Mesquite Independent School District

Mesquite Independent School District
Request For Proposal for:
Excess Workers’
Compensation Insurance
Proposal # 2016-028
Proposal Due June 14, 2016, No Later Than: 2:00 P.M.
Place:
MISD Purchasing Dept.
800 E. Kearney
Mesquite, Texas 75149
Mesquite Independent School District Proposal
Proposal # 2016-028
Excess Workers’ Compensation Insurance
Table of Contents
1
GENERAL INFORMATION ................................................................................. 3
Introduction ........................................................................................................ 3
General Conditions ............................................................................................ 3
Minimum Qualifications ..................................................................................... 4
Time Line for RFP.............................................................................................. 4
2
UNDERWRITING INFORMATION...................................................................... 5
Payroll Summary ............................................................................................... 5
Previous Companies ......................................................................................... 5
Employee Count and Projected Payroll by Location ........................................ 6
Vehicle Information ............................................................................................ 8
Specific Exposures ............................................................................................ 8
Safety Program Overview ................................................................................. 9
Claim History...................................................................................................... 9
Severity Report ................................................................................................ 10
Coverage to Quote .......................................................................................... 10
3
PROPOSAL RESPONSE FORMS ................................................................... 11
Company Information ...................................................................................... 11
Excess Workers’ Compensation Pricing ......................................................... 12
Underwriters' Confirmation .............................................................................. 13
4
FELONY CONVICTION NOTICE ...................................................................... 14
5
NOTICE OF NO RESPONSE ............................................................................ 15
6
EDUCATIONAL PURCHASING COOPERATIVE OF NORTH TEXAS .......... 16
7
CONFLICT OF INTEREST QUESTIONNAIRE................................................. 17
8
W-9 REQUEST FOR TAXPAYER ID NUMBER AND CERTIFICATION ........ 19
9
CERTIFICATE OF INTERESTED PARTIES (FORM 1295) ............................ 20
10
EXHIBITS………………………………………………………………………….. 21
Exhibit 1: Claims $50,000 and over…………………………………………… 22
2
1 General Information
Introduction
A.
The Mesquite Independent School District serves 38,000 students and includes portion of the cities of
Dallas, Balch Springs, Garland and Mesquite, Texas. The district employs approximately 5,130 full-time
and 40 part-time employees and has an annual budget of approximately $475,368,420. Additionally, an
automated substitute calling system has enrolled approximately 713 substitutes who are on-call per
district need. There are approximately 65 call-in substitute employees for the food service and custodial
departments who are called upon as needed by the district.
B.
The district is governed by an elected seven (7) member Board of Trustees who appoints a
Superintendent to manage the daily operations.
C.
The district consists of 60 locations. There are 33 elementary schools, 8 middle schools, 5 high schools,
the Mesquite Academy, plus 13 support facilities.
General Conditions
A.
The Mesquite Independent School District (hereafter referred to as MISD or the district) is requesting
proposals for excess workers’ compensation insurance.
B.
All relationships between your company and any company offering coverage must be revealed, as well
as any commission payments or fees that will be paid to the proposer as a result of this bid award.
C.
Proposers are expected to examine the complete RFP document. Failure to do so will be at the
proposer’s risk. Written questions about this RFP and requests for additional information may be mailed
to Christina Ford, CSRM, CTSBO Risk Management / Operations Manager, 405 E. Davis, Mesquite,
Texas 75149, or you may fax your request to 972-882-5565. The deadline for questions is May 27, 2016.
D.
Proposers must submit one original and two copies (three complete sets) of the proposal.
E.
Proposals will be received until 2:00 PM on June 14, 2016, at the MISD Purchasing Department.
Proposals should be mailed to: Mesquite Independent School District, Purchasing Department, 800 E.
Kearney Mesquite, Texas 75149, ATTN: Rusty Talbot, Executive Director.
F.
Proposals must be plainly marked on the outside of the envelope: “SEALED PROPOSAL FOR
EXCESS WORKERS’ COMPENSATION INSURANCE.”
G.
The MISD reserves the right to accept or reject any or all proposals, waive any formalities and/or
technicalities in the proposal and award the contract to best serve the interests of the district. The MISD
may negotiate with proposers as deemed advisable or necessary.
H.
All proposals must be submitted on the Proposal Forms attached hereto, in accordance with all
specified conditions. The contract will be for a one (1) year period, beginning on September 1, 2016 and
ending August 31, 2017. It will be renewable for two successive one (1) year periods upon the same
terms and conditions at the discretion of MISD, subject to funding and Board approval. The contract shall
be reviewed prior to renewal and changes made by agreeing parties. Multiple year proposals may be
offered as an additional option. See Coverage to Quote.
