Agenda 05/28/2019 Item #16E 4 (Procurement Services Change Orders Report)05/28/2019
EXECUTIVE SUMMARY
Recommendation to approve the administrative report prepared by the Procurement Services
Division for change orders and other contractual modifications requiring Board approval.
OBJECTIVE: To promote accountability and provide transpare ncy to the public and gain the
Board’s approval/ratification for various procurement -related transactions.
CONSIDERATIONS: In accordance with the Board’s Procurement Ordinance 2017-08 and the
Procurement Manual, the Procurement Services Division produces a regular Administrative Report which
provides for Board approval of the following transactions:
• Change Orders that do not exceed ten (10%) of the current Board approved aggregate amount,
and/or require change in schedule (number of days);
• Amendments to contracts;
• After the fact memos from various County Divisions, as requested by the Clerk’s Finance staff
for the timely process of invoices.
• Other items as determined by the County Manager or designee that require Board approval.
This administrative report includes the following:
• Four (4) change orders that in aggregate modify contracts by $77,890.40 and add 354 calendar
days to completion periods, see attached summary and backup for details; and
• Zero (0) amendments this period with a fiscal impact of $0.00; and
• Two (2) after the fact memos with a fiscal impact of $10,265.85
FISCAL IMPACT: The net total for the six (6) items is $88,156.25
LEGAL CONSIDERATIONS: This item is approved for form and legality and requires a majority
vote for Board action. -JAK
GROWTH MANAGEMENT IMPACT: There is no Growth Management Impact associated with this
action.
RECOMMENDATION: To ratify/approve change orders and/or contract amendments and other items
as determined by the County Manager or designee in accordance with Procurement Ordinance 2017-08.
Prepared By: Sara Schneeberger, Procurement Strategist, Procurement Services
ATTACHMENT(S)
1. 0528 Change Order Report - FY19 (PDF)
2. 0528 Change Order Backup - FY19 (PDF)
3. 0528 After the Fact Report - FY19 (PDF)
4. 0528 After the Fact Backup - FY19 (PDF)
16.E.4
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05/28/2019
COLLIER COUNTY
Board of County Commissioners
Item Number: 16.E.4
Doc ID: 8973
Item Summary: Recommendation to approve the administrative report prepared by the
Procurement Services Division for change orders and other contractual modifications requiring Board
approval.
Meeting Date: 05/28/2019
Prepared by:
Title: Business Technology Analyst, Senior – Procurement Services
Name: Sara Schneeberger
05/13/2019 11:11 AM
Submitted by:
Title: – Procurement Services
Name: Ted Coyman
05/13/2019 11:11 AM
Approved By:
Review:
Procurement Services Ted Coyman Additional Reviewer Completed 05/13/2019 11:21 AM
Procurement Services Opal Vann Level 1 Purchasing Gatekeeper Completed 05/13/2019 11:31 AM
Procurement Services Catherine Bigelow Additional Reviewer Completed 05/15/2019 4:40 PM
Administrative Services Department Paula Brethauer Level 1 Division Reviewer Completed 05/16/2019 8:08 AM
Administrative Services Department Michael Cox Level 2 Division Administrator Review Skipped 05/17/2019 10:30 AM
County Attorney's Office Jeffrey A. Klatzkow Level 3 County Attorney's Office Review Completed 05/17/2019 1:18 PM
Office of Management and Budget Valerie Fleming Level 3 OMB Gatekeeper Review Completed 05/17/2019 3:44 PM
Office of Management and Budget Laura Wells Additional Reviewer Completed 05/20/2019 8:44 AM
County Manager's Office Nick Casalanguida Level 4 County Manager Review Completed 05/20/2019 5:07 PM
Board of County Commissioners MaryJo Brock Meeting Pending 05/28/2019 9:00 AM
16.E.4
