Public 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
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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