Public Safety Medical Services/Fire/79,682.04/Materials for Department PhysicalsPublic Safey Medical Services, Inc.
Carmel Fire Department - 2016
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Appropriation #43-407.01 General Fund; P.0.#214831
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Contract Not To Exceed $79,682.04
AGREEMENT FOR PURCHASE OF GOODS AND SERVICES
THIS AGREEMENT FOR PURCHASE OF GOODS AND SERVICES ("Agreement") is
hereby entered into by and between the City of Carmel, Indiana, acting by and through its Board
of Public Works and Safety ("City"), and Public Safety Medical Services, Inc. an entity duly
authorized to do business in the State of Indiana ("Vendor")..
TERMS AND CONDITIONS
1, ACKNOWLEDGMENT, ACCEPTANCE:
Vendor acknowledges that it has read and understands this Agreement, and agrees that its execution of
same constitutes its acceptance of all of the Agreement's terms and conditions.
2. PERFORMANCE:
City agrees. to purchase the goods and/or services (the "Goods and Services") from Vendor using City
budget appropriation number 43-407.01 General funds. Vendor agrees to provide the Goods and Services
and to otherwise perform the requirements of this Agreement by applying at all times the highest technical
and industry standards. Vendor will not perform any of the Services detailed in Exhibit A prior to obtaining a
written Notice to Proceed from the City. Upon receiving a Notice to Proceed, the Vender shall perform only
those Services specifically detailed in the Notice. If the Vender desires clarification of the scope of any
Notice to Proceed, the Vendor shall obtain such clarification from the City in writing, prior to performing the
service set forth in the Notice to Proceed. Any services performed without the City's prior express written
authorization will nQt be compensated.
3. PRICE AND PAYMENT TERMS:
3.1 Vendor estimates that the total price for the Goods and Services to be provided to Cityfhereunder
shall be no more than Seventy Nine Thousand Six Hundred Eiohty TtNo Dollars and. Four Cents
($79,682.04) (the "Estimate"). Vendor shall submit an invoice to City no more than once every thirty
(30) days detailing the Goods and Services provided to City within such time period. City shall pay
Vendor for such Goods and Services within sixty (60) days after the date of City's receipt of Vendor's
invoice detailing same, so long as and to the extent such Goods and Services are not disputed, are
in conformance with the specifications set forth in Exhibit A, are submitted. on an invoice that
contains the information contained on attached Exhibit B, and Vendor has otherwise performed and
satisfied all the terms and .conditions of this Agreement.
3.2 Vendor agrees not to provide any Goods and Services to City that would cause the total cost of the
Goods and Services provided by Vendor to City hereunder to exceed the Estimate, unless City has
previously agreed, in writing, to pay an amount in excess thereof.
4. WARRANTY.-
Vendor
ARRANTY:
Vendor expressly warrants that the Goods and Services covered by this Agreement will conform to
those certain specifications, descriptions and/or quotations regarding same as were provided to
Vendor by City and/or by Vendor to and accepted by City, all of which documents are incorporated
herein by reference, and that the Goods and Services will be delivered In a timely, good and
workmanlike manner and free from defect. Vendor acknowledges that it knows of City's intended use
and expressly warrants that the Goods and Services provided to City pursuant to this Agreement
have been selected by Vendor based upon City's stated use and are fit and sufficient for their
particular purpose.
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Public Safey Medical Services, Inc.
Carmel Fire Department - 2016
Appropriation #43-407.01 General Fund-, P.O. #24831
Contract Not To Exceed $79,682.04
5. TIME AND PERFORMANCE:
This Agreement shall become effective as of the last date on which a party hereto executes same ("Effective
Date?% and both parties shall thereafter perform their obligations hereunder in a timely manner. Time is of the
essence of this Agreement.
