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HomeMy WebLinkAboutItem C09 COUNTY of MONROE BOARD OF COUNTY COMMISSIONERS Mayor Michelle Lincoln,District 2 The Florida Keys Mayor Pro Tern David Rice,District 4 y Craig Cates,District 1 James K. Scholl,District 3 � « Holly Merrill Raschein,District 5 Regular Meeting January 28, 2026 Agenda Item Number: C9 26-0207 BULK ITEM: Yes DEPARTMENT: Employee Services TIME APPROXIMATE: N/A STAFF CONTACT: Mark Gongre, Safety and Security Administrator 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: The Safety and Security program, of the Employee Services Department, manages the Workers' Compensation program for approximately 1,300 employees of 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 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 Third Party Administrator(TPA) services of Relation Insurance of Stuart, FL to administer the relevant aspects of our Workers' Compensation Program. In accordance with the Purchasing Policy and Board of County Commission approval, a Request for Proposals (RFP) was conducted in February of 2021, when Relation was selected as the preferred provider. A contract was awarded to the Relation in July of 2021. The contract had an initial 3-year term, with two 1-year renewal options, all of which were exercised. It is now time to conduct another Request for Proposals (RFP), to explore the market and ensure the County continues to receive good value and services. PREVIOUS RELEVANT BOCC ACTION: July 2021: BOCC approved agreement with Relation Insurance Services of Florida, Inc. to provide Third Party Administration for Monroe County Workers' Compensation program at an annual cost of$60,000. February 2021: BOCC approval to advertise the Request for Proposals (RFP) for Workers' Compensation Third Party Administration services. September 2016: BOCC executed a five year agreement with Employers Mutual, Inc. (the former name of Relation Insurance) at an annual cost of$73,500. INSURANCE REQUIRED: No CONTRACT/AGREEMENT CHANGES: N/A STAFF RECOMMENDATION: Approval DOCUMENTATION: Request for Proposals for Workers' Compensation Third Party Claims Administration Services FINANCIAL IMPACT: Fund 501-Workers' Compensation, CC_07502_Workers' Compensation Operations: $300 Advertising Approval to advertiseRequest for Proposals for es' Compensation Third Administrator services to include /7 claims intake; claims administration and management; field-case e compliance; e i billing; and other related services. MONROE COUNTY BOARD OF COUNTY COMMISSIONERS REQUEST FOR PROPOSALS FOR Workers' CoMID sation Third Partv Clai -Adn- tration Services NINE �U;iiiii. %/ ✓/ / / i ✓ / � sir //', // .............. r BOARD OF COUNTY COMMISSIONERS Mayor Michelle Lincoln, District 2 Mayor Pro Tem David Rice, District 4 Craig Cates, District 1 James K. Scholl, District 3 Holly Merrill Raschein, District 5 COUNTY ADMINISTRATOR Christine Hurley CLERK OF THE CIRCUIT COURT EMPLOYEE SERVICES DEPARTMENT Kevin Madok, CPA Workers' Compensation February 1, 2026 NOTICE OF REOUEST FOR COMPETITIVE SOLICITATIONS NOTICE IS HEREBY GIVEN that on Tuesday, June 30, 2026, 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 Pursuant to F.S. § 50.0211(3)(a), all published competitive solicitation notices can be viewed at: www.floridaDublicnotices.com, a searchable Statewide repository for all published legal notices. Requirements for submission and the selection criteria may be requested from the County's electronic bidding platform at htt : untr hu� OR ty :1 . -n. - The Public Record is available upon request. Monroe County Purchasing Department receives bids via the Bonfire electronic bidding platform. Please do not e m a i l, mail or attempt to deliver in person any sealed bids. Emailed/mailed/physically delivered bids/proposals/responses WILL NOT be accepted. The Monroe County Purchasing Department hereby directs that bids be submitted via the Bonfire electronic bidding platform at h.tt s// __ ter_ __ unt :.. ._ _n fir hu_ _ ., no later than 3:OOP.M. on June 30, 2026. There is no cost to the bidder to use the Bonfire platform. Please d o n o t submit your confidential financial information as part of your proposal. There are separate uploads for each set of documents, including confidential financial information. All proposals will be made public on the platform after an intended decision or 30 days, whichever is earlier, unless the bids/proposals are rejected in accordance with F.S. 119.071. If your proposal document includes financial information, that information will not be considered confidential and will be available and viewable to the public in accordance with public records law. The bid opening for this solicitation will be held virtually, via the internet, at 3:00 P.M., on Tuesday, June 30, 2026. You may call in by phone or internet using the following: Join Zoom Meeting https-.//mcbocc.zoom.us/j/­­­­­`l..5093261..56 Meeting ID: 4509326156 One tap mobile: +16465189805114509326156#US (New York) +16699006833114509326156#US (San Jose) Dial by your location: +1 646 518 9805 US (New York) +1 669 900 6833 US (San Jose) Publication Dates Keys Citizen: Sat., 05-23-2026 Keys Weekly: Thur., 05-28-2026 News Barometer: Fri., 05-29-2026 - 2 - MONROE COUNTY B C C REQUEST OSgF�WR OMMISSIONERS WORKERS' COMPENSATION THIRD PARTY CLAIMS ADMINISTRATION SERVICES Section I Information and Instructions 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). BACKGROUND INFORMATION 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. The population of the County is estimated at approximately 80,614. 