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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 12/2/2019 <br />Name Daniel Parker Department Admin & Finance <br />..M.... <br />BPW Date 12/10/2019 Phone Extension 9822 <br />^� ...... <br />Required Prior to Submittal to Board ta m <br />BPW Attorney Attorney Name Clara Daniels <br />Dept. Attorney Z Attorney Name Elliot Anderson <br />Purchasing Z Michael Schmidt <br />Check the App arititd Item l'y c za <br />Professional Services Agreement F. Contract <br />[] Open Market Contract [] Amendment/Addendum <br />Bid Opening E] Bid Award <br />Quote Opening ❑] Quote Award <br />Proposal Opening ❑ C/O & PCA No. <br />Chg. Order, No. ❑ Traffic Control <br />Other: <br />ired Information <br />fin- All Submissions <br />�.� Proposal <br />Special Purchase, QPA <br />❑ Req. to Advertise ❑ Title Sheet <br />Reject Bids/Quotes <br />j PCA <br />El Resolution <br />Ease./Encroach <br />Company or Vendor Name Gibson Insurance Agency <br />_. _......._. <br />New Vendor YesE] If Yes, Approved by Purchasing <br />® No <br />MBE/WBE Contractor WBE Completed E-Verify Form Attached ❑ Nos <br />Project Name <br />Project Number <br />Funding elf Fw <br />unded Em to ee Benefits Fund 4711) <br />Account No.Source �. P ��� ..._.� .� _.._.�.....� ._.. A,_ <br />11-0401-671.31-06 <br />Amount �. .�...ww _.... .....� ... _... <br />$ 2,676 annually <br />Terms of Contract 2�ear_contract <br />......... _.._ ........ <br />Purpose/Description Consultin for em to ee benefits — lan design, analysis claims monitorin . <br />com 1iann �, 111 s�i rr°l, etc <br />For "i°�a��ge Orders Only <br />Amount of ❑ Increase _.$ ...�...._�... _ �. <br />❑ Decrease ($ ) <br />Previous Amount <br />Current Percent of Change: <br />New Amount <br />Total Percent of Change: <br />Time Extension Amount: <br />New Completion Date: <br />E19 <br />Increase % <br />Decrease ( % <br />Increase % <br />Decrease ( % <br />