6. DISCLOSURE AND WARNINGS:
If requested by City, Vendor shall promptly furnish to City, in such form and. detail as City may direct, a list of
all chemicals, materials, substances and items used in or during the provision of the Goods and Services
provided hereunder, including the quantity, quality and concentration thereof and any other information
relating thereto. At the time of the delivery of the Goods and Services provided hereunder, Vendor agrees to
furnish to City sufficient written warning and notice (including appropriate labels on containers and packing)
of any hazardous material utilized in or that is a part of the Goods and Services.
7. LIENS:
Vendor shall not cause or permit the filing of any lien on any of City's property. In the event any such lien is
filed and Vendor fails to remove such lien within ten (10) days after the filing thereof, by payment or bonding,
City shall have the right to pay such lien or obtain such bond, all at Vendor's sole cost and expense.
8, DEFAULT:
in the event Vendor: (a) repudiates, breaches or defaults under any of the terms or conditions of this
Agreement, including Vendor's warranties; (b) fails to provide the Goods and Services as specified herein;
(c) fails to make progress so as to endanger timely and proper provision of the Goods and Services and does
not correct such failure or breach within five (5) business days (or such shorter period of time as is
commercially reasonable under the circumstances) after receipt of notice from City specifying such failure or
breach; or (d) becomes insolvent, is placed into 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
(1) terminate all or any parts of this Agreement, without liability to Vendor; and (2) exercise all other rights
and remedies available to City at late and/or in equity.
9. INSURANCE AND INDEMNIFICATION:
Vendor shall procure and maintain in full force and effect during the term of this Agreement, with an insurer
licensed to do business in the State of Indiana, such insurance as is necessary for the protection of City and
Vendor from all claims for damages under any workers' compensation, occupational disease and/or
unemployment compensation act; for bodily injuries including, but not limited to, personal injury, sickness,
disease or death of or to any of Vendor's agents, officers, employees, contractors and subcontractors; and,
for 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 in attached Exhibit C. Vendor .shall
cause its insurers to name City as an additional insured on all such insurance policies, shall promptly provide
City, upon request, with copies of all such policies, and shall provide that such insurance policies shall not be
canceled without thirty (30) days prior notice to City. Vendor shall indemnify and hold harmless City from and
against any and all liabilities, claims, demands or expenses (including, but not limited to, reasonable attorney
fees) for injury, death and/or damages to any person or property arising from or in connection with Vendor's
provision of Goods and Services pursuant to or under this Agreement or Vendor's use of City property.
Vendor further agrees to indemnify, defend and hold harmless City and its officers, officials, agents and
employees from all claims and suits of whatever type, including, but not limited to, all court costs, attorney
fees, and other expenses, caused by any act or omission of Vendor and/or of any of Vendor's agents,
officers, employees, contractors or- subcontractors in the performance of this Agreement. These
indemnification obligations shall survive the termination of this Agreement.
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Public Safey Medical Services, Inc.
Carmel Fire Department - 2016
Appropriation #43-407.01 General Fund; P.O. #24331
Contract Not To Exceed $79,642.04
10. GOVERNMENT COMPLIANCE:
Vendor agrees to comply with all federal, state and local laws, executive orders, rules, regulations and codes
which may be applicable to Vendor's performance of its obligations under this Agreement, and all relevant
provisions thereof are incorporated herein by this reference. Vendor agrees to indemnify and hold harmless
City from any loss, damage and/or liability resulting from any such violation of such laws, orders, rules,
regulations and codes. This indemnification obligation shall survive the termination of this Agreement.
11-. NONDISCRIMINATION:
Vendor represents and warrants that it and all. of its officers, employees, agents, contractors and
subcontractors shall comply with all laws of the United States, the State of Indiana and City prohibiting
discrimination against any employee, applicant for employment or other person in the provision of any Goods
and Services provided by this Agreement with respect to their hire, tenure,, terms, conditions and privileges of
employment and any other matter related to their employment or subcontracting, because of race, religion,
color, sex, handicap, national origin, ancestry, age, disabled veteran status and/or Vietnam era veteran
status.
