RP032-22 RFP

July 27, 2022

REQUEST FOR PROPOSAL

RP032-22

The Gwinnett County Board of Commissioners is soliciting competitive sealed proposals from qualified firms for the Provide Workers’ Compensation Claims Administration Services on an Annual Contract with Four (4) Options to Renew for the Department of Human Resources.

Proposals must be returned in a sealed container marked on the outside with the Request for Proposal number and Company Name. Proposals will be received until 2:50 P.M. local time on August 23, 2022 at the Gwinnett County Financial Services - Purchasing Division – 2nd Floor, 75 Langley Drive, Lawrenceville, Georgia 30046. Any proposal received after this date and time will not be accepted. Proposals will be publicly opened and only names of submitting firms will be read at 3:00 P.M. A list of firms submitting proposals will be available the following business day on our website www.gwinnettcounty.com.

A WebEx pre-proposal conference is scheduled for 10:00 A.M. on August 9, 2022. To access, dial 408-418-9388, enter access code 23456278265##. All firms are urged to attend. Questions regarding proposals should be directed to Dana Garland at dana.garland@gwinnettcounty.com or by calling 770-822-8723, no later than 3:00 P.M. on June 14, 2022. Proposals are legal and binding upon the proposer when submitted. One unbound single sided original, four (4) exact copies and one (1) electronic copy on a flash drive should be submitted.

Successful firm will be required to meet insurance requirements. The Insurance Company should be authorized to do business in Georgia by the Georgia Insurance Department, and must have an A.M. Best rating of A-5 or higher.

Gwinnett County does not discriminate on the basis of disability in the admission or access to its programs or activities. Any requests for reasonable accommodations required by individuals to fully participate in any open meeting, program or activity of Gwinnett County Government should be directed to the ADA Coordinator at the Gwinnett County Justice and Administration Center, 770-822-8165.

The written proposal documents supersede any verbal or written prior communications between the parties.

Selection criteria are outlined in the request for proposal documents. Gwinnett County reserves the right to reject any or all proposals to waive technicalities, and to make an award deemed in its best interest.

Award notification will be posted after award on the County website, www.gwinnettcounty.com and firms submitting a proposal will be notified via email.

We look forward to your proposal and appreciate your interest in Gwinnett County.

Dana Garland, CPPB, FOII, NIGP-CPP Purchasing Associate III

The following pages should be returned with your proposal:

Cost Schedule (Return in a separate envelope) Third Party Administrator Information Form, Pages 5-

Firm Information, Page 15 References, Page 16 Contractor Affidavit and Agreement, Page 17 Code of Ethics Affidavit, Page 18 http://www.gwinnettcounty.com/ mailto:dana.garland@gwinnettcounty.com

RP032-22 Page 2

I. Background and Introduction

A. Gwinnett County Board of Commissioners became self-insured for Workers’ Compensation & Employer’s Liability on January 1, 2008. On January 1, 2008, the County contracted with Alternative Service Concepts, LLC dba Davies Claim Solutions (Davies) to be our on-site Third- Party Administrator (TPA) to provide services for our Workers’ Compensation & Employer’s Liability Claims Program. In 2012, the County increased the retention to $1,000,000 for Workers’ Compensation & Employer’s Liability. This Self-Insured Retention (SIR) of $1,000,000 has continued through 2022. The County Workers’ Compensation insurance carrier is Safety National Insurance Company. The County has contracted with Safety National since 2014 and Midwest Employers was the prior carrier. The County requires an adjuster positioned in the County’s Human Resources Department on a full-time basis. The TPA must have its own independent claims administration system in order to handle claims, process claims, pay claims and provide loss-runs and other analytical reports. The TPA must make all claim payments. The County will reimburse the TPA for these payments on a twice monthly basis. Should the County make a TPA change, the new TPA will assume and manage any existing open claims. The County requires all tasks related to the request for proposal to be performed within the United State of America. The successful firm must have a “full- service” office in the State of Georgia.

The County requires the on-site claims examiner to provide ongoing training to management.

The County has approximately 5,000 full-time employees and approximately 1,000 part-time employees. The County is comprised of the following departments and offices:

• Child Advocacy & Juvenile Services

• Clerk of Court

• Clerk of Recorders Court

• Communications

• Community Services

• Correctional Services

• County Administration

• Court Administration

• District Attorney

• Financial Services

• Fire Services

• Human Resources

• Information Technology Services

• Juvenile Court

• Law Department

• Planning & Development

• Police Services

• Probate Court Judges

• Recorders Court Judges

• Sheriff

• Solicitor

• Support Services

• Tax Commissioner

• Transportation

• Water Resources

RP032-22 Page 3

The County’s claims administration system utilizes Riskonnect Clearsight, LLC. Davies also uses the Riskonnect Clearsight, LLC Information System. Each month the County receives a claims download from Davies. In addition, the County has on-line access to Davies claims administration system.

Of importance, the County pays an employee his/her full salary for up to 360 days versus State Indemnity Rates. Accordingly, the County has a very good alternative work program for its employees. A physician rarely approves an employee to be out of work.

Currently, claims can be submitted to Davies either by e-mail, fax, or mail. The County has averaged 456 claims per year since 2016.

