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HomeMy WebLinkAbout5495Contract Number: Vendor: Subject: Department: File Class: Begin Date: End Date: Review Date: Vault Date: 5495 BREMERTON AMBULANCE HIPPA Business Association Agreement Fire GS50-01-11 Rev. 3 General 3/30/2015 Comments : HIPAA Business Associate Agreement etween the City of Bremerton and Bremerton Ambulance This agreement is executed to ensure that Bremerton Ambulance ("Contractor”) will appropriately safeguard protected health information.("PHI") that is created, received, maintained, or transmitted on behalf of City of Bremerton in compliance with the applicable provisions of Chapter 70.02 RCW, the Uniform Health Care Information Act ("UHCIA") as amended, with Public Law 104-191 of August 21, 1996, known as the Health Insurance , Portability and Accountability Act of 1996, Subtitle F— Administrative Simplification, Sections 261 etseq. ("HIPAA") as amended, and with Public Law 111-5 of February 17, 2009, known as the American Recovery and Reinvestment Act of 2009, Title XII, Subtitle D— Privacy, Sections 13400 et seq., the Health Information Technology and Clinical Health Act (the "HITECH Act") as amended. A. General Provisions Meanin of Terms. The terms used in this Addendum shall have the same meaning as those terms defined in the UHCIA and HIPAA. Where definitions in the two Acts differ, UHCIA definitions shall control. 2. Reulatorv References. Any reference in this Addendum to a regulatory section means the section currently in effect or as amended. 3. Interpretation. Any ambiguity in this Addendum shall be interpreted to permit compliance with the UHCIA and HIPAA. B. bligations oi t3usiness Hssociaie Contractor agrees that it will: 1. Not use or further disclose PHI other than as permitted or required by this Addendum or as required by law; 2. Use appropriate safeguards and comply, where applicable, with UHCIA security safeguards and the HIPAA Security Rule with respect to electronic protected health information ("e-PHI") and implement appropriate physical, technical and administrative safeguards to prevent use or disclosure of PHI other than as provided for by this Addendum; 3. Report to City of Bremerton any use or disclosure of PHI not provided for by this Addendum of which it becomes aware, including any security incident (as defined in the HIPAA Security Rule) and any breaches of unsecured PHI as required by 45 CFR 164.410. Breaches of unsecured PHI shall be reported to City of Bremerton without unreasonable delay but in no case later than 60 days after discovery of the breach; 4. In accordance with 45 CFR 164.502(e)(1)(ii) and 164.308(b)(2), ensure that any subcontractors that create, receive, maintain, or transmit PHI on behalf of Contractor agree to the same restrictions, conditions, and requirements that apply to Contractor with respect to such information; 5. Make PHI in a designated record set available to City of Bremerton and to an individual who has a right of access in a manner that satisfies City of Bremerton's obligations to provide access to PHI in accordance with RCW 70.02.080 and 45 CFR 164.524, as promptly as required under the circumstances, but no later than 15 waricing days aifer receiving a request; 6. Make any amendment(s) to PHI in a designated record set as directed by City of Bremerton, or tal<e other measures necessary to satisfy City of Bremerton's obligations under RCW 70.02.100 and 45 CFR §164.526, as promptly as required under the circumstances, but no later than 10 days after