RFP No. PS143950 - Third Party Administrator (TPA) Conflict Claims.pdf

Los Angeles County Metropolitan Transportation Authority

Third Party Administrator (TPA) Conflict Claims

RFP No. PS143950

ISSUED: 08.25.26

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RFP NO. PS143950 TABLE OF CONTENTS

ISSUED: 08.25.26 SS/2019

i

TABLE OF CONTENTS

SECTION 1 – LETTER OF INVITATION ..................................................................... 1-0 EXHIBIT 4 - LIST OF CERTIFIED FIRMS (RESERVED) .................................................................. 1-6

SECTION 2 – CONTRACT DOCUMENTS .................................................................. 2-0

FIRM FIXED UNIT RATE EZ FORM SERVICES CONTRACT .............................................2-1 ARTICLE I: CONTRACT DOCUMENTS ORDER OF PRECEDENCE ......................................... 2-3 ARTICLE II: COMPENSATION ...................................................................................................... 2-3 ARTICLE III: CONTRACT TERM AND PERIOD OF PERFORMANCE ......................................... 2-4 ARTICLE IV: SBE PARTICIPATION ............................................................................................... 2-4 ARTICLE V: INSURANCE .............................................................................................................. 2-4 ARTICLE VI: SAFETY COMPLIANCE ............................................................................................... 2-4 ARTICLE VII: ENTIRE AGREEMENT ............................................................................................... 2-6 EXHIBIT 1 - PAYMENT CERTIFICATION ......................................................................................... 2-7 EXHIBIT A – SCOPE OF SERVICES................................................................................................. 2-8

REGULATORY REQUIREMENTS...................................................................................... 2-14 RR-01 ADMINISTRATIVE CODE * ............................................................................................ 2-14 RR-02 DISCRIMINATION * ....................................................................................................... 2-14 RR-03 WHISTLEBLOWER REQUIREMENTS * ....................................................................... 2-15 RR-04 PUBLIC RECORDS ACT * ............................................................................................. 2-15 RR-05 ACCESS TO RECORDS (RESERVED) ........................................................................ 2-15

RR-06 FEDERAL FUNDING, INCORPORATION OF FEDERAL TRANSIT ADMINISTRATION

(FTA) TERMS, AND FEDERAL CHANGES* (RESERVED) .......................................... 2-15 RR-07 ENERGY CONSERVATION REQUIREMENTS (RESERVED) ..................................... 2-15 RR-08 CIVIL RIGHTS REQUIREMENTS* ................................................................................ 2-15 RR-09 NO GOVERNMENT OBLIGATION TO THIRD PARTIES* (RESERVED) ..................... 2-17

RR-10 PROGRAM FRAUD AND FALSE OR FRAUDULENT STATEMENTS OR RELATED

ACTS* (RESERVED) ..................................................................................................... 2-17 RR-11 SUSPENSION AND DEBARMENT* (RESERVED) ....................................................... 2-17 RR-12 RECYCLED PRODUCTS (RESERVED) ....................................................................... 2-17 RR-13 CLEAN WATER AND CLEAN AIR REQUIREMENTS* (RESERVED) .......................... 2-17 RR-14 COMPLIANCE WITH FEDERAL LOBBYING POLICY* (RESERVED) ......................... 2-17 RR-15 BUY AMERICA* (RESERVED) ...................................................................................... 2-17 RR-16 CARGO PREFERENCE* (RESERVED) ........................................................................ 2-17 RR-17 FLY AMERICA (RESERVED) ........................................................................................ 2-17

RR-18 CONTRACT WORK HOURS AND SAFETY STANDARDS ACT* (RESERVED) ......... 2-17

RR-19 SEISMIC SAFETY (RESERVED)................................................................................... 2-17 RR-20 ADA ACCESS (RESERVED) ......................................................................................... 2-17 RR-21 ALCOHOL AND DRUG-FREE WORKPLACE PROGRAM* (RESERVED) ................... 2-17 RR-22 TRANSIT EMPLOYEE PROTECTIVE ARRANGEMENTS* (RESERVED) ................... 2-17 RR-23 CHARTER SERVICE OPERATIONS (RESERVED) ..................................................... 2-17 RR-24 SCHOOL BUS REQUIREMENTS (RESERVED) ........................................................... 2-17 RR-25 FEDERAL PATENT AND DATA RIGHTS* (RESERVED) ............................................. 2-17 RR-26 PUBLIC WORKS CONTRACTOR REGISTRATION LAW (RESERVED) ..................... 2-17

RR-27 COMPLIANCE WITH CALIFORNIA HEALTH AND SAFETY CODE (HSC) §25250.51

(RESERVED).................................................................................................................. 2-17 RR-28 SAFE OPERATION OF A MOTOR VEHICLE – SEAT BELT USE* .............................. 2-18 RR-29 SAFE OPERATION OF A MOTOR VEHICLE – DISTRACTED DRIVING* ................... 2-18 RR-30 FTA NOTIFICATION FOR FTA CONCERNS* ............................................................... 2-19

SPECIAL PROVISIONS (SERVICES) ................................................................................ 2-21 SP-01 SBE SET- ASIDE ........................................................................................................... 2-21 ii

SP-02 ORGANIZATIONAL CONFLICTS OF INTEREST* ........................................................ 2-21 SP-03 NOTICES AND SERVICE THEREOF* .......................................................................... 2-22 SP-04 APPROVED SUBCONTRACTORS AND SUPPLIERS* ................................................ 2-22 SP-05 RELEASE OF INFORMATION* ..................................................................................... 2-22

