HomeMy WebLinkAbout2012-216 CONT Addendum 1 - Tristar Risk Mgmt ,.-, .
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TR5TAR
RISK MANAGEMENT
March 28, 2012
Tina Gray
City of Ashland`
Human Resource Department
20 East Main Street
Ashland, OR 97520
4
Re: First Amendment to Agreement
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Dear Ms. Gray, z
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Please find enclosed k`one (1) fully executed First Amendment to Contract for Worker
Compensation TPA Services between the City of Ashland and TRISTAR Risk Management for
your files. d
Should you have any questions regarding this Agreement, please feel free to contact us at the
number listed below.
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Sincerely,
Nancy Henderson a
Administration F�
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Enclosures L
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100 Oceangate, Suite 700 • Long Beach, CA 90802 t -
(562) 495-6600 • (562) 432-8619 fax ~ ' 1
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FIRST AMENDMENT'ro CONTRACT FOR WORKERS' CONiPE'NSATION
TPA SERVICES
Cio- of Ashland
Effective March 1, 2012
This amendment is effective March I. 2012 between Citv of Ashland and Tristar Risk
Management, to amend the contract effecti%e March I,2011 between the two parties.
TERIM- Per request of the City of Ashland, the term of the Contract is extended to
provide services from March 1,2012 to February 28, 2013.
Fees- Per the terms of the original contract, the fees for claim administration are
increased by 3.5% to $983.25 1'or Indemnity claims and S 1 55.25 for medical only claims.
All other fees remain the same.
AGREED:
CONSGLTANT: CCTV OF ASHLAND
TRISTAR RISK MANAGEMENT
By: BY:
Thomas 1. Veal— -- - - - — Print name
Pasiilen[ f'a"t-uc%- S��'z6can'2-'
------`Title ------
Page 1 / 1
CITY OF
ASHLAND DATE PO NUMBER
20 E MAIN ST. 9/12/2012 11169
ASHLAND,OR 97520 '
(541)488-5300
VENDOR: 015885 SHIP TO: City Of Ashland :1'
TRISTAR RISK MANAGEMENT, CITIZENS BUSINE (541)488-6002
TRM 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
Quanh ._ ' .Unit t .'.`. • ..r � .-. -, .Descri"lion � � n. —.Unit Price .,'•. EzfEPricez,.:,,_
Workers' Compensation TPA Services 30,000.00' .
Estimate for FY 2013 -$30,000
Contract Addendum - Extended the
contract to February 28, 2013
Note: Contract may be extended for one
additional year.
,A
SUBTOTALI 30 000.00
BILL TO:Account Payable TAX 0.00
20 EAST MAIN ST FREIGHT 0.00
541-552-2010 TOTAL 30,000.00
ASHLAND, OR 97520
Acco'unt�Number '' .-- °P,r'oject Number_ ,Amount - Account Number ' ., Project..Numtie� '� , Amount ,'
E 720.03.00.00.60714 30 000.00
Authorized Signature VENDOR COPY
FORM #3 CITY OF
A revuest;or a Purch.ase 0sder ASHLAND
REQUISITION Date of request:
Required date for delivery:
Vendor Name T/Zl67ri9/z Q/S,e iyfA/l�i9CrLID�l7
Address,City,State,Zip /Q e
Contact Name&Telephone Number
Fax Number 166 q-3 2,-91,19
SOURCING METHOD
❑ Exempt from Competitive Bidding ❑ Emergency
❑ Reason for exemption: ❑ Invitation to Bid (Copies on file) ❑ Form#13,Witten.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$5.000eguest for Proposal (Copies on file) El State of Oregon
❑ Direct Award ate approved by Council: Contract#
❑ VerbalMritten quote(s)or proposal(s) ❑ 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 attached ❑ Form#4, Personal Services$5K to$75K Contract#
PERSONAL SERVICES ❑ Special Procurement Intergovernmental Agreement
$5.000 to$75.000 ❑ Form#9,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 attached Date approved by Council: (Date)
❑ Form#4, Personal Services$5K to$75K Valid until: Date
Demos/c�r�ip,ttio/n��off S(E�R�VIC�ESS -raj � [ Total Cost
�3, Yf1t
�f
2sfir {� FY N13
Item # Quantity unit Description of MATERIALS unit Price Total Cost
i
TOTALCOST
❑ Per attached quotelproposal g
l
Project Number______-___ Account Number___-__-__- -
Account Number -_--__- -______ 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:
ITDirector Date Support-Yes/No
By signing this requisifiiform,I certify that the City's public contracting require ants Lave satin ed.
Employee Signature: epartment Head Signature:
(Equal too reater than$5,000)
Additional signatures(if applicable):
1
Funds appropriated for current fiscal year. YES / NO I i 6
Financ Director-(Equal to orgreaterthan$5,000) Date
Comments:.
Form#3-Requisition