RFP 54-08/09REQUEST FOR PROPOSALS FOR CLAIMS ADMINISTRATION SERVICES FOR THE CITY OF MIAMI BEACH SELF-INSURED WORKERS’ COMPENSATION PROGRAM RFP # 54-08/09 PROPOSAL DUE DATE: September 3, 2009 at
3:00 PM GUS LOPEZ, PROCUREMENT DIRECTOR PROCUREMENT DIVISION 1700 Convention Center Drive Miami Beach, FL 33139 ??????
8/3/09 2 of 43 RFP No 54-08/09 Workers’ Compensation Program City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov PROCUREMENT DIVISION
PUBLIC NOTICE Tel: 305-673-7490, Fax: 786-394-4006 REQUEST FOR PROPOSALS (RFP) NO. 54-08/09, FOR CLAIMS ADMINISTRATION SERVICES FOR THE CITY OF MIAMI BEACH SELF-INSURED WORKERS’ COMPENSATION
PROGRAM The City of Miami Beach is seeking proposals for third party claims administration services for its self-insurance Worker’s Compensation program. The administrator will provide
all specified adjusting services for all claims as well as all other required services, such as administrative, managed care/medical case management, computerized claims/loss statistical
information (RMIS) and banking/loss fund reconciliation. The specific required services are outlined in greater detail within this request for proposals. The City is seeking a two (2)
year contract proposal with three (3) one-year option to renew periods. Sealed Proposals will will be received until 3:00 PM on September 3, 2009 at the following address: City of Miami
Beach, City Hall Procurement Division -Third Floor 1700 Convention Center Drive Miami Beach, Florida 33139 ANY PROPOSAL RECEIVED AFTER 3:00 PM ON SEPTEMBER 3, 2009 WILL BE RETURNED TO
THE PROPOSER UNOPENED. THE RESPONSIBILITY FOR SUBMITTING PROPOSALS BEFORE THE STATED TIME AND DATE IS SOLELY THE RESPONSIBILTY OF THE PROPOSER. The City will not be responsible for delays
caused by mail, courier service, including U.S. Mail, or any other occurrence. A Pre-Proposal Submission Meeting is scheduled for August 13, 2009 at 10:00 a.m. at the following address:
City of Miami Beach City Hall – Fourth Floor 1700 Convention Center Drive City Manager’s Small Conference Room Miami Beach, Florida 33139 Attendance (in person or via telephone) to this
Pre-Proposal Submission Meeting is encouraged and recommended as a source of information, but is not mandatory. Proposers interested in participating in the Pre-Proposal Submission Meeting
via telephone must follow these steps: (1) Dial the TELEPHONE NUMBER: 1-888-776-3766 (Toll-free North America) (2) Enter the MEETING NUMBER: *3384706* (note that number is preceded and
followed by the star (*) key).
8/3/09 3 of 43 RFP No 54-08/09 Workers’ Compensation Program Proposers who are interested in participating via telephone, please send an e-mail to Pamela Leja at: pamelaleja@miamibeachfl.gov
expressing your intent to participate via telephone at least one business day in advance of the meeting. The City of Miami Beach is using BidSync, a central notification system which
provides bid notification services to interested vendors. BidSync allows for vendors to register online and receive notification of new bids, amendments and awards. Vendors with Internet
access should review the registration options at the following website: www.bidsync.com. If you do not have Internet access, please call the BidSync’s vendor support group at 801-765-9245.
THE CITY OF MIAMI BEACH RESERVES THE RIGHT TO ACCEPT ANY PROPOSAL DEEMED TO BE IN THE BEST INTEREST OF THE CITY OF MIAMI BEACH, OR WAIVE ANY INFORMALITY IN ANY PROPOSAL. THE CITY OF
MIAMI BEACH MAY ALSO REJECT ANY AND ALL PROPOSALS. YOU ARE HEREBY ADVISED THAT THIS REQUEST FOR PROPOSALS IS SUBJECT TO THE FOLLOWING ORDINANCES/RESOLUTIONS, WHICH MAY BE FOUND ON THE
CITY OF MIAMI BEACH WEBSITE: http://web.miamibeachfl.gov/procurement • CONE OF SILENCE --ORDINANCE NO. 2002-3378 • CAMPAIGN CONTRIBUTIONS BY VENDORS ORDINANCE NO. 2003-3389. • CODE OF
BUSINESS ETHICS --RESOLUTION NO. 2000-23879. • DEBARMENT PROCEEDINGS --ORDINANCE NO. 2000-3234. • PROTEST PROCEDURES --ORDINANCE NO. 2002-3344. • LOBBYIST REGISTRATION AND DISCLOSURE
OF FEES --ORDINANCE NO. 2002-3363 • REQUIREMENT FOR CITY CONTRACTORS TO PROVIDE EQUAL BENEFITS FOR DOMESTIC PARTNERS -ORDINANCE NO. 2005-3494 Sincerely, Gus Lopez, CPPO Procurement Director
8/3/09 4 of 43 RFP No 54-08/09 Workers’ Compensation Program City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov PROCUREMENT Division
Tel: 305.673.7490 Fax: 786-394-4006 RFP No. 54-08/09 NOTICE TO PROSPECTIVE PROPOSERS If not submitting a Proposal at this time, please detach this sheet from the RFP documents, complete
the information requested, and return to the address listed above. NO PROPOSAL SUBMITTED FOR REASON(S) CHECKED AND/OR INDICATED: ______Our Company does not handle this type of product/service.
______We cannot provide the services requested in the scope of services. ______Our Company is simply not interested in bidding at this time. ______Due to prior commitments, I was unable
to submit a proposal. ______OTHER. (Please specify) _____________________ We do______ do not______ want to be retained on your mailing list for future Request for Proposals (RFPs) for
similar services outlined in this RFP. Signature: ______________________________ Title: ___________________________________ Company: _______________________________ Note: Failure to
respond, either by submitting a Proposal or this completed form, may result in your company being removed from the City's bid list.
8/3/09 5 of 43 RFP No 54-08/09 Workers’ Compensation Program City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov PROCUREMENT DIVISION
Tel: 305-673-7490, Fax: 786-394-4006 TABLE OF CONTENTS PAGE I. OVERVIEW AND PROPOSAL PROCEDURES 6-12 II. SCOPE OF SERVICES/MINIMUM REQUIREMENTS 13-19 III. PROPOSAL FORMAT 20-21 IV. EVALUATION/SELECTI
N PROCESS/CRITERIA FOR EVALUATION 22 V. SPECIAL TERMS AND CONDITIONS-INSURANCE 23-24 VI. PROPOSAL DOCUMENTS TO BE COMPLETED AND RETURNED TO CITY WITH PROPOSAL SUBMISSION -All items outlined
as required under Scope of Services/Minimum Requirements (Section II) And Proposal Format (Section III) -Signed Insurance Checklist 24 -Proposer Information 25 -Acknowledgment of Addenda
26 -Declaration 27 -Sworn Statement/Section 287.133(3) (a), Florida Statutes -Public Entity Crimes 28-29 -Questionnaire 30-33 -Declaration: Nondiscrimination in Contracts and Benefits
34-36 -Reasonable Measures Application (If Applicable) 37-38 -Substantial Compliance (If Applicable) 39-41 VII. DOCUMENTS TO BE COMPLETED BY CUSTOMERS OF THE RESPONDENTS -Performance
Evaluation Letters 42 -Performance Evaluation Survey 43 ATTACHMENT: Summary Loss Report
8/3/09 6 of 43 RFP No 54-08/09 Workers’ Compensation Program SECTION I -OVERVIEW AND PROPOSAL PROCEDURES: A. INTRODUCTION /BACKGROUND The City of Miami Beach (the “City”) is approved
by the Florida Department of Labor and Employment Security/Division of Workers’ Compensation to self-insure for Workers’ Compensation. Workers’ Compensation is a statutory benefit provided
to employees that sustain injury within the course and scope of their employment. Workers Compensation provides both medical and indemnity (wage) benefits to the injured employee. The
Division of Workers’ Compensation requires that the claims administration be provided by a State Certified Workers’ Compensation Claims Administrator. On January 12, 2005, the Mayor
and City Commission authorized the Administration to execute an Agreement with Johns Eastern Company, as the State Certified Workers’ Compensation Claims Administrator. The Agreement
period was for two (2) years with renewal options for two (2) additional one-year periods. The Administration has continued the Agreement through option years one (1) and two (2) for
a total service agreement period of four (4) years. The current Agreement expires on January 31, 2010, with no further options to renew. The Mayor and City Commission at its July 15,
2009 meeting, authorized the Administration to issue this RFP for claims administration services for the City Of Miami Beach self-insured workers’ compensation program. B. RFP TIMETABLE
The anticipated schedule for this RFP and contract approval is as follows: RFP Issued August 3, 2009 Pre-Proposal Submission Meeting August 13, 2009 at 10:00 am Deadline for receipt
of questions August 19, 2009 Deadline for receipt of Proposals September 3, 2009 at 3:00 pm Evaluation Committee meeting September, 2008 City Commission approval October, 2009 Contract
negotiations October/November 2009 Contract Start Date February 1, 2010 C. PROPOSAL SUBMISSION An original and ten (10) copies of complete Proposals must be received no later than 3:00
pm on September 3, 2009, at the following address: City of Miami Beach City Hall Procurement Division --Third Floor 1700 Convention Center Drive Miami Beach, Florida 33139 The original
and all copies must be submitted to the Procurement Division in a sealed envelope or container stating on the outside the Proposer’s name, address, telephone number, RFP number and title,
and due date. No facsimile, electronic, or e-mail responses will be considered. The responsibility for submitting Proposals to the Procurement Division on or before the stated time
8/3/09 7 of 43 RFP No 54-08/09 Workers’ Compensation Program and date will be solely and strictly that of the Proposer. The City will in no way be responsible for delays caused by the
U.S. Post Office or caused by any other entity or by any other occurrence. Proposals received after the RFP due date and time will not be accepted and will not be considered. D. REQUIREMENT
FOR CITY CONTRACTORS TO PROVIDE EQUAL BENEFITS FOR DOMESTIC PARTNERS Proposers are advised that this RFP and any contract awarded pursuant to this procurement process shall be subject
to the applicable provisions of Ordinance No. 2005-3494, entitled “Requirement for City Contractors to Provide Equal Benefits for Domestic Partners” (the “Ordinance”). The Ordinance
applies to all employees of a Contractor who works within the city limits of the City of Miami Beach, and the Contractor’s employees located in the United States, but outside of the
City of Miami Beach limits, who are directly performing work on the contract within the City of Miami Beach. All Proposers shall complete and return, with their Proposal, the “Declaration:
Non-discrimination in Contracts and Benefits” form contained herein. The City shall not enter into any contract unless the Proposer certifies that it does not discriminate in the provision
of Benefits between employees with Domestic Partners and employees with spouses and/or between the Domestic Partners and spouses of such employees. Proposers may also comply with the
Ordinance by providing an employee with the Cash Equivalent of such Benefit or Benefits, if the City Manager or his designee determines that: a. The Proposer shall complete and return
the “Reasonable Measures Application” contained herein, and the Cash Equivalent proposed; AND b. The Proposer shall complete and return the “Substantial Compliance Authorization Form”
contained herein. It is important to note that Proposer is considered in compliance if Proposer provides benefits neither to employees’ spouses nor to employees’ Domestic Partners. E.
