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HomeMy WebLinkAbout113272 VISION SERVICE PLAN - CONTRACT - RFP - 7648 BENEFITS - VISIONSERVICES AGREEMENT THIS AGREEMENT made and entered into the day and year set forth below by and between THE CITY OF FORT COLLINS, COLORADO, a Municipal Corporation, hereinafter referred to as the "City" and Vision Service Plan (VSP), hereinafter referred to as "Service Provider". WITNESSETH: In consideration of the mutual covenants and obligations herein expressed, it is agreed by and between the parties hereto as follows: 1. Scope of Services. The Service Provider agrees to provide services in accordance with the Scope of Services attached hereto as Exhibit "A", consisting of two (2) pages and incorporated herein by this reference and Exhibit “B” - Performance Guarantees, consisting of one (1) page, attached and incorporated herein by this reference. 2. Contract Period. This Agreement shall commence January 1, 2015, and shall continue in full force and effect until December 31, 2015, unless sooner terminated as herein provided. In addition, at the option of the City, the Agreement may be extended for additional one year periods not to exceed four (4) additional one year periods. Written notice of renewal shall be provided to the Service Provider and mailed no later than thirty (30) days prior to contract end. 3. Delay. If either party is prevented in whole or in part from performing its obligations by unforeseeable causes beyond its reasonable control and without its fault or negligence, then the party so prevented shall be excused from whatever performance is prevented by such cause. To the extent that the performance is actually prevented, the Service Provider must provide written notice to the City of such condition within fifteen (15) days from the onset of such condition. 4. Early Termination by City/Notice. Notwithstanding the time periods contained herein, the City may terminate this Agreement at any time without cause by providing written notice of termination to the Service Provider. Such notice shall be delivered at least fifteen (15) days prior to the termination date contained in said notice unless otherwise agreed in writing by the parties. All notices provided under this Agreement shall be effective when mailed, postage prepaid and sent to the following addresses: Service Provider: City: Copy to: VSP Attn: Devin Farrell 1050 17th Street, Ste. 1430 Denver, CO 80265 City of Fort Collins Attn: Amy Sharkey PO Box 580 Fort Collins, CO 80522 City of Fort Collins Attn: Purchasing Dept. PO Box 580 Fort Collins, CO 80522 In the event of early termination by the City, the Service Provider shall be paid for services rendered to the date of termination, subject only to the satisfactory performance of the Service Provider's obligations under this Agreement. Such payment shall be the Service Provider's sole right and remedy for such termination. Services Agreement 7648 Benefits - Vision Page 1 of 13 DocuSign Envelope ID: 6DE4EC58-5526-43E9-A6F4-A4DAD6922E5D 5. Contract Sum. The City shall pay the Service Provider for the performance of this Contract, subject to additions and deletions provided herein, employee fees in accordance with attached Exhibit “C” – VSP Choice Plan, consisting of two (2) pages, incorporated herein by this reference. The monthly rates stated in Exhibit C are firm for the initial four (4) year term. Service Provider shall submit invoices for employee fees to the City monthly. Payment will be made for all undisputed charges via Automatic Clearing House (“ACH”) direct account-to-account electronic deposit within thirty (30) days of receipt of an invoice. The Service Provider herein agrees to execute the applicable direct deposit authorization form. 6. City Representative. The City will designate, prior to commencement of the work, its representative who shall make, within the scope of his or her authority, all necessary and proper decisions with reference to the services provided under this agreement. All requests concerning this Agreement shall be directed to the City Representative. 7. Independent Service Provider. The services to be performed by Service Provider are those of an independent service provider and not of an employee of the City of Fort Collins. The City shall not be responsible for withholding any portion of Service Provider's compensation hereunder for the payment of FICA, Workmen's Compensation or other taxes or benefits or for any other purpose. 8. Subcontractors. Service Provider may not subcontract any of the work set forth in the Exhibit A, Statement of Services, without the prior written consent of the City, which shall not be unreasonably withheld. If any of the work is subcontracted hereunder (with the consent of the City), then the following provisions shall apply: (a) the subcontractor must be a reputable, qualified firm with an established record of successful performance in its respective trade performing identical or substantially similar work, (b) the subcontractor will be required to comply with all applicable terms of this Agreement, (c) the subcontract will not create any contractual relationship between any such subcontractor and the City, nor will it obligate the City to pay or see to the payment of any subcontractor, and (d) the work of the subcontractor will be subject to inspection by the City to the same extent as the work of the Service Provider. 