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 Constitutional Officers)is approximately 1,320. 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 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. The program extends to all agencies of the County including but not limited to: 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 firefighters and reserve law enforcement officials. -3 - GENERAL INFORMATION AND COVERAGES REQUESTED 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 assigns Medical Rehabilitation on a case by case basis. The effective date of the program will be September 21, 2026. 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 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 Partv Administrator must be acceptable to the Countv's Excess Workers' Compensation insurers. The County's current Excess insurer is the Florida Municipal Insurance Trust(FMIT). 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 will not serve to waive or modify any other portion of the proposed program. CURRENT PROGRAM 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 relationship exists between the two organizations. As of December 31, 2025 the County had approximately 82 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 The County prefers the successful Proposer to provide their pricing on a"Life of Contract"basis and agree to 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. "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. -4- 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. 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. Medical bills reduced to State fee schedule. All subrogation and Second Injury Fund activities. Preparation of all State mandated reports. 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 and complete all necessary First Report of Injury paperwork and forward same as appropriate. Annual Detail Report of Excess Recoveries received during the year. Annual Summary of Payments reflecting: o Number of Bills Processed o Total Amount Billed o Total Fee Schedule Amount o Fee Schedule Savings o PPO/Network Savings o Total Savings o Net Amount Paid 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 Loss Runs for the past 5 years(valued as of 12/31/25),to include a summary of open claims valued in excess of$50,000. TERM OF AGREEMENT 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, 2026 to September 20, 2029, with an option to renew at the County's option for two (2) additional years. -5 - REQUEST FOR PROPOSALS SCHEDULE The following schedule will be strictly adhered to. No extension of deadlines will be granted. Activity Date Posting of RFP on Bonfire February 1,2026 Deadline for Requests for Additional Information March 1, 2026 Posting of Addendum on Bonfire (If necessary) April 1,2026 Proposal Return Date (3:00 pm) (Bid Opening) June 30,2026 Presentations of Recommendations to Board of County Commissioners August 19 2026 Implementation Date September 21, 2026 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. Proposals received after the deadline will be returned unopened. The deadline for the submission of allproposallse is 3:00 PM tune 30. 2026. It is the sole responsibility of each proposer to ensure its proposal is received in a timely fashion. 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. PROPOSAL RESPONSE FORM DRUG-FREE WORKPLACE FORM SWORN STATEMENT UNDER ORDINANCE NO. 10-1990 NON-COLLUSION AFFIDAVIT PUBLIC ENTITY CRIME STATEMENT LOCAL PREFERENCE FORM(IF APPLICABLE) INSURANCE REQUIREMENTS, RESPONDENT'S STATEMENT, INSURANCE AGENT'S FORM, SCRUTINIZED COMPANIES FORM AFFIDAVIT ATTESTING TO NONCOERCIVE CONDUCT FOREIGN ENTITES AFFIDAVIT The Local Preference Form is optional in accordance with Section 2-349, Monroe County Code. VALID DATE OF PROPOSALS Proposals shall remain valid until November 1, 2026 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 proposals, and to re-advertise for proposals. -6 - 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 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. 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 adjuster's resumes should also be provided. 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 Proposals should be signed by an authorized representative of the Third Party Administrator providing the service. ADDITIONAL INFORMATION/INSPECTION 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: 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: Gongre-mark(a.monroecounty-fl.gov All requests for additional information must be received no later than 3:00 PM,March 1,2026. An addendum to the specifications will be posted on Bonfire to answer any requests for additional information. Oral requests for additional information will not be answered. -7 - 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. 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 addendum. RATE CHANGE 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. 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. 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. 