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HomeMy WebLinkAboutGUSTAVO ORTIZ - 2001-03-19CITY OF HUNTINGTON BEACH 2000 MAIN STREET CALIFORNIA 92648 OFFICE OF THE CITY CLERK CONNIE BROCKWAY CITY CLERK LETTER OF TRANSMITTAL OF ITEM APPROVED BY THE CITY COUNCIL/ REDEVELOPMENT AGENCY OF THE CITY OF HUNTINGTON BEACH DATE: March 28, 2001 TO: Gustavo Ortiz ATTENTION: Name 26741 Portola Pkwy, Suite 1E-444 DEPARTMENT: Street Foothill Ranch, CA 92610 REGARDING: Professional Services City, State, zip Contract — Workers Comu. Claims Serv. See Attached Action Agenda Item E-13 Date of Approval 3-19-01 Enclosed For Your Records Is An Executed Copy Of The Above Referenced Agenda Item. Remarks: Connie Brockway City Clerk Attachments: Action Agenda Page x CC: C. Martin Name M. Dolder Name K. Foster Agreement x RCA Admin. Serv. Department Fire Department Risk -Mgmt. Name Department Name Department C. Mendoza x Risk Management Dept. x RCA x RCA x RCA RCA x Bonds Insurance x Deed Other x x Agreement Insurance Other x x _ Agreement Insurance Other x x Agreement Insurance _ Other Agreement Insurance Other x Insurance (Telephone: 714536-5227 ) _ as C. MWI )I&I mnk-cv CITY OF HUNTINGTON BEACO as k- %0 51�, Ask Mh�7- MEETING DATE: March 19, 2001 DEPARTMENT ID ER: AS-01-005 Council/Agency Meeting Held: Deferred/Continued to: )l(A proved ❑ Condi ' nally Approved ❑ Denied _ —o *-city erk's Signature Council Meeting Date: March 19, 2001 Department ID Number: AS-01-005 CITY OF HUNTINGTON BEACH REQUEST FOR ACTION SUBMITTED TO: HONORABLE AND MAYOR AND CITY COUNCIL MEMBERS SUBMITTED BY: RAY SILVER, CITY ADMINISTRATOR �+'✓ PREPARED BY: CLAY MARTIN, DIRECTOR OF ADMINISTRATIVE SERVICES AND MICHAEL DOLDER, FIRE CHIEF/INFORMATION SYSTEMS DIRECTOR SUBJECT: APPROVE PROFESSIONAL SERVICES CONTRACT BETWEEN THE CITY OF HUNTINGTON BEACH AND GUSTAVO ORTIZ FOR WORKERS COMPENSATION CLAIMS SERVICES Statement of Issue, Funding Source, Recommended Action, Alternative Action(s), Analysis, Environmental Status, Attachment(s) Statement of Issue: Should the City enter into a professional services contract for workers compensation claims consulting. Funding Source: $150,000 is currently budgeted in the JD Edwards project for backfilling Administrative Services personnel assigned to the project. The funds are available in Temporary Salaries, account number 30143002.5200. Recommended Action: MOTION TO: 1) Approve and authorize the Mayor and City Clerk to execute the Professional Services Contract Between the City of Huntington Beach and Gustavo Ortiz for Workers Compensation Claims Services. 2) Approve the waiver of general liability and professional liability insurance requirements as recommended by the Settlement Committee meeting. E, RCA FOR Gus Ortiz 5a 3/8/01 12:21 PM L REQUEST FOR ACTION 0 MEETING DATE: March 19, 2001 DEPARTMENT ID NUMBER: AS-01-005 Alternative Actions : Do not approve the agreement. Analysis: Claims Supervisor Julie Russell was reassigned to the BEACH project on a full time basis in December 2000. It is necessary to have an experienced workers compensation claims professional to handle her case load. The City utilized Mr. Ortiz through a temporary agency. Due to the nature of this assignment and the need for immediate assistance in this work load, the City did not send out an RFP for these services, and instead went with a sole source through the temporary agency. The City is now desirous of utilizing Mr. Ortiz' services on an independent contractor basis for a savings of $800 per month. Mr. Ortiz has been working full time in the Risk Management division since December 2000. The quality and productivity of his work is excellent. Mr. Ortiz has his own workers compensation consulting business. The City will save $800 per month by eliminating the temporary agency and contracting directly with Mr. Ortiz for these services. On March 6, 2001, the City's Settlement Committee had approved a waiver of all insurance requirements for this contract due to the minimal exposure/risk to. the City. Environmental Status: Not applicable Attachment(s): 1 2 RCA Author: Karen Foster Professional Services Agreement between the City of Huntington Beach and Gustavo Ortiz Approved insurance certificate waiver RCA FOR Gus Ortiz -3- 3/8/01 12:21 PM ATTAC r '■ a' VT #1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 PROFESSIONAL SERVICES CONTRACT BETWEEN THE CITY OF HUNTINGTON BEACH AND GUSTAVO ORTIZ FOR WORKERS COMPENSATION CLAIMS SERVICES Table of Contents Scopeof Services.....................................................................................................1 