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2019-20 Health Ins Counselling Advocacy Prog (Volunteer) - Health and Wellness Daytev Qwkra - GFSt :,,r:;, DFStAT - MEMORANDUM TO: Christina Calderon, Community Resources Manager FROM: Caroline Doran, Community Resources Specialist DATE: November 7, 2019 RE: Health Insurance Counselling Advocacy Program (HICAP), offering FREE information and one on one Consultations to seniors and the community. Attached for your signature is a Volunteer Organization Service agreement for the Health and Wellness Day, October 22, 2019 and One on One Consultations. Please review and sign the attached agreements for processing. Reguestin-g department shall check and attach the items below as aooroariate• N/A Contract payments will be charged to account number: N/A Amount of Agreement, Amendment, Change Order, etc.: $ N/A A Conflict of Interest Form 700 Statement of Economic Interests from Consultant(s) is attached with no reportable interests in LQ or reportable interests N/A A Conflict of Interest Form 700 Statement of Economic Interests is not required because this Consultant does not meet the definition in FPPC regulation 18701(2). Authority to execute this agreement is based upon: N/A Approved by the City Council on N/A City Manager's signature authority provided under Resolution No. 2019-021 for budgeted expenditures of $50,000 or less. This expenditure is $ and authorized by Director N/A Initial to certify that 3 written informal bids or proposals were received and considered in selection The following required documents are attached to the agreement: X Insurance certificates as required by the agreement (approved by Risk Manager on date) N/A Performance bonds as required by the agreement (originals) N/A City of La Quinta Business License number N/A A requisition for a Purchase Order has been prepared (amounts over $5,000) VOLUNTEER ORGANIZATION SERVICE AGREEMENT Our organization, HEALTH INSURANCE COUNSELLING ADVOCACY PROGRAM will provide volunteers to perform only the services as outlined in the attached scope of work for the City of La Quinta ("City"). We understand that we will not be compensated for our work and we will complete our organization volunteer duties in a responsible manner. If we decide to discontinue our organization volunteer se es, o r cgntact person will notify Caroline Doran, City designee. We understand and agree that: No one in the group is to appear for volunteer service under the influence of any drugs or alcohol. ° Our organization will provide the City with a roster of individual participants including the names and hours worked. • Our organization will report any injuries sustained by participants during their volunteer activities to Caroline Doran, City designee immediately upon occurrence. ° Our organization is responsible for directly supervising the activities of all the individuals in our group who will be doing volunteer work, and therefore, in consideration of our organization and members being permitted to perform services on City property, our organization agrees to defend, indemnify, and hold harmless the City and its officials, employees, and agents from any damage claim or lawsuit for injury, illness, damage or other loss of any kind to anyone including members of our organization that might arise out of our activities or the actions of any individuals of our group, except for injuries or damages caused by the sole negligence of the City. • Our organization has commercial general liability insurance of at least one million dollars to cover our activities. A copy of the certificate of insurance, the additional insured endorsement, naming the City as an "additional insured," and a Primary and Non -Contributory endorsement is attached. • The City may terminate this agreement at any time without cause, and we agree that we