I.
Any restrictions, deviations or other modifications which either restrict or broaden coverage must be
shown separately and explained in writing. Failure to attach any modifications or deviations to the
specifications of this proposal will indicate your acceptance of the specifications as written.
3
J.
Proposers are required to submit specimen agreements/contracts that the MISD will be required to sign in
order to participate in your program.
K.
Due care and diligence have been used in the preparation of these specifications and the information
contained herein is believed to be substantially correct. However, the responsibility for determining the
full extent of the exposure and the verification of all information presented herein shall rest solely on the
proposer. The MISD and its representatives will not be responsible for any errors and omissions in the
specifications nor for the failure on the part of the proposer to determine the full extent of the exposures.
L.
Quotations shall be based on the underwriting information furnished by the MISD. Loss data is believed
to be correct but is not warranted. If inspections are required, contact Christina Ford, CSRM at 972-8827401.
Minimum Qualifications
A.
Proposers responding to this RFP must be licensed and/or authorized to do business in Texas and have
at least 5 years experience in writing Texas workers’ compensation coverage. Proposer qualifications
must be included as an exhibit to the proposal.
B.
Proposers must attach a brief biography describing the experience of the person assigned to handle this
account.
C.
Proposers must have an Errors and Omissions policy with a minimum limit of $1,000,000 per occurrence.
Proof of coverage must be attached to your proposal.
Time Line for RFP
May 18, 2016
RFP Release Date
May 27, 2016
Deadline for Questions
June 14, 2016
RFP Due Date – 2:00 PM CSDST
Insurance Coverage Begins
Binders Delivered to Risk Management/Operations
Manager
Policies Delivered to Risk Management/Operations
Manager
September 1, 2016
October 1, 2016
4
2 Underwriting Information
Payroll Summary
Payroll Information By Fund Year and Classification Code
Fund year
Professional
Code 8868
Bus Drivers
Code 7380
All Others
Code 9101
Total
Annual
Payroll
$216,756,714
$2,463,144
$27,094,589
$246,314,448
$210,443,411
$2,391,402
$26,305,427
$239,140,240
$207,392,579
$2,356,734
$25,924,072
$235,673,385
2013/2014
audited
$199,356,593
$2,265,416
$24,919,574
$226,541,583
2012/2013
audited
$187,151,961
$2,126,727
$23,393,995
$212,672,683
2011/2012
audited
$181,847,648
$2,066,451
$22,730,955
$206,645,054
2016/2017
Projected
2015/2016
Estimated
2014/2015
audited
Previous Companies
1.
2.
3.
4.
5.