12. E -VERIFY
Pursuant to I.C..§ 22-5-1.7 et seq., as the same may be amended from time to time, and as is incorporated
herein by this reference (the "Indiana E -Verify Law"), Vendor is required to enroll in and verify the work
eligibility status of its newly -hired employees using the E -Verify program, and to execute the Affidavit
attached herein as Exhibit D, affirming that it is enrolled and participating in the E -verify program and does
not knowingly employ unauthorized aliens. In support of the Affidavit, Vendor shall provide the City with
documentation indicating that it has enrolled and is participating in the E -Verify program. Should
Vendor subcontract for the performance of any work under and pursuant to this Agreement, it shall fully
comply with the Indiana E -Verify Law as regards each such subcontractor. Should the Vendor or any
subcontractor violate the Indiana E -Verify law, the City may require a cure of such violation and thereafter, if
no timely cure is performed, terminate this Agreement in accordance with either the provisions hereof or
those set forth in the Indiana E -Verify Law, The requirements of this paragraph shall not apply should the E -
Verify program cease to exist.
13. NO IMPLIED WAIVER:
The failure of either party to require performance by the other of any provision of this Agreement shall not
affect the right of such party to require such performance at any time thereafter, nor shall the waiver by any
party of a breach of any provision of this Agreement constitute a waiver of any succeeding breach of the
same or any other provision hereof.
14. NON -ASSIGNMENT:
Vendor shall not assign or pledge this Agreement, whether as collateral for a loan or otherwise, and shall not
delegate its obligations under this Agreement without City's prior written consent.
15. RELATIONSHIP OF PARTIES:
The relationship of the parties hereto shall be as provided for in this Agreement, and neither Vendor nor any
of its officers, employees, contractors, subcontractors and agents are employees of City. The contract price
set forth herein shall be the full and maximum compensation and monies required of City to be paid to
Vendor under or pursuant to this Agreement
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Public Safey Medical Services, Inc.
Carmel Fire Department - 2016
Appropriation #43-407.01 General Fund; P.O. #24831
Contract Not To Exceed $79,682.04
16. GOVERNING LAW; LAWSUITS:
This Agreement is to be construed in accordance with and governed by the laws of the State of Indiana,
except for its conflict of laws provisions. The parties agree that, in the event a lawsuit is filed hereunder, they
waive their right to a jury trial, agree to file any 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.
17. SEVERABILITY:
If any term of this Agreement is invalid or unenforceable under any statute, regulation, ordinance, executive
order or other rule of law, such term shall be deemed reformed or deleted, but only to the extent necessary to
comply with same, and the remaining provisions of this Agreement shall remain in full force and effect.
18, NOTICE:
Any notice provided for in this Agreement will be sufficient if it is in writing .and is delivered by postage
prepaid U.S. certified mail, return receipt requested, to the party to be notified at the address specified
herein:
If to City: City of Carmel
One Civic Square
Carmel, Indiana 46032
If to Vendor-
ATTENTION
endor.;
ATTENTION
324 East New York Street
Suite 300
Indianapolis, Indiana 46204
Lora Lex
AND Douglas C. Haney,
Corporation Counsel
Department of Law
One Civic Square
Carmel, Indiana 46032
Notwithstanding the above, notice of termination under paragraph 19 hereinbelow shall be effective if given
orally, as long as written notice is then provided as set forth hereinabove within five (5) business days from
the date of such oral notice.
19. TERMINATION:
19.1 Notwithstanding anything to the contrary contained in this Agreement, City may, upon notice to
Vendor, immediately terminate this Agreement for cause, in the event of a default hereunder by
Vendor and/or if sufficient funds are not appropriated or encumbered to pay for the Goods and
Services to be provided hereunder. In the event of such termination, Vendor shall be entitled to
receive only payment for the undisputed invoice amount representing conforming Goods and
Services delivered as of the date of termination, except that such payment amount shall not exceed
the Estimate amount in effect at the time of termination, unless the parties have previously agreed in
writing to a greater amount.
19.2 City may terminate this Agreement at any time upon thirty (30) days prior notice to Vendor. In the
event of such termination, Vendor shall be entitled to receive only payment for the undisputed
invoice amount of conforming Goods and Services delivered as of the date of termination, except
that such payment amount shall not exceed the Estimate amount in effect at the time of termination,
unless the parties have previously agreed in writing to a greater amount.
19.3 The City may terminate this Agreement pursuant to Paragraph 11 hereof, as appropriate,
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Public Safey Medical Services, Inc.
Carmel Fire Department - 2016
Appropriation #43-407.01 General Fund; P.O. #24531
Contract Not To Exceed $79,682.04
20. REPRESENTATIONS AND WARRANTIES
The parties represent and warrant that they are authorized to enter into this Agreement and that the persons
executing this Agreement have the authority to bind the party which they represent.
21. ADDITIONAL GOODS AND SERVICES
Vendor understands and agrees that City may, from time to time, request Vendor to provide additional goods
and services to City. When City desires additional goods and services from Vendor, the City shall notify
Vendor of such additional goods and services desired, as well as the time frame in which same are to be
provided. Only after City has approved Vendor's time and cost estimate for the provision of such additional
goods and services, has encumbered sufficient monies to pay for same, and has authorized Vendor, in
writing, to provide such additional goods and services, shall such goods and services be provided by Vendor
to City. A copy of the City's authorization documents for the purchase of additional goods and services shall
be numbered and attached hereto in the order in which they are approved by City.
22. TERM
Unless otherwise terminated in accordance with the termination provisions set forth in Paragraph 19
hereinabove, this Agreement shall be in effect from the Effective Date through December 31, 2016 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.
23. HEADINGS
All heading 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.
24. BINDING EFFECT
The parties, and their respective officers, officials, agents, partners, successors, assigns and legal
representatives, are bound to the other with respect to all of the covenants, terms, warranties and obligations
set forth in Agreement.
25, NO THIRD PARTY BENEFICIARIES
This Agreement gives no rights or benefits to anyone other than City and Vendor,
26. IRAN CERTIFICATION: Pursuant to I.C. § 5-22-16.5, the Vendor shall certify that, in signing this document,
it does not engage in investment activities within the Country of Iran.
27, ADVICE OF COUNSEL:
The parties warrant that they have read this Agreement and understand it, have had the opportunity to obtain
legal advice and assistance of counsel throughout the negotiation of this Agreement, and enter into same
freely, voluntarily, and without any duress, undue influence or coercion.
28. ENTIRE AGREEMENT:
This Agreement, together with any exhibits attached hereto or referenced herein, constitutes the entire
agreement between Vendor and City with respect to the subject matter hereof, and supersedes all prior oral
or written representations and agreements regarding same. Notwithstanding any other term or condition set
forth herein, but subject to paragraph 16 hereof, to the extent any term or condition contained in any exhibit
attached to this Agreement or in any document referenced herein .conflicts with any term or condition
contained in this Agreement, the term or condition contained in this Agreement shall govern and prevail.
This Agreement may only be modified by written amendment executed by both parties hereto, or their
successors in interest.
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Public Safey Medical Services, Inc. .
Carmel Fire Department - 2016
Appropriation #43-407.01 General Fund; P.O. 7#24$31
Contract Not To Exceed $79,682.04
IN WITNESS WHEREOF, the parties hereto have made and executed this Agreement as follows:
CITY OF CARMEL, INDIANA
by and through its Board of Public
Works and Safety
By:
N ()+ P
James Brainard, Presiding Officer
Date:
Mary An urke, er
Date: /S�
I_ofi S. Wats ' ; e ber
Date: :� � /�_
ATT
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Cluistine S PFa�le
Date:
D 9% /
Public Safety Medical Services, Inc.
By:
Authorized Signature
Printed Name
`b IC, L4 SU��
Title
FID/FIN.
Last Four of SSN if Sole Proprietor:
Date: �' 3 / — 2 Dl
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Carmel Fire Department 324 E. New Yoric Street
Indianapolis. 1N 46204-
2016 Service Agreement* 317.972.1160 Phone
r..