CityStaff Assistance................................................................................................2 Time of Performance...............................................................................................2 Compensation...........................................................:..............................................2 Priorities..................................................................................................................2 ExtraWork...............................................................................................................2 Methodof Payment..................................................................................................3 Disposition of Plans, Estimates and Other Documents...........................................4 HoldHarmless.........................................................................................................5 Workers' Compensation Insurance..........................................................................5 General Liability Insurance......................................................................................6 Professional Liability Insurance..............................................................................6 Certificates of Insurance..........................................................................................6 IndependentContractor............................................................................................7 Termination of Agreement.......................................................................................7 Assignment and Subcontracting...............................................................................8 Copyrights/Patents...................................................................................................7 City Employees and Officials..................................................................................8 Notices.....................................................................................................................8 Modification.............................................................................................................8 SectionHeadings.....................................................................................................9 Interpretation of this Agreement..............................................................................9 DuplicateOriginal....................................................................................................10 Immigration..............................................................................................................10 Legal Services Subcontracting Prohibited...............................................................10 Attorney's Fees.........................................................................................................10 Entirety..................................................................................................................... I I PROFESSIONAL SERVICES CONTRACT BETWEEN THE CITY OF HUNTINGTON BEACH AND GUSTAVO ORTIZ FOR WORKERS COMPENSATION CLAIMS SERVICES THIS Agreement is made and entered into this 19th day of March 2001, by and between the City of Huntington Beach, a municipal corporation of the State of California, hereinafter referred to as "CITY," and GUSTAVO ORTIZ, a sole proprietor, hereinafter referred to as "CONSULTANT." WHEREAS, CITY desires to engage the services of a consultant to provide Workers' Compensation claims services; and Pursuant to documentation on file in the office of the City Clerk, the provisions of the Huntington Beach Municipal Code, Chapter 3.03, relating to procurement of professional service contracts have been complied with; and CONSULTANT has been.selected to perform said services, NOW, THEREFORE, it is agreed by CITY and CONSULTANT as follows: SCOPE OF SERVICES CONSULTANT shall provide Workers' Compensation claims services under the direction of City's Risk Manager, Karen Foster. CONSULTANT's duties will include administration of City's Workers' Compensation benefits pursuant to the California Labor Code and other applicable codes, ordinances and policies. These services shall sometimes hereinafter be referred to as the "PROJECT." CONSULTANT hereby designates Gustavo Ortiz, who shall represent it and be its sole contact and agent in all consultations with CITY during the performance of this Agreement. g*2001agreements: Gustavo Ortiz RLS 2001-0116 2. CITY STAFF ASSISTANCE , CITY shall assign a staff coordinator to work directly with CONSULTANT in the performance of this Agreement. 