HomeMy WebLinkAbout2011-181 Contract - Tristar Risk Mgmt Contract for Workers' Compensation TPA Services
CITY O F CONSULTANT: Tristar Risk Management
ASHLAND CONTACT: Jeff Stromberg, Director Sales & Client Services
20 East Main Street
Ashland, Oregon 97520 ADDRESS: 1 Lincoln, 10300 SW Greenburg Road, Suite 265,
Telephone: 541/488-6002 Portland, Oregon 97223
Fax: 541/488-5311
TELEPHONE: 503-245-7592, Ext. 3429
DATE AGREEMENT PREPARED: 01/06/2011 FAX: 714-245-4714
BEGINNING DATE: March 1, 2011 COMPLETION DATE: February 28, 2012
COMPENSATION: Per attached fee schedule included in Consultant's proposal and attached as Exhibit A.
SERVICES TO BE PROVIDED: Workers' Compensation Third Party Administrative Services as outlined in the
original RFP and the Consultant's proposal.
ADDITIONAL TERMS: The initial one year contract includes the option of two one-year extensions for a
maximum term of three 3 ears.
— FIND=ING
Pursuant to AMC 2.52.040E and AMC 2.52.060, after reasonable inquiry and evaluation, the undersigned Department
Head finds and determines that: (1) the services to be acquired are personal services; (2) the City does not have
adequate personnel nor resources to perform the services; (3) the statement of work represents the department's plan for
utilization of such personal services; (4) the undersigned consultant has specialized experience, education, training and
capability sufficient to perform the quality, quantity and type of work requested in the scope of work within the time and
financial constraints provided; (5) the consultant's proposal will best serve the needs of the City; and (6) the
compensation negotiated herein is fair and reasonable.
NOW THEREFORE, in consideration of the mutual covenants contained herein the CITY AND CONSULTANT AGREE as
follows:
1. Findings/Recitations. The findings and recitations set forth above are true and correct and are incorporated herein
by this reference.
2. All Costs by Consultant: Consultant shall, at its own risk and expense, perform the personal services described
above and, unless otherwise specified, furnish all labor, equipment and materials required for the proper performance
of such service.
3. Qualified Work: Consultant has represented, and by entering into this contract now represents, that all personnel
assigned to the work required under this contract are fully qualified to perform the service to which they will be
assigned in a skilled and worker-like manner and, if required to be registered, licensed or bonded by the State of
Oregon, are so registered, licensed and bonded.
4. Completion Date: Consultant shall start performing the service under this contract by the beginning date indicated
above and complete the service by the completion date indicated above.
5. Compensation: City shall pay Consultant for service performed, including costs and expenses, the sum specified
above. Payments shall be made within 30 days of the date of the invoice. Should the contract be prematurely
terminated, payments will be made for work completed and accepted to date of termination.
6. Ownership of Documents: All documents prepared by Consultant pursuant to this contract shall be the property of
City.
7. Statutory Requirements: ORS 279C.505, 279C.515, 279C.520 and 279C.530 are made part of this contract.
8. Living Wage Requirements: If the amount of this contract is$18,703 or more, Consultant is required to comply with
chapter 3.12 of the Ashland Municipal Code by paying a living wage, as defined in this chapter, to all employees
performing work under this contract and to any Subcontractor who performs 50% or more of the service work under
this contract. Consultant is also required to post the notice attached hereto as Exhibit B predominantly in areas where
it will be seen by all employees.
9. Indemnification: Consultant agrees to defend, indemnify and save City, its officers, employees and agents Harmless
from any and all losses, claims, actions, costs, expenses,judgments, subrogations, or other damages resulting from
injury to any person (including injury resulting in death), or damage (including loss or destruction)to property, of
whatsoever nature arising out of or incident to the performance of this contract by Consultant(including but not
limited to, Consultant's employees, agents, and others designated by Consultant to perform work or services
attendant to this contract). Consultant shall not be held responsible for any losses, expenses, claims, subrogations,
actions, costs,judgments, or other damages, directly, solely, and proximately caused by the negligence of City.
10. Termination:
a. Mutual Consent. This contract may be terminated at any time by mutual consent of both parties.
b. Ci 's Convenience. This contract may be terminated at any time by City upon 30 da s' notice in writing
Contract for Personal Services,Revised 07/28/2010,Page 1 of 5
ana delivered by certlned mail or In person.
