164-22 Exhibits to Agreement for Workers Compensation Third Party Administration - 2022.pdf

I i national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, and that it will discontinue the use of any recruitment agency which engages in direct or indirect discriminatory practices. The contractor or subcontractor agrees to revise any of its testing procedures, if necessary, to assure that all personnel testing conforms with the principles of job-related testing, as established by the statutes and court decisions of the State of New Jersey and as established by applicable Federal law and applicable Federal court decisions. In conforming with the targeted employment goals, the contractor or subcontractor agrees to review ail procedures relating ¢o transfer, upgrading, downgrading and layoff to ensure that all such actions are taken without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, consistent with the statutes and court decisions of the State of New Jersey, and applicable Federal law and applicable Federal court decisions. The contractor shall submit to the public agency, after notification of award but prior to execution of a goods and services contract, one of the following three documents: Letter of Federal Affirmative Action Plan Approval Certificate of Employee Information Report Employee Information Report Form AA302 (electronically provided by the Division and distributed to the public agency through the Division’s website at www.state.nj.us/treasury/contract_compliance) The contractor and its subcontractors shall furnish such reports or other documents to the Division of Public Contracts Equal Employment Opportunity Compliance as may be requested by the office from time to time in order to carry out the purposes of these regulations, and public agencies shall furnish such information as may be requested by the Division of Public Contracts Equal Employment Opportunity Compliance for conducting a compliance investigation pursuant to Subchapter 10 of the Administrative Code at N.J.A.C. 17:27.

: STOCKHOLDER DISCLOSURE CERTIFICATION T certify that the list below contains the names and home addresses of all stockholders holding 10% or more of the issued and outstanding stock of the undersigned, I certify that no one stockholder owns 10% or more of the issued and outstanding stock of the undersigned. PLEASE COCK TYPE OF BUSINESS ORGANIZATION: Partnership Limited Partnership. Limited Liability Corp Corporation _X Sole Proprietorship Limited Liability Partnership Subchapter § Corp PLEASE CHECK APPROPRIATE BOXES AND SIGN BELOW aa Name: David Harris Home Address: 2295 Gulf of Mexico Drive, Longboat Key FL 34228 Stockholders i Name: _CRC-NJ Midco, Inc. Home Address: 2100 Ponce de Leon Blvd, Suite 730 Coral Gables FL 33134 Name_CRC-NJ Holding Corp. _ Home Address: 2100 Ponce de Leon Blvd, Suite 730 _ Coral Gables FL 33134 Name: _CRC-NJ Investors, LLC. Home Address: 2100 Ponce de Leon Blvd, Suite 730 hy Coral Gables FL 33484 x David Harris, President Print Name & Title NOTORY PUBLIC Swom before me this {2 day of May a a wily LAUREN F WALTER Notary Public - State of New Jersey My Commission Expires Aug 30, 2023

REQUIRED EVIDENCE AFFIRMATIVE ACTION REGULATIONS N.J, S.A. 10:5-31, et seq. (NLA. C. 17:27) If awarded a contract, the Bidder will be required to comply with the requirements of N.LLS.A. 10:5- 31, et seq, and N.LA.C_ 17:27. Within five (5) days after receipt of the notification of intent to award the contract, the Bidder shail present one of the following: 1. Appropriate evidence that the Contractor is operating under an existing federally approved or sanctioned affirmative action program; or 2. A Certificate of Employee Information Report Approval issued in accordance with N.LLA.C. 17:27-4; or 3. An initial Employee Information Report consisting of forms provided by the Affirmative Action Office and completed by Contractor in accordance with NJAC, 17:27-4. The Bidder must submit no later than three (3) days after the signing of the Contract an Initial Project Manning Table consisting of forms provided by the Affirmative Action Office and completed by Contractor in accordance with N.J.A.C. 17:27-7. Bidders are referred to the Bidder's Information Section of the Bid Packet for a further description of the above requirements. NO BIDDER MAY BE ISSUED A CONTRACT UNLESS THEY COMPLY WITH THE AFFIRMATIVE ACTION REGULATIONS OF N.J.S.A, 10:5-31, et seq. The following questions must be answered by all Bidders: . Do you have a federally-approved or sanctioned Affirmative Action Program? Yes (If yes, submit a copy of such approval.) No 2. Do you have a State Certificate of Employee Information Report approval? Yes X {If yes, submit a copy of such approval.) No The undersigned Bidder certifies that he is aware of the commitment to comply with the requirements of NJ.S.A. 10:5-31, ef seg., and agrees to furnish the requited documentation pursuant to the law. COMPANY: Claims ResobttGon 26fpbration, Inc, NAME: David Harris SIGNATURE: TITLE: _President NOTE: A bid must befefected as non-responsive if a Bidder fails to comply with requirements of N.J.S.A. 10:5-31, et seq., within the time frame stipulated. 13

rr Certification 52337, cee OF EMPLOYEE INFORMATION REPORT RENEWAL den das “ie 2 sNegenor naib appre ployee informailon Report pursuant to aport. This approval will remain in NALA.C. 17:27-1.1-6t. seq, and the effect for the perlod of 15-4RR CLAIMS RESOLUTION CoRPOR exon. 323 PEINBY ROAD, SUITE 209 GALLOWAY NJ 08205 ELIZABETH MAHER MUQIO State Treasurer uy if i

