HomeMy WebLinkAbout2013-284 CONT Addendum 2 - Tristar Risk Mgmt
SECOND AiMENDMEN TO CONTRACT FOR WORK P"RS' COi'VIPENSATION
`CPA SERVICES
Citti• of Ashland
]affective March 1, 2013
This amendment is cffective March 1. 2013 between City of Ashland and Tristar Risk
Management, to amend the contract effective March 1. 2011 bern"een the fxvo parties.
TERM- Per request of the City of Ashland, the term of the Contract is extended to
provide services Tram March 1; 2013 to February 23, 2014.
Fees- Per the terms of the original,contract, the Pees for claim administration are
increased by 3.5% to 51,017.66 for Indmnnity claims and S160.68 for medical only
claims. All other fees remain the same.
AGREED:
CONSULTANT: CPCY OFASIILAND
TRISTAR RISK 41ANAG1'si~ll%NT
By: - 13v: G~o~ tr"
v,_-\ "L.f-~,• ~ttNE41E~G _
Thomas.L.Veallt Print name
President ~fi~kAcE U~~~Eeusiz
-Title
Page 1 / 1
CITY OF
ASHLAND DATE PO NUMBER
20 E MAIN ST. 8/9/2013 11803
ASHLAND, OR 97520
(541) 488-5300
VENDOR: 015885 SHIP TO: City of Ashland
TRISTAR RISK MANAGEMENT, CITIZENS BUSINE (541) 488-6002
TRIM ITF CITY OF ASHLAND 20 E MAIN STREET
970 W. 190TH ASHLAND, OR 97520
TORRANCE, CA 90805
FOB Point: Req. No.:
Terms: Net Dept.:
Req. Del. Date: Contact: Tina Gray
Special Inst: Confirming? NO
Quantity Uriit Descri tion - Unit Price Ext. Price
Third Party Claims Administration for 200,000.00
Workers' Compensation
Contract Addendum
Completion date: February 28, 2014
SUBTOTAL 200 000.00
BILL TO: Account Payable _ TAX 0.00
20 EAST MAIN ST FREIGHT 0.00
541-552-2010 TOTAL 200,000.00
ASHLAND, OR 97520
Account Number Project Number Amount_ Account Number , Project Number - Amount
E 720.03.00.00.60714 200 000.00
i u-c~ ~ 1/rte. UL° ~ to vt.F/
Authors d Signature VENDORCOPY
,F0 RM#3 CITY OF
A request fo a Purchase Order ASHLAND
REQUISITION Date of request: EEL
Required date for delivery:
Vendor Name TP-f-STA , 4($~ ?Aly'A/7-7, l1T
Address, City, State, zip °170 W I'Y- Cr -A AI, "07
Contact Name & Telephone Number /N ~ ~ /11 71 ~ 3 a~`j~~ 1Z'?
Fax Number
SOURCING METHOD
❑ Exempt from Competitive Bidding ❑ Emergency
❑ Reason for exemption: ❑ Invitation to Bid (Copies on file) ❑ Form #13, Written findings and Authorization
❑ AMC 2.50 Date approved by Council: ❑ Written quote or proposal attached
❑ Written quote or proposal attached
❑ Small Procurement Cooperative Procurement
Less than $5,000 Request for Proposal (Copies on file) ❑ State of Oregon
❑ Direct Award Date a proved by Counc'I; Contract #
❑ Verbal/Written quote(s) or proposal(s) Mtf `I . 1` elel ❑ State of Washington
Intermediate Procurement ❑ Sole Source Contract #
GOODS & SERVICES ❑ Applicable Form (#5,6, 7 or 8) ❑ Other government agency contract
$5,000 to $100.000 ❑ Written quote or proposal attached Agency
❑ (3) Written quotes and solicitation attached ❑ Form #4, Personal Services $5K to $75K Contract #
PERSONAL SERVICES ❑ Special Procurement Intergovernmental Agreement
$5,000 to $75,000 ❑ Form #g, Request for Approval ❑ Agency
❑ Less than $35,000, by direct appointment ❑ Written quote or proposal attached Date original contract approved by Council:
❑ (3) Written proposals/written solicitation Dale approved by Council: (Dale)
❑ Form #4, Personal Services $5K to $75K Valid until: Date
Description of SERVICES Total Cost
'3, Fey t 3
#A 4 .2 S f. it a
Item # Quantity Unit Description of MATERIALS Unit Price Total Cost'
?ITOTAL<CO itl,'7
❑ Per attached quotelproposal $
Project Number Account Numberw~Lt•~~-~~{~~-(t~~/~O _••,s`
AccountNumber-__-__- Account Number
*Expenditure must be charged to the appropriate account numbers for the financials to accurately reflect the actual expenditures.
IT Director in collaboration with department to approve all hardware and software purchases:
IT Director Date Support -Yes/No
By ninng'thii~s requi'sirp form,II certify that the City's public contracting requirements have been satisfied.
Employee Signature: 4i1#l ~4/-`I" Department Head Signature:
reater tl ~n $5,000)
_ City Administrator:
(Equal to or greater than $25,000)
Funds appropriated for current fiscal year: YE / NO ~LJIIAJ kv ( L
q ce Director- (Equal to orgmater then $5,000) Date
Comments:
Form #3 - Requisition