12-14-1987 (City Council) Agenda Packet Date Posted 12-11-87
Tine Posted 5:00 P.M.
AGENDA
CALLED MEETING CITY COUNCIL
CITY OF WYLIE, TEXAS
MONDAY, DECEMBER 14, 1987
COMMUNITY ROOM, 800 THOMAS STREET
7:08 P.M.
CALL TO ORDER
INVOCATION 31411
ORDER OF
BUSINESS BUSINESS
1 Consider approval and authorized
execution of contract for provision
of Advanced Life Support Ambulance
Service to Lifeline Christian Care
Ambulances, Inc.
2 ADJOURN
CONTRACT FOR PROVISION OF
ADVANCED LIFE SUPPORT AMBULANCE SERVICE
This contract is entered into by and between the City of Wylie, Texas ("City"),
and Lifeline Christian Care Ambulances, Inc. ("Lifeline"), on the day of
December, 1987, and is to witness the following:
WHEREAS, the City currently operates an emergency ambulance service providing
basic life support; and
WHEREAS, the City desires to upgrade the current service level to advanced
life support; and
WHEREAS, the City Council has determined that it is in the best interests of
the City to contract with Lifeline for provision of such service; and
WHEREAS, Lifeline has agreed to provide such service on the following terms
and conditions.
NOW, THEREFORE, in consideration of the premises and the mutual promises and
obligations of the parties as recited herein, City and Lifeline agree as follows:
1. Scope of Service
A. Lifeline agrees, during the term of this contract, to provide advanced life
support (ALS) emergency ambulance service to all areas within the corporate limits of
the City.
B. The ALS service to be provided by Lifeline shall include an emergency
ambulance that carries the drugs, equipment, and telemetry of vital signs to a qualified
doctor as well as any and all other equipment or supplies required by law to provide
ALS service. Lifeline agrees to man such ambulance with fully trained paramedics
and/or emergency medical technicians who are authorized and qualified to administer
ALS.
C. City agrees to dispatch all E9-1-1 calls for emergency ambulance service
within the corporate limits of the City to Lifeline/Methodist-Dispatch during the term
of this contract or any renewal hereof.
D. This contract is based on the premise that Lifeline has a contract with
Methodist Hospitals of Dallas to provide all medical control and dispatch services,
including telemetry to a qualified doctor for stabilization of a patient at the scene, to
meet the minimum standards for ALS as required by state law. Such services are more
fully set out in the agreement for ambulance support services provided by Methodist
to Lifeline, which agreement is incorporated herein by reference and made a part hereof
for all purposes. This contract will terminate automatically and immediately in the
event such contract between Methodist and Lifeline is terminated for any reason and
no substitute contract is entered into of a like nature and on a basis acceptable to
the City.
2. Term
A. This contract shall be effective from December 15, 1987, through
December 31, 1989, unless sooner terminated as provided herein.
B. The parties have agreed that the first year service shall be subsidized in
part by the City as provided in Paragrah 3 below. The parties have not agreed on
the amount of subsidy for the second year of this contract, but have agreed to negotiate
the amount of such subsidy and to agree on the amount of the same or to agree to
terminate this contract. The parties agree to negotiate such term and reach a decision
on or before September 1, 1988, so that the amount of any subsidy agreed upon can
be included within the City's budget for the succeeding fiscal year.
3. Subsidy
A. The parties agree that the subsidy to Lifeline from the City for the first
year of this contract shall consist of two (2) existing ambulances and related equipment
owned by the City. City agrees to convey title to the two (2) ambulances and related
equipment to Lifeline in the manner provided by law, conditioned on other terms of
this contract stated below.
B. The parties agree that the subsidy for the second year of this contract
shall not exceed the sum of Fifty Thousand Dollars ($50,000.00) cash, subject to the
negotiations provided in Paragraph 2 above. The parties agree that if the subsidy for
the second year of this contract, beginning January 1, 1989, is not funded by appropriate
budget action of the City, this contract shall terminate on December 31, 1988.
4. Conditions of Service
A. Lifeline agrees to:
(1) Provide immediate ALS service for all emergency calls dispatched
to it within the corporate limits of the City for the term of this
contract.
(2) Be responsible for all hiring of employees, dispatching, billing and
collections.