SP-06 ORDERING (FOR INDEFINITE DELIVERY/QUANTITY CONTRACTS) (RESERVED) ... 2-

SP-07 INSURANCE REQUIREMENTS .................................................................................... 2-23 SP-08 WORKSITE ACCESS/RESTORATION (JANUARY 2002) (RESERVED) ..................... 2-25 SP-09 LOSS PREVENTION ...................................................................................................... 2-25 SP-10 CONTRACTOR EQUIPMENT* ...................................................................................... 2-25 SP-11 FINAL PAYMENT BOND (RESERVED) ........................................................................ 2-25

SP-12 HAZARDOUS MATERIAL IDENTIFICATION AND MATERIAL SAFETY DATA

(RESERVED).................................................................................................................. 2-25 SP-13 CONTRACT SPECIFIC DEFINITIONS* (RESERVED) ................................................. 2-25 SP-14 CLEAN UP ...................................................................................................................... 2-26

SP-15 PROTECTION OF METRO STRUCTURES, EQUIPMENT, AND VEGETATION

(RESERVED).................................................................................................................. 2-26

SP-16 PROTECTION OF EXISTING VEGETATION, STRUCTURES, EQUIPMENT, UTILITIES,

AND IMPROVEMENTS* (RESERVED) ......................................................................... 2-26 SP-17 ALLOWABILITY, ALLOCABILITY & REASONABLENESS DEFINITIONS* .................. 2-26

SP-18 SOFTWARE LICENSING AGREEMENT AND PROVISIONS FOR USE* (RESERVED) . 2-

SP-19 LIQUIDATED DAMAGES* (RESERVED) ...................................................................... 2-27 SP-20 THE CONTRACTOR'S LICENSE .................................................................................. 2-27 SP-21 INDIRECT COST RATES* ............................................................................................. 2-27 SP-22 METRO MANAGEMENT OF CONTRACTOR’S PERSONNEL* ................................... 2-31 SP-23 SUBCONTRACT ADMINISTRATION ............................................................................ 2-32 SP-24 PAYMENT AND REPORTING OF PREVAILING WAGE* (RESERVED)...................... 2-35

SP-25 LIVING WAGE/SERVICE CONTRACT WORKER RETENTION POLICY* (RESERVED) 2-

EXHIBIT 1 - RATE CERTIFICATION ............................................................................................... 2-36 APPENDIX A - PERFORMANCE BOND (RESERVED) .................................................................. 2-37 APPENDIX A - PAYMENT (MATERIAL AND LABOR) BOND (RESERVED) ................................. 2-38

APPENDIX B – 29 CFR §5.5 AND APPLICABLE FEDERAL PREVAILING WAGE

CLASSIFICATIONS (RESERVED) ................................................................................ 2-39

GENERAL CONDITIONS - EZ FORM SERVICES CONTRACT ......................................... 2-40

1.0 DEFINITIONS ................................................................................................................. 2-40

2.0 INDEPENDENT CONTRACTOR ................................................................................... 2-40

3.0 METRO AUTHORIZED REPRESENTATIVES .............................................................. 2-40

4.0 ACCEPTANCE BY METRO ........................................................................................... 2-40

5.0 ASSIGNMENT ................................................................................................................ 2-41

6.0 EXTENSION OF TIME ................................................................................................... 2-41

7.0 WARRANTY ................................................................................................................... 2-41

8.0 TERMINATION ............................................................................................................... 2-41

9.0 MODIFICATIONS ........................................................................................................... 2-42

10.0 RESOLUTION OF DISPUTES ....................................................................................... 2-42

11.0 INDEMNITY .................................................................................................................... 2-42

12.0 APPLICABLE LAW ......................................................................................................... 2-42

13.0 NO WAIVER ................................................................................................................... 2-42

14.0 RESERVED .................................................................................................................... 2-42

15.0 INSURANCE (RESERVED) ........................................................................................... 2-43

16.0 PAYMENT TO SUBCONTRACTORS * ......................................................................... 2-43

17.0 SAFETY AND LOSS PREVENTION * ........................................................................... 2-43

18.0 ENGLISH REQUIREMENTS * ....................................................................................... 2-44

19.0 RIGHTS IN TECHNICAL DATA, PATENTS AND COPYRIGHTS* ................................ 2-44 iii

20.0 COVENANT AGAINST CONTINGENT FEES* .............................................................. 2-45

SBE CONTRACT COMPLIANCE MANUAL (SET-ASIDE) .................................................. 2-47 SECTION 100 - SMALL BUSINESS REQUIREMENTS .................................................................. 2-47 SECTION 200 - SBE PARTICIPATION ............................................................................................ 2-48 SECTION 300 - CONTRACT COMPLIANCE MONITORING .......................................................... 2-51

SECTION 400 - RESOLUTION OF DISPUTES BETWEEN METRO CONTRACTOR AND

SUBCONTRACTORS .................................................................................................... 2-58 SECTION 500 - ADDING OR SUBSTITUTING OR TERMINATING A SBE .................................... 2-59 SECTION 600 - GOAL ATTAINMENT DURING LIFE OF CONTRACT .......................................... 2-61 SECTION 700 – SANCTIONS FOR SBE PROGRAM VIOLATIONS .............................................. 2-62 SECTION 800 - SMALL BUSINESS ENTERPRISE CERTIFICATION ............................................ 2-63 APPENDIX A – DIVERSITY AND ECONOMIC OPPORTUNITY MANUAL DEFINITIONS ............ 2-64 APPENDIX B - DIVERSITY AND ECONOMIC OPPORTUNITY MANUAL ..................................... 2-67 (NON-FEDERAL) SUBMITTAL FORMS .......................................................................................... 2-67

