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HomeMy WebLinkAbout2016-541-E HR - Gallagher Benefit Services for consulting services DocuSign Envelope ID:7B0EAFC2-08FE-4D8D-8809-FC9B16F772B3 „,,, -" (11, Arthur-J. Gallagher& Co. BUSINESS WITHOUT BARRIERS- CLIENT COVERAGE ACKNOWLEDGMENT AND COMPENSATION DISCLOSURE STATEMENT FOR Orange County,North Carolina This form documents that Gallagher Benefit Services, Inc. (Gallagher) will apply its professional judgment to access those insurance companies it believes are best suited to insure the Client's risks. The final decision to choose any insurance company has been made by the Client in its sole and absolute discretion.The Client understands and agrees that Gallagher does not take risk,and that Gallagher does not guarantee the financial solvency or security of any insurance company. The Client is responsible for immediate payment of premiums for all insurance placed by Gallagher on Client's behalf.If any premium amounts are not paid in full when due,the applicable insurance company for the Client's risks may cancel any applicable policies in accordance with the terms of such policies. The following is the disclosure of fees and/or commissions to be paid to Gallagher as a result of its Broker of Record relationship to Client's Group Health and Welfare Plan and any relationships, or agreements Gallagher has with any insurance companies selected by Client as noted above. Gallagher, as Broker of Record,will receive the following initial and renewal sale commissions expressed as percentage of gross premium payments, or fees as agreed upon by Client: Orange County,North Carolina Commission'/' Line of Coverage Insurance Company E DateVe Supplemental Direct Fees3 Compensation Direct Fee GBS 07/01/2016 If commissions for the N/A below lines do not reach a minimum of$105,000,a consulting fee amount for the difference will be billed and paid on a monthly basis. Medical United Healthcare 07/01/2016 $2 PEPM/$0-$2 PEPY N/A Dental Delta Dental of NC 07/01/2016 0% N/A Vision Community Eye Care 07/01/2016 10% N/A Life AD&D/Supplemental MetLife 07/01/2016 10.12%!1.25% N/A Life Short Term Disability AUL 07/01/2016 20% N/A It should also be noted that: • Gallagher is not an affiliate of the insurer whose contract is recommended. This means the insurer whose contract is recommended does not directly or indirectly have the power to exercise a controlling influence over the management or policies of Gallagher. Gallagher's ability to recommend other insurance contracts is not limited by an agreement with the insurance company. • Gallagher is effecting the transaction for the Plan(s)in the ordinary course of Gallagher business.The transaction set forth is at least as favorable to the Plan(s)as an arm's length transaction with an unrelated party. ' Commissions include all commissions/fees paid to Gallagher that are attributable to a contract or policy between a plan and an insurance company,or insurance service.This includes indirect fees that are paid to Gallagher paid by a third party,and includes,among other things,the payment of"finders'fees"or other fees to Gallagher for a transaction or service involving the plan. z Gallagher companies may receive supplemental compensation referred to in a variety of terms and definitions,such as contingent commissions,additional commissions and supplemental commission. 3 Direct Fees include compensation to Gallagher paid for directly by the plan sponsor/Client. Gallagher Client Coverage Acknowledgment 05302014 ©2016 GALLAGHER BENEFIT SERVICES,INC. ARTHUR J.GALLAGHER&CO.I AJG.COM DocuSign Envelope ID:7B0EAFC2-08FE-4D8D-8809-FC9B16F772B3 E`y -- Arthur J. Gallagher& Co. BUSINESS WITHOUT BARRIERS" • Gallagher is not a trustee of the Plan(s)and is neither the Plan Administrator of the Plan(s),a fiduciary of the Plan(s), nor an employer which has employees in the Plan(s). Gallagher shall not exercise discretionary authority or control with respect to plan management, the disposition of plan assets or plan administration. • Gallagher's liability to Client, or any party claiming by or through Client,on account of or relating to the provision of services to Client during the period of the relationship between Gallagher and Client shall not exceed $20 million in the aggregate. Without limiting the foregoing, Gallagher shall only be liable for actual damages incurred by Client, and shall not be liable for any indirect, consequential or punitive damages. For Employers and Plan Sponsors Subject to ERISA: This Disclosure Statement is being given to the Client (1)to make sure Client knows about Gallagher's and Gallagher affiliates' income before purchasing the insurance product and(2)for plans subject to ERISA,to comply with the disclosure, acknowledgment and approval requirement of Prohibited Transaction Class Exemption No. 84-244, which protects both Client and Gallagher5. Disclosure must be made to an independent plan fiduciary for the ERISA Plan(s), and Client acknowledges