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. Copies of all loss reports must be provided to the County's Risk Management Consultant, and to the County's Excess Insurers. COORDINATION WITH EXCESS INSURERS 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 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 four(4)times during the year to discuss the active claims and the procedures being followed by the TPA. The parties should plan that one meeting -8 - 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 are to be held electronically via video or web conference. CONTENT OF SUBMISSION 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 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. Format. The proposal shall be organized as follows and contain the following information: A. Cover Page 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. B. Tabbed Sections Tab 1. General Information (a) The name of the firm submitting proposal, address, contact person's name,telephone numbers, email 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 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. The overview should also include the length of time the firm has been providing claims administration services. (d) Explanation of fees,rates. (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 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 • Telephone number of client contact • Date of initiation and completion of contract • Summary of the services and area served -g - Tab 3. Services,Approach and Availability of Service to County 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 subcontractors 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. Tab 4. Litigation Pursuant to Section 2-347 of the Monroe County Code, all respondents must provide answers to the following questions regarding claims and suits: 1) A list of the person's or entity's shareholders with five percent or more of the stock or, if a general partnership, a list of the general partners; or, if a limited liability company, a list of its members; or, if a solely owned proprietorship,names(s)of owner(s); (2) A list of the officers and directors of the entity; (3) The number of years the person or entity has been operating and, if different,the number of years it has been providing the services, goods, or construction services called for in the bid specifications (include a list of similar projects); (4) The number of years the person or entity has operated under its present name and any prior names; (5)Answers to the following questions regarding claims and suits: a. Has the person,principals, entity, or any entity previously owned, operated or directed by any of its officers,major shareholders or directors, 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 person,principal of the entity, or entity, or any entity previously owned, operated or directed by any of its officers, directors, or general partners? If yes,provide details; c. Has the person,principal of the entity, entity, or any entity previously owned, operated or directed by any of its officers,major shareholders or directors, within the last five years,been a party to any lawsuit, arbitration, or mediation with regard to a contract for services, goods or construction services similar to those requested in the specifications with private or public entities?If yes,provide details; d. Has the person,principal of the entity, or any entity previously owned, operated or directed by any of its officers, owners,partners, major shareholders or directors, 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 years,the owner, an officer, general partner,principal, controlling shareholder or major creditor of the person or entity was an officer, director, general partner,principal, controlling shareholder or major creditor of any other entity that failed to perform services or furnish goods similar to those sought in the request for competitive solicitation; f. Customer references (minimum of three),including name, current address and current telephone number; 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; and i. Any financial information requested by the county department involved in the competitive solicitation, related to the financial qualifications,technical competence,the ability to satisfactorily perform within the contract time constraints, or other information the department deems necessary to enable the department and board of county commissioners to determine if the person responding is responsible. - 10- Please note: All documents submitted in response to this RFP are public records. If the respondent 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 all professional and occupational licenses and shall include them in this section, i.e. Tab 6: PROPOSAL RESPONSE FORM(from Section III of this RFP) NON-COLLUSION AFFIDAVIT DRUG-FREE WORKPLACE FORM SWORN STATEMENT UNDER 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. 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 no less than thirty(30)days prior to the change taking effect. Such notification should include the 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. 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. - 11- 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 County will need similar access to the TPA's computerized claim system. The County expects that if a 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 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. 8. During the period of 10/1/24 through 9/30/25, the County's TPA processed 1,186 medical bills on behalf of the County. The cumulative amount of the bills totaled $2,126,304. The TPA reduced the bills by $978,422 in accordance with State Fee Schedule. In addition, the bills were further discounted by $111,644 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 to comply with the provisions of this 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 that the TPA has established. Tab 8. Additional Information 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. 