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HomeMy WebLinkAboutPublic Safety Medical Services/Fire/90,000/Fire Department PhysicalsPublic Safety Medical Services Fire Department - 2017 Appropriation #43-407.01; P.O. # 100336 Contract Not To Exceed $90,000.00 JAO AGREEMENT FOR PROFESSIONAL SERVICES THIS AGREEMENT FOR PROFESSIONAL SERVICES ("Agreement') is hereby made and entered into by and between the City of Carmel,. Indiana, acting by and through its Board of Public Works and Safety (hereinafter "City"), and Public Safety Medical Services (hereinafter "Professional"). RECITALS WHEREAS City owns and is responsible for the operation and maintenance of its property, personnel, public works and infrastructure; and and -- WHEREAS, from time to time, City needs professional assistance in fulfilling its foregoing responsibilities; WHEREAS, Professional is experienced in providing and desires to provide to City the professional services ("Services") referenced herein; and WHEREAS,' City desires to engage Professional as an independent contractor for the purpose of providing to City the Services referenced herein; NOW, THEREFORE, in consideration of the foregoing recitals and the covenants and conditions set forth herein, City and Professional mutually agree as follows: SECTION 1. INCORPORATION OF RECITALS The foregoing Recitals are hereby incorporated into this Agreement and made a part hereof. SECTION 2. SCOPE OF SERVICES 2.1 City desires to engage Professional as an independent contractor for the Services set forth in attached Exhibit A, incorporated herein by this reference. 2.2 Professional understands and agrees that City may, from time to time, request Professional to provide additional or modified Services to City. When City desires additional Services from Professional, the City shall notify Professional of such additional Services desired, as well as the time frame in which same are to be provided. Only after City has approved Professional's time and cost estimate for the provision of such additional Services, has encumbered sufficient monies to pay for same, and has authorized Professional, in writing, to provide such additional Services, shall such Services be provided by Professional to City. A copy of the City's authorization documents for the purchase of additional Services shall be numbered and attached hereto in the order in which they are approved by City. 2.3 Time is of the essence -of this Agreement. [S1ContractMrof.Sv & Goods Sws\Fu'e Dept120171Public Safety Medical Services Professional Services.d=4/182017 3:06 PM] PUbl1: Safety Medical Services Fire Department - 2017 Appropriation #43-407.01; P.O. # 100336 Contract Not To Exceed $90,000.00 SECTION 3. CITY'S RESPONSIBILITIES 3.1 City shall provide such information as is reasonably necessary for Professional to understand the Services requested. 3.2 City shall provide all data required for provision of Services. Professional may assume that all data so provided is correct and complete. 3.3. City shall arrange for Professional to enter upon public and private property as reasonably required for Professional to perform the Services. 3.4 City shall designate payment of the Services from City budget appropriation number 43-407.01 funds. 3.5 City shall designate the Mayor or his duly authorized representative to act on City's behalf on all matters regarding the Services. SECTION 4. PROFESSIONAL'S RESPONSIBILITIES 4.1 Professional shall perform the Services pursuant to the terms of this Agreement and within any applicable time and cost estimate. 4.2 Professional shall coordinate with City its performance of the Services. 4.3 Professional shall provide the Services by following and applying at all times reasonable and lawful standards as accepted in the industry. SECTION 5. COMPENSATION 5.1 Professional estimates that the total price for the Services to be provided to City hereunder shall be no more than Ninety Thousand Dollars ($90,000.00) (the "Estimate"). Professional shall submit an invoice to City no more than once every thirty (30) days for Services provided City during the time period encompassed by such invoice. Invoices shall be submitted on a form containing the same information as that contained on the Professional Services Invoice attached hereto as Exhibit B, incorporated herein by this reference. City shall pay Professional for all undisputed Services rendered and stated on such invoice within thirty five (35) days from the date of City's receipt of same. 5.2 Professional agrees not to provide any Services to City that would cause the total cost of same to exceed the Estimate, without City's prior written consent. .SAC-namTW d.S— & Go.