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HomeMy WebLinkAbout2022-117 PO 20190155 AMND #4- Tristar Risk Mngt Purchase Order MA11 ; r n Cr �'COR w Fiscal Year 2019 Page: 1 of: 2 €£=_-p Jift'=3°==_ k--ii<- ) fi=t==E_v.t;o.=gam_ City of Ashland ATTN: Accounts Payable Purchase L 20 E. Main 20190155 Ashland, OR 97520 Order* T Phone: 541/552-2010 - r� O Email: payable@ashland.or.us (� V TRISTAR RISK MANAGEMENT S C/O Human Resources Division E TRM ITF CITY OF ASHLAND H 20 East Main Street N 970 W. 190TH D TORRANCE, CA 90805 P Ashland, OR 97520 Phone: 541/552-2110 O Email: T Fax: 541/488-5311 R TRM.TRUSTACCOUNTING@TRISTARGROUP.NET 0 ��-- (714) 543-0700 Tina Gra _��-_ 08/15/2018 916 FOB ASHLAND OR/NE-T-30 City Accounts__ Payable_ -_ .�3V Purchase Order FrAl. Fiscal Year 2019 LL Page: 2 of: 2 i� i El� l4ty� EE=C iE..` xi _ B City of Ashland _ ,Ti ATTN: Accounts Payable •20 E. Main Purchase 20190155 L Ashland, OR 97520 Order# T Phone: 541/552-2010 - O Email: payable@ashland.or.us TRISTAR RISK MANAGEMENT S E TRM ITF CITY OF ASHLAND H C/O Human Resources Division 970 W. 190TH I 20 East Main Street D TORRANCE, CA 90805 P Ph52520 Phoone:ne: 5411//552-2110 O Email: T Fax: 541/488-5311 R TRM.TRUSTACCOUNTING@TRISTARGROUP.NET 0 ©= `4 (a � L-..77. (714) 543-0700 543-0700 _ _ Tina Gray _ -- — _�— _ .�_=—__ —.�_-. -- - — 41:7=1;1-, _.l-[..-¢� '--I-cam - o�S 2�4iB— Se L_ �:-�.Y�..__—. S � �€€-i �i,. �-i4. -- - 1�3 i?i�a��[-le08/15/2018 916 FOB ASHLAND OR/NET30 City Accounts Payable_, — — .> — ss s,_ - tea; a es��6�^•=_- -.�=._�:: es taa4Paa..ai���«.` �-_ '-=-��n-��+�_-�=��C���iaa7t'�'�'��-��` ee� LSI� 9'��'=#�.gurirmr�l�'-' 9 ADDED: FY 2023 Estimate for ADMIN FEES $25,000 1.0 $0.01 $0.01 Project Account: *************** GL SUMMARY*************** 030022-607140 $365,000.01 030022—607240 $85,000.01 By: Date: M u horiz ignature = =. - $450,000.02 •• FORIVI CITY OF CONTRACT AMENDMENT APPROVAL REQUEST FORM Request for a Change Order Name of Supplier I Contractor I Consultant: TRISTAR RISK MANAGEMENT Total amount of this contract amendment: Purchase Order Number: PO 1120190155 (Amendment approved by City Council April 6,2021) $ See attached m Title I Description: WORKERS'COMPENSATION TPA SERVICES(Claims 030022 607140,Admin Fees 030022 607240) /.0-.a Q Per attached contract amendment Contract Amendment Original contract amount $ 100 %of original contract Total amount of previous contract amendments %of original contract Amount of this contract amendment %of original contract TOTAL AMOUNT OF CONTRACT $ %of original contract In accordance with OAR 137-047-0800:1)The amendment is within the scope of procurement as described in the solicitation documents,Sole Source notice or approval of Special Procurement.2)The amendment is necessary to comply with a change in law that affects performance of the contract.3)The amendment results from renegotiation of the terms and conditions,including the contract price,of a contract and the amendment is advantageous to the City of Ashland,subject to all of the following conditions:a)goods and services to be provided under the amended contract are the same as the goods and services to be provided under the unamended contract b)Th e City determines that,with all things considered,the amended contract is at least as favorable to the City as the unamended contract;c)The amended contract does not have a total term greater than allowed in the solicitation document, contract or approval of a Special Procurement An amendment is not within the scope of the procurement if the City determines that if it had described the changes to be made by the amendment in the procurement documents,it would likely have increased competition or affected award of contract LaQ p-Le / g— .2-/ Contract amendment is within the scope of procurement: YES • NO Ix (If"NO",requires Council approval I Attach copy of CC.) • Sourcing Method: SMALL PROCUREMENT—Not exceeding$5,000 INVITATION TO BID or COOPERATIVE PROCUREMENT,QRF or ❑"YES",the total amount of contract and cumulative REQUEST FOR PROPOSAL EXEMPTION PURSUANT TO AMC 2.50 amendments s$6,000. 0 "YES",the total amount of cumulative amendments 0"YES",the total amount of original contract and ❑If"NO",amount exceeding authority,requires s 25%of original contract amount or$250,000 cumulative amendments s$100K for Goods&Services,s Council approval.Attach copy of Council whichever is less. $75K for Personal Services,<$50K for Attomey Fees. Communication. 0 If"NO",amount exceeding authority requires 0 If"NO",amount exceeding authority requires Council ❑ Exempt—Reason: Council approval.Attach copy of Council approval.Attach copy of Council Communication. PERSONAL SERVICES(Direct Appointment) Communication. 0 Exempt—Reason: ❑ "YES",cumulative amendments s$35,000 0 Exempt—Reason: ❑ If"NO",requires council approval.