9. Personal Services. It is understood that the City enters into the Agreement based on the special abilities of the Service Provider and that this Agreement shall be considered as an agreement for personal services. Accordingly, the Service Provider shall neither assign any responsibilities nor delegate any duties arising under the Agreement without the prior written consent of the City. 10. Acceptance Not Waiver. The City's approval or acceptance of, or payment for any of the services shall not be construed to operate as a waiver of any rights or benefits provided to the City under this Agreement or cause of action arising out of performance of this Agreement. 11. Warranty. a. Service Provider warrants that all work performed hereunder shall be performed with the highest degree of competence and care in accordance with accepted standards for Services Agreement 7648 Benefits - Vision Page 2 of 13 DocuSign Envelope ID: 6DE4EC58-5526-43E9-A6F4-A4DAD6922E5D work of a similar nature. b. Unless otherwise provided in the Agreement, all materials and equipment incorporated into any work shall be new and, where not specified, of the most suitable grade of their respective kinds for their intended use, and all workmanship shall be acceptable to City. c. Service Provider warrants all equipment, materials, labor and other work, provided under this Agreement, except City-furnished materials, equipment and labor, against defects and nonconformances in design, materials and workmanship/workwomanship for a period beginning with the start of the work and ending twelve (12) months from and after final acceptance under the Agreement, regardless whether the same were furnished or performed by Service Provider or by any of its subcontractors of any tier. Upon receipt of written notice from the City of any such defect or nonconformances, the affected item or part thereof shall be redesigned, repaired or replaced by Service Provider in a manner and at a time acceptable to the City. 12. Default. Each and every term and condition hereof shall be deemed to be a material element of this Agreement. In the event either party should fail or refuse to perform according to the terms of this Agreement, such party may be declared in default thereof. 13. Remedies. In the event a party has been declared in default, such defaulting party shall be allowed a period of ten (10) days within which to cure said default. In the event the default remains uncorrected, the party declaring default may elect to (a) terminate the Agreement and seek damages; (b) treat the Agreement as continuing and require specific performance; or (c) avail himself of any other remedy at law or equity. If the non-defaulting party commences legal or equitable actions against the defaulting party, the defaulting party shall be liable to the non-defaulting party for the non-defaulting party's reasonable attorney fees and costs incurred because of the default. 14. Binding Effect. This writing, together with the exhibits hereto, constitutes the entire Agreement between the parties and shall be binding upon said parties, their officers, employees, agents and assigns and shall inure to the benefit of the respective survivors, heirs, personal representatives, successors and assigns of said parties. 15. Indemnity/Insurance. a. The Service Provider agrees to indemnify and save harmless the City, its officers, agents and employees against and from any and all actions, suits, claims, demands or liability of any character whatsoever brought or asserted for injuries to or death of any person or persons, or damages to property arising out of, result from or occurring in connection with the performance of any service hereunder. b. The Service Provider shall take all necessary precautions in performing the work hereunder to prevent injury to persons and property. c. Without limiting any of the Service Provider's obligations hereunder, the Service Provider shall provide and maintain insurance coverage naming the City as an additional insured under this Agreement of the type and with the limits specified within Services Agreement 7648 Benefits - Vision Page 3 of 13 DocuSign Envelope ID: 6DE4EC58-5526-43E9-A6F4-A4DAD6922E5D Exhibit “D”, consisting of one (1) page, attached hereto and incorporated herein by this reference. The Service Provider before commencing services hereunder, shall deliver to the City's Director of Purchasing and Risk Management, P. O. Box 580 Fort Collins, Colorado 80522 one copy of a certificate evidencing the insurance coverage required from an insurance company acceptable to the City. 16. Entire Agreement. This Agreement, along with all Exhibits and other documents incorporated herein, shall constitute the entire Agreement of the parties. Covenants or representations not contained in this Agreement shall not be binding on the parties. 