium charged, the individual(s) or entity(ies) designated below shall be an Insured, under Section III. PERSONS INSURED, but only with respect to such individual’s or entity’s liability arising solely out of an Incident caused by the sole negligence of another Insured: Additional Insured Address Orange County Government P.O. Box 8181 Hillsborough NC 27278 The premium for this endorsement is included in the premium shown on the Declarations unless a specific amount is shown here: Additional Premium: Return Premium: All other terms and conditions of this policy remain unchanged. ________________________ Authorized Agent DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 PF-22543 (05/07)© 2007 The Trust Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured Katrina Kuzyszyn-Jones Endorsement Number Policy Symbol CRL Policy Number 78G27815467 Policy Period 05/02/2023 to 05/02/2024 Effective Date 05/02/2023 Issued By (Name of Insurance Company) ACE American Insurance Company Landlord Additional Insured It is agreed that the designated individual(s) or entity(ies) shown below shall be included as (an) Insured(s)solely to the extent provided under Section III. PERSONS INSURED. Landlord Additional Insured Address Tican Properties 2828 Picket Rd Ste. 210 Durham NC 27705 The premium for this endorsement is included in the premium shown on the Declarations unless a specific amount is shown here: Additional Premium: Return Premium: All other terms and conditions of this policy remain unchanged. ________________________ Authorized Agent DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 PF-15282b (06/08)© 2007 The Trust Page 1 of 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. Named Insured Katrina Kuzyszyn-Jones Endorsement Number Policy Symbol CRL Policy Number 78G27815467 Policy Period 05/02/2023 to 05/02/2024 Effective Date 05/02/2023 Issued By (Name of Insurance Company) ACE American Insurance Company Amendatory Endorsement – North Carolina It is agreed that: 1. Section VIII. CONDITIONS, N. Automatic Extended Reporting Period, is amended by adding the following: The Automatic Extended Reporting Period shall not increase or reinstate the Limits of Liability, which shall be the maximum liability of the Company for the Policy Period and the Automatic Extended Reporting Period, combined. 2. Section VIII. CONDITIONS, O. Extended Reporting Period Option, is amended by adding the following at the end of 1., c.Extended Reporting Period Option Premium: There is an additional charge of 10% of the additional premium set forth above for such Extended Reporting Period Option for the reinstatement of the Limits of Liability. 3. Section VIII. CONDITIONS, O. Extended Reporting Period Option, 4. is deleted in its entirety and replaced with the following: Except with respect to any Extended Reporting Period Option provided in accordance with VIII. CONDITIONS, O. Extended Reporting Period Option, 2. Retiree Provision, or 3. Death or Disability of Insured, the Extended Reporting Period Option, if elected, shall reinstate Item 3 Limits of Liability stated in the Declarations of the policy for Claims first made during the Extended Reporting Period Option. Such Limit of Liability shall be the maximum liability of the Company for all Claims first made during the Extended Reporting Period Option. If any Claim is covered, in whole or in part, under both the Automatic Extended Reporting Period and the Extended Reporting Period Option, then only the Limit of Liability available for Extended Reporting Period Option shall apply. The Limit of Liability available for the Extended Reporting Period Option provided in accordance with VIII. CONDITIONS, O. Extended Reporting Period Option, 2. Retiree Provision, or 3. Death or Disability of Insured,shall be part of, and not in addition to, the Limit of Liability for the Policy Period. Such Extended Reporting Period Option, if elected, shall not increase or reinstate the Limit of Liability. Such Limit of Liability shall be the maximum Limit of Liability of the Company for the Policy Period, the Automatic Extended Reporting Period, and the Extended Reporting Period Option provided in accordance with VIII. CONDITIONS, O. Extended Reporting Period Option, 2. Retiree Provision, or 