"c. For Cause. City may terminate or modify this contract, in whole or in part, effective upon delivery of
written notice to Consultant, or at such later date as may be established by City under any of the following
conditions:
i. If City funding from federal, state, county or other sources is not obtained and continued at levels
sufficient to allow for the purchase of the indicated quantity of services;
ii. If federal or state regulations or guidelines are modified, changed, or interpreted in such a way
that the services are no longer allowable or appropriate for purchase under this contract or are
no longer eligible for the funding proposed for payments authorized by this contract; or
iii. If any license or certificate required by law or regulation to be held by Consultant to provide the
services,required by.this contract is for any reason denied, revoked, suspended, or not renewed.
d.. For Default or Breach.
i. Either City or Consultant may terminate this contract in the event of a breach of the contract by
the other. Prior to such termination the party seeking termination shall give to the other party
written notice of the breach and intent to terminate. If the parry committing the breach has not
entirely cured the breach within 15 days of the date of the notice, or within such other period as
the party giving the notice may authorize or require, then the contract may be terminated at any
time thereafter by a written notice of termination by the party giving notice.
ii. Time is of the essence for Consultant's performance of each and every obligation and duty under
this contract. City by written notice to Consultant of default or breach may at any time terminate
the whole or any part of this contract if Consultant fails to provide services called for by this
contract within the time specified herein or in any extension thereof.
i'rr—Th€rights-arrd-rem�di€s�f>rtyvi�J€d7�hiubsecfion d re no xcusve�n rein
addition to any other rights and remedies provided by law or under this contract.
e. Obligation/Liability of Parties. Termination or modification of this contract pursuant to subsections a, b, or
c above shall be without prejudice to any obligations or liabilities of either party already accrued prior to such
termination or modification. However, upon receiving a notice of termination (regardless whether such notice is
given pursuant to subsections a, b, c or d of this section, Consultant shall immediately cease all activities under
this contract, unless expressly directed otherwise by City in the notice of termination. Further, upon termination,
Consultant shall deliver to City all contract documents, information, works-in-progress and other property that are
or would be deliverables had the contract been completed. City shall pay Consultant for work performed prior to
the termination date if such work was performed in accordance with the Contract.
11. Independent Contractor Status: Consultant is an independent contractor and not an employee of the City.
Consultant shall have the complete responsibility for the performance of this contract. Consultant shall provide
workers'compensation coverage as required in ORS Ch 656 for all persons employed to perform work pursuant to
this contract. Consultant is a subject employer that will comply with ORS 656.017.
12. Assignment and Subcontracts: Consultant shall not assign this contract or subcontract any portion of the work
without the written consent of City. Any attempted assignment or subcontract without written consent of City shall be
void. Consultant shall be fully responsible for the acts or omissions of any assigns or Subcontractors and of all
persons employed by them, and the approval by City of any assignment or subcontract shall not create any
contractual relation between the assignee or subcontractor and City.
13. Default. The Consultant shall be in default of this agreement if Consultant: commits any material breach or default
of any covenant, warranty, certification, or obligation it owes under the Contract; its QRF status pursuant to the QRF
Rules or loses any license, certificate or certification that is required to perform the Services or to qualify as a QRF if
consultant has qualified as a QRF for this agreement; institutes an action for relief in bankruptcy or has instituted
against it an action for insolvency; makes a general assignment for the benefit of creditors; or ceases doing business
on a regular basis of the type identified in its obligations under the Contract; or attempts to assign rights in, or
delegate duties under, the Contract.
14. Insurance. Consultant shall at its own expense provide the following insurance:
a. Worker's Compensation insurance in compliance with ORS 656.017, which requires subject employers to I
provide Oregon workers' compensation coverage for all their subject workers
b. Professional Liability insurance with a combined single limit, or the.equivalent, of not less than Enter one:
$200,000, $500,000, $1,000,000, $2,000,000 or Not Applicable for each claim, incident or occurrence. This is to
cover damages caused by error, omission or negligent acts related to the professional services to be provided
under this contract.