B ID DER’S CHECK LIST Mandatory Items « Business Registration Certification © Stockholders Disclosure Statement « Affirmative Action Compliance Notice e Tranian Disclosure Form ¢ Non Collusion Affidavit * Proposal Form ¢ Political Disclosure Statement « Addendum

Claims Resolution Corporation, Ine. Fee Schedule Township of West Orange May 17, 2022 Services: Third Party Claims Administrator Fees Annual Fee Flat Annual Fee 01/01/22-12/31/22 $15,800.00 Data Conversion (one-time charge) $6,200.00 Take Over of Existing Claims INCLUDED Included in the above Fee: All claims management functions Claims investigation Subrogation State filings and reporting Creation of client handling instructions Creation of implementation plan Establishment of data hierarchy Set up of client users in RMIS system Creation and funding of loss fund account, establish funding, and check writing protocols Participation in quarterly claims reviews Quarterly stewardship meeting Reporting to excess/fronting carrier Risk Management Information System cost to include: 5 User ID’s, internet access to claim files, the ability to e-mail your adjuster, and access to our library of template risk management reports together with initial training and ongoing support Monthly loss runs and loss fund activities reports Medicare Reporting and claim filing Administration of Client directed medical providers and vendors 323 S. Pitney Road, Suite 200 # Galloway, NJ 08205 @ 973-731-5700

Services: Other Services: | Multiple PPO access and set up of all managed care services 15-28% of savings Fully Automated OSHA/PEOSHA Record Keeping/Reporting INCLUDED Subrogation Services INCLUDED 323 S. Pitney Road, Suite 200 # Galloway, NJ 08205 # 973-731-5700

All fees are quoted on an annual life of contract basis. Claims Resolution Corporation Inc. (CRC) will handle all reported losses through conclusion for so long as there. is a contractual relationship between the Client and CRC. CRC requires the execution of an annually renewable contract with a minimum of 90 days notice of termination and a 20% short rate penalty applicable to Client termination prior to the end of the contract period. The quoted claims administration fees do not include those fees normally associated with allocated loss adjustment expenses. Allocated Loss Adjustment Expenses (ALAE) shall mean all costs, charges or expenses incurred by Company, its agents or its employees, and approved by Client in writing, with respect to a Qualified Claim including without limitation, court costs, fees and expenses (including reasonable attorneys' fees); checks, printing costs and banking fees, appeal bonds; independent adjusters; investigators; appraisers; vocational services, training or evaluation; medical expenses and medical cost containment service providers and managed care fees (including those provided by Company, if applicable); medical case management; peer review; injury triage; field investigation, MMSEA reporting; MSA set-asides; MSA medical cost projections, utilization review fees; rehabilitation services; experts and witnesses; fees for obtaining statements and official reporis, payment processing, diagrams, reports, records, documents, transcripts, depositions, index bureau filings and re-filings and photographs; cost of file retrieval; cost associated with the pursuit of subrogation and/or Special Injury Fund claims and reasonable travel fees and expenses incurred by Company in the performance of the services contemplated herein. Client understands and acknowledges that the Company may have business agreements, including cost sharing arrangements, with vendor service providers that perform services related to this Agreement or in connection with the services provided under this Agreement including services related to allocated and unallocated expenses.As part of these business agreements, there may be financial considerations paid bythe vendor service provider to the Company for ihe resources and services that the Company may provide, which could include marketing, personnel, information technology, system access, and various

d bythe vendor service provider to the Company for ihe resources and services that the Company may provide, which could include marketing, personnel, information technology, system access, and various administrative services. Client understands and acknowledges that it is under no obligation to utilize any vendor provider that is recommended by the Company to perform services related this Agreement and if Self Insured elects not to utilize the services of a recommended vendor provider, then Self Insured can select a vendor service provider it chooses to the perform such services Self Insured acknowledges that if it selects a vendor service provider different than one that is recommended by Company then there may be an adjusiment to the Claims Administration Services fee. Self- Insured also acknowledges that it has control over the types of and amounts of services a vendor service provider performs under or in connection with this Agreement, whether recommended by the Company or selected by Client. 323 S. Pitney Road, Suite 200 # Galloway, NJ 08205 @ 973-731-5700