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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date December 3, 2019 <br />Name Benjamin Dougherty <br />Department Admin & Finance <br />m... <br />BPW Date December 10, 2019 <br />ttVWNIV411WIIWIPIl01VIVWIIWIVNIYtFF� � �GAYMUf�'�.�iiii�WMIWIIIM <br />Phone Extension 7..._e..._........ <br />678 <br />mIININMWII'pYINNN!�r.'N� mi...q,'.'�W�N!MIiIIWWWWWWWWWWVWWSYI H'.n�/IW'JNI"N' <br />.�.�, <br />... ,.asp,. mm�o ........o- --- ��i.i..-..mm...... -- ,�.�...�,�.... ,. <br />Required Prior to Submittal to Board <br />Legal® <br />Elliot Anderson <br />Controller ® <br />Controller review is required for all Contracts $5,000.00 or more and <br />greater than one year in <br />length per the City Purchasing Policy <br />Purchasing ❑ <br />Tr e <br />_ �. Check the Apprq, msRecuired <br />for /bmissions <br />❑ Agreement <br />Contract <br />Proposal ❑ Addend —um" dum <br />® Professional Services <br />El Amendment <br />❑ Bid Opening <br />❑ Bid Award <br />❑ Req. to Advertise ❑ Title Sheet <br />n Quote Opening <br />❑j <br />Quote Award <br />❑ Chg Order No. <br />El <br />C/O & PCA No. <br />❑ <br />PCA <br />❑' Ease./Encroach. <br />Traffic Control <br />F-1 <br />Resolution <br />r-1 Other: <br />R <br />Claim <br />Required Information <br />ONB Benefits Administration, LLC d/b/a J.W.F. Specialty <br />Company or Vendor Name <br />ComRany <br />..w..s <br />New Vendor <br />If Yes, Approved .. .._� � ...ru�..n.� ...w <br />El if by Purchasing <br />No <br />MBE/WBE Contractor <br />❑ MBE Completed E-Verify Form Attached El Yes <br />❑ WBE No <br />Project Name <br />Workers' Compensation TPA services <br />Project Number <br />None <br />Funding Source <br />Fund 226 <br />Account No. <br />�........ <br />226-04.1.8._6.7.1.....3........1-07 <br />Amount <br />$47,000 (first /wear <br />Terms of Contract _ <br />..... �..._ m......w <br />Purpose/Description Service agreement for JWF s provision of workers' compensation <br />claims administration for 2020-2022 (subject to appropriation). <br />For Charge Orders Only <br />....._Amount of .. .�._ Elincrease $ <br />Decrease $ <br />Previous Amount $ <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Time Extension: <br />Dispersal After Approval <br />Copy <br />Original <br />El <br />