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Item page #Contract/ Grant No.Change #DateProject Name Vendor Name Division ‐ Project ManagerOriginal Contract AmountCurrent Contract Amount Current Change Order AmountRevised Contract Amount% Over Board Approved AmountContract LengthChange in length (Days)Updated contract length Change in length (%)1 1 05-3865 10 4/22/2019Collier Blvd (GG Canal to GG Blvd)CH2M Hill, Inc.Transportation Engineering - Bee Thao$2,028,745.00 $3,287,253.00 $0.00 $3,287,253.00 0.00% 4617 330 4947 7.15%2 4 18-7391 1 5/2/2019NCRWTP - HVAC Lab ModificationsCedars Electro-Mechanical, Inc. PUD - Paul Abbott $217,000.00 $217,000.00 $0.00 $217,000.00 0.00% 120 24 144 20.00%3 7 18-7265 3 5/9/201939th Ave NE WM & RW Ext ProjectCoastal Concrete Products, LLC PUD - Paul Abbott $1,358,318.83 $1,358,318.83 $77,890.40 $1,436,209.23 5.73% 170 0 170 0.00%4 12 17-7199 3 5/2/2019Design Services for Collier County Sports ComplexDavidson EngineeringFacilities Management - Margaret Bishop$4,854,383.00 $4,854,383.00 $0.00 $4,854,383.00 0.00% 1825 0 1825 0.00%Meeting Date Total number of Change ordersTotal Dollar ChangeTotal Change in Days5/28/2019 4 $77,890.40 35416.E.4.aPacket Pg. 1037Attachment: 0528 Change Order Report - FY19 (8973 : Procurement Services Administrative Reports)
SchneebergerSara Digitally signed by SchneebergerSara
Date: 2019.05.06 12:14:05 -04'00'
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SchneebergerSara Digitally signed by SchneebergerSara
Date: 2019.05.06 12:08:41 -04'00'
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SchneebergerSara Digitally signed by SchneebergerSara
Date: 2019.05.09 14:03:50 -04'00'
8 16.E.4.b
Packet Pg. 1045 Attachment: 0528 Change Order Backup - FY19 (8973 : Procurement Services Administrative Reports)
4365 Radio Road · Suite 201 · Naples, FL 34104 · P: (239) 434.6060
1990 Main Street · Suite 750 · Sarasota, FL 34236 · P: (941) 309.5180
Civil Engineering • Planning • Permitting
D esigningE xcellence www.davidsonengineering.com
May 13, 2019
Collier County
Attn: Mr. Dayne Atkinson
Project Manager
Solid and Hazardous Waste Management
Public Utilities Logistics and Operations
Email: Dayne.Atkinson@colliercountyfl.gov
Re: 39th Avenue NE – Open Cut / Restoration
Coastal Concrete Products – Contract 18-7265
Dear Mr. Atkinson:
As engineer of record, Davidson Engineering reviewed the proposed open cut and restoration work along
Immokalee Road (39th Ave NE Project) prior to the work commencing. We found all work to be consistent
with existing rates, specifications, and general standards for the industry at time of construction.
Thank you,
Josh Fruth
Vice President
Davidson Engineering, Inc.
9 16.E.4.b
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SchneebergerSara Digitally signed by SchneebergerSara
Date: 2019.05.10 10:01:33 -04'00'
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Item page #Contract or Purchase OrderDateDescription of Project Vendor Name Division ‐ Director Fiscal Impact Description1118-7333 45001926394/4/2019 Bayshore Drive Paver Repairs Capital Contractors, LLC Bayshore CRA - Debrah Forester $7,133.00 Division staff did not complete the Independent Cost Estimate form as required by contract.2411-5729 45001903975/2/2019 Additional COBRA Vision FeesAllegiance Benefit Plan ManagementRisk Management - Jeff Walker $3,132.85Division staff did not complete an amendment to the contract prior to the beginning of the added services.Meeting DateTotal number of After the Fact MemosTotal Fiscal Impact5/28/20192$10,265.8516.E.4.cPacket Pg. 1059Attachment: 0528 After the Fact Report - FY19 (8973 : Procurement Services Administrative Reports)
Instructions
As per section 21 of the Procurement Manual, all purchases shall be consistent and in compliance with the Procurement
Ordinance (2017-08). Should work be authorized or purchases made that is inconsistent with County policy, procedure, or
contract terms, an After-the-Fact Procurement Form is required. This includes purchases made in advance of a Purchase Order,
when a Purchase Order is required to authorize such activity, and purchases made under an expired contract, or for goods and
services not covered by the current contract or purchase order. All such “After the Fact Procurements” will be reported to the
County Manager.
Requester Name: Division:
Division Director: Vendor Name:
Amount: Contract #: Purchase Order:
Why is this deemed a non-compliant purchase? Choose one.
