Item C05 C.5
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County of Monroe
y,4 ' �, "tr, BOARD OF COUNTY COMMISSIONERS
Mayor Michelle Coldiron,District 2
�1 `_ll Mayor Pro Tem David Rice,District 4
-Ile Florida.Keys ��� � � Craig Cates,District 1
Eddie Martinez,District 3
w Mike Forster,District 5
County Commission Meeting
February 17, 2021
Agenda Item Number: C.5
Agenda Item Summary #7795
BULK ITEM: Yes DEPARTMENT: Employee Services
TIME APPROXIMATE: STAFF CONTACT: Mark Gongre (305) 292-4559
N/A
AGENDA ITEM WORDING: Approval to advertise a Request for Proposals for Workers'
Compensation Third Party Administrator services to include 24/7 claims intake, claims
administration and management, field-case management, regulatory compliance, reporting, billing,
and other related services.
ITEM BACKGROUND: Approval to advertise a Request for Proposals for Workers'
Compensation Third Party Administrator(TPA) services to include: 24/7 claims intake, claims
administration and management, field-case management, regulatory compliance, reporting, billing,
and other related services.
The Employee Services Safety and Security Department manages the Workers' Compensation
program for approximately 1,300 employees in the Board of County Commissioners departments,
Monroe County Sheriff's Office, Monroe County Tax Collector, Monroe County Property
Appraiser, Monroe County Supervisor of Elections, Monroe County Clerk of the Circuit Court and
Comptroller, Monroe County Land Authority, and a few County-funded positions within state
agencies.
The County is self-insured for both medical claims and lost time wages for accidents and illnesses
incurred by employees during the course and scope of work.
The County currently retains the TPA services of Relation Insurance in Stuart, FL to administer the
relevant aspects of our Workers' Compensation program. An RFP was conducted in March of 2016,
where Relation was selected as the preferred provider, and a contract was awarded to them in
September of 2016. The contract was an initial 3-year term with two 1-year renewal options, which
were exercised.
It is now time to conduct another RFP, to explore the market and ensure the County continues to
receive good value and service.
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C.5
PREVIOUS RELEVANT BOCC ACTION:
March 23, 2016—RFP approved for Workers' Compensation Third Party Administrator
September 21, 2016 —Contract for Workers' Compensation Third Party Administrator services
awarded to EMI(the former name of Relation Insurance).
CONTRACT/AGREEMENT CHANGES:
n/a
STAFF RECOMMENDATION: Approval.
DOCUMENTATION:
Draft RFP TPA Workers Compensation
FINANCIAL IMPACT:
Effective Date: N/A
Expiration Date: N/A
Total Dollar Value of Contract: N/A
Total Cost to County: N/A
Current Year Portion: N/A
Budgeted: N/A
Source of Funds: N/A
CPI: N/A
Indirect Costs: N/A
Estimated Ongoing Costs Not Included in above dollar amounts: N/A
Revenue Producing: N/A If yes, amount:
Grant: N/A
County Match: N/A
Insurance Required: N/A
Additional Details: N/A
N/A
11/20/19 502-08001 - GROUP INS ADMIN $60,000.00
Benefits Admin System
REVIEWED BY:
Mark Gongre Completed 01/25/2021 3:42 PM
Bryan Cook Completed 01/25/2021 4:18 PM
Cynthia Hall Completed 01/27/2021 8:27 PM
Assistant County Administrator Christine Hurley Completed
01/28/2021 1:12 PM
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C.5
Purchasing Completed 01/28/2021 1:57 PM
Budget and Finance Completed 01/28/2021 2:01 PM
Maria Slavik Completed 01/28/2021 2:19 PM
Liz Yongue Completed 02/01/2021 3:56 PM
Board of County Commissioners Pending 02/17/2021 9:00 AM
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C.5.a
MONROE COUNTY
REQUEST FOR PROPOSALS
FOR
Workers' Compensation Third Party Claims Administration Services
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BOARD OF COUNTY COMMISSIONERS
Mayor, Michelle Coldiron, District 2
Mayor Pro Tern, David Rice, District 4
Craig Cates, District 1
Mike Forster, District 5
Eddie Martinez, District 3
COUNTY ADMINISTRATOR
Roman Gastesi CL
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CLERK OF THE CIRCUIT COURT EMPLOYEE SERVICES DEPARTMENT
Kevin Madok, CPA Workers' Compensation
March 2021
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C.5.a
NOTICE OF REQUEST FOR COMPETITIVE SOLICITATIONS
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NOTICE IS HEREBY GIVEN that on Thursday, May 13, 2021, at 3:00 P.M., the Monroe County Purchasing Office
will receive and open sealed responses for the following:
WORKERS' COMPENSATION THIRD PARTY CLAIMS ADMINISTRATION SERVICES
MONROE COUNTY,FLORIDA CL
Pursuant to F.S. § 50.0211(3)(a), all published competitive solicitation notices can be viewed at: www,floridlpublicnotices.com, a
searchable Statewide repository for all published legal notices. Requirements for submission and the selection criteria may be requested
from DemandStar by Onvia at www.demandstar.com OR www.monroecountybids.com. The Public Record is available upon
request.
In response to Covid-19,the Monroe County Purchasing Department has implemented a new electronic process for reviewing
and opening sealed bids. Monroe County is committed to continuing to receive and process competitive solicitations while lej
maintaining the health and safety of our employees and those who attend bid openings. Please do not mail or attempt to deliver
in person any sealed bids. Mailed/physically delivered bids/proposal/responses WILL NOT be accepted.
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The Monroe County Purchasing Department hereby directs that bids be submitted via email to: OMB-131WS'a monroecounty-
f1,gov,no later than 3:00 P.M.on May 13,2021. Please submit your confidential financial information in a SEPARATE EMAIL
from your bid and required documents. Your subject line on both emails must read as follows: 4-
Workers' Compensation Third Party Claims Admin. Serv. 05/13/2021
Files that do not contain this subject line WILL BE REJECTED. Please note that the maximum file size that will be
accepted by email is 25MB. Please plan accordingly to ensure that your bid is not rejected due to the file size. Should
your bid documents exceed 25MB or otherwise be rejected or undeliverable to OMB-BIDS(monroecountv- --------------
flm ov,
in advance of the bid opening,please email: o _ ®Purchasin (c� onroecounty-fl. ov so accommodations for delivery e
of your bid can be made prior to the bid opening. Please be advised that it is the bidder's sole responsibility to ensure 76
delivery of their bid and waiting until the bid opening to address or confirm your bid submission delivery will result
in your bid being rejected. 0.
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The bid opening for this solicitation will be held virtually,via the internet, at 3:00 P.M., on May 13,2021. You may
call in by phone or internet using the following: e
Join Zoom Meeting
https:Hmcbocc.zoom.us/i/4509326156
Meeting ID: 4509326156 l0j
One tap mobile:
+16465189805„4509326156#US (New York)
+16699006833994509326156#US (San Jose) e
Dial by your location:
+1 646 518 9805 US (New York) CL
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+1 669 900 6833 US (San Jose) CL
Publication Dates:
Key West Citizen:Sat.,03/27/2021
Keys Weekly: Thur.,04/01/2021
News Barometer: Fri.,04/02/2021 C1
03
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C.5.a
MONROE COUNTY
BOARD OF COUNTY COMMISSIONERS
REQUEST FOR PROPOSALS
FOR
WORKERS' COMPENSATION THIRD PARTY CLAIMS ADMINISTRATION SERVICES
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Section I
Information and Instructions
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GENERAL
The County is seeking competitive proposals from organizations that have the ability to administer workers'
compensation claims that are within the County's self-insured retention (currently, $500,000 per claim). c
BACKGROUND INFORMATION
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Monroe County ("County") is a non-chartered county established under the Constitution and the laws of the
State of Florida. The Clerk of the Circuit Court serves as the fiscal agent.
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The population of the County is estimated at approximately 74,200. The total number of individuals covered by
the County's self-insured workers' compensation program (including persons employed by Monroe County
Board of County Commissioners as well as those employed by the Monroe County Sheriff's Office and all y
Constitutional Officers) is approximately 1,470.
The Board of County Commissioners, constituted as the governing body, has all the powers of a body
corporate, including the powers to contract; to sue and be sued; to acquire, purchase, hold, lease and convey
real estate and personal property; to borrow money, and to generally exercise the powers of a public authority
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organized and existing for the purpose of providing community services to citizens within its territorial
boundaries. In order to carry out this function, the County is empowered to levy taxes to pay the cost of
operations.
County's Safety & Security Administrator oversees its Self-Funded program. The County has contracted with
Relation Insurance Services, which adjusts the claims on its behalf. c
The program extends to all agencies of the County including but not limited to:
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➢ Board of County Commissioners;
➢ Land Authority;
➢ Property Appraiser;
➢ Sheriff's Department;
➢ Supervisor of Elections;
➢ County Clerk's Office; and
➢ Tax Collector
In addition, coverage is extended to the County's volunteer fire fighters and reserve law enforcement officials. E
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C.5.a
GENERAL INFORMATION AND COVERAGES REQUESTED
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Monroe County is requesting proposals for the following:
➢ Workers' Compensation Third Party Claims Administration Services
Because of the limited network of health care providers located in Monroe County, the County no longer
participates in a managed care arrangement. It does take advantage of its current TPA's PPO network and
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assigns Medical Rehabilitation on a case by case basis.
The effective date of the program will be September 21, 2021. It is the intent of the County to agree to an initial
three (3) year term with rights to renew with the successful proposer(s) for two (2) additional one-year terms at c
the option of the County. Consideration may be given to longer-term agreements based on price, terms and
conditions.
As a prerequisite of being selected, the Third Party Administrator must be acceptable to the County's
Excess Workers' Compensation insurer. The County's current Excess insurer is the Florida Municipal
Insurance Trust (FMIT).
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Items contained in this Request For Proposals (RFP) are considered to be an integral part of the proposed
program. Adherence to the items listed here is intended by the County unless specifically otherwise accepted
by both the Proposer and the County. Acceptance of modification of any portion of the items contained herein CL
will not serve to waive or modify any other portion of the proposed program.
CURRENT PROGRAM y
Relation Insurance Services of Stuart, Florida currently administers all claims that fall within the County's self-
insured retention. The agreement with Relation requires Relation to administer the claims for an annual fee as
long as a contractual relation exists between the two organizations. As of December 31, 2020 the County had
approximately 140 open claims. Depending on the cost, the successful proposer may be requested to assume
the administration of all open claims. Proposers will be requested to provide separate pricing for the assumption
of all open claims. The County has been self-insured since 1976.
DESIRED PROGRAM c
The County prefers the successful Proposer to provide their pricing on a "Life of Contract" basis and agree to
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administer all claims until conclusion as long as the Proposer is retained as the County's TPA. The County will
consider alternative pricing structures, such as administering the County's claims on a "Cradle to Grave" basis.
