Employer Mandate Reporting Services Agreement Copyright 2014
City of Dubuque Consent Items # 10.
ITEM TITLE: Employer Mandate Reporting Services Agreement
SUMMARY: City Manager recommending approval of an agreement with
Cottingham & Butler Insurance Services to prepare and file
the required Internal Revenue Service forms 1094-C and
1095-C on behalf of the City.
SUGGESTED DISPOSITION: Suggested Disposition: Receive and File; Approve
ATTACHMENTS:
Description Type
Employer Mandate Reporting Services Agreement-MVM City Manager Memo
Memo
Employer Mandate Reporting Services Staff Memo
Employer Mandate Reporting Services Contract Supporting Documentation
Insurance Schedule C Supporting Documentation
THE CITY OF Dubuque
DUB E i"
Masterpiece on the Mississippi 2007.2012.2013
TO: The Honorable Mayor and City Council Members
FROM: Michael C. Van Milligen, City Manager
SUBJECT: Employer Mandate Reporting Services Agreement
DATE: November 28, 2016
The Patient Protection and Affordable Care Act requires employers to comply with
certain reporting and disclosure requirements for health insurance coverage provided
during the 2016 calendar year. The IRS requires all employers with 50 or more
employees to file 1094-C and 1095-C forms. Last year Cottingham & Butler Insurance
Services, Inc. prepared and filed the necessary forms with the IRS for a fee of $6,000
plus $3.50 for each form filed and prepared beyond 500 forms. This year, Cottingham &
Butler is proposing a fee of $6,250 plus $3.75 for each form prepared and filed beyond
500 forms.
Personnel Manager Randy Peck recommends City Council approval of an agreement
with Cottingham & Butler Insurance Services to prepare and file the required Internal
Revenue Service forms 1094-C and 1095-C on behalf of the City.
I concur with the recommendation and respectfully request Mayor and City Council
approval.
4114-14�1
Mic ael C. Van Milligen
MCVM:jh
Attachment
cc: Crenna Brumwell, City Attorney
Cindy Steinhauser, Assistant City Manager
Teri Goodmann, Assistant City Manager
Randy Peck, Personnel Manager
THE CITY OF Dubuque
F-AmedcaCily
ll/
Masterpiece on the Mississippi 2007-2012-2013
TO: Michael C. Van Milligen, City Manager
FROM: Randy Peck, Personnel Manager 0
SUBJECT: Employer Mandate Reporting Services Agreement
DATE: November 21, 2016
The Patient Protection and Affordable Care Act added Sections 6055 and 6056 to the
Internal Revenue Code. Under these provisions, employers must comply with certain
reporting and disclosure requirements for health insurance coverage provided during
the 2016 calendar year. The IRS requires all employers with 50 or employees to file
1094-C and 1095-C forms under these code sections. Rules under Section 6055
require employers providing minimum benefits coverage to an individual to file a return
and transmittal form with the IRS for every calendar year of coverage. Section 6056
requires employers to report information to both the IRS and their employees on the
healthcare coverage offered to employees.
Last year Cottingham & Butler Insurance Services, Inc. prepared and filed the
necessary forms with the IRS. Their fee last year was $6,000 plus $3.50 for each form
filed and prepared beyond 500 forms. This year they are proposing a fee of$6,250 plus
$3.75 for each form prepared and filed beyond 500 forms.
I recommend that we enter into the attached agreement with Cottingham & Butler
Insurance Services to prepare and file the required Internal Revenue Service forms
1094-C and 1095-C on behalf of the City of Dubuque. The requested action is for the
City Council to approve the agreement and authorizing you to sign the Agreement.
RP:Imh
Employer Mandate Reporting Services Contract
This Agreement (the "Agreement") between Cottingham & Butler Insurance Services, Inc.
("C&B"), and City of Dubuque, Iowa (the "Company") (collectively the "Parties"),
confirms that the Company will engage C&B to prepare and file required Internal Revenue
Service ("IRS") Forms 1094-C and 1095-C (collectively the "Forms") on behalf of the Company
and that C&B will provide to the Company an electronic copy of Form 1095-C for distribution to
employees.
ARTICLE I: Services, Term, and Fees
1.1 SCOPE OF SERVICES. C&B will provide services necessary for the Company to complete and
file the Forms. C&B will also provide to the Company electronic copies of completed Form 1095-C in a
format suitable for distribution the Company's employees, along with one submission of Social Security
Number and names to the IRS for TIN Matching.
1.2 TERM. C&B will provide services under the Agreement from the date the execution date of the
Agreement until March 31, 2017. The Company will provide to C&B complete calendar year
information as required for filing of the Forms no later than January 13, 2017.