receiving a request; 7. Maintain and make available information required to provide an accounting of disclosures to City of Bremerton or an individual wMo has a right to an accounting within 60 days and as necessary to satisfy City of Bremerton's obligations under RCW 70.02.020 and 45 CFR §164.528; 8. To the extent that Contractor is to carry out any of City of Bremerton's obligations under the UHCIA and HIPAA, Contractor shall comply with the requirements of the Acts that apply to City of Bremerton when it carries out that obligation; 9. Make its internal practices, books, and records relating to the use and disclosure of PHI received from, or created or received by Contractor on behalf of City of Bremerton, available to the Secretary of the Department of Health and Human Services for purposes of determining Contractor and City of Bremerton's compliance with HIPAA and the HITECH Act; 10. Restrict the use or disclosure of PHI if City of Bremerton notifies Contractor of any restriction on the use or disclosure of PHI that City of Bremerton has agreed to or is required to abide by under the UHCIA or 45 CFR §164.522; and 11. City of Bremerton may be subject to the Red Flags Rules (found at 16 CFR §681.1 et seq.) and in relation thereto has adopted an Identity Theft Prevention Program Resolution No. 3081). Contractor agrees to assist City of Bremerton in complying with its Program and the Red Flags Rules by: (a) implementing policies and procedures to detect relevant Red Flags (as defined under 16 C.F.R. §681.2); (b) takir all cta c naraccrv tn rnrn i N,ith tha elriPC nr n nrarirac pf C'jtv nfg .. . ..... _.,.. , R 1 , Z f Bremerton's Identity Theft Prevention Program; (c) ensuring that any agent or third party who performs services on its behalf in connection with covered accounts of City of Bremerton agrees to implement reasonable policies and procedures designed to detect, prevent, and mitigate the risk of identity theft; and (d) alerting City of Bremerton of any Red Flag incident (as defined by the Red Flags Rules) of which it becomes aware, and the steps it has taken to mitigate any potential harm that may have occurred, and providing a report to City of Bremerton of any threat of identity theft as a result of the incident. 12. Comply with all current rules and regulations pertaining to the OIG Compliance Program for ambulance suppliers and any current special bulletins regarding LEIE recommended screening of employees and any subcontractors. C. Permitted Uses and Disclosures by Business Associate The specific uses and disclosures of PHI that may be made by Contractor on behalf of City of Bremerton include: 1. The review of patient care information for providing adyice to City of Bremerton concerning a particular ambulance incident; 2. The review of patient care information and other medical records and submission of that information to carriers, insurers, and other payers and assisting City of Bremerton in an insuranceor Medicare audit or other similar action; and 3. Other uses or disclosures of PHI as permitted by the UHCIA or HIPAA necessary to perform the services that ontractor has been engaged to periorm on oehali oi i.iiy of Bremerton. D. Termination 1. City of Bremerton may terminate the Agreement if City of Bremerton determines that Contractor has violated a material term of the Addendum. 2. If either party knows of a pattern of activity or practice of the other party that constitutes a material breach or violation of the other party's obligations under this Addendum, that party shall take reasonable steps to cure the breach or end the violation, as applicable, and, if such steps are unsuccessful, terminate the Agreement, if feasible. 