(Attach CC) INTERMEDIATE PROCUREMENT SOLE SOURCE EMERGENCY PROCUREMENT Goods&Services->$5,000 and<$100,000 0 "YES",the total amount of cumulative amendments 0 Written Findings:Document the nature of the Personal Services->$5,000 and<$75,000 s 25%of original contract amount or$250,000 emergency,nduding necessity and circumstances ❑ "YES",the total amount of cumulative whichever is less. requiring the contract amendment amendments s 25%of original contract amount 0 If"NO",amount exceeding authority requires 0 Obtain direction and written approval from City 0 If"NO",amount exceeding authority requires Council approval.Attach copy of Council Administrator Council approval.Attach copy of Council Communication. 0 If applicable,attach copy of Council Communication Communication. 0 Exempt—Reason: ❑ Exempt—Reason: • ❑ Exempt—Reason: SPECIAL PROCUREMENT INTERGOVERNMENTAL AGREEMENT ❑"YES",the total amount of original contract and cumulative amendments are 0 Renewal Of Intergovernmental Agreement:Terms modified in accordance with initial within the amount and terms initially approved by Council as a Special agreement OR cost will not be more than 25%greater than initial agreement.Renewal Procurement. approved by City Attorney and department head affected by renewal and approved/signed ❑ If"NO",amount exceeding authority requires Council approval. by City Administrator.AMC 2.28.045(B) Attach copy of Council Communication. . 0 'Ma', approval is required.Attach copy of Council Communication Project Number Account Number 0 3 0 0 2 2- 6 0 7 1 4 o Account Number 0 3 9 0 2 2- 6 0 7 2 4 0 "Expenditure must be charged to the appropriate account numbers for the financials to reflect the actual expenditures saaccurately. .AAttach extra pages if needed. Employee Signature: Department Head Signature: .!/v►',a,(LV guar t greater the 54000) City Mana er: (Equal to or greater than$25,000 or 10%) Funds appropriated for cun"ent fiscal year: YE /No /fit,, Finance Director(Equal to or greater than$5,000) Date Comments: Form#10—Contract Amendment Approval Request Form, Request for a Change Order,Page 1 of 1,4/23/2020 • PO # 20190155 Tristar Risk Management Amounts to encumber for FY 2022 Claims $ -751 ,00 Admin Fees $ o"‘/0a Amounts to encumber for FY 2023 Claims $ 7C,000 Admin Fees $ Z / a�0 Signature: 41A400c2bitaAr Date: 41/00/202/ ' ® DATE(MMIDDM Y1t7 A` U . CERTIFICATE OF LIABILITY INSURANCE 5/4/2021 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(les)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 - CONTACT — NAME: Cert Requests Arthur J.Gallagher&Co. PHONE FAX Insurance Brokers of CA, Inc.License#0726293. EmsNo.Ext): - (A/C.No): 505 N.Brand Boulevard,Suite 600 ADDRESS: certrequests@ajg.com Glendale CA 91203 INSURER(S)AFFORDINGCOVERAGE NAIC0 INSURERA:Zurich American Insurance Company 16535 - INSURED TRISINS-03 INSURER B:Great American E&S Insurance Company 37532 - TRISTAR Insurance Group,Inc. 100 Oceangate Avenue,Suite 700 INSURER C:American Zurich Insurance Company 40142 Long Beach,CA 90802 INSURER D:XL Specialty Insurance Company 37885 INSURER E:Endurance American Specialty Ins Co • 41718 INSURER F: COVERAGES CERTIFICATE NUMBER:719193363 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 OFANYCONTRACT 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. ILTRR TYPE OF INSURANCE ' ,NSD SUBR POLICY NUMBER (MOM/DDIIYYYY) (MM DCD/YYYYYYY) _ LIMITS A X COMMERCIAL GENERAL LIABILITY ; Y 'CPO-5543602-08 1/1/2021 1/1/2022 EACH OCCURRENCE $1,000,000 — GE TO RENTED CLAIMS-MADE X OCCUR PRREM SES Ea occurrence) $1,000,000 MED EXP(Any one person) $10,000 _ X Contractual Liab PERSONAL&ADV INJURY $1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY 28i X LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER $ A 1 AUTOMOBILELIABILITY Y CPO-5543602-08 1/1/2021 1/1/2022 COM(Eaaccident)BINEDSINGLELIMIT " $1,000,000 I X 'ANY AUTO - ` BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED y NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY _AUTOS ONLY (Per accident)_ Comp.&Coll Ded. $500 C X UMBRELLALIAB X OCCUR AUC-5543479-08 1/1/2021 1/1/2022 EACH OCCURRENCE $4,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $4,000,000 DED RETENTION$ $ WORKERS COMPENSATION PER OTH AND EMPLOYERS'LIABILITY Y/NSTATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE pi N/A E.L.EACH ACCIDENT $ OFFICER/MEMBEREXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ - D Crime ELU173109-21 1/31/2021 1/31/2022 Aggregate $3,000,000 B Errors&Omissions TER 2861129 1/31/2021 1/31/2022 Aggfegate $3,000,000 E Cyber I PRV30003483200 1/31/2021 1/31/2022 Aggregate $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space la required) City of Ashland is named additional insured under General Liability and Automobile Liability as respects their interest in the operations of the Named Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Ashland• ACCORDANCE WITH THE POLICY PROVISIONS. 