17. Law/Severability. The laws of the State of Colorado shall govern the construction interpretation, execution and enforcement of this Agreement. In the event any provision of this Agreement shall be held invalid or unenforceable by any court of competent jurisdiction, such holding shall not invalidate or render unenforceable any other provision of this Agreement. 18. Prohibition Against Employing Illegal Aliens. Pursuant to Section 8-17.5-101, C.R.S., et. seq., Service Provider represents and agrees that: a. As of the date of this Agreement: 1. Service Provider does not knowingly employ or contract with an illegal alien who will perform work under this Agreement; and 2. Service Provider will participate in either the e-Verify program created in Public Law 208, 104th Congress, as amended, and expanded in Public Law 156, 108th Congress, as amended, administered by the United States Department of Homeland Security (the “e-Verify Program”) or the Department Program (the “Department Program”), an employment verification program established pursuant to Section 8-17.5-102(5)(c) C.R.S. in order to confirm the employment eligibility of all newly hired employees to perform work under this Agreement. b. Service Provider shall not knowingly employ or contract with an illegal alien to perform work under this Agreement or knowingly enter into a contract with a subcontractor that knowingly employs or contracts with an illegal alien to perform work under this Agreement. c. Service Provider is prohibited from using the e-Verify Program or Department Program procedures to undertake pre-employment screening of job applicants while this Agreement is being performed. d. If Service Provider obtains actual knowledge that a subcontractor performing work under this Agreement knowingly employs or contracts with an illegal alien, Service Provider shall: 1. Notify such subcontractor and the City within three days that Service Provider has actual knowledge that the subcontractor is employing or contracting with an illegal alien; and 2. Terminate the subcontract with the subcontractor if within three days of receiving the notice required pursuant to this section the subcontractor does not cease Services Agreement 7648 Benefits - Vision Page 4 of 13 DocuSign Envelope ID: 6DE4EC58-5526-43E9-A6F4-A4DAD6922E5D employing or contracting with the illegal alien; except that Service Provider shall not terminate the contract with the subcontractor if during such three days the subcontractor provides information to establish that the subcontractor has not knowingly employed or contracted with an illegal alien. e. Service Provider shall comply with any reasonable request by the Colorado Department of Labor and Employment (the “Department”) made in the course of an investigation that the Department undertakes or is undertaking pursuant to the authority established in Subsection 8-17.5-102 (5), C.R.S. f. If Service Provider violates any provision of this Agreement pertaining to the duties imposed by Subsection 8-17.5-102, C.R.S. the City may terminate this Agreement. If this Agreement is so terminated, Service Provider shall be liable for actual and consequential damages to the City arising out of Service Provider’s violation of Subsection 8-17.5-102, C.R.S. g. The City will notify the Office of the Secretary of State if Service Provider violates this provision of this Agreement and the City terminates the Agreement for such breach. 19. Special Provisions. Special provisions or conditions relating to the services to be performed pursuant to this Agreement are set forth in Exhibit “E“ - Confidentiality, consisting of one (1) page, attached hereto and incorporated herein by this reference. Services Agreement 7648 Benefits - Vision Page 5 of 13 DocuSign Envelope ID: 6DE4EC58-5526-43E9-A6F4-A4DAD6922E5D CITY OF FORT COLLINS, COLORADO a municipal corporation By:_______________________________ Gerry Paul Director of Purchasing and Risk Management Date:_____________________________ ATTEST: _________________________________ City Clerk APPROVED AS TO FORM: ________________________________ Assistant City Attorney VISION SERVICE PLAN (VSP) By:_______________________________ __________________________________ PRINT NAME __________________________________ TITLE Date:_____________________________ Services Agreement 7648 Benefits - Vision Page 6 of 13 DocuSign Envelope ID: 6DE4EC58-5526-43E9-A6F4-A4DAD6922E5D Secretary 10/13/2014 James M. McGrann 10/14/2014 EXHIBIT A SCOPE OF SERVICES The City of Fort Collins is expecting to partner with a qualified firm to administer the following employee benefit plan:  Vision Care TPA Services – fully insured and completely employee paid The City provides employee benefits to approximately 1,570 active employees. I. Account Management The Account Executive and Service