HomeMy WebLinkAboutCA Liability Claims Administration ServicesCLAIMS ADJUSTING AND ADMINISTRATION
SERVICE CONTRACT
This contract is made and entered into this 1st day of July 2019 by and between the CITY OF
SAN RAFAEL, hereinafter referred to as "CLIENT", and GEORGE HILLS COMPANY, INC.,
hereinafter referred to as "GH".
GH is a California Corporation doing business as licensed, independent insurance adjusters and
administrators, with John Chaquica, CEO, responsible for contract compliance and terms. Chris
Shafer, Vice President Claims Administration, shall oversee the daily operations. The
company's corporate office is located at 3043 Gold Canal Dr, Suite 200, Rancho Cordova,
California, 95670, telephone, (916) 859-4800.
The CLIENT is the City of San Rafael, located at 1400 Fifth Avenue, San Rafael, CA 94901.
IT IS HEREBY AGREED by and between the parties signing this contract as follows:
I. GENERAL
CLIENT is desirous of availing itself of liability claims adjusting and administration
services. GH is a Third -Party Claims Administrator handling self-insured claims and is
ready to and capable of performing such services. As such, GH may act as a
representative of the CLIENT when directed for the investigation, adjustment,
processing, and evaluation of general liability, motor vehicle, and potential money
damage claims or incidents filed by third parties against the CLIENT, or against parties
for whom the CLIENT is alleged to be legally responsible, which are premised upon
allegations of willful, intentional, negligent, or careless acts and/or omissions
("CLAIMS".).
II. SCOPE OF SERVICES
GH agrees to provide complete claim handling services on each accident or incident, as
directed by CLIENT. Each CLAIM will be subject to the GH Client Expressed Scope of
Work Standards and Instructions form in practice at that time. CLIENT shall determine
the scope of services to be provided by GH by signing the Client Expressed Scope of
Work Standards and Instructions for each contract. The Client Expressed Scope of
Work Standards and Instructions form shall be the controlling document for the scope of
claims adjusting services to be provided by GH for CLIENT. Services to be provided by
GH on behalf of CLIENTS for a CLAIM may include all or some of the following:
A. INVESTIGATIVE SERVICES
1) Receipt and examination of all reports of accidents or incidents that are or
may be the subject of claims.
2) Investigate accidents or incidents as warranted, to include on-site
investigation, photographs, witness interviews, determination of losses
and other such investigative services necessary to determine all CLIENT
losses but not to include extraordinary investigative services outside the
expertise of GH.
3) In the event CLIENT or other agency conducts any investigation, GH shall
review for completeness.
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4) Maintain service on a 24-hour, 7 days per week basis, to receive reports
of any incident or accident which may be the subject of a liability claim
and provide immediate investigative services to the extent necessary to
provide a complete investigation.
5) Undertake items of investigation requiring special handling for CLIENT at
the direction of the CLIENT's Attorney or authorized representative.
B. LIABILITY CLAIM HANDLING SERVICES
1) Promptly set up a claim file upon receipt of the claim and maintain a claim
file on each potential or actual claim reported.
2) Assess and evaluate the nature and extent of each claim and establish
claims reserves for indemnity and legal expense.
3) GH will follow any CLIENT policy regarding rejection instructions,
individual to send the rejection and if a denial letter should be sent
simultaneously.
4) Ensure timely claim handling, including contact and follow-up with
claimants regarding claim issues and processing.
5) Any bodily injury claim that is being pursued shall be indexed. Notice only
matters or precautionary bodily injury claims that are not pursued do not
need to be indexed.
6) Determine the need for defense representation, recommend legal
counsel, and manage litigation activity.
7) Report claims to the excess insurer in compliance with excess carrier's
reporting requirements and coordinate with the excess insurer on a
claim's progress in accordance with the excess insurer's reporting
requirements.
8) Maintain records on any such claim and notify CLIENT when CLIENT is
about to exhaust the Self -Insured Retention.
9) Obtain settlement contracts and releases upon settlement of claims or
potential claims not in litigation.
10) Perform periodic quality control reviews of CLIENT and excess insurance
(if applicable) statutory requirements to ensure compliance.
11) Perform the necessary data gathering for the Medicare, Medicaid, and
SCHIP Extension Act of 2007 (MMSEA) and the Set Aside Contracts in
compliance with Section 111 of the MMSEA including the required
reporting. (See Attachment B)
12) To the extent there is privileged information shared between agencies,
which is subject to protection under the HIPAA/PHI Act, GH shall
implement all necessary measures in compliance with the Act, via a
Business Associates Agreement (BAA) to be issued by the CLIENT.
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13) GH shall notify CLIENT via electronic mail at such time a file has been
closed.
C. LEGAL SUPPORT SERVICES
1) Upon notification by the CLIENT that litigation has been filed on an open
claim, GH shall follow the litigation referral process as outlined in the
Client Expressed Scope of Work Instructions form.
2) Obtain and maintain a Litigation Plan and Budget.
3) Review legal bills for compliance with Litigation Plan and reasonableness.
