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HomeMy WebLinkAboutHR17-552 - Original - R.L. Evans Co. Inc - Contract - 12/15/17 r Records KENT CONTRACT COVER SHEET This is to be completed by the Contract Manager prior to submission to the City Clerk's Office. All portions are to be completed. If you have questions, please contact the City Clerk's Office at 253-856-5725. Vendor Name: R.L. Evans Co. Inc. Vendor Number: ]D Edwards Number Contract Number: HR 17-552 This is assigned by City Clerk's Office Project Name: Health Care Insurance Brokerage and Consulting Services Description: ❑ Interlocal Agreement ❑ Change Order ❑ Amendment ® Contract ❑ Other: Contract Effective Date: 12/15/17 Termination Date: 12/31/18 Contract Renewal Notice (Days): Number of days required notice for termination or renewal or amendment Contract Manager: Laura Horea Department: Human Resources Contract Amount: gas nnn nn Approval Authority: ❑ Director ® Mayor ❑ City Council Meeting Date Detail: (i.e. address, location, parcel number, tax id, etc.): `M—✓ K E�OT CONSULTANT SERVICES AGREEMENT between the City of Kent and R.L. Evans Co., Inc. THIS AGREEMENT is made between the City of Kent, a Washington municipal corporation (hereinafter the "City"), and R.L. Evans Co., Inc. organized under the laws of the State of Washington, located and doing business at 3535 Factoria Blvd, SE, Suite 120, Bellevue, WA 98006 - 425.455.0501 (hereinafter the "Consultant"), I. DESCRIPTION OF WORK. Consultant shall perform the following services for the City in accordance with the following described plans and/or specifications: F insurance brokerage and consulting services related to the City's medical, dental, plans, including: otiating with insurers, analyzing options, and making recommendations; ising the City on insurance plan design issues, plan management, and potential savings; sting the City and vendors in resolving eligibility and claim issues; ting with City Administration and/or its Healthcare Committee on a quarterly basis, or as otherwise requested to discuss claim experience, updates, and discuss objectives; • Assisting with plan audits; Assisting employees/retirees with healthcare options after employment with City; • Informing the City of regulatory updates and assisting the City as necessary to ensure compliance; Managing Plan Changes with Vendors; Assisting the City with contract and policy review; • Assisting the City with annual renewal of its health care insurance plans, including providing Consultant's recommendations regarding mandates, negotiating carrier renewals, providing claim data and other required information to actuary for rate analysis and projections. • Meeting with City Administration and Actuary to review funding projections. Work under this Agreement includes the following insured and self-funded coverages or programs: Medical/Rx Individual Stop Loss Dental Aggregate Stop Loss Vision Third Party Administrative (TPA) Services Consultant further represents that the services furnished under this Agreement will be performed in accordance with generally accepted professional practices within the Puget Sound region in effect at the time those services are performed. II. TIME OF COMPLETION. The parties agree that work began under this Agreement on January 1, 2018, and will continue through December 31, 2018. All acts consistent with the terms and conditions of this Agreement are ratified and affirmed. CONSULTANT SERVICES AGREEMENT - 1 (Over$20,000) III. COMPENSATION. A. The City shall pay the Consultant as provided for within the attached and incorporated Exhibit A, which payment is based on a per employee/retiree per month (PEPM) rate for all employees/retirees covered under the City's self-funded medical and dental plans, and on a percentage of premium for the employees enrolled on the Kaiser Permanente medical plan, The total amount paid to the Consultant for its services shall not exceed $45,000, which is the maximum amount to be paid under this Agreement for the work described in Section I above and performed in 2018. This 2018 amount shall not be exceeded without the prior written authorization of the City in the form of a negotiated and executed amendment to this Agreement. The Consultant agrees that the rates delineated in Exhibit A shall remain fixed for the life of this Agreement, unless the parties agree otherwise through