Wisconsin In-Network Transportation Provider Checklist

iv)Provider warrants that it has not been excluded from participation inFederal health care programs under either Section 1128 or 1128A of theSocial Security Act.j) Insurance. Provider shall maintain the following minimum levels of insurancethroughout the term of the Agreement. All insurance coverage, except Workers’Compensation, shall name LGTC and the Client as “Additional Insured” and shallbe primary with respect to claims and co-insurance determinations. Insurancepolicies shall indicate that LGTC will be informed in writing prior to anytermination of or change in insurance coverage. Concurrently with executing thisAgreement the Provider shall submit to LGTC certificates of insurance from itsagent or carrier listing LGTC as “Certificate Holder” as well as LGTC and theClient as “Additional Insured. Provider shall submit additional certificates ofinsurance from its agent or carrier immediately upon the renewal of or change tosuch insurance coverage. The Certificate of Insurance submitted to LGTC shallconfirm that the Comprehensive General Liability policy provides coverage forsexual abuse and molestation and does not exclude professional misconduct, andshall confirm that the Vehicle Insurance policy provides coverage for either “AnyAuto” (symbol 1), or for “All Owned Autos,” “Hired Autos,” and “Non-ownedAutos” (symbols 2, 8 & 9), and does not exclude coverage for loading/unloadingaccidents. The Certificate of Insurance shall also include the Provider’s businessdescription as it appears on the policy declaration page. Provider agrees thatLGTC may communicate directly with its insurance agent or carrier to confirmdetails or obtain clarification of Provider’s insurance coverage or policy terms.(i) Vehicle Insurance.Taxis, Sedans and Multi-Passenger Vans and Wheelchair Vans: Therequired amount of insurance is the greater of the amount required by cityor county ordinance for taxis or $500,000 per occurrence per accident.Ambulances: The required amount of insurance is the greater of theamount required by city, county or State ordinance or regulation, or$500,000 per occurrence per accident.(ii)(iii)Comprehensive General Liability Coverage. $500,000, with “BroadForm” coverage including contractual liabilities as well as liabilities forsexual abuse and molestation.Workers’ Compensation Insurance as required by the State of Wisconsin.k) Indemnification. Provider shall indemnify, protect, and hold LGTC and theClient harmless from and against any and all claims, and/or liabilities of any kindor nature whatsoever arising or alleged to arise from or related to actionsconnected with services provided by or at the direction of Provider or its agents,including the cost of reasonable attorney fees and other expenses incurred by orWisconsin NET ProgramVersion: March 25 2011Page 17