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. EVALUATION CRITERIA A selection committee will be convened to review and evaluate the Proposals. The committee recommendations will be presented to the Board of County Commissioners. - 12- Evaluation Factor Points Compliance with UP specifications (required format,submission of forms 05 Ability to provide services listed(scope of services,County expectations) 25 Experience of adjusters assigned to the County's account 20 Length of time that Proposer has been providing claims administration services 15 Proximity of office adjusting the County's claims to the County 15 Quality of TPA's Computer Claim System and quality of Loss Runs 15 Caseload of adjusters that will be assigned to the County'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,plus up to 5 10 points if vendor uses a subcontractor that is a local business) Total 150 Total points earned are on a scale of 1 — 150 points (1 is the lowest ranking and 150 is the highest ranking). OPEN CLAIM COUNT AND ASSOCIATED RESERVES As of December 31, 2026,the County's current TPA reported the following open claim count and associated reserves. Valued as of 12/31/26 Policy Year Number Open Reserves of Open Claims 82/84 1 $201725 92/93 2 $470,828 97/98 2 $181945 00/01 1 $36,218 01/02 2 $145,767 05/06 1 $22,821 07/08 1 $221)951 09/10 2 $196,144 10/11 1 $351747 11/12 1 $341898 13/14 3 $518,035 14/15 1 $141102 15/16 1 $8,185 16/17 4 $313,775 17/18 2 $143,395 18/19 3 $731025 19/20 5 $90,530 20/21 1 $311107 21/22 2 $25,794 22/23 6 $167,204 23/24 14 $1,088,036 24/25 19 $2631605 25/26(Partial Year) 13 $61,997 Total 82 $303,842 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. - 13- In order that a complete history of the County's program can be maintained,the successful proposer will be 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 The successful proposer will be required to maintain throughout the life of the contract,insurance protection as specified in the attached forms. Experience Modification .76 - 14- MONROE COUNTY BOARD OF COUNTY COMMISSIONERS REQUEST FOR PROPOSALS FOR WORKERS' COMPENSATION THIRD PARTY CLAIMS ADMINISTRATION SERVICES Section II Draft Agreement Following is a draft agreement that the County will expect the successful proposer to sign. The County will be agreeable to reasonable modifications to the agreement. DRAFT AGREEMENT These contract documents should be used only after consultation with counsel. The documents are not 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. MONROE COUNTY CONTRACT FOR Services THIS AGREEMENT is made and entered into this day of ,by MONROE COUNTY ("COUNTY"),a political subdivision of the State of Florida,whose address is 1100 Simonton Street,Key West,Florida 33040 and ("CONTRACTOR"),whose address is 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. 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. 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 2.1 Provide all best available information as to the COiJNTY'S requirements for the scope of services described in Exhibit A to this Agreement. - 15 - 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. Section 3. TERM OF AGREEMENT 3.1 The initial Agreement will be for one(3)year term beginning the 21 st day of September,2026 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 provide at least ninety(90)days' notice of intent to terminate. The County must provide the Contractor 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. Section 4. COMPENSATION Compensation to CONTRACTOR shall be $ Section 5. PAYMENT TO CONTRACTOR 5.1 Payment will be made according to the Florida Local Government Prompt Payment Act. Any request for payment must be in a form satisfactory to the Clerk of Courts for Monroe County(Clerk). The request 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 Board of County Commissioners. Section 6. CONTRACT TERMINATION 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 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 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. - 16- 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 reputable manner. Proof of such licenses and approvals shall be submitted to COUNTY upon request. Section 8. NOTICES 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: To the COUNTY: Mark Gongre,Monroe County Safety and Security Administrator 1100 Simonton Street, Suite 2-268 Key West, Florida 33040 With a copy to: Monroe County Attorney's Office 1111 12th St., Suite 408 Key West, FL 33040 To the CONTRACTOR: 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 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. 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 subj ect 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. Section 11. CONVICTED VENDOR 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 - 17- 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. 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. 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 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. Section 14. ATTORNEY'S FEES AND COSTS 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. Section 16. AUTHORITY Each party represents and warrants to the other that the execution, delivery and performance of this Agreement have been duly authorized by all necessary County and corporate action, as required by law. Section 17. ADJUDICATION OF DISPUTES OR DISAGREEMENTS 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. - 18- 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 extent required by the other party, in all proceedings, hearings,processes,meetings, and other activities related 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. Section 19. NONDISCRIMINATION 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. 