3. Upon termination of the Agreement for any reason, Contractor shall return to City of Bremerton or destroy all PHI received from City of t3remerton, or created, maintained, or receivd by Contractor on behalf of City of Bremerton that Contractor still maintains in any form. Contractor shall retain no copies of the PHI. If 3 return or destruction is infeasible, the protections of this Addendum will extend to such PHI. Agreed to this 30th day of March, 2015. City of Bremer Signature: Title: l FFf Bremerton Ambulance Signature: Title: C.CEC (l i f7//Z C'- Date: , I — -Date: S --5 Policy No: CPW 6873977 9 Page 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AP 90 24 02 16 THIS ENDORSEMENT IDENTIFIES PERSONS) OR ORGANIZATIONS WHO ARE ALREADY AN "INSURED" UNDER THE WHO IS AN INSURED PROVISION OF THE POLICY. THIS ENDORSEMENT DOES NOT ALTER COVERAGE PROVIDED IN THE POLICY. PERSONS) OR ORGANIZATIONS) IDENTIFIED AS "INSURED(S)'nc'C This endorsement is for use with the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM JUL 0 6 2020 City of 8remertor Risk kanagement Each person or organization listed below is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision of Covered Autos Liability Coverage If no entry appears below, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Persons) or Organization(s): CITY OF BREMERTON C/0 CITY CLERK/CITY HALL 345 6TH ST SUITE 100 BREMERTON WA 98337 Page 1 of 1 Batch End Last Run Eff Date Pa es Yr PADDLINS 021 20175 06/22/20 2887 19 Rep Cur Date Run Seq FD9221 E G 20181 171 PMD Policy No: CPW 6873977 9 Page 2 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY. THIS PAGE IS BLANK Batch End Last Run Eff Date Pa es Yr PADDLINS 021 20175 06/22/20 2838 19 Rem Cur Date Run Seq FD9221 E G 20181 171 DECLARATIONS FOR A BUSINESS AUTO AMENDED 06/22/20 ITEM GIVE Named Insured and Address OLYMPIC AMBULANCE INC AND OR BREMERTON AMBULANCE IN 601 HENDRICKSON RD SEQUIN WA 98382 Producer Code: Policy Period: From 07/15/19 Insurer Company and Code: Policy No: CPW 6873977 9 Producer Name and Address FRYER INSURANCE AGENCY INC PO Box 1347 PORT ANGELES it WA 98362 100 Broker: Report Basis: ANNUAL t0 07/15/20 at 12:01 A.M. Standard Time at your mailing address shown above. NATIONAL CONTINENTAL INSURANCE COMPANY Named Insured's Business: 4 AMBULANCE SERVICE Form of Business: CORPORATION ADDITIONAL This policy may be subject to final audit. IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY ITEM TWO Schedule Of Coverages And Covered Autos This policy provides only those coverages where a coverages will apply only to those "autos" shown by the entry of one or more symbols from the fiha envarana PREMIUM 361 THE TERMS OF THIS POLICY, WE AGREE charge is shown in the premium column on the covered autos schedule. Each of these as covered "autos"."Autos" are shown as covered "autos" for a particular coverage Covered Autos section of the Business Auto Coverage Form next to the name of Covera es Covered Autos Limit Covered Autos Liability 1,000,000 CSL 7 8 9 Personal Injury Protection Separately Stated In Each PIP Endorsement Or Equivalent No—fault Coverage) Added Personal Injury Protection Separately Stated In Each Added PIP Endorsement Or Equivalent Added No—fault Coverage Property Protection Insurance Separately Stated In The P.P.I. Endorsement Michigan Only) Auto Medical Payments Each Insured Uninsured Motorists Underinsured