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HomeMy WebLinkAbout0288.093- Jun-e 17, 1993 THE HONORABLE CIT~ COUNCIL Palo Alto, California 5 Profession~vices of Healtb--R~source Cocrdinat9~ __ ~ ~ontract Renewal Members of the Council: ~in Brief The Police Department has contracted for professional provide for a stress management program sinc~ 1931. recommends renewal of the Health Resource Coordinator Background services to This report contract. The Health Resource Coordinator, approved by Council in April 1981 as part of the stress management program, has been successful in working ~ith police personnel to identify and minimize the organizational sources of stress. since the program was implemented, only t lve officers haVE-filed stress-related disability claims; ten claims were filee in the two years p~ecedinq the program. Sufficient funding for the program, not to exceed $39,745, is included in the 1993-94 Police Department budget. CQntractor Ellen Kirschman, the current Health Resou.rce Coordina.tor, Vias selected in June 1983, after competing in an extensive assessment process a Her background includes 23 years of experience as a psychotherapist 'With an emphasis on police officers and their families. She is a licensed psychologist and is nationally recognized as an expert on organizational behavior, especially in law enforcement. D=. Kirschman~s continuation in the program is recommended based upon her ten years of exceptional service ~ith the Police Department. The Health Resource Coordinator assists in conflict resolution betvee~ individuals and groups, identifies sources of organizatIonal stress and conSUlts with work units and individual managers to resolve issues. Dr. Kirschman a 1so educates police personnel in stress reduction/health enhancement techniques. CMR:288:93 " "L '. o Page Two Additionally. she designs and facilitates departm~nt team-building an~ probl~m-solvlng meetings, and maintain~ a library of health­ related materials for use by all employees. ~endatiQo staff recommends that the council authorize the Mayor to axecute an agreement with Or. Kirschman to prov~de professicnal services ~s Health Resource Coordinator. Funds, not to exceed $39,745 for this contr-act., are included in th·:;! Police Department's 1993-94 b 1Jdget. ~"o'-~."'.'. ~~L-IS DURI<IN Police Chief Attachment: Contract Agreement Exhibit -A- CHR::l88:93 ". , .• " . . ~ , , --- ~ G R E E MEN T BilTllEEN THE CITY OJ' PALO ALTO AND ELLEW XIRSCRMAN THIS AGRED':~NT is t!1ade !!Ind entered into this da:," of _____ , 19 __ by and between the CITY OF PALO :A.L'T'O, amunicipal corpo~ation {"CITY") and ELLEN .KIRSCHMAN (Tal<payer Identification Number 111-30-1884) I an Indep;:!ndent Health Resource coordinator with offices at 3978 Lyman Road, Oakland, California 9~602, hereinaft~r ~eferreQ to !!I6 "CONTRACTOR"; WHEREAS, CITY desires; certain services in conjunction vith its Police street Management Programj and WHEREAS, CITY desires to engage CONTRACTOR to provide these services by reason of its qualifications and experience fo= performing such services~ and CONTRACTOR h~s offered to provide tbe req-..lired services on the ten,s and in the manner set forth herein; NOW~ THEREFORE, in consid~ration of their mutual covenants, t.he parties hereto agree as f::>llows: 1.1 CITY The term "CITyn as used in this Agreement shall "mean the city of Palo Alto, a muniCipal corporation and body po~itic. organized ~nd existing under the laws of the state of California. 1.2 City Manage. The term "ei ty Manager" shall mean the duly appointed City Manager of the City of Palo Alto, California, or her designated representative~ 1.3 City Attorn~y The term "City Attorney" shall city Attorney of the City of Pa 10 }"lto, dCDiqnated representative. 