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 88352), 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; 6) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (PL 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 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 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. Section 20. COVENANT OF NO INTEREST COUNTY and CONTRACTOR covenant that neither presently has any interest, and shall not acquire any 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. Section 21. CODE OF ETHICS 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 and that it has not paid or agreed to pay any person, company, corporation, individual, or firm, other than a bona 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 - 19- 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. Section 23. PUBLIC ACCESS/PUBLIC RECORDS The COUNTY and CONTRACTOR shall allow and permit reasonable access to, and inspection of, all 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: 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. 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 records upon completion of the contract, the contractor shall meet all applicable requirements for retaining public 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,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 COiINTY'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 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. 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, GAELAN JONES, AT JONF.S-(TAF.T,AN(&MONROF,CnUNTV-Fi,.(TnV, (305)292-3470, 1111 12TH ST.,KEY WEST, FL 33040. -20- 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, selfinsurance coverage,or local government liability insurance pool coverage shall not be deemed a waiver of immunity to the extent of liability coverage, nor shall any Agreement entered into by the COUNTY be required to 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 this Agreement within the territorial limits of the COUNTY shall apply to the same degree and extent to the performance of such functions and duties of such officers, agents,volunteers, or employees outside the territorial limits of the COUNTY. 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 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 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 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. Section 29. NO PERSONAL LIABILITY 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 employee of Monroe County shall be liable personally on this Agreement or be subject to any personal liability or accountability by reason of the execution of this Agreement. Section 30. EXECUTION IN COUNTERPARTS This Agreement may be executed in any number of counterparts, each of which shall be regarded as an original, 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. -21- 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 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. 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 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 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. The County, at its sole option, has the right to request a certified copy of any or all insurance policies required 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. 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. 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 any other -22- agents, individually and collectively, from all fines, suits, claims, demands, actions, costs, obligations, 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. 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 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 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 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. Section 33. E-VERIFY REQUIREMENT (F.S. 448.095) Beginning January 1,2021,every public employer,contractor and subcontractor shall register with and use the E-Verify system to verify the work authorization of all newly hired employees. By entering into this Agreement, the vendor certifies that it registers with and uses the E-Verify system. If the contractor enters into a contract with a subcontractor, the subcontractor must provide the contractor with an affidavit stating that the subcontractor does not employ, contract with, or subcontract with an unauthorized alien. The contractor shall maintain a copy of such affidavit for the duration of the contract. IN WITNESS WHEREOF,the parties hereto have caused these presents to be executed on the day of 2026. (SEAL) MONROE COUNTY BOARD OF COUNTY COMMISSIONERS Attest: KEVIN MADOK, CLERK OF MONROE COUNTY, FLORIDA By by As Deputy Clerk Mayor/Chairman (CORPORATESEAL) (Name of Contractor) ATTEST: By by Title: -23- Exhibit A Scope of Services The Administrator will provide the following services: Initial contact with claimant within 24 hours. Recorded statements of the claimant. 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. 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. 