317.972,1190 FAX
Delivery Location: ® PSM-Indiaxtapolis or PSM -Fishers
The following when signed by Public Safety'Medical (PSIVI) at 324 E. New York. Street, Suite 300, Indianapolis, IN
46204 and Carmel Fire Department, 2 Civio-Square, Carmel, IN 46032 will constitute our agreement for delivery
of the services described below under the following terms and conditions.
Scrape of Services
PSM agrees to {provide the following services:
SEiZVIC>
t
DESCRIPTION
Code
All Firefighters
Stood & lab
�11(grk
CMP Com . Metabolic Panel
3522
$20.00
CBC Comp: Bldod Count) _
!
308-9
3523
$18.13
$21.26P
Venipuncture
3000
$3.14
i
s
Wellness°Med. resting:
i2416
_
Vital signs -Ill, wt. Wt, BP, respr-1), se
6000$0
Visiofl-ActiitY
G050. W—
$27.'18.
- - _
_
PFT-" Pulmonary Function Test
66110 _
$34.50
Medical
-
Audiomety__-
6090
$14.64
Testln�
EKG wlntar
6120
520,91
l•Jrinal sls.:I'Ji stick
„ ,6020
S3.94
Chest X-ray - PPJLAT (Digital)
(All ie, 2016, then evert 4 Years)
4Q00
$52.73 .
---$6233
i'hysicat
Exam
Res ROVtesv
6304
$16.73
_iratoriMedlcal
Comprehensive Physical Exam
I Health Risk Appraisal (Motivation)
,
12500 _
7001)
_ $102.46
$O
FUness
I Treadmill --.Subniak
20sa . -
$159.90
�
'Servlae�s -
B odv Fat Test- BIA
2011
$1$-04
Web t3.asrrd
-Seritcas
OnMed Program
_
8135
$0 .
5utltota!
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_._ ._.
1
No. Shou Fee
6080
$40.00
Age F3ase�t
ak Optional
Itit!-44'•Gen. (Rapid Test)
rut: 113£t7i:
3526
$24.56
Tests
PSA -Prostate Specific Ag (3i
3115
$36.59
Rectal/hem occult (men: age
Included
*The above pricing is valid through 2016 and assumes that all fire personnel are required to
,participate In the medical clearance program.
Billing
For services not being billed to insurance, Invoices are generated weekly,
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Phone: �» snsez2 e-mail: d�nyfe .^anndIna—
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Rightto 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 outhe 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 add, itionat testing at Carmel Fire Department expense and
at the request of the medical director, the Gartnel Fire Department rirpresentative will be notified In advance.
Policy on Repeat Testing
In the event that PSM finds it necessary to ratest a patient (lite 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 notifred:.ih advance. If the
retest is due to an error by PSM ora contracted laboratory at other representative, PSM will absorb any additional
retest costs. No recommended actions Will be made io Carmel l=ire Department until PSM has received accurate
retest information.
Policy on Reporting Resuits
P&A willt'rovide a medicallrespirator 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 atient are provided to any
representative without the written consent of -the patient unless required by taw fl.e. OSHA i: if during file
medical evaluation, findings are such that the Oatient 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 patients
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 13-14-15 Location: Fire Headquarters, 2 Civic Square Time: r:00A1vt
Blood Draws- Dates; July 25-26-27 Location: Station 45, 10701 N. College Ave. Time: 7-00AM
Examinations- Dates: August e — 24 Location: Public Safety Medical, Fishers Office.
Departmental Information
Contact person: Name: Mark Cromlich Title: Health & Safety Chief Phone: (317)409-0909
E-mail: mcromiich@carmei.in.gov
Address: 2 Civic Square, Carmel, iN 46032
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 December 31, 2016.
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
t5 miaules prior to their.appointment time.
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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 and No Shows
Cancellations should be made.at least 3 days (1 shift for ffre depart.Ments) prior to the scheduled ap-pointntent.
This enables PSM with enough notice to offer (lie appointments to another depbrtment.Md properly.prppare. Al
scheduled appointment that results in a No Show, or if the cancellation is less than a 3-d_ay notice, will
result In .a No Show penalty fee of $40 Per person. The Carmel Fire Department repmsiontattve will be
contacted prior to any fees being assessed.
