318-22 Exhibit A-Coronis Health for Emergency Transport Third Party Billing - 2022.pdf

ccount is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Part Il Certification Under penalties of perjury, | certify that: 1. The number shown on this form is my correct taxpayer identification number (or | am waiting for a number to be issued to me}; and 2. 1am not subject to backup withholding because: (a) | am exempt from backup withholding, or (b) | have not been notified by the Internal Revenue Service (IRS) that | am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the [RS has notified me that | am no longer subjact to backup withholding; and 3.1am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (f any) indicating that | am exempt from FATCA reporting is correct. Certification instructions. You must cross aut item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an Individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part Il, later. Sign | signature of Ss of 2am (pps to cecounts malntnd cueldo th US) Requester’s name and address (optional) Print or type. See Specific Instructions on page 3. [Social security number or ‘Employer identification number Bf QI -|LBISIOWN|G Ft Here | us. person General Instructions” oO Bestion references are to the Internal Revenue Code unless otherwise noted. Date > o/s 8/a0aa ‘* Form 1099-DIV (dividends, including those from stocks or mutual funds) Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. Purpose of Form ‘An individual or entity (Form W-9 requester) who is required to fle an Information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security

‘An individual or entity (Form W-9 requester) who is required to fle an Information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (TIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an Information return. Examples of information retums include, but are not limited to, the following. * Form 1099-INT (Interest earned or paid) * Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) * Form 1099-8 (stock or mutual fund sales and certain other transactions by brokers) ‘* Form 1099-S (proceeds from real estate transactions) ‘* Form 1099-K (merchant card and third party network transactions) * Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) * Form 1099-C (canceled debt) ‘* Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. Ifyou do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. No, 10281 Form W-9 (Rev. 10-2018)

PPP Orcs SORA R RT Certification 64860 CERTIFICATE OF EMPLOYEE INFORMATION REPORT ‘This Js to cenify that the ‘contractor ls a Information Report pursuant to NJAC, 17:27-4,1 at. seq. and tho i vad 52 ‘This spproval will remain In 24 gata anen a8! Serena, Meee) am Pyny R oa wt ate " Sarat) 8 et erey tye oS Masta ta A 3 5h 38344

@ = DATE (MMIDDIYYYY) ACORD CERTIFICATE OF LIABILITY INSURANCE ae 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 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). PRODUCER fiaues°” Dan McMullen. Woodruff-Sawyer & Co. oe 617-658-7103 TE One Liberty Square, Suite 600 4alC, to ext, 617-658-7 INE, Not: Boston MA 02109 AbbREss: dmemullen@woodruffsawyer.com INSURER(S) AFFORDING COVERAGE NAIC # insurer A: Hartford Fire Insurance Company 19682 INSURED : Hartford Casual Cc 29424 Coronis Health, LLC INSURER B wa a 7 a insurance ompany a (See Below for Full Named Insured Listing) usurer ¢: Trumbull Insurance Company 5963 Exchange Drive, Suite #114 INSURER D: Sykesville MD 21784 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 2133032501 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. re TYPE OF INSURANCE Rea POLICY NUMBER (HMIODH TY) | (MDB Lams C |X | COMMERCIAL GENERAL LIABILITY Y ‘OB8UUNBB1832 712ai2022 | 7/24/2023 | EacH OCCURRENCE $1,000,000 cuams-mave [X] occur PREMISES (ca cwsurence) | $300,000 |_| MED EXP (Any one person) _| § 10,000 ba PERSONAL & ADVINJURY | $ LIMITED | GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE __| $2,000,000 LX] poucy |_| S807 Loc PRODUCTS - CoMPIOP AGG | § 2,000,000 OTHER: Ss C | AUTOMOBILE LIABILITY ‘08UENBB9182 7124/2022 | 7/24/2023 |

| GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE __| $2,000,000 LX] poucy |_| S807 Loc PRODUCTS - CoMPIOP AGG | § 2,000,000 OTHER: Ss C | AUTOMOBILE LIABILITY ‘08UENBB9182 7124/2022 | 7/24/2023 | GOMBINEDSINGLELIMIT | $7,000,000 (ANY AUTO. BODILY INJURY (Per person) | $ SgHEQULED BODILY INJURY (Per aon] § NON-OWNED PROPERTY DAMAGE AUTOS ONLY (Per ident) ® |X Jumereuauas [XT occur ‘O8XHUBB1412 7242022 | 7124/2023 | EacH OCCURRENCE $5,000,000 EXCESS AB CLAIMS-MADE AGGREGATE $5,000,000 peo | X [RETENTIONS 4 ona ‘A [WORKERS COMPENSATION, vm ‘OBWEAGSB1U 7ieai2o22 | 7124/2023 |X |EERure | [eat ANYPROPRIETORUPARTNERVEXECUTIE aa EL. EACH ACCIDENT $1,000,000 |(Mandatory In NH) E.L, DISEASE - EA EMPLOYEE] § 1,000,000 ELL. DISEASE - POLICY LIMIT | $ 1,000,000 yes, describe under DESCRIPTION OF OPERATIONS bolow DESCRIPTION OF OPERATIONS / LOCATIONS // VEHICLES (ACORD 101, Additional Ramarks Schadulo, may bo attached If more space Is roquired) Additional Named Insureds: CORONIS HEALTH RCM, LLG SUPPORTMED, LLC CORONIS GLOBAL, LLC CRT MEDICAL SYSTEMS, INC. ML. MEDICAL BILLING COMPANY MEDICAL BILLING UNLIMITED, INC. CORONIS GLOBAL, INC. See Attached... CERTIFICATE HOLDER. CANCELLATION ‘SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. HORIZED REPRESENTATIVE = — WX © 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD

FORM BE BUSINESS ENTITY ANNUAL STATEMENT NEW JERSEY ELECTION LAW ENFORCEMENT COMMISSION sae (609) 292-8700 or Toll Free Within NJ 1-888-313-ELEC (3532) THIS FORM MUST BE ELECTRONICALLY FILED AT: wwnw-elec.nj.gov FOR STATE USE ONLY This statement is required to be filed by a business entity which has received $50,000 or more in the aggregate during a calendar year through agreements or contracts with a public entity or public entities. Part 1: General Information Date of Statement December 6, 2021 Activity for Calendar Year 2021 (1 Check if Amendment Part 2: Business Entity Information Business Name © onis Health RCM, LLC Business Type Other Business Organization Address 1 5963 Exchange Drive Address 2 City Sykesville : State Maryland Zip 21784 *(Area Code) Telephone Number ACKNOWLEDGEMENT | have been authorized by the above named business entity to complete the annual statement, and certify that the statements and/or information contained herein are true. | am aware that if any of the statements or information are willfully false, | may be subject to punishment. First Name Vlacl Last Name Busko Title/Position Staff Accountant Date December 6, 2021 Check this box to certify the above acknowledgement. A business entity which has received $50,000 or more in the aggregate during a calendar year through agreements or contracts with a public entity or public entities, but has made no contributions to candidates or committees, shall file the business entity annual disclosure statement with the Commission to report that no contributions were made during the calendar year. Check this box if the business entity has not made any reportable contributions during the calendar year. *Leave this field blank if your telephone number is unlisted. Pursuant to NS.A. 47:14-1.1, an unlisted telephone number is not a public record and must not be provided on this form. New Jersey Election Law Enforcement Commission Page 1 of 1 Form BE Revised Dec, 2020