Midwest Employers Casualty
Midwest Employers Casualty
Midwest Employers Casualty
Midwest Employers Casualty
Safety National
2015-2016
2014-2015
2013-2014
2012-2013
2011-2012
5
Premium - $76,764
Premium - $68,586
Premium - $61,077
Premium - $58,059
Premium - $51,918
Employee Count & Projected Payroll by Location
Address
Location
City
State Zip Code
Number of
Employees
Projected
Payroll
2015-2016
Elementary Schools
Achziger
Austin
Beasley
Black
Cannaday
Florence
Floyd
Galloway
Gentry
Gray
Hanby
Henrie
Hodges
Kimball
Lawrence
Mackey
McKenzie
McWhorter
Moss
Motley
Pirrung
Porter
Price
Range
Rugel
Rutherford
Seabourn
Shands
Shaw
Smith
Thompson
Tisinger
Tosch
*
*
3300 Ridgeranch Rd.
3020 Poteet Drive
919 Green Canyon
328 E. Newsom
2701 Chisolm Trail
4621 Gleneagle
3025 Hickory Tree
2329 Candleberry
1910 Twin Oaks Dr.
3500 Pioneer Rd.
912 Cascade
253 West Lawson Rd
Mesquite
Mesquite
Mesquite
Mesquite
Mesquite
Mesquite
Balch Springs
Mesquite
Mesquite
Balch Springs
Mesquite
Dallas
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
75181
75150
75150
75149
75150
75150
75180
75149
75181
75180
75149
75253
85
50
55
66
65
63
82
82
78
70
91
110
$3,162,062
$2,418,101
$3,061,883
$3,469,859
$2,764,108
$3,354,407
$4,404,574
$3,846,200
$3,155,604
$4,182,009
$4,673,369
$5,954,508
14401 Spring Oak
4010 Coryell
3811 Richman
14900 N. Spring Oaks
3535 Stephens Green
1700 Hickory Tree
1208 New Market
3719 Moon Drive
1500 Creek Valley
517 Via Avenida
630 Stroud Lane
2600 Bamboo
2701 Sybil
1607 Sierra
2300 Sandy Lane
4836 Shands
707 Purple Sage
2300 Mesquite Valley
2525 Helen Lane
1701 Hillcrest
2424 Larchmont
Balch Spring
Mesquite
Mesquite
Balch Springs
Mesquite
Mesquite
Mesquite
Mesquite
Mesquite
Mesquite
Garland
Mesquite
Mesquite
Mesquite
Mesquite
Mesquite
Mesquite
Mesquite
Mesquite
Mesquite
Mesquite
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
TX
75180
75150
75150
75180
75150
75149
75149
75150
75181
75150
75043
75150
75149
75149
75149
75150
75149
75149
75181
75149
75150
85
46
70
75
55
85
61
56
56
62
58
64
62
58
71
86
78
61
61
82
78
$3,967,412
$2,169,830
$3,275,121
$2,813,543
$2,700,222
$3,841,151
$3,663,493
$2,342,595
$2,774,467
$2,182,257
$2,444,171
$2,864,462
$2,888,686
$3,321,987
$3,222,157
$3,012,600
$3,838,821
$4,256,574
$3,534,276
$3,778,878
$2,936,432
6
Middle Schools
Agnew
729 Wilkinson
Mesquite
TX
75149
87
$5,101,994
Berry
2675 Cartwright Rd.
Mesquite
TX
75181
93
$5,222,672
Kimbrough
3900 N. Galloway
Mesquite
TX
75150
90
$4,552,429
2930 Town East
Mesquite
TX
75150
108
$5,057,037
New
3700 S. Beltline
Mesquite
TX
75181
118
$4,599,482
Terry
2351 Edwards Church
TX
75181
90
$4,863,552
Vanston
3230 Karla
Mesquite
Mesquite
TX
75150
92
$4,706,017
Wilkinson
2100 Crest Park
Mesquite
TX
75149
99
$5,200,051
2704 Motley Dr.
Mesquite
TX
75150
43
$3,310,502
McDonald
*
High Schools
Academy
Horn
*
3300 Cartwright Rd.
Mesquite
TX
75181
225
$8,034,476
Mesquite
*
300 E. Davis
Mesquite
TX
75149
275
$13,883,585
North Mesquite
*
18201 LBJ Freeway
Mesquite
TX
75150
280
$13,253,331
Poteet
*
Mesquite
TX
75150
183
$9,695,198
West Mesquite
*
3300 Poteet Dr.
2500 Memorial
Parkway
Mesquite
TX
75149
201
$9,217,178
230 Pioneer
Mesquite
TX
75149
69
$1,406,824
405 E. Davis
Mesquite
TX
75149
20
$8,987,025
329 E. Davis
Mesquite
TX
75149
28
$1,359,008
2133 N. Beltline Rd.
Mesquite
TX
75150
28
$1,048,258
405 E. Davis
Mesquite
TX
75149
55
$4,993,808
Benefits Building
105 S. Florence
Mesquite
TX
75149
5
$196,095
Planetarium
2501 Memorial Pkwy.
Mesquite
TX
75149
2
$51,474
Professional
Development
Center
2600 Motley Dr.
Mesquite
TX
75150
40
$1,740,572
800 E. Kearney
714 E. Kimbrough
612 E. Davis
Mesquite
Mesquite
TX
TX
75149
75149
210
95
$10,106,472
$3,779,832
Mesquite
TX
75149
20
$870,155
801 E. Main
Mesquite
TX
75149
185
$3,846,029
300 W. Kearney
Mesquite
TX
75149
19
$955,573
5,067
$246,314,448
Support
Facilities
The Learning
Center
Administration
Administration
Annex
Berry Support
Complex
Curriculum
Service Center
Student Support
Tech. Excel
Center
Transportation
Mesquite
Employee Health
Center
*
*
*
TOTALS
*These locations have 2 stories. All other locations are 1-story buildings.