& S—W" Dg117017T blic SafelyMedieal Servi=Peofezional Servicmdoc:4/17!2017 9:36 AM] 2 PublpcSafety Medical Services Fire Department - 2017 Appropriation #43-407.01; P.O. # 100336 Contract Not To Exceed $90,000.00 SECTION 6. TERM Unless otherwise terminated in accordance with the termination provisions set forth in Section 7.1 hereinbelow, this Agreement shall be in effect from the Effective Date through December 31, 2017, and shall, on the first day of each January thereafter, automatically renew for a period of one (1) calendar year, unless otherwise agreed by the parties hereto. SECTION 7. MISCELLANEOUS 7.1 Termination, 7.1.1 The obligation to provide all or any portion of the Services under this Agreement may be terminated by City or Professional, without cause, upon thirty (30) days' notice. 7.1.2 The obligation to provide all or any portion of the Services under this Agreement may be terminated by City, for cause, immediately upon Professional's receipt of City's "Notice To Cease Services." 7.1.3 In the event of full or partial Agreement termination, and as full and complete compensation hereunder, Professional shall be paid for all such Services rendered and expenses incurred as of the date of termination that are not in dispute, except that such payment amount shall not exceed the Estimate. Disputed compensation amounts shall be resolved as allowed by law. 7.2 Binding Effect. City and Professional, and their respective officers, officials, agents, partners and successors in interest are bound to the other as to all Agreement terms, conditions and obligations. 7.3 No Third Party Beneficiaries. Nothing contained herein shall be construed to give rights or benefits to anyone other than the parties hereto. 7.4 Relationship. The relationship of the parties hereto shall be as provided for in this Agreement, and neither Professional nor any of its agents, employees or contractors are City employees. Professional shall have the sole responsibility to pay to or for its agents, employees and contractors all statutory, contractual and other benefits and/or obligations as they become due. Professional hereby warrants and indemnifies City for and from any and all costs, fees, expenses and/or damages incurred by City as a result of any claim for wages, benefits or otherwise by any agent, employee or contractor of Professional regarding or related to the subject matter of this Agreement. This indemnification obligation shall survive the termination of this Agreement. iS:%ContmclsTrof.Sv s & Goods S=Vlm Dcp1%M]Wob1ic Snfoly Mediad S—i— [kofes ionnl S"A—doc:4/122017 9:39 AM) Public Safety Medical Services Fire Department - 2017 Appropriation #43-407.01; P.O. # 100336 Contract Not To Exceed 990,000.00 7.5 Insurance. Professional shall procure and maintain with an insurer licensed to do business in the State of Indiana such insurance as is necessary for the protection of City and Professional from all claims under workers' compensation, occupational disease and/or unemployment compensation acts, because of errors and omissions, because of bodily injury, including, but not limited to, the personal injury, sickness, disease, or death of any of Professional's employees, agents or contractors and/or because of any injury to or destruction of property, including, but not limited to, any loss of use resulting therefrom. The coverage amounts shall be no less than those amounts set forth on attached Exhibit C. Such insurance policies shall not be canceled without thirty (30) days' prior written notice to City, 7.6 Liens. Professional shall not cause or permit the filing of any lien on any of City's property. In the event such a lien is filed and Professional fails to remove it within ten (10) days after the date of filing, City shall have the right to pay or bond over such lien at Professional's sole cost and expense. 