21-R-02 - Agreement with a Mobil Integrated Healthcare (MIH) with Affinity Family CareRESOLUTION NO. 21 -R -02
A RESOLUTION BY THE CITY COUNCIL OF THE CITY OF
SCHERTZ, TEXAS AUTHORIZING A MOBILE INTEGRATED
HEALTHCARE (MIH) AGREEMENT WITH AFFINITY FAMILY CARE
AND OTHER MATTERS IN CONNECTION THEREWITH
WHEREAS, Schertz Emergency Medical Services provides regional emergency medical
services in a 220 square mile service area that includes the municipalities of Schertz, Cibolo,
Live Oak, Marion, Santa Clara, Selma, Universal City, western Guadalupe County, Comal
County ESD #6 and a small area of unincorporated Bexar County; and
WHEREAS, EMS also incorporates a Mobile Integrated Healthcare (MIH) program
staffed by one MIH Paramedic and a Community Health Coordinator to provide additional
services to our residents; and
WHEREAS, Area healthcare providers (physicians, physician assistants and nurse
practitioners) routinely use telemedicine for patient visits; and
WHEREAS, our MIH program can provide services missing with telemedicine visits; and
WHEREAS, the City staff of the City of Schertz (the "City ") has recommended that the
City enter into a Mobile Integrated Health ( "MIH ") agreement with Affinity Family Care Clinic
relating to Mobile Integrated Health Services; and
WHEREAS, the City Council has determined that it is in the best interest of the City to
contract with Affinity Family Care pursuant to the MIH Services Agreement attached hereto as
Exhibit A (the "Agreement ").
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF SCHERTZ, TEXAS
THAT:
Section 1. The City Council hereby authorizes the City Manager to execute and
deliver the Agreement with Affinity Family Care in substantially the form set forth on Exhibit A.
Section 2. The recitals contained in the preamble hereof are hereby found to be true,
and such recitals are hereby made a part of this Resolution for all purposes and are adopted as a
part of the judgment and findings of the City Council.
Section 3. All resolutions, or parts thereof, which are in conflict or inconsistent with
any provision of this Resolution are hereby repealed to the extent of such conflict, and the
provisions of this Resolution shall be and remain controlling as to the matters resolved herein.
Section 4. This Resolution shall be construed and enforced in accordance with the
laws of the State of Texas and the United States of America.
Section 5. If any provision of this Resolution or the application thereof to any person
or circumstance shall be held to be invalid, the remainder of this Resolution and the application
of such provision to other persons and circumstances shall nevertheless be valid, and the City
Council hereby declares that this Resolution would have been enacted without such invalid
provision.
Section 6. It is officially found, determined, and declared that the meeting at which
this Resolution is adopted was open to the public and public notice of the time, place, and subject
matter of the public business to be considered at such meeting, including this Resolution, was
given, all as required by Chapter 551, Texas Government Code, as amended.
Section 7. This Resolution shall be in force and effect from and after its final
passage, and it is so resolved.
PASSED AND ADOPTED, this 9t' day of February, 2021.
CITY OF SCHERTZ, TEXAS
1 G rrez, Mayor
ATTEST:
ca�� L'XW1 "�
Brenda Dennis, City Secretary
50234811.1
EXHIBIT A
AGREEMENT
50234811.1 A -1
CITY OF SCHERTZ
SERVICE AGREEMENT
THE STATE OF TEXAS §
GUADALUPE COUNTY §
This Agreement for Mobile Integrated Healthcare ( "MIH ") Services ( "Agreement") is made and
entered by and between the City of Schertz, Texas, (the "City ") a Texas municipality, and Amity
Family Care Clinic ( "Clinic ").
Section 1. Duration
This Agreement shall become effective upon the date of the final signature affixed hereto and shall
remain in effect through September 30, 2023 unless terminated as provided for in this Agreement.
Section 2. Scope of Work
(A) City shall provide Clinic with MIH Services in order to complete the work defined in the
agreement within areas served by City for Emergency Medical Services ( "EMS ") and/or
MIH Services as well as those services further described in Exhibit A.
