#06-3983 (CBSA)
Division, of Corporations
Page I of3
.t6E 1
Foreign Profit
CORPORATE BENEFIT SERVICES OF AMERICA, INC.
r.-.-..---...---........'.---- --.--.,--...,
PRINCIPAL ADDRESS
400 HWY 169 SOUTH
SUITE 800
MINNEAPOLIS MN 55426.1141 US
Changed 04/09/2004
MAILING ADDRESS
400 HWY 169 SOUTH
SUITE 800
MINNEAPOLIS MN 55426-1141 US
Changed 04/09/2004
Document Number
F97000002382
FE! Number
411704028
Date Filed
05/06/1997
State
MN
Slalus
ACTIVE
E ffeclive Dale
NONE
RegIstere A!!ent
I Name & Address I
LUTER, LARRY J MO
3965 HENDERSON BL YD
TAMPA FL 33629.5015
I Name Changed: 04/0912004 I
I Address Changed: 0713112000 I
d
I Name & Address II Title I
WOLF, RALPH E 8
400 HWY 169 SOUTH, SUITE 800
MINNEAPOLIS MN 55426-1141lJ5
BENNER, KEVIN M n
400 ItWY 16Q SOUTH, SUITE 800
OfficerlDirector Detail
http://www.sunbiz.org/scripts/cordet.exe?al =DETFIL&n 1 =F97000002382&n2=NAMFWD&n3=0000&... 9/14/2006
Division of Corporations
I MINNEAPOLlS MN 55426-1141 US II I
GOTTSCHALK. GARY H D
333 S 7TH ST. SUITE 2400
MINNEAPOLIS MN 55402 us
KERN. MITCHELL T D
])3 S 7TH ST., SUITE 2400
MINNEAPOLIS MN 55402 US
ROHR. DANIEL C D
3J3 S 7TH ST., SUITE 2400
MINNEAPOLIS MN 55402 US
DO, FRANK B D
11755 WILSHIRE BL VD.
LOS ANGELES CA 90025 US
Page 2 00
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nnua eports
I Report Year II Filed Date I
I 2004 II 04/0912004 I
I 2005 II 03/0312005 I
I 2006 II 03/0712006 I
A
lR
(-____________.__._._.___.__..______.........u
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[ Return to List
No Events
No Name History Information
I Next Filing I
,-.---------. --------.-.--.----------...-----........----..
Document Images
Listed below are the images available for this filing.
OJ/07aQQ6.. ANNUAL REPORT
!l3/03/lQ05" ANNUAL REPQRT
Q4/Q9/~Q04 .. ANNUAL REPORT
0;J/UaOQ3 ., Al'1NUAL REPQRT
0;)/1312002.. ANNUAL REPORT
04/0612001 .. Annual RepuI1
07/3112000.. Reg. Agent Change
03/1412000.. ANN REP/UNlFORM BUS REP
03/06/1999 .. ANNUAL REPORT
03118!J 996. -,ANNUAL REPORT
THIS IS NOT OFFICIAL RECORD; SEE DOCUMENTS IF QUESTION OR CONFLICT
http://www.sunbiz.org/scripts/cordet.exe?a ] =DETFIL&n 1 =F97000002382&n2=NAMFWD&n3=0000&... 9/] 412006
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BestUnda
[CJacobson@cbsainc.comJ
t 23. 2006
,
roup Insurance - ~'\
l/'\
Linda,
There have been changes here. As of Monday, CBSA merged with a company called Performax.
Our new company name is: CBSA Performax. Our new President and CEO is Jacob L. Canova.
Please update the company name and use Jacob's name in place of Ralph Wolf.
I
/
It was because of these changes that it has taken me a couple of days to provide this
information. Thanks for your patience.
~
'---------- -
\
1-'/
./
Party Administrator for Group Insurance
Hi,Corrina;
For notices, I used R.E. Wolf, President and CEO.
Is this acceptable?
Linda
-----Original Message-----
From: Corrina Jacobson (mailto:CJacobson@cbsainc.com]
Sent: Tuesday, August 22, 2006 4:47 PM
To: BestLincta
Subject: RE: RFP 06-3983, Third Party Administrator for Group Insurance
- Collier County Government
Hi Linda,
I'm sorry you weren't able to get through on the 888 number. I'm not aware of any issues
with the phone line, but will let someone know that you had trouble.
Thanks for the information on the contact name. Let me check on who we want to provide as
that contact and I will get back to you soon.
Was the other information I provided sufficient? Please let me know if you have any
questions, or need anything else from me.
