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Innovative Claims Solutions - 2016 Agreement
AGREEMENT FOR SERVICES (For contracts over $5,000 - CON ULTANT) o This AGREEMENT made this 41khay ofd, 2 6, between: CITY: City of Gilroy, having a principal place of business at 7351 Rosanna Street, Gilroy, California and CONSULTANT: Innovative Claims Solutions, Inc., having a principal place of business at 2430 Camino Ramon #200, San Ramon, CA 94583. ARTICLE 1. TERM OF AGREEMENT This Agreement will become effective on July 1, 2016 and will continue in effect through June 30, 2017, unless extended by adendum or unless terminated in accordance with the provisions of Article 7 of this Agreement. Any lapse in insurance coverage as required by Article 5, Section D of this Agreeme t s all terminate this Agreement regardless of any other provision stated herein. nitial ARTICLE 2. INDEPENDENT CONTRACTOR STATUS It is the express intention of the parties that CONSULTANT is an independent contractor and not an employee, agent, joint venturer or partner of CITY. Nothing in this Agreement shall be interpreted or construed as creating or establishing the relationship of employer and employee between CITY and CONSULTANT or any employee or agent of CONSULTANT. Both parties acknowledge that CONSULTANT is not an employee for state or federal tax purposes. CONSULTANT shall not be entitled to any of the rights or benefits afforded to CITY'S employees, including, without limitation, disability or unemployment insurance, workers' compensation, medical insurance, sick leave, retirement benefits or any other employment benefits. CONSULTANT shall retain the right to perform services for others during the term of this Agreement. ARTICLE 3. SERVICES TO BE PERFORMED BY CONSULTANT A. Specific Services CONSULTANT agrees to: Perform the services as outlined in Exhibit "A" ( "Specific Provisions ") and Exhibit "B" ( "Scope of Services "), within the time periods described in Exhibit "C" ( "Milestone Schedule "). B. Method of Performing Services CONSULTANT shall determine the method, details and means of performing the above - described services. CITY shall have no right to, and shall not, control the manner or determine the method of accomplishing CONSULTANT'S services. 4835 - 2267 -03610 LAC104706083 C. Employment of Assistants CONSULTANT may, at the CONSULTANT'S own expense, employ such assistants as CONSULTANT deems necessary to perform the services required of CONSULTANT by this Agreement, subject to the prohibition against assignment and subcontracting contained in Article 5 below. CITY may not control, direct, or supervise CONSULTANT'S assistants in the performance of those services. CONSULTANT assumes full and sole responsibility for the payment of all compensation and expenses of these assistants and for all state and federal income tax, unemployment insurance, Social Security, disability insurance and other applicable withholding. D. Place of Work CONSULTANT shall perform the services required by this Agreement at any place or location and at such times as CONSULTANT shall determine is necessary to properly and timely perform CONSULTANT'S services. ARTICLE 4. COMPENSATION A. Consideration In consideration for the services to be performed by CONSULTANT, CITY agrees to pay CONSULTANT the amounts set forth in Exhibit I'D" ( "Payment Schedule "). In no event however shall the total compensation paid to CONSULTANT exceed $80,612.00. B. Invoices CONSULTANT shall submit invoices for all services rendered. C. Payment Payment shall be due according to the payment schedule set forth in Exhibit "D ". No payment will be made unless CONSULTANT has first provided City with a written receipt of invoice describing the work performed and any approved direct expenses (as provided for in Exhibit "A ", Section IV) incurred during the preceding period. If CITY objects to all or any portion of any invoice, CITY shall notify CONSULTANT of the objection within thirty (30) days from receipt of the invoice, give reasons for the objection, and pay that portion of the invoice not in dispute. It shall not constitute a default or breach of this Agreement for CITY not to pay any invoiced amounts to which it has objected until the objection has been resolved by mutual agreement of the parties. D. Expenses CONSULTANT shall be responsible for all costs and expenses incident to the performance of services for CITY, including but not limited to, all costs of equipment used or provided by CONSULTANT, all fees, fines, licenses, bonds or taxes required of or imposed against CONSULTANT and all other of CONSULTANT'S costs of doing business. CITY shall not be 4835 - 2267 -03610 LAC \04706083 responsible for any expenses incurred by CONSULTANT in performing services for CITY, except for those expenses constituting "direct expenses" referenced on Exhibit "A." ARTICLE 5. OBLIGATIONS OF CONSULTANT A. Tools and Instrumentalities CONSULTANT shall supply all tools and instrumentalities required to perform the services under this Agreement at its sole cost and expense. CONSULTANT is not required to purchase or rent any tools, equipment or services from CITY. B. Workers' Compensation CONSULTANT agrees to provide workers' compensation insurance for CONSULTANT'S employees and agents and agrees to hold harmless, defend with counsel acceptable to CITY and indemnify CITY, its officers, representatives, agents and employees from and against any and all claims, suits, damages, costs, fees, demands, causes of action, losses, liabilities and expenses, including without limitation reasonable attorneys' fees, arising out of any injury, disability, or death of any of CONSULTANT'S employees. C. Indemnification of Liability, Duty to Defend 1. As to professional liability, to the fullest extent permitted by law, CONSULTANT shall defend, through counsel approved by CITY (which approval shall not be unreasonably withheld), indemnify and hold harmless CITY, its officers, representatives, agents and employees against any and all suits, damages, costs, fees, claims, demands, causes of action, losses, liabilities and expenses, including without limitation attorneys' fees, to the extent arising or resulting directly or indirectly from any willful or negligent acts, errors or omissions of CONSULTANT or CONSULTANT'S assistants, employees or agents, including all claims relating to the injury or death of any person or damage to any property. 2. As to other liability, to the fullest extent permitted by law, CONSULTANT shall defend, through counsel approved by CITY (which approval shall not be unreasonably withheld), indemnify and hold harmless CITY, its officers, representatives, agents and employees against any and all suits, damages, costs, fees, claims, demands, causes of action, losses, liabilities and expenses, including without limitation attorneys' fees, arising or resulting directly or indirectly from any act or omission of CONSULTANT or CONSULTANT'S assistants, employees or agents, including all claims relating to the injury or death of any person or damage to any property. D. Insurance In addition to any other obligations under this Agreement, CONSULTANT shall, at no cost to CITY, obtain and maintain throughout the term of this Agreement: (a) Commercial Liability Insurance on a per occurrence basis, including coverage for owned and non -owned automobiles, with a minimum combined single limit coverage of $1,000,000 per occurrence for all damages due to bodily injury, sickness or disease, or death to any person, and damage to property, 4835 - 2267 -0361 v1 _3 _ LAM04706083 including the loss of use thereof; and (b) Professional Liability Insurance (Errors & Omissions) with a minimum coverage of $1,000,000 per occurrence or claim, and $2,000,000 aggregate; provided however, Professional Liability Insurance written on a claims made basis must comply with the requirements set forth below. Professional Liability Insurance written on a claims made basis (including without limitation the initial policy obtained and all subsequent policies purchased as renewals or replacements) must show the retroactive date, and the retroactive date must be before the earlier of the effective date of the contract or the beginning of the contract work. Claims made Professional Liability Insurance must be maintained, and written evidence of insurance must be provided, for at least five (5) years after the completion of the contract work. If claims made coverage is canceled or non - renewed, and not replaced with another claims -made policy form with a retroactive date prior to the earlier of the effective date of the contract or the beginning of the contract work, CONSULTANT must purchase so called "extended reporting" or "tail" coverage for a minimum of five (5) years after completion of work, which must also show a retroactive date that is before the earlier of the effective date of the contract or the beginning of the contract work. As a condition precedent to CITY'S obligations under this Agreement, CONSULTANT shall furnish written evidence of such coverage (naming CITY, its officers and employees as additional insureds on the Comprehensive Liability insurance policy referred to in (a) immediately above via a specific endorsement) and requiring thirty (30) days written notice of policy lapse or cancellation, or of a material change in policy terms. E. Assignment Notwithstanding any other provision of this Agreement, neither this Agreement nor any duties or obligations of CONSULTANT under this Agreement may be assigned or subcontracted by CONSULTANT without the prior written consent of CITY, which CITY may withhold in its sole and absolute discretion. F. State and Federal Taxes As CONSULTANT is not CITY'S employee, CONSULTANT shall be responsible for paying all required state and federal taxes. Without limiting the foregoing, CONSULTANT acknowledges and agrees that: • CITY will not withhold FICA (Social Security) from CONSULTANT'S payments; • CITY will not make state or federal unemployment insurance contributions on CONSULTANT'S behalf; • CITY will not withhold state or federal income tax from payment to CONSULTANT; • CITY will not make disability insurance contributions on behalf of CONSULTANT; • CITY will not obtain workers' compensation insurance on behalf of CONSULTANT. 4835- 2267 -0361v1 _4_ LAM04706083 ARTICLE 6. OBLIGATIONS OF CITY A. Cooperation of City CITY agrees to respond to all reasonable requests of CONSULTANT and provide access, at reasonable times following receipt by CITY of reasonable notice, to all documents reasonably necessary to the performance of CONSULTANT'S duties under this Agreement. B. Assignment CITY may assign this Agreement or any duties or obligations thereunder to a successor governmental entity without the consent of CONSULTANT. Such assignment shall not release CONSULTANT from any of CONSULTANT'S duties or obligations under this Agreement. ARTICLE 7. TERMINATION OF AGREEMENT A. Sale of Consultant's Business/ Death of Consultant. CONSULTANT shall notify CITY of the proposed sale of CONSULTANT's business no later than thirty (30) days prior to any such sale. CITY shall have the option of terminating this Agreement within thirty (30) days after receiving such notice of sale. Any such CITY termination pursuant to this Article 7.A shall be in writing and sent to the address for notices to CONSULTANT set forth in Exhibit A, Subsection V.H., no later than thirty (30) days after CITY' receipt of such notice of sale. If CONSULTANT is an individual, this Agreement shall be deemed automatically terminated upon death of CONSULTANT. B. Termination by City for Default of Consultant Should CONSULTANT default in the performance of this Agreement or materially breach any of its provisions, CITY, at CITY'S option, may terminate this Agreement by giving written notification to CONSULTANT. For the purposes of this section, material breach of this Agreement shall include, but not be limited to the following: 1. CONSULTANT'S failure to professionally and /or timely perform any of the services contemplated by this Agreement. 2. CONSULTANT'S breach of any of its representations, warranties or covenants contained in this Agreement. CONSULTANT shall be entitled to payment only for work completed in accordance with the terms of this Agreement through the date of the termination notice, as reasonably determined by CITY, provided that such payment shall not exceed the amounts set forth in this Agreement for the tasks described on Exhibit C" which have been fully, competently and timely rendered by CONSULTANT. Notwithstanding the foregoing, if CITY terminates this Agreement due to CONSULTANT'S default in the performance of this Agreement or material breach by CONSULTANT of any of its provisions, then in addition to any other rights and remedies CITY 4835 - 2267 -03610 LAC104706083 may have, CONSULTANT shall reimburse CITY, within ten (10) days after demand, for any and all costs and expenses incurred by CITY in order to complete the tasks constituting the scope of work as described in this Agreement, to the extent such costs and expenses exceed the amounts CITY would have been obligated to pay CONSULTANT for the performance of that task pursuant to this Agreement. C. Termination for Failure to Make Agreed -Upon Payments Should CITY fail to pay CONSULTANT all or any part of the compensation set forth in Article 4 of this Agreement on the date due, then if and only if such nonpayment constitutes a default under this Agreement, CONSULTANT, at the CONSULTANT'S option, may terminate this Agreement if such default is not remedied by CITY within thirty (30) days after demand for such payment is given by CONSULTANT to CITY. D. Transition after Termination Upon termination, CONSULTANT shall immediately stop work, unless cessation could potentially cause any damage or harm to person or property, in which case CONSULTANT shall cease such work as soon as it is safe to do so. CONSULTANT shall incur no further expenses in connection with this Agreement. CONSULTANT shall promptly deliver to CITY all work done toward completion of the services required hereunder, and shall act in such a manner as to facilitate any the assumption of CONSULTANT's duties by any new consultant hired by the CITY to complete such services. ARTICLE 8. GENERAL PROVISIONS A. Amendment & Modification No amendments, modifications, alterations or changes to the terms of this Agreement shall be effective unless and until made in a writing signed by both parties hereto. B. Americans with Disabilities Act of 1990 Throughout the term of this Agreement, the CONSULTANT shall comply fully with all applicable provisions of the Americans with Disabilities Act of 1990 ( "the Act ") in its current form and as it may be amended from time to time. CONSULTANT shall also require such compliance of all subcontractors performing work under this Agreement, subject to the prohibition against assignment and subcontracting contained in Article 5 above. The CONSULTANT shall defend with counsel acceptable to CITY, indemnify and hold harmless the CITY OF GILROY, its officers, employees, agents and representatives from and against all suits, claims, demands, damages, costs, causes of action, losses, liabilities, expenses and fees, including without limitation reasonable attorneys' fees, that may arise out of any violations of the Act by the CONSULTANT, its subcontractors, or the officers, employees, agents or representatives of either. 4835 - 2267 -03610 _6_ LAC104706083 C. Attorneys' Fees If any action at law or in equity, including an action for declaratory relief, is brought to enforce or interpret the provisions of this Agreement, the prevailing party will be entitled to reasonable attorneys' fees, which may be set by the court in the same action or in a separate action brought for that purpose, in addition to any other relief to which that party may be entitled. D. Captions The captions and headings of the various sections, paragraphs and subparagraphs of the Agreement are for convenience only and shall not be considered nor referred to for resolving questions of interpretation. E. Compliance with Laws The CONSULTANT shall keep itself informed of all State and National laws and all municipal ordinances and regulations of the CITY which in any manner affect those engaged or employed in the work, or the materials used in the work, or which in any way affect the conduct of the work, and of all such orders and decrees of bodies or tribunals having any jurisdiction or authority over the same. Without limiting the foregoing, CONSULTANT agrees to observe the provisions of the Municipal Code of the CITY OF GILROY, obligating every contractor or subcontractor under a contract or subcontract to the CITY OF GILROY for public works or for goods or services to refrain from discriminatory employment or subcontracting practices on the basis of the race, color, sex, religious creed, national origin, ancestry of any employee, applicant for employment, or any potential subcontractor. F. Conflict of Interest CONSULTANT certifies that to the best of its knowledge, no CITY employee or office of any public agency interested in this Agreement has any pecuniary interest in the business of CONSULTANT and that no person associated with CONSULTANT has any interest that would constitute a conflict of interest in any manner or degree as to the execution or performance of this Agreement. G. Entire Agreement This Agreement supersedes any and all prior agreements, whether oral or written, between the parties hereto with respect to the rendering of services by CONSULTANT for CITY and contains all the covenants and agreements between the parties with respect to the rendering of such services in any manner whatsoever. Each party to this Agreement acknowledges that no representations, inducements, promises or agreements, orally or otherwise, have been made by any party, or anyone acting on behalf of any party, which are not embodied herein, and that no other agreement, statement or promise not contained in this Agreement shall be valid or binding. No other agreements or conversation with any officer, agent or employee of CITY prior to execution of this Agreement shall affect or modify any of the terms or obligations contained in any documents comprising this Agreement. Such other agreements or conversations shall be considered as unofficial information and in no way binding upon CITY. 4835 - 2267 -03610 LAN4706083 -7- H. Governing Law and Venue This Agreement shall be governed by and construed in accordance with the laws of the State of California without regard to the conflict of laws provisions of any jurisdiction. The exclusive jurisdiction and venue with respect to any and all disputes arising hereunder shall be in state and federal courts located in Santa Clara County, California. I. Notices Any notice to be given hereunder by either party to the other may be effected either by personal delivery in writing or by mail, registered or certified, postage prepaid with return receipt requested. Mailed notices shall be addressed to the parties at the addresses appearing in Exhibit "A ", Section V.H. but each party may change the address by written notice in accordance with this paragraph. Notices delivered personally will be deemed delivered as of actual receipt; mailed notices will be deemed delivered as of three (3) days after mailing. J. Partial Invalidity If any provision in this Agreement is held by a court of competent jurisdiction to be invalid, void or unenforceable, the remaining provisions will nevertheless continue in full force without being impaired or invalidated in any way. K. Time of the Essence All dates and times referred to in this Agreement are of the essence. L. Waiver CONSULTANT agrees that waiver by CITY of any one or more of the conditions of performance under this Agreement shall not be construed as waiver(s) of any other condition of performance under this Agreement. Executed at Gilroy, California, on the date and year first above written. CONSULTANT: CITY: Innovative Claims Solutions, Inc. CITY OF GILROY By: Z Social Security or Taxpayer Identification Number (A 70 1��h 4835- 2267 -03610 LAM04706083 By: Name: Gabriel A. Gonzalez Title: City Administrator Approved as to Form City Attorney 4835 - 2267 -0361v1 LAC104706083 EXHIBIT "A" SPECIFIC PROVISIONS I. PROJECT MANAGER CONSULTANT shall provide the services indicated on the attached Exhibit "B ", Scope of Services ( "Services "). (All exhibits referenced are incorporated herein by reference.) To accomplish that end, CONSULTANT agrees to assign Cheryl Westeren, who will act in the capacity of Project Manager, and who will personally direct such Services. Except as may be specified elsewhere in this Agreement, CONSULTANT shall furnish all technical and professional services including labor, material, equipment, transportation, supervision and expertise to perform all operations necessary and required to complete the Services in accordance with the terms of this Agreement. II. NOTICE TO PROCEED /COMPLETION OF SERVICE A. NOTICE TO PROCEED CONSULTANT shall commence the Services upon delivery to CONSULTANT of a written "Notice to Proceed ", which Notice to Proceed shall be in the form of a written communication from designated City contact person(s). Notice to Proceed may be in the form of e-mail, fax or letter authorizing commencement of the Services. For purposes of this Agreement, LeeAnn McPhillips shall be the designated City contact person(s). Notice to Proceed shall be deemed to have been delivered upon actual receipt by CONSULTANT or if otherwise delivered as provided in the Section V.H. ( "Notices ") of this Exhibit "A ". B. COMPLETION OF SERVICES When CITY determines that CONSULTANT has completed all of the Services in accordance with the terms of this Agreement, CITY shall give CONSULTANT written Notice of Final Acceptance, and CONSULTANT shall not incur any further costs hereunder. CONSULTANT may request this determination of completion when, in its opinion, it has completed all of the Services as required by the terms of this Agreement and, if so requested, CITY shall make this determination within two (2) weeks of such request, or if CITY determines that CONSULTANT has not completed all of such Services as required by this Agreement, CITY shall so inform CONSULTANT within this two (2) week period. III. PROGRESS SCHEDULE The schedule for performance and completion of the Services will be as set forth in the attached Exhibit "C ". IV. ' PAYMENT OF FEES AND DIRECT EXPENSES Payments shall be made to CONSULTANT as provided for in Article 4 of this Agreement. 