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Home My WebLink About09/01/04 AGENDA FiLE 239 4th Street · Bremerton, WA 98337 · Phone (360) 478-5280 · Fax (360) 478-5251 SEPTEMBER 1, 2004 CITY COUNCIL MEETING AGENDA 1. PRE-COUNCIL STUDY SESSION: 5:00 - 5:30 P.M. in Council Conference Room A. General Council Business 2. CALL TO ORDER: 5:30 P.M. in Council Chambers A. Pledge of Allegiance a. Invocation ~?_~_ 3. MAYOR'S REPORT 4. CONSENT AGENDA A. Claims & Check Register (#AB04-172) B. Minutes of Meeting -August 25, 2004 (#AB04-173) C. Contract Award to COATING APPLICATORS, INC. for Interior Coating Replacement for Reservoir No. 15 (#AB04-174) D. Supplemental Agreement No. 6 to the existing Professional Services Agreement with PARAMETRIX, INC. for 8R304 Transportation Improvement Project (#AB04-175) E, 2004 Contract Approval with KITSAP PHYSICIANS SERVICES (KPS) (#AB04-176) F. Governmental Services Agreement with Kitsap County for Programming Services on BREMERTON-KITSAP ACCESS TELEVISION (BKAT) (#AB04-177) . Setting the Salary Level of Mark McLaughlin as the Budget Analyst at Pay Band~,~Rate 6 of the 2003 Professional, Confidential, & Fiduciary Pay Plan (#AB04-178) ~ N__EW BUSINESS - There are no New Business items this week... R, 6. PUBLIC HEARINGS - ORDINANCES & RESOLUTIONS A. Resolution No. 2939 for 2005-2010 Six-Year Transportation Improvement Plan (#AB04-179) I'/~' B. Ordinance [First Reading] amending Chapter 3.01, "Rate Table C" of the Bremerton | l~. Municipal Code relating to Community Development Fees (#AB04-180) O~dina~ce [First Re~:ling] amendind~hapters 15.~)1 and 15.06 of. the Bremerten MunicipaJ, . _, Co'd~ rel~g to As~nts, Rat~s,~s, and C~ f~r wate~ewa~l Storrfl~ateC,~rvices (#A~)4¢-181) ~ -- -- 7. PUBLIC RECOGNITION - Comments limited to 3-minutes 8. COUNCIL MEMBER REPORTS 9. ADJOURNMENT OF CITY COUNCIL BUSINESS MEETING E-mail: citycouncil@ci.brernerton.wo.us · Web: www.ci.bremerton.wa.us AGENDA BILL C~T-~ COLh',~C~L SU~JE£'T: ApproYai o.f C'h;ims and ,Checks Commit'tee _Meeting Date: ~e~i~tm' COL~fCtL t'~~ ~ ~. ~. Depamnent: Financial Sen'ices Presenter: Cathy Phone: 473-5296 SUMMARY: Consent agenda item. Approval of pa}roll, checks and electronic tired trauslbrs. ATTACHMENTS: FISCAL IMPACTS (Include Budgeted Amount):. APPROVALS: DEPARTMENT DIRECTOR: CIT¥ ATTORNEY: FINANCE DIRECTOR: MAYOR: FISCAL/BUDGET: OPERATIONS: CONSENT AGENDA COUNCIL PRESIDENT: RECOMMENDED MOTION: Move to Approve: l) Cheek #'s ~ff ,~'~/_ through~,O~'-~..~ and EFT's &'3 ~'hrough~:~_ in the amount of $oQ~¢:Sn~, 2) Regular Payroll for the pay period ending in the amount ors 3) Retiree Payroll for the pay period ending ,,~'~3/~_-O~/ in the amount of $ ~25 ~O<~SZ COUNCIL ACTION': [] Approve [] Den;, [] Table [] Continue [] ['lc,/<.cti,:a DATE SUBMITTED: BILL # 0q ' tT~ AUGUST 26, 2004 AGENDA BILL CItY OF BREMERTON ~ B CITY COUNCIL SUBJECT: Minutes of Meeting - Committee Meeting Date: N/A AUGUST 25, 2004 COUNCIL MEETING Date: St.~'~Mt~-K ~, 2004 Department: City Council Presenter: Daren Nygren, Council President Phone: (360) 473-5280 SUMMARY: Attached are the minutes for the Council Meeting held AUGUST 25, 2004. ATTACHMENTS: Minutes for AUGUST 25, 2004. FISCAL IMPACTS (Include Budgeted Amount): 0 APPROVALS: DEPARTMENT DIRECTOR: CITY ATTORNEY: FiNANCE DIRECTOR: MAYOR: FISCAL/BUDGET: CONSENT AGENDA [] OPERATIONS: COUNCIL PRESIDENT: RECOMMENDED MOTION: Move to pass the Consent Agenda as presented. · ' N' ~ Fable I~1 Continue [] No Action (t)tNC1L AC~IIO= , ~ App!-ose ~_3 Den)' TAPE #1967 CITY COUNCIL MEETING MINUTES Wednesday, August 25, 2004 The weekly meeting of the City Council of the City of Bremerton was called to order in the City Council Chambers, 239 4th Street, Bremerton, Washington, Wednesday, August 25, 2004, at 5:30 P.M., with Council President Daren Nygren presiding. Council members present were Mike Short, Will Maupin, Carol Arends, Dianne Robinson, Mike Shepherd, Wendy Priest, Cecil McConnell, and Brad Gehring. Also present were City Attorney Roger Lubovich; City Clerk Paula Johnston; and Council Assistant Christine Grenier Ellingson. The meeting opened with the Pledge of Allegiance led by Council Member Cecil McConnell, followed by the invocation provided by Pastor Danny Allen of Grace Pentacostal Church. President Ny.qren made the following announcements: 1. A Pre-Council session was held in the Council Conference Room from 5:00 to 5:30 P.M.; and 2. A LEGISLATIVE REVIEW SESSION will be held immediately following the Council Meeting in the Council Conference Room. This meeting is also open to the public. CONSENT AGENDA A. Check numbers 293078 through 293463; EFT-6384; EFT-6385; EFT-6387 through EFT- 6389; and EFT-6391 through EFT-6394 in the amount of $1,995,295.32; and Regular Payroll for the pay period ending August 15, 2004 in the amount of $629,708.64 (#AB04-170) B. Minutes of Meeting -August 18, 2004 (#AB04-171) #0070 M/S/C (Priest~McConnell) Move to approve the Consent Agenda as presented. Voted in favor of the Motion: Gehring, McConnell, Priest, Robinson, Arends, Maupin, Short, Nygren Abstained: Shepherd Motion carried: 8-Yes; 1-Abstention With no further business, the meeting of the City Council was adjourned at 5:33 P.M. The Council reconvened in the Council Conference Room to hold a LEGISLATIVE REVIEW SESSION which would include presentations on upcoming agenda items. Prepared and Submitted by: CHRISTINE GRENIER ELLINGSON Council Assistant Attest: PAULA JOHNSTON, City Clerk DAREN NYGREN, City Council President City of Bremerton DN/PJ/Is/cge 2 DATE SUBMITTED: August 4, 2004 BILL # 0 q- / 7q AGENDA BILL CITY OF BREMERTON ~ ~ CITY COUNCIL SUBJECT: CONTRACT AWARD - Committee Meeting Date: August 25, 2004 Coating Applicators, Inc. - Reservoir No. 15 - COUNCIL MEETING Date: September 2, 2004 Interior Coating Replacement Department: Public Works & Utilities Presenter: Dan Miller, Proj. Mgr. Phone: 473-2314 SUMMARY: Bids were opened on Monday, August 2, 2004 for the Reservoir No. 15, Interior Coating Replacement Project. A total of five (5) bids were received for the project (see attached Bid Opening List). The Iow bidder is Coating Applicators, Inc. from Stanwood, WA for the Lump Sum Bid of $108,000.00. The total contract amount, including Washington State Sales Tax, is $117~288.00. ATTACHMENTS: Bid Opening List; and Water Resources - Water Fund 401 FISCAL IMPACTS (Include Budgeted Amount): The attached Water Fund 401 Maintenance Budget listed under "Structures & Grounds - 54830' in the amount of $200,000 shall support this project. APPROVALS: DEPARTMENT DIRECTOR: CITY ATTORNEY: FINANCE DIRECTOR: MAYOR: OPERATIONS:FiSCAL/BUDGET: COUNCIL PRESIDENT: RECOMMENDED MOTION: That City Council approve the contract award to Coating Applicators, Inc. in the amount of $117,288.00 including Washington State Sales Tax, and authorize the Mayor to finalize and execute the contract. COUNCIL ACTION: [] Approve [] Deny [] Table [] Continue [] No Action Reservoir 15 Interior Coating Replacement Supplemental Information to the Agenda Bill August 2004 The City of Bremerton Water Utility has 17 treated water reservoirs. Twelve of these reservoirs are above-ground steel tanks. Each of these tanks has exterior and interior protective coatings that must be replaced on a regular basis (approximately every 20 - 30 years depending on material used) to protect the integrity of the structure. The Water Utility has a prioritized plan for replacing these coatings. The funding for this work is budgeted under the Public Works and Utilities Department Water Resources Division operations and maintenance. Reservoir 15 is a one million gallon above ground steel reservoir that was placed on line in 1966. The interior coating is coal tar and long past its useful life. The interior of Reservoir 15 is currently the number one priority for interior coating replacement. The coating will be replaced with an epoxy product with an expected service life of 25-30 years. 5 DATE SUBMITTED: BILL # Oq- I?~ AGENDA BILL CITY OF BREMERTON q b CITY COUNCIL SUBJECT: SR 304 Transportation Committee Meeting Date: August 25, 2004 Improvement Project -Supplemental COUNCIL MEETING Date: September 1, 2004 Agreement #6 to Parametfix, Inc. Consultant Department: PW&U, Engineering Agreement (City Contract No. 3796) Presenter: Lynn Price Phone: 473-5272 SUMMARY: The City entered into an agreement with Parametrix, Inc. on February 10, 1997 for design and fight-of-way services for the SR 304 Transportation Improvement Project. Supplemental Agreement #6 increases the contract amount by $229,201.35 to $2,792,366.46 and modifies the scope of work for surveying, design and environmental work required for the Navy Yard Highway Stage of the project between Charleston Beach Road and the SR3/304 Interchange. The contract completion date is extended to December 31, 2006. ATTACHMENTS: 1) Supplemental Agreement #6 agenda bill summary sheet 2) Supplemental Agreement #6 3) Exhibit A - Amended Scope of Work; 4) Exhibit B - Budget Information FISCAL IMPACTS (Include Budgeted Amount): Supplement #6 increases the contract amount by $229,201.35 over the amount approved in Supplemental Agreement #4. The revised budget is not to exceed $2,792,366.46. APPROVALS: DEPARTMENT DIRECTOR~""'~ ~/~-_~'~~ FINANCE DIRECTOR: MAYOR: ( d..~ ']'/~ __ · ~ t fi/ CONSENT AG OPERATIONS: COUNCIL PRESIDENT: RECOMMENDED MOTION: Move to approve Supplemental Agreement No. 6 to the existing Professional Services Agreement with Parametrix, Inc. and authorize the Mayor to finalize and execute the necessary contract documents for the agreement· COUNCIL ACTION: [] Approve [] Deny [] ']'able [] Continue [] No Action SR 304 Transportation Improvement Project/Final Design City of Bremerton Contract #: 3796 SUPPLEMENTAL AGREEMENT #6 - AGENDA BILL SUMMARY Introduction Supplemental Agreement #6 to the SR 304 Transportation Improvement Project/Final Design (Project) will modify the agreement between the City of Bremerton (City) and Parametrix, Inc. (Consultant) originally executed on February 10, 19974. This supplement modifies the scope of work for surveying and design and includes additional environmental work that was identified from the initial site investigation results. This supplement pertains to the portion of SR 304 along Navy Yard Highway between Charleston Beach Road and SR 3. The budget will be increased by approximately $229K. The contract completion date is extended to December 31, 2006. Modifications to the Scope of Work The City originally intended for the Consultant to perform the design to 100% completion. This amendment reduces the design scope to 30% completion by the Consultant and the City will do the remainder of the design with its own staff. Exhibit A contains the amended scope of work for survey and design. Budget information for the survey/design scope of work is contained in Appendix B. Results from initial site investigations for the properties associated with this project indicated that 18 of the properties would require additional environmental investigation. Whether this additional work would be required could only be determined once the initial site investigations had been performed; therefore budget could not have been previously allocated for the additional envirenmental investigation. This new work includes more detailed site investigations involving groundwater monitoring and soil sampling for individual properties being acquired by the City. The information acquired from the investigations will be used in assessing the property value, since the property value is affected by the cost to perform environmental cleanup of the property. Exhibits A.1 through A. 11 (11 total) contain the scopes of work for additional environmental investigations of properties identified during the initial site investigation. Budget information for these additional investigations is included in Exhibit B. Exhibit A.20 is a groundwater study to determine if the City can receive a waiver from the Department of Ecology so that future groundwater monitoring in the project area will not be required. This groundwater study will be funded out of the existing budget. Fiscal summary The budget for the newly identified environmental work (Task 6104) is $323K. An additional $16K is being requested for management reserve of the 30% design (Task 3701) and $2500 (Task 5101) for work performed that was not in the original scope of work. The total budget increase is approximately $342K. However, due to a reduction in the design scope of work and the Consultant performing the prior work under budget, $113K of the previously approved budget will not be spent. Therefore, a budget increase of only $229K is required. Exhibit B CiO: of Bremerton SR 304 Supplement g6 ~ ugust 2004 7 contains budget information, including a spreadsheet which shows the overall cost breakdown for the contract, The SR 304 project, including this additional work by Parametrix, is budgeted in the Arterial Street Fund. ~ The original agreement was subsequently modified on five occasions prior to Supplemental Agreement #6. Supplemental Agreements #1, #2, and #3 modified the scope of work but did not revise the maximum contract payment amount. Supplemental Agreement #3 extended the contract completion date to December 31, 2002. Supplemental Agreement g4 increased the maximum contract payment amount to $2,563,166 and extended the contract completion date to March 31, 2003. Supplement Agreement #5 extended the contract completion date to December 31, 2005. Ciiy of Bremerton SR 304 Supplement #6 August 2004 8 SUPPLEMENTAL AGREEMENT # 6 Project No.: P-STPF-TA96(058); STPF-0304(008) Agency: City of Bremerton Name of Project: SR 304 Transportation Improvement ProjectJFinal Design City Contract No.: 3796 The City of Bremerton (City) and Parametrix, Inc., (Consultant) desire to supplement the standard Consultant Agreement (City Contract No. 3796) executed on February 10, 1997 and supplemented on the following dates: June 3, 1997 (Supplement #1); September 4, 1998 (#2); July 20, 1999 (#3); October 31, 2000 (CFA); March 3, 2003 (#5). Recitals 1. The City originally intended for the Consultant to perform the design on the SR 304 Transportation Improvement ProjectJFinal Design (Project) to 100% completion. 2. Results from initial site investigations for the properties associated with this project indicated that 18 of the properties would require additional environmental investigation. 3. Whether this additional work would be required could only be determined once the initial site investigations had been performed; therefore budget could not have been previously allocated for the additional environmental investigation. This new work includes more detailed site investigations involving groundwater monitoring and soil sampling for individual properties being acquired by the City. The information acquired from the investigations will be used in assessing the property value, since the property value is affected by the cost to perform environmental cleanup of the property. Exhibits A.1 through A.11 (11 total) contain the scope of work for additional environmental investigations of properties identified during the initial site investigation. Budget information for these additional investigations is included in Exhibit B. 4. Because the Environmental Investigations will cause an unforeseen increase in costs to this project the City desires to reduce the costs of design by utilizing its own forces for a portion of this work. 5. This amendment reduces the design scope to 30% completion by the Consultant and the City will do the remainder of the design with its own staff. Exhibit A contains the amended scope of work for survey and design. Budget information for the survey/design scope of work is contained in Appendix B. Agreement Section II, SCOPE OF WORK, is amended as set forth in attached Exhibit A. II. Section IV, TIME FOR BEGINNING AND COMPLETION, is amended by extending the date for completion to December 31, 2006. III. Section V, PAYMENT, is amended as set forth in the attached Exhibit B. The maximum amount payable under this agreement as modified herein, inclusive of all fees and other costs, is changed as a result of this supplement to $2,792,366.46. 9 IV. Section VI; SUBCONTRACTING, remains the same. All provisions in the Agreement remain in effect except as expressly modified in this Supplemental Agreement. IN WITNESS WHEREOF, the parties have executed this supplement and agree to the changes as stated above as of this day of ,2004. Parametrix, Inc City of Bremerton Phil Struck Cary Bozeman, Mayor Operations Manager Date: Date: DEPARTMENTAL APPROVAL: Phil Williams, Director of Public Works and Utilities RECEIVED FOR FILING: APPROVED AS TO FORM: Paula Johnston, City Clerk David Horton, Assistant City Attorney 10 SR 304 Transportation Improvement Project Supplemental Agreement #6 August 2004 EXHIBIT A Table of Contents 1. Exhibit A - Amended Scope of Work, Phase III Stage ID, 30 Percent Design (13 pages) 2. Exhibits A.1 through A.12 - Preliminary Site Investigations · Exhibit A. 1 - 1145 to 1149 Charleston Beach Road (4 pages) · Exhibit A.2 - 1215 Charleston Beach Road (4 pages) · Exhibit A.3 - 1227 Charleston Beach Road (3 pages) · Exhibit A.4 - 1229 Charleston Beach Road (3 pages) · Exhibit A.5 - 1233 Charleston Beach Road (3 pages) · Exhibit A.6 - 1515 Charleston Beach Road (4 pages) · Exhibit A.7 - 1550 Charleston Beach Road (4 pages) · Exhibit A.8- 1666 Charleston Beach Road (4 pages) · Exhibit A.9 - Parcel 3-08365, Pidduck (3 pages) · Exhibit A. 10 - Parcels 3-08376 to 3-08378, Berg (4 pages) · Exhibit A. 11 - Parcels 3-08380 to 3-08383, Berg (3 pages) · Exhibit A.12 - Kitsap County Right of Way (3 pages) 3. Exhibit A.20 - Scope of Work, Phase VI Stage 1 D, Groundwater Investigation (4 pages) EXHIBIT A - AMENDED SCOPE OF WORK City Of Bremerton SR 304 Transportation Improvement Project Phase III Stage 1D - Navy Yard Highway 30 Percent Design (PS&E) INTRODUCTION SR 304 will be improved throughout its entire length from the SR 3/SR 304 Interchange to the Bremerton Ferry Terminal. Design and right-of-way services are required to complete the improvements. Through previous agreements the improvements have been divided into five stages: · Stage lA - Burwell Street from Pacific Avenue to Montgomery Avenue (Complete) · Stage lB - Gateway Segment from Burwell Street and Montgomery to Porter Street and Cambrian Avenue (Complete) · Stage 1C - Navy Yard Highway from Porter Street to the revised Missouri Gate (Complete) · Stage 1D - Navy Yard Highway from Missouri Gate to the SR 3/SR 304 Interchange (This Amendment) · Stage 1E - Downtown Roadway Improvements (Complete) This amended scope of work recognizes that the availability of project funding and construction sequencing have required additional Plans, Specifications & Estimates (PS&E) packages be prepared to complete the Project. This scope of work identifies the tasks necessary to prepare PS&E for the remaining Project Stage. To accommodate cost tracking and reporting requirements, the work was divided into separate phases of work as follows: · Phase I- Previous Work (Complete) · Phase II Stage 1C - PS&E Navy Yard Highway (Porter To Missouri Gate/Charleston Beach Road) (Complete) · Phase III Stage 1D - PS&E Navy Yard Highway (SR 3 I/C To Missouri Gate/Charleston Beach Road) (This Amendment) · Phase IV Stage 1E - PS&E Downtown (Complete) · Phase V Stage 1C - Right-Of-Way Acquisition Support (Porter To Missouri Gate) (Complete) · Phase VI Stage 1D - Right-Of-Way Acquisition Support (Missouri Gate To SR 3/SR 304 I/c) City of Bremerton 234 1896~036 SR 304 1 Ju~ 2004 Amended Scope of Work for Design $~rvices SR 304 - Amemled SOW -Phase III lD This scope is intended to amend previous task descriptions included in Exhibit B of the existing agreement between Parametrix and the City of Bremerton (City). This amended scope of work provides a detailed description of work, project deliverables and assumptions used in developing cost estimates for Phase III. PHASEIII STAGE 1D - PS&E NAVY YARD HIGHWAY (SR 3 I/C TO MISSOURI GATE/CHARLESTON BEACH ROAD) The following tasks describe work elements and work products needed to complete 30 percent PS&E for highway design from Charleston Beach Road (Missouri Gate) to SR 3/SR 304 Interchange. This effort assumes that the design shall remain consistent with the February 1998 design report prepared by Parametrix and that the City will complete the remaining phase of the PS&E. PHASE 31 ADMINSTRATION Task 3101 Project Administration Goal: The goal of this task is to provide for the overview, direction, monitoring and reporting of task activities in a manner that allows for the delivery of the Project in accordance with the negotiated scope, budget and schedule. Since this phase of the project has changed significantly, reviewing and modifying the scope of work is included in this work. Approach: Parametrix will use a combination of in-house review, routine client meetings and monthly progress reports to deliver elements of work described in this task. Quality control is a key element and will be included as part of this task. · Conduct weekly conference calls with the City project manager during the active portions of the project. Calls are to include progress to date and anticipated activities. · Conduct monthly meetings with the City project manager on during the active portions of the project. Meetings are to include progress to date, anticipated activities, and may include representatives of other agencies and utility owners. Assumptions: The Project Management task incorporates the following assumptions: · Parametrix will participate in three (3) interagency meetings related to this particular phase of work. · The active project duration for Phase III is approximately four (4) months, ending October 2004. Time extension of Phase III work beyond the four (4) months is not included in the cost estimate. Deliverables: The following deliverables apply: · Monthly Progress Reports Parametrix assumes four (4) reports as part of this task. · Meeting summaries. CiO2 of Bremerton 234-1896 036 SR 304 2 Jul3' 2004 Amended Scope of Work for Design Services SR 304 - Amended SOW Phase Ill ID · Revised scope of work and budget. Task 3201 Community Outreach Not applicable to this Phase. PHASE 33 PS&E Goal: To provide the City with a complete 30 percent PS&E package per the subtasks listed below. Assumptions: The following assumptions apply: · Up to 15 Plan Sheets are included in this 30 percent PS&E package. Plan Sheets will contain plan and profile on a single sheet at a 1" to 20' scale. Detail sheets at I" to 20', or as appropriate for clarity. Channelization, traffic control, signing, temporary pollution control and site preparation Plan Sheets are not included in this package. · Parametrix will provide a preliminary layout of the stormwater infrastructure only. A stormwater analysis will be performed by Parametrix. Plans, including stormwater treatment for quality, were not assumed for this PS&E based on the assumption that no additional impervious area is being constructed. This is documented in the BA prepared in 1999. · Parametrix will incorporate existing survey data from the prior phases of work into this phase of work. Any survey data needed for construction administration will be shown on the 30 percent Plans or made available to the City prior to handing offthe final PS&E to the City. Deliverables: 30 percent PS&E. Task 3301 Survey Base Map and Right-of-Way Preparation GoM: The surveyor will provide mapping for the design of utilities, for the construction of the roadway, and other facilities. · Design mapping for the SR 304 Charleston Beach Phase from Sta 25+00 to Sta 56+50. The City will design this project (final PS&E) with Parametfix field mapping and right-of-way services. · This scope of services amends the existing contract "SR 304 Charleston Beach Design" to include survey base mapping and right-of-way calculations. Approach: Parametrix will use the following approach to accomplish the survey work: Survey Base Map · SR 304 Mainline City of Bremerton 234-1896-036 SR 304 3 July 2004 AmendedScopeofWorkforDesignServices SR304 AtnendedSOW-Phaselll lD 14 100 foot intervals: stake C/L or offset position 25 foot intervals: grade shots at all proposed crowns, lane striping & pavement edges. $0 foot intervals: Staggered shots on all existing crowns, lane striping, meetlines, grade breaks & pavement edges. 3. Additional railroad topographic data is required, including top of ballast and rail alignment at the south end of the project from Sta 29+00 to Sta 33+00. The remainder of the project already has sufficient railroad data. 3. Where possible locate old post and fence holes, fences, depressions & evidence of old utilities. · Properties between SR304 & Charleston Beach Road (CBR) Map all building comers, cave comers, slab outlines, doors, finish floor elevations, billboards, signs, posts & type of pavement. 3. Where possible locate old post & fence holes, fences, depressions & evidence of old utilities. ~. Locate existing monitoring wells and pavement coring holes. · CBR Roadbed 3. Locate existing monitoring wells and pavement coring holes. 3, MC 22[27 to 100' into existing new construction. · CBR properties on the northwesterly side of the road from MC 22[27 to Webster St. Map front half of houses, garages, and driveways. Locate existing monitoring wells and pavement coring holes. Where possible locate old post and fence holes, fences, depressions and evidence of old utilities. · CBR properties on the northwesterly side of the road from Webster St. to the new construction on CBR. 3. Demolition area: only minimal topographic shots for buildings and ground shots. Provide full topographic survey only up to the existing brush line prior to demolition. > Locate monitoring wells, pavement coring holes, and monitoring wells. C;icy of Bremerton 234-1896-036 SR 304 4 Ju~r 2004 Amended Scope of Work for Design Services SR 304 Amended SOW Phase III ID 3. Where possible locate old post and fence holes, fences, depressions and evidence of old utilities. · Measure Downs } Perform measure downs over the entire area, with sketches. · Culverts } Low tide investigation and survey ties. Right-of-Ways and Property Lines · Parametfix will determine the location of the fight-of-ways for the CBR and SR 304 within the limits of the project. · The lateral property boundaries will be determined for those properties lying between the CBR and SR 304 and those properties lying westerly of the CBR north of Cliff's Cycle to existing new construction. · The City will negotiate with Reed Muller for copies of his survey records for highway monuments and property coruers set on previous surveys by themselves or others. · The State has initiated the request for title reports for 33-36 properties. The City will request that copies of documents referenced in the title reports be included with the reports. · Determine the positions of individual property boundaries. Receive and index 33 to 36 individual title reports with copies of referenced documents. Examine the individual title report property descriptions together with the accompanying documents. Calculate the boundaries and easements of each property honoring the calls of the property description and monuments recovered by our own surveys or surveys by others. 3. Examine the location of the calculated property boundaries relative to existing improvements/structures as mapped and apart of the existing base map. } Attempt to resolve conflicts with adjoining property boundaries, with existing improvements/structures and with existing property comers set by others. · Determine the position of the right-of-ways of the CBR and SR 304. Obtain copies of all highway right-of-way plans for the two highways. City of Bremerton 234-1896-036 SR 304 .5 Jul3, 2004 Amend,,d Scope of Work for D~sign Services SR 304 - ,~lmend~d SOW-Phase Ill ID Examine the right-of-way plans for ties to any monumentation shown or referenced. Perform initial calculations between monuments and centerline alignment as shown on the right-of-way plans. Compare the distance and angular relationships between recovered monuments to those shown on the highway right-of-way plans or the highway as-built plans. Compare the mathematical alignment of the highway to the existing physical highway centerlines. Obtain and examine all deeds that granted the highway right-of-ways to the State/County/Municipality. Compare the deeded right-of-ways to the right-of-way plans. Examine any surveys recorded or unrecorded that show the location of the highway right-of-ways relative to highway monuments, to property lines or comers and to section subdivisional comers. Attempt to resolve differences in the location of the highway right-of-ways based on deeded right-of-way, based on highway monumentation, based upon the physical location of the highway and based upon surveys by others. · Evaluate records provided by Reed Muller on past surveys performed by himself or others in this portion of SR 304 corridor. Examine the individual documents provided, looking for similarities and differences of comers set or found to those recovered during the mapping effort. Perform analysis and comparisons of the positions for highway right-of-ways and property boundaries as determined by others. Perform miscellaneous calculations necessary to compare conflicting positions of right-of-ways and property comers and lines. Search for old property comers and monuments disclosed by review of Reed's surveys and those identified in the deed calls. ~ Perform angular and distance comparison calculations between uncovered monuments. ~ Resolve differences in right-of*way and property comer/line positions. · Preparation of monumentation map after the completion of construction. This work will be negotiated (scope and budget) following the completion of the final roadway plans. Cit), of Bremerton 234-1896-036 SR 304 6 July 2004 Amended Scope oJ Work for Desigtl Services SR 304 - Amended SOW -Phase 11! ID ~7 Property comers to be set replacing those destroyed by construction and found property comers. Set street and highway monument positions designated by the City. Listing of the highway acquisition documents and the vacation documents provided by the city or contained within the tile reports. ~ Notes relative to monument histories and right-of-way determinations. ~' Ties between highway alignments and section and/or plat monuments. Assnmptions: The Survey/Right-of-Way Task incorporates the following assumptions: · The City will provide fight of entry for Parametrix survey crews to perform mapping on private property. · The City will transmit to Parametrix copies of survey information from Muller survey records. · Lateral boundaries required on total take parcels only. Estimate that there are 36 total take parcels. · Kitsap County GIS data will be used for the position of lateral boundaries of non-take parcels. · This estimate does not include potholing services from a Subconsultant. Parametrix will provide Survey support for potholing performed by others. · This estimate does not include topographic surveys after the demolition of buildings and site clearing. After the completion of demolition Parametrix will amend the scope of work and budget to include topographic surveys in the demolition area to the limits of the new construction. Deliverables: · Develop separate exhibit drawings for right-of-way negotiation purposes, up to three parcels (3-08389, 3-08390, 3-08391) at a sketch level. · Stake the SR 304 right-of-way on the northwesterly side of the alignment. Provide temporary marking with PK nails of lot comers, jogs in right-of-way and along the fight-of-way line at 200 ft intervals, and lateral boundaries. Identify markings using the right-of-way stationing. Following construction, permanent property comers will be set to replace those destroyed by new construction. The monument map will suffice as the record of survey for the comers set. · Provide paint marking of the proposed westerly CBR right-of-way fronting parcels 3- 08364, 3-08366, 3-08367, and 3-08370 assisting the City and WSDOT right-of-way negotiators. Identify paint marks using the right-of-way stationing. C~ty of Bremerton 234-1896 036 SR 304 7 du(r 2004 Amended Scope of Work for Design Se~'ices SR 304 - Amended SOW Phase III ID · Provide red/green markups to the WSDOT right-of-way plans. The City will transmit the plan to WSDOT. Task 3302 I/C Plan for Approval Not applicable to this Phase. Task 3303 Signals and Illumination Not applicable to this Phase. Task 3304 Structures and Walls This work is not currently anticipated. However, the City may authorize the work in writing as needed. Budget to accomplish this work would be estimated later and come from the management reserve. Task 3305 Drainage Plans and Details GoaI: This task consists of the design and preparation of the 30 percent Drainage Plan and Profile Sheets, including the hydrologic and hydraulic analysis of the site. Approach: Parametrix will use the following approach to accomplish the drainage work: · A brief hydrologic analysis letter report to provide estimates of expected flows for the design of the storm sewer conveyance system within the project area. Determine the design flow design parameters for stormwater water conveyance facilities. Estimate design flows using land-use assumptions and mapping provided by the City and from Kitsap County. Hydrologic estimates will be generated using Ecology Stormwater Management Manual for Western Washington (1992) methodology or the Kitsap County Stormwater Management Manual (1997). · Drainage plan and profile sheets for CBR and SR 304. Five (5) sheets each roadway. · Perform the hydrologic and hydraulic analysis to determine the size of the conveyance systems for on-site and bypass stormwater flows. · Stormwater facilities such as conveyance pipes and catch basins, excluding water quality or flow control (Detention/Retention) facilities, will be shown on the plans. · Identify drainage culverts that require replacement. Assumptions: The Drainage Task incorporates the following assumptions: · Conveyance pipes, culverts, and catch basins will be sized for use in later design phases. CiO' of Bremerton 234-1896-036 SR 304 8 July 2004 Amended Scope of Work for Design Services SR 304 - Amended SOW Phase Ill ID 3_9 · Prior phases of work did not include water quality treatment for stormwater. The Environmental Site Investigation stipulated that water quality treatment was not necessary. This phase of work does not include water quality treatment design. Task 3306 Traffic Control Plans Not applicable to this Phase. Task 3307 Roadway Plans (Alignment & Profile) This task consists of the design and preparation of the following 30 percent Plan sheets: · Roadway Sections. Two sheets. } Provide roadway sections for SR 304, CBR, Webster Ave. and National Ave. · Alignment and Right-of-Way } Incorporate the information gained in Task 3301. · Plan and Profile Sheets Incorporate the information derived in Task 3305 onto these plans. Identify limits of cut and fill, areas where retaining walls might be required, superelevation, lane lines, shoulders, curb, gutter and sidewalk. ~ Five (5) sheets for SR 304 and five sheets for CBR. · Proposed Utilities Show preliminary plan location only for proposed water lines, reuse water, and sanitary sewer. · Intersection Details Details for Webster Ave., National Ave., and the cul-de-sac at the south end of CBR. } Intersection details will be plan only. } Three sheets, one for each intersection/side road. · Estimate > Provide a preliminary quantity and cost estimate of the 30 percent PS&E. Assumptions: The Roadway Plans Task incorporates the following assumptions: Ctiy of Bremerton 234-1896 036 SR 304 9 dui) 2004 Amended Scope of Work for Design Services SR 304 - Amemled SOW Phase Ill ID 20 · These sheets will be based on current Right-of-Way and Channelization Plans as presented in the Design Report. Task 3308 Miscellaneous Plan Sheets Not applicable to this Phase. Task 3309 Contract Provisions and Estimates Not applicable to this Phase. Task 3310 Permits Goal: To prepare permit applications for the proposed improvements and provide support during the permit review process. Approach: Parametrix will prepare applications for the following permits/approvals: · Washington State Department of Transportation Right-of-Way Permit · Kitsap County Shoreline Substantial Development Permit · Kitsap County Site Development Activity Permit In addition Parametrix will also complete the following tasks: Attend one (1) site visit. · Attend a pre-application conference with Kitsap County. · Submit completed permit applications for the permits listed above. · Attend the hearing on the Shoreline Substantial Development Permit and provide City with support (i.e., presentation materials, supporting documents, etc.). · Respond to requests for additional information or clarification from the permitting authorities. · Monitor the permit approval process to determine the status/timing of permits. Assumptions: The Permit Task incorporates the following assumptions: · It is assumed that there will be no need for any additional NEPA or SEPA compliance documentation (i.e., the existing documentation will be adequate to allow approval of the permits). · The City will be responsible for all fees associated with the permit applications. Citp' of Bremerton 234-1896 036 SR 304 10 dui) 2004 Amended Scope of Work for Design ~ervices SR 304 - Amended SOW-Phase H1 ID 23_ Parametrix will respond to requests for additional information for up to 24 hours of response time (at a Planner level). Additional time needed to respond to requests will be on a time and materials basis. · Support to the City at the Shoreline Permit hearing will be limited to providing presentation materials such as graphics boards (up to $500 in value), providing copies of supporting documents, or helping to present information to the hearing examiner (typically the City presents the staff report and related information to the heating examiner, however Parametrix staff could assist in this effort if requested by the City). For budgeting purposes, it is assumed that there will be up to four 2-hour coordination meetings related to the permitting effort, a site visit, and attendance at the public hearing on the shoreline permit. Task 3311 Plan Review and Revisions Not applicable to this Phase. Task 3312 Geotechnical Investigation (Myers Biodynamics) This work is not currently anticipated. However, the City may authorize the work in writing as needed. Budget to accomplish this work would be estimated later and come from the management reserve. Task 3313 Utility Coordination · Obtain location information on public utilities. Utility information will be used by Parametrix for the purposes of defining utility locations and displaying them on the base map. · Coordinate with utility owners. The following utility companies/agencies may have utilities within the proposed right-of-way.: Puget Power Comcast Cable Qwest Cascade Natural Gas City Water Kitsap County Sanitary Sewer Storm Sewer A$$UmlJtion$: The Utility Coordination Task incorporates the following assumptions: City of Bremerton 254-1896-036 SR 304 ] I du~y' 2004 Amended Scope of Work fi>r Design Services SR 304 ~ Amended SOW-Phase HI ID 22 · The City will provide "potholing" of utilities where necessary to determine exact locations. · Paramethx has included up to two (2) meetings with each utility company/agency to accomplish this subtask. · Private utilities shall be notified by the City who will request their record information also. · The City will provide to Parametrix copies of record information regarding storm, water, sanitary and force mains from both City and County sources. · Sanitary sewer and associated lateral underground location work will be done by Kitsap County. · The City will locate the water lines. · The franchised utilities will locate their utilities. Security requirements may preclude obtaining certain documents and may impact the locating of certain utilities. Task 3314 Landscaping (JGM) Not applicable to this Phase. PHASE 34 BIOLOGICAL ASSESSMENT TASK 3401 Biological Assessment Goal: To provide updates to the BA on a periodic basis throughout the duration of the Contract. Approach: Parametrix will prepare updates to the BA as follows: · Parametrix will provide updates to the BA if required under the guidelines provided in Supplement Agreement No. 3. The BA was prepared under Phase 1 for the complete Project from SR 3 to the Bremerton Ferry Terminal. Regular updates to the BA do not include response to changes in law which might require modification or re-submittal of the BA that are not consistent with the assumptions contained in Phase 1 work. Assumptions: The BA Task incorporates the following assumptions: · According to Attachment B Federal Agencies' Responsibilities Under Sections 7(a) and 7(c) of the Endangered Species Act of 1973, as Amended Section 7C states: "To complete the BA, your agency or its designee should...(3) interview experts including those within the FWS, National Marine Fisheries Service, state conservation department, universities, and others who may have data not yet published in scientific literature..." CiO' of Bremerton 234-1896-036 SR 304 12 J"5' 2004 Amended Scope of ~f/~>rk for Design Se~ewes SR 304 Amended SOW Phase [[/ID 23 3, Information is downloadable from the National Marine Fisheries, and } Information must be requested from the Washington Department of Fish and Wildlife. The process takes approximately two (2) to three (3) weeks to provide the information at a cost of about $40 for the information. · The BA requires an update every six months through 2006, or the completion of construction of this phase. An estimated six (6) updates are required. · This work assumes that them will be no significant changes to the existing BA. PHASE 35 MANAGEMENT RESERVE Task 3501 Management Reserve Parametrix may utilize the contingency only upon written notification from the City. CI0' of Bremerton 234-1896 036 SR 304 13 Jul)' 2004 A mended Scope of Work for Design S~rvices SR 304 - A rnemted SO W -Phase Ill 1D 24 EXHIBIT A.1 - SCOPE OF WORK City of Bremerton SR304 Transportation Improvement Project Phase VI, Stage 1D Right-of-Way Acquisition Support 1145 to 1149 Charleston Beach Road INTRODUCTION The City of Bremerton (City) has requested Parametrix conduct a Preliminary Site Investigation at 1145 to 1149 Charleston Beach Road in Bremerton, Washington (WSDOT Parcels 3-08359 through 3-08363). The property currently contains a vacant building that was formerly used as an auto repair shop. Potential contaminants include metals, petroleum products, and volatile organics. The Preliminary Site Investigation will be conducted to support potential property acquisition relating to the SR304 Transportation Improvement Project. The results of this investigation will also be used to provide data for assessing remedial action, if necessary. Specific elements of work required to complete the project include: · Project Management · Soil Sampling and Analysis · Asbestos Survey and Sampling · Technical Report Preparation Parametrix will complete the evaluation of data collected and prepare a Preliminary Site Investigation Report that describes the findings and conclusions of the investigations. PHASE 61 STAGE 10 ROW ACQUISITION Task 6104.1 Project Management Objective: Coordination and documentation of the project by the Project Manager. Approach: Specific work elements will include: · The primary objective of this task will be budget and progress tracking. · Meetings with the City and various agencies (Department of Ecology, etc.) to discuss investigation, results, etc. · Coordination with the City. Assumptions: Work will be completed under the following assumptions: City of Bremerton 234-1896-036 SR 304 Final Dest~gn ! Jul)' 2004 SOW SR304 P2 ll45 25 · Attend two meetings, three hours each. · This Scope does not include negotiations with property owners. Dellverables: Monthly progress reports, as needed. Task 6104.2 Soil Sampling and Analysis Objective: Assess soil quality and condition at the project site. Use results of assessment to determine remedial action, if necessary. Approaclt: Collect soil samples for analysis to assess soil quality and remedial options, as needed. Specific work elements may include: · Prepare a short (2 to 3 page) work plan/sampling and analysis plan for boring installation and sample collection. · Conduct a subsurface utility survey prior the start of boring installation. · Install up to 8 borings to a maximum depth of 20 feet (or to an estimated 1 foot above groundwater) using a Geoprobe or similar equipment. From each boring, collect one soil sample at the surface and every 5 feet for the full depth of the boring and field screen each sample using a photoionization detector. · Up to 6 surface or shallow subsurface soil samples will be collected using hand tools at areas of obvious or suspected contamination. · Based on the results of the field screening, select and analyze up to three soil samples from each boring and up to 6 surface soil samples (for a total of 20 samples, including one field duplicate and one rinsate blank) for the chemicals of concern listed below: NWTPH-HCID NWTPH-Dx NWTPH~Gx RCRA 13 metals using EPA Method 6010/7470 Volatile Organic Compounds (VOCs) using EPA Method 8260 Polynuclear Aromatic Hydrocarbons by EPA Method 83 l0 · Complete soil boring logs and sampling paperwork. Assumptions: The following assumptions are made: City of Bremerton 234-1896 036 (619 SR 304 Final D~sign 2 Ju~! 