SECTION 3 – BID/PROPOSAL DOCUMENTS ........................................................... 3-0

INSTRUCTIONS TO PROPOSERS ......................................................................................3-1 IP-01 PREQUALIFICATION REQUIREMENTS ........................................................................ 3-1 IP-02 BIDDERS LIST FORM ..................................................................................................... 3-1 IP-03 RESERVED ...................................................................................................................... 3-2 IP-04 EXAMINATION OF RFP DOCUMENTS .......................................................................... 3-2 IP-05 INTERPRETATION OF RFP DOCUMENTS .................................................................... 3-2 IP-06 COMMUNICATION WITH METRO .................................................................................. 3-2 IP-07 AMENDMENT................................................................................................................... 3-3 IP-08 PREPARATION OF SUBMITTAL..................................................................................... 3-3 IP-09 MODIFICATIONS AND ALTERNATIVE PROPOSALS ................................................... 3-3 IP-10 SIGNING OF PROPOSAL AND AUTHORIZATION TO NEGOTIATE ............................ 3-4 IP-11 SUBMISSION OF PROPOSAL ........................................................................................ 3-4 IP-12 PROPOSAL EVALUATION PROCESS ........................................................................... 3-4 IP-13 WITHDRAWAL OF SUBMITTAL ...................................................................................... 3-5 IP-14 PRE-AWARD AUDIT ........................................................................................................ 3-5 IP-15 METRO RIGHTS .............................................................................................................. 3-5 IP-16 PUBLIC RECORDS ACT ................................................................................................. 3-6 IP-17 DISQUALIFICATION OF PROPOSERS .......................................................................... 3-6 IP-18 FILING OF PROTESTS .................................................................................................... 3-7

SBE INSTRUCTIONS TO BIDDERS/PROPOSERS AND FORMS (SET ASIDE) .................3-8

SECTION 100 SBE PROGRAM ......................................................................................................... 3-8 SECTION 200 CALCULATING AND COUNTING SBE PARTICIPATION ....................................... 3-10 SECTION 300 SMALL BUSINESS ENTERPRISE CERTIFICATION .............................................. 3-13 SECTION 400 - CONTRACT COMPLIANCE ................................................................................... 3-14

EXHIBIT 1 - SBE PROPOSAL FORMS .............................................................................. 3-15

SUBMITTAL REQUIREMENTS .......................................................................................... 3-23

1.1 GENERAL FORMAT ...................................................................................................... 3-23

1.2 PROPOSAL CONTENT ................................................................................................. 3-23

EXHIBIT 3 – EVALUATION CRITERIA ............................................................................... 3-27

SECTION 4 – BID/PROPOSAL FORMS ..................................................................... 4-0

EXHIBIT 2A – SCHEDULE OF QUANTITIES AND PRICES .................................................4-2

EXHIBIT 2B - FORM 60 AND INSTRUCTIONS ....................................................................4-3

EXHIBIT 5 - PROPOSAL LETTER........................................................................................4-8 iv

EXHIBIT 6 - LIST OF CURRENT PROJECTS (BACKLOG) ................................................ 4-12

EXHIBIT 7 - LIST OF COMPLETED PROJECTS - LAST FIVE (5) YEARS ........................ 4-13

SECTION 5 – REQUIRED CERTIFICATIONS ............................................................ 5-0

EXHIBIT 8 - ETHICS DECLARATION ..................................................................................5-1

EXHIBIT 9 - GENERAL CERTIFICATIONS ........................................................................ 5-10

EXHIBIT 10 - CERTIFICATE OF COMPLIANCE WITH 49 CFR PART 655, PREVENTION OF

ALCOHOL MISUSE AND PROHIBITED DRUG USE IN TRANSIT OPERATIONS ............. 5-12

EXHIBIT 11- NONCOLLUSION AFFIDAVIT TO BE EXECUTED BY BIDDER AND

SUBMITTED WITH BID ...................................................................................................... 5-14

* All Articles, Sub articles, or portions of the Contract noted by an asterisk (*) shall be included in (flow-down to) all Subcontracts of any tier.

SECTION 1 – LETTER OF INVITATION

METRO

RFP NO. PS143950

ISSUED: 08.25.26

1-1

LOI - RFP

PRO FORM 120

REVISION DATE: 05.14.24

ISSUED: 08.25.26

1-2

LOI - SUPPL SBE/DVBE RFP NON-FEDERAL

PRO FORM 032B

REVISION DATE: 07.08.2025

August 25, 2026

ATTENTION: Prospective Proposer

SUBJECT: REQUEST FOR PROPOSALS (RFP) FOR RFP No. PS143950, Los Angeles County Metropolitan Transportation Authority (Metro) has established a contracting opportunity to provide comprehensive claims administration services of Metro’s Workers’ Compensation Program as outlined in the Scope of Services. The resultant Contract, if awarded, will be state/locally funded.

This solicitation is open to Certified Small Business Enterprise (SBE) firms Only. SBEs responding to this solicitation must be SBE certified with Metro in the appropriate NAICS codes at the time the proposal is submitted. An SBE submitting a proposal must perform a commercially useful function (CUF) during the performance of the contract. An SBE is presumed to be performing a CUF when it performs and exercises responsibility for at least thirty percent (30%) of the total cost of the contract work - actually performing, managing, or supervising the work involved with its own workforce.

You are requested to submit a proposal to furnish all the labor, materials, and other related items required for the performance of a contract resulting from RFP No. PS143950 on a firm fixed unit rate basis. This Contract will be for a term of three (3) years. Funding is contingent on fiscal year availability.