C. General Liability insurance with a combined single limit, or the equivalent, of not less than Enter one:
$200,000, $500,000, $1,000,000, $2,000,000 or Not Applicable for each occurrence for Bodily Injury and Property
Damage. It shall include contractual liability coverage for the indemnity provided under this contract.
d. Automobile Liability insurance with a combined single limit, or the equivalent, of not less than Enter one:
$200,000, $500,000, $1,000,000, or Not Applicable for each accident for Bodily Injury and Property Damage,
including coverage for owned, hired or non-owned vehicles, as applicable.
e. Notice of cancellation or change. There shall be no cancellation, material change, reduction of limits or
intent not to renew the insurance coverage(s)without 30 days'written notice from the Consultant or its insurer(s)to
the City.
f. Additional Insured/Certificates of Insurance. Consultant shall name The City of Ashland, Oregon, and its
Contract for Personal Services,Revised 07128/2010,Page 2 of 5.
elected officials, officers and employees as Additional Insureds on any insurance policies regwrea nerein our only
Nth respect to Consultant's services to be provided under this Contract.The consultant's insurance is primary and
non-contributory. As evidence of the insurance coverages required by this Contract, the Consultant shall furnish
acceptable insurance certificates prior to commencing work under this contract. The certificate will specify all of
the parties who are Additional Insureds. Insuring companies or entities are subject to the City's acceptance. If
requested, complete copies of insurance policies; trust agreements, etc. shall be provided to the City. The
Consultant shall be financially responsible for all pertinent deductibles, self-insured retentions and/or self- .
insurance.
15. Governing Law; Jurisdiction; Venue: This contract shall be governed and construed in accordance with the laws
of the State of Oregon without resort to any jurisdiction's conflict of laws, rules or doctrines. Any claim, action, suit or
proceeding (collectively, "the claim") between the City(and/or any other or department of the State of Oregon) and
the Consultant that arises from or relates to this contract shall be brought and conducted solely and exclusively within
the Circuit Court of Jackson County for the State of Oregon. If, however, the claim must be brought in a federal
forum, then it shall be brought and conducted solely and exclusively within the United States District Court for the
District of Oregon filed in Jackson County, Oregon. Consultant, by the signature herein of its authorized
representative, hereby consents to the in personam jurisdiction of said courts. In no event shall this section be
construed as a waiver by City of any form of defense or immunity, based on the Eleventh Amendment to the United
States Constitution, or otherwise, from any claim or from the jurisdiction.
16. THIS CONTRACT AND ATTACHED EXHIBITS CONSTITUTE THE ENTIRE AGREEMENT BETWEEN THE
PARTIES. NO WAIVER, CONSENT, MODIFICATION OR CHANGE OF TERMS OF THIS CONTRACT SHALL
BIND EITHER PARTY UNLESS IN WRITING AND SIGNED BY BOTH PARTIES. SUCH WAIVER, CONSENT,
MODIFICATION OR CHANGE, IF MADE, SHALL BE EFFECTIVE ONLY IN THE SPECIFIC INSTANCE AND FOR
IVEN. i KERE-ARE`N'O-M ERS MUngGS,—kG _ —
REPRESENTATIONS, ORAL OR WRITTEN, NOT SPECIFIED HEREIN REGARDING THIS CONTRACT.
CONSULTANT, BY SIGNATURE OF ITS AUTHORIZED REPRESENTATIVE, HEREBY ACKNOWLEDGES THAT
HE/SHE HAS READ THIS CONTRACT, UNDERSTANDS IT,AND AGREES TO BE BOUND BY ITS TERMS AND
CONDITIONS.
17. Nonappropriations Clause. Funds Available and Authorized: City has sufficient funds currently available and
authorized for expenditure to finance the costs of this contract within the City's fiscal year budget. Consultant
understands and agrees that City's payment of amounts under this contract attributable to work performed after the
last day of the current fiscal year is contingent on City appropriations, or other expenditure authority sufficient to allow
City in the exercise-of its reasonable administrative discretion, to continue to make payments under this contract. In
the event City has insufficient appropriations, limitations or other expenditure authority, City may terminate this
contract without penalty or liability to City, effective upon the delivery of written notice to Consultant, with no further
liability to Consultant.
Certification. Consultant shall sign the certification attached hereto as Exhibit A and herein incorporated by reference.
Consultant: City of Ashland
B j By 09
By Si 9 nCap,
bra Department Head
L
fIOmcs
Print Name Print Name
�r CiC1r'r� -1y/zey/
Title Date
Note: W-9 is to be submitted with signed contract.
Approve as to form
ro
p A Q_Qa
Legal impartment Date
Purchase Order No.