an amendment to this Agreement. B. The Consultant shall bill the City for Consultant's services under this Agreement through the City's healthcare vendors (Prernera Blue Cross, Delta Dental Service, and Kaiser Permanente), and the Consultant's bill will be added as part of the healthcare vendors' monthly administrative or insured premium billings. If the City objects to all or any portion of an invoice, it shall notify the Consultant and the City reserves the option to only pay that portion of the invoice not in dispute, In that event, the parties will immediately make every effort to settle the disputed portion. IV. INDEPENDENT CONTRACTOR. The parties intend that an Independent Contractor- Employer Relationship will be created by this Agreement. By their execution of this Agreement, and in accordance with Ch. 51.08 RCW, the parties make the following representations; A. The Consultant has the ability to control and direct the performance and details of its work, the City being interested only in the results obtained under this Agreement. B. The Consultant maintains and pays for its own place of business from which Consultant's services under this Agreement will be performed. C, The Consultant has an established and independent business that is eligible for a business deduction for federal income tax purposes that existed before the City retained Consultant's services, or the Consultant is engaged in an independently established trade, occupation, profession, or business of the same nature as that involved under this Agreement. D. The Consultant is responsible for filing as they become due all necessary tax documents with appropriate federal and state agencies, including the Internal Revenue Service and the state Department of Revenue. E. The Consultant has registered its business and established an account with the state Department of Revenue and other state agencies as may be required by Consultant's business, and has obtained a Unified Business Identifier (UBI) number from the State of Washington. F. The Consultant maintains a set of books dedicated to the expenses and earnings of its business. V. TERMINATION. Either party may terminate this Agreement, with or without cause, upon providing the other party thirty (30) days written notice at its address set forth on the signature block of this Agreement. After termination, the City may take possession of all records and data within the Consultant's possession pertaining to this project, which may be used by the City without restriction. If the City's use of Consultant's records or data is not related to this project, it shall be without liability or legal exposure to the Consultant. CONSULTANT SERVICES AGREEMENT - 2 (Over$20,000) VI. DISCRIMINATION. In the hiring of employees for the performance of work under this Agreement or any subcontract, the Consultant, its subcontractors, or any person acting on behalf of the Consultant or subcontractor shall not, by reason of race, religion, color, sex, age, sexual orientation, national origin, or the presence of any sensory, mental, or physical disability, discriminate against any person who is qualified and available to perform the work to which the employment relates. Consultant shall execute the attached City of Kent Equal Employment Opportunity Policy Declaratlon, Comply with City Administrative Policy 1.2, and upon completion of the contract work, file the attached Compliance Statement, VII. INDEMNIFICATION. Consultant shall defend, indemnify and hold the City, its officers, officials, employees, agents and volunteers harmless from any and all claims, injuries, damages, losses or suits, including all legal costs and attorney fees, arising out of or in connection with the Consultant's performance of this Agreement, except for that portion of the injuries and damages caused by the City's negligence. The City's inspection or acceptance of any of Consultant's work when completed shall not be grounds to avoid any of these covenants of indemnification, Should a court of competent jurisdiction determine that this Agreement is subject to RCW 4,24.115, then, in the event of liability for damages arising out of bodily injury to persons or damages to property caused by or resulting from the concurrent negligence of the Consultant and the City, its officers, officials, employees, agents and volunteers, the Consultant's duty to