2004 SOW SR304 P2 · Property access will be the responsibility of the City and will be obtained prior to the start of work. · This work will be completed in conjunction with other preliminary site investigation being performed for this project and will not require remobilization. · Only the portion of the property located south-southwest of the bluff or that can be readily accessed will be characterized. · Boring installation and sampling can be completed in one, 8-hour day. · Sample analysis will be completed on standard turnaround time (30 business days). · Only Tier II data deliverables will be required from the analytical laboratory. · No groundwater samples will be collected under this task. · Disposal of investigation-derived waste will be the responsibility of the City. DeIiverables: The following will be provided: · Copies of all field notes, logs, etc. · Copies of all laboratory analytical data. Task 6104.3 Asbestos Survey and Sampling Objective: Determine if asbestos containing material (ACM) is present in existing site structures. Approach: Conduct an asbestos survey and collect samples of suspected ACM for analysis. Specific work elements will include: · Conduct a "good faith" asbestos survey following the requirements of WAC 296-62- 07721. · Collect a maximum of l 0 samples of suspected ACM for analysis in accordance with EPA-600/M4-82-020. · Estimate the quantity of ACM present (if any) in onsite structures and develop a cost estimate for removal and disposal of ACM. · Complete a brief summary of asbestos survey and sampling results. This will be included in the Preliminary Site Investigation report (Task 4). Assumptions: The following assumptions are made: · Property access will be the responsibility of the City and will be obtained prior to the start of work. CiO, of Bremerton 234-1896-036 (619 SR 304 Final Dest~n 3 July 2004 SOW SR304 P2 1145 27 This work will be completed in cOnJunction with other preliminary site investigation being performed for this project and will not require remobilization. · Asbestos survey and sampling can be completed in one, 8-hour day. · Building conditions will safely allow access inside for sampling. The onsite building is in average condition. Samples will only be collected from safe working areas. · Sample analysis will be completed on standard tumaround time (30 business days). · The results of the asbestos survey and sampling will be included in the Preliminary Site Investigation report (Task 4). No additional reports will be produced under this task. · No lead survey or sampling will be conducted for the onsite building. It is assumed that the existing building on the site will be demolished. Based on conversations with Waste Management, Inc., it appears that analysis for lead would not be required to dispose of the demolition debris. Deliverables: The following will be provided: · Copies of all field notes, togs, etc. · Copies of all laboratory analytical data. Task 6104.4 Technical Report Preparation Objective: Prepare a draft and final Phase II Environmental Site Assessment report summarizing the results of the investigation. Approach: Specific work elements will include: · Prepare a technical report summarizing the results of soil sampling and analysis. · Prepare recommendation for further action at the project site including additional investigation, remedial action, or "no further action." · Finalize the draft technical report following receipt of review comments from the City. · Produce an order-of-magnitude cost estimate for site cleanup, structure demolition, and remediation, if necessary. Assumptions: The following assumptions are made: · Only one revision of the draft technical report will be required for finalization. Deliverables: The following will be provided: · Five copies each of the draft and final technical report. C¥~ of Bremerton 234-1896-036 SR 304 Final Design 4 ~]u(* 2004 SOW SR304 P2 1145 28 EXHIBIT A.2 - SCOPE OF WORK City of Bremerton SR304 Transportation Improvement Project Phase VI, Stage 1D Right-of-Way Acquisition Support 1215 Charleston Beach Road INTRODUCTION The City of Bremerton (City) has requested Parametrix conduct a Preliminary Site Investigation at 1215 Charleston Beach Road in Bremerton, Washington (WSDOT Parcel 3-08364). The property formerly contained the Treasure Mountain Gold Company storage yard. The property currently contains a vacant building and several old vehicles and debris. Potential contaminants include metals, petroleum products, and volatile organics. The Preliminary Site Investigation will be conducted to support potential property acquisition relating to SR304 Transportation Improvement Project. The results of this investigation will also be used to provide data for assessing remedial action, if necessary. Specific elements of work required to complete the project include: · Project Management · Soil Sampling and Analysis · Asbestos Survey and Sampling · Technical Report Preparation Parametrix will complete the evaluation of data collected and prepare a Preliminary Site Investigation Report that describes the findings and conclusions of the investigations. PHASE 61 STAGE 1D ROW ACQUISITION Task 6104.1 Project Management Objective: Coordination and documentation of the project by the Project Manager. Approach: Specific work elements will include: · The primary objective of this task will be budget and progress tracking. · Meetings with the City and various agencies (Department of Ecology, etc.) to discuss investigation, results, etc. · Coordination with the City. CiO of Bremerton 234-1896-036 (6l) SR 304 Final Design I Jul) 2004 SOWSR304 P2 1215 2S Assumptions: Work will be completed under the following assumptions: ·Attend two meetings, three hours each. · This Scope does not include negotiations with property owners. Deliverables: Monthly progress reports, as needed. Task 6104.2 Soil Sampling and Analysis Objective: Assess soil quality and condition at the project site. Use results of assessment to determine remedial action, if necessary. Approacl~: Collect soil samples for analysis to assess soil quality and remedial options, as needed. Specific work elements may include: · Prepare a short (2 to 3 page) work plan/sampling and analysis plan for boring installation and sample collection. · Conduct a subsurface utility survey prior the start of boring installation. · Install up to 8 borings to a maximum depth of 20 feet (or to an estimated 1 foot above groundwater) using a Geoprobe or similar equipment. · From each boring, collect one soil sample at the surface and every 5 feet for the full depth of the boring and field screen each sample using a photoionization detector. · Based on the results of the field screening, select and analyze up to three soil samples from each boring (for a total of 14 samples, including one field duplicate and one rinsate blank) for the chemicals of concern listed below: NWTPH-HCID NWTPH-Dx NWTPH-Gx RCRA 13 metals using EPA Method 6010/7470 Volatile Organic Compounds (VOCs) using EPA Method 8260 Polynuclear Aromatic Hydrocarbons by EPA Method §310 · Complete soil boring logs and sampling paperwork. Assnmptions: The following assumptions are made: · Property access will be the responsibility of the City and will be obtained prior to the start of work. CiO' of Bremerton 234-1896 036 (61) SR 304 Final Design 2 July 2004 SOWSR304 P2 1215 30 · This work will be completed in conjunction with other preliminary site investigation being performed for this project and will not require remobilization. · Only the portion of the property located south-southwest of the bluff or that can be readily accessed will be characterized. · Boring installation and sampling can be completed in one, 8-hour day. · Sample analysis will be completed on standard tumaround time (30 business days). · Only Tier II data deliverables will be required from the analytical laboratory. · No groundwater samples will be collected under this task. · Disposal of investigation-derived waste will be the responsibility of the City. Deliverables: The following will be provided: · Copies of all field notes, logs, etc. · Copies of all laboratory analytical data. Task 6401.3 Asbestos Survey and Sampling Objective: Determine if asbestos containing material (ACM) is present in existing site structures. Approach: Conduct an asbestos survey and collect samples of suspected ACM for analysis. Specific work elements will include: · Conduct a "good faith" asbestos survey following the requirements of WAC 296-62- 07721. · Collect a maximum of 10 samples of suspected ACM for analysis in accordance with EPA-600/M4-82-020. · Estimate the quantity of ACM present (if any) in onsite structures and develop a cost estimate for removal and disposal of ACM. · Complete a brief summary of asbestos survey and sampling results. This will be included in the Preliminary Site Investigation report (Task 4). Assumptions: The following assumptions are made: · Property access will be the responsibility of the City and will be obtained prior to the start of work. · This work will be completed in conjunction with other preliminary site investigation being performed for this project and will not require remobilization. Cio' of Bremerton 234-1896-036 (61) SR 304 Final Design 3 Jttl~ 2004 SOWSR304 P2 1215 31 · Asbestos survey and sampling can be completed in one, 8-hour day. · Building conditions will safely allow access inside for sampling. The onsite building is in average condition. Samples will only be collected from safe working areas. · Sample analysis will be completed on standard turnaround time (30 business days). · The results of the asbestos survey and sampling will be included in the Preliminary Site Investigation report (Task 4). No additional reports will be produced under this task. · No lead survey or sampling will be conducted for the onsite building. It is assumed that the existing building on the site will be demolished. Based on conversations with Waste Management, Inc., it appears that analysis for lead would not be required to dispose of the demolition debris. Deliverables: The following will be provided: · Copies of all field notes, logs, etc. · Copies of all laboratory analytical data. Task 6401.4 Technical Report Preparation Objective: Prepare a draft and final Phase II Environmental Site Assessment report summarizing the results of the investigation. Approach: Specific work elements will include: · Prepare a technical report summarizing the results of soil sampling and analysis. · Prepare recommendation for further action at the project site including additional investigation, remedial action, or "no further action." · Finalize the draft technical report following receipt of review comments from the City. · Produce an order-of-magnitude cost estimate for site cleanup, structure demolition, and remediation, if necessary. Assumptions: The following assumptions are made: · Only one revision of the draft technical report will be required for finalization. DeIiverables: The following will be provided: · Five copies each of the draft and final technical report. Ui(y of Bremerton 234-1896-036 SR 304 Final Design 4 Jul)' 2004 SOWSR304 P2 1215 EXHIBIT A.3 - SCOPE OF WORK City of Bremerton $R304 Transportation Improvement Project Phase VI, Stage 1D Right-of-Way Acquisition Support 1227 Charleston Beach Road INTRODUCTION The City of Bremerton (City) has requested Parametrix conduct a Preliminary Site Investigation at 1227 Charleston Beach Road in Bremerton, Washington (WSDOT Parcel 3-08366). The property currently contains a five-bay auto repair shop, but formerly contained the Peninsula Fuels Storage facility. Potential contaminants include petroleum products, waste oil, metals, and volatile organics. The Preliminary Site Investigation will be conducted to support potential property acquisition relating to SR304 Transportation Improvement Project. This investigation will focus only on the right-of-way access portion of the parcel. The balance of the parcel will not be investigated and is assumed to be a viable economic remnant. The results of this investigation will also be used to provide data for assessing remedial action, if necessary. Specific elements of work required to complete the project include: · Project Management · Soil Sampling and Analysis · Technical Report Preparation Parametrix will complete the evaluation of data collected and prepare a Preliminary Site Investigation Report that describes the findings and conclusions of the investigations. PHASE 61 STAGE 1D ROW ACQUISITION Task 6104.1 Project Management Objective: Coordination and documentation of the project by the Project Manager. Approach: Specific work elements will include: · The primary objective of this task will be budget and progress tracking. · Meetings with the City and various agencies (Department of Ecology, etc.) to discuss investigation, results, etc. · Coordination with the City. City of Bremerton 234 1896-036 SR 304 Final Design ] .Iu!)' 2004 SOWSR304 P2 1227 33 Assumptions: Work will be completed under the following assumptions: ·Attend two meetings, three hours each. · This Scope does not include negotiations with property owners. Deliverubles: Monthly progress reports, as needed. Task 6104.2 Soil Sampling and Analysis Objective: Assess soil quality and condition at the project site. Use results of assessment to determine remedial action, if necessary. Approach: Collect soil samples for analysis to assess soil quality and remedial options, as needed. Specific work elements may include: · Prepare a short (2 to 3 page) work plan/sampling and analysis plan for boring installation and sample collection. · Conduct a subsurface utility survey prior the start of boring installation. · Complete concrete coring, as needed, to access onsite soil. · Install up to 4 borings to a maximum depth of 20 feet (or to an estimated 1 foot above groundwater) using a Geoprobe or similar equipment. · From each boring, collect one soil sample at the surface and every 5 feet for the full depth of the boring and field screen each sample using a photoionization detector. · Based on the results of the field screening, select and analyze up to three soil samples from each boring samples (for a total of 8 samples, including one field duplicate and one rinsate blank) for the chemicals of concern listed below: NWTPH-HCID NWTPH-Dx NWTPH-Gx RCRA 13 metals using EPA Method 6010/7470 Volatile Organic Compounds (VOCs) using EPA Method 8260 Polynuclear Aromatic Hydrocarbons by EPA Method 8310 · Complete soil boring logs and sampling paperwork. Assumptions: The following assumptions are made: Ci~)' of Bremerton 234-1896-036 (61) SR 304 Final Destgn 2 July 2004 SOWSR304 P2 1227 34 · Property access will be the responsibility of the City and will be obtained prior to the start of work. · This work will be completed in conjunction with other preliminary site investigation being performed for this project and will not require remobilization. · Only the portion of the property located in the planned right-of-way will be characterized. · Boring installation and sampling can be completed in one, 8-hour day. · Sample analysis will be completed on standard tumaround time (30 business days). · Only Tier II data deliverables will be required from the analytical laboratory. · No groundwater samples will be collected under this task. · Disposal of investigation-derived waste will be the responsibility of the City. JDeliverables: The following will be provided: · Copies of all field notes, logs, etc. · Copies of all laboratory analytical data. Task 6104.3 Technical Report Preparation Objective: Prepare a draft and final Phase II Environmental Site Assessment report summarizing the results of the investigation. Approach: Specific work elements will include: · Prepare a technical report summarizing the results of soil sampling and analysis. · Prepare recommendation for further action at the project site including additional investigation, remedial action, or "no further action." · Finalize the draft technical report following receipt of review comments from the City. · Produce an order-of-magnitude cost estimate for site cleanup, structure demolition, and remediation, if necessary. Assumptions: The following assumptions are made: · Only one revision of the draft technical report will be required for finalization. Deliverables: The following will be provided: · Five copies each of the draft and final technical report. City of Bremerton 234 1896-036 (6/) SR 304 Final Design 3 Jul3 2004 SOW SR304 P2 1227 EXHIBIT A.4 - SCOPE OF WORK City of Bremerton SR304 Transportation Improvement Project Phase VI, Stage 1D Right-of-Way Acquisition Support 1229 Charleston Beach Road INTRODUCTION The City of Bremerton (City) has requested that Parametrix conduct a Preliminary Site Investigation at 1229 Charleston Beach Road in Bremerton, Washington (WSDOT Parcel 3-08367). The property currently contains an active auto repair business called "Davis Motor Sports." Significant features on the property include a Quonset Hut, a concrete pad with piping from a former fuel AST, parking and equipment storage area, and a mounded area that appears to contain auto parts and a 55-gallon dram. The property was also used in the past as a bulk fuel storage facility ("Peninsula Fuels Storage"). Potential contaminants include petroleum products, waste oil, metals, and volatile organics. The Preliminary Site Investigation will be conducted to support potential property acquisition relating to the SR304 Transportation Improvement Project. The results of this investigation will also be used to provide data for assessing remedial action, if necessary. Parametrix will complete the work for the Preliminary Site Investigation according to the requirements specified in the WSDOT Environmental Procedures Manual M31-1 l. Specific elements of work required to complete the project include: Project Management · Soil Sampling and Analysis · Technical Report Preparation Parametrix will complete the evaluation of data collected and prepare a Preliminary Site Investigation Report that describes the findings and conclusions of the investigations. PHASE 61 STAGE lO ROW ACQUISITION Task 6104.1 Project Management Objective: Coordination and documentation of the project by the Project Manager. Approach: Specific work elements will include: · The primary objective of this task will be budget and progress tracking. · Meetings with the City and various agencies (Department of Ecology, etc.) to discuss investigation, results, etc. City of Bremerton 234-1896-036 (6l) SR 304 ~nal Design ] Jrt& 2004 SOWSR304 P2 1229 · Coordination with the City. Assumptions: Work will be completed under the following assumptions: ·Attend two meetings, three hours each. · This Scope does not include negotiations with property owners. Deliverables: Monthly progress reports, as needed. Task 6104.2 Soil Sampling and Analysis Objective: Assess soil quality and condition at the project site. Use results of assessment to determine remedial action, if necessary. Approach: Collect soil samples for analysis to assess soil quality and remedial options, as needed. Specific work elements may include: · Prepare a short (2 to 3 page) work plan/sampling and analysis plan for boring installation and sample collection. · Conduct a subsurface utility survey prior the start of boring installation. · Complete concrete coring, as needed, to access onsite soil. · Install up to 4 borings to a maximum depth of 20 feet (or to an estimated 1 foot above groundwater) using a Geoprobe or similar equipment. · From each boring, collect one soil sample at the surface and every 5 feet for the full depth of the boring and field screen each sample using a photoionization detector. · Based on the results of the field screening, select and analyze up to three soil samples from each boring (for a total of 8 samples, including one field duplicate and one rinsate blank) for the chemicals of concern listed below: NWTPH-HCID NWTPH-Dx NWTPH-Gx RCRA 13 metals using EPA Method 6010/7470 Volatile Organic Compounds (VOCs) using EPA Method 8260 Polynuclear Aromatic Hydrocarbons by EPA Method 8310 · Complete soil boring logs and sampling paperwork. City of Sremerton 234-1896-036 (61) SR 304 Final Design 2 July 2004 SOWSR304 P2 1229 Assumptions: The following assumptions are made: Property access will be the responsibility of the City and will be obtained prior to the start of work. This work will be completed in conjunction with other preliminary site investigation being performed for this project and will not require remobilization. · Only the portion of the property located in the planned fight-of-way will be characterized. · Boring installation and sampling can be completed in one, 8-hour day. · Sample analysis will be completed on standard tumaround time (30 business days). · Only Tier II data deliverables will be required from the analytical laboratory. · No groundwater samples will be collected under this task. · Disposal of investigation-derived waste will be the responsibility of the City. Deliverables: The following will be provided: · Copies of all field notes, logs, etc. · Copies of all laboratory analytical data. Task 6104.3 Technical Report Preparation Objective: Prepare a draft and final Phase II Environmental Site Assessment report summarizing the results of the investigation, Approach: Specific work elements will include: · Prepare a technical report summarizing the results of soil sampling and analysis. · Prepare recommendation for further action at the project site including additional investigation, remedial action, or "no further action." · Finalize the draft technical report following receipt of review comments from the City. · Produce an order-of-magnitude cost estimate for site cleanup, structure demolition, and remediation, if necessary. Assumptions: The following assumptions are made: · Only one revision of the draft technical report will be required for finalization. Deliverables: The following will be provided: Five copies each of the draft and final technical report. City of Bretnerton 234-1896-036 (61~ SR 304 Final Design 3 July, 2004 SOWSR304 P2 1229 38 EXHIBIT A.5 - SCOPE OF WORK City of Bremerton SR304 Transportation Improvement Project Phase VI, Stage 1D Right-of-Way Acquisition Support 1233 Charleston Beach Road INTRODUCTION The City of Bremerton (City) has requested Parametrix conduct a Preliminary Site Investigation at 1233 Charleston Beach Road in Bremerton, Washington (WSDOT Parcel 3-08370). Parcel 70 is being used as a storage yard for Pro Rentals. Several pieces of construction equipment were observed. On the west side of the parcel is a raised area thought to be remnant from the past solid waste operation that occupied the site. A garage is located on the southside of the property along Charleston Beach Road. The building is currently unoccupied but was in use until several months ago. The Preliminary Site Investigation will be conducted to support potential property acquisition relating to SR304 Transportation Improvement Project. This investigation will focus only on the right~of-way access portion of the parcel. The balance of the parcel will not be investigated and is assumed to be a viable economic remnant. The results of this investigation will also be used to provide data for assessing remedial action, if necessary. Specific elements of work required to complete the project include: · prOJect Management · Soil Sampling and Analysis · Technical Report Preparation Parametrix will complete the evaluation of data collected and prepare a Preliminary Site Investigation Report that describes the findings and conclusions of the investigations. PHASE 61 STAGE 1D ROW ACQUISITION Task 6104.1 Project Management Objective: Coordination and documentation of the project by the Project Manager. Approaclt: Specific work elements will include: · The primary objective of this task will be budget and progress tracking. · Meetings with the City and various agencies (Department of Ecology, etc.) to discuss investigation, results, etc. CiO: of Bramerton 234-1896-036 (6l) gR 304 Final Design l Jul) 2004 SOW SR304 P2 1233 39 · Coordination with the City. Assumptions: Work will be completed under the following assumptions: ·Attend two meetings, three hours each. · This Scope does not include negotiations with property owners. Deliverables: Monthly progress reports, as needed. Task 6104.2 Soil Sampling and Analysis Objective: Assess soil quality and condition at the project site. Use results of assessment to determine remedial action, if necessary. Approach: Collect soil samples for analysis to assess soil quality and remedial options, as needed. Specific work elements may include: · Prepare a short (2 to 3 page) work plan/sampling and analysis plan for boring installation and sample collection. · Conduct a subsurface utility survey prior the start of boring installation. · Complete concrete coring, as needed, to access onsite soil. · Install up to 4 borings to a maximum depth of 20 feet (or to an estimated 1 foot above groundwater) using a Geoprobe or similar equipment. · From each boring, collect one soil sample at the surface and every 5 feet for the full depth of the boring and field screen each sample using a photoionization detector. · Based on the results of the field screening, select and analyze up to three soil samples from each boring (for a total of 8 samples, including one field duplicate and one rinsate blank) for the chemicals of concern listed below: NWTPH-HC1D NWTPH-Dx NrWTPH-Gx RCRA 13 metals using EPA Method 6010/7470 Volatile Organic Compounds (VOCs) using EPA Method 8260 Polynuclear Aromatic Hydrocarbons by EPA Method 8310 · Complete soil boring logs and sampling paperwork. City of Bremerton 2 34-1896~0 36 (617 SR 304 Final Design 2 dui)' 2004 SOWSR304 P2 1233 Assumptions: The following assumptions are made: · Property access will be the responsibility of the City and will be obtained prior to the start of work. · This work will be completed in conjunction with other preliminary site investigation being performed for this project and will not require remobilization. · Only the portion of the property located in the planned right-of-way will be characterized. · Boring installation and sampling can be completed in one, 8-hour day. Sample analysis will be completed on standard turnaround time (30 business days). · Only Tier II data deliverables will be required from the analytical laboratory. · No groundwater samples will be collected under this task. · Disposal of investigation-derived waste will be the responsibility of the City. Deliverables: The following will be provided: · Copies of all field notes, logs, etc. · Copies of all laboratory analytical data. Task 6104.3 Technical Report Preparation Objective: Prepare a draft and final Phase II Environmental Site Assessment report summarizing the results of the investigation. Approach: Specific work elements will include: · Prepare a technical report summarizing the results of soil sampling and analysis. · Prepare recommendation for further action at the project site including additional investigation, remedial action, or "no further action." · Finalize the draft technical report following receipt of review comments from the City. · Produce an order-of-magnitude cost estimate for site cleanup, structure demolition, and remediation, if necessary. Assumptions: The following assumptions are made: · Only one revision of the draft technical report will be required for finalization. Deliverables: The following will be provided: Five copies each of the draft and final technical report. Ct/)' of Bremerton 234 1896-036 (61) SR 304 Final Design 3 Jld)r 2004 SOW SR304 P2 1233 EXHIBIT A.6 - SCOPE OF WORK City of Bremerton $R304 Transportation Improvement Project Phase VI, Stage t D Right-of-Way Acquisition Support 1515 Charleston Beach Eoad INTRODUCTION The City of Bremerton (City) has requested that Parametrix conduct a Preliminary Site Investigation at 1515 Charleston Beach Road in Bremerton, Washington (WSDOT Parcels 3-08387 and 3-08388). The property currently contains a motorcycle sales and repair business called "Cliff's Cycle Center." The property was also used in the past as a marina. Potential contaminants include petroleum products, waste oil, metals, and volatile organics. This scope of work will be held at the City's option until it is determined that this investigation will be required. The Preliminary Site Investigation will be conducted to support potential property acquisition relating to the SR304 Transportation Improvement Project. The results of this investigation will also be used to provide data for assessing remedial action, if necessary. Parametrix will complete the work for the Preliminary Site Investigation according to the requirements specified in the WSDOT Environmental Procedures Manual M31-11. · Project Management · Soil Sampling and Analysis · Asbestos Survey and Sampling · Technical Report Preparation Parametrix will complete the evaluation of data collected and prepare a Preliminary Site Investigation Report that describes the findings and conclusions of the investigations. PHASE 61 STAGE 1D ROW ACQUISITION Task 6104.1 Project Management Objective: Coordination and documentation of the project by the Project Manager. Approaclt: Specific work elements will include: · The primary objective of this task will be budget and progress tracking. · Meetings with the City and various agencies (Department of Ecology, etc.) to discuss investigation, results, etc. Ci~ofBremerton 234-1896-036 SR 304FinalDesign l Ju~,2004 SOWSR304 P2 1515 42 ,, Coordination with the City. Assumptions: Work will be completed under the following assumptions: ·Attend two meetings, three hours each. · This Scope does not include negotiations with property owners. Deliverables: Monthly progress reports, as needed. Task 6104.2 Soil Sampling and Analysis Objective: Assess soil quality and condition at the project site. Use results of assessment to determine remedial action, if necessary. Approach: Collect soil samples for analysis to assess soil quality and remedial options, as needed. Specific work elements may include: · Prepare a short (2 to 3 page) work plan/sampling and analysis plan for boring installation and sample collection. · Conduct a subsurface utility survey prior the start of boring installation. · Install up to 4 borings to a maximum depth of 20 feet (or to an estimated 1 foot above groundwater) using a Geoprobe or similar equipment. · From each boring, collect one soil sample at the surface and every 5 feet for the full depth of the boring and field screen each sample using a photoionization detector. · Based on the results of the field screening, select and analyze up to three soil samples from each boring (for a total of 14 samples, including one field duplicate and one rinsate blank) for the chemicals of concem listed below: NWTPH-HCID NWTPH-Dx NWTPH-Gx RCRA 13 metals using EPA Method 6010/7470 Volatile Organic Compounds (VOCs) using EPA Method 8260 Polynuclear Aromatic Hydrocarbons by EPA Method 8310 Polychlorinated biphenyls (PCBs) · Complete soil boring logs and sampling paperwork. City of Bremerton 234~]896-036 SR 304 Final Design 2 Jul)' 2004 SO~VSR304 P2 1515 43 Assumptions: The following assumptions are made: · Property access will be the responsibility of the City and will be obtained prior to the start of work. · Boring installation and sampling can be completed in one, 8-hour day. · Sample analysis will be completed on standard turnaround time (30 business days). · Only Tier II data deliverables will be required from the analytical laboratory. · No groundwater samples will be collected under this task. · Disposal of investigation-derived waste will be the responsibility of the City. Deliverables: The following will be provided: Copies of all field notes, logs, etc. Copies of all laboratory analytical data. Task 6104.3 Asbestos Survey and Sampling Objective: Determine if asbestos containing material (ACM) is present in existing site structures. Approach: Conduct an asbestos survey and collect samples of suspected ACM for analysis. Specific work elements will include: · Conduct a "good faith" asbestos survey following the requirements of WAC 296-62- 07721. · Collect a maximum of 10 samples of suspected ACM for analysis in accordance with EPA-600/M4-82-020. · Estimate the quantity of ACM present (if any) in onsite structures and develop a cost estimate for removal and disposal of ACM. · Complete a brief summary of asbestos survey and sampling results. This will be included in the Preliminary Site Investigation report (Task 4). Assumptions: The following assumptions are made: · Property access will be the responsibility of the City and will be obtained prior to the start of work. · This work will be completed in cOnJunction with other preliminary site investigation being performed for this project and will not require remobilization. C~/3, of Bretnerlon 234-1896 036 SR 304 PTnal Design 3 Jul~ 2004 SOW SR304 P2 1515 44 · Asbestos survey and sampling can be completed in one, 8-hour day. · Building conditions will safely allow access inside for sampling. The onsite building is in average condition. Samples will only be collected from safe working areas. · Sample analysis will be completed on standard turnaround time (30 business days). · The results of the asbestos survey and sampling will be included in the Preliminary Site Investigation report (Task 4). No additional reports will be produced under this task. · No lead survey or sampling will be conducted for the onsite building. It is assumed that the existing building on the site will be demolished. Based on conversations with Waste Management, Inc., it appears that analysis for lead would not be required to dispose of the demolition debris. Deliverables: The following will be provided: · Copies of all field notes, logs, etc. · Copies of all laboratory analytical data. Task 6104.4 Technical Report Preparation Objective: Prepare a draft and final Phase II Environmental Site Assessment report summarizing the results of the investigation. Approacl~: Specific work elements will include: · Prepare a technical report summarizing the results of soil sampling and analysis. · Prepare recommendation for further action at the project site including additional investigation, remedial action, or "no further action." · Finalize the draft technical report following receipt of review comments from the City. · Produce an order-of-magnitude cost estimate for site cleanup, structure demolition, and remediation, if necessary. Assttmptions: The following assumptions are made: ~, Only one revision of the draft technical report will be required for finalization. Deliverables: The following will be provided: · Five copies each of the draft and final technical report. C~~ of Bremerton 234 1896-036 SR 304 Final Design 4 Jtt(v 2004 SOWSR304 P2 1515 45 EXHIBIT A.7 - SCOPE OF WORK City of Bremerton SR304 Transportation Improvement Project Phase VI, Stage 1D Right-of-Way Acquisition Support 1550 Charleston Beach Road INTRODUCTION The City of Bremerton (City) has requested that Parametrix conduct a Preliminary Site Investigation at 1550 Charleston Beach Road in Bremerton, Washington (WSDOT Parcel 3-08389). The property currently contains a storage facility for Clifffs Cycle Center and an auto parts business called "West Bay Auto Supplies." Engine repair also occurs on the property. Former property use appears to have been commercial. Potential contaminants include petroleum products, waste oil, metals, and volatile organics. This scope of work will be held at the City's option until it is determined that this investigation will be required and that the property will be acquired. The Preliminary Site Investigation will be conducted to support potential property acquisition relating to the SR304 Transportation Improvement Project. The results of this investigation will also be used to provide data for assessing remedial action, if necessary. Parametrix will complete the work for the Preliminary Site Investigation according to the requirements specified in the WSDOT Environmental Procedures Manual M31-11. · Project Management · Soil Sampling and Analysis · Asbestos Survey and Sampling · Technical Report Preparation Parametrix will complete the evaluation of data collected and prepare a Preliminary Site Investigation Report that describes the findings and conclusions of the investigations. PHASE 61 STAGE 1D ROW ACQUISITION Task 6104.1 Project Management Objective: Coordination and documentation of the project by the Project Manager. Approach: Specific work elements will include: · The primary objective of this task will be budget and progress tracking. · Meetings with the City and various agencies (Department of Ecology, etc.) to discuss investigation, results, etc. City of Bremerton 234-1896-036 (61) SR 304 Final Design July 2004 SOWSR304 P2 1550 · Coordination with the City. Assnmptions: Work will be completed under the following assumptions: ·Attend two meetings, three hours each. · This Scope does not include negotiations with property owners. Deliverables: Monthly progress reports, as needed. Task 6104.2 Soil Sampling and Analysis Objective: Assess soil quality and condition at the project site. Use results of assessment to determine remedial action, if necessary. Approach: Collect soil samples for analysis to assess soil quality and remedial options, as needed. Specific work elements may include: · Prepare a short (2 to 3 page) work plan/sampling and analysis plan for boring installation and sample collection. · Conduct a subsurface utility survey prior the start of boring installation. · Complete concrete coring, as needed, to access onsite soil. · Install up to 4 borings to a maximum depth of 20 feet (or to an estimated 1 foot above groundwater) using a Geoprobe or similar equipment. · From each boring, collect one soil sample at the surface and every 5 feet for the full depth of the boring and field screen each sample using a photoionization detector. · Based on the results of the field screening, select and analyze up to three soil samples from each boring (for a total of 14 samples, including one field duplicate and one rinsate blank) for the chemicals of concern listed below: > NWTPH-HCID }NWTPH-Dx NWTPH-Gx RCRA 13 metals using EPA Method 6010/7470 Volatile Organic Compounds (VOCs) using EPA Method 8260 Polynuclear Aromatic Hydrocarbons by EPA Method 8310 Polychlorinated biphenyls (PCBs) Ci~' of Bremerton 234-1896-036 (6l) SR 304 Final Design 2 July 2004 SOWSR304 P2 1550 47 · Complete soil boring logs and sampling paperwork. Asstnnptions: The following assumptions are made: · Property access will be the responsibility of the City and will be obtained prior to the start of work. · Boring installation and sampling can be completed in one, 8-hour day. · Sample analysis will be completed on standard turnaround time (30 business days). · Only Tier II data deliverables will be required from the analytical laboratory. · No groundwater samples will be collected under this task. · Disposal of investigation-derived waste will be the responsibility of the City. Dellver~bles: The following will be provided: · Copies of all field notes, logs, etc. · Copies of all laboratory analytical data. Task 6104.3 Asbestos Survey and Sampling Objective: Determine if asbestos containing material (ACM) is present in existing site structures. Approach: Conduct an asbestos survey and collect samples of suspected ACM for analysis. Specific work elements will include: · Conduct a "good faith" asbestos survey following the requirements of WAC 296-62- 07721. · Collect a maximum of 10 samples of suspected ACM for analysis in accordance with EPA-600/M4-82-020. · Estimate the quantity of ACM present (if any) in onsite structures and develop a cost estimate for removal and disposal of ACM. · Complete a brief summary of asbestos survey and sampling results. This will be included in the Preliminary Site Investigation report (Task 4). Assumptloas: The following assumptions are made: · Property access will be the responsibility of the City and will be obtained prior to the start of work. ( YO' of Bremerton 2344896-036 (61) SR 304 Final Design 3 Jul3 2004 SOWSR304 P2 1550 · This work will be completed in conjunction with other preliminary site investigation being performed for this project and will not require remobilization. · Asbestos survey and sampling can be completed in one, 8-hour day. · Building conditions will safely allow access inside for sampling. The onsite building is in average condition. Samples will only be collected from safe worl~ing areas. · Sample analysis will be completed on standard turnaround time (30 business days). · The results of the asbestos survey and sampling will be included in the Preliminary Site Investigation report (Task 4). No additional reports will be produced under this task. · No lead survey or sampling will be conducted for the onsite building.i It is assumed that the existing building on the site will be demolished. Based o~ conversations with Waste Management, Inc., it appears that analysis for lead would ~ot be required to dispose of the demolition debris. Deliverables: The following will be provided: · Copies of all field notes, logs, etc. · Copies of all laboratory analytical data. Task 6104.4 Technical Report Preparation Objective: Prepare a draft and final Phase II Environmental Site Assessment report sqmmarizing the results of the investigation. Approaelt: Specific work elements will include: · Prepare a technical report summarizing the results of soil sampling andi analysis. · Prepare recommendation for further action at the project site including additional investigation, remedial action, or "no further action." · Finalize the draft technical report following receipt of review comn~ents from the City. · Produce an order-of-magnitude cost estimate for site cleanup, structt~re demolition, and remediation, if necessary. Assumptions: The following assumptions are made: · Only one revision of the draft technical report will be required for finalization. Deliverables: The following will be provided: · Five copies each of the draft and final technical report. City of Bremerton 234 1896-036 (61) SR 304 Final Design 4 duly 2004 SOW SR304 P2 1550 EXHIBIT A.8 - SCOPE OF WORK City of Bremerton SR304 Transportation Improvement Project Phase VI, Stage 1D Right-of-Way Acquisition Support 1666 Charleston Beach Road INTRODUCTION The City of Bremerton (City) has requested that Parametrix conduct a Preliminary Site Investigation at 1666 Charleston Beach Road in Bremerton, Washington (WSDOT Parcel 3-08391). The property currently contains a commercial storage facility. The property formerly contained a repair garage with several USTs which have been removed. Residual petroleum contamination is known to exist beneath the onsite building. Potential contaminants include petroleum products, waste oil, metals, and volatile organics. This scope of work will be held at the City's option until it is determined that this investigation will be required and that the property will be acquired. The Preliminary Site Investigation will be conducted to support potential property acquisition relating to the SR304 Transportation Improvement Project. The results of this investigation will also be used to provide data for assessing remedial action, if necessary. Parametrix will complete the work for the Preliminary Site Investigation according to the requirements specified in the WSDOT Environmental Procedures Manual M31-11. · Project Management · Soil Sampling and Analysis · Asbestos Survey and Sampling · Technical Report Preparation Parametrix will complete the evaluation of data collected and prepare a Preliminary Site Investigation Report that describes the findings and conclusions of the investigations. PHASE 61 STAGE 1D ROW ACQUISITION Task 6'104.1 Project Management Objective: Coordination and documentation of the project by the Project Manager. Approach: Specific work elements will include: · The primary objective of this task will be budget and progress tracking. · Meetings with the City and various agencies (Department of Ecology, etc.) to discuss investigation, results, etc. Ciiy of Bremerton 234-1896-036 (61) SR 304 Final Design I July 2004 SOWSR304 P2 1666 50 · Coordination with the City. Assumptions: Work will be completed under the following assumptions: ·Attend two meetings, three hours each. · This Scope does not include negotiations with property owners. Deliverables: Monthly progress reports, as needed. Task 6104.2 Soil Sampling and Analysis Objective: Assess soil quality and condition at the project site. Use results of assessment to determine remedial action, if necessary. Approach: Collect soil samples for analysis to assess soil quality and remedial options, as needed. Specific work elements may include: · Prepare a short (2 to 3 page) work plan/sampling and analysis plan for boring installation and sample collection. · Conduct a subsurface utility survey prior the start of boring installation. · Install up to 4 borings to a maximum depth of 20 feet (or to an estimated 1 foot above groundwater) using a Geoprobe or similar equipment. · From each boring, collect one soil sample at the surface and every 5 feet for the full depth of the boring and field screen each sample using a photoionization detector. · Based on the results of the field screening, select and analyze up to three soil samples from each boring (for a total of 14 samples, including one field duplicate and one rinsate blank) for the chemicals of concern listed below:: 3. NWTPH-HCID 3. NWTPH-Dx 3. NWTPH-Gx RCRA 13 metals using EPA Method 6010/7470 Volatile Organic Compounds (VOCs) using EPA Method 8260 Polynuclear Aromatic Hydrocarbons by EPA Method 8310 Polychlorinated biphenyls (PCBs) · Complete soil boring logs and sampling paperwork. City of Bremerton 234 I896-036 (61) SR 304 Final Design 2 d~dl 2004 SO}F SR304 P2 1666 Assumptions: The following assumptions are made: · Property access will be the responsibility of the City and will be obtained prior to the start of work. · Boring installation and sampling can be completed in one, 8-hour day. · Sample analysis will be completed on standard turnaround time (30 business days). · Only Tier II data deliverables will be required from the analytical laboratory. · No groundwater samples will be collected under this task. · Disposal of investigation-derived waste will be the responsibility of the City. Dellverables: The following will be provided: · Copies of all field notes, logs, etc. · Copies of all laboratory analytical data. Task 6104.3 Asbestos Survey and Sampling Objective: Determine if asbestos containing material (ACM) is present in existing site structures. Appro~cl~: Conduct an asbestos survey and collect samples of suspected ACM for analysis. Specific work elements will include: · Conduct a "good faith" asbestos survey following the requirements of WAC 296-62- 07721. · Collect a maximum of 10 samples of suspected ACM for analysis in accordance with EPA-600/M4-82-020. · Estimate the quantity of ACM present (if any) in onsite structures and develop a cost estimate for removal and disposal of ACM. · Complete a brief summary of asbestos survey and sampling results. This will be included in the Preliminary Site Investigation report (Task 4). Assnmptions: The following assumptions are made: · Property access will be the responsibility of the City and will be obtained prior to the start of work. · This work will be completed in conjunction with other preliminary site investigation being performed for this project and will not require remobilization. Ci0' of Bremerton 234-1896-036 SR 304 Final Design 3 Jul) 2004 SOW SR304 P2 1666 · Asbestos survey and sampling can be completed in one, 8-hour day. · Building conditions will safely allow access inside for sampling. The onsite building is in average condition. Samples will only be collected from safe working areas. · Sample analysis will be completed on standard turnaround time (30 business days). · The results of the asbestos survey and sampling will be included in the Preliminary Site Investigation report (Task 4). No additional reports will be produced under this task. · No lead survey or sampling will be conducted for the onsite building. It is assumed that the existing building on the site will be demolished. Based on conversations with Waste Management, Inc., it appears that analysis for lead would not be required to dispose of the demolition debris. Deliverables: The following wilt be provided: · Copies of all field notes, logs, etc. · Copies of all laboratory analytical data. Task 6104.4 Technical Report Preparation Objective: Prepare a draft and final Phase II Environmental Site Assessment report summarizing the results of the investigation. Approach: Specific work elements will include: · Prepare a technical report summarizing the results of soil sampling and analysis. · Prepare recommendation for further action at the project site including additional investigation, remedial action, or "no further action." · Finalize the draft technical report following receipt of review comments from the City. · Produce an order-of-magnitude cost estimate for site cleanup, structure demolition, and remediation, if necessary. Assumptions: The following assumptions are made: · Only one revision of the draft technical report will be required for finalization. Deliversbles: The following will be provided: · Five coptes each of the draft and final technical report. CiO' of Bremerton 234-1896~036 (6l) SR 304 Final Destgn 4 July 2004 SOWSR304 P2 1666 EXHIBIT A.9 - SCOPE OF WORK City of Bremerton SR304 Transportation Improvement Project Phase VI, Stage 1D Right-of-Way Acquisition Support Parcel 3-08365 (Pidduck) Charleston Beach Road INTRODUCTION The City of Bremerton (City) has requested Parametrix conduct a Preliminary Site Investigation (WSDOT Parcel 3-08365). This parcel is covered with blackberry bushes, mobile home, abandoned pickup truck and an Aboveground Storage Tank (AGST). The contents of the tank were not determined. The tank appears to be a remnant of the AGSTs of Peninsula Fuel. There is also a building foundation with partial walls. The Preliminary Site Investigation will be conducted to support potential