Thanks,
Corrina
-----Original Message-----
From: BestLinda [mailto:LindaBest@colliergov.net]
Sent: Tuesday, August 22, 2006 7:33 AM
To: Corrina Jacobson
Subject: RE: RFP 06-3983, Third Party Administrator for Group Insurance
- Collier County Government
Hi, Corrina,
I attempted to call you back this morning, however, for some apparent reason, I am getting
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CORPORATE BENEFIT SERVICES OF AMERICA, 1Ne.
Action of the Board ofDireclors
bv Unanimous Wl'ilten Consenl
Augusl 21,2006
The undersigned, being the solc director of CORPORATE BENEr-IT SERVtCES OF
AMERICA, INC., a Minnesota corporation (the "Col:poratiou"), pursuant \0 Minn. Stat. Section
302A.239 does hereby consent to the adoption of the following resolutions:
NOW, THEREFORE, be it resolved us Follows:
WHEREAS, in cOl\llectiol1 with th" Corporation's recelll acqllisition by
Perfonnax Holdings. Inc., Ralph E. Wolf, Kevin M. Brenner and Larry]. Lllter
resigned as officers of the Corporalion.
WHEREAS, Lbe undersigned wishes to acccpt the resignations of the officers
below and appoint and re-appoint Ihe officers set faith below:
RESIGNATION AND APPOINTMENT OF OFFICERS
RESOLVED: ThaI the resignations of Aidan Riordan and Neil Towllsend be, and they hereby
areJ accepted.
RESOLVED; That the following persons be, nnd hereby are, electcd to the offices set forth
opposite their names, ench to hold office until the first mlllunl meeting of the
Board of Directors and until a successor has been duly elected and qualified:
Jacob L. Cnnova
President and
Executive Officor
Chief
Sleven C. Berger
Treasurer & ChiefFinanciaJ
Officer
Donald B. Davis, Jr.
Secretary, General Counsel
and Executive Vice
President
Richard S. Bukovinsky Corpo1'l\te Vice President
Brent J. Hillier
Corporate Vice President
NYOOCSl 1204918. II
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NVOOCS/12114886.:iI
Chadly-Jay L. Myers
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2
Assistant Secretary
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3
OMNIBUS RESOLUTION
WQLVED:
That, In addition to and nol in limitation of the foregoing. any officer or
the COI1,oration be, and each or Ihem hereby is, authorized, empowered,
and directed 10 make. sign, execute. acknowledge. deliver, tile, record anel
publish any and all orders, directions, requests. receipts. ceniflcales 01'
other instruments, papers and doculUents, and to perform any ~llld all such
acts and things as may be required aI' appropriate to corry out tho tenus
and provisions of each of tbe foregoing resolutions and the transactions
contemplated thereby, and all such actions bel'etofore taken by any offieer
of the Corporation ore hel'ehy ratified.
Daled: August _, 2006
(Dircclor Consenl -J3enctils}
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NVOQCSl1284gaS.2
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TO:
Sheree Mediavilla
Risk Management Department
rY
o~l
MEMORANDUM
FROM:
Linda Jackson Best, Contract Specialis~. ~
Purchasing Department J U
September 26, 2006
DATE:
RE:
Review of Contract No. 06-3983, Third Party Administrator for Group
Insurance Benefits. Review of Insurance
Awardee: Corporate Benefit Services of America, Inc. (CBSA)
The Contract was approved by the BCe on September 26, 2006; Agenda Item
( 16 )(E)(1).
Please review the Insurance Certificate in this Agreement for the
above-referenced contract. If everything is acceptable, please forward to the
County Attorney for further review and approval. Please advise me when it
has been forwarded.
NOTE: After negotiations were complete, CBSA advised that they merged
with Performax Holdings, Inc. I have sent the name change information to
them, the State documents were not ready at the time of BCC award, I will
follow up with the name change after award. The new name is
CBSAlPerformax
The insurance certificate reads Performax Holding. Inc. as the holder- there is
no CBSAlPerformax Holding, Inc. certificate. Further, in the FL State of
Corporations, CBSA is still listed as Corporate Benefit Services of America,
Inc.
If you have any questions. please contact me at extension 8990.
C4.I.J In-.
I3n 1m
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Thank you.
16E 1
AGREEMENT 06-3983
for
Third party Administrator for Group Insurance Benefits
THIS AGREEMENT, made and entered into on this 26th day of September 2006, by and
between Corporate Benefit Services of America, Inc. (CBSA), authorized to do business in the
State of Florida, whose business address is 400 Highway 169 South, Suite 800, Minneapolis,
MN 55426-1141 hereinafter called the "Consultant" and Collier County, a political
subdivision of the State of Florida, Collier County, Naples, hereinafter called the "County":
WITNESSETH:
1. COMMENCEMENT. This Agreement shall commence after receipt of the Notice to
Proceed, in the form of a letter from the Contract Manager. The Contract shall be for a
two (2) year period, commencing on January 1, 2007 and terminating on December 31,
2009.