1.4 C'it.y Clerk mean the duly appoir~ted Cal ifornia, or his/her Thg term "City Cler~n shall mean the duly appointed city Clerk of the City of Palo Alto, California, or her designated representatl ve. 1.5 Prcjer:t The term Exhibit -A-entitled part hereof. ~project~ m2ans the services described in "ScDpe of Proje~tn attached hereto and made a SECTrQ~ 2 -PROJECT COORDINATIQll 2.1 = The city Manage.r shall be representative of CITY for all purposes under this Agreement. Lieutenant John Foster is designated as the PROJECT MANAGER fer the Cit}' Manager and shall supervise the progress and execution of this Agreement. 2.2 Contnlctor The sE:.r .... ices under this agreement are personal services to be provided solely by Ell~n ¥irschrnan and shall not be delegated to or performed ny any other pe~son. SECTION 3 -D~7IES OF CONTRACTOR 3.1 servi.ces to be furni~:!}_ed CONTRACTOR shall provide all specified services as set forth in Exhibit '"Aw attactled hereto and made a part here.of. CONTRACTOR si".a 11 : 3.2.1 Procure all permits and licenses, pay all charges and fees, and give all notices which may be necessary and incident to the due and lal;olful prosecution of the service.s to be performed by CONTRACTOR under this ~greement; 3.2.2 Stat fully infor:rned of all exis'ting and future federal, state, and local la~.s, ordinances, regulations, orders, and decrees which ay affect the performance of the services under this Agreement; 3.2.3 At all times observe and comply ~ith all of said laws, ordinances, regulations, ord~rs and decrees mentioned above; and in writing ordinances, relation to 3.2.4 Immediately report to the PROJECT MANAGEP. any discrepancy or inconsistency in said laws, regulations, orders, and decrees mentioned above in any provisions of this Agreement. - . <": 3.3 Release Qf ..Beports and I.ll!.Q.~t..2D Any reports, information, data or other -material given to, or prepared or assembled by ~ CONTR.l\C1'OR under this Agreement shall be the property of C!TY and shiill not be made availaole to any individ!..lal or organization by CONTRACTOR .... ithout the prior written approval ot the City Manager. gc-rrON .4 -COM"PENSATJ . .Ql! For the performance of the services desribed herein by CONTRACTOR, CITY shall pay CONTRACTOR the sum of Thirty Nine Thousand Seven Hundred Forty Five Dollars ($39,?45.00) per month, payable upon submission by CONTRACTOR of itemized billings in triplicate; provided" hOil/ever, that the total sum payable to CONTRACTOR shall not exceed Thirty Nine Thousand Seven Hundred Forty Five{$39.745.00). SECTION 5 -DUTIES _.9F C!TY CIT~; shall provide all specified services and facilities as .Jet forth belo· .. : (a) coordination and scheduling :by the COORDINATOR of all arrangements for management services which CITY requires performed by CONTRACTOR. PROJECT stress to be (b) Office space within the Police Department, if available, or in other CITY facilities, at all times when services are required to be performed by CONTRACTOR. ee) Secretarial a~d other logistical support as needed. SEC'l'JON 6 -TEPJoo! The services to be performed hereunder shall commence on July 1, 1993, and shall extend ttlrolJgh and including June 30, 1994. SECTION 7 -:: TEM.POFARY SUSPENS ION The City Manager Agreement, ~holly or in necessary~ shall have t~e authority to suspend this part, tor any period as she deems SECTION S -T.~)~Mn{A.T.ION OF AGREEMENT 8.1 Right to Terminate 'l'he City Manager may terminate this Agreement for any reason by giving written notice to CONTRACTOR. Upon receipt of such notice, CON~~CTOR shall immediately discontinue performance under thi8 agreement. -~-'=---L-,---'~ . ....,. '" , i !i ._---,--_ ........ --" .. CONTRACTOR may termlndte this Agr~ement or suspend on the Project upon thirty (30) dais written notice to City. 8.2 payment_upon Suspen~io!'l or Termination Upon such suspension or termination by CITY, CONTRACTOR shall be paid fo!' all services actually rendered to CITY to tr.e date of such suspension or termination; provided~ h"..,ever~ if this Agreement is suspended or terminated for f~ult of CONTRACrOR~ CITY $~all be obligQted to co~pensate CONTRACTOR only for that portion of CONTRACTOR's ser_ices which aLe of benefit to CITY. e.3 Return of Mat~};l....