7.7 Default. In the event Professional: (a) repudiates, breaches or defaults under any of the terms or conditions of this Agreement, including Professional's warranties; (b) fails to perform the Services as specified; (c) fails to make progress so as to endanger timely and proper completion of the Services and does not correct such failure or breach within five (5) business days after receipt of notice from City specifying same; or (d) becomes insolvent, files, or has filed against it, a petition for receivership, makes a general assignment for the benefit of creditors or dissolves, each such event constituting an event of default hereunder, City shall have the right to terminate all or any part of this Agreement, without liability to Professional and to exercise any other rights or remedies available to it at law or in equity. 7.8 Government Compliance. Professional agrees to comply with all laws, executive orders, rules and regulations applicable to Professional's performance of its obligations under this Agreement, all relevant provisions of which being hereby incorporated herein by this reference, to keep all of Professionals' required professional licenses and certifications valid and current, and to indemnify and hold harmless City from any and all losses, damages, costs, liabilities, damages, costs and attorney fees resulting from any failure by Professional to do so. This indemnification obligation shall survive the termination of this Agreement. 7.9 Indemnification. Professional shall indemnify and hold harmless City and its officers, officials, employees and agents from all losses, liabilities, claims, judgments and liens, including, but not limited to, all damages, costs, expenses and attorney fees arising out of any intentional or negligent act or omission of Professional and/or any of its employees, agents or contractors in the performance of this Agreement. This indemnification obligation shall survive the termination of this Agreement. JSACunazctslProf.Svcs R Gaudy Sveall:im DepA20171Poblic Safely Medical Services Prufmional S—ic d=4/12/017 938 AM] Public Safety Medical Services Fire Department - 2017 Appropriation #43-407.01; P.O. # 100336 Contract Not. To Exceed $90,000.00 7.10 Discrimination Prohibition. Professional represents and warrants that it and each of its employees, agents and contractors shall comply with all existing and future laws prohibiting discrimination against any employee, applicant for employment and/or other person in the subcontracting of work and/or in the performance of any Services contemplated by this Agreement with respect to hire, tenure, terms, conditions or privileges of employment or any matter directly or indirectly related to employment, subcontracting or work performance hereunder because of race, religion, color, sex, handicap, national origin, ancestry, age, disabled veteran status or Vietnam era veteran status. This indemnification obligation shall survive the termination of this Agreement. 7.11 E -Verify Pursuant to I.C. § 22-5-1.7 et seq., Professional shall enroll in and verify the work eligibility status of all of its newly -hired employees using the E -Verify program, if it has not already done so as of the date of this Agreement. Professional is further required to execute the attached Affidavit, herein referred to as Exhibit D, which is an Affidavit affirming that: (i) Professional is enrolled and is participating in the E -verify program, and (ii) Professional does not knowingly employ any unauthorized aliens. This Addendum incorporates by reference, and in its entirety, attached Exhibit D. In support of the Affidavit, Professional shall provide the City with documentation that it has enrolled and is participating in the E -Verify program. This Agreement shall not take effect until said Affidavit is signed by Professional and delivered to the City's authorized representative. Should Professional subcontract for the performance of any work under this Addendum, the Professional shall require any subcontractor(s) to certify by affidavit that: (i) the subcontractor does not knowingly employ or contract with any unauthorized aliens, and (ii) the subcontractor has enrolled and is participating in the E -verify program. Professional shall maintain a copy of such certification for the duration of the term of any subcontract. Professional shall also deliver a copy of the certification to the City within seven (7) days of the effective date of the subcontract. If Professional, or any subcontractor of Professional, knowingly employs or contracts with any unauthorized aliens, or retains an employee or contract with a person that the Professional or subcontractor subsequently learns is an unauthorized alien, Professional shall terminate the employment of or contract with the unauthorized alien within thirty (30) days ("Cure Period"). Should the Professional or any subcontractor of Professional fail to cure within the Cure Period, the City has the right to terminate this Agreement without consequence. The E -Verify requirements of this Agreement will not apply, should the E -Verify program cease to exist. 