The County may, at its discretion and with the consent of the Consultant, extend the
Agreement under all of the terms and conditions contained in this Agreement for two
(2) additional one (1) year periods. The County shall give the Consultant written notice
of the County's intention to extend the Agreement term not less than ten (10) days prior
to the end of the Agreement term then in effect.
2. STATEMENT OF WORK. The Consultant shall furnish Third Party Administration for
Group Insurance Benefits in accordance with the terms and conditions of RFP #06-3983
and the Consultant's proposal hereto attached and made an integral part of this
agreement.
3. THE CONTRACT SUM. The County shall pay the Consultant for the performance of
this Agreement in accordance with Exhibit A, Cost Proposal, hereto attached and made
an integral part of this agreement. Payments shall be made to the Consultant not more
frequently than once per month.
Payment will be made upon receipt of a proper invoice and in compliance with Section
218.70 F.S. otherwise known as the "Florida Prompt Payment Act".
4. NOTICES. All notices from the County to the Consultant shall be deemed duly served
if mailed or faxed to the Consultant at the following Address:
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Corporate Benefit Services of America, Inc.
400 Highway 169 South, Suite 800
Minneapolis, MN 55426-1141
Attn: R. E. Wolf, President and CEO
FAX: 952.546.9468
All Notices from the Consultant to the County shall be deemed duly served if mailed or
faxed to the County to:
Collier County Government Center
Purchasing Department. Purchasing Building
3301 Tamiami Trail, East
Naples, Florida 34112
Attn: Steve Carnell
FAX: 239.732-0844
The Consultant and the County may change the above mailing address at any time
upon giving the other party written notification. All notices under this Service
Agreement must be in writing.
5. NO PARTNERSHIP. Nothing herein contained shall create or be construed as creating
a partnership between the County and the Consultant or to constitute the Consultant as
an agent of the County.
6. PERMITS: LICENSES: TAXES. In compliance with Section 218.80, F.S., all permits
necessary for the prosecution of the Work shall be obtained by the Consultant. Payment
for all such permits issued by the County shall be processed internally by the County.
All non-County permits necessary for the prosecution of the Work shall be procured
and paid for by the Consultant. The Consultant shall also be solely responsible for
payment of any and all taxes levied on the Consultant. In addition, the Consultant shall
comply with all rules, regulations and laws of Collier County, the State of Florida, or the
U. S. Government now in force or hereafter adopted. The Consultant agrees to comply
with all laws governing the responsibility of an employer with respect to persons
employed by the Consultant.
7. NO IMPROPER USE. The Consultant will not use, nor suffer or permit any person to
use in any manner whatsoever, county facilities for any improper, immoral or offensive
purpose, or for any purpose in violation of any federal, state, county or municipal
ordinance, rule, order or regulation, or of any governmental rule or regulation now in
effect or hereafter enacted or adopted. In the event of such violation by the Consultant
or if the County or its authorized representative shall deem any conduct on the part of
the Consultant to be objectionable or improper, the County shall have the right to
suspend the contract of the Consultant. Should the Consultant fail to correct any such
violation, conduct, or practice to the satisfaction of the County within twenty-four (24)
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hours after receiving notice of such violation, conduct, or practice, such suspension to
continue until the violation is cured. The Consultant further agrees not to commence
operation during the suspension period until the violation has been corrected to the
satisfaction of the County.
8. PROHIBmON OF GIFTS TO COUNTY EMPLOYEES. No organization or individual
shall offer or give, either directly or indirectly, any favor, gift, loan, fee, service or other
item of value to any County employee, as set forth in Chapter 112, Part III, Florida
Statutes, Collier County Ethics Ordinance No. 2004-05, and County Administrative
Procedure 5311. Violation of this provision may result in one or more of the following
consequences: a. Prohibition by the individual, firm, and/ or any employee of the firm
from contact with County staff for a specified period of time; b. Prohibition by the
individual and/or firm from doing business with the County for a specified period of
time, including but not limited to: submitting bids, RFP, and/ or quotes; and, c.
immediate termination of any contract held by the individual and/ or firm for cause.
9. TERMINATION. Should the Consultant be found to have failed to perform his
services in a manner satisfactory to the County as per this Agreement, the County may
terminate said agreement immediately for cause; further the County may terminate this
Agreement for convenience with a seven (7) day written notice. The County shall be
sole judge of non. performance.
10. NO DISCRIMINATION. The Consultant agrees that there shall be no discrimination
as to race, sex, color, creed or national origin.
11. INSURANCE. The Consultant shall provide insurance as follows:
A. Commercial General Liability: Coverage shall have minimum limits of $1,000,000
Per Occurrence, Combined Single Limit for Bodily Injury Liability and Property
Damage Liability. This shall include Premises and Operations; Independent
Consultants; Products and Completed Operations and Contractual Liability.