property acquisition relating to SR304 Transportation Improvement Project. This investigation will focus only on the right-of-way access portion of the parcel. The balance of the parcel will not be investigated and is assumed to be a viable economic remnant. The results of this investigation will also be used to provide data for assessing remedial action, if necessary. Specific elements of work required to complete the project include: · Project Management · Soil Sampling and Analysis · Technical Report Preparation Parametrix will complete the evaluation of data collected and prepare a Preliminary Site Investigation Report that describes the findings and conclusions of the investigations. PHASE 61 STAGE 1D ROW ACQUISITION Task 6104.1 Project Management Objective: Coordination and documentation of the project by the Project Manager. Appro~clt: Specific work elements will include: · The primary objective of this task will be budget and progress tracking. · Meetings with the City and various agencies (Department of Ecology, etc.) to discuss investigation, results, etc. · Coordination with the City. City of Bremerton 234-1896-036 (61) SR 304 Final Destgn l Jul)' 2004 SOW SR304 P2 3-08365 (Pidduck) 54 Assnmptions: Work will be completed under the following assumptions: · Attend two meetings, three hours each. · This Scope does not include negotiations with property owners. Deliverables: Monthly progress reports, as needed. Task 6104.2 Soil Sampling and Analysis Objective: Assess soil quality and condition at the project site. Use results of assessment to determine remedial action, if necessary. Approach: Collect soil samples for analysis to assess soil quality and remedial options, as needed. Specific work elements may include: · Prepare a short (2 to 3 page) work plan/sampling and analysis plan for boring installation and sample collection. · Conduct a subsurface utility survey prior the start of boring installation. · Complete concrete coring, as needed, to access onsite soil. · Install up to 4 borings to a maximum depth of 20 feet (or to an estimated 1 foot above groundwater) using a Geoprobe or similar equipment. · From each boring, collect one soil sample at the surface and every 5 feet for the full depth of the boring and field screen each sample using a photoionization detector. · Based on the results of the field screening, select and analyze up to three soil samples from each boring (for a total of 8 samples, including one field duplicate and one rinsate blank) for the chemicals of concern listed below: ~ NNVTPH-HCID NWTPH-Dx NWTPH-Gx RCRA 13 metals using EPA Method 6010/7470 Volatile Organic Compounds (VOCs) using EPA Method 8260 Polynuclear Aromatic Hydrocarbons by EPA Method 83 l0 · Complete soil boring logs and sampling paperwork. Assuraptlons: The following assumptions are made: C/0' of Bremerton 234-1896-036 (61) SR 304 Final D~s(~n 2 Jttl) 2004 SOW SR304 P2 3-08365 (Pidduck) · Property access will be the responsibility of the City and will be obtained prior to the start of work. · This work will be completed in conjunction with other preliminary site investigation being performed for this project and will not require remobilization. · Only the portion of the property located in the planned right-of-way will be characterized. · Boring installation and sampling can be completed in one, 8-hour day. · Sample analysis will be completed on standard turnaround time (30 business days). · Only Tier II data deliverables will be required from the analytical laboratory. · No groundwater samples will be collected under this task. · Disposal of investigation-derived waste will be the responsibility of the City. Deliverables: The following will be provided: · Copies of all field notes, logs, etc. · Copies of all laboratory analytical data. Task 6104.3 Technical Report Preparation Objective: Prepare a draft and final Phase II Environmental Site Assessment report summarizing the results of the investigation. Approach: Specific work elements will include: · Prepare a technical report summarizing the results of soil sampling and analysis. · Prepare recommendation for further action at the project site including additional investigation, remedial action, or "no further action." · Finalize the draft technical report following receipt of review comments from the City. · Produce an order-of-magnitude cost estimate for site cleanup, structure demolition, and remediation, if necessary. Assnmptions: The following assumptions are made: · Only one revision of the draft technical report will be required for finalization. Deliverables: The following will be provided: · Five copies each of the draft and final technical report. CiG' of Bremerton 234-1896-036 (61) SR 304 Final Design 3 July 2004 SO~V SR304 P2 3-08365 (Pi&hick) EXHIBIT A.10 - SCOPE OF WORK City of Bremerton SR304 Transportation Improvement Project Phase VI, Stage 1D Right-of-Way Acquisition Support Parcels 3-08376 to 3-08378 (Berg) Charleston Beach Road INTRODUCTION The City of Bremerton (City) has requested that Parametrix conduct a Preliminary Site Investigation on seven parcels of property (WSDOT 3-08372 through 3-08378) located near the southern intersection of State Highway 304 and Charlestown Beach Road in Bremerton, Washington. The properties are currently used as a junk car and equipment storage area. Three of the properties (3-08376 through 3°08378) contain a storage area for debris material, 55-gallon drums, used tires, and vehicles. The remaining properties (3-08372 through 3-08375) are mainly used for storage of vehicles and miscellaneous equipment. All seven of the properties were used in the past as a solid waste transfer station and for parking. Potential contaminants include metals and organic contaminants. The Preliminary Site Investigation will be conducted to support potential property acquisition relating to the SR304 Transportation Improvement Project. The results of this investigation will also be used to provide data for assessing remedial action, if necessary. Parametrix will complete the work for the Preliminary Site Investigation according to the requirements specified in the WSDOT Environmental Procedures Manual M31-11. · Specific elements of work required to complete the project include: · Project Management · Soil Sampling and Analysis · Technical Report Preparation Parametrix will complete the evaluation of data collected and prepare a Preliminary Site Investigation Report that describes the findings and conclusions of the investigations. PHASE 61 STAGE 1D ROW ACQUISITION Task 6104.1 Project Management Objective: Coordination and documentation of the project by the Project Manager. Approach: Specific work elements will include: The primary objective of this task will be budget and progress tracking. CiO, of Bremerton 234-1896-036 SR 304 Final Design [ dldy 2004 SOW SR304 P2 3-08376 to 3-08378 (Berg) 57 · Meetings with the City and various agencies (Department of Ecology, etc.) to discuss investigation, results, etc. · Coordination with the City. Ass#mptions: Work will be completed under the following assumptions: ·Attend two meetings, three hours each. · This Scope does not include negotiations with property owners. DeliverabIes: Monthly progress reports, as needed. Task 6104.2 Soil Sampling and Analysis Objective: Assess soil quality and condition at the project site. Use results of assessment to determine remedial action, if necessary. Approach: Collect soil samples for analysis to assess soil quality and remedial options, as needed. Specific work elements may include: · Prepare a short (2 to 3 page) work plan/sampling and analysis plan for boring installation and sample collection. · Conduct a subsurface utility survey prior the start of boring installation. · Complete concrete coring, as needed, to access onsite soil. · Install up to 4 borings to a maximum depth of 20 feet (or to an estimated 1 foot above groundwater) using a Geoprobe or similar equipment. Four of the borings will be drilled in the vicinity of the storage area for debris material, 55-gallon drums, and used tires. The remaining borings will be drilled in the areas where junk cars are parked or when evidence of contamination is present. · From each boring, collect one soil sample at the surface and every 5 feet for the full depth of the boring and field screen each sample using a photoionization detector. · Based on the results of the field screening, select and analyze up to three soil samples from each boring (for a total of 23 samples, including one field duplicate and one rinsate blank) for the chemicals of concern listed below: NWTPH-HCID NWTPH-Dx NWTPH-Gx RCRA 13 metals using EPA Method 6010/7470 City of Bremerton 234-1896-036 SR 304 Final Design 2 Jul3 2004 SOW SR304 P2 3-08376 to 3-08378 (Be~;v,) Volatile Organic Compounds (VOCs) using EPA Method 8260 Polynuclear Aromatic Hydrocarbons by EPA Method 8310 Polychlorinated biphenyls (PCBs) · Complete soil boring logs and sampling paperwork. Assumptions: The following assumptions are made: · Property access will be the responsibility of the City and will be obtained prior to the start of work. · This work will be completed in conjunction with other preliminary site investigation being performed for this project and will not require remobilization. · Only the portion of the property located south-southwest of the bluff or that can be readily accessed will be characterized. · Boring installation and sampling can be completed in one, 8-hour day. · Sample analysis will be completed on standard turnaround time (30 business days). · Only Tier II data deliverables will be required from the analytical laboratory. · No groundwater samples will be collected under this task. · Disposal of investigation-derived waste will be the responsibility of the City. Deliverables: The following will be provided: · Copies of all field notes, logs, etc. · Copies of all laboratory analytical data. Task 6t04.3 Technical Report Preparation Objective: Prepare a draft and final Phase II Environmental Site Assessment report summarizing the results of the investigation. Approach: Specific work elements will include: · Prepare a technical report summarizing the results of soil sampling and analysis. · Prepare recommendation for further action at the project site including additional investigation, remedial action, or "no further action." City of Brernerton 234-1896-036 SR 304 Final Design 3 July 2004 gow SR304 P2 3-08376 to 3-08378 (BergJ 59 · Finalize the draft technical report following receipt of review comments from the City. · Produce an order-of-magnitude cost estimate for site cleanup, structure demolition, and remediafion, if necessary. Assumptions: The following assumptions are made: · Only one revision of the draft technical report will be required for finalizafion. Deliverables: The following will be provided: · Five copies each of the draft and final technical report. City of Bremerton 234-1896-036 SR 304 Final Design 4 .July 2004 SOW SR304 P2 3-08376 to 3-08378 (Berg) EXHIBIT A.11 - SCOPE OF WORK City of Bremerton SR304 Transportation Improvement Project Phase VI, Stage ID Right-of-Way Acquisition Support Parcels 3-08380 to 3-08383 (Berg) Charleston Beach Road INTRODUCTION The City of Bremerton (City) has requested Parametrix conduct a Preliminary Site Investigation (WSDOT Parcels 3-08380 through 3-08383). An abandoned residential structure, inundated with vegetation is present on parcel 82. The remaining parcels are utilized as a junk yard and are littered with vehicles, vehicle parts, tires, 55-gallon drams, car batteries, storage containers, dilapidated construction equipment, and building materials. Spills and stains where not observed through the limited sight access of the properties. The Preliminary Site Investigation will be conducted to support potential property acquisition relating to the SR304 Transportation Improvement Project. The results of this investigation will also be used to provide data for assessing remedial action, if necessary. Specific elements of work required to complete the project include: · Project Management · Soil Sampling and Analysis · Technical Report Preparation Parametrix will complete the evaluation of data collected and prepare a Preliminary Site Investigation Report that describes the findings and conclusions of the investigations. PHASE 61 STAGE 1D ROW ACQUISITION Task 6104.1 Project Management Objective: Coordination and documentation of the project by the Project Manager. Approach: Specific work elements will include: · The primary objective of this task will be budget and progress tracking. · Meetings with the City and various agencies (Department of Ecology, etc.) to discuss investigation, results, etc. · Coordination with the City. Assumptions: Work will be completed under the following assumptions: Ci~ofBremermn 234-1896-036(61) SR304FinaIDesign ! Ju~,2004 SOWSR304P23 08380 to 3-08383 (Berg) · Attend two meetings, three hours each. · This Scope does not include negotiations with property owners. l~eliverables: Monthly progress reports, as needed. Task 6104.2 Soil Sampling and Analysis Objective: Assess soil quality and condition at the project site. Use results of assessment to determine remedial action, if necessary. Approacis: Collect soil samples for analysis to assess soil quality and remedial options, as needed. Specific work elements may include: · Prepare a short (2 to 3 page) work plan/sampling and analysis plan for boring installation and sample collection. · Conduct a subsurface utility survey prior the start of boring installation. · Install up to 4 borings to a maximum depth of 20 feet (or to an estimated 1 foot above groundwater) using a Geoprobe or similar equipment. · From each boring, collect one soil sample at the surface and every 5 feet for the full depth of the boring and field screen each sample using a photoionization detector. · Up to 6 surface or shallow subsurface soil samples will be collected using hand tools at areas of obvious or suspected contamination. · Based on the results of the field screening, select and analyze up to three soil samples from each boring and up to 6 surface soil samples (for a total of 14 samples, including one field duplicate and one rinsate blank) for the chemicals of concern listed below: >NWTPH-HCID NWTPH-Dx >NWTPH-Gx RCRA 13 metals using EPA Method 6010/7470 Volatile Organic Compounds (VOCs) using EPA Method 8260 Polynuclear Aromatic Hydrocarbons by EPA Method 8310 · Complete soil boring logs and sampling paperwork. Assumptions: The following assumptions are made: Cio of Bremerton 234-1896-036 (61) SR 304 Final Design 2 Ju(~ 2004 SOW SR304 P2 3 08380 to 3-08383 (Berg? 62 · Property access will be the responsibility of the City and will be obtained prior to the start of work. · This work will be completed in conjunction with other preliminary site investigation being performed for this project and will not require remobilization. · Only the portion of the property located south-southwest of the bluff or that can be readily accessed will be characterized. · Boring installation and sampling can be completed in one, 8-hour day. · Sample analysis will be completed on standard turnaround time (30 business days). · Only Tier II data deliverables will be required from the analytical laboratory. · No groundwater samples will be collected under this task. · Disposal of investigation-derived waste will be the responsibility of the City. Deliverables: The following will be provided: · Copies of all field notes, logs, etc. · Copies of ali laboratory analytical data. Task 6104.3 Technical Report Preparation Objective: Prepare a draft and final Phase II Environmental Site Assessment report summarizing the results of the investigation. Approacl~: Specific work elements will include: · Prepare a technical report summarizing the results of soil sampling and analysis. · Prepare recommendation for further action at the project site including additional investigation, remedial action, or "no further action." · Finalize the draft technical report following receipt of review comments from the city. · Produce an order-of-magnitude cost estimate for site cleanup, structure demolition, and remediation, if necessary. Assumptions: The following assumptions are made: · Only one revision of the draft technical report will be required for finalization. Deliverables: The following will be provided: · Five copies each of the draft and final technical report. Cit~ of Bremerton 234-1896-036 (61) SR 304 Final Design 3 Ju(~' 2004 S0~/ SR304 P2 3-08380 to 3-08383 (Bergj EXHIBIT A.12 - SCOPE OF WORK City of Bremerton SR304 Transportation Improvement Project Phase VI, Stage 1D Right-of-Way Acquisition Support Kitsap County Right-of-Way INTRODUCTION The City of Bremerton (City) has requested Parametrix conduct an investigation to evaluate shallow subsurface contamination along the Kitsap County (County) right-of-way adjacent to properties located between 1515 Charleston Beach Road and 1666 Charleston Beach Road. The purpose of this investigation is to determine whether contamination exists that could affect the ability of the County to install utilities such as bioswales or other shallow lines. The investigation will be conducted to support potential property acquisition relating to SR304 Transportation Improvement Project. This investigation will focus only on the right-of-way access portion of the parcel. The results of this investigation will also be used to provide data for assessing remedial action, if necessary. Specific elements of work required to complete the project include: · Project Management · Soil Sampling and Analysis · Technical Report Preparation Parametfix will complete the evaluation of data collected and prepare a Preliminary Site Investigation Report that describes the findings and conclusions of the investigations. PHASE 61 STAGE 1D ROW ACQUISITION Task 6104.1 Project Management Objective: Coordination and documentation of the project by the Project Manager. Approach: Specific work elements will include: · The primary objective of this task will be budget and progress tracking. · Meetings with the City and various agencies (Department of Ecology, etc.) to discuss investigation, results, etc. · Coordination with the City. City of Bremerton 234-1896-036 (61) fill 304 Final Design Jul), 2004 SOW SR304 P2 County ROW Assumptions: Work will be completed under the following assumptions: · Attend two meetings, three hours each. · This Scope does not include negotiations with property owners. Deliverables: Monthly progress reports, as needed. Task 6104.2 Soil Sampling and Analysis Objecti~'e: Assess soil quality and condition in the right-of-way area. Use results of assessment to determine remedial action, if necessary. Approach: Collect soil samples for analysis to assess soil quality and remedial options, as needed. Specific work elements may include: · Prepare a short (2 to 3 page) work plan/sampling and analysis plan for boring installation and sample collection. · Conduct a subsurface utility survey prior the start of boring installation. · Complete concrete coring, as needed, to access onsite soil. Install up to 16 borings to a maximum depth of 20 feet (or to an estimated 1 foot above groundwater) using a Geoprobe or similar equipment. · From each boring, soil will be composited and placed in a sealed plastic bag. Composite samples from 4 borings will be further composited. From each of these multiple composite samples, one aliquot will be collected for laboratory analysis. · 4 borings will be located approximately in front of each subject property located within the section of right-of-way (parcels 3-08389, 3-08390, and 3-08391). · A total of 3 samples will be analyzed for the following: ~ NWTPH-HCID. } NWTPH-Dx. > NWTPH-Gx. ~- RCRA 13 metals using EPA Method 6010/7470 ~' Volatile Organic Compounds (VOCs) using EPA Method 8260 ~ Polynuclear Aromatic Hydrocarbons by EPA Method 8310 · Complete soil boring logs and sampling paperwork. City of Bremerton 234-1896-036 (6l) SR 304 Final Design 2 dub 2004 SOWSR304 P2 (bunt) ROW 65 Assnmptions: The following assumptions are made: · Property access will be the responsibility of the City and will be obtained prior to the start of work. · This work will be completed in conjunction with other preliminary site investigation being performed for this project and will not require remobilization. Only the portion of the property located in the planned right-of-way will be characterized. Boring installation and sampling can be completed in one, 8-hour day. · Sample analysis will be completed on standard turnaround time (30 business days). · Only Tier II data deliverables will be required from the analytical laboratory. · No groundwater samples will be collected under this task. · Disposal of investigation-derived waste will be the responsibility of the City. Deliverables: The following will be provided: · Copies of all field notes, logs, etc. · Copies of all laboratory analytical data. Task 6104.3 Technical Report Preparation Objective: Prepare a draft and final Phase II Environmental Site Assessment report summarizing the results of the investigation. Approach: Specific work elements will include: · Prepare a technical report summarizing the results of soil sampling and analysis. · Prepare recommendation for further action at the project site including additional investigation, remedial action, or "no further action." · Finalize the draft technical report following receipt of review comments from the City. · Produce an order-of-magnitude cost estimate for site cleanup, structure demolition, and remediation, if necessary. Assumptions: The following assumptions are made: · Only one revision of the draft technical report will be required for finalization. Deliverables: The following will be provided: Five copies each of the draft and final technical report. Ctty of Bremerton 254-1896-056 (61) SR 304 Final Design 3 Jul3' 2004 SOW SR304 P2 County ROW EXHIBIT A.20 - SCOPE OF WORK City of Bremerton SR304 Transportation Improvement Project Phase VI, Stage 1D Right-of-Way Acquisition Support Groundwater Investigation The City of Bremerton (City) has requested Parametrix conduct a groundwater investigation in the area of Charleston Beach Road and State Route 304 (SR304) in Bremerton, Washington. The groundwater investigation will be conducted to suppor~ potential property acquisition relating to SR304 Transportation Improvement Project. The results of this investigation will also be used to provide data for assessing remedial action or a "no further action" determination. Specific elements of work required to complete the project include: · Project Management · Historical Data Review · Groundwater Sampling and Analysis ,, Technical Report Preparation This scope of work provides a semi-phased approach to assessing groundwater conditions at the project site. The results of Task 2 (Historical Data Review) will be used to determine the final scope for Task 3 (Groundwater Sampling and Analysis). TASK 6104 SR304 GROUNDWATER INVESTIGATION - PRELIMINARY SITE INVESTIGATION Task 1 Project Management Coal: Coordination and documentation of the project by the Project Manager. Approacl~: Specific work elements will include: · The primary objective of this task will be budget and progress tracking. · Meetings with the City and various agencies (Department of Ecology, etc.) to discuss investigation, results, etc. · Coordination with the City. Assumptioas: Work will be completed under the following assumptions: · Attend two (2) meetings, one hour each. Deliverables: Monthly progress reports, as needed, assuming 1 report per month for two months. CIo of Brernerton 234 I896-036 SR 304 Final Design I May2004 SOW Phase 6I Groundwater Investigation 67 Task 2 Historical Data Review Goal: To determine the usability of available data in assessing local groundwater quality. To assess if the available data is sufficient to characterize the extent of groundwater impacts and to determine if the impacted aquifer can be classified as a non-potable water soume. It is possible that existing data from other sources exist that can be used to fulfill the objectives of this study. Existing data from other sources will be utilized if practicable to reduce sampling quantities in Task 3, thereby reducing cost of this investigation. Approach: Review available data from historical investigation, etc. conducted at or adjacent to the project site to determine if addition investigation is necessary. Specific work elements will include: · Review of historical data collected at and adjacent to the project site to assess usability in characterizing local groundwater conditions. · Determine potential data gaps and develop strategy for filling these gaps. · Based on the results of this review, propose locations for additional borings and or groundwater wells to further assess groundwater condition, if necessary. · Formally request data from the Navy (and possibly other sources) to use in this study. Assumptions: The following assumptions are made: · This is a paper study only. No actual groundwater samples will be collected under this task. · Historical data for the project area is available from various sources including the Navy (Puget Sound Naval Shipyard). Deliverables: The following will be provided: · Short (2 to 3 pages) technical memorandum discussing the results of the data review. Task 3 Groundwater Sampling and Analysis Goal: Assess groundwater quality and condition at the project site. Use results of assessment to determine remedial action, if necessary. Locations will be selected as practicable to assess each property and the state of groundwater as a whole. This work will be performed to assist the City in making appropriate property acquisition decisions and in negotiating solutions with the Washington State Department of Ecology after the acquisitions are completed. Approach: Collect groundwater samples for analysis to assess groundwater quality. This data will be used to supplement historical groundwater data for the project area and fill any data gaps. The exact scope of this task will be dependant on the results of the Task 2 data review. Specific work elements may include: CiO' of Bremerton 234-1896-036 ,¥R 304 Final Design 2 Ma32004 SOW Phase 61 Grolmdlsater lnvesltgation 68 · Prepare a draft and final work plan/sampling analysis plan for boring installation and sample collection. · Install up to 20 borings to a maximum depth of 30 feet using a Geoprobe or similar equipment. This will include installation of small diameter (0.5- to 1-inch) monitoring well. · Collect one grab groundwater sample from each of the borings (a maximum of 20 samples plus 2 to 3 quality control samples total). · At a minimum, collected groundwater samples will be analyzed for the following chemicals of concern: NWTPH-HC1D NWTPH-Dx (diesel) NWTPH-Gx (gasoline) Priority Pollutant metals using EPA Method 6010/7470 Volatile Organic Compounds (VOCs) using EPA Method 8260. Salinity · Produce soil boring logs and groundwater sampling records. · Collect and analyze investigation-derived waste, as needed. Assnraptions: The following assumptions are made: · The actual number of borings to be installed and groundwater samples collected will be based on the results of the review of available data (Task 2). · Boring installation and sampling can be completed in two, 10 hour days. · Proposed analyses may change based on the results of the Task 2 data review. If additional analyses are necessary, additional funding may be required. · Sample analysis will be completed on standard turnaround time (10 business days). · Only Tier II data deliverables will be required from the analytical laboratory. Deliverables: The following will be provided: · Copies of all field notes, logs, etc. · Copies of all laboratory analytical data. CiO' of Bremerton 234-1896-036 SR 304 Final Design 3 Ma12004 SOD' Phase 6l Groundwater Investigation 69 Task 4 Technical Report Preparation Goal: Prepare a draft report summarizing the results of the Task 3 investigation. Approacl~: Specific work elements will include: · Prepare a technical report summarizing the results of groundwater sampling and analysis. · Prepare recommendation for further action at the project site including additional investigation, remedial action, or "no further action" for use in the property acquisition process. · Finalize the draft technical report following receipt of review comments from the City. Assumptions: The following assumptions are made: · One (1) report will be prepared for the entire project site. · Only one (1) revision of the draft technical report will be required for finalization. Deliverables: The following will be provided: · Five (5) copies each of the draft and final technical reports. City of Bremerton 234-1896-036 SR 304 Final Design 4 Mt~v2004 SOW Phase 61 Ground~ater Investig~ition 70 SR 304 Transportation Improvement Project Supplemental Agreement #6 August 2004 EXHIBIT B Table of Contents 1. Exhibit B - Budget Information · Budget Summary Spreadsheet (1 page) · Cost Breakdowns for Exhibit A - SR 304 Amended Scope of Work for 30% Design (8 pages) · Cost Breakdowns for Exhibits A.1 to A. 12 (12 pages) 72 C C ?~ I= ' i~ t ! 73 77 79 Attachment 1 Budget Estimate PROJECT: SR340 Preliminary Site Investigation - 1145 to 1149 Charleston Beach Rd. CLIENT: City of Bremerton ~Didsiofl Manager) Attachment ! Budget Estimate PROJECT: SR340 Preliminary Site Investigation - 1215 Charleston Beach Rd. CLIJENT: City of Bremerton Attachment 1 Budget F~timat e PROJECT: SR340 Preliminary Site Investigation - 1227 Charleston Beach Rd. CLIENT: City of Bremerton Attachment 1 Budget Estimate PROJECT: SR340 Preliminary Site Investigation - 1229 Charleston Beach Rd. CLIENT: City of Bremerton Attachment 1 Budget Estimate PROJECT: SR340 Preliminary Site Investigation - 1233 Charleston Beach Rd. CLIENT: City of Bremerton Attachment 1 Budget Estimate PROJECT: SR340 Preliminary Site Investigation - 1515 Charleston Beach Rd. CLIENT: Cit~ of Bremerton Attachment 1 Budget Estimate PROJECT: SR340 Preliminary Site Investigation ~ 1550 Charleston Beach Rd. CLIENT: City of Bremerton Attachment 1 Budget Estimate PROJECT: SR340 Preliminary Site Investigation - 1666 Charleston Beach Rd. CLIENT: City of Bremerton PRO~ECTTOTAL I I Attachment 1 Budget Estimate PROJECT: SR340 Preliminary Site Investigation - 3-08365 (Pidduck) Charleston Beach Rd. CLIENT: City of Bremerton -t Outside Expenses Desc~n D~-~Y; C~a ' ~ Attachment 1 Budget Estimate PROJECT: SR340 Preliminary Site Investigation - 3~08376 to 3-08378 (Berg) CLIENT: City of Bremerton I I " '" I '" I '~I .'~..[ I t I ['"1","'."'° Attachment 1 Budget Estimate PROJECT: SR340 Preliminary Site Investigation - 3-08380 to 3-08383 (Berg) Charleston Beach Rd. CLIENT: City of Bremerton Attachment ! Budget Estimate PROJECT: SR340 Preliminary Site Investigation - IOtsap County Right-of-Way CLIENT: City of Bremerton DATE SUBMITTED: August 11, 2004 BILL AGENDA BILL CITY OF BREMERTON CITY COUNCIL SUBJECT: 2004 KPS Contracts Approval Committee Meeting Date: 8-1-8'-04 COUNCIL MEETING Date: ~ ~--I--~ Department: Human Resources Presenter: Carol Conley Phone: 473-5846, ext. 6347 SUMMARY: Approval and authorization of formal execution of the 2004 contracts between the City and Kitsap Physicians Service (KPS) for employee group health insurance coverage. The new contracts,which were negotiated on our behalf by our benefits consultants, Willis of Seattle, reflect a 14.3% rate increase above 2003 levels. ATTACHMENTS: KPS 2004 Premium Rates & Underwriting Criteria; Contracts: Plan A (LEOFF I Active, LEOFF II Active) and Plan A (LEOFF I Retirees under 65); Plan B (Management & Professional employees/dependents, Teamsters employees/dependents and Fire fighter dependents). FISCAL IMPACTS (Include Budgeted Amount): $1,500,000 for active employees; $850,000 for LEOFF I retirees APPROVALS: DEPARTMENT DIRECTOR: ~y~,~. ~..-.~ CITY ATTORNEY: / ~.~-- ,~.~__~.~Z~ FINANCE DIRECTOR: ~;:~_._ dt~ .~'"'~,-), ? __ ~ ,. ~.. CONSENT AGEN OPERATIONS: ~'~~ --"~. COUNCIL PRESIDENT: /'-~,a.~ /~/'x .t~ RECOMMENDED MOTION: I move to approve the 2004 KPS premium rates, underwriting criteria and the contracts between the City and KPS, and authorize the Mayor to execute said contracts. COUNCIL ACTION: [] Approve [] Deny 9[~ Table [] Continue [] No Action KPS Health Plans, In Rehabilitation 400 Warren Avenue P.O. Box 339 Bremerton, WA 98337-0039 CITY OF BREMERTON -- PLAN A COVERAGE CONTRACT Group Number: 21001-21006 Effective Date: 1/1/2004 Renewal Month: January Open Enrollment December This Coverage Contract includes the following: Attachment A - Benefits Booklet Attachment B - Premium Rates and Underwriting Criteria Riders: N/A Optional Riders: Occupational Injury Coverage - LEOFF I Employees Only Endorsements: N/A KPS Health Plans, In Rehabilitation, hereinafter referred to as KPS, is a duly licensed health care services contractor (HCSC) in Washington State. In its capacity as an HCSC, KPS agrees to underwrite and provide the benefits and services described in Attachment A - Benefits Booklet, to the eligible Employees, and their Eligible Dependents, of the above-named Group, provided the Group, its eligible Employees and their Eligible Dependents, meet and comply with the provisions of this Contract. Contract Form: BREMA-22900-2004 TABLE OF CONTENTS DEFINITIONS ................................................................................................................................... 1 CONTRACT EXAMINATION PERIOD ................................................................................................... 2 EFFECTIVE DATE, DURATION AND RENEWAL .................................................................................... 2 PREMIUM PAYMENT PROVISIONS ..................................................................................................... 2 Payment Due Date/Grace Period ............................................................................................................. 2 Premium Rate Adjustments ...................................................................................................................... 3 Premiums Paid by Subscribers/Dependents ............................................................................................ 3 Premium Refunds ..................................................................................................................................... 3 ELIGIBILITY AND ENROLLMENT ......................................................................................................... 3 Group Eligibility ......................................................................................................................................... 3 SubscribedDependent Eligibility Requirements ........................................................................................ 4 Enrollment ................................................................................................................................................. 4 Enrollment Under Special Circumstances ................................................................................................ 4 When Coverage Begins ............................................................................................................................ 5 Coverage Waiting Periods ........................................................................................................................ 5 TERMINATION OF COVERAGE .......................................................................................................... 6 Continuity of Coverage .............................................................................................................................. 6 Termination of Group Contract .................................................................................................................. 6 Re-EnrollmentJReinstatement ................................................................................................................... ? Termination of Enrollee Coverage ............................................................................................................ ? Continuation of Inpatient Coverage .......................................................................................................... 7 Continuation of Coverage for a Disabled Child ......................................................................................... 8 CONTINUATION OF COVERAGE ........................................................................................................ 8 Coverage During a Labor Dispute ............................................................................................................ 8 Continuation of Group Coverage .............................................................................................................. 9 COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) ........................................................ 9 Individual Conversion Coverage ............................................................................................................... 9 COORDINATION OF BENEFITS (COB) .............................................................................................10 General Provision .................................................................................................................................... 10 Definitions ................................................................................................................................................ 10 Claim Determination Pedod .................................................................................................................... 11 Effect on Benefits .................................................................................................................................... 11 Order of Benefit Determination ............................................................................................................... 11 Facility of Payment .................................................................................................................................. 11 Right of Recovery .................................................................................................................................... 12 Right to Receive and Release Information ............................................................................................. 12 Disclosure of Coordination ...................................................................................................................... 12 KPS' RIGHT OF RECOVERY ........................................................................................................... 12 Limitations and Exclusions ...................................................................................................................... 12 Third Party Liability: Reimbursement and Subrogation .......................................................................... 12 Collection and Reimbursement by Enrollee (or the Enrollee's Representative) ..................................... 13 Subrogation: Assignment of Third Party Claim to KPS ........................................................................... 13 Trust and Cooperation Between the Enrollee (or the Enrollee's Representative) and KPS ................... 14 Agreement to Arbitrate ............................................................................................................................ 14 Recovery of Claims Payments ................................................................................................................ 14 SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS ........................................................................... 14 Subscriber/Dependent Liability ............................................................................................................... 14 KPS Privacy Policy .................................................................................................................................. 15 COMPLAINTS AND APPEALS PROCESS ........................................................................................... 17 Complaints .............................................................................................................................................. 17 Standard Appeals Process ...................................................................................................................... 17 Expedited Appeals Process .................................................................................................................... 18 GENERAL TERMS AND CONDITIONS ...............................................................................................18 Applicable Law ........................................................................................................................................ 18 Assignment of Benefits ........................................................................................................................... 18 95 Binding Agreement .................................................................................................................................. 18 Confidentiality .......................................................................................................................................... 18 Contract Modifications ............................................................................................................................. 18 Coverage Limits ...................................................................................................................................... 19 Entire Agreement .................................................................................................................................... 19 Equity of Application ................................................................................................................................ 19 False or Misleading Information .............................................................................................................. 19 Force Majeure ......................................................................................................................................... 19 Group Cooperation .................................................................................................................................. 19 Headings ................................................................................................................................................. 19 Notices .................................................................................................................................................... 20 Severability .............................................................................................................................................. 20 Third Party Beneficiaries ......................................................................................................................... 20 Waiver of Breach ..................................................................................................................................... 