Metro does not guarantee award of Work to the selected Contractors and reserves unconditional rights to perform all work stated herein by own or other agency forces. Metro may make changes within the general scope of the resultant Contracts in the best interest of Metro and the general public.

Proposals in response to this solicitation shall be submitted electronically via email to LiewK@metro.net. Proposals must be received no later than 4:00 p.m. (PDT) on Tuesday, September 8, 2026.

Time of receipt is determined by the date/time stamp imprinted upon the email system. It is recommended that proposers send their email(s) allowing for sufficient time to ensure that the proposer can meet the proposal’s due date.

Additionally, it is recommended that proposer's email(s) are sent with a Delivery and Read receipt for their records. Lastly, proposers should send a verification email to the named Contract Administrator of the RFP after the email submission(s) of proposal to LiewK@metro.net. The verification email should indicate that a proposal has been submitted by Vendor Name for RFP No. PS143950 on X number of emails. It is recommended that proposers submit their proposals with PDF or ZIP file attachments only and must allow for sufficient time to ensure that the Proposer can meet the proposal’s due date. Website links to file-sharing services and platforms such as Citrix, Dropbox, etc. are unacceptable.

For this solicitation, the resulting Contract is set up to be conducted electronically, including the use of electronic signatures. If you wish to opt out of electronic transactions for the Contract, you must notify the Contract Administrator in writing.

mailto:liewk@metro.net

ISSUED: 08.25.26

1-3

LOI - SUPPL SBE/DVBE RFP NON-FEDERAL

All communications in connection with this RFP shall be provided as follows:

By U.S. Mail, FedEX, UPS, or courier

Los Angeles County Metropolitan Transportation Authority One Gateway Plaza Los Angeles, CA 90012-2952 Attention: Kacie Liew, Contract Administrator

• By Phone to (213) 922-3968

• By e-mail to LiewK@metro.net

Diversity & Equal Opportunity – Lisa Tousant at

(213) 922-5419 or via email at DEOD@metro.net.

Ethics or Lobbyist Registration Information, (213) 922-2900

Pre-Qualification Department, (213) 922-4130

The Contract award will be made to the proposer whose proposal meets the requirements of the RFP and is most advantageous to Metro based upon the proposal evaluation criteria. Metro reserves the right to reject any or all proposals, to waive informalities or irregularities to the extent permitted by law in any proposal received, and to be the sole judge of the merits of the respective proposal received.

Issued by:

LOS ANGELES COUNTY METROPOLITAN TRANSPORTATION AUTHORITY

Kacie Liew Contract Administrator mailto:LiewK@metro.net

ISSUED: 08.25.26

1-4

LOI - SUPPL SBE/DVBE RFP NON-FEDERAL

LETTER OF INVITATION SUPPLEMENT RFP (NON - FEDERAL)

Proposers are hereby notified that:

This project is funded, in whole or in part, with non-federal funds and will comply with LACMTA’s Small Business Enterprise (SBE) and Disabled Veteran Business Enterprise (DVBE) or Medium-Size Business Enterprise (MSZ) program requirements. It is LACMTA’s policy that it shall not discriminate on the basis of race, color, national origin, or sex in the award and performance of any non-federally funded contract or in the administration of its SBE/DVBE or MSZ programs.

Please note: Proposers are notified of changes made to this Invitation Supplement.

The box(es) checked below is/are applicable for this contract:

A. LACMTA has determined that this solicitation is a race neutral “Small Business Enterprise Set-Aside” project, pursuant to the LACMTA SBE Program Race-Neutral SBE Set-Aside Policy where there is at least three LACMTA or BART certified SBEs with the appropriate North American Industry Classification System (NAICS) code(s):

1. Proposers are hereby notified that bids or proposals for this state and/or locally funded project shall only be considered from certified SBE firms in accordance with LACMTA’s or the Bay Area Rapid Transit (BART) SBE Certification requirements.

2. Proposers must be certified by LACMTA or BART as an SBE at the time of proposal due date to be eligible for a set-aside contract award. Proposers shall provide, as part of its proposal, copies of SBE certification letters issued by LACMTA or BART.

3. If at least one responsive and responsible proposal is received from a LACMTA or

BART certified SBE firm, LACMTA may make an award. If no responsive and responsible proposal is received, the procurement will be resolicited to the open market with an SBE and DVBE goal, if applicable.

4. Any firm seeking to be certified as an SBE shall comply with LACMTA’s or BART’s SBE certification process. Firms may apply for certification by heading to https://metro.gob2g.com/.

5. Proposers must perform a commercially useful function (CUF) during the performance of the contract. An SBE is presumed to be performing a CUF when it performs and exercises responsibility for at least thirty percent (30%) of the total cost of the contract work with its own workforce. LACMTA encourages SBE Primes to consider joint venture opportunities with other SBEs firms. However, should an SBE choose to joint venture with a non-SBE, the SBE partner shall perform a CUF.

Currently, instructions for counting and calculating SBE credit are included in the SBE Instructions to Proposers and Forms (Set-Aside). As referenced in the Instructions, LACMTA will only credit SBE participation, for firms performing a CUF.

6. Bidders/Proposers shall provide LACMTA, as part of its proposal, a complete list (including names and addresses) of all subcontractors (SBE and non-SBE) who will https://metro.gob2g.com/

ISSUED: 08.25.26

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LOI - SUPPL SBE/DVBE RFP NON-FEDERAL

perform any portion of the contract work. Instructions to Bidders/Proposer provide the SBE Set-Aside Forms that must be completed and submitted by all Offerors at time of bid or proposal due date.

