HomeMy WebLinkAboutInnovative Claims Solutions - Workers' Compensation Third Party Claims Administration (2019)AGREEMENT FOR SERVICES
(For contracts over $5,000 - CONSULTANT)
This AGREEMENT made this Chi d of July, 2019 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 I; 2.019 and will continue in effect through June
30. 2022. 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 tV
terminate this Agreement regardless of any other provision stated herein.
itial
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.
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C. Employment of Assistants
CONSULTANT may, at the CONSULTANT'S own expense, employ such assistants as
CONSULTANT deems necessary to perfonn 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 "D" ("Payment Schedule"). In no event
however shall the total compensation paid to CONSULTANT exceed $442,251.00.
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
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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 perfonn 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,
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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.
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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
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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.
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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.
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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:
Innovative Claims Solutions, Inc.
BNye $G—ry
r ibald
aV
Title: Presiders
Social Security or Taxpayer
Identification Number 68-0454747
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CITY:
CITY OF GILROY
By:
Name: Gabriel A. Gonzalez --
Title: Citv Administrator
Approved as Form
City Attorney
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A
City Clerk
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.
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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.
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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.
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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/C 10
11344 Coloma Road, Suite 745
Gold River, CA 95670
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.
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.
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SCOPE OF SERVICES
Workers Compensation Third Party Claims Administration 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.
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City of Gilroy
Proposal for Workers' Compensation Claim
Administration
February 2019
Prepared and presented by:
Innovative Claim Solutions, Inc.
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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
Bav Area Office
2430 Camino Ramon. Suite 200
San Ramon, CA 94583
Contact: Cheryl Westeren, COO and President
(925) 904-2400
cesteren@ics-claims.com
Human Resources & Risk Management Department
Attention: Human Resources Director/Risk Manager
City of Gilroy
Re: City of Gilroy Workers' Compensation Third Party Claims Administration Services
No. 19-RFP-HR-425
Innovative Claim Solutions, Inc. is pleased to submit a proposal to continue claims administration
services for the City of Gilroy. 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, 11344 Coloma Rd., Ste 745,
Gold River, CA, 95670, or e-mail at Parch ibald (EDics-claims.com, if you have any questions.
Sincerely,
Gary Archibald
President and CIO
Table of Contents
Response to Request for Proposal............................................................. Page 4
Addendum 1 —Audit Results
Addendum 2 — RMIS and Sample Reports
Addendum 3 — Best Claim Practices
City of Gilroy
Response to Request for Proposal
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 ENTITY'S claims, and
• Office that would service the ENTITY'S 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:
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
City of Gilroy 4
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: aarchibald aaics-claims.com, phone# 916-852-8588,
and fax # 916-852-0642.
Resumes of key staff are located on pages 13 to 21 of this proposal.
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.
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
City of Gilroy 5
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.
Laura Saleh, Senior Claims Examiner has been the examiner on your program for the last three
years. Laura has over 28 years' experience, with over 20 years of public agency experience.
Laura has been with ICS for over six years and spends 95% of her time in the office. Time
outside the office is for client meetings and training and education. Laura's total caseload would
not exceed 150 open indemnity claims.
Please refer to pages 13-21 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.
Leilani Ramos, Employee Relations Manager, City of Daly City, (650) 991-8028,
Iramos(o)dalvcitv.orq. ICS client since 2001
Debra Gill, HR Manager, City of Pleasanton, (925)931-5054, daill @,ci.pleasanton.ca.us. ICS client
since 2001
Janet Hamilton, Risk Manager, City of Livermore, (925) 960-4172, jlhamilton(oDcitvoflivermore.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 Berkeley
City of Fairfield
City of Millbrae
City of Vacaville
City of Morgan Hill
County of Kings
City of Modesto
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.
City of Gilroy 6
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 clients 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.
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.
City of Gilroy 7
Experience with Carve Out Programs
While none of our clients have actually approved of a Carve -Out Program for one of their unions,
several have asked us to research, evaluate and participate in discussions about them.
We have attended multiple seminars through PARMA, CALPELRA and others on this topic. In
addition, we have met with individuals from the Public Law Group to discuss their proposals on
Carve Outs. We have attended Client meetings between their unions, Carve Out Administrators
and Risk Management staff. We have reviewed the limited amount of data from public agencies
that have instituted a Carve Out Program. As a result of our research on Carve Outs, we can
provide our clients with a detailed evaluation for the approximate costs, benefits and pros and
cons of instituting such a program.
We feel that it is extremely important that ICS and Risk Management, or whoever oversees the
worker's compensation program at each entity, be involved in the entire process of decision
making and implementation of a Carve Out program. We have information on the startup
administrative process and have developed a list of specific questions to ask during the
evaluation process.
We also understand that there are several varieties of Carve Out Programs. We have insight into
the reasons Carve Out programs are typically implemented and can shared opportunities for
Clients to modify their existing procedures and protocols that might address problem areas
without moving to a formal Carve Out Program.