7
Vehicle Information
MISD owns/leases approximately 407 vehicles that are used for various purposes, including transporting
students, equipment delivery, and maintenance work. In general, district vehicles stay within a travel radius of
approximately 30 miles. MISD vehicles are not used to transport hazardous or toxic materials. The following
shows the number of district leased/owned vehicles and the average number of employees occupying each
vehicle:
Type of Vehicle
Cars
Vans
Light trucks
Heavy trucks
Truck tractors
Trailers
Number of
Units
10
77
127
1
0
47
Type of
Vehicle
Police cars
Fire trucks
Ambulance
Motorcycles
Buses
ATVs
Average # of
Employees
1
2
2
2
0
0
Number of
Units
0
0
0
0
173
0
Average # of
Employees
0
0
0
0
2
0
Specific Exposures
The following table outlines MISD’s involvement in some common specific exposures:
Specific Exposure
Own, lease or charter aircraft?
Own, lease or charter watercraft?
Load/unload, repair or construct watercraft or work on barges or docks?
Operations or employees subject to the Longshoremen’s and Harbor Workers’ Act,
Jones Act or Federal Employer’s Liability Act?
Own, operate or maintain a railroad or railroad equipment?
Foreign operations or employees who travel to foreign countries?
Occupational disease exposures? (i.e. asbestos, silica, toxic substances, etc.)
Operations resulting in carpal tunnel syndrome or repetitive motion claims?
Store gasoline or other flammables?
Manufacture, store, distribute, transport, or handle explosives?
Underground, tunneling, mining, cofferdam or sub-aqueous operations?
Wrecking, dismantling, or demolition work?
Operations subcontracted to others?
Operations involving exposure to heights?
Operations involving exposure to burns?
Volunteer or donated labor?
Leased employees?
Any substantial or unusual changes in the last 5 years?
Workers’ compensation coverage cancelled or non-renewed in the last 5 years?
8
Yes
No
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Safety Program Overview
The MISD Risk Management Department continually strives to prevent employee injuries through a
combination of approaches. The following is a list of risk management practices that are used to improve safety
and health throughout the district:
o
The Risk Management Department developed and periodically updates the MISD Safety
Handbook. The safety handbook outlines safety-related policies that district employees are
expected to follow.
o
Monthly safety meeting handouts are developed and distributed for training of all auxiliary
personnel, food service employees, and custodians. Department supervisors conduct the monthly
training sessions. An average of 885 employees receive monthly training via safety meetings
developed by Risk Management.
o
Defensive driving courses are held at least quarterly and are conducted by Risk Management.
Any employee who drives a vehicle that is owned or leased by MISD must attend a defensive
driving course at least once every three years.
o
Risk Management coordinates and/or conducts equipment training as needed by district
employees. Employees are required to attend training before operating construction equipment
such as forklifts.
o
Each employee receives Hazardous Communication (HAZCOM) training. Material safety data
sheets (MSDS) are made available to all employees, and each facility has an MSDS binder that
lists all chemicals at the facility. Risk Management keeps track of all documentation related to
HAZCOM training.
o
Risk Management coordinates annual safety in-services for auxiliary personnel, food services
employees, and custodians. Presenters from outside the district are sometimes brought in to
present on various safety topics.
o
Risk Management controls a video library that is available to all departments at no cost. All videos
are safety-related and can be used by department supervisors during safety meetings.
o
The Risk Management Department authors a safety-related article once a month that is published
in the MISD monthly newsletter (In-Touch).
o
All MISD facilities undergo on-site safety inspections with the district’s safety officer. Inspection
reports are produced that outline safety hazards that need to be addressed.
o
Risk Management coordinates all activities related to Senate Bill 11 compliance. Senate Bill 11
activities include conducting security audits of each campus.
o
Risk Management utilizes E-Learning, a computer generated software program, to create
innovative use of on-line learning to increase safety awareness to all MISD campus and office
employees for the prevention of accidents. An average of 1,250 employees receive this training
quarterly.
Claim History
A detailed five-year claim loss run is available in PDF format (5 pages) by contacting the MISD Risk
Management Department at 972-882-5561.
9
Severity Report
See Exhibit 1 – Claims Cost with Incurred Cost $50,000 and Above.
Coverage to Quote
The MISD desires to make a three-year commitment to the selected insurance program in order to promote the
stability of its coverages and costs. Multi-year proposals must allow for annual renewal/appropriation
requirements. The contract may be extended in additional one-year periods up to a maximum of three
years (i.e., two one-year extensions) at the unilateral discretion of the MISD based on factors such as, but
not limited to, unit prices, delivery satisfaction, compliance with terms/conditions, and needs of the MISD.