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. -24- MONROE COUNTY BOARD OF COUNTY COMMISSIONERS REQUEST FOR PROPOSALS FOR WORKERS' COMPENSATION THIRD PARTY CLAIMS ADMINISTRATION SERVICES SECTION III PROPOSAL RESPONSE FORM Name of Third Party Administrator Address Telephone Number Are the following services included within the price quoted? Initial contact with claimant within 24 hours Yes No Recorded statements of claimant Yes No Contact with treating physician Within 24 hours Yes No Narrative Summaries on major claims every 3 mos. Yes No Medical Bills reduced to State Fee Schedule Yes No Medical Bills reduced in accordance with PPO Provider discounts Yes No Subrogation and Second Injury Fund activities Yes No Preparation of all State mandated reports Yes No Notification of all potential excess claims To insurers Yes No Quarterly meetings with the County Yes No -25- Provide monthly loss reports to the County Yes No Provide monthly loss reports to the Consultant Yes No If any of the responses are no,please explain and include the full pricing for the services. Will one Lost Time adjuster and one Medical Only adjuster be assigned to the County's account? Yes No Are resumes of adjusters attached? Yes No Will the County be able to continue contracting and paying directly for all legal defense services? 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 its Field Case Manager? Yes No What charge will be made for accessing the TPA's claims system? Yes No Will the TPA develop a user manual for the operations of the TPA's claim system? Yes No Will the County have 24/7 access to the TPA's Claims system? Yes No Will the TPA conduct an onsite (in Key West) demonstration on the use of their claim system before implementation? Yes No Will the TPA update the user manual when any changes are made to the claim system? Yes No Has information regarding the PPO networks established by the TPA been provided as requested? Yes No Does price quoted include processing claims -26- until conclusion? Yes No If not explain duration included in fee. Will the Proposer charge any initial or maintenance Fee? Yes No Please explain required banking arrangements Does the Proposer have an approved Safety Program with the State? Yes No Does the Proposer agree with the handling of claim Payments in accordance with the County's Administrative Instruction7400.4? Yes No Please describe how claims will be classified as Lost Time and Medical Only for administration billing Quoted Price: Claims Administration Cost Per Claim Cost Per Run-Off Claim Workers Compensation Medical Only Claims Indemnity Claims Flat Annual Fee Charge for Reducing Medical Bills to State Fee Schedule Per Bill Flat Annual Fee(payable in monthly installments) -27- Charge for Reducing Medical Bills in Accordance with PPO Arrangements Per Bill Flat Annual Fee(payable in monthly installments) The County strongly prefers a flat annual fee for all Bill Reduction services. Is an alternative pricing structure proposed? Yes No If so,please describe Will a minimum fee apply to the contract? Yes No If so,please specify Are there any exceptions to the specifications? Yes No If so,please specify 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. Signature of Authorized Representative Date Printed Name - 28- MONROE COUNTY BOARD OF COUNTY COMMISSIONERS REQUEST FOR PROPOSALS FOR WORKERS' COMPENSATION THIRD PARTY CLAIMS ADMINISTRATION SERVICES SECTION N SUPPORTING DOCUMENTS, OPTIONAL FORM AND REQUIRED FORMS 1, PROJECTED PAYROLLS 2. DRUG FREE WORKPLACE POLICY 3, DRUG-FREE WORKPLACE FORM* 4, ORDINANCE NO, 10-1990 ETHICS CLAUSE SWORN STATEMENT* 5. NON-COLLUSION AFFIDAVIT* 6. PUBLIC ENTITIES CRIMES STATEMENT* 7. LOCAL PREFERENCE FORM 8. INSURANCE REQUIREMENTS and INDEMNIFICATION CLAUSE 9. VENDOR CERTIFICATION REGARDING SCRUTINIZED COMPANIES LIST* 10, MONROE COUNTY ADMINISTRATIVE INSTRUCTION 7400.4 — WORKERS' COMPENSATION THIRD PARTY ADMINISTRATOR TPA DIRECT PAYMENT SYSTEM *REQUIRED FORMS MUST BE SUBMITTED WITH THE PROPOSAL ALONG WITH RESPONSE FORM(SECTION III) -29- PROJECTED PAYROLLS -30- MONROE COUNTY PROJECTED PAYROLLS BY WC CLASSIFICATION FOR PERIOD 10/1/25TO 9/30/26 Code Classification Projected Payroll Computer Device Installation, Inspection, Service or Repair 5191 $6781522 Street or Road Maintenance or Beautification& 5509 Drivers $1,18 7,101 6217 Excavation&Drivers $270,454 7370 Taxicab Co: All Other Employees&Drivers $337,472 Aviation-Transportation of Personnel in Conduct of Employers Business Ground 7403 Crew& Drivers $1,309,597 Aircraft or Helicopter Operation: NOC— 7425 Helicopters: Flying Crew $2,512,125 p y g 7704 Firefighters&Drivers $11,980,741 7720 Police Officers &Drivers $3000,984 8380 Automobile Service or Repair Center&Drivers $1,73 81969 8742 Salespersons or Collectors Outside $611025 8810 Clerical Office Employees NOC $3114471728 Attorney, -All Employees& Clerical,Messengers, 8820 $3,355,283 Drivers 8824 Retirement Living Centers,Health Care Employees $15%079 8832 Physician& Clerical $490,795 Nursing—Home Health , Public and Traveling—All 8835 Employees $354,985 Buildings—Operation: By Owner, Lessee or Real 9015 Estate Management Firm: All Other Employees $5,257,311 g 9063 YMCA, YWCA,YMHA or YWHA, Institution—All Employees & Clerical," $1201517 9102 Park NOC—All Employees &Drivers $5511148 9403 Garbage,Ashes or Refuse Collection&Drivers $3551260 Municipal, Township, County or State Employee,NOC 9410 $8,2001836 Total $10110591932 Footnote: Class 7704 includes 53 volunteers each with an assumed salary of$10,000 -31- DRUG FREE WORKPLACE POLICY -32 - NOTICE TO EMPLOYEES DRUG-FREE WORKPLACE POLICY Monroe County has aDrug-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. -33- REQUIRED FORMS TO BE COMPLETED BY PROPOSER -34- DRUG-FREE WORKPLACE FORM The undersigned vendor in accordance with Florida Statute 287.087 hereby certifies that: (Name of Business) 1. 