ISSUED: 08.25.26

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LOI - SUPPL SBE/DVBE RFP NON-FEDERAL

EXHIBIT 4 - LIST OF CERTIFIED FIRMS (RESERVED)

(SBE Supplemental Instructions to Proposers/Proposers Form 069 – Attachment I)

NOT APPLICABLE

SECTION 2 – CONTRACT DOCUMENTS

ISSUED: 08.25.26

2-1

EZ FORM SERVICES CONTRACT FFP

PRO FORM 102

REVISION DATE: 06.03.25

CONTRACT NO. ___

THIRD PARTY ADMINISTRATOR (TPA) CONFLICT CLAIMS

FIRM FIXED UNIT RATE EZ FORM SERVICES CONTRACT

BETWEEN

AND

(NAME OF CONTRACTOR TO BE FILLED IN AT TIME OF AWARD)

TO BE FILLED IN AT TIME OF AWARD

EFFECTIVE DATE

ISSUED: 08.25.26

2-2

EZ FORM SERVICES CONTRACT FFP

FIRM FIXED UNIT RATE EZ FORM SERVICES CONTRACT

CONTRACT NO:

Between

LOS ANGELES COUNTY

METROPOLITAN TRANSPORTATION AUTHORITY

ONE GATEWAY PLAZA

LOS ANGELES, CA 90012-2952

and

(NAME OF CONTRACTOR TO BE FILLED IN AT TIME OF AWARD)

THIRD PARTY ADMINISTRATOR (TPA) CONFLICT CLAIMS

This state/locally funded Contract is entered into by and between the Los Angeles County Metropolitan Transportation Authority (Metro), and____________________________________ (Contractor).

In consideration of the mutual covenants of the parties as set forth below, the parties hereby agree as follows:

ARTICLE 0: SIGNATURES

A. Pursuant to California Civil Code Section 1633.1 et seq., the Parties agree that this Contract and any Purchase Orders, Task Orders, Change Notices, Change Orders, and Modifications to the Contract may be electronically delivered and signed, and that any electronic signatures appearing on such documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

B. The Parties agree that this authorization only applies to Purchase Orders, Task Orders, Change Notices, Change Orders, and Modifications and does not alter any other provisions of the Contract that require certain notifications to be signed by hand, notarized, delivered via personal service, registered mail, or any other certifiable delivery service.

C. The Parties further agree that all electronic delivery and electronic signatures for documentation described above in paragraph 1 will be sent, received, and signed through an approved application, pursuant to California Civil Code

ISSUED: 08.25.26

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EZ FORM SERVICES CONTRACT FFP

Section 1633.1 et seq. and/or Government Code 16.5. No other forms of electronic signature will be accepted.

D. Either Party may withdraw its consent to receive and sign Purchase Orders, Task Orders, Change Notices, Change Orders, and Modifications electronically, at any time. In order to withdraw consent, the withdrawing Party must notify the other Party, in writing, that it wishes to withdraw consent and wishes to issue/receive Purchase Orders, Task Orders, Change Notices, Change Orders, and Modifications in paper format. After withdrawing consent, if at any point in the future the Parties wish to utilize the electronic system again, a further modification to the Contract is required.

ARTICLE I: CONTRACT DOCUMENTS ORDER OF PRECEDENCE

A. This Contract includes this Form of Contract, the Contract Documents listed in Section B, and all Attachments, all of which are incorporated herein and made a part of this Contract.

PLEASE READ ALL CONTRACT DOCUMENTS; THEY ALL APPLY.

B. Except as otherwise specified herein, in the event of any conflict, the precedence of the Contract Documents shall be as follows:

1. Form of Contract

2. Regulatory Requirements (Pro Form 039, Dated 04/10/26)

3. General Conditions, (Pro Form 103, Dated 06/19/17)

4. Scope of Services (SOS 3950, Dated 08/25/26)

C. An Amendment or Change to this Contract shall take its precedence from the term it amends. All other documents and terms and conditions shall remain unchanged.

ARTICLE II: COMPENSATION

A. Total Contract Price - As full and complete compensation for the Contractor’s performance of the Services, and in accordance with the terms of the Contract, Metro will pay the Contractor the Not-to-Exceed (NTE) Contract Price of $________ (Contract Price) based on the firm fixed unit rates set forth in Exhibit B – Pricing Agreement.

Unless otherwise specifically provided in the Contract Documents, the Contract Price includes compensation for all taxes the Contractor is required to pay by laws in effect on the date the Contractor's Proposal was opened. The Contractor shall pay all federal, state, and local taxes, and duties applicable to and assessable against any Services, including, but not limited to, retail sales and use, transportation, export, import, business, and special taxes.

The Contractor shall ascertain and pay the taxes when due. The Contractor will maintain auditable Records, subject to LACMTA reviews, confirming that tax payments are current at all times.

B. Invoicing. The Contractor shall electronically submit all invoices to Metro at accountspayable@metro.net. Each invoice shall include the date, contract number, and description of the work completed. The Contractor shall also submit a Certification for mailto:accountspayable@metro.net

ISSUED: 08.25.26

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EZ FORM SERVICES CONTRACT FFP

Request for Payment attached as Exhibit 1. Metro shall pay the Contractor within thirty (30) days after the receipt of an acceptable invoice.

The Application for Final Payment shall be labeled "FINAL."