Motorists 7 100,000 PER PERSON When Not Included In Uninsured 300,000 PER ACCIDENT Motorists Coverage) 50,000 PER ACCIDENT Physical Damage Actual Cash Value Or Cost Of Repair, Whichever Comprehensive Coverage Is Less Minus $ Ded. For Each Covered Auto. But No Deductible Applies To Loss Caused By Fire Or Lightning. See Item Four for Hired or Borrowed Autos. Physical Damage Specified Actual Cash Value Or Cost Ot Repair, Whichever Causes Of Loss Coverage Is Less Minus $ Ded. For Each Covered Auto For Loss Caused By Mischief Or Vandalism. See Item Four for Hired or Borrowed Autos. Physical Damage Actual Cash Value Or Cost Of Repair, Whichever Collision Coverage Is Less Minus $ Ded. For Each Covered Auto. See Item Four for Hired or Borrowed Autos. Physical Damage For Each Disablement Of A Private Passenger Auto Towing And Labor Not available in California) EFFECTIVE 062220, ADDED VEHICLE 93-2019 FORD 5267, 94-2020 FORD 1788 AND 95-2015 GMC 0015 CA DS 03 10 13 Batch Rem Cur Date Run Seq End Last Run Eff Date Pa es Yr PADDLIN DEC FD9221 E G 20181 172 021 20175 06/22/20 2845 19 7u`C DECLARATIONS FOR A BUSINESS AUTO Page 2 Endorsements Attached To This Policy: SEE SCHEDULE ATTACHED FILINGS OTHER CHARGES INCLUDED WITH POLICY TOTAL PREMIUM COUNTERSIGNED 06/22/20 BY Copyright Insurance Services Office, Inc. 2011 CA DS 03 10 13 Batch End Last Run Eff Date Pa es Yr PADDLIN DEC 021 20175 06/22/20 2846 19 Cur Date Run Seq FD9221 E G 20181 172 17u1 CITY OF BREMERTON C/0 CITY CLERK/CITY HALL 345 6TH ST SUITE 100 BREMERTON 0740 WA 98337 Batch Ree Cur Date Run Seq End Last Run Eff Date Pa es Yr PADMAIL FD9221 E G 20181 170 021 20175 06/22/20 2829 19 IJu17 Policy No: CPW 6873977 9 Page THIS PAGE IS BLANK Batch ReP Cur Date Run Seq End Last Run Eff Date Pa es FD9221 E G 20181 170 021 20175 06/22/20 2830 Yr PADMAIL 19 Policy No: CPW 6873977 0 Page 1 THIS ENDORSEIVIENT CHANGES THE POLICY, PLEASE READ IT CAREFULLY. AP 90 24 02 16 THIS ENDORSEMENT IDENTIFIES PERSONS) OR ORGANIZATIONS WHO ARE ALREADY AN "INSURED" UNDER THE WHO IS AN INSURED PROVISION OF THE POLICY, THIS ENDORSEMENT DOES NOT ALTER COVERAGE PROVIDED IN THE POLICY, PERSONS) OR ORGANIZATIONS) IDENTIFIED AS "INSURED(S)" This endorsement is for use with the following; AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM Each person or organization listed below is an "'insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision of Covered Autos Liability Coverage If no entry appears below, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Persons) or Organization(s): CITY OF 13REMERTON C/0 CITY CLERK/CITY HALL 345 6TH ST SUITE 100 13REMERTON WA 98337 DECEIVED oEc 1 zozo OFFICE OF THE CITY CLERK Page 1 of 1 Batch Rem Cur Date Run Seq End Last Run Eff Uate Pa es Yr PADDLINS FD9966 E G 20337 104 013 20219 10/01/20 3037 20 PMD Policy Noa CPW 6873977 0 Page 2 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY, THIS PAGE IS BLANK Batch End Last Run Eff Date Pa es Yr PADDLINS 013 20219 10/01/20 3038 20 Cur Date Run Seq FD9966 E G 20337 104 DECLARATIONS FOR A BUSINESS 1 00/20AMENDED ITEM ONE Named insured and Address OLYMPIC AMBULANCE INC AND OR BREMERTON AMBULANCE IN 601 HENDRICKSON RD WASEQUIM Producer Code: .100 Page 1 Policy No: CPW 6873917 0 Producer Name and Address FRYER INSURANCE AGENCY INC PO BOX 1347 WA 98362 98382 PORT ANGELES Broker: Report Basis: ANNUAL Policy Period: From 07/15/20 to 07/15/21 at NATIONAL CONTINENTALYINSURANCE dCOMPANYn above, Insurer Company and Code: Named insured's Business: 4 AMBULANCE SERVICE RETURN PREMIUM $1,182 Form of