Contract Ordinance Manual P-Card Other
Details of Purchase: Explain the circumstances behind this purchase.
Action Required: What are you asking to be done to remedy the situation, include list of invoices if applicable?
Corrective/Preventive Action: What action is being taken to prevent this violation from re-occurring?
The requestor affirms that to the best of their knowledge the information provided in this document is true.
Requested by: Signature: Date:
Division Director: Signature: Date:
Collier County
After the Fact Form
Shirley Garcia Bayshore CRA
Debrah Forester Capital Contractors, LLC
$7,133.00 18-7333 4500192639
✔
This was an emergency repair for pedestrian pavers to avoid health and safety issues in the Bayshore Gateway Triangle
CRA.
Procurement advised staff to use contract 18-7333 under Small Projects & General Contracting Services to make the
repairs. The primary vendor on contract 18-7333 would not respond to the quote request, but staff received a quote from
the secondary vendor, Capital Contractors, immediately.
CRA staff followed the terms outlined in the contract. "Work Under $10,000 - A quote will be obtained from the primary
vendor on contract. Evaluated by staff for cost reasonableness."
However, after the work was complete and the invoice submitted, Finance staff requested an ICE form be submitted. The
opinion was shared by Procurement staff that an ICE form would be a reasonable way to conduct the transaction, but this
was never outlined in the referenced contract, nor communicated to staff utilizing the contract and therefore was not
provided.
Division staff requests payment to Capital Contractors in the amount of $7,133.00.
For future use of Contract 18-7333, the PM will use the ICE form as requested by Collier County
staff.
Shirley Garcia
GarciaShirley Digitally signed by GarciaShirley
Date: 2019.04.03 12:08:49
-04'00'04/03/19
Sean Callahan
CallahanSean Digitally signed by CallahanSean
Date: 2019.04.04 08:54:15 -04'00'04/04/19
1 116.E.4.d
Packet Pg. 1060 Attachment: 0528 After the Fact Backup - FY19 (8973 : Procurement Services Administrative Reports)
Invoice
Invoice Date:12/28/2018
Invoice #:18-110
Bill To:
Collier County Board of County Commission
Attn: Accounts Payable
3299 Tamiami Trl E Ste 700
Naples, Fl 34112-5749
P.O. Number:4500192639
Due Date:12/28/2018
Project:Bayshore Pav...
Total
Balance Due
Payments/Credits
Description Order Qty Price Per Unit Amount
Subcontractor 3,500 1.00 3,500.00
Subcontractor 15% mark up 525 1.00 525.00
Skilled Labor (GC License) - Project Management, Work Plan
Development, Permit Requirements, Project Oversight24
24 70.00 1,680.00
Non-Skilled Labor (No License Required) - Project Visit, Data
Collection, Kick Off Meeting, Communication Plan, Project Field
Notes,Final Project Visit5
24 59.50 1,428.00
$7,133.00
$7,133.00
$0.00
2 16.E.4.d
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Palermo Pavers, Inc. INVOICE
"no job too small" DATE:12/15/2018
Palermo Pavers, Inc. INVOICE #18-066
5900 Painted Leaf Lane Customer ID Capital Contr.
Naples, FL. 34116 Help
Office 239-451-2277
Fax: 239-263-0593
palermopavers@yahoo.com
Capital Contractors
c/o Oliver Mayville
5633 Strand Blvd. #312
Naples, Fl. 34110
239-285-2923
oliver.mayville@capitalEngr.com
DESCRIPTION AMOUNT
REF: Invoice for Bayshore Dr. paver repairs
Contract amount: $3,550.00
Provide labor and setting materials for various repairs of paver sidewalk. $3,550.00
Balance of contract upon completion.
Please call if you have any questions.