(B) Clinic shall provide City with the services and obligations described in Exhibit B
(C) All work performed under the agreement shall be done in compliance with all statutory,
regulatory and contractual requirements now or hereafter in effect as may be applicable to
the rights and obligations set forth in the Agreement.
Section 3. Compensation
(A) City shall be paid in the manner set forth in Exhibit "A ", Exhibit `B" and as provided herein.
(B) Billing Period Subject to Chapter 2251, Texas Government Code (the "Prompt Payment
Act "), payment is due within thirty (30) days of the Clinic's receipt of the City's invoice.
Interest on overdue payments shall be calculated in accordance with the Prompt Payment
Act.
(C) Reimbursable Expenses. Any and all reimbursable expenses related to the Project shall be
included in the scope of Work (Exhibit A) and accounted for in the total contract amount.
Section 4. Insurance
Before commencing work under this Agreement, Affinity Family Care shall obtain and maintain
the liability insurance provided for in attached Exhibit D throughout the term of this Agreement
and thereafter as required herein.
The insurance required by this Agreement shall be written by non - assessable insurance company
licensed to do business in the State of Texas and currently rated "B +" or better by the A.M. Best
CITY OF SCHERTZ PAGE 1
Affinity Family Care Clinic Service Agreement
Companies. All policies shall be written on a "per occurrence basis" and not a "claims made" form.
The City shall be named as an "additional insured" except for any Professional Liability policy.
Evidence of such insurance shall be attached as Exhibit "C ".
Section 5. Miscellaneous Provisions
(A) Subletting. Neither Party shall sublet or transfer any portion of the work under this
Agreement or any Scope of Work issued pursuant to this Agreement unless specifically
approved in writing by the all parties to the agreement, which approval shall not be
unreasonably withheld. Subcontractors shall comply with all provisions of this Agreement
and the applicable Scope of Work. The approval or acquiescence in the subletting of any
work shall not relieve the parties of any responsibility for work done by such subcontractor.
(B) Compliance with Laws. Clinic shall comply with all federal, state and local laws, statutes,
ordinances, rules and regulations, and the orders and decrees of any courts, administrative, or
regulatory bodies in any matter affecting the performance of this Agreement, including,
without limitation, worker's compensation laws, minimum and maximum salary and wage
statutes and regulations, and licensing laws and regulations.
(C) Independent Contractor. Clinic acknowledges that it is an independent contractor of the City
and is not an employee, agent, official or representative of the City. Clinic shall not represent,
either expressly or through implication, that Clinic is an employee, agent, official or
representative of the City.
(D) Non - Boycott of Israel. Pursuant to Section 2270.002 of the Texas Government Code, Clinic
certifies that either (i) it meets an exemption criterion under Section 2270.002; or (ii) it does
not boycott Israel and will not boycott Israel during the term of the contract resulting from
this solicitation. Clinic shall state any facts that make it exempt from the boycott certification
as an attachment to this agreement.
Relevant definitions from the bill:
"Company" means a for -profit sole proprietorship, organization, association, corporation,
partnership, joint venture, limited partnership, limited liability partnership, or limited liability
company, including a wholly owned subsidiary, majority -owned subsidiary, parent company,
or affiliate of those entities or business associations that exists to make a profit.
"Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise
taking any action that is intended to penalize, inflict economic harm on, or limit commercial
relations specifically with Israel, or with a person or entity doing business in Israel or in an
Israeli - controlled territory, but does not include an action made for ordinary business
purposes.