Effective January 1, 2009, Metro started payment of invoices via Electronic Funds Transfer (EFT), which guarantees faster payments and is a more secure and efficient way to make payments. If you have not already done so, you will be required to sign up for EFT, unless you request a waiver in writing. Please call (213) 922-6811, then press option # 7 for EFT forms.

ARTICLE III: CONTRACT TERM AND PERIOD OF PERFORMANCE

The Effective Date of this three-year base Contract is ____________. The Period of Performance of this Contract shall commence on ____________ ("Contract Commencement Date"). Contractor shall complete all Services under the Contract no later than ______________ ("Contract Completion Date"), unless this Contract is terminated earlier or extended by LACMTA, in writing, as provided in this Contract.

ARTICLE IV: SBE PARTICIPATION

Metro has determined that this solicitation is a Small Business Enterprise Set-Aside. The Contractor shall perform a Commercially Useful Function throughout the performance of the contract. The Contractor shall comply with the SBE Program requirements provided in the Contract Compliance Manual Federal or Non-Federal.

ARTICLE V: INSURANCE

Please see SP-07.

ARTICLE VI: SAFETY COMPLIANCE

A. Contractor Actions

1. The Contractor must at all times conduct its operations in such a manner as to avoid risk of bodily harm to employees and other Persons, damage to property and goods, and work interruptions. For these purposes, the Contractor must:

a Following issuance of any Notice to Proceed for an Early Works

Package requiring Work at the Worksite or for the Phase 2 Work and the grant of Access to the Worksite under Section 6.2 (Access to the Worksite), be responsible for Worksite safety during the performance of the Work;

b promptly take all reasonable precautions to safeguard against risk of bodily harm to employees and other Persons, damage to property and

ISSUED: 08.25.26

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EZ FORM SERVICES CONTRACT FFP

goods, and work interruptions and shall make regular safety inspections of its Work activities;

c comply with the Construction Safety and Security Manual, Applicable

Law and any additional safety provisions under the Project Requirements;

d provide suitable personal protective equipment for any of the Contractor's or its Subcontractors' personnel that are required to visit the Worksite to perform the Work and enforce the use of such equipment by those personnel;

e maintain accurate records; and f ensure that its Subcontractors comply with the terms of this Article 11.

2. The Contractor shall be solely responsible for the discovery, determination, and correction of any unsafe conditions related to the Contractor's performance of the Work or Goods supplied by the Contractor.

B. Cooperation

The Contractor must cooperate and coordinate with LACMTA and with other LACMTA Contractors on safety matters and must promptly comply with any specific safety instructions or directions Notified to the Contractor by

LACMTA.

C. Corrective action

LACMTA may at any time, Notify the Contractor of the safety measures LACMTA determines are reasonably necessary for the Contractor and its Subcontractors to take as corrective action to comply with this Article 11 or otherwise with the safety requirements under this Contract, including under the Construction Safety and Security Manual, and immediately upon receipt of such Notice, the Contractor shall perform the required corrective action.

If:

1. The Contractor fails or refuses to take corrective action promptly in accordance with this Section 11.3;

2. The Contractor's failure to comply with this Article 11 or otherwise with the safety requirements under this Contract has or may, in LACMTA's judgment, adversely affect the safety of life; or

3. LACMTA is entitled to order a work stoppage under the Construction

Safety and Security Manual, LACMTA may issue a Stop Work Notice suspending the performance of the Work (or a part of the Work) in accordance with Section 17.8 (Suspension) until satisfactory corrective

ISSUED: 08.25.26

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EZ FORM SERVICES CONTRACT FFP

action has been taken as determined by LACMTA, in which case the Contractor will immediately comply with such Stop Work Notice, except to the extent of any corrective action authorized by LACMTA by Notice to continue.

ARTICLE VII: ENTIRE AGREEMENT

This Contract includes this Form of Contract, all other Contract Documents incorporated pursuant to Article I herein, and all Attachments and other documents incorporated herein by inclusion or by reference, and constitutes the complete and entire agreement between the Metro and Contractor and supersedes any prior representations, understandings, communications, agreements or proposals, oral or written.

CONTRACTOR NAME

PHYSICAL ADDRESS

EMAIL ADDRESS

PHONE NUMBER

LOS ANGELES COUNTY

METROPOLITAN

TRANSPORTATION AUTHORITY

STEPHANIE WIGGINS

CHIEF EXECUTIVE OFFICER

BY:___________________________________

SIGNATURE OF AUTHORIZED OFFICIAL

BY:_______________________________ DATE

(PRINT OR TYPE NAME)

APPROVED AS TO FORM

DAWYN R. HARRISON

TITLE COUNTY COUNSEL

DATE BY:

DEPUTY

TAX ID NO.: _______________________

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EXHIBIT 1 - PAYMENT CERTIFICATION

1. I hereby certify to the best of my knowledge and belief that:

A. This Payment Request represents a true and correct statement of the Work performed;

B. The Work completed to date under this Contract is in full accordance with the terms of the Contract; and

C. All Subcontractors and/or Suppliers who have performed Work on the project through the closing date of the prior Payment Request have been paid their proportionate share of all previous payments from the Metro.

2. I understand that it is a violation of both the federal and California False Claims Acts to knowingly present or cause to be presented to the Metro a false claim for payment or approval. A claim includes a demand or request for money. It is also a violation of the False Claims Acts to knowingly make use of a false Record or statement to get a false claim paid. The term "knowingly" includes either actual knowledge of the information, deliberate ignorance of the truth or falsity of the information, or reckless disregard for the truth or falsity of the information. Proof of specific intent to defraud is not necessary under the False Claims Acts. I understand that the penalties under the Federal False Claims Act and State of California False Claims Act are non-exclusive and are in addition to any other criminal and/or civil remedies which the Metro may have either under contract or law.