(3) Save, indemnify, and hold harmless the City, its officers, agents and
employees from any claim, suit, damage, judgment, or attorney's
-2-
fees arising out of or in any way related to any claim of negligence
by third parties against any employee of Lifeline as a result of
providing the ambulance services outlined in this contract.
(4) To provide ALS emergency service to any location within the
corporate limits of the City in a time of eight (8) minutes or less
from dispatch time to arrival at the scene in not less than ninety
percent (90%) of all dispatches within the City.
(5) To provide nonemergency response within fifteen (15) minutes of
any dispatch within the City in ninety percent (90%) of nonemergency
dispatch runs.
(6) To provide such services at a reasonable cost to the citizens of
the City. The initial approved fee schedule for such services is
attached hereto as Exhibit "A" and made a part hereof for all
purposes.
(7) To provide monthly run statements to the City, including the type
of run, response time, disposition of patients, and any unusual
circumstances.
(8) To provide an annual financial statement of Lifeline to the City.
(9) To notify the Police Department of the City immediately upon
observance of any unusual circumstance in conducting an ambulance
run, either emergency or nonemergency.
(10) To receive and respond accordingly to City dispatches directly from
the emergency number system or to citizens referred by the City
directly in the manner required by this contract.
B. The City agrees to:
(1) Call Lifeline directly when a call is received for emergency
ambulance service through the City's E9-1-1 emergency service
number system and to give nonemergency callers Lifeline's direct
telephone number upon request to the City for nonemergency
ambulance service.
(2) To dispatch emergency and nonemergency ambulance service calls
exclusively to Lifeline during the term of this contract.
-3-
(3) To convey two (2) ambulances currently owned by the City and any
other personal property or equipment related thereto in the manner
provided by law, subject to the terms and conditions of this contract.
(4) To provide liaison by the City Manager or his representative between
the City and Lifeline.
(5) To review and approve all reasonable requests by Lifeline for
increases in fees for services rendered in connection with the
ambulance service.
5. Insurance
Lifeline agrees to maintain comprehensive general liability insurance to
cover all insurable risks arising out of or in any way connected with the provision of
ambulance services in accordance with this contract, including emergency or
nonemergency services, ALS services, vehicle operations, and any and all personnel of
Lifeline while acting within the course and scope of their employment in providing any
of the services covered by this contract. Lifeline agrees to furnish such insurance in
accordance with the schedule attached hereto as Exhibit "B" and to show the City as
an additional named insured therein as its interest may appear. Lifeline agrees to
furnish the City a certified copy of any and all policies of insurance held by Lifeline
pursuant to and required by this section on or before the effective date of this contract.
6. Termination
A. Either party to this contract may terminate the contract upon the giving
of ninety (90) days written notice, such notice to be given by certified mail, return
receipt requested, or by hand delivery to:
Lifeline Christian Care Ambulances, Inc.
5353 Maple, Suite 200
P. O. Box 35033
Dallas, Texas 75235
City of Wylie, Texas
Attn: City Manager
P. O. Box 428
Wylie, Texas 75098
B. In the event Lifeline terminates this contract before the expiration of six
(6) months from the effective date hereof, it agrees to transfer title to the two (2)
ambulances to be conveyed hereunder back to the City on or before such termination
date. In the event Lifeline terminates this contract before the expiration of one (1)
year from the effective date hereof, it agrees to convey one (1) of the two (2) ambulances
-4-
back to the City, the choice of which ambulance to be conveyed to be within the
discretion of the City. If necessary, Lifeline may sell either or both ambulances prior
to the end of the first year of this contract. If it does and the contract is then
terminated as provided in this section, Lifeline agrees to reimburse the City an amount
equivalent to the sale price of the ambulance(s). If improvements or additions are made
to the ambulance(s), they may be removed if the ambulance(s) is returned to the City
pursuant to this section.
C. As provided above, if the subsidy to be provided by the City to Lifeline
during the second year of this contract is not budgeted during the required fiscal year
by the appropriate legal process, this contract shall terminate and be of no further
force or effect after December 31, 1988.
7. Performance Guaranty
Lifeline agrees that it will maintain its qualifications as a provider of ALS
in accordance with all requirements of state law and appropriate agency regulations.