1.3 FEES AND COSTS. For completion of 500 or fewer Forms, the Company agrees to pay the
greater of $3,125 or $12.50 per Form completed. For completion of over 500 Forms, the Company
agrees to pay $6,250 plus $3.75 for each Form beyond 500. The Company furthermore agrees to pay
$600 for each additional Employer Identification Number, if applicable. Printing and / or mailing of
forms must be requested in advance and the Company will pay an additional $1.30 per form.
In addition to the fees outlined above, C&B will charge the Company for any actual out-of-pocket
costs that are incurred in rendering services. These costs may include travel expenses, delivery and
courier services, express mail, air courier services and outside contractor document reproduction,
C&B may ask Company to pay directly any expenses in excess of $100.00. Out-of-pocket costs are
not subject to any mark-up.
C&B will provide to the Company an invoice for all estimated fees and costs no later than
December 16, 2016, with payment due from the Company no later than December 31, 2016. Upon
filing and delivery of the Forms, C&B will provide to the Company a final invoice reconciling any
difference between estimated and actual costs. Any remaining payments resulting from the final
invoice will be due within 30 days.
1.4 TERMINATION. The Company may terminate the Agreement at any time upon written notice to
C&B. C&B may terminate the Agreement if (a) the Company fails to pay any fees or expenses that
have been billed to the Company within the time set out in paragraph 1.3 above, or (b) the Company
fails to provide required data to C&B by January 13, 2017, or (c) for no cause with 14 days written
notice. The Company will be liable for any and all fees and expenses incurred up to the termination
date, including the base fees described in paragraph 1.3 above.
C&B Insurance Services Inc is not a law firm and does not provide legal services. There is no attorney-client relationship.
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ARTICLE II: PROVISION OF DATA AND LIMITATION OF LIABILITY
2.1 REQUIRED DATA. The Company will provide to C&B any and all data required for the completion
of the Forms. Such data will include names, addresses, and social security numbers of employees of
the Company as well as data concerning employment numbers and health plan offerings for
employees of the Company. The Company acknowledges that the Company bears sole responsibility
for gathering applicable data and providing the data to C&B for completion of the Forms.
2.2 LIMITATION OF LIABILITY AND ACKNOWLEDGEMENT OF COMPLIANCE
RESPONSIBILITIES. C&B will not undertake any independent investigation or verification of Company
data, and C&B does not guarantee the accuracy of the completed Forms 1094-C and 1095-C. The
Company hereby recognizes, acknowledges, and agrees that it bears the ultimate responsibility for
complying with any state or federal law, including but not limited to provisions of the Patient Protection
and Affordable Care Act and the Health Insurance Portability and Accountability Act. Moreover, the
Company hereby recognizes and acknowledges that federal law is subject to change at any time. C&B
accepts no responsibility for Company's compliance with these laws.
2.3 AGREEMENT TO INDEMNIFY AND HOLD HARMLESS. The Company and its officers, directors,
employees, agents, successors, and assigns hereby agree to defend, indemnify, and hold harmless
C&B and C&B's officers, directors, employees, agents, successors, and assigns, from and against any
and all claims, costs, damages, losses, liabilities, actions, recoveries, judgments, and expenses
(including attorney fees and expenses regardless of whether litigation was commenced) arising out of
or in connection with the Company's failure to comply with any state or federal law, including but not
limited to provisions of the Patient Protection and Affordable Care Act and the Health Insurance
Portability and Accountability Act.
ARTICLE III: GENERAL TERMS AND CONDITIONS
3.1 DISCLAIMER OF WARRANTIES. IN NO EVENT WILL C&B INCUR LIABILITY FOR ANY
CONSEQUENTIAL, SPECIAL, PUNITIVE, OR INDIRECT LOSS OR DAMAGES,. REGARDLESS OF
WHETHER SUCH DAMAGES ARE BASED ON CONTRACT, TORT (INCLUDING NEGLIGENCE),
STRICT LIABILITY, OR ANY OTHER THEORY OR FORM OF ACTION, AND REGARDLESS OF
WHETHER C&B KNEW OR SHOULD HAVE KNOWN OF THE LIKELIHOOD OF SUCH DAMAGES IN
ANY CIRCUMSTANCES. THE COMPANY ACKNOWLEDGES THAT C&B MAKES NO
WARRANTIES, EXPRESS OR IMPLIED, INCLUDING WITHOUT LIMITATION THE WARRANTIES
OF MERCHANTABILITY AND OF FITNESS FOR A PARTICULAR PURPOSE.