Business: CORPORATION This policy may be subject to final audit. IN RETURN FOR THE PAYTHEE INSURANCERAS I STATEDD IN THISCPOLIOCy LL THE TERMS OF THIS POLICY, WE A WITH YOU TO PROVIDE ITEM TWO Schedule Of Coverages And Covered AutosThispolicyprovidesonlythosecoverageswhere a charge is shown in the premium column on the covered autos schedule. Each of t ese coveae entrvillofpolneoory moreh symbols©fromothe CoveredeAutos sectAonoof the Bus nesssAutoeCoverage sForm next rto the nameaof by t Y the coverage. Llmlt Covera es Covered Autos 1,000,000 CSL Covered Autos Liability Personal Injury Protection Oe Equivalent No—fault Coverage) Added Personal Injury Protection Or Equivalent.. Added No—fault Covera Insurance Michigan Only) Auto Medical Payments Uninsured Motorists Underinsured Motorists When Not Included In Uninsured Motorists Coverage) Physical Damage Comprehensive Coverage Physical Damage Specified Causes Of Loss Coverage Physical Damage Collision Coverage 7 8 9 fl Physical Damage ITowingAndLabor Not available in California) EFFECTIVE 100120, CHANGED CITY TO SEQUIM AND TERRITORY TO 031 FOR VEHICLE 86-2010 FORD 3294 CA DS 03 10 13 Separately Stated In Each PIP Endorsement Separately Stated In Each Added PIP Endorsement Separately Stated In The P.P.I. Endorsement Each Insured 100,000 PER PERSON 300,000 PER ACCIDENT 50,000 PER ACCIDENT Actual Cash Value Or Cost Of Repair, Whichever Is Less Minus $ Ded. For Each Covered Auto. But No Deductible Applies To Loss Caused By Fire Or Lightning. See Item Four for Hired or Borrowed Autos. Actual Cash Value Or Cost Of Repair, Whichever Is Less Minus $ Ded. For Each Covered Auto For Loss Caused By Mischief Or Vandalism. SeeItemFourforHiredorBorrowedAutos. Actual Cash Value Or Cost O Ded.pFor Each CoveredIsLessMinus $ Auto. See Item Four for Hired or Borrowed Autos. For Each Disablement Of A Private Passenger Auto Yr PADDLIN DEC End Last Run Eff Date Pages 20BatchRepCurDateRunSe0132021910/01/20 3045 FD9966 E G 20337 105 PMD DECLARATIONS FOR A BUSINESS AUTO Page 2 Endorsements Attached To This Policy: SEE SCHEDULE ATTACHED OTHER CHARGES INCLUDED WITH POLICY TOTAL PREMIUM COUNTERSIGNED 10/01/20 CA DS 03 10 13 L 1 C®pyright Insurance Services Office, Inc. 2011 Batch Rem Cur Date Run Seq End Last Run Eff Date Pa es Yr PADDLIN DEGFD9966EG203371050132021910/01/2p 3046 20 Policy No: CPW 6873977 0 Page 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AP 90 24 02 16 THIS ENDORSEMENT IDENTIFIES PERSONS) OR ORGANIZATIONS WHO ARE ALREADY AN "INSURED" UNDER THE WHO IS AN INSURED PROVISION OF THE POLICY. THIS ENDORSEMENT DOES NOT ALTER COVERAGE PROVIDED IN THE POLICY. PERSONS) OR ORGANIZATIONS) IDENTIFIED AS "INSURED(S)" This endorsement is for use with the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM Each person or organization listed below is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision of Covered Autos Liability Coverage If no entry appears below, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Persons) or Organization(s): CITY OF BREMERTON C/0 CITY CLERK/CITY HALL 345 6TH ST SUITE 100 BREMERTON WA 98337 Page 1 of 1 Batch Red Cur Date Run Seq End Last Run Eff Date Pa es Yr PADDLINS FD9980 E G 20339 84 014 20337 11/27/20 1273 20 Policy No: CPW 6873977 4 Page 2 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. THIS PAGE IS BLANK Batch End Last Run Eff Date Pa es Yr PADDLINS 014 20337 11/27/20 1274 20 Rep Cur Date Run Seq FD9980 E G 20339 84 1'u17 DECLARATIONS FOR A BUSINESS AUTO AMENDED 11/27/20 ITEM ONE Named Insured and Address OLYMPIC