Contract for Personal Services,Revised 07/28/2010,Page 3 of 5
EYJ:UBIT A
CERTIFICATIONS/REPRESEN'T'ATIONS: Contractor, under penalty of perjury, certifies that(a)the number
shown on the attached W-9 form is its correct taxpayer ID (or is waiting for the number to be issued to it and
(b) Contractor is not subject to backup withholding because (i) it is exempt from backup withholding or(ii) it has
not been notified by the Internal Revenue Service (IRS)that it is subject to backup withholding as a result of a
failure to report all interest or dividends, or(iii)the IRS has notified it that it is no longer subject to backup
withholding. Contractor further represents and warrants to City that(a) it has the power and authority to enter into
and perform the work, (b)the Contract, when executed and delivered, shall be a valid and binding obligation of
Contractor enforceable in accordance with its terms, (c)the work under the Contract shall be performed in
accordance with the highest professional standards, and(d) Contractor is qualified,professionally competent and
duly licensed to perform the work. Contractor also certifies under penalty of perjury that its business is not in
violation of any Oregon tax laws, and it is a corporation authorized to act on behalf of the entity designated above
and authorized to do business in Oregon or is an independent Contractor as defined in the contract documents, and
has checked four or more of the following criteria:
(1)I carry out the labor or services at a location separate from my residence or is in a specific portion of
my residence, set aside as the location of the business.
ice)-Gommereial-aduertising-or-business-cards-or aFtrade=association=membership=are=putehased--fnj--
business.
(3) Telephone listing is used for the business separate from the personal residence listing.
(4) Labor or services are performed only pursuant to written contracts.
(5) Labor or services are performed for two or more different persons within a period of one year.
(6) I assume financial responsibility for defective workmanship or for service not provided as
evidenced by the ownership of performance bonds, warranties, errors and omission insurance or
liability insurance relating,to the labor or services to be provided.
Contractor (Date)
Contract for Personal Services,Revised 07/28/2010,Page 4 of 5
Response to Request for Proposal � P�'
Workers Compensation Third Party Administration Services Mr,
Fee Schedule
Provide a detailed breakdown of costs to perform the services described in this RFP,
including but not limited to:
i
1. Indemnity claims
$950 per Indemnity Claim
2.Medical only claims
$150 per Medical Only Claim
r
3—Complex.medicaL-clai
$150 per Complex Medical Only Claim
4.Annual administration fees
No Administration Fee
5. AnnuaLRAUS fees
$500 per;W&
6.Data conversion/tiaiisfer.fees
$2,000 One-Time ConVe—rsion F.ee
7.Fee for assuming claims manageinent respomsibility foriclaims incurred prior
to January 31,2010
No Charge for Assumption of Claims
S. Fee for managing claims after expiration of contract
$250 Per Year for Open Indemnity Claims. No Charge for Open Medical Only Claims.
9.Fee for MMSEA reporting,etc.
The fee for all services related to query and reporting is a one-time fee per claim of
$7.85 which includes any on-going reporting as long as TRISTAR is handling the
claims.
T R 0 STA R December 9, 2010
RISK MANA®EMENT Page 62
Response to Request for Proposal
Workers Compensation Third Party Administration Services �r
10.Fee for State annual Report of Losses,Legal Expenses Paid, and Federal LS513
and LS-274 reports, etc.
No Charge
Note: Fees proposed must cover the cost of handling to conclusion all claims
incurred or reopened during the contract period.
Provide a detailed breakdown of costs associated with photographs,tapes used for
statements, appraisals, and any other anticipated ancillary expense,including but not
limited to:
1. Costs for services requiring billing on a time and expense basis,including
AllocatQd—expenses_as_descdbed—above=ar.e_bllled—at==—approved=rates �tsmtreetF
vendors. TRISTAR does not supply these s2rVic2s in-house.
2. hourly billing rates of individuals performing%the task
Not Applicable
3. Cost associated with RAUS,if•any, such as the cost of placing terminals in the City's
offices,liue:or time charges
TRISTAR's system:i§;accessible through thdInterrief and as such, we do not anticipate
any hardware!requiremenfs.
4. Wire transfer, banking:or:other aecount.charges
i
The following bankft g�opiiohs forfundi'i claim payments are varied and adaptable to
individual client pte`ference;+rangingfioffluIly.automaticallytreconciled trust accounts to
client maintaineil:andze o''balance<account..!Full recon"cilia ion includes the transfer of
all payment Aa616iik—eee'banlc'in'electr6f ii format. The banking option decision is made
between TRISTAfi acid the City rep resentatiGe,�setting up the account, addressing specific
client needs.
