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HomeMy WebLinkAboutContract 47462-R1 A 22 '` �Qtl► A RECEIVED RErENE� NOV ? 9 2018 NAV X3201 0 - a- CITY OF FORT WORTH CSC No. CITYSECRETARY a CITY OF FORT WORTH CONTRACT RENEWAL NOTICE September 1,2018 Discovery Benefits,Inc. 432120"'Avenue Fargo,ND 58103 Re: NOTICE OF CONTRACT RENEWAL COBRA Administrative Services—Group ID 25345 Contract No.CSC No.47462(the"Contract") Renewal Term No. 1:January 1,2019 to December 1,2019 The above referenced Contract will expire on December 31,2018.Pursuant to the Contract,contract renewals are at the sole option of the City. This letter is to inform you that the City is exercising its right to renew CSC No.47462 for an additional one year period, which will begin immediately upon the expiration of the current term and will end on December 31, 2019. All other terms and conditions of CSC No. 47462 remain unchanged. Please return this signed acknowledgement letter, along with a copy of your current insurance certificate,to the address set forth below,acknowledging receipt of the Notice of Contract Renewal. Please log onto BuySpeed Online at htt-o:Hfortworthtexas.gov/purchasing to insure that your company information is correct and up- to-date. If you have any questions concerning this Contract Renewal Notice,please contact me at the telephone number listed below. Sincerely yours, Meagan Whitwell Sr.Benefits Analyst Human Resources Department 817-392-7787 I hereby acknowledge receipt of the Contract Renewal Notice for CSC No.47462 for a one year period ending on December 31,2019. By: 2t3+�1{1 1ZP �R. CGS E J7' Date: /C) Printed Name and Title Signhture ' CITY OF FORT WORTH: A Su nis,Assistant City Manager ary J. ays ity ecretary ��;;•.,, *r Date: I I ; �g M&C No. not required ~ RECOMMENDED BY: Name and Title (1/" OFFIcIAI.REcoR® CITY SECRETARY J B. Strong, ' tant City Attorney FT. WORTH,TX D (5C'0U6v-y C10812 r� C SC 4-��Co � Contract Compliance Manager: By signing I acknowledge that I am the person responsible for the monitoring and administration of this contract, including ensuring all performance and reporting requirements. Name of Employee/Signature v bs�� Title ❑ This form is N/A as No City Funds are associated with this Contract Printed Name Signature OFFICIAL RECORD CITY SECRETARY FT. WORTHo TX AC D® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE F10i29i2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Joni Alfson Dawson Insurance Agency PHONE FAX 721 1st Avenue North •701-237-3311 AIC No):7O1-232-4442 Fargo ND 58102 ADDRRLEss: jonia@dawsonins.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Travelers Insurance Group 19038 INSURED DISCO-2 INSURER 8 Discovery Benefits Inc. INSURER C: 4321 20th Ave SW Fargo ND 58103-7194 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:2098231314 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILICY EXP NR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM DDPOLICY/YYYY MEFF M/DDfYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY 660BH733164 11/8/2017 11/8/2018 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED CLAIMS-MADE FX1 OCCUR PREMISES Ea occurrence $500,000 MED EXP(Any one person) $5,000 PERSONAL 8 ADV INJURY $1,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 POLICY 7 JE I 7 LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ A AUTOMOBILE LIABILITY BA81­174823A 11/8/2017 11/8/2018 COMBINED SINGLE LIMIT $1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident A X UMBRELLA LIAB X OCCUR CUP91-1104445 11/8/2017 11/8/2018 EACH OCCURRENCE $10,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000 DED I X I RETENTION$ $ PER A WORKERS COMPENSATION UB9J051455 1/1/2018 1/1/2019 X STATUTE X ERHND Em I Liab AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers Compensation includes the following states:AZ,CO,GA,ID,IA,MN,SD,TX,WI CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Fort Worth 1000 Throckmorton Street AUTHORIZED REPRESENTATIVE Fort Worth TX 76102 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD