2023-12-31_COI.pdf

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

INSURER(S) AFFORDING COVERAGE

INSURER F :

INSURER E :

INSURER D :

INSURER C :

INSURER B :

INSURER A :

NAIC #

NAME:

CONTACT

(A/C, No):

FAX

E-MAIL

ADDRESS:

PRODUCER

(A/C, No, Ext):

PHONE

INSURED

REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES

IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 lieu of such endorsement(s).

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.

OTHER:

(Per accident)

(Ea accident)

N / A

SUBR

WVD

ADDL

INSD

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

$PROPERTY DAMAGE

BODILY INJURY (Per accident)

BODILY INJURY (Per person)

COMBINED SINGLE LIMIT

AUTOS ONLY

AUTOSAUTOS ONLY

NON-OWNED

SCHEDULEDOWNED

ANY AUTO

AUTOMOBILE LIABILITY

Y / N

WORKERS COMPENSATION

AND EMPLOYERS' LIABILITY

OFFICER/MEMBER EXCLUDED?

(Mandatory in NH)

DESCRIPTION OF OPERATIONS below If yes, describe under

ANY PROPRIETOR/PARTNER/EXECUTIVE

E.L. DISEASE - POLICY LIMIT

E.L. DISEASE - EA EMPLOYEE

E.L. EACH ACCIDENT

ER

OTH-

STATUTE

PER

LIMITS(MM/DD/YYYY)

POLICY EXP

(MM/DD/YYYY)

POLICY EFF

POLICY NUMBERTYPE OF INSURANCELTR

INSR

DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

EXCESS LIAB

UMBRELLA LIAB $EACH OCCURRENCE

$AGGREGATE

OCCUR

CLAIMS-MADE

DED RETENTION $

$PRODUCTS - COMP/OP AGG

$GENERAL AGGREGATE

$PERSONAL & ADV INJURY

$MED EXP (Any one person)

$EACH OCCURRENCE

DAMAGE TO RENTED

$PREMISES (Ea occurrence)

COMMERCIAL GENERAL LIABILITY

CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY

PRO-

JECT LOC

CERTIFICATE OF LIABILITY INSURANCE

DATE (MM/DD/YYYY)

CANCELLATION

AUTHORIZED REPRESENTATIVE

ACORD 25 (2016/03)

© 1988-2015 ACORD CORPORATION. All rights reserved.

CERTIFICATE HOLDER

The ACORD name and logo are registered marks of ACORD

HIRED

AUTOS ONLY

6/28/2023

Lovitt-Touche A Marsh & McLennan Agency LLC Co 4703 E Camp Lowell Drive, #101 Tucson AZ 85712

Julie Reed 520-722-7114 jreed@lovitt-touche.com

Philadelphia Indemnity Insurance Co. 18058 MARIPCOMMU Sequoia Insurance Company 22985

Mariposa Community Health Center Inc 825 N. Grand Ave., Suite 100 Nogales AZ 85621

427372590

A X 1,000,000 X 1,000,000

20,000

1,000,000

2,000,000 X

Y Y PHPK2501311 1/1/2023 1/1/2024

2,000,000

A 1,000,000

X

Y Y PHPK2501311 1/1/2023 1/1/2024

B XY QWC1259659 1/1/2023 1/1/2024

1,000,000

1,000,000

1,000,000

Sexual Abuse and Molestation coverage is included on the GL policy with separate limits of$1,000,000 Each Claim and $2,000,000 Aggregate.

Re: Contract No. CTR066198, Domestic Violence - Statewide

General Liability: The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, official, agents, and employees are additional insureds with respect to liability arising out of activities performed by or on behalf of the Contractor.

Business Auto Liability: The State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees are additional insureds with respect to liability arising out of the activities performed by, or on behalf of, the Contractor involving automobiles owned, hired and/or See Attached...

The State of Arizona, Department of Economic Security 1789 W. Jefferson Street Mail Drop 1541 Phoenix AZ 85007

ACORD 101 (2008/01)

The ACORD name and logo are registered marks of ACORD

© 2008 ACORD CORPORATION. All rights reserved.

THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,

FORM NUMBER: FORM TITLE:

ADDITIONAL REMARKS

ADDITIONAL REMARKS SCHEDULE Page of

AGENCY CUSTOMER ID:

LOC #:

AGENCY

CARRIER NAIC CODE

POLICY NUMBER

NAMED INSURED

EFFECTIVE DATE:

MARIPCOMMU

1 1

Lovitt-Touche Mariposa Community Health Center Inc 825 N. Grand Ave., Suite 100 Nogales AZ 85621

25 CERTIFICATE OF LIABILITY INSURANCE

non-owned by the Contractor.