AMBULANCE INC AND OR BREMERTON AMBULANCE IN 601 HENDRICKSON RD SEQUIM WA Producer Code: .100 Page Policy No: CPW 6873977 0 Producer Name and Address FRYER INSURANCE AGENCY INC PO BOX 1347 98382 PORT ANGELES WA Broker: Report Basis: ANNUAL 1 98362 Policy Period: From 07/15/20 t0 07/15/21 at 12:01 A.M. Standard Time at your mailing address shown above. Insurer Company and Code: NATIONAL CONTINENTAL INSURANCE COMPANY Named Insured's Business: 4 AMBULANCE SERVICE Form of Business: CORPORATION ADDITIONAL PREMIUM $4,012 This policy may be subject to final audit. IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY ITEM TWO Schedule Of Coverages And Covered AutosThispolicyprovidesonlythosecoverageswhere a charge is shown in the premium column on the covered autos schedule. Each of thesecoverageswillapplyonlytothose "autos" shown as covered "autos"."Autos" are shown as covered "autos" for a particular coveragebytheentryofoneormoresymbolsfromtheCoveredAutossectionoftheBusinessAutoCoverageFormnexttothenameof the t:uve ayc. Covera es Covered Autos Limit Covered Autos Liability 1, 000, 000 CSL 7 8 9 Personal Injury Protection Separately Stated In Each PIP Endorsement Or Equivalent No—fault Coverage) Added Personal Injury Protection Separately Stated to Each Added PIP Endorsement fOr Equivalent Added No—fault Coverage Property Protection Insurance Separately Stated In The P.P.I. Endorsement Michigan Only) Auto Medical Payments Each Insured Uninsured Motorists Underinsured Motorists 7 When Not Included In Uninsured Motorists Coverage) 100,000 PER PERSON 300,000 PER ACCIDENT 50,000 PER ACCIDENT Physical Damage Actual Cash Value Or Cost Of Repair, is ever Comprehensive Coverage Is Less Minus $ Ded. For Each Covered Auto. But No Deductible Applies To Loss Caused By Fire Or Lightning. See Item Four for Hired or Borrowed Autos. Physical Damage Specified Actual Cash Value Or Cost Of Repair, Whichever Causes Of Loss Coverage Is Less Minus $ Ded. For Each Covered Auto For Loss Caused By Mischief Or Vandalism. See Item Four for Hired or Borrowed Autos. Physical Damage Actual Cash Value Or Cost Of Repair, Whichever Collision Coverage Is Less Minus $ Ded. For Each Covered Auto. See Item Four for Hired or Borrowed Autos. Physical Damage $ For Each Disablement Of A Private Passenger Auto Towing And Labor Not available in California) EFFECTIVE 112720, ADDED VEHICLE 96-2ov3 FOKu 31j1 AND VEHICLE 97-2008 FORD 8191 PER REQUEST CA DS 03 10 13 Batch Rem Cur Date Run Se End Last Run Eff Date Pa es Yr PADDLIN DEC FD9980 E G 20339 85 014 20337 11/27/20 1281 20 PMD DECLARATIONS FOR A BUSINESS AUTO Page Fa Endorsements Attached To This Policy: SEE SCHEDULE ATTACHED FILINGS OTHER CHARGES INCLUDED WITH POLICY TOTAL PREMIUM COUNTERSIGNED 11 /27/20 BY Copyright Insurance Services Office, Inc. 2011 CA DS 03 10 13 Batch End Last Run Eff Date Pa es Yr PADDLIN DEC 014 20337 11/27/20 1282 20 Ree Cur Date Run Seq FD9980 E G 20339 85 NOTICE OF CANCELLATION VUUY* / DATE OF MAILING: 01/15/21 NOTE: MINIMUM DUE REPRESENTS ONLY THE AMOUNT DUE AND UNPAID AS OF THE'DATE OF MAILING', PRODUCER POLICY NUMBER CANCEL EFFECTIVE DATE PAST DUE AMOUNT CURRENT INSTALLMENT 646- CPW 6873977-0 02/14/21 977.00 00 ADDL INSURED CITY OF BREMERTON C/0 CITY CLERK CITY HALL 345 6TH ST SUI E 100 BREMERTON WA 98337 POUCYPERIOD: O7/15/2O TO Q7/15/21 AI 1201 A. M. SIANUAHU IIMt I MINIMUM DUE 977.00 INSURED TOTAL OUTSTANDING BALANCE 977.00 OLYMPIC AMBULANCE INC AND OR BREMERTON AMBULANCE IN 601 HENDRICKSON RD SEQUIM WA 98382 IssuED ev: NATIONAL CONTINENTAL INS . CAIP