HomeMy WebLinkAbout2011-027 Contract - Tristar Risk Management
,
,
Contract for Workers' Com ensation TPA Services
CITY OF
ASHLAND
20 East Main Street
Ashland, Oregon 97520
Telephone: 541/488-6002
Fax: 541/488-5311
CONSULTANT: Tristar Risk Management
CONTACT: Jeff Stromberg, Director Sales & Client Services
ADDRESS: 1 Lincoln, 10300 SW Greenburg Road, Suite 265,
Portland, Oregon 97223
TELEPHONE: 503-245-7592, Ex!, 3429
DATE AGREEMENT PREPARED: 01/06/2011 FAX: 714-245-4714
BEGINNING DATE: March 1, 2011 COMPLETION DATE: Februa 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
ori inal RFP and the Consultant's ro osal.
ADDITIONAL TERMS: The initial one year contract includes the option of two one-year extensions for a
maximum term of three 3 ears,
FINDINGS:
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-iike 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, c.osts, 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, Cit 's Convenience, This contract ma be terminated at an time b Ci u on 30 da s' notice in writin
Contract for Personal Services, Revised 07/28/20 I 0, Page I of 5
c!nd delivered by certified 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 aliowable 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 party 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,
iii. The rights and remedies of City provided in this subsection (d) are not exclusive and are in
addition to any other rights and remedies provided by law or under this contract.
e, Obliaation/Liabilitv 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, cor 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 Comoensation insurance in compliance with ORS 656,017, which requires subject employers to
provide Oregon workers' compensation coverage for all their subject workers
b, Professional Liabilitv 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 Appiicable 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 Liabilitv 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 Liabilitv 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 chanae, 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 Citv of Ashland, Oreoon, and its
Contract for Personal Services, Revised 07/2812010, Page 2 of5
" elected officials, officers and employees as Additional Insureds on any insurance policies required herein but only
With 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
THE SPECIFIC PURPOSE GIVEN, THERE ARE NO UNDERSTANDINGS, AGREEMENTS, OR
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
contractwithout penalty or liability to City, effective upon the delivery of written notice to Consultant, with no further
liability to Consultant.
Certification, Consultant shall si n the certification attached hereto as Exhibit A and herein incor orated b reference,
onsultant: City of Ashland
By
By
-&f/. c:J- . (] 7
Department Head
Print Name
_7((,;A~-" l-
Title
..-
U--L / ...I'IMbLc.
Print Name
-z-./'I/2-011
, Date
Note: W-9 is'to be submitted with signed contract.
Approved as to form:
\.~'r\- ~)
Date U
Purchase Order No.
,/ t9',C? r 7
Contract for Personal Services, Revised 07/28/2010, Page 3 of 5
EXHIBIT A
CERTIFICATIONS/REPRESENTATIONS: 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:
(I) 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,
(2) Commercial advertising or business cards or a trade association membership are purchased for the
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
//;z::>~/
(Date)
Contract for Personai Services, Revised 07/28/2010, Page 4 of 5
Response to Request for Proposal
Workers Compensation Third Party Administration Services
'.'
6~.b'c-~ 4-
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Fee Schedule
Provide a detailed breakdown of costs to perform the services described in this RFP,
including but not limited to:
1. Indemnity claims
$950 per Indemnity Claim
2. Medical only claims
$150 per Medical Only Claim
3. Complex medical claims
""'\;':'~0'
$150 per Complex Medical Oilly!GI<iim
",~...,....\/:t'!",-
~" ," '-. .
4. Annual administration fel\s:- "
"-'. -.-',-
~~)~'''~~~;:;::~;-':'::jirf:':: .
'~ '~\" j'::~":(~~'-;~'
No Administrationf;,ee
. '-:,~' . h. ,Co.' ~"~
5. Ailnn'aIIRMIS,fees:','
:; ~,:~~t%1~~~~'~l~&ilil"~':;:: <..""
$500'p~!JJ,~;,} ,
~ -J- 'j'" ,~.... .