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 tQ protect it and Carmel Fire Department from the claims set forth below which may
arise out of or result from PSM operations tinder this Agreement, whether such operations be by PStA 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,
i. Claims under Workers' Compensation and Cccupatioria) 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_
Confidorttiality
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 l=ire Department furnished to or
obtained by PSM in the course of providing the agreed-upon seivices. PSM will not disclose ar release any such
confidential information to any person, except its en'ipfoyees, 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.
Terminafion for Convenience
Either PSM or Cannel Plre 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.
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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
GoodslServices Provided
(Describe each good/service
separately and in detail)
Cosi Per
Item
Hourly
Rate/
Hours
'Worked
Total
GIALND TOTAL
Signature
Printed Name
EXHIBIT C
INSURANCE COVERAGES
Worker's Compensation & Disability Statutory Limits
Employer's Liability:
Bodily Injury by Accident/Disease:
$100,000 each employee
Bodily Injury by Accident/Disease:
$250,000 each accident
Bodily Injury by Accident/Disease-,
$500,000 policy limit
Property damage, contractual liability,
products -completed operations:
General Aggregate Limit (other than
Products/Completed Operations): $500,000
Products/Completed Operations: $500,0.00
Personal & Advertising Injury
Policy Limit:
$500,000
Each Occurrence Limit:
$250,000
Fire Damage (any one fire):
$250,000
Medical Expense Limit (any one person):
$ 50,000
Comprehensive Auto Liability (owned, hired and non -owned)
Bodily Single Unit:
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
AFFIDAVIT
/bjC Iq [—• L_E;k�::, , being first duly sworn, deposes and says that
he/she is familiar with and has 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 now and at all t' e. relevant he ein h� ve bee e}}nnployed by
�L(-/3 Ll L' A E� RM l EW (the "Employer")
in the position of �l&Z-'-Tv Pe QF CJ -1 E�t`G Y SueW L -e-5
I 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. Documentation
of this enrollment and participation is attached and incorporated herein.
5. The Employer does not knowingly employ any unauthorized aliens.
6, To the best of my information and belief, the Employer does not currently employ any
unauthorized aliens.
7. FURTHER AFFIANT SAYETH NOT.
EXECUTED on the i day of
Printed (op -A b-
I certify under the penalties for perjury under the laws of the United States of America and the State of
Indiana that the foregoing factual statements and representations are true and correct.
5 > /o 7
Printed:
icity®� ��}o��
INDIANA RETAIL TAX EXEMPT
CERTIFICATE NO.003120165 002 0
_ Pete 7 Of 9^—
PURCHASE ORDER NUMBERJjtt��
FEDERAL EXCISE TAX EXEMPT
24831000972
I ONE CIVIC SQUARE
35-6000972
_THIS NUMBER MUST APPEAR GNINVOICES. AIP
CARMEL, [NDIANA46032-2564
$62.73
VOUCHER. DELIVERY MEMO, PACKING SLIPS,
[FORM APPROVED BY STATE BOARD OF ACCOUNTS FOR CITY OF CARMEL - 1997
I
SHIPPING LABELS AND ANY CORRESPONDENCE
;PURCHASE ORDER DATE
DATE REQUIRED REQUISITION NO.
VENDOR NO.
Medical Testing - Vital/Vision
DESCRIPTION
5116/2016
00350364
Department Physicals
146 Each
Physical Exam-Respirator/Comprehensive/Health Risk
$139.19
$17,401.74
PUBLIC SAFETY MEDICAL SERVICES
Fire Department
;VENDOR 324 E NEW YORK ST SUITE 300
SNIP 2 Civic Square
INDIANAPOLIS, IN 46204 -
TO
Carmel, IN
46032 -
-PURCHASE ID -E BLANKET CONTRACT
PAYMENT TERMS ...-.��
.Y. iv�FREIGHT
i
4873 t t
$79,682.04
E:-.
f QUANTITY UNIT OF MEASURE
DESCRIPTION -�� .
