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Date <br />Name <br />BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />2/23/17 <br />Jen Hockenhull <br />Department A/F <br />BPW Date 2/28/17 1Phone Extension 9822 <br />Required Prior to Submittal to Board <br />Legal ® Attorney Name Michael Schmidt <br />Controller ® Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in length per the City Purchasing Policy <br />Purchasing <br />Check the Appropriate Item Type — Required for All Submissions <br />❑ Agreement ® Contract ❑ Proposal ❑ Addendum <br />❑ Professional Services ❑ Resolution <br />❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet <br />❑ Quote Opening ❑ Quote Award <br />❑ Change Order No. ❑ C/O & PCA No. ❑ PCA <br />1—I Ease/Encroach. I-1 Traffic Control <br />uired Information <br />Company or Vendor Name Infinisource <br />New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE ❑ WBE <br />MBEM/BE Contractor Requested ❑ No ❑ Yes Name of Company <br />Project Name COBRA Renewal Agreement <br />Project Number <br />Funding Source Self -Funded Employee Benefits <br />Account No. 711-0401-671-31-06 <br />Amount <br />Terms of Contract <br />Purpose/Description <br />Amount of <br />$6, 540.00 <br />Annual Payment —3/1/17-2/28/18 <br />Prior years — no increase in price <br />❑ Required Contractor's Certification Form Attached (Non - <br />Collusion. Non -Discrimination. Non -Debarment. E-Verifv. Iran. etc <br />Increase <br />Decrease <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Copy <br />Original <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />uired For Change Orders <br />% <br />Dispersal After Approval <br />