3. TIME OF PERFORMANCE Time is of the essence of this Agreement. The services of CONSULTANT are to commence as soon as practicable after the execution of this Agreement. The term of this Agreement shall commence on the date this Agreement is approved by CITY, and shall expire six months from the date of commencement. 4. COMPENSATION In consideration of the performance of the services described herein, CITY agrees to pay CONSULTANT a fee on a time and materials basis at the rate of $40.00 per hour, not to exceed Thirty-two Thousand Dollars ($32,000.00). 5. CONFIDENTIALITY CONSULTANT acknowledges that the nature of the services it will provide CITY requires it to obtain sensitive financial data, employee information, methods of operation, policy statements, and other related confidential information. CONSULTANT will restrict its use of such information to the performance of its duties as required herein, and will refrain to the maximum extent provided by law, from the disclosure of said information to third parties. 6. EXTRA WORK In the event CITY requires additional services not described herein, or changes in the scope of services described herein, CONSULTANT will undertake such work only after receiving written authorization from CITY. Additional compensation for such extra work shall be allowed only if the prior written approval of -CITY is obtained. 2 g*2001agreements: Gustavo Ortiz RLS 2001-0116 7. METHOD OF PAYMENT A. CONSULTANT shall be entitled to progress payments toward the fixed fee set forth herein in accordance with the progress and payment schedules set forth below. B. Delivery of work product: A copy of every memorandum, letter, report, calculation and other documentation prepared by CONSULTANT shall be submitted to CITY to demonstrate progress toward completion of tasks. In the event CITY rejects or has comments on any such product, CITY shall identify specific requirements for satisfactory completion. Any such product which has not been formally accepted or rejected by CITY shall be deemed accepted. C. CONSULTANT shall submit to CITY an invoice for each progress payment due. Such invoice shall: 1) Reference this Agreement; 2) Describe the services performed; 3) Show the total amount of the payment due; 4) Include a certification by a principal member of CONSULTANT's firm that the work has been performed in accordance with the provisions of this Agreement; and 5) For all payments include an estimate of the percentage of work completed. Upon submission of any such invoice, if CITY is satisfied that CONSULTANT is making satisfactory progress toward completion of tasks in accordance with this Agreement, CITY shall promptly approve the invoice, in which event payment shall be made within thirty (30) days of receipt of the invoice by CITY. Such approval shall not be unreasonably withheld. 3 g:4:2001 agreements: Gustavo Ortiz RLS 2001-0116 • • If CITY does not approve an invoice, CITY shall notify CONSULTANT in writing of the reasons for non -approval within seven (7) calendar days of receipt of the invoice, and the schedule of performance set forth herein shall be suspended until the parties agree that past performance by CONSULTANT is in, or has been brought into compliance, or until this Agreement is terminated as provided herein. D. Any billings for extra work or additional services authorized by CITY shall be invoiced separately to CITY. Such invoice shall contain all of the information required above, and in addition shall list the hours expended and hourly rate charged for such time. Such invoices shall be approved by CITY if the work performed is in accordance with the extra work or additional services requested, and if CITY is satisfied that the statement of hours worked and costs incurred is accurate. Such approval shall not be unreasonably withheld. Any dispute between the parties concerning payment of such an invoice shall be treated as separate and apart from the ongoing performance of the remainder of this Agreement. DISPOSITION OF PLANS, ESTIMATES AND OTHER DOCUMENTS CONSULTANT agrees that all materials prepared hereunder, including all original drawings, designs, reports, both field and office notices, calculations, maps, memoranda, letters and other documents, shall be turned over to CITY upon termination of this Agreement or upon PROJECT completion, whichever shall occur first. In the event this Agreement is terminated, said materials may be used by CITY in the completion of the PROJECT or as it otherwise sees fit. Title to said materials shall pass to CITY upon payment of fees determined to be earned by CONSULTANT to the point of termination or completion of the PROJECT, whichever is applicable. CONSULTANT shall be entitled to retain copies of all data prepared hereunder. 