PRE-PROPOSAL SUBMISSION MEETING A Pre-Proposal Submission Meeting is scheduled for August 13, 2009 at 10:00 am at the following address: City of Miami Beach City Hall – 4th Floor City
Manager’s Small Conference Room 1700 Convention Center Drive Miami Beach, Florida 33139 Attendance (in person or via telephone) is encouraged and recommended as a source of information,
but is not mandatory. Proposers interested in participating in the Pre-RFP Submission Meeting via telephone must follow these steps: (1) Dial the TELEPHONE NUMBER: 1-888-776-3766 (Toll-free
North America) (2) Enter the MEETING NUMBER: *3384706* (note that number is preceded and followed by the star (*) key).
8/3/09 8 of 43 RFP No 54-08/09 Workers’ Compensation Program Proposers, who are interested in participating via telephone, please send an e-mail to the contact person listed below, expressing
your intent to participate via telephone. F. CONTACT PERSON/ADDITIONAL INFORMATION/ADDENDA The contact person for this RFP is Pamela Leja, Sr. Procurement Specialist, who may be reached
by phone: 305-673-7490; fax 786-394-4006; or e-mail: pamelaleja@miamibeachfl.gov. Communications between a Proposer, bidder, lobbyist, and/or consultant and the Procurement Director
are limited to matters of process or procedure. Requests for additional information or clarifications must be made in writing to the Procurement Division. Facsimile or e-mail requests
are acceptable. Please send all questions to pamelaleja@miamibeachfl.gov, no later than the date specified in the RFP timetable. The Procurement Division will issue replies to inquiries
and any other corrections or amendments, as it deems necessary, in written addenda issued prior to the deadline for responding to the RFP. Proposers should not rely on representations,
statements, or explanations, other than those made in this RFP or in any written addendum to this RFP. Proposers should verify with the Procurement Division prior to submitting a Proposal
that all addenda have been received. Proposers are advised that oral communications between the Proposer, or their representatives, and the Mayor and City Commissioners and their respective
staff, or members of the City’s Administrative staff (including but not limited to the City Manager and his staff), or evaluation committee members, is prohibited. G. MODIFICATION/WITHDRAWALS
OF PROPOSALS A Proposer may submit a modified Proposal to replace all or any portion of a previously submitted Proposal up until the Proposal due date and time. Modifications received
after the Proposal due date and time will not be considered. Proposals shall be irrevocable until contract award unless withdrawn in writing prior to the Proposal due date or after expiration
of 120 calendar days from the opening of Proposals without a contract award. Letters of withdrawal received after the Proposal due date and before said expiration date and letters of
withdrawal received after contract award will not be considered. H. RFP POSTPONEMENT/CANCELLATION/REJECTION The City may, at its sole and absolute discretion, reject any and all, or
parts of any and all, Proposals; re-advertise this RFP; postpone or cancel, at any time, this RFP process; or waive any irregularities in this RFP, or in any Proposals received as a
result of this RFP. I. COSTS INCURRED BY PROPOSERS All expenses involved with the preparation and submission of Proposals to the City, or any work performed in connection therewith,
shall be the sole responsibility of the Proposer and shall not be reimbursed by the City. J. EXCEPTIONS TO RFP Proposers must clearly indicate any exceptions they wish to take to any
of the terms in this RFP,
8/3/09 9 of 43 RFP No 54-08/09 Workers’ Compensation Program and outline what alternative is being offered; which exceptions and alternatives shall be included and clearly delineated
in Proposer’s submittal response. The City, at its sole and absolute discretion, may accept or reject any or all exceptions. In cases in which exceptions are rejected, the City shall
require the Proposer to comply with the particular term and/or condition of the RFP which Proposer takes exception to (as said term and/or condition was originally set forth on the RFP).
K. SUNSHINE LAW Proposers are hereby notified that all Proposals including, without limitation, any and all information and documentation submitted therewith, will be available for public
inspection after opening of Proposals, in compliance with Chapter 286, Florida Statutes (the Florida “Government in the Sunshine Law”). L. NEGOTIATIONS The City may award a contract
on the basis of initial offers received, without discussion, or may require Proposers to give oral presentations based on their Proposals. The City reserves the right to enter into further
negotiations with the top-ranked Proposer, (following authorization of negotiations by the City). No Proposer shall have any rights in the subject project or property or against the
City arising from such negotiations. Notwithstanding the preceding, the City is in no way obligated to enter into a contract with the top-ranked and/or successful Proposer, in the event
the parties are unable to negotiate a contract. M. PROTEST PROCEDURE Proposers that are not selected may protest any recommendation for selection of award in accordance with the proceedings
established pursuant to the City’s bid protest procedures (Ordinance No. 2002-3344), as codified in Sections 2-370 and 2-371 of the City Code. Protest(s) not timely made pursuant to
the requirements of Ordinance No. 2002-3344 shall be barred. N. OBSERVANCE OF LAWS Proposers are expected to be familiar with, and comply with, all Federal, State, County, and City laws,
ordinances, codes, rules and regulations, and all orders and decrees of bodies or tribunals having jurisdiction or authority which, in any manner, may affect the services and/or project
contemplated by this RFP (including, without limitation, the Americans with Disabilities Act, Title VII of the Civil Rights Act, the EEOC Uniform Guidelines, and all EEO regulations
and guidelines). Ignorance of the law(s) on the part of the Proposer will in no way relieve it from responsibility for compliance. O. DEFAULT Failure or refusal of the successful Proposer
to execute a contract following award by the City Commission, or untimely withdrawal of a Proposal before such award is made and approved, may result in forfeiture of that portion of
any surety required as liquidated damages to the City. Where surety is not required, such failure may result in a claim for damages by the City and may be grounds for removing the Proposer
from the City’s vendor list. P. CONFLICT OF INTEREST All Proposers must disclose, within their Proposal, the name(s) of any officer, director, agent, or
8/3/09 10 of 43 RFP No 54-08/09 Workers’ Compensation Program immediate family member (spouse, parent, sibling, and child) who is also an employee of the City of Miami Beach. Further,
all Proposers must disclose the name of any City employee who owns, either directly or indirectly, an interest of ten (10%) percent or more in the Proposer entity or any of its affiliates.
Q. COMPLIANCE WITH THE CITY'S LOBBYIST LAWS This RFP is subject to, and all Proposers are expected to be or become familiar with, all City lobbyist laws, as amended from time to time.
Proposers shall ensure that all City lobbyist laws are complied with, and shall be subject to any and all sanctions, as prescribed therein, including, without limitation, disqualification
of their Proposals, in the event of such non-compliance. R. PROPOSER’S RESPONSIBILITY Before submitting a Proposal, each Proposer shall be solely responsible for making any and all investigations
and examinations, as it deems necessary, to ascertain all conditions and requirements affecting the full performance of the contract. Ignorance of such conditions and requirements, and/or
failure to make such investigations and examinations, will not relieve the Proposer from any obligation to comply with every detail and with all provisions and requirements of the contract,
and will not be accepted as a basis for any subsequent claim whatsoever for any monetary consideration on the part of the Proposer. S. RELATIONSHIP TO THE CITY It is the intent of the
City, and Proposers hereby acknowledge and agree, that the successful Proposer is considered to be an independent contractor and that neither the Proposer, nor the Proposer’s employees,
agents, and/or contractors, shall, under any circumstances, be considered employees or agents of the City. T. PUBLIC ENTITY CRIME A person or affiliate who has been placed on the convicted
vendor list following a conviction for public entity crimes may not submit a bid on a contract to provide any goods or services to a public entity, may not submit a bid on a contract
with a public entity for the construction or repair of a public building or public work, may not submit bids on leases of real property to public entity, may not be awarded or perform
work as a contractor, supplier, sub-contractor, or consultant under a contract with a public entity , and may not transact business with any public entity in excess of the threshold
amount provided in Sec. 287.017, for CATEGORY TWO for a period of 36 months from the date of being placed on the convicted vendor list. U. ASSIGNMENT The successful consultant shall
not enter into any sub contract, retain consultants, or assign, transfer, convey, sublet, or otherwise dispose of this contract, or of any or all of its right, title, or interest therein,
or its power to execute such contract to any person, firm, or corporation without prior written consent of the City. Any unauthorized assignment shall constitute a default by the successful
consultant. V. INDEMNIFICATION The successful consultant shall be required to agree to indemnify and hold harmless the City of Miami Beach and its officers, employees, and agents, from
and against any and all actions, claims,
8/3/09 11 of 43 RFP No 54-08/09 Workers’ Compensation Program liabilities, losses and expenses, including but not limited to attorneys fees, for personal, economic or bodily injury,
wrongful death, loss of or damage to property, in law or in equity, which may arise or be alleged to have arisen from the negligent acts or omissions or other wrongful conduct of the
successful consultant, its employees, or agents in connection with the performance of service pursuant to the resultant Contract; the successful consultant shall pay all such claims
and losses and shall pay all such costs and judgments which may issue from any lawsuit arising from such claims and losses, and shall pay all costs expended by the City in the defense
of such claims and losses, including appeals. W. TERMINATION FOR DEFAULT If through any cause within the reasonable control of the successful consultant, it shall fail to fulfill in
a timely manner, or otherwise violate any of the covenants, agreements, or stipulations material to the Agreement, the City shall thereupon have the right to terminate the services then
remaining to be performed by giving written notice to the successful consultant of such termination which shall become effective upon receipt by the successful consultant of the written
termination notice. In that event, the City shall compensate the successful consultant in accordance with the Agreement for all services performed by the consultant prior to termination,
net of any costs incurred by the City as a consequence of the default. Notwithstanding the above, the successful consultant shall not be relieved of liability to the City for damages
sustained by the City by virtue of any breach of the Agreement by the consultant, and the City may reasonably withhold payments to the successful consultant for the purposes of set off
until such time as the exact amount of damages due the City from the successful consultant is determined. X. TERMINATION FOR CONVENIENCE OF CITY The City may, for its convenience, terminate
the services then remaining to be performed at any time without cause by giving written notice to successful consultant of such termination, which shall become effective thirty (30)
days following receipt by consultant of such notice. In that event, all finished or unfinished documents and other materials shall be properly delivered to the City. If the Agreement
is terminated by the City as provided in this section, the City shall compensate the successful consultant in accordance with the Agreement for all services actually performed by the
successful consultant and reasonable direct costs of successful consultant for assembling and delivering to City all documents. No compensation shall be due to the successful consultant
for any profits that the successful consultant expected to earn on the balanced of the Agreement. Such payments shall be the total extent of the City's liability to the successful consultant
upon a termination as provided for in this section. Y. INSURANCE Successful Consultant shall obtain, provide and maintain during the term of the Agreement the following types and amounts
of insurance as indicated on the Insurance Checklist which shall be maintained with insurers licensed to sell insurance in the State of Florida and have a B+ VI or higher rating in the
latest edition of AM Best's Insurance Guide. Name the City of Miami Beach as an additional insured on all liability policies required by this contract. When naming the City of Miami
Beach as an additional insured onto your policies, the insurance firms hereby agree and will endorse the policies to state that the City will not be liable for the payment of any premiums
or assessments.
