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BOARD OF PUBLIC WORKS <br />AGENDA ITEM REVIEW REQUEST FORM <br />Date 11 /5/2018 <br />Name Kvra Clark <br />Department Human Capital& <br />Inclusion <br />BPW Date 11/13/2018 Phone Extension 7500 <br />Re wired Prior to Submittal to Board <br />Legal ® Attorney Name Danielle Campbell <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 <br />Z Agreement <br />Z Professional Services <br />❑ Bid Opening <br />❑ Quote Opening <br />Change Order No. <br />❑ Ease/Encroach. <br />F] Other: <br />iroriate Item Tyke - fo <br />❑ Contract <br />El Resolution <br />0 Bid Award <br />El Quote Award <br />F-I C/O & PCA No. <br />Traffic Control <br />for All Submissions <br />Proposal <br />❑ Req. to Advertise <br />❑ PCA <br />Addendum <br />❑ Title Sheet <br />__Required Information <br />- <br />Company or Vendor Name ANTHEM <br />New Vendor ❑ Yes Z No ❑ If Yes, Approved by Purchasing <br />MBE/WBE Contractor ❑ MBE F WBE <br />MBE/WBE Contractor Requested ® No F Yes Name of Company <br />Project Name Administrator Self -Funded Medical Insurance for City employees <br />Project Number <br />_._................_w._ ��.�.. .... ......_.. ,�. w_ ���� ........ .� _.............. <br />Funding Source Health Insurance Fund <br />Account No. 711-0401-671-31-06 <br />Amount Stop Loss Premium: $589,162.56 <br />Medical Administration Costs: $793,879.80 <br />Prescription: Varies —see Pharmacy Pricing Guarantees <br />.._...._.....__ <br />e a .......� .....6 mm_ <br />Terms of Contract Threement covers the 2019 calendar. year�mmmmmmmm w_w <br />Purpose/Description Anthem administers the Cit 's self -funded health insurance medical <br />and prescription) program and serves as the Cit 's stop loss carrier. <br />Required Contractor's Certification Form Attached (Non - <br />Collusion, Non -Discrimination, Non -Debarment, E-Verify, Iran, etc.) <br />._.. Re pyre Far <br />_.. ._m. <br />an e Orders <br />Amount of El Increase $ <br />Decrease $ <br />Previous Amount <br />Current Percent of Change <br />New Amount <br />Total Percent of Change: <br />Dispersal After Approval <br />Copy Original <br />® ❑ _Kyra wClark, Ben Dougherty, Tierra Davis <br />❑ ❑ _ ...... <br />