are volunteering our services at will and may be asked to discontinue such without prior notice or reason. This agreement will be in effect for the duration of our volunteer services or one year, whichever is less, beginning on this date. Dated this %yam day of O C 6-cr 201 Paqe 1 of 2 CITY OF LA QUINTA, a Ca�rfia Municipal �et-pory�tion I" GbMSTINA CALDERON, Community Resources Manager City of La Quinta, California Dated: ATTEST: MONIKA RA15EVA, i Clerk La Quinta, California APPROVED AS TO FORM: WILLIAM IHRKE, City Attorney City of La Quinta, California c \1 it ORM \ nICID A Name_4 Organization ature on Organization "Dim6i Li-, 7 Printed Name @n C Title 91 L, H v(r� cu 22SJ Rn arncaiCA q0 _ Ate._.=_ � � c Address Email Address Phone Number Paqe 2 of 2 Attachment Scope of Work Health Insurance Counselling Advocacy Program (HICAP) provides free, confidential one-on-one counseling, education, and assistance to individuals and their families on Medicare, Long -Term Care insurance, other health insurance related issues, and planning ahead for Long -Term Care needs. Paqe 3 of 2 AiCCI I CERTIFICATE OF LIABILITY INSURANCE DATE I MrDD/YYYYI 04/022019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(lies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in Neu of such endorsement(s). PRODUCER CONTACT Cindy Hales NAME,dy Milestone Risk Management & Insurance Services PHONE (949) 852.0909 FAX AIC NoI: (949) 252-1131 License No. OB72786 A13DRESS: cnalesamilesianepramise rom 8 Corporate Park, Suite 130 IN SURER(% A FFOROING COVERAGE NAiC a Irvine CA 92605 rNSURERA: Stale Compensation Ins Funo 35076 INSURED INSURER B : Scottsdale Indemnity Co 15580 Council on Aging - Southern California, Inc INSURER C :Dy Lloyds of London 2 Executive Circle, Suite 175 INSURER D INSURER E . Irvine CA 92614 INSURER F .+GR I IrjL/m IC mumotR: —r V111.r THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE 2EEN ISSUFO TO THE INSURED NAMED INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. N SIR LTR TYPE OF INSURANCE POLICY NUMBER MMrDD1YYYY YMIOD/YYYY COMMERCIAL GENERAL LIABILITY CLAIMS4AADE 71 OCCUR €I. L Aw-ES7.T T- U'd-" : IP-KS PEF. POLICY ❑ � T ❑ Lac TrEF- AUTOMOBILE LIABILITY ANYAUTO IVIED SCHEDULED AUTOS ONLY AUTOSMJ HIRED NON-O'ED AUTOSONLY AUTOS CNLY UMBRELLA LIAB OCCUR EXCESS LIAR WORnERs COMPENSATION AND EMPLOYERS' LIABILITY rrN ANY PRQPRiETOR1PART1i4ER/EAE',.'UTi1 A DFFICERiMEMBFAEXCLUD= , N NIA 92429872019 01/0112019 01/01/2020 IA1 andr" In NHI Ir ym. dewift uMer loyment Practices ab B Claims Made and Reported l EKI3273509 11/02/2018 f 11/022019 DESCRIPTION OF OPERATIONS LOCATIONSI VEHICLES (ACORD 101. Addluonal Remarks Schedule, may be adactwd if mom apaw ra required) Carrier B mftnUed: Policy includes Director, ,and Officers Liability and Fiduciary Liability with a S3M Shared Limit per claim, EPLUDSO and Fduciary Liability. Aso retention applies to D & 0 and Fiduciary Liability REVISION NUMBER: IBOVE FOR THE POLICY PERIOD WITH RESPECT TO WHICH THIS iUBJECT TO ALL THE TERMS. LIMBS EACH OCCURRENCE E PREMISES occurranrw S MED E%P:Wn .na xrwrl7 E PERSONAL&ADVIILJURY S GENERALAGGAEf..ATE� S PRODUCTS • COMP OPAGG S 3 CWENNED SIN LE LINT' $ E¢acudenl BODILY INJURY (Per aarson) S BODILY INJURY IPor acudernl S PROPERTY DA>NAGE S arr aC63M S EACH OCCURRENCE S AGGREGATE S E STATUTE ER E L EACHACCr0ENt y 1,000.000 E L "EASE • FA EMPLOYEE S 1.000,000 E L DISEASE - POLICY JVIT i S 1,000,000 Shared Ea. Claim Limit S31000,000 Retention $5,000 I 53M Aggregate Limit applies to SHOULID ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATnN DATE THEREOF, NOTICE WILL BE DELIVERED IN Riverside C:St ty, $OCial -5 ACCORDANCE WITH THE POLICY PROVISIONS. 102B1 Kidd AUTHORIZED REPRESENTATIVE Riverside - . I : • %ate kJ�f •. ©1988-2015 ACORD CORPORATION. All rights reserved. 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