90 N.Mountain Ave. Ashland OR 97520 AUTHORIZED REPRESENTATIVE USA PO.,0&1)/1117L-- ©19882015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD a. Your 'Volunteer workers" only while performing duties related to the conduct of your business, or your "employees", other than either your "executive officers" (if you are an organization other than a partnership, joint venture or limited liability company) or your managers (if you are a limited liability company), but only for acts within the scope of their employment by you or while performing duties related to the conduct of your business. However, none of these"employees"or'Volunteer workers"are insureds for: (1) "Bodily injury"or"personal and advertising injury": (a) To you, to your partners or members (if you are a partnership or joint venture), to your.members (if you are a limited liability company),to a co-"employee"while in the course of his or her employment or performing duties related to the conduct of your business, or to your other"volunteer workers"while performing duties related to the conduct of your business; (b) To the spouse, child, parent, brother or sister of that co"employee" or 'Volunteer worker" as a consequence of Paragraph (1)(a) above; (c) For which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in Paragraphs(1)(a) or(b)above; or (d) Arising out of his or her providing or failing to provide professional health care services. However: Paragraphs(1)(a) and (1)(d) do not apply to your"employees" or"volunteer workers", who are not employed by you or volunteering for you as health care professionals, for"bodily injury"arising out of-"Good Samaritan Acts"while the"employee"or'Volunteer worker" is performing duties related to the conduct of your business. "Good Samaritan Acts" means any assistance of a medical nature rendered or provided in an emergency situation for which no remuneration is demanded or received. Paragraphs (1)(a), (b) and (c) do not apply to any "employee" designated as a supervisor or higher in rank, with respect to 'bodily injury" to co-"employees". As used in this provision, "employees" designated as a supervisor or higher in rank means only "employees" who are authorized by you to exercise direct or indirect supervision or control over"employees"or'Volunteer workers"and the manner in which work is performed. ig5<Ad°itiona Section — ' " - • � f.� ott� nnsur-•, �a -npep rgaltiMiCiMaXica.euro a!insure, an .10erson•a?ar°anizatiano easesre.iens a ea. o;' le p,:-musees`vou own or`'manage:VW;0 you a:e ,eguIreo• o a'. as an as ol Iu st• lWri en co veto? •i ` c, ilt,.oii :,onnt_res0ec to la.Ili ar sino ou o ners 10 maintena=ce '°repair iciRkMmt t pjut-mg,wan mozorrt f"r : - ( `( occu®-nc ,Citperson C2oroaniza'ton cjs"%an •:fi e ant a -ssee. rr-11==bninsurarte a or.-B o suc ao o fio a =a 0 o n—ATT lies o:t e ex en @- .t o mom illnot be;0roader than ,ha filch ou are. ;ec Cured" the;writ en Contract:or written:aereemeht to orov d- sue,'aoa itiona-Ills r-®,,ari,o, (43 tgiMMIZIIAID 0ersonyi 1 oroaniza ion-ceases f ro ou WS res®a' e;�= a oroeo° o ap o1 was ns reps i"' ne o=seme :� ..i .ee o=owin o;la.o e o:if (Sec ion im o nsurane fola e '1 ��;10. v; o- i lona;triMMise o aInsura ee Dmiu rep .i 64-wri n con rae mitar ao .eemen I re er-n.-.o;ttn ,klp MUM o pAAL, -Q ov- orsernen . 1 =: vai. e. -p o i e id's of ttliEiNEEMOL9 n T o c aro ions, • +�`�is P erre is ass: .. ._ 11 J rao t, increaseIncrease`Uaao o icao# nsurance s owf alil`tM3 aeoarat ons gi (Kamm fns`u':r—wen ors tai ftutcwina;'c a oe a001-. 111 Goveraoe "a :.roviees . o ou fie °Poor i EEtig b ope faain—Wilifreridaiiiitni3IMIlszcoorno a e o o o erations f,mane U-GL-1330-C CW(04/13) Page 2 of 12 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. • (Section H - Who is An Insured is amended to include as an additional insured any person or organization) ((referred 'to throughout t ih i Paragraph.E. as vendor) who yoiu have agreed;in a wn-en con ract or wri en (agreement, prior't loss, to name at an addi zona insured:tut only with respect to"bodimtu y- or, prope ' amage `arising'ou o our pro•uc s w is are •istn.ute. or so•:in a regu ar course'o e ven•or s: (business) owever _the insurance afforded to such vendor: (On app les to the extent permitted rby law and • • -Mii not be.broader than that which you areerequired_by-the written contract or written agreement,to,provide, (for si.ich vendor.) • (2) (With respect o e insurance a ore to hese vendors,the o lowing additional exclusions apply:) [a (fh insurance a or ed t e ven e or a peen° appy o: ({ o•1 iniury or erode •amage 'for which the vendor is oblige es. o pay •amages ey reason o e a sum. ion o Valli i in a con rac dor a.reemen . is exc union oes no a•of foil-all or •ama•es (#fiat the vendor word have in the absence o3 the contrad or agreement;) ' ()) ( express warrenunau oried by you') (3 j nX p ical or chemicalchange in tie-product made