HomeMy WebLinkAboutR 2015-393-E HR - UnitedHealthCare (UHC) for UHC Application for Excess Loss Insurance Policy DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8
ORANGE COUNTY—CONTRACT CONTROL SHEET
Routing Order: (1)Department, (2)IT,(3)Risk Management,(4)Financial Services,(5)Attorney,(6)Manager,(7)Clerk
This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above. If the Manager
determines the contract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval. Contracts for
BOCC approval must be submitted through,and complete,the routing process prior to agenda review. Contracts for legal review should
be completed through the legal review process prior to being routed for signature.
Deuartment
Party/Vendor Name: United HealthCare Party/Vendor Contact Person: Patricia Martin Contact Phone:919-840-3106 Party/Vendor
Address:3131 RDU Center Drive City Morrisville State:NC Zip:27560 Department: Amount: $1,265,095.00 Purpose:United
HealthCare Application for Excess Loss Insurance Policy Budget Code(s): Vendor 4 47140 (N/A if new vendor) Vendor is a
BOCC consultant? Yes ❑No® Contract Type: (Check one)New ❑ Renewal ® Amendment ❑ Effective Date 7/1/2015
Approved by Board Yes®No❑ Agenda Date:3/3/2015 Title of Contract: 1)UnitedHealthcare Stop Loss Policy and 2)
UnitedHealthcare Application of Excess Loss Insurance
If this is a Grant Agreement,pre-application has been approved by the Board of Commissioners Yes❑No®. If submitted for bid were
bids/RFPs received Yes❑No❑ Bid/RFP number This contract has been reviewed and approved by the Department Director as to
technical content: DocuSigned by: ,J(�
IBA-CQ802-69FO-148F?ftJnj& f�a�,"^"(hMt,W 7/24/2015
Department Director's Signature: Date:
IT Director
(Applicable only to hardware/software purchases or related services)This contract has been reviewed and approved by the Information
Technology Director as to technical content and information technology specifications:
IT Director's Signature: Date:
Risk Management
Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; OR No Insurance Required ❑. Hold
Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shown,this contract is approved
by the Risk Manager: DocuSigned""by:
QUs& 66vvt,e 6 7/28/2015
Risk Manager's Signature: Fetes��aoo4�s__. Date:
Financial Services
This Contract is conditioned upon appropriation by the Board of Commissioners Yes❑No❑. A budget amendment is necessary
before approval Yes❑ No❑. If budget amendment is necessary,please attach to this form. This instrument has been pre-audited in the
manner required by the Local Government 7P9i2nF ROT` eM' 1 Control Act:
AaVU 8/5/2015
Financial Services Director's Signature: Date:
Countv Attornev
Approval by Board ❑ (Contracts $90,000.00 or more for goods or services, $250,000.00 or more for construction, or any BOCC
consultant contract). Approval by Manager❑ (Most other contracts$1,000 and above). Department Director approval only ❑ (Under
$1,000). This contract heooimvky�ved and approved by the Attorney as to legal form and sufficiency:
1 8/5/2015
Attorney's Signature Date:
Countv Manager
This contract has been reviewed and is approved by the County Manager Yes❑No❑.
This contract has been reviewed and is for signature by the Chair Yes❑No❑.
Manager's Signature: Date:
Clerk to the Board
Approved by BOCC on the day of 20 . Submitted for Chair signature on the day of 20__
Clerk's Signature: Date:
Revised March 2012