8/3/09 12 of 43 RFP No 54-08/09 Workers’ Compensation Program Any exceptions to these requirements must be approved by the City’s Risk Management Department. FAILURE TO PROCURE INSURANCE:
Successful consultant's failure to procure or maintain required insurance program shall constitute a material breach of Agreement under which City may immediately terminate the proposed
Agreement. Z. CONE OF SILENCE Proposers are hereby advised that this RFP is subject to the City’s Cone of Silence requirements, as set forth in Section 2-486 of the City Code. AA. DEBARMENT
ORDINANCE Proposers are hereby advised that this RFP is subject to the City’s Debarment Ordinance (Ordinance No. 200-3234), as codified in Section 2-397 through 2-406 of the City Code.
BB. COMPLIANCE WITH THE CITY’S CAMPAIGN FINANCE REFORM LAWS This RFP is subject to, and all Proposers are expected to be or become familiar with, the City’s Campaign Finance Reform laws,
as codified in Sections 2-487 through 2-490 of the City Code, as amended from time to time. Proposers shall insure that all applicable provisions of the City’s Campaign Finance Reform
laws are complied with, and shall be subject to any and all sanctions, as prescribed therein, including disqualification of their Proposals, in the event of such noncompliance. CC. CODE
OF BUSINESS ETHICS Pursuant to City Resolution No.2000-23879 each person or entity that seeks to do business with the City shall adopt a Code of Business Ethics ("Code") and submit that
Code to the Procurement Division with its bid/response or within five (5) days upon receipt of request. The Code shall, at a minimum, require the Proposer, to comply with all applicable
governmental rules and regulations including, among others, the conflict of interest, lobbying and ethics provision of the City of Miami Beach and Miami Dade County. DD. AMERICAN WITH
DISABILITIES ACT (ADA) Call 305-673-7490/VOICE to request material in accessible format; sign language interpreters (five days in advance when possible), or information on access for
persons with disabilities. For more information on ADA compliance, please the Public Works Department, at 305-673-7080. EE. ACCEPTANCE OF GIFTS, FAVORS, SERVICES Proposers shall not
offer any gratuities, favors, or anything of monetary value to any official, employee, or agent of the City, for the purpose of influencing consideration of this Proposal. Pursuant to
Sec. 2-449 of the City Code, no officer or employee of the City shall accept any gift, favor or service that might reasonably tend improperly to influence him in the discharge of his
official duties.
8/3/09 13 of 43 RFP No 54-08/09 Workers’ Compensation Program SECTION II --SCOPE OF SERVICES/MINIMUM REQUIREMENTS The City of Miami Beach (the “City”) is approved by the Florida Department
of Labor and Employment Security/Division of Workers’ Compensation to self-insure for Workers’ Compensation. Workers’ Compensation is a statutory benefit provided to employees that sustain
injury within the course and scope of their employment. Workers Compensation provides both medical and indemnity (wage) benefits to the injured employee. The Division of Workers’ Compensation
requires that the claims administration be provided by a State Certified Workers’ Compensation Claims Administrator. On January 12, 2005, the Mayor and City Commission authorized the
Administration to execute an Agreement with Johns Eastern Company, as the State Certified Workers’ Compensation Claims Administrator. The Agreement period was for two (2) years with
renewal options for two (2) additional one-year periods. The Administration has continued the Agreement through option years
one (1) and two (2) for a total service agreement period of four (4) years. The current Agreement expires on January 31, 2010, with no further options to renew. The Mayor and City Commission
at its July 15, 2009 meeting, authorized the Administration to issue this RFP for claims administration services for the City Of Miami Beach self-insured workers’ compensation program.
The City of Miami Beach is seeking proposals for third party claims administration services for its self-insurance Worker’s Compensation program. The administrator will provide all specified
adjusting services for all claims as well as all other required services, such as administrative, managed care/medical case management, computerized claims/loss statistical information
(RMIS) and banking/loss fund reconciliation. The specific required services are outlined in greater detail within this request for proposals. The City is seeking a two (2) year contract
proposal with three (3) one-year option to renew periods. Proposals to handle only selected parts will not be considered. It is understood by the successful proposer that all services
are to be provided by the proposer's employees and cannot be contracted out to another party without the prior approval of the City. The commencement date of the contract will be February
1, 2010. The City's current claims administrator is John Eastern Company. Johns Eastern has provided administration for the City's self-insured worker's compensation program since 1986.
The City has approximately 1,900 employees, and averages 425 claims annually. The breakdown is estimated at 300 for medical only and 125 for lost time. Currently there are approximately
446 open claims. Prior to October 1996, the City purchased excess workers' compensation insurance. The City does not currently purchase excess workers' compensation insurance. The City
currently pays full salary (for a maximum of 32 weeks) for service related injury (ISC). In view of this, temporary total indemnity benefits will not need to be paid by the claims administrator
unless the injured employee is eligible for temporary total benefits in excess of 32 weeks. In addition, certain medical conditions and work related activities are covered as workers'
compensation for police and fire personnel pursuant to the respective union contracts. The City is currently not under a Managed Care Arrangement. All proposers are to assume the complete
handling of all future and past claims now being handled by our present administrator along with all new claims. The information provided regarding the volume and type of pending claims
to be assumed is based on the latest information provided to the City and cannot be guaranteed as to its accuracy. If the amount of prior claim files to be taken over
8/3/09 14 of 43 RFP No 54-08/09 Workers’ Compensation Program is 25% greater than represented in this RFP, the City will consider a proportionate adjustment to the proposer's flat annual
fee. It is the responsibility of the proposer to review prior claim files to determine the additional proposed cost, if any, to take over these files. It is also required that the claim
data associated with all claims occurring prior to February 1, 2010, be transferred into the proposer's computer information system, so that future loss runs will contain a complete
history of all claim years. The transfer of all claims data must be completed by June 1, 2010. The proposer is responsible for specifically indicating in their proposal the fees, if
any, for assumption of prior claims and the data conversion. The program is run on an "occurrence" basis, therefore, all claims occurring in the contract year, regardless of when reported,
are to be handled per the requirements of this agreement. The claim administrator is required to to handle all claims to their conclusion or to the conclusion of the contract, whichever
occurs first, at no additional charge to the City other than the annual fee. The contract may be terminated by either party with ninety (90) days written notice to the other. However,
any cancellation does not alter the administrator's obligation to handle all claims prior to the termination date. WORKERS’ COMPENSATION CLAIMS ADJUSTING AND INVESTIGATION SERVICES:
Upon receipt of all workers' compensation claims, the claims administrator shall perform the following: 1. The claim manager or supervisor will review all notices of injury received
from the City prior to the assignment to an adjuster. 2. Accept or deny all reported claims for employees' injuries on behalf of the City in accordance with the applicable Workers' Compensation
Law. 3. To conduct the required investigations as deemed necessary as it relates to workers' compensation including scene investigations and personal claimant contact on all lost time
or light duty cases. Contact with claimants is to be made within 24 hours of the administrator's receipt of the claim. 4. Subject to the prior approval of, and at the expense of the
City, employ outside professionals such as surveillance, rehabilitation, experts and attorneys to assist in the investigation and adjustment of claims. Payment will be made by the administrator
from the loss fund as an allocated expense. 5. Review all medical bills and other services for which a claim is being made for reasonableness and conformity to appropriate medical and
surgical fee schedules and network discounts. 6. Coordinate the medical treatment of all claims by setting appointments and authorizing necessary physician referrals and treatments.
7. Every 14 days provide written notification indicating all employees that are not working in a full duty unrestricted capacity. 8. Every 90 days, submit a full summary report to the
City on all claims of the following types: -any claim in which an employee is not working full duty -total incurred value exceeding $50,000
8/3/09 15 of 43 RFP No 54-08/09 Workers’ Compensation Program -potentially controverted cases -claims in which settlement (washout) is recommended 9. The administrator must have approval
for all settlements. For settlements for more than $10,000, the administrator will submit a full captioned report to the City summarizing all issues and evaluating exposures along with
a settlement recommendation for City approval. All settlements must be reported to Medicare as required. 10. Prepare and maintain files necessary for legal defense of claims and/or other
litigation (such as actions for subrogation) or other proceedings. 11. Pay in a timely fashion all claims and expenses from the loss fund account established by the City, which will
be maintained by the administrator. Fees, interest and civil penalties required due to late payments or adjuster mishandling are to be paid by the administrator unless caused by late
reporting from the City. 12. Pursue all possibilities of excess insurance recovery (including reporting), subrogation, liens and recovery from the Special Disability Fund. 13. The City
will approve and assign the attorneys that provide the defense of claims. The administrator is to provide the defense attorney a complete copy of the file in question at the time an
assignment is made. The administrator will provide a monthly report to the City regarding new legal assignments. 14. The administrator will attend workers' compensation hearings and
mediation as requested by the City. 15. Have the ability to provide managed care services/and or medical case management pursuant to Florida Statutes with nurses/medical case managers
employed by the administrator and located in the local claims office. Provide your fees for these services separately, as these fees will be paid as allocated expenses. STAFFING AND
PERSONNEL: It is the City's claims management philosophy that the proper and most cost-effective method to handle claims and thereby reduce and control the City's self-insured loss payments
is to ensure the the administrator hires and retains the appropriately qualified professionals to handle our claims. Additionally, the adequate number of adjusters and a manageable caseload
enables qualified adjusters to perform the required services. The City therefore requires that the proposer agree to staffing, qualifications and caseload criteria established by the
City. The City reserves the right to the final prior approval of the hiring and/or assignment of the claims manager, supervisors and adjusters that are to handle the City's claims. The
required maximum open case loads per adjusters (may have more than one adjuster assigned to the account) are to be as follows (claims manager should not handle files): workers' compensation
(lost time) -100 workers' compensation (medical only) -500 The administrator agrees to add staff as necessary to maintain these maximum pending caseload levels. Explain how the office
or unit will be staffed and explain the level of supervision that will be
8/3/09 16 of 43 RFP No 54-08/09 Workers’ Compensation Program provided. Claims personnel must be employees of the administrator. The use of independent adjusters, subcontractors or temporary
adjusters is not acceptable without prior approval of the City. Adjuster trainees are not acceptable for handling of the City's claims. Additionally, resumes of all claims professionals
specifically assigned to this account are to be submitted with this proposal. All claims professionals must possess a current Florida Workers, Compensation adjuster's license. ADMINISTRATION
SERVICES: The administrator will additionally perform the following related services: 1) State required filings 2) Loss fund management 3) Computer generated loss runs and other management
reports as required including on line access to claims data STATE/FEDERAL REQUIRED FILINGS: 1. The administrator will prepare and file, on behalf of the City, with the appropriate state
agency, all applications required for the City's continued qualification as a self-insurer. 2. Prepare, maintain, and file all records and reports as may be required by legal authorities
(state or federal). 3. Prepare, maintain and file statistical information required by workers' compensation rating bureaus, including all data required for the promulgation of the City's
experience modification and state assessments. (BSI-17) 4. Prepare and file any other reports as required by the City, state agencies, or federal agencies (Medicare reporting) relating
to claims experience, payments, etc. LOSS FUND MANAGEMENT: 1. The Claim Payment Account will be maintained at the City's commercial banking institution. The account will be classified
as part of the analysis group of City accounts. The City will pay all service fees that are normal and customary in this account. All interest earned or service credits generated will
accrue to the benefit of the City. 2. The claims administrator is required to follow Florida law concerning public deposits. Failure to comply with Florida law is sufficient cause for
the City to terminate the contractual agreement with the claims administrator. 3. All claims, expense and legal payments will be made by the claims administrator on checks drawn on an
account set up by the administrator and funded monthly by the City. It is understood that all funds in this account are City funds and are to be returned to the City upon request or
at termination of this contract. 4. The administrator is responsible for the monthly reconciliation of this account and will provide bank statements to the City monthly, along with a
request for a deposit from the City to maintain the monthly balance in the loss fund, as determined by the City. 5. The monthly reconciliation statement submitted by the administrator
to the City will include the following:
8/3/09 17 of 43 RFP No 54-08/09 Workers’ Compensation Program -balance at inception of statement period -total disbursements which cleared, by date and claimant/payee -balance at close
of statement period -amount of deposit required 6. A list of all checks is to be submitted monthly. COMPUTER LOSS INFORMATION: All charges related to these services are to be included
in the annual claims administration fee. Any costs associated with programming changes that are necessary to create a report required by the City are the responsibility of the administrator.