,., , ,
l~'
'-'):
')'.1:'
-, .;".....:;:::,<-
"}o, ,Mr",
'"":'-"i",'~~~io;\ "
;,.'.:;" . ;~.>, 't:
"J!'~
8. Fee for mari'ii~ing claim~ after expiration of ~il't;~ct
f;r ~~
$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
$7,85 which includes anyon-going reporting as long as TRISTAR is handling the
claims,
* J:B~ ~~A~~E~
December 9, 2010
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,'. Response to Request for Proposal
Workers Compensation Third Party Administration Services
rAl
10. Fee for State annual Report of Losses, Legal Expenses Paid, and Federal LS513
and LS-274 reports, etc.
No Charge
Note: Fees proposed ,must cover the cost of handling to conclusion all claims
incurred or reo ened durin the contract eriod.
Provide a detailed breakdown of costs associated with photographs, tapes used for
statements, appraisals, and any other anticipated ancillary expense, including but not
limited to:
1. Costs for services requiring billing on a time and expense basis, including
Allocated expenses as des:~,~~d aboveZ.\IJ.~'~~il~ed at approved rates by outsourced
vendors. TRISTAR does not ~l!l?ply these'~,e.fII!.!~$!s In-house,
.,-,'y....' ",,::."',<:,-"<'
Not Applicable
,
- ~ .
. ,":' ",.~_.~},;..., ':':" '~ . , .::" -,+J; ~"'. ,',' "'_ , ' :' "
3. C,ost,associated ll;it~J\M.~~,':!f'~!!y, ~ucbas the C?st ?fpliicing termil!lIlsin the City's
offices, IirieortiW~!!I;..Il~):;g~s' "" ,{..:", '.'
" _ , ' . '~;':-': -;:.~~.,~~:" .~~-;'~.:_ " , , _' _:'_: ::": '''), ':,~:i':'-t>'!_,.;~,:
TRIS'f'AR;Sl\YS~~;~f..!\~!~itliro!Jill~~~%~I~~J~PCl'3S'S~th, we do not anticipate
any hardwateir,eg'iJirements:."" ' ,'.:".i::;:'?~., .,', '
'. :." ~'~l.':~~]\~lf~~:.,;~,;'::" ",' _ " ':',,':'<S:;....".~~.-\!:V~:f':
4. Wire transfe~,b'adl'til-l}"Oj;~'tIih,ifCCOun't!(!tr~rges \,
t,:: ~~:r~~~~ti~ i~;,-::,: ---:' :. ,,' :::,', _:~;t~~;:'> \ ,_ '.':':;_;'
The following ~~pking O'p.t~~~f~f{tqnai~~ Glaim payii\~~~~~.re varied and adaptable to'
individual c1ie~refer.enGenr~Ji.ging~fr.om fUlly!automa'f~,econciled trust accounts to
client maintainea ana zer.o ~'ar~~a'GGount, F.ull recoiiGiliati5n includes the transfer of
all paymentl1i~ta'tb tli,e l5ank'J~,~li!tt~oniG for.mat. The ~ option decision is made
between T~is~'WiW~ijthe;6ity represe~atiYH~,Wng up t~~punt, 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
* "!:B~ !=A"!"~E~
December 9, 2010
Page 63
" Response to Request for Proposal
Workers Compensation Third Party Administration Services
rA1
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,~ signatory on the account established and
managed by the City, Funds are transferrili nightly from the interest-bearing account
into the checking account to ;cover the ,~~~~ks that cleared that day. There may be
check-printing charges for t~l~'type of <!~iiW~t depending on the bank the City uses,
Under this scenario, the bank:statementS\~~~ent from the bank directly to the City for
monthly reconciliation, '
,> "
TRISTAR has also deve!qp'l,!E1!~f;!veral interf~~s~~,ith different banks for positive pay
procedures, whichalsc:l,~~!~'*ed,IlGeiOr eliminf.~~c;~ fraud,
, . . ' ~ -~:p'-".'!.' ,
O.,~.e"",r,,'!:l~,%, o;o,:"'"",f,,,.lF, .~".~.,','.~,!, ~~,,,,t,~r'-,,,~~, ~L,e,,~~~s.have i,mP.'f'e'St iThq:(Ofi:s ~1lP'fditizen.' s Business
<Ba,I)~.,!~j~Sdi!!~~~~fg~'l~~~twe Ii~ve Internal fiJla~~~lIfr~cesses In place to
p~ovlg~i19,~:9~~}g~rsl""'~~~~,~~~;nanclal controls a~ificlencles that are created
with ED',~tE!i7f~,9~",~"!;,L",w.,,,' e,"'s, p,,~n,,~\tn,p,.,' ,~s,"', ,~[1", 11, s" O~,lIoll~rs e,'{,.*~,~,l&~ear for the development of
interfaces thatre~~,gIQ;li1I),~'gYJoa~~fi1.l!~,*~~yres tOJ~~ients:
i,.' :1'-',' :',:)i'~',:;~:L :,L;:~"" . ,~', ';~' ,;:'; ~-~::.:" L1;',:':-: ;;,:\'",
Benefits includ~ill)ut are notlirnJ!.e<i!\tW.~';"':., \":,,~?:
· Direct on-116:~{{.e1L~~,~91~~f6tW(v:~'~4;;,,;, \fj~~'-.
· Positive P~Yli.\tt~,ilt.'Mje'c~a,~i!t1lbl'YI!!9.~~c[!checks i~I;!..~1from TRISTAR claim system
to Citizen\ '",:/" ' <<,;,., , > .
. Same da'Y;C::9Y~~~!-\Ser~i<;esfor cheak'~~'~ifs; , ,'..
· ACH caR~liintjl!s for"qur clients which '~.pr electronic'fr~bsfer of funds at minimal
cost corripar~d to ";";;ire transfers" ; ;:;',,' '
· IndustrY only electronic and manual check c1ellfl!lg process
These controls are a key to our compliance with SAS 70 Tvpe 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.
* J:B~ ~=A~~E~
December 9, 2010
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Response to Request for Proposal
Workers Compensation Third Party Administration Services
rtl1
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).
6. Cost of subrosalsurveillance 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
8.
9,
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
* Jar: ~=A~~E~
December 9,2010
Page 65
Response to Request for Proposal
Workers Compensation Third Party Administration Services
r.t. ,
,I
I
:
12. Any additional charges not specifically commented on above or elsewhere in
this proposal.
TRISTAR Bill Review Services
Flat Fee Per Bill
PPO
Nurse Case Management
Field Case Management
is greater. Subject to
.~.,
* J:B~ ~=A~~E~
December 9, 2010
Page 66
~
ACORD" CERTIFICA TE OF LIABILITY INSURANCE I DATE {MMfDDIYYYY)
~ 01/26/2011
PRODUCER 1-818-539-2300 THIS CERTIFICATE IS ISSUED AS A MA TIER OF INFORMATION
Arthur J. Gallagher &. Co. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Insurance Brokers of California, Inc. License #0726293 HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
505 North Brand Boulevard, Suite 600 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Glendale, CA 91203-3944 INSURERS AFFORDING COVERAGE
818-539-2300 NAIC#
INSURED INSURER A:. PEDERAL INS CO 20281
TRISTAR Insurance Group, Inc.
INSURER B: HARTFORD UNDERWRITERS INS CO 30104
100 Oceangate Avenue, Suite 700 INSURER c: NATIONAL UNION FIRE INS CO OF PITTS 19445
Long Beach, CA 90802 INSURER 0: Chartis Snecialtv Insurance Comnanv 26883
I INSURER E: TRAVELERS CAS &. SURETY CO 10n,.
COVERAGES
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 BYTHE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I,N~~ r.,~~',L ~O, POLICY NUMBER I rfP}JCY EFFECTIVE POLICY EXPIRATION LIMITS
A ~NERAL LIABILITY 35848060 01/01/11 01/01/12 EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAl L1ABILlTY P~C~~J9E~~~~nce $ 1,000,000
I CLAIMS MADE [!] OCCUR MED EXP (Anyone person) $10,000
r-"- Incl. Contractual Li~ PERSONAL & ADV INJURY $ 1,000,000
I- GENERAl AGGREGATE $ 2,000,000
n'L AGG~nE LIMIT AP~S PER: PRODUCTS - COMP/OP AGG $ Inc 1 . Above
POLlCY ~~g: X LOC
B ~TOMOBILE LIABILITY 72UECKR9463 01/01/11 01/01/12 COMBINED SINGLE LIMIT
$ 1,000,000
i-"-- ANY AUTO (Eaaccidenl)
C- ALL OWNED AUTOS BODILY INJURY
(Per person) ,
C- SCHEDULED AUTOS
I- HIRED AUTOS BODILY INJURY
S
NON-oWNED AUTOS (Pereccidenl)
c-
c- PROPERTY DAMAGE ,
(Per accident)
RRAGE LIABILITY AUTO ONLY. EA ACCIDENT ,
ANY AUTO OTHER THAN EA ACC S
AUTO ONLY: AGG ,
C 8ESS / UMBRELLA L1ABILllY BE015832676 01/01/11 01/01/12 EACH OCCURRENCE $ 5,000,000
X OCCUR 0 CLAIMS MADE AGGREGATE $ 5,000,000
,
R DEDUCTIBLE ,
RETENTION , ,
WORKERS COMPENSATION I WCSi:UN~ I IOJ~-
AND EMPLOYERS' LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE D E.L. EACH ACCIDENT ,
OFFICERlMEMBER EXCLUDED?