20 DEFINITIONS Capital[zed words found in the text of this section are defined below or in the Benefits Booklet section. Child means any one of the following: (i) An unmarried natural child, adopted child, stepchild or other legally designated ward under the Limiting Age who is primarily dependent upon the Subscriber or the Subscriber's Spouse for support. (ii) An unmarried child under the Limiting Age who is legally entitled to receive medical coverage as a result of a court order binding either the Subscriber or the Subscriber's Spouse, regardless of whether or not the Subscriber or Subscriber's Spouse has legal custody of the Child. (iii) An unmarried child who has reached the Limiting Age, or is older than the Limiting Age, is incapable of self-sustaining employment due to developmental disability or physical handicap, and is primarily dependent upon the Subscriber or the Subscriber's Spouse for support and maintenance (see Continued Eligibility for a Disabled Dependent). Contract means this document and any other attachments, exhibits, Riders or Endorsements listed on the title page or otherwise described herein, and any subsequent amendments or modifications to the Contract or its attachments, exhibits, Riders or Endorsements. Contract Renewal Month means the calendar month specified on the title page of this Group Contract during which the Group may renew its coverage each year under this Group Plan. Covered Benefit or Service means those Medically Necessary services described in Attachment A - Benefits Booklet that an Enrollee is entitled to receive. Eligible Dependent means the legal Spouse or Child of a LEOFF I or LEOFF II law enforcement officer. Employee means (a) LEOFF I employees who are full-time law enforcement officers or firefighters hired prior to October 1, 1977, and who are members of the LEOFF system as defined in Sections (3) and (4), CH 131, Law of 1972, 1s~ Ex. Session; or (b) LEOFF II employees who are full-time law enforcement officers or firefighters hired on or after October 1, 1977, and who are not members of the LEOFF system as defined in Sections (3) and (4), CH 131, Law of 1972, Is~ Ex. Session. Endorsement means an amendment to the conditions of coverage or the benefits provided by this Group Plan. Enrollee means a person enrolled in this Group Plan. Group means the employer entity, association or other group that has entered into this Contract with KPS. Group Plan means the Benefits Booklet plus any Riders, Endorsements or other attachments that state the terms and conditions for administration of the Enrollee's benefits. Group Master Application means the application form completed by the Group and submitted to KPS prior to securing coverage under this Group Plan. The Group Master Application identifies the size, participation and contribution eligibility requirements applicable to the Group. Limiting Age means the age at which a Child may no longer be covered under this Group Plan as an Eligible Dependent of the Subscriber. The Limiting Age is specified in the Benefits Summary included in this Benefits Booklet. Medical Director means the licensed physician acting as chief medical advisor for KPS. Non-Participating Provider/Facility means any Provider or facility not contracted directly with KPS, or indirectly through First Choice Health Network, Providence Preferred Provider Organization or MultiPlan. Page 1 97 Open Enrollment Period means the thirty-one (31) day period, or some other period agreed to by both KPS and the Group, beginning one (1) month prior to the Group's Renewal Month, or at some other mutually agreeable time, but at least annually. During the Open Enrollment Period, Subscribers may add or delete Eligible Dependents, and all eligible Employees and their Eligible Dependents have the opportunity to select from alternative health plans offered by the Group. Coverage will be effective as of the renewal date. Premium means the periodic payment made by, or on behalf of the Enrollee, as consideration for this Group Plan and in accordance with the terms of this Contract. Premium Due Date means the scheduled, periodic dates by which Premium payments must be received by KPS as a condition for continued enrollment in this Group Plan. This date is typically the first day of each month of coverage. Provider means a licensed or certified health care practitioner acting within the scope of his/her license or certificate. Rider means an additional benefit over and above those listed in the Benefits Summary. Rider documents are attached at the back of the Benefits Booklet and provide detailed benefit information. Spouse means an individual who is living in a marital relationship with the Subscriber. The marital relationship must be legally recognized by the state of Washington. Subscriber means the primary person, generally the Employee, enrolled in this Group Plan. CONTRACT EXAMINATION PERIOD If, after examination, the Group is not satisfied with this Contract for any reason, the Group may return the Contract to KPS within ten (10) days of the date it is received. Upon receipt of the returned Contract, KPS will refund to the Group any pre-paid Premiums. The Contract shall subsequently be deemed null and void. EFFECTIVE DATE~ DURATION AND RENEWAL This Contract shall begin at 12:01 a.m. Pacific Time on the Effective Date (as indicated on the title page), and shall remain in effect until the Contract Renewal Month unless terminated according to the previsions set forth herein. Thereafter, this Contract may be renewed automatically at 12:01 a.m. on the same date (month and day) in subsequent calendar years unless otherwise terminated according to the provisions set forth herein. PREMIUM PAYMENT PROVISIONS Payment Due Date/Grace Period The initial Premium payment is due and payable to KPS on or before the effective date of this Contract indicated on the title page. Thereafter, Premium payments are due and payable on or before the first day of every month ("Premium Due Date") for which coverage is provided. A roster of current enrollment and enrollment changes must accompany each Premium payment. A ten (10) day grace period following the Premium Due Date is allowed, during which time this Contract shall not be terminated. However, KPS may, at its sole discretion, elect to extend the grace period for up to sixty (60) days from the Premium Due Date, or cancel this Contract immediately, without notice to the Group if payment is not received by the end of the grace period. If KPS elects to immediately cancel this Contract due to non-payment of Premium, the effective date of cancellation will be retroactive to the last day of the month for which payment was received. No further liability for claims will accrue to KPS. Enrollees in thJs Group Plan shall not be entitled to benefits during any calendar month for which the Premium, on his/her behalf, was not received by KPS. Page: 2 98 Premium Rate Adjustments The Premium rates applicable to this Group Plan are defined in Attachment B - Premium Rates and Underwriting Criteria. Rates are guaranteed until the Contract Renewal Month each calendar year. Notwithstanding the foregoing, KPS reserves the right to revise the rates as follows: As part of the annual Contract renewal process; As a result of any state or federal law or regulation that imposes an additional tax, new tax or other assessment on KPS revenue; and > In the event there is a material change in the basis upon which KPS assumed risk under this Contract. Such changes may include false or misleading information presented by the Group, changes in the benefits or other Contract terms required by statute or regulation, adverse claims or underwriting experience, or fluctuations of ten percent (10%) or more in the number of enrolled Subscribers and/or Eligible Dependents. KPS will give the Group sixty (60) days prior written notice of any change in Premium rates not associated with the annual Contract renewal process. KPS will give the Group thirty (30) days prior written notice of rate increases associated with the annual Contract renewal process. Premiums Paid by Subscribers/Dependents In certain instances, Subscribers and their enrolled Eligible Dependents may be required to self-pay their Premiums in order to continue coverage. Those instances include: > Strikes, lockouts and other labor disputes that cause a disruption in Employee benefits ~- When the Subscriber and/or Eligible Dependent(s) elects to continue coverage under a COBRA provision or other coverage continuation provision available under this Group Plan The Group is required to collect self-paid Premiums for continuation coverage and forward payments to KPS on or before the Premium Due Date. In the instance of strikes, lockouts and labor disputes, the Subscriber may self-pay their Premium directly to KPS on or before the Premium Due Date. Premium Refunds KPS will refund to the Group any Premium paid, in advance, for periods after the termination date of this Group Plan. In the case of ineligible persons enrolled in this Group Plan, KPS will refund to the Group any Premium paid during a period of ineligibility that is in excess of claim payments made on behalf of the ineligible person(s) during the period of ineligibility. This refund will not exceed an amount equal to three (3) months of Premium payments. ELIGIBILITY AND ENROLLMENT Group Eligibility In order to be eligible to participate in this Group Plan, the Group must continuously meet all eligibility, participation, Group size, contribution and other requirements specified in the Group Master Application form. KPS reserves the right to audit the Group's employment, payroll and eligibility records to ensure that the Group continues to meet its participation requirements, and to ensure that eligible Employees and their Eligible Dependents are properly enrolled in this Group Plan. Page 3 Subscriber/Dependent Eligibility Requirements Active, full-time LEOFF I and LEOFF II Employees, as defined in the Definitions section are eligible to enroll in this Group Plan. Eligible Dependents of an active, full-time LEOFF I or LEOFF II law enforcement officer, as defined in the Definitions section, are also eligible to enroll in this Group Plan. The Child of an Eligible Dependent, other than the Child of the Spouse, is not eligible to enroll in this Group Plan. Enrollment Premium payments, if appricable, must accompany all applications for coverage. Current LEOFF I and LEOFF II Employees, including Eligible Dependents of active, full-time LEOFF I and LEOFF II taw enforcement officers, are initially eligible to apply for coverage beginning on the effective date of this Group Plan. Application for coverage must be made within thirty-one (31) days of initial eligibility. New LEOFF II Employees, including Eligible Dependents of active, full-time LEOFF I and LEOFF II raw enforcement officers, may initially apply for coverage on the first day of the first full month following their first day of employment. Application for coverage must be made within thirty-one (31) days of initial eligibility. Those Employees who do not enroll immediately following their probationary period(s) must wait until the next Open Enrollment Period. A new Spouse and the Spouse's Child(ren) may initially apply for coverage as of the date of marriage. Application for coverage must be made within thirty-one (31) days of initial eligibility. Newborn, Adopted Child(ten) and Child/children placed for adoption are initially eligible for coverage as follows: ;> A natural newborn Child is eligible as of the date of birth and is covered automatically for a period of three (3) weeks. In order for coverage to continue after the initial three (3) week period, the Child must qualify as an Eligible Dependent. If additional Premium is required, the Child must be enrolled in this Group Plan within sixty (60) days of birth; ~- Adopted Child(ren) and Child(ren) placed for adoption are eligible (i) on the date of their adoption, (ii) on the date the Employee or Spouse assumes legal obligation for total or partial support in anticipation of adoption, or (iii) on the date the Employee or Spouse acquires partial or complete legal custody. If additional Premium is required, the application for coverage must be submitted within sixty (60) days of the date of placement for adoption. NOTE: When additional Premium is not required, we encourage enrollment as soon as possible to prevent delays in claims processing. In the case of court-ordered covera~le, a dependent Child becomes initially eligible on the date the Subscriber or Spouse receives the order to provide medical coverage for the Child, even if neither the Subscriber nor the Spouse is the custodial parent. Application for coverage must be submitted within thirly- one (31) days of the date of the order. Employees and their Eligible Dependents who do not enroll when they are initially eligible must wait until the next Open Enrollment Period except Jn certain circumstances (see Enrollment Under Special Circumstances), Enrollment Under Special Circumstances Loss of Other Coverage When Employees and/or their Eligible Dependents lose coverage under another health plan, they may apply for coverage under this Group Plan if the following applies: They declined initial enrollment in this Group Plan in writing; They lose eligibility in another health plan or their coverage is terminated; and They make application to enroll in this Group Plan within thirty-one (31) days of losing other coverage. Otherwise, they must wait until the next Open Enrollment Period to apply for coverage. NOTE: Dependents may not enroll in this Group Plan unless the Employee is a Subscriber. Page: 4 Marriage, Birth, Adoption or Placement for Adoption Employees who declined initial enrollment in this Group Plan in writing, may apply for coverage for themselves and their Eligible Dependents in the event of marriage, birth of a Child, adoption or placement for adoption. Application for enrollment must be received by KPS: within thirty-one (31) days following the date of marriage, or within sixty (60) days, if additional Premium Js required, following the date of birth, adoption or placement for adoption, or ~ at the next Open Enrollment Period if these time frames are not met. NOTE: When additional Premium is not required, we encourage enrollment as soon as possible to prevent delays in claims processing. Court-Ordered Coverage Employees who declined initial enrollment in this Group Plan in writing, may subsequently apply for coverage for themselves and their Eligible Dependents in the event they are required to provide health care coverage for an Eligible Dependent Child as a result of a court order. Application for enrollment must be received within thirty-one (31) days folrowing the date of the court order, or wait until the next Open Enrollment Period. When Coverage Begins Coverage for new Enrollees begins on their date of initial eligibility provided they enrolled in this Group Plan within the specified time limits (see Enrollment) and any applicable Premium amounts have been paid. If the Employee enrolls during an Open Enrollment Period the coverage will begin on the first of the month following the Open Enrollment Period. A newborn Child who meets eligibility requirements is covered automatically for a period of three (3) weeks from the date of birth, provided either the female Subscriber, or male Subscriber's Spouse, is eligible for maternity coverage under this Group Plan at the time of the Child's birth. If additional Premium Js required, coverage will not extend beyond the three week period unless the Child is enrolled within sixty (60) days of the date of birth. Any applicable Premium amount must accompany the enrollment application. If additional Premium is required, coverage for an adopted Child is retroactive to the date the Child was legally placed for adoption, provided the Child was enrolled within sixty (60) days from the date of placement, and provided any applicable Premium amount has been paid by the Premium Due Date. NOTE: When additional Premium is not required, we encourage enrollment as soon as possible to prevent derays in claims processing. Coverage Waiting Periods (This section does not apply to LEOFF I Employees) Pre-Existing Conditions KPS imposes a three (3) month waiting period before providing coverage for a Pre-existing Condition. A "Pre-existing Condition" is any condition about which, during the three (3) month period immediately before enrolring in this Group Plan, an Enrollee received medical advice, or for which his/her Provider recommended or provided treatment. Genetic information shall not be treated as a pre-existing condition unless there has been a diagnosis of the condition related to the specific genetic information. However, this waiting period may be reduced by the number of months of Creditable Coverage the Enrollee has accrued under other health care programs prior to their enrollment in this Group Plan. "Creditable Coverage" means periods of other health coverage an Enrollee may use to reduce pro-existing waiting periods. These include group health coverage; Medicare; Medicaid; military health coverage; Indian Health Service or tribal coverage; state high risk pool; federal or public health plans; Peace Corps Plan; other health insurance coverage. The Enrollee will receive credit for prior Creditable Coverage if it occurred anytime during the three (3) month period immediately preceding enrollment in this Group Plan and there was no break in the prior coverage. No credit will be given if there was more than a three (3) month break in coverage between the Enrollee's prior plan and enrollment in this Group Plan. Any Employer imposed probationary period wilt not be considered a break in coverage or creditable coverage. Page 5 101 To request credit of the Pre-existing Condition waiting period, the Enrollee must submit a Certificate of Creditable Coverage from the prior health plan carrier with his/her enrollment application. In lieu of a Certificate of Creditable Coverage, the Enrollee must provide all of the following information: The name of the prior health plan carrier The dates of coverage under the prior plan Proof of coverage under the prior plan that documents the coverage period(s) There are no waiting periods for: Pregnancy Formulas necessary for the treatment of phenylketonuria (PKU) Prescription drugs included in the Pharmacy Benefit (if applicable) A newborn Child or an adopted Child whose effective date of coverage is the date of birth or placement for adoption Transplant Procedures KPS provides coverage for transplant procedures only after an Enrollee has been continuously covered under this Group Plan for six (6) months. This transplant waiting period applies to the transplant procedure as well as any pre- and post-transplant care directly related to a transplant they receive while covered under this Group Plan. If the Enrollee was covered under another KPS plan immediately prior to enrolling in this Group Plan, KPS will credit to this Group Plan the portion of the transplant waiting period that was satisfied under the prior KPS plan. TERMINATION OF COVERAGE Continuity of Coverage Continuity of coverage under this Contract is guaranteed to all eligible Enrollees provided the Group continues to meet eligibility requirements and continues to pay applicable Premium payments on a timely basis. Termination of Group Contract This Group Plan may be terminated if any of the following occurs: The Group falls to make full Premium payments The Group violates, or refuses to comply with, the terms and conditions of this Contract The Group violates, or refuses to comply with, any published KPS policies and procedures that have been approved by the Insurance Commissioner ~ There is a change to, or implementation of, federel or state law that prohibits the continued offering of this Group Plan ~ KPS replaces this Group Plan. In this case, the replacement plan will (i) include the services covered under the replaced Group Plan; (ii) be offered to the Group's eligible Employees and their Eligible Dependents; and (iii) not significantly limit access to the kind of services covered under the replaced Group Plan In addition, the Group may terminate this Contract, at any time, by providing thirty (30) days written notice to KPS. If this Group Contract terminates, for any reason, coverage for all Enrollees will end automatically on the effective date of termination, or on the last day of the last month for which the Group paid the Premium, whichever occurs first. KPS will refund to the Group any Premium paid in advance for periods after the termination date. In the case of termination or non-renewal of this Group Contract, the Group shall be responsible for providing the following information to all affected Employees and their Eligible Dependents: ~- The effective date of termination of coverage; and ~' The reason(s) for termination or non-renewal. Page: 6 3.02 Re-Enrollment/Reinstatement If this Group Contract has been cancelled by KPS due to non-payment of Premium, the Group automatically forfeits all rights to guaranteed renewal of coverage afforded under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Any decision to reinstate or reenrell the Group is at the sole discretion of KPS. If the Group voluntarily cancels this Group Contract prior to the Open Enrollment Period, KPS may, at its sole discretion, impose up to a twelve {12) month waiting period before the Group is eligible to reapply for coverage. Termination of Enrollee Coverage Coverage for an individual Enrollee under this Group Contract will end if any one of the following events occurs: Non-payment of any Premium amount, when Premium payment is the responsibility of the Enrollee The Enrollee loses eligibility for coverage under this Group Contract The Enrollee commits a fraudulent act with regard to KPS and this Group Plan The Enrollee refuses to comply with the terms and conditions of this Group Plan as described in the Benefits Booklet The Enrollee voluntarily disenrolls from this Group Plan There is a change in either state or federal laws that no longer permit KPS from offering this Group Plan > This Group Contract is terminated Additionally, Eligible Dependent coverage ends if: The Subscriber is no longer employed or no longer meets eligibility requirements The Subscriber dies The Subscriber and Spouse divorce The Child reaches the Limiting Age or marries Coverage ends on the last day of the month in which the Enrollee was eligible for coverage, provided all applicable Premium amounts have been paid. In the case of non-payment of Premium, coverage ends on the last day of the month for which KPS received a Premium payment. Upon termination of coverage either KPS or the Group shall issue a Certificate of Creditable Coverage certifying the period(s) during which the Enrollee was enrolled in this Group Plan. An Enrollee who loses coverage under this Group Plan may be eligible to continue coverage or enroll in a KPS individual Conversion Plan (see Continuation of Coverage), A Subscriber who voluntarily disenrolls from this Group Plan while still an Employee will not be eligible to re- enroll in this Group Plan until the next Open Enrollment Period. See Enrollment Under Special Circumstances for exceptions to this policy. Continuation of Inpatient Coverage An Enrollee who is receiving care as an inpatient in an accredited general Hospital, or other approved facility, on the date that coverage would otherwise end, is eligible to continue receiving benefits under this Group Plan provided the following conditions are met: > KPS pre-authorized the inpatient care (see Prior Authorization of Inpatient Care); and ;* All applicable Premium amounts continue to be paid KPS will continue to provide benefits, under this Group Plan, until one of the following events occurs: The Enrollee is no longer receiving inpatient care The KPS Medical Director determines that inpatient care is no longer Medically Necessary The Enrollee has exhausted the inpatient benefits offered under this Group Plan (annual reinstatement of benefits does not apply under this provision) Page 7 103 Non-payment of Premium Throe (3) consecutive months have elapsed since the date coverage would have otherwise ended The Enrollee enrolls in another KPS plan or in any other health plan that provides inpatient hospital benefits The Enrollee is not eligible for the extended coverage described above if, on the date coverage would otherwise end: ~ The Enrollee is covered under any other group or individual medical plan with similar inpatient benefits; or ~, The Enrollee is eligible for continuation of coverage under COBRA or any other continuation provision Continuation of Coverage for a Disabled Child An Eligible Dependent Child who has reached the Limiting Age remains eligible for coverage under this Group Plan provided both of the following conditions aro met: )' The Child is primarily dependent upon the Subscriber or the Subscriber's Spouse for support; and ~. The Child is incapable of self-sustaining employment due to developmental disability or physical handicap. Proof of the Child's dependence, obtained from their primary provider, must be submitted to KPS within thirty-one (31) days of the date the Child reaches the Limiting Age. Thereafter, KPS may roquire periodic proof of the Child's continuing dependence. Generally this proof is roquested annually after the two-year period following the Child's attainment of the Limiting Age. A disabled Child will continue to be eligible for coverage until any one of the following events occurs: Failure to submit proof of the Child's continuing dependence as a result of disability or physical handicap KPS determines that the Child is no longer developmentally disabled or physically handicapped (based on the evidence submitted). The Subscriber is no longer covered under this Group Plan Non-payment of Premium KPS terminates the Group Plan Coverage for a disabled Child ends on the last day of the month in which the disabled Child is eligible for coverage, provided any applicabre Premium amounts have been paid. In the case of non-payment of Promium, coverage ends on the last day of the month for which KPS received a Premium payment. A dependent who is no longer eligible for coverage as a disabled Child may be eligible for coverage under COBRA or a KPS Individual Conversion Plan (see Continuation of Coverage). CONTINUATION OF COVERAGE Coverage During a Labor Dispute In the event of a strike, lockout or other labor dispute which causes a disruption of health care compensation benefits or wages, Subscribers and their enrolled Eligible Dependents may elect to continue coverage under this Group Plan, for a period not to exceed six (6) months, by self-paying their Premiums. During this period of continued coverage, benefits and Premium may not be altered from that of the existing Group Plan. The Subscriber is required to pay any applicable Premium directly to KPS. Failuro on the part of the Subscriber to make Premium payments will result in termination of coverage as of the last day of the month for which Premium was paid. Coverage terminated for non-payment of Premium will not be roinstated. This provision does not apply to Subscribers and their enrolled Eligible Dependents who are entitled to continue coverage under COBRA or any other continuation of coverage provision. Page: 8 104 Continuation of Group Coverage At the Group's option, Subscribers and their enrolled Eligible Dependents who lose eligibility for coverage under this Group Plan may elect to extend their coverage for a period not to exceed three (3) months unless: >. Coverage was terminated as a result of a strike, lockout or other labor dispute; or > Employment was terminated for gross misconduct Application for coverage must be made within thirty-one (31) days of the date coverage under the Group Plan ended. During this period of continued coverage, benefits and Premium may not be altered from that of the existing Group Plan. The Subscriber is required to pay any applicable Premium directly to the Group. The Group is required to remit Premium to KPS in accordance with the Premium Due Date and grace periods defined in this Contract. Failure on the part of the Subscriber to make Premium payments will result in termination of coverage as of the last day of the month for which Premium was paid. Coverage terminated for non- payment of Premium will not be reinstated. COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) Employers who are required by law to comply with the provisions of the 1985 COBRA act must notify all eligible Employees, and their Eligible Dependents, who lose eligibility for coverage under this Group Plan of their right to continue coverage under this provision. Eligible individuals are required to apply for continued coverage within sixty (60) days of the date coverage under this Group Plan ends. The Group is required to notify KPS of each individual's election of COBRA continuation coverage within thirty-one (31) days of that election. Failure on the part of the eligible individual to make a timely election, or failure on the part of the Group to provide KPS with timely notification of the election, will be interpreted by KPS as a waiver of the individual's right to continue coverage under this provision. Failure by the Group to provide timely notification to KPS may not, in all cases, eliminate the Group's obrigation to provide continuation coverage. It will, however, eliminate any obligation on the part of KPS to provide continuation coverage under this Contract. Individual Conversion Coverage Employees who are under age sixty-five (65) may be entitled to transfer to a KPS Individual Conversion Plan if: They are not otherwise eligible for coverage under Medicare They are currently eligible for continuation of Group coverage but have elected not to enroll in the Group Plan >' Coverage under this Group Plan or a COBRA continuation plan has terminated (for any reason except non-payment of Premium, when it is the individual's responsibility to pay the Premium) >' This Group Plan terminates and the Group does not provide other health care coverage to its Employees Application for coverage must be made within thirty-one (31) days of the date coverage under this Group Plan, or other KPS continuation or COBRA plan ends. Applicable Premium payments for the first month of coverage must be submitted with the enrollment application. Eligible Dependents may apply for coverage separately under this option in the event they Jose coverage under this Group Plan due to the death of the Subscriber, or if the Subscriber and Spouse divorce Page 9 105 When an Enrollee enrolls in a conversion plan, he/she loses certain protections guaranteed under the Health Insurance Portability and Accountability Act (HtPAA) of 1996. Most notably, if the Enrollee wants to transfer to a non-conversion individual plan, he/she could be denied coverage based on a previous or existing health condition. If the Enrollee does qualify for coverage under a non-conversion individual plan, his/her coverage will be subject to any waiting periods for pre-existing conditions. For more information, please contact KPS Member Services at 360-478-6796 or toll free 1-800-552-7114. Employees who are age sixty-five (65) or older when coverage under this Group Contract terminates may be eligible for coverage under a Medicare Supplement Plan. To determine Employee eligibility for a Medicare Supplement Plan, please contact KPS Member Services. COORDINATION OF BENEFITS (COB) General Provision Benefits are provided under this Group Plan only to the extent that Subscribers and their enrolled Eligible Dependents could not have received benefits for the same service(s) under any other Plan, had a claim for benefits been made. The purpose of this COB provision is to ensure that the sum of claim benefits paid by KPS and all other Plans under which Subscribers and their Eligible Dependents are covered does not exceed 100% of the Allowable Expense. All of the benefits provided under this Group Plan are subject to this COB provision. Definitions "Allowable Expense" means the usual, customary or reasonable charge for any necessary health care service or supply when the service or supply is a covered benefit, at least in part, under any of the Plans involved. When a Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service provided shall be considered an Allowable Expense. The difference between the cost of a private Hospital room and the cost of a semi-private Hospital room is not considered an Allowable Expense under the above definition unless the Enrollee's stay in a private Hospital room is considered to be Medically Necessary under at least one of the Plans involved. "Double Coveraqe" means when Enrollees have coverage under another Plan. "Plan" means a policy or contract which provides benefits or services for, or because of, medical or dental care, through one of the following: This Group Plan Any group, individual or blanket disability insurance policy Any group or individual contractual prepayment or indemnity plan such as those issued by health care service contractors, health maintenance organizations or other health carriers or health insurers Any labor-management trusteed plan or labor organization plan Any employer organization plan or Employee benefit organization plan Any governmental program Any insurance coverage required or provided by statute, including automobile policies which provide medical benefits ~ Any other similar soume The term "Plan" does not include accident-only coverage, including athletic injuries, for school-age Children from Kindergarten through twelfth grade (K through 12), or for college students, either on a 24-hour basis or on a "to and from school" basis. Each of the Plans under which the Enrollees are covered, and each benefit payable under those Plans, are considered separately when benefits are coordinated under this provision. Page: 10 106 Claim Determination Period The claim determination period means a Calendar Year. Effect on Benefits When an Enrollee has double coverage, during a Calendar Year, one Plan normally pays its benefits in full as the primary payer and the other Plan pays a reduced benefit as the secondary payer. KPS determines which coverage is primary according to the National Association of Insurance Commissioners' guidelines. When KPS is the pdmary payer, we will pay the benefits described in this Benefits Booklet. When KPS is the secondary payer, we will determine the Allowable Expense. After the primary Plan pays, we will pay what is left of the Allowable Expense, up to our regular benefit. We will not pay more than our allowance. Order of Benefit Determination When more than one Plan contains a COB provision, the decision as to which Plan is the primary Plan is made in the following order: The Plan that covers the person as a Subscriber rather than as an Eligible Dependent is primary When an Eligible Dependent Child is covered under more than one Plan, the Plan of the parent whose date of birth (month and day only) occurs earlier in a Calendar Year is primary, except when the Child's parents are legally divomed or separated ~' When the parents of a covered Eligible Dependent Child are divorced or separated and there is no court decree which establishes financial responsibility for the medical or dental expenses of the Eligible Dependent Child, then benefits for the Child's Covered Expenses are determined as follows: · The Plan of the parent with custody is primary, provided the parent with custody has not remarried · If the parent with custody has remarried, the order for determining the primary Plan is: (i) The Plan of parent with custody (ii) The Plan of the stepparent (iii) The Plan of the parent without custody Despite the above, if the court has determined which parent is financially responsible for the health care of the Eligible Dependent Child, then the Plan of that parent is always the primary Plan. When the above rules do not establish an order of determination, then the Plan which has covered the person for the longer period shall be primary, except that: > The benefits of the Plan which covers the person, on whose expenses the claim is based, as a laid- off or retired Subscriber, or a Dependent of such a Subscriber, shall be determined after the benefits of the Plan which covers that person as a Subscriber (other than as a laid-off or retired Subscriber), or the Dependent of such a Subscriber; and ~> If either of the Plans does not have a provision regarding laid-off or retired Subscribers, which results in each Plan determining its benefits after the other, then the above provision shall not apply. If none of the above rules apply, the Plan that has covered the person for the longest period of time shall be considered the primary Plan. Facility of Payment Whenever another Plan makes payments that should have been provided under this Group Plan and in accordance with this COB provision, KPS may, at its sole discretion, choose to reimburse the Plan making such other payments, the amount necessary to satisfy the intent of this COB provision. Any amount paid under this subsection shall be considered as benefits paid under this Group Plan, and KPS shall be fully discharged from liability to the extent of such payments. Page 11 lg7 Right of Recovery Whenever KPS makes payments that are in excess of the maximum amount of payment necessary to satisfy this COB provision, KPS shall have the right to recover the excess payment amount from the Enrollee, from the Provider, or from another Plan, as applicable. Right to Receive and Release Information As a condition of receiving benefits under this Group Plan, Subscribers and their enrolled Eligible Dependent(s) agree to provide KPS with any necessary information, and authorize KPS to release to or obtain from any other insurer, organization or person, any information necessary to admir~ister this COB provision. Disclosure of Coordination Failure on the part of Subscribers and their enrolled Eligible Dependents to cooperate with KPS regarding this COB provision could result in the loss of benefits under this Group PJan. KPS recommends that Subscribers and their enrolled Eligible Dependent(s) submit claims to KPS, and each other plan, at the same time to help minimize delays and facilitate claims payment. KPS' RIGHT OF RECOVERY Limitations and Exclusions Coverage under this Group Plan is excluded for expenses incurred or services rendered if the Enrollee's illness or injury is caused (or alleged by the Enrollee to be caused) by another party, to the extent that benefits are available under the terms of any other insurance coverage or source of payment, including but not limited to: Vehicle medical, personal injury protection ("PIP"), no-faurt, uninsured or underinsured motorist, workers' compensation insurance or benefits and third party liabiJity insurance, or similar contract of insurance. ~ Homeowner's, property or any other insurance policy (except for individual or group health insurance). ~' An agreement, judgment or settlement pursuant to which a third party pays or agrees to pay for the costs of such services from assets other than a policy of insurance. This exclusion applies whenever any such contract of insurance, agreement, judgment or settlement is issued to or provides benefits for the Enrollee, whether or not they assert a claim against the responsible third party or its insurers. Third Party Liability: Reimbursement and Subrogation As a condition of KPS' agreement to advance payment to the Enrollee or their Provider for medical expenses for illnesses or injuries caused (or arleged by the Enrollee to be caused) by another party, the Enrollee agrees to make a claim against, or otherwise pursue recovery from all responsible parties and their insurer(s) for all payments advanced to the Enrollee or their Provider by KPS. If the Enrollee does not make a claim or otherwise pursue recovery of KPS' payments, all such payments made by KPS may be denied or recouped. By providing benefits onder this provision, KPS is fulfilling its obligations under this Group Plan. However, by so doing, KPS does not waive any rights to reimbursement or subrogation. Provided, the benefits of this Group Plan will be advanced to the Enrollee if they are injured by a third party, before compensation is recovered from the third party or its insurers, only under the following conditions: ~- The Enrollee, and their representative(s), must fully cooperate with KPS in recovering payment of medical bills paid, and to be paid by KPS, from the parties who allegedly caused the injury or illness, including but not limJted to their liability insurance carriers, any applicable PIP, uninsured or underinsured motorist policy, homeowners policy, workers compensation or any other reachable assets of the responsible party or parties; Page: 12 108 The Enrollee notifies KPS, in writing, of the details of the injury or illness, the names and addresses of the parties believed to be responsible and the names and addresses of the responsible party's insurers, if known; Any claim or lawsuit filed by the Enrollee against the third party or the third party's insurer(s) must include a demand for repayment of benefits paid by, or to be paid, by KPS on the Enrollee's behalf; or :~ The Enrollee must agree to assign to KPS their right to recover compensation for the medical costs paid (subrogation), or to be paid, by KPS as a result of injuries caused by the third party responsible for the injury. > The Enrollee must agree to reimburse KPS for the medical expenses paid or that will be paid by KPS as a result of the injury, from the settlement, judgment, insurance proceeds or other recovery obtained by the Enrollee from any third party or its insurers. Collection and Reimbursement by Enrollee (or the Enrollee's Representative) If the Enrollee elects to demand recovery for KPS' payments from the responsible third party, they must: NotiflJ KPS in advance of any settlement, mediation, arbitration or trial. Inform the responsible third party and its insurer(s) of the amount of the lien asserted by KPS, for the recovery of payments made on their behalf, against any recovery or potential recovery obtained by them. Obtain prior consent from KPS before compromising or settling claims involving medical costs paid by KPS. ~- Not enter into any agreement with the responsible third party or its insurer(s), or do anything else that would release KPS' lien or prejudice our subrogation or reimbursement rights, without first obtaining express pdor written consent from KPS. Reimburse KPS for that portion of the settlement, award or judgment that is compensation for medical bills paid and to be paid by us. If the Enrollee obtains a settlement or recovery for less than the insurance policy limits or reachable assets of the liable party, they are obligated to reimburse KPS for the full amount of benefits paid on their behalf after they have been fully compensated for their loss. If, however, the Enrollee obtains a settlement or recovery that is equal to or greater than the liable party's insurance policy limits or reachable assets, they are only obligated to reimburse KPS in the amount that is left after they have been fully compensated for their loss. The Enrollee, or their representative(s), must obtain a written agreement from KPS prior to settling any claim if they want KPS to share, on an equitable basis, any reasonable attorney fees they incurred in pursuit of any subrogation or reimbursement claim. In the absence of a prior written agreement, KPS, at its sole discretion, will determine whether or not to reduce our reimbursement amount in order to share, on an equitable basis, any reasonable attorney fees incurred by the Enrollee. However, such a reduction will only be considered if KPS has benefited from the services of their attorney. In no event will KPS' reimbursement be reduced by more than twenty percent (20%) to offset attorney fees incurred by the Enrollee, and KPS will not pay for costs incurred by them. Subrogation: Assignment of Third Party Claim to KPS If the Enrollee elects to assign their rights to KPS to pursue a claim seeking recovery from a responsible third party or its insurer(s), they and their representative(s) must cooperate fully with KPS in pursuing the claim against the responsible parties. Such cooperation includes, among other things: Providing evidence and testimony consistent with the testimony in the case against the responsible parties. >- Refusing to assist the responsible parties, in any way, in defending against a claim brought by KPS. > Cooperating with KPS by not taking any action that might release, limit, reduce, or otherwise prejudice our efforts to pursue a claim against any responsible third party. Page 13 109 Trust and Cooperation Between the Enrollee (or the Enrollee's Representative) and KPS The Enrollee and their representative(s) must deal in good faith with KPS by adhering to all of the conditions set forth in this section. In turn, KPS agrees to cooperate with the Enrollee and their representative(s) in their effort to recover reimbursement, and will advance payments on their behalf for injuries or medical conditions caused, or asserted by them to be caused, by any third party. The Enrollee and their representative(s) must cooperate fully with KPS in protecting, preserving, and recovering the amounts KPS has paid or will pay on their behalf under this Group Plan. Failure to cooperate may result in the denial of coverage for injuries or conditions caused, or asserted by them to be caused, by any third party to the extent that coverage or payment for such injuries or illnesses is, or would have been, available under the terms of any other insurance coverage or source of payment. Agreement to Arbitrate Any dispute that arises between the Enrollee and KPS as a result of the preceding recovery provisions shall be settled through arbitration. Both the Enrollee and KPS shall be bound by the decisions of the arbitration proceedings. Disputes will be presented to, and resolved by, a single arbitrator in accordance with the current rules of the American Arbitration Association. Either the Enrollee or KPS may demand arbitration by serving notice of this demand on the other. Each party to the arbitration agrees to bear its own costs and to share equally in the fees of the arbitrator. This agreement to resolve disputes through arbitration is in effect as of the effective date of the Group Plan, and shall remain in effect until the dispute between us has been resolved. Recovery of Claims Payments Ineligible Persons If KPS knowingly or unknowingly makes any payment on behalf of an individual who for any reason was not eligible to receive the services and benefits provided herein, KPS is entitled to full reimbursement from such ineligible individual or from a Subscriber who applied for the ineligible benefits on behalf of such individual. If KPS knowingly or unknowingly receives Premium payment on behalf of an individual who for any reason was not eligible to receive the services and benefits provided herein, KPS reserves the right to refund any Premium payment(s) in excess of claims paid for the time the individual was ineligible, and shall have the right to recover the cost of any benefit furnished while such individual was improperly enrolled in this Group Plan. Incorrect Claim Payment KPS is entitled to full reimbursement from the payee for any incorrect claim payment. The term "incorrect claim payment" includes but is not limited to the following: Payment to the wrong Provider Payment of an incorrect amount Payment for a service that is not a Covered Benefit or Service Duplicate payment for the same service Payment on behalf of the wrong Enrollee Incorrectly billed procedure or diagnosis SUBSCRIBERJDEPENDENT LIABILITY AND RIGHTS Subscriber/Dependent Liability Subscribers and their Eligible Dependents who are enrolled in this Group Plan are liable for the following costs: > Deductible ~- Copayments Page: 14 110 Charges for non-covered services Coinsurance, up to the Coinsurance Stoploss limit defined in Attachment A - Benefits Booklet Charges incurred after an annual or lifetime maximum benefit, for a specific service or supply, has been exhausted (such as the annual maximum benefit for durable medical equipment) >' Charges in excess of the amount paid by KPS to non-participating Providers If KPS fails to reimburse a Participating Provider for the cost of Medically Necessary Covered Services provided in accordance with the terms of this Contract, neither the Enrollee nor the Group shall be required to compensate the Participating Provider for such services beyond the limit of Deductibles, Copayments or Coinsurance amounts specified in the Benefits Booklet. KPS will continue to reimburse a Participating Provider for Medically Necessary Covered Services rendered to an Enrollee after the Participating Provider's contract with KPS has ended, for such time as the Enrollee remains covered under this Group Plan, until (i) the Enrollee's course of treatment has been completed, or (ii) the care of the Enrofiee has been appropriately transferred to another Participating Provider. The KPS Medical Director is responsible for determinations regarding the completion of a course of treatment and the transfer of patient care. KPS Privacy Policy KPS Health Plans is committed to protecting the privacy of Enrollees' personal and health information. We are required by applicable federal and state law to maintain the privacy of personal and health information. KPS Health Plans is also required to give this notice to Enrollees to tell them how KPS may use and give out ("disclose") their personal and health information held by KPS Health Plans. Personal and health information (referred to in this notice as "personal information") means any information that is identifiable as personal information, including information regarding health care and treatment, identifiable factors such as the Enrollee's name, age, and address; or financial information. We may collect personal information about the Subscriber, or members covered by KPS Health Plans through the Subscriber, from the following sources: Information we receive from the Enrollee, including information provided on applications or other forms, ¢r Information we receive from the Enrollee's health care providers or other companies, such as other health insurance companies, relating to medical claims and billings, * General information about the health care services the Enrollee has received, such as the quality and availability of services. We restrict access to personal information about the Enrollee to only those who need to know that information to provide treatment, payment or health care operations services to the Enrollee. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard the Enrollee's personal information. We do not disclose any personal information about our members or former members to anyone, except as permitted or required by law. However, KPS Health Plans will use and give out personal health information: To the Enrollee or someone who has the legal dght to act for the Enrollee (their personal representative), To the Secretary of the Department of Health and Human Services, if necessary, to make sure the Enrollee's privacy is protected, * To law enforcement officials when investigating and/or prosecuting alleged civil or criminal actions, and ¢r Where required bylaw. KPS Health Plans has the right to use and give out personal information to arrange for treatment, payment of, and health care operations services, including: Medical quality reviews * Accounting Legal and risk management services Page 15 111 KPS Health Plans may use or give out personal information for the following purposes under limited circumstances: * For Government healthcare oversight activities (such as fraud and abuse investigations) * To avoid a serious and imminent threat to health or safety By law, KPS Health Plans must have wdtten permission (an "authorization") to use or give out personal information for any purpose that is not set out in this notice. The Enrollee may take back ("revoke") their written permission at any time, except if KPS has already acted based on their permission. By law, Enrollees have the right to: *' See and get a copy of their personal information held by KPS Health Plans, except in certain limited situations. '* Make a reasonable request in writing to amend any of their personal information created by KPS Health Plans if they believe that it is wrong or if information is missing, and KPS Health Plans agrees. If KPS Health Plans disagrees, we will notify the Enrollee why Jn writing. Enrollees may have a statement of their disagreement added to their personal information. * Get a listing of those obtaining their personal information from KPS Health Plans in the past 6 years. The listing will not include information: That was given to the Enrollee or their personal representative, That the Enrollee authorized KPS Health Plans to release, or · That was given out for law enforcement purposes, or That was given out to pay for the Enrollee's health care claim or a disputed claim. * Request in writing that KPS communicate with them in confidence about their personal information by alternative means or to an altemative location. If they advise us that disclosure of all or any part of their personal information could endanger them, we must comply with any reasonable request provided it specifies an alternative means or location. * Ask KPS Health Plans to place additional restrictions on our use or disclosure of their personal information for treatment, payment, health care operations or to persons they identify. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). * Get a separate electronic or paper copy of this notice. For more information about exercising their rights set out in this notice, Enrollees may call KPS Health Plans' Member Services department at (360) 478-6796 or toll free at (800) 552-7114. They can also reach KPS Health Plans' privacy official for this purpose at (800) 552-7114. If an Enrollee believes KPS Health Plans has violated their privacy rights set out in this notice, they may file a complaint with KPS Health Plans at the following address: KPS Health Plans Compliance Department P.O. Box 339 Bremerton, WA 98337 Filing a complaint will not affect the Enrollee's benefits under KPS Health Plans. They may also file a complaint with the Secretary of the Department of Health and Human Services. KPS Health Plans does have the right to change the way personal information is used and given out. If KPS Health Plans makes any changes, Enrollees will get a new notice by mail within 60 days of the change, and that notice will become effective on the date the revised notice is issued. Please note: Telephone calls to and from KPS Health Plans may be recorded for quality assurance and training purposes. If the Enrollee is the primary Subscriber with KPS Health Plans and other persons are covered by KPS Health Plans through them, we suggest that the Subscriber share this information with each other to ensure that each of them is aware of our policy and their privacy rights. Please refer to KPS Health Plans' website at www. KPSHealthPlans.com for more information about our privacy practices. Page: 16 112 COMPLAINTS AND APPEALS PROCESS Complaints All Enrollees have the right to contact KPS whenever they have a question, complaint or concern regarding: ~' Their benefits ~- Their access to care or how to arrange for care > Any KPS Participating Provider > Service they receive from KPS ~. Any other issue related to this Group Plan or KPS. In the event an Enrollee has a complaint, KPS Member Services Representatives are available Monday through Friday, from 8:00 a.m. until 5:00 p.m. Pacific Time, except on nationally recognized holidays. Although a Member Services Representative can resolve most matters, Enrollees may choose to file a complaint, or request an appeal, if they are not satisfied with the Member Services response. The following steps outline the procedure for filing a complaint: EITHER KPS Member Services will work The service provided by KPS Send a written statement of ' with the Enrollee and try to the complaint to: resolve the complaint over the Eligibility KPS Health Plans phone. Otherwise. KPS will Coverage or Benefits Attn: Member Services send a written response within I Resolution Department 30 days of receiving the Claims Payment PO Box 339 complaint. Access to Care Bremerton, WA 98337 Quality of Care OR Complaints about Participating Providers are investigated KPS Participating Providers Call KPS Member Services at thoroughly and are reviewed 360-478-6796 periodically. or toll free at 1-800-552-7114 Standard Appeals Process Enrollees have the right to appeal any decision regarding a complaint or any aspect of their health care coverage that is not in their favor. The request for an appeal must be made within 180 days of the date they receive an EOB, letter or other type of communication, from KPS, that contains an unfavorable decision regarding their benefits. Such decisions could affect: The service received from KPS Access to health care services or Providers Eligibility for coverage Benefit coverage Termination of coverage under this Group Plan (except termination for non-payment of Premium) Non-payment of a claim, either completely or partially A denial or modification of a request for pre-authorization of any health care service or supply A denial of a request for coverage of an experimental or investigational service or supply To file an appeal, the Enrollee, his/her designated representative, or his/her Provider may either call or write KPS at the phone number or address listed above. Any documentation supporting the Enrellee's position may be included with the appeal. Page 17 KPS will notify the Enrollee, in writing, that the appeal request has been received and include additional information regarding the Appeals Process and the Enrollee's rights and responsibilities during an appeal. The Enrollee has the right to send an appeal directly to an Independent Review Organization (IRO) if KPS does not respond to the Enrollee within the allotted time period, as follows: Decisions Regarding: Days to Respond: Service-Related Appears 30 Days Denials of Experimental and/or Investigational Procedures or Supplies 20 Days All other Adverse Determinations 14 Days Expedited Appeals Process If the Enrollee's health care Provider, or the KPS Medical Director, reasonably determines that by following the Standard Appeals Process the Enrollee's life, health, or ability to regain maximum function would be jeopardized, KPS will invoke an Expedited Appeals Process and make a decision within 72 hours after it is received. The Enrollee will receive notice of this action. (~ENERAL TERMS AND CONDITIONS Applicable Law This Contract shall be governed by, and construed in accordance with, the laws of the state of Washington. Venue for this Contract shall be Kitsap County. Assignment of Benefits The benefits of this Contract shall accrue to Subscribers and their enrolled Eligible Dependents. Neither this Contract, nor its payments or Covered Benefits and Services are assignable to a third party. KPS reserves the right to make benefit payments to the Subscriber, the Provider, or jointly, as KPS deems necessary and appropriate, subject to federal and/or state laws. Binding Agreement This Contract is binding on KPS and the Group, and their respective executors, administrators, successors and assigns. By election of coverage or payment of applicable Premiums, or if the Group's Subscribers or their enrolled Eligible Dependents seek the services provided under this Contract, all of the terms, covenants and conditions contained herein shall become valid and binding on the Group and its Subscribers and enrolled Eligible Dependents, notwithstanding the failure of the Group to sign this Contract. This Contract shall not bind KPS until (i) it has been executed by a person authorized by KPS, and (ii) an executed copy has been delivered to the Group. Confidentiality The underwriting and financial terms of this Contract are confidential and shall not be disclosed except as is necessary for the performance of this Contract, or as required by law. Contract Modifications Except as set forth under Premium Rate Adjustments, KPS reserves the right to modify the provisions of this Contract, or the services described in the Benefits Booklet, upon thirty (30) days written notice to the Group. The Group may elect to reject such modifications by providing KPS with fifteen (15) days written notice. However, rejection of a modification will result in the termination of this Contract as of the last day of the month for which Premium payment has been received. Lack of notification of rejection by the Group shall be interpreted as acceptance of the modification and this Contract will be renewed as modified. Page: 18 114 No modification of the terms of this Contract shall be binding upon KPS unless endorsed, in writing, and signed by an authorized officer of KPS. Such endorsement shall be deemed a part of this Contract, effective as of the effective date of the endorsement. Any amendment or Contract modification required by law or regulation shall become effective as of the effective date required by such law or regulation. Coverage Limits The Covered Benefits and Services offered under this Contract are subject to the coverage limits and maximums set forth in Attachment A - Benefits Booklet. Entire Agreement This Contract, together with Attachment A - Benefits Booklet; Attachment B - Premium Rates and Underwriting Criteria; and any riders and/or endorsements attached hereto, constitute the entire agreement. This Contract supersedes all previous communications, representations or agreements, either verbal or written between KPS and the Group, with respect to the subject matter herein. Equity of Application This Contract is intended to apply equally to all Enrollees. False or Misleading Information If the Group provides statements or other information on the Group Master Application form, or any other form required by KPS, that affects the acceptability of the Group for coverage, or the risk assumed by KPS for providing coverage, KPS may, at its sole discretion, elect to immediately terminate this Group Contract and recover any claims and/or administrative costs from the Group, Enrollee(s), or any other person(s) responsible for providing the false or misleading information. Force Majeure In the event KPS is unable to perform its obligations hereunder by reason of fire, casualty, lockout, strike, labor condition, riot, war, act of God or by ordinance, law, order or decree of any legally constituted authority, then this Contract may, at the option of KPS, be suspended. During any period of suspension, KPS shall not be required to perform any service hereunder, nor shall KPS be liable for any damages arising from any event that precipitated the suspension. If this Contract is suspended pursuant to this provision, any obligation by the Group and/or an Enrollee to make Premium payments shall also be suspended for the same period of time. Group Cooperation The Group agrees to cooperate with KPS in the administration of this Contract by: (i) Advising Subscribers and their enrolled Eligible Dependents of policies and procedures applicable to this Group Plan. (ii) Providing Subscribers and their enrolled Eligible Dependents with a Benefits Booklet, ID cards and any applicable notices or other information regarding this Group Plan. (iii) Providing information about Enrollees that is relevant to the determination of eligibility, claim reimbursement, coordination of benefits or other information required for the administration of this Contract. (iv) Making appropriate payroll deductions, if applicable, to facilitate Premium payment. Headings The headings of sections and paragraphs in this Contract are for convenience and reference purposes only and do not affect in any way the meaning or interpretation of any provision of this Contract. Page 19 115 Notices Any notice that may affect the provisions of this Contract shall be deemed delivered to the Group when deposited in the United States mair with prepaid postage, addressed to the Group at the most recent address listed for the Group. Any notice that may affect the provisions of this Contract shalr be deemed delivered to KPS when deposited in the United States mail with prepaid postage, addressed to KPS at the following address: P.O. Box 339, Bremerton, WA 98337-0039. Any requirement of KPS to provide notice to Enrollees shall be fulfilled when the Group has received such notice. It is the responsibility of the Group to disseminate notices to Enrollees within thirty-one (31) days of receipt. Severability If any term, provision, endorsement or condition of this Contract is deemed invalid or unenforceable by a court of competent jurisdiction, the same shall be deemed severable from this Contract. However, the remainder of this Contract shall remain in full force and effect and shall in no way be affected, impaired or invalidated as a result of such decision. Third Party Beneficiaries There are no third party beneficiaries to this Contract. Waiver of Breach Waiver of a breach of any provision of this Contract shall not be deemed to be a waiver of any other breach of the same or different provision. Page: 20 216 KPS Health Plans, In Rehabilitation 400 Warren Avenue P.O. Box 339 Bremerton, WA 98337-0039 CITY OF BREMERTON -- PLAN A COVERAGE CONTRACT Group Number: 21001-21006 Effective Date: 1/1/2004 Renewal Month: January Open Enrollment December This Coverage Contract includes the following: Attachment A - Benefits Booklet Attachment B - Premium Rates and Underwriting Criteria Riders: N/A Optional Riders: Occupational Injury Coverage - LEOFF I Employees Only Endorsements: N/A This Contract is entered into and delivered in the state of Washington and is governed by Washington State laws, except to the extent state laws are preempted by federal law. Signature by a qualified Group representative or payment of the Premium shall constitute acceptance of the terms and conditions set forth herein. FOR KPS: FOR GROUP: Elizabeth A. Gilje, President Signature Date Print Name Title Date 117 KPS Health Plans, In Rehabilitation 400 Warren Avenue P.O. Box 339 Bremerton, WA 98337-0039 CITY OF BREMERTON -- PLAN B COVERAGE CONTRACT Group Number: 21010, 21014 Effective Date: 1/1/2004 Renewal Month: January Open Enrollment December This Coverage Contract includes the fo[lowing: Attachment A - Benefits Booklet Attachment B - Premium Rates and Underwriting Criteria Riders: N/A Optional Riders: N/A Endorsements: N/A KPS Health Plans, In Rehabilitation, hereinafter referred to as KPS, is a duly licensed health care services contractor (HCSC) in Washington State. Jn its capacity as an HCSC, KPS agrees to underwrite and provide the benefits and services described in Attachment A - Benefits Booklet, to the eligible Employees, and their Eligible Dependents, of the above-named Group, provided the Group, its eligible Employees and their Eligible Dependents, meet and comply with the provisions of this Contract. Contract Form: BREMB-22900-2004 118 TABLE OF CONTENTS DEFINITIONS ................................................................................................................................... 1 CONTRACT EXAMINATION PERIOD ................................................................................................... 2 EFFECTIVE DATE, DURATION AND RENEWAL .................................................................................... 2 PREMIUM PAYMENT PROVISIONS ..................................................................................................... 2 Payment Due Date/Grace Period ............................................................................................................. 2 Premium Rate Adjustments ...................................................................................................................... 3 Premiums Paid by Subscribers/Dependents ............................................................................................ 3 Premium Refunds ..................................................................................................................................... 3 ELIGIBILITY AND ENROLLMENT ......................................................................................................... 3 Group Eligibility ......................................................................................................................................... 3 Subscriber/Dependent Eligibility Requirements ........................................................................................ 3 Enrollment ................................................................................................................................................. 4 Enrollment Under Special Circumstances ................................................................................................ 4 When Coverage Begins ............................................................................................................................ 5 Coverage Waiting Periods ........................................................................................................................ 5 TERMINATION OF COVERAGE .......................................................................................................... 6 Continuity of Coverage .............................................................................................................................. 6 Termination of Group Contract .................................................................................................................. 6 Re-Enrollment/Reinstatement ................................................................................................................... 7 Termination of Enrollee Coverage ............................................................................................................ 7 Continuation of Inpatient Coverage .......................................................................................................... 7 Continuation of Coverage for a Disabled Child ......................................................................................... 8 CONTINUATION OF COVERAGE ........................................................................................................ 8 Coverage During a Labor Dispute ............................................................................................................ 8 Continuation of Group Coverage .............................................................................................................. 9 COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) ........................................................ 9 Individual Conversion Coverage ............................................................................................................... 9 COORDINATION OF BENEFITS (COB) .............................................................................................10 General Provision .................................................................................................................................... 10 Definitions ................................................................................................................................................ 10 Claim Determination Period .................................................................................................................... 11 Effect on Benefits .................................................................................................................................... 11 Order of Benefit Determination ............................................................................................................... 11 Facility of Payment .................................................................................................................................. 11 Right of Recovery .................................................................................................................................... 12 Right to Receive and Release Information ............................................................................................. 12 Disclosure of Coordination ...................................................................................................................... 12 KPS' RIGHT OF RECOVERY ........................................................................................................... 12 Limitations and Exclusions ...................................................................................................................... 12 Third Party Liability: Reimbursement and Subrogation .......................................................................... 12 Collection and Reimbursement by Enrollee (or the Enrollee's Representative) ..................................... 13 Subrogation: Assignment of Third Party Claim to KPS ........................................................................... 13 Trust and Cooperation Between the Enrollee (or the Enrollee's Representative) and KPS ................... 14 Agreement to Arbitrate ............................................................................................................................ 14 Recovery of Claims Payments ................................................................................................................ 14 SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS ........................................................................... 14 SubscribedDependent Liability ............................................................................................................... 14 KPS Privacy Policy .................................................................................................................................. 15 COMPLAINTS AND APPEALS PROCESS ........................................................................................... 17 Complaints .............................................................................................................................................. 17 Standard Appeals Process ...................................................................................................................... 17 Expedited Appeals Process .................................................................................................................... 18 GENERAL TERMS AND CONDITIONS ...............................................................................................18 Applicable Law ........................................................................................................................................ 18 Assignment of Benefits ........................................................................................................................... 18 Binding Agreement .................................................................................................................................. 18 Confidentiality .......................................................................................................................................... 18 Contract Modifications ............................................................................................................................. 18 Coverage Limits ...................................................................................................................................... 19 Entire Agreement .................................................................................................................................... 19 Equity of Application ................................................................................................................................ 19 False or Misleading Information .............................................................................................................. 19 Force Majeure ......................................................................................................................................... 19 Group Cooperation .................................................................................................................................. 19 Headings ................................................................................................................................................. 19 Notices .................................................................................................................................................... 20 Severability .............................................................................................................................................. 20 Third Party Beneficiaries ......................................................................................................................... 20 Waiver of Breach ..................................................................................................................................... 20 120 DEFINITIONS Capitalized words found in the text of this section are defined below or in the Benefits Booklet section. Child means any one of the following: (i) An unmarried natural child, adopted child, stepchild or other legally designated ward under the Limiting Age who is primarily dependent upon the Subscriber or the Subscriber's Spouse for support, (ii) An unmarried child under the Limiting Age who is legally entitled to receive medical coverage as a result of a court order binding either the Subscriber or the Subscriber's Spouse, regardless of whether or not the Subscriber or Subscriber's Spouse has legal custody of the Child. (iii) An unmarried child who has reached the Limiting Age, or is older than the Limiting Age, is incapable of self-sustaining employment due to developmental disability or physical handicap, and is primarily dependent upon the Subscriber or the Subscriber's Spouse for support and maintenance (see Continued Eligibility for a Disabled Dependent). Contract means this document and any other attachments, exhibits, Riders or Endorsements listed on the title page or otherwise described herein, and any subsequent amendments or modifications to the Contract or its attachments, exhibits, Riders or Endorsements. Contract Renewal Month means the calendar month specified on the title page of this Group Contract during which the Group may renew its coverage each year under this Group Plan. Covered Benefit or Service means those Medically Necessary services described in Attachment A - Benefits Booklet that an Enrollee is entitled to receive. Eligible Dependent means the legal Spouse or Child of an Eligible Employee, or the legal Spouse or Child of an active, full-time LEOFF I or LEOFF II firefighter. Employee means an active, full-time Employee who is not a LOEFF I or LEOFF II Employee. Endorsement means an amendment to the conditions of coverage or the benefits provided by this Group Plan. Enrollee means a person enrolled in this Group Plan. Group means the employer entity, association or other group that has entered into this Contract with KPS. Group Plan means the Benefits Booklet plus any Riders, Endorsements or other attachments that state the terms and conditions for administration of the Enrollee's benefits. Group Master Application means the application form completed by the Group and submitted to KPS prior to securing coverage under this Group Plan. The Group Master Application identifies the size, participation and contribution eligibility requirements applicable to the Group. LEOFF I Employee means an active, full-time law enforcement officer or flrefighter hired prior to October 1, 1977, and who is a member of the LEOFF system as defined in Sections (3) and (4), CH 131, Law of 1972, 1s~ EX. Session LEOFF II Employee means an active, full-time law enforcement officer or firefighter hired on or after October 1, 1977, and who is not a member of the LEOFF system as defined in Sections (3) and (4), CH 131, Law of 1972, 1st Ex. Session. Limiting Age means the age at which a Child may no longer be covered under this Group Plan as an Eligible Dependent of the Subscriber. The Limiting Age is specified in the Benefits Summary included in this Benefits Booklet. Medical Director means the licensed physician acting as chief medical advisor for KPS. Non-Participating Provider/Facility means any Provider or facility not contracted directly with KPS, or indirectly through First Choice Health Network, Providence Preferred Provider Organization or MultiPlan. Page1 121 Open Enrollment Period means the thirty-one (31) day period, or some other period agreed to by both KPS and the Group, beginning one (1) month prior to the Group's Renewal Month, or at some other mutually agreeable time, but at least annually. During the Open Enrollment Period, Subscribers may add or delete Eligible Dependents, and all eligible Employees and their Eligible Dependents have the opportunity to select from alternative health plans offered by the Group. Coverage will be effective as of the renewal date. Premium means the periodic payment made by, or on behalf of the Enrollee, as consideration for this Group Plan and in accordance with the terms of this Contract. Premium Due Date means the scheduled, periodic dates by which Premium payments must be received by KPS as a condition for continued enrollment in this Group Plan. This date is typically the first day of each month of coverage. Provider means a licensed or certified health care practitioner acting within the scope of his/her license or certificate. Rider means an additional benefit over and above those listed in the Benefits Summary. Rider documents are attached at the back of the Benefits Booklet and provide detailed benefit information. Spouse means an individual who is living in a marital relationship with the Subscriber. The marital relationship must be legally recognized by the state of Washington. Subscriber means the primary person, generally the Employee, enrolled in this Group Plan. CONTRACT EXAMINATION PERIOD. If, after examination, the Group is not satisfied with this Contract for any reason, the Group may return the Contract to KPS within ten (10) days of the date it is received. Upon receipt of the returned Contract, KPS wilt refund to the Group any pre-paid Premiums. The Contract shall subsequently be deemed null and void. EFFECTIVE DATE~ DURATION AND RENEWAL,, This Contract shall begin at 12:01 a.m. Pacific Time on the Effective Date (as indicated on the title page), and shall remain in effect until the Contract Renewal Month unless terminated according to the provisions set forth herein. Thereafter, this Contract may be renewed automatically at 12:01 a.m. on the same date (month and day) in subsequent calendar years unless otherwise terminated according to the provisions set forth herein. PREMIUM PAYMENT PROVISIONS Payment Due Date/Grace Period The initial Premium payment is due and payable to KPS on or before the effective date of this Contract indicated on the title page. Thereafter, Premium payments are due and payable on or before the first day of every month ("Premium Due Date") for which coverage is provided. A roster of current enrollment and enrollment changes must accompany each Premium payment. A ten (10) day grace period following the Premium Due Date is allowed, during which time this Contract shall not be terminated. However, KPS may, at its sole discretion, elect to extend the grace period for up to sixty (60) days from the Premium Due Date, or cancel this Contract immediately, without notice to the Group if payment is not received by the end of the grace period. if KPS elects to immediately cancel this Contract due to non-payment of Premium, the effective date of cancellation will be retroactive to the last day of the month for which payment was received. No further liability for claims will accrue to KPS. Enrollees in this Group Plan shali not be entitled to benefits during any calendar month for which the Premium, on his/her behalf, was not received by KPS. Page: 2 122 Premium Rate Adjustments The Premium rates applicable to this Group Plan are defined in Attachment B - Premium Rates and Unden~vriting Criteria. Rates are guaranteed until the Contract Renewal Month each calendar year. Notwithstanding the foregoing, KPS reserves the right to revise the rates as follows: As part of the annual Contract renewal process; As a result of any state or federal law or regulation that imposes an additional tax, new tax or other assessment on KPS revenue; and > In the event there is a material change in the basis upon which KPS assumed risk under this Contract. Such changes may include raise or misleading information presented by the Group, changes in the benefits or other Contract terms required by statute or regulation, adverse claims or underwriting experience, or fluctuations of ten percent (10%) or more in the number of enrolled Subscribers and/or Eligible Dependents. KPS will give the Group sixty (60) days prior written notice of any change in Premium rates not associated with the annual Contract renewal process. KPS will give the Group thirty (30) days prior written notice of rate increases associated with the annual Contract renewal process. Premiums Paid by Subscribers/Dependents In certain instances, Subscribers and their enrolled Eligible Dependents may be required to self-pay their Premiums in order to continue coverage. Those instances include: ~' Strikes, lockouts and other labor disputes that cause a disruption in Employee benefits ~' When the Subscriber and/or Eligible Dependent(s) elects to continue coverage under a COBRA provision or other coverage continuation provision available under this Group Plan The Group is required to collect self-paid Premiums for continuation coverage and forward payments to KPS on or before the Premium Due Date. In the instance of strikes, lockouts and ~abor disputes, the Subscriber may self-pay their Premium directly to KPS on or before the Premium Due Date. Premium Refunds KPS will refund to the Group any Premium paid, in advance, for periods after the termination date of this Group PJan. In the case of ineligible persons enrolJed in this Group Plan, KPS will refund to the Group any Premium paid during a period of ineligibility that is in excess of claim payments made on behalf of the ineligible person(s) during the period of ineligibility. This refund will not exceed an amount equal to three (3) months of Premium payments. ELIGIBILITY AND ENROLLMENT Group Eligibility In order to be eligible to participate in this Group Plan, the Group must continuously meet all eligibility, participation, Group size, contribution and other requirements specified in the Group Master Application form. KPS reserves the right to audit the Group's employment, payroll and eligibility records to ensure that the Group continues to meet its participation requirements, and to ensure that eligible Employees and their Eligible Dependents are properly enroJled in this Group Plan. Subscriber/Dependent Eligibility Requirements Active, full-time Employees, as defined in the Definitions section and their Eligible Dependents, are eligible to enroll in this Group Plan. Page 3 123 Eligible Dependents of active, full-time LEOFF I or LEOFF II firefighters, as defined in the Definitions section, are also eligible to enroll in this Group Plan. The Child of an Eligible Dependent, other than the Child of the Spouse, is not eligible to enroll in this Group Plan. Enrollment Premium payments, if applicable, accompany must all applications for coverage. Current Employees and their Eliqible Dependents, including Eligible Dependents of active, full-time LEOFF I and LEOFF Il firefighters, are initially eligible to apply for coverage beginning on the effective date of this Group Plan. Application for coverage must be made within thirty-one (31) days of initial eligibility. New Employees and their EliRible Dependents, including Eligible Dependents of active, full-time LEOFF I and LEOFF II fireflghters, may initially apply for coverage on the first day of the first full month following their first day of employment. Application for coverage must be made within thirty-one (31) days of initial eligibility. Those Employees who do not enroll immediately following their probationary period(s) must wait until the next Open Enrollment Period. A new Spouse and the Spouse's Child(ren) may initially apply for coverage as of the date of marriage. Application for coverage must be made within thirty-one (31) days of initial eligibility. Newborn, Adopted Child(ren) and Child/children placed for adoption are initially eligible for coverage as follows: > A natural newborn Child is eligible as of the date of birth and is covered automatically for a period of three (3) weeks. In order for coverage to continue after the initial three (3) week period, the Child must qualify as an Eligible Dependent. If additional Premium is required, the Child must be enrolled in this Group Plan within sixty (60) days of birth; ~. Adopted Child(ren) and Child(ten) placed for adoption are eligible (i) on the date of their adoption. (ii) on the date the Employee or Spouse assumes legal obligation for total or partial support in anticipation of adoption, or (iii) on the date the Employee or Spouse acquires partial or complete legal custody. If additional Premium is required, the application for coverage must be submitted within sixty (60) days of the date of placement for adoption. NOTE: When additional Premium is not required, we encourage enrollment as soon as possible to prevent delays in claims processing. In the case of court-ordered coverage, a dependent Child becomes initially eligible on the date the Subscriber or Spouse receives the order to provide medical coverage for the Child, even if neither the Subscriber nor the Spouse is the custodial parent. Application for coverage must be submitted within thirty- one (31) days of the date of the order. Employees and their Eligible Dependents who do not enroll when they are initially eligible must wait until the next Open Enrollment Period except in certain circumstances (see Enrollment Under Special Circumstances). Enrollment Under Special Circumstances Loss of Other Coverage When Employees and/or their Eligible Dependents lose coverage under another health plan, they may apply for coverage under this Group Plan if the following applies: They declined initial enrollment in this Group Plan in writing; They lose eligibility in another health plan or their coverage is terminated; and They make application to enroll in this Group Plan within thirty-one (31) days of losing other coverage. Otherwise, they must wait until the next Open Enrollment Period to apply for coverage. NOTE: Dependents may not enroll in this Group Plan unless the Employee is a Subscriber. Page: 4 124 Marriage, Birth, Adoption or Placement for Adoption Employees who declined initial enrollment in this Group Plan in writing, may apply for coverage for themselves and their Eligible Dependents in the event of marriage, birth of a Child, adoption or placement for adoption. Application for enrollment must be received by KPS: within thirty-one (31) days following the date of marriage, or within sixty (60) days, if additional Premium is required, following the date of birth, adoption or placement for adoption, or ~' at the next Open Enrollment Period if these time frames are not met. NOTE: When additional Premium is not required, we encourage enrollment as soon as possible to prevent delays in craims processing, Court-Ordered Coverage Employees who declined initial enrollment in this Group Plan in writing, may subsequently apply for coverage for themselves and their Eligible Dependents in the event they are required to provide health care coverage for an Eligible Dependent Child as a result of a court order. Application for enrollment must be received within thirty-one (31) days following the date of the court order, or wait until the next Open Enrollment Period. When Coverage Begins Coverage for new Enrollees begins on their date of initial eligibility provided they enrolled in this Group Plan within the specified time limits (see Enrollment) and any applicable Premium amounts have been paid. If the Employee enrolls during an Open Enrollment Period the coverage will begin on the first of the month following the Open Enrollment Period. A newborn Child who meets eligibility requirements is covered automatically for a period of three (3) weeks from the date of birth, provided either the female Subscriber, or male Subscriber's Spouse, is eligible for maternity coverage under this Group Plan at the time of the Child's birth. If additional Premium is required, coverage will not extend beyond the three week period unless the Child is enrolled within sixty (60) days of the date of birth. Any applicable Premium amount must accompany the enrollment application. If additional Premium is required, coverage for an adopted Child is retroactive to the date the Child was legally placed for adoption, provided the Child was enrolled within sixty (60) days from the date of placement, and provided any applicable Premium amount has been paid by the Premium Due Date. NOTE: When additional Premium is not required, we encourage enrollment as soon as possible to prevent delays in claims processing. Coverage Waiting Periods Pre-Existing Conditions KPS imposes a three (3) month waiting period before providing coverage for a Pre-existing Condition. A "Pre-existing Condition" is any condition about which, during the three (3) month period immediately before enrolling in this Group Plan, an EnroJlee received medical advice, or for which his/her Provider recommended or provided treatment. Genetic information shall not be treated as a pre-existing condition unless there has been a diagnosis of the condition related to the specific genetic information. However, this waiting period may be reduced by the number of months of Creditable Coverage the Enrollee has accrued under other health care programs prior to their enrollment in this Group Plan. "Creditable Coverage" means periods of other health coverage an Enrollee may use to reduce pre-existing waiting periods. These include group health coverage; Medicare; Medicaid; military health coverage; Indian Health Service or tribal coverage; state high risk pool; federal or public health plans; Peace Corps Plan; other health insurance coverage. The Enrollee will receive credit for prior Creditable Coverage if it occurred anytime during the three (3) month period immediately preceding enrollment in this Group Plan and there was no break in the prior coverage. No credit will be given if there was more than a three (3) month break in coverage between the Enrollee's prior plan and enrollment in this Group Plan. Any Employer imposed probationary period will not be considered a break in coverage or creditable coverage. Page 5 125 To request credit of the Pre-existing Condition waiting period, the Enrollee must submit a Certificate of Creditable Coverage from the prior health plan carrier with his/her enrollment application. In lieu of a Certificate of Creditable Coverage, the Enrollee must provide all of the following information: The name of the prior health plan carrier The dates of coverage under the prior plan Proof of coverage under the prior plan that documents the coverage period(s) There are no waiting periods for: Pregnancy Formulas necessary for the treatment of phenylketonuria (PKU) Prescription drugs included in the Pharmacy Benefit (if applicable) A newborn Child or an adopted Child whose effective date of coverage is the date of birth or placement for adoption Transplant Procedures KPS provides coverage for transplant procedures only after an Enrollee has been continuously covered under this Group Plan for six (6) months. This transplant waiting period applies to the transplant procedure as well as any pre- and post-transplant care directly related to a transplant they receive while covered under this Group Plan. If the Enrollee was covered under another KPS plan immediately prior to enrolling in this Group Plan, KPS will credit to this Group Plan the portion of the transplant waiting period that was satisfied under the prior KPS plan. TERMINATION OF COVERAGE Continuity of Coverage Continuity of coverage under this Contract is guaranteed to all eligible Enrollees provided the Group continues to meet eligibility requirements and continues to pay applicable Premium payments on a timely basis. Termination of Group Contract This Group Plan may be terminated if any of the following occurs: The Group fails to make full Premium payments The Group violates, or refuses to comply with, the terms and conditions of this Contract The Group violates, or refuses to comply with, any published KPS policies and procedures that have been approved by the Insurance Commissioner ~' There is a change to, or implementation of, federal or state law that prohibits the continued offering of this Group Plan KPS replaces this Group Plan. In this case, the replacement plan will (i) include the services covered under the replaced Group Plan; (ii) be offered to the Group's eligible Employees and their Eligible Dependents; and (iii) not significantly limit access to the kind of services covered under the replaced Group Plan In addition, the Group may terminate this Contract, at any time, by providing thirty (30) days written notice to KPS. If this Group Contract terminates, for any reason, coverage for all Enrollees will end automatically on the effective date of termination, or on the last day of the last month for which the Group paid the Premium, whichever occurs first. KPS will refund to the Group any Premium paid in advance for periods after the termination date. Page: 6 126 In the case of termination or non-renewal of this Group Contract, the Group shall be responsible for providing the following information to all affected Employees and their Eligible Dependents: ~' The effective date of termination of coverage; and ~- The raason(s) for termination or non-renewal. Re-Enrollment/Reinstatement If this Group Contract has been cancelled by KPS due to non-payment of Premium, the Group automatically forfeits all dghts to guaranteed renewal of coverage afforded under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Any decision to reinstate or reenrell the Group is at the sole discretion of KPS. If the Group voluntarily cancels this Group Contract prior to the Open Enrollment Period, KPS may, at its sole discretion, impose up to a twelve (12) month waiting period before the Group is eligible to reapply for coverage. Termination of Enrollee Coverage Coverage for an individual Enrollee under this Group Contract will end if any one of the following events Occurs: Non-payment of any Premium amount, when Premium payment is the responsibility of the Enrollee The Enrollee loses eligibility for coverage under this Group Contract The Enrollee commits a fraudulent act with regard to KPS and this Group Plan The Enrollee refuses to comply with the terms and conditions of this Group Plan as described in the Benefits Booklet The Enrollee voluntarily disenrolls from this Group Plan There is a change in either state or federal laws that no longer permit KPS from offering this Group Plan ~' This Group Contract is terminated Additionally, Eligible Dependent coverage ends if: The Subscriber is no longer employed or no longer meets eligibility requirements The Subscriber dies The Subscriber and Spouse divorce The ChiJd reaches the Limiting Age or marries Coverage ends on the last day of the month in which the Enrollee was eligible for coverage, provided all applicable Premium amounts have been paid. In the case of non-payment of Premium, coverage ends on the last day of the month for which KPS received a Premium payment. Upon termination of coverage either KPS or the Group shall issue a Certificate of Creditable Coverage certifying the period(s) during which the Enrollee was enrolled in this Group Plan. An Enrollee who loses coverage under this Group Plan may be eligible to continue coverage or enroll in a KPS Individual Conversion Plan (see Continuation of Coverage). A Subscriber who voluntarily disenrolls from this Group Plan while still an Employee will not be eligible to re- enroll in this Group Plan until the next Open Enrollment Period. See Enrollment Under Special