Thank You,
Tony Palermo 451-2277
Total:[42]$3,550.00
OTHER COMMENTS TAX RATE
1. Total payment due TAX
2. Please include the invoice number on your check OTHER
3. Please call for check pick up @ 451-2277, Tony TOTAL $3,550.00
Make all checks payable to
If you have any questions about this invoice, please contact
Anthony Palermo @ 239-451-2277
Bill Collier $3,500 Only
3 16.E.4.d
Packet Pg. 1062 Attachment: 0528 After the Fact Backup - FY19 (8973 : Procurement Services Administrative Reports)
Instructions
As per section 21 of the Procurement Manual, all purchases shall be consistent and in compliance with the Procurement
Ordinance (2017-08). Should work be authorized or purchases made that is inconsistent with County policy, procedure, or
contract terms, an After-the-Fact Procurement Form is required. This includes purchases made in advance of a Purchase Order,
when a Purchase Order is required to authorize such activity, and purchases made under an expired contract, or for goods and
services not covered by the current contract or purchase order. All such “After the Fact Procurements” will be reported to the
County Manager.
Requester Name: Division:
Division Director: Vendor Name:
Amount: Contract #: Purchase Order:
Why is this deemed a non-compliant purchase? Choose one.
Contract Ordinance Manual P-Card Other
Details of Purchase: Explain the circumstances behind this purchase.
Action Required: What are you asking to be done to remedy the situation, include list of invoices if applicable?
Corrective/Preventive Action: What action is being taken to prevent this violation from re-occurring?
The requestor affirms that to the best of their knowledge the information provided in this document is true.
Requested by: Signature: Date:
Division Director: Signature: Date:
Collier County
After the Fact Form
Sonja Sweet Risk Management
Jeff Walker Allegiance Benefit Plan Mgmt
$3,132.85 11-5729 4500190397
✔
Due to the new Vision Option (insured vs. a discounted plan) being offered as of January 1,
2019, our Benefits Consultant opined that pursuant to Federal law the option is subject to
COBRA and must be offered at separation in the same manner as our medical and dental
programs. COBRA administration is outsourced to Allegiance for a fee. As a result, we
requested that they provide that same service for our Vision Options which requires a separate
fee, not anticipated in their original contract. A contract amendment to add the additional
COBRA Vision fee was not approved until April 15, 2019 due to discovering this technical issue
late in the process and due to unexpected new/updated contract language requested by the
vendor. Services were needed and provided for the months of January 2019 through April 2019.
The invoices for those months have been short paid and we are seeking to pay the vendor for
the additional services provided to comply with Federal law.
Please authorize payment of the short paid invoices for the months of Jan - April that included
the additional COBRA Vision services totaling $3,132.85.
Staff has been instructed to pay more attention to the details when adding new benefits and to
make sure necessary amendments are complete prior to the implementation of the additional
benefits.
Sonja Sweet
SweetSonja Digitally signed by SweetSonja
Date: 2019.05.02 10:27:47
-04'00'5/2/2019
Jeff Walker
Jeff Walker Digitally signed by Jeff Walker
Date: 2019.05.02 11:06:06
-04'00'5/2/2019
4 216.E.4.d
Packet Pg. 1063 Attachment: 0528 After the Fact Backup - FY19 (8973 : Procurement Services Administrative Reports)
INVOICE
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5 16.E.4.d
Packet Pg. 1064 Attachment: 0528 After the Fact Backup - FY19 (8973 : Procurement Services Administrative Reports)
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Packet Pg. 1065 Attachment: 0528 After the Fact Backup - FY19 (8973 : Procurement Services Administrative Reports)
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sa 1lSIGN BEtOW. DETACH THIS PORTION ANII RETURN IT TIITH YoUR PAYMENT
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MISSOUIIA. MT S9806
COLLIER COUNTY @VERNI.IENT
]301 EAST TATTA}iI TR,AIL BL
NAPLES FL 34112
GROUP IDENTIFJCA?TOJV DIV.
2003021 ALL
ENTE& A.iTCUTT
OF PAYT'ANT
$
rl{i/o.reE
DATE
CUSTOMER
NrdI4BER
02 /at/2019 23021-2000
orv .)