4 g:4:2001 agreements: Gustavo Ortiz RLS 2001-0116 9. HOLD HARMLESS CONSULTANT shall protect, defend, indemnify and hold harmless CITY, its officers, officials, employees, and agents from and against any and all liability, loss, damage, expenses, costs (including without limitation, costs and fees of litigation of every nature) arising out of or in connection with CONSULTANT's performance of this Agreement or its failure to comply with any of its obligations contained in this Agreement by CONSULTANT, its officers, agents or employees except such loss or damage which was caused by the sole negligence or willful misconduct of CITY. CITY shall be reimbursed by CONSULTANT for all costs and attorney's fees incurred by CITY in enforcing this obligation. 10. WORKERS' COMPENSATION INSURANCE Pursuant to California Labor Code Section 1861, CONSULTANT acknowledges awareness of Section 3700 et seq. of said Code, which requires every employer to be insured against liability for workers' compensation; CONSULTANT covenants that it will comply with such provisions prior to commencing performance of the work hereunder; and shall indemnify, defend and hold harmless CITY from and against all claims, demands, payments, suit, actions,. proceedings, and judgments of every nature and description, including attorney's fees and costs presented, brought or recovered against the CITY, for or on account of any liability under any of said acts which may be incurred by reason of any work to be performed by CONSULTANT under this Agreement. CONSULTANT shall maintain workers' compensation insurance in an amount of not less than One.Hundred Thousand Dollars ($100,000) bodily injury by accident, each occurrence, One Hundred Thousand Dollars ($100,000) bodily injury by disease, each employee, Two Hundred Fifty Thousand Dollars ($250,000) bodily injury by disease, policy limit. g:4:2001agreements: Gustavo Ortiz RLS 2001-0116 CONSULTANT shall require all subcontractors to provide such workers' compensation insurance for all of the subcontractors' employees. CONSULTANT shall furnish to CITY a certificate of waiver of subrogation under the terms of the workers' compensation insurance and CONSULTANT shall similarly require all subcontractors to waive subrogation. 11. GENERAL LIABILITY INSURANCE Waived by Settlement Committee 3-6-01. 12. PROFESSIONAL LIABILITY INSURANCE Waived by Settlement Committee 3-6-01. 13. CERTIFICATES OF INSURANCE Prior to commencing performance of the work hereunder, CONSULTANT shall furnish to CITY certificates of insurance subject to approval of the City Attorney evidencing the foregoing insurancecoverages as required by. this Agreement; the certificates shall: A. provide the name and policy number of each carrier and policy; B. shall state that the policy is currently in force; and C. shall promise that such policies shall not be suspended, voided or canceled by either party, reduced in coverage or in limits except after thirty (30) days' prior written notice; however, ten (10) days' prior written notice in the event of cancellation for nonpayment of premium. CONSULTANT shall maintain the foregoing insurance coverages in force until the work under this Agreement is fully completed and accepted by CITY. The requirement for carrying the foregoing insurance coverages shall not derogate from the provisions for indemnification of CITY by CONSULTANT under the Agreement. CITY or its representative shall at all times have the right to demand the original or a copy of all g:4:2001 agreements: Gustavo Ortiz RLS 2001-0116 said policies of insurance. CONSULTANT shall pay, in a prompt and timely manner, the premiums on all insurance hereinabove required. 14. INDEPENDENT CONTRACTOR CONSULTANT is, and shall be, acting at all times in the performance of this Agreement -as an independent contractor herein and not as an employee of the CITY. CONSULTANT shall secure at its expense, and be responsible for any and all payment of all taxes, social security, state disability insurance compensation, unemployment compensation and other payroll deductions for CONSULTANT and its officers, agents and employees and all business licenses, if any, in connection with the services to be performed hereunder. 