B. Business Auto Liability: Coverage shall have minimum limits of $1,000,000 Per
Occurrence, Combined Single Limit for Bodily Injury Liability and Property
Damage Liability. This shall include: Owned Vehicles, Hired and Non-Owned
Vehicles and Employee Non-Ownership.
C. Workers' Compensation: Insurance covering all employees meeting Statutory
Limits in compliance with the applicable state and federallaws.
D. Professional Liability Insurance: The Consultant shall maintain Insurance to
insure it's legal liability for claims arising out of the performance of professional
services under this Agreement. Coverage shall have minimum limits of $1,000,000
Per Occurrence.
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Special Requirements: Collier County shall be listed as the Certificate Holder and
included as an Additional Insured on the Comprehensive General Liability
Policy.
Current, valid insurance policies meeting the requirement herein identified shall
be maintained by Consultant during the duration of this Agreement. Renewal
certificates shall be sent to the County thirty (30) days prior to any expiration date.
There shall be a thirty (30) day notification to the County in the event of
cancellation or modification of any stipulated insurance coverage.
Consultant shall insure that all subConsultants comply with the same insurance
requirements that he is required to meet. The same Consultant shall provide
County with certificates of insurance meeting the required insurance provisions.
12. INDEMNIFICATION. To the maximum extent permitted by Florida law, the
Consultant or Consultant shall indemnify and hold harmless Collier County, its officers
and employees from any and all liabilities, damages, losses and costs, including, but not
limited to, reasonable attorneys' fees and paralegals' fees, to the extent caused by the
negligence, recklessness, or intentionally wrongful conduct of Consultant or Consultant
or anyone employed or utilized by the Consultant or Consultant in the performance of
this Agreement. This indemnification obligation shall not be construed to negate,
abridge or reduce any other rights or remedies which otherwise may be available to an
indemnified party or person described in this paragraph.
This section does not pertain to any incident arising from the sole negligence of Collier
County .
13. CONTRACT ADMINISTRATION. This Agreement shall be administered on behalf of
the County by the Risk Management Department.
14. CONFLICT OF INTEREST: Consultant represents that it presently has no interest and
shall acquire no interest, either direct or indirect, which would conflict in any manner
with the performance of services required hereunder. Consultant further represents
that no persons having any such interest shall be employed to perform those services.
15. COMPONENT PARTS OF THIS CONTRACT. This Contract consists of the attached
component parts, all of which are as fully a part of the contract as if herein set out
verbatim: Exhibit A, Cost Proposal; Insurance Certificate; Consultant's Proposal; and
RFP #06-3983, "Third Party Administrator for Group Insurance Benefits.
16. SUBJECT TO APPROPRIATION. It is further understood and agreed by and between
the parties herein that this agreement is subject to appropriation by the Board of County
Commissioners.
17. VENUE. This agreement shall be construed in compliance with Florida Laws. Venue
shall be in Collier County, Florida.
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IN WITNESS WHEREOF, the Consultant and the County, have each, respectively, by an
authorized per!\on'c,r agent, hereunder set their hands and seals on the date and year first above
written.
ATTEST:
Dwight E. Brock, Clerk of Courts
~.
By: . fLCl.l.
D"lf ': =-,.... ·
(SEAL)
BOARD OF COUNTY COMMISSIONERS
COLLIER COUNTY, FLORIDA
~~2~ J'
Frank Halas, Chairman
By:
Corporate Benefit Services of America, Inc.
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(-) L--
FIrst WItness
~4' ~ ~~
.
Type~tness name
i, iJll LVJ
Second Witness
By:
~~/f~_
Signature
J aco b L Canova
President, Chief Executive Officer
Typed signature and title
_YY'l'.che'~ (nll'N
Type/print witness name
Approved as to form and
legal sufficiency:
~IYI~-
Colleen M. Gre'en
Assistant County Attorney
Item# \to f I
Agendq, Jlo '0
Date
D.t4 D'/o -Q<O
Reclct
4f.
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Exhibit A
Cost Proposal
Collier County Government
Exhibit A, Cost Proposal from CBSA
Annual fee for on.slte customer service
representative
Additional fees for custom re orts
Fees for dedicated account service
Fees for toll free customer service line
Fees for interface with a custom direct
contracted rovlder network
Fees for interface with Community Health
Partners Utilization review and case and
disease mana ement services
Identl an additional com nents for which
List an additional item In left mar in.
Programming for data feed from SAP
system to CBSA, or for programming
of any new or changed data feeds
with other vendors. Data file transfer
programming for SAP will be
operational on or before January 1,
2007.