4) Cooperate with and assist any defense counsel assigned to litigation of
open claims and provide such investigative services as directed during
pre-trial and trial stages.
5) Assist in responding to discovery or preparing discovery.
6) At the request of the CLIENT, attend mandatory settlement conferences
on behalf of CLIENT.
7) Appear on behalf of CLIENT in small claims actions filed against CLIENT
on open claims handled by GH.
8) Review, evaluate and adjust defense counsel invoices for services.
9) Regularly discuss, review, and direct investigation issues, discovery, and
case strategy with counsel.
10) Review and evaluate case evaluations, correspondence and status
reports forwarded to GH by counsel.
11) Cooperate with counsel as a team with an open communication approach
on each case to obtain the most economical and best result for the
CLIENT.
D. REPORTS AND PROCEDURES:
1) Within thirty (30) days of assignment, or sooner if practicable, required, or
requested, GH will provide CLIENT with a full factual report pursuant to
specified claims handling instructions, showing name(s) of claimant(s),
type of claim, date of loss, comments on liability, reserve
recommendations, settlement recommendations, and other pertinent
information. Subsequent to the initial thirty (30) day report, the GH will
report as often as warranted by any important change in status but no
longer than every (90) days until the claim closes unless extended diary is
appropriate.
2) All original reports, documents, and claim data of every kind or
description, that are prepared in whole or in part by or for the GH in
connection with this contract shall be CLIENT's property and constitute
the GH's work product for which compensation is paid. A copy of all
reports, documents, and claim data of every kind or description that is in
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whole or in part by or for the CLIENT is the property of the GH. Additional
copies of original reports, documents, and data requested by the CLIENT
will be at the CLIENT's expense in accordance with this contract.
3) GH agrees that CLIENT have access and the right to audit and reproduce
any of the GH's relevant records to ensure that the CLIENT is receiving
all services to which the CLIENT is entitled under this Contract or for any
purpose relating to the Contract.
4) CLIENT shall provide GH with written authorization allowing any other
agency or person to obtain similar access to confidential information as
noted in 3 above. Such authorization is inclusive of HIPAA Act or PHI
privileged information.
E. DATA
1) Utilize its claims system—CXP (Claims Xpress).
2) Record all claim information including all financial data.
3) Provide CLIENT and broker Read only on-line access to the claims data
system, if desired by CLIENT. (up to five users)
4) Provide monthly standard loss run and check register.
5) Provide annual claims data report upon request. Written authorization
may be required for confidential information.
6) Provide assistance to CLIENT in developing customized reports when
requested (may require additional charge).
7) Arrange for electronic file conversion for any open and closed claims at
the direction of CLIENT.
F. CLAIM REVIEW MEETINGS
GH shall, on a mutually agreed periodic basis, meet with Client to review and
discuss claims inventory and claims results of past period and delivery of
services by CLAIM ADMINISTRATOR.
G. FINANCIAL ACCOUNTING
1) Establish and maintain a trust fund for the purpose of paying indemnity
and expenses that may be due on the claims. The amount to be
maintained in the trust fund shall be determined by the Client.
2) Maintain a copy of all checks drawn by the GH to pay claims and claims
related expenses.
3) Submit monthly check registers of all transactions made for the period.
4) Complete or update Attachment B "Preferred Method of Check
Processing" for check processing options.
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5) Approval process shall be documented in GH Client Expressed Scope of
Work Standards and Instruction Form.
6) GH will provide monthly bank reconciliation reports to CLIENT for audit
purposes.
H. SUBROGATION SERVICES
GH is a claim administrative firm experienced in the handling of subrogation
claims and is ready and capable of performing such services. CLIENT may retain
GH for Subrogation Services by signing a separate agreement, an example of
which is attached hereto as Exhibit A. Such services are distinct from
subrogating a loss from an additional insured from a claim filed by a third party.
Our services are unique to a first party loss of the CLIENT caused by the
intentional or negligent act of a third party. Such losses generally are for the
recovery of damages, loss, and/or additional types of damages.
• Labor costs, fully loaded and including benefit costs, for district or other
personnel responding to or in any manner providing services;
■ Services or materials provided by outside vendors or contractors;
Internal or external Vehicle or equipment use and/or rental;
• Materials and/or goods utilized for the repair/replacement of damaged
property; and/or
• Additional fees that may be specific to the individual entity that are
provided for within district ordinances or other governing document.
III. DENIAL, COMPROMISE OR SETTLEMENT OF CLAIMS
It is agreed that CLIENT has granted $0 authority to GH for the purpose of
compromising, settling, and paying any claims against CLIENT being handled by GH.
GH will issue payment for legal expenses as defined in the Client Expressed Scope of
Work form. Prior approval to compromise or settle any claim, or pay any expense will be
obtained from the designated claims officer or employee on matters exceeding the
authority granted above.
IV. FILE RETENTION
GH shall electronically retain CLIENT's records consistent with CLIENT's retention policy
or up to a maximum of seven (7) years whichever is shorter. CLIENT and GH may agree
via a separate signed agreement to retain records for a longer period of time.