3.2 NO PROVISION OF LEGAL ADVICE. C&B will not provide any legal or financial advice to the
Company nor will C&B act as a fiduciary of the Company under this Agreement.
3.3 CONFIDENTIALITY. C&B, its employees and agents will hold in strict confidence all data furnished
by the Company or produced by C&B under this Agreement. However, such parties will not be held
liable if such data is released through other sources, or if C&B, its employees or agents release the
data because Company has consented to such disclosure.
C&B Insurance Services Inc is not a law firm and does not provide legal services. There is no attorney-client relationship.
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3.4 RECORD RETENTION. This Agreement does not relieve the Company of its obligations under
federal or state laws or regulations to retain records relating to any data provided to C&B.
3.5 ENTIRE AGREEMENT. This Agreement and any addendum to this Agreement (hereinafter called
"Contract Documents") constitutes the entire agreement between C&B and the Company.
3.6 NOTICE. Any person identified by Company in this Agreement or any certification, notice or other
communication delivered to C&B may receive information, communications and notices regarding the
service, and is authorized to transact all business, make all agreements and sign and deliver all
documents in connection with the service. If the identity of such a person changes, the Company will
promptly notify C&B in writing of the change. C&B will have a reasonable time after receipt of a
certification, notice or other communication to act on it.
3.7 GOVERNING LAW. This Agreement shall be governed by the laws of the State of Iowa.
3.8 BINDING AGREEMENT. This Agreement shall be binding on and inure to the benefit of the
parties to this Agreement and their respective heirs, representatives, successors and assigns.
3.9 ASSIGNABILITY. This Agreement may not be assigned by either party without the express written
consent of the other party, which consent shall not be unreasonably withheld, except that C&B may
delegate and assign any of its duties hereunder to any affiliate of C&B or to any third party
subcontractor, without the need for prior approval.
3.10 NO IMPLIED WAIVER. The failure of C&B to enforce or insist upon compliance with any of the
terms or conditions of this Agreement, the waiver of any term or condition of this Agreement, or the
granting of an extension of time for performance, shall not constitute the permanent waiver of any term
or condition of this Agreement and this Agreement and each of its provisions shall remain at all times in
full force and effect.
3.11 AUTHORITY. The undersigned warrants and represents that the undersigned has full power and
authority to enter into this Agreement, to bind each Party hereto, and to grant the rights set forth herein.
3.12 SEVERABILITY. If any term in this Agreement is held by a court of competent jurisdiction to be
invalid or unenforceable, then the Agreement, including all of the remaining terms, will remain in full
force and effect as if such invalid or unenforceable provision had never been included.
C&B Insurance Services Inc is not a law firm and does not provide legal services. There Is no attorney-client relationship.
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, the Parties hereby enter into this Agreement as of the date listed below.
COTTINGHAM AND BUTLER
INSURANCE SERVICES, INC.
[CLIENT NAME]
City of Dubuque, Iowa
By:
Mic 2-----
el C. Van Milligen
Title: City Manager
Date: Date: /OA
C&B Insurance Services Inc Is not a law firm and does not provide legal services. There Is no attorney-client relationship.
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City of Dubuque Insurance Requirements for Professional Services
Insurance Schedule C
Cottingham & Bulter Insurance
1 Services, Inc. shall furnish a signed Certificate of Insurance to the City of Dubuque, Iowa for the
coverage required in Exhibit I prior to commencing work and at the end of the project if the term of work
is longer than 60 days. Providers presenting annual certificates shall present a Certificate at the end of
each project with the final billing. Each Certificate shall be prepared on the most current ACORD form
approved by the Iowa Department of Insurance or an equivalent. Each certificate shall include a
statement under Description of Operations as to why issued. Eg: Project# or Project Location at
or construction of
2. All policies of insurance required hereunder shall be with a carrier authorized to do business in Iowa and
all carriers shall have a rating of A or better in the current A.M. Best's Rating Guide.
3. Each Certificate shall be furnished to the contracting department of the City of Dubuque.
4. Failure to provide minimum coverage shall not be deemed a waiver of these requirements by the City of
Dubuque. Failure to obtain or maintain the required insurance shall be considered a material breach of
this agreement.
5. Consultants shall require all subconsultants and sub-subconsultants to obtain and maintain during the
performance of work insurance for the coverages described in this Insurance Schedule and shall obtain
certificates of insurances from all such subconsultants and sub-subconsultants.Consultants agree that it
shall be liable for the failure of a subconsultants and sub-subconsultants to obtain and maintain such
coverages. The City may request a copy of such certificates from the Consultants.