4835 - 2267 -0361 v1 LAC104706083 Direct expenses are charges and fees not included in Exhibit "B ". CITY shall be obligated to pay only for those direct expenses which have been previously approved in writing by CITY. CONSULTANT shall obtain written approval from CITY prior to incurring or billing of direct expenses. Copies of pertinent financial records, including invoices, will be included with the submission of billing(s) for all direct expenses. V. OTHER PROVISIONS A. STANDARD OF WORKMANSHIP CONSULTANT represents and warrants that it has the qualifications, skills and licenses necessary to perform the Services, and its duties and obligations, expressed and implied, contained herein, and CITY expressly relies upon CONSULTANT'S representations and warranties regarding its skills, qualifications and licenses. CONSULTANT shall perform such Services and duties in conformance to and consistent with the standards generally recognized as being employed by professionals in the same discipline in the State of California. Any plans, designs, specifications, estimates, calculations, reports and other documents furnished under this Agreement shall be of a quality acceptable to CITY. The minimum criteria for acceptance shall be a product of neat appearance, well- organized, technically and grammatically correct, checked and having the maker and checker identified. The minimum standard of appearance, organization and content of the drawings shall be that used by CITY for similar purposes. B. RESPONSIBILITY OF CONSULTANT CONSULTANT shall be responsible for the professional quality, technical accuracy, and the coordination of the Services furnished by it under this Agreement. CONSULTANT shall not be responsible for the accuracy of any project or technical information provided by the CITY. The CITY'S review, acceptance or payment for any of the Services shall not be construed to operate as a waiver of any rights under this Agreement or of any cause of action arising out of the performance of this Agreement, and CONSULTANT shall be and remain liable to CITY in accordance with applicable law for all damages to CITY caused by CONSULTANT'S negligent performance of any of the services furnished under this Agreement. C. RIGHT OF CITY TO INSPECT RECORDS OF CONSULTANT CITY, through its authorized employees, representatives or agents, shall have the right, at any and all reasonable times, to audit the books and records (including, but not limited to, invoices, vouchers, canceled checks, time cards, etc.) of CONSULTANT for the purpose of verifying any and all charges made by CONSULTANT in connection with this Agreement. CONSULTANT shall maintain for a minimum period of three (3) years (from the date of final payment to CONSULTANT), or for any longer period required by law, sufficient books and records in accordance with standard California accounting practices to establish the correctness of all charges submitted to CITY by CONSULTANT, all of which shall be made available to CITY at the CITY's offices within five (5) business days after CITY's request. 4835 - 2267 -0361v1 _2_ LAC104706083 D. CONFIDENTIALITY OF MATERIAL All ideas, memoranda, specifications, plans, manufacturing procedures, data (including, but not limited to, computer data and source code), drawings, descriptions, documents, discussions or other information developed or received by or for CONSULTANT and all other written and oral information developed or received by or for CONSULTANT and all other written and oral information submitted to CONSULTANT in connection with the performance of this Agreement shall be held confidential by CONSULTANT and shall not, without the prior written consent of CITY, be used for any purposes other than the performance of the Services, nor be disclosed to an entity not connected with the performance of the such Services. Nothing furnished to CONSULTANT which is otherwise known to CONSULTANT or is or becomes generally known to the related industry (other than that which becomes generally known as the result of CONSULTANT'S disclosure thereof) shall be deemed confidential. CONSULTANT shall not use CITY'S name or insignia, or distribute publicity pertaining to the services rendered under this Agreement in any magazine, trade paper, newspaper or other medium without the express written consent of CITY. E. NO PLEDGING OF CITY'S CREDIT. Under no circumstances shall CONSULTANT have the authority or power to pledge the credit of CITY or incur any obligation in the name of CITY. F. OWNERSHIP OF MATERIAL. All material including, but not limited to, computer information, data and source code, sketches, tracings, drawings, plans, diagrams, quantities, estimates, specifications, proposals, tests, maps, calculations, photographs, reports and other material developed, collected, prepared (or caused to be prepared) under this Agreement shall be the property of CITY, but CONSULTANT may retain and use copies thereof subject to Section V.D of this Exhibit "A ". CITY shall not be limited in any way in its use of said material at any time for any work, whether or not associated with the City project for which the Services are performed. However, CONSULTANT shall not be responsible for, and City shall indemnify CONSULTANT from, damages resulting from the use of said material for work other than PROJECT, including, but not limited to, the release of this material to third parties for work other than on PROJECT. G. NO THIRD PARTY BENEFICIARY. This Agreement shall not be construed or deemed to be an agreement for the benefit of any third party or parties, and no third party or parties shall have any claim or right of action hereunder for any cause whatsoever. 4835 - 2267 -03610 _3 LAM04706083 H. NOTICES. Notices are to be sent as follows: CITY: LeeAnn McPhillips, Human Resources Director /Risk Manager City of Gilroy 7351 Rosanna Street Gilroy, CA 95020 CONSULTANT: Innovative Claims Solutions, Inc. Attention: Gary Archibald, President/CIO 11344 Coloma Road, Suite 745 Gold River, CA 95670 I. FEDERAL FUNDING REQUIREMENTS. ❑ If the box to the left of this sentence is checked, this Agreement involves federal funding and the requirements of this Section V.I. apply. ® If the box to the left of this sentence is checked, this Agreement does not involve federal funding and the requirements of this Section V.I. do not apply. 1. DBE Program CONSULTANT shall comply with the requirements of Title 49, Part 26, Code of Federal Regulations (49 CFR 26) and the City- adopted Disadvantaged Business Enterprise programs. 2. Cost Principles Federal Acquisition Regulations in Title 48, CFR 31, shall be used to determine the allowable cost for individual items. 3. Covenant against Contingent Fees The CONSULTANT warrants that he /she has not employed or retained any company or person, other than a bona fide employee working for the CONSULTANT, to solicit or secure this Agreement, and that he /she has not paid or agreed to pay any company or person, other than a bona fide employee, any fee, commission, percentage, brokerage fee, gift or any other consideration, contingent upon or resulting from the award or formation of this Agreement. For breach or violation of this warranty, the Local Agency shall have the right to annul this Agreement without liability or, at its discretion, to deduct from the agreement price or consideration, or otherwise recover, the full amount of such fee, commission, percentage, brokerage fee, gift or contingent fee. 4835 - 2267 -0361v1 LAC104706083 EXHIBIT "B" SCOPE OF SERVICES The proposal submitted to the City of Gilroy by Innovative Claims Solutions, Inc. for Workers Compensation Third Party Claims Administration Services is attached and incorporated to this agreement and describes the services that shall be rendered under this agreement. Changes from the original proposal that have been agreed upon by the parties are stated in this agreement. 4835 - 2267 -03610 _ LAM04706083 _ 1 City of Morgan Hill and City of Gilroy Proposal for Workers' Compensation Claim Administration Marcia 2 016 Prepared and presented by: VAVO%,^ Innovative Claim Solutions, Inc. i Sacramento Area Office 11344 Coloma Road, Suite 745 Gold River, CA 95670 Contact: Gary Archibald, CIO and President (916) 852 -8588 Ext. 201 garchibald @ics- claims.com Bay Area Office 2430 Camino Ramon. Suite 200 San Ramon, CA 94583 Contact: Cheryl Westeren, COO and President (925) 904 -2400 cwresteren @ics- claims.com T A"N Cr Innovative Claim Solutions, Inc. ZVV48MY www.ics- claims.com 1 800.427.5511 Ali A Workers' Compensation Claims Administrator serving your needs in California Office of the City Clerk City of Morgan Hill Finance Department — Attention Purchasing Coordinator City of Gilroy Re: City of Morgan Hill and City of Gilroy Workers' Compensation Claims Administration Services Innovative Claim Solutions, Inc. is pleased to submit a proposal to continue claims administration services for the City of Pleasanton. We have been providing these services since 2011 and have achieved very positive results during this time. ICS takes a different approach to the administration of workers' compensation claims in California. The Workers' Compensation industry is changing rapidly every day. Constantly new laws, regulations, programs, and directions bombard us. Innovative Claim Solutions, Inc. has the answers for all of your workers' compensation problems both for today and for tomorrow. We fully understand the claims administration process and are committed to providing our clients with quality claims administration as well as ensuring that their most valuable asset — their employees - receive timely benefits and medical care which allows a prompt return to work. Providing optimal results requires a precarious balance between assertive claims management, litigation avoidance, fraud awareness, staff retention and customer service. We feel we have achieved that balance and the results attained on your program have been verified. ICS is one of the few remaining stand -alone third party claims administrators who do not sell ancillary services. We focus on the one thing we do best — managing our clients' claims. We team with our clients to select the best in class for every vendor and provider involved with claims management. We think that claims handling is the most important piece and should not be the loss leader to support other services. We feel it is in our client's best interest to retain the best in each field — the best in claims handling, bill review, utilization review, investigation, litigation defense and all other medical management facets. We want to ensure that these cost saving tools are utilized only when necessary and want to avoid the enticement to use these services to bolster our bottom line. Both Gary Archibald and Cheryl Westeren would be the individuals with authority to bind the proposal during the period in which the City is evaluating the proposal. Please do not hesitate to reach me 800 -427 -5511, 916- 852 -0642 fax, PO Box 2070, Rancho Cordova, CA, 95741, or e-mail at aarchibald(d_)ics- claims.com, if you have any questions. Sincerely, Gary Archibald President and CIO Rancho Cordoaa P.O. Box 2070, Rancho Cordova, CA 95741 -2070 1 S.in R..;nnn P.O. Box 5128, San Ramon, CA 94583 -5138 City of Morgan Hill /City of Gilroy Response to Request for Proposal 1. Submit a cover letter that contains the name, title, address and telephone number of the individual(s) with authority to bind the proposal during the period in which the ENTITY is evaluating the proposal. The bidder shall also identify the legal form of their firm, i.e., sole proprietor, partnership, corporation, etc. If the firm is a corporation, the cover letter shall identify the state in which the firm was incorporated. The cover letter shall be signed by a principal of the firm or other person fully authorized to act on behalf of the firm. Our cover letter has been included in this proposal. 2. The Written Proposal shall include references and experience of the proposer. A. Please give a brief description of proposer including: • Names and background of principal owners, partners, or officers including a resume detailing experience, • Length of time the firm has been in business of administering workers' compensation claims, • Number of offices and locations, • Office that would service the city's claims, and • Office that would service the city for loss data or functions other than claims adjusting. Innovative Claims Solutions, Inc. is a California corporation since August of 2000 and owned and operated by Gary Archibald, CIO and Cheryl Westeren, COO. We have been exclusively administering workers compensation claims for California employers since inception. Currently ICS administers workers' compensation claims for 27 cities, 2 counties, 2 fire districts and 34 housing authorities. Our experience provides not only expert claims administration but also resources for issues such as new legislation and case law, LC 4850, Presumptions, ADA, volunteers, seasonal employment and TD rates, coordination with PERS retirement programs, return to work, coordination with the Interactive Process for permanent accommodation and many others. We offer cities, counties, districts and joint powers authorities' quality programs that keep pace with the complex business of managing workers' compensation claims in California. Our Management Team has been recognized within the industry as experts in their field. We have provided presentations at such organizations as PARMA, COSIPA, VICA, CALPELRA, the University of California at Davis, and at CSAC -EIA. Currently, ICS has 37 full time staff, 15 of which are claims examiners. We have two claim offices: TA"%CA Innovative Claim Solutiom, Inc. i %./ V.,7 City of Morgan Hill /City of Gilroy 3 2430 Camino Ramon, Suite 200 San Ramon, 94583 925 - 327 -8050 925 - 327 -8078 fax 888 -427 -2424 11344 Coloma Rd., Suite 745 Gold River, CA 95670 916- 852 -8588 916- 852 -0642 800427 -5511 We propose administration of this workers' compensation program out of our San Ramon office. The Gold River office would be responsible for all loss data functions. Contact Person For purposes of this proposal, the contact person is Gary Archibald, President and CIO and he is listed above at our Gold River location. Gary is currently responsible for overseeing all Information Systems, Marketing, New Product Development, Customer service and Educational Operations for ICS. His email address is: garchibaid(@-ics- claims.com, phone# 916- 852 -8588, and fax # 916- 852 -0642. B. Please advise whether there are any major changes (e.g. relocation of firm /consolidation) planned for proposer during the next 12 months. ICS does not anticipate any changes in the next 12 months. C. Identify the specific personnel (including supervisory and management) who would be assigned to administer City's claims. In addition, provide detailed responses to the following: • The position each individual occupies; • The education, years, and type of experience of each (Please attach a resume or curriculum vitae); • The experience each has adjusting California public agency claims, and municipal government (city or county) claims in particular, • The length of time each individual has been with the proposer, • The percentage of time each is in the office versus the field, • The job duties of each outside the office, and • The caseload for every person assigned to handle any portion of the City's claims. Cheryl Westeren, President and COO, and Angela Argiros, Vice President of Operations will handle account management for your program. Both of their resumes are attached in our section labeled Staff Resumes. Cheryl has over 38 years' experience in the workers' compensation claims field and has been administering claims for public agencies since 1980. Cheryl has been with ICS since 1993 and spends 80% of her time in the office. Time spent out of the office usually involves meeting with our client or training at client locations or attendance at various industry related conferences. T AM C% Innovative Claim Solwimis, Inc. - L%./V.7 City of Morqan Hill /City of Gilroy 4 Angela has over 26 years of experience in worker's compensation claims and has been administering claims for public agencies since 1990. Angela has been with ICS since 1997 and spends over 90% of her time•in the office. Time spent outside of the office usually involves client meetings or training. Angela will be available to handle selected, sensitive claims at client's request. Janie Tebb, Unit Manager, will handle claims supervision for your program. Janie's resume is also located in our section labeled Staff Resumes. Janie has over 23 years' experience in the workers' compensation claims field including public agency experience. Janie has been with ICS since 1997 and spends 95% of her time in the office. Time spent outside of the office usually involves attendance at client meetings. Janie will not have a caseload and can also handle sensitive claims at the client's request. Dan Stovall, Senior Claims Examiner has been the examiner on your program for the last five years. Dan has over 23 years' experience, with over 15 years of public agency experience. Dan has been with ICS for over nine years and spends 95% of his time in the office. Time outside the office is for client meetings and training and education. Dan's total caseload would not exceed 150 open indemnity claims. Please refer to the Staff Resumes section of this proposal for more information on our staffing. D. Provide a list of clients for which similar types of claims - related services are currently provided, preferably in the Northern California area. Please include the name, title, and phone number of three people, in three different companies, other than the requesting City, whom the City can contact to discuss the proposer's performance. Margarita Zamora, Employee Relations Manager, City of Berkeley, (510) 981 -6821, mzamora(_)ci.berkeley.ca.us. ICS client since 2000 Debra Gill, HR Manager, City of Pleasanton, (925)931 -5054, dgilci.pleasanton.ca.us. ICS client since 2001 Janet Hamilton, Risk Manager, City of Livermore, (925) 960 -4172, ilhamilton (a-)-cityoflivermore.net. ICS client since 1998 The following is a listing of additional Public Agency clients. Contact information is available upon request. Bay Cities JPIA (comprised of 16 cities in the Bay Area) California Housing Authority JPA (comprised of 34 housing authorities around the state) City of Benicia City of Daly City City of Fairfield City of Millbrae City of Vacaville County of Kings twovadve 'Y C 1.%.*t. Y City of Morgan Hill /City of Gilroy 5 County of Merced Town of Los Gatos Menlo Park Fire District San Ramon Fire District E. Provide a list of clients who have elected to contract with other TPA's during the past 24 months. No clients have elected to contract with other TPA's during the past 24 months. F. Identify any owned ancillary services. There are no owned ancillary services provided by ICS. 3. Describe how your TPA ensures compliance with workers' compensation statutes and rules and regulations promulgated by the Department of Industrial Relations. ICS management staff has responsibility for reviewing and developing ICS procedures and manuals to ensure that we are in compliance with statutes, rules and regulations promulgated by the Department of Industrial Relations. We receive regular notices from the DWC on new regs and procedures. We also access other resources including WorkCompCentral and defense attorney newsletters and updates. All new rules and regulations are incorporated in the ICS Procedure Manual. ICS has regular in -house training classes for staff on our procedures for implementation of any changes due to DIR rule or regulation changes. Unit Managers review all claim files on a regular basis to ensure that staff are following any new guidelines or procedures. We also provide updated information to our clients pertaining to any changes in legislation that would impact their operations, and periodically host seminars when major changes are taking place. Attendance is offered to our client's at no additional charge. 4. Please indicate whether the proposer can comply with the SCOPE OF WORK as outlined in Section III, above. ICS can comply with the SCOPE OF WORK as outlined in Section III with the following exceptions: ICS has established examiner caseloads and communications standards with the employer, injured worker and physician that are in compliance with the LAWCX mandatory claims administration standards as detailed in the Claims Management Policy that all LAWCX members must adhere to. Under #12, Medical Payments, ICS proposes that we will oversee "complete medical management services" but many of these services will be contracted out and paid off the claim file such as Bill Review Services, Utilization Review and Nurse Case Management. TA ACr lnwvatiw Claim Solutions, Inc. .L %0# UJ City of Morqan Hill /City of Gilroy g Under #25, Loss Runs, the Requests for status of claims will be generated by our computer system. Claim Review information will be delivered by the examiner when formal claim reviews take place. Additionally, while ICS offers quarterly claim reviews to all clients, the number of files prepared in writing for presentation are for a select number of targeted claims, and is limited to 10% of each examiner's caseload. We want to ensure the number of claim reviews each examiner must prepare can be completed by the examiner while still maintaining all other performance standards. On the other hand, we offer all clients on -line access which allows them to view all claim details, including up to date plans of action, medical report synopsis and all other claim details. 