Representative(s) will deal directly with the City. This environment requires the Account Management team to:  Be able to devote the time necessary to the account, including being available for frequent telephone and on-site consultations with the City;  Be extremely responsive to all inquiries;  Be comprised of individuals with specialized knowledge of the following: - Claims and Eligibility Systems - Provider Networks - Systems Reporting Capabilities - Claims Adjudication Policies and Procedures - Terms of this Agreement - Standard and Non-Standard Banking Arrangements - Relationships with Third Parties;  Act on behalf of the City in “cutting through the red tape”. This facet of account management cannot be emphasized enough; the Account Management team must be able to effectively advance the interests of the City through the Service Provider’s corporate structure. II. Enrollment/Eligibility The City will provide initial enrollments electronically or on paper. The initial enrollment and updates will be provided directly to the service Provider by the City. The Service Provider will perform direct eligibility certification to providers and verify coverage as a part of the claims management and adjudication process. A quarterly reconciliation between payroll and eligibility will be required of the Service Provider. III. Fee Administration The Service Provider will invoice the City monthly, based on the number of enrolled employees. IV. Customer Service The Service Provider must make efficient and effective processing of all inquiries Services Agreement 7648 Benefits - Vision Page 7 of 13 DocuSign Envelope ID: 6DE4EC58-5526-43E9-A6F4-A4DAD6922E5D a primary focus. Satisfactory customer service will include prompt, courteous and accurate responses to the City and employee inquiries regarding claim submissions, applicable provider networks, plan design and provisions, etc. A toll free number shall be available for eligibility certification and claim submission inquiries. V. Financial Accounting On a monthly basis, the Service Provider must provide an accounting reconciliation of any “central bank” accounts utilized. The Service Provider shall obtain the City’s written approval prior to incurring any administrative expenses outside the scope of this Agreement. The Service Provider must present a report detailing and justifying proposed fees for the coming year by September 1st of the preceding year. VI. Right to Audit The Service Provider must agree to allow the City, or its representative, the right to audit all claims, applicable provider credentialing, financial data and other information relevant to the City’s account. VII. Data and Management Information Reporting The Service Provider must provide monthly paid claim summaries and detailed claim listings, in Excel format or through a secure website. The Service Provider must also provide its standard reporting package. Ad hoc reports will periodically be requested. Enrollment, claims and premium/fee information must be accurate and supplied in a timely manner upon request. VIII. “No Loss/No Gain” for Covered Employees There shall be no loss of coverage for any employees. Therefore it is required that the Service Provider waives any “actively at work”, “dependent confinement”, or any other policies that would prevent 100% continuity of coverage for any employees or dependents that are currently covered under the plans. Services Agreement 7648 Benefits - Vision Page 8 of 13 DocuSign Envelope ID: 6DE4EC58-5526-43E9-A6F4-A4DAD6922E5D Exhibit B – Performance Guarantees The City of Fort Collins will receive the following comprehensive service guarantees: Claims Processing Standards Financial accuracy 99% Processing accuracy 99% VSP Doctor claims processed within 5 business days 95% Other provider claims processed within 5 business days 95% Other provider claims processed within 15 business days 99% Call Center Management Abandoned call rate ≤3% Average speed of answer ≤25 seconds Average call blockage rate ≤2% Call resolution (same day response) 98% Complaint acknowledgement within 5 business days 96% Complaint resolution within 30 calendar days 99% Average response to e-mail inquiries within 2 business days 100% Satisfaction Patient satisfaction (satisfied w/level of coverage) Overall satisfaction with VSP Overall experience with VSP Doctor 96% 96% VSP Doctor retention rate (based on voluntary turnover) 98% Account Administration Electronic eligibility online within 24 hours1 98% Online reports on vsp.com by 25th of month 100% Web portal availability 99% We consistently meet or exceed the proposed performance standards and we would be happy to share our results with the City on a quarterly basis in lieu of financial penalties. Services Agreement 7648 Benefits - Vision Page 9 of 13 DocuSign Envelope ID: 6DE4EC58-5526-43E9-A6F4-A4DAD6922E5D 6/14 VSP Choice Plan® Prepared for City of Ft. Collins The VSP Choice Plan is a premier full-service plan that offers choice, flexibility, and maximum value through a VSP Preferred Provider. We also have arrangements with high quality retail chains as affiliate providers1. Whether your employees choose a preferred or affiliate provider, they will receive a covered-in-full benefit experience. Provider Choices VSP Preferred Providers  54,000 access points nationwide. VSP preferred providers are located in retail, neighborhood, medical and professional settings. Retail Chain Affiliate Providers1  More than 600 Visionworks locations, approximately 400 Costco® Optical locations, and other high quality retail chains. Other Providers  We also have a direct pay or assignment of benefits arrangement with Walmart Vision Center and Sam's Club Optical Center.  