Sub atlon Services
Mailing of employee packets/lD
cards to employees' homes for new
employees, or during open
enrollment
Annual Flex Administrative Fees
Included in medical fee
ou assess a se
$150 per hour
250/0 of the total recove
$3.50 per packet
750 annual fee
A-I
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run out
CCG may also consider purchasing additional service related to COBRA, HIPAA, and spending account
administration. Please use the following table to present your cost quotations for 2007, 2008, 2009
for the areas indicated:
Additional Services
COBRA Administration
HIPAA Administration
Medical Reimbursement Aocount Administration
1.05 1.05
.35 .35
$3.50 per $3.50 per
participating participating
em 10 ee em 10 ee
Included In price above
1.05
.35
$3.50 per
participating
em 10 ee
Dependent Care Reimbursement Account
Administration
**The onsite customer Advocate would be terminated on the date that CCG terminates the services
of CBSA. There would not be an onslte customer Advocate during the run-out period.
End of Schedule A
. ".j
DATE (MM/DO/VY).
09 19 06
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERnFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
A TER TH COVE GE AFRO C BY THE POLICIES BEL W.
COMPANIES AFFORDING COVERAGE
ACORD.
PRODUCER
Aon Risk services ,Inc. of Maryland
500 East Pratt Street
Baltimore MD 21202
PHONE. (866) 183-7114
INSURED
performax Holdings, Inc.
1 south 5t
10th Floor
Baltimore MD 21202 USA
COM?ANY
A
Executive Risk Indemnity
FAX. (866) 430-1035
COMPANY
B
Federal Insurance Company
COMPANY
C
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THIS IS TO CERl1FY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POliCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFn:CTIVE POLICY EXPIllA TIO
DATI: (MMIDDNY) DATE (MMfDDIYYJ
COMMERCIAL GENERAL LIABILITY
CLAIMS MAOE 0 OCCUR
OWNER'S & CONTRACTOR'S PROT
35366812BAL
Commercial package
GENERAL AGGREGATE
PRODUCTS - COMPIOP AGG
PERSONAL & ADV INJURY
EACH OCCURRENCE
01/01/06
01/01/07
FIRE DAMAGE{Anv one (Iflt)
MED EXP (Anv OJU! person)
B
AUTOMOBILE I..lABILlTY
ANY AUTO
ALL OWNEO AUTOS
SCHEDULED AUTOS
X HIRED AUTOS
X NON.OWNEDAUTOS
0673518969
Automobile Liability
COMBINED SINGLE LlMIT
01/01/06
01/01/07
BODILY INJURY
( Petpersonl
BODILY INJURY
(Peraccldenl)
PROPERTY DAMAGE
GARAGE UABILITY
AUTO ONLY. EA ACCIDENT
OTHER THAN AUTO ONLY:
EACH ACCIDENT
AGGREGATE
EACH OCCURRENCE
AGGREGATE
ANY AUTO
EXCESS LIABILITY
UMBRELLA FORM
LIMITS
$1,000,000
$1,000,000
$1,000,000
$1,000,000
$1,000,000
$10,000
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EMPLOYERS'LIABllITY workers compensati on
THE PROPRIETOR! INCL
PARTNERS/EXECUTIVE
OFFICERS ARE' EXCL
A 61604004
Fiduciary Liability
x
S500,000
S500,OaO
J2,OOO,000_
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excluding workers' Compensation and Employers' liability as ~
operations of the Insured under said contract, and always subject ~
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SHOULD ANY OF THE ABOVE JESCR1BEO POLICIES BE CANCELLED BEFORE THE ~
:OX~:~;I~RI~~:: ::~~EEO:~ ~:E I:SE~~~I~;:P::LD;~LLN~:~~A~~RT:~ L:~ ~
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01/01/06
01/01/07
EL DISEASE-POLICY LIMIT
EL OISEASE.EA EMPLOYEE
10/27/05
10/27/06
Fiduriaryliabi1ity
X Fiduciilry Liab
DESCRIPTION OF OPERATIONSlL.OCATIONSNEHICL.ESJSPECIAL ITEM~
RE: Contract No. 06-3983
collier county i5 added as an Additional Insured
required by written contract but limited to the
Collier county
Attention: Purchasing Building
3301 E. Tamiami Trail
Naples FL 34112 USA
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KINO UPON THE COMPANY. ITS AGENTS OR REPRESENTATives
AUTHORIZED REPRESENTATIVE ---"'"--~~~ ~ _ _"
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The terms, conditions and provisions noted below are hereby attached to the captioned certificate as additional description of the coverage
afforded by the insurer(s). This attachment does not contain all terms, conditions, coverages or exclusions contained in the policy.
Attachment to ACORD Certificate for
performax Holdings, Inc.
COMPANY
INSURED
Performax Holdings, Inc.