UNDERWRITING — WA RELATED TO POLICY COVERAGESUESTIONS R BILLING CALL: 1-800-937-2247 Premium due O1/11/21 is still unpaid. Therefore, you are hereby notified in accordance with the terms and conditions of the above mentioned policy, that your insurance will cease from the hour and date mentioned above due to non payment of premium. No further notice will be sent. TO KEEP YOUR POLICY IN FORCE... Make payment of the MINIMUM DUE to the company BY THE CANCEL EFFECTIVE DATE shown above. Upon receipt of your payment, we will send you a Reinstatement Notice. If you have any questions, please contact your producer or company, ADDL INSURED REDEIVED IAN 2 2021 City of Bremerton Risk Management SEE IMPORTANT NOTICE ON BACK DETACH AND RETURN THIS PORTION WITH YOUR PAYMENT CISX) ARCNXF51 02/28/95 q INDICATE CHANGE OF ADDRESS ON REVERSE SIDE. MINIMUM DUE TOTAL OUTSTANDING BALANCE 2 WRITE YOUR POLICY NUMBER ON CHECK OR MONEY ORDER. 9 ] J 0 Q Q 9 ] ] . Q Q PoucvPERloo: 07/15/20 TO 07/15/21 MAKE PAYMENT TO: NATIONAL CONTINENTAL INS. OLYMPIC AMBULANCE INC AND CAIP UNDERWRITING — WA OR BREMERTON AMBULANCE IN P.O. BOX 94921 601 HENDRICKSON RD CLEVELAND OH 44101 SEQUIM WA 983$2 IF YOU DO NOT KEEP YOUR LIABILITY INSURANCE IN FORCE DURING THE ENTIRE REGISTRATION PERIOD, YOUR REGISTERING AND DRIVING PRIVILEGES WILL BE SUBJECT TO SUSPENSION. BY LAW YOUR INSURANCE CARRIER IS REQUIRED TO REPORT SPECIFIC TERMINATION INFORMATION TO THE MOTOR VEHICLE DEPARTMENT. Appeal to Automobile Insurance Plan Governing Committee: As your policy was one obtained through your state Automobile Insurance Plan, you are hereby advised, regarding this notification of cancellation, that you may have the right to appeal to the governing committee of the Plan in your state: Governing Committee Washington Automobile Insurance Plan PO Box 6530 Providence RI 02940 IF AN APPEAL OF A CANCELLATION IS GOING TO BE MADE TO THE INSURANCE DEPARTMENT, A COPY OF THIS CANCELLATION NOTICE SHOULD ACCOMPANY THE APPEAL. WACNI691 O t/03/ 19 IMPORTANT: IF YOUR ADDRESS HAS CHANGED PLEASE SHOW THE NEW ADDRESS BELOW: STREET CITY OR TOWN STATE, ZIP PLEASE CONTACT YOUR AGENT CONCERNING ANY OF THE FOLLOWING CHANGES NOT ALREADY REPORTED TO THE COMPANY: t. CHANGE IN USE 0F AUTO{S) 2. CHANGE OF AUTOS) 3. CHANGE OF OPERATORS) 4. CHANGE OF COVERAGE X NATIONAL CONTINENTAL INSURANCE CO P.Q. BOX 94921 CLEVELAND OH 44101 DATE OF PRODUCER POLICY NUMBER NOTICE 646— CPW 6873977-0 01/21/21 POLICY PERIOD FROM: TO: 07/15/20 07/15/21 YOUR POLICY IS BEING CONTINUED IN FULL FORCE AND EFFECT FOR THE POLICY PERIOD SHOWN ABOVE AND THE NOTICE OF CANCELLATION OR NONRENEWAL PREVIOUSLY SENT TERMINATING COVERAGE AS OF 02/14/21 HAS BEEN WITHDRAWN, ADDITIONAL INSURED: M CITY OF BREMERTON C/O CITY CLERK/CITY HALL 345 6TH ST SUITE 100 BREMERTON WA LL NK 98337 NOTICE OF REINSTATEMENT INSURED: 0028 OLYMPIC AMBULANCE INC AND OR BREMERTON AMBULANCE IN 601 HENDRICKSON RD SEQUIM WA 98382 RECEIVE® FEB 10 2021 Ciry of Bremerton Risk Management Policy No: CPW 6873977 0 Page 1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AP 90 24 02 16 THIS ENDORSEMENT IDENTIFIES PERSONS) OR ORGANIZATIONS WHO ARE ALREADY AN "INSURED" UNDER THE WHO IS AN INSURED PROVISION OF THE POLICY. THIS ENDORSEMENT DOES NOT ALTER COVERAGE PROVIDED IN THE POLICY. PERSONS) OR ORGANIZATIONS) IDENTIFIED AS "INSURED(S)" This endorsement is for use with the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM Each person or organization listed below is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision of Covered Autos Liability