7.12 Severability. If any provision of this Agreement is held to be invalid, illegal or unenforceable by a court of competent jurisdiction, that provision shall be stricken, and all other provisions of this Agreement that can operate independently of same shall continue in full force and effect. ls:wontractslPmf.s a &Goods Sves118mDcp1120171Poblie Sukty Medical Serves Pmfessienal Smi—dae:4/12/20179:38 AMJ I'ublic Safety Medical Services Fire Department - 2017 Appropriation #43-407.01; P.O. # 100336 Contract Not To Exceed $90,000.00 7.13 Notice. Any notice, invoice, order or other correspondence required or allowed to be sent pursuant to this Agreement shall be written and either hand -delivered or sent by prepaid U.S. certified mail, return receipt requested, addressed to the parties as follows: CITY: City of Carmel Fire Department Two Civic Square Carmel, Indiana 46032 ATTENTION: Dave Haboush PROFESSIONAL: Public Safety Medical Services Rhonda Gallagher 324 E New York Street Indianapolis, IN 46204 Douglas C. Haney Corporation Counsel One Civic Square Carmel, Indiana 46032 Notwithstanding the above, City may orally provide to Professional any notice required or permitted by this Agreement, provided that such notice shall also then be sent as required by this paragraph within ten (10) business days from the date of such oral notice. 7.14 Effective Date. The effective date ("Effective Date") of this Agreement shall be the date on which the last of the parties hereto executes same. 7.15 Governing Law; Lawsuits. This Agreement shall be governed by and construed in accordance with the laws of the State of Indiana, except for its conflict of laws provisions, as well as by all ordinances and codes of the City of Carmel, Indiana. The parties agree that, in the event a lawsuit is filed hereunder, they waive any right to a jury trial they may have, agree to file such lawsuit in an appropriate court in Hamilton County, Indiana only, and agree that such court is the appropriate venue for and has jurisdiction over same. 7.16 Waiver. Any delay or inaction on the part of either party in exercising or pursuing its rights and/or remedies hereunder or under law shall not operate to waive any such rights and/or remedies nor in any way affect the rights of such party to require such performance at any time thereafter. ]SAConlractaTmLSves & Goods Sv wane Dept120171public Safety Medical Smites Professional Servic doe,4/12/2017 9:38 AM] Public Safety Medical Services Fire Department - 2017 Appropriation #43-407.01; P.O. # 100336 Contract Not To Exceed $90,000.00 7.17 Non -Assignment. Professional shall not assign or pledge this Agreement nor delegate its obligations hereunder without City's prior written consent. 7.18 Entire Agreement. This Agreement contains the entire agreement of and between the parties hereto with respect to the subject matter hereof, and no prior agreement, understanding or representation pertaining to such subject matter, written or oral, shall be effective for any purpose. No provision of this Agreement may be amended, added to or subtracted from except by an agreement in writing signed by both parties hereto and/or their respective successors in interest. To the extent any provision contained in this Agreement conflicts with any provision contained in any exhibit attached hereto, the provision contained in this Agreement shall prevail. 7.19 Representation and Warranties. Each party hereto represents and warrants that it is authorized to enter into this Agreement and that any person or entity executing this Agreement on behalf of such party has the authority to bind such party or the party which they represent, as the case may be. 7.20 Headings. All headings and sections of this Agreement are inserted for convenience only and do not form a part of this Agreement nor limit, expand or otherwise alter the meaning of any provision hereof. 