(E) Force Majeure. If the performance of any covenant or obligation to be performed hereunder
by any party is delayed as a result of circumstances which are beyond the reasonable control
of such party (which circumstances may include, without limitation, pending litigation, acts
of God, war, acts of civil disobedience, fire or other casualty, shortage of materials, adverse
weather conditions [such as, by way of illustration and not of limitation, severe rain storms or
CITY OF SCHERTZ PAGE 2
Affinity Family Care Clinic Service Agreement
below freezing temperatures, or tornados] labor action, strikes or similar acts, moratoriums or
regulations or actions by governmental authorities), the time for such performance shall be
extended by the amount of time of such delay, but no longer than the amount of time
reasonably occasioned by the delay. The party claiming delay of performance as a result of
any of the foregoing force majeure events shall deliver written notice of the commencement
of any such delay resulting from such force majeure event not later than seven (7) days after
the claiming party becomes aware of the same, and if the claiming party fails to so notify the
other party of the occurrence of a force majeure event causing such delay and the other party
shall not otherwise be aware of such force majeure event, the claiming party shall not be
entitled to avail itself of the provisions for the extension of performance contained in this
subsection.
Section 6. Termination
(A) This Agreement may be terminated:
(1) By the mutual agreement and consent of both Clinic and City;
(2) By either party, upon the failure of the other party to fulfill its obligations as set forth
in either this Agreement or a Scope of Work issued under this Agreement;
(3) By the City, immediately upon notice in writing to the Clinic, as consequence of the
failure of Clinic to perform the Work contemplated by this Agreement in a timely or
satisfactory manner;
(4) By the City, at will and without cause upon not less than thirty (30) days written notice
to the Clinic.
Section 7. Indemnification
CLINIC AGREES TO INDEMNIFY AND HOLD THE CITY OF SCHERTZ, TEXAS AND ALL OF ITS
PRESENT, FUTURE AND FORMER AGENTS, EMPLOYEES, OFFICIALS AND REPRESENTATIVES
HARMLESS IN THEIR OFFICIAL, INDIVIDUAL AND REPRESENTATIVE CAPACITIES FROM ANY AND
ALL CLAIMS, DEMANDS, CAUSES OF ACTION, JUDGMENTS, LIENS AND EXPENSES (INCLUDING
ATTORNEYS FEES, WHETHER CONTRACTUAL OR STATUTORY), COSTS AND DAMAGES (WHETHER
COMMON LAW OR STATUTORY), COSTS AND DAMAGES (WHETHER COMMON LAW OR
STATUTORY, AND WHETHER ACTUAL, PUNITIVE, CONSEQUENTIAL OR INCIDENTAL), OF ANY
CONCEIVABLE CHARACTER, FOR INJURIES TO PERSONS (INCLUDING DEATH) OR TO PROPERTY
(BOTH REAL AND PERSONAL) CREATED BY, ARISING FROM OR IN ANY MANNER RELATING TO THE
WORK OR GOODS PERFORMED OR PROVIDED BY CLINIC - EXPRESSLY INCLUDING THOSE
ARISING THROUGH STRICT LIABILITY OR UNDER THE CONSTITUTIONS OF THE UNITED STATES.
Section 8. Notices
Any notice required or desired to be given from one party to the other party to this Agreement
shall be in writing and shall be given and shall be deemed to have been served and received
(whether actually received or not) if (i) delivered in person to the address set forth below; (ii)
deposited in an official depository under the regular care and custody of the United States Postal
CFrY OF SCHERTZ PAGE 3
Affinity Family Care Clinic Service Agreement
Service located within the confines of the United States of America and sent by certified mail,
return receipt requested, and addressed to such party at the address hereinafter specified; or (iii)
delivered to such parry by courier receipted delivery. Either party may designate another address
within the confines of the continental United States of America for notice, but until written notice
of such change is actually received by the other party, the last address of such parry designated for
notice shall remain such party's address for notice.
Section 9. No Assign, moment
Neither party shall have the right to assign that party's interest in this Agreement without the prior
written consent of the other party.
Section 10. Severability
If any term or provision of this Agreement is held to be illegal, invalid or unenforceable, the
legality, validity or enforceability of the remaining terms or provisions of this Agreement shall not
be affected thereby, and in lieu of each such illegal, invalid or unenforceable term or provision,
there shall be added automatically to this Agreement a legal, valid or enforceable term or provision
as similar as possible to the term or provision declared illegal, invalid or unenforceable.