V. CONFIDENTIALITY
All data, documents, discussions, or other information developed or received by or for
GH in PERFORMANCE of this contract are confidential and not to be disclosed to any
person except as authorized by CLIENT or CLIENT's designee, or as required by law.
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VI. CONFLICT OF INTEREST
In the event GH receives a claim from the CLIENT in which there arises a "conflict of
interest," GH shall immediately notify CLIENT. CLIENT may then, at their expense
choose to hire another well-qualified claims firm to handle that particular claim to a
conclusion. GH covenants that it presently knows of no interest, direct or indirect, which
would conflict in any manner with the performance of services required under this
contract.
VII. CLIENT RESPONSIBILITY
CLIENT agrees to the following.
1) CLIENT shall cooperate with GH as reasonably necessary for GH to perform its
services
2) CLIENT agrees to provide direction to GH as requested regarding particular
project requirements.
3) CLIENT shall identify a primary contact person(s) for an account as well as for
billing and loss run submission. In addition, CLIENT shall be responsible for
reporting all changes in the primary point of contact to GH.
4) CLIENT shall be responsible for reporting all Bodily Injury Claims in addition to all
other items noted in Attachment B to this Agreement "Medicare, Medicaid, and
SCHIP Extension Act of 2007 (MMSEA)"
5) CLIENT shall be responsible for updating GH on any changes to coverage/policy
language; including limits, retentions/deductibles and coverage changes by April
30 of each year.
6) CLIENT shall obtain any necessary consent in the collection of any CLIENT data
that is transmitted to a third party (ie. actuary or auditor). CLIENT shall provide
GH with reasonable assurances that it has the necessary consent to transmit
CLIENT data to a third party. CLIENT acknowledges that the claims data may
contain confidential and/or protected health information. In the event CLIENT
authorizes and directs GH to provide claims data to a third party, CLIENT will
indemnify, defend and hold harmless GH from and against all claims, damages,
losses and expenses, including court costs and reasonable attorneys' fees,
arising out of or resulting from:(i) any action against GH that is based on any
negligent act or omission of CLIENT or a third party in transmitting and/or
disclosing the claims data; or (ii) the violation of any statute, ordinance, or
regulation by CLIENT or a third party in transmitting and/or disclosing the claims
data.
VIII. COMPENSATION
CLIENT agrees to pay GH for services described in Section II — Scope of Services.
Adjuster fees will be incurred only when necessarily required in the form of adjuster's
fees as delineated in Section II, Scope of Services and will be invoiced as worked.
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1) Adjuster fees will be as follows:
a. Annual Flat Fee as follows:
• FY19-20 $89,500
The above compensation shall apply to services provided during the year
of this contract. Compensation for services provided during subsequent
years shall be re -negotiated as a result of services or other factors
unanticipated by either party.
b. Compensation: Is based on the Client Expressed Scope of Work
Instructions form, completed and signed by CLIENT. In the event claims
volume has deviated from information provided due to being incomplete,
inaccurate, or claims being re -opened additional fees shall be discussed
to reconcile with scope of services. (Applicable to Flat Fee and Time and
Expense with a Cap billing)
c. Auto Expense: Standard IRS rate
d Claims Processor: Should there be a need for a Claims Processor, the
rate shall be $70* per hour.
e. Allocated file expenses to be paid at cost. (See Attachment D)
f. Custom reporting beyond the above will be furnished upon request at an
additional cost to be agreed upon by the GH and CLIENT.
g. Catastrophic: Should a catastrophic event occur resulting in 10 or more
claimants or claims from a single occurrence, CLIENT shall be billed as
follows:
0 Time and Expense at a rate of $95*.
2) Startup Fee: N/A.
There is a one-time startup fee to include, but not limited to, onboarding process
and documentation, data entry, location code hierarchy setup, report template
creation, new client setup — bank account, vendors, W-9, etc.
3) MMSEA Reporting Fee(s):
a. One-time CMS setup fee (paid to ExamWorks): $150 N/A
b. Annual Account Maintenance/Reporting Fee (paid to ExamWorks): $250
4) Annual Administration Fee as Follows:
• FY19-20 $3,600
And shall be for the following:
a. Data access to claims data system.
b. Monthly listing of open claims by date of loss, department, location, and
alpha by name showing expense categories, reserves and total incurred.
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c. Monthly claim summary reports, within 15 days of month-end
d. Provide loss run data required reports and respond to/discuss with
actuaries and auditors (claims and financials).
e. Provide annual reports to outside agencies.
f. Financial accounting if applicable.
g. Filing of regulatory reports such as 1099, W-9, etc.
