Athens_Administrators_CSM_2022-2026_Contract_Amendment_One_00600-23-R078936-A1_executed.pdf

County of San Mateo

Contract Amendment Coversheet and Contract Amendment for > $200K

Amendment Template Version May 2021

CONTRACT SUMMARY

Contract No: Contractor Name Amendment No:

00600-23-R078936 Athens Insurance Service, Inc. dba Athens Administrators 00600-23-R078936-A1

THE AGREEMENT HAS CHANGED AS FOLLOWS:

Agreement Amount Original Amount: $3,043,217 over the course of three years plus $1,085,191 if the County exercises its fourth-year option, plus $1,122,630 if the County exercises its fifth-year option Amendment 1 Amount: $1,085,191 (previously approved by Resolution No. 078936 authorizing the Human

Resources Director or the Director's designee to execute contract amendments)

(NTE $4,128,408)

Current Amount: Addition or Reduction: New Total:

$3,043,217 $1,085,191 $4,128,408

Agreement Term Original Start Date: July 1, 2022 Original End Term: June 30, 2025 Amendment 1 Start Date: July 1, 2022 Amendment 1 End Date: June 30, 2026

Paragraph Changes:

The three-year agreement has two one-year options to extend the agreement. This amendment is to elect the first option to extend the agreement in an amount not to exceed $1,085,191 in year 4.

Docusign Envelope ID: B13183BA-658C-4282-AEF1-7531364F05C3

Amendment Template Version May 2021 Page | 1

AMENDMENT ONE TO AGREEMENT

BETWEEN THE COUNTY OF SAN MATEO AND ATHENS INSURANCE SERVICE, INC.

THIS AMENDMENT TO THE AGREEMENT, entered into this ___________. 20___, by and between the COUNTY

OF SAN MATEO, hereinafter called "County," and Athens Insurance Service, Inc. dba Athens Administrators, hereinafter called "Contractor";

W I T N E S S E T H:

WHEREAS, pursuant to Government Code, Section 31000, County may contract with independent contractors for the furnishing of such services to or for County or any Department thereof;

WHEREAS, on June 14, 2022, the Board of Supervisors approved Resolution No. 078936 authorizing an agreement with Contractor, and the standard provision which authorized the Human Resources Director or the Director's designee to execute contract amendments including, but not limited to, two one-year extensions of this agreement not to exceed $1,085,191 in year 4 and $1,122,630 in year 5 for Athens

Administrators; and

WHEREAS, the parties entered into an Agreement that Contractor be retained for the purpose of the

Workers' Compensation claims administration services for the County of San Mateo on June 14, 2022, for the term of July 1, 2022, through June 30, 2025, in an amount not to exceed $3,043,217; and

WHEREAS, the parties wish to amend the Agreement to extend the Agreement term as described below.

NOW, THEREFORE, IT IS HEREBY AGREED BY THE PARTIES HERETO AS FOLLOWS:

1. Paragraph 3, Payments, of the agreement is amended to read as follows:

In consideration of the services provided by Contractor in accordance with all terms, conditions, and specifications set forth in this Agreement and in Exhibit A, County shall make payment to Contractor in twelve

(12) equal installments and will be due and payable at the end of each month during the period this Agreement is in force. County reserves the right to withhold payment if County determines that the quantity or quality of the work performed is unacceptable. In no event shall County’s total fiscal obligation under this Agreement exceed $4,128,408, with a one-year option to extend the agreement, in an amount not to exceed $1,122,630 in year 5. In the event that the County makes any advance payments, Contractor agrees to refund any amounts in excess of the amount owed by the County at the time of contract termination or expiration. Contractor is not entitled to payment for work not performed as required by this agreement.

2. Paragraph 4, Term, of the agreement is amended to read as follows:

Subject to compliance with all terms and conditions, the term of this Agreement shall be from July 1, 2022, through June 30, 2026 with the option of a one (1) year extension through June 30, 2027.

3. All other terms and conditions of the agreement dated June 14, 2022, between the County and Contractor shall remain in full force and effect.

Docusign Envelope ID: B13183BA-658C-4282-AEF1-7531364F05C3

Agreement ID: 00600-23-R078936-A1

3/31/2025 | 12:20 PM PDT

Amendment Template Version May 2021 Page | 2

In witness of and in agreement with this Agreement’s terms, the parties, by their duly authorized representatives, affix their respective signatures:

For Contractor: Athens Insurance Service, Inc.