Section 11. Waiver
Either City or the Clinic shall have the right to waive any requirement contained in this Agreement
that is intended for the waiving party's benefit, but, except as otherwise provided herein, such
waiver shall be effective only if in writing executed by the party for whose benefit such
requirement is intended. No waiver of any breach or violation of any term of this Agreement shall
be deemed or construed to constitute a waiver of any other breach or violation, whether concurrent
or subsequent, and whether of the same or of a different type of breach or violation.
Section 12. Governing Law; Venue
This Agreement and all of the transactions contemplated herein shall be governed by and construed
in accordance with the laws of the State of Texas. The provisions and obligations of this
Agreement are performable in Guadalupe County, Texas such that exclusive venue for any action
arising out of this Agreement shall be in Guadalupe County, Texas.
Section 13. Para ,2raph Headini„s; Construction
The paragraph headings contained in this Agreement are for convenience only and shall in no way
enlarge or limit the scope or meaning of the various and several paragraphs hereof. Both parties
have participated in the negotiation and preparation of this Agreement and this Agreement shall
not be construed either more or less strongly against or for either party.
Section 14. Binding Effect
Except as limited herein, the terms and provisions of this Agreement shall be binding upon and
inure to the benefit of the parties hereto and their respective heirs, devisees, personal and legal
representatives, successors and assigns.
Section 15. Gender
Within this Agreement, words of any gender shall be held and construed to include any other
gender, and words in the singular number shall be held and construed to include the plural, unless
the context otherwise requires.
CITY OF SCHERTZ PAGE 4
Affinity Family Care Clinic Service Agreement
Section 16. Counterparts
This Agreement may be executed in multiple counterparts, each of which shall be deemed an
original, and all of which shall constitute but one and the same instrument.
Section 17. Exhibits & Attachments
All exhibits and attachments to this Agreement are incorporated herein by reference for all
purposes wherever reference is made to the same.
Section 18. Entire Agreement
It is understood and agreed that this Agreement contains the entire agreement between the parties
and supersedes any and all prior agreements, arrangements or understandings between the parties
relating to the subject matter. No oral understandings, statements, promises or inducements
contrary to the terms of this Agreement exist. This Agreement cannot be changed or terminated
orally.
Section 19. Relationship of Parties
Nothing contained in this Agreement shall be deemed or construed by the parties hereto or by any
third party to create the relationship of principal and agent or of partnership or of joint venture or
of any association whatsoever between the parties, it being expressly understood and agreed that
no provision contained in this Agreement nor any act or acts of the parties hereto shall be deemed
to create any relationship between the parties other than the relationship of independent parties
contracting with each other solely for the purpose of effecting the provisions of this Agreement.
Section 20. Ri(_,ht To Audit
City shall have the right to examine and audit the books and records of Clinic with regards to the
work described in Exhibit A, Exhibit B, or any subsequent changes, at any reasonable time. Such
books and records will be maintained in accordance with generally accepted principles of
accounting and will be adequate to enable determination of. (1) the substantiation and accuracy of
any payments required to be made under this Agreement; and (2) compliance with the provisions
of this Agreement.
Section 21. Dispute Resolution
In accordance with the provisions of Subchapter I, Chapter 271, TEX. LOCAL Gov'T CODE, the
parties agree that, prior to instituting any lawsuit or other proceeding arising from a dispute under
this agreement, the parties will first attempt to resolve the dispute by taking the following steps:
(1) A written notice substantially describing the nature of the dispute shall be delivered by the
dissatisfied party to the other party, which notice shall request a written response to be delivered
to the dissatisfied party not less than 5 days after receipt of the notice of dispute. (2) If the response
does not reasonably resolve the dispute, in the opinion of the dissatisfied party, the dissatisfied
party shall give notice to that effect to the other party whereupon each party shall appoint a person
having authority over the activities of the respective parties who shall promptly meet, in person,
in an effort to resolve the dispute. (3) If those persons cannot or do not resolve the dispute, then
the parties shall each appoint a person from the highest tier of managerial responsibility within
each respective party, who shall then promptly meet, in person, in an effort to resolve the dispute.