Advise what reports can be provided beyond those requested by the City and whether there is an additional charge for these optional reports. Indicate any fees to be charged for the creation
of any special reports requested by the City, as necessary. All reports currently provided to the City are required from the successfully selected administrator. All claims data is the
property of the City and any data and media will be provided to the City upon request or upon termination of this agreement. All computer notes will be printed out and placed in the
files prior to file transfer to a successive administrator. The selected administrator, at their expense, will ensure all claim and payment data is included in their loss runs by June
1, 2010. Historical data from our current administrator's database cannot be purged. Claims data for all open and closed claims must be transferred. The selected administrator’s computer
software system must be compatible with Johns Eastern’s system for data conversion. Information regarding Data Conversion from Johns Eastern to a New TPA is attached to the proposal.
Loss runs are to be provided on a semi annual basis (2 copies) with cd backup, sorted separately by policy year, and department/location. Loss runs should list each claim separately.
Specific summary reports also must be provided. The following reports are required: 1. Claims list -lists all claims alphabetically including department/location 2. Check register/disbursements
3. Annual summary reports 4. Location report 5. Large loss or severity report 6. Loss prevention reports to include accident frequency and severity, cause, nature and body part 7. Litigation
report 8. Legal payments report 9. SAF 200 (OSHA log) Workers' compensation claims involving no payment or no medical treatment are reported by the City for inclusion in the data base
as reporting purpose only (RPO) or first aid or no pay cases and should be identified in the system that way. The administrator must provide the City the ability to access the system
via the internet for file review, e-mail or other purposes. CLAIMS HISTORY: The information provided as to current pending claims data is provided by our current administrator
8/3/09 18 of 43 RFP No 54-08/09 Workers’ Compensation Program and is accurate to the best of the City's knowledge. The proposer has the right to contact the present administrator to
review current files if desired and it is the responsibility of the proposer to confirm the pending claim counts in order to determine any takeover fees. Please see attached for a claim
experience. MINIMUM REQUIREMENTS /QUALIFICATIONS: 1. Proposer Must be approved as Claim Administrator by the State of Florida Division of Worker’s Compensation for a minimum of Ten Years
(10) 2. Response to Supplemental Questions (included herein) 3. Provide samples of loss runs. 4. Explain and provide all managed care/medical management information for approval by the
City (network information, grievance procedure, experience level of staff etc.). SUPPLEMENTAL QUESTIONS: Specific requirements regarding services have been outlined in prior sections
of this RFP. In addition to information that may be provided in your proposal and required elsewhere in this RFP, please answer the following (restate question in each answer): 1. Where
is your office located? 2. Number of professional claim staff at that location. 3. Number of clerical and/or support staff at location. 4. Name, experience, resume and professional designations
of claim manager. 5. Name, experience, license type, resume and professional designations of any supervisory level employees that will have responsibility for this account. 6. Name,
experience, license type, resume and professional designations of the designated adjusters that will have responsibility for this account. 7. Advise the current pending case load for
each designated adjuster. 8. What is the current number of monthly new assignments to each adjuster? 9. Will the award of this contract necessitate an increase in your staff size to
meet the City's staffing and caseload requirements and will that be in place by February 1, 2010? 10. Name the 4 law firms (2 workers' compensation, 2 liability) that you currently handle
the most cases with. Provide a contact person and phone number. 11. Estimate the percentage of time your adjusters are out of the office doing field work. If all are telephone adjusters,
please indicate. 12. Do you utilize independent contracted adjusters? If so, under what circumstances?
8/3/09 19 of 43 RFP No 54-08/09 Workers’ Compensation Program 13. Name, address, phone and contact person for independents you utilize. 14. Can you provide all the required services
with your own personnel? 15. Do your adjusters receive any continuing education and training? Explain. 16. Do you currently file state and excess insurance forms on behalf of your clients?
Explain. 17. Do you have the capability to provide all the loss data reports required? Explain. 18. Do you have the ability to transfer the City's prior claims data to your information
system by February 1, 2010? 19. Explain any fees proposed for managed care, medical case management, bill review, UR and rehabilitation services. These are not to be included in the
annual fee proposed. 20. Explain, in detail, any deviation from the services or fee structure type required, specifically indicating any services you cannot perform. Specifically indicate
what you consider as allocated expenses and therefore not included in your annual fee proposal am
ount. 8/3/09 20 of 43 RFP No 54-08/09 Workers’ Compensation Program SECTION III – PROPOSAL FORMAT Proposals must contain the following documents, each fully completed and signed, as
required. If any items are omitted, Proposers must submit the documentation within five (5) calendar days upon request from the City, or the Proposal shall be deemed non-responsive.
The City will not accept the proposed cost of services (fee) information after the deadline for receipt of Proposals. 1. Table of Contents Outline in sequential order the major areas
of the Proposal, including enclosures. All pages must be consecutively numbered and correspond to the table of contents. 2. Proposal Points to Address: Proposers must respond to all
minimum requirements listed below. Proposals which do not contain such documentation may be deemed non-responsive. a) Introduction letter: outlining the Proposer’s professional specialization;
provide past experience to support the qualifications of the Proposer. b) Proposer’s must provide documentation: Proposer’s shall submit such supporting documentation as they deem necessary
to demonstrate the capability to provide and implement the services as outlined in this RFP. c) References: Provide a list of at least five (5) client references, that have provided
services as outlined in this RFP, to include contact name, title, company, address, telephone number, e-mail address, fax number. d) Qualifications of Proposer/Management Team and Key
Personnel: Outline in detail the experience and qualifications of the Proposers entity, and the Proposer’s management team, in providing services as outlined in this RFP. e) Past Performance
Client Survey Information: Past performance information will be collected on all Proposers. Proposers are required to identify and submit their best projects. Proposers will be required
to send out Performance Evaluation Surveys to each of their clients. Please provide your client with the Performance Evaluation Letter and Survey attached herein on pages 42 and 43,
and request that your client submit the completed survey to Pamela Leja, Sr. Procurement Specialist, at (Fax) 786-394-4006 or (e-mail) pamelaleja@miamibeachfl.gov. The City will not
accept Client Surveys sent to the Procurement Division from the office of the Proposer. Surveys must be sent to the Procurement Division directly from your client’s office(s). Proposers
are responsible for making sure their clients return the Performance Evaluation Surveys to the City. The City reserves the right to verify and successful Proposer any information submitted
in this process. Such verification may include, but is not limited to, speaking with current and former clients, review of relevant client documentation, site-visitation, and other independent
confirmation of data. f) Methodology and Approach. The Proposer must specifically describe its Proposal methodology and approach for completing the services required in the scope of
work.
8/3/09 21 of 43 RFP No 54-08/09 Workers’ Compensation Program g) Cost Information: Cost and/or revenue sharing information must be submitted with Proposal. Notwithstanding any cost and/or
revenue sharing Proposals submitted, the City reserves the right to further negotiate same with the successful Proposer. 3. Acknowledgment of Addenda: (IF REQUIRED BY ADDENDUM) and Proposer
Information forms. 4. Any other Documents Required by this RFP.
8/3/09 22 of 43 RFP No 54-08/09 Workers’ Compensation Program SECTION IV – EVALUATION/SELECTION PROCESS After the City’s Procurement Division receives responses from qualified Proposers,
a determination will be made if the Proposals meet the minimum standards of responsiveness. An Evaluation Committee, appointed by the City Manager, shall meet to evaluate the responsive
proposals in accordance with the requirements of the RFP. If further information is desired, Proposers may be requested to make additional written submissions or oral presentations to
the Evaluation Committee. The Evaluation Committee will recommend to the City Manager the proposal(s) which the Evaluation Committee deems to be in the best interest of the City by using
the following criteria: • The proposer's qualifications and experience in providing Florida Workers’ Compensation administration services: Twenty Percent (20%) • The qualifications and
experience of the proposer's personnel that will be assigned to the account: Twenty Percent (20%) • Cost of services provided (fee): Thirty Percent (30%) • Demonstration of successful
prior performance in providing these services and knowledge of Florida municipal agencies: Twenty Percent (20%) • Proposer's references. Submit a list of Florida based current clients.