Policies shall contain a Waiver of Subrogation in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents and employees for losses arising for work performed by on or behalf of the Contractor. Notice of cancellation per attached form. Sexual Abuse and Molestation coverage is included.

Workers’ Compensation: Policy shall contain a Waiver of Subrogation endorsement in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor.

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CANCELLATION NOTICE TO SCHEDULED ADDITIONAL INSURED OR

CERTIFICATE HOLDER

COMMERCIAL GENERAL LIABILITY COVERAGE PART

PROFESSIONAL LIABILITY COVERAGE PART

COMMERCIAL CRIME COVERAGE PART

COMMERCIAL INLAND MARINE COVERAGE PART

COMMERCIAL PROPERTY COVERAGE PART

COMMERCIAL AUTOMOBILE COVERAGE PART

SCHEDULE OF ADDITIONAL INSUREDS OR CERTIFICATE HOLDERS

AI or CH Additional Insured or Certificate Holder Address

A. CANCELLATION

A.

SCHEDULE

CANCELLATION NOTICE TO ADDITIONAL INSURED

OR CERTIFICATE HOLDER

MANUSCRIPT (06/11)

Revised 6/13/12 Page 1 of 1

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

ADDITIONAL INSURED – STATE OF ARIZONA

This endorsement modifies insurance provided under the following:

COMMERCIAL GENERAL LIABILITY COVERAGE PART

HUMAN SERVICES ORGANIZATION PROFESSIONAL LIABILITY COVERAGE FORM

SEXUAL OR PHYSICAL ABUSE OR MOLESTATION VICARIOUS LIABILITY COVERAGE FORM

BUSINESS AUTO COVERAGE FORM

Policy No. PHPK2501311 Policy Term. 01/01/2023 to 01/01/2024

SCHEDULE

Name of Person or Organization:

The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, employees, shall be named as additional insured with respect to liability arising out of the activities performed by or on behalf of Contractor.

The State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, employees, shall be named as additional insured with respect to liability arising out of the activities performed by or on behalf of Contractor, involving automobiles owned, leased, hired or borrowed by Contractor.

The following provisions are added to the policy:

1. WHO IS AN INSURED is amended to include as an insured the person or organization shown in the above SCHEDULE, but only with respect to their liability for activities performed by you or on your behalf relating to the conduct of your business;

2. The coverage provided by this endorsement includes the assumption of liability in a written or oral contract between the named insured and the person or organization shown in the above SCHEDULE for work performed by you or on your behalf relating to the conduct of your business;

3. The coverage provided by this endorsement only is primary. Any other applicable insurance will apply as excess; and

4. We agree to waive any right of subrogation against the State of Arizona, its departments, agencies, boards, commissions, universities and its officers, officials, agents, and employees for losses arising from work performed by or on behalf of Contractor.

1. ISSUE DATE: (MM/DD/YYYY)

8/23/2022

DEPARTMENT OF HEALTH AND HUMAN SERVICES

HEALTH RESOURCES AND SERVICES ADMINISTRATION

NOTICE OF DEEMING ACTION

FEDERAL TORT CLAIMS ACT AUTHORIZATION:

Federally Supported Health Centers Assistance Act(FSHCAA), as amended, Sections 224(g)-(n) of the Public Health Service (PHS) Act, 42 U.S.C. § 233(g)-(n)

2a. FTCA DEEMING NOTICE NO.:

1-F00000052-22-01

2b. Supersedes: [ ]

3. COVERAGE PERIOD:

From: 1/1/2023 Through: 12/31/2023

4. NOTICE TYPE:

Renewal

5. ENTITY NAME AND ADDRESS:

MARIPOSA COMMUNITY HEALTH CENTER, INC

1852 N MASTICK WAY

NOGALES, AZ 85621

6. ENTITY TYPE:

Grantee

7. EXECUTIVE DIRECTOR:

Ed Sicurello

8a. GRANTEE ORGANIZATION:

MARIPOSA COMMUNITY HEALTH CENTER, INC

8b. GRANT NUMBER:

H80CS00752

9. THIS ACTION IS BASED ON THE INFORMATION SUBMITTED TO, AND AS APPROVED BY HRSA, AS REQUIRED UNDER 42 U.S.C. § 233(h) FOR THE ABOVE TITLED ENTITY AND IS

SUBJECT TO THE TERMS AND CONDITIONS INCORPORATED EITHER DIRECTLY OR BY REFERENCE IN THE FOLLOWING:

a. The authorizing program legislation cited above.

b. The program regulation cited above, and,

c. HRSA's FTCA-related policies and procedures.