2021 Workers’ Compensation Payroll

Code Classification 2021 Audited Payroll

8831 Animal Control $1,842,284 8820 Attorney $10,350,081 8380 Auto Shop - Parts - Drivers $2,403,048 9015 Building Maintenance $5,057,824 9410 County Employees $38,583,328 8810 Clerical $92,248,030 7710 Fightfighters - Drivers $60,972,101 7425 Pilots $181,785 7720 Police/Law Enforcement Drivers $106,496,992 9102 Parks & Recreation $12,819,572 5506 Roads - Construction $4,408,638 8742 Sales $285,471 8868 School Professionals $393,784 7580 Sewer Workers $10,846,136 7520 Water Works - Drivers $7,482,063

$354,371,137

RP032-22 Page 4

The County has in place an Excess Workers’ Compensation and Employer’s Liability insurance policy providing Statutory Limits of liability for Workers’ Compensation claims and a $1,000,000 Limit of Liability for Employer’s Liability claims. The self-insured retention is $1,000,000. The following is a recap of the historical Workers’ Compensation claims for the County.

Fiscal Year

Number Lost- Time

Claims

Number Medical

Only Claims

Record Only

Total

Claims

Total Incurred Total Paid Total

Recoveries Total

Reserves Valued as of

2016 91 280 100 471 $2,459,562 $2,394,095 $27,469 $65,467 12/31/2021 2017 68 284 74 426 $2,910,272 $2,839,905 $1,606,473 $70,368 12/31/2021 2018 89 307 95 491 $2,884,862 $2,685,544 $26,534 $199,318 12/31/2021 2019 78 303 123 504 $2,568,006 $2,205,331 $4,350 $362,675 12/31/2021 2020 66 272 137 475 $1,787,779 $1,211,660 $16,542 $576,119 12/31/2021 2021 68 206 95 369 $3,381,483 $880,826 $- $2,500,657 12/31/2021

The County’s Safety Policy and Procedure manual is attached.

*The County’s policy year for Workers’ Compensation is January 1st to December 31st of each year.

II. Proposal Submission Format Responses should follow the form of this request for proposal, responding to each section per the following outline:

A. Cover Letter and Introduction of Responding Firm B. Third Party Administrator Information Form C. Responses to each of the below Evaluation Criteria

a. Responsiveness to the Request for Proposal

b. Vendor qualifications/Ability to deliver services

c. Proposed methodology

d. Cost

RP032-22 Page 5

III. Third Party Administrator Information Form Section I - General Information

1. Legal Name of Organization:

D/B/A Name (If different than above):

Principal Location: City: State:

Zip Code: County: Tel. #: Fax#:

Please list all other office locations on an additional sheet.

Account Executive: Tel. #: Fax#:

Email: Mobile#:

2. Please indicate how your Organization is organized (Corporation, Partnership, LLC, etc.):

What is your state of organization?

How long has your Organization been in business?

3. Federal Tax ID Number:

Section II - Administrative Information

4. Describe any reports your organization generates on a monthly, quarterly, annual, and ad hoc basis (please provide an example of each).

5. Will your organization provide on-line computer access (via modem / internet) to Gwinnett County for the purposes of case file review, report generation, and claim payment issues, etc.?

YES / NO

6. Do you understand that Gwinnett County (or an authorized agent) reserves the right to audit your organization's administrative processes including, but not limited to, the following items?

YES / NO

Data Processing Claims Processing Internal Control Functions Managed Care / Utilization Review Procedures and Results

Section III - Implementation

7. Under separate cover provide a complete outline including a detailed time schedule of the implementation process specifically for Gwinnett County assuming a January 1, 2023, start-up date.

8. What organizational resources, including personnel, can your organization provide to Gwinnett to assist in the implementation process?

RP032-22 Page 6

When applicable, please provide sample copies of the materials your organization will make available for the implementation process.

Section IV - Customer Service Issues

9. Provide the location and means of contact (i.e., 800 number, e-mail address, etc.) for customer service related issues.

Location:

Contact Options:

10. What are the hours of operation for your organization's claims processing function (In Eastern Standard Time)? Customer service function?

11. Is your organization offering the County a dedicated resources unit? YES / NO

If so, how is this unit structured? Provide the names of the permanent and dedicated service team members and their full resumes. If not, detail how resources will be allocated to handle the County’s caseload.

12. What are your organization's procedures for processing a Workers' Compensation claim (i.e., points- of- contact, client interaction, etc.)?

IV. Evaluation Criteria A. Responsiveness to the Request for Proposals:

• Demonstrates ability to provide necessary services and has submitted the required information.

B. Vendor Qualifications/Ability to deliver services:

• Experience: Experience of the Proposer’s organization, proven track record, and experience of persons selected to handle the County’s account.

o Please provide a brief description and history of your organization.

o What percentage of your business is Workers’ Compensation?

o What percentage of your business is self-insured and how much is insured?

o What percentage of your business is public entity and how much is private industry?

o Does your business provide any Value-Added services?

• Transition Plan: Demonstrated comprehension of the task to assume control of the claims administrative responsibilities efficiently; and demonstrate a cohesive, organized plan to achieve the task.

• Staffing of the County’s Account: Demonstrates the ability to properly staff the account with the appropriate number of quality individuals.

o Identify the individual service team members/structure responsible for administering the County’s account.