I certify under penalty of perjury, under the laws of the State of California, that the foregoing is true and correct

Firm:

Signature:

Name of Certifying Official:

Title:

Date of Execution:

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EXHIBIT A – SCOPE OF SERVICES

1.0 BACKGROUND

Metro’s workforce of nearly 12,000 employees reports approximately 1,650 workers’ compensation claims annually. Metro self-insures and self-administers its Workers’ Compensation (WC) liability, which is administered by Metro’s Workers’ Compensation Division (WCD) of the Risk, Safety and Asset Management (RSAM) Department. The WCD employs approximately 16 claims professionals and various clerical staff to administer benefits on approximately 2450 open WC files. Metro’s computerized workers’ compensation claims management system is the Riskonnect iVOS system. The WCD is dedicated to providing a high level of customer service, the best medical care, and all appropriate indemnity benefits to injured employees through quality and cost-efficient claims management.

2.0 PROJECT

The Los Angeles County Metropolitan Transportation Authority (Metro) is seeking a qualified third-party administrator (TPA) for claims administration of Metro’s Workers’ Compensation Program (Conflict Claims). The contract is for comprehensive claims administration services to include managed care, computer hardware, and office supplies appropriate for the management of the Program. Metro requires a TPA partner with an innovative and effective claims management process that is streamlined and user-friendly, has a strong customer service focus, solid reporting capabilities, proactive and consistent management of employee occupational absences, competitive rates and fees, and the ability and willingness to comply with Metro’s performance standards. The Contractor’s staff should have proper licensing to perform claims administration services. The Contractor should have a strong regional presence in California, and depth of staff necessary to perform the claims administration services requested now and into the future.

3.0 INTENT

The Third‑Party Administrator (TPA) is required to deliver defined administrative, operational, and compliance‑related services on behalf of Metro for conflict claims. The TPA will provide these services in accordance with applicable laws, regulatory requirements, industry standards, and agreed‑upon performance metrics. The selected TPA will be required to provide the following services:

• Program Administration through day-to-day management of the benefit or claims program, including processing, tracking, and documentation for conflict claims.

• Claims Processing through intake, adjudication, validation, payment coordination, and appeals handling.

• Recordkeeping and Data Management through secure storage, updates, reconciliation, and reporting of participant and plan data.

• Regulatory Compliance by ensuring adherence to the Employee Retirement Income

Security Act (ERISA), Health Insurance Portability and Accountability Act (HIPAA), ISSUED: 08.25.26

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Internal Revenue Service (IRS), Department of Labor (DOL), state regulations, and required filings.

• Customer Service and Participant Support through call center operations, email support, issue resolution, and participant education.

• Financial Administration through payment processing and financial reconciliation.

• Data Security and Privacy through Safeguards for Protected Health Information (PHI)/

Personally Identifiable Information (PII), breach protocols, encryption, and access controls.

• Vendor Coordination by working with designated service providers.

• Ongoing Governance through Meetings, issue escalation, and continuous improvement.

4.0 CONTRACTOR REQUIREMENTS

1. General Qualification Requirements The Contractor must:

• Demonstrate the specialized expertise, operational capacity, and regulatory compliance necessary to administer a public‑sector workers’ compensation program of conflict claims.

• Maintain all qualifications throughout the contract term and comply with all applicable

California workers’ compensation statutes, public‑entity procurement rules, and reporting requirements.

• Meet both contractual obligations and regulatory or statutory requirements to ensure compliance, quality service, and accountability during the performance period.

2. Compliance with Federal and Statutory Requirements The Contractor must comply with:

• U.S. Constitution, applicable statutes, and regulations (e.g., anti-discrimination, environmental, public welfare protections).

• Performance measurement requirements: clear goals, objectives, timelines, reporting expectations, and data collection responsibilities.

• Equipment use and disposal rules if applicable: equipment must be used for authorized purposes, not encumbered without approval, and disposed of in compliance with laws and agency guidance.

3. Contractual and Service Standards The Contractor must adhere to minimum performance standards:

• Caseload limits: Indemnity adjusters capped at 110–120 open claims (medical-only claims counted 2:1).

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• Timely file setup: prepare claim files within 1 business day of receiving employer reports, with initial reserves documented within 5 business days.

• Reporting timelines: meet deadlines for physician contact (24-hour contact) and compensability determination within 90 days of claim reported.

• Conflict of interest: avoid situations that could compromise impartiality.

4. Operational and Administrative Duties The Contractor must adhere to:

• Data accuracy and documentation: maintain complete, accessible claim files with all medical and factual information.

• Communication: provide timely updates to Metro and coordinate with agents and other stakeholders.

• Quality control: ensure claims are adjudicated consistently and in line with policy and legal standards.

5. Oversight and Accountability

• Performance measurement: Track and report on key performance indicators (KPIs) such as case resolution time, accuracy rates, and compliance with timelines.

• Audits and inspections: Be prepared for audits by the Federal agency, state regulators, or program administrators.

• Corrective action: Address deficiencies promptly and document improvements

6. Personnel Qualifications The Contractor must employ:

• Licensed claims adjusters with workers’ compensation experience of at least 3 years.

• Supervisors with advanced credentials (e.g., Workers’ Compensation Claims

Administration (WCCA) and/or Workers’ Compensation Claims Professional (WCCP).

7. Operational Capacity The Contractor must maintain:

• Sufficient staffing levels (one Claims Adjuster, one Claims Supervisor and one Claims

Assistant) to meet statutory deadlines and service‑level requirements.