Section 22. Disclosure of Business Relationships /Affiliations; Conflict of Interest
Questionnaire
CITY OF SCHERTZ PAGE 5
Affinity Family Care Clinic Service Agreement
Clinic represents that it is in compliance with the applicable filing and disclosure requirements of
Chapter 176 of the Texas Local Government Code.
Certificate of Interested Parties
Effective January 1, 2016, pursuant to House Bill 1295 passed by the 84th Texas Legislature
(Section 2252.908, Texas Government Code, as amended) and formal rules released by the Texas
Ethics Commission (TEC), all contracts with private business entities requiring approval by the
Schertz City Council will require the on -line completion of Form 1295 "Certificate of Interested
Parties." Form 1295 is also required for any and all contract amendments, extensions or renewals.
Clinic is required to complete and file electronically with the Texas Ethics Commission using the
online filing application.
Please visit the State of Texas Ethics Commission website,
ht€i)s://www.ethics.state.tx.us/whatsnew/elf info forml295.htm and
hts 4)s: / /www. ethics .state.tx.us /tec /1295 - Info.htm for more information.
IF YOU HAVE ANY QUESTIONS ABOUT COMPLIANCE, PLEASE CONSULT YOUR
OWN LEGAL COUNSEL. COMPLIANCE IS THE INDIVIDUAL RESPONSIBILITY OF
EACH PERSON OR AGENT OF A PERSON WHO IS SUBJECT TO THE FILING
REQUIREMENT. AN OFFENSE UNDER CHAPTER 176 IS A CLASS C MISDEMEANOR.
Section 23. HIPAA
(A) It is the intent of the parties to comply fully with the Health Insurance Portability and
Accountability Act, Texas Health and Safety Code Chapter 181, and implementing
regulations issued pursuant thereto (collectively " HIPAA" herein). The parties agree
that confidential health information (hereinafter referred to as "Protected Health
Information" or "PHI ") is subject to protection under, and it is the intent of the parties
to be in full compliance with, state and federal law, including applicable provisions
of HIPAA, the Health Information Technology for Economic and Clinical Health Act
( "HITECH "), its related regulations, and all applicable state privacy and security laws
related to access of PHI by the parties. To the extent that the services performed herein
are determined to be performing a transaction subject to HIPAA or HITECH Act, the
Business Associate Agreement shall control. Contemporaneously with the execution
of this Agreement, the parties have executed a HIPAA compliant Business Associate
Agreement.
(B) Each party shall implement and maintain such safeguards as are necessary to ensure
that the PHI is not used or disclosed except as is provided in this Agreement and any
referenced documents.
[The remainder of this page is intentionally left blank.]
CITY OF SCHERTZ PAGE 6
Affinity Family Care Clinic Service Agreement
EXECUTED on this the day of , 20
CITY:
By:
Name:
Title:
Dr. Mark Browne
City Manager
ADDRESS FOR NOTICE:
CITY:
City of Schertz
Attn: Dr. Mark Brown, City Manager
1400 Schertz Parkway
Schertz, Texas 78154
CITY OF SCHERTZ
Affinity Family Care Clinic Service Agreement
CLINIC:
By:
Name: Sean Dittman, NP
Title: Family Nurse Practitioner
CLINIC:
Affinity Family Care Clinic
Attn: Sean Dittman, NP
232 Brite Rd #117
Cibolo, TX 78108
PAGE 7
Exhibit "A"
CITY OF SCHERTZ REQUIREMENTS
The City agrees to provide Clinic the following services:
a. City MIH personnel shall make contact with the patient as determined
by Clinic.
b. City shall keep patient care records for every contact and w i I I provide
them to Clinic as outlined in the agreement.