"Life of Contract" is defined to mean that the claims are administered until conclusion for the term of the contract.
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"Cradle to Grave" is defined to mean that the claims are administered until conclusion regardless of the term of
the contract.
Due to the limited number of quality healthcare networks located in Monroe County, the County has opted out of
managed care in accordance with Florida Statutes. Medical rehabilitation services may be requested on a case
by case basis.
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C.5.a
The County utilizes the current claims administrator to reduce all medical bills to the State Fee Schedule.
Proposers are therefore requested to include this service in their pricing structure. If a separate charge is
required for this service, it should be clearly stated within the proposal.
The successful proposer may be required to assume the administration for all prior claims. All proposals should '®
clearly state the cost associated with the assumption of all such claims ("run off claims").
The successful proposer will be expected to provide the following services.
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➢ Initial contact with claimant within 24 hours.
➢ Recorded statements of the claimant as needed.
➢ Contact with the treating physician within 24 hours.
➢ Narrative summaries on major claims every 3 months. y
➢ Medical bills reduced to State fee schedule.
➢ All subrogation and Second Injury Fund activities.
➢ Preparation of all State mandated reports. c
➢ Notification of all potential excess claims to insurer(s).
➢ Quarterly meetings with the County.
➢ Provide monthly loss reports to the County.
➢ Provide monthly loss reports to the County's consultant.
➢ Maintain and make available to the County a PPO network that offers reduced fees to the County.
➢ Provide (or contract to provide) staff to receive incoming calls to the Monroe County Injury Helpline CL
and complete all necessary First Report of Injury paperwork and forward same as appropriate.
RATING DATA
The following information has been included as attachments to assist in the underwriting of the account:
➢ Projected payrolls by workers' compensation classification codes; >
➢ A copy of the County's Drug Free Work Place policy statement; and
➢ Confirmation of the County's Experience Modification Factor
Current loss runs for the past 5 years, to include a summary of open claims valued in excess of$50,000 will be
provided upon written request. Please direct your requests to: y
Mr. Mark Gongre, Safety and Security Administrator
Office of Workers' Compensation c
Monroe County BOCC
1100 Simonton Street, Suite 2-268
Key West, Florida 33040
Facsimile: (305) 295-4301
Email: Gong re- ark _ oroecouy- l._ o
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Facsimile and Email requests for loss runs will be honored, however, it is the sole responsibility of each Proposer
to verify that their requests have been received in a timely fashion. The County assumes no liability for
incomplete or misdirected requests.
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C.5.a
TERM OF AGREEMENT c
The County wishes to enter into an Agreement with the successful proposer, whereby the initial term of the _
Agreement will be for three (3) years, from September 21, 2021 to September 20, 2024, with an option to renew
at the County's option for two (2) additional years.
REQUEST FOR PROPOSALS SCHEDULE CL
The following schedule will be strictly adhered to. No extension of deadlines will be granted.
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Activity Date
Posting of RFP on Demand Star March 27, 2021
Deadline for Requests for Additional Information Aril 22, 2021
Proposal Return Date May 13, 2021
Bid Opening May 13, 2021
Selection Committee Meeting May 25, 2021 we
Presentations of Recommendations to Board of County June 16, 2021 c
Commissioners
Implementation Date August 21, 2021
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SUBMISSION OF PROPOSALS
All proposals must be submitted in accordance with the instructions in the Notice of Request for Competitive
Solicitations at the beginning of this RFP.
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Proposals received after the deadline will be returned unopened. The deadline for the submission of all
proposals is 3:00 PM, May 13, 2021. It is the sole responsibility of each proposer to ensure its proposal is
received in a timely fashion. 0.
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All proposers are required to complete the following forms that are attached to this RFP from Sections III and
Section IV and attach the forms to their Proposal. c
PROPOSAL RESPONSE FORM (from Section III of this RFP)
DRUG-FREE WORKPLACE FORM
SWORN STATEMENT UNDER ORDINANCE NO. 10-1990
NON-COLLUSION AFFIDAVIT
PUBLIC ENTITIES CRIMES STATEMENT
LOCAL PREFERENCE FORM (IF APPLICABLE)
INSURANCE REQUIREMENTS, RESPONDENT'S STATEMENT, INSURANCE AGENT'S FORM CL
SCRUTINIZED COMPANIES FORM CL
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The Local Preference Form is optional in accordance with Section 2-349, Monroe County Code.
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C.5.a
VALID DATE OF PROPOSALS
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Proposals shall remain valid until November 1, 2021 to provide additional time for clarification in the event that
an extension of the current program(s) is undertaken.
RIGHT TO REJECT PROPOSALS
The County reserves the right to reject any or all proposals, to waive irregularities and informalities in any or all COL
proposals, and to re-advertise for proposals.
The County specifically reserves the right to separately accept or reject any item and/or items of a proposal and
to award and/or negotiate a contract in the best interest of the County.
ADHERENCE TO INFORMATION AND PROPOSAL c
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Information presented in this Request for Proposal and all statements contained in the proposals received are
intended to be relied upon by the County. All coverages and services must be issued as proposed unless the
County authorizes individual changes. Any changes authorized by the County will not alter any other items
contained in this Request for Proposal.
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PROPOSER QUALIFICATIONS
All Proposers must be currently licensed in Florida as a Third Party Administrator in accordance with Florida
Statutes §626.88— 626.8991. In addition, all individuals involved with the administration of the County's claims
must be licensed in accordance with Florida Statutes §626.88 — 626.8991. Copies of the licenses for the firm
and those of the individual adjusters who will be assigned to the County's account must be provided as part of
each proposal. Copies of the adjusters resumes should also be provided. 76
The County also believes that all adjusters should be adequately supervised. All proposals should include
information on the supervisor who will oversee the adjuster's activities. Such information should include a copy of the supervisor's claims administration license, a statement reflecting if the supervisor only is responsible for
supervisory activities or if they have their own individual case load, a copy of the supervisor's resume and the
number of adjusters the supervisor manages.
AUTHORITY OF PROPOSER c
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Proposals should be signed by an authorized representative of the Third Party Administrator providing the
service.
ADDITIONAL INFORMATION/INSPECTION CL
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Every attempt has been made to furnish complete and accurate information to the best of Monroe's knowledge.
Proposers are encouraged to determine, at their sole expense, additional information required to develop their
proposals including any inspections and loss control surveys.
If additional information is required, requests must be submitted in writing to:
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C.5.a
Mr. Mark Gongre, Safety and Security Administrator
Office of Workers' Compensation
Monroe County BOCC
1100 Simonton Street, Suite 2-268
Key West, Florida 33040
Facsimile: (305) 295-4301
Email: Gong re- ark _ oroecou - l._ o
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All requests for additional information must be received no later than 3:00 PM, April 22, 2021. An addendum to
the specifications will be posted on Demand Star to answer any requests for additional information. Oral requests
for additional information will not be answered. c
Facsimile and Email requests will be honored, however, it is the sole responsibility of each Proposer to
verify that their requests have been received in a timely fashion. The County assumes no liability for
incomplete or misdirected requests. c
RATE CHANGE
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All proposers must ensure that the fees proposed will apply for a minimum of 1 year. Proposers will be required
to provide Ninety (90) days written notice of the rates that will be charged for subsequent contract years.
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TERMINATION/NON-RENEWAL NOTICE
Proposer will be required to provide ninety (90) days written notice prior to the termination or non-renewal of the
agreement.
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CLAIM REPORTS
Claim reports shall be furnished monthly. Reports should be completed in plain English and received by the
County within twenty (20) days following the end of each month. The reports should include a brief description .�
of individual claims and the amount paid for each claim and any open reserves that are assigned. Individual
allocation by operating locations may be necessary. Proposers are requested to provide sample copies of all
reports that will be furnished to the County for the proposed fees. In addition, sample copies of any additional
reports that can be furnished for an additional fee should also be included with the proposal. The fees associated
with these additional reports should be clearly identified. c
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Claim reports must continue to be furnished without charge until the last open claim is closed, or until the
Proposer is no longer providing a service to the County.
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Copies of all loss reports must be provided to the County's Risk Management Consultant, and to the County's
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Excess Insurers.
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COORDINATION WITH EXCESS INSURER
The Proposer will adhere to any and all reporting requirements of the County's Excess Insurers and to coordinate
all specific and aggregate recoveries.
SUBROGATION AND SECOND DISABILITY FUND RECOVERIES
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The Proposer will coordinate all subrogation and Second Disability Fund recoveries for all claims being
administered by the Administrator even if such a claims are no longer active.
QUARTERLY CLAIM REVIEW MEETINGS
The County will expect the successful Proposer to meet with them a minimum of 4 times during the year to
discuss the active claims and the procedures being followed by the TPA. Subject to coronavirus restrictions, CL
the parties should plan that one meeting is to be held at the Office of the Proposer at the expense of the
County. One meeting is to be held at the Office of the County at the expense of the Proposer and two meetings e®
are to be held electronically via video or web conference.
In addition, if an addendum to this request is issued, the Proposer must acknowledge receipt of such addendum
by completing and returning with their proposals the acknowledgment form, which will accompany the c
addendum.
CONTENT OF SUBMISSION
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The proposal submitted in response to this RFP shall be submitted in electronic form; shall be clear and
concise, tabulated, and provide the information requested herein. Proposals submitted without the required
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information will not receive full consideration. Responses shall be organized as indicated below. The
Proposer should not withhold any information from the written response in anticipation of presenting the
information orally or in a demonstration, since oral presentations or demonstrations may not be solicited. Each
Proposer must submit adequate documentation to certify the Proposer's compliance with the County's
requirements. Proposers should focus specifically on the information requested.
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Format. The proposal shall be organized as follows and contain the following information:
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A. Cover Page.
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A cover page that states "Monroe County Workers' Compensation Third Party Claims
Administration Services". The cover page should contain Proposer's name, address, telephone number,
and the name of the Proposer's contact person. c
B. Tabbed Sections
Tab 1. General Information c
(a) The name of the firm submitting proposal, address, contact person's name, telephone numbers, email
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address and the name of the individual authorized to sign for the proposing organization.
(b) A clear statement of what services are being proposed. If more than one type of service or plan is CL
proposed, separate proposals must be made for each one so that they can be reviewed independently
of any other service or benefit plan.
(c) An overview of the firm's experience along with a summary of experience with Government Entities. a
The overview should also include the length of time the firm has been providing claims administration
services.
(d) Explanation of fees, rates.
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(e) Samples of any claims and statistical reports.
(f) Other terms proposed. Please be specific regarding amounts and time schedule.
(g) Resumes of all key members of the account team who will be assigned including professional
designations.