5) Legal Services and Consultation (Optional):
a. Litigation Management: $_N/A_* p/hour
These services include the oversight of all assigned claims adjusters and
monitoring and handling of "watch list" (highest exposure, most complex
litigation). These services are also available on a claim by claim basis in
support of the Lead Adjuster assigned due to the complexity of the
claims.
b. Monitoring Counsel: $ _N/A* p/hour
This case specific service includes evaluating coverage issues,
monitoring claim and litigation strategy, analyzing liability and damage
issues, participating in discussions regarding resolution by trial or
settlement, and controlling costs.
c. Outside General and Special Counsel: $_N/A* p/hour
These services include confidential analysis and problem solving for
managing risk and avoiding unnecessary litigation and provides
immediate access to legal advice This includes analyzing coverage
issues, Public Records Act Requests, tort claim handling and strategy,
conflicts of interest, oversight of outside litigation counsel and providing
legal opinions on potential and active litigation.
d. Coverage Counsel: $_N/A* p/hour
These services include review and analysis of memorandums of
coverage and excess/umbrella policies to address and offer advice and
consultation regarding coverage issues.
e. Trial/Mediation/Board Meetings Attendance: $ N/A* p/hour
These services include attending Board Meetings, trial, mediation, and
other court hearing attendance including appearing before Courts of
Appeal. Analysis and consultation provided before, during and after these
significant litigation events can reduce exposure and maximize
opportunities for resolution.
Legal Training and Seminars:$N/A* p/hour
These services include providing customized seminars and training upon
request. Subject areas include memorandums of coverage, all aspects of
risk management, claims handling and litigation, employment law and
general liability claims. Courses are customized to address the client's
specific needs.
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NOTE: These services are traditionally Time and Expense; however, an
annual fee can be considered.
6) Conversion Fee: $0
GH will charge for any services related to conversion storage, copying, scanning,
shipping and disposal. This fee is intended to cover costs associated with data
conversion, transition, and contract close out. The data conversion fee is
dependent on many factors which will need to be discussed. ON/A
7) The above compensation shall apply to services provided during the term of this
contract. Any changes in the terms of compensation shall be submitted to
CLIENT by June 15t each year. Submission changes in the terms of
compensation shall be in writing and subject to mutual agreement that shall be
an amendment to this Agreement.
8) A General Administrative File shall be established and maintained to track effort
related to services necessary to fulfill the contractual obligations not otherwise
associated to a claim.
9) *GH Hourly Rate — The hourly rates identified in this Agreement are subject to an
annual COLA of up to 3%.
IX. PAYMENT SCHEDULE
GH will submit its invoices to CLIENT, and payment shall be made by CLIENT, within a
reasonable period of time, not to exceed thirty (30) days from the date of the invoice.
X. TERM AND TERMINATION
The term of this contract shall commence on July 1, 2019 through and including June
30, 2020. Either party may terminate this contract for any reason upon issuing a 90 day
written notice to the other party.
Termination for Convenience: CLIENT may at any time and for any reason terminate this
Agreement upon ninety (90) days written notice to GH. Notice shall be deemed served
on the date of mailing. Upon receipt of such notice, GH shall immediately discontinue
services in connection with the scope of services of this Agreement. Upon such
termination, GH shall be entitled to payment from CLIENT for services completed and
provided prior to notice of termination, at GH's current hourly rate.
Upon completion of data conversion and return of data back to CLIENT (electronic
and/or hard copy), GH will destroy any remaining files.
XI. FAIR EMPLOYMENT
It is the policy of GH to provide fair and equal treatment to all staff members. GH is an
Equal Opportunity Employer and does not discriminate in any way against any person
on the basis of age, race, sex, color, national origin, national ancestry, physical disability,
medical condition, mental disability, religion, creed, marital status, sexual orientation,
gender identification, gender expression, use of family care leave or any other
classification deemed protected by law.
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XII. INDEPENDENT CONTRACTOR
In performing claims administrative services herein agreed upon, GH shall have the
status of an independent contractor and shall not be deemed to be an officer, employee,
or agent of CLIENT.
X111. INDEMNIFICATION
GH will defend, indemnify, and hold harmless CLIENT from and against all claims,
demands, actions, or causes of action, which may arise, from the action, conduct, or
failure to act by GH personnel ("Indemnity Event"). For an Indemnity Event, the
maximum amount recoverable by CLIENT against GH for damages and costs (inclusive
of attorneys' fees) is limited to the insurance policy limits in place at the time of the
Indemnity Event.
In those cases wherein the GH is named in a filed or verified complaint simply by virtue
of the fact it is the CLAIMS ADMINISTRATION firm on a given claim, the CLIENT will
defend the GH, at no cost to the GH; CLIENT will defend, indemnify, and hold harmless
the GH from and against all claims, demands, actions, or causes of action, which may
arise, from the action, conduct, or failure to act by CLIENT.
XIV. INSURANCE
The GH shall provide CLIENT with Certificates of Insurance duly executed by an
insurance company or companies authorized to transact business in the State of
California, and said Certificates shall certify that the GH has in full force and effect: (1)
$1,000,000 coverage applying to bodily injury, personal injury, property damage; (2)
$1,000,000 coverage applying to errors and omissions; (3) statutory limits for workers
compensation coverage; and (4) GH shall maintain an employee fidelity bond in the
amount of $500,000, (5) GH shall name CLIENT as additional insured by separate
endorsement.