7.21 Advice of Counsel. The parties warrant that they have read this Agreement and fully understand it, have had an opportunity to obtain the advice and assistance of counsel throughout the negotiation of same, and enter into same freely, voluntarily, and without any duress, undue influence or coercion. 7.22 Copyright. City acknowledges that various materials which may be used and/or generated by Professional in performance of Services, including forms, job description formats, comprehensive position questionnaire, compensation and classification plan and reports are copyrighted. City agrees that all ownership rights and copyrights thereto lie with Professional, and City will use them solely for and on behalf of its own operations. City agrees that it will take appropriate action with its employees to satisfy its obligations with respect to use, copying, protection and security of Professional's property. 7.23 Personnel. Professional represents that it has, or will secure at its own expense, all personnel required in performing the services under this agreement. Such personnel shall not be employees of or have any contractual relationship with City. All of the services required hereunder will be performed by Professional or under his supervision and all personnel engaged in the work shall be fully qualified to perform such services. ISAConnnelsTMESves & Goods Sues\ ire Dep112017\Public Safety MMial Services Professional Scrviees.dwAn 2/2017 9.38 AM] Public Safety Medical Services Fire Department - 2017 Appropriation #43-407.01; P.O. # 100336 Contract Not To Exceed $90,000.00 7.24 Records and Inspections Professional shall maintain full and accurate records with respect to all matters covered under this agreement for three (3) years after the expiration or early termination of this Agreement. City shall have free access at all proper times to such records and the right to examine and audit the same and to make transcripts there from, and to inspect all program data, documents, proceedings and activities. 7.25 Accomplishment of Proiect Professional shall commence, carry on, and complete the project with all practicable dispatch, in a sound economical and efficient manner, in accordance with the provisions thereof and all applicable laws. In accomplishing the project, Professional shall take such steps as are appropriate to ensure that the work involved is properly coordinated with related work being carried on within City's organization. 7.26 IRAN CERTIFICATION. Pursuant to I.C. § 5-22-16.5, the Professional shall certify that, in signing this Agreement, it does not engage in investment activities within the Country of Iran. 7.27 ACCESS TO PUBLIC RECORDS ACT Professional understands and agrees that any "public record", as that term is defined in Indiana Code 5-14-3- 2(m), as amended, that is related to the subject matter of this Agreement, whether the same is in the possession or control of the Professional or the City, shall be subject to release under and pursuant to the provisions of Indiana's Access to Public Records Act, as codified in Indiana Code 5-14-3-1, et seq., as amended. (remainder of page intentionally left blank) ]S:WonaelsWrof.Sves & Garfs SKs1Frc Dep11301Wub1ie Safety Medi.. S—i— Prof=ional S—i—doc:4113/1017 9:38 AM] Public Safety--Med.icd Services R6 Departh , ient -1,2011 Appropriation .03-407. --, P.O ., # 100336 Contract Not TO Ex.dbed $90,000.00 IN WITNESS WHEREOF. the parties.hereto have mAde'and executed this Agreement as follows:. OITY 05 CARMEL, INDIANA, by : and, through its -Board of Public Works and Safety m. J'6hOs &6ihard, Pre iding'Officer Date: Mary Ann ,Aurke, Me_nb 'r g e I)ate:' --I- Lori S. W tson, "#mby Date: fpbli.c:S6fe.ty Medical SerVices. Rm DJ_ z *uto6zzed'Signa ure .Printed Name.' oea&v 1114 k o-- A I j Title: r FIU/T.IN.. Last Poor of,8SN'Lif Sole. Proprietor; . '�// /. Date:. Carmel Fire Department 324 E. New York Street Indian-� 2017-2018 Service Agreement 317.9 2.118, 1N 46204 g 317.972.1180 Phone 317.972,1190 FAX Delivery Location: ® Public Safety Medical (Fishers or Indpls.) The following when signed by Public Safety Medical (PSM) at 324 E. New York Street, Suite 300, Indianapolis, IN 46204 and Carmel Fire Department, 2 Civic Square Carmel, IN 46032will constitute our agreement for delivery of the services described below under the following terms and conditions. Scope. of Services PSM agrees to provide the following services: SERVICE DESCRIPTION Code �rt�f .ry 2017 201'S (2%)" Blood Blood Panel CMP, CBC, Lipid, Veni. 3500 §1MLIM liffAMMtj CMP (Comp. Metabolic Panel 3522 II 32 Vj1 $22!86 CBC (Comp. Blood Count 3083 $20 29 1 20�r70 and Lab Work Lipid Panel total chol., HDL. LDL, ratio 3523 iilill320P13 JKV_' 5,0� Venipuncture 3000gT53 I $3!!60 t TSH,(Thyrdid�Stimulating Hormone) Upon3126" : De` f. Re uestONLY:.' 