(Mandatory In NH) E.L. DISEASE - EA EMPLOYE ,
If yes, describe under
SPECIAL PROVISIONS below E.L DISEASE - POLICY LIMIT $
OTHER
D Errors &. Omissions 014232708 01/01/11 01/01/12 Aggregate 10,000,000
E Crime 104864721 01/01/11 01/01/12 Aggregate: 5,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
City of Ashland is named additional insured under General Liability as respects their interest in the operations of
the Named Insured.
nAdditinnAl InAured hv Andorsemen~ MRO-02-2367 Rrl. 8-04n
CERTIFICATE HOLDER
USA
CANCELLATION *10 da notice for non- a ent of remium
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES B E CAN CELL EO B EFQRE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE 4,~ If.
City of Ashland
Attn: Kari Olson
90 N. Mountain Ave.
Ashland, OR 97520
ACORD 25 (2009/01) niccart
19498366
@1988.2009ACORDCORPORATION, All rights reserved,
The ACORD name and logo are registered marks of ACORD
Liability Insurance
EndorsemfJnt
Policy Number
3584-8D-611VUC
Insured
TRISTARINSURANCEOROUP
Neme of Compeny
FEDERALJNSURANCECOMPANY
"".......~~.~
~
~
=
--~
This Blldorsementapptics to the following forms:
GENERALLIABILlTY
- "'_""l,]:l:T"~
Who Is An Insured
Schedu/edPersonOr '
Organization
=.-
L1abRity fnsura1lce
Form 8o-02-23tJ7(Rev. 8-04)
=\i;;..!;l.L.;;e..."~"\li:""'"
-~_.
~
Under Who IsAn Insured, the following provision is added:
. Subject to all ofthe ternlS and condltlons afthis insurance, any person or organlzationahown in tho.
Schedule, acting pursuant to a written contract or agreement between you and snch person or
organization. is an insured; but they are fnsnredsol11ywithrespect to liabilityariswg outofyour
opelallons, or your premises, if you are obligated, pursuant to suoh C0111ract or agreement. to provide
them with such insurance as is afforded by this policy.
. '.Howeveri no such person or. organization is an,Jns\lred with respect to any:
assumptiollof liability by them in a contract or agreement. This limitation does not apply to
the liability for damages for injury or damage, to which this insurance appHes, that the person
or organization would have in the absence of such contract or agreement.
damages arising out of their sole negligence.
"~!'"".a.z:
-="--"~':"-~~
..~~-
Schedule
PERSONS OR ORGANlZATIONSTHATYOU AREOBLlGATED,PURSUANTTO
WRIITENCONTRACTORAGREBMBNTBETIVEBNYOU AND SUCHPERSON
OR ORGANlZATlON,TO PROVIDB WITH SUCHINSURANCEAS IS
APFORDEDBYTIlISPOLlCY; BUTTHEY ARE INSUREDS ONLY
IF AND TO THEMINlMUMEXTENTTHA T SUCH CONTRACTOR AOREEMENT
REQUillESTHEPBRSONOR ORGANlZATIONTO BE AFFORDED
STATUS AS AN INSURED.
HOWEVER,NO PERSON OR OROANlZATIONIS ANJNSUREDUNDER THIS
PROVISIONWHO IS MORBSPECIFlCALL YDESCRffiEDUNDERANY OTHER
Endorsement
continued
Paget
Liability Endorsement
(continued)
LlabU/ty Insurance
Form 80-02-2367(Rev. 8-04)
PROVlSIONOF THE WHO IS AN INSURED SECTION OF THrS POLICY
(RBGARDLESSOF ANY LIMlTATIONAPPLTCABLETHERETO).