•---.. !
UNIT PRICE -- EXTENSION
Department, 1120
Account. 43-407.01 Fund: 101 General Fund
146 Each
Blood and Lab Work- CMPICBC/LipidNenipuncture
$62.53
$9,129.38
146 Each
Chest X -Ray
$62.73
$9,158.58
8 Each
HIV Testing
$24.56
$196.48
146 Each
Medical Testing - Vital/Vision
$100.37
$14,654.02
AcglPFT/Au diometryIEKGIUrinalysis
146 Each
Physical Exam-Respirator/Comprehensive/Health Risk
$139.19
$17,401.74
100 Each
Prostate Exam
$36.59
$3,659.00
146 Each
Treadmill and Body Pat Testing
$174.54
$25,482.84
Sub Total —
$79,682.04
-
Send Invoice To:
Fire Department
2 Civic Square = _ -
J
Carmel, IN 46032-
PLEASE INVOICE IN DUPLICATE _
I DEPARTMENT ACCOUNT — PROJECT { - PROJECTACCOUNT AMOUNT
— -
SHIPPING INSTRUCTIONS
'SHIP PREPAID.
'C.O.D.6HIP&4ENTCANNOT BEACCEPTED.
'PURCHASE ORDER NUTAGER MUSTAPPEAR ON ALL SHIPPING LABEL
'THIS ORDER ISSUED IN COMPLIANGS WITH CHAPTER 99, ACTS 194:
ANDACTSAMM- ATORYTHEREOFANDSUPPLEMENTTHERETO. ORDERED BY
TITLE
CONTROL NO. 24831 CLERK -TREASURER
PAYMENT $79,682.04
NP VOUCHER 'CANNOT BE APPROVED FOR PAYMENT UNLESS -1 HE P.O. NUMBER IS IAADEA
PART OF THE VOUCHER AND EVERY INVOICE AND VOUCHER HAS THE PROPER WORN
AFFIDAVIT ATTACHED. I HEREBY CERTIFY THAT THERE IS AN UNOBLIGATED BALANCE IN
THIS APPROPRIATION SUFFICIENTTO PAY FORTHE ABOVE ORDER.
Denise Snyder
Budget & Accreditation Manager
Steve Engeiking
Administration
Company ID Number: 435624
To be accepted as a participant in E -Verify, you should only sign the Employer's Section
of the signature page. If you have any questions, contact E -Verify at 888-464-4218.
Page 12 of 14 1 E -Verify MOU for Employer I Revision Date 09/01/09 www.dhs.gov/E-Verify
in=
Information relating to the Program Administrator(s) for `your Company on policy
questionsor operational, problems: -
Page 13 of 14 1 E -Verify MOU for Employer I Revision Date 09/01/09 www.dhs.gov/E-Verify
Name:
Lauren E Moffatt
Telephone Number:
(317) 972 -1180 ext. 339
Fax Number:
(317) 972 -1190
.E -Mail Address:.
lauren.moffatt@ publiesafetymed.com .
Name:
Steven M Moffatt
TelephoneNumber:
(317) 972 `-1180 "ext: 323.
Fax Number:
(317) 972.,- 1 ISO
E-mail Address: "
stcven.moffatt@pgb lies afetymed. com
Name:`
Chris Costlow
Telephone Number:
(317) 972 - 1180, ext. 324
Fax Number:
(317) 972 -1190
E-mail Address:
chris.costlow@ubliesafet}med;com
'Name::..
Lora Les
'.
'"Telephone Number:
(317) 972 - 1180.ext. 345 "
Fax Number.
(317) 972 -1190
E-mail Address:
lora.lex@publiesafetymed.com
Page 13 of 14 1 E -Verify MOU for Employer I Revision Date 09/01/09 www.dhs.gov/E-Verify
Y R
czgm
'
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Company ID Number: 435624
Page 14 of 14 [ E -Verify MOU for Employer I Revision Date 09/01/09 www.dhs.gov/E-Verify