GH will provide thirty (30) days written notice, prior to the cancellation or reduction in
insurance coverage will be provided.
XV. EMPLOYEE SOLICITATION
During the period of this contract, and for a period of one (1) year thereafter, GH agrees
not to solicit for employment any CLIENT employee contacted during the performance of
this contract; CLIENT agrees not to solicit for employment, or employ, during the period
of this contract, and for a period of one (1) year thereafter, any employee of GH
contacted by the CLIENT during the performance of this contract.
XVI. PERMITS, LICENSES, CERTIFICATES
GH, at GH'S sole expense, shall obtain and maintain during the term of this Contract, all
permits, licenses, and certificates required in connection with the performance of
services under this Contract, including appropriate business license.
XVII. ARBITRATION
GH and CLIENT agree that in the event of any dispute with regard to the provisions of
the Contract, the services rendered or the amount of GH'S compensation the dispute
shall be submitted to arbitration upon mutual contract of the parties, under such
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procedures as the parties may agree upon, or, if the parties cannot agree, then under
the Rules of the American Arbitration Association,
XVIII. NOTICES
All notices to GH shall be personally served or mailed, postage prepaid, to the following
address:
GH
George Hills Company
Attn: John Chaquica, CEO
3043 Gold Canal Drive, Suite 200,
Rancho Cordova, CA 95670
All notices to the CLIENT shall be personally served or mailed, postage prepaid, to the
following address:
Client: Copy to:
Lisa A. Goldfien
Assistant City Attorney
City of San Rafael
1400 Fifth Avenue
San Rafael, CA 94901
GH and CLIENT agree that the terms and conditions of the Contract may be reviewed or
modified at any time. Any modifications to this Contract, however, shall be effective only
when agreed to in writing by both the CLIENT and GH.
XIX. ENTIRE CONTRACT
GH and CLIENT agree that this contract constitutes the entire contract of the parties
regarding the subject matter described herein and supersedes all prior communications,
contracts, and promises, either written or oral.
XX. TIME OF ESSENCE
Time is of the essence in respect to all provisions of this Contract that specify a time for
performance: provided, however that the foregoing shall not be construed to limit or
deprive a party of the benefits of any grace or use period allowed in this Contract.
3 / q BY: 05
Date V John E. Chaquica, CEO
FORGE HILLS COMPANY INC.
$I22I2011 BY:
Date( ) Ji Schutz, City Manager
UJ ITY OF SAN RAFAEL
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ATTACHMENT A
SUBROGATION AGREEMENT
This Subrogation Agreement is made and entered into this _ day of 2019 by and
between the CITY OF SAN RAFAEL, hereinafter referred to as "CLIENT", and GEORGE HILLS
COMPANY, INC., hereinafter referred to as "GH".
I. CLIENT may, at CLIENT's own expense:
a. Authorize GH to act as a representative of CLIENT for the investigation,
adjustment, processing, supervision and evaluation of an ultimate
recovery of potential money from damage claims against parties for
whom it is alleged to be legally responsible.
b. Authorize GH to engage the services of a litigation attorney to consult,
review, and determine the best legal strategy available at the time to
obtain the best possible result for CLIENT. Upon determination by the
attorney that a civil action is in the best interest of CLIENT, GH will notify
CLIENT and obtain authorization to pursue recovery in accordance with
the recommendations of the litigation attorney; orc.
C. While GH is handling a subrogation claim for CLIENT pursuant to the
terms of this Contract, the institution of a civil action is determined by
CLIENT to be the best course of action, CLIENT may elect to do so at
CLIENT's own expense.
i. Recall the claim to CLIENT's control so that CLIENT may pursue
recovery in a manner to be determined by the CLIENT's attorney
to be in the best interest of the CLIENT.
ii. In the event CLIENT recalls the claim as indicated above, CLIENT
shall be responsible for payment to GH for any and all time and
expense incurred by GH's subrogation claim adjuster and/or other
subrogation division staff up to the time wherein the claim has
been recalled by CLIENT.
II. Subrogation Fee in the amount of 30% of each and every recovery obtained. The
minimum amount to be paid to GH will be $250 per claim upon recovery. However,
GH has the authority to reject any claim for any reason, relieving CLIENT of any
fiscal responsibility for rejected claims only.
a. Generally, no recovery shall be agreed to involving payment plans if the
recovery is less than $5,000 and/or greater than a one-year term.
Exceptions can be made on a case-by-case basis. If a recovery is
agreed to exceed this amount and/or length of time, Subrogation fee shall
be 45%. In the event a payment plan is authorized and entered into, the
subrogation fee will be based upon the total amount of the lien and will be
invoiced to the CLIENT upon the entry of the payment agreement. GH
will make every attempt to enforce the provisions of the payment
agreement with the claimant, but in no way guarantees the fulfillment of
the terms of the payment agreement. In the event the terms of the
payment agreement are not fulfilled and warrant pursuit the
the small
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claims process, authority to pursue through small claims will be
requested.
b. Authorize GH to appear in small claims court for recovery of funds.