15. TERMINATION OF AGREEMENT All work required hereunder shall be performed in a good and workmanlike manner. CITY may terminate CONSULTANT's services hereunder at any time with or without cause, and whether or not PROJECT is fully complete. Any termination of this Agreement by CITY shall be made in writing, seven days advance notice of which shall be delivered to CONSULTANT as provided herein. In the event of termination, all finished and unfinished documents, exhibits, report, and evidence shall, at the option of the CITY, become its property and shall be delivered to it by CONSULTANT. 16. ASSIGNMENT AND SUBCONTRACTING This Agreement is a personal service contract and the supervisory work hereunder shall not be delegated by CONSULTANT to any other person or entity without the express written consent of CITY. g:4:2001agreements: Gustavo Ortiz RLS 2001-0116 17. COPYRIGHTS/PATENTS CITY shall own all rights to any patent or copyright on any work, item or material produced as a result of this Agreement. 18. CITY EMPLOYEES AND OFFICIALS CONSULTANT shall employ no CITY official nor any regular CITY employee in the work performed pursuant to this Agreement. No officer or employee of CITY shall have any financial interest in this Agreement in violation of the applicable provisions of the California Government Code. 19. NOTICES Any notice or special instructions required to be given in writing under this Agreement shall be given either by personal -delivery to CONSULTANT's agent (as designated in Section 1 hereinabove) or to CITY's Director of Administrative Services as the situation shall warrant, or by enclosing the same in a sealed envelope, postage prepaid, and depositing the same in the United States Postal Service, addressed as follows: TO CITY: Director of Administrative Services City of Huntington Beach 2000 Main Street Huntington Beach, CA 92648 20. MODIFICATION TO CONSULTANT: Gustavo Ortiz 26741 Portola Pkwy, Suite 1 E-444 Foothill Ranch, CA 92610 Telephone: (949) 830-2027 No waiver or modification of any language in this Agreement shall be valid unless in writing and duly executed by both parties. 8 g*2001agreements: Gustavo Ortiz RLS 2001-0116 21. SECTION HEADINGS The titles, captions, section, paragraph, subject headings and descriptive phrases at the beginning of the various sections in this Agreement are merely descriptive and are included solely for convenience of reference only and are not representative of matters included or excluded from such provisions, and do not interpret, define, limit or describe, or construe the intent of the parties or affect the construction or interpretation of any provision of this Agreement. 22. INTERPRETATION OF THIS AGREEMENT The language of all parts of this Agreement shall in all cases be construed as a whole, according to its fair meaning, and not strictly for or against any of the parties. If any provision of this Agreement is held by an arbitrator or court of competent jurisdiction to be unenforceable, void, illegal or invalid, such holding shall not invalidate or affect the remaining covenants and provisions of this Agreement. No covenant or provision shall be deemed dependent upon any other unless so expressly provided here. As used in this Agreement, the masculine or neuter gender and singular or plural number shall be deemed to include the other whenever the context so indicates or requires. Nothing contained herein shall be construed so as to require the commission of any act contrary to law, and wherever there is any conflict between any provision contained herein and any present or future statute, law, ordinance or regulation contrary to which the parties have no right to contract, then the latter shall prevail, and the provision of this Agreement which is hereby affected shall be curtailed and limited only to the extent necessary to bring it within the requirements of the law. g:4:2001agreements: Gustavo Ortiz RLS 2001-0116 23. DUPLICATE ORIGINAL The original of this Agreement and one or more copies hereto have been prepared and signed in counterparts as duplicate originals, each of which so executed shall, irrespective of the date of its execution and delivery, be deemed an original. Each of the parties hereto shall retain an originally signed copy hereof. Each duplicate original shall be deemed an original instrument as against any party who has signed it. 24. IMMIGRATION CONSULTANT shall be responsible for full compliance with the immigration and naturalization laws of the United States and shall, in particular, comply with the provisions of the United States Code regarding employment verification. 