3. Death or Disability of Insured combined. All other terms and conditions of this policy remain unchanged. ________________________ Authorized Agent DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 U.S. Treasury Department’s Office Of Foreign Assets Control ("OFAC") Advisory Notice to Policyholders This Policyholder Notice shall not be construed as part of your policy and no coverage is provided by this Policyholder Notice nor can it be construed to replace any provisions of your policy. You should read your policy and review your Declarations page for complete information on the coverages you are provided. This Notice provides information concerning possible impact on your insurance coverage due to directives issued by OFAC. Please read this Notice carefully. The Office of Foreign Assets Control (OFAC) administers and enforces sanctions policy, based on Presidential declarations of "national emergency". OFAC has identified and listed numerous: Foreign agents; Front organizations; Terrorists; Terrorist organizations; and Narcotics traffickers; as "Specially Designated Nationals and Blocked Persons". This list can be located on the United States Treasury's web site – http//www.treas.gov/ofac. In accordance with OFAC regulations, if it is determined that you or any other insured, or any person or entity claiming the benefits of this insurance has violated U.S. sanctions law or is a Specially Designated National and Blocked Person, as identified by OFAC, this insurance will be considered a blocked or frozen contract and all provisions of this insurance are immediately subject to OFAC. When an insurance policy is considered to be such a blocked or frozen contract, no payments nor premium refunds may be made without authorization from OFAC. Other limitations on the premiums and payments also apply. PF-17914 (2/05)Reprinted, in part, with permission of Page 1 of 1 ISO Properties, Inc. DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 812 Rate Summary Page | 1 June 12, 2023 Rate Summary Named insured Katrina Kuzyszyn-Jones Switch Over Credit No Application ID/ Policy 78G27815467 BOP Credit No Effective Date 05/02/2023 CE Discount No Retroactive Date 05/02/2007 Group PCF No Prescription Privileges No # of Employees for EPLI No Limits of Liability Professional Liability $1,000,000 Each Incident $3,000,000 Aggregate Wrongful Employment Practices $5,000 Aggregate Reimbursements Licensing Board Defense $100,000 per Proceeding Other Governmental Regulatory Body Defense $15,000 per Proceeding Deposition Expense $5,000 per Insured Premises Medical Payment $2,500 per Person $75,000 Aggregate Assault and/or Battery $1,000 Aggregate Loss of Earnings $500 per day, per Insured $15,000 Aggregate per Incident Owners Name Field of Practice Degree Retroactive Date Hours Worked CE Credit PCF Rate Katrina Kuzyszyn-Jones Psychologist PsyD 05/02/2007 20 0%No $ 493 Employees Name Field of Practice Degree Retroactive Date Hours Worked CE Credit PCF Rate Mackenzie Howard Counselor MA 07/01/2021 30 0%No $ 372 Julianne Ludlam Psychologist PhD 06/01/2022 20 0%No $ 242 Kaytie Mero Counselor MA 06/01/2022 20 0%No $ 159 Lisa Foss Counselor MA 06/01/2022 20 0%No $ 159 Independent Contractors Name Field of Practice Retroactive Date Rate Michelle Chase Counselor 05/02/2023 $ 8 Whitney Wall Psychologist 05/02/2017 $ 37 Vicarious Parties Name Type Degree Rate Date Rate Stephanie Skibba Employee PsyD 09/19/2022 $ 39 Additional Insureds Name Type Rate Date Rate Orange County Government Organization 07/19/2021 $ 72 Additional Insured - Landlords Name Address City State Zip DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6 Tican Properties 2828 Picket Rd Ste. 210 Durham NC 27705 Additional Named Insured Name Address City State Zip KKJ Forensic and Psychological Services, PLLC 5317 Highgate Dr Ste 213 Durham NC 27713 The Purpose Center 5317 Highgate Dr Ste 213 Durham NC 27713 RATING DETAIL Base Premium:$2,580.00 35% Part-Time Credit $-591.00 4%Staff-Size Credit $-60.00 10% Vicarious Liability Surcharge $-348.00 Licensing Board Defense/Other Governmental Regulatory Body Defense $75.00 TOTAL PREMIUM $1,656.00 812 Rate Summary Page | 2 Rate Summary (continued) 78G27815467 DocuSign Envelope ID: ACEF8EF9-2EFA-4F7D-B215-CAC4F234E1F6