Also submit a list of clients which discontinued using your service in the past two (2) years: Ten Percent (10%) After considering the recommendation(s) of the Evaluation Committee,
the City Manager shall recommend to the Mayor and Commission the Proposal or Proposals acceptance of which the City Manager deems to be in the best interest of the City. The City Commission
shall consider the City Manager’s recommendation(s) as it deems appropriate and may: approve the City Manager’s recommendation(s); make its own recommendation(s); reject all Proposals;
or may prescribe such other action, as it deems necessary and in the best interest of the City. Following recommendation of award by the City Commission, negotiations between the selected
Proposers and the City Administration take place to arrive at a contract. If the Mayor and Commission has so directed, the City Manager may proceed to negotiate a contract with a Proposer
other than the top-ranked Proposer if the negotiations with the top-ranked Proposer fail to produce a mutually acceptable contract within a reasonable period of time. A proposed contract
(or contracts) is presented to the Mayor and Commission for approval, modification and approval, or rejection. If and when a contract (or contracts) acceptable to the respective parties
is approved by the Mayor and Commission, the Mayor and City Clerk sign the contract(s) after the selected Proposer(s) has (or have) done so. By submitting a Proposal, all Proposers shall
be deemed to understand and agree that no property interest or legal right of any kind shall be created at any point during the aforesaid evaluation/selection process until and unless
a contract has been agreed to and signed by both parties.
8/3/09 23 of 43 RFP No 54-08/09 Workers’ Compensation Program SECTION V – SPECIAL TERMS AND CONDITIONS: INSURANCE INSURANCE: The successful Proposer shall obtain, provide and maintain
during the term of the contract the following types and amounts of insurance, which shall be maintained with insurers licensed to sell insurance in the State of Florida and have a B+
VI or higher rating in the latest edition of AM Best's Insurance Guide. Commercial General Liability. A policy including, but not limited to, comprehensive general liability, including
bodily injury, personal injury, property damage, in the amount of a combined single limit of not less than $1,000,000. Coverage shall be provided on an occurrence basis. The City of
Miami Beach must be named as certificate holder and additional insured on policy. 1. Workers' Compensation and Employer's Liability per the statutory limits of the state of Florida.
2. Comprehensive General Liability (occurrence form), limits of liability $ 1,000,000.00 per occurrence for bodily injury property damage to include Premises/Operations; Products, Completed
Operations and Contractual Liability. Contractual Liability and Contractual Indemnity (Hold harmless endorsement exactly as written in "insurance requirements" of specifications). 3.
Automobile Liability -$1,000,000 each occurrence -owned/non-owned/hired automobiles included. Worker's Compensation. A policy of Worker's Compensation and Employers Liability Insurance,
in accordance with worker’s compensation, laws as required per Florida Statutes. Said policies of insurance shall be primary to and contributing with any other insurance maintained by
Proposer or City, and shall name the City of Miami Beach, as an additional insured. No policy can be canceled without thirty (30) days prior written notice to the City. The successful
Proposer shall file and maintain certificates of all insurance policies with the City’s Risk Management Department showing said policies to be in full force and effect at all times during
the course of the contract. Such insurance shall be obtained from brokers of carriers authorized to transact insurance business in Florida and satisfactory to City. Evidence of such
insurance shall be submitted to and approved by City prior to commencement of any work or tenancy under the proposed contract. If any of the required insurance coverages contain aggregate
limits, or apply to other operations or tenancies of Proposer outside the proposed contract, Proposer shall give City prompt written notice of any incident, occurrence, claim settlement
or judgment against such insurance which may diminish the protection such insurance affords the City. Proposer shall further take immediate steps to restore such aggregate limits or
shall provide other insurance protection for such aggregate limits. FAILURE TO PROCURE INSURANCE: The successful Proposer’s failure to procure or maintain required the insurance program
shall constitute a material breach of the contract by which City may immediately terminate same.
8/3/09 24 of 43 RFP No 54-08/09 Workers’ Compensation Program INSURANCE CHECK LIST XXX Workers' Compensation and Employer's Liability per the statutory limits of the state of Florida.
XXX Comprehensive General Liability (occurrence form), limits of liability $ 1,000,000.00 per occurrence for bodily injury property damage to include Premises/Operations; Products, Completed
Operations and Contractual Liability. Contractual Liability and Contractual Indemnity (Hold harmless endorsement exactly as written in "insurance requirements" of specifications). XXX
Professional Liability -$300,000 ____ Automobile Liability -$1,000,000 each occurrence -owned/non-owned/hired automobiles included. XXX The City must be named as an additional insured
on the liability policies; and it must be stated on the certificate. ____ Thirty (30) days written cancellation notice required. ____ Best's guide rating B+: VI or better, latest edition.
____ The certificate must state the RFP number and title PROPOSER AND INSURANCE AGENT STATEMENT: I understand the Insurance Requirements of these specifications and that evidence of
this insurance may be required within five (5) days after Proposal opening. If I am selected as the successful Proposer, I further understand and agree and acknowledge that failure to
procure or maintain the required
insurance policy shall constitute a material breach of the contract by which the City may immediately terminate same. _____________________________________ _____________________________________
For Proposer/Print Name /Title Signature of Proposer
8/3/09 25 of 43 RFP No 54-08/09 Workers’ Compensation Program PROPOSER INFORMATION Submitted by: Proposer (Entity): Signature: Name (Printed: Address: City/State: Telephone: Fax: E-mail:
Federal Tax ID# It is understood and agreed by Proposer that the City reserves the right to reject any and all Proposals, to make awards on all items or any items according to the best
interest of the City, and to waive any irregularities in the RFP or in the Proposals received as a result of the RFP. It is also understood and agreed by the Proposer that by submitting
a Proposal, Proposer shall be deemed to understand and agree than no property interest or legal right of any kind shall be created at any time until and unless a contract has been agreed
to and signed by both parties. _____________________________________ _____________________________________ For Proposer: (Authorized Signature) (Date) _____________________________________
(Printed Name)
8/3/09 26 of 43 RFP No 54-08/09 Workers’ Compensation Program ACKNOWLEDGEMENT OF ADDENDA Directions: Complete Part I or Part II, whichever applies. Part I: Listed below are the dates
of issue for each Addendum received in connection with this RFP: 54-08/09: Addendum No. 1, Dated _____________________________________ Addendum No. 2, Dated _____________________________________
Addendum No. 3, Dated _____________________________________ Addendum No. 4, Dated _____________________________________ Addendum No. 5, Dated _____________________________________ Part
II: _______ No addendum was received in connection with this RFP. Verified with Procurement staff _____________________________________ _____________________________________ Name of
staff Date _____________________________________ _____________________________________ Proposer -Name Date _____________________________________ Signature
8/3/09 27 of 43 RFP No 54-08/09 Workers’ Compensation Program DECLARATION TO: City of Miami Beach City Hall 1700 Convention Center Drive Procurement Division Miami Beach, Florida 33139
Submitted this ______ day of _____________________________________, 2009. The undersigned, as Proposer, declares that the only persons interested in this Proposal are named herein; that
no other person has any interest in this responses or in the contract to which this response pertains; that this response is made without connection or arrangement with any other person;
and that this response is in every respect fair and made in good faith, without collusion or fraud. The Proposer agrees if this response is accepted, to execute an appropriate City of
Miami Beach document for the purpose of establishing a formal contractual relationship between the Proposer and the City, for the performance of all requirements to which the response
pertains. The Proposer states that the response is based upon the documents identified by the following number: RFP No. 54-08/09 _____________________________________ ________________________________
____ WITNESS PROPOSER SIGNATURE _____________________________________ _____________________________________ PRINTED NAME PRINTED NAME _____________________________________ ___________________________
_________ WITNESS TITLE _____________________________________ PRINTED NAME
8/3/09 28 of 43 RFP No 54-08/09 Workers’ Compensation Program SWORN STATEMENT UNDER SECTION 287.133(3) (a), FLORIDA STATUTES, ON PUBLIC ENTITY CRIMES THIS FORM MUST BE SIGNED AND SWORN
TO IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER OATHS. This sworn statement is submitted to ____________________________________ [print name of public
entity] By________________________________________________________________ [print individual's name and title] For _______________________________________________________________ [print
name of entity submitting sworn statement] Whose business address is _______________________________________________ And (if applicable) its Federal Employer Identification Number (FEIN)
is ______(If the Entity has no FEIN, include the Social Security Number of the individual signing this sworn statement: ________________________________________________). I understand
that a "public entity crime" as defined in Paragraph 287.133(1)(g), Florida Statutes, means a violation of any state or federal law by a person with respect to and directly related to
the transaction of business with any business with any public entity or with an agency or political subdivision of any other state or of the United States, including, but not limited
to, any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving antitrust,
fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation. I understand that "convicted" or "conviction" as defined in Paragraph 287.133(1)(b), Florida
Statutes, means a finding of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges
brought by indictment or information after July 1, 1989, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere. I understand that an "affiliate"
as defined in Paragraph 287.133 (1)(a), Florida Statutes, means: 1) A predecessor or successor of a person convicted of a public entity crime; or 2) An entity under the control of any
natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term "affiliate" includes those officers, directors, executives,
partners, shareholders, employees, members, and agents who are active in the management of an affiliate. The ownership by one person of shares constituting a controlling interest in
another person, or a pooling of equipment or income among persons when not for fair market value under an arm's length agreement, shall be a prima facie case that one person controls
another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered
an affiliate.
8/3/09 29 of 43 RFP No 54-08/09 Workers’ Compensation Program 3) I understand that a “person” as defined in Paragraph 287.133 (1)(e), Florida Statutes means any natural person or entity
organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of
goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term "person" includes those officers, directors, executives,
partners, shareholders, employees, members, and agents who are active in management of an entity. Based on information and belief, the statement which I have marked below is true in
relation to the entity submitting this sworn statement. [Indicate which statement applies.] ______Neither the entity submitting this sworn statement, nor any officers, directors, executives,
partners, shareholders, employees, members, or agents who are active in neither the management of the entity, nor any affiliate of the entity has been charged with and convicted of a
public entity crime subsequent to July 1, 1989. ______The entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees,
members or agents who are active in management of the entity or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. ______The
entity submitting this sworn statement, or one or more of its officers, directors, executives, partners, shareholders, employees, members, or agents who are active in the management
of the entity or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989. However, there has been a subsequent proceeding before
a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final Order entered by the hearing Officer determined that it was not in the public interest to
place the entity submitting this sworn statement on the convicted vendor list. [Attach a copy of the final order] I UNDERSTAND THAT THE SUBMISSION OF THIS FORM TO THE CONTRACTING OFFICER
FOR THE PUBLIC ENTITY IDENTIFIED IN PARAGRAPH 1 (ONE) ABOVE IS FOR THAT PUBLIC ENTITY ONLY AND, THAT THIS FORM IS VALID THROUGH DECEMBER 31 OF THE CALENDAR YEAR IN WHICH IT IS FILED.