Tab 2. Relevant Experience
A record of performance and professional accomplishments by Proposer and employees, including
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professional accomplishments, and to the extent allowed, any work with large companies or government
entities.
The Proposer shall provide a list of similar contracts or agreements currently in force to include:
• Name and full address v
• Telephone number of client contact
• Date of initiation and completion of contract c
• Summary of the services and area served
Tab 3. Services, Approach and Availability of Service to County
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The Proposer shall describe the philosophy, approach and methodology he/she will take to accomplish the
services defined herein. This shall include information on schedule and availability, staffing, whether sub-
contractors are used, and any other relevant information explaining how the services will be accomplished.
In particular, please describe your firm's philosophy on managing the case loads of their adjusters and the
current case load for both the Lost Time adjuster and the Medical Only adjuster that will be assigned to the
County's account. n
Tab 4. Litigation
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Pursuant to Section 2-347 of the Monroe County Code, all respondents must provide answers to the
following questions regarding claims and suits:
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(a) Has the Proposer ever failed to complete work or provide the goods for which it has contracted? (If yes,
provide details.)
(b) Are there any judgments, claims, arbitration proceeding or suits pending or outstanding against the
Proposer, or its officers or general partners? (If yes, provide details.) y
(c) Has the Proposer, within the last five (5) years, been a party to any lawsuit or arbitration with regard to
a contract for services, goods or construction services similar to those requested in the RFP? (If yes, the
Proposer shall provide a history of any past or pending claims and litigation in which the Proposer is c
involved as a result of the provision of the same or similar services which are requested or described
herein.)
(d) Has the Proposer ever initiated litigation against the county or been sued by the county in connection
with a contract to provide services, goods or construction services? (If yes, provide details.)
(e) Whether, within the last five (5) years, an officer, general partner, controlling shareholder or major CL
creditor of the Proposer was an officer, general partner, controlling shareholder or major creditor of anyCL
other entity that failed to perform services or furnish goods similar to those sought in the request for bids.
(f) Customer references (minimum of three), including name, current address and current telephone
number. Preference will be given to Florida government clients.
(g) Credit references (minimum of three), including name, current address, and current telephone number.
(h) Financial statements for the prior three years for the responding entity or for any entity that is a
subsidiary to the responding entity.
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Please note: All documents submitted in response to this RFP are public records. If the respondent c
wishes to keep the financial statements required under this tab confidential, then please follow the
instructions in the Notice of Request for Competitive Solicitations at the beginning of this RFP, for
instructions on how to submit confidential financial information separately. Financial information that
has been marked as confidential is exempt from a Florida public records request.
Tab 5. Loss Runs
Sample copies of all loss runs that will be provided to the County for no additional charge must be provided
within this Tab. Also, any additional reports that are available for an additional fee should also be
included. These additional reports must be clearly identified and reflect the additional charge that will be
imposed for the reports.
Tab 6. County Forms and Licenses
Proposer shall complete and execute the forms specified below and located in this RFP,as well as copies of c
all professional and occupational licenses and shall include them in this section, i.e. Tab 6:
Forms
PROPOSAL RESPONSE FORM (from Section III of this RFP) c
NON-COLLUSION AFFIDAVIT
DRUG-FREE WORKPLACE FORM
ORDINANCE NO. 10-1090 ETHICS CLAUSE SWORN STATEMENT
PUBLIC ENTITIES CRIMES STATEMENT
If applicable, the Local Preference Form, in accordance with Section 2-349, Monroe County Code.
Tab 7. County Expectations
The Proposers shall describe their ability to meet each of the following County expectations regarding the
administration of its claims as indicated below.
1. One Lost Time adjuster and one Medical Only adjuster will be assigned to the County's account.
These adjusters will be held responsible for all activities associated with the administration of the
claims.
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2. The County strongly believes that the number of claims assigned to individual adjusters will have a
direct impact on the quality of attention given to issues as they arise. All proposals shall specify the
maximum number of cases assigned for both the Lost Time adjuster and the Medical Only adjuster
that will be used for the County's account.
3. If the administration of the County's claims must be re-assigned to a new adjuster, the County should
be advised of the change 30 days prior to the change taking effect. Such notification should include the c
name of the new adjuster, the new adjuster's qualifications and the approach the new adjuster will take
in becoming familiar with the County's claims.
4. The County currently utilizes Raquelin Fals for all Field Case Management activities. The County has
been extremely pleased with the services Raquelin Fals has provided and wants to continue using her
for all Field Case Management needs. If the TPA does not have a business relationship with Raquelin
Fals, the County will expect that such a relationship will be developed.
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5. The County has stringent protocols that must be followed when hiring outside legal services. While the
County will consider recommendations for the hiring of defense counsel, the County will have to select
and contract directly with the legal firm. In addition, the County will have to directly pay the legal firm's
bills. The TPA will be notified when such payments are made and the TPA will be responsible for
capturing these costs in the appropriate claim.
6. The County will expect the TPA to pay any and all fines and penalties imposed by the State caused by
the negligence of the TPA. The County will remain responsible for all fines and penalties caused by the
County's negligence.
7. The County currently has direct access to their TPA's computerized claim system. This permits the
County to view the financial aspects of individual claims and to review the adjusters claim notes. The c
County will need similar access to the TPA's computerized claim system. The County expects that if a y
new TPA is selected, they will conduct a training session for the County's Workers' Compensation
Department on the effective use of the system. In addition, the TPA will be responsible for the
production of a user manual on the use of their computerized claim system. The TPA will be held c
responsible for providing timely notification of any changes made to their computerized claim system
and the implications of these changes on the operation of the system. In addition, the TPA will be held
responsible for updating the user manual when changes are made. Access to the TPA's computerized
claim system should be through the internet and access should be available 24 hours a day and 7 days
a week. Any fees associated with access to the TPA's computerized claim system should be clearly
stated in the proposals. CL
8. During the period of 10/1/19 through 9/30/20, the County's TPA processed 1,767 medical bills on behalf
of the County. The cumulative amount of the bills totaled $2,376,885. The TPA reduced the bills by
$1,293,388 in accordance with State Fee Schedule. In addition, the bills were further discounted by
$204,033 in accordance with PPO agreements the TPA has with various medical facilities. The County
desires to continue taking advantage of PPO network discounts. Proposals should reflect the PPO
networks the TPA has established reflecting the number of physicians, by major discipline (such as
General Practitioner and Chiropractor) participating in the network. Specific information regarding the
number of medical facilities located in Monroe County should also be provided. In addition, the
average percentage of discounts being offered by these networks should be provided. All proposals
should reflect other arrangements the TPA has arranged for ancillary medical services such as IMEs,
MSAs and Medical Review experts.
9. The County has issued Monroe County Administrative Instruction 7400.4 (Workers' Compensation
Third Party Administrator (TPA) Direct Payment System). A copy of the Administrative Instruction is
included as an attachment to this RFP. The successful proposer must agree with the provisions of this c
Administrative Instruction.
10. The County would prefer to pay an annual fee, in monthly installments, for all bill reduction services to
include reducing bills to the State Fee Schedule and all fee reductions associated with PPO networks c
that the TPA has established.
CL
Tab 8. Additional Information CL
Proposer shall provide any additional information which will present evaluators with insight about the
knowledge, skills and abilities of the Proposer. Also describe any additional services, reports,
information, training materials, software, or capabilities provided by or available through the Proposer
that could enhance the County's workers' compensation and safety programs or otherwise improve
efficiency.
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Tab 9. Other Information
If the Proposer cannot fully comply with any of the terms contained in the Request for Proposal, all deviations
to the terms must be spelled out in this section, i.e. Tab 9.
Tab 10. Proposal Response Forms CL
The Proposal Response Forms in Section III shall be completed and submitted behind Tab 10 in the response.
Full consideration may not be given to Proposals not including the required Proposal Forms.
c
EVALUATION CRITERIA
A selection committee will be convened to review and evaluate the Proposals. The committee recommendations 01
be presented to the Board of County Commissioners.
Evaluation Factor Points
Compliance with RFP specifications (required format,submission of forms) 05
Ability t0 provide services listed (scope of services, County expectations) 25
Experience of adjusters assigned to the Count 's account 20 0.
Len th of time that Proposer has been providing claims administration services 15
Proximity of office adjusting the Count 's claims to the County 15
Quality of TPA's Computer Claim System and quality of Loss Runs 15 v
Caseload of adjusters that will be assigned to the Count 's account 20
Pricing 25
Additional points if vendor meets definition of"local business" (up to 5 points if
vendor is local business as defined in Section 2-349, Monroe County Code, 10
plus up to 5 points if vendor uses a subcontractor that is a local business) c
Total 150
Total points earned are on a scale of 1 — 150 points (1 is the lowest ranking and 150 is the highest ranking). �--
c
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Continued Next Page.
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OPEN CLAIM COUNT AND ASSOCIATED RESERVES
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As of December 31, 2020, the County's current TPA reported the following open claim count and associated
reserves.
Valued as of 12/31/20
Policy Number of Open
Year Open Claims Reserves
82/84 1 7,690 CL
88/89 1 4,725
92/93 2 10,768
94/95 1 3,527
97/98 2 3,153
99/00 1 2,036 y
00/01 1 163,389
01/02 2 131,695 0.
05/06 1 2,676
06/07 1 100,837
09/10 3 4,478
11/12 1 27,507
12/13 1 2,183
13/14 4 432,045
14/15 2 51,113
15/16 4 43,806 CL
16/17 5 203,617
17/18 2 146,315
18/19 12 98,748
19/20 58 626,222 Mn
20/21 (partial) 35 91,285.01
Total 140 2,137,815 W
While the County believes the reserves to be accurate, the successful proposer will be required to review each
open claim and establish its independent evaluation of the projected cost.
In order that a complete history of the County's program can be maintained, the successful proposer will be0.
required to capture all prior years' financial data within their claim data base. The County will work with the .�
successful proposer to develop a system whereby older closed claims can be summarized. It is anticipated
that claims for the most recent five years will be individually captured.
Insurance Requirements
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The successful proposer will be required to maintain throughout the life of the contract, insurance protection as E
specified in the attached forms.
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End of Section I.
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Section II Begins Next Page. °CL
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MONROE COUNTY
BOARD OF COUNTY COMMISSIONERS
REQUEST FOR PROPOSALS
FOR
WORKERS' COMPENSATION THIRD PARTY CLAIMS ADMINISTRATION SERVICES
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Section II
Draft Agreement
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Following is a draft agreement that the County will expect the successful proposer to sign. The County will be
0.
agreeable to reasonable modifications to the agreement.