intent nally-by the vendor; ( (Re(3aCblaQings except when unpacked solely for the purpose O inspec ion, lemons ra ion; es ing; or (the subs i u ion o pa s unser ins ruc ions from e menu acturer,an. en.repac'•g-• to e angina) (container: ((5)) n4 _ i ure to ma a suc inspe 'ons,a•lus men s, tes s or servicing as e ven•or as agr--. oma e (or normally undertakes to make in the usual course of business in connection with the distribution or (sale o e pro uct"s ( CDemonstration, installation, servicing or repair operations= except such operaloaf s performed vat the') (vendor's premises in connection with the sale of the product;) ' In Products Which,after distribution or sale by you,have been labeled or relabeled_or used as a container;), art or'in re tic_ olegy other thing'or substance by or for the vendor;52!) ((g ("Boal" mtury or proper damage"arising out of the sole neggigence of the vendor iorits own acts or) (omissions or those of ifs employees or anyone else acting on its behalf. libwever,_this exclusion does.) (not apply to:) (Cly y e• eexceions con ainedin :-u •ara•ra•s 4 or • ,or OFSITth inspec ions, a•1us men s; -sts or servicing as t a yen.or ;as agr--• to ma e or nortna y undertakes a ma e in e usua.,course o •usiness, in connec ion WI e •is nu ion ar sa ice. epro.uc s. = • is insurance •oes not apply to any insure• person or organization, rom w.om you ave'acqure. sue '(produucts, or any ingredient part or container,entering into,accompanying or containing such products.) d (This insurance goes not appy o any o our pro.ucts or w 1c coverage is exc use., un der is -overage) (Part-) t11 respec o e insurance a' or.?•"moo he ven or un a lfiis Paragraph E;`tf e'toilowing is add to'S ti iiolI) ' F[ln insuranoa - (T e mom we vui I pay on betial ;o a yen.or is a amoun o insurance:) aJ'. (Required by the -written contract or Written'agreement referenced iii Subparagraph E,1, above (cif-this) en orsemen ;:or bre. -(Avertable under the app1icablIImL fs ofInsurance shown in th-Deec a.ions)' (whichever is less.) s 'aragrap s a no increase a app ica•a :imi s o ;nsurance s own in a ®ec gra (Additional Insured=Managers,Lessors or Gove rEn U-GL-1330.0 CW(04/13) Page 3 of 12 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. • . in (Section': ,F< o�.s� ., Insuredis amen to iriO U e as an:.:insure. ;any person or_organization_,w,o is a) (manager,jessor.;o"r,goveriimen a:en i w o "ou are require• o`e.• as<an additionarinsured on t.is o`ofi" under a;wri ten'contract, wriften agreeme.ntor permit;but'on with .res" pact IiaSility for''bodi y iC�ifi ry;t'propertar (damage"orersona a' i aavertismq;njury""caused,in who a or in pat t,by.) 0our ao s'or,nmisstons;.or e=acs or omissions o ose ac rri+a'on yd ur bah ;'and &esulting:'_ire _ from:. 0 (Operations:performedTh you or on your be1i`alrfor which the state or DOJO'S@ I subdn Psion 'has issued-a) permit (Owner is p, rnaintenance, occupancy or use of premises by you;or) Q ( in enance, operation or use by you of equipment leased to you by such person or organization.) owever . e_insurance a or•e_�.o sue ,a itiona insure, :. (On app les'"o e ex en permi`e. •y law;and) t) Oil!,not beibroader than that which you are required=by-the written contract or"written agreement to provide) orsuc ee•i lona insure.; �, . , is provision oesA1"1wy`� (Jn_ess a wri ten contract or written agreement has been executed, or, e perms as n issue ,.pnor. o e. :o iy iniury.,frope damage or o ense'' a cause• person. ,an. aver isinq inJury (b) :(16 any person or-Organization ihcluded as ah insured'under Paragraph 3.of'Secti n If '1s Aa lnsureefp Q .(Id any, essor o equipment ifthe"occurrence'r or offense takesplace:after the equipment lease expires '(0).(to any: Hers ar.oer in ares s from Whom land has been teased by you;or) ((2Friagers'or lessors Of premisesLi ((al Theoccu or oerase kap pp acealter the expiration of the lease or.you cease,lo be'a tenant n) :f#Ft premises; CM [he'bodily inlu y,"property damage' or person an- .advertisinginjury`arises Aut.of the structural) alterations,new construction or demolition opera ions=pe orrr .by'or'on 155-aal_foV e manager (less-cif; or) ((c)—The premises are excluded under this Coverage Part. O (With respect folhe insurance`afforded:to thea; i Ionainsure sun er this Paragraph,_ ., ilie'falrowing (s a 6 ,°o ~aeetiona)1-Liimits,OfInsurance (The most}we will pay on behalf of theadditionalinsu'red is t e,amoun o 'insurance€ _ (i-Required by Ihe:written contract or wri en agreemen re erence m : uoparagrap : :.a®ova. o is _ _ .. .. ._ (b.'Available under the'applicable Limifs ansurance s own`,in t e- ciarations) . .. .. .. . Ffi is ;atagra"`phli-F.11•all no increase tl ae ppli' e-Timi s of insurance sIown in;(fie.Declara'tions) G. Damage to Premises Rented or Occupied by You 1. The last paragraph under Paragraph 2. Exclusions of Section I — Coverage A — Bodily Injury And Property Damage Liability is replaced by the following: Exclusions c. through n. do not apply to damage by "speciific perils" to premises while rented to you or temporarily occupied by you with permission of the owner. A separate Damage To Premises Rented To You Limit of Insurance applies to this coverage as described in Section III —Limits Of Insurance. 