5. Please describe any services not previously covered which you believe may be of particular value to the ENTITY, such as provider and facility networks, on -line access to claim files, litigation management, etc. Program Reviews, Training and Experience Our most prestigious service is our Annual Program Reviews. We provide our clients with a detailed report showing trends and costs in many aspects of their claims. This extensive review also shows results for bill review, excess and subrogation recoveries, settlements, denials, and lag time for reporting. ICS Management has provided hundreds of training sessions at no cost for our clients' supervisors dealing with workers' compensation law changes, procedures, and new programs. ICS and our staff have extensive experience in handling claims in your geographic area and we are uniquely aware of the challenges you face with medical care, vendors and applicants bar. ICS provides service and programs that support several innovative opportunities for cost containment on behalf of our clients. What follows is a description of what we feel are some key areas, programs and unique philosophies that have helped reduce the worker's compensation costs on our client's programs. Employee Advocacy We feel we have a unique approach to interaction with injured workers at ICS. We refer to it as out `Employee Advocacy' philosophy. As part of this philosophy we focus on recognizing that your injured employees are our customers, and interact with them accordingly. We hope to have an opportunity to explain this approach in more detail. The bottom line is we want your employees to view our examiners as part of the solution, not part of a problem. With this core philosophy our clients have experienced reduced litigation and faster closing ratios thus saving our clients money. ! J"% C n�a�'m 0— so City of Morqan Hill/City of Gilroy 7 Litigation Management The above described philosophy is also the first step towards litigation management, by avoiding litigation to start with. For those occasions where litigation is unavoidable, we have developed extensive procedures for litigation management. The purpose of the ICS litigation management program is to reduce the client's overall cost of risk, taking into consideration both loss and cost factors in litigated claims. ICS accomplishes this by taking a proactive approach to litigation. We encourage and foster early resolution. We closely monitor the activities of defense counsel and hearing representatives to assure early disposition. It is contrary to ICS' operating procedures for the examiner to relegate claims handling tasks to a defense attorney or hearing representative. Rather, the claims examiner will continue to actively manage all such litigated claims. The mere fact that a claim goes into litigation is insufficient cause to trigger outside referral. ICS' preference in many cases is that the claims examiners continue with the day -to -day handling of the claim. The second choice is referral to a qualified defense attorney with the client's concurrence. When a defense attorney is optioned, ICS holds defense counsel to strict standards of reporting frequency, report content, cost containment, billing protocol and overall handling. Attorneys will not be authorized to perform or be reimbursed for tasks that are the responsibility of ICS. This program is described in more detail in the Scope of Work section of the proposal. ICS is a huge proponent of early return to work, modified duty and early intervention disability management programs. We would work with the Client to customize our approach to any programs you have in place at this time, or will work with the County to create a program that is specific to their needs. ICS has worked with many different client programs and designated consultants. Iniury Management Partnership Program We also suggest the creation of a customized Medical Referral Form designed to optimize results and communication with treating physicians. The goal of such a form would be to force the treating physician to outline detailed work restrictions on every patient at every visit, or explicitly explain why that is not feasible. We find this to be a valuable tool in supporting return to work programs. Once specific work restrictions have been outlined, or confirmation obtained that the employee has been removed from work, we work to ensure those details have been shared with the designated person for each client immediately so that accommodations can be evaluated at the earliest possible time. We focus on what we call the 'window of opportunity' which is the first 72 hours following an injury. If we can return employees to work, even in a modified duty capacity, within this window we can help our clients avoid the high costs of temporary disability associated with indemnity claims. TJ1CA Imovafi a CW. S..—, Inc. i %.1 V.Y City of Morgan Hill /City of Gilroy 8 ICS suggests establishing procedures, protocols and performance standards for your designated medical clinics, along with the development of customized medical referral forms, as mentioned above. We have worked to develop these standards with other clients, and compile all of the information into booklets. We then suggest meetings be scheduled with your providers to advise of these standards and engage them as partners. We refer to this program as our Injury Management Partnership Program. This heightened level of communication and "partnerships" with the provider network have resulted in optimal treatment and disability cost savings. Utilization Review Triggers We would like to draw your attention to our Utilization Review procedures and triggers described in the Scope of Work addendum of this proposal. We feel our customized referral triggers allow our clients to control medical expenses and duration of treatment without increasing litigation, or expending more funds than are cost effective for use of this tool. On -Line Access ICS provides on -line access to the claim files to designated representatives of our Client. This access includes payment history, claim notes and letters. Clients can print out information from the claim system at their own location. Clients can input new claims directly in to the claim system or by using our internet reporting system. Please refer to our proposal for more extensive descriptions of all of these services and procedures. There are many other customized programs, procedures and resources that are available to our clients, all of which are detailed in our proposal. 6. Please provide a proposed Service Fee Schedule including an estimated annual cost to the City for each of the two years of the contract. ICS offers the City of Morgan Hill and the City of Gilroy the following pricing structure based on a cap of 150 open indemnity claims for the examiner and all other services detailed in our proposal. Fee Proposal: For City of Morgan Hill Flat Annual Fee First Year $34,380 Flat Annual Fee Second Year $34,700 For City of Gilroy Flat Annual Fee First Year $89,000 Flat Annual Fee Second Year $90,000 T AVON r Innovative Claim Solonoov. Inc. i<IV J City of Morqan Hill /City of Gilroy g The above described fees are based on the following assumptions: • Open Indemnity inventory of approximately 24 and 68 claims respectively and all open medical only claims Should the open Indemnity Claim inventory at time of conversion, or the new Indemnity claim submissions increase or decrease by more than 10 %, resulting in a change to the actual open inventory, ICS will contact the Client to negotiate an increase or decrease in fees, as appropriate. We propose continuing to staff these programs with the same senior claim examiner and staff who have been assigned since beginning with ICS in 2011. As a result, the costs are likely higher than other bids as ours reflect the higher salary commanded by individuals with this much experience who have been with ICS for many years. There are no extra fees for: • Account Management • Annual Administration • Medicare Reporting • Examiner handling of subrogation • Monthly Adjustments for open inventory • Claim Reviews • Client Meetings • Standard and most Ad Hoc reports • Internet claim reporting • On -line access to claim system • Legislative and Case Law Updates • Training Programs There is NO Cost for claims data conversion as we are your current TPA. If each ENTITY requires ICS to establish and maintain a bank account there is an annual banking fee of $5,000 for each ENTITY. If the ENTITY manages and reconciles their own account, and simply provides ICS check writing and signing authority, there are no additional fees. 7. It is expected that there will be approximately 24 open files for the City of Morgan Hill and approximately 53 for the City of Gilroy that will be transferred to the new TPA. The proposer must state whether or not the cost of handling these existing open files are included in the annual fee quoted above. If not, then proposer shall indicate the costs for these existing open files. In addition, the proposal should discuss how the new TPA would organize and plan for a smooth transition of files with the least amount of disruption to the ENTITY and its employees. City of Morgan Hill /City of Gilroy 10 Our proposal includes administration of all old and new claims. While the above states the City of Gilroy has 53 open files, we notice that there are an additional 15 future medical files that would bring the total to 68 open indemnity files. Since we are your current TPA there is no transition or disruption to the Entity and its employees. 8. The proposal must indicate that the TPA agrees to be bound by the proposal and shall enter into a contract to provide services in a form as approved by the ENTITY. ICS agrees to be bound by the proposal and will enter into a contract to provide services in a form as approved by the City. 9. The proposal must be valid for one hundred and twenty (120) calendar days from the final submission date of bids. ICS agrees to our proposal being valid for one hundred and twenty (120) calendar days from the final submission date of bids 10. Samples of computer - generated reports must accompany the proposal. Please see the RMIS Addendum in this proposal where we have included sample computer - generated reports. TA"''%C Innovative Claim Solutions, Inc. i. %./'1111111.0 City of Morqan Hill /City of Gilroy 11 Staff Resumes Innovative Claim Solutions, Inc. actively recruits only those individuals who can fully embrace the ICS philosophy and who meet the training and experience requirements for each position. ICS is also an equal opportunity employer. Senior examiners are required to be certified by the state of California Self- Insurance Plans and must have at least five (5) years' experience administering claims. Resumes of the principal management team of Innovative Claim Solutions, Inc. can be found immediately following this section. Our management team works to transition all new clients to ICS to ensure timely benefits delivery during the initial process of transition. The management team is also involved in every aspect of the day -to -day claims operation of your program. City of Morqan Hill /City of Gilroy 12 Gary A. Archibald President and CIO An industry professional with forty years' experience, several being dedicated to the management of various private and public workers' compensation programs and fourteen years experience in staff management, development and training, case control, medical management and settlements. Strengths include: • Development of successful cost - containment programs • Team development and training • Loss prevention programs • Client program coordination Professional Experience Innovative Claim Solutions, Inc. President, CIO, Workers' Compensation 1996 to Present • Direct and manage on -site and regional workers' compensation operations. Develop procedures and assess workflow and staffing needs. Coordinate communications between operations staff and clients. Responsible for program coordination and reviews. Responsible for new business development and all IMS services. Claims Management Inc., 1985 -1996 Executive Vice President, Claims Management • Responsible for minimal caseload involving reserving, medical management, paralegal work -up, case control and settlements. Supervised the work of all claims examiners including training and development. Responsible for quarterly review and program coordination with all CMI clients. Also responsible for all administrative operations of 135 employee third party administrator. County of Sacramento Workers' Compensation Specialist 1981 -1985 • Responsible for the administration and management of the workers' compensation programs for the various Sacramento County departments, including Sheriff, District Attorney, Marshal, and Coroner. Initiated and implemented programs for employee stress counseling, light -duty assignment, long -term job modification and medical management. Reviewed and updated operating manuals, reporting forms, and benefit notices. Reviewed and made recommendations on disability retirement applications. ThC I im- Claim Sol—m. Inc. \.I 1111!J City of Morqan Hill /City of Gilroy 13 California Casualty Insurance Company Claims Adjuster 1979 -1981 • Investigated and handled claims of automobile and liability losses for insurers including the California Teachers' Association. Negotiated and settled cases. Advised counsel on defenses. Pursued subrogation and contributions from all sources involved in claims. Liberty Mutual Insurance Company Senior Claims Adjuster Education and Certification 1976 -1979 • Bachelor of Arts, Communications Studies, CSU, Sacramento, 1975 • Instructor, University of California, Davis, 1980 - Present • University of California Davis 1991 Instructor of the Year Award • Instructor, Insurance Education Association, 1985 - Present • Written test for Administrator, Self Insurance Plans, 1982 • Permanent Disability Rating, VICA, 1978 and Alumni Campus Advancement Award, CSUS, 1975 'T J"% CC i. \.I fJ City of Morqan Hill /City of Gilroy 14 Cheryl Westeren President and COO A Workers' Compensation specialist, with thirty -eight years' experience managing programs for a variety of clientele including both public and private sector. Over thirteen years experience in management, with recent emphasis on transition of large programs, staffing and restructuring offices. Major strengths include: • Procedure development • Training and education • Motivating and team development • Assessing work flow strategies • Transition game - planning Professional Experience Innovative Claim Solutions, Inc. 1993 to Present President, COO, Workers' Compensation • Direct and manage on -site and centralized workers' compensation operations. Responsible for coordinating communications between operations staff and clients. Liaison for operations and senior management. Develop and integrate MIS into operations. Develop procedures and assess workflow and staffing needs. Responsible for client satisfaction with operational work product. Associated Claims Management, Inc Vice President 1985 to 1993 • Developed from Senior Claims Examiner to Vice President of ACMI's Pleasanton operation with a staff of approximately ninety employees servicing forty clients. Liaison between all operation offices and MIS. Key in developing procedures and computerization of claims examiner capabilities. Developed annual reports for all Pleasanton clients and regularly assisted with trend analysis. Scott Wetzel Services Senior Claims Examiner 1984 to 1983 • Managed caseload of 300 files while training and mentoring Junior Examiner. Directed work of claims assistant and maintained communications with clients. To—Net City of Morgan Hill /City of Gilroy 15 UR Insurance Services, Inc. Claims Examiner 1978 to 1983 • Progressed through all technical support positions. Evolved from Claims Assistant and Medical Only Examiner to Claims Examiner. Trained technical support staff and developed medical only suspense system. Certifications • Self- Insurance Administrator, 1986 • Insurance Education Association, Diablo various Workers' compensation seminars. Valley Industrial Claims Association and City of Morgan Hill /City of Gilroy 16 Angela Argiros Vice President of Operations A state - certified workers' compensation management specialist for the last twenty -six years, Angela directs claims management for ICS ensuring adherence to policy, procedures, and philosophies. Major strengths include: • Policy and Procedure development • Training and education • Motivating and team development • Assessing work flow strategies • Loss prevention programs • Client program coordination Professional Experience Innovative Claim Solutions, Inc. 1997 to Present Director of Claims 2000 to Present Unit Manager 1997 to 2000 • Responsible for program management and oversight of several public and private agencies. Manage claim staff of examiners, assistant, and technicians. This includes but is not limited to medical management, monitoring of disability and 4850 benefits, litigation, subrogation recoveries, vocational rehabilitation, calculation and preparation of benefits and settlements. Attend regular scheduled claim reviews and other client meetings as necessary. CIGNA Claims Manager 1993 to 1997 • Directed claims management of self- insured and insured programs ensuring adherence to policy. Managed 7 Supervisors, 40 claims examiners and clerical support staff. Reported directly to the Claims Vice - President. Associated Claims Management Services Claims Examiner 1990 to 1992 • Managed a 200 caseload. Investigation of claims, administration of benefits to injured employees, setting claim reserve levels and negotiations of claim settlements. TA"1CC I ... v i,e G.- SoWl —, Inc. & %.,o City of Morqan Hill /City of Gilroy 17 San Francisco French Bread Company 1984 to 1990 Administrator of Industrial Relations Supervised workers' compensation claims program and safety program. Worked directly with Director of Industrial Relations on several projects, including, union contracts employee relations, and recruitment. Education and Certification • California Self- Insurance Certification 1990 • IEA Certification City of Morqan Hill /City of Gilroy 18 Janie Tebb Unit Manager A Workers' compensation Unit Manager with over twenty -three years' experience in claims administration, client and claimant communications, and modified duty, return to work programs. Major strengths include: • Workflow organization and management • Excellent communication skills • Claim resolution Professional Experience Innovative Claim Solutions, Inc. Unit Manager 1997 - Present 2004 - Present Claims Examiner, Workers' Compensation 1997-2004 Responsible for an increasingly complex caseload, in -depth and frequent communication with the account and injured worker to ensure a proactive plan of action is in place in each claim file. Responsible for establishing appropriate and timely reserves. Direct medical providers and utilize cost containment programs when applicable. Attend WCAB & Rehabilitation Unit appearances, whenever possible, to keep defense attorney expenditures to a minimum. Work directly with applicant's attorneys to negotiate fair resolution of claims. Responsible for all phases of claims management including litigation and vocational rehabilitation. Pacific Eagle Insurance Company. 