and confirms that this is a reasonable transaction in the best interest of participants in its ERISA Plan(s). For more information on Gallagher's compensation arrangements, please visit www.ajg.com/compensation. In the event a Client wishes to register a formal complaint regarding compensation Gallagher receives,please send an email to Compensation Complaints @ajg.com or send a letter to: AVC Compliance Officer,do Internal Audit Department,Arthur J. Gallagher&Co.,Two Pierce Place,Itasca,IL 60143. Thank you for your business and continued confidence in the services Gallagher provides to you and your employees. We sincerely appreciate the opportunity to serve Orange County, North Carolina. Please let us know if you have any questions regarding this information or would like more detail. GALLAGHER BENEFIT SERVICES,INC. DocuSigned by: By: GVt0SfblA, 2mE2AFr`511194B1._- Name: Wes Grigston Title: Area Vice President Date: 08/22/2016 Accepted by:INSERT FULL LEGAL CLIENT NAME DocuSigned by: By: bv't,lit.A 1561446644o B-1-998B-269P91481- Name: Brenda Bartholomew Title: HR Director Date: Which allows an exemption from a prohibited transaction under Section 408(a)of the Employee Retirement Income Security Act of 1974 (ERISA). 5 In making these disclosures,no position is taken,nor is one to be inferred,regarding the use of assets of a plan subject to ERISA to purchase such insurance. Gallagher Client Coverage Acknowledgment 05302014 02016 GALLAGHER BENEFIT SERVICES,INC. ARTHUR J.GALLAGHER&CO.I AJG.COM DocuSign Envelope ID:7B0EAFC2-08FE-4D8D-8809-FC9B16F772B3 ORANGE COUNTY—DEPARTMENT USE ONLY Department Party/Vendor Name: Gallagher Benefit Services Party/Vendor Contact Person: Eric Black Contact Phone: 704- 971-2553 Party/Vendor Address:4064 Colony Road Suite 450 City Charlotte State: NC Zip: 28211 Department: Human Resources Amount: $105,000.00 Purpose: Consulting Services Budget Code(s): 70395210/999999 Vendor#63188 (N/A if new vendor) Vendor is a BOCC consultant? Yes❑No Contract Type: (Check one)New❑ Renewal ® Amendment ❑ Effective Date 3/4/15 Approved by Board Yes[E]No ❑ Agenda Date: 3/3/15 This agreement is approved as to to co tent: �rc.,,N , �P d l�¢d., Ir v (MAO 9/27/2016 Department Director's Signature R+raaazsaFOl45F Date: Information Technologies (Applicable only to hardware/software purchases or related services)This agreement has been reviewed and is approved as to information technology content and specifications: Office of the Chief Information Officer Date: Risk Management This agreement is approved for sufficiency 'fl8Ilisi e""'+fann1dards,specifications, and requirements: a�SA. Orwttb 9/28/2016 Office of the Risk Management Officer 7FDCF9176800498... Date: is Financial Services This instrument has been pre-audited in the manner required by the Local Government Budget and Fiscal Control Act: DocuSigned by: sG/orLitiiaosL 9/28/2016 Office of the Chief Financial Officer � o Date: N4�5i81 ACC 1409... :. Legal Services This agreement is approved as t 7 d sufficiency: Office of the County Attorney p8 Date: 9/28/2016 Clerk to the Board Received for record retention: All Docusign contracts must be copied to Donna Lloyd upon completion @ Dolloyd @orangecountync.gov The following signature block is for hard copies only and is not required for Docusign contracts: Office of the Clerk to the Board Date: Revised 10/14 10 DocuSign Envelope ID:7B0EAFC2-08FE-4D8D-8809-FC9B16F772B3 ACC0R U CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 9/1/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONT PRODUCER NAMEACT Direct All Inquiries to Email Arthur J. Gallagher Risk Management Services, Inc. PHONE FAX 300 S. Riverside Plaza, Suite 1900 (A/C,No,Ext): (A/C,No): Chicago IL 60606 ADDRESS:chi certificates @ajg.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Lexington Insurance Company 19437 INSURED ARTHJGA113 INSURER B XL Specialty Insurance Company 37885 Arthur J. Gallagher&Co. and its Subsidiaries INSURER C: The Gallagher Centre Two Pierce Place INSURER D: Itasca IL 60143-1203 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER:689347840 REVISION NUMBER: THIS IS TO CERTIFY 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP W /Y LIMITS LTR INSD VD POLICY NUMBER (MMIDDYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE RETE CLAIMS-MADE OCCUR PREMISES O(Ea occur ence) $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GE 'L AGGREGATE LIMIT APPLIES PER. GENERAL AGGREGATE $ POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y I N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Primary E&O Liability N N 017788170 9/1/2016 9/1/2017 Aggregate Limit: $17,000,000 B Excess E&O Liability N N ELU14606816 9/1/2016 9/1/2017 Aggregate Limit: $3,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Coverage extends to: Arthur J. Gallagher&Co. 4064 Colony Road Suite 425&450 Charlotte, NC 28211 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidence of Insurance THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD