Agreement - Innovative Claims Solutions, Inc. - 1st Amendment - Workers Compensation 3rd Party Claims Administrator - Signed 2022-07-01City of Gilroy
Agreement/Contract Tracking
Today’s Date:
May 30, 2022 Your Name: LeeAnn McPhillips
Contract
Type:
Services over $5k - Consultant Phone Number: 408-846-0205
Contract Effective Date:
(Date contract goes into effect)
7/1/2022
Contract Expiration Date: 6/30/2024
Contractor / Consultant Name:
(if an individual’s name, format as
last name, first name)
Innovatie Claims Solutions, Inc.
Contract Subject:
(no more than 100 characters)
Workers Compensation Third Party Claims Administrator; City Council
approved 5 yr. agreement in 2019
Contract Amount:
(Total Amount of contract. If no
amount, leave blank)
$442251
By submitting this form, I confirm
this information is complete:
➢ Date of Contract
➢ Contractor/Consultant name and complete address
➢ Terms of the agreement (start date, completion date or “until
project completion”, cap of compensation to be paid)
➢ Scope of Services, Terms of Payment, Milestone Schedule and
exhibit(s) attached
➢ Taxpayer ID or Social Security # and Contractors License # if
applicable
➢ Contractor/Consultant signer’s name and title
➢ City Administrator or Department Head Name, City Clerk
(Attest), City Attorney (Approved as to Form)
Routing Steps for Electronic Signature
Risk Manager
City Attorney Approval As to Form
City Administrator or Department Head
City Clerk Attestation
DocuSign Envelope ID: 155EF889-2F3C-4E7D-A223-72BD243F2064
5/31/2022
5/31/2022
6/6/2022
6/6/2022
TYPE OF
PROCURMENT
DOLLAR THRESHOLD / SIGNING AUTHORITY
STAFF LEVEL DEPARTMENT HEAD CITY ADMINISTRATOR COUNCIL APPROVAL
$0-$999.99 $1,000-$49,999.99 $50,000-$99,999.99 $100,000-Above
EQUIPMENT
/SUPPLIES/
MATERIALS
Furniture, hoses,
parts, pipe
manholes, office
supplies, fuel, tools,
PPE items, etc…
• Vendor selection at
discretion of staff
Payment Method
Purchase Card or
Payment Request (if
vendor does not accept
credit cards)
• Informal
bid/quotation –
3 quotes (verbal
or written)
• Purchasing
Summary form
w/ Purchasing
Approval
• Purchase
Requisition
Payment Method
Purchase Order*
• Informal
bid/quotation –
3 written quotes
• Purchasing
Summary form w/
City Administrator
Approval
• Purchase
Requisition
Payment Method
Purchase Order
• Formal Bid
• Advertisement
• Council Approval
• Purchase
Requisition signed
by City
Administrator
Payment Method
Purchase Order
GENERAL SERVICES
Janitorial, landscape
maintenance,
equipment repair,
installation, graffiti
abatement, service
inspections,
uniform cleaning,
etc…
• Vendor selection at
discretion of staff
• May require insurance
documents depending
on scope/ nature of
work
Payment Method
Purchase Card (if
incorporated)
Signed Payment Request (if sole
proprietor or partner)
• Informal
bid/quotation –
3 quotes (verbal
or written)
• Purchasing
Summary form
w/ Department
Head Approval
• Standard
Agreement
• Purchase
Requisition
Payment Method
Purchase Order*
• Informal Bid/RFP
quotation – 3
written quotes
• Purchasing
Summary form w/
City Administrator
Approval
• Standard
Agreement
• Purchase
Requisition
Payment Method
Purchase Order
• Formal
Bid/RFP/RFQ
• Advertisement
• Council Approval
• Standard
Agreement
• Purchase
Requisition
Payment Method
Purchase Order
PROFESSIONAL
SERVICES
Consultants,
architects,
designers, auditors,
etc...
• Vendor selection at the
discretion of staff
• Purchase Summary
Form w/ Purchasing
Approval
• Standard Agreement
signed by Department
Head
• Purchase Requisition
Payment Method
Purchase Order
• RFP/RFQ to at
least 3
consultants
• Purchase
Summary Form
w/ Department
Head Approval
• Standard
Agreement
• Purchase
Requisition
Payment Method
Purchase Order
• RFP/RFQ to a list
of consultants
• Evaluation
Spreadsheet w/
City Administrator
Approval
• Standard
Agreement
• Purchase
Requisition
Payment Method
Purchase Order
• Formal RFP/RFQ
• Advertisement
• Council Approval
• Standard
Agreement signed
by City
Administrator
• Purchase
Requisition
Payment Method
Purchase Order
DocuSign Envelope ID: 155EF889-2F3C-4E7D-A223-72BD243F2064
-1- 4845-8215-5540v1
MDOLINGER\04706083
FIRST 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, 2019, 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 June 30, 2022 and will continue in effect through June 30,
2024, unless extended by addendum or unless terminated in accordance with the provisions of Article
7 of the Original Agreement.
2. Exhibit D is amended to officially add Year 4 and Year 5 to this Agreement. The cost for these
two years was already included in the dollar amount of the original Agreement.
3. This Amendment shall be effective on June 30, 2022.
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 INNOVATIVE CLAIMS SOLUTIONS, INC.
By: By:
[signature] [signature]
Jimmy Forbis Dan Greco
[employee name] [name]
City Administrator Vice-President, Client Services
[title/department] [title]
Date: Date:
DocuSign Envelope ID: 155EF889-2F3C-4E7D-A223-72BD243F2064
5/31/20226/6/2022
-2- 4845-8215-5540v1
MDOLINGER\04706083
APPROVED AS TO FORM: ATTEST:
City Attorney City Clerk
DocuSign Envelope ID: 155EF889-2F3C-4E7D-A223-72BD243F2064
-3- 4845-8215-5540v1
MDOLINGER\04706083
EXHIBIT “D”
PAYMENT SCHEDULE
CONSULTANT’S Claims Administration fee shall be as follows:
Fiscal Year Annual Fee Agreement/Option
7/1/19 - 6/30/20 $83,300 payable monthly at
rate of $6,941.67
Agreement - Year One
7/1/20 - 6/30/21 $85,799 payable monthly at
rate of $7,149.92
Agreement - Year Two
7/1/21 - 6/30/22 $88,373 payable monthly at
rate of $7,364.42
Agreement - Year Three
7/1/22 - 6/30/23 $91,024 payable monthly at
rate of $7,585.33
Addendum to Agreement -
Year Four
7/1/23 - 6/30/24 $93,755 payable monthly at
rate of $7,812.92
Addendum to Agreement -
Year Five
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.
DocuSign Envelope ID: 155EF889-2F3C-4E7D-A223-72BD243F2064
DocuSign Envelope ID: 155EF889-2F3C-4E7D-A223-72BD243F2064
DocuSign Envelope ID: 155EF889-2F3C-4E7D-A223-72BD243F2064
DocuSign Envelope ID: 155EF889-2F3C-4E7D-A223-72BD243F2064
DocuSign Envelope ID: 155EF889-2F3C-4E7D-A223-72BD243F2064
DocuSign Envelope ID: 155EF889-2F3C-4E7D-A223-72BD243F2064