2. Paragraph 6. of Section III—Limits Of Insurance is replaced by the following: U-CL-1330-C CW(04/13) Page 4of12 Includes copyrighted material of Insurance Services Office,Inc.,with its permission. ACS DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 12/23/2020 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 LIC #63238 - 1-610-941-7751' I CONTACT u NAME: Keystone Risk Partners, LLC PHONE - FAX IA/C.No.Ext): (AIC,No): E-MAIL . 604 E. Baltimore Pike ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Media, PA 19063 INSURERA: ACE AMER INS CO . 22667 INSURED - INSURER B: ACE FIRE UNDERWRITERS INS CO 20702 Tristar Insurance Group • INSURER C: 100 Oceangate INSURERD: Suite 700 INSURERE: Long Beach, CA 90802 INSURERF: - COVERAGES CERTIFICATE NUMBER: 60976252 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. - INSR ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MM/DD/YYYY) (MMIDDIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR \ DAMAGE TO RENTED PREMISES(Ea occurrence) $ MED EXP(Any one person) $ ' PERSONAL 8 ADV INJURY $ — GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ _ _ POLICY PRO- POLICY LOC PRODUCTS-COMP/OPAGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ , . (Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURYPer accident) $ AUTOS ONLY AUTOS • ( HIRED NON-OWNED • PROPERTY DAMAGE r_AUTOS ONLY AUTOS ONLY (Per accident) $ - $ . UMBRELLA LIAB OCCUR • EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WLR C67810612 (AOS) 12/31/20 12/31/21 X STATUTE ERH AND EMPLOYERS'LIABILITY Y I N A ANYPROPRIETOR/PARTNER/EXECUTIVESCF C67810570 FL,MA,OR 12/31/20 12/31/21 EACHACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? nE.L. NIA 12/31/21 1,000,000 B (MandatorylnNH) SCF C67810533 (WI) 12/31/20 E.L.DISEASE $ , If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 1 1 -i DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,AddItIonal Remarks Schedule,may be attached If more space Is required) • CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Ashland THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN • ACCORDANCE WITH THE POLICY PROVISIONS. ATTN: Kari Olson, Purchasing Rep 90 N. Mountain Avenue AUTHORIZED REPRESENTATIVE Ashland, OR 97520 _ • I USA ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD •ljarvis ' 60976252 AMENDMENT FIVE This Amendment Five("Amendment Five"),effective July 1,2021 is incorporated into and made part of that certain Contract for Workers' Compensation TPA Services effective July 1, 2016, by and between TRISTAR Risk Management,Inc.("Consultant")and the City of Ashland("City"). • Conflict Resolution. In the event of a conflict of any kind,be it direct or indirect,between any or all terms of this Amendment Five and those of the Contract for Workers'Compensation TPA Services,including the First Addendum to Contract effective July 1,2016,Amendment One effective July 1,2018,Amendment Two effective July 1,2016,Amendment Three effective July 1 2019,and Amendment Four effective July 1,2020("collectively"Contract"),then the terms and conditions of this Amendment Five shall control. WHEREAS,the Contract covers the July 1,2016 to June 30, 2018 period and up to three(3)additional one(1)year extension periods;and _ WHEREAS,the City and Consultant wish to modify the Additional Terms section of the Contract to allow for an additional two(2)year extension of the Contract;and i WHEREAS,the City and Consultant wish to extend the Contract for the July 1,2021 to June 30,2023 period("Fourth Extension Period")subject to the terms and conditions of this Amendment Five,including the revised fees set forth herein; NOW THEREFORE,in consideration of the covenants and agreements set forth herein and for other good and valuable consideration,the receipt and sufficiency of which are hereby acknowledged, the,City and Consultant hereby agree as follows: 1. City and Consultant have mutually agreed to modify the Additional Termssection of the Contract to allow for an additional two(2)year extension of the Contract. Accordingly,the first full sentence of the Additional Terms section of the Contract which reads: Contract may be extended annually for up to three(3)additional years for a maximum term of five (5)years. 1_ shall be deleted in its entirety and replaced by the following: Contract may be extended for up to five(5)additional years for a maximum term of seven(7)years. 