I
or"
I
I rrvvor(I annrerrE
MF]D I CA I,02 / 2019 COBRA ADMIN
Sstl. ss
7 16.E.4.d
Packet Pg. 1066 Attachment: 0528 After the Fact Backup - FY19 (8973 : Procurement Services Administrative Reports)
INVOICE
FROM
AtLEcIANcE BENEFIT PLAN Mr it"tT
P. O. BOX 3 018
2806 OARFIELD ST
MISSOUT,A MT 5 9 g06-3018
COI.IIER COUNTY GOVERNMENT
3 311 E. TAMIAT',I TRAIL
NAPLAS FL 3 4I ],3
INVOICE
NUMBEA
rlwercE
DATE
CUSTOMER
NUMBER
100935 03 / 01120L9 23021-0001
DIV.FOR ATLI,TNG
QUES?'IOIS CAiL
1406) 12r-2722
BTLLTNG
MONTH
COYERAGE
CATEGOR Y
DESCRI PTION
OF SERVICES
CREDIT
AMOUNT
alYOtJIvf
DUE
DENTAL
DSNTAL
DENTAIJ
I.IgDICAL
MEDICA',
,4ED I CAL
MBDICAL
P3/2ole
P
3 /201e
03/2019
03/2019
03/2019
03/2019
03/2019
DENTAL ADMIN
UEDICAL CLAIM FUND
CI]AIM FTJND CREDIT
CIJAIMS ADMIN PEES
PPO CHARGE
NEDI CAL CIJAIM FI.,ND
CIJAIM YUND CREDIT
I Ss.81o. ?s
91a7.662. ss
sl{?,552.5S-
s38. ?6S.95
s12.3s3. oo
$3.151.21?.21
s3. rsr,217 . 2l -re
7
INVOICE
AMOUNT
95, 810 . 75
9147 ,562 .55
;L41 ,662.s5-
$38, 755 . 96
$12, 353 .00
9! , Lst ,211 .2L
s 3 , 1s1, 217 .2r -
I so'oo
s0.00
s0.00
90.00
s0.00
g
\a3 053
)-,lC I'l'i
90.00
$0.00
+I# 4s(
1fl* 5ul
pLEllSA PAy THE FOIT|,OWINA AJ{OIIIIT -:.s=...E===., SS?.?t{.06
*ALL PAYMENTS ARE DUE BY THE 1OTH OF THE COVERAGE }IONTHT*TIF PAYING BY CHECK, DETACH BOTTPU PORTION & RETIJRN IIITH YOUR REMITTA}ICE**r**IF SET UP TO ACH, F'UNDS WIIJIJ BE PUI,II'|E[I ON THE SPECIFIED DATETA*}T*TJF SET TO PUSH FUNDS, PI.,EASE SEND FU}'DS BY THE IOTI{TT*T
AIJLECIANCE BEIIEFIT PLAI.I MGMT
P. O. BOX 3 018
2806 GARPIEI.D ST
MrsgouI.A MT 59806- 3018
r&'!ror(
NL,{MBEI
.rM/oreE
DA?A
{00936 03/01/20r9
CUSTOMER
NUMBER A.I'{O{,M?
'UE23021-0001 s5?, ?l{.05
COTLIER COUIITY GOVERNI'IENr
3311 E- TA.I.IIAIT TRATL
NAPLES FIJ 3{ II3
GROUP IDENTIFTCATTON DIV.
2003021 ALL
s
5'O-C
8 16.E.4.d
Packet Pg. 1067 Attachment: 0528 After the Fact Backup - FY19 (8973 : Procurement Services Administrative Reports)
INVOICE
FROM
ALLSGIANCE BENEFIT PI,AN
P. O. BOX 3 018
2806 SOUTH OARFIEI!
UISSOUIJA, MT 59806
I IGMT
GROUP I, )EN?I FTCATTON
CELLIER COUNTY GOVERNMENT
]fOI EAST TA],IIAT,II TRAIL BL
TNVOICE
NTJMEER
CUSTOMER
NUMBER
:r00937 03/01/a0re 2302L -2000
gr v.FOR ETLLTNG
OUESTTONS CAIL
ALL 1406t 721-2222
AII'OUNT
DUE
BT-LITNG
MONTH
COVERAGE
cA?EGO& I'
DESCRIPTION
OF SERVICES
DENTAL
DENTAL
DENTAL
DENTAL
MEDICAL
MEDICAIJ
MEDICAI,
MEDICAL
EDICAL
p3/20re
03/2019
03/20r9
!, r,0,.,
[3/201e
[3/2o1e
Pr/2o1e
03/2019
03 /20!9
DENTAI ADI4IN
tiiEDICAL CLAIM !'UND
EITAIM PUND CREDIT
2t COBRA ADMIN. DEIIT
CIAIMS
'TDUIN
FEES
PPO CHAROE
2t COBRA AD!.IIN MED
COBR A lr.rED PIrND
COBRA FI,JND CREDIT
s63.25
sl. 0{0 . 01
sr.040.01-
$22.08
$69.04
s22.00
s90.63
${.529.3?