7 $28 01 $28 57 Wellness Med. Testing: 12416 Medical Testing Vital Signs -ht, wt, BMI, BP, resp.. pulse 6000 Vision -Acuity 6050 3$3494'Sm 13x106 `` lJrine`CancerBladder Screen (if Indidated) U onDe t.Re uest.ONLY.1'r;:; 6033 527;1- $5376 PFT— Pulmonary Function Test 6110 a$38(65e $3942x' Audiometry 6090 $,1°640;316713 EKG w/interp 6120 I' $23 42? ii $23!85 w Urinalysis — Di stick 6020 I9$3!5$ $,5T 0 Physical Exam Respirator/Medical Review 6304 Illli'$@,r8j74 $1119.1 Comprehensive Physical Exam 12500 jj$,1�14'Wt7A llllli"$,11i1f7j07fftt,' Health Risk ApEraisal 7000 $0?00 $0T O ti Fitness Services Treadmill — Submax 2080UN 91a 1 $1,82 697 Body Fat Test — BIA 2019 $11i6740 ! $f,6 13a `Muscular Strer gth,Endurance Test Upori De `t Re uesfONLY, t,.<:. 2040 $3045 $31 06, Flezibill ,Tesf:.U' on'De tRe" uest:ONLY :';2030':- $11:72 `$11.95 Welsh/ Hlp Ratio Upon'Dept. Request ,"2016-1,, ; , $3 53 $3 60 ; ONLY;. Web -Based Services OnMed Program 8135 $00 $000 '4 -co No Show Fee 8080 Age Based &Optional Tests HIV—$1 Gen. (Rapid Test) (at -the Dept. Direction 3526$25:931 �� 4$2645 �✓ PSA -Prostate Specific (ages 40+ Men) 3115 $4fl.99 $41.81 `- Rectallhemoccult (men: ages 40+) 6130$0.00 $OAO, ` Chest X-ray - PA/LAT (Digital) (Captured 2016 already, Eve 4 Years)�,: 4000717.26 $71 67 Billing Invoices are generated weekly. Payment terms are Net 30dav . F: marketing/Goldmine 1 Of 4templates "EXHIBIT • Denise Snyder --�nait of Contact `� tls _de�carrre�l;�ngo�, Right to Receive Notice of Breach As required by the Health Insurance Portability and Accountability Act (HIPAA), PSM will provide a written notice to all Carmel Fire Department employees in the event we learn of any unauthorized acquisition, use or disclosure of your personal health information (PHI) as a result of not being properly secured as required by HIPAA. We will notify employees of the breach as soon as possible but no later than sixty (60) days after the breach has been discovered. PSM will incur all expenses for notification and actions necessary to correct breach. Policy on Additional Testing In the event that PSM finds it necessary to perform additional testing at Carmel Fire Department expense and at the request of the medical director, the Carmel Fire Department representative will be notified in advance. Policy on Repeat Testing In the event that PSM finds it necessary to retest a patient due to a positive test result or the recommendation of the PSM medical director, the cost incurred will be billed to Carmel Fire Department if the retest was not based upon an error on the original test. The Carmel Fire Department representative will be notified in advance. If the retest is due to an error by PSM or a contracted laboratory or other representative, PSM will absorb any additional retest costs. No recommended actions will be made to Carmel Fire Department until PSM has received accurate retest information. Policy on Reporting Results PSM will provide a medical/respirator clearance letter for every patient. The letter will state whether or not the employee is medically cleared for duty. No specific medical test results for any patient are provided to any representative without the written consent of the patient unless required by law (i.e. OSHA). If during the medical evaluation, findings are such that the patient cannot be medically -cleared for duty, the patient will be counseled as to the medical concerns and the need to limit duty assignment. The designated Carmel Fire Department representative will be notified, in general terms, of the need for duty restriction and any safety - sensitive responsibilities. It will also be recommended that the patient be re-evaluated by PSM, after appropriate medical treatment, to provide final clearance of return to full duty after a release is first made by the patient's treating physician. PSM will assist the employee with providing related medical information and their job requirements to the treating physician to assist in their care. Dates and Location of Services BLOOD DRAWS Dates: July 10-12 & July 25-27 Location: 2 Civic Square Carmel, IN 46032 Time: lam Location: Station 45 10701 N. College Avenue EXAMS Dates: August Location: Public Safety Medical, Fishers Office Departmental Information Contact person: Name: Mark Cromlich Title: Health & Safety Chief Phone: (317)571-2600 E-mail: mcromlich@carmel.in.gov Address: 2 Civic Square Carmel, IN 46032 thief o.