FORM BE BUSINESS ENTITY ANNUAL STATEMENT NEW JERSEY ELECTION LAW ENFORCEMENT COMMISSION (609) 292-8700 or Toll Free Within NJ 1-888-313-ELEC (3532) THIS FORM MUST BE ELECTRONICALLY FILED AT: www.elec.nj.gov FOR STATE USE ONLY This statement is required to be filed by a business entity which has received $50,000 or more in the aggregate during a calendar year through agreements or contracts with a public entity or public entities. Part 1: General Information Date of Statement December 6, 2021 __ Activity for Calendar Year 2021 LF] CheckifAmendment Part 2: Business Entity Information Business Name Coronis Health RCM, LLC Business Type Other Business Organization Address 1 5963 Exchange Drive Address 2 City Sykesville __ State Maryland _ Zip 21784 *(Area Code) Telephone Number ACKNOWLEDGEMENT | have been authorized by the above named business entity to complete the annual statement, and certify that the statements and/or information contained herein are true. | am aware that if any of the statements or information are willfully false, | may be subject to punishment. First Name Vlad Last Name Busko Title/Position Staff Accountant __ Date December 6, 2021 *(Area Code) Telephone Number 410-753-3358 Check this box to certify the above acknowledgement. A business entity which has received $50,000 or more in the aggregate during a calendar year through agreements or contracts with a public entity or public entities, but has made no contributions to candidates or committees, shall file the business entity annual disclosure statement with the Commission to report that no contributions were made during the calendar year. [x] Check this box if the business entity has not made any reportable contributions during the calendar year. *Leave this field blank if your telephone number is unlisted, Pursuant to NJ1S.A. 47:1-1.1, an unlisted telephone number is not a public record and must not be provided on this form. New Jersey Election Law Enforcement Commission Page 1 of 1 Form BE Revised Dec, 2020

FORM BE BUSINESS ENTITY ANNUAL STATEMENT NEW JERSEY ELECTION LAW ENFORCEMENT COMMISSION (609) 292-8700 or Toll Free Within NJ 1-888-313-ELEC (3532) THIS FORM MUST BE ELECTRONICALLY FILED AT: www.elec.nj.gov FOR STATE USE ONLY This statement is required to be filed by a business entity which has received $50,000 or more in the aggregate during a calendar year through agreements or contracts with a public entity or public entities. Part 1: General Information Date of Statement December 6, 2021 Activity for Calendar Year 2021 [Check if Amendment Part 2: Business Entity Information Business Name Coronis Health RCM, LLC Business Type Other Business Organization Address 1 5963 Exchange Drive Address 2 City Sykesville ___ State Maryland Zip 21784 *(Area Code) Telephone Number ACKNOWLEDGEMENT Ihave been authorized by the above named business entity to complete the annual statement, and certify that the statements and/or information contained herein are true. | am aware that if any of the statements or information are willfully false, | may be subject to punishment. First Name Vlad LastName Busko_ Title/Position Staff Accountant ____ Date December 6, 2021 *(Area Code) Telephone Number 410-753-3353 Check this box to certify the above acknowledgement. A business entity which has received $50,000 or more in the aggregate during a calendar year through agreements or contracts with a public entity or public entities, but has made no contributions to candidates or committees, shall file the business entity annual disclosure statement with the Commission to report that no contributions were made during the calendar year. Check this box if the business entity has not made any reportable contributions during the calendar year. “Leave this field blank if your telephone number is unlisted. Pursuant to NJ.S.A. 47:1A-1.1, an unlisted telephone number is not a public record and must not be provided on this form. New Jersey Election Law Enforcement Commission Page 1 of 1 Form BE Revised Dec, 2020

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TOWNSHIP OF WEST ORANGE BIDDER’S CHECK LIST Mandatory Items ct e¢ Completed Bid Proposal Form L. Business Registration Certification Public Works’ Contractors Certification (if applicable) 20 SL sey Stockholders Disclosure Statement S Cc Affirmative Action Compliance Notice S CC Co 76 SC/ if SE Bid Deposit Surety for Performance Bond (If applicable) Iranian Disclosure Form Acknowledgement of Addenda SL a Township Political Contribution Statement S ¢ Please provide two (2) additional copies of entire bid package, one of which can be on a flash drive. Please review your proposal carefully before submitting. 19