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. 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. 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). 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 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. 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. 6. Makes a good faith effort to continue to maintain a drug-free workplace through implementation of this section. As the person authorized to sign the statement,I certify that this firm complies fully with the above requirements. (Signature) Date: STATE OF: COUNTY OF: Subscribed and sworn to(or affirmed)before me,by means of physical presence or online notarization, on (date)by .(name of affiant). LJ He LJ She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC My Commission Expires: -35- SWORN STATEMENT UNDER ORDINANCE NO.10-1990 MONROE COUNTY,FLORIDA 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. (signature) Date: STATE OF: COUNTY OF: Subscribed and sworn to(or affirmed)before me,by means of physical presence or online notarization, on (date)by .(name of affiant). L He LJ She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC -36- NON-COLLUSION AFFIDAVIT I, of the city of according to law on my oath, and under penalty of perjury, depose and say that a. I am of the firm of the bidder making the Proposal for the project described in the Request for Proposals for , and that I executed the said proposal with full authority to do so; b. 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 anycompetitor; C. 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 competitor; and d. No attempt has been made or will be made by the bidder to induce any other person,partnershiporcorporation to submit,or not to submit,a bid for the purpose ofrestricting competition; e. 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. (Signature) Date: STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me, by means of El physical presence or D online notarization, on (date)by (name of affiant). ❑He El She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC OMB—D.10 -37- 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,proposal,or reply on a contract to provide any goods or services to a public entity,may not submit a bid,proposal, or reply on a contract with a public entity for the construction or repair of a public building or public work,may not submit bids,proposals,or replies on leases of real property to a 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 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 have read the above and state that neither (Respondent's name) nor any Affiliate has been placed on the convicted vendor list within the last 36 months. (Signature) Date: STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed) before me, by means of El physical presence or D online notarization, on (date)by (name of affiant) J He J She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC My Commission Expires: OMB-D.8 Revised BOCC 7/17/2024 -38- LOCAL PREFERENCE FORM A. Vendors claiming a local preference according to Ordinance 023-2009 must complete this form. 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. ) 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: 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? If yes,please provide: 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. 2. Subcontractor Address within Monroe County from which the subcontractor operates: Tel.Number Print Name: Signature and Title of Authorized Signatory for Bidder/Responder STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed)before me,by means of:J physical presence or::] online notarization, on (date)by _(name of affiant). ::1 He❑ She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC -39- REQUIRED NSURANCE TO BE MAINTAINED BY SUCCESSFUL PROPOSER Prior to execution of the final contract, the successful proposer will be required to provide evidence that the following insurance is in place. Type of Insurance Limits Workers' Compensation Statutory Employers' Liability $100,000/$500,000/$100,000 General Liability $1 million Vehicle Liability $1 million Professional Liability $1 million Cyber 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. Respondent's Insurance and Indemnification Statement 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 of the CONSULTANT's failure to purchase or maintain the required insurance, the CONSULTANT shall 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. RESPONDENT"S STATEMENT I understand the insurance that will be mandatory if awarded the contract and will comply in full with all the requirements. Respondent Signature -40- VENDOR CERTIFICATION REGARDING SCRUTINIZED COMPANIES LISTS Project Description(s): Respondent Vendor Name: Vendor FEIN: Vendor's Authorized Representative Name and Title: 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. 