Authority for the pursuit of recovery through small claims will be
requested prior to the filing of documents with the court to initiate the
small claims action. Each appearance will be an additional fee of $150.
All costs for the handling of the small claims, i.e. service of process of
documents on the responsible parties, mileage, parking, and toll shall be
an additional cost and will be the responsibility of the CLIENT. Additional
allocated costs shall be billed separately upon the cost being incurred,
such as, but not limited to: skip tracing, service of process, and third -party
sub contracted investigation.
C. GH reserves the right to cease working on any claim whereas information
has not been made available to GH within 120 days after GH has
submitted the information and/or documentation request to CLIENT, at
such time the claim will be closed.
d. Due to the nature of these services, in that compensation is contingent
upon recovery, if the contract is terminated prior to recovery or other
closure of any claim, the CLIENT shall pay GH for all expenses and time
spent, to date, on any claim(s) currently open and recovery in process.
Payment shall be based on the current hourly rate of GH. GH will submit
the final invoice within five business days of termination.
General Terms and Conditions
A. Successors and Assigns.
All of the rights, benefits, duties, liabilities, and obligations of the parties shall inure to the
benefit of, and be binding upon, their respective successors and assigns.
B. Construction.
The title and headings of the Sections in this Agreement are intended solely for
reference and do not modify, explain, or construe any provision of this Agreement. All
references to sections, recitals, and the preamble shall, unless otherwise stated, refer to
the Sections, Recitals, and Preamble of this Agreement. In construing this Agreement,
the singular form shall include the plural and vice versa. This Agreement shall not be
construed as if it had been prepared by one of the parties, but rather as if both parties
have prepared the Agreement.
C. Integration.
This Agreement, and all related documents referred to in this Agreement, constitute the
entire Agreement between the parties. There are no oral agreements which are not
expressly set forth in this Agreement and the related documents being executed in
connection with this Agreement. This Agreement may not be modified, amended, or
otherwise changed except by a writing executed by the party to be charged.
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D. Third -Party Rights.
Nothing in this Agreement, express or implied, is intended to confer upon any person,
other than the parties and their respective successors and assigns, any rights or
remedies.
E. Severability.
If any term or provision of this Agreement is held invalid or unenforceable, the remainder
of this Agreement shall not be affected.
F. Waivers.
No waiver or breach of any provision shall be deemed a waiver of any other provision,
and no waiver shall be valid unless it is in writing and executed by the waiving party. No
extension of time for performance of any obligation or act shall be deemed an extension
of time for any other obligation or act.
G. Counterparts.
This Agreement may be executed in one or more counterparts, each of which shall be
deemed an original and all of which taken together shall constitute one and the same
instrument. The execution of this Agreement shall be deemed to have occurred, and
this Agreement shall be enforceable and effective, only upon the complete execution of
this Agreement by Seller and Purchaser.
H. Authority of Parties.
All persons executing this Agreement on behalf of a party warrant that they have the
authority to execute this Agreement on behalf of that party.
I. Governing Law.
This Agreement shall be governed by and construed in accordance with California law.
AM
Date
FUI
Date
John E. Chaquica, CEO
GEORGE HILLS COMPANY INC.
Jim Schutz, City Manager
CITY OF SAN RAFAEL
Claims Adjusting and Administration Services Between the City of San Rafael and George Hills Company
page 14 of 19
ATTACHMENT B
MEDICARE, MEDICAID, AND SCHIP EXTENSION ACT OF 2007 (MMSEA)
This law requires liability insurers, self -insurers, no fault insurers and workers' compensation
insurers to report certain information to The Centers for Medicare and Medicaid Services (CMS)
concerning Medicare beneficiaries. The penalty for failure to comply is $1,000 per day, per
claimant.
George Hills Company, Inc. (GH) has contracted with ExamWorks for Mandatory Insurer
Reporting (MIR) for the CLIENT. ExamWorks shall represent the CLIENT—and Responsible
Reporting Entity (RRE) to this existing contract and this addendum, and will be the designated
reporting agent. GH will be responsible for gathering and reporting accurate claims data
required by MMSEA to ExamWorks in a timely manner. GH agrees to assume the responsibility
for reporting data to ExamWorks to meet all reporting requirements in accordance with MMSEA,
on behalf of the RRE; including assuming responsibility for any fines or penalties that are
directly caused by GH's non-compliance. GH further agrees to indemnify and hold -harmless,
RRE, and staff, for any penalties or fines resulting from GH's direct failure to timely and
accurately provide the reporting data to ExamWorks. The above-mentioned obligations to
indemnify and hold -harmless shall not be applicable to matters relating to delays caused by
RRE or other third parties, or inaccurate data supplied to GH by RRE or other third parties.
By contract with GH, ExamWorks will indemnify and hold GH harmless from and against any
claim, damage, fine, loss and expense, arising in connection with, or as a result of, any error,
omission, or negligent performance of its obligations as reporting agent, which indemnity will
include all reasonable costs of litigation and attorneys' fees incurred. Without in any way limiting
the indemnity set forth in this Contract, all work performed by ExamWorks will be done in a
professional manner.
