Backup Documents 04/12/2016 Item #16E3 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO •
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE F
Routed by Purchasing Department to
Office Initials Date
the Following Addressee(s) (In routing order)
1. Risk Management Risk
2. County Attorney Office County Attorney Office
3. BCC Office Board of County -17.)'F
Commissioners -// A\\-�\\ic)
4. Minutes and Records Clerk of Court's Office
(4)13I, 4. 4/;3 c-
5. Return to Purchasing Department Purchasing
Contact: Diana DeLeon
PRIMARY CONTACT INFORMATION
Name of Primary Diana De Leon for Rhonda Burns Phone Number 252-8375
Purchasing Staff April 12,2016
Contact and Date _
Agenda Date Item was April 12,2016 Agenda Item Number 16.E.3✓
Approved by the BCC
Type of Document Amendment -Arw din nle kor- Number of Original 2
Attached %rda.(J \XV -Srck Documents Attached
PO number or account N/A Solicitation/Contract 11-5729 Allegiance
number if document is Number/Vendor Name i/
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not
appropriate. (Initial) Applicable)
1. Does the document require the chairman's original signature?
2. Does the document need to be sent to another agency for additional signatures? If yes, N/A
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be
signed by the Chairman,with the exception of most letters,must be reviewed and signed
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's N/A
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chairman's signature line date has been entered as the date of BCC approval of the N/A
document or the final negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's DD
signature and initials are required.
7. In most cases(some contracts are an exception), an electronic copy of the document and DD
this routing slip should be provided to the County Attorney's Office before the item is
input into SIRE.
8. The document was approved by the BCC on the date above and all changes made DD
during the meeting have been incorporated in the attached document. The County
Attorney's Office has reviewed the changes,if applicable.
9. Initials of attorney verifying that the attached document is the version approved by the
BCC,all changes directed by the BCC have been made, and the document is ready for the X11►
Chairman's signature.
1 F 3
MEMORANDUM
Date: April 14, 2016
To: Diana De Leon, Contracts Technician
Purchasing & General Services Department
From: Teresa Cannon, Deputy Clerk
Minutes & Records Department
Re: Amendment #3 to Contract #11-5729 "Third Party Administrator
for Health Benefits"
Contractor: Allegiance Benefit Plan Management, Inc.
Attached is an original of the document referenced above, (Item #16E3) approved by
the Board of County Commissioners on Tuesday, April 12, 2016.
The original has been held by the Minutes and Records Department as part of the
Board's Official Record.
If you have any questions, please contact me at 252-8411.
Thank you.
Attachment
1 6 E 3
EXHIBIT A-3 Contract Amendment#3 to Contract#11-5729
"Third Party Administrator for Health Benefits"
This amendment, dated hen.( ( ,2016 to the referenced agreement shall be by and between the
parties to the original Agreement, Collier County Government (to be referred to as "the Plan Sponsor")
and Allegiance Benefit Plan Management, Inc.,(to be referred to as"the TPA").
Statement of Understanding
RE: Contract# 11-5729"Third Party Administrator for Health Benefits"
In order to continue the services provided for in the original agreement document referenced above, the
TPA agrees to amend the existing Agreement by extending the original renewal term and incorporating an
extension period,as provided below.
Note: Language deleted has been stvek-thfeugh. New language has been underlined.
Change No.1: Amend Page 1 of the Agreement as follows:
THIS Administrative Services Agreement (hereinafter "Agreement"), effective for the thirty-six (36)
month period beginning January 1, 2012, and ending December 31, 2014, and may be renewed for two
(-2)three(3)additional one(1)year periods as mutually agreed by the parties in writing, is entered into by
COLLIER COUNTY GOVERNMENT, a political subdivision of the State of Florida, Collier County,
Naples, (hereinafter referred to as the "Plan Sponsor"), ALLEGIANCE BENEFIT PLAN
MANAGEMENT, INC., a corporation duly organized and existing under the laws of the State of
Montana(hereinafter referred to as the"TPA").
Change No.2: Amend Article V: Duration of Agreement,Page 10 as follows:
g
5.1 The Plan Sponsor may, at its discretion, extend the Agreement under all of the terms and conditions
contained in this Agreement for up to one hundred eighty (180) days. The Plan Sponsor shall give TPA
written notice of the Plan Sponsor's intention to extend the Agreement term not less than thirty(30) days
prior to the end of the Agreement term then in effect.
***
All other terms and conditions of the agreement shall remain in force.
(Signature page to follow)
IIPaa
Amendment#3 to Contract 411-5729
"Third Party Administrator for Health Benefits"
1 6 E 3,
IN WITNESS WHEREOF, the parties have each, respectively, by an authorized person or agent, have
executed this Amendment on the date(s)indicated below.
Accepted: 4-j2r-t ( (a- , 2016
THE PLAN SPONSOR:
BOARD OF COUNTY COMMISSIONERS
OF CO LIER COUNTY,FLORIDA
Dwight.. Brock,Cler
I:4,BoiLit.ka
By:
Attest as to C i► lerk D nna Fiala,Chairman
TPA's it itdenature on)yness: .
THE TPA:
/�A lA4-i-t.,
Allegiance Benefit Plan Management, Inc.
By 4vvv
try V1 t �--V1 z By: li
47,therstpsi,,i
Print Name / AiAb4, korrAuti) ---ro.gi.,-
,� Print Name and Title
7 YA's Secon fitness:
By:
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Print Natpe
Approv `I a , ?I-- -. . -ga lty:
Ir
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Nil 4
Jeffrey Al la '.kow, County Attorney
'
item# «E3
Agenda
Date - f (a1'1 /b
Date Cf/N !Recd b
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D✓ =''y Clerk
2IPage
Amendment#3 to Contract#11-5729
"Third Party Administrator for Health Benefits"