RP032-22 Page 7 o Will you provide a single point-of-contact (i.e., an Account Executive) to act as the liaison with the County regarding contract administration, staff changes, etc.?

o Are the assigned adjusters assigned to Workers’ Compensation claims only?

o What is the Claims Adjuster’s average and maximum lost-time caseloads?

o What is your organization’s annual turnover-ratio for claims personnel?

o Describe your organization’s formal training program for claims personnel.

o Are supervisors responsible for handling claims? If so, what are the average caseloads for supervisors?

o What is your organization’s supervisor to adjuster ratio?

o Which office(s) will handle Gwinnett County’ claims?

o Please provide a copy of your internal claims audit procedures.

o Will the Claims examiner be on site for Gwinnett County?

o Should turnover occur involving the Gwinnett County Service

Team, will you allow the County to have a say in team member replacement?

• Approach to service: Describe your approach and processes to Litigation, claim investigation, Communication, risk control and Information systems and reporting.

Litigation Management o Describe your litigation management strategies including assignment of defense counsel.

o Describe your organization’s procedures for maintaining current information in case law or changes in laws and regulations.

o Provide a sample Hearing Prep Packet used to communicate your instructions and expectations to Hearing Representatives.

o Identify the law firms, attorneys, hearing reps you propose to use on the

County’s account.

Claim Investigation o List your internal guidelines and timeframes, if any, for initial three-point contact (injured worker, employer, medical provider) after receipt of a new injury or illness report. Would these same guidelines apply to Gwinnett County cases? What is your current success rate (%) in meeting these guidelines?

o Describe your organization’s use of the index bureau and any other similar resources.

o Describe the criteria for taking recorded statements from injured workers.

At what point in the claims process are recorded statements taken?

o Describe your fraud control procedures.

o Describe your claim triage process, and how you determine the required level of investigation.

o Describe the requirements of adjusters to maintain a claims diary.

RP032-22 Page 8 o Do supervisors have the ability to access and to add to individual adjuster diaries?

o Describe your organization’s employee performance management system.

o What firms do you use for private investigation and surveillance?

Communication o State your organization’s policy for returning phone calls, and responding to written correspondence (including e-mail), and how compliance is tracked.

o Describe claim reporting procedures and special account handling instructions.

o Assuming a general settlement authority for Workers’ Compensation Claims of $5,000 (hypothetical) – describe your organization’s proposed procedures for obtaining settlement authority on settlements above this amount.

o Describe your organization’s approach to pursuing subrogation when warranted. Do you require client consensus in pursuing subrogation?

o Describe your organization’s procedures for reporting reserve changes of $5,000 or more.

o Describe your organization’s procedures for denial of claims or appealing an adverse outcome.

o Describe your organization’s recommendations for conducting claims reviews with the client.

o Describe your organization’s standard level of interaction and communication, between your claims team and the client, for self-insured accounts.

o How does your organization enact any special handling instructions, such as assignment to a specific adjuster or other instructions due to a politically sensitive nature of a claim, etc.? Are there any cost implications as a result of special handling instructions?

o How do you communicate overpayments / duplicate payments and other errors of a financial nature to the client?

Risk Control o Describe your ability to identify loss trends and to recommend actions to ameliorate or eliminate those trends.

o Describe specifically the expertise your firm has relative to safety and loss prevention services.

o Do you offer a library of safety training materials? Is there a fee for these materials?

• On-line Access to Information: Ease of information transfer and access to file data, including examiner's comments, plan, and payment schedule.

Information System and Reporting o Please provide a description of your current claims information system.

o How long has this system been in place?

o When was the last major software update to the system?

o Do you anticipate any major software updates in the coming 24 months?

RP032-22 Page 9 o Do your clients have real- time access to the system, including adjuster notes?

o How long do you retain detailed claim information in your system?

o Describe your data back-up procedures, disaster recovery, and business continuity plans.

o Is on-line claim reporting available?

o What options exist for claim reporting?

o Describe your organization’s ability to allocate losses to individual client / plan participant locations / departments / divisions.

C. Proposed methodology to be used:

• Demonstrates the ability to provide the County with a comprehensive variety of loss- runs, reports and analytics, as well as the capability of inputting the special loss-codes plus the capability of allowing the County to create certain reports from their location(s).

o What capabilities do you have to generate ad-hoc reports?

o Is there a charge for ad-hoc reports?

o What information is available in your standard Risk Management

Information System (RMIS)?

o Gwinnett County desires to receive loss runs on a monthly, quarterly, and annual basis. Additionally, Gwinnett County also desires to conduct a quarterly review and “round-table” review of claims including a discussion of major reserve changes either upward, or downward. In the appendix, please provide a sample loss run and the other reports and analytical reports/exhibits described in this item.

o The County requires the ability to create reports from their location(s).

Explain in detail the report generation capabilities of your system.

o Provide details on the training you will provide to the County on system use and capabilities.

o Provide sample(s) of a status report and/or case summary report.

o Provide a sample of your Annual Stewardship Report.

• Willingness to enter into a performance-based contract in which all or a portion of the fees paid will be placed at risk for failure to perform to the satisfaction of the County, all of the agreed upon service functions and deliverables.

• Willingness to enter into an agreement which guarantees a minimum level of gross- cost containment savings or be responsible for refunding the difference.