To exercise each option to renew, the MISD must give written notice to the vendor of its election to renew for
one (1) additional year within forty-five (45) days of the expiration of the agreement. If the MISD fails to timely
exercise any of the options to renew, all remaining options to renew shall expire and terminate. An annual
escalation provision must be submitted and the district will have the option to rescind the contract if the
proposed price increase is not reasonable in the opinion of district officials. Allowable price increases from one
year to the next will be based on the percent increase for the 12-month period ended in November (of the
current year) as reported in the Consumer Price Index Summary for all urban consumers (CPI-U).
10
3 Proposal Response Forms
Company Information
Name of your company:
Address:
Primary business:
Type of company:
(corp., partnership, etc.):
Account Executive
Year started in business:
Office Hours:
Number of years administering
Workers' Compensation in Texas:
Telephone: (
)
Fax: (
E-Mail:
)
Website:
Proposers must include in the proposal a notice as to whether the person submitting the bid or an owner or
operator of the business entity has been convicted of a felony and the description of the conduct resulting in the
conviction. The contract may be terminated if it is determined that the person or business entity failed to give
notice or misrepresented the conduct resulting in the conviction.
The proposer, in compliance with the invitation for proposal on workers' compensation coverage, having
examined the specifications and being familiar with all conditions in the specifications, hereby proposes to
provide the services in accordance with the proposal documents on the attached response sheets.
"The undersigned affirms that they are duly authorized to execute this contract, that this company, corporation,
firm, partnership or individual has not prepared this proposal in collusion with any other proposer, and that the
contents of this proposal as to prices, terms or conditions of said proposal have not been communicated by the
undersigned nor by any employee or agent to any other person engaged in this type of business prior to the
official opening of this proposal."
Having reviewed the specifications, we have complied with all requirements and conditions except as noted on
the attachment labeled “Deviations.”
Signature and title of authorized representative
Proposing Company
Date
11
Excess Workers’ Compensation Pricing
Retention
Premium:
$250,000
$_______________________
$300,000
$_______________________
$350,000
$_______________________
$400,000
$_______________________
$500,000
$_______________________
12
Underwriters’ Confirmation
The undersigned affirms:
1. That the insurer did not agree to submit proposals on an exclusive basis through a designated agent/broker
prior to May 18, 2016.
2. That the insurer’s proposal is based solely on material provided in RFP
(Note that the following is to be signed by an individual who has underwriting authority for the insurer
that is proposing coverage to MISD).
Signature
13
Felony Conviction
State of Texas Legislative Senate Bill No. 1, Section 44.034, Notification of Criminal History, Subsection
(a), states "a person or business entity that enters into a contract with a school district must give
advance notice to the district if the person or an owner or operator of the business entity has been
convicted of a felony. The notice must include a general description of the conduct resulting in the
conviction of a felony."
Subsection (b) states "a school district may terminate a contract with a person or business entity if the
district determines that the person or business entity failed to give notice as required by Subsection (a)
or misrepresented the conduct resulting in the conviction. The district must compensate the person or
business entity for services performed before the termination of the contract."
THIS NOTICE IS NOT REQUIRED OF A PUBLICLY-HELD CORPORATION
I, the undersigned agent for the firm named below, certify that the information concerning
notification of felony convictions has been reviewed by me and the following information furnished
is true to the best of my knowledge.
VENDOR'S NAME:
AUTHORIZED COMPANY OFFICIAL'S NAME (PRINTED):
A.
My firm is a publicly held corporation; therefore, this reporting requirement is not applicable.
Signature of Company Official:
B.
My firm is neither owned nor operated by anyone who has been convicted of a felony:
Signature of Company Official:
C.
My firm is owned or operated by the following individual(s) who has/have been convicted of a felony
Name of Felon(s):
Detail of Conviction(s):
Signature of Company Official:
14
Notification of No Response
NOTIFICATION OF NO RESPONSE
RFP # 2016-028
Excess Worker’s Compensation Insurance
Mesquite ISD
405 E. Davis
Mesquite, TX 75149
If applicable, please sign and return this form to the attention of:
Christina Ford, CSRM, CTSBO Risk Management / Operations Manager
(at the above address)
The District would appreciate receiving this notification to better utilize our resources in corresponding
with potential vendors throughout the solicitation process.
After a review of RFP # 2016-028, it was decided that there would not be a response to the request
for proposal. The decision is based upon one or more reasons checked below.
1.