1993- 1997 State Act Claims Representative Responsible for all aspects of both State Act and Longshore jurisdictions as well as handling the day to day concerns of the Northern California branch office. Education & Certifications • IEA Certified, SIP Certified. Graduated Cal -Poly, with a major in British Literature, 1989 Honors: Dean's List TA"NCt Innovative Claim Soluenns, Inc. City of Morqan Hill /City of Gilroy 19 Dan Stovall Claims Examiner A workers' compensation claims examiner with twenty -three years' experience in claims administration, client and claimant communications, modified duty and return to work programs. Major strengths include: • Workflow organization and management • Claim resolution • Claims administration Professional Experience Innovative Claim Solutions, Inc. April 2006 to Present Senior Claims Examiner Responsible for all aspects of managing an indemnity caseload, to include medical management, monitoring and management of 4850 and temporary disability benefits, obtaining work restrictions and working with clients to return employees to regular or modified duty as early as possible. Also responsible for litigation management, subrogation management and recoveries, calculation and preparation of benefits and settlements, communication with clients and injured workers and maintenance of appropriate reserves on all claims. Regularly attends client meetings and presents claims, attending other client meetings, as necessary. Attends WCAB hearings, as required. Zenith Insurance 1993 —2006 Claims Examiner ACMI 1992-1993 Claims Assistant Education & Certificates: • SIP certification — 1999 • B.A. degree in Business Administration from California State University, Hayward • IEA Administrator certificate • Strategic Negotiation certificate, Pepperdine University TA"'%CA Innovmive Claim Solmions, Inc. JL 1111111.0 V1.JT City of Morqan Hill /City of Gilroy 20 Scope of Work Innovative Claim Solutions, Inc. takes pride in its systems and its people. We feel a balanced combination of both provide our clients with a working atmosphere that greatly enhances and improves their claims administration program. What follows is a description of key service areas in the execution of our claims management program. Caseloads ICS standard calls for each examiner to handle no more than 150 open indemnity claims including resolved future medical and companion claims on a rolling quarterly average. Caseloads are reviewed each month to make sure staff is in compliance with this standard. Communication In serving our clients, we recognize that there are two customers: the employer and the employee. Each has very different needs and must be communicated within a manner appropriate to their needs. We feel we have a unique approach to interaction with injured workers at ICS. We refer to it as out `Employee Advocacy' philosophy. As part of this philosophy we focus on recognizing that your injured employees are our customers, and interact with them accordingly. The bottom line is we want your employees to view our examiners as part of the solution, not part of a problem. Our communications with your injured worker begins when ICS is notified of a new lost time injury. This initial telephonic communication is part of our 24 -hour strategy. It is vital that immediate communication begins with the injured employee to address any questions or concerns, explain compensation benefits and review the processes to come. Additionally we obtain factual information surrounding this incident, i.e., witnesses, past medical history, etc. We also receive information regarding the quality of medical care from the employee's perspective. In this manner we will encourage future communication and avoid litigation. We will send each injured worker an Injury Questionnaire that asks questions regarding past injuries and treatment that can assist with apportionment issues, should permanent disability result, and based on recent legislative changes. In addition, this unsolicited communication continues when the claims examiner contacts the injured worker at least monthly while off of work and periodically during the life of the claim especially prior to the issuance of any benefit letter. We expect our examiners to work hard at building positive rapport with all injured workers and are viewed as a resource. It is their responsibility to ensure each injured worker thoroughly understands all processes to come, up to and including claim resolution. Through this commitment of communication we assist our clients in reducing litigation, which in turn reduces costs. T **IN 1—am c o;m so fi-, JL V %a Communication with clients and claimants is a blend of verbal, written and via email. All communication efforts are clearly documented in the claim notes. Subject to client request, ICS conducts quarterly claim reviews, providing our clients with an opportunity to review in detail jointly selected, key claims. We would recommend the Unit Manager attend all meetings, but would propose a rotational attendance for the assigned claims examiners to ensure coverage in the office for your program. We also want to ensure the volume of claims selected for review will not detract from the examiners ability to stay current on their caseloads, therefore we limit the number of claims selected for review to 10% of the examiners caseload at each meeting. Semi - annual program evaluations are conducted providing our clients with extensive information regarding trends in frequency and severity, patterns of claims, risk control recommendations and their expected results, and medical management activities as well as other important claims management information. We also outline areas where ICS feels improvement may be realized including a clear plan to assist in implementing recommended improvements. Daily Communications We have continual interaction and communications with our clients during normal day -to- day claims management. Our policies require that all phone calls shall be returned within 1 day and all efforts to do so are clearly documented in the notes. Additionally, all written inquiries are responded to within 5 days of receipt. The following is a brief list of selected, daily communications: • Initial contact upon receipt of new lost time claims as part of our 24 -hour strategy, i.e., contact with employer, employee and medical provider for early intervention and implementation /exploration of modified work possibilities. • Discussion of and strategic planning on all claims placed on delay status. • Discussion of and strategic planning on all claims recommended for denial. • Written and verbal communications on all prospective settlements in accordance with the client's requirements. • Discussion of claims involving potential referral for outside investigation including subrosa investigations. • Communication at any other interval as required by each client. New Claim Reporting ICS offers our clients several different ways to report new claims. Clients can mail, fax or e -mail new reports of claims to ICS staff. In addition, clients have two options to electronically transmit claims. First, using the ICS Web Site, the client can log in and input all relevant claims information on -line. ICS will download the information into our claim system for claim setup. Second, the client can go directly in to our claim system through their dial -up connection and input the claim into the claim system. ThC% 1_w� 0a,mso�,o. n i�� ICS Management reviews all new claims to make sure the data is accurate and complete. The claim staff then reviews the claim data regularly to update fields with the most current information. New Claim Setup All new claims are entered as pending claims in the claim management system upon receipt and immediately routed to the appropriate Unit Manager for urgent handling. Each unit manager reviews these new claims and documents initial recommendations for acceptance, denial or investigation as appropriate, and routes them to the appropriate examiner for immediate handling. Additionally, the unit manager enters all new claims in a log and tracks for completion of set -up. The examiner evaluates each new claim and begins execution of ICS' procedures for handling of new claims. All communication is clearly documented and new claims creations must be complete within 72 hours of ICS knowledge. Initial Contact All injured employees will be contacted within 24 hours of ICS' knowledge of the claims on all lost time claims. This contact serves several purposes. We establish a non - adversarial relationship, answering questions and giving direction. Additionally we obtain factual information surrounding this incident, i.e., witnesses, past medical history, etc. We also receive information regarding the quality of medical care from the employee's perspective. In this manner we will encourage future communication and avoid litigation. We will send each injured worker an Injury Questionnaire that asks questions regarding past injuries and treatment that can assist with apportionment issues, should permanent disability result. ICS requires all examiners to maintain unsolicited communication with each injured worker until they return to work. These calls take place monthly, at least. We also require each examiner to contact all injured workers prior to issuing any mandatory benefit notices for the duration of the claim. The state - required language in these notices can be perceived as adversarial, so contact is required to explain why the notice is being sent and to ensure the injured employee understands the language contained in each notice and the processes to come. This approach towards Employee Advocacy is also the first step in the ICS litigation avoidance process and continues until each claim is closed. Contact is also established with the employer to obtain information regarding the specifics of the incident, witnesses and any other pertinent information the employer may have to contribute. We encourage the individual departments to participate in the workers' compensation process, extending their control whenever possible. ICS will assure modified work alternatives have been explored. IMOVaIiVC Claim Solutions, In,. iV�..i The medical provider is contacted within 24 hours of our knowledge to obtain information regarding the nature and extent of injuries, prognosis, and estimations on length of disability, etc., on all lost time claims. ICS will continually explore with the treating physicians the possibility of releasing the injured employee to modified work at the earliest possible date. ICS claims examiners will maintain close ongoing communications with injured employees, medical providers as well as individual departments on lost time claims. All communication will be clearly documented in the computer system, which is accessible to the Unit Manager as well as the designated client contacts. Compensability Determination All claims are initially reviewed by a Unit Manager who gives instruction on any claims that appear to be questionable based solely on the information contained in the initial report. As the examiner executes our three point contact and gathers additional information, another assessment regarding compensability is made. A claim would likely be accepted if the description of the injury is consistent and in line with that employee's job responsibilities, if the medical history and diagnosis are also consistent with the facts surrounding the incident and the employer has provided no contradicting information and has no concerns regarding compensability. The examiner would also take into consideration factual and medical information /history obtained through contact with the injured employee. The most crucial information required is an accurate description of the injury, a thorough medical history and a medical opinion supporting compensability. In addition to all of the above, the examiner must ensure each claim meets the legal threshold for compensability. All decisions to delay claims must be approved by a Unit Manager, and all decisions to accept compensability once a claim has been placed on delay, or to deny claims, must also be approved by a Unit Manager. Discussion and decisions on delaying or denying benefits is also discussed with each client. On all claims that will be delayed, ICS will issue a delay notice within 14 days from the employer's date of knowledge, or 14 days from the return of the DWC -1 claim form. Investigations ICS investigates all lost -time claims. The initial investigation is completed by the Unit Manager who is responsible for reviewing all new claims each day outlining any AOE /COE issues to be explored when completing initial calls. When deemed necessary by the Unit Manager, recorded statements will be obtained from injured workers or witnesses, and referral may be made to an outside investigative firm with your advance approval. Typically, all alleged stress or psychiatric injuries are placed on delay and investigated by our staff. Initial investigation includes discussions with immediate supervisors or T *IN r% Luwva4,e Claim Sulut -, Inc. Z V iJ' managers of the allegedly injured employee and possible discussion with co- workers. We also obtain copies of personnel files and assess the need for scheduling of medical evaluations. On questionable indemnity claims, investigative assignments will be made to outside vendor within 5 days of ICS notice of claim to obtain statements from witnesses and the injured employee. ICS will contact the injured employee via telephone within 24 hours of notice of injury on all lost time or questionable cases to verify injury, prior related medical history, and accident information and to explain benefits. The results of this contact and all contact attempts will be documented in the claim file. Subsequent regular contact with disabled employees will be maintained. Medical verification of causation and disability will be obtained prior to each payment of disability benefits. An estimate as to length of disability and extent of disability will be obtained. Where medical causation is unclear, a medical evaluation will be requested with a qualified physician through the QME /AME process. All relevant medical records and investigative information will be provided to the physician for review prior to the date of examination All referrals to investigators will be specific in nature, outlining time frames for completion. We will have original reports addressed to defense attorneys utilized by your agency to avoid obligations to provide copies of any investigative reports should claim files be subpoenaed. Investigative assignments will address the applicability of apportionment, subrogation potential and the need for surveillance or activity checks. Outside investigative services will be retained on an as- needed basis with concurrence from the Client. The need for outside services will be clearly documented in the file. ICS recommends development of a specific panel of investigators to be utilized in concert with your organization. We further recommend identifying specific firms for use in fraud investigations and subrosa. Diary All unresolved indemnity claim files are on an examiner 30 -day diary and manager 90- day diary for Plan of Action management. Additionally, all unresolved claims are on diary for reserve reviews every 90 days, while resolved claims are reviewed for reserves every 180 days. Future Medical claims are on an examiner 90 -day diary and manager 180 -day diary. Each Plan of Action entry is clearly labeled as such, as are Reserve entries. Reserve entries are a combined Reserve and Plan of Action review. The following is a brief list of items that are reviewed at each diary: VAMCA lauovauve Claim Solutlmu, 1= JL %.** V.0 • Reserves • Plan of Action • Coding • Subrogation Status • Excess Reporting • Treatment Status • Disability Status • Closure Posture • Plan for resolution Claim Supervision ICS has developed a claim review /audit frequency we feel affords us optimal quality control. Instead of conducting audits on a specified group of claims we have scheduled mandatory reviews, or audits, of all claims. Unit Managers are responsible for conducting these reviews and we have customized audit forms that are completed in association with each review. There is one specific form that is completed at the initial supervisor 90 day review and another that is completed for every subsequent review. These forms are placed in each claim file as they are completed and documented in the notes. What follows is a list of mandatory supervisory reviews: • All New Claims • All claims after file creation • All proposed denials • All proposed delayed claims • Delayed claims every 45 days until a decision is made • Delayed claims when the examiner proposes acceptance • All reserve changes made beyond the first 30 days, other than legal reserves • All proposed claim closures • All proposed settlements, prior to submission to the client • All legal mail All award calculations before award payments are made • Unresolved open indemnity files at 90 days from date of creation, and every 90 days thereafter until closure or claim settlement • Settled indemnity files every 180 days • 15 days prior to mandatory settlement conferences • 15 days prior to scheduled trials • All medical only claims open after 90 days from date entered • All medical only claims whose payments exceed $3000 • All medical only claims for injured workers on modified duty for more than 60 days T /^l C: lnn-a we Claim Saluti —, Inc. i16A U.P High Visibility Claims ICS recognizes that each client may have unique circumstances that generate claims that may involve sensitive or high profile issues. ICS can offer our clients the option of suppressing those injured worker names in reports and limit viewing of those designated claims through on -line access. We also realize that some of these claim circumstances may require special handling and an elevated level of communication. In some extreme circumstances our clients may elect to have the Unit Manager or Vice President of Operations handles those cases. ICS is prepared and able to offer our clients many options to support their needs for these unique circumstances. Benefits Delivery Initial and subsequent indemnity payment and DWC notices will be processed in full compliance with the Labor Code. Through utilization of the computer system's automated payment system, we can virtually eliminate any penalty exposure. Additionally, ICS can tailor a payment- tracking system to meet your organization's needs for any potential salary continuation program. This system can encompass payments by check, voucher posting, or a combination of the two. Disability Payment Options With our current clients we have developed Temporary Disability, Salary Continuation and LC 4850 payment procedures that coincide with payroll periods or other directives from the client. We can pay LC 4850 as full salary or break -out the TD portion and the non -TD portion as separate payments based on client request. We can make payments as checks or vouchers posting, or any combination of the two, as directed by our clients. We are confident of our ability to customize a process to meet the Client's needs. Assuring Reserve Accuracy ICS trains its professional staff to reserve all claims based on their ultimate probable cost. We understand the importance of establishing accurate reserves as early in the life of a claim as possible. Reserving files accurately requires a combination of experience, skill, judgment and astute analysis of all available data. All open unresolved indemnity claims will be scheduled for reserve review and potential adjustment at 30 days from date of creation, 90 days from date of creation and every 90 days thereafter for the duration of the claim. Reserves will also be adjusted when developments are revealed that will likely affect the ultimate cost of a given claim. This approach will preclude any reserve "stair stepping ". Once claims are settled they are moved to a diary review for reserves every 180 days. All reserve changes beyond the first 30 days must be reviewed and approved by a supervisor and documented in our computer system. A reserve analysis worksheet is also created on -line. The client can review this information on -line, as well. V 0"1%r i�„I�..7 When reserving for future medical files, examiners will review all medical payments made in the last three years. Non - recurring medical expenses will be deleted from the analysis. The remaining amount will be evaluated and then multiplied by the injured worker's life expectancy. This reserve may be adjusted based on medical opinion relating to life expectancy as well. All future medical reserves are then reviewed by the Unit Manager. Managed Care Program ICS oversees a medical management program that encompasses Bill Review, Utilization Review, Preferred Provider Organization access, and other Medical Management services. Actual bill review for reduction to fee schedule and appropriateness of charges is completed by the outside bill review company. However examiners are responsible for reviewing and approving each bill for payment ensuring all prescriptions, or treatment provided, adheres to what has been authorized. All treatment requests are responded to timely and documented in the claim management system. Referrals are made to the selected utilization review company for concurrent reviews when treatment appears to be excessive, or at time of treatment requests if they meet the referral trigger criteria. Additionally, examiners are responsible for reviewing all medical reports and documenting a brief recap of all reports in the claim management system. Medical verification of disability will be obtained in a timely manner and maintained in the claim file to document the need for continuing indemnity benefits. Medical treatment provided will be reviewed for necessity, reasonableness, and relationship to the industrial injury. Catastrophic injury claims and extensive lost -time claims will be reviewed by a qualified medical management provider. Claims referred for outside medical management services will reflect the intent and scope of services requested. Pre - existing medical conditions and medical records will be explored /obtained on all lost - time claims. Treatment recommendations for care such as physical therapy, chiropractic manipulations, etc., will be verified with the physician as to duration, frequency and anticipated results. ICS has partnered with a Pharmacy Benefit Program, (PBM), provider that provides a pharmacy card to the injured worker. The injured worker will take the card to any pharmacy. The pharmacy will use the card to confirm authorization for the meds, give the meds to the injured worker and submit their billing to the PBM provider. Medications will be billed at OMFS with the exception of a $20 discount per prescription filled through mail order. The PBM will monitor for duplicate therapy, early refill, and control access to medications strictly for the industrial injury. T ArA rA Innovative Claim Solutlons. Inc. i `►�/ V.P Medical bills submitted without a supporting medical report shall not be paid until a medical report is obtained. All bills will be adjusted according to the fee schedule and paid or objected to according to the law. Medical -legal costs will be reviewed for appropriateness and necessity. Bills which do not qualify as valid medical -legal expense will be objected to on a timely basis. Since MTUS was established we felt there would be a declining need for Nurse Case Management services. Also, the only method we can use to address temporary or permanent disability disputes is the QME process. Treatment disputes now must go through the UR and IMR process. That being said, we see the role, or value, of utilizing nurse case managers declining substantially. The following is an outline of situations where we feel a nurse case manager may be beneficial: • A client has implemented an early intervention program and is using nurses to aid in early return to work. These referrals are usually short term, and the nurse's role is to challenge the doctor to outline work restrictions every time the patient is seen so that the client can maximize their modified duty program, or identify when work restrictions do not impede a return to full duty. When a client isn't using such a program, this role reverts to the examiner. • Catastrophic cases where the treating physicians aren't familiar with worker's compensation and aren't readily providing needed updates, or detailed enough information. In these situations the role of the nurse case manager is to gather the information the examiner needs from the doctors and relay it on, as well as providing the examiner with realistic information about prognosis and treatment needs, based on his /her medical knowledge and background. These types of referrals may be on a long term basis, depending on the progression of treatment. Examples of these types of cases would be serious burns or head traumas. • Cases where the condition is uncommon and treatment is provided by doctors that are not familiar with worker's compensation, as this type of condition is not typically work related. The nurses roll would be the same as outlined above. Examples might be a diagnosis of TMJ, hepatitis C or bone necrosis. Referrals should be limited to obtaining an understanding, from the nurse's perspective, about what the duration of treatment should be. Once that is obtained, the nurse assignment should be terminated. Thereafter, the course of action to control duration of treatment, end of temporary disability or