2. City and Consultant have mutually agreed to extend the Contract for the Fourth Extension Period,such extension to be in accordance with the terms and conditions of the Contract and this Amendment Five, including the revised fees set forth herein. 3. The"Per Claim Fees—Newly Reported Claims"table in the Cost Proposal attached to the Contract as Exhibit C is deleted in its entirety and replaced with the following table for the period of July 1,2021 to June 30,2023: • PER CLAIM FEES—NEWLY REPORTED CLAIMS: LIFE OF CONTRACT HANDLING Indemnity—All Other States $1,225:00 Medical Only $180.00 Complex Medical $380.00 Record Only -$35.00 The"Schedule of Preferred Provider Specialty Services"table attached to Amendment Four is deleted • in its entirety and replaced with Schedule of Preferred Provider Specialty Services for the period incepting July 1, 2021 attached hereto as Schedule A, which is incorporated into the Agreement and made part thereof. All other fees remain the same. CmroFAsHuwo:(3-31-21) page 1 • 4. All other terms and conditions of the Contract not modified by this Amendment Five are hereby ratified and affirmed. • CITY AND CONSULTANT CERTIFY BY THEIR UNDERSIGNED AUTHORIZED OFFICERS THAT THEY HAVE READ THIS AMENDMENT FIVE AND AGREE TO BE BOUND BY ITS TERMS AND CONDITIONS. City of Ashland TRISTAR Risk genre I t,Inc. By: By: -" Print Name: , ,„ ,L4jr Print Name: THO ;� EALE Title: Gil Avik,,,,lpr 4 , T...... Title: PR=r" ENT Date: yf�2/ Date: WA-47Z • Cur OF ASHLAND(3-31-21) Page 2 Schedule A Preferred Provider Specialty Services Schedule A is effective July 1,2021 and is subject to change from time to time thereafter without prior notice. These Preferred Provider Specialty Services fees are paid as Allocated Loss Adjustment Expenses or, where required by state law,as loss. :•.:: S?• IERICES SPECIALTSERVICESPEES. •aIECA :':.• .::° • • . .. _•,.,.. MANAGED CARE• MedlCai BIlLRevlew : Provider/Ancillary Bill Review $9 per bill Hospital Bill Review(in and outpatient) 12%of savings Clinical'Nurse Review 27%of savings Implantable Device Review 30%of savings PPO/Pharmacy/DME 27%of Savings(all savings are post fee schedule or U&C) Specialty Bill/Out of Network Review 30%of Savings(all savings are post fee schedule or U&C) e-billing $1 per bill - Historical Bill Review Conversion $2,000 One Time Fee at Implementation Duplicate Bills 1 Duplicate Line Items } No Charge Monthly Savings Reporting J Pre-clinical review $25 per pre-clinical review. Fee waived if case proceeds to utilization review Pre-Certification(In-or Out-Patient and medications) $140 per pre-certification Concurrent Review $125 per hour. (Review during hospitalization or outpatient treatment, as treatment progresses to ensure duration and type of treatment meet appropriate guidelines) Level 1 $275 flat rate for peer review of episodes of care identified' ! (Includes review of medical records and communication of on medical bill review. decision in writing to all parties) Level 2 $295 flat rate when assigned by a nurse case manager (Includes review of medical records,discussion with treating following case manager file review,or receipt of a referral by physician and communication of decision in writing to all .adjuster for review. parties) ;Enhanced Intake and'Nuisivied e Enhanced Telephonic First Notice $25 per intake call(waived if call moves to triage) (Operator service by medical assistants.Injured employee and/or supervisor calls to report claims,assistance with PPO direction,questions and referrals. Optional integration with nurse triage services.) Telephonic Nurse Triage $120 per intake call !j (Nurse aids Injured worker in self-treatment or sets up appointment with appropriate provider utilizing medical triage guidelines/follow up calls) Implementation Fee FNOI or Nurse Triage $1,000(one time) CITY OFAsHnuao(3.31-21) page 3 • rSPECIALTY SERVICES SPECIALTY SERVICES FEES Telephonic Case Management $105 per hour,except the following states: • Alaska and Hawaii $150 per hour • California and New York $125 per hour Field Case Management $105 per hour,with the following state exceptions: • Alaska and Hawaii $150 per hour • California and New York $130 per hour •'plus Mileage at IRS mileage rate Field Case Management-Tasks One time visit to provider $475 plus mileage Two visits to provider $750 plus mileage Medical record retrieval $135 plus mileage Job Analysis . $475 plus mileage Catastrophic Case Management $175 per hour plus mileage (High level of RN interaction with Immediate response • to significant Injury,e.g..severe head injury,severe • burns,gunshot.Available 24x7) :.Pharmacy Clinician Intervention:Complex Pharmacy Management, $125 per hour Weaning Protocols (Available when opioids have been prescribed for 60+days with no evidence that physician will end treatment pattern.) Physician Intervention: Complex Pharmacy Management. $125 per hour nursing intervention plus pass through of (Utilized in instances of numerous drug interactions of actual physician fees opioids,hypnotics and anti-depressants,requiring a physician-to-physician review of treatment pattern and weaning options. Follow up calls made by nurse case manager.) Drug Testing:Full,Quantitative Testing $425 per test with report summary (Candidates may be referred or identified by TRISTAR Managed Care,Inc.