Unable to meet specification for:
Vendor qualification
YES ______ NO _____ I would like
Coverages specified
to remain on the list to receive
Timeline
2.
Unable to utilize desired markets
3.
Able to, but just prefer not to respond
4.
Other
future RFPs
Any elaboration to the above would be most appreciated. The District wants to receive feedback to
consider for future solicitations. Please use the space below to share your comments.
Signature
Printed Vendor Name & Phone Number
Printed Name & Title of Signature
15
Educational Purchasing Cooperative of North Texas
Educational Purchasing Cooperative of North Texas
Several governmental entities around the Mesquite Independent School District have indicated an interest
in being included in this contract. Should these governmental entities decide to participate in this
contract, would you, the vendor, agree that all terms, conditions, specifications, and pricing would apply?
Yes
No
If you, the vendor, checked yes, the following will apply. Governmental entities utilizing Internal Governmental
contracts with the Mesquite Independent School District will be eligible, but not obligated, to purchase
materials/services under the contract(s) awarded as a result of this solicitation. All purchases by governmental
entity other than Mesquite Independent School District will be billed directly to that governmental entity and paid
by that governmental entity. Mesquite Independent School District will not be responsible for another
governmental entity’s debts. Each governmental entity will order its own material/service as needed. For
information regarding the Educational Purchasing Cooperative of North Texas, please visit their website at the
following address: http://www.epcnt.com.
16
17
18
W-9
Form
(Rev. December 2014)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the IRS.
Print or type
See Specific Instructions on page 2.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification; check only one of the following seven boxes:
C Corporation
S Corporation
Partnership
Trust/estate
Individual/sole proprietor or
single-member LLC
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) a
Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for
the tax classification of the single-member owner.
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
(Applies to accounts maintained outside the U.S.)
Other (see instructions) a
5 Address (number, street, and apt. or suite no.)
Requester’s name and address (optional)
6 City, state, and ZIP code
7 List account number(s) here (optional)
Part I
Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN on page 3.
Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for
guidelines on whose number to enter.
Social security number
–
–
or
Employer identification number
–
Part II
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding
because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on page 3.
Sign
Here
Signature of
U.S. person a
Date a
General Instructions
• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T
(tuition)
Section references are to the Internal Revenue Code unless otherwise noted.
• Form 1099-C (canceled debt)
Future developments. Information about developments affecting Form W-9 (such
as legislation enacted after we release it) is at www.irs.gov/fw9.
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident alien), to
provide your correct TIN.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an information
return with the IRS must obtain your correct taxpayer identification number (TIN)
which may be your social security number (SSN), individual taxpayer identification
number (ITIN), adoption taxpayer identification number (ATIN), or employer
identification number (EIN), to report on an information return the amount paid to
you, or other amount reportable on an information return. Examples of information
returns include, but are not limited to, the following:
If you do not return Form W-9 to the requester with a TIN, you might be subject
to backup withholding. See What is backup withholding? on page 2.
• Form 1099-INT (interest earned or paid)
3. Claim exemption from backup withholding if you are a U.S. exempt payee. If
applicable, you are also certifying that as a U.S. person, your allocable share of
any partnership income from a U.S. trade or business is not subject to the
withholding tax on foreign partners' share of effectively connected income, and
By signing the filled-out form, you:
1. Certify that the TIN you are giving is correct (or you are waiting for a number
to be issued),
2. Certify that you are not subject to backup withholding, or
• Form 1099-DIV (dividends, including those from stocks or mutual funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
• Form 1099-B (stock or mutual fund sales and certain other transactions by
brokers)
4. Certify that FATCA code(s) entered on this form (if any) indicating that you are
exempt from the FATCA reporting, is correct. See What is FATCA reporting? on
page 2 for further information.
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
Cat. No. 10231X
19
Form W-9 (Rev. 12-2014)
CERTIFICATE OF INTERESTED PARTIES (FORM 1295)
In 2015, the Texas Legislature adopted House Bill 1295, which added section 2252.908
of the Government Code. The law states that a governmental entity or state agency
may not enter into certain contracts with a business entity unless the business entity
submits a disclosure of interested parties to the governmental entity or state agency at
the time the business entity submits the signed contract to the governmental entity or
state agency. The law applies only to a contract of a governmental entity or state
agency that either (1) requires an action or vote by the governing body of the entity or
agency before the contract may be signed or (2) has a value of at least $1 million. The
disclosure requirement applies to a contract entered into on or after January 1, 2016.