# E�ept: David G. Haboush __ ___- ° °IXHIBIT A F: markeGngtGoldmine 2 of 4templates Price Increases Price increases for the following year will be made known by end of April of the current year. Pricing reflected above is valid through ecember 31 .201'7 Records and Accounts PSM shall maintain accurate records and accounts of all transactions relating to the Services performed by it pursuant to this Agreement. Exam Arrival Time To optimize the service provided to Carmel Fire Department personnel, we request that you send your personnel 15 minutes prior to their abpointment time. When Running Late If your personnel are running late for their appointment(s), please call your client manager whose name and number is listed on the signature page. This will ensure that appropriate arrangements may be made at PSM to accommodate your personnel or potential rescheduling. Cancellations Cancellations should be made at least 3 days (1 shift for fire departments) prior to the scheduled appointment. This enables PSM with enough notice to offer the appointments to another department and properly prepare. Liability and .Indemnification PSM shall have no liability whatsoever to Carmel Fire Department for any error, act or omission in connection with the services to be rendered by PSM to Carmel Fire Department hereunder unless any such error, act or omission derives from willful misconduct or gross negligence. Insurance PSM maintains insurance to protect it and Carmel Fire Department from the claims set forth below which may arise out of or result from PSM operations under this Agreement, whether such operations be by PSM or by its subcontractors or by anyone directly or indirectly employed by any of them, or by anyone directly for whose acts any of them may be liable: 1. Claims under Workers' Compensation and Occupational Disease Acts, and any other employee benefits acts applicable to the performance of the work; 2. Claims for damages because of bodily injury and personal injury, including death, and; 3. Claims for damages to property PSM insurance shall be not less than the acceptable industry standards for the performance of medical and occupational health-related services. Confidentiality PSM agrees to hold in strict confidence, and to use reasonable efforts to cause its employees and representatives to hold in strict confidence, all confidential information concerning Carmel Fire Department furnished to or obtained by PSM in the course of providing the agreed-upon services. PSM will not disclose or release any such confidential information to any person, except its employees, representatives and agents who have a need to know such information in connection with PSM performance under this Agreement or by the express written consent of a Carmel Fire Department employee. Proprietary Information PSM asks that all information provided within this document be held confidentially and not shared with any related providers, those organizations who could be considered competition to PSM, other fire or law enforcement organizations, or unnecessary personnel within the Carmel Fire Department. Ft marketing/Goldmine 3 of 4templates °EXHIBIT n Termination for Convenience Either PSM or Carmel Fire Department may terminate this Agreement at any time by giving thirty (30) days written notice. PSM shall be entitled to payment for deliverables in progress, to the extent the work has been performed satisfactorily. Term of Agreement This agreement will be reviewed and updated annually. Questions regarding this Agreement may be directed to the Client Manager below. Public Safety Medical Rhonda Gallacher Name Printed Name Signed Asst. Director Client Services Title January 26, 2017 Date Your Public Safety Medical Contact Carmel Fire Department Name Printed Name Signed Title Date . Rhonda Gallagher Office: 317.972.1180, ext. 349 Mobile: 