Your employees have the freedom to choose any provider, national retailer, or local retail chain. Benefits through a VSP Choice Preferred Provider 1 Exam Services Comprehensive WellVision Exam covered in full2 Contact lens exam (fitting and evaluation): Standard and Premium fit are covered in full after copay. Member receives 15% off of contact lens exam services; member's copay will never exceed $60.3 Routine retinal screening covered after a no more than $39 copay.3 Lenses Glass or plastic: Single vision Lined bifocal Lined trifocal Lenticular Covered in full2 Covered in full2 Covered in full2 Covered in full2 Lens Enhancements The most popular lens enhancements are covered after a copay, saving members an average of 20-25%; members should see their doctor for special pricing on additional lens enhancements.3 Patient Option Anti-reflective coating Polycarbonate for children Polycarbonate Progressive Photochromic Scratch-resistant coating Single Vision $41 No copay $31 N/A $70 $17 Multifocal $41 No copay $35 $55 $82 $17 Frame  Frames covered in full2 up to the retail allowance. Costco® Optical allowance is equivalent to the frame allowance at preferred providers and other affiliate locations.  Frame allowances backed by a wholesale allowance guarantee, ensuring over 16,000 6/14 Necessary Contact Lenses Covered in full2 for members who have specific conditions Additional Pairs of Glasses 20% off unlimited additional pairs of prescription glasses and/or non-prescription sunglasses3, 6 Laser VisionCare Program Discounts average 15-20% off or 5% off a promotional offer for laser surgery, including PRK, LASIK, Custom LASIK, and IntraLase7 VSP Diabetic EyeCare Plus ProgramSM Additional coverage for members with diabetic eye disease, glaucoma or age-related macular degeneration. Eye Health Management Program ®  VSP collects HIPAA-compliant patient condition data and shares it with your health plan or disease management vendor  ICD-9 code-based reporting of certain chronic conditions supports your disease management efforts  Exam reminder letters sent to VSP members with certain conditions who have not had an eye exam in 14 months Open Access Schedule We offer a generous reimbursement schedule for services from other providers Exam Lenses: Single vision Lined bifocal Lined trifocal Lined lenticular Frame Elective contact lenses (in lieu of lenses and frame) $45 $30 $50 $60 $100 $70 $105 Monthly Rates Exam/Lens/Frame Copay Allowances 12/12/24 $15/15 $150/150 Employee Only $7.01 Employee + Spouse $14.04 Employee Child(ren) $14.04 Employee + Family $22.07 Rate Details Rates are guaranteed for four years and are valid until 1/1/15. Coverage offered: 100% employee paid. Rates are net of commission. Rates include any applicable taxes and health assessment fees known as of the date of the proposal. Exclusions The following items are excluded under this plan: two pairs of glasses instead of bifocals; replacement of lenses, frames, or contacts; medical or surgical treatment; orthoptics; vision training or supplemental testing Items not covered under the contact lens coverage: insurance policies or service agreements; artistically painted or non-prescription lenses; additional office visits for contact lens pathology; contact lens modification; polishing or cleaning 1 Benefits vary at affiliate locations. 2 Less any applicable copay. 3 Based on applicable laws, benefits may vary by doctor location. EXHIBIT D INSURANCE REQUIREMENTS 1. The Service Provider will provide, from insurance companies acceptable to the City, the insurance coverage designated hereinafter and pay all costs. Before commencing work under this bid, the Service Provider shall furnish the City with certificates of insurance showing the type, amount, class of operations covered, effective dates and date of expiration of policies, and containing substantially the following statement: "The insurance evidenced by this Certificate will not be cancelled or materially altered, except after ten (10) days written notice has been received by the City of Fort Collins." In case of the breach of any provision of the Insurance Requirements, the City, at its option, may take out and maintain, at the expense of the Service Provider, such insurance as the City may deem proper and may deduct the cost of such insurance from any monies which may be due or become due the Service Provider under this Agreement. The City, its officers, agents and employees shall be named as additional insureds on the Service Provider's general liability and automobile liability insurance policies for any claims arising out of work performed under this Agreement. 