c. City shall provide monthly reports on utilization of the MIH Program and
any other requested data as defined in the agreement.
d. Patient visits will include either a basic or advanced assessment
determined by Affinity Family Care as outlined below:
1. Basic Assessment
Basic Assessment shall include the following services:
• Vision Assessment
• Breath Sounds
• Heart murmurs
• Blood Pressure
• Pulse
• Respirations
• Temperature
• Weight
• Medication Review
Basic Assessment Fee: $25.00
2. Advanced Assessment
Advanced Assessment shall include those services included in
the Basic Assessment as well as:
• Blood Glucose
• ETCO2 w/ wave form
• SP02 w/ wave form
• EKG
• 12 lead EKG
CITY OF SCHERTZ PAGE 8
Affinity Family Care Clinic Service Agreement
• Blood work
• Medication administration (no additional charge if provided
by Affinity Family Care
Advanced Assessment Fee: $35.00
e. All other services provided will be billed in accordance with CITY OF
SCHERTZ EMS Rates.
f. City shall create and provide access to Clinic a Sharepoint site for the
express purpose of exchanging patient records, schedules, and any other
material needed to provide the services outlined in the Agreement.
CITY OF SCHERTZ PAGE 9
Affinity Family Care Clinic Service Agreement
Appendix B.
AFFINITY FAMILY CARE REQUIREMENTS
The Clinic agrees to provide City the following services:
a. Clinic shall schedule patient visits and provide a mutual agreed upon
schedule to City.
b. Clinic shall identify the type of patient visit required and notify City.
c. Clinic shall provide necessary patient care records to City
d. Clinic shall provide City any required testing material and /or
medications needed for administration to patient.
CITY OF SCHERTZ PAGE 10
Affinity Family Care Clinic Service Agreement
Exhibit "C"
REQUIREMENTS FOR ALL INSURANCE DOCUMENTS
The Clinic shall comply with each and every condition contained herein. The Clinic shall provide and maintain the minimum
insurance coverage set forth below during the term of its agreement with the City. Any Subcontractor(s) hired by the Clinic
shall maintain insurance coverage equal to that required of the Clinic. It is the responsibility of the Contractor to assure
compliance with this provision. The City of Schertz accepts no responsibility arising from the conduct, or lack of conduct,
of the Subcontractor.
INSTRUCTIONS FOR COMPLETION OF INSURANCE DOCUMENT
With reference to the foregoing insurance requirements, Contractor shall specifically endorse applicable insurance policies
as follows:
1. The City of Schertz shall be named as an additional insured with respect to General Liability and Automobile
Liability on a separate endorsement.
2. A waiver of subrogation in favor of The City of Schertz shall be contained in the Workers Compensation and all
liability policies and must be provided on a separate endorsement.
3. All insurance policies shall be endorsed to the effect that The City of Schertz will receive at least thirty (30) days
written notice prior to cancellation or non - renewal of the insurance.
4. All insurance policies, which name The City of Schertz as an additional insured, must be endorsed to read as primary
and non - contributory coverage regardless of the application of other insurance.
5. Chapter 1811 of the Texas Insurance Code, Senate Bill 425 82(R) of 2011, states that the above endorsements
cannot be on the certificate of insurance. Separate endorsements must be provided for each of the above.
6. All insurance policies shall be endorsed to require the insurer to immediately notify The City of Schertz of any
material change in the insurance coverage.
7. All liability policies shall contain no cross liability exclusions or insured versus insured restrictions.
8. Required limits may be satisfied by any combination of primary and umbrella liability insurances.
9. Clinic may maintain reasonable and customary deductibles, subject to approval by The City of Schertz.
10. Insurance must be purchased from insurers having a minimum AmBest rating of B +.
11. All insurance must be written on forms filed with and approved by the Texas Department of Insurance. (ACORD
25 2010/05). Coverage must be written on an occurrence form.
12. Contractual Liability must be maintained covering the Contractors obligations contained in the contract. Certificates
of Insurance shall be prepared and executed by the insurance company or its authorized agent and shall contain
provisions representing and warranting all endorsements and insurance coverages according to requirements and
instructions contained herein.