defend, indemnify, and hold the City harmless, and Consultant's liability accruing from that obligation shall be only to the extent of the Consultant's negligence. IT IS FURTHER SPECIFICALLY AND EXPRESSLY UNDERSTOOD THAT THE INDEMNIFICATION PROVIDED HEREIN CONSTITUTES THE CONSULTANT'S WAIVER OF IMMUNITY UNDER €NC?USGRIAL INSURANCE, TITLE 51 RCW, SOLELY FOR THE PURPOSES OF THIS INDEMNIFICATION. THE PARTIES FURTHER ACKNOWLEDGE THAT THEY HAVE MUTUALLY NEGOTIATED THIS WAIVER. In the event Consultant refuses tender of defense in any suit or any claim, if that tender was made pursuant to this indemnification clause, and if that refusal is subsequently determined by a court having jurisdiction (or other agreed tribunal) to have been a wrongful refusal on the Consultant's part, then Consultant shall pay all the City's costs for defense, including all reasonable expert witness fees and reasonable attorneys'fees, plus the City's legal costs and fees incurred because there was a wrongful refusal on the Consultant's part. The provisions of this section shall survive the expiration or termination of this Agreement. VIII. INSURANCE. The Consultant shall procure and maintain for the duration of the Agreement, Insurance of the types and in the amounts described in Exhibit s attached and incorporated by this reference. IX. EXCHANGE OF INFORMATION. The City will provide its best efforts to provide reasonable accuracy of any information supplied by it to Consultant for the purpose of completion of the work under this Agreement. X. OWNERSHIP AND USE OF RECORDS AND DOCUMENTS. Original documents, drawings, designs, reports, or any other records developed or created under this Agreement shall belong to and become the property of the City. All records submitted by the City to the Consultant will be safeguarded by the Consultant, Consultant shall make such data, documents, and files available to the City upon the City's request. The Consultant acknowledges that the City is a public agency subject to the Public Records Act codified in Chapter 42.56 of the Revised Code of Washington. As such, the Consultant agrees to cooperate fully with the City in satisfying the City's duties and obligations under the Public Records Act. The City's use or reuse of any of the documents, data, and files created by Consultant for this project by anyone other than Consultant on any other project shall be without liability or legal exposure to Consultant. XI. CITY'S RIGHT OF INSPECTION. Even though Consultant is an independent contractor with the authority to control and direct the performance and details of the work authorized under this Agreement, CONSULTANT SERVICES AGREEMENT - 3 (Over$20,000) the work must meet the approval of the City and shall be subject to the City's general right of inspection to secure satisfactory completion. XII, WORK PERFORMED AT CONSULTANT'S RISK. Consultant shall take all necessary precautions and shall be responsible for the safety of its employees, agents, and subcontractors in the performance of the contract work and shall utilize all protection necessary for that purpose. All work shall be done at Consultant's own risk, and Consultant shall be responsible for any loss of or damage to materials, tools, or other articles used or held for use in connection with the work. XIII. MISCELLANEOUS PROVISIONS. A. Recyclable Materials. Pursuant to Chapter 3,80 of the Kent City Code, the City requires its contractors and consultants to use recycled and recyclable products whenever practicable. A price preference may be available for any designated recycled product. B. Non-Waiver of Breach. The failure of the City to insist upon strict performance of any of the covenants and agreements contained in this Agreement, or to exercise any option conferred by this Agreement in one or more instances shall not be construed to be a waiver or relinquishment of those covenants, agreements or options, and the same shall be and remain in full force and effect. C. Resolution of Disputes and Governing l.aw. This Agreement shall be governed by and construed in accordance with the laws of the State of Washington. If the parties are unable to settle any dispute, difference or claim arising from the parties' performance of this Agreement, the exclusive means of resolving that dispute, difference or claim, shall only be by filing suit exclusively under the venue, rules and