All other tenns and conditions remain unchunged.
Authorized ReprosentarIva
I2w-lL4r
/
Endolsement
(
fast page
Page 2
~
ACORD'" CERTIFICATE OF LIABILITY INSURANCE I DATE (MMIOOIYYYY)
~' 01/26/2011
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 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 LIe #63238 1-610-941-7751 CONTACT
NAME:
Keystone Risk Partners, LLC I r.tl.~~N,,7... !:vil. I r..e~ No';
100 Front Street E-MAil
ADDRESS:
Suite 275 PRODUCE~ In.,
Conshohocken, PA 19428
INSURERfSJ AFFORDING COVERAGE HAle.
INSURED INSURER A : Mitsui Sumitomo Insurance Group
Tristar Insurance Group INSURER B :
100 Oceangate INSURER C :
Suite 700 INSURER D :
Long Beach, CA 90802
INSURER E :
INSURER F :
COVERAGES
CERTIFICATE NUMBER: 1949'019
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 TYPE OF INSURANCE ~~;= f:3Mg~ ~g~~~ UMITS
LTR POLlCY NUMBER
GENERAL UASIUTY EACH OCCURRENCE S
- ~~~~~~J9E~~~~,?ence
COMMERCiAl GENERAL LIABILITY S
I CLAIMS-MADE D OCCUR MED EXP (Anyone person) S
f-- PERSONAl & ADV INJURY S
f-- GENERAL AGGREGATE S
rl'L AGG~EnE FLlMIT APFlSIPER: PRODUCTS-COMPfOPAGG S
POLICY ~~g LOC S
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S
f-- (Essccident)
c- ANY AUTO
BODILY INJURY (Per person) S
f- ALL OWNED AUTOS BODILY INJURY (Per accident)
S
f-- SCHEDULED AUTOS PROPERTY DAMAGE
HIRED AUTOS (Peraccidenl) S
f--
NON-OWNED AUTOS S
f--
S
UMBRELLA LIAB H OCCUR EACH OCCURRENCE S
c-
EXCESS LIAB CLAIMS-MADE AGGREGATE S
- DEDUCTIBLE S
RETENTION S S
A WORKERS COMPENSATION WCP9109929; WCP9109930 12/31/1 12/31/11 X I WC STATU-: I IOJb'-
AND EMPLOYERS' LIABILITY ""
ANY PROPRIETORIPARTNERlEXECUTIVE D E.L. EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? "fA
(MandatorylnNH) E.L. DISEASE - EA EMPLOYE $ 1,000,000
~~;~~i~fr3~ O~~PERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (A~ch ACORD 101, Additional Remarks Schedule, If more spaee i. required)
CERTIFICATE HOLDER
CANCELLATION
City of Ashland SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCelLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
ATTN: Kari Olson, Purchasing Rep
90 N. Mountain Avenue
AUTHORIZEO REPRESENTATIVE
Ashland, OR 97520 \-;~
, USA
ljarvis
ACORD 25 (2009/09)
19498019
@1988-2009ACORDCORPORATION, All rights reserved,
The ACORD name and logo are registered marks of ACORD
>,
CITY RECORDER
Page 1/1
r~'
CITY OF
ASHLAND
20 E MAIN ST,
ASHLAND, OR 97520
(541) 488-5300
lii:r:.:Di. i' DA ~E:,-~;~~T)f:.j A~~pbjNl!JMBER~~M
2/10/2011 10017
VENDOR: 015853
TRISTAR RISK MANAGEMENT
PO BOX 513869
SHIP TO: City of Ashland
(541) 488-6002
20 E MAIN STREET
ASHLAND, OR 97520
FOB Point:
Terms: Net
Req, Del. Date:
Speciallnst:
Req, No,:
Dept.:
Contact: Tina Gray
Confirming? No
,: :QuantitY:tY ~~'~Uniit~ ~~~rr,~i:~:!-:'~l(i-r-"";:i~{-;l~>:_:t:"j<~';:~-~ ~2::;;:':~D'escriptlon:~:~~ ;,~ '::) ~S:_:: '.::':.;;0: ;:,I':r+:'C~ :'r~;.-2~: ~'~~1f-:!Fi.i:1 r~1tiOnltP.nce~
~Eil1tF.!ricel>>~
Administration of Workers' Compensation
CJaimsjocludjogj 0 itiaLSet=up.Costs
10,000,00
Note: Transition to Tristar as new TPA
for Workers' Compensation Claims -
includes transfer of data costs and
estimate for 4 months (March 1, 2011 -
June 30, 2011)
Contract for Workers' Comp TPA Services
Beginning date: March 1, 2011
Completion date: February 28, 2012
Insurance required/On file
BILL TO: Account Payable
20 EAST MAIN ST
541-552-2028
ASHLAND, OR 97520
SUBTOTAL
TAX
FREIGHT
TOTAL
10000,00
0,00
0,00
10,000,00
~:t~::Accoi:rntrNumBer;t~ l#.:~t~~jecrNumber.;::'t~ ;t:4~~;Amount~~:~';)j' 2if?A'CcoLiiffiNnmiJerz~~'_~:~ ~~P.rojeCt1Nu""rir~;~ __Affioum- ..