The Texas Ethics Commission was required to adopt rules necessary to implement that
law, prescribe the disclosure of interested parties form, and post a copy of the form on
the commission’s website. The commission adopted the Certificate of Interested Parties
form (Form 1295) on October 5, 2015. The commission also adopted new rules
(Chapter 46) on November 30, 2015, to implement the law. The commission does not
have any additional authority to enforce or interpret House Bill 1295.
Filing Process:
By January 1, 2016, the commission will make available on its website a new filing
application that must be used to file Form 1295. A business entity must use the
application to enter the required information on Form 1295 and print a copy of the
completed form, which will include a certification of filing that will contain a unique
certification number. An authorized agent of the business entity must sign the printed
copy of the form and have the form notarized. The completed Form 1295 with the
certification of filing must be filed with the governmental body or state agency with which
the business entity is entering into the contract.
The governmental entity or state agency must notify the commission, using the
commission’s filing application, of the receipt of the filed Form 1295 with the certification
of filing not later than the 30th day after the date the contract binds all parties to the
contract. The commission will post the completed Form 1295 to its website within seven
business days after receiving notice from the governmental entity or state agency.
Information regarding how to use the filing application will be available on this site by
January 1, 2016. https://www.ethics.state.tx.us/whatsnew/elf_info_form1295.htm
The Form 1295 will be completed by the awarded vendor upon notification by the
District.
20
EXHIBIT 1
Claims $50,000 and Over
21
Workers' Compensation Program
Severity Report as of March 31, 2016
Open and Closed Claims
A\Mesquite ISD
Severity Amount: $50,000
Paid to Date
Claim
Number
Claimant Name
Accident
Date
Claim Claim
Stat Type
Nature Body Cause
of
Part
of
Injury Injured Injury
Case Base Incurred
Comp
Medical
Expense
Total
Comp
Medical
Expense
Total
Reserve
Coverage Period: 09/01/1984 - 09/01/1985
1589602
WATSON, DOUGLAS
06/22/1985
C
Totals:
I
37,744
33,108
11,756
82,608
37,744
33,108
11,756
82,608
0
1
37,744
33,108
11,756
82,608
37,744
33,108
11,756
82,608
0
I
33,176
23,085
6,178
62,439
33,176
23,085
6,178
62,439
0
1
33,176
23,085
6,178
62,439
33,176
23,085
6,178
62,439
0
I
30,091
76,375
16,785
123,250
30,091
76,375
16,785
123,250
0
1
30,091
76,375
16,785
123,250
30,091
76,375
16,785
123,250
0
59
42
99
28
33
31
28
10
26
Coverage Period: 09/01/1985 - 09/01/1986
1589627
WILSON, BETTE
04/07/1986
C
Totals:
Coverage Period: 09/01/1986 - 09/01/1987
1589633
SANDERS, SHIRLE
09/16/1986
C
Totals:
Coverage Period: 09/01/1987 - 09/01/1988
1589684
PAYNE, IMOGENE
01/14/1988
C
I
34,737
33,184
5,847
73,767
34,737
33,184
5,847
73,767
0
52
42
56
1401800
BERRY, CINDY J
05/26/1988
C
I
31,563
37,865
17,115
86,544
31,563
37,865
17,115
86,544
0
52
90
81
1400268
RIVERA, JOE
11/09/1987
C
I
36,469
63,035
3,852
103,357
36,469
63,035
3,852
103,357
0
52
42
31
1589674
BARKER, DEBRA
10/28/1987
C
52
42
50
Totals:
I
29,543
79,693
5
109,241
29,543
79,693
5
109,241
0
4
132,312
213,777
26,819
372,908
132,312
213,777
26,819
372,908
0
Coverage Period: 09/01/1988 - 09/01/1989
1401832
SMITH, PATSY