P &S status should be pursued through either the UR referral process or by obtaining a QME. • Limited referrals might be made if the patient doesn't seem to be interpreting the doctor's opinion, instructions or work status the same as we are. A referral would be made on a limited basis, and the nurse would act as an interpreter repeating back the doctor's opinion(s) in the presence of the patient, to ensure all are understanding what the doctor is saying. In most cases, the referral would be limited to attending one or two doctor appointments with the patient. This may also be the type of referral that could be beneficial when someone has sustained a career ending injury, and doesn't seem to be understanding, or embracing that fact. This is especially true with injuries to safety officers. T A "M i V1J Limited referrals might be made when the examiner has been ineffective in obtaining a needed opinion regarding a return to work, treatment plan, or permanent and stationary status. It may be beneficial for a doctor to communicate with someone they view as a peer, someone who can comfortably challenge the doctor's opinion. In most cases, the referral would be limited to a couple of attempts at phone communication with the doctor and perhaps attending an appointment or two. If the nurse hasn't obtained what is needed by then, they are no more effective than we are and their assignment should be terminated. The examiner should then probably pursue a QME. Limited referrals may be beneficial when a patient is scheduled for an in- patient hospitalization that may require coordination of post - hospitalization care. That care may involve durable medical equipment or in -home patient care after hospitalization. Again, this sort of referral would be made on a limited basis, and the assignment should be terminated once the required information is obtained. Any other client directed referrals, or special programs, would be appropriate. On the other hand, we feel it is our responsibility to ensure a client understands when referrals, or services, are no longer cost effective. That responsibility may rest with the examiner, unit manager or ICS management. The following details the ICS list of triggers that should be used as a guideline for referring cases to UR. • All requests for spinal surgery that are not being authorized outright. If there is any question regarding authorization a referral must be made to UR immediately. If UR denies the surgery, we must formally object and request a 2nd opinion. All of this must take place within 10 days of receipt of the request for surgery. If the UR decision is late, we must authorize the surgery. Likewise, if UR recommends the surgery, it must be authorized immediately — there is no option for a 2nd opinion. This applies only to claims with dates of injury prior to 1/1/13 — and only until 6/30/13. Thereafter, only submit requests for spinal surgery to UR if the request meets another referral trigger detailed below. • Physical Therapy /Occupational Therapy, Chiropractic or Acupuncture treatment requests when the number of recommended visits has reached or exceeded 18, not including post- operative treatment. • Post - Operative Physical /Occupational Therapy or Chiropractic treatment requests when the number of recommended post- operative visits has reached or exceeded 18. • All authorization requests for experimental, new, or not commonly performed surgical or other procedures. • All requests for authorization of Durable Medical Equipment, expected to be used for more than 60 days, or suggested for a purchase price in excess of $500. • All authorization requests for inpatient surgery if the expected admission is beyond 4 days in duration. (The exception would be requests for spinal surgeries, as detailed above.) • All authorization requests for referrals to nursing, convalescent or residential homes or for home health care services not related to post - surgical care. ,* i V %WP • All home health care service requests for a period beyond 2 weeks post- surgery, or 2 weeks post release from hospital. • All cases where psychiatric or psychological therapy extends beyond 180 days. • All cases where the doctor specialty does not match diagnosis, i.e. chiropractic care for the diagnosis of a fracture, etc. • Any other additional criteria requested by our clients. On occasion, a referral to Utilization is inappropriate. Instead, we are seeking the opinion of a physician regarding past or future treatment recommendations. Those occasions require referral for a Peer or Physician Review. As these services are more costly, Unit Manager approval is required prior to referral. The following is the ICS list of triggers that should be used as a guideline for when a Peer or Physician Review referral is recommended: • All authorization requests for repeat diagnostic testing (CT /myelogram, discogram, diagnostic injections, angiogram, MRI, and EMG's) unless required due to the poor quality of prior studies, or when requested by a QME /AME, or when original studies are more than 12 months old. • All authorization requests for referrals to Pain Management Programs. • All authorization requests for Inpatient or Outpatient chemical dependency or weight loss programs. • All cases where there is a need to obtain a second opinion on long -term need /use of prescriptions. • Requests for treatment not recognized within LC 4600, such as massage therapy, gym memberships, etc. • Any other additional criteria requested by our clients. The following details the step by step process ICS has in place and puts in play following a serious, or potential catastrophic, injury or circumstance: • Each client should have access to after hours or emergency contact telephone numbers allowing them access to the appropriate Unit Manager, Vice President of Operations or co- Presidents of ICS. • Upon notice, from any source, of a catastrophic situation, the Unit Manager, Vice President of Operations and client must be notified immediately. • Depending on the severity of injuries that have occurred, a medical case manager should immediately be assigned to the case. In serious injury cases we frequently are dealing with medical practitioners not familiar with the reporting and communication responsibilities associated with treatment of work related injuries. A medical case manager will assist in ensuring we are provided timely and frequent information regarding the status of the injured workers' medical condition. • In most circumstances, an investigator should be immediately dispatched to the site of the incident to screen and identify witness, ascertain the potential of subrogation opportunities, evaluate exposure for Serious and Willful Misconduct, T A "' C Innovative Cl Solutions. In, JL %.,.# V.1 obtain or determine if police reports will be available and ascertain information required to determine compensability. • The appropriate client Safety or Loss Control personnel should immediately be notified and they likely will be dispatched for purposes of a site visit, especially in circumstances where OSHA has been contacted. • In circumstances where injured workers are hospitalized for longer than overnight for purposes other than observation, an ICS representative should meet with the injured worker or their family members, whenever possible. The purpose of the visit would be to personally explain benefits due, explain the processes to come, notify who will be the daily contact person available to them and answer any other questions they may have. • When feasible, the medical case manager assigned should jointly meet the injured worker or family members with the ICS representative. • Depending on each client's excess coverage and policy, the excess carrier should immediately be notified. • In circumstances involving multiple injured workers, all files should be coded to reflect they are part of a catastrophic incident to ensure appropriate excess reporting and tracking capabilities are in place. • In cases of serious injury, updates should be provided to the Unit Manager, Vice President of Operations and client no less frequently than monthly for a period of time to be determined, depending on the seriousness of each incident. Claim Settlements Intertwined in all of the ICS procedures and philosophies is one ultimate goal: claim resolution in a cost - effective manner. This is accomplished either by claim closure or claim settlement. It is ICS' responsibility to identify as early as possible the potential for permanent disability. If none is anticipated or documented, claim closure is pursued rapidly. If permanent residuals are anticipated, a plan for claim resolution is placed in motion. We recommend that the client provide settlement authority to ICS that would allow us to resolve cases of nominal value in a time and cost effective manner. Cases beyond an agreed to dollar value should follow the agreed to procedure for procuring settlement authority. Regardless of the settlement authority value, all settlements will be discussed and approved by the Unit Manager, and basis for recommendations will be clearly documented in the claims management system. Medicare Reporting Per CMS guidelines, we submit a Query file of all claims from 2010 to CMS quarterly. CMS will process and return that file identifying Medicare Recipients to ICS. That information is uploaded to Renaissance. We also keep a log each time of all of the claims that have been reported and those that are Medicare Recipients. VAv-%or! A V �7 We then go to each newly identified Medicare Recipient in Renaissance and input the necessary data to complete the Claim report to CMS. We also review other claims to determine if an update or change needs to be reported such as a TPOC or legal representation. We transmit the new and updated Claim files to CMS quarterly with all of the new claim information. Medicare Recipient claims are flagged in the Renaissance system so the examiners will make sure their settlements incorporate the protection of Medicare's interests. Subrogation ICS aggressively pursues subrogation on behalf of its clients atno additional cost. Clear policies and procedures are in place to assure that any case offering subrogation potential is thoroughly and expeditiously pursued. ICS identifies all opportunities for subrogation although action is not taken unless your organization has specifically authorized such action. ICS will identify subrogation opportunities immediately upon receipt of a claim and put in motion a plan to obtain information regarding the responsible party. As soon as a responsible third party is identified, notice of our intent to pursue recovery will be issued, and regular contract will be maintained until a recovery is made. Often, it is not financially feasible to pursue subrogation or a claim may involve a conflict of interest for your organization. All subrogation efforts that also involve a property loss to your organization will be coordinated with you and /or your liability program administrator. ICS will notify the client as soon as it is felt a complaint in Civil court may be needed to protect the statute of limitations so appropriate legal referrals can be made. ICS will ensure credits are asserted against an injured workers' net recovery for future benefits whenever possible. In addition, the claims supervisor maintains a separate diary of all claims on which we are pursuing subrogation recoveries to ensure all statutes are protected. Excess Claims ICS will provide the initial report, follow -up reports and settlement requests to the Client Excess Insurance Carrier when necessary. ICS maintains a listing of all reporting requirements as well as the Self Insured Retention level for each policy period. ICS will also prepare and send requests for reimbursement on claims that have payments exceeding the SIR. ICS examiners and managers have diaries set to ensure timelines are met for reporting claims and requesting reimbursements. Offers of Permanent Modified or Alternate Positions The ICS standard is to forward any Permanent and Stationary reports that detail permanent disability within 1 business day of receipt with an inquiry regarding the ability ThC Ino —fi,e Claim Solutions, Inc. J. %..* 1J to extend an offer of continuing employment, with or without restriction, and provide the corresponding form that needs to utilized for any offer. ICS will work with each Client on procedures that meet timelines and provide necessary information to all individuals' involved so informed decisions can be made. Fraud Claims Management ICS has an in -house fraud investigations unit that consists of both Presidents, VP of Operations and all Unit Managers, however, we do not have in -house investigators. The actual investigative assignment would be referred to an outside vendor. All ICS examiners are trained as to the "red flags" indicative of potential fraud cases. Additionally, ICS will incorporate fraud awareness training into our training program for all of your supervisors and managers. In addition to training your supervisors in fraud awareness, we conduct extensive training of our staff as well. Subrosa Investigation While a subrosa investigation can be a useful tool, referrals of this nature must be justified due to the high cost and the relative low ratio of success. All subrosa investigations must have both supervisory and client approval. Subrosa Guidelines • Examiner will specify number of hours authorized. • Investigator will stop, or request authority to continue, if no activity in four continuous hour period. • No use of second vehicle or investigator without prior approval of examiner. • All videotapes will be sent with the report and are the property of the Client. • Examiner must approve all records checks prior to conducting them. • All expenses are to be itemized, including office expenses, and must show date of activity. • Reports should be received by ICS within 10 working days of completion of assignment. Litigation Management The purpose of the ICS litigation management program is to reduce the client's overall cost of risk, taking into consideration both loss and cost factors in litigated claims. ICS accomplishes this by taking a proactive approach to litigation. We encourage and foster early resolution. We closely monitor the activities of defense counsel and hearing representatives to assure early disposition. It is contrary to ICS' operating procedures for the examiner to relegate claims handling tasks to a defense attorney or hearing i %./V.7 representative. Rather, the claims examiner will continue to actively manage all such litigated claims. The mere fact that a claim goes into litigation is insufficient cause to trigger an outside referral. ICS' preference in many cases is that the claims examiners continue with the day -to -day handling of the claim. The second choice is referral to a qualified defense attorney with the client's concurrence. When a defense attorney is optioned, ICS holds defense counsel to strict standards of reporting frequency, report content, cost containment, billing protocol and overall handling. Attorneys will not be authorized to perform or be reimbursed for tasks that are the responsibility of ICS. We will also ensure the assigned defense attorneys produce written status reports on all claims on a regular basis. The ICS Claims Examiner is responsible for the following: • Refer file to specific attorney • Direct and approve plan of action • Subpoena medical records • Serve original medical reports on all parties prior to DOR • Set defense med evaluation and send mileage and TTD • Obtain settlement authority • Review file with attorney prior to conference or trial • Respond to attorney phone call within one working day The Defense Attorney is responsible for the following: • Assign file to specific attorney requested • Consult with and follow direction of examiner • Unless otherwise directed, complete an initial file review within 15 days of receipt of file • Serve medical reports on WCAB when necessary • Not refer to another attorney for deposition or appearance without prior examiner approval • Prepare purpose letter for medical evaluation • Evaluate and request settlement authority from examiner • Respond to examiner phone calls within one working day • Meet with examiner and /or employer at request • Within 5 days of receipt of DOR provide written analysis of case strategy and settlement authority requested • Fax notice of hearing /conference /trial to examiner within one day of receipt • Initiate call to examiner to discuss strategy at least two weeks prior to hearing /conference /trial including proposed witnesses and settlement recommendations VhMet innova've Clann SoWrioos, Inc. JL `�Ir.+' V..7 • Report by fax, email or phone call to examiner within one working day, results of conference, hearing or trial • Fax award notice to examiner within one day of receipt • Use ICS directed copy service • Manage overall cost of litigation • Produce litigation status reports on a regular basis By mutual consent the defense attorney may subpoena medical records and set evaluations with Unit Manager approval. Closing Ratios Closing ratios are directly related to examiner competence, staffing levels, and indemnity caseloads. ICS standards require a minimum - closing ratio of 100% in the first six months after transfer of the program. After the transition period, we will be substantially more familiar with employee demographics and the program's operating environment to establish appropriate on -going closing ratio goals above 100% and develop appropriate performance benchmarks. ICS employs a continuous improvement philosophy. Therefore, merely attaining the initial closing -ratio goal is viewed as a temporary accomplishment. Once we have assimilated your program, we will then strive toward higher closing ratios and enhanced performance benchmarks. Medical Only Claims Management ICS has developed a separate set of standards and protocol for the management of Medical Only claims. While most of our competitors place little or no effort towards management of these claims, ICS has established work flow that addresses claims management criteria similar to the standards required for management of lost time claims. ICS has created a Medical Only Examiner position that handles a blend of medical only and future medical claims and requires mandatory supervisor review of all open medical only claims every 90 days in addition to other review triggers. The medical only examiner is required to review all open claims every 30 days. We believe early and effective management of these claims can assist in controlling their progression to higher cost indemnity claims. If requested, we would be happy to share our procedures and protocol for managing these claims. File Documentation and Structure Although the computer system offers many capabilities, hard copy files are still maintained. ICS maintains hard copies of all benefit notices issued and all other correspondence in each claim file, although those documents can also be viewed on -line in the claim management system. ICS scans all AME, QME, IMR and P &S reports and all Applications for Adjudication and WCAB awards in to the claim system. ICS also documents all file balancing. Claims that have been closed for six months or more are stored off -site in a secure sub - contracted data storage facility. Z� � uve olu c. .