I South St
10th Floor
Baltimore MD 21202 USA
COMPANY
COMPANY
COMPANY
COMPANY
ADDITIONAL POLICIES
If a policy below does not include limit information, refer to the corresponding policy on the ACORD
certificate fonn for policy limits
POLICY POLICY
CO TYPE OF TNSURAI'o'CE POLICY NUMBER EFFECTrvE EXPllU TION LrMITS
lTll POUCY DESCRIPTION D,\TE DATE
OESCRIPTION OF DPERATIONSIlOCATIONSNEHtCL.E9ISPEClAL ITEMS
to the policy terms, conditions and exclusions.
cancellation provision shown herein is subject to shorter or longer time periods depending on the
jurisdiction of, and reason for, the cancellation.
Certificate No:
570019530597
ACORD.
DATE MM!OO/VV)
09 06
IS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE OVE GE AFFORDED BY THE POLICIE BELOW.
COMPANIES AFFORDING COVERAGE
PRODUCER
Aon Risk services ,Inc. of Maryland
500 East Pratt Street
Baltimore MD 21202
PHONE. (866) 283-7124
INSURED
Performax Holdings, Inc.
1 South St
10th Floor
Baltimore MD 21202 USA
FAX. (866) 430.1035
COMPANY
A
Federal Insurance company
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COMPANY
B
COMPANY
C
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUEO OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POliCIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
mE OF INSURANCE POUCY NUMBER POUCY EWECTIVE POUCY EXPIRATlO LIMITS
DAllt{MMlDDfYY) DATE (MMlDDIYY) ~
35366812BAL 01/01/06 01/01/07 52.000,000 N
GENERAL AGGREGATE ~
commercial package '"
PRODUCTS - COMP/OP AGG 52.000,00 ....
COPo'MERClAL GENERAL llABlUTY m
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[R] OCCUR PERSONAl & ADV INJURY $1,000.000 ....
CLAIMS MADE 0
51,000.000 0
OWNER'S & CONTRACTOR'S PROT EACH OCCURRENCE ~
~
FIRE DAMAGE/An... one fire) 51,000.00 <;
MEO EX? IAny 0011 person) 510,00 ;z:
1l
. AUTOMOBILE UABlUfY 0673518969 01/01/06 01/01/07 .
COMBINED SINGLE UMIT n, 000 ,000 u
Automobi 1 e Liability '"
ANY AUTO 'f!
ALL O'NNEO AUTOS BODILY INJURY ~
U
SCHEDULED AUTOS (PllfpllfSOO)
X HIRED AUTOS BeDIL Y INJURY
X NO~OlNNED AUTOS (PerllCCldlMll)
PROPERTY DAMAGE
GARAGE UASlUTY AUTO ONLY. EA ACCIDENT
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT
AGGREGATE
EXCESS L.lASIUTY EACH OCCURRENCE
UMBRELLA FORM AGGREGATE
OTHER THAN UMBRELLA FORM
0771648211 01/01/06 01/01/07 X we STATU-
. WORKER" COMPENIAT1ON AND T RY lMIT
EMPLOYERS' UABlUTY workers compensation El EACH ACCIDENT
THE PROPRIETORJ INCL EL DISEASE-POLICY LIMIT 5500,000
PARTNERS/EXECUTNE
OFFICERS ARE: EXCL a DISEASE-Ell. EMPLOYEE 5500,000
collier county
Attention: purchasing Building
3301 E. Tam; am; Trai 1
Naples FL 34112 USA
SHOULD N4Y OF THE ABOVE DESCRIBEO POLICIES BE CANCElLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE lEFT,
BUT FAILURE TO MAll SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANV KINO UPON THE COMPANY ITS AGENTS OR REPR S NTAT1VES.
AUTHORIZED REPRESENTATIVE ~~~~ >'" If4' _"
I
~
~
~
.....,
~
~
..
~
~
.....
...~
:i'!
~
-
OESCRIP11ON Of OPERATJONSlLOCATtONSlVEHICLESlSPECLAL ITEMS
RE: Contract No. 06-3983
collier county is added as an Additional Insured
required by written contract but limited to the
exclud1ng workers' compensation and Employers' Liability as
operations of the Insured under said contract, and always subject
, ~';" 'w~~:1L~__ ..1<__==-----....,__ 'l~"L _ ..:. ~ ~ _ ~r:{lJ:.~if:I1lTII..~_~- -___ __~. -,' ."':~: - ::..'- - ~ ==-J
i~~ 1l:1. "~~rltJ~'or~ ~ '''~~~ ~~o:._ ::=:::= :..::"" ~ ~ - ~_ _1'1 _ ~~:m"-~ci :~~:---::~."'LI. ~~.i~j:{~~~1]~~(.f.1ffi~~;~,~~ ~1~~l<<i rl
Attachment to ACORD Certificate for performax Holdings, Inc.