jurisdiction of the King County Superior Court, King County, Washington, unless the parties agree in writing to an alternative dispute resolution process. In any claim or lawsuit for damages arising from the parties' performance of this Agreement, each party shall pay all its legal costs and attorney's fees incurred in defending or bringing such claim or lawsuit, including all appeals, in addition to any other,recovery or award provided by law; provided', however, nothing in this paragraph shall be construed to limit the City's right to indemnification under Section VII of this Agreement. D. Written Notice. All communications regarding this Agreement shall be sent to the parties at the addresses listed on the signature page of the Agreement, unless notified to the contrary. Any written notice hereunder shall become effective three (3) business days after the date of mailing by registered or certified mail, and shall be deemed sufficiently given if sent to the addressee at the address stated in this Agreement or such other address as may be hereafter specified in writing. E. Assic of gng. Any assignment of this Agreement by either party without the written consent of the non-assigning party shall be void. If the non-assigning party gives its consent to any assignment, the terms of this Agreement shall continue in full force and effect and no further assignment shall be made without additional written consent. F. Modification. No waiver, alteration, or modification of any of the provisions of this Agreement shall be binding unless in writing and signed by a duly authorized representative of the City and Consultant. G. Entire Agreement. The written provisions and terms of this Agreement, together with any Exhibits attached hereto, shall supersede all prior verbal statements of any officer or other representative of the City, and such statements shall not be effective or be construed as entering into or forming a part of or altering In any manner this Agreement. All of the above documents are hereby made a part of this Agreement. However, should any language in any of the Exhibits to this Agreement conflict with any language contained in this Agreement, the terms of this Agreement shall prevail. H. Compliance with Laws. The Consultant agrees to comply with all federal, state, and municipal laws, rules, and regulations that are now effective or in the future become applicable to Consultant's business, equipment, and personnel engaged in operations covered by this Agreement or accruing out of the performance of those operations. CONSULTANT SERVICES AGREEMENT - 4 (Over$20,000) 1. pgbPic I'tecnrds Act. The Consultant acknowledges that the City is a public agency subject to the Public Records Act codified in Chapter 42.56 of the Revised Code of Washington and documents, notes, entails, and other records prepared or gathered by the Consultant In its performance of this Agreement may be subject to public review and disclosure, even if those records are not produced to or possessed by the City of Kent. As such, the Consultant agrees to cooperate fully with the City in satisfying the City's duties and obligations under the Public Records Act. J. Cdkw Busiajesa I_Icense Reeuired, Prior to commencing the tasks described in Section 1, Contractor agrees to provide proof of a current city of Kent business license pursuant to Chapter 5.01 of the Kent City Code. K. Co This Agreement may be executed in any number of counterparts, each of which shall constitute an original, and all of which will together constitute this one Agreement. Further, upon executing this Agreement, either party may deliver the signature page to the other by fax or email and that signature shall have the same force and effect as If the Agreement bearing the original signature was received In person. IN WITNESS, the parties below execute this Agreement, which shall become effective on the last date entered below. All acts consistent with the authority of this Agreement and prior to its effective date are ratified and affirmed, and the terms of the Agreement shall be deemed to have applied. CONSULT N : CITY: R.L. E Co , I'o, City of Kent , By: r� .,,. By: _ (signature) (signature) Print Nature:Its —...-... P it Nam a _t„_ ette Cook- avor DATE: i z f .