13. Upon request, Clinic shall furnish The City of Schertz with certified copies of all insurance policies.
14. A valid certificate of insurance verifying each of the coverages required above shall be issued directly to the City
of Schertz within ten (10) business days after contract award and prior to starting any work by the successful Clinic
insurance agent of record or insurance company. Also, prior to the start of any work and at the same time that the
Certificate of Insurance is issued and sent to the City of Schertz, all required endorsements identified in sections A,
B, C and D, above shall be sent to the City of Schertz. The certificate of insurance and endorsements shall be sent
to:
City of Schertz
Purchasing Department
1400 Schertz Parkway
Schertz, TX 78154
CITY OF SCHERTZ
Affinity Family Care Clinic Service Agreement
emailed to: hurchasinr schertz.com
Faxed to: 210 - 619 -1169
PAGE 11
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AUTHORIZIM 8 RATURE REQUIReOlIERE _
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CITY OF SCHERTZ PAGE 12
Affinity Family Care Clinic Service Agreement
(Instructions for completing and submitting a certificate to the City of Schertz)
Complete the certificate of insurance with the information listed below:
A) Certificate of Insurance date
B) Producer (Insurance Agency) Information — complete name, address, telephone information, & email address.
C) Insured's (Insurance Policy Holder) Information — complete name & address information
D) Insurer (name /names of insurance company) * *(Remember the city requires all insurance companies to be
Authorized to do business in the State of Texas be rated by A.M. Best with a rating of B+ (or better) Class VI (or
higher) or otherwise be acceptable to the City if not rated by A.M. Best)
E) NAIC # (National Association of Insurance Commissioners, a # that is assigned by the State to all insurance
companies)
F) Insurer letter represents which insurance company provides which type of coverage from D
G) General Liability Insurance Policy — must have an (x) in box. Also, "Occurrence" type policy — must have an (x) in
the box (occurrence policy preferred but claims made policy can be accepted with special approval)
H) This section shall be filled in with "Y" for yes under Additional Insured for all coverages, except for Clinic Liability
and Workers' Compensation. There shall also be a "Y" for yes under all coverages for subrogation waived.
I) Automobile Liability Insurance — must be checked for Any Auto, All Owned Autos, Hired Autos
J) Umbrella Coverage — must be checked in this section and by occurrence whenever it is required by written contract
and in accordance with the contract value.
K) Worker's Compensation and Employers Liability Insurance — information must be completed in this section of the
certificate of insurance form (if applicable).
L) Builder's Risk Policy — for construction projects as designated by the City of Schertz.
Professional Liability Coverage — for professional services if required by the City of Schertz.
M) Insurance Policy #'s
N) Insurance policy effective dates (always check for current dates)
O) Insurance Policy limits (See Insurance Requirements Checklist)
P) This section is to list projects, dates of projects, or location of project. Endorsements to the insurance policy(ies)
must be provided separately and not in this section. The following endorsements are required by the City of Schertz.
(1) Adding the City of Schertz as an additional insured. The "additional insured" endorsement is not required for
professional liability and workers compensation insurance; and
(2) Waiver of Subrogation
(3) Primary and Non - Contributory
(4) Cancellation Notice
Q) City of Schertz's name and address information must be listed in this section
R) Notice of cancellation, non - renewal, or material change to the insurance policy(ies) must be provided to the City of
Schertz in accordance with a cancellation notice endorsement to the policy and/or per the policy provisions based
on the endorsement adding the city as an additional insured. (Sec. 1811.155, Tex. Ins. Code)
S) The certificate must be signed by the Authorized Agent in this section of the certificate form.
CITY OF SCHERTZ PAGE 13
Affinity Family Care Clinic Service Agreement
Exhibit "D"
EVIDENCE OF INSURANCE
CITY OF SCHERTZ PAGE 14
Affinity Family Care Clinic Service Agreement