(°TMC")based on risk factors such as claim age,high medication use,safety risk,injury type, etc.) Drug Testing Interpretation and Outreach:Complex $125 per hour Pharmacy Management,Weaning (Pharmacist to review and interpret drug testing results. Findings would be communicated to the examiner and, where permitted,to the provider with the goals of ensuring patient safety and reducing fraud,waste,and abuse.) Pharmacist Medication Review: 1-2 medications with full record review and recommendations $450 flat rate 3-6 medications with full record review and recommendations $675 flat rate 7 or more medications with full record review/recommendations $900 flat rate OTHER SERVICES Special Investigations Outsourced,at cost—typically$89-$95 per hour Central Index Bureau/OFAC/CSE $18 per report MSA Cost Projection $2,200 flat rate • Claim Reporting:Fax or Internet $10 per report MMSEA Reporting $10 per claim Mileage IRS allowance rate • • CITY OFASHUWD' (3-31-21) page 4 Kariann Olson From: Tina Gray \ , Sent: Tuesday,May 04,2021 2:54 PM To: Kariann Olson Subject FW:Certificates of Insurance Attachments: City-of-Ashland TRISTAR-Insuran_21-22-GL-AL-XS_5-4-2021 719193363.pdf Thank you, Kariann. I hope this works. Tina Gray,IPMA-SCP Human Resource Director City of Ashland Human Resource Department 20 East Main Street Ashland, OR 97520 Phone:541.552.2101 TTY: 800-735-2900 Fax: 541.488.5311 This email transmission is official business of the City of Ashland,and is subject to the Oregon Public Records Law for disclosure and retention. If you have received this message in error, please contact me at 541.552.2101.Thank you. From: Nancy Henderson<Nancy.Henderson@tristargroup.net> J Sent:Tuesday, May 4,2021 2:34 PM To:Tina Gray<Tina.Gray@ashland.or.us> Subject: RE: Certificates of Insurance [EXTERNAL SENDER] Hi Tina, Sorry for the delay. Attached is the revised Certificate of Insurance. Please let me know if I can further assist. Thank you. Nancy Henderson Executive Assistant TRISTAR Insurance Group Office: 562-495-6600 Ext. 1046 Fax: 562.495.6685 Nancy Henderson a@tristargroup.net . _ . _ From:Tina Gray<Tina.Gray(c�ashland.or.us> .. .._ �.._._..�.....��._ __._.�__,._._,.. Sent:Tuesday, May 4,2021 11:54 AM To: Nancy Henderson<Nancy.Henderson@tristargroup.net> Subject: FW: Certificates of Insurance • CAUTION: This email originated from outside of the TRISTAR network. Do not click links or open attachments unless you recognize the sender and know the content is safe. 1 Council Business Meeting April 6, 2021 Approval of a Two-year Contract Extension with TriStar Risk Management for Agenda Item. Third-Party Administration (TPA) of Workers' Compensation Claims From Tina Gray Human Resource Director Contact Tina.grayaashland.or.us; (541) 552-2101 SUMMARY As concluded by an Actuarial Analysis conducted in 2019,the City has enjoyed long-term savings in our Workers' Compensation program by being self-insured for more than 20 years. However, many changes on the horizon Make being self-insured more of a risk., The City would usually put Third-Party Claims Administration services out for competitive bids. Staff is requesting the City Council, acting as the Local Contract Review Board, approve a two-year extension to the contract with TriStar for Workers' Compensation Third Party Administrative Services for several reasons: • TriStar Risk Management has been our TPA for 10+years;the long-term relationship has helped them better understand our busines , and they provide exceptional service to our injured employees. We have gone out to bid to ensure their rates are competitive. • Moving our business to another TPA is an arduous process that significantly affects employees who have open claims and local medical providers billing for medical services. Changing TPA's requires filing and approval of the State of Oregon. Records retention is a top consideration in transferring older cases electronically, and TPA's must be able to report electronically to Medicare on our behalf. The Third-Party claims administration market has changed due to continued legislation, so many TPA's have merged. The list of TPA's who can service a small account like the City's at a reasonable price has gotten smaller over the past few years. • Senate Bill 801 proposes to require all self-insured employers in Oregon to contract with SAIF to process their claims (SB-801-1) and would create a presumption of compensability for medical conditions secondary to COVID-19 and allow workers 30 years to file a claim(SB- 802-1). Staff is watching legislative