I ALSO UNDERSTAND THAT I AM REQUIRED TO INFORM THE PUBLIC ENTITY PRIOR TO ENTERING INTO A CONTRACT IN EXCESS OF THE THRESHOLD AMOUNT PROVIDED IN SECTION 287.017, FLORIDA STATUTES FOR
CATEGORY TWO OF ANY CHANGE IN THE INFORMATION CONTAINED IN THIS FORM. [Signature] Sworn to and subscribed before me this day of ________________________ , 2009 Personally known ______________
OR Produced identification_____ Notary Public -State of ________________ _________________________ My commission expires _________________ (Type of Identification) (Printed typed or
stamped Commissioned name of Notary Public)
8/3/09 30 of 43 RFP No 54-08/09 Workers’ Compensation Program QUESTIONNAIRE Proposer’s Name: Principal Office Address: Official Representative: Individual Partnership (Circle One) Corporation
If a Corporation, answer this: When Incorporated: In what State: If a Foreign Corporation: Date of Registration with Florida Secretary of State: Name of Resident Agent: Address of Resident
Agent: President's Name: Vice-President's Name: Treasurer's Name:
8/3/09 31 of 43 RFP No 54-08/09 Workers’ Compensation Program Questionnaire (continued) Members of Board of Directors: _______________________________________________________________________
_______________________________________________________________________ _______________________________________________________________________ If a Partnership: _____________________________________
_________________________________ _______________________________________________________________________ Date of organization: General or Limited Partnership*: Name and Address of Each
Partner: NAME ADDRESS _____________________________________ _____________________________________ _____________________________________ _____________________________________ _________________________
___________ _____________________________________ * Designate general partners in a Limited Partnership 1. Number of years of relevant experience in operating same or similar business:_______________
_ 2. Have any agreements held by Proposer for for a project ever been canceled? Yes ( ) No ( ) If yes, give details on a separate sheet. 3. Has the Proposer or any principals of the
applicant organization failed to qualify as a responsible bidder/proposer, refused to enter into a contract after an award has been made, failed to complete a contract during the past
five (5) years, or been declared to be in default in any contract in the last 5 years? If yes, please explain: 4
8/3/09 32 of 43 RFP No 54-08/09 Workers’ Compensation Program 4. Has the Proposer or any of its principals declared bankrupt or reorganized under Chapter 11 or put into receivership?
Yes ( ) No ( ) If yes, give date, court jurisdiction, action taken, and any other explanation deemed necessary on a separate sheet. 5. Person or persons interested in this RFP and Qualification
Form have ( ) have not ( ) been convicted by a Federal, State, County, or Municipal Court of any violation of law, other than traffic violations. To include stockholders over ten percent
(10%). (Strike out inappropriate words) Explain any convictions: 6. Lawsuits (any) pending or completed involving the corporation, partnership or individuals with more than ten percent
(10%) interest: A. List all pending lawsuits: B. List all judgments from lawsuits in the last five (5) years: C. List any criminal violations and/or convictions of the Proposer and/or
any of its principals: 7. Conflicts of Interest. The following relationships are the only only potential, actual, or perceived conflicts of interest in connection with this Proposal:
(If none, state same.) 8. Public Disclosure. In order to determine whether the members of the Evaluation Committee for this Request for Proposals have any association or relationships
which would constitute a conflict of interest, either actual or perceived, with any Proposer and/or individuals and entities comprising or representing such Proposer and in an attempt
to ensure full and complete disclosure regarding this contract, all Proposers are required to disclose all persons and entities who may be involved with this Proposal. This list shall
include public relation firms, lawyers and lobbyists. The Procurement Division shall be notified in writing if any person or entity is added to this list after receipt of Proposals.
8/3/09 33 of 43 RFP No 54-08/09 Workers’ Compensation Program The Proposer understands that information contained in this Questionnaire will be relied upon by the City in awarding the
RFP, and such information is warranted by the Proposer to be true and accurate. The Proposer agrees to furnish such additional information, prior to acceptance of any Proposal, relating
to the qualifications of the Proposer, as may be requested by the City Manager. The Proposer further understands that the information contained in this Questionnaire may be confirmed
through a background investigation conducted by the City, through the Miami Beach Police Department. By submitting this Questionnaire the Proposer agrees to cooperate with this investigation,
including but not limited to, fingerprinting and providing information for a credit check. PROPOSER WITNESS: IF INDIVIDUAL: _____________________________________ _____________________________________
Signature Signature _____________________________________ _____________________________________ Print Name Print Name WITNESS: IF PARTNERSHIP: _____________________________________ __________________
__________________ Signature Print Name of Successful Proposer _____________________________________ _____________________________________ Print Name Address By: _____________________________________
General Partner _____________________________________ Print Name ATTEST: IF CORPORATION: _____________________________________ _____________________________________ Secretary Print Name
of Corporation _____________________________________ _____________________________________ Print Name Address By: _____________________________________ President (Print Name) (CORPORATE
SEAL) ___________________________________
8/3/09 34 of 43 RFP No 54-08/09 Workers’ Compensation Program CITY OF MIAMI BEACH DECLARATION: NONDISCRIMINATION IN CONTRACTS AND BENEFITS Section 1. Vendor Information Name of Company:
_________________________Name of Company Contact Person: __________________________ Phone Number: ______________________Fax Number: ____________________E-mail: ________________________
Vendor Number (if known): ________________________________________ Federal ID or Social Security Number: _______________________________ Approximate Number of Employees in the U.S. :___________(If
50 or less, skip to Section 4, date and sign) Are any of your employees covered by a collective bargaining agreement or union trust fund? ___Yes___No Union name(s): __________________________________
__________________________________________ Section 2. Compliance Questions Question 1. Nondiscrimination -Protected Classes A. Does your company agree to not discriminate against your
employees, applicants for employment, employees of the City, or members of the public on the basis of the fact or perception of a person’s membership in the categories listed below?
Please note: a “YES” answer means your company agrees it will not discriminate; a “NO” answer means your company refuses to agree that it will not discriminate. Please answer yes or
no to each category. Race _ Yes _ No Sex _Yes_ No Color _ Yes _ No Sexual orientation _ Yes _ No Creed _ Yes _ No Gender identity (transgender status) _ Yes _ No Religion _ Yes _ No
Domestic partner status _ Yes _ No National origin _ Yes _ No Marital status _ Yes _ No Ancestry _ Yes _ No Disability _ Yes _ No Age _ Yes _ No AIDS/HIV status _ Yes _ No Height _ Yes
_ No Weight _ Yes _ No B. Does your company agree to insert a similar nondiscrimination provision in any subcontract you enter into for the performance of a substantial portion of the
contract you have with the City? Please note: you must answer this question, even if you do not intend to enter into any subcontracts. _ Yes _ No
8/3/09 35 of 43 RFP No 54-08/09 Workers’ Compensation Program Question 2. Nondiscrimination -Equal Benefits for Employees with Spouses and Employees with Domestic Partners Questions
2A and 2B should be answered YES even if your employees must pay some or all of the cost of spousal or domestic partner benefits. A. Does your company provide or offer access to any
benefits to employees with spouses or to spouses of employees? _ Yes _ No B. Does your company provide or offer access to any benefits to employees with (same or opposite sex) domestic
partners* or to domestic partners of employees? _ Yes __No *The term Domestic Partner shall mean any two (2) adults of the same or different sex, who have registered as domestic partners
with a government body pursuant to state or local law authorizing such registration, or with an internal registry maintained by the employer of at least one of the domestic partners.
A Contractor may institute an internal registry to allow for the provision of equal benefits to employees with domestic partner who do not register their partnerships pursuant to a governmental
body authorizing such registration, or who are located in a jurisdiction where no such governmental domestic partnership exists. A Contractor that institutes such registry shall not
impose criteria for registration that are more stringent than those required for domestic partnership registration by the City of Miami Beach If you answered “NO” to both Questions 2A
and 2B, go to Section 4 (at the bottom of this page), complete and sign the form, filling in all items requested. If you answered “YES” to either or both Questions 2A and 2B, please
continue to Question 2C below. Question 2. (Continued) C. Please check all benefits that apply to your answers above and list in the “other” section any additional benefits not already
specified. Note: some benefits are provided to employees because they have a spouse or domestic partner, such as bereavement leave; other benefits are provided directly to the spouse
or domestic partner, such as medical insurance. Note: If you can not offer a benefit in a nondiscriminatory manner because of reasons outside your control, (e.g., there are no insurance
providers in your area willing to offer domestic partner coverage) you may be eligible for Reasonable BENEFIT Yes for Employees with Spouses Yes for Employees with Domestic Partners
No, this Benefit is Not Offered Documentation of this Benefit is Submitted with this Form Health ? ? ? ? Dental ? ? ? ? Vision ? ? ? ? Retirement (Pension, 401(k), etc.) ? ? ? ? Bereavement
? ? ? ? Family Leave ? ? ? ? Parental Leave ? ? ? ? Employee Assistance Program ? ? ? ? Relocation & Travel ? ? ? ? Company Discount, Facilities & Events ? ? ? ? Credit Union ? ? ? ?
Child Care ? ? ? ? Other ? ? ? ?
8/3/09 36 of 43 RFP No 54-08/09 Workers’ Compensation Program Measures compliance. To comply on this basis, you must agree to pay a cash equivalent, submit a completed Reasonable Measures
Application with all necessary attachments, and have your application approved by the City Manager, or his designee. Section 3. Required Documentation YOU MUST SUBMIT SUPPORTING DOCUMENTATION
to verify each benefit marked in Question 2C. Without proper documentation, your company cannot be certified as complying with the City’s Equal Benefits Requirement for Domestic Partner
Ordinance. For example, to document medical insurance submit a statement from your insurance provider or a copy of the eligibility section of your plan document; to document leave programs,
submit a copy of your company’s employee handbook. If documentation for a particular benefit does not exist, attach an explanation. Have you submitted supporting documentation for each
benefit offered? _Yes _ No Section 4. Executing the Document I declare under penalty of perjury under the laws of the State of Florida that the foregoing is true and correct, and that
I am authorized to bind this entity contractually. Executed this _______ day of __________, in the year _________, at _________________, ____ City State _____________________________________
___________________________________ Signature Mailing Address ___________________________________ ____________________________________ Name of Signatory (please print) City, State, Zip
Code _____________________________________ Title
8/3/09 37 of 43 RFP No 54-08/09 Workers’ Compensation Program CITY OF MIAMI BEACH REASONABLE MEASURES APPLICATION Declaration: Nondiscrimination in Contracts and Benefits Submit this
form and supporting documentation to the City’s Procurement Division ONLY IF you: a. Have taken all reasonable measures to end discrimination in benefits; and b. Are unable to do so;
and c. Intend to offer a cash equivalent for employees to whom equal benefits are not available. You must submit the following information with this form: 1. The names, contact persons
and telephone numbers of benefits providers contacted for the purpose of acquiring nondiscriminatory benefits; 2. The dates on which such benefits providers were contacted; 3. Copies
of any written response(s) you received from such benefits providers, and if written responses are unavailable, summaries of oral responses; and 4. Any other information you feel is
relevant to documenting your inability to end discrimination in benefits, including, but not limited to, reference to federal or state laws which preclude the ending of discrimination
in benefits. I declare (or certify) under penalty of perjury under the laws of the State of Florida that the foregoing is true and correct, and that I am authorized to bind this entity
contractually. _____________________________________ _____________________________________ Name of Company (please print) Mailing Address of Company _____________________________________
_____________________________________ Signature City, State, Zip _____________________________________ _____________________________________ Name of Signatory (please print) Telephone
Number _____________________________________ _____________________________________ Title Date
8/3/09 38 of 43 RFP No 54-08/09 Workers’ Compensation Program Definition of Terms A. REASONABLE MEASURES The City of Miami Beach will determine whether a City Contractor has taken all
reasonable measures provided by the City Contractor that demonstrates that it is not possible for the City Contractor to end discrimination in benefits. A determination that it is not
possible for the City Contractor to end discrimination in benefits shall be based upon a consideration of such factors as: (1) The number of benefits providers identified and contacted,
in writing, by the City Contractor, and written documentation from these providers that they will not provide equal benefits; (2) The existence of benefits providers willing to offer
equal benefits to the City Contractor; and (3) The existence of federal or state laws which preclude the City Contractor from ending discrimination in benefits. B. CASH EQUIVALENT “Cash
Equivalent” means the amount of money paid to an employee with a Domestic Partner (or spouse, if applicable) in lieu of providing Benefits to the employees’ Domestic partner (or spouse,
if applicable). The Cash Equivalent is equal to the employer’s direct expense of providing Benefits to an employee for his or her spouse. Cash Equivalent. The cash equivalent of the
following benefits applies: a. For bereavement leave, cash payment for the number of days that would be allowed as paid time off for death of a spouse. Cash payment would be in the form
of wages of the domestic partner employee for the number of days allowed. b. For health benefits, the cost to the Contractor of the Contractor’s share of the single monthly premiums
that are being paid for the domestic partner employee, to be paid on a regular basis while the domestic partner employee maintains the such insurance in force for himself or herself.