~.L~ upon such suspens ion or termir,ation: CONTRACTO~ shall turn over to the city Manager immediately any and all copies of reports or other data, whether or !'lot co~pletedl prepared by CONTRACTOR or-given to CONTRACTOF<. in connection with this Agreement. Such materials shall become the per~anent property of CITY. CONTRACTOR~ however, shall not be liable for CI1,·t~5 use of inco"'IDplete. m.a.terid.~s or for CITY's use of co!:',plete documents if used foZ'" other than the project corlternplated by this Agreement. SECTION 9 -ASSTGNXENT Both parties shall give their personal attention to the faithful performance of this Agreement and shall not assi9n, transfer. convey, or otherwise dispose of this Agreement or any right,. title or interest in or to the same or any part thereof ~ithout the prior written consent of the other party, and then only subje(,.':t to such tents and conditions as the other party may require~ A conse!1.t to one assignment shallnot be deemed to be a. consent to any subsequent assignments. Any assignment 'Without such appro·,ral shall be void an;!, at the option of the other party,. shall terminate this Agreement and any license or priveleqe granted herein. This Agreement and any ~nterest herein shall not be assiqnatlle b:r" operation of la .... without the prior written consent of the other party. SECTION 10 -NOTICES All notices to hereunder shall be given in writing and mailed~ postage prepaid, by ce~tified mail~ addressed as follo~s: To CITY: Office of the city Clerk 250 Rami 1 ton AVen'.le ralo Alto~ C~ 94303 To CONTRACTOR: Ellen Kirschman at the address of CO~TRACTOR recited above. , , - ·r ____ :to __ ~TIO~l 11 -J.ll_It..REST OF C.)NTRa.CTOR In accepting this Agree!llent. CCNiP..ACTOR covenants th3t sh-e presently has no interest, and sball not acquire any interest, direct or indirect. financial or otherwise~ which would conflict in any manner or degree with the perfor:mance of the ser .... ices hereunder ~ CONTRACTOR further co·"enar·ts that, in the performance of this Agreement. no person :having such an interest shall he e:mployed. CONTRAC'I'O.R certifies that no one who has or .... ill have any financia.l interest under this Agreement is an officer or employee of CITY. It is expressly agre.ed that in the perfonnance of the professional services required under this Agreement CONTRACTOR, and any employees, shall at all times be considered independer.t contractors and not agents or eI!lployees of CITY. SECTION 12 INDEMNITY CONTRACTOR agrees to inde'ltnify. defend and hold harmless CITY, its officers, agents and employees from any and all demands, clai~s. or liability of anynature, including death or injury to any person, p~operty da~aqe or any other loss~ caused by or arising out of CONTRACTOR's, its officers' ~ agents', subcon~ractorsf or employees' negligent ~cts, errors, or omissions, or w-illful misconduct, or conduct for which the law imposes strict liability on CONTRACTOR in the perfonnance or failure to perform this Agreement. SECTION 13 -WOEJ{ERS' COMPE_~SATION CONTRACTOR, by executing this AgreeIi'.ent, certifies that she is awa~e of the provisions of the Labor Code of the State of California which require every employer to be insured against liability for worke~s' compensation or to undertake self-insurance in accordance with the provisions of that Code, and certifies that she will comply ~ith such provisions before commencing the pe:r-ionr.al'lce of the 'Worx of this AgreelTlent. CONTRACTOR, a~ her sole cost and expe~se, shall obtain and maintain in full force and effect throughout the entire term of this Agreement professional errors and omissions insurance with respect to activities and services per£ormed by CONTRACTOR for or on behalf of CITY und~r the provisions of this Agreement. The city of Palo Alto, its officers, agents, and employees