�07, DATE: " 7 - _-- _. NOTICES TO BE SENT TO: FNOTIESTOBE SENT TO:CONSULTANT: OF KENT: Douglas Evans Horea, Benefits Manager R.L. Evans Co., Inc. Kent 3535 Factoria Blvd SE, Suite 120 Resources Department Bellevue, WA 98006 220 Fourth Avenue South 425.455.0501 (telephone) Kent, WA 98032 425.467.5264 (facsimile) (253) 856.5290 (telephone) (253) 856.6270 (facsirnile) APPR V D AS TO FORM: ,r w Department CONSULTANT SERVICES AGREEMENT - 5 (Over$20,000) DECLARATION CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY POLICY The City of Kent is committed to conform to Federal and State laws regarding equal opportunity. As such all contractors, subcontractors and suppliers who perform work with relation to this Agreement shall comply with the regulations of the City's equal employment opportunity policies. The following questions specifically identify the requirements the City deems necessary for any contractor, subcontractor or supplier on this specific Agreement to adhere to. An affirmative response is required on all of the following questions for this Agreement to be valid and binding. If any contractor, subcontractor or supplier willfully misrepresents themselves with regard to the directives outlines, it will be considered a breach of contract and it will be at the City's sole determination regarding suspension or termination for all or part of the Agreement; The questions are as follows: 1. I have read the attached City of Kent administrative policy number 1.2. 2. During the time of this Agreement I will not discriminate in employment on the basis of sex, race, color, national origin, age, or the presence of all sensory, mental or physical disability. 3. During the time of this Agreement the prime contractor will provide a written statement to all new employees and subcontractors indicating commitment as an equal opportunity employer. 4. During the time of the Agreement I, the prime contractor, will actively consider hiring and promotion of women and minorities, 5. Before acceptance of this Agreement, an adherence statement will be signed by me, the Prime Contractor, that the Prime Contractor complied with the requirements as set forth above. By signing Y0w tree to fulfill the five requirements referenced above. By:_,_,_ .._.. For: Title: ._. __.. �..- Date: ..... EEC COMPLIANCE DOCUMENTS - 1 CITY OF KENT ADMINISTRATIVE POLICY NUMBER: 1.2 EFFECTIVE DATE: January 1, 1998 SUBJECT: MINORITY AND WOMEN SUPERSEDES: April 1, 1996 CONTRACTORS APPROVED BY Jim White, Mayor POLICY: Equal employment opportunity requirements for the City of Kent will conform to federal and state laws. All contractors, subcontractors, consultants and suppliers of the City must guarantee equal employment opportunity within their organization and, if holding Agreements with the City amounting to $10,000 or more within any given year, must take the following affirmative steps: 1. Provide a written statement to all new employees and subcontractors indicating commitment as an equal opportunity employer. 2. Actively consider for promotion and advancement available minorities and women. Any contractor, subcontractor, consultant or supplier who willfully disregards the City's nondiscrimination and equal opportunity requirements shall be considered in breach of contract and subject to suspension or termination for all or part of the Agreement. Contract Compliance Officers will be appointed by the Directors of Planning, Parks, and Public Works Departments to assume the following duties for their respective departments. 1. Ensuring that contractors, subcontractors, consultants, and suppliers subject to these regulations are familiar with the regulations and the City's equal employment opportunity policy. 2. Monitoring to assure adherence to federal, state and local laws, policies and guidelines. EEO COMPLIANCE DOCUMENTS - 2 CITY OF KENT EQUAL EMPLOYMENT OPPORTUNITY COMPLIANCE STATEMENT This form shall be filled out AFTER COMPLETION of this project by the Contractor awarded the Agreement. I, the undersigned, a duly represented agent of L 'J < C _ -�, Company, hereby acknowledge and declare that the before-mentioned compiny was the prime contractor for the Agreement known as a. = y - that was entered into on the C& (date), between the firm I represent and the City of Kent, I declare that I complied fully with all of the requirements and obligations as outlined in the City of Kent Administrative Policy 1,2 and the Declaration City of Kent Equal Employment Opportunity Policy that was part