Coverage If no entry appears below, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) Persons) or Organization(s): CITY OF BREMERTON C/0 CITY CLERK/CITY HALL 345 6TH ST SUITE 100 BREMERTON WA 98337 Page 1 of 1 Batch Cur Date Run Se End Last Run Eff Date Pa es Yr PADDLINS FD9172 E G 20356 84 015 20339 12/14/20 1473 20 I9uI 7 Policy No: CPW 6873977 0 Page 2 THIS ENDORSEMENT CHANGES THE POLICY PLEASE READ IT CAREFULLY. THIS PAGE IS BLANK Batch Rem Cur Date Run Seq End Last Run Eff Date Pa es Yr PADDLINS FD9172 E G 20356 84 015 20339 12/14/20 1474 20 Ie731 DECLARATIONS FOR A BUSINESS AUTO AMENDED 12/14/20 ITEM ONE Named Insured and Address OLYMPIC AMBULANCE INC AND OR BREMERTON AMBULANCE IN 601 HENDRICKSON RD SEQUIN WA 98382 Producer Code: .100 Page 1 Policy No: CPW 6873977 0 Producer Name and Address FRYER INSURANCE AGENCY Broker: INC PO BOX 1347 PORT ANGELES WA 98362 Report Basis: ANNUAL Policy Period: From 07/15/20 t0 07/15/21 at 12:01 A.M. Standard Time at your mailing address shown above. Insurer Company and Code: NATIONAL CONTINENTAL INSURANCE COMPANY Named Insured's Business: 4 AMBULANCE SERVICE Form of Business: CORPORATION RETURN PREMIUM $1.857- This policy may be subject to final audit. IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY ITEM TWO Schedule Of Coverages And Covered Autos This policy provides only those coverages where a charge is shown in the premium column on the covered autos schedule. Each of thesecoverageswillapplyonlytothose "autos" shown as covered "autos"."Autos" are shown as covered "autos" for a particular coveragebytheentryofoneormoresymbolsfromtheCoveredAutossectionoftheBusinessAutoCoverageFormnexttothenameof t/IC I:VYG1 PIG. Covera es Covered Autos Limit Covered Autos Liability 1,000,000 CSL 7 8 9 Personal Injury Protection Separately Stated In Each PIP Endorsement Or Equivalent No—fault Coverage) Added Personal Injury Protection Separately Stated In Each Added PIP Endorsement Or Equivalent Added No—fault Coverage Property Protection Insurance Separately Stated In The P.P.I. Endorsement Michigan Only) Auto Medical Payments Each Insured Uninsured Motorists Underinsured Motorists When Not Included In Uninsured Motorists Coverage) 7 100,000 PER PERSON 300,000 PER ACCIDENT 50,000 PER ACCIDENT Physical Damage Actual Cash Value Or Cost Of Repair, Whichever Comprehensive Coverage Is Less Minus $ Ded. For Each Covered Auto. But No Deductible Applies To Loss Caused By Fire Or Lightning. See Item Four for Hired or Borrowed Autos. Physical Damage Specified Actual Cash Value Or Cost Of Repair, Whichever Causes Of Loss Coverage Is Less Minus $ Ded. For Each Covered Auto For Loss Caused By Mischief Or Vandalism. See Item Four for Hired or Borrowed Autos. Physical Damage Collision Coverage Physical Damage Towing And Labor Not available in Californ EFFECTIVE 121420, DELETED VEHICLE 96-2003 FORD 3231 PER REQUEST CA DS 03 10 13 Actual Cash Value Or Cost Of Repair, Whichever Is Less Minus $ Ded. Foe Each Covered Auto. See Item Four for Hired or Borrowed Autos. For Each Disablement Of A Private Passenger Auto Batch ReP Cur Date Run Se End Last Run Eff Date Pa es Yr PADDLIN DEC FD9172 E G 20356 85 015 20339 12/14/20 1481 20 1:751 7 DECLARATIONS FOR A BUSINESS AUTO F Endorsements Attached To This Policy: SEE SCHEDULE ATTACHED FILINGS OTHER CHARGES INCLUDED WITH POLICY TOTAL PREMIUM COUNTERSIGNED 12/14/20 BY Copyright Insurance Services Office, Inc. 2011 CA DS 03 10 13 Batch End Last Run Eff Date Pa es Yr PADDLIN DEC 015 20339 12/14/20 1482 20 Cur Date Run Seq FD9172 E G 20356 85