shall be endorsed as additional insured under this insurance coverage. Certificates of such insurance shall be filed with CITY's PROJECT MANAGER concurrently with the execution of this Agreement or, 'With CITY'S PROJEC'1' MANAGER's approva.l, \lI'ithin ten (10) .... orxing days thereafter. , .. '. - CONTRACTOR aqrees to permit CITY to ~udit, at any reasonable time during the term of this ~9rement and foe three (3) years ther:eafte~ J CONTRACTOR's records par1:.aiT,ing to ma~ters covered b r· this Agreement ot~er than I"ecords the disclOSUre of 'Which is prohibited ur.der the psychotherapist/patient privilege pursuant to California Evidence Code or PrinCiple 5 of the American Psychological AS5ociationl"s Ethical standards conccrnir.g Privacy ana Con! identiali ty. CONTRACTOR !\,;rthE>.!' agrees to :maintain all records pertaining to matters cover-ed by this AgrE.ement fo-r at least thrae (3) years after the te~ of this Agreement. SECTION Hi __ :: AGREEMENT BINDING The terms, covenants, and conditions of this Agreement shall apply to, and shaoll bind l the heirs, S1Jccessors, executors, administrators, assigns, and subcontractors of both parties. SECTION 17 -WAIVEE~ The ~aiver by either party of any breach or violation of any teLm I covenant, or condition of this Agreement or of any provision, ordir.ance. or la~ shall not be deemed to be a waiver of any other t~rm, covenant, condition, ordinance, or la ..... or of any subsequent breach or viol~tion of the same or of any other term, covenant, condition, ordinance, or law~ The subsequent acceptance by either party of any fee or other money ...... hich may become due hereunder shall not be deemed to be a waiver of any preceding breach or violation by the other party of any term, covenant, or condition of this Agreement or of any applicable law or ordinance. SECTION 18 -COSTS &~D ATTOR~S' FEES The prevailing party in any action bro~ght to enforce the terms of this Agreement or arising out of this Agreement may recover its reasonable costs and attorney fees expended in connection with such a~ actioM fro~ the other party. §_ECTION 19 -NO IMPLIED WAIVER No payment, partial payment, accepta::1ce, or partial acceptance bi CITY shall operate as a ~aiver on tne part of CITY of any of its rights under this Agreenent. SECTION 20 -NONDISCRJHIN.:'TION; PENALT.Y No discrimination shall be Ulade in the employment of pe:s~ns under this Agreement because of the race, color, national or~g~nl" ancestry, religion or sex of such persoM. If the value of this Agreement iS I or may bel Five Thousand Dollars ($5,000.00) or more, CONTRACTOR agrees to meet all requirementa of the Palo Alto :L " ... ..,.;" .::;- .\ - ~, Municipal Code "ertaining to nondiscrimLiation in e.mployment. including completing the ncoi1lpliance Feport--NondiscI" imination Provisions of City ot Palo Alto Contracts" on the form furnished by CITY and attac~ed her-eto as Exhibit "Dn and ~ .... d~ a ?art hereof ::-y 'this reference. If CONTRACTOR is found in violation of the nondiscrimin~tion provisions of the State of California Fair Employment Practices Act -:)r similar provisions of federal 1~'W or executive order in the performance of, this Agreement, it shall thereby be found in material breach of this Aqreement. Thereupon, CITY shall have the power to cancel or susper-.d this .1t"qreement, in 'Whole or in part... or to deduct from the amount payable to CONTRACTOR the sum of Twenty-Five Dollars ($25.00) for each person tor each calenda~ day during which such person ~as discriminated against, as damages for said breach of co~tr3ct, or beth. Only a finding of the state of California Fail' Employment ?ractic~s commission or the equivalent .federal agency or officer shall constitute evidence of a violation of contract under this section. If CONTRACTOR is found in violation of the nondiscrimination proviSions of this Agreement or the applicable affirmative action quideli~es pertaining to this Agreement, CONTRACTOR shall be found in material breach of this Agreement. Thereupon, CITY shall have the po .... er to cancel or suspend this Agreement... in whole or in part, or to deduct from the amount payable to CONTRACTOR the sum of T..,o H,mdred Fifty Dollars ($250.00) for each calendar day during which CONTRACTOR is found to have been in such noncompliance as damages for said breach of contract, or both. SECTION 21 NlENDME1U: AGREEMENT CONTAINS ,ALL UltDEBSTA...