of the before-mentioned Agreement. For: Title: Date: EEO COMPLIANCE DOCUMENTS - 3 EXHIBIT A FEES AND PAYMENT SCHEDULE The CITY shall compensate the CONSULTANT for services pursuant to this Agreement as follows: For services rendered under this Agreement, Consultant will be paid as follows: Darr"ng Calendar Year 2013 For each employee/retiree covered under the City's self-funded medical/Rx plan the Consultant will be paid at the rate of$3.50 per month. For each employee/retiree covered under the City's self-funded dental/vision plan, the Consultant will be paid at the rate of$.60 per month. For employees enrolled on the fully-insured Kaiser Permanente plan the Consultant will be paid 2.5°/o of the paid premium. * The City recognizes that the Consultant may qualify for contingency bonuses from insurance companies with whom the Contractor conducts business. As these amounts are not guaranteed and are typically earned based on factors that are not client-specific, any such payments received by Consultant will not be offset against the fees noted above, Upon request Consultant will provide a detailed listing of all contingency commissions received for the prior year. Any services that are requested by the CITY that are outside of the scope of work as noted in "I. DESCRIPTION OF WORK", or not covered by a separate agreement, will be billed at the rate of $300/hour for Lead Broker/Consultant and $175/hour for Account Manager. EXHIBIT A EXHIBIT B INSURANCE COVERAGE The Consultant shall procure and maintain for the duration of the Agreement, insurance of the types and in the amounts described below: • Agents' and Brokers' Errors & Omissions insurance with a minimum limit of $2,000.000 • General Liability Coverage with a minimum limit of $1,000,000 EXHIBIT B C CERTIFICATE OF LIABILITY INSURANCE DATENMMIDD"r"' -'" 11127/2017 .. ......................... _........._........._......._...........�.n... 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 p011cy(ies)must have ADDITIONAL INSURED provislons or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement, A staternenton this certificate does not center rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONNAME: i Mardi E.Anderson NAME: R.L. Evans Company, Inc. I+ C.Nareo (426)456.0501 -._,FAX Nat (425)467-5264 _ e-Mm 3535 Pactoria Blvd SE, Ste 120 ¢DeRSys mardl�rPevansca.aam Bellevue,WA 98006 INSURER(S)AFFORDING COVERAGE NAICH INSURER A: The Hartford INSURED INSURER B American Alternative Ins Corp_ R.L.Evans Company INsugERC 3535 Factoria Blvd SE Ste 120 INSURER O, Bellevue,WA 98006 INSURER E: INSURER E. --... _.. COVERAGES_ CERTIFICATE NUMBER: 00000000-305577 REVISION NUMBER: 10 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 SVBJECT TOALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCI I POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INtt1 ,.._. Al5r5L SUBR POLICY EPX` POLECYE%P eJR_ TYPE aF INSURANCE rNSn wrvn FeLICY NUMBER fMIM)MY MlL�ppY'YYW LIMITS A X COMMERCIAL GENERAL LIABILITY Y 52SBATZ7827 1210v2017 12101/201B EACH OCCURRENCE S 2,000,000 CLAIMS MADE X OCCUR DAMAGE Tp RENTED PREMISES NE.m,41flmrxL) .., -..-.. -. MED EXP(nny rime Per.un) .S. 10,000 PERSON4,L$AOV INJURY $ 2,000,000 GEN L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ _ 4,000,000 POLICY PRO JECT LOG PRODUCTS COMPIOP AGO $ 4,000,000 ornEo-z, Bus Pere Prn,-REPL s 228 200 A AUTOMOBILE LIABILITY 52$BATZ7827 1210V2017 12101/2018 OMBINEO$I. 'LE L°,M17 0 ANY AUTO l-m @l4lJmintf S_,_ 2,g00,UQ0 BODILY INJURY(Per Person) S :OWNED ...� SCHEDULED BODILY INJURY IPere a6ent) $ AUTOS ONLY AUTOS HIRED ..,NON CANNED PROPERTY DAMAGE ,(AUTOS ONLY X i AUTO$ONLY (Per ecodeno 5 5 1 UMBRELLA LIAB {OCCUR EACH OCCURRENCE S EXCESS LIAB ! l OWMS-MADE AGGREGATE S OLD -, RErBNT10NS .S WORKERS COMPENSATION ..