16E 1
The tenns, conditions and provisions noted below are hereby attached to the captioned certificate as additional description of the coverage
afforded by the insurer(s). lbis attachment does Dot contain all terms, conditions, coverages or exclusions contained in the policy.
COMPANY
INSURED
Perfonmax Holdings. Inc.
1 south St
10th Floor
Baltimore MD 21202 USA
COMPANY
COMPANY
COMPANY
COMPANY
ADDITIONAL POLICIES
If a policy below does not include limit information, refer to the oorresponding policy on the ACORD
certificate form for policy limits.
POlley !"OUCY
co TYPE OP' INSURA.NCX POlley NUMBER EFFECTIVE EXPIRATION lJMlnl
Ln POlley DFSCRIPTION DATE DAnl
DESCRIPl10N OF OPERATIONSfLOCATION8IVEHtcLESISPECiAL.ITEMS
to the policy terms, conditions and exclusions.
cancellation provision shown herein ;s subject to shorter or longer time periods depending on the
jurisdiction of, and reason for, the cancellation.
Certificate No:
570019316328
Patricia L. Morgan
From:
Sent:
To:
Cc:
Subject:
Attachments:
DeLeonDiana [DianaDeLeon@colliergov.net]
Wednesday. March 10, 2010 11:33AM
Patricia L. Morgan; Patricia L. Morgan
Wood, Lyn; Toppe. Alice
06.3983 Third Party Admin for Group Insurance
06-3983 Meritain.Amend (Name Chg & Termination).pdf
Trish,
This amendment needs to be attached to the referenced contract.
Thanks,
Diana De Leon
Purchasing Dept
(239)252-8375
Under Florida Law, e-mail addresses are public records. If you do not want your e.mail address released in response to d public r~~co(ds reqUt~st do not S8t!d
electronic mail to this entity. Instead, contact this office t)y telephone or in writinp
AMENDMENT TO AGREEMENT 06.3983
FOR
THIRD PARTY ADMINISTRATOR FOR GROUP INSURANCE BENEFITS
This Amendment. effective November 1, 2009 ("Effective Date"), amends Agreement 06.3983 for
Third Party Administrator Group Insurance Benefits ("Agreement"), made and entered into on September
26. 2006. by and between Corporate Benefit Services of America, Inc. (Consultant) and Collier County
("County"), as follows:
1. Name Chanqe. The name of the Consultant is hereby changed to be Meritain Health, Inc.
("Meritain") (defined to include its affiliates and any entities they acquire). All references in the
Agreement to "Corporate Benefit Services of America. Inc.", "CBSA". or "Consullant" shall be
deemed to mean Meritain.
2 Section 9. Termination. Section 9 of the Agreement is deleted in its entirety and is replaced
with the following language
9 Termination Should the Consultant be found to have failed to perform his
services in a manner salisfactory to the County as per thiS Agreement, the County may
terminate said Agreement immediately for cause; further the County may terminate thiS
Agreement with at least thirty (30) days written notice prior to the end of the current
contract term. The County shall be the sole Judge of non.performance.
In Witness Whereof, the parties have executed this Amendment on the dates set forth below
Meritain Health, Inc.
Collier County
~/~ ;;;j~/
By C~~'\"~\l?
Alice Toppe, Project Manager
Melissa Elwood
Senior Vice President, Client Relations
BY',/~~
/7,/ //
k:'
Jeff Walker, Director. Risk Management
Date Z It r / Ie)
By.
} , '-1'*
Lyn M.
od, Contract Specialist
Date:
I
A (
//
ITEM NO.:
FILE NO.:
ROUTED TO:
16E
. {.I.~p)nh Rr=CEIVED:
VI . I~_,~ ,;r t I Tt.
\;OU0i1Y ATTORi\IE':
1
---
()fo -fJ~(! - 0057 t,
2006 OCT - 2 PI\ ~: II,
DO NOT WRITE ABOVE THIS LINE
REQUEST FOR LEGAL SERVICES
\ixJ~O~~1;
~~ (fCJ
Date:
September 26, 2006
From:
Office of the County Attorney
Attention: Colleen M. Green
Linda Jackson, Contract Specialist .A~
Purchasing Department, Extension 8990 d\J
Support Services Division
To:
RE: Review of Contract No. 06-3983, Third Party Administrator for Group
Insurance Benefits- Review of Insurance
Awardee: Corporate Benefit Services of America, Inc. (CBSA)
BACKGROUND OF REQUEST:
The Contract was approved by the BCC on September 26, 2006; Agenda Item
( 16 )(E)(1 ).
This item has not been previously submitted.
