Amendment No. 4 to the PSA with Frederick M. Keroff Ot3 — 2'/ 2?
AMENDMENT NO. 4 TO THE PROFESSIONAL SERVICES AGREEMENT
BETWEEN THE CITY OF MIAMI BEACH, FLORIDA
AND
FREDERICK M. KEROFF, DATED FEBRUARY 25, 2013
FOR MEDICAL DIRECTOR OF MIAMI BEACH FIRE DEPARTMENT ADVANCED
LIFE SUPPORT PROVIDER
This Amendment No. 4 to the Professional Services Agreement is made and
entered into this 2.5 _ day of 1W s/ , 2016 by and between the City of Miami
Beach, Florida (City), and Frederick M. Keroff(Contractor).
RECITALS:
1. City Manager, acting on behalf of the City, hereby exercises the City's option to
renew the Agreement, upon the same terms and conditions, for an additional one (1)
year. Accordingly, such renewal term shall commence on October 1, 2016, and shall
terminate on September 30, 2017.
2. All other terms and conditions of this Agreement shall remain unchanged and in
full force and effect.
IN WITNESS WHEREOF, the parties hereto have caused this Amendment No. 4
to be executed by their appropriate officials, as of the date first entered above.
FOR CITY: CITY OF MIA . BEACH, FLORIDA
ATTEST: 1CONIOX I
e ,1 _
By: C' y CI � k ''. .0 y a ger
Rafael Granado �' ' = :r.,r my . Morales
z� I = r• 'PI pRATED: r
Date '•. agate
WITNESSES: • 't,a -, FREDERICK . KEROFF, M.D.
Witness C�ractor
Print Print Name
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itness Date
L�' G C APPROVED AS TO
Print Name -FORM & LANGUAGE
Y_d 1,6 &FOR EXECUTION
Date
City AttorneC Date
AC D® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
�� 5/16/2016
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 pollcy(les)must 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 Ileu of such endorsement(s).
PRODUCER CONTACT Credentialing Department
Alliant Insurance Services,LLC
5444 Westheimer !(A 1C N .Pay 800-342-2898 NC.NoI
Suite 900 p DRES�claimh lsloryrequest @teamhealth.com
Houston TX 77056 INSURER(S)AFFORDING COVERAGE NAIC 0
INSURER A:ProAssurance Specialty Insurance Co 10179
INSURED INSURER B:
InPhyNet South Broward,Inc. INSURER C:
1431 Centerpoint Blvd.,Ste. 100
Knoxville,TN 37932 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:1785788159 REVISION NUMBER:
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.
ILTR TYPE OF INSURANCE I�NSO WEIR POLICY NUMBER POLICY EFF POLICY EXP
IMMOD/YYYY) IMM/ODIYYYY) LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
I CLAIMS-MADE I OCCUR DAMAGE TO RENTED -
PREMISES(Ea occurrence) $
MED EXP(Any one person) $
—
PERSONAL 6 ADV INJURY $
GENL AGGREGATE LIMIT APPLIES PER
JECF I I LOC GENERAL AGGREGATE $
— POLICY PRODUCTS•COMPOPAGO S
OTHER
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S
(Ea accident)
ANY AUTO _
Af OS EO gq BODILY INJURY(Per person) S
NON-0 L WN ED BODILY INJURY(Per accident) S
— HIRED AUTOS — AUTOS (Pe acddenlDAMAGE $
S
UMBRELLA LIAR _ OCCUR EACH OCCURRENCE _ S
EXCESS LIAR C(AIMS•MADE AGGREGATE $
(
DED I I RETENTIONS $
. WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY YIN j STATUTE I_ ER
ANY PROPRIETOR/PARTNER/EXECUTIVE I 1 N!A EL.EACH ACCIDENT S
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) E.L DISEASE-EA EMPLOYEE S
If yes describe under
DESCRIPTION OF OPERATIONShelox EL.DISEASE-POLICYLIMIT $ _
A Medical Professional ES1800 6/1/2016 8/1/2017 Incident $250,000
Llabllily
(Claims Made Coverage) Aggregate $120,000
Total Policy $120,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,AddlUonal Remarks Schedule,may be attached II more space Is required)
The policy(les)provides coverage for all medical professionals employed or contracted by the above Insured only for medical professional
services provided for or on behalf of the insured.The limits shown above are inclusive of the applicable policy self insured retention.
Keroff,Frederick M,MD
CERTIFICATE HOLDER CANCELLATION 30
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Memorial Regional Hospital North Campus THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
3501 Johnson Street ACCORDANCE WITH THE POLICY PROVISIONS.
Hollywood FL 33021
AUTHORIZED REPRESENTATIVE
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