We are not necessarily opposed to Carve Out Programs. We are not financially involved with any
Carve Out administrator, so we can provide an objective evaluation for our clients.
Program Reviews, Traininq 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.
Emplovee Advocacv
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
City of Gilroy 8
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.
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 Proqram
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.
City of Gilroy 9
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 Trippers
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 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 Gilroy
Flat Annual Fee First Year $85,500
Flat Annual Fee Second Year $88,000
The above described fees are based on the following assumptions:
• Open inventory of approximately 68 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 are currently assigned to your program. As a result, the costs are likely higher than other bids
City of Gilroy 10
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 65 active claim files for the City of Gilroy that
will be transferred to the new TPA, plus historical information/claims. 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.
Our proposal includes administration of all old and new claims. 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 indicate that the TPA is able to sign the City of Gilroy Standard
Agreement for Services (copy attached) and can provide the required insurance as noted
in the Agreement.
ICS will sign the Standard Agreement and can provide the required insurance as noted in the
agreement.
City of Gilroy 11
10. 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
11. 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.
City of Gilroy 12
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 Gilroy 13
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. 1996 to Present
President, CIO, Workers' Compensation
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.
City of Gilroy 14
California Casualty Insurance Company 1979-1981
Claims Adjuster
• 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
City of Gilroy 15
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.
City of Gilroy 16
LJR 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 Valley Industrial Claims Association and various
Workers' compensation seminars.
City of Gilroy 17
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.
City of Gilroy 18
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 Gilroy 19
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. 1997 - Present
Unit Manager 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.
State Act Claims Representative
1993 - 1997
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
City of Gilroy 20
Laura Saleh
Claims Examiner
A workers' compensation claims examiner with eleven 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.
Claims Examiner 2013— Current
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.
Essential Staffing
Claims Examiner — Assignments with ESIS, Zenith and City of San Jose
Matrix Absence Management
Keenan & Associates
Athens Administrators
JT2 Integrated Resources
Republic Indemnity
Education and Certification
Associate of Science Degree
SIP certification — 1999
IEA and WCCP Certificates
ABA Approved Paralegal Certificate
2012 — 2013
2008 — 2010
2006 — 2008
2002 — 2008
1999 — 2001
1991 — 1999
City of Gilroy 21
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
LA004706083
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 finds 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"' 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
Initial Reserve
90 Day Review
Reserve Change
Claimant Insured
Claim Number
A W W
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 $
Perm. Dis. Formula:
Nurse Activity/Mgmt. $
%, Weeks, $ _
Medical Total Incurred $
Life Pension $
Expenses
Death Benefits $
P-T-D $
Burial Expense $
Future Expenses $
Total Penn. Dis. Reserve $
Expense Total Incurred $
Indemnity Total Incurred $
Rehabilitation
No. of VRTD Weeks
Total Incurred Amount: $
Counselor Fees $
Tuition/Books $
IILAWCX 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 4-2012
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. Comnensability
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. Emolover 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 Indemnitv Pavment
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 4-2011 Attachment 2
14. Litigated Cases
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. Riaht 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 15t" calendar day of the month following the closing date.
Corrections to the loss run made by the 20t" 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 beine 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, 2012 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.ora) or via
our Secure Insurance data transfer web site accessible at httt)s:Hsi.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 http), IoRin 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/UserReaister.do) on the home page and following the
registration instructions. LAWCX files sent using Secure Insurance should be delivered to
lawcxdata i0ickmore.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 nu»/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
1 I 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 Attachment 2
22 FM Award Flag 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
23 Cause of Loss Code text (3) Alphanumeric Cause of Loss code
24 Cause Description text (80) Ex.: Fall. Only include description (no codes
accepted)
25 Nature of Injury Code text (3) 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
46 Paid VR/SJDB
47 Paid ALAE
48 Paid Legal Expenses
49 Total Paid
Attachment 2
$#,###.## Amount paid to date for VR/SJDB
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)
Amount paid to date for legal expenses (fees for
defense attorney and depositions)
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 shall be as follows:
Fiscal Year Annual Fee Agreement/Option
7/1/19 - 6/30/20 $83,300 payable monthly at Agreement -Year One
rate of $6,941.67
7/l/20 - 6/30/21 $85,799 payable monthly at Agreement - Year Two
rate of $7,149.92
7/1/21 - 6/30/22 $88,373 payable monthly at Agreement -Year Three
rate of $7,364.42
7/1/22 - 6/30/23 $91,024 payable monthly at Option to Add Year Four
rate of $7,585.33
7/1/23 - 6/30/24 $93,755 payable monthly at Option to Add Year Five
rate of $7,812.92
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 I I I Mandatory Reporting to the Centers for Medicare & Medicaid Services
(CMS) for the periods stated above.
4835-2267-0361v1
LAC104706083