Options available to the City for payment methods to TRISTAR for trust account
replenishments include, but are not limited to,the following:
1. Wire Transfer-funds are wired by the City to their trust account.
2. ACH Transfer - TRISTAR transfers funds via our bank's automated banking service
from the City's account to the trust account,weekly or monthly.
TRISTAR can set up escrow or imprest account on behalf of the City. Generally, these
,AvT R 0 STAR December 9, 2010
RI5K MANAGEMENT Page 63
Response to Request for Proposal W
Workers Compensation Third Party Administration Services IVr
accounts require a deposit from the City of 2.5 times the average monthly claims
payments. This deposit may be less if the City can replenish the account in a short
period of time using ACH or wire transfer. TRISTAR will make payments from this
account and invoice the City monthly to replenish the funds to maintain the deposit
amount agreed upon. TRISTAR may request a pre-fund for any large losses to avoid
depleting the account and to maintain adequate funding for a lower deposit. TRISTAR
will manage and reconcile the checking account for the City. The City does not incur any
charges for checks or banking charges for this type of account.
Alternatively, a zero balance checking account can maximize funds in interest bearing
accounts for the City. TRISTAR would be .a signatory on the account established and
managed by the City. Funds are transferred nightly from the interest-bearing account
into the checking account to cover the thecks that cleared that day. There ma be
ch—ec -printing charges for this type of account depending on the bank the City uses.
Under this scenario, the bank statements ai'`eisent from the bank directly to the City for
monthly reconciliation.
TRISTAR has also developed several interfaces ;with different banks for positive pay
procedures,which also help reduce-or eliminateicheck fraud.
Over 95% of TRISTAR's,self=insured-dients:hade�iinpfest:aecounts with-Citizen's Business
Bank. It is helpfui, and critical, that we 'haWin`te naI1financial 'processes in place to
1 rc6An'--o"_
provide our custome"rs'wif fisextensive�financiahcontrols•and-efficiencies that are created
with EDI interfaces. We spend thousands rofedoll`ars every year for the development of
interfaces that extend-many:key.banking features to ourdc`-lients:
Benefits include, b'dvaee not limited:to:
• Direct on-line access to the account
• Positive pay'inte'rface -daily downloads of checks issued.from TRISTAR claim system
to Citizen's.
• Same day courier services for check deposits
• ACH capabilities for our clients which alloW for electronic transfer of funds at minimal
cost compared to "wire transfers"
• Industry only electronic and manual check clearing process
These controls are a key to our compliance with SAS 70 Type II Standards and financial
audit performance.
TRISTAR requires Positive Pay in order to keep the client's funds secure per SAS 70 Type
II protocol. In addition to CBB, TRISTAR has positive pay interfaces with a number of
banks including Wells Fargo, Bank of America, Northern Trust, Comerica, California Bank
and Trust, U.S. Bank, and Union Bank of California.
T R O STA R December 9, 2010
Risti MIANAMEMENT Page 64
Response to Request for Proposal
Workers Compensation Third Party Administration Services
Should the City choose a bank other than CBB or other approved TRISTAR banks, an
additional fee may be charged for interface set up and positive pay features.
5. Cost of indexing claimants and injured workers
Indexing is charged at$6.50 and is an allocated expense against the claim file(s).
i
6. Cost of subrosa/surveillance work
This allocated expense is billed at approved rates by outsourced vendors. TRISTAR does
not supply these services in-house.
7. Cost to maintain/store files
TRISTAR does not charge their clients for st6 Page of files.
8. Cost of program transition and implementation
TRISTAR does not charge�forprogram transitiiii' nd implementation other than the one-
time data conversion fee.
9. Costs for in.Ments.(ze'ro value.clainis)
There is no change'-forlhousing1ncid6hf 6nnlydateJfAflie City,eiiters such claims into the
system via on line,access 'Iffthe Gity would Tike TRISTAR to enter such claims there
would be a 6harget6'f}$35:per•iii6iddnt:
10. Costs for onsite visits'by your staff
No Charge if in-personiclairf reviews areaimited to two,.(2) per year at the City and two
(2) per year at the TRISTAR service location:
If three in-person claim reviews are required gat the City 'during a program year, the
charge would be $750. This fee is charged to'cover travel expenses for the examiner and
account manager to attend.
If four in-person claim reviews are required at the City during a program year,the charge
would be $1,500. This fee is charged to cover travel expenses for the examiner and
account manager to attend.