changes to Workers' Compensation closely. We don't expect an immediate change, but it is another reason for the City to remain with a trusted provider to ensure a smooth transition if change is mandated. • City-County Insurance (CIS) is partnering with SAIF to provide an affordable workers' compensation choice for public sector employers. We have requested a quote, but an immediate move away from self-insurance is not feasible given the City's fiscal condition. Moving to a fully insured program would require the City to pay insurance premiums under a new program while at the same time funding runout or the "tail" of existing self-insured claims. POLICIES,PLANS & GOALS SUPPORTED City Council 2009-2021 Biennial,Goals: A.Prioritize "Essential Services" E.Analyze various departments/programs to gain efficiencies, reduce costs, and improve City services. Page l of 3 , CITY OF ASHLAND PREVIOUS COUNCIL ACTION On July 19. 2016,the City Council approved the most recent contract with TriStar,which included the option % to extend by mutual agreement. - BACKGROUND AND ADDITIONAL INFORMATION In addition to the risks outline above,we are still seeing COVID-19 costs reverberating through the Workers' Compensation system. For employees exposed to COVID at work,the medical,testing, and mandated quarantine came at a high price under the workers' compensation system. We also see cost increases due to Cancer Presumption. Cancer Presumption dictates that certain cancers for firefighters are presumed to be work-caused,removing barriers to treatment under workers' compensation. The City has remained stable with very few large claims,which is why self-insurance has worked well for many years. However,the entire Workers' Comp System is changing rapidly, and we want to be in the best possible position to evaluate options and make responsible choices at the right time. FISCAL IMPACTS TriStar Risk Management proposes the following fee structure to extend our contract and continue Administering the City's Workers' Compensation claims: CURRENT YEAR 1 "YEAR 2 Per Claim Fee,Indemnity: $1,190 Per Claim Fee,Indemnity: $1,225 Per Claim Fee,Medical Only: $180. Per Claim Fee,Medical Only: $180 Per Claim Fee, Complex Medical: Per Claim Fee,Complex Medical: • $370 $380 Per Claim Fee,Record Only: $35 Per Claim Fee,Record Only: $35 No Fee Increase • Indemnity Claims are claims when a doctor orders the employee off work for three or more workdays, and time-loss benefits become payable. • Medical Only are claims which require a single office visit to resolve_(i.e.,stitches, observation,wound cleaning). • Complex Medical claims require multiple visits and treatment to resolve. (i.e.,repetitive stress injuries, sprains, and strains). • Record only are claims that require no follow-up and serve as a record of injury. The City predicted$75,000 in the budget for Workers' Compensation TPA costs annually. Still, fees vary from year to year based on the number of'claims and can be difficult to predict accurately. We have an excellent Risk and Safety program in place in the City to prevent accidents. The City pays the TPA Administrative fees to evaluate claims and decide compensability according to complex Oregon Workers' Compensation laws. The TPA compensates injured workers with time-loss benefits when eligible and works on the City's behalf to review medical bills for savings. The TPA decides to accept or deny a claim based on medical evidence. The City pays actual claims costs in addition to the Administrative expenses up to certain thresholds where we have excess insurance to protect from significant losses. STAFF RECOMMENDATION Staff is recommending that we extend our contract with TriStar Risk Management for a period of up to three years. A two-year extension would allow for legislative changes to take shape and provide the City additional time to review options and plan financially for the future of our Workers' Compensation program while continuing to work with one of the best TPA's on the west coast. When the decision to change is clear,we will only have to make the change once rather than move our business multiple times. Page 2 of 3 CITY OF ASHLAND 2) ACTIONS, OPTIONS & POTENTIAL.MOTIONS 1) I move that City Council, acting as the Local Contract Review Board, approve a two-year extension to the contract with TriStar for Workers' Compensation Third Party Administrative Services. 2) I move to delay the approval of a two-year contract extension for TPA Services and request that staff return with other options. REFERENCES & ATTACHMENTS Attachment 1: Most recent contract and Amendment outlining the terms of service (The TriStar Corporate Office will produce an Amendment for final signature upon approval) Attachment 2: Workers' Compensation Analysis conducted by Bickmore Actuarial Attachment 3: Excess Policy Binder Page 3 of 3 CITY OF ASHLAND :