Circumstances for exceptions to this policy. Continuation of Inpatient Coverage An Enrollee who is receiving care as an inpatient in an accredited general Hospital, or other approved facility, on the date that coverage would otherwise end, is eligible to continue receiving benefits under this Group Plan provided the following conditions are met: ~, KPS pre-authorized the inpatient care (see Prior Authorization of Inpatient Care); and ~ All applicable Premium amounts continue to be paid Page 7 127 KPS will continue to provide benefits, under this Group Plan, until one of the following events occurs: The Enrollee is no longer receiving inpatient care The KPS Medical Director determines that inpatient care is no longer Medically Necessary The Enrollee has exhausted the inpatient benefits offered under this Group Plan (annual reinstatement of benefits does not apply under this provision) Non-payment of Premium Three (3) consecutive months have elapsed since the date coverage would have otherwise ended The Enrollee enrolls in another KPS plan or in any other health plan that provides inpatient hospital benefits The Enrollee is not eligible for the extended coverage described above if, on the date coverage would otherwise end: > The Enrollee is covered under any other group or individual medical plan with similar inpatient benefits; or ~' The Enrollee is eligible for continuation of coverage under COBRA or any other continuation provision Continuation of Coverage for a Disabled Child An Eligible Dependent Child who has reached the Limiting Age remains eligible for coverage under this Group Plan provided both of the following conditions are met: ~ The Child is primarily dependent upon the Subscriber or the Subscriber's Spouse for support; and ~ The Child is incapable of self-sustaining employment due to developmental disability or physical handicap. Proof of the Child's dependence, obtained from their primary provider, must be submitted to KPS within thirty-one (31) days of the date the Child reaches the Limiting Age. Thereafter, KPS may require periodic proof of the Child's continuing dependence. Generally this proof is requested annually after the two-year period following the Child's attainment of the Limiting Age. A disabled Child will continue to be eligible for coverage until any one of the following events occurs: Failure to submit proof of the Child's continuing dependence as a result of disability or physical handicap KPS determines that the Child is no longer developmentally disabled or physically handicapped (based on the evidence submitted). The Subscriber is no longer covered under this Group Plan Non-payment of Premium KPS terminates the Group Plan Coverage for a disabled Child ends on the last day of the month in which the disabled Child is eligible for coverage, provided any applicable Premium amounts have been paid. In the case of non-payment of Premium, coverage ends on the last day of the month for which KPS received a Premium payment. A dependent who is no longer eligible for coverage as a disabled Child may be eligible for coverage under COBRA or a KPS Individual Conversion Plan (see Continuation of Coverage). CONTINUATION OF COVERAGE Coverage During a Labor Dispute In the event of a strike, lockout or other labor dispute which causes a disruption of health care compensation benefits or wages, Subscribers and their enrolled Eligible Dependents may elect to continue coverage under this Group Plan, for a period not to exceed six (6) months, by self-paying their Premiums. During this period of continued coverage, benefits and Premium may not be altered from that of the existing Group Plan. The Subscriber is required to pay any applicable Premium directly to KPS. Failure on the part of the Subscriber to make Premium payments will result in termination of coverage as of the last day of the month for which Premium was paid. Coverage terminated for non-payment of Premium will not be reinstated. Page: 8 128 This provision does not apply to Subscribers and their enrolled Eligible Dependents who are entitled to continue coverage under COBRA or any other continuation of coverage provision. Continuation of Group Coverage At the Group's option, Subscribers and their enrolled Eligible Dependents who lose eligibility for coverage under this Group Plan may elect to extend their coverage for a period not to exceed three (3) months unless: ~, Coverage was terminated as a result of a strike, lockout or other labor dispute; or ~- Employment was terminated for gross misconduct Application for coverage must be made within thirty-one (31) days of the date coverage under the Group Plan ended. During this period of continued coverage, benefits and Premium may not be altered from that of the existing Group Plan. The Subscriber is required to pay any applicable Premium directly to the Group. The Group is required to remit Premium to KPS in accordance with the Premium Due Date and grace periods defined in this Contract. Failure on the part of the Subscriber to make Premium payments will result in termination of coverage as of the last day of the month for which Premium was paid. Coverage terminated for non- payment of Premium will not be reinstated. COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) Employers who are required by law to comply with the provisions of the 1985 COBRA act must notify all eligible Employees, and their Eligible Dependents, who lose eligibility for coverage under this Group Plan of their right to continue coverage under this provision. Eligible individuals are required to apply for continued coverage within sixty (60) days of the date coverage under this Group Plan ends. The Group is required to notify KPS of each individual's election of COBRA continuation coverage within thirty-one (31) days of that election. Failure on the part of the eligible individual to make a timely election, or failure on the part of the Group to provide KPS with timely notification of the election, will be interpreted by KPS as a waiver of the individual's right to continue coverage under this provision. Failure by the Group to provide timely notification to KPS may not, in all cases, eliminate the Group's obligation to provide continuation coverage. It will, however, eliminate any obligation on the part of KPS to provide continuation coverage under this Contract. Individual Conversion Coverage Employees who are under age sixty-five (65) may be entitled to transfer to a KPS Individual Conversion Plan if: They are not otherwise eligible for coverage under Medicare They are currently eligible for continuation of Group coverage but have elected not to enroll in the Group Plan ~. Coverage under this Group Plan or a COBRA continuation plan has terminated (for any reason except non-payment of Premium, when it is the individual's responsibility to pay the Premium) ~. This Group Plan terminates and the Group does not provide other health care coverage to its Employees Application for coverage must be made within thirty-one (31) days of the date coverage under this Group Plan, or other KPS continuation or COBRA plan ends. Applicable Premium payments for the first month of coverage must be submitted with the enrollment application. Eligible Dependents may apply for coverage separately under this option in the event they lose coverage under this Group Plan due to the death of the Subscriber, or if the Subscriber and Spouse divorce Page 9 fWhen an Enrollee enro s n a conversion plan he/she loses certain protections guaranteed under the Health nsurance Portability and Accountability Act (HIPAA) of 1996. Most notably, if the Enrollee wants to transfer to a non-convere on nd v dual plan, he/she could be denied coverage based on a previous or exist ng health condition, f the Enro ee does qualify for coverage under a non-conversion individual plan, h s/her coverage will be subject to any waiting periods for pre-existing conditions. For more information, please contact KPS Member Services at 360--478-6796 or toll free 1-800-552-7114. Employees who are age sixty-five (65) or older when coverage under this Group Contract terminates may be eligible for coverage under a Medicare Supplement Plan. To determine Employee eligibility for a Medicare Supplement Plan, please contact KPS Member Services. COORDINATION OF BENEFITS (COB) General Provision Benefits are provided under this Group Plan only to the extent that Subscribers and their enrolled Eligible Dependents could not have received benefits for the same service(s) under any other Plan, had a claim for benefits been made. The purpose of this COB provision is to ensure that the sum of claim benefits paid by KPS and all other Plans under which Subscribers and their Eligible Dependents are covered does not exceed 100% of the Allowable Expense. All of the benefits provided under this Group Plan are subject to this COB provision. Definitions "Allowable Expense" means the usual, customary or reasonable charge for any necessary health care service or supply when the service or supply is a covered benefit, at least in part, under any of the Plans involved. When a Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service provided shall be considered an Allowable Expense. The difference between the cost of a private Hospital room and the cost of a semi-private Hospital room is not considered an Allowable Expense under the above definition unless the Enrollee's stay in a private Hospital room is considered to be Medically Necessary under at least one of the Plans involved. "Double Coveraqe" means when Enrollees have coverage under another Plan. "Plan" means a policy or contract which provides benefits or services for, or because of, medical or dental care, through one of the following: This Group Plan Any group, individual or blanket disability insurance policy Any group or individual contractual prepayment or indemnity plan such as those issued by health care service contractors, health maintenance organizations or other health carriers or health insurers Any labor-management trusteed plan or labor organization plan Any employer organization plan or Employee benefit organization plan Any governmental program Any insurance coverage required or provided by statute, including automobile policies which provide medical benefits > Anyother similar source The term "Plan" does not include accident-only coverage, including athletic injuries, for school-age Children from Kindergarten through twelfth grade (K through 12), or for college students, either on a 24-hour basis or on a "to and from school" basis. Each of the Plans under which the Enrollees are covered, and each benefit payable under those Plans, are considered separately when benefits are coordinated under this provision. Page: 10 130 Claim Determination Period The claim determination period means a Calendar Year. Effect on Benefits When an Enrollee has double coverage, during a Calendar Year, one Plan normally pays its benefits in full as the primary payer and the other Plan pays a reduced benefit as the secondary payer. KPS determines which coverage is primary according to the National Association of Insurance Commissioners' guidelines. When KPS is the primary payer, we will pay the benefits described in this Benefits Booklet. When KPS is the secondary payer, we will determine the Allowable Expense. After the primary Plan pays, we will pay what is left of the Allowable Expense, up to our regular benefit. We will not pay more than our allowance. Order of Benefit Determination When more than one Plan contains a COB provision; the decision as to which Plan is the primary Plan is made in the following order: The Plan that covers the person as a Subscriber rather than as an Eligible Dependent is primary When an Eligible Dependent Child is covered under more than one Plan, the Plan of the parent whose date of birth (month and day only) occurs earlier in a Calendar Year is primary, except when the Child's parents are legally divorced or separated > When the parents of a covered Eligible Dependent Child are divomed or separated and there is no court decree which establishes financial responsibility for the medicat or dental expenses of the Eligible Dependent Child, then benefits for the Child's Covered Expenses are determined as follows: · The Plan of the parent with custody is primary, provided the parent with custody has not remarried · If the parent with custody has remarried, the order for determining the primary Plan is: (i) The Plan of parent with custody (ii) The Plan of the stepparent (iii) The Plan of the parent without custody Despite the above, if the court has determined which parent is financially responsible for the health care of the Eligible Dependent Child, then the Plan of that parent is always the primary Plan. When the above rules do not establish an order of determination, then the Plan which has covered the person for the longer period shall be primary, except that: > The benefits of the Plan which covers the person, on whose expenses the claim is based, as a laid- off or retired Subscriber, or a Dependent of such a Subscriber, shall be determined after the benefits of the Plan which covers that person as a Subscriber (other than as a laid-off or retired Subscriber), or the Dependent of such a Subscriber; and If either of the Plans does not have a provision regarding laid-off or retired Subscribers, which results in each Plan determining its benefits after the other, then the above provision shall not apply. If none of the above rules apply, the Plan that has covered the person for the longest period of time shall be considered the primary Plan. Facility of Payment Whenever another Plan makes payments that should have been provided under this Group Plan and in accordance with this COB provision, KPS may, at its sole discretion, choose to reimburse the Plan making such other payments, the amount necessary to satisfy the intent of this COB provision. Any amount paid under this subsection shall be considered as benefits paid under this Group Plan, and KPS shall be fully discharged from liability to the extent of such payments. Page 11 131 Right of Recovery Whenever KPS makes payments that are in excess of the maximum amount of payment necessary to satisfy this COB provision, KPS shall have the right to recover the excess payment amount from the Enrollee, from the Provider, or from another Plan, as applicable. Right to Receive and Release Information As a condition of receiving benefits under this Group Plan, Subscribers and their enrolled Eligible Dependent(s) agree to provide KPS with any necessary information, and authorize KPS to release to or obtain from any other insurer, organization or person, any information necessary to administer this COB provision. Disclosure of Coordination Failure on the part of Subscribers and their enrolled Eligible Dependents to cooperate with KPS regarding this COB provision could result in the loss of benefits under this Group Plan. KPS recommends that Subscribers and their enrolled Eligible Dependent(s) submit claims to KPS, and each other plan, at the same time to help minimize delays and facilitate claims payment. KPS' RIGHT OF RECOVERY Limitations and Exclusions Coverage under this Group Plan is excluded for expenses incurred or services rendered if the Enroltee's illness or injury is caused (or alleged by the Enrollee to be caused) by another party, to the extent that benefits are available under the terms of any other insurance coverage or source of payment, including but not limited to: Vehicle medical, personal injury protection ("PIP"), no-fault, uninsured or underinsured motorist, workers' compensation insurance or benefits and third party liability insurance, or similar contract of insurance. ~, Homeowner's, property or any other insurance policy (except for individual or group health insurance). ~ An agreement, judgment or settlement pursuant to which a third party pays or agrees to pay for the costs of such services from assets other than a policy of insurance. This exclusion applies whenever any such contract of insurance, agreement, judgment or settlement is issued to or provides benefits for the Enrollee, whether or not they assert a claim against the responsible third party or its insurers. Third Party Liability: Reimbursement and Subrogation As a condition of KPS' agreement to advance payment to the Enrollee or their Provider for medical expenses for illnesses or injuries caused (or alleged by the Enrollee to be caused) by another party, the Enrollee agrees to make a claim against, or otherwise pursue recovery from all responsible parties and their insurer(s) for all payments advanced to the Enrollee or their Provider by KPS. If the Enrollee does not make a claim or otherwise pursue recovery of KPS' payments, all such payments made by KPS may be denied or recouped. By providing benefits under this prevision, KPS is fulfilling its obligations under this Group Plan. However, by so doing, KPS does not waive any rights to reimbursement or subrogation. Provided, the benefits of this Group Plan will be advanced to the Enrollee if they are injured by a third party, before compensation is recovered from the third party or its insurers, only under the following conditions: ~ The Enrollee, and their representative(s), must fully cooperate with KPS in recovering payment of medical bills paid, and to be paid by KPS, from the parties who allegedly caL~sed the injury or illness, including but not limited to their liability insurance carriers, any applicable PIP, uninsured or underinsured motorist policy, homeowners policy, workers compensation or any other reachable assets of the responsible party or parties; Page: 12 132 The Enrollee notifies KPS, in writing, of the details of the injury or illness, the names and addresses of the parties believed to be responsible and the names and addresses of the responsible party's insurers, if known; Any claim or lawsuit filed by the Enrollee against the third party or the third party's insurer(s) must include a demand for repayment of benefits paid by, or to be paid, by KPS on the Enrollee's behalf; or > The Enrollee must agree to assign to KPS their right to recover compensation for the medical costs paid (subrogation), or to be paid, by KPS as a result of injuries caused by the third party responsible for the injury. The Enrollee must agree to reimburse KPS for the medical expenses paid or that will be paid by KPS as a result of the injury, from the settlement, judgment, insurance proceeds or other recovery obtained by the Enrollee from any third party or its insurers. Collection and Reimbursement by Enrollee (or the Enrollee's Representative) If the Enrollee elects to demand recovery for KPS' payments from the responsible third party, they must: Notify KPS in advance of any settlement, mediation, arbitration or trial. Inform the responsible third party and its insurer(s) of the amount of the lien asserted by KPS, for the recovery of payments made on their behalf, against any recovery or potential recovery obtained by them. Obtain prior consent from KPS before compromising or settling claims involving medical costs paid by KPS. ~* Not enter into any agreement with the responsible third party or its insurer(s), or do anything else that would release KPS' lien or prejudice our subrogation or reimbursement rights, without first obtaining express pdor written consent from KPS. > Reimburse KPS for that portion of the settlement, award or judgment that is compensation for medical bills paid and to be paid by us. If the Enrollee obtains a settlement or recovery for less than the insurance policy limits or reachable assets of the liable party, they are obligated to reimburse KPS for the full amount of benefits paid on their behalf after they have been fully compensated for their loss. If, however, the Enrollee obtains a settlement or recovery that is equal to or greater than the liable party's insurance policy limits or reachable assets, they are only obligated to reimburse KPS in the amount that is left after they have been fully compensated for their loss. The Enrollee, or their representative(s), must obtain a written agreement from KPS prior to settling any claim if they want KPS to share, on an equitable basis, any reasonable attorney fees they incurred in pursuit of any subrogation or reimbursement claim. In the absence of a prior written agreement, KPS, at its sole discretion, will determine whether or not to reduce our reimbursement amount in order to share, on an equitable basis, any reasonable attorney fees incurred by the Enrollee. However, such a reduction will only be considered if KPS has benefited from the services of their attorney. In no event will KPS' reimbursement be reduced by more than twenty percent (20%) to offset attorney fees incurred by the Enrollee, and KPS will not pay for costs incurred by them. Subrogation: Assignment of Third Party Claim to KPS If the Enrollee elects to assign their rights to }(PS to pursue a claim seeking recovery from a responsible third party or its insurer(s), they and their representative(s) must cooperate fully with KPS in pursuing the claim against the responsible parties. Such cooperation includes, among other things: Providing evidence and testimony consistent with the testimony in the case against the responsible parties. ~' Refusing to assist the responsible parties, in any way, in defending against a claim brought by KPS. > Cooperating with KPS by not taking any action that might release, limit, reduce, or otherwise prejudice our efforts to pursue a claim against any responsible third party. Page 13 133 Trust and Cooperation Between the Enrollee (or the Enrollee's Representative) and KPS The Enrollee and their representative(s) must deal in good faith with KPS by adhering to all of the conditions set forth in this section. In turn, KPS agrees to cooperate with the Enrollee and their representative(s) in their effort to recover reimbursement, and will advance payments on their behalf for injuries er medical conditions caused, or asserted by them to be caused, by any third party. The Enrollee and their representative(s) must cooperate fully with KPS in protecting, preserving, and recovering the amounts KPS has paid or will pay on their behalf under this Group Plan. Failure to cooperate may result in the denial of coverage for injuries or conditions caused, or asserted by them to be caused, by any third party to the extent that coverage or payment for such injuries or illnesses is, or would have been available under the terms of any other insurance coverage or source of payment. Agreement to Arbitrate Any dispute that arises between the Enrollee and KPS as a result of the preceding recovery provisions shall be settled through arbitration. Both the Enrollee and KPS shall be bound by the decisions of the arbitration proceedings. Disputes will be presented to, and resolved by, a single arbitrator in accordance with the current rules of the American Arbitration Association. Either the Enrollee or KPS may demand arbitration by serving notice of this demand on the other. Each party to the arbitration agrees to bear its own costs and to share equally in the fees of the arbitrator. This agreement to resolve disputes through arbitration is in effect as of the effective date of the Group Plan, and shall remain in effect until the dispute between us has been resolved. Recovery of Claims Payments Ineligible Persons If KPS knowingly or unknowingly makes any payment on behalf of an individual who for any reason was not eligible to receive the services and benefits provided herein, KPS is entitled to full reimbursement from such ineligible individual or from a Subscriber who applied for the ineligible benefits on behalf of such individual. If KPS knowingly or unknowingly receives Premium payment on behalf of an individual who for any reason was not eligible to receive the services and benefits provided herein, KPS reserves the right to refund any Premium payment(s) in excess of claims paid for the time the individual was ineligible, and shall have the dght to recover the cost of any benefit furnished while such individual was improperly enrolled in this Group Plan. Incorrect Claim Payment KPS is entitled to full reimbursement from the payee for any incorrect claim payment. The term "incorrect claim payment" includes but is not limited to the following: Payment to the wrong Provider Payment of an incorrect amount Payment for a service that is not a Covered Benefit or Service Duplicate payment for the same service Payment on behalf of the wrong Enrollee Incorrectly billed procedure or diagnosis SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS Subscriber/Dependent Liability Subscribers and their Eligible Dependents who are enrolled in this Group Plan are liable for the following costs: > Deductible ~> Copayments Page: 14 134 Charges for non-covered services Coinsurance, up to the Coinsurance Stoploss limit defined in Attachment A - Benefits Booklet Charges incurred after an annual or lifetime maximum benefit, for a specific service or supply, has been exhausted (such as the annual maximum benefit for durable medical equipment) > Charges in excess of the amount paid by KPS to non-participating Providers If KPS fails to reimburse a Participating Provider for the cost of Medically Necessary Covered Services provided in accordance with the terms of this Contract, neither the Enrollee nor the Group shall be required to compensate the Participating Provider for such services beyond the limit of Deductibles, Copayments or Coinsurance amounts specified in the Benefits Booklet. KPS will continue to reimburse a Participating Provider for Medically Necessary Covered Services rendered to an Enrollee after the Participating Provider's contract with KPS has ended, for such time as the Enrollee remains covered under this Group Plan, until (i) the Enrollee's course of treatment has been completed, or (ii) the care of the Enrollee has been appropriately transferred to another Participating Provider. The KPS Medical Director is responsible for determinations regarding the completion of a course of treatment and the transfer of patient care. KPS Privacy Policy KPS Health Plans is committed to protecting the privacy of Enrollees' personal and health information. We are required by applicable federal and state law to maintain the privacy of personal and health information. KPS Health Plans is also required to give this notice to Enrollees to tell them how KPS may use and give out ("disclose") their personal and health information held by KPS Health Plans. Personal and health information (referred to in this notice as "personal information") means any information that is identifiable as personal information, including information regarding health care and treatment, identifiable factors such as the Enrollee's name, age, and address; or financial information. We may collect personal information about the Subscriber, or members covered by KPS Health Plans through the Subscriber, from the following sources: Information we receive from the Enrollee, including information provided on applications or other forms, '~ Information we receive from the Enrollee's health care providers or other companies, such as other health insurance companies, relating to medical claims and billings, '~ General information about the health care services the Enrollee has received, such as the quality and availability of services. We restrict access to personal information about the Enrollee to only those who need to know that information to provide treatment, payment or health care operations services to the Enrollee. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard the Enrollee's personal information. We do not disclose any personal information about our members or former members to anyone, except as permitted or required by law. However, KPS Health Plans will use and give out personal health information: -k To the Enrollee or someone who has the legal right to act for the Enrollee (their personal representative), ~- To the Secretary of the Department of Health and Human Services, if necessary, to make sure the Enrollee's privacy is protected, ~r TO law enfomement officials when investigating and/or prosecuting alleged civil or criminal actions, and ~' Where required by law. KPS Health Plans has the right to use and give out personal information to arrange for treatment, payment of, and health care operations services, including: Medical quality reviews Accounting Legal and risk management services Page 15 135 KPS Health Plans may use or give out personal information for the following purposes under limited circumstances: * For Government healthcare oversight activities (such as fraud and abuse investigations) * To avoid a serious and imminent threat to health or safety By law, KPS Health Plans must have written permission (an "authorization") to use or give out personal information for any purpose that is not set out in this notice. The Enrollee may take back ("revoke") their written permission at any time, except if KPS has already acted based on their permission. By law, Enrollees have the right to: ~r See and get a copy of their personal information held by KPS Health Plans, except in certain limited situations. -k Make a reasonable request in wdting to amend any of their personal information created by KPS Health Plans if they believe that it is wrong or if information is missing, and KPS Health Plans agrees. If KPS Health Plans disagrees, we will notify the Enrollee why in writing. Enrollees may have a statement of their disagreement added to their personal information. .k Get a listing of those obtaining their personal information from KPS Health Plans in the past 6 years. The listing will not include information: · That was given to the Enrollee or their personal representative, That the Enrollee authorized KPS Health Plans to release, or That was given out for law enforcement purposes, or That was given out to pay for the Enrollee's health care claim or a disputed claim. * Request in writing that KPS communicate with them in confidence about their personal information by alternative means or to an alternative location. If they advise us that disclosure of all or any part of their personal information could endanger them, we must comply with any reasonable request provided it specifies an alternative means or location. -k Ask KPS Health Plans to place additional restrictions on our use or disclosure of their personal information for treatment, payment, health care operations or to persons they identify. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). * Get a separate electronic or paper copy of this notice. For more information about exercising their rights set out in this notice, Enrollees may call KPS Health Plans' Member Services department at (360) 478-6796 or tol~ free at (800) 552-7114. They can also reach KPS Health Plans' privacy official for this purpose at (800) 552-7114. If an Enrollee believes KPS Health Plans has violated their privacy rights set out in this notice, they may file a complaint with KPS Health Plans at the following address: KPS Health Plans Compliance Department P.O. Box 339 Bremerton, WA 98337 Filing a complaint will not affect the Enrollee's benefits under KPS Health Plans. They may also file a complaint with the Secretary of the Department of Health and Human Services. KPS Health Plans does have the right to change the way personal information is used and given out. If KPS Health Plans makes any changes, Enrollees will get a new notice by mail within 60 days of the change, and that notice will become effective on the date the revised notice is issued. Please note: Telephone calls to and from KPS Health Plans may be recorded for quality assurance and training purposes. If the Enrollee is the primary Subscriber with KPS Health Plans and other persons are covered by KPS Health Plans through them, we suggest that the Subscriber share this information with each other to ensure that each of them is aware of our po[icy and their privacy rights. Please refer to KPS Health Plans' website at www. KPSHealthPlans.com for more information about our privacy practices. Page: 16 136 COMPLAINTS AND APPEALS PROCESS Complaints All Enrollees have the right to contact KPS whenever they have a question, complaint or concern regarding: > Their benefits ~. Their access to care or how to arrange for care > Any KPS Participating Provider > Service they receive from KPS ~' Any other issue related to this Group Plan or KPS. In the event an Enrollee has a complaint, KPS Member Services Representatives are available Monday through Friday, from 8:00 a.m. until 5:00 p.m. Pacific Time, except on nationally recognized holidays. Although a Member Services Representative can resolve most matters, Enrollees may choose to file a complaint, or request an appeal, if they are not satisfied with the Member Services response. The following steps outline the procedure for filing a complaint: EITHER KPS Member Services will work The service provided by KPS Send a written statement of with the Enrollee and try to the complaint to: resolve the complaint over the Eligibility KPS Health Plans phone. Otherwise, KPS will Coverage or Benefits Attn: Member Services send a written response within Resolution Department 30 days of receiving the Claims Payment PO Box 339 complaint. Access to Cato Bremerton, WA 98337 Quality of Care OR Complaints about Participating Providers are investigated KPS Participating Providers Call KPS Member Services at thoroughly and are reviewed 360-478-6796 periodically. or toll free at 1-800-552-7114 Standard Appeals Process Enrollees have the right to appeal any decision regarding a complaint or any aspect of their health care coverage that is not in their favor. The request for an appeal must be made within 180 days of the date they receive an EOB, letter or other type of communication, from KPS, that contains an unfavorable decision regarding their benefits. Such decisions could affect: The service received from KPS Access to health care services or Providers Eligibility for coverage Benefit coverage Termination of coverage under this Group Plan (except termination for non-payment of Premium) Non-payment of a claim, either completely or partially A denial or modification of a request for pro-authorization of any health care service or supply A denial of a request for coverage of an experimental or investigational service or supply To file an appeal, the Enrollee, his/her designated representative, or his/her Provider may either call or write KPS at the phone number or address listed above. Any documentation supporting the Enrollee's position may be included with the appeal. Page 17 ~.37 KPS will notify the Enrollee, in writing, that the appeal request has been received and include additional information regarding the Appeals Process and the Enrollee's rights and responsibilities during an appeal. The Enrollee has the right te send an appeal directly to an Independent Review Organization (IRO) if KPS does not respond to the Enrollee within the allotted time period, as follows: Decisions Regarding: Days to Respond: Service-Related Appeals 30 Days Denials of Experimental and/or Investigational Procedures or Supplies 20 Days All other Adverse Determinations 14 Days Expedited Appeals Process If the EnroUee's health care Provider, or the KPS Medical Director, reasonably determines that by following the Standard Appeals Process the Enrellee's life, health, or ability to regain maximum function would be jeopardized, KPS will invoke an Expedited Appeals Process and make a decision within 72 hours after it is received. The Enrollee will receive notice of this action. GENERAL TERMS AND CONDITIONS Applicable Law This Contract shall be governed by, and construed in accordance with, the laws of the state of Washington. Venue for this Contract shall be Kitsap County. Assignment of Benefits The benefits of this Contract shall accrue to Subscribers and their enrolled Bigible Dependents. Neither this Contract, nor its payments or Covered Benefits and Services are assignable to a third party. KPS reserves the right to make benefit payments to the Subscriber, the Provider, or jointly, as KPS deems necessary and appropriate, subject to federal and/or state laws. Binding Agreement This Contract is binding on KPS and the Group, and their respective executors, administrators, successors and assigns. By election of coverage or payment of applicable Premiums, or if the Group's Subscribers or their enrolled Eligible Dependents seek the services provided under this Contract, all of the terms, covenants and conditions contained herein shall become valid and binding on the Group and its Subscribers and enrolled Eligible Dependents, notwithstanding the failure of the Group to sign this Contract. This Contract shall not bind KPS until (i) it has been executed by a person authorized by KPS, and (ii) an executed copy has been delivered to the Group. Confidentiality The underwriting and financial terms of this Contract are confidential and sharl not be disclosed except as is necessary for the performance of this Contract, or as required by law. Contract Modifications Except as set forth under Premium Rate Adjustments, KPS reserves the right to modify the provisions of this Contract, or the services described in the Benefits Booklet, upon thirty (30) days written notice to the Group. The Group may elect to reject such modifications by providing KPS with fifteen (15) days written notice. However, rejection of a modification will result in the termination of this Contract as of the last day of the month for which Premium payment has been received. Lack of notification of rejection by the Group shall be interpreted as acceptance of the modification and this Contract will be renewed as modified. Page: 18 138 No modification of the terms of this Contract shall be binding upon KPS unless endorsed, in writing, and signed by an authorized officer of KPS. Such endorsement shall be deemed a part of this Contract, effective as of the effective date of the endorsement. Any amendment or Contract modification required by law or regulation shall become effective as of the effective date required by such law or regulation. Coverage Limits The Covered Benefits and Services offered under this Contract are subject to the coverage limits and maximums set forth in Attachment A - Benefits Booklet. Entire Agreement This Contract, together with Attachment A - Benefits Booklet; Attachment B - Premium Rates and Underwriting Criteria; and any riders and/or endorsements attached hereto, constitute the entire agreement. This Contract supersedes all previous communications, representations or agreements, either verbal or written between KPS and the Group, with respect to the subject matter herein. Equity of Application This Contract is intended to apply equally to all Enrollees. False or Misleading Information If the Group provides statements or other information on the Group Master Application form, or any other form required by KPS, that affects the acceptability of the Group for coverage, or the risk assumed by KPS for providing coverage, KPS may, at its sole discretion, elect to immediately terminate this Group Contract and recover any claims and/or administrative costs from the Group, Enrollee(s), or any other person(s) responsible for providing the false or misleading information. Force Majeure In the event KPS is unable to perform its obligations hereunder by reason of fire, casualty, lockout, strike, labor condition, riot, war, act of God or by ordinance, law, order or decree of any legally constituted authority, then this Contract may, at the option of KPS, be suspended. During any period of suspension, KPS shall not be required to perform any service hereunder, nor shall KPS be liable for any damages arising from any event that precipitated the suspension. If this Contract is suspended pursuant to this provision, any obligation by the Group and/or an Enrollee to make Premium payments shall also be suspended for the same period of time. Group Cooperation The Group agrees to cooperate with KPS in the administration of this Contract by: (i) Advising Subscribers and their enrolled Eligible Dependents of policies and procedures applicable to this Group Plan. (ii) Providing Subscribers and their enrolled Eligible Dependents with a Benefits Booklet, ID cards and any applicable notices or other information regarding this Group Plan. (iii) Providing information about Enrollees that is relevant to the determination of eligibility, claim reimbursement, coordination of benefits or other information required for the administration of this Contract. (iv) Making appropriate payroll deductions, if applicable, to facilitate Premium payment. Headings The headings of sections and paragraphs in this Contract are for convenience and reference purposes only and do not affect in any way the meaning or interpretation of any provision of this Contract. Page 19 Notices Any notice that may affect the provisions of this Contract shall be deemed delivered to the Group when deposited in the United States mail with prepaid postage, addressed to the Group at the most recent address listed for the Group, Any notice that may affect the provisions of this Contract shall be deemed delivered to KPS when deposited in the United States mail with prepaid postage, addressed to KPS at the following address: P,O. Box 339, Bremerton, WA 98337-0039. Any requirement of KPS to provide notice to Enrollees shall be fulfilled when the Group has received such notice. It is the responsibility of the Group to disseminate notices to Enrollees within thirty-one (31) days of receipt. Severability If any term, provision, endorsement or condition of this Contract is deemed invalid or unenforceable by a court of competent jurisdiction, the same shall be deemed severable from this Contract. However, the remainder of this Contract shall remain in full force and effect and shall in no way be affected, impaired or invalidated as a result of such decision. Third Party Beneficiaries There are no third party beneficiaries to this Contract. Waiver of Breach Waiver of a breach of any provision of this Contract shall not be deemed to be a waiver of any other breach of the same or different provision. Page: 20 140 KPS Health Plans, in Rehabilitation 400 Warren Avenue P.O. Box 339 Bremerton, WA 98337-0039 CITY OF BREMERTON - PLAN B COVERAGE CONTRACT Group Number: 21010, 21014 Effective Date: 1/1/2004 Renewal Month: January Open Enrollment December This Coverage Contract includes the following: Attachment A - Benefits Booklet Attachment B - Premium Rates and Underwriting Criteria Riders: N/A Optional Riders: N/A Endorsements: N/A This Contract is entered into and delivered in the state of Washington and is governed by Washington State laws, except to the extent state laws are preempted by federal law. Signature by a qualified Group representative or payment of the Premium shall constitute acceptance of the terms and conditions set forth herein. FOR KPS: FOR GROUP: Elizabeth A. Gilje, President Signature Date Print Name Title Date 141 KPS Health Plans, In Rehabilitation 400 Warren Avenue P.O. Box 339 Bremerton, WA 98337-0039 CITY OF BREMERTON -- UNDER 65 LEOFF I RETIREES (SUBSCRIBERS ONLY) COVERAGE CONTRACT Group Number: 21001-21006 Effective Date: 1/1/2004 Renewal Month: January Open Enrollment December This Coverage Contract includes the following: Attachment A - Benefits Booklet Attachment B - Premium Rates and Underwriting Criteria Riders: N/A Optional Riders: N/A Endorsements: N/A KPS Health Plans, In Rehabilitation, hereinafter referred to as KPS, is a duly licensed health care services contractor (HCSC) in Washington State. In its capacity as an HCSC, KPS agrees to underwrite and provide the benefits and services described in Attachment A - Benefits Booklet, to the eligible Employees, and their Eligible Dependents, of the above-named Group, provided the Group, its eligible Employees and their Eligible Dependents, meet and comply with the provisions of this Contract. Contract Form: BREMRET-22900-2004 142 TABLE OF CONTENTS DEFINITIONS ................................................................................................................................... 1 CONTRACT EXAMINATION PERIOD ................................................................................................... 2 EFFECTIVE DATE, DURATION AND RENEWAL .................................................................................... 2 PREMIUM PAYMENT PROVISIONS ..................................................................................................... 2 Payment Due Date/Grace Period ............................................................................................................. 2 Premium Rate Adjustments ...................................................................................................................... 2 Premiums Paid by Subscribers/Dependents ............................................................................................ 3 Premium Refunds ..................................................................................................................................... 3 ELIGIBILITY AND ENROLLMENT ......................................................................................................... 3 Group Eligibility ......................................................................................................................................... 3 Subscriber/Dependent Eligibility Requirements ........................................................................................ 3 Enrollment ................................................................................................................................................. 4 Enrollment Under Special Circumstances ................................................................................................ 4 When Coverage Begins ............................................................................................................................ 4 TERMINATION OF COVERAGE .......................................................................................................... 4 Continuity of Coverage .............................................................................................................................. 4 Termination of Group Contract .................................................................................................................. 4 Re-EnrollmentJReinstatement ................................................................................................................... 5 Termination of Enrollee Coverage ............................................................................................................ 5 Continuation of Inpatient Coverage .......................................................................................................... 5 Continuation of Coverage for a Disabled Child ......................................................................................... 6 CONTINUATION OF COVERAGE ........................................................................................................ 6 Coverage During a Labor Dispute ............................................................................................................ 6 Continuation of Group Coverage .............................................................................................................. 7 COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) ........................................................ 7 Individual Conversion Coverage ............................................................................................................... 7 COORDINATION OF BENEFITS (COB) ............................................................................................... 