In the event there are conflicting or otherwise inconsistent policies applicable to the program, the above order of precedence shall prevail.

10. Remarks:

The check box [x] in the supersedes field indicates that this notice supersedes any and all active NDAs and rescinds any and all future NDAs issued prior to this notice.

Electronically signed by Tonya Bowers, Deputy Associate Administrator for Primary Health Care on: 8/23/2022 1:57:50 PM

A printer version document only. The document may contain some accessibility challenges for the screen reader users. To access same information, a fully 508 compliant accessible

HTML version is available on the HRSA Electronic Handbooks in the FTCA Folder. If you need more information, please contact the BPHC Helpline at 877-974-BPHC (2742); Weekdays from 8:30 AM to 5:30 PM ET.

FTCA DEEMING NOTICE NO.:

1-F00000052-22-01

GRANT NUMBER:

H80CS00752

MARIPOSA COMMUNITY HEALTH CENTER, INC

1852 N MASTICK WAY

NOGALES, AZ85621

Dear Ed Sicurello:

The Health Resources and Services Administration (HRSA), in accordance with the Federally Supported Health Centers Assistance Act (FSHCAA), as amended, sections 224(g)-(n) of the Public Health Service (PHS) Act, 42 U.S.C. §§ 233(g)-(n), deems MARIPOSA COMMUNITY HEALTH CENTER, INC to be an employee of the PHS, for the purposes of section 224, effective 1/1/2023 through 12/31/2023.

Section 224(a) of the PHS Act provides liability protection under the Federal Tort Claims Act (FTCA), 28 U.S.C. §§ 1346(b), 2672, or by alternative benefits provided by the United States where the availability of such benefits precludes a remedy under the FTCA, for damage for personal injury, including death, resulting from the performance of medical, surgical, dental, or related functions by PHS employees while acting within the scope of such employment. This protection is exclusive of any other civil action or proceeding. Coverage extends to deemed entities and their (1) officers; (2) governing board members; (3) full- and part-time employees; and (4) contractors who are licensed or certified individual health care practitioners providing full-time services (i.e., on average at least 32½ hours per week for the entity for the period of the contract), or, if providing an average of less than 32½ hours per week of such service, are licensed or certified providers in the fields of family practice, general internal medicine, general pediatrics, or obstetrics/gynecology. Volunteers are neither employees nor contractors and therefore are not eligible for FTCA coverage under FSHCAA.

This Notice of Deeming Action (NDA) is also confirmation of medical malpractice coverage for both MARIPOSA COMMUNITY HEALTH CENTER, INC and its covered individuals as described above. This NDA, along with documentation confirming employment or contractor status with the deemed entity, may be used to show liability coverage for damage for personal injury, including death, resulting from the performance of medical, surgical, dental, or related functions by PHS employees while acting within the scope of such employment.

In addition, FTCA coverage is comparable to an "occurrence" policy without a monetary cap. Therefore, any coverage limits that may be mandated by other organizations are met.

This action is based on the information provided in your FTCA deeming application, as required under 42 U.S.C. § 233(h), with regard to your entity’s: (1) implementation of appropriate policies and procedures to reduce the risk of malpractice and litigation; (2) review and verification of professional credentials and privileges, references, claims history, fitness, professional review organization findings, and licensure status of health professionals; (3) cooperation with the Department of Justice (DOJ) in the defense of claims and actions to prevent claims in the future; and (4) cooperation with DOJ in providing information related to previous malpractice claims history.

Deemed health centers must continue to receive funding under Section 330 of the PHS Act, 42 U.S.C. § 254b, in order to maintain coverage as a deemed PHS employee. If the deemed entity loses its Section 330 funding, such coverage will end immediately upon termination of the grant. In addition to the relevant statutory and regulatory requirements, every deemed health center is expected to follow HRSA's FTCA-related policies and procedures, which may be found online at http://www.bphc.hrsa.gov.

For further information regarding FTCA, please contact the Health Center Program Support (Formally the BPHC Helpline) at 877-464-4772, option 1, or using the BPHC Contact Form.

A printer version document only. The document may contain some accessibility challenges for the screen reader users. To access same information, a fully 508 compliant accessible

HTML version is available on the HRSA Electronic Handbooks in the FTCA Folder. If you need more information, please contact the BPHC Helpline at 877-974-BPHC (2742); Weekdays from 8:30 AM to 5:30 PM ET.