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DRAFT AGREEMENT
These contract documents should be used only after consultation with counsel. The documents are not c
intended as legal advice appropriate to any specific situation, nor do they purport to address all issues which
may arise between the contracting parties. The documents should be amended or supplemented where
appropriate. CL
MONROE COUNTY
CONTRACT FOR y
Services
THIS AGREEMENT is made and entered into this day of by MONROE COUNTY
0
("COUNTY"), a political subdivision of the State of Florida, whose address is 1100 Simonton Street, Key West,
Florida 33040 and ("CONTRACTOR"), whose address is
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Section 1. SCOPE OF SERVICES
CONTRACTOR shall do, perform and carry out in a professional and proper manner certain duties as
described in the Scope of Services— Exhibit A—which is attached hereto and made a part of this agreement. y
CONTRACTOR shall provide the scope of services in Exhibit A for COUNTY. CONTRACTOR warrants that it
is authorized by law to engage in the performance of the activities herein described, subject to the terms and
conditions set forth in these Agreement documents. The CONTRACTOR shall at all times exercise
independent, professional judgment and shall assume professional responsibility for the services to be
provided. Contractor shall provide services using the following standards, as a minimum requirement:
A. The CONTRACTOR shall maintain adequate staffing levels to provide the services required under
the Agreement resulting from this RFP process. CL
B. The personnel shall not be employees of or have any contractual relationship with the County. To
the extent that Contractor uses subcontractors or independent contractors, this Agreement
specifically requires that subcontractors and independent contractors shall not be an employee
of or have any contractual relationship with County.
C. All personnel engaged in performing services under this Agreement shall be fully qualified, and,
if required, to be authorized or permitted under State and local law to perform such services.
Section 2. COUNTY'S RESPONSIBILITIES
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2.1 Provide all best available information as to the COUNTY'S requirements for the scope of services
described in Exhibit A to this Agreement.
2.2 Designate in writing a person with authority to act on the COUNTY'S behalf on all matters concerning
said services.
2.3 Provide a schedule that is mutually agreeable to the COUNTY and CONTRACTOR.
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Section 3. TERM OF AGREEMENT
3.1 The initial Agreement will be for one (3) year term beginning the _day of 2021
and renewable at the County's option for two (2) additional consecutive one year terms.
3.2 The terms of this Agreement shall be from the effective date hereof and continue for a period of one
year. This Agreement shall be automatically renewed for successive one-year periods until either party
gives the other notice of cancellation in accordance with the terms set forth below. The Contractor must c
provide at least ninety 90 days' notice of intent to terminate. The Count must provide the Contractor
p Y ( ) Y Y p �
with at least thirty (30) days' notice of intent to terminate. If either party desires to modify this Agreement,
it shall notify the other in writing at least thirty (30) days prior to the effective date of such modification. In
the case of proposed modification the party receiving the notification of the proposed modification shall
itself notify the other party within ten (10) days after receipt of notice of its agreement to the proposed
modification. Failure to do so shall terminate this Agreement. 0.
Section 4. COMPENSATION
Compensation to CONTRACTOR shall be $
Section 5. PAYMENT TO CONTRACTOR
0
5.1 Payment will be made according to the Florida Local Government Prompt Payment Act. Any request for 76
payment must be in a form satisfactory to the Clerk of Courts for Monroe County (Clerk). The request b.
must describe in detail the services performed and the payment amount requested. The CONTRACTOR
must submit invoices to the appropriate offices marked The respective
office supervisor and the Director of Employee Services will review the request, note his/her approval on
the request and forward it to the Clerk for payment.
5.2 Continuation of this Agreement is contingent upon annual appropriation by Monroe County.
Section 6. CONTRACT TERMINATION c
U
Either party may terminate this Agreement because of the failure of the other party to perform its obligations
under the Agreement. COUNTY may terminate this Agreement with or without cause upon thirty (30) days'
notice to the CONTRACTOR. COUNTY shall pay CONTRACTOR for work performed through the date of c
termination.
Section 7. CONTRACTOR'S ACCEPTANCE OF CONDITIONS
A. CONTRACTOR hereby agrees that he has carefully examined the RFP, his response, and this
Agreement and has made a determination that he/she has the personnel, equipment, and other
requirements suitable to perform this work and assumes full responsibility therefore. The provisions of
the Agreement shall control any inconsistent provisions contained in the specifications. All specifications
have been read and carefully considered by CONTRACTOR, who understands the same and agrees to
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C.5.a
their sufficiency for the work to be done. Under no circumstances, conditions, or situations shall this
Agreement be more strongly construed against COUNTY than against CONTRACTOR.
B. Any ambiguity or uncertainty in the specifications shall be interpreted and construed by COUNTY, and
its decision shall be final and binding upon all parties.
C. The passing, approval, and/or acceptance by COUNTY of any of the services furnished by
CONTRACTOR shall not operate as a waiver by COUNTY of strict compliance with the terms of this
Agreement, and specifications covering the services.
D. CONTRACTOR agrees that County Administrator or his designated representatives may visit
CONTRACTOR'S facility (ies) periodically to conduct random evaluations of services during
CONTRACTOR'S normal business hours.
E. CONTRACTOR has, and shall maintain throughout the term of this Agreement, appropriate licenses and
approvals required to conduct its business, and that it will at all times conduct its business activities in a c
reputable manner. Proof of such licenses and approvals shall be submitted to COUNTY upon request. y
Section 8. NOTICES
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Any notice required or permitted under this agreement shall be in writing and hand delivered or mailed,
postage prepaid, to the other party by certified mail, returned receipt requested, to the following:
0
To the COUNTY: Mark Gongre, Monroe County Safety and Security Administrator
1100 Simonton Street, Suite 2-268
Key West, Florida 33040 CL
With a copy to: Monroe County Attorney's Office
1111 12th St., Suite 408 y
Key West, FL 33040
To the CONTRACTOR:
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Section 9. RECORDS
CONTRACTOR shall maintain all books, records, and documents directly pertinent to performance under this
Agreement in accordance with generally accepted accounting principles consistently applied. Each party to this
Agreement or their authorized representatives shall have reasonable and timely access to such records of each
other party to this Agreement for public records purposes during the term of the agreement and for five years
following the termination of this Agreement. If an auditor employed by the COUNTY or Clerk determines that c
monies paid to CONTRACTOR pursuant to this Agreement were spent for purposes not authorized by this
Agreement, the CONTRACTOR shall repay the monies together with interest calculated pursuant to Section
55.03 of the Florida Statutes, running from the date the monies were paid to CONTRACTOR.
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Section 10. EMPLOYEES SUBJECT TO COUNTY ORDINANCE NO. 010-1990
The CONTRACTOR warrants that it has not employed, retained or otherwise had act on its behalf any former
County officer or employee subject to the prohibition of Section 2 of Ordinance No. 010-1990 or any County
officer or employee in violation of Section 3 of Ordinance No. 010-1990. For breach or violation of this provision
the COUNTY may, in its discretion, terminate this agreement without liability and may also, in its discretion,
deduct from the agreement or purchase price, or otherwise recover the full amount of any fee, commission,
percentage, gift, or consideration paid to the former County officer or employee. E
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Section 11. CONVICTED VENDOR
c
A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity
crime may not submit a bid on an Agreement with a public entity for the construction or repair of a public building
or public work, may not perform work as a CONTRACTOR, supplier, subcontractor, or CONTRACTOR under '®
Agreement with any public entity, and may not transact business with any public entity in excess of the threshold
amount provided in Section 287.017 of the Florida Statutes, for the Category Two for a period of 36 months from
the date of being placed on the convicted vendor list.
CL
Section 12. GOVERNING LAW, VENUE, INTERPRETATION, COSTS AND FEES
This Agreement shall be governed by and construed in accordance with the laws of the State of Florida applicable
to Agreements made and to be performed entirely in the State. y
In the event that any cause of action or administrative proceeding is instituted for the enforcement or
interpretation of this Agreement, the COUNTY and CONTRACTOR agree that venue shall lie in the appropriate
court or before the appropriate administrative body in Monroe County, Florida.
Section 13. SEVERABILITY
If any term, covenant, condition or provision of this Agreement (or the application thereof to any circumstance or
person) shall be declared invalid or unenforceable to any extent by a court of competent jurisdiction, the
CL
remaining terms, covenants, conditions and provisions of this Agreement, shall not be affected thereby; and
each remaining term, covenant, condition and provision of this Agreement shall be valid and shall be enforceable
to the fullest extent permitted by law unless the enforcement of the remaining terms, covenants, conditions and
provisions of this Agreement would prevent the accomplishment of the original intent of this Agreement. The
COUNTY and CONTRACTOR agree to reform the Agreement to replace any stricken provision with a valid
provision that comes as close as possible to the intent of the stricken provision.
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Section 14. ATTORNEYS FEES AND COSTS 76
The COUNTY and CONTRACTOR agree that in the event any cause of action or administrative proceeding is
initiated or defended by any party relative to the enforcement or interpretation of this Agreement, the prevailing
party shall be entitled to reasonable attorney's fees, and court costs, as an award against the non-prevailing
party. Mediation proceedings initiated and conducted pursuant to this Agreement shall be in accordance with
the Florida Rules of Civil Procedure and usual and customary procedures required by the Circuit Court of Monroe
County.
Section 15. BINDING EFFECT
The terms, covenants, conditions, and provisions of this Agreement shall bind and inure to the benefit of the
COUNTY and CONTRACTOR and their respective legal representatives, successors, and assigns. c
Section 16. AUTHORITY CL
CL
Each party represents and warrants to the other that the execution, delivery and performance of this Agreement UR
have been duly authorized by all necessary County and corporate action, as required by law.
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Section 17. ADJUDICATION OF DISPUTES OR DISAGREEMENTS
c
COUNTY and CONTRACTOR agree that all disputes and disagreements shall be attempted to be resolved by
meet and confer sessions between representatives of each of the parties. If no resolution can be agreed upon
within 30 days after the first meet and confer session, then any party shall have the right to seek such relief or '®
remedy as may be provided by this Agreement or by Florida law. This Agreement shall not be subject to
arbitration.
