HomeMy WebLinkAboutPSA Renewal - Infinisource - City COBRA Provider Agreement1316 COUNTY -CITY BUILDING
227 W. JEFFERSON BOULEVARD
SOUTH BEND. INDIANA 46601-1830
CITY OF SOUTH BEND PETE BUTTIGIEG, MAYOR
BOARD OF PUBLIC WORKS
February 28, 2017
Mercedes Smith
Infinisource
15 E Washington St.
PO Box 889
Coldwater, MI 49036
RE: Professional Services Agreement Renewal
Dear Ms. Smith:
PHONE 574/235-9251
FAX 574/235-9171
The Board of Public Works, at its meeting held on February 28, 2017, approved the above
referenced renewal of the City COBRA Provider agreement in the amount of $6,540.
Enclosed please find a copy of the agreement for your records.
If you have any further questions regarding this matter, please call this office at (574) 235-
9251.
Sincerely,
(IC -Y�aA,�
Linda M. Martin, Clerk
Enclosure
c: Jen Hockenhull, Administration and Finance
GARY A. GILOT SUZAMA M. FRITZBERG ELIZABETH A. MARADIK JAMEs A. MUELLER THERESE J. DORAU
Infinisource COBRA Renewal Agreement
Section 1: Fees and Consideration Appendix- Fees due with agreement unless otherwise noted
Employer shall pay as compensation to Infinisource, for its performance as herein described for the services indicated, said sum itemized
and payable as follows:
Employer Legal Name: City of South Bend
Insured employees: 1,090 Number of reporting locations: 1
COBRA fees are based upon one reporting location. Separate tracking for additional locations will require an additional annual fee per location. Employer
agrees to pay$10 per premium remittance check Issued. Direct deposit remittance is at no additional cost.
Special notes: *Service date is from 3/1/2017 - 2/28/2018. Discount applied.
All fees are non-refundable.
AppkonA
%ard of Pteblic Works
Please sign, date and return via
Employer
Signature
Infinisource Authorized Signature
Infinisource use only
Internal agent#
Date
Date
Agreement valid for 30 days from
Account# FC9945629
Service effective date
15 E. Washington St. • PO Box 889 • Coldwater. MI 49036-0889. 800-300-3838 • Fax: 517-278-0764 - E-mail: solutions@infinisource.com
Copyright 0 2012 Infinisource, Inc. All rights reserved. 0042
Date
Name
BOARD OF PUBLIC WORKS
AGENDA ITEM REVIEW REQUEST FORM
2/23/17
Jen Hockenhull
Department A/F
BPW Date 2/28/17 1Phone Extension 9822
Required Prior to Submittal to Board
Legal ® Attorney Name Michael Schmidt
Controller ® Controller review is required for all Contracts $5,000.00 or more and
greater than one year in length per the City Purchasing Policy
Purchasing
Check the Appropriate Item Type — Required for All Submissions
❑ Agreement ® Contract ❑ Proposal ❑ Addendum
❑ Professional Services ❑ Resolution
❑ Bid Opening ❑ Bid Award ❑ Req. to Advertise ❑ Title Sheet
❑ Quote Opening ❑ Quote Award
❑ Change Order No. ❑ C/O & PCA No. ❑ PCA
1—I Ease/Encroach. I-1 Traffic Control
uired Information
Company or Vendor Name Infinisource
New Vendor ❑ Yes ® No ❑ If Yes, Approved by Purchasing
MBE/WBE Contractor ❑ MBE ❑ WBE
MBEM/BE Contractor Requested ❑ No ❑ Yes Name of Company
Project Name COBRA Renewal Agreement
Project Number
Funding Source Self -Funded Employee Benefits
Account No. 711-0401-671-31-06
Amount
Terms of Contract
Purpose/Description
Amount of
$6, 540.00
Annual Payment —3/1/17-2/28/18
Prior years — no increase in price
❑ Required Contractor's Certification Form Attached (Non -
Collusion. Non -Discrimination. Non -Debarment. E-Verifv. Iran. etc
Increase
Decrease
Previous Amount
Current Percent of Change:
New Amount
Total Percent of Change:
Copy
Original
❑
❑
❑
❑
❑
❑
uired For Change Orders
%
Dispersal After Approval