$a, s29.3? -
s0.00
$0.00
$0.00
$0.00
s0. 00
$0.00
s0.00
$0. 00
s0.00
**34-rO.
*
+ft
(
u-['Do r q
5TD ra'3
c 3n1
1)to A O
$63 .2s
$1,040.0r
s1, 0!10 . or-
$22.08
$59.0t
s22.00
s90.63
$4,s29.t?
$4, s29.3?-
PAY THIS AIirOuNr .------
S]GN BETPW. DETACH THIS PORTION ANI RETURN IT WITH YOUR PAYMENT
s268.40
TO
I CERTIFY THAT NO PERSON COVERED UNDER TII1S COBRA POLICYIS COVERED BY MEDICARE OR AI{OTHER GROUP }IEAIJTH PT'AN.
ATLEGIAI{CE BENEFIT PLAN T4GMT
P. O. BOX 3 018
2806 SOuIH GARFIEI,D
MISSOUIA, MT 59806
COLIJI gR COUI{TY @VERNI.IENT
3301 EA6T TAIITATT TRAIL BL
NAPLES FL 3 {].I2
GROUP TDENTIFTCATTON DIV.
200302 t ALL
EMTER A.\'OUI\'T
CF PAYT{EMT
INVOI C
IVUMBET 1
rJ.OrCB
DATE
CUSTOMER
Nu?4,BER .A.IUOT'I\T DUE
03/01/20r9 23A2t-2000 s26L 40
F'OR
{00937
NAPLES FL 3 4112
rNvo-[cE
DATA
INVO I CE
At40wT
CREDIT
AMOUNT
MEDlCAL
9 16.E.4.d
Packet Pg. 1068 Attachment: 0528 After the Fact Backup - FY19 (8973 : Procurement Services Administrative Reports)
FROM
AI,I,EGIANCE BENEFIT PLAN MGMT
P.O. BOX 3018
2806 GARFIELD ST
MrssoULA MT 59806-3018
COIJIJ]ER COUNTY GOVERNMENT
33]"1 E. TAMIAMI TRAIL
NAPI,ES FL 34113
TO
GROUP IDENTIFICATION DIV.
2003021 ALL
20790407 c
INVOICE
NLMEER
INVOICE
DATE
CUSTOMER
NUMBER AI,\OUNT DUE
40L57'7 04/01,/2OL9 23021--0001 5230 ,2L7 .25
sS'j,(,
*ALI,PAYMENTSAREDUEBYTHE]-oTHoFTHECoVERAGEMoNTH*
**IF PAYING BY CHECK, DETACH BOTTOM PORTION & RETURN WITH YOTIR REMITTANCE**
***IFSETUPToACH,FUNDSWILLBEPULLEDoNTHESPECIFIEDDATE***
****IFsETToPUSHFUNDS,PLEASESENDFUNDSBYTHEI0TH****
TO
.EN?ER AMOUNT
OF PAYMEN?-
t
AT,I,EGIANCE BENEFIT PLAN MGMT
P.O. BOX 3018
2805 GARFIELD ST
Mrssoul,A MT 59805-3018
COLI,]ER COUNTY GOVERNMENT
3311 E. TAMIAMI TRAII,
NAPLES FL 341]-3
INIVOICE
NLIJVIBER
INVOICE
DATE
CUSTOMER
NUMBER
GROUP IDENTIFICATION DIV FOR BILLING
QUEST rONS CALL
40L517 04 / o1 /2ots 2302l"- O00a 200302].ALL (405) '721-2222
AMOWT
DUE
CREDIT
AMOUNT
INVOICE
AMOUNT
DESCRIPTION
OF SERVICES
I
MONTH
COVERAGE
CATEGORY
$s,7so.2s
$145,579.51
$a46,579 -51--
$38, 593.36
$l-2,298 .00
$3, 106 ,922 .91-
$3,106 ,922.94-
$o .00
$0.00
$0.00
$o. oo
$o. oo
$0.00
$0.00
$0.00
sL7 2 ,'l 81, .'1 9
$5, 750.25
$l-45, 579.51
$L45,5'19.54-
$38, 593 .36