CL
Section 18. COOPERATION
In the event any administrative or legal proceeding is instituted against either party relating to the formation,
execution, performance, or breach of this Agreement, COUNTY and CONTRACTOR agree to participate, to the c
extent required by the other party, in all proceedings, hearings, processes, meetings, and other activities related y
to the substance of this Agreement or provision of the services under this Agreement. COUNTY and
CONTRACTOR specifically agree that no party to this Agreement shall be required to enter into any arbitration
proceedings related to this Agreement. c
Section 19. NONDISCRIMINATION
0
The parties agree that there will be no discrimination against any person, and it is expressly understood that
upon a determination by a court of competent jurisdiction that discrimination has occurred, this Agreement
automatically terminates without any further action on the part of any party, effective the date of the court order. CL
The parties agree to comply with all Federal and Florida statutes, and all local ordinances, as applicable, relating
to nondiscrimination. These include but are not limited to: 1) Title VII of the Civil Rights Act of 1964 (PL 88-
352), which prohibit discrimination in employment on the basis of race, color, religion, sex, and national origin;
2) Title IX of the Education Amendment of 1972, as amended (20 USC §§ 1681-1683, and 1685-1686), which
prohibits discrimination on the basis of sex; 3) Section 504 of the Rehabilitation Act of 1973, as amended (20
USC § 794), which prohibits discrimination on the basis of handicaps; 4) The Age Discrimination Act of 1975, as
amended (42 USC §§ 6101-6107), which prohibits discrimination on the basis of age; 5) The Drug Abuse Office
and Treatment Act of 1972 (PL 92-255), as amended, relating to nondiscrimination on the basis of drug abuse; 76
6) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (PL o.
91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; 7) The Public
Health Service Act of 1912, §§ 523 and 527 (42 USC §§ 690dd-3 and 290ee-3), as amended, relating to
confidentiality of alcohol and drug abuse patent records; 8) Title VIII of the Civil Rights Act of 1968 (42 USC
§§ 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; 9) The '2
Americans with Disabilities Act of 1990 (42 USC §§ 1201), as amended from time to time, relating to
nondiscrimination in employment on the basis of disability; 10) Monroe County Code Chapter 13, Article VI,
which prohibits discrimination on the basis of race, color, sex, religion, national origin, ancestry, sexual c
orientation, gender identity or expression, familial status or age; and 11) any other nondiscrimination provisions
in any federal or state statutes which may apply to the parties to, or the subject matter of, this Agreement.
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Section 20. COVENANT OF NO INTEREST
COUNTY and CONTRACTOR covenant that neither presently has any interest, and shall not acquire any
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interest, which would conflict in any manner or degree with its performance under this Agreement, and that only
interest of each is to perform and receive benefits as recited in this Agreement.
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Section 21. CODE OF ETHICS
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COUNTY agrees that officers and employees of the COUNTY recognize and will be required to comply with the
standards of conduct for public officers and employees as delineated in Section 112.313, Florida Statutes,
regarding, but not limited to, solicitation or acceptance of gifts; doing business with one's agency; unauthorized
compensation; misuse of public position, conflicting employment or contractual relationship; and disclosure or
use of certain information.
Section 22. NO SOLICITATION/PAYMENT
The COUNTY and CONTRACTOR warrant that, in respect to itself, it has neither employed nor retained any
company or person, other than a bona fide employee working solely for it, to solicit or secure this Agreement c
and that it has not paid or agreed to pay any person, company, corporation, individual, or firm, other than a bona y
fide employee working solely for it, any fee, commission, percentage, gift, or other consideration contingent upon
or resulting from the award or making of this Agreement. For the breach or violation of the provision, the
CONTRACTOR agrees that the COUNTY shall have the right to terminate this Agreement without liability and,
at its discretion, to offset from monies owed, or otherwise recover, the full amount of such fee, commission,
percentage, gift, or consideration.
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Section 23. PUBLIC ACCESS/ PUBLIC RECORDS
0
The COUNTY and CONTRACTOR shall allow and permit reasonable access to, and inspection of, all CL
documents, papers, letters or other materials in its possession or under its control subject to the provisions of
Chapter 119, Florida Statutes, and made or received by the COUNTY and CONTRACTOR in conjunction with
this Agreement; and the COUNTY shall have the right to unilaterally cancel this Agreement upon violation of this
provision by CONTRACTOR.
Pursuant to Section 119.0701, Florida Statutes, the contractor at all times must comply with Florida public
records law, specifically, to:
76
1. Keep and maintain public records required by the public agency to perform the service.
2. Upon request from the public agency's custodian of public records, provide the public agency with a
copy of the requested records or allow the records to be inspected or copied within a reasonable time at
a cost that does not exceed the cost provided in this chapter or as otherwise provided by law.
3. Ensure that public records that are exempt or confidential and exempt from public records disclosure
requirements are not disclosed except as authorized by law for the duration of the contract term and
following completion of the contract if the contractor does not transfer the records to the public agency. c
4. Upon completion of the contract, transfer, at no cost, to the public agency all public records in
possession of the contractor or keep and maintain public records required by the public agency to perform
the service. If the contractor transfers all public records to the public agency upon completion of the
contract, the contractor shall destroy any duplicate public records that are exempt or confidential and
exempt from public records disclosure requirements. If the contractor keeps and maintains public recordsCL
upon completion of the contract, the contractor shall meet all applicable requirements for retaining publicCL
records. All records stored electronically must be provided to the public agency, upon request from the
public agency's custodian of public records, in a format that is compatible with the information technology
systems of the public agency.
A request to inspect or copy public records relating to a COUNTY contract must be made directly to the COUNTY,
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but if the COUNTY does not possess the requested records, the COUNTY shall immediately notify the
CONTRACTOR of the request, and the CONTRACTOR must provide the records to the COUNTY or allow the
records to be inspected or copied within a reasonable time.
If the CONTRACTOR does not comply with the COUNTY's request for records, the COUNTY shall enforce the
public records contract provisions in accordance with the contract, notwithstanding the COUNTY's option and
right to unilaterally cancel this contract upon violation of this provision by the CONTRACTOR. A CONTRACTOR
who fails to provide the public records to the COUNTY or pursuant to a valid public records request within a
CL
reasonable time may be subject to penalties under section 119.10, Florida Statutes.
The CONTRACTOR shall not transfer custody, release, alter, destroy or otherwise dispose of any public records
unless or otherwise provided in this provision or as otherwise provided by law. c
IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF
CHAPTER 119, FLORIDA STATUTES, TO THE CONTRACTOR'S DUTY TO
PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE "
MONROE COUNTY CUSTODIAN OF PUBLIC RECORDS, BRIAN BRADLEY, AT ew
le
(305) 292-3470, 1111 12T" ST., KEY
WEST, FL 33040.
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Section 24. NON-WAIVER OF IMMUNITY
Notwithstanding the provisions of Sec. 768.28, Florida Statutes, the participation of the COUNTY and the
CONTRACTOR in this Agreement and the acquisition of any commercial liability insurance coverage, self- A
insurance coverage, or local government liability insurance pool coverage shall not be deemed a waiver of '10�)
immunity to the extent of liability coverage, nor shall any Agreement entered into by the COUNTY be required to 26
contain any provision for waiver.
Section 25. PRIVILEGES AND IMMUNITIES >
All of the privileges and immunities from liability, exemptions from laws, ordinances, and rules and pensions and
relief, disability, workers' compensation, and other benefits which apply to the activity of officers, agents, or
employees of any public agents or employees of the COUNTY,when performing their respective functions under c
this Agreement within the territorial limits of the COUNTY shall apply to the same degree and extent to the y
performance of such functions and duties of such officers, agents, volunteers, or employees outside the territorial
limits of the COUNTY.
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Section 26. LEGAL OBLIGATIONS AND RESPONSIBILITIES
Non-Delegation of Constitutional or Statutory Duties. This Agreement is not intended to, nor shall it be construed
as, relieving any participating entity from any obligation or responsibility imposed upon the entity by law except
to the extent of actual and timely performance thereof by any participating entity, in which case the performance CL
may be offered in satisfaction of the obligation or responsibility. Further, this Agreement is not intended to, nor
shall it be construed as, authorizing the delegation of the constitutional or statutory duties of the COUNTY, except
to the extent permitted by the Florida constitution, state statute, and case law.
Section 27. NON-RELIANCE BY NON-PARTIES
No person or entity shall be entitled to rely upon the terms, or any of them, of this Agreement to enforce or
attempt to enforce any third-party claim or entitlement to or benefit of any service or program contemplated
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hereunder, and the COUNTY and the CONTRACTOR agree that neither the COUNTY nor the CONTRACTOR
or any agent, officer, or employee of either shall have the authority to inform, counsel, or otherwise indicate
that any particular individual or group of individuals, entity or entities, have entitlements or benefits under this
Agreement separate and apart, inferior to, or superior to the community in general or for the purposes
contemplated in this Agreement.
Section 28. ATTESTATIONS
CONTRACTOR agrees to execute such documents as the COUNTY may reasonably require, including, but not CL
being limited to, a Public Entity Crime Statement, an Ethics Statement, and a Drug-Free Workplace Statement,
Lobbying and Conflict of Interest Clause, and Non-Collusion Agreement.
c
Section 29. NO PERSONAL LIABILITY y
No covenant or agreement contained herein shall be deemed to be a covenant or agreement of any member,
officer, agent or employee of Monroe County in his or her individual capacity, and no member, officer, agent or c
employee of Monroe Count shall be liable personally on this Agreement or be subject to an personal liability
Y p Y 9 J any Y �
or accountability by reason of the execution of this Agreement.
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Section 30. EXECUTION IN COUNTERPARTS
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This Agreement may be executed in any number of counterparts, each of which shall be regarded as an original, 0.
all of which taken together shall constitute one and the same instrument and any of the parties hereto may
execute this Agreement by signing any such counterpart.
Section 31. SECTION HEADINGS
Section headings have been inserted in this Agreement as a matter of convenience of reference only, and it is
agreed that such section headings are not a part of this Agreement and will not be used in the interpretation of
any provision of this Agreement.
Section 32. INSURANCE POLICIES
32.1 General Insurance Requirements for Other Contractors and Subcontractors.
As a pre-requisite of the work governed, the CONTRACTOR shall obtain, at his/her own expense, insurance as
specified in any attached schedules, which are made part of this contract. The CONTRACTOR will ensure that
the insurance obtained will extend protection to all Subcontractors engaged by the CONTRACTOR. As an
alternative, the CONTRACTOR may require all Subcontractors to obtain insurance consistent with the attached c
schedules; however CONTRACTOR is solely responsible to ensure that said insurance is obtained and shall
submit proof of insurance to COUNTY. Failure to provide proof of insurance shall be grounds for termination of
this Agreement.
0
The CONTRACTOR will not be permitted to commence work governed by this contract until satisfactory evidence
of the required insurance has been furnished to the COUNTY as specified below. Delays in the commencement
of work, resulting from the failure of the CONTRACTOR to provide satisfactory evidence of the required
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insurance, shall not extend deadlines specified in this contract and any penalties and failure to perform
assessments shall be imposed as if the work commenced on the specified date and time, except for the
CONTRACTOR's failure to provide satisfactory evidence.