09/01/1988
C
I
32,743
16,465
1,240
50,448
32,743
16,465
1,240
50,448
0
52
42
60
1402742
COX, DARREL L
08/25/1989
C
I
21,614
35,657
1,836
59,107
21,614
35,657
1,836
59,107
0
52
42
13
1589710
TANNER, DONALD G
10/25/1988
C
I
48,177
27,531
5
75,713
48,177
27,531
5
75,713
0
52
42
56
1401847
SHIPPLETT, TOMMIE C
10/13/1988
C
I
29,462
50,555
15
80,032
29,462
50,555
15
80,032
0
52
42
56
1402668
RENFRO, WANDA C
01/24/1989
C
I
40,472
81,884
18
122,374
40,472
81,884
18
122,374
0
52
31
56
5
172,469
212,093
3,113
387,675
172,469
212,093
3,113
387,675
0
Totals:
Coverage Period: 09/01/1989 - 09/01/1990
22
Workers' Compensation Program
Severity Report as of March 31, 2016
Open and Closed Claims
A\Mesquite ISD
Severity Amount: $50,000
Paid to Date
Claim Claim
Stat Type
Nature Body Cause
of
Part
of
Injury Injured Injury
Case Base Incurred
Claim
Number
Claimant Name
Accident
Date
1402719
REAVIS, LILLIE
09/01/1989
C
I
36,804
21,095
1,703
59,601
36,804
21,095
1,703
59,601
0
52
42
60
1404603
CRAKER, ELSIE A
08/06/1990
C
I
34,781
56,340
14
91,135
34,781
56,340
14
91,135
0
52
33
60
1404483
HULTS, MARGAR D
02/05/1990
C
I
28,577
72,259
5
100,841
28,577
72,259
5
100,841
0
52
42
56
1404512
ARAIZA-KINSER, JUDITH E
03/29/1990
C
I
70,271
43,838
995
115,104
70,271
43,838
995
115,104
0
52
42
60
1402729
TOMPKINS, JACK
10/18/1989
C
I
59,750
57,792
1,080
118,621
59,750
57,792
1,080
118,621
0
59
90
50
5
230,184
251,323
3,796
485,303
230,184
251,323
3,796
485,303
0
Totals:
Comp
Medical
Expense
Total
Comp
Medical
Expense
Total
Reserve
Coverage Period: 09/01/1990 - 09/01/1991
1408554
SHELTON, EVON
08/22/1991
C
I
22,866
51,125
4,246
78,237
22,866
51,125
4,246
78,237
0
52
42
56
1404741
DILLEHAY, TOMMY
12/11/1990
C
I
58,915
52,363
165
111,442
58,915
52,363
165
111,442
0
52
50
56
1408404
MEJIA, RAUL
05/10/1991
C
I
47,314
71,451
8,848
127,612
47,314
71,451
8,848
127,612
0
59
42
99
1404652
WALLACE, THERES
09/26/1990
C
I
34,604
311,616
7,348
353,567
34,604
311,616
7,348
353,567
0
52
42
60
4
163,699
486,553
20,606
670,859
163,699
486,553
20,606
670,859
0
49
42
56
Totals:
Coverage Period: 12/01/1991 - 09/01/1992
1422144
TRUE, BEVERLY D
02/04/1992
C
Totals:
I
30,354
95,327
2,881
128,561
30,354
95,327
2,881
128,561
0
1
30,354
95,327
2,881
128,561
30,354
95,327
2,881
128,561
0
Coverage Period: 09/01/1992 - 09/01/1993
629749
SMITH, LARRY W
04/16/1993
C
I
34,818
25,552
2,942
63,312
34,818
25,552
2,942
63,312
0
52
30
58
622784
CARTER, SHELIA A
04/21/1993
C
I
20,489
62,976
277
83,742
20,489
62,976
277
83,742
0
52
42
56
2
55,307
88,528
3,219
147,054
55,307
88,528
3,219
147,054
0
Totals:
23
Workers' Compensation Program
Severity Report as of March 31, 2016
Open and Closed Claims
A\Mesquite ISD
Severity Amount: $50,000
Paid to Date
Claim
Number
Claimant Name
Accident
Date
Claim Claim
Stat Type
Case Base Incurred
Comp
Medical
Expense
Total
Comp
Medical
Expense
Total
Reserve
Nature Body Cause
of
Part
of
Injury Injured Injury
Coverage Period: 09/01/2014 - 09/01/2015
2550461
WOODARD, MARY
06/16/2015
O
I
18,151
29,420
856
48,426
18,753
30,500
1,000
50,253
1,827
28
32
27
2550448
NIX, SHARON D
06/03/2015
O
I
0
29,876
826
30,702
13,776
37,500
1,050
52,326
21,624
10
51
31
2550298
ADAMS, JAMES
11/25/2014
O
I
17,570
30,091
568
48,228
17,570
35,000
1,050
53,620
5,392
90
90
77
3
35,721
89,386
2,249
127,356
50,099
103,000
3,100
156,199
28,843
27
921,056
1,569,555
97,403
2,588,014
935,435
1,583,170
98,254
2,616,858
28,843
Totals:
Report Totals:
24