6. All required endorsements to various policies shall be attached to Certificate of insurance.
7. Whenever a specific ISO form is listed,an equivalent form may be substituted subject to the provider
identifying and listing in writing all deviations and exclusions that differ from the ISO form.
8. Provider shall be required to carry the minimum coverage/limits,or greater if required by law or other
legal agreement, in Exhibit 1. If provider's limits of liability are higher than the required minimum limits
then the provider's limits shall be this agreement's required limits.
9. Whenever an ISO form is referenced the current edition of the form must be used.
Page 1 of 3 Schedule C Professional Services May 2016
City of Dubuque Insurance Requirements for Professional Services
Insurance Schedule C (continued)
Exhibit I
A) COMMERCIAL GENERAL LIABILITY
General Aggregate Limit $2,000,000
Products-Completed Operations Aggregate Limit $1,000,000
Personal and Advertising Injury Limit $1,000,000
Each Occurrence $1,000,000
Fire Damage Limit(any one occurrence) $ 50,000
Medical Payments $ 5,000
a) Coverage shall be written on an occurrence, not claims made,form. The general liability
coverage shall be written in accord with ISO form CG0001 or business owners form BP0002.
All deviations from the standard ISO commercial general liability form CG 0001,or Business
owners form BP 0002, shall be clearly identified.
b) Include ISO endorsement form CG 25 04 "Designated Location(s)General Aggregate Limit"
or CG 25 03 "Designated Construction Project(s)General Aggregate Limit"as appropriate.
c) Include endorsement indicating that coverage is primary and non-contributory.
d) Include endorsement to preserve Governmental Immunity. (Sample attached).
e) Include an endorsement that deletes any fellow employee exclusion.
f) Include additional insured endorsement for:
The City of Dubuque, including all its elected and appointed officials,all its employees
and volunteers, all its boards, commissions and/or authorities and their board members,
employees and volunteers. Use ISO form CG 2026.
B) AUTOMOBILE LIABILITY $1,000,000 (Combined Single Limit)
C) WORKERS'COMPENSATION & EMPLOYERS LIABILITY
Statutory benefits covering all employees injured on the job by accident or disease as prescribed by
Iowa Code Chapter 85 as amended.
Coverage A Statutory—State of Iowa
Coverage B Employers Liability
Each Accident $100,000
Each Employee-Disease $100,000
Policy Limit-Disease $500,000
Policy shall include an endorsement providing a waiver of subrogation to the City of Dubuque.
Coverage B limits shall be greater if required by Umbrella Carrier.
D) UMBRELLA LIABILITY $1,000,000
Umbrella liability coverage must be at least following form with the underlying policies included
herein.
E) PROFESSIONAL LIABILITY $1,000,000
a) Provide evidence of coverage for 5 years after completion of project.
F) CYBER LIABILITY $1,000,000
Coverage for First and Third Party liability including but not limited to lost data and
restoration, loss of income and cyber breach of information.
Yes X No
Page 2 of 3 Schedule C Professional Services May 2016
City of Dubuque Insurance Requirements for Professional Services
Preservation of Governmental Immunities Endorsement
1. Nonwaiver of Governmental Immunity.The insurance carrier expressly agrees and states that the
purchase of this policy and the including of the City of Dubuque, Iowa as an Additional Insured does
not waive any of the defenses of governmental immunity available to the City of Dubuque, Iowa
under Code of Iowa Section 670.4 as it is now exists and as it may be amended from time to time.
2. Claims Coverage.The insurance carrier further agrees that this policy of insurance shall cover only
those claims not subject to the defense of governmental immunity under the Code of Iowa Section
670.4 as it now exists and as it may be amended from time to time. Those claims not subject to
Code of Iowa Section 670.4 shall be covered by the terms and conditions of this insurance policy.
3. Assertion of Government Immunity.The City of Dubuque, Iowa shall be responsible for asserting any
defense of governmental immunity, and may do so at any time and shall do so upon the timely
written request of the insurance carrier.
4. Non-Denial of Coverage.The insurance carrier shall not deny coverage under this policy and the
insurance carrier shall not deny any of the rights and benefits accruing to the City of Dubuque, Iowa
under this policy for reasons of governmental immunity unless and until a court of competent
jurisdiction has ruled in favor of the defense(s) of governmental immunity asserted by the City of
Dubuque, Iowa.
No Other Change in Policy.The above preservation of governmental immunities shall not otherwise
change or alter the coverage available under the policy.
SPECIMEN
Page 3 of 3 Schedule C Professional Services May 2016