2. Insurance coverages shall be as follows: A. Workers' Compensation & Employer's Liability. The Service Provider shall maintain during the life of this Agreement for all of the Service Provider's employees engaged in work performed under this agreement: 1. Workers' Compensation insurance with statutory limits as required by Colorado law. 2. Employer's Liability insurance with limits of $100,000 per accident, $500,000 disease aggregate, and $100,000 disease each employee. B. Commercial General & Vehicle Liability. The Service Provider shall maintain during the life of this Agreement such commercial general liability and automobile liability insurance as will provide coverage for damage claims of personal injury, including accidental death, as well as for claims for property damage, which may arise directly or indirectly from the performance of work under this Agreement. Coverage for property damage shall be on a "broad form" basis. The amount of insurance for each coverage, Commercial General and Vehicle, shall not be less than $1,000,000 combined single limits for bodily injury and property damage. In the event any work is performed by a subcontractor, the Service Provider shall be responsible for any liability directly or indirectly arising out of the work performed under this Agreement by a subcontractor, which liability is not covered by the subcontractor's insurance. Services Agreement 7648 Benefits - Vision Page 12 of 13 DocuSign Envelope ID: 6DE4EC58-5526-43E9-A6F4-A4DAD6922E5D No new insurance needed EXHIBIT E CONFIDENTIALITY IN CONNECTION WITH SERVICES provided to the City of Fort Collins (the “City”) pursuant to this Agreement (the “Agreement”), the Service Provider hereby acknowledges that it has been informed that the City has established policies and procedures with regard to the handling of confidential information and other sensitive materials. In consideration of access to certain information, data and material (hereinafter individually and collectively, regardless of nature, referred to as “information”) that are the property of and/or relate to the City or its employees, customers or suppliers, which access is related to the performance of services that the Service Provider has agreed to perform, the Service Provider hereby acknowledges and agrees as follows: That information that has or will come into its possession or knowledge in connection with the performance of services for the City may be confidential and/or proprietary. The Service Provider agrees to treat as confidential (a) all information that is owned by the City, or that relates to the business of the City, or that is used by the City in carrying on business, and (b) all information that is proprietary to a third party (including but not limited to customers and suppliers of the City). The Service Provider shall not disclose any such information to any person not having a legitimate need-to-know for purposes authorized by the City. Further, the Service Provider shall not use such information to obtain any economic or other benefit for itself, or any third party, except as specifically authorized by the City. The foregoing to the contrary notwithstanding, the Service Provider understands that it shall have no obligation under this Agreement with respect to information and material that (a) becomes generally known to the public by publication or some means other than a breach of duty of this Agreement, or (b) is required by law, regulation or court order to be disclosed, provided that the request for such disclosure is proper and the disclosure does not exceed that which is required. In the event of any disclosure under (b) above, the Service Provider shall furnish a copy of this Agreement to anyone to whom it is required to make such disclosure and shall promptly advise the City in writing of each such disclosure. In the event that the Service Provider ceases to perform services for the City, or the City so requests for any reason, the Service Provider shall promptly return to the City any and all information described hereinabove, including all copies, notes and/or summaries (handwritten or mechanically produced) thereof, in its possession or control or as to which it otherwise has access. The Service Provider understands and agrees that the City’s remedies at law for a breach of the Service Provider’s obligations under this Confidentiality Agreement may be inadequate and that the City shall, in the event of any such breach, be entitled to seek equitable relief (including without limitation preliminary and permanent injunctive relief and specific performance) in addition to all other remedies provided hereunder or available at law. Services Agreement 7648 Benefits - Vision Page 13 of 13 DocuSign Envelope ID: 6DE4EC58-5526-43E9-A6F4-A4DAD6922E5D Holder Identifier : 7777777707070700077761616045571110767717016204447207442027772507300072640577046230130777415153167440307177154633275103075736330235337650767551423406665607724055530076570076727242035772000777777707000707007 7777777707070700073525677115456000723111406126002107123227342173111070233263520631110702222724307311007133336342172001070223262530731110702333725306211007122337342063011077756163351765540777777707000707007 Certificate No : 570055567176 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 10/10/2014 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). 