GH shall perform the necessary data gathering for RRE and ExamWorks; as such GH shall
include in our monthly invoicing the time incurred for such work at our contract hourly rate, or
will be included in your monthly flat fee or claims adjusting.
ExamWorks will perform the MMSEA Mandatory Insurer Reporting function for GH, and its
RREs, shall be charged as an Allocated Expense, as defined in Attachment C, subject to the
following. RRE will designate ExamWorks, unless otherwise requested, as its exclusive vendor
for all of RRE's "Qualified Referrals" (those claims determined to require Medicare Set Aside
(MSA) or a Claim Settlement Allocation (CSA) and RRE will utilize other ExamWorks services
related to Medicare Secondary Payer (MSP) compliance identified in their fee schedule.
Claims Adjusting and Administration Services Between the City of San Rafael and George Hills Company
page 15 of 19
ATTACHMENT C
PREFERRED METHOD OF CHECK PROCESSING
1. Selection of Bank
a) ® Clients Choice
Name Westamerica Bank
Address 1108 Fifth Avenue, San Rafael, CA 94901
Please provide signature cards, sample check, starting check number, name of
contact person
b) ❑ GH uses CA Bank & Trust
2. Trust Balance Desired $ -0- (zero balance account with automatic transfers as GHC
issues checks)
3. Account funding: GH will notify client when the balance falls below required balance
4A. Number of Signatures Required AS IS
a) ❑ One
b) ❑ Two on all checks
C) ❑ Two on checks in excess of $
4B If two signatures are required please specify:
a) ❑Both GH
b) ® One GH, one client
GH signers: John Chaquica, CEO; Randy Rendig, President; Kimberly Santin,
Finance Director
5. Accountability
a) Yes ❑ No ❑ Positive Pay
GH recommends positive pay to mitigate the potential for fraud.
b) Yes ❑ No ❑ Daily check registers
C) ® Statement to be balanced by client, or
d) ❑ Statement to be balanced by GH with copies to client
Claims Adjusting and Administration Services Between the City of San Rafael and George Hills Company
page 16 of 19
ATTACHMENT D
ALLOCATED EXPENSES
Typically, allocated expenses are those expenses that are generated by a claim (by outside vendors other than George Hills) that cannot be
foreseen nor included in an agreement. These are generally allocated back to the specific claim file for which the cost was incurred and then
charged back to the entity whose claim incurred that cost. In most situations are pass-through costs (with processing fees) for services
and/or fees not directly generated by the TPA, but rather by a third -party consultant where the TPA has acted as an agent on behalf of the
entity to necessarily outscore services to a third -party consultant and/or miscellaneous fees applicable to the specific claim applied by an
outside entity, such as a court or copy service. Below, George Hills has provided a list, by no means an exhaustive list, of typical allocated
expenses.
• Fees of outside counsel for claims in suit, coverage opinions, and litigation, and for representation and hearings or pretrial
conferences;
• Fees of court reporters;
• All court costs, court fees, and court expenses;
• Fees for service of process;
• CMS reporting costs and fees (ExamWorks);
• Costs of undercover operatives and detectives;
• Costs for employing experts for the preparation of maps, professional photographs, accounting, chemical or physical analysis, or
diagrams;
• Costs for employing experts for the advice, opinions, or testimony concerning claims under investigation or in litigation of for which
a declaratory judgment is sought;
• Costs for independent medical examination or evaluation for rehabilitation;
• Costs of legal transcripts of testimony taken at coroner's inquests, or criminal or civil proceeding;
• Costs for copies of any public records or medical records;
• Costs of depositions and court reporting;
• Costs and expenses of subrogation, (if not George Hills);
• Costs of engineers, handwriting experts, or any other type of expert used in the preparation of litigation or used in a one-time basis
to resolve disputes;
• Witness fees and travel expenses;
• Costs of photographers and photocopy services (if not George Hills—our costs for this is included in our rate);
• Costs of appraisal fees and expenses not included in flat fee or performed by others;
• Costs of indexing claimants;
• Services performed outside the TPA's normal geographical regions;
• Costs associated with Medicare Set -Aside analysis and submission or Medicare Conditional Lien negotiation;
• Investigation of possible fraud including SIU services and related expenses; and/or
• Any other similar cost, fee, or expense that is not otherwise included in the TPA's service fees that is reasonably chargeable to the
investigation, negotiation, settlement, or defense of a claim or loss or to the protection or perfection of the subrogation rights of the
entity.
Claims Adjusting and Administration Services Between the City of San Rafael and George Hills Company
page 17 of 19
ATTACHMENT E
CLIENT EXPRESSED SCOPE OF WORK FORM
CLIENT NAME: San Rafael, City of CONTRACT PERIOD: 7/1/19 — 6/30/20
This document is intended to provide specific service expectations in the Service Contract, that would not
otherwise require revision during the contract period that may differ or elaborate from our Client Service
Profile.