$12,298.00
$3, l"06 ,922 .9L
3, 106 ,922 .91'
/ 2o19
4/2oa9
4 / 2oL9
/2oa9
4 /2oL9
4 / 2oL9
/ 2or9
PREVIOUS BAI,ANCE
DEIITAL ADMIN
MEDICAL CI,AIM FUND
CLAIM FUND CREDIT
CI,AIMS ADMIN FEES
PPO CHARGE
MEDICAIJ CI,AIM FI]ND
CI.AIM FUND CREDIT
DENTAIJ
DENTAL
DE}ilTAI]
MEDICAT,
MEDICAL
MEDICAL
MEDICAL
q1
L{tl
D 1103
)iav1
pr++ +
PLEASE PAy fHE FOtIOWING AMOUMr =========i==->$rarffii-5-
FOR
. 85 .00
10 16.E.4.d
Packet Pg. 1069 Attachment: 0528 After the Fact Backup - FY19 (8973 : Procurement Services Administrative Reports)
FROM TO
MONTH
ILL COVERAGE
CATEGORY
DESCRIPTION
o,' s.&'RyrcE^s
IAMOICE
AMOWT
CREDIT
AMOUNT
AMOUNT
DUE
4/20]-9
4/20L9
4/2O79
4 / 2019
4/2079
4/2OL9
4/2079
4/2079
/ 2019
DE}ITAT
MEDICAI,
MED]CAL
MEDICAI
MEDICAIJ
MEDICA],
DE}.ITAIJ
DENTAI,
DENTAIJ
PREVIOUS BAI,ANCE
DEMTAI ADMIN
MEOICAL CLAIM FUND
CIAI!.{ FUND CREDIT
2I COBRA .ADMIN-DEM
CI.AIMS ADMIN FEES
PPO CHARGE
2T COBRA ADMIN MED
COBRA MED FUND
COBRA FUND CRED]T
$63 .2s
$1, 189 . 77
$1,189.7?-
92s.08
$59.04
s22 . OO
s90.53
$4,s29 .37
s4 ,s29 .37 -
$0.00
$0. 00
s0.00
$0.00
$o. oo
$0.00
so. o0
$0.00
$o. oo
6o. oo
9811.98
$63.2s
$1, 199 . ??
$1,189.7?-
$2s.08
$69.04
s22.00
$90.53
$4 , s29 .37
$4 , s2s .37 -
a
\?D b
11.4D
Er-r-E=!E=E-E>$+48+.i€PAY T1IIS AT+IOTINT
AIIJEGTANCE BENEFIT PLAN MGMT
P. O. BOX 3 01s
2806 SOUTH GARF]ELD
MISSOUIA, MT 598 06
COI,LTER COUNTY GOVERNMENT
3301 EAST TA}4IA!.!I TRA]L BL
NAPLES FIJ 34112
INVOICE
NUMBER
INVOICE
DATE
CUSTOMER
NAMBER
GROUP IDENTIFICATION DIV.FOR BILLING
QUESTIONS CALI)
2302r-2000 200302r ALIJ (406) 727-2222
SIGN BELOW, DETACH
I^CERTIFY THAT NO PERSONIS COVERED BY MEDICARE OR
THTS PORTION AND RETURN IT WITH YOUR PAYMENT
"sHfif E.Ti8$"'fi i.i" ii"xio$?", ""TO AILEG
P.O.
rANCE BEMFIT PIAN MGMT
BOX 3 018
2805 SOUrH GARFTEIJD
MISSOULA, MT 598 06
COLLIER COU}ITY GOVERMENT
3301 EAST TAMIAMI ?RATT BL
NAPIJES FL 3 4112
20790a07 c
EN?AR AMOUNT
$
INVOICE
DATE
CUSTOMER
NUMBER A]yIOA;U DUE
407578 04/0t/20ae 2302L-2000 $1,083.38
I F I CATIONGROUPIDEMI DIV .
2003021 ALL
r,OR
40157B 04/01-/2o1,s
9
q
INVOI CE
NWBER
11 16.E.4.d
Packet Pg. 1070 Attachment: 0528 After the Fact Backup - FY19 (8973 : Procurement Services Administrative Reports)