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. PRODUCER Aon Risk Insurance Services West, Inc. Sacramento CA Office 2277 Fair Oaks Blvd, Suite 250 Sacramento CA 95825 USA PHONE (A/C. No. Ext): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # (916) 369-4800 INSURED INSURER A: National Union Fire Ins Co of Pittsburgh 19445 INSURER B: Safety National Casualty Corp 15105 INSURER C: INSURER D: INSURER E: INSURER F: FAX (A/C. No.): (916) 369-4801 CONTACT NAME: Vision Service Plan 3333 Quality Drive Rancho Cordova CA 95670-9757 USA COVERAGES CERTIFICATE NUMBER: 570055567176 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. Limits shown are as requested POLICY EXP (MM/DD/YYYY) POLICY EFF (MM/DD/YYYY) SUBR WVD INSR LTR ADDL TYPE OF INSURANCE INSD POLICY NUMBER LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR POLICY LOC EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence) Additional Named Insured: AGENCY CUSTOMER ID: ADDITIONAL REMARKS SCHEDULE LOC #: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance EFFECTIVE DATE: CARRIER NAIC CODE POLICY NUMBER AGENCY NAMED INSURED See Certificate Number: See Certificate Number: Aon Risk Insurance Services West, Inc. 570000055831 570055567176 570055567176 Page _ of _ Vision Service Plan Marchon Eyewear, Inc. Marchon Eyewear, Inc. its subsidiaries, affiliates & divisions Monkey Software Pty. Ltd. (Australia) Marchon Canada Marchon UK Ltd. OfficeMate Software Solutions, Inc. Allure Eyewear, LLC Altair Eyewear, Inc. Dragon Alliance ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DocuSign Envelope ID: 6DE4EC58-5526-43E9-A6F4-A4DAD6922E5D MED EXP (Any one person) PERSONAL & ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP/OP AGG X X GEN'L AGGREGATE LIMIT APPLIES PER: $1,000,000 $1,000,000 $10,000 $1,000,000 $2,000,000 $2,000,000 SIR/Deductible $25,000 A 11/01/2013 11/01/2014 General Liability GL5364105 PRO- JECT OTHER: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON-OWNED AUTOS BODILY INJURY ( Per person) PROPERTY DAMAGE (Per accident) X X X X BODILY INJURY (Per accident) $1,000,000 A 11/01/2013 11/01/2014 Business Auto Liability COMBINED SINGLE LIMIT (Ea accident) CA3447492 EXCESS LIAB OCCUR CLAIMS-MADE AGGREGATE EACH OCCURRENCE DED UMBRELLA LIAB RETENTION E.L. DISEASE-EA EMPLOYEE E.L. DISEASE-POLICY LIMIT E.L. EACH ACCIDENT $1,000,000 X OTH- ER B 10/01/2014 10/01/2015 PER STATUTE Workers' Comp. $1,000,000 Y / N (Mandatory in NH) ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY If yes, describe under DESCRIPTION OF OPERATIONS below $1,000,000 LDM4049682 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The workers' comp. deductible is $250,000 Certficate holder is additional insured as respects auto liability and gene liability CERTIFICATE HOLDER CANCELLATION City of Fort Collins AUTHORIZED REPRESENTATIVE PO Box 580 Ft Collins CO 80522 USA ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. DocuSign Envelope ID: 6DE4EC58-5526-43E9-A6F4-A4DAD6922E5D 4 Featured frame brands are subject to change and the promotional allowance does not apply at Costco® Optical. 5 Rebates subject to change 6 20% off unlimited additional pairs of glasses valid through any VSP Preferred Provider within 12 months of the last covered eye exam. 7 Custom LASIK coverage only available using wavefront technology with the microkeratome surgical device. Other LASIK procedures may be performed at an additional cost to the member. LaserVision Care discounts are only available from VSP-contracted facilities. Services Agreement 7648 Benefits - Vision Page 11 of 13 DocuSign Envelope ID: 6DE4EC58-5526-43E9-A6F4-A4DAD6922E5D frames are covered-in-full  Members who select a featured frame brand including Anne Klein, bebe ® , Calvin Klein, Flexon, Lacoste, Nike, Nine West and more will receive an extra $20 toward their frame allowance, beginning January 1, 20144  20% off any amount above the retail allowance3  Members can choose from virtually any frame on the market Elective Contact Lenses  Prescription contact lens materials covered-in-full up to the retail allowance (in lieu of frame & lenses)  VSP members get exclusive mail-in rebate savings5 on eligible Bausch + Lomb contacts  Members can choose from any available prescription contact lens materials Services Agreement 7648 Benefits - Vision Page 10 of 13 EXHIBIT C DocuSign Envelope ID: 6DE4EC58-5526-43E9-A6F4-A4DAD6922E5D