& %.Of %k.0 Records, Files and Transcripts As stated above, although the computer system offers many capabilities, hard copy files are still maintained. Claims that have been closed for six months or more are stored off - site in a secure sub - contracted data storage facility. Closed files are maintained free of charge for each client for the duration of the contract. ICS requires all examiners maintain a uniform segregation of information in our claim files. All bills and EOB's are maintained in one section while medical reports are contained in another. All remaining communication is maintained in chronologic order. Most work is completed in a paperless environment, however the hard files are maintained for ease of audits and permanent record storage. All claim activity is documented and maintained in the notepad area of our claims management system. Every phone call, every email, etc., are all clearly documented. ICS requires all examiners enter all mail received in the notepad area as well and our expectations are that this is done on a daily basis. ICS requires a Plan of Action entry on all unresolved claims every 30 days and a more extensive Plan of Action entry and Reserve recap every 90 days on unresolved claims. For resolved claims these detailed reviews are conducted every 90 days. Evidence of file balancing is also reflected in the notes. Index System ICS subscribes to the Index Systems; a clearinghouse that receives and facilitates the sharing of reported claims information among some 3000 organizations nationwide. ICS files its Index reports electronically. ICS proposes that all indemnity claims, as well as, medical only claims with extensive treatment issues be indexed. The initial report should be made immediately upon receipt of sufficient information, then at annual intervals thereafter. ICS will promptly file inquiries on any matches that the system finds. Trust Fund Trust Fund or Zero Balance accounts will be maintained for all clients. Check production is password - protected and signature requirements are client- specific. ICS works with each client on specific funding and banking procedures including frequency of reimbursement, bank reconciliation and signature authority. ICS will customize a reporting mechanism of checks issued to meet each client's need. ICS ensures that safeguards are in place for the check printing process so that individuals entering checks and vendors into the system cannot also be the ones to sign and release the checks. VA"Ne% Iw vativc Claim Solutions, Inc. JL %W %%.R We do not have "check stock" but instead each account has the MICR coding embedded by the printer and check software. Only certain individuals are able to access the check printing system as it is password and rights protected. All checks over a client's designated threshold amount must be reviewed by a manager prior to signatures or mailing. Closed File Storage ICS uses the services of a professional file storage company for off -site storage of older closed claims. All closed claims are inventoried prior to transfer to the storage company. Closed claims are easily obtained from the off -site company if needed. ICS will maintain closed claims at our cost for five years from closing date. Closed files can be retrieved by the client upon contract termination. If the Client terminates the services with ICS and selects a new TPA for claims administration, ICS will box up all open and closed files so that the new TPA can pick them up at our location. ICS will not pay for transport of the files to the new location. Claim Roundtables At ICS, our Vice President of Operations conducts random file audits to ensure compliance to all ICS and client performance requirements. Additionally, each Unit Manager meets weekly with their team to discuss procedure and case law updates and to roundtable challenging claims, in addition to other topics. ICS senior management has bi- monthly meetings with all Unit Managers where a number of topics are discussed, including roundtable discussions on claims. The ICS Claim Examiner may initiate a roundtable discussion with senior management staff, defense counsel, the client and others on an as needed basis to discuss issues and resolution of individual claims. YAMet lmo�e— C M so tim, 1'V 1J' Y0"1% ICA Innovative Claim Solutions, Inc. A %wd# %*Mir KV A AMR www.ics-claims.com , 800.427.5511 A Workers' Compensation Claims Administrator serving your needs in California Computer Services - RMIS ICS utilizes the David Corp Renaissance system which is Windows based. Renaissance has the ability to export any of the data to all of the Microsoft window products or can provide data through a flat file. We are also very capable of completing data conversions for any other claims management software system. Renaissance for Workers Compensation is a product designed to facilitate a user's management of claims based on the regulations dictated by the respective State agency. Within the Claims Management module, a user can easily and efficiently enter new claims, update existing claim information, set reserves, issue payments and create loss reports with a few quick clicks of the mouse. More than 50 standard reports are included in the core product that detail claim activity and provide analysis of financial patterns, thus providing Claim Managers with a comprehensive look into claim and financial activities. Security is a primary concern in today's corporate world, consequently, Renaissance allows the system administrator to assign permissions by user or by group access all the way from network rights to database rights down to individual screen and field access. ICS adheres to the IT Standards as adopted by CAJPA in their Accreditation Standards. ICS maintains our own servers on -site and has a complete IMS department that oversees all hardware and software support for client and internal use. System Flexibility Our computer system allows ICS to customize the software for each ICS client. Our IMS Department that is able to provide help desk support and custom programming. We can adjust each table according to client requests. The organization structure in the system allows for use of client numeric and alpha codes for each level. In short, we are able to adjust our computer system to meet your needs. Claim Reporting ICS offers our clients several different ways to report new claims. Clients can mail, fax or call in new reports of claims to ICS staff. We have an 800 number for call in claims reporting. In addition, clients have two options to electronically transmit claims. First, using the ICS Web Site client can log in and input all relevant claims information on -line. ICS will download the information into our claim system for claim setup. Second, the client can go to our claim system through their dial -up connection and input the claim directly into the claim system. On -line Access Our current configuration allows clients to access their claims data free of charge in several ways. We provide access directly by using our website. Clients can also access through the "remote access" Rancho Cordova P.O. Box 2070, Rancho Cordova. CA 95741 -2070 1 San Ramon P.O. Box 5128, San Ramon, CA 94583 -5138 Innovative Claim Solutions, Inc. UL www.ics- claims.com , 800.427.5511 A Workers' Compensation Claims Administrator serving your needs in California feature on their computer. We would provide the IP address to be utilized. All of these processes require security logins and passwords. There is no special software or cost associated with client access. Through use of our claims management system, you not only have the opportunity to see all active information, you can also manage a diary of your own. You can enter notes and update coding as well. We allow our client's to be users of the system and give them the capability to view all data that we maintain. Our claim management system is a fully interactive program designed with such flexibility and simplicity of function that it may be operated at maximum efficiency by non - computer oriented users. Claim Reports ICS will provide each client with a customized set of claim reports based on client need. These reports can be done daily, weekly, monthly, quarterly or whenever the client requests. The reports can be downloaded to Word, Excel, Adobe or other formats and e- mailed or we can print and mail them to the client. Reports will be delivered to the client within 10 days of the end of each month. Claim Activity Report Report produces a detailed listing of claims, the associated financial activity, and indicates if each claim has one (or more) of nine categories of claim activity. Location Summary by Year Report Report produces a listing of claim counts and totals, broken into report categories (loss type), and grouped by annual periods (claim years) and by organization. Claim Summary by Year Report Report produces a listing of claim counts and totals, grouped by annual periods and broken into report categories (loss type /LOB categories). Claim Cost Detail Report Report produces a detailed listing of claims and their associated financial activity broken down by reserve category. Claims Cost Summary Report Report produces a single -line, detailed listing of claims and their associated financial activity. Claim Log Report produces a listing of claims dated within a user - specified date - range, sorted by either claimant name or claim number. Examiner Activity Report Report produces a listing of claims, which 1) have been Opened, Closed, or Reopened during the activity period, or 2) are dated within the activity period. Rancho Cordova P.O. Box 2070, Rancho Cordova, CA 95741 -2070 V San Ramon P.O. Box 5128, San Ramon, CA 94583 -5138 i lei* Innovative Claim Solutions, Inc. vita X www.ics- claims.com ' 800.427.5511 A Workers' Comoensation Claims Administrator serving your needs in California Management Summary Report Report produces a listing of claim counts and totals, grouped by user - specified location levels. Examiner Case Log Report produces one of three listings of claims, sorted by examiner: 1) Claims with activity in period; 2) Claims dated within the period; or 3) Claims, which are open at the end of the period. If "claims with activity within the period" is chosen, a summary section showing New, Closed, or Reopen counts is also produced. Frequency Analysis Reports Nine reports, each of which produces a different listing showing the frequency of claim incidences. All reports have the same parameters, and most display information in the same way. Each report is ordered by the total number of claims for the type, highest count to lowest. The following nine types of frequency analysis are available: • Body Part - claim counts by body part code. • Line of Business - claim counts by line of business code. • Loss Age - claim counts by claimant age on the loss date (whole years only) • Loss Agency - claim counts by loss agency code. • Loss Cause - claim counts by loss cause code. • Loss Nature - claim counts by loss nature code. • Loss Time - claim counts by loss time hour • Loss Type - claim counts by loss type code. • Loss Day of Week - claim counts by loss day of week. • Class Code — claim counts by class code. • Length of Service — claim counts by number of years' claimant has been employed. • Claim Location (Org Tree) — claim counts by location in your organization tree. • Loss Location — claim counts by loss location (using the loss location field). Financial Reconciliation Ledger Report produces a listing of financial transactions within a user - entered effective date range and /or a user - entered check number range. Financial Location Summary by Year Report produces a listing of claim counts and totals, grouped by Annual Periods (claim years). Payment Type Totals Report Report produces either a summary or detail report, showing totals by payment types. The summary report shows totals for each pay type grouped by reserve summary type. The detail report shows totals for each pay type grouped by individual claims. Loss Triangle Report Eight reports, each of which produces a trend analysis for specific claim activity for annual reporting periods, with aging based on the claim year, or based on claim life, i.e. the actual claim date chosen Rancho Cordova P.O. Box 2070, Rancho Cordova. CA 95741 -2070 l P.O. Box 5128, San Ramon, CA 94583-5138 T A"N r Innovative Claim Solutions, Inc. www.ics- claims.com 800.427.551-1 A Workers' Compensation Claims Administrator serving your needs in California according to the parameter choice entered. All reports have the same parameters, and display information in the same way. • Case Reserves - Net open reserves of all claims as of each period. • Claims Entered - Displays the number of claims entered for each period based on claim entry date. • Claims with Incurred - Claims which have an incurred amount. Note: a reduction in the claim count within a development period represents the zeroing out of reserves. • Closed Claims - Number of claims closed as of each development period. • Closed with Paid - Number of closed claims which have payments as of each development period. • Incurred Loss - Total incurred loss of all claims as of each period. • Open Claims - Number of claims open as of each development period. • Paid Loss - Total paid loss of all claims as of each period. Vendor Payments by Claim Report Report produces a listing of payment counts and totals to selected vendors, summarized for each claim and grouped by vendor. Vendor Payments Summary Report Report produces either a single -line summary of payment totals for each vendor, or a listing of totals grouped by payment type within vendor. Reported information is for payments within the extract Activity Period. Multiple Claims Report Report produces a list showing multiple instances of a common tax ID number on different claims. A user - specified number of instances controls how many times claims must be found in order to be reported. Occurrence Cost Detail Report Report produces a detailed listing of occurrences and their associated financial activity broken down by reserve category. Occurrence Cost Summary Report Report produces a single -line, detailed listing of occurrences and their associated financial activity. SIP Annual Report Report produces a completed Consolidated Liabilities report and Open Claim Log as required by SIP. OSHA 300 Report Report produces OSHA 300 log for calendar year and can be broken out by department. ICS will prepare IRS Form 1099's and all other State mandated reports. We are able to download data to Excel, Word, Adobe and to most other software programs. ICS currently utilizes Microsoft® Office 2007 and Windows Server 2007. Rancho Cordova P.O. Box 2070, Rancho Cordova, CA 95741 -2070 1 San Ramon P.O. Box 5128, San Ramon, CA 94583 -5138 T AM Cr Innovative Claim Solutions, Inc. A www.ics- claims.com 1 800.427.5511 ML A Workers' Compensation Claims Administrator serving your needs in California - Claim Audits ICS is constantly audited by our clients, LAWCX, Self- Insurance Plans, CSAC -EIA, DWC and other organizations. We are proud to report that we have consistently achieved very high scores on these audits. Sample Audit Scoring Summaries are included in this addendum. Rancho Cordova P.O. Box 2070, Rancho Cordova. CA 95741 -2070 1 San Ramon P.O. Box 5128, San Ramon, CA 94583 -5138 Workers' Compensation Claims Audit — 2015 City of 2 Exhibit 1 —Workers' Compensation Audit Scoring Summary Audit Category 2015 Audit Scores Critical Claim Audit Areas Contact with injured worker* ? 100% Contact with member 100% Diary systems: how often are files reviewed ?* 100% Dccumentation/explanation of file activities* 100% Planning, direction, and follow -up 100% Medical direction and control* 100% _ Handling permanent disability issues 100% Settlement of claims and closure efforts* 100% Organization, appearance, and file maintenance 100% Direction of Special Issues and Control of Vendors Litigation direction and management* 100% Rehabilitation /SJ17B direction and management 100% Investigation and subrosa activity* 100% Subrogation identification and management n/a Excess insurance identification and management 100% Excess insurance identification and reporting 100% Financial Accountability Reserve adequacy and accuracy* Medical payment processing 100% 100% _ Indemnity payments processed accurately* —File 100% information equals computer data* 100% Reconciling or "balancing" the claim file 100% Aggregate Scoring — Weighted The overall score achieved by ICS is 100 %. This score applies additional significance to categories marked with an asterisk ( *) (weighted averaging). Those marked categories make up 75% of the scoring impact. FARLEY CONSULTING SERVICES Workers' Compensation Claims Audit - 2013 City � 2 Exhibit 1 — Workers' Compensation Audit Scoring Summary Audit Category 2013 Audit Scores Critical Claim Audit Areas Contact with injured worker* 92.8% Contact with member 92.8% Diary systems: how often are files reviewed ?* 100% Documentationlexplanation of file activities* 92.8% Planning, direction, and follow -up 100% Medical direction and control* 100% Handling permanent disability issues 100% Settlement of claims and closure efforts* 100% Organization, appearance, and file maintenance 100% Direction of Special Issues and Control of Vendors Litigation direction and management* 100% Rehabilitation /SJDB direction and management 100% Investigation and subrosa activity* 100% i Subrogation identification and management n/a 100% — j Excess insurance identification and management Excess insurance identification and reporting 100% Financial Accountability Reserve adequacy and accuracy* 92.8% Medical payment processing 100% Indemnity payments processed accurately* 100% File information equals computer data* 92.8% Reconciling or "balancing" the claim file 100% Aggregate Scoring — Weighted The overall score achieved by ICS is 97.64 %. This score applies additional significance to categories marked with an asterisk ( *) (weighted averaging). Those marked categories compose 75% of the scoring impact. FARLEY CONSULTING SERVICES Workers' Compensation Claims Audit - 2013 M 1111111111k 2 Exhibit 1 —Workers' Compensation Audit Scoring Summary Aggregate Scoring — Weighted The overall score achieved by ICS is 98.8 %. This score applies additional significance to categories marked with an asterisk ( *) (weighted averaging). Those marked categories compose 75% of the scoring impact. FARLEY CONSULTING SERVICES Page 41 of 204 2013 Audit Audit Category Scores Critical Claim Audit Areas Contact with injured worker* 100 % Contact with member 100% Diary systems: how often are files reviewed ?* 100% Documentation /explanation of file activities* 100% Planning, direction, and follow -up 100% Medical direction and control* 100% Handling permanent disability issues 100% Settlement of claims and closure efforts* 100% Organization, appearance, and file maintenance 100% Direction of Special Issues and Control of Vendors Litigation direction and management* 100% Rehabilitation /S)DB direction and management 100% Investigation and subrosa activity* 100% Subrogation identification and management 100% Excess insurance identification and management 86% Excess insurance identification and reporting 86% Financial Accountability Reserve adequacy and accuracy* 93% Medical payment processing 100% Indemnity payments processed accurately* 100% File information equals computer data* 90% Reconciling or "balancing" the claim file 100% Medicare Set Aside identification /handling 100% Aggregate Scoring — Weighted The overall score achieved by ICS is 98.8 %. This score applies additional significance to categories marked with an asterisk ( *) (weighted averaging). Those marked categories compose 75% of the scoring impact. FARLEY CONSULTING SERVICES Page 41 of 204 Workers` Compensation Claims Audit — 2012 3 Exhibit 1 — Workers' Compensation Audit Scoring Summary Audit Category 2012 Audit Scores Critical Claim Audit Areas Contact with injured worker* 100% Contact with member 100% Diary systems: how often are files reviewed ?* 81.3% Documentation /explanation of file activities* 93.8% Planning, direction, and follow -up 93.8% Medical direction and control* 100% Handling permanent disability issues (e.g., apportionment) 100% Settlement of claims and closure efforts* 88% Organization, appearance, and claim information maintenance 100% i Direction of Special Issues and Control of Vendors Litigation direction and management* 100% Rehabilitation /SJDB direction and management 100% Investigation and subrosa activity* 100% Subrogation identification and management 100% Excess insurance identification and management* 100% Excess insurance identification and reporting* 100% Financial Accountability Reserve adequacy and accuracy* 93.8% _ Medical payment processing 100% Indemnity payments processed timely and accurately* 100% File information equals computer data* 100% Reconciling or "balancing" the claim file 100% MSA identification and handling 100% Aggregate Scoring - Weighted The overall score achieved by ICS is 97.1 %. This score applies additional significance to categories marked with an asterisk ( *) (weighted averaging). Those marked categories carry 75% of the overall score. Score of asterisked items Score of non - asterisked items Overall weighted score 96.4% average x.75 = 72.3% 99.3% average x.25 = 24.8% = 97.1% FARLEY CONSULTING SERVICES Workers' Compensation Claims Audit - 2011 City of� 2 Workers' Compensation Audit Scoring Summary Audit Category 2011 Audit Scores Critical Claim Audit Areas Contact with injured worker* 100% Contact with member 100% Diary systems (examiner and supervisor); review frequency* 78% Documentation — file activity* 100% Documentation — plan of action adherence 100% Medical direction and control* 100% Permanent disability management (e.g., apportionment) 100% Settlement/closure efforts* 100% Organization, appearance, and file maintenance 85% Direction of Special Issues and Control of Vendors Litigation management* 100% VR/S)DB management 100% Investigation and subrosa activity* 78% Subrogation identification and management 100% Excess insurance identification and management* 100% Excess insurance identification and reporting* 100% Financial Accountability Reserve adequacy and accuracy* 70% Medical payment processing 100% Indemnity payments processed timely and accurately* 89% File information versus electronic data integrity* 100% Claim balancing consistency 100% Aggregate Scoring - Weighted The overall score achieved by ICS is 94.22 %. Categories marked with an asterisk ( *) carry 75% of the overall score: 92.92 x .75 = 69.69 is added to 98.13 x .25 = 24.53, yielding a total score of 94.22% FARLEY CONSULTING SERVICES Workers' Compensation Claims Audit - 2011 3 Exhibit 1 - Audit Scoring Summary Aggregate Scoring FCS utilized a weighted scoring methodology. The categories marked with an asterisk ( *) comprised 75% of the overall scoring. The average weighted score achieved by ICS for this audit is 97.8 %. FARLEY CONSULTING SERVICES % Compliance with Industry Standards Audit Category 2011 Audit Score Technical Claim Audit Areas Contact with injured worker* 96.7% Contact with member 96.7% Diary systems (files reviewed timely)* 97.1% Medical direction and control* 98% Handling permanent disability issues 98% Settlement of claims and closure efforts* 97.1% Organization, appearance, and file maintenance 99% Direction of Special Issues and Control of Vendors Litigation direction and management* 98% Vocational Rehabilitation direction and management 100% Investigation and subrosa activity* 96.7% Subrogation identification and management 100% Excess insurance identification and reporting" 92.3% Supervision 98% Staffing Adequacy 100% { Financial Accountability Reserve adequacy and accuracy* 96.7% Medical payment processing 100% Indemnity payments calculated and processed accurately* 98% File information reconciles with computer data 100% Aggregate Scoring FCS utilized a weighted scoring methodology. The categories marked with an asterisk ( *) comprised 75% of the overall scoring. The average weighted score achieved by ICS for this audit is 97.8 %. FARLEY CONSULTING SERVICES EXHIBIT "C" MILESTONE SCHEDULE The Milestone Schedule is documented in the form of City of Gilroy and LAWCX Performance Standards for Claims Administrators and the standards attached for reference and incorporation to this agreement for services. 