D. References:

• 3 Current clients (prefer governmental entities of similar scope and size of the

County), in the following format:

o Name of individual contact o Name of company/entity o Mailing address o E-mail address o Phone number o Fax number o Number of years doing business with the reference

RP032-22 Page 10

E. Cost (to be submitted in separate envelope)

Cost Containment o Explain in detail how you will lower the County’s overall annual expenses associated with Workers Compensation.

o Provide a list of medical cost containment services available to the

County and the cost for each service.

o Provide details on your organization’s use of and fees for Nurse Case

Management and Telephonic Nurse Case Management.

o Provide details on your organization’s Pharmaceutical Cost Containment

Programs.

o Provide details on how your organization responds to and manages catastrophic losses.

o What Preferred Provider Organization (PPO) Network(s) do you currently use and are they readily accessible in Gwinnett County? Explain. Do you own or rent PPO networks?

o Please provide a statement as to how your organization will ensure complete transparency of fees related to cost containment efforts.

o Do you charge per line or per claim cost containment charges and to who are those fees paid? Please provide details of the specific fees related to cost containment, including retention of fees by the claims administrator.

o Please describe any cost sharing and contingent fee arrangements between your organization and any cost containment or PPO organizations whether performed by a separate company, or a wholly owned or partially owned operation of your firm.

o Describe your organization’s methodology for paying medical bills, including the maximum time allowed for payment of medical bills and how your organization ensures compliance with that methodology.

o Describe in detail your organization’s procedures for authorizing diagnostic testing, surgery, therapy and medical case management.

o Is there a cost for subrogation / 2nd injury recoveries? Is that cost included in your per claim fee or is it treated as an allocated expense?

Please detail the cost, if any.

o Do you perform recovery services or do you outsource this function?

o Describe in detail all items that would be considered by your organization as Allocated Loss Adjustment Expenses (ALAE).

o Describe the criteria used to determine when vocational rehabilitation, an independent medical examination (IME), a mediator, private investigator or an attorney would be used.

RP032-22 Page 11

For comparative purposes, and in consideration of your proposed fees, Proposer must include example calculations showing the amount of the discount to be applied, plus the administrative fee for the item, for typical ORTHOPAEDIC injury charges for the Current Procedural Terminology (CPT) codes shown:

A. CPT Code 99243 OFFICE CONSULTATION 40 MIN Typical charge for CPT Code 99243 $ 240.00 Minus recommended allowed payment - ___________ Equal Savings $ ___________ Recommended allowed payment $ ___________ Contractor’s % fee times Savings + ___________ Total cost (recommended payment + fee) $ ___________ B CPT Code 73110 X-RAY WRIST COMPLETE MINIMUM 3 VIEWS Typical charge for CPT Code 73110 $ 73.00 Minus recommended allowed payment - ___________ Equal Savings $ ___________ Recommended allowed payment $ ___________ Contractor’s % fee times Savings + ___________ Total cost (recommended payment + fee) $ ___________ C CPT Code 97110 – THERAPY 1+ AREAS EA 15 MIN Typical charge for CPT Code 97110 $ 72.00 Minus recommended allowed payment - ___________ Equal Savings $ ___________ Recommended allowed payment $ ___________ Contractor’s % fee times Savings + ___________ Total cost (recommended payment + fee) $ ___________ D CPT Code 97140 – MANUAL THERAPY 1+ REGIONS EA 15 MIN.

Typical charge for CPT Code 97140 $ 39.00 Minus recommended allowed payment - ___________ Equal Savings $ ___________ Recommended allowed payment $ ___________ Contractor’s % fee times Savings + ___________ Total cost (recommended payment + fee) $ ___________ E CPT Code 99213 – OFFICE OUTPATIENT EST. 15 MIN.

Typical charge for CPT Code $ 94.00

Minus recommended allowed payment - ___________

Equal Savings $ ___________

Recommended allowed payment $ ___________ Contractor’s % fee times Savings + ___________

Total cost (recommended payment + fee) $ ___________

Total cost to county for the above example charges $ ___________

RP032-22 Page 12

F. Interview (if requested by the County).

Selection Procedures

Basis of Short-Listing/Selection

Part I – Initially, proposals will be evaluated based on their relative responsiveness to the criteria described above and will be scored based on the point values as shown. Please note that references, and subsequent reference checks, are a required component of Part I scoring.

Part II – Firms may be short-listed for further consideration. The Proposal Fee Schedules of the short-listed firms from Part I will be opened, reviewed, and scored with the lowest cost receiving the most points and the other firms receiving proportional points based on the differences in proposal costs.

Part III – At Gwinnett’s discretion, or as deemed in Gwinnett’s best interest, firms may be short-listed a second time for an interview. At this time, Gwinnett may request further information, explanations, clarifications, presentations, interviews, or meetings with some or all of the remaining firms. If interviews are necessary for selection, details on the scoring criteria for interviews will be provided along with notification of the scheduled interview. Interviews should be conducted within five (5) working days after request. All presentations/interviews will be the sole responsibility of the proposing firms and at no cost to Gwinnett.

The County will then enter contract negotiations with the highest scoring firm(s). If an agreement with the highest ranked firm(s) cannot be reached, Gwinnett County may then negotiate with the next ranked firm(s) and so on until satisfactory agreements has been reached.

This is an “On Demand” recruiting contract and will be used throughout the contract period for Gwinnett County’s executive and specialized position recruiting needs. The County reserves the right to select multiple firm(s) to do business with. The number of future positions will be wholly dependent upon the requirements of the County. Gwinnett County does not guarantee any work.

Gwinnett County reserves the right to require evidence of technical, production, managerial, financial, or other abilities prior to the award.