Lifeline agrees that its personnel providing ALS services will be fully trained and
qualified as paramedics and/or emergency medical technicians as may be required for
giving the level of service they are providing and that such personnel will accomplish
all of continuing education requirements of the state or its agencies or as required by
the ambulance support services agreement with Methodist Hospital.
8. Miscellaneous Provisions
A. This contract is performable in the City of Wylie, Collin County, Texas.
B. Venue of any cause of action with regard hereto shall be in Collin County,
Texas.
C. This contract contains all the agreements of the parties, and no prior or
contemporaneous oral agreements shall modify any term or provision hereof. No
amendment of any provision hereof shall be effective unless and until executed in writing
by the parties hereto.
D. Amendments hereto on behalf of the City of Wylie shall not be effective
unless and until such amendment has been approved by appropriate resolution of the
City Council.
E. This contract shall be governed by the laws of the State of Texas.
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EXECUTED in duplicate originals on the date first written above.
CITY OF WYLIE, TEXAS
By:
Mayor
ATTEST:
City Secretary
LIFELINE CHRISTIAN CARE AMBULANCES, INC.
By:
President
By:
Executive Vice President
Administration
ATTEST:
Secretary
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Replacing NEW
ice►
�` PROFESSIONAL LIABILITY POLICY
ADMIRALt ?1, INSURANCE
COMPANY (CLAIMS-MADE FORM)
A STOCK COMPANY A87 MP1191
therein called the Company")
DECLARATI01
INSURN/
LIFELINE CHRISTIAN CARE i
NAMED AMBULANCE, INC . WflUM'49
INSURED 5353 MAPLE AVE . , SUITE 200
DALLAS, TEXAS 75235 DWYER
MAILING C Q.
ADDRESS
POLICY PERIOD: From 06-18-87 To 06-18-88 I
At 12:01 A.M. Standard Time at the address of the Named Insured as stated herein.
In consideration of the payment of premium, in reliance upon the statements herein or attached hereto,and subject to all of the terms of this policy, the
Company agrees with the Named Insured as follows:
NOTICE
Except to such extent as may otherwise be
1. NAMED INSURED'S BUSINESS: AMBULANCE SERVpir 6&Yed herein, the coverage cf this policy is
lim'ted generally to liability for only those claims
tF.at are first made against the insured while t!-
2. LIMITS OF LIABILITY: S 10 0 0 0 0 . each clai
"�o{:cy is in force. Please review the policy care-
$ 100, 000 . aggregate
futiy and discuss the coverage thereunder with
your insurance agent or broker.
3. DEDUCTIBLE (Including Expenses): $2, 5 0 0 . 0 0 PER C LA I M
4. CLAIMS EXTENSION PERI00: (APPLIES ONLY I F THE COMPANY CANCELS OR REFUSES TO
RENEW) : 6 MONTHS FROM THE CANCELLATION OR EXPIR—
ATION OF THIS POLICY .
5. RETROACTIVE DATE: 0 6—18—8 7
6. PREMIUM: PROFESSIONAL LIABILITY — $3, 500 . 00 FLAT CHARGE
EXTENDED DISCOVERY PERIOD — $1, 000 . 00 FLAT CHARGE, FULLY
EARNED AT INCEPTION
CGL — $500 . 00 (TOTAL: $5, 000 . 00)
7. FORMS AND ENDORSEMENTS ATTACHED AT INCEPTION:
JC-0076, JC-0078, ENDORSEMENTS 41, #2, #3, #4, #5, #6
A SIGNED COPY OF THE NAMED INSURED'S APPLICATION FOR THIS POLICY IS
ATTACHED HERETO. AND MADE A PART HEREOF, AT INCEPTION.
i/f/
Countersigned On:_ 0 9—0 4—8 7/SSG
At: AU-ST-I-N TEXAS By:
Authorized Representative
ID-0028 ;1183)
Tex .. Auto Insurance pal-- 5`,„,ti:7E . V , za.
6 13 34 90 xx Trinity Universal Insurance Company
Na_. IC Security National Insurance Company 111 i "i`_'r
N DECLARATIONS— PART B p y
Trinity Universal Insurance Company l^�t i It�.�•.•a`
Items
of Kansas, Inc.
1. Named Insured and Address: •�• E,
' Lifeline Christian Care Ambulance, Inc .
5353 Maple, Suite 200
Dallas,TX 75235 The named insured is:
Li individual; partnership; Li corporation; !I joint venture;
2. Policy Period: 1Mo. Day Yr.i
other
From 4-10-87 to
12:01 A.M.,standard time at the address of the named mOsured 88as stated herein. Business of the named insured is
3. Schedule as of Effective Date of this insurance—As to: tat Sections A, B & C—Otwned Automobiles; ibl Section D—Covered Automobiles (including newly acquit'
:etudes, subject to the provisions of paragraph 1oi of the "covered automobile" definitiont
111 Description; Purpose of Use iP & Eli = Pleasure and Business; C = Commercial)
AUTO Year o. Modal Trade Name Body Type—Capacity ;Truck Load. , Seating,: Identification lU. Principally Garagedin
N y y Gallonage Bus Set e,' Y y Purpose Classy-
- Serial •Si, Motor iMi No.: Cylinders ,No.': Model Town, Stater
) ----__-- _— of Use fication
1980 Chevrolet type 1 Ambulance 1 T. #7251 Terr:02 7931(3 .00)+15%
2
122 f acts Respecting Purchase: As to Section D. any loss as
AUTO List Actual Purchased Rating under Coverages other than is payable
No. Price cost Mo. & yr.—New kW; Used Dui Symbol Interest may appear to the named insured and the Loss Payee named below
I
2
tci Automobile Medical Payments Coverage: Designated Person Insured
Designation of Automobiles—Division
AUTO Nu.
Idi Uninsured/Underinsured Motorists Coverage: Designated Person Insured
Insured Motor Vehicles
AUTO No.
4. The insurance afforded is only with respect to such of the fo;lowing coverages. and under each such Section D coverage to such covered automobiles described in the
Schedule of Covered Automobiles, as are indicated by specific premium :harge or charges. The limit of the company's liability against each such coverage shall be as stated
herein. subject to all the terms of this insurance having reference thereto
SECTION COVERAGES LIMITS OF LIABILITY PREMIUMS
•
ACV rnenns Actua Cash Value Auto No I ( I Auto No. _-
I
A. Bodily Injury Liability * S 20 000 each person
A S 40,000 cacti occurrence S 714 $ _B. Property Damage Liability * S 15,000 each occurrence S
B I C. Automobile Medical Payments S 722 $
each person $ $
D Uninsured/Underinsured
e Motorists Coverage g 20,000 each Person $ S
Bodily Injury S 40,000 each occurrence I 13
L Property Damage S 15,000 each occurrence Is S
E. Comprehensive I (RATE) 1 Auto No. 1 I (RATE) Auto No. 2 10
ACV Unless otherwise slated y I$ $
less deductible -> S $ $
$
F. Collision
ACV less deductible i
D $ $ $ S
G. Fire, Lightning or Transportation I
ACV unless otherwise stated 4. $ I S IS
H. Theft $
— ACV unless otherwise stated i I$ i$
I. Combined Additional $
ACV unless otherwise stated 4. $ j $ S
J. Towing $
:40 for such disablement $ $
Personal Injury Protection $ 2,500 per End. No. Attached 241 h S 49 S
Endorsement Identification ' TOTAL PREMIUM BY AUTO NO $ 1,508 $
TX0613,TX1069B,TX1097 Premium for Endorsements $
TX1007 ,Z41b TOTAL POLICY PREMIUMS 1,508^ 1
5. Except with respect to bailment lease. conditional sale. purchase agreement. mortgage or otnei encumbrance, the named insured is the sole owner of every vehicle described
In Item 3 above, unless otherwise stated herein:
- i 3.1.,r4<' (-
Coumersi lied. 6-10-87 Dallas,TX B :� i (--��
Authorize Representative
I ORM Ni) S'-,i4E4 THIS DECLARATIONS PAGE;PART El)WITH POLICY PRO'.-'SIONS -PART A".AND ENDORSEMENTS.
IF ANY. ISSUED TO FORM A PART THEREOF COMP(rTES THE ABOVE NUMBERED POLICY JDLiREVIJi-EM)
*UNLESS A SPECIFIC PREMIUM CHARGE IS MADE FOR SECTION A COVERAGES, THIS POLICY DOES NOT PROVIDE BODILY INJURY OR PROPERTY DAMAGE
LIABILITY INSURANCE AND DOES NOT COMPLY WITH ANY FINANCIAL RESPONSIBILITY LAW.