4835 - 2267 -03610 LAM04706083 RESOLUTION NO. 4 -2012 Resolution of the Board of Directors of the Local Agency Workers' Compensation Excess Joint Powers Authority Establishing a Claims Management Policy for Members WHEREAS, the Board desires to ensure the member entities' claims administrators are handling claims in the most prudent manner, and WHEREAS, the Board is establishing a policy in order to protect the pooled funds of LAWCX; NOW, THEREFORE, BE IT RESOLVED, in June of each year, every member entity will be required to certify, in writing, that the following mandatory requirements have been met. CLAIMS ADMINISTRATION 1. The claims administrator shall utilize a reserve worksheet when setting or changing claim reserves. If the claims administrator does not utilize a reserve worksheet, they shall utilize the worksheet authorized by LAWCX (see Attachment 1); 2. The claims examiner handling the members entity's claim files shall receive training at least once per year, be certified by the State of California; and have a minimum of at least two (2) years of workers' compensation claims experience at the examiners level except as authorized by the LAWCX Executive Committee; MEMBER ENTITY 1. A representative from the member entity shall meet with the claims administrator at least semi - annually to review and discuss their open indemnity claims; 2. The member entity shall utilize performance standards as part of the contract with the claims administrator (refer to Attachment 2 as a guideline). A copy of the current contract shall be on file with the LAWCX. The LAWCX Executive Committee will address substantial non - compliance on an individual member basis. The member entity may appeal the decision made by the Executive Committee to the Board of Directors at the next meeting. The member must also comply with the requirements within 180 days following the date of the Executive Committee's decision and such compliance may be determined by an audit. Resolution No. 4 -2012 Page 2 This Resolution of the Board of Directors was adopted this 13`x' day of November 2012 in Sacramento, California by the following vote: Weighted Votes in Favor Weighted Votes in Opposition Weighted Votes Abstaining Weighted Votes Absent Scott Ellerbrock, President Attest: Karen Thesing, Executive Director Attachment 1 LAWCX CLAIM REVIEW /RESERVE WORKSHEET i Initial Reserve ! 90 Day Review I Reserve Change Claimant Insured Claim Number AWW DOI Age Occupation Temp. Dis. Rate Date of Legal Representation Subrogation Perm. Dis Rate Action Taken Temporary Disability Medical Temp. Dis. P -T -D $ P -T -D $ Future Temp. Dis. Weeks Physician $ 4850 P -T -D $ Hospital $ Future 4850 $ Medications $ Total Temp. Dis. Reserve $ Transportation $ Permanent Disability P.T., Other Nurse Activity/Mgmt. $ $ Perm. Dis. Formula: %, Weeks, $ _ Medical Total Incurred $ Life Pension $ Expenses Death Benefits $ P -T -D $ Burial Expense $ Future Expenses $ Total Perm. Dis. Reserve $ Expense Total Incurred $ Indemnity Total Incurred $ Rehabilitation Total Incurred Amount: $ No. of VRTD Weeks Counselor Fees $ Tuition/Books $ JILAWCX Reporting Level $ Mileage $ Misc. $ Rehab. Total Incurred $ Nature of injury, treatment, and estimated future disability: Plan of Action: Completed By: Approved By: Date: Date: Resolution 4 -2011 LAWCX PERFORMANCE STANDARDS FOR CLAIMS ADMINISTRATORS 1. Case load Attachment 2 Each adjustor shall have a caseload not to exceed one hundred seventy -five (175) open indemnity claims, which includes future medical cases. Each claims assistant, future medical clerk, or junior adjustor shall have a caseload not to exceed two hundred (200) open claims. The supervisor shall have a caseload not to exceed thirty (30) open indemnity claims. 2. Compensability The compensability determination (accept claim, deny claim, or delay acceptance pending the results of additional investigation) and the reasons for such determination will be made and documented in the file within three (3) business days of the receipt of the notification of the loss. Delay and denial of benefit letters shall be mailed in compliance with the Division of Industrial Relations' guidelines. In no case shall a final compensability decision be extended beyond ninety (90) calendar days from receipt of the Employee Claim Form. 3. Employee Contact In all non - litigated, lost time cases, where the employee has not returned to work, telephone or personal contact will be established with the injured employee within three (3) business days of receipt of notice of claim. Such contact will continue as often as necessary, but at least monthly. Such contact with the employee shall be clearly documented in the computer notepad. Return phone calls to employees will be accomplished within one (1) business day. All correspondence from employees will be responded to within five (5) business days of receipt. 4. Employer Contact The claims administrator shall contact the employer within three (3) business days of receipt of notice of a claim by any source to conduct an initial and meaningful investigation. Such contact with the employer shall be clearly documented in the computer notepad. Return phone calls to employers shall be made within one (1) business day. 5. Initial Indemnity Payment The initial indemnity payment or voucher will be issued and mailed to the injured employee together with a properly completed DWC notices within fourteen (14) calendar days of the first day of disability. Page 1 of 7 Resolution 4 -2012 Attachment 2 Late payments must include the self - imposed 10% penalty in accordance with Labor Code Section 4650. 6. Subsequent Indemnity Payments All indemnity payments or vouchers subsequent to the first payment will be verified, except for obvious long -term disability, and issued in compliance with Labor Code Section 4651. Late payments must include the self - imposed 10% penalty in accordance with Labor Code Section 4650. 7. Permanent Disability The claims administrator shall determine the nature and extent of permanent disability and arrange for an informal disability rating whenever possible to avoid Workers' Compensation Appeals Board (WCAB) litigation. The claims administrator shall take advantage of any potential apportionment to prior claims, disabilities, and impairments. The claims administrator shall also advise the employer of potential credits and penalties to permanent disability benefits should the employer accommodate permanent/alternative work for at least twelve (12) months. 8. Diary Review All claim files shall be reviewed at least every forty -five (45) calendar days for active claims and at least every six (6) months for claims that have settled but are open to monitor future medical care. The adjustor shall distinguish the regular diary review from routine file documentation in the computer notepad. A plan of action will be included and separately labeled in the file notes during a diary review. The plan of action shall include, but not limited to, the employee's current work status, medical status, review of reserves, and future activity to move the claim towards resolution. The supervisor shall monitor the diary reviews by printing a "No Activity" report each month to identify any files that have fallen off the diary system. 9. Plan of Action Each claim file shall contain the adjustor's plan of action for the future handling of that claim. The plan of action on new claims will be clearly documented in the computer notepad within fourteen (14) calendar days of initial claim set up. Such plan of action shall be clearly stated including the reasoning for the plan. The plan of action will be updated at least every forty -five (45) calendar days on active claims and at least every six (6) months on claims that have settled but are open to monitor future medical care. Each plan of action will be clearly identified in the computer notepad. Page 2 of 7 Resolution 4 -2012 10. Claim Supervision Attachment 2 The claims administrator shall provide supervisory staff that will regularly review the work product of the adjustors. Supervisors handling claims for LAWCX members with SIR'S of $500,000 or less shall review 20% of the adjustors' caseloads monthly and conduct quarterly reviews on claims with reserves in excess of $50,000. Supervisors handling claims for members with SIRS in excess of $500,000 shall review 10% of the adjustors' caseloads monthly and conduct quarterly reviews on claims with reserves in excess of $100,000. Supervisors shall conduct the reviews to ensure each adjustor is following the performance standards. Such reviews shall be labeled as "Supervisor Review" and clearly documented in the computer notepad. The supervisor must review all medical only claims open beyond ninety (90) calendar days from the date of entry by the claims administrator for potential closure or conversion to indemnity claim status. Claims with $3,000 or more paid -to -date on any claim open beyond one hundred eighty (180) calendar days from date of entry shall be converted to indemnity status and a reasonable, precautionary indemnity reserve placed on the claim. 11. Transportation Expense Transportation reimbursement will be mailed within five (5) calendar days of the receipt of the claim for reimbursement. Advance travel expense payments will be mailed to the injured employee at least ten (10) calendar days prior to the anticipated date of travel. 12. Medical Payments Medical bills will be reviewed for correctness, approved for payment, and paid within the time limits established by Labor Code Section 4603.2. If all or part of the bill is being disputed, the claims administrator will notify the medical provider, on the appropriate form letter, within time limits established by Labor Code Section 4603.2. Complete medical management services will be provided to the employer. 13. Physician Contact Physician's office will be contacted within three (3) business days of notice of all new claims to conduct an initial investigation of the medical aspects of the claim and discuss the member entity's return-to -work goals. Contact with the physician's office shall be maintained to ensure injured workers receive proper medical treatment and are returned to full or modified employment at the earliest possible date. Such contact will continue as needed during the continuation of temporary disability to assure that treatment is related to a compensable injury or illness. Page 3 of 7 Resolution 4 -2012 14. Litigated Cases Attachment 2 The claims administrator shall promptly initiate investigation of issues identified as material to potential litigation. The employer shall be alerted to the need for an outside investigation as soon as possible and shall appoint an outside investigator who is acceptable to the employer. Such referrals will be documented in the claims administrator's computer notepad. The employer shall be kept informed on the scope and results of all investigations. All assignments to outside counsel will be done with the employer's authorization and consent. Such referrals will be documented in the claims administrator's computer notepad. In conjunction with the employer, the claims administrator shall monitor the outside counsel's progress. The claims administrator shall audit all bills before payment. Settlement proposals directed to the employer shall be forwarded by the claims administrator or defense counsel in a concise and clear written form with a reasoned recommendation. All preparation for a trial shall involve the employer so that all material evidence and witnesses are utilized to obtain a favorable result for the defense. 15. Settlements The claims administrator shall obtain the employer's authorization on all settlement or stipulations. Should the total incurred amount exceed the member's self insured retention, the claims adjustor shall obtain written settlement authority from the applicable excess carrier. 16. Future Medical Claims Claims that remain open to monitor future medical care shall remain open for two (2) years from the last payment of benefit. Reviews shall be documented in the claim notes to include settlement information, outline future medical care, last date and type of treatment, name of excess carrier, excess carrier reporting level, and excess carrier reporting history. Reserves for future medical treatment will be reviewed every six (6) months and adjusted for use over a three (3) year average and the injured employee's life expectancy based on the current version of the U.S. Life Table. The reason(s) and calculation(s) for the adjustment(s) shall be clearly documented in the computer notepad. The claims administrator shall evaluate the claim at least once a year to determine a reasonable amount for settlement of future medical benefits and any remaining benefits due. The reason(s) and calculation(s) for the recommended settlement amount shall be clearly documented in the computer notepad. The claims administrator shall clearly document the computer notepad with the outcome of the settlement negotiations with the employee or applicant's attorney. Page 4 of 7 Resolution 4 -2012 17. Subrogation Attachment 2 In all cases where a third party is responsible for the injury to the employee, the third party shall be contacted within ten (10) business days with notification of the employer's right to subrogation and the recovery of certain claim expenses. Such contact will be documented in the claims administrator's computer notepad. If the third party is a governmental entity, a claim shall be filed with the governing board within six (6) months of the injury or notice of injury. Periodic contact shall be made with the responsible party and /or insurer to provide notification of the amount of the estimated recovery to which the employer will be entitled. Such contact will be documented in the claims administrator's computer notepad. If the injured worker brings a civil action against the party responsible for the injury, the claims administrator shall consult with the employer about the value of the subrogation claim and other considerations. Upon employer authorization, subrogation counsel shall be assigned to file a Lien or a Complaint in Intervention in the civil action. Whenever practical, the claims administrator should take advantage of any settlement in a civil action by attempting to settle the workers' compensation claim by means of a Third Party Compromise and Release. If the parties are unable to agree on a reasonable Third Party Compromise and Release, then every effort should be made through the WCAB to offset claim expenses through a credit against the proceeds from the injured worker's civil action. 18. Vocational Rehabilitation (VR) /Supplemental Job Displacement Benefits (SJDB) In accordance with all applicable California laws in place at the date of injury, the claims administrator shall: A. Determine the Qualified Injured Worker/Non- Qualified Injured Worker status; B. Advise the injured worker of his/her right to VR/SJDB; C. Provide appropriate VR/SJDB; D. Control rehabilitation costs; E. Attempt to secure the prompt conclusion of VR/SJDB; and F. Provide notification to the employer should work restrictions require permanent or modified alternative accommodations. 19. Excess Insurance Potential Workers' Compensation excess cases shall be reported in accordance with the reporting criteria established by the Bylaws of the Local Agency Workers' Compensation Excess Joint Powers Authority (LAWCX). All cases that meet the established reporting criteria are to be reported within ten (10) business days of the day on which it is known the criterion is met. Page 5 of 7 Resolution 4 -2012 20. Award Payment Attachment 2 Payments on Awards, Computations, or Compromise and Releases will be issued within ten (10) business days following receipt of the appropriate document. 21. Penalties Late payment of all benefits must include the self - imposed penalty in accordance with California law. The claims administrator will provide the member a quarterly listing of any administrative penalties paid the quarters ending March 31, June 30, September 30, and December 31, which were the responsibility of the claims administrator, and a check from the claims administrator payable to the member for reimbursement. The check and report shall be submitted to the member within thirty (30) calendar days after the quarter ends. 22. Reserves Reserves shall be established based on the facts of the claim and the ultimate probable cost of each claim. All reserve categories shall be reviewed on a regular basis but not less than at least every ninety (90) calendar days on active claims and every six (6) months on claims that have settled but are open to monitor future medical care. Such reviews shall be clearly documented in the computer notepad. Any changes to reserves shall include an explanation for the change. 23. Case Closure All indemnity cases, where permanent disability is not an issue, will be closed within sixty (60) calendar days of the final financial transaction or final correspondence to the injured worker as required by law. All indemnity claims, where permanent disability is an issue, will remain open for two (2) years from the last payment of benefits and then closed within sixty (60) calendar days from that date. 24. Right to Audit or Review The member or its designated representative is authorized to visit the claim administrator's processing and /or storage premises, for purpose of performing a claims audit or review, and have access to all data, including paper documents, microfilm, microfiche, and magnetically stored data which relate to payments or non - payments made by the employer. Any assistance or service provided in response to a claims audit described above will be rendered at no additional cost to the member or employer. 25. Loss Runs The loss run shall be issued by the 15th calendar day of the month following the closing date. Corrections to the loss run made by the 201h calendar day of the month shall be reflected in the following month's loss run. Page 6 of 7 Resolution 4 -2012 Attachment 2 Requests for status of claims generated by the employer shall be provided within thirty (30) calendar days. 26. Loss Data Specification Submissions The claims administrator shall provide loss data information to the excess carrier on a monthly basis in the format outlined in Attachment I, "Request for Detail Information ". The submissions shall be submitted to the excess carrier's secure File Transfer Protocols (FTP) server by the 15th of the following month. The submission shall include the 65 required fields outlined in Attachment 3. The submissions will be made to the FTP server in addition to the loss runs provided to the members and will be made at no additional costs to the member, employer, or excess carrier. 27. Compliance with Labor Code The claims administrator shall comply with all provisions of the Labor Code and Rules and Regulations in effect at the applicable date of injury. Page 7 of 7 Resolution 4 -2012 Attachment 2 Request for Detail Information — Universal Electronic Loss Data Submission Workers' Compensation Claims Information Specifications The data outlined in this request will be utilized for the member's and excess carrier's underwriting process, loss analysis, benchmarking, and actuarial study. Please provide an electronic data file in Microsoft Excel format. If you are submitting data for more than one member, please combine the data into one Excel file. The requested file is a data file only, and should not contain any formatting, macros, formulas, hidden columns or rows, report headers, blank rows, or any other Excel "features ". Files will be accepted in Excel 1997 -2003, 2007 -2009, and 2010 formats. If you need any help generating the loss data file in the required format, please contact the Bickmore IS team at (916) 244 -1100. When compiling your data, please pay careful attention to the following: • Data must be evaluated as of the last day of the month being reported. • If the data is being provided for a Joint Powers Authority (JPA), please use the member /entity's name in the Entity Name Field (described below) and not just the JPA's name. • Workers' compensation claims data should be provided for the entire claim history — all the years you maintain in your risk management /claims information system. • Workers' compensation claims data transferred from any prior third party administrators (TPA) shall be incorporated into the data submission. • Loss amounts should include the full amount of the claim and not be limited to any excess insurance recovery (please do not cap payment, reserve, or recovery amounts). • Losses should be detailed on a per claim basis. • The file should include all open and closed workers' compensation claims including "Incident Only" (also known as "Information Only ", "Record Only ", or "Notice Only ") and "First Aid" claims. Incident Only and First Aid claims must be identified using the "Claim Type" field (described below.) • Medical Management, Bill Review, and /or Cost Containment fees incurred prior to J u 1 y 1, 2 012 should be included in the individual claim paid and reserved medical loss amounts rather than as a separate claim record. Claims coded as "Bill Review ", "Cost Containment ", "Dummy ", or "Ouch" will not be accepted. • Medical Management, Bill Review, and/or Cost Containment fees incurred after July 1, 2012 should be included in the individual claim paid and reserved ALAE loss amounts rather than as a separate claim record. Claims coded as "Bill Review ", "Cost Containment ", "Dummy ", or "Ouch" will not be accepted. • For claims involving Labor Code (LC) 4850 and LC 4856 benefits, please be sure to include the claim information and show separately any payments and reserves specifically designated for LC 4850 and LC 4856 ( "Paid 4850" and "Reserve 4850 "). Do not include Page 1 Resolution 4 -2012 Attachment 2 these amounts in the "Paid Indemnity" or "Reserve Indemnity" columns. • Closed claims cannot have reserve amounts included. By definition, a closed claim cannot have case reserves. Therefore, closed claims with reserve amounts will not be accepted. • All paid, reserve, and incurred amounts must be "positive" numbers. A negative amount may be listed only if it pertains to a subrogation or excess recovery ( "Subro Recovery Amount" and "Excess Recovery Amount"). Per the group's governing documents, members are required to submit loss data. If the data is not submitted in a timely fashion, the member may be penalized. Please note that if the data is not submitted in the proper format or the record layout does not match the following criteria the submission will not be accepted. Should the submission be rejected, the member may be penalized. ELECTRONIC DATA FILE LAYOUT This information will only be accepted via the LAWCX web site (http: / /www.lawcx.org) or via our Secure Insurance data transfer web site accessible at https: / /si.brsrisk.com. Please do not send files through the e-mail system. You may use whichever site you prefer. To upload the files using the LAWCX site, go to "Data Submission" on the main menu ( http:// www .lawcx.org/DataSubmission.aspx) and click on "Enter ". Follow the instructions listed to upload the loss data file(s). To use the LAWCX site you must already have site login credentials which should have been previously provided to you. If you do not have credentials, or have forgotten your user ID or password, please contact the Bickmore Information Services Team at (916) 244 -1100 for assistance. To upload the files using Secure Insurance (https: / /si.brsrisk.com) (note that this is an SSL (secure) site and the prefix is https and not hap), login to the site using your e-mail address and password. If you have not previously used the site, you can easily register by clicking on the registration link ( https:// si. brsrisk. com/ secureinsurance /UserRe,gister.do) on the home page and following the registration instructions. LAWCX files sent using Secure Insurance should be delivered to lawcxdataa,bickmore.net. If you need any assistance registering or submitting the data, please contact Bickmore at (916) 244 -1100. If for any reason you are unable to use either of the data transfer sites, please contact us for alternative electronic transfer solutions, or you can send the data via CD or DVD media through overnight shipping or the U.S. mail. Please utilize the following specifications when submitting your information to us. Each record must consist of the 65 data fields described below. If there is no data for a specific field, please indicate by leaving blank (null); do not use spaces, "NULL ", "UNKNOWN", or " / / " as placeholders. Note that only fields 3 (Location Name), 7 (Claimant First Name), 11 (Occupation Code), and 39 (Date Closed) can be left blank, and only under specific circumstances. All numeric (amount) fields must be coded as a dollar amount. If there is no amount, code as "$0.00 "; do Page 2 Resolution 4 -2012 Attachment 2 not leave blank. If using dollar signs ( "$ ") and /or commas ( ", ") in a loss amount field causes problems with your submission process, they can be omitted. The first row of the file must contain a header identifying the columns exactly as specified below. If using spaces (" ") in column names causes problems with your submission process, you may substitute underscores instead. A template of the file with the correct header and a sample claim row is attached for your use /information. These specifications and the sample template are also available for download at the secure data transfer site. SPECIFICATIONS: No. Field Name Format Description 1 Evaluation Date mm /dd /yyyy The date the loss data was evaluated, which should always be the last day of the month being reported 2 Entity Name text (80) Name of the member entity, district, or employer. For members of a JPA or group, this field should contain the member /entity name, not the name of the JPA or group. The individual employer /entity name will be used to determine the group 3 Location Name text (80) Name of the claimant's assigned location, building, facility, school, or division (if the same as Department Name, then leave blank). Do not include location numbers 4 Department Name text (80) Name of the claimant's department. Do not include department numbers 5 Claim Number text (40) Claim or file number 6 Original Claim Number text (40) If the claim has been transferred from another TPA or entity, or is the excess or pool layer loss amount on another claim, include the original claim or file number. Otherwise code the same as 5 (Claim Number) above 7 Claimant First Name text (40) First name of the claimant. Must be mixed case and only include the claimant's first name 8 Claimant Last Name text (40) Last name of the claimant. Must be mixed case and not include the claimant's first name Page 3 Resolution 4 -2012 Attachment 2 9 Date of Birth mm /dd /yyyy Claimant's date of birth 10 Gender text (1) Claimant's gender. Code F for female or M for male 11 Occupation text (40) Job title of claimant at time of injury/illness 12 Safety Flag text (1) Code "Y" if the claimant is eligible for full salary benefits under Labor Codes (LC) 4850 and 4856 or "N" if not 13 Class Code text (4) NCCI standard class code based on claimant's occupation at time of injury/illness. (If the code is not captured, then leave blank.) 14 Date of Hire mm /dd/yyyy Claimant's hire date 15 Avg. Weekly Wages $ #,###.## Average weekly wages at time of injury/illness. If unknown, code $0.00 16 Claim Type text (2) Code as IO = Incident (or Record or Notice) Only, FA = First Aide, MO = Medical Only, TD = Temporary Disability, PP = Permanent Partial Disability, PT = Permanent Total Disability (100 %), DC = Death Claim, or FM = Future Medical. No other codes will be accepted 17 PD Rating ###.## Percentage of rating established by the TPA, State, or independent rater 18 PD Amount $ #, # # #. ## Amount of PD associated with percentage of rating established by the TPA, State, or independent rater 19 Settlement Type text (2) Code as CR = Compromise and Release, FA = Findings and Award, ST = Stipulated Award, OS = Other Settlement Type, NS = Not Settled. No other codes will be accepted 20 Settlement Amount $ #,###. ## Amount of settlement agreed by all parties and approved by a WCAB judge 21 Settlement Date mm/dd /yyyy Date judge approved settlement Page 4 Resolution 4 -2012 22 FM Award Flag 23 Cause of Loss Code 24 Cause Description Attachment 2 text (1) Code "Y" if the claim will remain open to monitor future medical care or "N" if the claimant is not entitled to future medical care text (3) text (80) 25 Nature of Injury Code text (3) Alphanumeric Cause of Loss code Ex.: Fall. Only include description (no codes accepted) Alphanumeric Nature of Injury code 26 Injury Description text (80) Ex.: Sprain. Only include description (no codes accepted) 27 Body Part Code text (3) Alphanumeric Body Part code 28 Body Part Description text (80) Ex.: Foot. Only include description (no codes accepted) 29 Text Description text (255) Free form text description of the claim. This field should list the actual description of the injury or event as listed by the employer. Do not include quotes (`), double quotes ( "), or carriage return or end -of -line characters (CRLF) 30 Fatality Flag text (1) Code "Y" if the injury or illness caused or allegedly caused the claimant's death or "N" if it did not 31 Litigated Flag text (1) Code "Y" if the claimant is or was represented by an attorney or the employer retained legal representation at any time or "N" if there are no attorneys involved 32 Accepted Date mm /dd /yyyy Date the claim or a portion of the claim is accepted 33 Delayed Date mm/dd /yyyy Date the claim or a portion of the claim was once or is currently delayed 34 Denied Date mm /dd /yyyy Date the claim or a portion of the claim is denied Page 5 Resolution 4 -2012 Attachment 2 35 Date of Loss mm/dd /yyyy Date the incident, injury, or illness occurred or was alleged. If cumulative trauma is alleged, the date of injury shall be listed as the last date of the injurious exposure 36 Date Reported mm/dd /yyyy Date claim was reported by the claimant to his or her employer. Also known as date of knowledge 37 Date Received mm /dd/yyyy Date claim was received /reported to the claims administrator /adjuster 38 Date Entered mm/dd /yyyy Date claim was entered into the risk management/claims information system. Also known as system date, open date, or registration date 39 Date Closed mm/dd /yyyy Date this claim was closed (if not closed then leave blank) 40 Status text (2) Code as follows: OP = Open, CL = Closed, RO = Re- opened, RC = Re- closed. No other codes will be accepted 41 Paid TD $ #,###. ## Amount paid to date on the claim for temporary benefits (does not include amount paid per LC 4850 and 4856 or Vocational Rehabilitation (VR) /supplemental job displacement benefits (SJDB) 42 Paid PD $ #,###.## Amount paid to date on the claim for permanent benefits 43 Paid 4850 $ #,###. ## Amount paid to date for losses /injuries to public safety officers per LC 4850 and 4856. Do not include amount in field 41 (Paid TD) 44 Paid Other Indemnity $ #,###. ## Amount paid to date for other indemnity benefits not including TD, PD, or LC 4850 benefits. This includes death benefits and /or penalties 45 Paid Medical $ #,###. ## Amount paid to date for medical benefits and medical management fees (bill review, nurse case management, utilization review incurred prior to 07/01 /12) Page 6 Resolution 4 -2012 Attachment 2 46 Paid VR/SJDB $ #,## #.## Amount paid to date for VR/SJDB 47 Paid ALAE $ #, # # #.## Amount paid to date for all non -legal expenses (fees for copy service, surveillance /sub rosa, interpreters, indexing, witnesses, investigations, and expenses incurred after 06/30/12 for bill review, nurse case management, and utilization review services) 48 Paid Legal Expenses $ #,###. ## Amount paid to date for legal expenses (fees for defense attorney and depositions) 49 Total Paid $ #,## #. ## Total paid on this claim to date. Must total the sum of fields 41 +42 +43 +44 +45 +46 +47 +48 50 Reserved TD $ #, ###. ## Current case reserve for only temporary benefits (does not include amount reserved per LC 4850 and 4856 or VR/SJDB) 51 Reserved PD $ #,###.## Current case reserve for only permanent benefits (does not include amount reserved per LC 4850 and 4856 or VR/SJDB) 52 Reserved 4850 $ #, ###.## Current case reserves for losses /injuries to public safety officers per LC 4850 and 4856. Do not include this amount in field 50 (Reserved TD) 53 Reserved Other Indemnity$ #, ###.## Current case reserves for other indemnity benefits not including TD, PD, or LC 4850 and 4856 benefits. This includes death benefits and /or penalties 54 Reserved Medical $ #, # # #. ## Current case reserve for medical benefits and medical management fees (bill review, nurse case management, utilization review incurred prior to 07/01/12) 55 Reserved VR/SJDB $ #,## #.## Current case reserve amount for VR/SJDB 56 Reserved ALAE $ #,###.## Current case reserves for non -legal expenses (fees for copy service, surveillance /sub rosa, interpreters, indexing, witnesses, investigations, and expenses incurred after 06/30/12 for bill review, nurse case management, and utilization review services) Page 7 Resolution 4 -2012 Attachment 2 57 Reserved Legal Expense $ #, # # #. ## Current case reserves for legal expenses (fees for depositions and defense attorney) 58 Total Reserved $ #,###.## Total current case reserves on this claim. Must total the sum of fields 50 +51 +52 +53 +54 +55 +56 +57 59 Total Incurred $ #,###.## Total Incurred losses for this claim. This amount shall be exclusive of any subro or excess recovery amounts. Must total the sum of fields 49 (Total Paid) and 58 (Total Reserved) 60 Subrogation Recovery $ #,###.## Amount recovered for subrogation recovery on this claim file. This amount shall not be deducted from the paid to date, reserve, or total incurred amounts 61 Excess Recovery $ #, # # #.## Amount recovered from excess carrier on this claim file. This amount shall not be deducted from the paid to date, reserve, or total incurred amounts 62 4850 Days Paid #, # ## Number of LC 4850/4856 days paid. Code as "0" if none has been paid. This field will contain the number of days and not the amount of benefits paid to the claimant per LC 4850 and 4856 63 Mod. Duty Days Worked #, # ## Number of modified duty days claimant worked. Code as "0" if none worked. This field will contain the number of days and not the amount of salary paid to the claimant 64 OSHA Days Paid #, # ## Number of OSHA days paid. Code as "0" if none paid. This field will contain the number of days and not the amount of temporary disability benefits paid to the claimant 65 TD Days Paid #, # ## Number of temporary disability days paid. Code as "0" if none paid. This field will contain the number of days and not the amount of TD benefits paid Paper loss runs and/or Adobe Acrobat files are not acceptable. Page 8 EXHIBIT "D" PAYMENT SCHEDULE CONSULTANT'S Claims Administration fee for the period July 1, 2016 through June 30, 2017 shall be $80,612.00. The Claims Administration fees are payable monthly in advance by the City of Gilroy upon receipt of CONTRACTOR'S invoice. The City of Gilroy shall establish, maintain, and reconcile the workers compensation trust/bank account as such there will be no charge from CONTRACTOR for these services. The City of Gilroy shall be responsible for all Managed Care Services and Loss Adjustment Expenses. Managed Care Services shall include medical bill review, utilization review, and medical case management. Costs for such services are documented in Exhibit B; however, bill review services shall be billed at a rate not to exceed $30.00 per bill. Loss Adjustment Expenses shall include all reasonable expenses necessary to the adjustment of a claim in accordance with the Service Agreement, including, but not limited to, fees for engaging defense counsel, court reporters, expert witnesses and field investigators, incurred on behalf of the City of Gilroy. On behalf of the City of Gilroy, Innovative Claims Solutions, Inc. will perform all workers compensation claims reporting services required by the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) Section 111 Mandatory Reporting to the Centers for Medicare & Medicaid Services (CMS) for the periods stated above. 4835 - 2267 -03610 LAC104706083 ACORO0 CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD/YYYY) 3/30/2016 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 terns 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 Andreini & Company- Stockton 2431 W. March Lane, Suite 300 Stockton CA 95207 NAME: Connie Lundquist PHONE g77- 469 -0507 FAX 650-378-4361 E-MAIL . clundquist @andreini.com INSURERS AFFORDING COVERAGE NAIC # INSURER A: Federal Insurance Company 20281 4/1/2016 INSURED INNOV -5 INSURER B: $1,000,000 INSURER C CLAIMS -MADE ❑X OCCUR Innovative Claim Solutions Inc Attn: Gary Archibald 11344 Coloma Rd., Suite 745 INSURER D Gold River CA 95670 INSURER E: $1,000,000 INSURER F: MED EXP (Any one person) $10,000 COVERAGES CERTIFICATE NUMBER- 110749312 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 LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MMIDDIYYYY LIMITS • X COMMERCIAL GENERAL LIABILITY 35754610 4/1/2016 4/1/2017 EACH OCCURRENCE $1,000,000 CLAIMS -MADE ❑X OCCUR DAMAGE TO RENTED PREMISES Ea occurr nce $1,000,000 MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY ❑ PRO F LOC JECT PRODUCTS - COMP /OP AGG $Incl Agg 1 $ OTHER: • AUTOMOBILE LIABILITY 73513506 4/1/2016 4/1/2017 OMBI ED $1,000,000 BODILY INJURY (Per person) $ ANY AUTO AUT OWNED SCHEDULED BODILY INJURY (Per accident) $ HIRED AUTOS X NON -OWNED AUTOS X PROPERTY DAMAGE Per accident $ • X UMBRELLA LIAB X OCCUR 79797000 4/1/2016 411/2017 EACH OCCURRENCE $5,000,000 AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED I X RETENTION$0 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N PER OTH- STATUTE I JER E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? ❑ N/A E.L. DISEASE - EA EMPLOYE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A A Professional Liability Fidelity Limit 81722762 81815467 4/1/2016 4/112016 4/1/2017 4/1/2017 Professional Limit $3,000,000 Fidelity Limit $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Gilroy, its officers, respentatives, agents and employees are included as additional insured as respects to the General Liability as their interest may appear per the attached Blanket Additional Endorsement Form #80 -02- 2367(05/07) where required by written contract. This insurance is primary and non- contibutory per the attached form #17 -02 -3080 (04/01). GtK I IFIGA I It HL)LUtK GANGELLATION City of Gilroy HR Director /Risk Manager 7351 Rosanna Street Gilroy CA 95020 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988 -2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 0 0 ! 1 NE Liability Insurance Endorsement Policy Period APRIL 1, 2016 TO APRIL 1, 2017 Effective Date APRIL 1, 2016 Policy Number 3575 -46 -10 WCE Insured INNOVATIVE CLAIM SOLUTIONS INC. Name of Company FEDERAL INSURANCE COMPANY Date Issued JANUARY 8, 2016 : t• }.•r }:tkt'.,•:;a::k :.5:'o`�s"», 2: iskka'; J' G!.J..e:i...,..:a.',Og;�Cc:t;�ti i { }::;: :..,::i ? }:t {{ { <:.......: N•:k wx:5. }?.C<?b:K:...:........i4....., { n: r.: XC#:: <:,{tvS.::'cS::S {:fik�::t:: kiCCi .:fi'0k�..X.9i'S.iA?kr:'G Y.: k: �'.{•.'.: :R't•:•".:.:^.5:..}w,y.{nY,. ?k: {{:' tkkk : { { {:� {`:. }: ?::::'t•{:kkk:S:: This Endorsement applies to the following forms: GENERAL LIABILITY n:.......:: ...::::::::::::::::::• �:::;:• r.:::.. v.:...... vi4A}., Q•...\,.....:\`.......... Y. iu{. .............:..,.n.:�'i.•k+vi� vw:..,.:. x....., 2..}.::::% iw:.,:.::::::::' N.+.$ ��v:{ Cb::: h{.::::., v{. v:}?r 1.{.,T kn.::?:::::::? :::::..}$:kC: \};.vv : }} }::;,{}:: }.b::::::::.::.t::. Under Who Is An Insured, the following provision is added. Who Is An Insured Additional Insured - Persons or organizations shown in the Schedule are insureds; but they are insureds only if you are Scheduled Person obligated pursuant to a contract or agreement to provide them with such insurance as is afforded by Or Organization this policy. However, the person or organization is an insured only: • if and then only to the extent the person or organization is described in the Schedule; • to the extent such contract or agreement requires the person or organization to be afforded status as an insured; • for activities that did not occur, in whole or in part, before the execution of the contract or agreement; and • with respect to damages, loss, cost or expense for injury or damage to which this insurance applies. No person or organization is an insured under this provision: • that is more specifically identified under any other provision of the Who Is An Insured section (regardless of any limitation applicable thereto). • with respect to any assumption of liability (of another person or organization) by them in a contract or agreement. This limitation does not apply to the liability for damages, loss, cost or expense for injury or damage, to which this insurance applies, that the person or organization would have in the absence of such contract or agreement. :.::.,. Vk'- .....•....:4:........,:...! `.< sc.: 2w..:?.,..•».,.:.» i'..: w:.•.? Y.,..,.,,,..,k4.,:..n..•.th >.�: ka »:: >9b{a.S�.•}.,\,dk'R, :: ..... ..,. . +.x <.:•, •:.,•. �:• }:•;:.>•.:•::• } ?:.•::• „?:•. .•»».•;}: a?:' t• { {:. +.k::.'::•:;k::kkkk:Y'..... wt:{: k:?�},::• :::::......::::....... n.. Y.:R:;k:t }:i: :5;t::ki;: { n�i' l :{i;?:tiRkk:{S'Yk >uS}TX7k�i%'• "r i:.•,,•. Liability Insurance Additional Insured - Scheduled Person Or Organization Form 80-02 -2367 (Rev. 5 -07) Endorsement continued Page 1 Liability Endorsement (continued) Under Conditions, the following provision is added to the condition titled Other Insurance. Conditions Other Insurance — If you are obligated, pursuant to a contract or agreement, to provide the person or organization Primary, Noncontributory shown in the Schedule with primary insurance such as is afforded by this policy, then in such case Insurance — Scheduled this insurance is primary and we will not seek contribution from insurance available to such person Person Or Organization or organization. ` iiiT ::: } }ti:�in {::f: },CY.:::i•+.i:: �:< vi:! i. 3! S.`• f:: hk,::t::i }:::'•>:':1`.i:v.`w'^n "w:: ii$'.i: n'i�ii'.22•`.Y4��i n` viii? L 'iT2v'"R�•"+v`t.:>.�.......::.t i.`$9.v... +.•:4'iF9 S�:{���j:v�S::,'•:`v'v .`�. .{SA`•!�$ \�:Lvv�rv..il.:. n:.:.4.lfn .2......... Schedule 0 Persons or organizations that you are obligated, pursuant to a contract or agreement, to provide with such insurance as is afforded by this policy. All other terms and conditions remain unchanged. Authorized Representative p��, low 0 Liability Insurance Additional Insured - Scheduled Person Or Organization fast page Form 80-02 -2367 (Rev. 5 -07) Endorsement Page 2 0 0 0 ic cr�utaB Conditions Legal Action Against Us (continued) General Liability A person or organization may sue us to recover on an agreed settlement or on a final judgment against an insured obtained after an actual: trial in a civil proceeding; or arbitration or other alternative dispute resolution proceeding; but we will not be liable for damages that are not payable under the terms and conditions of this insurance or that are in excess of the applicable Limits Of Insurance. : ..:.:.:..::.:.::............... .. ..................... ................. Other Insurance If other valid and collectible insurance is available to the insured for loss we would otherwise cover under this insurance, our obligations are limited as follows. Primary Insurance This insurance is primary except when the Excess Insurance provision described below applies. If this insurance is primary, our obligations are not affected unless any of the other insurance is also primary. Then, we will share with all that other insurance by the method described in the Method of Sharing provision described below. Excess Insurance This insurance is excess over any other insurance, whether primary, excess, contingent or on any other basis: A. that is Fire, Extended Coverage, Builder's Risk, Installation Risk or similar insurance for your work, B. that is insurance that applies to property damage to premises rented to you or temporarily occupied by you with permission of the owner; C. if the loss arises out of aircraft, autos or watercraft (to the extent not subject to the Aircraft, Autos Or Watercraft exclusion), D. that is insurance: 1. provided to you by any person or organization working under contract or agreement for you; or 2. under which you are included as an insured; or E. that is insurance under any Property section of this policy. When this insurance is excess, we will have no duty to defend the insured against any suit if any other insurer has a duty to defend such insured against such suit If no other insurer defends, we will undertake to do so, but we will be entitled to the insured's rights against all those other insurers. When this insurance is excess over other insurance, we will pay only our share of the amount of loss, if any, that exceeds the sum of the total: Liability Insurance Form 17 -02 -3080 (Rev. 4 -01) Contract amount that all other insurance would pay for loss in the absence of this insurance; and of all deductible and self- insured amounts under all other insurance. Page 23 of 32