Contractor Signature

Date

Contractor Name (please print)

For County:

Purchasing Agent Signature County of San Mateo (Department Head of Authorized Designee)

Date

Purchasing Agent Name (please print) County of San Mateo (Department Head of Authorized Designee)

Docusign Envelope ID: B13183BA-658C-4282-AEF1-7531364F05C3

3/24/2025 | 10:27 AM PDT James Jenkins

Rocio Kiryczun3/31/2025 | 12:20 PM PDT

Certificate Of Completion Envelope Id: B13183BA-658C-4282-AEF1-7531364F05C3 Status: Completed

Subject: Athens Administrators_CSM 2022-2026 Contract Amendment One 00600-23-R078936

Source Envelope:

Document Pages: 3 Signatures: 2 Envelope Originator:

Certificate Pages: 5 Initials: 0 Carling Luk

AutoNav: Enabled

EnvelopeId Stamping: Enabled

Time Zone: (UTC-08:00) Pacific Time (US & Canada)

455 County Center

5th Floor, HRD 121

Redwood City, CA 94063 cluk@smcgov.org

IP Address: 162.228.90.42

Record Tracking Status: Original

3/24/2025 9:24:08 AM

Holder: Carling Luk cluk@smcgov.org

Location: DocuSign

Security Appliance Status: Connected Pool: StateLocal

Storage Appliance Status: Connected Pool: San Mateo County Human Resources Location: Docusign

Signer Events Signature Timestamp James Jenkins jjenkins@athensadmin.com

President

Athens Insurance Services, INc.

Security Level: Email, Account Authentication (None)

Signature Adoption: Pre-selected Style

Using IP Address: 71.6.45.227

Sent: 3/24/2025 9:36:46 AM

Viewed: 3/24/2025 10:27:18 AM

Signed: 3/24/2025 10:27:25 AM

Electronic Record and Signature Disclosure:

Accepted: 3/24/2025 10:27:18 AM ID: dbeaf252-c141-4244-b21a-dd1e8a3e488f

Rocio Kiryczun

Rkiryczun@smcgov.org

Security Level: Email, Account Authentication (None)

Signature Adoption: Pre-selected Style

Using IP Address: 99.152.112.7

Sent: 3/24/2025 10:27:26 AM

Viewed: 3/31/2025 12:19:42 PM

Signed: 3/31/2025 12:20:02 PM

Electronic Record and Signature Disclosure:

Accepted: 3/31/2025 12:19:42 PM ID: ba42451d-6f1f-438a-add5-6e0a8185b6ac

In Person Signer Events Signature Timestamp

Editor Delivery Events Status Timestamp

Agent Delivery Events Status Timestamp

Intermediary Delivery Events Status Timestamp

Certified Delivery Events Status Timestamp

Carbon Copy Events Status Timestamp HR Finance

HR_Finance@smcgov.org

Security Level: Email, Account Authentication (None)

Sent: 3/31/2025 12:20:03 PM

Electronic Record and Signature Disclosure:

Not Offered via Docusign

Carbon Copy Events Status Timestamp Zhanna Abuel

ZAbuel@smcgov.org

Security Level: Email, Account Authentication (None)

Sent: 3/31/2025 12:20:04 PM

Electronic Record and Signature Disclosure:

Not Offered via Docusign

Sarah Prince sprince@smcgov.org

Security Level: Email, Account Authentication (None)

Sent: 3/31/2025 12:20:04 PM

Electronic Record and Signature Disclosure:

Not Offered via Docusign

Witness Events Signature Timestamp

Notary Events Signature Timestamp

Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 3/24/2025 9:36:47 AM

Certified Delivered Security Checked 3/31/2025 12:19:42 PM

Signing Complete Security Checked 3/31/2025 12:20:02 PM

Completed Security Checked 3/31/2025 12:20:04 PM

Payment Events Status Timestamps

Electronic Record and Signature Disclosure

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Electronic Record and Signature Disclosure created on: 8/3/2021 11:07:32 AM Parties agreed to: James Jenkins, Rocio Kiryczun

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