The CONTRACTOR shall maintain the required insurance throughout the entire term of this contract and any
extensions specified in the attached schedules. Failure to comply with this provision may result in the immediate
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suspension of all work until the required insurance has been reinstated or replaced and/or termination of this
Agreement and for damages to the COUNTY. Delays in the completion of work resulting from the failure of the
CONTRACTOR to maintain the required insurance shall not extend deadlines specified in this contract and any
penalties and failure to perform assessments shall be imposed as if the work had not been suspended, except
for the CONTRACTOR's failure to maintain the required insurance. -
The CONTRACTOR shall provide, to the COUNTY, as satisfactory evidence of the required insurance, either:
• Certificate of Insurance
or -
• A Certified copy of the actual insurance policy.
c
The County, at its sole option, has the right to request a certified copy of any or all insurance policies required y
by this contract.
All insurance policies must specify that they are not subject to cancellation, non-renewal, material change, or
reduction in coverage unless a minimum of thirty (30) days prior notification is given to the County by the
insurer.
0
The acceptance and/or approval of the Contractor's insurance shall not be construed as relieving the
Contractor from any liability or obligation assumed under this contract or imposed by law.
0.
Monroe County Board of County Commissioners, its employees and officials will be included as "Additional
Insured" on all policies, except for Workers' Compensation (including Employers' Liability and Professional
Liability).
Section 33. INDEMNIFICATION
The CONTRACTOR does hereby consent and agree to indemnify and hold harmless the COUNTY, its Mayor,
the Board of County Commissioners, appointed Boards and Commissions, Officers, and the Employees, and 76
any other agents, individually and collectively, from all fines, suits, claims, demands, actions, costs, obligations, o.
attorneys'fees, or liability of any kind arising out of the sole negligent actions of the CONTRACTOR or substantial
and unnecessary delay caused by the willful nonperformance of the CONTRACTOR and shall be solely
responsible and answerable for any and all accidents or injuries to persons or property arising out of its
performance of this contract. The amount and type of insurance coverage requirements set forth hereunder
shall in no way be construed as limiting the scope of indemnity set forth in this paragraph. Further the
CONTRACTOR agrees to defend and pay all legal costs attendant to acts attributable to the sole negligent act
of the CONTRACTOR. c
At all times and for all purposes hereunder, the CONTRACTOR is an independent contractor and not an
employee of the Board of County Commissioners. No statement contained in this agreement shall be construed c
so as to find the CONTRACTOR or any of his/her employees, contractors, servants or agents to be employees
of the Board of County Commissioners for Monroe County. As an independent contractor the CONTRACTOR _
shall provide independent, professional judgment and comply with all federal, state, and local statutes,
ordinances, rules and regulations applicable to the services to be provided.
The CONTRACTOR shall be responsible for the completeness and accuracy of its work, plan, supporting data,
and other documents prepared or compiled under its obligation for this project, and shall correct at its expense
all significant errors or omissions therein which may be disclosed. The cost of the work necessary to correct
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those errors attributable to the CONTRACTOR and any damage incurred by the COUNTY as a result of
additional costs caused by such errors shall be chargeable to the CONTRACTOR. This provision shall not apply
to any maps, official records, contracts, or other data that may be provided by the COUNTY or other public or
semi-public agencies.
The CONTRACTOR agrees that no charges or claims for damages shall be made by it for any delays or
hindrances attributable to the COUNTY during the progress of any portion of the services specified in this
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contract. Such delays or hindrances, if any, shall be compensated for by the COUNTY by an extension of time
for a reasonable period for the CONTRACTOR to complete the work schedule. Such an agreement shall be
made between the parties.
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IN WITNESS WHEREOF, the parties hereto have caused these presents to be executed on the day of
2021.
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(SEAL) MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
Attest: KEVIN MADOK, CLERK
OF MONROE COUNTY, FLORIDA
0
By by 0.
As Deputy Clerk Mayor/Chairman
(CORPORATE SEAL) (Name of Contractor)
ATTEST:
By by
Title:
76
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Exhibit A
Scope of Services
The Administrator will provide the following services.
➢ Initial contact with claimant within 24 hours.
➢ Recorded statements of the claimant.
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➢ Contact with the treating physician within 24 hours.
➢ Narrative summaries on major claims every 3 months.
➢ Medical bills reduced to State fee schedule.
➢ All subrogation and Second Injury Fund activities.
➢ Preparation of all State mandated reports. y
➢ Notification of all potential excess claims to insurer(s).
➢ Quarterly meetings with the County.
➢ Provide monthly loss reports to the County. c
➢ Provide month) loss reports to the Count 's consultant.
Y p Y �
➢ Provide (or contract to provide) staff to receive incoming calls to the Monroe County Injury Helpline and
complete all necessary First Report of Injury paperwork and forward same as appropriate.
0
0.
End of Section II.
SECTION III BEGINS NEXT PAGE.
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MONROE COUNTY
BOARD OF COUNTY COMMISSIONERS
REQUEST FOR PROPOSALS
FOR
WORKERS' COMPENSATION THIRD PARTY CLAIMS ADMINISTRATION SERVICES
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SECTION III
PROPOSAL RESPONSE FORM
Please complete this proposal response form and attach behind Tab 10 in the Proposal.
Additional information can be attached to the forms.
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Name of Third Party Administrator?
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Address:
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Telephone Number: y
Are the following services included within the price
quoted?
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Initial contact with claimant within 24 hours? Yes No >
Recorded statements of the claimant? Yes No
Contact with the treating physician within 24 hours? Yes No
Narrative summaries on major claims? Yes No
Medical bills reduced to State fee schedule? Yes No c
Medical bills reduced in accordance with PPO
Provider discounts? Yes No
Subrogation and Second Injury Fund activities? Yes No
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Preparation of all State mandated reports? Yes No
Notification of all potential excess claims
to insurer? Yes No
Quarterly meetings with the County? Yes No E
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Provide monthly loss reports to the County? Yes No
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Provide monthly loss reports to Consultant? Yes No
Provide staff for Injury Helpline? Yes No
If any of the above responses are no, please explain
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and include the full pricing for the services.
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Will one Lost Time adjuster and one Medical
Only adjuster be assigned to the County's c
Account? Yes No
Are resumes of adjusters attached? Yes No
What is the maximum caseload that will be assigned to each of the
County's adjusters?
Lost Time
Medical Only
Is the TPA agreeable to providing 30 day notice
before any changes to adjusters are made? Yes No
Will the County be able to continue using
Raquelin Fals as their Field Case Manager? Yes No
Will the County be able to continue contracting
and paying directly for all legal defense services? Yes No
Will the TPA be responsible for all State imposed
fines and penalties caused by the negligence of c
the TPA? Yes No
Will the County have 24/7 access to the TPA's
claim system? Yes No c
What charge will be made for accessing the TPA's
claim system?
Will the TPA conduct an onsite (in Key West)
demonstration of the County's use of the
TPA's claim system prior to implementation? Yes No
Will the TPA develop a user manual on the
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operations of the TPA's claim system? Yes No
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Will the TPA update the user manual when
any changes to their claim system are made? Yes No
Has information regarding the PPO networks established
by the TPA been provided as requested? Yes No
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What fee will be charged for accessing the TPA's
PPO networks?
Does price quoted include processing claims
until their conclusion? Yes No y
If not, explain duration included in fee:
0
0
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Will the proposer charge any initial or maintenance CL
fees? Yes No
If so, please explain:
Please explain required banking arrangements.
2
Does the proposer have an approved safety program
filed with the State of Florida? Yes No
Does the proposer agree with the handling of c
claim payments in accordance with the County's
Administrative Instruction 7400.4? Yes No
Please describe how claims will be classified c
as Lost Time and Medical Only for administration
billing purposes.
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0
Quoted Price:
Claims Administration _
Cost Per Claim Cost Per Run-Off Claim
Workers Compensation
Medical Only Claims
Indemnity Claims CL
Flat Annual Fee
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Charge for Reducing Medical Bills to State Fee y
Schedule
0
Flat Annual Fee (payable
in monthly installments
0
Cost to reduce bills in accordance with PPO
Arrangements (flat annual fee strongly preferred)
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Is an alternative pricing structure proposed? Yes No
If so, please describe y
0
Will a minimum fee apply to the contract? Yes No
If so, please specify --
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Are there any exceptions to the specifications? Yes No
If so, please specify
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The Proposer stated below is the authorized agent of the company or companies proposed, and is
authorized to commit the proposing company to the terms and conditions stated above.
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Signature of Authorized Representative Date
Printed Name:
End of Section III.
SECTION IV BEGINS NEXT PAGE.
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MONROE COUNTY
BOARD OF COUNTY COMMISSIONERS
REQUEST FOR PROPOSALS
FOR
WORKERS' COMPENSATION THIRD PARTY CLAIMS ADMINISTRATION SERVICES CL
SECTION IV
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SUPPORTING DOCUMENTS, OPTIONAL FORM AND REQUIRED FORMS
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1. EXPERIENCE MODIFICATION LETTER
2. PROJECTED PAYROLLS
3. DRUG FREE WORKPLACE POLICY
4. DRUG-FREE WORKPLACE FORM* CL
5. ORDINANCE NO. 10-1990 ETHICS CLAUSE SWORN STATEMENT*
6. NON-COLLUSION AFFIDAVIT*
7. PUBLIC ENTITIES CRIMES STATEMENT*
8. LOCAL PREFERENCE FORM*
9. INSURANCE REQUIREMENTS, INDEMNIFICATION CLAUSE,AND INSURANCE
AGENT'S STATEMENT* >
10. VENDOR CERTIFICATION REGARDING SCRUTINIZED COMPANIES LIST*
11. MONROE COUNTY ADMINISTRATIVE INSTRUCTION 7400.4: .�
WORKERS' COMPENSATION THIRD PARTY ADMINISTRATOR (TPA) DIRECT
PAYMENT SYSTEM y
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* = REQUIRED FORMS, MUST BE SUBMITTED WITH THE PROPOSAL ALONG WITH RESPONSE E
FORM (SECTION III)
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0
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CONFIRMATION OF0.
EXPERIENCE MODIFICATION
FACTOR
2
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L.
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August 10,2020
fors a co.Bd. of Co,co 'scion
Ms,Men-lie J.MercWo,Ad€n,i€iistratur" _
1100 Simonton Street,Suite 2-2 S
Key West,Fl, 33040
:E: Payroll Report,Form I FS-F2-S1-- ,for the period said y
d Lanw r xp"icn"Mctificatio
Ms-Mercado:
0
Attached is a blan l3FS-F I, , Self-lrasri rs hyroll Report, which is essential to the promulgation of the �
expenence rating.. Please lob into the START System welasitc at id 4I_ I ,lrr � 1 .st., t , t0 tttlte a�
Pay all no later than December 1.2020, Ifyou have not ived your user id em. pawwom,for logging into
this sysim,Tease send an email rcqucsit to
Please "Grow Payroll"rounded to the nearest dollar. Irayrotl reported for-Executive ffi- °-should be 0
limitod to a maxinium of$2,8Wweek, Failure to so it either a.umpleted self-inauxer payroll report including
explanation (if needed)or a request for an a tcrrsion prior to the dry date will result in the issuance of a civil U.
penalty fir toncomplimwe.,You mug gttLylde a brief errWana#ion if mmv of the folj2MLInj gbmm Arse[have
oceutrred r~iiage the lest ipsyroU art Drys stthi�tltt l: ct3
t, A new anployee classification has been added or changed,circumstances place craplayces in a classification
not listed on this (sale)the proper classification to t ).