\WINGS; This document represenets the entire and integrated agreement between CIT"i and CONTRACTOR and supercedes all prior negotiations, representations, and a;reements, either written or oral. This document may be a:c;ended only by written instrument, signed by both CITY and CONTRACTOR. SECTION :?~ GOVEP .. NING LAW This Agreement shall be governed b z' the la'\ols of the state of California. ATTEST: CITY OF PALO ALTO "C"i·t""y"'C"l-:::e::r"k---------Mayor A.PPROVED A.S TO Fa!m: APPROVED: city Manag~e~r~--------------- D irector 0 f F"i"o"a"'n"c:::::e,.-------- APPROVED A.S TO CONTENT: Police Department Attachl!ents: EXHIBIT "Aw: EXHIBIT tlB": .'_. CONTRACTOR: ELLEN KIRSCHMA,..."{ Taxpayer Identification No. 111-30-1884 SCOPE OF PROJECT NONDISCRIMINATION COMPLIANCE FORM , , 2888 --,-< AGREEMENT 8Y n-!IS AGREEMENT IM-DE ,'NO Ii'NH:F,lOO IrHO ~ 'il1f _______ 0,0."(;';: _~ __ e'l AND 8ET'~eN TJ-jE CITY OF PAlO ALTO iliE:RE:!NM"Tt;B RUiftR(O TO.-.s Ciiy, .... 'I! ,"N.'-"tEijll Pi leo xi rsch,,,,-'m ..E.h...._D~ 12' _________ _ No. { :JATE. rCeEE"{~-E;:>:::" ,'--,~-;3', CIT,' P,-i;:;O-lllSI"::; :HEREFNAF;ER "FER~010.\S CONTRACTOR}, IN CDl'SID(q,.,TI~ OF TkE.,P /,AUruM C-O\fE·I."N~S, THE: P .... FF'ES HE RfT,:J AC.RE~ ./O,s ;:OL!..OW5 • COtITRA.CTOR S:-V.U PRO',IC£OO FI..;R"lIS'" T>-jE:.fOLLOWINo::;' Sl'E,:;"FIEO S--ERil:<";o..S"-NC,'C'R",,.,ITUI:,,-'._5 $;>0::1 .. 1;:'(1 I~H!-IIt>IT ~ __ _ ._TT'-'CHED HtR[TO A. ... O I~F'oP.ATEO HE~DN ElY TH5 RE:FER .. N,::.e: To provide professional services as Health Re50urce Coo~~inator to police department personnel. Exhibit "'A": Contractor's w~rk State~ent • TERMS THE st~''''fCi"S ANCo'OR U'/o'TE~l~.LS ;;LR"'ISI-;ED I)NC'EA TH!S ... .;."E~MENT Sf/A;.J_ C-()M~fN'::E'ON ~_u~.l...q~ __ 3._ .'.NO SI-WJ... BE COI.i?LETEO flEFOOE J1' De 3 O_ ... mml.9_.9..4_ • COMPENSATION FQf! tl-li: FU:..L PERFORMANCE ~-;F nilS AG'RE~"'l:.N7 . a CITY SHALl f>AY CCWTf\ACiOR upon rece lpt of l.nVOl.ce:: o CONTRACTOR: SHALl P.I,,, CIT'>' • PAYMENT RECORD [llEPA.ATME.m;JSEREVERS£SIDE) P.C. BOX 10250 PALO M. TO, C ... 94303 Te{epnor.e ..(.A..l..5.L.~1.Q3 • INVOICING SE-~D AU IN''''O~(S TD THE erN, A:rl~ PF-~OJECT I.1Ai'O/IoCER • L TO APPROVALS: IR :,UTE FOR S~GNArURES .... C,;OF1[;oI"<,G TO I\UMSE.C1S 1"-APPROV ....... eOl(E.S SE:.OW; -------I f!~;.,k~!: L ~~",~ -:."'~~~'.."" ~;"~IS 1. 2. o EXHIBIT "A: kllliI.RACTQR'S WQP.K STATEME lilT , ELLEN KIRSCHMAN Pro>J'ide counsel"lng, critical incident debrie~'lng and referrars fo,.. ;ndividuais experiencfng high stress. Provide conflict reschJtion for jndrvia'ua~s and grolJPs. 3. identify sources of organizationar stress and consult with work units and individual managp..rs to resolve them. 4. Manito( 1"'l3nagement decisions with regard to their stress impact, seare,", for implementation methods whicr, minimize tl",8 stressful impact, and advise management staff. 5. Trein FTO's, supervisors, and managers 'In communication, problem solving. conflict resolution, and supervisory skins which can m,nimize stress for subordinates 6. Counsel individual managers or. stress producFng practices and events within their units. 7. Educate all PAPD personnel in the range of stress reductkonl health enhancemem techniques a\laJlabie in the Palo Alto area, and encourage their use. 8. Design and facilitate team building and problem solving meetings for managers and their work units. 9. Counsef new officers ano FTO stoff regarding ways to rninjmize stress and optimize learning. 