Tab Criteria Points Allowed Phase I

A Responsiveness to the Request for Proposals 10

B Vendor Qualifications/Ability to deliver services 35

C Proposed methodology to be used 25

D References 10 Sub-Total 80

Phase II E Cost 20

Sub-Total 100 Phase III

F Optional Interview 10 Total 110

RP032-22 Page 13

V. Proposed Pricing (NOT included in the Technical portion of your response; to be submitted in a separate envelope)

Due to the importance of the fee schedule for the services that will be provided to Gwinnett County, any and all fees and/or reimbursements that may be paid by the County they must be identified in this section. All of the information contained in this section will be considered as your organization's full Proposal and GWINNETT COUNTY WILL NOT MAKE PAYMENTS TO YOUR ORGANIZATION IF THEY ARE NOT CLEARLY IDENTIFIED AND QUOTED. For your Proposal to be accepted by Gwinnett County, a Corporate Officer of your organization who has pricing approval authority must sign-off on the fees and/or reimbursements.

Provide proposed pricing for all applicable Administrative, Consulting, Utilization Review and Management, Network Access, or any and all other services related to the provision of Workers' Compensation Administrative Services. As noted above, the County will not make any payments to your organization if they are not clearly identified in this section. Should your organization not offer a specific service, you must put a N/A symbol in the response line. Should your organization not delineate services out to the level noted below, you must describe in specific detail what services your fees include.

a.1 Workers' Compensation Administrative Services (per claim)

1.1. New Lost Time Claim

1.2. New Medical-Only Claim

OR

a.2 Workers' Compensation Administrative Service (flat fee)

2.1. Flat, Non Auditable ALL INCLUSIVE Annual Fee

MISCELLANOUS FEES AND CHARGES

b. Hearing Representation (if not included in base administrative fee) _________________

c. Consultant Medical Exams (per exam cost) _________________

d. Medical Rehabilitation (per hour basis or per claim fee) _________________

e. Vocational Rehabilitation (per hour basis or per claim fee) _________________

f. Managed Care Program (per hour basis or per claim fee) _________________

g. Loss Control and Safety Engineering Services (Flat Fee) _________________

h. Full Installation Charges (Flat Fee) _________________

i. Private Investigation Services (hourly) _________________

Firm Name

RP032-22 Page 14

j. Miscellaneous Charges:

Affiliated PPO network Access Fees _________________

Banking Fees _________________

Customized Report Generation Fees _________________

Underwriting Charges _________________

Other Fees _________________

Value-Added Services _________________

Gwinnett County requires pricing to remain firm for the duration of the initial term of the contract.

Failure to hold firm pricing for the initial term of the contract will be sufficient cause for Gwinnett County to declare bid non-responsive. Contract to begin January 1, 2023.

Unless otherwise noted, quoted prices will remain firm for four (4) additional one (1) year periods.

• If a percentage decrease will be a part of this bid, please note this in the space provided together with an explanation.

1st renewal 3rd renewal

2nd renewal 4th renewal

• If a percentage increase will be a part of this bid, please note this in the space provided together with an explanation.

1ST Renewal 3rd Renewal

2ND Renewal 4th Renewal

Certification Of Non-Collusion In Proposal Preparation Signature Date

In compliance with the attached specifications, the undersigned offers and agrees, if this proposal is accepted by the Board of Commissioners within one hundred twenty (120) days of the date of proposal opening, to furnish any or all of the items upon which prices are proposed, at the price set opposite each item, delivered to the designated point(s) within the time specified in the proposal schedule.

Firm Name ____________________________________________________________________________________

RP032-22 Page 15

FAILURE TO RETURN THIS PAGE AS PART OF YOUR PROPOSAL DOCUMENT MAY RESULT IN

REJECTION OF PROPOSAL.

Firm Information

The undersigned acknowledges receipt of the following addenda, listed by number and date as issued appearing on each:

Addendum No. Date Addendum No. Date

Certification Of Non-Collusion in Proposal Preparation

(Signature) (Date)

In compliance with the attached specifications, the undersigned acknowledges all requirements outlined in the "Instructions to Proposers" and all documents referred to therein. offers and agrees, if this proposal is accepted by the Board of Commissioners within one hundred twenty (120) days of the date of proposal opening, to furnish any or all of the items upon which prices are quoted, at the price set opposite each item, delivered to the designated point(s) within the time specified in the fee schedule.

Legal Business Name (If your company is an LLC, you must identify all principals to include addresses and phone numbers in your submittal)

Federal Tax ID

Address

Does your company currently have a location within Gwinnett County? Yes No

Representative Signature

Printed Name

Telephone Number

E-mail address

RP032-22 Page 16

References

FAILURE TO RETURN THIS PAGE AS PART OF YOUR PROPOSAL DOCUMENT MAY RESULT IN

REJECTION OF PROPOSAL.

Gwinnett County requests a minimum of three (3) references where work of a similar size and scope has been completed within the last five (5) years.

Note: References should be customized for each project, rather than submitting the same set of references for every project bid. The references listed should be of similar size and scope of the project being bid on. Do not submit a project list in lieu of this form.