11.Any charges for account executive/coordinator
No Charge
T R 0 STAR December 9, 2010
RISK MANAGEMENT Page 65
Response to Request for Proposal
Workers Compensation Third Party Administration Services VIA
12.Any additional charges not specifically commented on above or elsewhere in
this proposal.
TRISTAR Bill Review Services
Flat Fee Per Bill $8.50 for all fee schedule review/reductions on all medical
billings
PPO 25%of savings beyond fee schedule
Nurse Case Management $95 per hour
Field Case Management $105 per hour
Utilization Review $95 per hour
t�methortoiogy-forextensiosaf�ates in subsequen con ac years.
TRISTAR utilizes the following methodology for subsequent year increases:
Per Claim Rates
CPI increase for the client aiiomiciled area or 43? ?o whichever is greater. Subject to
i
negotiation resulting'frodi,unai
Page 1 1
CIT i RtCORDER /
V CITY OF
ASHLAND DATE .� �� - PO NUMBER .'
,J 20 E MAIN ST. 7/29/2011 10358
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
Ouariti . , Unit � �"'
_, Description Unit Price.; Ext.Price
Third Party Administration of Workers' 30,000.00
Compensation Claims for FY 2012
Estimate $30,000
Contract for Workers' Comp TPA Services
Beginning date: March 1, 2011
Completion date: February 28,•2012
Insurance required/On file
SUBTOTAL 30 000.00
BILL TO:Account Payable TAX 0.00
20 EAST MAIN ST FREIGHT 0.00
541-552-2028 TOTALI 30,000.00
ASHLAND, OR 97520
:Account Number ..'Project Number ,_ -Amount. " Account Number,,.i-,4 `;:Project Number ' Amount. '.
E 720.03.00.00.60714 30 000.00 y
Aye-
Authori Slgnatu VENDOR COPY -
F0 RM #3 CITY OF
A request for a Purchase Order ASHLAND
REQUISITION Date of request: 7 "27
Required date for delivery:
Vendor Name 791,5 8 L 9t6K V AAM&EM611LT
Address,City,State,Zip 51
Contact Name&Telephone Number (05�fN4 - 1 � 94!951_W� (r.3J)ZVS_79q�
Fax Number —fj
SOLICITATION PROCESS
❑ Exempt from Competitive Bidding ❑ Emergency
❑ Written Findings(Form attached) ❑ Invitation to Bid (Copies on file) ❑ Written findings attached
❑ Quote or Proposal attached Date approved by Council: ❑ Quote or Proposal attached
❑ Small Procurement Cooperative Procurement
Less than$5.000 Request for Proposal (Copies on Ole) ❑ State of Oregon
Note:Total contract amount,including any Date approved by Council: Contract#
amendments may not exceed$6,000 ❑ State of Washington
Intermediate Procurement ❑ Sole Source Contract#
GOODS&SERVICES ❑ Written Findings(Form attached) ❑ Other government agency contract
$5,000 to$100,000 ❑ Quote or Proposal attached Agency
❑ (3)Written quotes attached Contract#
PERSONAL SERVICES ❑ Special Procurement ❑ Intergovernmental Agreement
$5,000 to$75.000 ❑ Written Findings(Form attached) Agency
❑ Less than$35,000,by direct appointment ❑ Quote or Proposal attached ' Contract#
❑ (3)Written proposals attached Date approved by Council: Date approved by Council:
Description of SERVICES Total Cost
Ti+r2� Per/ �ornrN�srn�T�cr� oF was' Co�rivs47W 5
Item# Quantity Unit Description of MATERIALS Unit Price Total Cost
"��,sTOT1►L�COSTty�;�'
❑ Per attached QUOTE
Elk
� x}t
Project Number______-___ Account Number___-__-__-__-______ Account Number___•__-__- -______
Account Number -__-_ • • _____ Account Number /20 L QI_:O_- (07/10
'Expenditure must be charged to the appropriate account numbers for the financials to reflect the actual expenditures accurately. Attach extra pages if needed.
By signing this requisition form,I certify that the information provided above meets the City's public contracting requirements,Othe documentation can be provided
upon request. "WAV(OX2
Employee Signature: Department Head Signatur
Additional signatures(if applicable):
Funds appropriated for current fiscal year YES% NO ;z,.
Finance Director Date
Comments.,
G:FinancelPnxxdurelAPTomislForm#3-Requisition(3).doc Updated on:72612011