SRB10017R0005-A001.pdf

1. CONTRACT ID CODE

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT PAGE 1 OF 2

2. AMENDMENT/MODIFICATION NO. 3. EFFECTIVE DATE 4. REQUISITION/PURCHASE REQ. 5. PROJECT NO. (If applicable)

A001 May 23, 2017

NO.

6. ISSUED BY CODE I 7. ADMINISTERED BY {If other than Item 6) I CODE American Embassy Bui. Kneza A. Karadjordjevica 92 11040 Belgrade, Serbia

8. NAME AND ADDRESS OF CONTRACTOR (NO., street,city,county,State,and ZIP Code) 9a. AMENDMENT OF SOLICITATION NO.

SRB10017R0005

./ 9b. DATED (SEE ITEM 11)

April 27 , 2017

10a. MODIFICATION OF CONTRACT/ORDER NO.

- 10b. DATED (SEE ITEM 13)

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

ILi The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers is l:'...lis extended,0 is not extended

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

(a) By completing Items 8 and 15, and returning copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

D A. THIS CHANGE ORDER IS ISSUED PURSUANT TO (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE

CONTRACT ORDER NO. IN ITEM 10A.

D B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b)

D C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D D. OTHER (Specify type of modification and authority)

E. IMPORTANT: Contractor 0 is not, 0 is required to sign this document and return copies to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

Amendment A001 is to make the following changes to the solicitation:

1. EXHIBIT - A - GENERIC LISTING OF ELIGIBLE FSN/PSC EMPLOYEES AND SALARIES is deleted.

2. EXHIBIT - B - ORE EMPLOYEES RIDER is changed to read:

1) Single Employee (self only) - 3

2) Family Plan - 4

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 1 OA, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER (Type or print) 16A. NAME OF CONTRACTING OFFICER

Michael J. Moody

15B. NAME OF CONTRACTOR/OFFEROR 15C.DATE SIGNED 16B. UNITED STATES OF AMERICA 16C.DATE SIGNED

BY BY ~Jf[M ~-23-2oq.

(Siqnature of person authorized to siqn) // (Skmature of Cbntractinq Officer)

STANDARD FORM 30 (REV. 11-2016)

PREVIOUS EDITION UNUSABLE Prescribed by GSA

FAR (48 CFR) 53.243

Djordjevicz Highlight

SRB10017R0005-A001

3. EXHIBIT – C - AEERA EMPLOYEES RIDER is changed to read as follows:

1) Single Employee (self only) - 3

2) Family Plan - 4

4. New EXHIBIT E, EMBASSY EMPLOYEE DATA BY GENDER AND AGE RANGES is added:

EMPLOYEES BY GENDER WITHIN AGE RANGES

Age (years) FEMALE MALE TOTAL

18-34 5 16 21

35-45 37 71 108

46-55 27 89 116

56-60 7 25 32

61-65 0 12 12

TOTAL 76 213 289

EMPLOYEE SPOUSES BY GENDER WITHIN AGE RANGES

18-34 14 0 14

35-45 87 19 106

46-55 49 16 65

56-65 21 6 27

66+ 0 0 0

TOTAL 171 41 212

DEPENDENT CHILDREN BY GENDER WITHIN AGE RANGES

0-10 78 68 146

11-18 47 69 116

19-22 (if a full time student) 26 25 51

TOTAL 151 162 313

5. New EXHIBIT F, RIDER EMPLOYEE DATA BY GENDER AND AGE RANGES is added:

RIDER EMPLOYEES BY GENDER WITHIN AGE RANGES

18-34 0 3 3

35-45 2 4 6

46-55 2 1 3

56-60 1 0 1

61-65 1 0 1

TOTAL 6 8 14

RIDER EMPLOYEE SPOUSES BY GENDER WITHIN AGE RANGES

18-34 3 1 4

35-45 2 0 2

46-55 0 0 0

56-65 0 1 1

66+ 0 0 0

TOTAL 5 2 7

RIDER

DEPENDENT CHILDREN BY GENDER WITHIN AGE RANGES

Age (years) FEMALE MALE TOTAL

0-10 4 0 4

11-18 3 2 5

19-22 (if a full time student) 1 0 1

TOTAL 8 2 10

6. New EXHIBIT G, PREMIUMS, CLAIMS AND OTHER HISTORICAL DATA is added:

7. H.4. CONTRACTOR RESPONSIBILITY IN CLAIMS AND REIMBURSEMENT TO

CLAIMANTS, (a) Administrative Records (3) is changed to read "(3) The Contractor shall use the Serbian (Latin) spelling of the employees' names in all transactions, including reimbursement checks."

8. H.4. CONTRACTOR RESPONSIBILITY IN CLAIMS AND REIMBURSEMENT TO

CLAIMANTS, (b) Medical Insurance Claims, (4) is changed to read "(4) Settlement shall be by bank transfer directly to the employee's account for each claim submitted. A form providing details of the amount reimbursed with an explanation of deductions, if any shall be mailed directly to the employee.

9. The deadline for submitting offers is extended from 17:00 local time on May 30, 2017 to

17:00 local time on June 1, 2017.

(End of Amendment)

2017 2016 2015 2014 2013

Number

Total

EUR

Number Total

EUR

Number Total

EUR

Number Total

EUR

Number Total

EUR

Claims history 2,744 39,681 13,957 248,830 13,395 248,691 10,624 173,544 11,535 230,161

Premium history x 97,756 x 196,441 x 156,885 x 172,978 x 105,855

Number of losses in excess of EUR 10,000

0 X 0 X 1 X 1 X 2 X

HIV/AIDs cases 0 X 0 X 0 X 0 X 0 X

Major illnesses treated*

11 X 65 X 51 X 22 X 10 X

Total Members 867 X 846 X 791 X 795 X 775 X

* Catastrophic cases presented last year, such as: Hemodynamics, Open Heart Surgery, Orthopedic Mayor Surgeries, Organ Transplant, Traumatic Accident, Cancer and Oncology Cases (Radio and Chemotherapy), and hospitalizations with more than 10 days.

Periods covered start January 7 and end on January 6 the next calendar year except for 2017 which ends on July 6.

SRB10017R0005-A001b