Innovative Claims Solutions - 2016 Agreement - Amendment No. 1FIRST AMENDMENT TO WORKERS COMPENSATION THIRD PARTY CLAIMS
ADMINISTRATION AGREEMENT BETWEEN THE CITY OF GILROY AND
INNOVATIVE CLAIMS SOLUTIONS INC.
WHEREAS, the City of Gilroy, a municipal corporation ( "City"), and Innovative Claims
Solutions, Inc. entered into that certain agreement entitled Agreement for Services — Workers
Compensation Third Party Claims Administration, effective on July 1, 2016, hereinafter referred to as
"Original Agreement "; and
WHEREAS, City and Innovative Claims Solutions, Inc. have determined it is in their mutual
interest to amend certain terms of the Original Agreement.
NOW, THEREFORE, FOR VALUABLE CONSIDERATION, THE PARTIES AGREE AS
FOLLOWS:
1. Article 1. Term of Agreement of the Original Agreement shall be amended to read as follows:
This amendment will become effective on July 1, 2017 and will continue in effect through June 30,
2018, unless extended by addendum or unless terminated in accordance with the provisions of Article
7 of the Original Agreement.
2. Article 4. Compensation of the Original Agreement shall be amended to read as follows: In
consideration for the services to be performed by CONSULTANT, CITY agrees to pay
CONSULTANT the amounts set forth in the attached revised Exhibit D ( "Payment Schedule "). In no
event however shall the total compensation paid to CONSULTANT EXCEED $89,000.00.
3. This Amendment shall be effective on June 30, 2017.
4. Except as expressly modified herein, all of the provisions of the Original Agreement shall
remain in full force and effect. In the case of any inconsistencies between the Original Agreement and
this Amendment, the terms of this Amendment shall control.
5. This Amendment may be executed in counterparts, each of which shall be deemed an original,
but all of which together shall constitute one and the same instrument.
IN WITNESS WHEREOF, the parties have caused this Amendment to be executed as of the
dates set forth besides their signatures below.
CITY OF GILROY
By: -1-11
[signature]
Gabriel A. Gonzalez
[employee name]
City Administrator
[titletdepartmentl
Date:
4845-8215.5540v1
MDOLINGER104706083
INNOVATIVE C1 IMS SOLUTIONS, INC.
B si rel
Gary A
[namel
President/CIO
[title]
Date: J VA,-e. 30 k 2.0 k,4-
APPROVED AS TO FORM:
jKjo
City Attorney
4845 - 8215- 5540v1
MDOLINGER104706083 -2-
EXHIBIT D
PAYMENT SCHEDULE
CONSULTANT'S Claims Administration fee for the period July 1, 2017 through June 30,
2018 shall be $89,000.00 payable in monthly installments of $7,416.66.
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 trustibank
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.
4845 -8215 -55400 _3 _
MDOLINGER104706083
ACOR ®® CERTIFICATE OF LIABILITY INSURANCE
DATE(MMIDD/YYYY)
4/4/2017
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 have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsements .
PRODUCER
Andreinl & Company- Stockton
2431 W. March Lane, Suite 300
Stockton CA 95207
CONTACT" -
NAME Connie Lundquist
PHONE 877.469 -0507 FAx 650 - 378 -4361
E-MAIL clundqulst @andrelnl.com
INSURER(S) AFFORDING COVERAGE
NAIC q
INSURER Federal Insurance Company
20281
4/1/2017
INSURED INNOV -5
INSURER B
$1,000,000
INSURER
CLAIMS -MADE FX 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: 857957376 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 M_ A_Y HAVE BEEN REDUCED BY PAID CLAIMS
INSR
LTR
TYPE OF INSURANCE
INSD
WVD
POLICY NUMBER _ _
POLICY EFF
MM/DD/YYYY
POLICY EXP
MM /DDIYYYY
LIMITS
A
X
COMMERCIALGENERALLIABIUTY
35754610
4/1/2017
4/1/2018
EACH OCCURRENCE
$1,000,000
CLAIMS -MADE FX OCCUR
DAMAGE TO RENTED
PREMISES Ea occurrence
$1,000,000
MED EXP (Any one person)
$10,000
_
PERSONAL BADVINJURY
$1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE
$2,000,000
X POLICY❑ JECT PRO F—] LOC
PRODUCTS - COMP/OP AGG
Agg
$ _
OTHER
A
AUTOMOBILE
LIABILITY
73513506
4/1/2017
4/1/2018
Ea accident
$1,000,000
BODILY INJURY (Per person)
$
ANY AUTO
OWNED SCHEDULED
AUTOS ONLY AUTOS
BODILY INJURY (Per accident)
$
HIRED NON -OWNED
AUTOS ONLY X AUTOS ONLY
X
PROPERTY DAMAGE
Per accident
$
A
X
UMBRELLALIAB
X
OCCUR
79797000
4/1/2017
4/1/2018
EACH OCCURRENCE
$5,000,000
AGGREGATE
$5,000,000
EXCESS LIAR
CLAIMS -MADE
DED X RETENTION $0
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
PER H
STATUTE ER
L EACH ACCIDENT
$
ANY PROPRIETORIPARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDEDI El
NIA
E L DISEASE - EA EMPLOYEE
$
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
E L DISEASE - POLICY LIMIT
$
A
A
Professional Liability
Fidelity Limit
81722762
81815467
4/1/2017
4/1/2017
4/1/2018
4/1/2018
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- contlbutory per the attached form #17 -02 -3080 (04/01)
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.
ATIVE
zoi
@ 1988 -2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
C H U B 8° Liability Insurance
0 Endorsement
Policy Period APRIL 1, 2017 TO APRIL, 1, 2018
Effective Date APRIL 1, 2017
Policy Number 3575 -46-10 WCE
Insured INNOVATIVE CLAIM SOLUTIONS INC.
Name of Company FEDERAL INSURANCE COMPANY
Date Issued JANUARY 31, 2017
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This Endorsement applies to the following forms:
GENERAL LIABILITY
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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
17-.�
• 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.
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Liability Insurance Addibonal Insured - Scheduled Person Or Organization continued
Form 8042 -2367 (Rev. 5-07) Endorsement Page 1
CHUBB°
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.
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Schedule
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
0
Liability Insurance Additional Insured - Scheduled Person Or Organization last page
Form 80-02 -2367 (Rev. 5-07) Endorsement Page 2
(=HUBS* General Liability
0 Conditions
•
Legal Action Against Us A person or organization may sue us to recover on an agreed settlement or on a final judgment
(continued) against an insured obtained after an actual:
• trial to 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, Builders 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:
• 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.
Liability Insurance
Form 17-02 -3080 (Rev 4 -01) Contract Page 23 of 32
Conditions
Other Insurance We will share the remaining loss, if any, with any other insurance that is not described in this
(continued) Excess Insurance provision and was not negotiated specifically to apply in excess of the Limits Of
Insurance shown in the Declarations of this insurance.
Method of Sharing
If all of the other insurance permits contribution by equal shares, we will follow this method also.
Under this method each insurer contributes equal amounts until it has paid its applicable limits of
insurance or none of the loss remains, whichever comes first.
If any of the other insurance does not permit contribution by equal shares, we will contribute by
limits. Under this method, each insurer's share is based on the ratio of its applicable limits of
insurance to the total applicable limits of insurance of all insurers.
Premium Audit We will compute all premiums for this insurance in accordance with our rules and rates.
In accordance with the Estimated Premiums section of the Premium Summary, premiums shown
with an asterisk ( +) are estimated premiums and are subject to audit.
In addition to or in lieu of such designation in the Premium Summary, premiums may be designated
as estimated premiums elsewhere in this policy. In that case, these premiums will also be subject to
audit, and the second paragraph of the Estimated Premiums section of the Premium Summary will
apply.
Separation Of Insureds Except with respect to the Limits Of Insurance, and any rights or duties specifically assigned in this
insurance to the first named Insured, this insurance applies:
• as if each named insured were the only named insured; and
• separately to each insured against whom claim is made or suit is brought.
Transfer Or Waiver Of We will waive the right of recovery we would otherwise have had against another person or
Rights Of Recovery organization, for loss to which this insurance applies, provided the insured has waived their rights
Against Others of recovery against such person or organization in a contract or agreement that is executed before
such loss.
To the extent that the insuredss rights to recover all or part of any payment made under this
insurance have not been waived, those rights are transferred to us. The insured must do nothing
after loss to impair them At our request, the insured will brig suit or transfer those rights to us
and help us enforce them.
This condition does not apply to medical expenses.
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is
Liability Insurance
Form 17-02 -3080 (Rev 4 -01) contact Page 24 of 32