c. For family medical leave, cash payments for the number of days that would be allowed as time off for an employee to care for a spouse that has a serious health condition. Cash payment
would be in the form of wages of the domestic partner employee for the number of days allowed.
8/3/09 39 of 43 RFP No 54-08/09 Workers’ Compensation Program CITY OF MIAMI BEACH SUBSTANTIAL COMPLIANCE AUTHORIZATION FORM Declaration: Nondiscrimination in Contracts and Benefits This
form, and supporting documentation, must be submitted to the Procurement Division by entities seeking to contract with the City of Miami Beach that wish to delay ending their discrimination
in benefits pursuant to the Rules of Procedure, as set out below. Fill out all sections that apply. Attach additional sheets as necessary. A. Open Enrollment Ending discrimination in
benefits may be delayed until the first effective date after the first open enrollment process following the date the contract with the City begins, provided that the City Contractor
submits to the Procurement Division evidence that reasonable efforts are being undertaken to end discrimination in benefits. This delay may not exceed two years from the date the contract
with the City is entered into, and only applies to benefits for which an open enrollment process is applicable. Date next benefits plan year begins: Date nondiscriminatory benefits will
be available: Reason for Delay: Description of efforts being undertaken to end discrimination in benefits:
8/3/09 40 of 43 RFP No 54-08/09 Workers’ Compensation Program B. Administrative Actions and Request for Extension Ending discrimination in benefits may be delayed to allow administrative
steps to be taken to incorporate nondiscriminatory benefits into the City Contractor’s infrastructure. The time allotted for these administrative steps shall apply only to those benefits
for which administrative steps are necessary and may not exceed three months. An extension of this time may be granted at the discretion of the Procurement Director, upon the written
request of the City Contractor. Administrative steps may include, but are not limited to, such actions as computer systems modifications, personnel policy revisions, and the development
and distribution of employee communications. Description of administrative steps and dates to be achieved: If requesting extension beyond three months, please explain basis: C. Collective
Bargaining Agreements (CBA) Ending discrimination in benefits may be delayed until the expiration of a City Contractor’s Current collective bargaining agreement(s) where all of the following
conditions have been met: 1. The provision of benefits is governed by one or more collective bargaining agreement(s); 2. The City Contractor takes all reasonable measures to end discrimination
in benefits either by requesting that the Unions involved agree to reopen the agreements in order for the City Contractor to take whatever steps necessary to end discrimination in benefits
or by ending discrimination in benefits without reopening the collective bargaining agreements; and 3. In the event that the City Contractor cannot end discrimination in benefits despite
taking all reasonable measures to do so, the City Contractor provides a cash equivalent to eligible employees for whom benefits are not available. Unless otherwise authorized in writing
by the Procurement Director, this cash equivalent payment must begin at the time the Unions refuse to allow the collective bargaining agreements to be reopened, or in any case no longer
than three (3) months from the date the contract with the City is entered into.
8/3/09 41 of 43 RFP No 54-08/09 Workers’ Compensation Program For a delay to be granted
under this provision, written proof must be submitted with this form that: • The benefits for which the delay is requested are governed by a collective bargaining agreement; • All reasonable
measures have been taken to end discrimination in benefits (see Section C.2, above); and • A cash equivalent payment will be provided to eligible employees for whom benefits are not
available. I declare (or certify) under penalty of perjury under the laws of the State of Florida that the foregoing is true and correct, and that I am authorized to bind this entity
contractually. _____________________________________ _____________________________________ Name of Company (please print) Mailing Address of Company _____________________________________
_____________________________________ Signature City, State, Zip _____________________________________ _____________________________________ Name of Signatory (please print) Telephone
Number _____________________________________ _____________________________________ Title Date
8/3/09 42 of 43 RFP No 54-08/09 Workers’ Compensation Program City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov PROCUREMENT DIVISION
Tel: 305-673-7490, Fax: 786-394-4006 To: Phone: Fax: E-mail: Subject: Performance Evaluation of: __________________________________ Number of pages including cover: 2 To Whom It May
Concern: The City of Miami Beach has implemented a process that collects past performance information pursuant to the submittal of responses to this Request for Proposal (RFP) No. 54-08/09
entitled For Claims Administration Services for the City of Miami Beach Self-Insured Workers’ Compensation Program. The information will be used to assist City of Miami Beach in the
evaluation of Proposals received in response to the RFP. The company listed in the subject line has chosen to participate in this RFP. They have listed you as a past client for which
they have provided services. Both the company and City of Miami Beach would greatly appreciate you taking a few minutes of your time to complete the accompanying questionnaire. Please
review all items in the following document and answer the questions to the best of your knowledge. If you cannot answer a particular question, please leave it blank. Please return this
questionnaire to Pamela Leja by September 2, 2009 via fax: 786-394-4006; or email PamelaLeja@miamibeachfl.gov. Thank you for your time and effort. Gus Lopez, CPPO Procurement Director
8/3/09 43 of 43 RFP No 54-08/09 Workers’ Compensation Program City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov PROCUREMENT DIVISION
Tel: 305-673-7490, Fax: 786-394-4006 PERFORMANCE EVALUATION SURVEY RFP No. 54-08/09 Company Name: ____________________________________________________________________________ Point of
Contact: ____________________________________________________________________________ Phone and email: ___________________________________________________________________________ Please
evaluate the performance of the company (10 means you are very satisfied and have no questions about hiring them again, and 1 is if you would never hire them again because of very poor
performance). Please leave blank if you don’t know. NO. CRITERIA UNIT 1 Experience and qualifications in obtaining insurance coverage. (1-10) 2 Experience and knowledge of municipal
needs. (1-10) 3 Level of satisfaction with customer service (1-10) 4 Overall customer satisfaction and and hiring again based on performance (comfort level in hiring vendor again) (1-10)
Overall Comments: Company providing Referral: _____________________________________________ Contact Name: _____________________________________________ Contact Phone and e-mail: _____________________
______________ Date of Services: ____________________________________________ Dollar Amount for Services: __________________________________ Thank you for your time and effort. Please
return this form via fax to 786-394-4006 Attn: Pamela Leja, or via e-mail: pamelaleja@miamibeachfl.gov, on or before September 2, 2009.
649826-wl-excl-9-ind-med.xls Johns Eastern Company, Inc. Coverage: WorkComp City of Miami Beach Summary Loss Report Page 1 of 2 Valuation: 06/30/2009 Run Date: 7/30/2009 8:51:42 AM Processing
Complete at 7/30/2009 8:51:46 AM Data as of: 06/30/2009 Pol Effect Dt Pol Expire Dt File Type Line Type Tot Clms Open Clms Total Paid Reserve Bal Tot Incurred Recoveries Excess Recovs
Pol Effect Dt Pol Exp Dt File Type CYSHORTLBLTot Claims # Open TOTPAID RESERVEBAL TOTINCUR RECOV EXCRECOV 10/01/86 09/30/87 W REPORT 53 0 $ -$ -$ -$ -$ -10/01/87 09/30/88 W REPORT 114
0 $ -$ -$ -$ -$ -10/01/88 09/30/89 W REPORT 116 0 $ -$ -$ -$ -$ -10/01/89 09/30/90 W REPORT 112 0 $ -$ -$ -$ -$ -10/01/90 09/30/91 W REPORT 110 0 $ -$ -$ -$ -$ -10/01/91 09/30/92 W REPORT
111 0 $ -$ -$ -$ -$ -10/01/92 09/30/93 W REPORT 68 0 $ -$ -$ -$ -$ -10/01/93 09/30/94 W REPORT 69 0 $ -$ -$ -$ -$ -10/01/94 09/30/95 W REPORT 33 0 $ -$ -$ -$ -$ -10/01/95 09/30/96 W
REPORT 46 0 $ -$ -$ -$ -$ -10/01/96 09/30/97 W REPORT 29 0 $ -$ -$ -$ -$ -10/01/97 09/30/98 W REPORT 56 0 $ -$ -$ -$ -$ -10/01/98 09/30/99 W REPORT 38 0 $ -$ -$ -$ -$ -10/01/99 09/30/00
W REPORT 5 0 $ -$ -$ -$ -$ -10/01/02 09/30/03 W REPORT 1 0 $ -$ -$ -$ -$ -10/01/03 09/30/04 W REPORT 1 0 $ -$ -$ -$ -$ -10/01/04 09/30/05 W REPORT 11 0 $ -$ -$ -$ -$ -10/01/05 09/30/06
W REPORT 10 0 $ 12.50 $ -$ 12.50 $ -$ -10/01/06 09/30/07 W REPORT 16 0 $ 25.75 $ -$ 25.75 $ -$ -10/01/07 09/30/08 W REPORT 14 0 $ 13.75 $ -$ 13.75 $ -$ -10/01/08 09/30/09 W REPORT 8
0 $ 13.75 $ -$ 13.75 $ -$ -REPORT ONLY Totals 1,021 0 $ 65.75 $ -$ 65.75 $ -$ -Paid/Reserve/Incurred dollar figures are gross -they have NOT been reduced by recovery figures provided.