FELTS, SKEELS, MULLENS & FUOS
750 N. St. Paul, Suite 520 Tel: (214)953-0707•Fax: (214)953-1487•TELEX: 535212 SKEEL
Dallas, Texas 75201
BINDER NO: A87MP1191
DATE: 6/24/87 TO: Williams-Dwyer Co.
Drawer 270
ASSURED: LIFELINE CHRISTIAN CARE Wichita Falls, TX 76308
AMRIII ANCF, INC_
53C3 jAaple Ave_ Suite 200
Dallas, Texas 75235 ATTN: Frankie Wooster
THIS IS TO CERTIFY THAT THE FOLLOWING INSURANCE HAS BEEN EFFECTED FOR YOUR ACCOUNT SUBJECT TO THE TERMS AND
CONDITIONS CONTAINED HEREIN.
BINDER TERM: 6/18/87 to 8/18/87
COVERAGE: CGL/Ambulance Attendants E & 0
POLICY PERIOD: 6/18/87 to 6/18/88
LIMITS: $100,000 each claim/aggregate - defense costs included
within limits
FORM: Claims Made - Retroactive Date: 6/18/87
CONDITIONS: Includes 6 month discovery clause
Excludes: prior acts
THE 'S WITH ;.N INSURCR NOT
LI;..—;r 7; ,.
LUG t!'lES
(; i1: ... ...\rl,:hkt4t s1 JUTES
',;\ICE CODE. REQUIRES
PAYMENT 0f 3.85*TAX ON GROSS PREMIUM.
DEDUCTIBLE: $2.500 Par claim incl LAE COMPANY: Admiral Insurance Co.
PREMIUM: $5,000_00
POLICY FEE: [FULLY EARNED] $150_00 INSPECTION FEE: --- TAX: $198_28
$2,200. MINIMUM EARNED APPLIES:NO FLAT CANCELLATIONS ALLOWED.
This binder is based on cable and/or mail and/or telephone advices from the above insurer(s)and is subject to policy conditions when,as and if issued and is issued by the
undersigned without any liability whatsoever as insurer,being solely for the convenience of the insured and is to be automatically cancelled and superceded by the policy upon
issuance.
Cancellation.This binder may be cancelled by either the insured or the insurer by written notice to the other.In the event of ca ellation,the earned premium will be computed
short rate if cancelled by the insured unless subject to minimum premium and pro rata if cancelled by the insurer.
IMPORTANT
THIS INSURANCE CANNOT BE AUTHORIZED REPRESENTATIVE
CANCELLED FLAT. EARNED JS/jjs
PREMIUM MUST BE PAID FOR FELTS, SKEELS, MULLENS & FUOS
THE TIME INSURANCE HAS
BEEN IN FORCE.
•`- APPLICATION FOR AUTOMOBILE LIABILITY INSURANCE
t
under the •
' INSURANCE CJexas 1'tutomo6ile Insurance Plan
708 Colorado,Suite 404.404 Brown Building•Austin,Texas 78701•S12/477-5322
Check a Amount S
(FOR INSURANCE PLAN OFFICE USE ONLY)
IMPORTANT-(1)This application must be submitted in duplicate together with the appropriate premium for the insurance applied for.(2)Remittance for the premium mast
be payable only to Texas Automobile Insurance Plan.(3)N this application is assigned to on insures operating under Ch.19,Texas Insurance Code(Reciprocals),applicant accepts
all filings required by low to be mode with the State Beard of Insurance.
THIS APPUCATION MUST BE PRINTED OR TYPED.
