HomeMy WebLinkAboutBack-Up DocumentCQNTRACT-EX-TENSION FORM
Date: 8/6/15
From: Annie Perez, Director
Department of Procurement
To: Department/Division/Office: Risk Management
Department Liaison Name: Gisela Rodriguez
Subject: Contract Number: RFP No, 207193(12) Expiration Date: February 14, 2016
Bid Title: Claims Administration Services & Managed Care Services
Option to Renew Year: Fifth & Final Renewal Resolution Number(s): 10-0556: 14-0377
Instructions: Please review and complete the Contract extension form and return to Aimee Gandarilla via e-
mail no later than Wednesday, August 12, 2015. NOTE: Failure to meet this deadline seriously
jeopardizes our ability to renew the contract. Legally, expired contracts cannot be renewed.
SUMMARY/DESCRIPTION OF CONTRACT EXTENSION:
Please evaluate the contractor's performance within the last contract term: For ratings of 1 and/or 2,
Departments must fill out a Vendor Performance Form found at http://citynet/procurement/index.asp. Fill out
both forms in their entirety and return to me via e-mail for further processing.
Contractor's Name: Vendor Performance: (Mandatory fields) zy
❑Gallagher Bassett Services 0(1) Unsatisfactory ❑(2) Needs Improvement Satisfactory 0(4) Excellent
CONDITIONS FOR RENEWAL: Upon receipt of department approval, the Purchasing Department will
proceed to secure the appropriate approvals from the City Manager, and the vendor(s), if applicable. Should
the contractor be unwilling to extend the contract, a new bid, will have to be obtained and you will be
advised.
Upon approval by the City Manager, and acceptance of the extension by the successful vendor, copies of
the Contract Award (Renewal) sheet will be posted on the City's Intranet for your reference, so that a
requisition may be entered into the system.
DO YOU WISH TO EXTEND THE ABOVE -REFERENCED CONTRACT? (Mandatory fields)
YES ❑ NO ❑ If No, Specify reasons:
BUDGETARY INFORMATION Are funds budgeted? YES ki NO ❑ (Mandatory fields)
Total Dollar Amount: $1,530,410.96 (not to exceed)
Account Code(s):
Authorized By:
Telephone Number:
50001.301001.524000.0000.00000
Date: ®' fl/f ., (Mandatory fields)
16-1381 Fax Number: (305)416-1710 (Mandatory fields)
Should you have any questions regarding this form, please contact Aimee Gandarilla at 305-416-1906
agandarilla(agmiamigov.com