1. Company Name

Brief Description of Project

Completion Date

Contract Amount $ Start Dates

Contact Person Telephone

E-Mail Address

2. Company Name

Contract Amount $ Start Date

3. Company Name

Contract Amount $ Start Date

Firm Name

RP032-22 Page

Contractor Affidavit and Agreement

RP032-22 Provide Workers’ Compensation Claims Administration Services on an Annual

(THIS FORM SHOULD BE FULLY COMPLETED AND RETURNED WITH YOUR SUBMITTAL)

By executing this affidavit, the undersigned contractor verifies its compliance with The Illegal Immigration

Reform Enhancements for 2013, stating affirmatively that the individual, firm, or corporation which is contracting with the Gwinnett County Board of Commissioners has registered with and is participating in a federal work authorization program* [any of the electronic verification of work authorization programs operated by the United States Department of Homeland Security or any equivalent federal work authorization program operated by the United States Department of Homeland Security] to verify information of newly hired employees, pursuant to the Immigration Reform and Control Act, in accordance with the applicability provisions and deadlines established therein.

The undersigned further agrees that, should it employ or contract with any subcontractor(s) in connection with the physical performance of services or the performance of labor pursuant to this contract with the Gwinnett County Board of Commissioners, contractor will secure from such subcontractor(s) similar verification of compliance with the Illegal Immigration Reform and Enforcement Act on the Subcontractor Affidavit provided in Rule 300-10-01-.08 or a substantially similar form. Contractor further agrees to maintain records of such compliance and provide a copy of each such verification to the Gwinnett County Board of Commissioners at the time the subcontractor(s) is retained to perform such service.

E-Verify * User Identification Number Date Registered

Legal Company Name

Street Address

City/State/Zip Code

BY: Authorized Officer or Agent Date (Contractor Signature)

Title of Authorized Officer or Agent of Contractor

Printed Name of Authorized Officer or Agent

SUBSCRIBED AND SWORN

BEFORE ME ON THIS THE

_______ DAY OF ______________________, 20_______

Notary Public My Commission Expires: _______________________

For Gwinnett County Use Only:

Document ID #________________ Issue Date: ___________________ Initials: ______________________

* As of the effective date of O.C.G.A. 13-10-91, the applicable federal work authorization program is “E-Verify” operated by the U.S. Citizenship and Immigration Services Bureau of the U.S. Department of Homeland Security, in conjunction with the Social Security Administration (SSA).

RP032-22 Page

Code of Ethics Affidavit

RP032-22 Provide Workers’ Compensation Claims Administration Services on an Annual Contract

(THIS FORM SHOULD BE FULLY COMPLETED AND RETURNED WITH

YOUR SUBMITTAL AND WILL BE REQUIRED PRIOR TO EVALUATION)

In accordance with Section 54-33 of the Gwinnett County Code of Ordinances the undersigned bidder/proposer makes the following full and complete disclosure under oath, to the best of his/her knowledge, of the name(s) of all elected officials whom it employs or who have a direct or indirect pecuniary interest in or with the bidder/proposer, its affiliates, or its subcontractors:

1.

(Company Submitting Bid/Proposal)

2. (Please check one box below)

No information to disclose (complete only section 4 below)

Disclosed information below (complete section 3 & section 4 below)

3. (if additional space is required, please attach list)

Gwinnett County Elected Official Name Gwinnett County Elected Official Name

Gwinnett County Elected Official Name Gwinnett County Elected Official Name

4. Sworn to and subscribed before me this

BY: day of , 20

Authorized Officer or Agent Signature

Printed Name of Authorized Officer or Agent Notary Public

Title of Authorized Officer or Agent of Contractor (seal)

Note: See Gwinnett County Code of Ethics Ordinance EO2011, Sec. 54-33. The ordinance will be available to view in its’ entirety at www.gwinnettcounty.com

RP032-22 Page 19

Professional Services Insurance Requirements

(For projects less than $5,000,000)

1. Statutory Workers' Compensation Insurance

(a) Employers Liability:

Bodily Injury by Accident - $100,000 each accident Bodily Injury by Disease - $500,000 policy limit Bodily Injury by Disease - $100,000 each employee

2. Commercial General Liability Insurance

(a) $1,000,000 limit of liability per occurrence for bodily injury and property damage

(b) The following additional coverage must apply:

1986 (or later) ISO Commercial General Liability Form Dedicated Limits per Project Site or Location (CG 25 03 or CG 25 04) Additional Insured Endorsement (Form B CG 20 10 with a modification for completed operations or a separate endorsement covering Completed Operations) Blanket Contractual Liability Broad Form Property Damage Severability of Interest Underground, explosion, and collapse coverage Personal Injury (deleting both contractual and employee exclusions) Incidental Medical Malpractice Hostile Fire Pollution Wording

3. Auto Liability Insurance

(a) $500,000 limit of liability per occurrence for bodily injury and property damage

(b) Comprehensive form covering all owned, non-owned, leased, hired, and borrowed vehicles

(c) Additional Insured Endorsement

(d) Contractual Liability

4. Professional Liability Insurance - $1,000,000 (project specific for the Gwinnett County project) limit of liability per claim/aggregate or a limit of $1,000,000 per occurrence and $2,000,000 aggregate.

Insurance company must be authorized to do business in the State of Georgia.

Dedicated Limits per Project Site or Location (CG 25 03 or CG 25 04 or some other form)

5. Gwinnett County Board of Commissioners (and any applicable Authority) should be shown as an additional insured on General Liability and Auto Liability policies.

6. The cancellation should provide 10 days’ notice for nonpayment and 30 days’ notice of cancellation.

7. Certificate Holder should read:

Gwinnett County Board of Commissioners 75 Langley Drive Lawrenceville, GA 30046-6935

8. Insurance Company, except Worker' Compensation carrier, must have an A.M. Best Rating of A-5 or higher. Certain

Workers' Comp funds may be acceptable by the approval of the Insurance Unit. European markets including those based in London and domestic surplus lines markets that operate on a non-admitted basis are exempt from this requirement provided that the contractor’s broker/agent can provide financial data to establish that a market is equal to or exceeds the financial strengths associated with the A.M. Best’s rating of A-5 or better.

9. Insurance Company should be licensed to do business by the Georgia Department of Insurance.

*See above note regarding Professional Liability

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10. Certificates of Insurance, and any subsequent renewals, must reference specific bid/contract by project name and project/bid number.

11. The Contractor shall agree to provide complete certified copies of current insurance policy(ies) or a certified letter from the insurance company (ies) if requested by the County to verify the compliance with these insurance requirements.

12. All insurance coverages required to be provided by the Contractor will be primary over any insurance program carried by the County.

13. Contractor shall incorporate a copy of the insurance requirements as herein provided in each and every subcontract with each and every Subcontractor in any tier and shall require each and every Subcontractor of any tier to comply with all such requirements. Contractor agrees that if for any reason Subcontractor fails to procure and maintain insurance as required, all such required Insurance shall be procured and maintained by Contractor at Contractor's expense.

14. No Contractor or Subcontractor shall commence any work of any kind under this Contract until all insurance requirements contained in this Contract have been complied with and until evidence of such compliance satisfactory to Gwinnett County as to form and content has been filed with Gwinnett County. The Acord Certificate of Insurance or a preapproved substitute is the required form in all cases where reference is made to a Certificate of Insurance or an approved substitute.

15. The Contractor shall agree to waive all rights of subrogation against the County, the Board of Commissioners, its officers, officials, employees, and volunteers from losses arising from work performed by the contractor for the County.

16. Special Form Contractors’ Equipment and Contents Insurance covering owned, used, and leased equipment, tools, supplies, and contents required to perform the services called for in the Contract. The coverage must be on a replacement cost basis. The County will be included as a Loss Payee in this coverage for County owned equipment, tools, supplies, and contents.

17. The Contractor shall make available to the County, through its records or records of their insurer, information regarding a specific claim related to any County project. Any loss run information available from the contractor or their insurer relating to a County project will be made available to the county upon their request.

17. Compliance by the Contractor and all subcontractors with the foregoing requirements as to carrying insurance shall not relieve the Contractor and all Subcontractors of their liability provisions of the Contract.

18. The Contractor and all Subcontractors are to comply with the Occupational Safety and Health Act of 1970, Public

Law 91-956, and any other laws that may apply to this Contract.

19. The Contractor shall at a minimum apply risk management practices accepted by the contractors’ industry.

RP032-22 Page 21

GENERAL CONDITIONS

TO CONSULTANT AGREEMENT

TABLE OF CONTENTS

Article

1 Definitions

2 Contract Documents

3 Changes and Extra Work

4 Personnel and Equipment

5 Accuracy of Work

6 Findings Confidential

7 Termination of Agreement for Cause

8 Termination for Convenience of the COUNTY

9 CONSULTANT to Cooperate with other Consultants

10 Indemnification

11 Covenant Against Contingent Fees

12 Insurance

13 Prohibited Interests

14 Subcontracting

15 Assignability

16 Equal Employment Opportunity

17 Anti-Kickback Clause

18 Audits and Inspectors

19 Ownership, Publication, Reproduction and Use

20 Verbal Agreement or Conversation

21 Independent Consultant

22 Notices

RP032-22 Page 22

1. DEFINITIONS

Wherever used in this Agreement, whether in the singular or in the plural, the following terms shall have the following meanings:

1.1 COUNTY-means Gwinnett COUNTY, Georgia, a political subdivision of the State of Georgia.

1.2 Supplemental Agreement-means a written order to CONSULTANT signed by COUNTY and accepted by CONSULTANT, effecting an addition, deletion or revision in the Work, or an adjustment in the Agreement Price or the Contract Time, issued after execution of this Agreement.

1.3 Contract-means the Agreement Documents specifically identified and incorporated herein by reference in Section 2, CONTRACT DOCUMENTS.

1.4 Agreement Execution-means the date on which CONSULTANT executes and enters into a Agreement with COUNTY to perform the Work.

1.5 Agreement Price-means the total monies, adjusted in accordance with any provision herein, payable to the CONSULTANT under this Agreement.

1.6 Contract Time-means the period of time stated in this Agreement for the completion of the Work.

1.7 CONSULTANT-means the party or parties contracting directly with the COUNTY to perform Work pursuant to this Agreement.

1.8 DEPARTMENT-means the Director or designee of requesting department(s) named in this solicitation.

1.9 Drawings-means collectively, all the drawings, receipt of which is acknowledged by COUNTY, listed in this Agreement, and also such supplementary drawings as the CONSULTANT may issue from time to time in order to clarify or explain such drawing or to show details which are not shown thereon.

1.10 Specifications-means the written technical provisions including all appendices thereto, both general and specific, which form a part of the Agreement Documents.

1.11 Subconsultant-means any person, firm, partnership, joint venture, company, corporation, or entity having a contractual agreement with CONSULTANT or with any of its subconsultants at any tier to provide a part of the Work called for by this Agreement.

1.12 Work-means any and all obligations, duties and responsibilities, including furnishing equipment, engineering, design, workmanship, labor and any other services or things necessary to the successful completion of the Project, assigned to or undertaken by CONSULTANT under this

1.13 Liaison-Representative of the COUNTY who shall act as Liaison between the COUNTY and the

CONSULTANT for all matters pertaining to this Agreement, including review of CONSULTANT's plans and work.