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 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. Certified By: , who is authorized to sign on behalf of the above referenced company. Authorized Signature: Print Name: Title: Note: The List are available at the following Department of Management Services Site: http-//www.dms. ..orida.com/business...........operations/state...........purch sin /vendor......... .for _atio on i_eted.........suspended..........d s ri in atory..........e pla® .is...........vendor lists -41- AFFIDAVIT ATTESTING TO NONCOERCIVE CONDUCT FOR LABOR OR SERVICES Entity/Vendor Name: Vendor FEIN: Vendor's Authorized Representative: (Name and Title) Address: City: State: Zip: Phone Number: Email Address: As a nongovernmental entity executing, renewing, or extending a contract with a government entity, Vendor is required to provide an affidavit under penalty of perjury attesting that Vendor does not use coercion for labor or services in accordance with Section 787.06, Florida Statutes. As defined in Section 787.06(2)(a), coercion means: 1.Using or threating to use physical force against any person; 2.Restraining, isolating, or confining or threating to restrain, isolate, or confine any person without lawful authority and against her or his will; 3.Using lending or other credit methods to establish a debt by any person when labor or services are pledged as a security for the debt, if the value of the labor or services as reasonably assessed is not applied toward the liquidation of the debt, the length and nature of the labor or service are not respectively limited and defined; 4.Destroying, concealing, removing, confiscating, withholding, or possessing any actual or purported passport, visa, or other immigration document, or any other actual or purported government identification document, of any person; 5.Causing or threating to cause financial harm to any person; 6.Enticing or luring any person by fraud or deceit; or 7.Providing a controlled substance as outlined in Schedule I or Schedule II of Section 893.03 to any person for the purpose of exploitation of that person. As a person authorized to sign on behalf of Vendor, I certify under penalties of perjury that Vendor does not use coercion for labor or services in accordance with Section 787.06. Additionally, Vendor has reviewed Section 787.06, Florida Statutes, and agrees to abide by same. Certified By: , who is authorized to sign on behalf of the above referenced company. Authorized Signature: Print Name: Title: -42- FOREIGN ENTITIES AFFIDAVIT F.S. 287.138 I, of the city of according to law on my oath, and under penalty of perjury, depose and say that: a. I am of the firm of ("Entity"), the bidder making the Proposal for the project described in the Request for Proposals for and that I executed the said proposal with full authority to do so; b. In accordance with section 287.138, Florida Statutes, the Entity is not owned by the government of a Foreign Country of Concern, as that term is defined in F.S. 287.138, is not organized under the laws of nor has its Principal Place of Business in a Foreign Country of Concern, and the government of a Foreign Country of Concern does not have a Controlling Interest in the entity. c. 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. (Signature) Date: STATE OF: COUNTY OF: Subscribed and sworn to (or affirmed)before me, by means of❑ physical presence or ❑ online notarization, on (date)by (name of affiant). He/She is personally known to me or has produced (type of identification) as identification. NOTARY PUBLIC My Commission Expires: -43- MONROE COUNTY ADMINISTRATIVE INSTRUCTION 7400.410* WORKERS' COMPENSATION THIRD PARTY ADMINISTRATOR (TPA) DIRECT PAYMENT SYSTEM /Comaty of Miarime Msy"t"w''r3am.ray/ If, � ,, � 'wr� � /I f � a� I.x"cWhig"c"",1Y ric"I 11 I C Y prat.Dimmica Hg mr �I�N r� I W�i I iWr �� ra�k I o�rl I 'r;�jIII�IpI'rw" �;r I rm IIP jp�� ,v„'IIIII�y��I off v'<n -.. �ro� R f. oCF IC'r'' rM,l O tiw'nr/a/A ,�a�iP �er 1, VA'r Wr,Id Na,I, +1�'�n al� Key r m IFµ"rt. " 'ateM1 Octobmr aria, g„ trzin Ike&rence.: Payment System urn , x County I ,n r I p^i I„lm of system. 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Workers' . e Will provide r the c v a �Il{tir c r ) r I I : t N that a, , , „ , m l o i ,i. w ". �ro71 WI, i, �., pry has (� � i� 1 I � ul9 ,����(r �I Ie IU��'; ' "I'N�r IY r fKf v I Wuwrvu �I A'n I If u,�i N7JN F- U ' ait: 6o I{ �n�i I��,�I rss(N' , ..11xd. , ce 9 Po , Wi Ad I; 1" "I I�J'r rIVa"U'I'I"CIY I. rvWd'gl N bN IiNI!' i°, 'W.' I r Y :OI Ilb II y Pro, r 1 ,,,. 1 1 F w Ir W 'I u ri ,r,7 P � ! ,,,v i r/�, � I ,rr I, � r; I ' r he k, I @YN I., 11 No r ��,,, a ';°�r''N fl �,,, o i Kure, ., m e k I »y r�l�l' �a , ,.I i : 1 PI elm r ID,I I IU)yy, I I{i 1 �'(V; ��III,�", p,. wl,;�I��,Y!�(i s,;.,. um I I� ,N, that I�„,V y..... ,g Nj. ils,lol�r I, I p, tv, . '�,ah,,�:''n rlI I�' 3IN �Hr'!`Pi,... a ..'a�WfVll� � !9!b �: , 1,i I IW r,0 `il!�ro�1, I r blNiMI $" PWt., u ! i 4 � I .., , Administrative r iu will, " , r u , ^Nr Ufii ",nN, f if Nu�,V1 0:" , the "; U� I,a1 ` I r"II W� I,i 4 `Nf"A r 'W r,r... I P J r;,.,:..I" ' „ and ,`: y,u..., ittoo"UrTe) r ,I dS I�N E. OfW"� 19� I J n�, Q',�,.,.. A SIGN .._ G.'N r e t Y i til ,B"! or d stop I✓l „ I 41 w I fu,, I ��ryV' I",request � w I "' ¢�ryfn ; I,'� � �I,� wy� umWl �I� I I � ,�I� II I"),,.; Wrn>�'V INN� ,�9 r '&, � o ,�u g r ', '�, r I 6ve Er e -is >J'' r'i J r�e " r ' 1!r l 4'it '1 ,.,ill r!"NM4 i§i 1 ";'+,e will r r�"'�1', I the l,i ,N n III u r1 s I 1I', � N i IIV rVd J�TFPV.nd rolsrr9r,� el ,. -46- M CA.Inst.,7AX"'V4 Owe!, 16.20 1,55' 4 h ,','mpvnsavtion OfTice will, audit" "the"TPA claitnstt I ig ji. V,c Workers" Cc, and payn,,,wetus on a Tbrm wtua], claim files, ad.ni,inistered b,y the AIM II will be auditred.no tes timi j(,,',)ncc a,ye, 71m, WarkerI4.,;"' C o m;*msa,tion ORO:will tirwiew fficreports all Work,ers' Prricwicleid iit cacb ttudit b,,,,y(the"TFIA and provide a n , , ), o hI u rflwTittc ,r,'cjxrt ttpar c,mdoflinniaudinding o'nrttee , nH i supqst. 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