317.437.4005 F: marketing/Goldmine 4 of 4templates "E "BIT „ EXHIBIT B Invoice Name of Company: Address & Zip: Telephone No.: Fax No.: Project Name: Invoice No. Purchase Order No: Date: Signature Printed Name Goods Services Person Providing Goods/Services Date Goods/ Service Provided Goods/Services Provided (Describe each good/service separately and in detail) Cost Per Item Hourly Rate/ Hours Worked Total GRAND TOTAL Signature Printed Name EXHIBIT C INSURANCE COVERAGES Worker's Compensation & Disability Employer's Liability: Bodily Injury by Accident/Disease: Bodily Injury by Accident/Disease: Bodily Injury by Accident/Disease: Property damage, contractual liability, products -completed operations: General Aggregate Limit (other than Products/Completed Operations): Products/Completed Operations: Personal & Advertising Injury Policy Limit: Each Occurrence Limit: Fire Damage (any one fire): Medical Expense Limit (any one person): Statutory Limits $100,000 each employee $250,000 each accident $500,000 policy limit $500,000 $500,000 $500,000 $250,000 $2.50,000 $ 50,000 Comprehensive Auto Liability (owned, hired and non -owned) Bodily Single Limit: Injury and property damage: Policy Limit: Umbrella Excess Liability Each occurrence and aggregate: Maximum deductible: $500,000 each accident $500,000 each accident $500,000 $500,000 $ 10,000 EXHIBIT D AFFIDAVIT �Rpf�, 1 //4 9),P- � being first duly sworn, deposes and says that ,he/she is familiar with an as personal knowledge of the facts herein and, if called as a witness in this matter, could -testify as follows: 1. I am over eighteen (.18) years of age and am competent to testify to the facts contained herein. 2. I am now and at all t'mes r'e�} evant here}'n :have been employed by u �`C �a /`►(,2G�i't� r (the `.`Employer") in the position of irtc7� �.�tC ��,;St FVi C C� 3. 1 am familiar with the employment policies, practices, and procedures of the Employer and have the authority to act on behalf of the Employer. 4. The Employer .is enrolled and participates in 'the federal E -Verify program and has provided documentation of such enrollment and, participation to the City of Carmel, Indiana, 5'. The Company does not kn6 wingly employ any unauthorized aliens: FURTHER AFFIANT SA'YETH NOT. EXECUTED on the % 4. day of &rl 20�r Printed: I certify under the penalties for- perjury under the laws of the United''States of America and the State of Indiana thafthe foregoing factual statements and representations are true and correct. Printed: ?=LwrdAJ /to r ke City ®f Carmel INDIANA RETAIL TAX EXEMPT CERTIFICATE NO. 003120155 002 0 Page 1 of 1 PURCHASE ORDER NUMBER SHIPPING INSTRUCTIONS FEDERAL EXCISE TAX EXEMPT 100336 ONE CIVIC SQUARE 35-6000972 THIS NUMBER MUST APPEAR ON INVOICES, AIP CARMEL, INDIANA 46032-2584 THIS APPROPRIATION SUFFICIENT TO PAY FOR THE ABOVE ORDER. VOUCHER, DELIVERY MEMO, PACKING SLIPS, SHIPPING LABELS AND ANY CORRESPONDENCE FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL - 1997 PURCHASE ORDER DATE DATE REQUIRED REQUISITION NO. VENDOR NO. DESCRIPTION 4/6/2017 00350364 Fire Department Physicals PUBLIC SAFETY MEDICAL SERVICES Fire Department VENDOR 324 E NEW YORK ST SUITE 300 SHIP 2 Civic Square TO Carmel, IN 46032 - INDIANAPOLIS, IN 46204 - PURCHASE ID BLANKET CONTRACT PAYMENT TERMS FREIGHT 14255 QUANTITY UNIT OF MEASURE DESCRIPTION UNIT PRICE EXTENSION Department., 1120 Account., 43-407.01 1 Each 1 Each Send Invoice To: Fire Department 2 Civic Square Carmel, IN 46032 - Fund. 101 General Fund Fire Department Physicals Not To Exceed - Reimbursed by Clay Township Trustee PLEASE INVOICE IN DUPLICATE $0.00 $0.00 $90,000.00 $90,000.00 Sub TOW $90,000.00 DEPARTMENT ACCOUNT PROJECT PROJECT ACCOUNT AMOUNT PAYMENT $90,000.00 SHIPPING INSTRUCTIONS • AIP VOUCHER CANNOT BE APPROVED FOR PAYMENT UNLESS THE P.O. NUMBER IS MADE A PART OF THE VOUCHER AND EVERY INVOICE AND VOUCHER HAS THE PROPER SWORN 'SHIP PREPAID. AFFIDAVIT ATTACHED. I HEREBY CERTIFY THAT THERE IS AN UNOBLIGATED BALANCE IN 'C.O.D. SHIPMENT CANNOT BE ACCEPTED. THIS APPROPRIATION SUFFICIENT TO PAY FOR THE ABOVE ORDER. 'PURCHASE ORDER NUMBER MUST APPEAR ON ALL SHIPPING LABEL 'THIS ORDER ISSUED IN COMPLIANCE WITH CHAPTER 99, ACTS 1945 AND ACTS AMENDATORY THEREOF AND SUPPLEMENT THERETO. ORDERED BY TITLE CONTROL NO. 100336 CLERK -TREASURER Denise Snyder Douglas Haney Budget & Accreditation Manager Corporation Counsel