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2. CONTRACT DOCUMENTS

2.1 List of Documents

The Agreement, any required bonds, the General Conditions, the Appendices, the Detailed Scope of Work, the Specifications, the Drawings, the Exhibits, and all Agreement Supplemental Agreements shall constitute the Agreement Documents.

2.2 Conflict and Precedence

2.0.1 The Agreement Documents are complementary, and what is called for by one is as binding as if called for by all. In the event there are any conflicting provisions or requirements in the component parts of this Agreement, the several Agreement Documents shall take precedence in the following order:

1. Supplemental Agreements

2. Agreement

3. General Conditions

4. Detailed Scope of Work

5. Specifications

6. Drawings

3. CHANGES AND EXTRA WORK

The COUNTY may, at any time, request changes in the work to be performed hereunder. All such changes, including any increase or decrease in the amount of the CONSULTANT's compensation, which are mutually agreed upon by and between the COUNTY and the CONSULTANT, shall be incorporated in written Supplemental Agreements to the Agreement.

4. PERSONNEL AND EQUIPMENT

The CONSULTANT represents that it has secured or will secure, at its own expense, all personnel necessary to complete this Agreement; none of whom shall be employees of, or have any contractual relationship with, the COUNTY. Primary liaison with the COUNTY will be through its designee. All of the services required hereunder will be performed by the CONSULTANT under its supervision, and all personnel engaged in the work shall be fully qualified and shall be authorized or permitted under law to perform such services.

The CONSULTANT shall employ only persons duly registered in the appropriate category in responsible charge of supervision and design of the work; and further shall employ only qualified surveyors in responsible charge of any survey work.

The CONSULTANT shall endorse all reports, contract plans, and survey data. Such endorsements shall be made by a person duly registered in the appropriate category by the Georgia State Board of Registration, being in the full employ of the CONSULTANT and responsible for the work prescribed by this Agreement.

5. ACCURACY OF WORK

The CONSULTANT shall be responsible for the accuracy of the work and shall promptly correct errors and omissions in its plans and specifications without additional compensation.

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Acceptance of the work by the COUNTY will not relieve the CONSULTANT of the responsibility for subsequent correction of any errors and the clarification of any ambiguities.

6. FINDINGS CONFIDENTIAL

The CONSULTANT agrees that its conclusions and any reports are for the confidential information of the COUNTY and that it will not disclose its conclusions in whole or in part to any persons whatsoever, other than to submit its written documentation to the COUNTY, and will only discuss the same with it or its authorized representatives. Upon completion of this Agreement term, all documents, reports, maps, data and studies prepared by the CONSULTANT pursuant thereto shall become the property of the COUNTY and be delivered to DEPARTMENT.

Articles, papers, bulletins, reports, or other materials reporting the plans, progress, analyses, or results and findings of the work conducted under this Agreement shall not be presented publicly or published without prior approval in writing of the COUNTY.

It is further agreed that if any information concerning the PROJECT, its conduct, results, or data gathered or processed should be released by the CONSULTANT without prior approval from the COUNTY, the release of same shall constitute grounds for termination of this Agreement without indemnity to the CONSULTANT, but should any such information be released by the COUNTY or by the CONSULTANT with such prior written approval, the same shall be regarded as public information and no longer subject to the restrictions of this Agreement.

7. TERMINATION OF AGREEMENT FOR CAUSE

If through any cause, the CONSULTANT shall fail to fulfill in a timely and proper manner its obligations under this Agreement, or if the CONSULTANT shall violate any of the covenants, agreements or stipulations of this Agreement, the COUNTY shall thereupon have the right to terminate this Agreement by giving written notice to the CONSULTANT of such termination, and specifying the effective date thereof, at least ten (10) days before the effective date of such termination. Failure to maintain the scheduled level of effort as proposed and prescribed, or deviation from the aforesaid schedule without prior approval of the COUNTY, shall constitute cause for termination. In such event, all finished or unfinished documents, maps, data, studies, work papers and reports prepared by the CONSULTANT under this Agreement shall become the property of the COUNTY, and the CONSULTANT shall be entitled to receive just and equitable compensation for any satisfactory work completed on such documents, as determined by the COUNTY.

8. TERMINATION FOR CONVENIENCE OF THE COUNTY

The COUNTY may terminate this Agreement for its convenience at any time upon 30 days notice in writing to the CONSULTANT. If the Agreement is terminated by the COUNTY as provided in this Article 8, the CONSULTANT will be paid compensation for those services actually performed. Partially completed tasks will be compensated for based on a signed statement of completion to be submitted by the CONSULTANT which shall itemize each task element and briefly state what work has been completed and what work remains to be done.

All such expenses shall be properly documented and submitted to the Director or his designee for processing and payment. The Gwinnett County Board of Commissioners shall be the final authority in the event of any disputes over authorized costs between the Director and the CONSULTANT.

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9. CONSULTANTS TO COOPERATE WITH OTHER CONSULTANTS

If the COUNTY undertakes or awards other contracts for additional related work, the CONSULTANT shall fully cooperate with such other consultants and the COUNTY employees or appointed committee(s), and carefully fit its own work to such additional work as may be directed by the COUNTY. The CONSULTANT shall not commit or permit any act which will interfere with the performance of work by any other CONSULTANT or by COUNTY employees.

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