Data Source: prpt Policy Set: Y
649826-wl-excl-9-ind-med.xls Johns Eastern Company, Inc. Coverage: WorkComp City of Miami Beach Summary Loss Report Page 2 of 2 Valuation: 06/30/2009 Run Date: 7/30/2009 8:51:42 AM RECOVERIES
-Include Subrogation (WC/LB), Salvage, Indemnify, Controvert, Deductible (LB), SDTF (Special Disability Trust Fund) (WC) EXCESS RECOVS -Includes only Excess type recoveries Data Source:
prpt Policy Set: Y
649826-wl-excl-9-ind-med.xls Johns Eastern Company, Inc. Coverage: WorkComp City of Miami Beach Summary Loss Report Page 1 of 2 Valuation: 06/30/2009 Run Date: 7/30/2009 8:51:42 AM Processing
Complete at 7/30/2009 8:51:46 AM Data as of: 06/30/2009 Pol Effect Dt Pol Expire Dt File Type Line Type Tot Clms Open Clms Total Paid Reserve Bal Tot Incurred Recoveries Excess Recovs
10/01/73 09/30/74 W MEDICAL 1 0 $ 393.13 $ -$ 393.13 $ -$ -10/01/76 09/30/77 W MEDICAL 1 1 $ 278,618.21 $ 38,381.79 $ 317,000.00 $ -$ -10/01/86 09/30/87 W MEDICAL 346 1 $ 76,505.83 $
43,016.19 $ 119,522.02 $ 709.52 $ -10/01/87 09/30/88 W MEDICAL 351 0 $ 146,523.61 $ -$ 146,523.61 $ -$ -10/01/88 09/30/89 W MEDICAL 333 0 $ 106,305.23 $ -$ 106,305.23 $ 4,097.88 $ -10/01/89
09/30/90 W MEDICAL 399 1 $ 164,310.00 $ 11,581.68 $ 175,891.68 $ 1,746.00 $ -10/01/90 09/30/91 W MEDICAL 320 1 $ 241,582.46 $ 20,483.49 $ 262,065.95 $ 3,244.78 $ -10/01/91 09/30/92 W
MEDICAL 363 11 $ 642,076.05 $ 109,613.46 $ 751,689.51 $ -$ -10/01/92 09/30/93 W MEDICAL 418 0 $ 156,298.97 $ -$ 156,298.97 $ 353.03 $ -10/01/93 09/30/94 W MEDICAL 486 0 $ 148,272.75
$ -$ 148,272.75 $ 130.90 $ -10/01/94 09/30/95 W MEDICAL 543 2 $ 233,239.74 $ 28,281.45 $ 261,521.19 $ -$ -10/01/95 09/30/96 W MEDICAL 567 2 $ 336,196.61 $ 11,624.91 $ 347,821.52 $ 182.75
$ -10/01/96 09/30/97 W MEDICAL 528 5 $ 393,873.49 $ 60,012.62 $ 453,886.11 $ -$ -10/01/97 09/30/98 W MEDICAL 496 1 $ 290,126.74 $ 16,848.64 $ 306,975.38 $ -$ -10/01/98 09/30/99 W MEDICAL
358 4 $ 227,352.46 $ 46,077.12 $ 273,429.58 $ -$ -10/01/99 09/30/00 W MEDICAL 431 6 $ 357,354.30 $ 50,783.86 $ 408,138.16 $ 3,235.63 $ -10/01/00 09/30/01 W MEDICAL 361 6 $ 420,306.24
$ 75,782.58 $ 496,088.82 $ -$ -10/01/01 09/30/02 W MEDICAL 345 12 $ 507,537.51 $ 93,503.99 $ 601,041.50 $ -$ -10/01/02 09/30/03 W MEDICAL 336 11 $ 463,688.80 $ 114,473.44 $ 578,162.24
$ 2,838.00 $ -10/01/03 09/30/04 W MEDICAL 321 9 $ 437,870.25 $ 73,317.61 $ 511,187.86 $ 2,102.06 $ -10/01/04 09/30/05 W MEDICAL 327 11 $ 540,879.14 $ 101,146.37 $ 642,025.51 $ -$ -10/01/05
09/30/06 W MEDICAL 325 8 $ 454,701.92 $ 94,716.71 $ 549,418.63 $ 161.00 $ -10/01/06 09/30/07 W MEDICAL 261 14 $ 334,061.91 $ 98,078.79 $ 432,140.70 $ -$ -10/01/07 09/30/08 W MEDICAL
266 30 $ 313,836.00 $ 1 05,955.27 $ 419,791.27 $ -$ -10/01/08 09/30/09 W MEDICAL 171 63 $ 147,387.19 $ 97,571.01 $ 244,958.20 $ -$ -Medical Only Total 8,654 199 $ 7,419,298.54 $ 1,291,250.98
$ 8,710,549.52 $ 18,801.55 $ -Data Source: prpt Policy Set: Y
649826-wl-excl-9-ind-med.xls Johns Eastern Company, Inc. Coverage: WorkComp City of Miami Beach Summary Loss Report Page 2 of 2 Valuation: 06/30/2009 Run Date: 7/30/2009 8:51:42 AM Paid/Reserve/Incur
ed dollar figures are gross -they have NOT been reduced by recovery figures provided. RECOVERIES -Include Subrogation (WC/LB), Salvage, Indemnify, Controvert, Deductible (LB), SDTF (Special
Disability Trust Fund) (WC) EXCESS RECOVS -Includes only Excess type recoveries Data Source: prpt Policy Set: Y
649826-wl-excl-9-ind-med.xls Johns Eastern Company, Inc. Coverage: WorkComp City of Miami Beach Summary Loss Report Page 1 of 2 Valuation: 06/30/2009 Run Date: 7/30/2009 8:51:42 AM Processing
Complete at 7/30/2009 8:51:46 AM Data as of: 06/30/2009 Pol Effect Dt Pol Expire Dt File Type Line Type Tot Clms Open Clms Total Paid Reserve Bal Tot Incurred Recoveries Excess Recovs
10/01/57 09/30/58 W INDEMNITY 1 1 $ 232,494.67 $ 24,133.33 $ 256,628.00 $ -$ -10/01/71 09/30/72 W INDEMNITY 1 0 $ 91,000.15 $ -$ 91,000.15 $ -$ -10/01/73 09/30/74 W INDEMNITY 1 0 $ 13,328.76
$ -$ 13,328.76 $ -$ -10/01/74 09/30/75 W INDEMNITY 1 0 $ 33,820.45 $ -$ 33,820.45 $ -$ -10/01/86 09/30/87 W INDEMNITY 128 1 $ 980,698.52 $ 49,649.60 $ 1,030,348.12 $ 24,894.10 $ -10/01/87
09/30/88 W INDEMNITY 112 1 $ 1,768,147.22 $ 30,495.92 $ 1,798,643.14 $ 3,500.00 $ 260,740.92 10/01/88 09/30/89 W INDEMNITY 75 4 $ 2,571,398.62 $ 460,235.59 $ 3,031,634.21 $ 6,395.74
$ 799,917.32 10/01/89 09/30/90 W INDEMNITY 71 2 $ 2,433,847.46 $ 338,502.09 $ 2,772,349.55 $ 573,845.01 $ 394,952.44 10/01/90 09/30/91 W INDEMNITY 68 5 $ 3,973,874.91 $ 542,423.75 $
4,516,298.66 $ 51,428.44 $ 2,168,428.86 10/01/91 09/30/92 W INDEMNITY 71 7 $ 2,145,450.71 $ 665,217.92 $ 2,810,668.63 $ 25,244.04 $ -10/01/92 09/30/93 W INDEMNITY 75 7 $ 2,011,605.02
$ 897,169.89 $ 2,908,774.91 $ 24,223.83 $ 149,030.46 10/01/93 09/30/94 W INDEMNITY 54 6 $ 2,475,178.38 $ 558,818.88 $ 3,033,997.26 $ 230,885.44 $ 46,912.68 10/01/94 09/30/95 W INDEMNITY
64 3 $ 1,737,149.26 $ 58,055.23 $ 1,795,204.49 $ 6,700.00 $ 209,825.69 10/01/95 09/30/96 W INDEMNITY 62 8 $ 3,205,713.36 $ 896,717.78 $ 4,102,431.14 $ 100,428.39 $ 288,860.59 10/01/96
09/30/97 W INDEMNITY 71 11 $ 2,403,529.99 $ 740,812.00 $ 3,144,341.99 $ 12,000.00 $ 630,794.75 10/01/97 09/30/98 W INDEMNITY 55 5 $ 711,649.48 $ 222,122.88 $ 933,772.36 $ 400.00 $ -10/01/98
09/30/99 W INDEMNITY 68 3 $ 752,034.57 $ 116,461.99 $ 868,496.56 $ -$ -10/01/99 09/30/00 W INDEMNITY 73 7 $ 1,524,974.89 $ 447,286.18 $ 1,972,261.07 $ 9,697.65 $ -10/01/00 09/30/01 W
INDEMNITY 64 8 $ 1,534,325.84 $ 642,409.26 $ 2,176,735.10 $ 60,000.00 $ -10/01/01 09/30/02 W INDEMNITY 78 16 $ 2,943,401.20 $ 1,277,274.20 $ 4,220,675.40 $ -$ -10/01/02 09/30/03 W INDEMNITY
54 7 $ 1,383,927.83 $ 673,263.35 $ 2,057,191.18 $ 3,158.20 $ -10/01/03 09/30/04 W INDEMNITY 72 7 $ 1,246,973.01 $ 250,376.65 $ 1,497,349.66 $ 4,211.28 $ -10/01/04 09/30/05 W INDEMNITY
90 15 $ 2,216,019.16 $ 437,694.24 $ 2,653,713.40 $ 4,492.03 $ -10/01/05 09/30/06 W INDEMNITY 100 12 $ 1,499,126.72 $ 327,049.92 $ 1,826,176.64 $ 27,000.00 $ -10/01/06 09/30/07 W INDEMNITY
133 17 $ 1,570,291.88 $ 626,369.59 $ 2,196,661.47 $ 2,500.00 $ -10/01/07 09/30/08 W INDEMNITY 137 30 $ 1,668,583.81 $ 911,988.39 $ 2,580,572.20 $ -$ -10/01/08 09/30/09 W INDEMNITY 96
53 $ 601,906.27 $ 1,181,957.07 $ 1,783,863.34 $ -$ -Indemnity Total 1,875 236 $43,730,452.14 $12,376,485.70 $56,106,937.84 $1,171,004.15 $ 4,949,463.71 Data Source: prpt Policy Set:
Y
649826-wl-excl-9-ind-med.xls Johns Eastern Company, Inc. Coverage: WorkComp City of Miami Beach Summary Loss Report Page 2 of 2 Valuation: 06/30/2009 Run Date: 7/30/2009 8:51:42 AM Paid/Reserve/Incur
ed dollar figures are gross -they have NOT been reduced by recovery figures provided. RECOVERIES -Include Subrogation (WC/LB), Salvage, Indemnify, Controvert, Deductible (LB), SDTF (Special
Disability Trust Fund) (WC) EXCESS RECOVS -Includes only Excess type recoveries Data Source: prpt Policy Set: Y