Applicant's esStreet
I. full name Lifeline Christian Care Ambulance, Inc .addrsP• O. Box 35033 No
Dallas Dallas Texas 75235 ( 214 ) 630-4555
City County State Zip Code Home Telephone(Area Code) Business(Area Code)
2 __ Non-Emer_ganny_Ambulance Service
e 5po„�s Occupation
Occupation Employers Nome 8 Address
2o. Is applicant a resident of Texas? YPR If not, give permanent home address
3. OPERATOR INFORMATION
Applicant's former addresses past 3 years-
r—
Relationship Principal driver Birth dote Sex I Driver's
Applicant and other drivers to applicant Noj Yesi Veh. No. Mot Day Yr M-FI MIS* License No. State
APPLICANT Applicant ,
i
Cnnnie Conley Fleming !V-Pres . ! x 1 07t01 52 F M 06126608 TX
Tiffany ('hP I 1 Mllrra �1 PrPs _ x 2 104 06 68 F S 01934088 TX
TX
Larry James McVey river 1 j. x 3 01 08 44 !M ] S 03692222 „!
•MIS=Marital status. S=Single M=Married W=Widowed D=Divorced Sep=Separat�
4. DESCRIPTION 8 USE OF VEHICLE(s): This information must be furnished for each motor vehicle to be insured.
YEAR AND MAKE BODY TYPE V.I.N. STATE LIC.PLT.NO. PP CLASSIFICATION
No. ] 1980 Chevrolet Type 1 Ambulance 1 Tnn, CCW33AV157751, TX 385-778
No 2_ 1984 Ford XL Desiel Ambulance, 1FfKF3716F.KA90012 TX 59(I sm.
No. 3 1985 Ford XL Desiel Ambulance, 1FDKF3710PKA75958 TX 591 SCi•
No. 4
No 5
Is vehicle registered in name of applicant?YPS If "No" give name and relationship
NOTE: If application is for commercial vehicles, list the vehicle(s)above, complete and ottuch TAIP 1000 C for ruling purposes
5. Motor vehicle(s)will be principally garaged or kept in: WV
lie Collin Co. 28 Texas
County Territory Stare
If military, give name of base and state
6. Named non-owner policy. Will the occupational, professional, or business duties other than driving to and from work require or involve the use of motor vehicles?
No If"YES"state type of such vehicles .Give named non-owner premium classification .Give name of insurance company
presently insuring vehicle
7. IMPORTANT.Is applicant or spouse required to file or maintain proof of financial responsibility(SR22)with any state? NO If"YES"give the following information
in full Nome Relationship to Applicant
State Requiring SR-22 Give reason for suspension or required filing Dote occurred
T.D.P.S. File Number
8. Is a filing required to comply with(o)Any other state? NO (b)Local ordinance? If"YES"list states and cities requiring such filings,and limits of liability
required by each
9. The applicant's present automobile liability policy on all vehicles listed in Item.4 terminates or will be cancelled on 12-16-8 7 Previous insurance
(Month)(Day)(Year)
camponyTrinity Universal Ins . CA,, ,, ,va. TC 6 13 34 90
IMP 1000-Rev.7-1-86
TX-03-77a. ADDITION, SUBSTITUTION OR ELIMINATION OF AUTOMOBILE
This endorsement forms a part of Policy Na. TC---6133490 ,:sued rd Lifeline Christian Care Ambulance
Inc .
by the Trinity Universal Insurance Company at its Agency
(Name of Insurance Company)
located (city and state) - Dallas-, .Texas. _- _. and is effective from 9-8-87
(12:01 A.M. Standard Time)
(The information above is required only when this endorsement is issued subsequent to preparation of the policy.)
This endorsement forms a part of the policy to which attached, effective from its date of issue unless otherwise stated herein.
This endorsement modifies such insurance as is afforded by the provisions of the policy relating
to the following:
COMPREHENSIVE AUTOMOBILE LIABILITY INSURANCE
BASIC AUTOMOBILE LIABILITY INSURANCE
AUTOMOBILE MEDICAL PAYMENTS INSURANCE
PERSONAL INJURY PROTECTION
UNINSURED/UNDERINSURED MOTORISTS COVERAGE
AUTOMOBILE PHYSICAL DAMAGE INSURANCE (Fleet Automatic)
AUTOMOBILE PHYSICAL DAMAGE INSURANCE (Non-Fleet)
In consideration of ... _Addi t.iena1 premium of $ 1542 it is agreed that as of the effective dote
(Additional—Return)
hereof the policy is hereby amended in the following particulars: _Amending Class on. unit._#1 .to_-7.9.1.3.-
no change in premium
Automobile Added
Division I
To afford insurance with respect to the automobile described in this Division, subject to all the terms of the policy except as
specifically amended herein:
Description of the Automobile and Facts Respecting its Purchase by the Named Insured.
Year of Trade Body Type; Truck Size; Tank Identification Number
Model Name Model Gallonage Capacity;or Bus or Serial Number Cyr;dersber f
Seating Capacity Motor Number
#2 1984 Ford XL pesiel Ambulance 0012 •
#3 1985 Ford XL esiel Ambulance 5958
Any loss under Coverages other than
List Actual Purchased Rating Towing is payable as interest may
Price Cost Symbol appear to the named insured and the
Mo.3 Yr.—New(N); Used(U) Loss Payee named below:
$ $
The automobile will be principally garaged in the Town, County and State shown in the address of the insured in the policy,
unless otherwise stated herein Te.rr;_._.02
The purposes for which the automobile is to be used ore 791-3_ (3.00)-__--_ -_
The following endorsements attached to this policy ore applicable to this endorsement: .-.. .
Division II Automobile Eliminated
To discontinue insurance with respect to the automobile described in this Division;
Year of Trade Name Model Identification Serial Motor
Model Number Number Number
Division III
The insurance afforded for the added automobile is only with respect to such and so many of the following ccvercges as ore
indicated by an additional or return premium or the words '"no charge" in the premium column. The limit of the company's lia-
bility against each such coverage shall be as stated herein, subject to all of the terms of this policy having reference there o:R .586
PREMIUMS
COVERAGES LIMITS OF LIABILITY
2 Annual3 2 Additionel3 Return
$ 20,000 each person
Bodily Injury Liability $ 40,000 each occurrence $621 621;s364 364--F$ _
Property Damage Liability $ 15 ,000 each occurrence 628 628 368 368
Automobile Medical Payments $ each person
Personal Injury Protection $ 2}r500 each person 43 431 25 25
Uninsured/Underinsured Motorists Coverage
Bodily Injury $ 20 ,000 each person
$ 40 ,000 each occurrence 13 13' 8 8
Property Damage . $ 15_2_000 each occurrence 10 16 6 6
Deductible
Comprehensive $ $
ACV
Collision $ Deductible
Fire, Lightning and Transportation •
S
Theft $ —
Windstorm, Hail, Earthquake or Explosion $
Combined Additional Coverage $
Towing $ for each disablement
— i
Special Charge for
as per endorsement attached
Totals $ - $ 1,542 i$
Note: If automobile is eliminated and no automobile is substituted therefor in Division I, return premiums for the automobile
eliminated are to be stated in the premiums column.
By
(Duly Authorized Representative)
FORM TX-03-77o.—ADDITION, SUBSTITUTION OR ELIMINATION OF AUTOMOBILE
Texas Standard Automobile Endorsement 10-27-87 PR/se
Revised August 29. 1977
---� 280 OneI exas Workers' Compensation Assigned Risk Pool
La Costa • 1016 La Posada Drive • Austin. Texas 78752 • (512) 458-9181
APPLICATION FOR INSURANCE F;ie in TRIPLICATE with Pool Manager)
To the above designated Pool: As an employer entitled in good faith to Workers' Compensation Insurance in Texas, the undersigned hereby makes application for such .n-
surance in accordance with the provisions of Article 5.76 of the Insurance Code of Texas. The undersigned recognizes and agrees that such insurance as IS applied for
herewith, is subject to such rates, premium modifications and surcharges as are now or may hereafter be approved by the Texas State Board of Insurance. The under-
signed further agrees that the Producer of Record herein shown acts solely as the agent of the undersigned and is not an agent of or for the Texas Workers' Compensation
Assigned Risk Pool or of the company assigned to issue and service such insurance.
1. The Insurance herewith applied for has been tendered to and rejected, this rejection being a condition precedent to applying to the Pool for Insurance.
Name of rejecting Insurance Company __ Aetna Casualty & Surety en .
Date of rejection 4-6-8 7 — —
2. Applicant's official Trade Name: _ LlIeline Christian Carp AmhnlanrpTne _
Mailing address 5353 Maple, Suite 200, Dallas, Texas 75735_—_—
Telephone Number 6 3 0-0 0 0 8 area code 714 . The street address, city and state where payroll books and records will be maintained for audit is
5353 Maple , Sure 200, Dallas , Texas 75735__—_
3. A. Name of owner if individual —
Is coverage to be provided for the owner? ❑ Yes ❑ No. If Yes, show classification code and remuneration in Item 6 below.