• Quality assurance processes including file audits, supervisory reviews, and corrective‑action protocols.

8. Data Security & Privacy Controls The Contractor must maintain:

• Encryption of data in transit and at rest.

• Public‑sector compliance with cybersecurity standards (e.g., NIST, SOC 2 preferred).

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• Breach‑notification procedures aligned with state and public‑entity requirements.

• Compliance with public‑records laws while protecting PHI/PII.

9. Compliance, Security & Governance The Contractor must provide:

• SOC2-aligned controls

• Role-based access

• Data privacy compliance

10. Customer Service & Stakeholder Support The Contractor must maintain:

• Dedicated account management for the public entity.

• Clear communication protocols with Metro injured employees, supervisors, HR, and risk management.

• Multichannel support (phone, email, portal) with defined response times.

• Experience supporting unionized workforces and public‑safety departments.

11. Ongoing Qualification Maintenance The Contractor must:

• Maintain required Certificate to Administer Claims issued by the California Office of Self-

Insured Plans and required insurance.

• Notify the public entity of any material changes affecting qualifications.

• Participate in periodic audits, performance reviews, and governance meetings.

5.0 CONTRACTOR RESPONSIBILITIES

The contractor shall provide:

A. Claims Intake & Initial Processing by receiving, documenting, and processing all First Reports of Injury within required statutory timeframes. The Contractor shall establish claim files promptly with complete documentation and notify the public entity of all new claims and significant incidents.

B. Compensability determinations in accordance with California workers’ compensation laws and public‑entity policies.

C. Claims Investigation and Management by conducting timely and thorough investigations, including interviews, statements, and evidence gathering. The Contractor should also coordinate with supervisors, HR, safety personnel, and union representatives as needed.

D. Maintenance of accurate, up‑to‑date claim notes and documentation and manage medical‑only, lost‑time, litigated, and catastrophic claims through closure.

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E. Medical Management by coordinating medical treatment, ensuring compliance with state fee schedules and utilization review requirements. The Contractor shall also monitor treatment plans, medical progress, and return‑to‑work readiness, in addition to facilitating qualified medical evaluations or Agreed Medical Examiner (QMEs & AMEs) when appropriate, while ensuring timely and accurate payment of medical bills.

F. Indemnity and Benefit Administration by calculating and issuing indemnity payments in accordance with statutory requirements, maintaining accurate wage statements and benefit calculations with timely processing of temporary disability, permanent disability, and supplemental benefits. The Contractor shall also manage overpayments, offsets, and benefit adjustments.

G. Litigation and Legal Coordination by coordinating with approved defense counsel for litigated claims, providing complete claim files, documentation, and recommendations to counsel and participating in settlement evaluations, hearings, and mediations.

H. Return‑to‑Work and Modified Duty Coordination by collaborating with Metro to identify modified duty or transitional work opportunities, communicating regularly with injured employees, supervisors, and HR. The Contractor shall also track employee progress and readiness for full duty to support early and safe return‑to‑work strategies.

I. Subrogation and Recovery by identifying potential third‑party recovery opportunities, pursuing subrogation claims, liens, and reimbursements and maintaining documentation of recovery efforts and outcomes.

J. Reporting and Analytics services by providing monthly, quarterly, and annual reports, including loss runs and claim status summaries.

K. Support public‑entity reporting requirements, including open‑records requests.

L. Compliance and Regulatory Requirements by ensuring all claims activities comply with the California workers’ compensation statutes.

M. Public‑entity reporting requirements through HIPAA and data‑privacy laws. The

Contractor shall file all required Electronic Data Interchange (EDI) reports, state forms, and notices on time and maintain adjuster licensing and continuing education.

N. Customer Service and Stakeholder Communication through clear communication with injured employees, supervisors, and human resources by responding to inquiries within agreed‑upon service levels.

O. Data Security and Confidentiality through protection of all PHI/PII in accordance with public‑sector cybersecurity standards. The Contractor shall maintain secure systems with encryption, access controls, and audit trails and follow breach‑notification protocols consistent with state and public‑entity requirements.

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6.0 DELIVERABLES

Contractors shall submit the deliverables to the Chief Risk, Corporate Safety, and Asset Management Officer in accordance with the Statement of Work and the schedule indicated below.

TASK

DELIVERABLE

DATE REQUIRED

REFERENCE

No.1 General Qualification Requirements

Through the duration of the

Contract

SOS: Item 4.1

No.2 Compliance with Federal and Statutory Requirements

Through the duration of the

Contract

SOS: Item 4.2

No.3 Contractual and Service Standards

Through the duration of the

Contract

SOS: Item 4.3

No.4 Operational and Administrative Duties

Through the duration of the

Contract

SOS: Item 4.4

No.5 Oversight and Accountability Through the duration of the

Contract

SOS: Item 4.5

No.6 Personnel Qualifications Through the duration of the

Contract

SOS: Item 4.6

No.7 Operational Capacity Through the duration of the

Contract

SOS: Item 4.7

No.8 Data Security & Privacy Controls and Compliance, Security &

Governance

As needed SOS: Item 4.8- 4.9

No.9 Customer Service & Stakeholder Support and Ongoing Qualification

Maintenance

Within 90 days of RFP award

SOS: Item 4.10-4.11

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REGULATORY REQUIREMENTS

PRO FORM 039

REVISION DATE: 04.10.26

REGULATORY REQUIREMENTS

RR-01 ADMINISTRATIVE CODE *

A. Applicability

This Article applies to all contracts.

B. Metro…