Scope of Services
INVESTIGATION:
O George Hills will conduct all investigations
❑ CLIENT will conduct all investigations
XX CLIENT will direct GH on each claim as to who performs investigations
In the event the Client or other agency conducts any investigation, GH shall review for completeness.
Retention of Vendors (appraisers, translators, copy services, Independent Adjuster, IME's Surveillance, etc.):
XX Must be preauthorized by CLIENT
❑ Does not need preauthorization
REJECTION OF CLAIMS:
CLIENTS position regarding rejections (e.g. if entity so dictates, a claim will be rejected for insufficiency)
Protocols for Rejections
XX GH needs authorization
❑ GH does not need authorization
XX GH sends the Rejection
❑ CLIENT sends the Rejection
XX GH sends out Denial Letter simultaneously with Rejection outlining the reason
LITIGATION:
❑ GH will handle litigated claims
❑ Full
XX As assigned
XX Check Issuance and Data Input
❑ Data Input only
❑ CLIENT will handle litigated claims inhouse, with GH to capture data into SIMS
❑ CLIENT will send data to GH weekly ❑ CLIENT will send data to GH monthly
Claims Adjusting and Administration Services Between the City of San Rafael and George Hills Company
page 18 of 19
Mandatory Settlement Conferences
XX GH always attends
❑ At CLIENT request only
Small Claims Actions filed against CLIENT
XX GH always appears
❑ At CLIENT request only
Legal Counsel
XX GH must have CLIENT authorization to refer to outside Legal Counsel
❑ GH does not need CLIENT authorization to refer to outside Legal Counsel
❑GH must use CLIENT approved Legal Panel for Attorney selection
❑ CLIENT does not have an approved Legal Panel for Attorney selection
❑ All Litigation to be handled by CLIENT inhouse Legal
❑ GH sends Litigation Assignment packets to Legal Counsel
CLIENT specific Litigation Guidelines:
CLIENT specific Litigation Referral Form/Letter:
CLIENT specific Litigation Budget Form:
Pay fees for Experts, photocopies, medical records as: XX Expense
AUTHORITY LEVELS:
Reserve within SIR:
XX $500,000.00 ❑Other: $
❑ Yes XX No ❑ N/A
❑ Yes XX No ❑ N/A
❑ Yes XX No ❑ N/A
XX Legal
Adjuster must seek approval from (client contact) to post indemnity reserves above authority level.
Medical Treatment:
XX Medical Authorizations should only be sent to the claimant once liability is determined to be adverse to the
CLIENT.
❑ Medical Authorizations should go out as soon as it is determined that a BI claim is being pursued.
CLAIMS EXCEEDING SIR:
❑ GH stops tracking activity once the SIR has been reached.
XX GH will continue to track all activity at and/or above the SIR.
XX GH will reserve to Full Value and track recoveries.
Claims Adjusting and Administration Services Between the City of San Rafael and George Hills Company
page 19 of 19
CONTRACT ROUTING FORM
INSTRUCTIONS: Use this cover sheet to circulate all contracts for review and approval in the order shown below.
TO BE COMPLETED BY INITIATING DEPARTMENT PROJECT MANAGER:
Contracting Department: City Attorney
Project Manager: Lisa A. Goldfien Extension: 3080
Contractor Name: George Hills Company
Contractor's Contact: John Chaquica Contact's Email: John.Chaquica@GeorgeHills.com
❑ FPPC: Check if Contractor/Consultant must file Form 700
Step
RESPONSIBLE
DESCRIPTION
COMPLETED
REVIEWER
DEPARTMENT
DATE
N/A
Check/Initial
1
Project Manager
a. Email PINS Introductory Notice to Contractor
b. Email contract (in Word) and attachments to City
5/24/19
Attorney c/o Laraine.Gittens@cityofsanrafael.org
2
City Attorney
a. Review, revise, and comment on draft agreement
7/24/2019
and return to Project Manager
b. Confirm insurance requirements, create Job on
N/A
Department Director
PINS, send PINS insurance notice to contractor
3
Approval of final agreement form to send to
8/8/2019
contractor
Forward three (3) originals of final agreement to
4
Project Manager
contractor for their signature
5
Project Manager
When necessary, contractor -signed agreement
❑ N/A
agendized for City Council approval *
*City Council approval required for Professional Services
Agreements and purchases of goods and services that exceed
Or
$75,000; and for Public Works Contracts that exceed $175,000
8/19/2019
PRINT
Project Manager
Date of City Council approval
CONTINUE ROUTING PROCESS WITH HARD COPY
6
Forward signed original agreements to City
Attorney with printed copy of this routing form
7
City Attorney
Review and approve hard copy of signed
agreement
9' 2,0
p �,
1L11.
8
City Attorney
Review and approve insurance in PINS, and bonds
:io26l
(for Public Works Contracts)
1Q
9
City Manager/ Mayor
Agreement executed by City Council authorized
)
official
10
City Clerk
Attest signatures, retains original agreement and
�•�
forwards copies to Project Manager