2, Employee classiftation Wood on this repoTt lam Jae n dieted (mart the payroll for the classification as
Sly) 0
3. A significant increase or decrease in payroll for any dlass code has oceumNi compared, to the last payroll
report(201/16 deviation).
2
In addition,attached is a t ray of the October 1.2020 Florida Self-Insurers expwitnce rating for the,workers'
compensation prograin of ssloom. Infornambion.supplied an the self-insurers' ._
payroll and loss reports was used to promulgate this rating.The experience roodification of M will too used to
Aust the premium vol'ura (and Chris the Division's assessments) whiChr will rc ult frOTnr pall during the 2
period beginning,on the rating's effective date. y
If them owe any questions concerning the OUMpletirUnr of dais report, pleaw contact Dwayne Manning at Q)
413-1254.
0
U
Sincerely,
Dwaync Manning
Insurance Admini-StratUT CL
FLORIDAEPAR'rM r+T OF FINANCIAL SERVICES
DwayncManifiq a, 1n616wLoeAdYyia air CL
01-y sicm of'4Wurk 'C,arnrwensmian a Senior M Am Aniflym Siiptemar
200 Easi:Gaines Sur + 70Wi Florida 323 r224 s 'r't9.HUr41 7N4 * Fm 100
Emil* 17e .Nrn�6sgt }rrari3a. - ts
.AWIRMATIVE'.At"rX)N, . EQuA1.UP lR'rr.N ITY EMPL.aG I R
U
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PROJECTED PAYROLLS CL
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0
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MONROE COUNTY
PROJECTED PAYROLLS
BY WC CLASSIFICATION
FOR PERIOD
10/1/20TO 10/1/21
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Code Classification Projected Payroll
Computer Device Installation, Inspection, Service
5191 $1,223,204
or Repair
Street or Road Maintenance or Beautification &
5509 $1,115,187
Drivers
7370 Taxicab Co: All Other Employees & Drivers $361,369 0
U
Aviation-Transportation of Personnel in Conduct
7403 $1,813,051
of Employers Business Ground Crew& Drivers
Aircraft or Helicopter Operation: NOC- 0
7425 $1,246,369
Helicopters: Flying Crew
7704 Firefighters & Drivers $7,719,633 CL
7720 Police Officers & Drivers $25,257,233
8380 Automobile Service or Repair Center& Drivers $886,364
0
8810 Clerical Office Employees NOC $30,285,076
Attorney, -All Employees &Clerical Messengers,
8820 $1,758,646
Drivers
0
8824 Retirement Living Centers, Health Care Employees $246,350
Nursing— Home Health, Public and Traveling—All
8835 $248,350 0.
Employees 0.
Social Services Organization—All Employees & '✓
8864 $121,194
Salespersons, Drivers
Buildings—Operation: By Owner, Lessee or Real
9015 $1,615,570 0
Estate Management Firm:All Other Employees
9102 Park NOC—All Employees & Drivers $675,605 0
9403 Garbage, Ashes or Refuse Collection & Drivers $254,653
0
Municipal,Township, County or State Employee,
9410 NOC 5,496,491 0
Total $80,324,345 CL
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Footnote: Class 7704 includes 53 volunteers each with an assumed salary of$10,000
0
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E
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E
0
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DRUG FREE
0
0.
WORKPLACE POLICY
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NOTICE TO EMPLOYEES
Monroe County has a Drug-free workplace Policy which complies with the requirements of Florida law. This
policy came into effect on August 1, 1996. Copies of the policy were provided to all employees prior to the
effective date and a summary is included with all new hire paperwork.
It is a condition of employment for employees to refrain from reporting to work or working with the presence of
drugs or alcohol in his or her body. Any employee who is taking any prescription medication which might impair
safety, performance or any motor functions should advise his or her supervisor before commencing work under
such medication. The supervisor will maintain the confidentiality of such information.
If you have any questions, please contact the Human Resources Department.
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0
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REQUIRED FORMS
TO BE COMPLETED 0.
BY
PROPOSER
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0
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DRUG-FREE WORKPLACE FORM
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The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies that:
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(Name of Business)
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I. Publishes a statement notifying employees that the unlawful manufacture,distribution,dispensing,
possession,or use of a controlled substance is prohibited in the workplace and specifying the actions that
will be taken against employees for violations of such prohibition.
0
2. Informs employees about the dangers of drug abuse in the workplace,the business's policy of
maintaining a drug-free workplace,any available drug counseling, rehabilitation,and employee assistance
programs,and the penalties that may be imposed upon employees for drug abuse violations.
0
3. Gives each employee engaged in providing the commodities or contractual services that are under bid a
copy of the statement specified in subsection (1).
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4. In the statement specified in subsection (1), notifies the employees that,as a condition of working on the
commodities or contractual services that are under bid,the employee will abide by the terms of the
statement and will notify the employer of any conviction of,or plea of guilty or nolo contendere to,any y_
violation of Chapter 893 (Florida Statutes)or of any controlled substance law of the United States or any
state,for a violation occurring in the workplace no later than five(5)days after such conviction. >
0
5. Imposes a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is
available in the employee's community,or any employee who is so convicted. >
0
6. Makes a good faith effort to continue to maintain a drug-free workplace through implementation of this
section.
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As the person authorized to sign the statement, I certify that this firm complies fully with the above y
requirements.
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Bidder's Signature
Date CL
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SWORN STATEMENT UNDER ORDINANCE NO.10-1990
MONROE COUNTY, FLORIDA o
ETHICS CLAUSE _
warrants that he/it has not employed, retained or otherwise had act on
his/its behalf any former County officer or employee in violation of Section 2 of Ordinance No.10-1990 or any County
officer or employee in violation of Section 3 of Ordinance No. 10-1990. For breach or violation of this provision the County
may, in its discretion, terminate this contract without liability and may also, in its discretion, deduct from the contract or
purchase price, or otherwise recover, the full amount of any fee, commission, percentage, gift, or consideration paid to _
the former County officer or employee.
0
(signature)
Date:
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STATE OF
COUNTY OF
PERSONALLY APPEARED BEFORE ME,the undersigned authority, who,after first
being sworn by me, affixed his/her signature (name of individual signing) in the space provided above on this CL
day of
19
NOTARY PUBLIC
My commission expires:
OMB- MCP FORM#4 >
2
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NON-COLLUSION AFFIDAVIT
I, of the city
of according to law on my oath, and under
penalty of perjury, depose and say that;
1) 1 am ,the bidder making the CL
Proposal for the project described as follows:
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2) The prices in this bid have been arrived at independently without collusion,
consultation, communication or agreement for the purpose of restricting competition, as
to any matter relating to such prices with any other bidder or with any competitor; c
3) Unless otherwise required by law, the prices which have been quoted in this bid
have not been knowingly disclosed by the bidder and will not knowingly be disclosed by
the bidder prior to bid opening, directly or indirectly, to any other bidder or to any c
competitor; and
0
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4) No attempt has been made or will be made by the bidder to induce any other
person, partnership or corporation to submit, or not to submit, a bid for the purpose of
restricting competition;
5) The statements contained in this affidavit are true and correct, and made with
full knowledge that Monroe County relies upon the truth of the statements contained in
this affidavit In awarding contracts for said project. c
STATE OF
(Signature of Bidder)
COUNTY OF c
DATE v
PERSONALLY APPEARED BEFORE ME, the undersigned authority,
0
who, after first being sworn by me, (name of
individual signing) affixed his/her signature In the space provided above on this
0
day of ,19
My commission expires:
NOTARY PUBLIC
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PUBLIC ENTITY CRIME STATEMENT
"A person or affiliate who has been placed on the convicted vendor list
following a conviction for public entity crime may not submit a bid on a
contract to provide any goods or services to a public entity, may not submit a
bid on a contract with a public entity for the construction or repair of a public
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building or public work, may not submit bids on leases of real property to
public entity, may not be awarded or perform work as a contractor, supplier, subcontractor, or
consultant under a contract with any public entity, and may
not transact business with any public entity in excess of the threshold amount y
provided in Section 287.017, Florida Statutes, for CATEGORY TWO for a period of 36
months from the date of being placed on the convicted vendor list."
I state that this Proposer complies with the above.
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Signed:
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Printed Name:
Date: y
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LOCAL PREFERENCE FORM
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A.Vendors claiming a local preference according to Ordinance 023-2009 must complete this form.
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Name of Bidder/Responder Date:
1. Does the vendor have a valid receipt for the business tax paid to the Monroe County Tax Collector dated at least one
year prior to the notice or request for bid or proposal? (Please furnish copy. ) CL
2. Does the vendor have a physical business address located within Monroe County from which the vendor operates or
performs business on a day to day basis that is a substantial component of the goods or services being offered to Monroe
County?
List Address:
0
Telephone Number:
B. Does the vendor/prime contractor intend to subcontract 50%or more of the goods, services or construction to local
businesses meeting the criteria above as to licensing and location?
0
If yes, please provide: CL
1. Copy of Receipt of the business tax paid to the Monroe County Tax Collector by the subcontractor dated at least one
year prior to the notice or request for bid or proposal. y
2. Subcontractor Address within Monroe County from which the subcontractor operates:
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Tel. Number76
_
2
Print Name:
Signature and Title of Authorized Signatory for
Bidder/Responder
STATE OF
COUNTY OF o
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On this day of 20 before me, the undersigned notary public, personally appeared
known to me to be the person whose name is subscribed above or who produced
as identification, and acknowledged that he/she is the person who executed the above Local
Preference Form for the purposes therein contained. CL
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Notary Public
Print Name
My commission expires: Seal
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REQUIRED INSURANCE TO BE MAINTAINED BY SUCCESSFUL
PROPOSER
Prior to execution of the final contract, the successful proposer will be required to provide evidence 0
that the following insurance is in place.
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Type of Insurance Limits
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Workers' Compensation Statutory
Em to ers' Liability $100,000/$500,000/$100,000
General Liability $1 million
Vehicle Liability $1 million y
Professional Liability $1 million
The successful proposer will be required to maintain the above insurance during the entire term and any
extensions of the contract. The successful proposer will be required to provide certificates of insurance
showing the above coverages at or prior to the time of initial execution of the contract. Therefore, the
proposer/vendor will be required to maintain the coverages in force at all times during the term of the
agreement, and to provide new certificates of insurance showing active coverage whenever the coverages .�
lapse. All coverages must be provided by insurers licensed to conduct business within the State of Florida and
be acceptable to the County. Monroe County must be named as an additional insured on the General Liability
and Vehicle Liability policies.