B. Names of partners and percentage ownership of each if partnership_
Is coverage to be provided for the partners? ❑ Yes ❑ No. If yes, give name of each partner to be covered; also, show classification code and remuneration of each
in Item 6 below.
C. Name and title of executive officers, if a corporation and percentage of stock each owns plus the remaining distribution of stock to equal 100% Walt Pr C_
Crocker—III, President 51%;Connie Fleming,
Is coverage to be provided for executive officers? - Y=Pies . S��Tiffany M. Murray-V—Pre,
dyes 0 no. If yes, check appropriate block to indicate basis of coverage desirer5%;Julia Feria ,
I. ❑ Workers' Compensation is elected for all executive officers. Secretary 5%;Joan Rae Murray, Treasurer 0%;
2X0V3Norkers' Compensation is elected for the following executive officers only: 34% of stock unsold
Show names :,rid titles; also, show classification code and remuneration of each in Item 6 below.
Connie S. -.Fleming_ - __Ambul anPP ceryice—=-l+iat Funeral--D-i-r--a.= ____.
Tiff_anx�1__ Murray - Ambulance Service - Not FnnP mor 720
__ ral-Dat.recto 7
r - 7720
D. Name of trustee or administrator if trust or estate ,
NO WORKERS' COMPENSATION ACT COVERAGE WILL BE PROVIDED UNDER THE POLICY FOR INDIVIDUALS, PARTNERS, OR EXECUTIVE OFFICERS UNLESS REQUESTED
ABOVE AND ENDORSED ON POLICY.
4. Location of all factories, shops, yards, buildings, premises or other work places of applicant, by town or city, with street and number
5353 Maple, Suite 200, Dallas , Texas
5. Detailed description of operations and number of employees at each location:
Non—Emergency _Transfer Ambulance Servirp — 5
IF MORE THAN ONE NAMED INSURED OR LOCATION,IDENTIFY CLASSIFICATIONS APPLICABLE TO EACH
6. Code No. Classification of Operations ——
7720 Ambulance Service - Not Funeral No. gyp' Remuneration Rate Est. Premium
Director
5_ ;7 ,2 00. 00 5 . 74 2 ,100 . 00
Insert below name, code and remuneration of each individual OWNER, PARTNER or EXECUTIVE OFFICER to be covered.
7720 Connie S . Fleming
7720 Tiffany M. Murray
.11
Each exposure and each premium item shall be shown to the nearest dollar, counting Loss Constant (if applicable) $$
fifty cents and over as an extra rintlar.
Expense Constant (if applicable) $ 85 . 00
Deposit Premium $_ 2.' 169 . 00___ Minimum Premium $_29 6- 00
7. a. NO U. S. LONGSHOREMEN'S AND HARBOR WORKERS' ACT COVERAGE WILL BE PROVIDED UNDER THE POLICY TUNLESS REQUESTED AND otal Est.Annual Premium$ENDORS D ON POLICY.O
U. S. Longshoremen's and Harbor Workers' Coverage requested. ❑ Yes$XNo. Loading 96
7. b. NO COVERAGE WILL BE PROVIDED FOR EXPOSURES IN OTHER STATES, UNLESS THE ASSIGNED RISK POOL—SPECIAL ALL STATES ENDORSEMENT—TEXAS IS ATTACHED
TO THE POLICY AND THEN ONLY FOR INCIDENTAL EXPOSURES. Assigned Risk Pool—Special All States Endorsement—Texas is requested. ❑ Yes XIX No
8. MINIMUM DEPOSIT PREMIUM REQUIRED: (Not to be less than the MINIMUM PREMIUM.)
100% of Estimated Annual Premium on Risks under $500.00. Interim reporting may be required due to the nature of the risk.
75% of Estimated Annual Premium on Risks between $500.00 and $1,000.00. Semi-Annual reporting usually required.
50% of Estimated Annual Premium on Risks between $1,000.00 and $1,500.00. Quarterly reporting usually required.
25% of Estimated Annual Premium on Risks $1,500.00 and over. Monthly reporting required.
- P 1 :th Rev.) 11.85 (Continued on reverse side)