PSA - ONB Benefits Administration dba J.W.F. Specialty Company

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BOARD OF PUBLIC WORKS AGENDA ITEM REVIEW REQUEST FORM Date 12/30/16 Name John M, by Department Adm/Finance BPW Date 1/10/16 Phone Extension 7678 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 ® George King 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 ❑ Ease/Encroach. ❑ Traffic Control ❑ Other: Required Information Company or Vendor Name ONB Benefits Administration, LLC d/b/ J.W.F. Specialty Company New Vendor MBE/WBE Contractor Project Name Project Number Funding Source Account No. Amount Terms of Contract Purpose/Description Amount of Previous Amount Yes Z No ❑ If Yes, Approved by Purchasing MBE I-1 WBE Worker's Compensation Claims Adminstration None Liability Insurance Fund 226-0418-671-31-07 (2017 Budget) $ Three -Year Agreement - January 1, 2017 to December 31, 2019 - $51,000 (2017), $52,000 (2018), $53,000 (2019) Three-year agreement for worker's compensation claims administration and reporting. Expiring cost is $50,000 per year. The City has used JWF for an extended period of time and is satisfied with the quality of the services provided. A separate purchase order will be issued for each year covered by this agreement. ❑ Required Contractor's Certification Form Attached (Non - Collusion, Non -Discrimination, Non -Debarment, E-Verifv. Iran, etc Increase Decrease Current Percent of Change: New Amount Total Percent of Change: Copy Original ❑ ❑ ❑ ❑ ❑ ❑ red For Chance Orders /0 Dispersal After