IO\6/ctP
~ l}~ wi ~. &a-
~ pvtf L.ioJ?i~ Ins ~
please sign and - htW.c.ta..tj
i()bW1~ J
.QX~ IOJL' Dlp
ACTION REQUESTED:
Please review for Legal Sufficiency, if acceptable,
forward to the BCC for final execution.
OTHER COMMENTS:
NOTE: After negotiations were complete, CBSA advised that they merged
with Performax Holdings, Inc. I have sent the name change information to
them, the State documents were not ready at the time of BCC award, I will
follow up with the name change after award. The new name is
CBSAlPerformax
The insurance certificate reads Performax Holding. Inc. as the holder. there is
no CBSAlPerformax Holding, Inc. certificate. Further, in the FL State of
Corporations, CBSA is still listed as Corporate Benefit Services of America,
Inc.
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SL! 6 E 1
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. Original documents should be hand delivered to the Board Office. The completed routing slip and original
documents are to be forwarded to the Board Office only!1l.u the Board has taken action on the item.)
ROUTING SLIP
Complete routing lines #1 through #4 as appropriate for additional signatures, dates, and/or infonnation needed. tflhe document is already complete with the
ex. "00 of the CbaimulD'ss' draw aJiDcthrou routin Iines#lthrou #4 com lctcthecheckJis and forward to Sue Filson liDeNS.
Route to Addressee(s) Office Initials Date
list in routin order
1.
2.
3.
4. CoUeen M, Greene
Assistant County Attorney
10/6/06
5. Sue Filson, Executive Manager Board of County Commissioners
6. Minutes and Records Clerk of Court's Office
, PRIMARY CONTACT INFORMATION.
(The primary contact is the holder of the original document pending ace approval. Nonnany the primary contact is the person who created/prepared the
executive summary. Primary contact infonnation is needed in the event one of the addressees above, including Sue Filson, need to contact ataff for additional
or missing infonnation. AU original documents needing the BCC Chairman's signalUre are to be delivered to the Bee office only after the Bee has acted to
lh' )
approve .,tem.
Name of Primary Linda Jackson, Contract Specialist Phone Number 774-8990
Staff Contact
Agenda Date Item was September 26 2006 Agenda Ilem (I6)(E)(1)
Approved by the Bee Number
Type of Document Review of Contrael No. 06-39S3, Third Party Admlnlmalor for Number of Six (6)
Attached Group Insurance Benefits - Review of Insuranee, Original
Documents
Attached
Initial the Yes column or mark "N/A" in the Not Applicable column, wbichever is Yes N/A (Nol
aDDrooriale. (Initial) Anolicable)
1. Original documenl has been signed/initialed for legal sufficiency. (All documents to be CMG
signed by the Chairman, with the exceplion of moslletters, musl be reviewed and signed
by the Office of the Counly Attorney. This includes signature pages from ordinances,
resolutions, etc. signed by the County Attorney', Office and signature pages from
contracts, agreements, etc. thai bave been fully executed by all parties excepl the BCC
Chairman and Clerk to the Board and nossiblv Stale Officials:)
2. All handwritten strike.through and revisions have been initialed by the County Attorney', CMG
Office and all other Darties excent the BCC Chairman and the Clerk 10 the Board
3. The Chairman's signature line dale has been entered as the dale of BCC approval of the CMG
documenl or the final negotialed contract date whicbever is aDDUcable.
4. "Sign here" tabs are placed on the appropriate pages indicating where the Chairman's CMG
sil<I1llture and initials are reQuired.
5. In most cases (some contracts are an exception), the original document and this routing slip CMG
should be provided to Sue Filson in the BCC office within 24 hours of BCC approval.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware ofvour deadlines!
6. The document was approved by lhe BCC on SeDlember 26. 2006 (enter dale) and all CMG
changes made during the meeting have beeD incorporated in the attached document.
The Counlv Attornev's Office has reviewed lbe ebanee.. if aDDiieable.
INSTRUCTIONS & CHECKLIST
L Forms! County Forms/ Bee Forms! Original Documen1s Routing Slip WWS Original 9.03.04, Revised 1.26.05, Revised 2.24.0.5
16E 1
MEMORANDUM
Date:
October 9, 2006
To:
Linda Jackson, Contract Specialist
Purchasing Department
From:
Ann Jennejohn, Deputy Clerk
Minutes & Records Department
Re:
Review of Contract No. 06-3983; Third Party Administrator
for Group Health Insurance Benefits - Review ofInsurance
Awardee: Corporate Benefit Services of America, Inc.
(CBSA)
Enclosed please find four (4) original contracts, as referenced above,
(Agenda Item #16EI) approved by the Board of County Commissioners
on Tuesday, September 26, 2006.
Please forward the documents to the appropriate parties for their records.
The Finance Department and the Minutes & Records Department have
also retained an original..
If you should have any questions, please contact me at 774-8406.
Thank you.
Enclosures (4)