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Respondent's Insurance and Indemnification Statement
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Indemnification, Hold Harmless and Defense. The CONSULTANT covenants and agrees to indemnify, hold
harmless and defend Monroe County, its Commissioners, officers, employees, agents and servants from any
and all claims for bodily injury, including death, personal injury, and property damage, including damage to
property owned by Monroe County, and any other losses, damages, and expenses of any kind, including
attorneys' fees, costs and expenses, which arise out of, in connection with, or by reason of services provided by
the CONSULTANT or any of its Subconsultant(s) in any tier, occasioned by the negligence, recklessness, or
intentionally wrongful conduct of the CONSULTANT, or its Subconsultant(s) in any tier, their officers, employees,
servants or agents.
In the event that the completion of the project (to include the work of others) is delayed or suspended as a result c
of the CONSULTANT's failure to purchase or maintain the required insurance, the CONSULTANT shall y
indemnify the COUNTY from any and all increased expenses resulting from such delay. Should any claims be
asserted against the COUNTY by virtue of any deficiency or ambiguity in the plans and specifications provided
by the CONSULTANT, the CONSULTANT agrees and warrants that CONSULTANT shall hold the COUNTY
harmless and shall indemnify it from all losses occurring thereby and shall further defend any claim or action on
the COUNTY's behalf. The first ten dollars ($10.00) of remuneration paid to the CONSULTANT is consideration
for the indemnification provided for above.
The extent of liability is in no way limited to, reduced, or lessened by the insurance requirements contained
elsewhere within this agreement. This indemnification shall survive the expiration or earlier termination of the
Agreement. 0.
RESPONDENT'S STATEMENT
I understand the insurance that will be mandatory if awarded the contract and will comply in full with all the requirements.
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Respondent Signature
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INSURANCE AGENT'S STATEMENT
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I have reviewed the above requirements with the bidder named above. The following deductibles apply to the
corresponding policy.
POLICY DEDUCTIBLES
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Liability policies are Occurrence Claims Made
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Insurance
Agency Signature 0.
Print Name:
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VENDOR CERTIFICATION REGARDING SCRUTINIZED COMPANIES LISTS
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Project Description(s):
Respondent Vendor Name:
Vendor FEIN:
Vendor's Authorized Representative Name and Title:
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Address:
City: State: Zip:
Phone Number Email Address:
Section 287.135, Florida Statutes prohibits a company from bidding on, submitting a proposal for, or entering into or
renewing a contract for goods or services of any amount if, at the time of contracting or renewal, the company is on the
Scrutinized Companies that Boycott Israel List, created pursuant to Section 215.4725, Florida Statutes, or is engaged in a
Boycott of Israel. Section 287.135, Florida Statutes, also prohibits a company from bidding on, submitting a proposal for,
or entering into or renewing a contract for goods or services of $1,000,000 or more, that are on either the Scrutinized
Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector
Lists which were created pursuant to s. 215.473, Florida Statutes, or is engaged in business operations in Cuba or Syria.
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As the person authorized to sign on behalf of Respondent, I hereby certify that the company identified above in the Section
entitled "Respondent Vendor Name" is not listed on the Scrutinized Companies that Boycott Israel List or engaged in a
boycott of Israel and for Projects of$1,000,000 or more is not listed on either the Scrutinized Companies with Activities in
Sudan List, the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List, or engaged in business A
operations in Cuba or Syria.
I understand that pursuant to Section 287.135, Florida Statutes,the submission of a false certification may subject company
to civil penalties, attorney's fees, and/or costs. I further understand that any contract with the COUNTY may be terminated,
at the option of the COUNTY, if the company is found to have submitted a false certification or has been placed on the >
Scrutinized Companies that Boycott Israel List or engaged in a boycott of Israel or placed on the Scrutinized Companies
with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List or been
engaged in business operations in Cuba or Syria. �--
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Certified By: who is authorized to sign on behalf
of the above referenced company.
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Authorized Signature:
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Print Name:
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Title:
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Note: The List are available at the following Department of Management Services Site:
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http://www.dms.myfiorida.com/business operations/state purchasing/vendor information/convicted suspended discrimin
story complaints vendor lists
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MONROE COUNTY ADMINISTRATIVE INSTRUCTION 7400.4: 0.
WORKERS' COMPENSATION THIRD PARTY ADMINISTRATOR
(TPA) DIRECT PAYMENT SYSTEM
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OFFICE 'l"THE COUNTY ADMlNlta ,AT R
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MONR OF,COUNTY ADMIN MYRATIV1".IMS'Il• UCI told 74,00 Av,
Date- October 16,2015
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of jecu Woekers'f".omfK-nti4atif.)n"Fh,irs.3 Party,Adrnmi.st1-wor
(TPA)Direv Payment Syqpmi.,i, �
Re:ferer,ce Mortxoe t,,'oujat$Pr€jevt•.vd Clamirn Pay]115ent Systern
Atrachr unitq. (A,) Audit Reports
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E'ffecfivi; Dew; Immediately
Purpose- last an e(Torl:to expedite the laayinenL process of ffie Workers'
Compensation Pj� og rn,Monrcic Unirlty has approved to direct clairn payment >
systtm, his system will allow payrnentc for s rvi,c s provided forworkers'
cots pensadon to lac dimudy mailed from the office oft h TT'TT'A to dic srrvicki
prow�i lcr in accordai ee witli l-1 ri a S$atLjlvs.
>
0
r<2_l Backgroujt&. f)n 044/17,499,the MonToe,County Berard of C"oura y Com7rrtiW510T7crs 0.
approved the creation of an Escrow Buk I ing Account,and dcle Ated limited s.
payrneru authori�a ialt to the TPA for the process6g ofpay m ons ]or theWorkers'
Compensation Prograr t
0
(1) Rule A;1Mov rnInEr C imct payment Process for Uai= Cn
a:, The County will establish an A",ount in a'bank of lu choice for use:l� �
th "I A for clairm— aynients..
0
, The Wor ers"Co+mpensation-1 1,21rd Party AdffliniStTalor(7`RA)will entail actala, �
of the p a�rr, rTt register to thed°ke.rs' t o�atfer�sati�tl^i�'�il ve ca;� ed.rmesda�, �
and Friday. lipari receipt the Workers"Compamado C) 4dr,a tai.Mrnti';ar or
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designee will review the re ist' rand tli n.notify the Finwice raj-.)artom nt's Staff
ccoumit:°axit via -mail to,deposit ski ii i rrt, needed to meet,the cla.irns
t i : ,� r,tttrt..arwc,� °lll u�tt,if�, th,� and the ` ' err' : ar`rp rrs t rat
mirkistrrat rw or clesignee via -rAnrul that fiunclilng is complete and wili gVeord the CL
drposit into tf c ,=n� , ci.al a c untia g system- 'J"he'll'TA W 11 rrtwt issue checks, or
drafts until at revel ves confin-nation from the C urn 'tl lat T]"'Iere are su flicient
ffinds available in tie ecotrttt
d,, The, TPA will have sigriatory Privileges Ori the ncour t rap tOS5,000 requiring the
si notu of two Supervisor)! c°i see ite l of tlhe TP. ,..
e® Checks over $5,000 am sit (-Tom. than TPA m th.e Workers' c
Administrawr forprocessing., port receir t Ofthc chcQ s, the r r ' ca
ompeiL atimL Ade inistrat r OT,design,,cc with theapprupriate, signature aut:horit @ a
wil1 complete the payiuextt at th,o i t,io-r'i 'rrt, ri Attacl-u- rent B , attaeh a copy °
the chct: s arid file it, with d -e c rr latlil r$e .i ter tr'w (lie Workers'
r��lreitr ttiF . rr th.e .l thri, i iatel taillt' t the
appropriate, l CL
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l. ]'fit:� :� �a ° aetrt �.ruthrit ° l s l irrt.it �9.t tlge l�a�'rttrrt I:m sati�ftri l reri.
lair rs for t tf irmaal expmiscs and i d .nllgy sae 1 maid in artar(Juirwe W1111
the I.eri a Workers' Crrrriperisat.io Statute- then a Iiea, le., In a iti rr, die
TPA. isairthorized to a certain expenses ofdaliars, a r�ai fist ti n inclzitli,n:,
rnedical case nu agp'anent,, investigatiort expenses, tr n p fat.ixii,.aims the costs
f obtaiiiing, medic l iyeeor �6 and mpoiis,.
;,. I'] whei-expens.es, particularl.y legal defense eosLs and,any ayiTt nits issued', to
the '11-111 , or,related nt:ity wi I l be,paid ky the County directly in accordance wi th,
.
the unt 's a c unts pa, abLe,pr'oc6dijr y
fit, 'With in five (5)days of receipt ofthe paytitent r iste 1. - the. the
Workers'
at,i m Offiec i]l provid4e the Staff`A cc i rrtmi't a sigitect n
c,crtified reistr wills. ffi rnis,thai'die Work Comprnsati,on.A.dmi.ni: 1r°aet° a
has reviewcd, the register wid that.the a menu, , belti,,g rmarl I efior r ri
covered under the M�t�`rtr Crttlmy WCHkers" r e sati Progr n. � �i
certification, wdI detall milltic.lr lira ,it nis are U:� r 4'Jebited in the workers
CoMpensan't,ry fund.
0
is Should a v idl or stop rx,yrmnt mqucston a check.that has beert. issued t
re uired, L e Fl.nmikee DepmIn ents Adirin Assistant wiil, atfier a
r are t rc([,t.tir�vd,,docum.entotion and present It to Lfive Flnan r Department's CL
authorized Once the transacti.on has beur voldea OT die st.
meat ire tr st is processed, fie Aa` mini trativc Assistant will notit , the
pmo rrat rirtics (TPA, and WCiui atop° :.
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J, T-h (Yr r:s,' ("'ompcnsallun Ofl[ku,will audit tie"I"A &I'ains 11 ut liti
procedures nd. .a me t ort atcmonwus basl& The actual claim tiles —
adu i t y° th ' A 'wi 1. b audits d no lessdtati on ra °r orker '
(","ornglensatriori Moe Neill. revjc.w the reports ( ttachin ;nt A)on all cipen
Workers :" tn nsa:don files pr v Wed u eadi audit by the and provide
Written report t ,the Deprtment dead u,di ning, audit i l�lin upon reqtiest.,
�Ptritirs .r� , ° n
Assistant County Adrvia ni trat(tr �
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END OF SECTION IV
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END OF REQUEST FOR PROPOSALSCL
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