25. LEGAL SERVICES SUBCONTRACTING PROHIBITED CONSULTANT and CITY agree that CITY is not liable for payment of any subcontractor work involving legal services, and that such legal services are expressly outside the scope of services contemplated hereunder. CONSULTANT understands that pursuant to Huntington Beach City Charter Section 309, the'City Attorney is the exclusive legal counsel for CITY; and CITY shall not be liable for payment of any legal services expenses incurred by CONSULTANT. 26. ATTORNEY'S FEES In the event suit is brought by either party to enforce the terms and provisions of this Agreement or to secure the performance hereof, each party shall bear its own attorney's fees. 10 g*2001agreements: Gustavo Ortiz RLS 2001-0116 27. ENTIRETY The Agreement contains the entire agreement between the parties respecting the subject matter of this Agreement and supercedes all prior understanding and agreements whether oral or in writing. The foregoing sets forth the entire Agreement between the parties. IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed by and through their authorized offices the day, month and year first above written. CONSULTANT CITY OF HUNTINGTON BEACH, a GUSTAVO ORTIZ, a municipal corporation of the State of California sole proprietor --JVa�, B : " " Ma or Y Y Gustavo Ortiz ATTEST: egx('� oww"9�— City Clerk . 07— fS--dl . REVIEWED AND APPROVED: City Admini rator APPROVED AS TO FORM: City orney p 3 1� Z 8 INITIATZ-D'-APR ED 11 g*2001agreements: Gustavo Ortiz RLS 2001-01 16 GUSTAVO L. ORTIZ Workers Compensation Services & Strategic Solutions February 12, 2001 City of Huntington Beach Risk Management Department Karen Foster, Director 2000 Main St. Huntington Beach, CA 92648 Dear Ms. Foster: RE: WORKERS COMPENSATION ADJUSTING/CONSULTING PROJECT This letter will confirm our discussion concerning the terms of retainer and nature of services to be performed for you. These terms are as follows: 1. TERM: This agreement will commence on February 26, 2001 or when services are approved by the responsible parties, whichever is first. Either of us may terminate this agreement with one (1) week written notice to the other party. In the event of termination, I will be compensated for services rendered through the date of termination. 2. DUTIES: Duties will include administering workers compensation benefits per the California Labor Code on behalf of the City of Huntington Beach (COHB)Risk Management Department and the employees of the the City. 3. CONFIDENTIALITY: It is understood that in the performance of these duties, I will obtain information about the Company, and that such information may include financial data, employee -information, methods of operating, policy statements, and other confidential data. I agree to restrict my use of such above -mentioned information to the performance of duties described in this agreement. 4. COMPENSATION: The compensation for my services shall be at the rate of $40.00 per hour, payable upon weekly receipt as billed to include office time (on or off -site), meetings attended, and training time. Other out-of-pocket costs, such as travel expenses, phone bills, and administrative costs will be billed in addition. I fully understand that I am an independent contractor, working on a 1099 tax basis and am responsible for my personal health benefits and workers compensation. Page 1 of 2 GUSTAVO I. ORTIZ Workers Compensation Adjusting & Strategic Solutions February 12, 2001 Re: W.C. Adjusting/Consulting Project Page 2 of 2 If the terms of this agreement are agreeable, please sign below and return this agreement to me at your earliest convenience. Facsimile containing both signatures is binding and may serve as an original. If you have any questions, please give me a call. I look forward to working with you on this project! Sincerely, Gustavo L. Ortiz Owner/W.C. Consultant Accepted and agreed to: Karen Foster Date Director, COHB Risk Management Dept. • • Gustavo L. Ortiz 8 Belcrest Street Foothill Ranch, CA 92610 (949)716-9776 SUMMARY: Over 12 years of professional workers compensation and in-depth field investigations and safety experience. Excellent interpersonal and communication skills. Excellent with computers and information. Strong team and customer service orientation. Exceptional research skills. EXPERIENCE: 1991 - 1998 California Compensation Insurance Co. Orange, CA Field Investigator • Conduct comprehensive workers compensation investigations including obtaining recorded statements, gathering physical evidence, identifying subrogation, photographing accident scenes, performing activity checks, and completing written statements/reports. • Interact with and advise employers to minimize work -related incidents and assess risk management program. Conduct safety review on site. • Counsel claimants regarding benefit entitlement. • Recommend appropriate action items for claims representatives. • Provide training and direction to other staff. • Act as liaison between claims adjusters and employers promoting customer service. 