10. Provide consultCltion to the peer support program and sponsor special events or workshops related to persoral and organizational hea~th. 11. Assist in program evaluation as it relates to personal and organizatiOnal health and employee retention, , 2. Maintain a health related bulletin board and health related materials available for use by all employees. 13. Provide career counseling snd life assessment gu~dance for individuals. 14. Prepare a quarterlv activity report. • ~~ , , j 15. Develop an objective, measurable-metho:J tQ e .... aluate the HRC program. ~6. Provide 772 hours of consu!tirg services per current contract year. See specific schedule to be approved by HIe Proj'ect Mar.ager. - £4/£Jl~;t 1"t~ll'l~,~c""'v· __ ._._~_~~~. 11:;.-.'.'.,...-:::".::':-"'.-.'·7"·,"'-'-'-'-· Exhibit PART II -SUPPLEMENTS TO PROPOSAL FORMS SECTION 00410 CERTIFICATION OF NON-DISCRIMINATiON C4rtjficapon of Nan·discriminatiQn: As suppliers of goods or servi.t::es to the Cfty of Palo Alto, the firm and individuals listed below certifies that they do not discriminate in employment with regards tv race, reHgior., creed or national or1gin; that they are in compliance with all Federe!, State and local directive~ and executive orders regarding non-discrlmtnatton in employmen.t; and that th.ey agree to demonstrate pasitiveiy and aggressively th-e principle of equal GDPortunrty in employment. The Proposer agrees specifically: 1.0 To estabrish or observe employment po~icies which affirmativeiy promote opportunities far minority persons at at( fob leve!s. 2.0 To communicate this policy to ali persons concerned, inc1udlng aH company emptayees, outside recruiting services, espe.cially those seNing minority communities, and to the minority communities at large. 3.0 To take affirmative steps to hire minor it>,' emplo'y'e:es w\thin the organization. 4.0 To. be knowledgeable afthe.!ocal, state, and federal laws and re.gutations concerning affirmative action policies and provide opportuni!ies for employees, Fi rm: \b \0 ~ \\'D -\:::;;::,\,~, c "--" '\)c;J:-:ZSl(' +, "\ '"'C": I~ Title of 0 ffiCO)" jign ing '''-=1J'----7/'--,:---. '~ Signature i: LJvY' '~ ,~"t"''''c."",(===- Date_+!-",,,,:--""t-!--";i-'---" Ptease Lnc1lJde 1j any additional information available rega~ding employment program.s now in eJ-iec"[ withIn your company. equal opportllnity --------------,--,------ (Please anach additiona~ pages if necessaryJ END OF SECTION CITY 01 PALO ALTO: Non-discrimination '1'9.2) SfCTJON (1\,)410-1 .-" A.CCO',-,'t;T NO' t K tl:q;~91-Q 0086213 ))OUCYNC: 'pS\"-3613~91 ~ JTI£M t .{al NN>'I~ ANO ADDRESS OF tNS~O' ITEM 1.{b) AD01TIONAl ~lAMED tNS.URE~S ELLEN F .. KIRSCHMAN, 391B L'tI":.lN "RCA!) 0.4;( U •. N.O t' CA. 94602 --------- ITEM.2. ADC>:T:o~,rAL :NSUREC'S: CtTY OF I-lAY'Io,i;\RO POLICE DEPARTMENT 300 ~. ~INTON AVENUE HAY·\ofARD, CA. 94544 Pouey Pr::F:;IOO' PH .. D ClTV OF PALO ALTO POlfeE D~PART~ENT 275 FOREST 4VENUE PALO AtTO, tA ~1301 CITY Qf PALO AllG FrRE DEPARTMENT 275 FOREST AVE~UE PALO ALTO, CA 91301 FROM 03/01/93 TC 03/01/94 1:2 01 A.M Sr;.,NDARO TIME AT THE AOD?ESS Of T~E iNSUPEO .1.5 ST ATW "i!::.t1EIN' nEM". ITEM 5. ITEM 5 ITEM a lIMJTSN UA8IUr{ D£OUC"TIBlE , t,ooo ... ooo EASH 1,I'1"RONG::-UL ACT OR SERI:':-S OF CONTIr->UOUS, REPEAiED __ CR IhTERRELP.TED WRO~,JGFljl A.CTS OR OCCUR:::;ENCE S 1,000,000 ~ NONE E~CM "'ipm~GI'"U!.. ,ACT OR 5[RiES OF CONTINUOuS, .qi:P£,6.TED ___ .... __ . ____ CA ,f\,'TfRREL.AiED wRor'Grl.'l :"::"'S OR O':'GIjRRE~,CE ----------- PREMIUM SC~EDiJlE.. F. --=c~LAf:A1s~s[U"~,l'c:;;AITI~ciE"C-::.::. ===== J PSYCHOlOGI ST5r ~~LJM8EA j _ ........ :: .. ::. ~1==A~N~·i!:N[;:I.i,t'k.l!:3PH.f::~~!g!.1 I 15 I, 662.00'1 662 .. 00 ~ IDO.CC I I I '---------------- RORDACTiVE DATE. 03/01/92 EXTENDED fl.EPORirNG PERtOD ADDITIONAL PREMIUM lH exerclsed):.$ } ... ' 334.00 I i : I L iTEII.'9. pouey FORMS A.ND ENDORSEMENTS AnACHED TO THJS POUCY: )RM : 52349 -8-91 FORM: 52338 8-91 THIS IS NOT A BILL PREMIUM HAS BEEN PAID . . -:.