� R OTH AAND EMPLOYFR$1LIARU.ITY YIN 52SBATZ7827 12101/2017 12101)2018 IMTOTE. ER ANY PROPRIFTORIPARTNERIEXLCOTIVE OL,EACH ACCIDENT 5 1,000,000 OPP GERIMEMBER EXCLUDED' NIA (ftlt.q It NH) E,L,DISEASE-EAEMPLOYEE S 1,000,000 If Aerobe Under _..Y. Porter•rK,JN OFOrPRATIONS _ CL DISEASE-POLICY LIMIT S 1'.000r000 B Errors& Omissions 3TA2PL0005173-00 03I3ii2o�F" 031311201e z000aomz000000 each claim/agg DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES NACDRD 101,AOtlIfI00el RemerXs Schedule,may be alWchetl H mare apace Is regolretll Certificate Holder is Additional Insured per endorsement IH12001186 and Business Liability Coverage Form SS00080405 attached to Policy No: 62SBATZ827 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Kent THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Human Resources Office ACCORDANCE WITH THE POLICY PROVISIONS, 220 Fourth Ave So ----- Kent, WA 98032 AUm aRErw.Ess TA4� ' S _ _ (MLA} ©1988-2015 ACORD CORPORATION. it rights reserved. ACORD 26(2016103) The ACORD name and logo are registered marks of ACORD Printed by MEA on November 27,2017 at 11:03AM POLICY NUMBER: 52 SBA TZ7827 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL. INSURED - PERSON-OR('ANT ZATION CITY OF ISSAQUAH 130 E. SUNSET WAY ISSAQUAH, WA 98027 CITY OF TUKWILA 6200 SOOTHCENTER 2LVD TUKWILA, WA 98188 CITY OF RENTON 1055 S. GRADY WAY RENTON, WA 980S7 CITY OF FEDERAL WAY 33325 - STH AVE SO FEDERAL WAY, WA 98003 CITY OF KENI' 220 FOURTH AVENUE SOUTH KENT, WA 98032 Form IH 12 00 11 85 T SEQ. NO. 001 Printed in U.S.A. Page 001 Process Date: 10/16/I7 Expl ration Date: 12/01/18 COMPENSATION DISCLOSURE FORM This form is for use if the compensation received by an insurance producer who is dealing directly with the Insured includes a fee. Separate disclosure forms should be used for each policy. AGENCY/PRODUCER', INSURED/CLIENT ❑ PART 1 - Place a check in the box and complete this section if the licensed Producer's compensation is ONLY FROM CHARGING A FEE to the client: A FEE IN THE AMOUNT OF $ HAS BEEN CHARGED TO THE CLIENT, PART 2 - Place a check in the box and complete this section if the licensed Producer's compensation is FROM CHARGING A FEE to the prospective client AND RECEIVING A COMMISSION from the insurance company: H3.sC, pe_P �- u4 - A FEE IN THE AMOUNT OF $ ",4,,b C , XcrttHAS BEEN CHARGED TO THE CLIENT. COMMISSION IN THE AMOUNT OF $ 1 0.0 ____„_HAS BEEN/WILL BE RECEIVED FROM: Kr 5�ery .....,.................... (INSURER) THE WRITING PRODUCER MAY OFFSET SOME, OR THE ENTIRE FEE THAT IS CHARGED TO YOU. AN EXPLANATION OF HOW THE OFFSET WORKS IS AS FOLLOWS 1'�: U: ...� r )"�.. ---3x•s..>,s _z �' •=--'�i.,..,..u1_.4'- r,. '��irv^^ #,._, PART 3 - Place a check in the box and complete this section when the licensed Producer may receive any ADDITIONAL (CONTINGENT) COMMISSIONS from the insurance company for the sale of this policy: The writing producer/agency may receive additional commission in the form of future incentive compensation from the insurer, including contingent commissions and other awards and bonuses based upon factors that TYPICALLY INCLUDE THE TOTAL SALES VOLUME, GROWTH, PROFITABILITY AND RETENTION OF BUSINESS PLACED BY THE INSURANCE PRODUCER WITH THE INSURER and incentive compensation is only paid if the performance criteria established in the Agency/Insurer agreement is met by the insurance producer of the business entity with which the hisurance producer is affiliated. Specific information relation to Additional(Contingent) Commissions will be provided upon request. INSURED SIGNATURE: DATE: PRODUCER SIGNATURE: _„ :�r� ry __ __ DATE: ,..L REQUEST FOR MAYOR'S SIGNATURE *NT Print on Cherry-Colored Paper KE Routing Information: (ALL REQUESTS MUST FIRST BE ROUTED THROUGH THE LAW DEPARTMENT) Approved by Director_ Originator: Laura Horea Phone (Originator): 253.856.5290 Date Sent: 12/15/17 Date Required: 12/27/17 Return Signed Document to: Laura Horea Contract Termination Date: 12/31/2018 VENDOR NAME: Date Finance Notified: RL Evans CO., Inc. (Only required on contracts 09/28/17 $20.000 and over or on anv Grant) DATE OF COUNCIL APPROVAL: N/A Date Risk Manager Notified:09/28/17 (.Required on Non-City Standard Contracts/Aareements) Has this Document been Specifocall Account Number: Authorized in the Budget?" o YES NO . ........ ..................._.................... .— ....... -------... Brief Explanation of Document: Health Care Insurance Brokerage and Consulting Services related to the City's medical, dental and vision plans. —..._..........................— ... . __._....__ ........ ..._.,......... _f --. ................................. �r AH Contracts Must Be Routed Through The Law De� tm"i 1 (This ar to e p leted by e Law Department) I f Ov Received: Approval of Law Dept.: Law Dept. Comments: Date Forwarded to Mayor: Shaded Areas To iC leted By Administration Staff Received': 'Recommendations and Comments Disposition: 1,/PJ1,;7 / Date Returned: r.— "—w�—..Tr.ereum2l1 uvuia a oNnex r�nww�i.w.x .