1990 - 1991 National American Insurance Company Rancho Dominguez, CA Sr. Claims Representative • Administered benefits relating to workers compensation injury claims. • Performed supervisory duties over unit. • Handled highly litigated caseload and negotiated settlements. • Appeared at WCAB as hearing representative. • Adjusted caseload with six -figure reserves. 1988 - 1990 Hartford Insurance Co. Brea, CA Claims Representative • Administer benefits relating to workers compensation injury claims including negotiating settlements in litigated cases, adjusting proper reserves, counseling claimants regarding benefits, and obtaining recorded interviews. 1986- 1988 Great American -West Insurance Orange, CA Claims Representative • Administer benefits relating to workers compensation injury claims including negotiating settlements in litigated cases, adjusting proper reserves, counseling claimants regarding benefits, and obtaining recorded interviews. EDUCATION: California State University, Fullerton Bachelor of Arts - Communications/Journalism SPECIAL SKILLS: • Computer literate • Strong investigative, research, and interviewing skills • Bilingual - Fluent Speaking, Reading & Writing in Spanish and English • Work with minimal supervision • Excellent written and oral skills ATTACHMENT #2 � CITY OF HUNTINGTON BEACH APPLICATION FOR INSURANCE REQUIREMENTS WAIVER OR MODIFICATION 1. Name/Title/Department of v Reques ' g Staff Member6�tr- 70 S k� Z "Vt pt V C r 2. Date of Request Z L) /() 3. Name of Contractor/Permittee / `1-u � Tx V 6) V %Z- 4. Description of work to be performed W 1YL(-(r 5 c-r 6WIKJ ;,Q vz)�-e S S 'f-7LcJ 5. Value of Contract 52 , W 6. Length of Contract to fvl,.m � Vl S— 7. Type of Insurance Waiver or Modification Requested: (a) Limits: (b) Coverage Have you contacted Risk Management to determine if professional liability coverage is available through SCOPE? 9. Reason for Request for Waiver or Reduction of Limi 10. Identify the risks to the City if this request for waiver or modifications granted & ( n tt-A_ Department Head Si (This section to be completed"by Risk Manager) Recommendation: Approve -1� Deny Risk Manager's Signature/Date /_,2,1,Z -)7A (This section to be completed by City Attorney) Recommendation: Approve V Deny t City Attorney's Signature/Date Settlement Committee approv is] required for this waiver. If Settlement Committee approval is required, submit this form to City Attorney ice o be placed on the agenda. Recommendation: Approve' Deny City -Council appro [is] is quired for this waiver. If City Council approval is required, attach this form to the - RCA after considera �g a Settlement Committee. This insurance waiver [is not] on City Council agenda. Reviewer's initials j mp/mis/inswaiver/3/ 14/00 File Notes Office of the City Clerk Huntington Beach, California RCA ROUTING SHEET INITIATING DEPARTMENT: Admin. Svcs SUBJECT: Professional Services. Contract with. Gustavo Ortiz for Workers Compensation- Claims Services COUNCIL MEETING DATE: March 19, 2001 ATTACHMENTS Ordinance (w/exhibits & legislative draft if applicable) Not Applicable Resolution (w/exhibits & legislative draft if applicable) Not Applicable Tract Map, Location Map and/or other Exhibits Not Applicable Contract/Agreement (w/exhibits if applicable) (Signed in full by the City Attome Attached Subleases, Third Party Agreements, etc. (Approved as to form by City Attome) Not Applicable Certificates of Insurance (Approved by the City Attomey) Not Attached (Explain) Financial Impact Statement (Unbudget, over $5,000) Not Applicable Bonds If applicable) Not Applicable Staff Report (If applicable) Not Applicable Commission, Board or Committee Report If applicable) Not Applicable Findings/Conditions for Approval and/or Denial Not Applicable ;EXPLANATION FOR MISSING ATTAC.HMENT$`` Request for City Council approval for a waiver of all insurance requirements. _EXPLANATION FOR RETU:RN.OF,:ITEM.