E 720,03,00,00,60714 10 000,00
~~~~
Authorized . nature
VENDOR COPY
I. FORM #3 I
RECEIVED
FEB 10 2011
ACCOUNTS PAYABLEoate of request: ,
ReqUired date for delivery:
-r,e16Tf11Z. RJ6f( Y11At\JI/6t6MelVT
PO BOX 22>lgq
776/H?b, OR. o;7~/-.3/6q
PJ?Mf..- "":;6?r 215 - 751;)- FAX.- :::03 -216'- 7SZ1'1
CITY OF
ASHLAND
A request for a Purchase Order
REQUISITION
':i~.{":~~' ..<:;':4":"~?~;1{4
1!,'2-'iJ.'drl<<,:o!1fJ
({~:D'?~j~ };5J84~f
"'!.>"~'~'.-.I'''l-.'?"*,,'l!.::
Vendor Name
Address, City, State, Zip
Contact Name & Telephone Number
Fax Number
~.- .. - .. \.. ' -..... - ,- -
O_ll!..[einittance.aqdr:.essJor.payments is P,O. Box 513869, Los Angeles, CA 90051-3869:
Thanks!
Clarissa Murillo
5taff Accountant II
TRI5TAR Insurance Group
Office: 562-495-6600 Ext.1029
Fax: 562-432-8258
Cia rissa, M u ri 1I0@tristargroup.net
.
",,,,,uuu LU ;,1 a.uuu
D Less than $35,000, by direct appointment
D (3) Written proposals attached
Description of SERVICES
,4,frnli1i6f!'a:fl?nJ. t)tMrxer~/ CrPmpsat1tT'1? {!b:t(pnS
li7tludUlJ JI1/1Ut/ <Xt-UjJ {:,psis
U wrlnen Tlnamgs arracnea
D Quote or Proposal attached
Date a roved b Council:
"tl""'"
Contract #
Date approved by Council:
Total Cost
;;:;.. ..' ..' :..
. 't' .. ~.> ~ ;. '. ~ 0< 'j,' , ;>.; ;
".,j J! . - ,,"'> '.,
.@ "~~oOOQ): .~,
Item # Quantity Unit
Description of MATERIALS
Unit Price
Total Cost
o Per attached QUOTE
Project Number ______. ___
Account Number
. . . -
--- -- -- -- ------
Account Number
. . . -
--- -- -- -- ------
Account Number ___' __' __'__ '____n Account Number ]j.2.Q'2.PQ, f2~.It?PJJ!ff)
'Expenditure must be charged to the appropriate account numbers for the financiets to reflect the actual expenditures eccuretely, Affach extra pages if needed,
By signing this requisition form, 1 certify that the information provided above meets the City's public contrecting requirements, and the documentation can be provided
upon request,
f)mfJ ~
Department Head Signature:
Employee Signature:
Additional signatures (if applicable):
JJ4 j -~ viLt/i/
Finance Director ' te
Comments. -rransitlon ~ 1Y'lsmr a~ NM TPA- F'Dr rJJOrk;fS' ~()'{pel1sa;tilJY]
Clal'm~ - inCludu tyM1S{er 0{- D/tIfu Com/U1d t8t/fuafe. f1;v Lima.
G: Finance\ProcedureIAPIForms\Form #3, Requisition (2)
@/NO
Funds appropriated for current fiscal year:
Updale<l on: 21712011