8 General Provision ...................................................................................................................................... 8 Definitions .................................................................................................................................................. 8 Claim Determination Period ...................................................................................................................... 9 Effect on Benefits ...................................................................................................................................... 9 Order of Benefit Determination ................................................................................................................. 9 Facility of Payment .................................................................................................................................... 9 Right of Recovery .................................................................................................................................... 10 Right to Receive and Release Information ............................................................................................. 10 Disclosure of Coordination ...................................................................................................................... 10 KPS' RIGHT OF RECOVERY ........................................................................................ '. ................. 10 Limitations and Exclusions ...................................................................................................................... 10 Third Party Liability: Reimbursement and Subrogation .......................................................................... 10 Collection and Reimbursement by Enrollee (or the Enrollee's Representative) ..................................... 11 Subrogation: Assignment of Third Party Claim to KPS ........................................................................... 11 Trust and Cooperation Between the Enrollee (or the Enrollee's Representative) and KPS ................... 12 Agreement to Arbitrate ............................................................................................................................ 12 Recovery of Claims Payments ................................................................................................................ 12 SUBSCRIBER/DEPENDENT LIABILITY AND RIGHTS ........................................................................... 12 SubscribedDependent Liability ............................................................................................................... 12 KPS Privacy Policy .................................................................................................................................. 13 COMPLAINTS AND APPEALS PROCESS ........................................................................................... 15 Complaints .............................................................................................................................................. 15 Standard Appeals Process ...................................................................................................................... 15 Expedited Appeals Process .................................................................................................................... 16 GENERAL TERMS AND CONDITIONS ...............................................................................................16 Applicable Law ........................................................................................................................................ 16 Assignment of Benefits ........................................................................................................................... 16 Binding Agreement .................................................................................................................................. 16 143 Confidentiality .......................................................................................................................................... 16 Contract Modifications ............................................................................................................................. 16 Coverage Limits ...................................................................................................................................... 17 Entire Agreement .................................................................................................................................... 17 Equity of Application ................................................................................................................................ 17 False or Misleading Information .............................................................................................................. 17 Force Majeure ......................................................................................................................................... 17 Group Cooperation .................................................................................................................................. 17 Headings ................................................................................................................................................. 18 Notices .................................................................................................................................................... 18 Severability .............................................................................................................................................. 18 Third Party Beneficiaries ......................................................................................................................... 18 Waiver of Breach ..................................................................................................................................... 18 144 DEFINITIONS Capitalized words found in the text of this section are defined below or in the Benefits Booklet section. Child means any one of the following: (i) An unmarried natural child, adopted child, stepchild or other legally designated ward under the Limiting Age who is primarily dependent upon the Subscriber or the Subscriber's Spouse for support. (ii) An unmarried child under the Limiting Age who is legally entitled to receive medical coverage as a result of a court order binding either the Subscriber or the Subscriber's Spouse, regardless of whether or not the Subscriber or Subscriber's Spouse has legal custody of the Child. (iii) An unmarried child who has reached the Limiting Age, or is older than the Limiting Age, is incapable of self-sustaining employment due to developmental disability or physical handicap, and is primarily dependent upon the Subscriber or the Subscriber's Spouse for support and maintenance (see Continued Eligibility for a Disabled Dependent). Contract means this document and any other attachments, exhibits, Riders or Endorsements listed on the title page or otherwise described herein, and any subsequent amendments or modifications to the Contract or its attachments, exhibits, Riders or Endorsements. Contract Renewal Month means the calendar month specified on the title page of this Group Contract during which the Group may renew its coverage each year under this Group Plan. Covered Benefit or Service means those Medically Necessary services described in Attachment A - Benefits Booklet that an Enrollee is entitled to receive. Eligible Dependent means the Subscriber's legal Spouse or Child. Employee means a retired LEOFF I Employee who is under the age 65 and who is eligible for a Premium contribution by his/her payroll office. Endorsement means an amendment to the conditions of coverage or the benefits provided by this Group Plan. Enrollee means a person enrolled in this Group Plan. Group means the employer entity, association or other group that has entered into this Contract with KPS. Group Plan means the Benefits Booklet plus any Riders, Endorsements or other attachments that state the terms and conditions for administration of the Enrollee's benefits. Group Master Application means the application form completed by the Group and submitted to KPS prior to securing coverage under this Group Plan. The Group Master Application identifies the size, participation and contribution eligibility requirements applicable to the Group. LEOFF I Employee means a full-time law enforcement officer or firefighter hired prior to October 1, 1977, and who is a member of the LEOFF system as defined in Sections (3) and (4), CH 131, Law of 1972, lS* Ex. Session Limiting Age means the age at which a Child may no longer be covered under this Group Plan as an Eligible Dependent of the Subscriber. The Limiting Age is specified in the Benefits Summary included in this Benefits Booklet. Medical Director means the licensed physician acting as chief medical advisor for KPS. Non-Participating Provider/Facility means any Provider or facility not contracted directly with KPS, or indirectly through First Choice Health Network, Providence Preferred Provider Organization or MultiPlan. Open Enrollment Period means the thirty-one (31) day period, or some other pedod agreed to by both KPS and the Group, beginning one (1) month prior to the Group's Renewal Month, or at some other mutually agreeable time, but at least annually. During the Open Enrollment Period, Subscribers may add or delete Eligible Dependents, and all eligible Employees and their Eligible Dependents have the opportunity to select from alternative health plans offered by the Group. Coverage will be effective as of the renewal date. Page1 145 Premium means the periodic payment made by, or on behalf of the Enrollee, as consideration for this Group Plan and in accordance with the terms of this Contract. Premium Due Date means the scheduled, periodic dates by which Premium payments must be received by KPS as a condition for continued enrollment in this Group Plan. This date is typically the first day of each month of coverage. Provider means a licensed or certified health care practitioner acting within the scope of his/her license or certificate. Rider means an additional benefit over and above those listed in the Benefits Summary. Rider documents are attached at the back of the Benefits Booklet and provide detailed benefit information. Spouse means an individual who is living in a marital relationship with the Subscriber. The madtal relationship must be legally recognized by the state of Washington. Subscriber means the pdmary person, generally the Employee, enrolled in this Group Plan. CONTRACT EXAMINATION PERIOD If, after examination, the Group is not satisfied with this Contract for any reason, the Group may return the Contract to KPS within ten (10) days of the date it is received. Upon receipt of the returned Contract, KPS will refund to the Group any pre-paid Premiums. The Contract shall subsequently be deemed null and void. EFFECTIVE DATE, DURATION AND RENEWAL This Contract shall begin at 12:01 a.m. Pacific Time on the Effective Date (as indicated on the title page), and shall remain in effect until the Contract Renewal Month unless terminated according to the provisions set forth herein. Thereafter, this Contract may be renewed automafical(y at 12:01 a.m. on the same date (month and day) in subsequent calendar years unless otherwise terminated according to the provisions set forth herein. PREMIUM PAYMENT PROVISIONS Payment Due Date/Grace Period The initial Premium payment is due and payable to KPS on or before the effective date of this Contract indicated on the title page. Thereafter, Premium payments are due and payable on or before the first day of every month ("Premium Due Date") for which coverage is provided. A roster of current enrollment and enrollment changes must accompany each Premium payment. A ten (10) day grace period following the Premium Due Date is allowed, during which time this Contract shall not be terminated. However, KPS may, at its sole discretion, elect to extend the grace period for up to sixty (60) days from the Premium Due Date, or cancel this Contract immediately, without notice to the Group if payment is not received by the end of the grace period. If KPS elects to immediately cancel this Contract due to non-payment of Premium, the effective date of cancellation will be retroactive to the last day of the month for which payment was received. No further liability for claims will accrue to KPS. Enrollees in this Group Plan shall not be entitled to benefits during any calendar month for which the Premium, on his/her behalf, was not received by KPS. Premium Rate Adjustments The Premium rates applicable to this Group Plan are defined in Attachment B - Premium Rates and Underwriting Criteria. Rates are guaranteed until the Contract Renewal Month each calendar year. Page: 2 146 Notwithstanding the foregoing, KPS reserves the right to revise the rates as follows: As part of the annual Contract renewal process; As a result of any state or federal law or regulation that imposes an additional tax, new tax or other assessment on KPS revenue; and > In the event there is a material change in the basis upon which KPS assumed risk under this Contract. Such changes may include false or misleading information presented by the Group, changes in the benefits or other Contract terms required by statute or regulation, adverse claims or underwriting experience, or fluctuations of ten percent (10%) or more in the number of enrolled Subscribers and/or Eligible Dependents. KPS will give the Group sixty (60) days prior wdtten notice of any change in Premium rates not associated with the annual Contract renewal process. KPS will give the Group thirty (30) days prior written notice of rate increases associated with the annual Contract renewal process. Premiums Paid by Subscribers/Dependents In certain instances, Subscribers and their enrolled Eligible Dependents may be required to self-pay their Premiums in order to continue coverage. Those instances include: > Strikes, lockouts and other labor disputes that cause a disruption in Employee benefits ~. When the Subscriber and/or Eligible Dependent(s) elects to continue coverage under a COBRA provision or other coverage continuation provision available under this Group Plan The Group is required to collect self-paid Premiums for continuation coverage and forward payments to KPS on or before the Premium Due Date. In the instance of strikes, lockouts and labor disputes, the Subscriber may self-pay their Premium directly to KPS on or before the Premium Due Date. Premium Refunds KPS will refund to the Group any Premium paid, in advance, for periods after the termination date of this Group Plan. In the case of ineligible persons enrolled in this Group Plan, KPS will refund to the Group any Premium paid during a period of ineligibility that is in excess of claim payments made on behalf of the ineligible person(s) during the period of ineligibility. This refund will not exceed an amount equal to three (3) months of Premium payments. ELIGIBILITY AND ENROLLMENT Group Eligibility In order to be eligible to participate in this Group Plan, the Group must continuously meet all eligibility, participation, Group size, contribution and other requirements specified in the Group Master Application form. KPS reserves the right to audit the Group's employment, payroll and eligibility records to ensure that the Group continues to meet its participation requirements, and to ensure that eligible Employees and their Eligible Dependents are properly enrolled in this Group Plan. SubscribeflDependent Eligibility Requirements Retired LEOFF I Employees, as defined in the Definitions section, are eligible to enroll in this Group Plan. As of March 1, 2001, Eligible Dependents of retired LEOFF I Employees are no longer eligible to enroll in this Group Plan. Eligible Dependents who enrolled prior to March 1, 2001, may remain on this Group Plan. Page 3 147 Enrollment Premium payments, if applicable, must all for ~ accompany applications coverage. Currantly retired LEOFF I Employees, are initially eligible to apply for coverage beginning on the effective date of this Group Plan. Application for coverage must be made within thirty-one (31) days of initial eligibility. Newly retired LEOFF I Employees, may initially apply for coverage on their effective date of retirement. Application for coverage must be made within thirty-one (31) days of initial eligibility. Retired LEOFF I Employees who do not enroll when they are initially eligible may not apply for coverage at a later date except in certain circumstances (see Enrollment Under Special Circumstances). Enrollment Under Special Circumstances Retired LEOFF I Employees who, when they were initially eligible to enroll, declined coverage in this Group Plan, in writing, based on existing coverage under another health plan, may apply for coverage under this Group Plan if they lose eligibility for coverage under their other health plan, or if the other health plan terminates. Retired LEOFF I Employees must apply for coverage within thirty-one (31) days of losing coverage under their prior plan. When Coverage Begins Coverage for new Enrollees begins on their date of initial eligibility provided they enrolled in this Group Plan within the specified time limits (see Enrollment) and any applicable Premium amounts have been paid. TERMINATION OF COVERAGE Continuity of Coverage Continuity of coverage under this Contract is guaranteed to all eligible Enrollees provided the Group continues to meet eligibility requirements and continues to pay applicable Premium payments on a timely basis. Termination of Group Contract This Group Plan may be terminated if any of the following occurs: The Group faiJs to make full Premium payments The Group violates, or refuses to comply with, the terms and conditions of this Contract The Group violates, or refuses to comply with, any published KPS policies and procedures that have been approved by the Insurance Commissioner > There is a change to, or implementation of, federal or state law that prohibits the continued offering of this Group Plan KPS replaces this Group Plan. In this case, the replacement plan will (i) include the services covered under the replaced Group Plan; (ii) be offered to the Group's eligible Employees and their Eligible Dependents; and (iii) not significantly limit access to the kind of services covered under the replaced Group Plan In addition, the Group may terminate this Contract, at any time, by providing thirty (30) days written notice to KPS. ff this Group Contract terminates, for any reason, coverage for all Enrollees will end automatically on the effective date of termination, or on the last day of the last month for which the Group paid the Premium, whichever occurs first. KPS will refund to the Group any Premium paid in advance for periods after the termination date. Page: 4 148 In the case of termination or non-renewal of this Group Contract, the Group shall be responsible for providing the following information to all affected Employees and their Eligible Dependents: ~- The effective date of termination of coverage; and > The reason(s) for termination or non-renewal. Re-Enrollment/Reinstatement If this Group Contract has been cancelled by KPS due to non-payment of Premium, the Group automatically forfeits all rights to guaranteed renewal of coverage afforded under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Any decision to reinstate or reenroll the Group is at the sole discretion of KPS. If the Group voluntarily cancels this Group Contract prior to the Open Enrollment Period, KPS may, at its sole discretion, impose up to a twelve (12) month waiting period before the Group is eligible to reapply for coverage. Termination of Enrollee Coverage Coverage for an individual Enrollee under this Group Contract will end if any one of the following events occurs: Non-payment of any Premium amount~ when Premium payment is the responsibility of the Enrollee The Enrollee loses eligibility for coverage under this Group Contract The Enrollee commits a fraudulent act with regard to KPS and this Group Plan The Enrollee refuses to comply with the terms and conditions of this Group Plan as described in the Benefits Booklet The Enrollee voluntarily disenrolls from this Group Plan There is a change Jn either state or federal laws that no longer permit KPS from offering this Group Plan ~- This Group Contract is terminated Additionally~ Eligible Dependent coverage ends if: The Subscriber is no longer emproyed or no longer meets eligibility requirements The Subscriber dies The Subscriber and Spouse divorce The Child reaches the Limiting Age or marries Coverage ends on the last day of the month in which the Enrollee was eligible for coverage, provided all applicable Premium amounts have been paid. In the case of non-payment of Premium, coverage ends on the last day of the month for which KPS received a Premium payment. Upon termination of coverage either KPS or the Group shall issue a Certificate of Creditable Coverage certi~ing the period(s) during which the Enrollee was enrolled in this Group Plan. An Enrollee who loses coverage under this Group Plan may be eligible to continue coverage or enroll in a KPS Individual Conversion Plan (see Continuation of Coverage). A Subscriber who voluntarily disenrolls from this Group Plan while still an Employee will not be eligible to re- enroll in this Group Plan until the next Open Enrollment Period. See Enrollment Under Special Circumstances for exceptions to this policy. Continuation of Inpatient Coverage An Enrollee who is receiving care as an inpatient in an accredited general Hospital, or other approved facility, on the date that coverage would otherwise end, is eligible to continue receiving benefits under this Group Plan provided the following conditions are met: ~ KPS pre-authorized the inpatient care (see Prior Authorization of Inpatient Care); and ~- All applicable Premium amounts continue to be paid Page 5 149 KPS will continue to provide benefits, under this Group Plan, until one of the following events occurs: The Enrollee is no longer receiving inpatient care The KPS Medical Director determines that inpatient care is no longer Medically Necessary The Enrollee has exhausted the inpatient benefits offered under this Group Plan (annual reinstatement of benefits does not apply under this provision) Non-payment of Premium Three (3) consecutive months have elapsed since the date coverage would have otherwise ended The Enrollee enrolls in another KPS plan or in any other health plan that provides inpatient hospital benefits The Enrollee is not eligible for the extended coverage described above if, on the date coverage would otherwise end: ~' The Enrollee is covered under any other group or individual medical plan with similar inpatient benefits; or ~' The Enrollee is eligible for continuation of coverage under COBRA or any other continuation provision Continuation of Coverage for a Disabled Child An Eligible Dependent Child who has reached the Limiting Age remains eligible for coverage under this Group Plan provided both of the following conditions are met; ~' The Child is primarily dependent upon the Subscriber or the Subscriber's Spouse for support; and ,~ The Child is incapable of self-sustaining employment due to developmental disability or physical handicap. Proof of the Child's dependence, obtained from their primary provider, must be submitted to KPS within thirty-one (31) days of the date the Child reaches the Limiting Age. Thereafter, KPS may require periodic proof of the Child's continuing dependence. Generally this proof is requested annually after the two-year period following the Child's attainment of the Limiting Age. A disabled Child will continue to be eligible for coverage until any one of the following events occurs: Failure to submit proof of the Child's continuing dependence as a result of disability or physical handicap KPS determines that the Child is no longer developmentally disabled or physically handicapped (based on the evidence submitted). The Subscriber is no longer covered under this Group Plan Non-payment of Premium KPS terminates the Group Plan Coverage for a disabled Child ends on the last day of the month in which the disabled Child is eligible for coverage, provided any applicable Premium amounts have been paid. In the case of non-payment of Premium, coverage ends on the last day of the month for which KPS received a Premium payment. A dependent who is no longer eligible for coverage as a disabled Child may be eligible for coverage under COBRA or a KPS Individual Conversion Plan (see Continuation of Coverage). CONTINUATION OF COVERAGF Coverage During a Labor Dispute In the event of a strike, lockout or other labor dispute which causes a disruption of health care compensation benefits or wages, Subscribers and their enrolled Eligible Dependents may elect to continue coverage under this Group Plan, for a period not to exceed six (6) months, by self-paying their Premiums. During this period of continued coverage, benefits and Premium may not be altered from that of the existing Group Plan. The Subscriber is required to pay any applicable Premium directly to KPS. Failure on the part of the Subscriber to make Premium payments will result in termination of coverage as of the last day of the month for which Premium was paid. Coverage terminated for non-payment of Premium will not be reinstated. Page: 6 150 This provision does not apply to Subscribers and their enrolled Eligible Dependents who are entitled to continue coverage under COBRA or any other continuation of coverage provision. Continuation of Group Coverage At the Group's option, Subscribers and their enrolled Eligible Dependents who lose eligibility for coverage under this Group Plan may elect to extend their coverage for a period not to exceed three (3) months unless: ~ Coverage was terminated as a result of a strike, lockout or other labor dispute; or > Employment was terminated for gross misconduct Application for coverage must be made within thirty-one (31) days of the date coverage under the Group Plan ended. During this period of continued coverage, benefits and Premium may not be altered from that of the existing Group Plan. The Subscriber is required to pay any applicable Premium directly to the Group. The Group is required to remit Premium to KPS in accordance with the Premium Due Date and grace periods defined in this Contract. Failure on the part of the Subscriber to make Premium payments will result in termination of coverage as of the last day of the month for which Premium was paid. Coverage terminated for non- payment of Premium will not be reinstated. COBRA (Consolidated Omnibus Budget Reconciliation Act - 1985) Employers who are required by law to comply with the provisions of the 1985 COBRA act must notify all eligible Employees, and their Eligible Dependents, who lose eligibility for coverage under this Group Plan of their right to continue coverage under this provision. Eligible individuals are required to apply for continued coverage within sixty (60) days of the date coverage under this Group Plan ends. The Group is required to notify KPS of each individual's election of COBRA continuation coverage within thirty~one (31) days of that election. Failure on the part of the eligible individual to make a timely election, or failure on the part of the Group to provide KPS with timely notification of the election, will be interpreted by KPS as a waiver of the individual's right to continue coverage under this provision. Failure by the Group to provide timely notification to KPS may not, in all cases, eliminate the Group's obligation to provide continuation coverage, it will, however, eliminate any obligation on the part of KPS to provide continuation coverage under this Contract. Individual Conversion Coverage Employees who are under age sixty-five (65) may be entitled to transfer to a KPS Individual Conversion Plan if: They are not otherwise eligible for coverage under Medicare They are currently eligible for continuation of Group coverage but have elected not to enroll in the Group Plan ~ Coverage under this Group Plan or a COBRA continuation plan has terminated (for any reason except non-payment of Premium, when it is the individual's responsibility to pay the Premium) ~' This Group Plan terminates and the Group does not provide other health care coverage to its Employees Application for coverage must be made within thirty-one (31) days of the date coverage under this Group Plan, or other KPS continuation or COBRA plan ends. Applicable Premium payments for the first month of coverage must be submitted with the enrollment application. Eligible Dependents may apply for coverage separately under this option in the event they lose coverage under this Group Plan due to the death of the Subscriber, or if the Subscriber and Spouse divorce Page 7 151 When an Enrollee enrolls in a conversion plan, he/she loses certain protections guaranteed under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Most notably, if the Enrollee wants to transfer to a non-conversion individual plan, he/she could be denied coverage based on a previous or existing health condition. If the Enrollee does qualifl7 for coverage under a non-conversion individual plan his/her coverage will be subject to any waiting periods for pre-existing conditions. For more information p ease contact KPS Member Services at 360-478~6796 or toll free 1-800-552-7114. Employees who are age sixty-five (65) or older when coverage under this Group Contract terminates may be eligible for coverage under a Medicare Supplement Plan. To determine Employee eligibility for a Medicare Supplement Plan, please contact KPS Member Services. COORDINATION OF BENEFITS (COB) General Provision Benefits are provided under this Group Plan only to the extent that Subscribers and their enrolled Eligible Dependents could not have received benefits for the same service(s) under any other Plan, had a claim for benefits been made. The purpose of this COB provision is to ensure that the sum of claim benefits paid by KPS and all other Plans under which Subscribers and their Eligible Dependents are covered does not exceed 100% of the Allowable Expense. All of the benefits provided under this Group Plan are subject to this COB provision. Definitions "Allowable Expense" means the usual, customary or reasonable charge for any necessary health care service or supply when the service or supply is a covered benefit, at least in part, under any of the Plans involved. When a Plan provides benefits in the form of services rather than cash payments, the reasonable cash value of each service provided shall be considered an Allowable Expense. The difference between the cost of a private Hospital room and the cost of a semi-private Hospital room is not considered an Allowable Expense under the above definition unless the Enrollee's stay in a private Hospital room is considered to be Medically Necessary under at least one of the Plans involved. "Double Coveraqe" means when Enrollees have coverage under another Plan. "Plan" means a policy or contract which provides benefits or services for, or because of, medical or dental care, through one of the following: This Group Plan Any group, individual or blanket disability insurance policy Any group or individual contractual prepayment or indemnity plan such as those issued by health care service contractors, health maintenance organizations or other health carriers or health insurers Any labor-management trusteed plan or labor organization plan Any employer organization plan or Employee benefit organization plan Any governmental program Any insurance coverage required or provided by statute, including automobile policies which provide medical benefits ~ Any other similar source The term "Plan" does not include accident-only coverage, including athletic injuries, for school-age Children from Kindergarten through twelfth grade (K through 12), or for college students, either on a 24-hour basis or on a "to and from school" basis. Each of the Plans under which the Enrollees are covered, and each benefit payable under those Plans, are considered separately when benefits are coordinated under this provision. Page: 8 152 Claim Determination Period The claim determination period means a Calendar Year. Effect on Benefits When an Enrollee has double coverage, during a Calendar Year, one Plan normally pays its benefits in full as the primary payer and the other Plan pays a reduced benefit as the secondary payer. KPS determines which coverage is primary according to the National Association of Insurance Commissioners' guidelines. When KPS is the primary payer, we will pay the benefits described in this Benefits Booklet. When KPS is the secondary payer, we will determine the Allowable Expense. After the primary Plan pays, we will pay what is left of the Allowable Expense, up to our regutar benefit. We will not pay more than our allowance. Order of Benefit Determination When more than one Plan contains a COB provision, the decision as to which Plan is the primary Plan is made in the following order: The Plan that covers the person as a Subscriber rather than as an Eligible Dependent is primary When an Eligible Dependent Child is covered under more than one Plan, the Plan of the parent whose date of birth (month and day only) occurs eaHier in a Calendar Year is primary, except when the Child's parents are legally divorced or separated ~, When the parents of a covered Eligible Dependent Child are divomed or separated and there is no court decree which establishes financial responsibility for the medical or dental expenses of the Eligible Dependent Child, then benefits for the Child's Covered Expenses are determined as follows: · The Plan of the parent with custody is primary, provided the parent with custody has not remarried · If the parent with custody has remarried, the order for determining the primary Plan is: (i) The Plan of parent with custody (ii) The Plan of the stepparent (iii) The Plan of the parent without custody Despite the above, if the court has determined which parent is financially responsible for the health care of the Eligible Dependent Child, then the Plan of that parent is always the pdmary Plan. When the above rules do not establish an order of determination, then the Plan which has covered the person for the longer period shall be primary, except that: ~ The benefits of the Plan which covers the person, on whose expenses the claim is based, as a laid- off or retired Subscriber, or a Dependent of such a Subscriber, shall be determined after the benefits of the Plan which covers that person as a Subscriber (other than as a laid-off or retired Subscriber), or the Dependent of such a Subscriber; and ~' If either of the Plans does not have a provision regarding Paid-off or retired Subscribers, which results Jn each Plan determining its benefits after the other, then the above provision shall not apply. If none of the above rules apply, the Plan that has covered the person for the longest period of time shall be considered the primary Plan. Facility of Payment Whenever another Plan makes payments that should have been provided under this Group Plan and in accordance with this COB prevision, KPS may, at its sole discretion, choose to reimburse the Plan making such other payments, the amount necessary to satisfy the intent of this COB provision. Any amount paid under this subsection shall be considered as benefits paid under this Group Plan, and KPS shall be fully discharged from liability to the extent of such payments. Page 9 153 Right of Recovery Whenever KPS makes payments that are in excess of the maximum amount of payment necessary to satisfy this COB provision, KPS shall have the dght to recover the excess payment amount from the Enrollee, from the Provider, or from another Plan, as applicable. Right to Receive and Release Information As a condition of receiving benefits under this Group Plan, Subscribers and their enrolled Eligible Dependent(s) agree to provide KPS with any necessary information, and authorize KPS to release to or obtain from any other insurer, organization or person, any information necessary to administer this COB provision. Disclosure of Coordination Failure on the part of Subscribers and their enrolled Eligible Dependents to cooperate with KPS regarding this COB provision could result in the loss of benefits under this Group Plan. KPS recommends that Subscribers and their enrolled Eligible Dependent(s) submit claims to KPS, and each other plan, at the same time to help minimize delays and facilitate claims payment. KPS' RIGHT OF RECOVERY Limitations and Exclusions Coverage under this Group Plan is excluded for expenses incurred or services rendered if the Enrollee's illness or injury is caused (or alleged by the Enrollee to be caused) by another party, to the extent that benefits are available under the terms of any other insurance coverage or source of payment, including but not limited to: Vehicle medical, personal injury protection ("PIP"), no-fault, uninsured or underinsured motorist, workers' compensation insurance or benefits and third party liability insurance, or similar contract of insurance. ~. Homeowner's, property or any other insurance policy (except for individual or group health insurance). ~ An agreement, judgment or settlement pursuant to which a third party pays or agrees to pay for the costs of such services from assets other than a policy of insurance. This exclusion applies whenever any such contract of insurance, agreement, judgment or settlement is issued to or provides benefits for the Enrollee, whether or not they assert a claim against the responsible third party or its insurers. Third Party Liability: Reimbursement and Subrogation As a condition of KPS' agreement to advance payment to the Enrollee or their Provider for medical expenses for illnesses or injuries caused (or alleged by the Enrollee to be caused) by another party, the Enrollee agrees to make a claim against, or otherwise pursue recovery from all responsible parties and their insurer(s) for all payments advanced to the Enrollee or their Provider by KPS. If the Enrollee does not make a claim or otherwise pursue recovery of KPS' payments, all such payments made by KPS may be denied or recouped. By providing benefits under this provision, KPS is fulfilling its obligations under this Group Plan. However, by so doing, KPS does not waive any rights to reimbursement or subrogation. Provided, the benefits of this Group Plan will be advanced to the Enrollee if they are injured by a third party, before compensation is recovered from the third party or its insurers, only under the following conditions: ~, The Enrollee, and their representative(s), must fully cooperate with KPS in recovering payment of medical bills paid, and to be paid by KPS, from the parties who allegedly caused the injury or illness, including but not limited to their liability insurance carriers, any applicable PIP, uninsured or underinsured motorist policy, homeowners policy, workers compensation or any other reachable assets of the responsible party or parties; Page: 10 154 The Enrollee notifies KPS, in writing, of the details of the injury or illness, the names and addresses of the parties believed to be responsible and the names and addresses of the responsible party's insurers, if known; Any claim or lawsuit filed by the Enrollee against the third party or the third party's insurer(s) must include a demand for repayment of benefits paid by, or to be paid, by KPS on the Enrollee's behalf; or > The Enrollee must agree to assign to KPS their right to recover compensation for the medical costs paid (subrogation), or to be paid, by KPS as a result of injuries caused by the third party responsible for the injury. ~. The Enrollee must agree to reimburse KPS for the medical expenses paid or that will be paid by KPS as a result of the injury, from the settlement, judgment, insurance proceeds or other recovery obtained by the Enrollee from any third party or its insurers. Collection and Reimbursement by Enrollee (or the Enrollee's Representative) If the Enrollee elects to demand recovery for KPS' payments from the responsible third party, they must: Notify KPS in advance of any settlement, mediation, arbitration or trial. Inform the responsible third party and its insurer(s) of the amount of the lien asserted by KPS, for the recovery of payments made on their behalf, against any recovery or potential recovery obtained by them. Obtain prior consent from KPS before compromising or settling claims involving medical costs paid by KPS. ~- Not enter into any agreement with the responsible third party or its insurer(s), or do anything else that would release KPS' lien or prejudice our subrogation or reimbursement rights, without first obtaining express prior written consent from KPS. ~' Reimburse KPS for that portion of the settlement, award or judgment that is compensation for medical bills paid and to be paid by us. If the Enrollee obtains a settlement or recovery for less than the insurance policy limits or reachable assets of the liable party, they are obligated to reimburse KPS for the full amount of benefits paid on their behalf after they have been fully compensated for their loss. If, however, the Enrollee obtains a settlement or recovery that is equal to or greater than the liable party's insurance policy limits or reachable assets, they are only obligated to reimburse KPS in the amount that is left after they have been fully compensated for their loss. The Enrollee, or their representative(s), must obtain a written agreement from KPS prior to settling any claim if they want KPS to share, on an equitable basis, any reasonable attorney fees they incurred in pursuit of any subrogation or reimbursement claim. In the absence of a prior wdtten agreement, KPS, at its sole discretion, will determine whether or not to reduce our reimbursement amount in order to share, on an equitable basis, any reasonable attorney fees incurred by the Enrollee. However, such a reduction will only be considered if KPS has benefited from the services of their attorney. In no event will KPS' reimbursement be reduced by more than twenty percent (20%) to offset attorney fees incurred by the Enrollee, and KPS will not pay for costs incurred by them. Subrogation: Assignment of Third Party Claim to KPS If the Enrollee elects to assign their rights to KPS to pursue a claim seeking recovery from a responsible third party or its insurer(s), they and their representative(s) must cooperate fully with KPS in pursuing the claim against the responsible parties. Such cooperation includes, among other things: Providing evidence and testimony consistent with the testimony in the case against the responsible parties. ~' Refusing to assist the responsible parties, in any way, in defending against a claim brought by KPS. ~' Cooperating with KPS by not taking any action that might release, limit, reduce, or otherwise prejudice our efforts to pursue a ctaim against any responsible third party. Page 11 155 Trust and Cooperation Between the Enrollee (or the Enrollee's Representative) and KPS The Enrollee and their representative(s) must deal in good faith with KPS by adhering to all of the conditions set forth in this section. In turn, KPS agrees to cooperate with the Enrollee and their representative(s) in their effort to recover reimbursement, and will advance payments on their behalf for injuries or medical conditions caused, or asserted by them to be caused, by any third party. The Enrollee and their representative(s) must cooperate fully with KPS in protecting, preserving, and recovering the amounts KPS has paid or will pay on their behalf under this Group Plan. Failure to cooperate may result in the denial of coverage for injuries or conditions caused, or asserted by them to be caused, by any third party to the extent that coverage or payment for such injuries or illnesses is, or would have been, available under the terms of any other insurance coverage or source of payment. Agreement to Arbitrate Any dispute that arises between the Enrollee and KPS as a result of the preceding recovery provisions shall be settled through arbitration. Both the Enrollee and KPS shall be bound by the decisions of the arbitration proceedings. Disputes will be presented to, and resolved by, a single arbitrator in accordance with the current rules of the American Arbitration Association. Either the Enrollee or KPS may demand arbitration by serving notice of this demand on the other. Each party to the arbitration agrees to bear its own costs and to share equally in the fees of the arbitrator. This agreement to resolve disputes through arbitration is in effect as of the effective date of the Group Plan, and shall remain in effect until the dispute between us has been resolved. Recovery of Claims Payments Ineligible Persons If KPS knowingly or unknowingly makes any payment on behalf of an individual who for any reason was not eligible to receive the services and benefits provided herein, KPS is entitled to full reimbursement from such ineligible individual or from a Subscriber who applied for the ineligible benefits on behalf of such individual. If KPS knowingly or unknowingly receives Premium payment on behalf of an individual who for any reason was not eligible to receive the services and benefits provided herein, KPS reserves the right to refund any Premium payment(s) in excess of claims paid for the time the individual was ineligible, and shall have the right to recover the cost of any benefit furnished while such individual was improperly enrolled in this Group Plan. Incorrect Claim Payment KPS is entitled to full reimbursement from the payee for any incorrect claim payment. The term "incorrect claim payment" includes but is not limited to the following: Payment to the wrong Provider Payment of an incorrect amount Payment for a service that is not a Covered Benefit or Service Duplicate payment for the same service Payment on behalf of the wrong Enrollee Incorrectly billed procedure or diagnosis SUBSCRIBEPJDEPENDENT LIABILITY AND RIGHTS Subscriber/Dependent Liability Subscribers and their Eligible Dependents who are enrolled in this Group Plan are liable for the following costs: > Deductible >' Copayments Page: 12 156 Charges for non-covered services >- Coinsurance, up to the Coinsurance Stoploss limit defined in Attachment A- Benefits Booklet Charges incurred after an annual or lifetime maximum benefit, for a specific service or supply, has been exhausted (such as the annual maximum benefit for durable medical equipment) >-Charges in excess of the amount paid by KPS to non-participating Providers If KPS fails to reimburse a Participating Provider for the cost of Medically Necessary Covered Services provided in accordance with the terms of this Contract, neither the Enrollee nor the Group shall be required to compensate the Participating Provider for such services beyond the limit of Deductibles, Copayments or Coinsurance amounts specified in the Benefits Booklet. KPS will continue to reimburse a Participating Provider for Medically Necessary Covered Services rendered to an Enrollee after the Participating Provider's contract with KPS has ended, for such time as the Enrollee remains covered under this Group Plan, until (i) the Enrollee's course of treatment has been completed, or (ii) the care of the Enrollee has been appropriately transferred to another Participating Provider. The KPS Medical Director is responsible for determinations regarding the completion of a course of treatment and the transfer of patient care. KPS Privacy Policy KPS Health Plans is committed to protecting the privacy of Enrollees' personal and health information. We are required by applicable federal and state law to maintain the privacy of personal and health information. KPS Health Plans is also required to give this notice to Enrollees to tell them how KPS may use and give out ("disclose") their personal and health information held by KPS Health Plans. Personal and health information (referred to in this notice as "personal information") means any information that is identifiable as personal information, including information regarding health care and treatment, identifiable factors such as the Enrellee's name, age, and address; or financial information. We may collect personal information about the Subscriber, or members covered by KPS Health Plans through the Subscriber, from the following sources: * Information we receive from the Enrollee, including information provided on applications or other forms, * Information we receive from the Enrollee's health care providers or other companies, such as other health insurance companies, relating to medical claims and billings, * General information about the health care services the Enrollee has received, such as the quality and availability of services. We restrict access to personal information about the Enrollee to only those who need to know that information to provide treatment, payment or health care operations services to the Enrollee. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard the Enrollee's personal information. We do not disclose any personal information about our members or former members to anyone, except as permitted or required by law. However, KPS Health Plans will use and give out personal health information: * To the Enrollee or someone who has the legal right to act for the Enrollee (their personal representative), To the Secretary of the Department of Health and Human Services, if necessary, to make sure the Enrollee's privacy is protected, * To law enforcement officials when investigating and/or prosecuting alleged civil or criminal actions, and * Where required by law. KPS Health Plans has the right to use and give out personal information to arrange for treatment, payment of, and health care operations services, including: Medical quality reviews * Accounting * Legal and risk management services Page 13 157 KPS Health Plans may use or give out personal information for the following purposes under limited circumstances: ~r For Government healthcare oversight activities (such as fraud and abuse investigations) * To avoid a serious and imminent threat to health or safety By law, KPS Health Plans must have written permission (an "authorization") to use or give out personal information for any purpose that is not set out in this notice. The Enrollee may take back ("revoke") their written permission at any time, except if KPS has already acted based on their permission. By law, Enrollees have the right to: See and get a copy of their personal information held by KPS Health Plans, except in certain limited situations. * Make a reasonable request in writing to amend any of their personal information created by KPS Health Plans if they believe that it is wrong or if information is missing, and KPS Health Plans agrees. If KPS Health Plans disagrees, we will notify the Enrollee why in writing. Enrollees may have a statement of their disagreement added to their personal information. Get a listing of those obtaining their personal information from KPS Health Plans in the past 6 years. The listing will not include information: That was given to the Enrollee or their personal representative, That the Enrollee authorized KPS Health Plans to release, or That was given out for law enforcement purposes, or That was given out to pay for the Enrollee's health care claim or a disputed claim. Request in writing that KPS communicate with them in confidence about their personal information by alternative means or to an alternative location. If they advise us that disclosure of all or any part of their personal information could endanger them, we must comply with any reasonable request provided it specifies an alternative means or location. '* Ask KPS Health Plans to place additional restrictions on our use or disclosure of their personal information for treatment, payment, health care operations or to persons they identify. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). *' Get a separate electronic or paper copy of this notice. For more information about exercising their rights set out in this notice, Enrollees may call KPS Health Plans' Member Services department at (360) 478-6796 or toll free at (800) 552-7114. They can also reach KPS Health Plans' privacy official for this purpose at (800) 552-7114. If an Enrollee believes KPS Health Plans has violated their privacy rights set out in this notice, they may file a complaint with KPS Health Plans at the following address: KPS Health Plans Compliance Department P.O. Box 339 Bremerton, WA 98337 Filing a complaint will not affect the Enrollee's benefits under KPS Health Plans. They may also file a complaint with the Secretary of the Department of Health and Human Services. KPS Health Plans does have the right to change the way personal information is used and given out. If KPS Health Plans makes any changes, Enrollees will get a new notice by mail within 60 days of the change, and that notice will become effective on the date the revised notice is issued. Please note: Telephone calls to and from KPS Health Plans may be recorded for quality assurance and training purposes. If the Enrollee is the primary Subscriber with KPS Health Plans and other persons are covered by KPS Health Plans through them, we suggest that the Subscriber share this information with each other to ensure that each of them is aware of our policy and their privacy rights. Please refer to KPS Health Plans' website at www. KPSHealthPlans.com for more information about our privacy practices. Page: 14 158 COMPLAINTS AND APPEALS PROCESS Complaints All Enrolrees have the right to contact KPS whenever they have a question, complaint or concern regarding: Their benefits Their access to care or how to arrange for care Any KPS Participating Provider Service they receive from KPS Any other issue related to this Group Plan or KPS. In the event an Enrollee has a complaint, KPS Member Services Representatives are available Monday through Fdday, from 8:00 a.m. until 5:00 p.m. Pacific Time, except on nationarly recognized holidays. Although a Member Services Representative can resolve most matters, Enrollees may choose to file a complaint, or request an appeal, if they are not satisfied with the Member Services response. The following steps outline the procedure for filing a complaint: EITHER The service provided by KPS Send a written statement of the complaintto: with the Enrollee and try toI resolve the complaint over the Eligibility KPS Health Plans phone. Otherwise, KPS will Coverage or Benefits Attn: Member Services send a written response within Claims Payment Resolution Department 30 days of receiving the PO Box 339 complaint. Access to Care Bromerton, WA 98337 Quality of Cato OR Complaints about Participating Providers are investigated KPS Participating Providers Calf KPS Member Services al thoroughly and are reviewed 360-478-6796 periodically. or toll free at 1-800-552-7114 Standard Appeals Process Enrollees have the right to appeal any decision regarding a complaint or any aspect of their health cato coverage that is not in their favor. The request for an appeal must be made within 180 days of the date they receive an EOB, letter or other type of communication, from KPS, that contains an unfavorable decision regarding their benefits. Such decisions could affect: The service received from KPS Access to health care services or Providers Eligibility for coverage Benefit coverage Termination of coverage under this Group Plan (except termination for non-payment of Premium) Non-payment of a claim, either completely or partially A denial or modification of a request for pro-authorization of any health care service or supply A denial of a request for coverage of an experimental or investigational service or supply Page 15 To file an appeal, the Enrollee, his/her designated representative, or his/her Provider may either call or write KPS at the phone number or address listed above. Any documentation supporting the Enrollee's position may be included with the appeal. KPS will notify the Enrollee, in writing, that the appeal request has been received and include additional information regarding the Appeals Process and the Enrollee's rights and responsibilities dudng an appeal. The Enrollee has the right to send an appeal directly to an Independent Review Organization (IRO) if KPS does not respond to the Enrollee within the allotted time pedod, as follows: Decisions Regarding: Days to Respond: Service-Related Appeals 30 Days Denials of Experimental and/or Investigational Procedures or Supplies 20 Days All other Adverse Determinations 14 Days Expedited Appeals Process If the Enmllee's health care Provider, or the KPS Medical Director, reasonably determines that by following the Standard Appeals Process the Enrollee's life, heatth, or ability to regain maximum function would be jeopardized, KPS will invoke an Expedited Appeals Process and make a decision within 72 hours after it is received. The Enrollee will receive notice of this action. GENERAL TERMS AND CONDITIONS Applicable Law This Contract shall be governed by, and construed in accordance with, the laws of the state of Washington. Venue for this Contract shall be Kitsap County. Assignment of Benefits The benefits of this Contract shall accrue to Subscribers and their enrolled Eligible Dependents. Neither this Contract, nor its payments or Covered Benefits and Services are assignable to a third party. KPS reserves the right to make benefit payments to the Subscriber, the Provider, or jointly, as KPS deems necessary and appropriate, subject to federal and/or state laws. Binding Agreement This Contract is binding on KPS and the Group, and their respective executors, administrators, successors and assigns. By election of coverage or payment of applicable Premiums, or if the Group's Subscribers or their enrolled Eligible Dependents seek the services provided under this Contract, all of the terms, covenants and conditions contained herein shall become valid and binding on the Group and its Subscribers and enrolled Eligible Dependents, notwithstanding the failure of the Group to sign this Contract. This Contract shall not bind KPS until (i) it has been executed by a person authorized by KPS, and (ii) an executed copy has been delivered to the Group. Confidentiality The underwriting and financial terms of this Contract are confidentia~ and shall not be disclosed except as is necessary for the performance of this Contract, or as required by Jaw. Contract Modifications Except as set forth under Premium Rate Adjustments, KPS reserves the right to modify the provisions of this Contract, or the services described in the Benefits Booklet, upon thirty (30) days written notice to the Group. The Group may elect to reject such modifications by providing KPS with fifteen (15) days written Page: 16 160 notice. However, rejection of a modification will result in the termination of this Contract as of the last day of the month for which Premium payment has been received. Lack of notification of rejection by the Group shall be interpreted as acceptance of the modification and this Contract will be renewed as modified. No modification of the terms of this Contract shall be binding upon KPS unless endorsed, in writing, and signed by an authorized officer of KPS. Such endorsement shall be deemed a par[ of this Contract, effective as of the effective date of the endorsement. Any amendment or Contract modification required by law or regulation shall become effective as of the effective date required by such law or regulation. Coverage Limits The Covered Benefits and Services offered under this Contract are subject to the coverage limits and maximums set forth in Attachment A - Benefits Booklet. Entire Agreement This Contract, together with Attachment A - Benefits Booklet; Attachment B - Premium Rates and Underwriting Criteria; and any riders and/or endorsements attached hereto, constitute the entire agreement. This Contract supersedes all previous communications, representations or agreements, either verbal or written between KPS and the Group, with respect to the subject matter herein. Equity of Application This Contract is intended to apply equally to all Enrollees. False or Misleading Information If the Group provides statements or other information on the Group Master Application form, or any other form required by KPS, that affects the acceptability of the Group for coverage, or the risk assumed by KPS for providing coverage, KPS may, at its sole discretion, elect to immediately terminate this Group Contract and recover any claims and/or administrative costs from the Group, Enrollee(s), or any other person(s) responsible for providing the false or misleading information. Force Majeure In the event KPS is unable to perform its obligations hereunder by reason of fire, casualty, lockout, strike, labor condition, riot, war, act of God or by ordinance, law, order or decree of any legally constituted authority, then this Contract may, at the option of KPS, be suspended. During any period of suspension, KPS shall not be required to perform any service hereunder, nor shall KPS be liable for any damages arising from any event that precipitated the suspension. If this Contract is suspended pursuant to this provision, any obligation by the Group and/or an Enrollee to make Premium payments shall also be suspended for the same period of time. Group Cooperation The Group agrees to cooperate with KPS in the administration of this Contract by: (i) Advising Subscribers and their enrolled Eligible Dependents of policies and procedures applicable to this Group Plan. (ii) Providing Subscribers and their enrolled Eligible Dependents with a Benefits Booklet, ID cards and any applicable notices or other information regarding this Group Plan. (iii) Providing information about Enrollees that is relevant to the determination of eligibility, claim reimbursement, coordination of benefits or other information required for the administration of this Contract. (iv) Making appropriate payroll deductions, if applicable, to facilitate Premium payment. Page 17 Headings The headings of sections and paragraphs in this Contract are for convenience and reference purposes only and do not affect in any way the meaning or interpretation of any provision of this Contract. Notices Any notice that may affect the prows~ons of this Contract shall be deemed delivered to the Group when deposited in the United States mail with prepaid postage, addressed to the Group at the most recent address listed for the Group. Any notice that may affect the provisions of this Contract shall be deemed delivered to KPS when deposited in the United States mail with prepaid postage, addressed to KPS at the following address: P.O. Box 339, Bremerton, WA 98337-0039. Any requirement of KPS to provide notice to Enrollees shall be fulfilled when the Group has received such notice. It is the responsibility of the Group to disseminate notices to Enrollees within thirty-one (31) days of receipt. Severability If any term, provision, endorsement or condition of this Contract is deemed invalid or unenforceable by a court of competent jurisdiction, the same shall be deemed severable from this Contract. However, the remainder of this Contract shall remain in full force and effect and shall in no way be affected, impaired or invalidated as a result of such decision. Third Party Beneficiaries There are no third party beneficiaries to this Contract. Waiver of Breach Waiver of a breach of any prevision of this Contract shall not be deemed to be a waiver of any other breach of the same or different provision. Page: 18 162 KPS Health Plans, In Rehabilitation 400 Warren Avenue P.O. Box 339 Bremerton, WA 98337-0039 CITY OF BREMERTON UNDER 65 LEOFF I RETIREES (SUBSCRIBERS ONLY) COVERAGE CONTRACT Group Number: 21001-21006 Effective Date: 1/1/2004 Renewal Month: January Open Enrollment December This Coverage Contract includes the following: Attachment A - Benefits Booklet Attachment B - Premium Rates and Un~lerwriting Criteria Riders: N/A Optional Riders: N/A Endorsements: N/A This Contract is entered into and delivered in the state of Washington and is governed by Washington State laws, except to the extent state laws are preempted by federal law. Signature by a qualified Group representative or payment of the Premium shall constitute acceptance of the terms and conditions set forth herein. FOR KPS: FOR GROU~': Elizabeth A. Gitje, President Signature Date Print Name Title Date 163 DATE SUBMITTED: 8/18/04 BILL # Oq- /77 AGENDA BILL CITY OF BREMERTON q ~ CITY COUNCIL SUBJECT: Governmental Services Committee Meeting Date: 8/25/04 Agreement with Kitsap County for COUNCIL MEETING Date: 9/I/04 Programming Services on Bremerton Kitsap Department: Financial Services Access TV Presenter: Charleen Burnette Phone: 308-0139 SUMMARY Currently the City and Kitsap County have been working together to craft a more equitable compensation schedule for BKAT programming services. The rate card attached to the agreement outlines the increased fees that will enable BKAT to realize more fully the budgeted allocation of 2004 funds bom the County of approximately $40,000. The term of this agreement is January 1, 2004 to December 31, 2004. The attached memereflects work in progress on the future governance of BKAT. S~t-~ fef~or-q-- ATTACHMENTS: memo and agreement FISCAL IMPACTS (Include Budgeted Amount): BKAT will realize the total $40,000 for program services compared to the historic $20,000 annually received. APPROVALS: / DEPARTMENT DIRECTOR: ~_~ CITY ATTORNEY: /'~ <.~-~ FINANCE DIRECTOR: MAYOR: ( 2... '/~' - __ OPERATIONSFISCAL/BUDGET: .~~ : - t CONSENT AGEND~ COUNCIL PRESIDENT: RECOMMENDED MOTION: Move to approve the Governmental Services Agreement between the City of Bremerton and Kitsap County for providing programming services through Bremerton Kitsap Access Television (BKAT) and authorize the Mayor to execute this agreement in substantially the same form as presented. COUNCIL ACTION: [] Avvrove [] Deny [~ Table [] Continue [] No Action GOVERNMENTAL SERVICES AGREEMENT KC-222-04 This Agreement is made by and between Kitsap County (County) and the City of Bremerton (City), who agree as follows: Section 1. Scope of Services. In exchange for funding provided by Kitsap County to City of Bremerton pursuant to this Agreement, City of Bremerton shall operate and manage through Bremerton Kitsap Access Television (BKAT) the governmental programming services for the County including but not limited to video production and program scheduling. Governmental programming may include, but not be limited to the following monthly programming: 1. County Commissioner Hearings 2. Hearing Examiner 3. Planning Commission 4. Kitsap magazine format program 5. Other programming as requested City shall provide, technical support, consultation; pre-production and post-production services; properly trained staff and volunteers including videographer for field assignments; proceeding/event tape duplication and delivery no later than the 2"d business day following completion of project to program sponsor; and coordinate programming hours and studio time. BKAT will work with the County to establish playback slots for programs produced under this Agreement. Once scheduled, program slots shall not be moved, altered or deleted without consent of the County. County shall control the content of County produced programming. All regularly scheduled programming shall be replayed a minimum of two times. The County shall provide to BKAT ten (10) days advance notice for videotaping of County Commissioner heatings, Hearing Examiner hearings, and Planning Commission meetings. The County shall purchase and store tape stock used for its productions. Footage is the property of BKAT until production is complete. When completed, the finished production becomes the property of the County. VHS copies shall be maintained in the County video archives. Master SVHS originals shall be maintained at BKAT for seven years before erasure or disposal. For the production of"Other Programming" as requested, Section 1 (5), above, the County shall give ten (10) days notice. All requests shall be made by designated county representative by phone, fax or e-mail directly to the BKAT Manager. The City, through Bremerton Kitsap Access Television, will respond to the requestor within one (1) working day that they can or cannot schedule production of the request. The City agrees that conflicting requests on the same day for production services, which are submitted, with less than ten (10) days notice shall be satisfied on a first come, first serve basis unless other arrangements are made. Govcmmental Services Agreement (8104) Page I of 4 Section 2. Funding. City shall receive funding in exchange for delivery of the services delineated in Section One of this Agreement. County shall make funds available to City as follows: The County shall be billed at the current rate card level (see Attachment "A') for services and equipment provided under Section One. Proposed changes to the rate card during the term of this Agreement shall be negotiated and mutually agreed to by the parties. BKAT invoices will be detailed to pre-production, event production, and post-production services by event type and date. Except for tapes covered in Section One, all other expenses associated with the various production activities shall be calculated according the BKAT Rate Card, Attachment A, or unless otherwise agreed upon. The County will be billed for time related to time taken to travel to off- site venues. Direct employee expenses and volunteer travel time to production sites is not submitted to the County. The County shall make a lump sum payment at the beginning of the year in the amount of $20,000. Monthly statements detailing production expenses will be provided to the County with a tally of expenses year to date. Once $20,000 in County production expenses is reached, the City shall provide monthly invoices to the County for payment following receipt on invoice, payable within thirty (30) days. The amount of this Agreement will not exceed $40,500. Section 3. Term of Agreement. The term of this Agreement shall be for a one year period commencing on January 1, 2004 and ending on December 31, 2004. Section 4. Hold Harmless. The City of Bremerton and Kitsap County shall each indemnify, defend, and hold the other harmless from and against any and all claims, suits, actions, causes of action, losses, damage or liabilities arising or resulting from any alleged negligent or intentional acts or omissions arising out of the performance or non performance of their respective responsibilities as set out in this contract. Section 5. Termination. A. This Agreement may be terminated by either party without cause upon giving one hundred twenty (120) days written notice. Section 6. Non-discrimination in Employment and Service. A. City shall not discriminate against any person, employee or applicant for employment or subcontractor on the basis of race, color, creed, religion, sex, marital status, ancestry, national origin or physical or mental handicap. B. City shall not discriminate in the delivery of services on the basis of race, color, creed, religion, sex, marital status, an ancestry, national origin or physical or mental handicap. C. City shall comply with Americans with Disabilities Act (ADA) requirements. Section 7. Severability. Should any part of this Agreement be found void, the balance of the Agreement shall remain in full force and effect. Governmental Services Agreement (8t04) Page 2 of 4 Section 8. Entire Agreement. This Agreement and its Exhibits constitutes the entire agreement between the Parties, and the Parties acknowledge that there are no other agreements, written or oral, that have not been set forth in the text of this Agreement. Section 9. Modification. This Agreement may only be modified by written instrument signed by both Parties. Section 10. Written Notices. All communication regarding this Agreement shall be sent to the parties at the addresses listed below, unless notified to the contrary. Any written notice hereunder shall become effective upon the date of mailing by registered or certified mail, and shall be deemed sufficiently given if sent to the addressee at the address stated in this Agreement or such other address as may be hereafter specified in writing. CITY: COUNTY: City of Bremerton Kitsap County 239 Fourth Street 614 Division Street Bremerton, WA 98337 Port Orchard, WA 98366 IN WITNESS WHEREOF, the parties have executed this Agreement on the day of _, 2004. CITY OF BREMERTON KITSAP COUNTY, WASHINGTON CARY BOZEMAN, Mayor PATTY LENT, Chair Departmental Approval: CHRIS ENDRESEN, Commissioner MICHAEL WILSON Director of Financial Services JAN ANGEL, Commissioner Approved as to Form: Attest: ROGER LUBOVICH, City Attorney OPAL ROBERTSON, Clerk of the Board Attest: PAULA JOHNSTON, City Clerk Governmental Services Agreement (8/04) Page 3 of 4 ATTACHMENT A BKAT RATE CARD 2004 ~re-production ---quipment Consultation, per hour $125.0C ~rogram Development, per hour 125.0f~ Research, per hour 125.0f'1 Location Survey, per hour 125.00 Scripting, per hour 125.0( Graphics Development, per hour 125.0£ =quipment Transport Remote Van transport to/from site, per hour 60.0f] Studio Suitcase transport to/from site, per hour 60.00 Producition * Crew Set-up, per hour 125.0(: Crew: Production, per hour 125.0~ ,.,few. Breakdown, per hour 125.0¢ rninlmum 2 hours for any productions ~ost Production --diting, per hour 125.00 Voice Over, per hour 125.00 Audio Sweetening, per hour 125.00 Miscellaneous Training, per hour 125.0, Equipment Installation, per hour 125.0¢ Equipment Troubleshooting and Repair, per hour 125.0¢ ]'ape Duplication (max. 120 minutes), each 35.0(* Video Tape** .abels $1.80 · * Labels: No charge for program Masters 4of 4 168 Bremerton Kitsap Access Television (BKAT) Agenda I. Govemance/Interlocal (Partnership) Agreement II. Funding/Franchise Agreemems III. Staffing IV. Facilities - CENCOM Facility V. 2004 Governmental Service Contract VI. Public Access - Screening VII. Process (Our next steps) I. Governance/Interlocal (Partnership) Agreement The organizational structure of BKAT to change from the current "service" arrangement to a business enterprise partnership with all entities served by BKAT participating in the governance and funding of the service A. Participants: Ideally all governmental entities, school districts and tribes within Kitsap would be participants in a partnership arrangement for providing governmental, educational and public access television services. · Governmental Entities: Kitsap County, Bremerton, Port Orchard, Poulsbo · Educational Entities: Bremerton School District, Central Kitsap School District, South Kitsap School District, North Kitsap School, Olympic College · Tribes: Suquamish, S'klaham B. Organizational Structure: · Policy Board - Comprised of elected officials of participating entities; meets 2-3 times per year Approve budget and long-range funding plan, prepares mission statement and goals · Executive Board - Comprised of administrators of participating entities; meets quarterly Prepares and recommends policies, budgets for approval by policy board; reviews operation procedures and operational planning · Citizens Advisory Board - Comprised of community members; meets on bi-monthly basis Provides community feedback, programming direction for public access television II. Funding The City of Bremerton would administer BKAT budget. BKAT staff would be employed by the City with these employees receiving the appropriate level of benefits. Each municipality would provide BKAT with pass through fees to be used to support capital equipment/facilities costs. Each participating entity would pay for their programming services based on an agreed to formula (i.e., number of subscribers, hours of service, population) Franchise agreements are up for renewal for KJtsap County and thc City of Bremerton within thc next few years. New renewal agreements should be negotiated and coordinated between both jurisdictions to provide continuity in terms, services and rates/fees. Example: Below are contributions paid to TCTV(Thurston County Television) for programming services. Thurston County contributes $125,000.000 700 hours of services City of Tumwater contributes $47,000.00 650" " " City of Olympia contributes $100,000 700" City of Lacey contributes $68,000.00 650 ...... Rainier Communications Model: 1/10 of Franchise fee is paid to RCC for a seat at the table (Board Member) .25 pass through fee to RCC (Capital only) IlL Staffing Staffing should be a sufficient level to operate adequately operate BKAT to provide the desired governmental, educational and public access programming and customer services, Staff would be employees of the City (or County) with salary and benefits paid for through authorization from a interlocal partnership agreement with the participating entities. Optimal staffing would be: Public Access Manager (1) Production Coordinator (1) Technical Assistants (2 P/T) - supervise productions in Government and Public Access, Education - not needed since school districts and college do their own productions) Technical Aides (2 P/T) (mn camera, set up productions) Program Coordinator (1) Office Assistant (1) VI. Facilities BKAT needs to relocate to another facility where both the administrative offices and production studio are in the same facility. The CENCOM facility would appear to be a desirable facility. · Pro: } Good location - optimum visibility, good bus access, close to OC and large population of people. Available because of the relocation of CENCOM to its new facilities City of Bremerton owns the building CenCom is designed for easy wiring of studio Able to place studio, truck, and offices within same site Close to Comcast... may be able to include playback system in same building Close to Olympic College for easy joint access to facilities and services CenCom has two moms next to each other making an ideal studio control mom (we could move the current control room there with minor expense in purchasing new control room equipment) } Due to decrease in travel time we can increase our playback schedule ~' Greater flexibility over reader board } Greater possibility of increasing/maintaining volunteer base } Better accessibility for disabled individuals · Con: } A little further for NK residents } Studio space is not as large as our current studio V. 2004 Governmental Service Agreement A new agreement needs to be entered into between the City of Brmerton and Kitsap County for the continuation of BKAT service through 2004. This agreement needs to provide for a fair share contribution by Kitsap County (minimum $40,000) toward the operational support of BKAT. VI. Public Access - screening BKAT provides "public access" service to the Kitsap community. If such public access should continue as a BKAT service, what limitations may BKAT impose on content, format and timing for broadcasting public-produced programs? What should be the screening procedures? VII. Process (What steps to take) · Meet with each potential participating entity · Set up the organizational structure and governance mechanism · Examine franchise agreements and determine strategy for negotiating new agreements · Negotiate and enter into new 2004 service agreement with Kitsap County and the City of Bremerton · Evaluate "public access" component · Reach an agreement relative to use of CENCOM facility · Determine operational and capital funding structure, level of funding, and funding formula for operational costs CITY OF BREMERTON BREMERTON/KITSAP PUBLIC ACCESS TELEVISION PROPOSED 2007 BUDGET 2004 2007 BUDGET PROPOSED REVENUES Beginning Cash & Investments 3,620 PASS THROUGH FEES: City of Bremerton 39,000 40,000 City of Pod Orchard 6,000 City of Poulsbo 9,000 Kitsap County 78,000 78,000 SUBTOTAL FOR CAPITAL 117,000 133,000 CONTRACTS: City of Bremerton (2002 Population 37,530) 35,000 50,000 City of Port Orchard (2002 Population (7,900) 20,000 City of Poulsbo (2002 Population (7,500) 16,500 20,000 Kitsap County (2002 Unincorporated Pop. 160,850) 35,000 100,000 Other Contracts 8,000 50,000 SUBTOTAL CONTRACTS 94,500 240,000 OTHER REVENUES Tape Sales 500 User Fees (New) 1,500 Printing & Duplicating 1,500 Sales of Memhandise 300 Class Tuitions 500 500 SUBTOTAL OTHER 2,300 2,500 TOTAL REVENUES 217,420 375,500 EXPENDITURES PERSONNEL Manager 41,573 56,816 Clerical 20,000 20,800 Program Staff 27,940 31,320 Technical Staff 31,200 41,760 Extra Labor 20,000 52,000 Benefits 22,207 58,358 SUBTOTAL PERSONNEL 162,920 261,054 OPERATIONS & MAINTENANCE Office & Operating 8,000 20,000 Small Tools 7,300 5,000 Computer Related 100 5,000 Professional Services 1,000 10,000 Telecommunications 5,000 6,000 Postage 1,000 1,000 Travel 2,000 5,000 Advertising 500 1,000 Small Equipment 2,500 2,500 Garbage 600 600 Equipment Repair 9,000 6,000 Miscellaneous 4,000 5,000 SUBTOTAL SUPPLIES, SERVICES & TAXES 41,000 67,100 CAPITAL Capital Equipment 133,000 SUBTOTAL CAPITAL 0 133,000 ENDING FUND BALANCE 13,500 TOTAL EXPENDITURES 217,420 461,154 ATTACHMENT A BIZ, AT RATE CARD 2004 Pre-production Equipment Consultation, per hour $125.00 Program Development, per hour 125.00 Research, per hour 125.00 Location Survey, per hour 125.0( Scripting, per hour 125.0C 3raphics Development, per hour 125.0C Equipment Transport Remote Van transport to/from site, per hour 60.0( Studio Suitcase transport to/from site, per hour 60.0( Producition * 3rew Set-up, per hour 125.0C 3few: Production, per hour 125.0C 3rew: Breakdown, per hour 125.0C minimum 2 hours for any productions Post Production Editing, per hour 125.00 Voice Over, per hour 125.00 Audio Sweetening, per hour 125.00 Miscellaneous Training, per hour 125.0C Equipment Installation, per hour 125.0, :quipment Troubleshooting and Repair, per hour 125.0C l'ape Duplication (max. 120 minutes), each 35.0(' Video Tape** Labels $1.8(1 · * Labels: No charge for program Masters 6 of 6 174 DATE SUBMITTED: August 18, 2004 BlLL# AGENDA BELL CITY OF BREMERTON CITY COUNCIL SUBJECT: Setting the Salary Level for the Committee Meeting Date: August 25, 2004 Budget Analyst position COUNCIL MEETING Date: September 1, 2004 Department: Financial Services Presenter: Michael R. Wilson Phone: 473-5590 SUMMARY: The BMC Chapter 2.50, Section 2.50.032 (a) requires Council approval for an initial salary rate which exceeds Rate 1. Council approval is requested to hire Mark MeLaughlin as Budget Analyst for the Department of Financial Services at Pay Band 10, Rate 6 ($4,666/month) based upon his more than twenty-five years of extensive experience primarily serving in the state government (Office of Financial Management, Office of the State Treasurer). The current Budget Analyst is compensated at Pay Band 10, Rate 8 - $4,903/month. The new employee will start on September 7 in order to obtain training from the current Budget Almlyst before she retires on September 30. ATTACItMENTS: City of Bremerton Professional/Confidential/Fiduciary Pay Plan & Mr. McLaughlin's resume FISCAL IMPACTS (Include Budgeted Amount): There will be a monthly salary savings of $237 due to the proposed salary level of the new Budget Analyst being lower than the incumbent. Additional monies were set aside in the Non-Departmental, General Fund budget (salaries/benefits) to cover the cost to train the new Budget Analyst; therefore, no additional budget appropriation is required. The net financial impact will be approximately $3,300. APPROVALS: DEPARTMENT DIRECTOR: CITY ATTORNEY: FINANCE DIRECTOR: MAYOR: FISCAL/BUDGET: OPERATIONS: COUNCIL PRESIDENT: RECOMMENDED MOTION: Move to approve of the salary of Mark McLanghlin as Budget Analyst for the Department of Financial Services at Pay Band 10, Rate 6, commencing on September 7, 2004. COUNCIL ACTION: [] Approve [] Deny [] Table [] Continue [] No Action 175 MARK MCLAUGHLIN SUMMARY OF QUALIFICATIONS · Extensive experience in financial analyses and money markets Comprehensive knowledge of government and the legislative process Seasoned personnel manager and office administrator · Excellent communication and interpersonal skills EDUCATION BA in Political Science: Graduated with Honors, Eastern Washington University. EMPLOYMENT HISTORY · Consultang Northwest Cooperative Development Center, 2003 to Present Listed consultant of the Northwest Cooperative Development Center. Available to facilitate cooperatives in de- veloping strategic business plans. Specific areas of expertise include affordable housing and tax exempt fi- nancing L TC Coordinator, Legislative Transportation Committee, State of Washington, 1999 to 2002 Provided research and office support to the Committee formulating state transportation policy. Maintained ef- fective bipartisan communication with members the Senate and the House of Representatives. Ensured con- strucfive dialogue with the executive branch, stakeholders and constituents. Managed technical studies performed through contract Office support included payroll, purchasing and information systems. Appointed to the Western Washington Growth Management Hearings Board Peer Review Panel. Supervised staff. · Deputy Director, Housing Finance Commission, State of Washington, 1995 to 1999 Managed the daily operations of the Commission that provides financing for affordable housing and cul- tural/sociai service facilities through private/public partnerships with banks, developers, nonprofit organizations and governments. Directed the human resources and public information programs. Provided oversight of the Co.m_mi. ss on budget and bond portfo os Ad,in stercd information systems. Activities required daily in- volvement with the Executive Director. Interacted with Co~lmissi0ners, ke~ officialS, underwriters, bankers, financial advisors, legal counsel and the public. Supervised staff. · Administrative Assistant (ExempO, Office of the State Treasurer, State of Washington, 1987 to 1994 Appointed agency Fiscal Officer to develop, execute and monitor the office budget. Served as Commissioner Designee and Secretary to the Housing Finance Commission. Appointed Intemai Auditor to ensure regulatory compliance, safeguard assets, and coordinate external audits. Required daily contact with elected officials, key financial officers, bond counsel and state personnel. Mark McLaughlin Senior Executive Policy Coordinator, O~tce of Financial Managemen~ State of Washington, 1982 to 1987 Developed the Governor's capital budget recommendation. Calculated the state's debt capacity and bond sale needs. Performed the initial allocation of private activity bonds under the Federal Tax Reform Act of 1986. Reviewed economic forecasts and maintained the revenue database. Translated the state's budget from a modi- fied cash basis to a modified accrual basis in conformance with Generally Accepted Accounting Principles (GAAP). Evaluated state salary and benefit options. Responsibilities required extensive interaction with the Governor's Office, the Legislature, agencies and financial institutions. Supervised staff · Cash Flow Coordinator, O~ce of Financial Management, State of Washington, 1981 Developed and administered a daily cash balance projection system for the Creneral Fund and General Fund counts. The projections documented the issuance and retirement of Revenue Anticipation Notes required to maintain General Fund solvency. Drained implementing legislation and rules. Research Analyst, Senate, Republican Caucus and Ways & Means Committee, Washington State Leglsla- tnre, 1981 Provided senior staff support on budget programs and policy issues; emphasis on higher education. Coordi- nated technical production of the Omnibus Operating and Capital Budgets. · Consttltang Washington State Research Counci~ 1980 to 1981 Researched and recommended higher education policies for gubernatorial transition. Results included the en- actment of policies and appropriations. Staff Director, Senate Ways and Means Committee, Washington State Legislature, 1980 Managed staff in conducting research and fiscal policy analysis. Required extensive interaction with the House of Representatives and the Governor's Office. Supervised staff. Budget Analyst, Senate Ways and Means, Washington State Legislature, 1974 to 1980 Analyzed general government and higher education budgets. Reviewed revenue proposals. Drafted legislation. Conducted topical research, Responsible for overall technical coordination of the Omnibus Operating and Capital Budgets. ASSOCIATIONS · Early Music Guild: Board Member, 2002 to Present Treasurer, 2003 to Present Washington State Employees Credit Union: Board of Credit Union Service Organization, 2001 to 2004 Board of Directors, 1992 to 2001 Chair, 1996 Various Committees, 1988 to 1992 Supervisopj Committee, 1985 to 1987 Chair, 1987 · Friends of Tim Kerr (Monorail Board, Position 9, Nonpartisan), Treasurer, 2003 · North Beacon Hill Urban Village Planning Committee, Member, 1997 to 1998 Seattle Mountaineers Climbing Committee Member- Basic Administration, Member, 1994 178 DATE SUBMITTED: August 10, 2004 BILL # 0q - 1 79 AGENDA BILL CITY OF BREMERTON 6 A CITY COUNCIL SUBJECT: RESOLUTION NO. o~q.3~ Committee Meeting Date: August 25, 2004 2005 - 2010 SIX YEAR COUNCIL MEETING Date: SEPTEMBER 1, 2004 TRANSPORTATION IMPROVEMENT Department: PW&U, Engineering., PLAN. Presenter: Michael M echam .,~',d/~ Phone: 473.5288 SUMMARY: The Six Year Transportation Improvement Plan is prepared pursuant to RCW 35.77.010 and RCW 36.81.121. The Plan is updated annually and filed with the Secretary of Transportation, Local Programs Office. It is intended as a planning tool for the local, State and Federal transportation funding entities. The attached plan has been prepared for City Council approval by Resolution and will be submitted to the Washington State Department of Transportation. ATTACHMENTS: A. Council Summary B. 2005-2010 Six Year Transportation Improvement Plan C. Resolution No. ,2 q3 ~ FISCAL IMPACTS (Include Budgeted Amount): None. The 2005 - 2010 Six Year Transportation Improvement Plan is a planning tool that is implemented through the annual Capital Improvement Program. ~__~..) , APPROVALS: (/ ~- ~--~/ ~ ~ ./// / / DEPARTMENT CITY ATTORNEY: "/ )~-. 7~_~-:r-':'- Q :: 7 3 -- ' FoIpSEC2L;~NDsG.. E X: '-.~~ - CONSENT AGENDA RECOMMENDED MOTION: I move to approve Resolution No. ~2-.q.~, which approves the City's 2005 - 2010 Six Year Transportation Improvement Plan, and direct the Mayor to forward the Resolution and Plan to the Department of Transportation, Local Programs Office. COUNCIL ACTION: [] Approve [] Deny [] Table [] Continue [] No Action ab, Agenda Bills 2003, Six Yr T1P, 8-03 179 ~u~-Ju-uq MON 9:25 AM OLYMPIC REGION TRANSAID FAX NO. 3603572794 P. Washington State Department ol Transportat ~' August 27, 2004 Mike M~ham ~.wsootwa nov City Engineer Cily 3027 Ol~lpus Drive Bremerton, WA 98310 Re: SR 304 Downtown Breme~ton P~estfian / BTC Access Improvements Transpo~a~ion Improvemenl Program Dear Mr. Mecham: This leuer is in response to your recent question: "Since l~d agency status has been ~ransferred from Bremerton to WSDOT for the Downtown Breme~on Pedestrian / BTC Access Improvement project why does Brem~on need to continue Ihe ciiy's six-year transportation plan?" When ~l~e decision was made to transfer the projec~ to WSDOT, represematives of the City and ll~e Depatlment of ~ansportation met to discuss adm~istra~ive issues ~elating to the transfer, It was mutually agr~ fl~a~ in order to avoid cumbersome conflicts and time dela~ in ~e- eslablishing public and private contacts (~ese con,acts exist between the Cily, WSD~ ~d the design eonsultan0 the City would remain ~esponsible for administering fin~cial agreements flarough the desi~ phase. Cu~ently, WSDOT is pl~ung to ca~ future phases (ri~t-of ~vay and ~nstrt~ction) on the WSDOT s~-ye~ ~sportation pl~. As a condition of this decision i~ was dete~ed thai llie City must maintain the project ~ part of the cunent six-year plan. The re~oning is fairly simple, in accord~ce with state and ~eral law, an agency must show a project as pa~ of the agency's plan ~n order to be eligible for federal fimding. Cun-ently, fnnding has o~y be~a obligated ~o ca~ the p~oj~t throu~ approximately 30% design. In order for the Cily ~o obligate the remaining funding needed to complete ~l~is phase, the City will need to maintain the Dowmown Bremenon Pedestrian / BTC Access ~mprovements proj~t as p~ of the City's Tr~po~ation Improvement Pro,'am. I[you have may addilional questions or concerns please feel flee to comact me at 360.357.2631. Assisiallt I~cal Programs Ol~lpic Rcgion Cc: File RESOLUTION NO. ,~q3~ A RESOLUTION of the City Council of the City of Bremerton, Washington, adopting the 2005 - 2010 Six Year Transportation Improvement Plan. WHEREAS, after proper notice, the City Council of the City of Bremerton held a public hearing at the regular meeting of the City Council at 5:30 p.m. on September 1, 2004, to consider public testimony on the City's proposed 2005 - 2010 Six Year Transportation Improvement Plan and, having considered public testimony to the Plan and in accordance with the provisions of RCW 47.80; NOW THEREFORE, THE CITY COUNCIL OF THE CITY OF BREMERTON, WASHINGTON, DOES HEREBY RESOLVE AS FOLLOWS: SECTION 1. The 2005 through 2010 Six Year Transportation Improvement Plan, set forth in Exhibit "A" attached hereto and herewith filed with the City Clerk, is hereby adopted. SECTION2. Severabilitv. If any one or more sections, subsections, or sentences of this Resolution are held to be unconstitutional or invalid, such decision shall not affect the validity of the remaining portion of this Resolution and the same shall remain in full force and effect. SECTION 3. Effective Date. This Resolution shall take effect and be in force immediately upon its passage. PASSED by the City Council of the City of Bremerton, Washington this __ day of ,2004 DAREN NYGREN, Council President APPROVED AS TO FORM: ATTEST: ROGER A. LUBOVICH, City Attomey PAULA JOHNSTON, City Clerk Six Year Transportation Plan 180 Council Summary 2005-2010 Six-Year Transportation Improvement Program RCW 35.77.010 and RCW 36.81.121 require that all cities and counties prepare an annual six-year Transportation Improvement Program (TIP) and file it with the Department of Transportation. The Six-Year TIP is a planning tool, implemented by the City's Capital Improvement Program. The law requires that the plan include all "regionally-significant" and federally funded projects. Typically, the plan also includes all locally-funded major capital transportation projects. The 2004 TIP covers the planning period from 2005 to 2010. Revisions to this year's TIP as compared to the 2003 TIP consist primarily of changes in the cost and schedule of the various projects. In addition, the SR 304 project has been restructured to remove all completed phases (or those phases being completed in 2004) from the TIP. Also, two projects have been added to this year's TIP: · Harlow Drive/Kitsap Lake Elementary Pedestrian Improvements- Improve pedestrian safety by constructing a pedestrian pathway (shoulder/sidewalk) on the west side of Harlow Drive near Kitsap Lake Elementary. The project is being included in the TIP because of pending federal funding. ,, SR 303 (Warren Ave) at 11th Street - Reduce congestion and neighborhood cut- through traffic by lengthening the existing right turn pocket from southbound SR 303 to westbound 11th Street. Approximately one-half of the projects in the 6-year TIP are funded. The Downtown Pedestrian/BTC Access Improvements project has committed federal funding. The final remaining phase of SR 304 is primarily funded through the state nickel gas tax package. The Warren Avenue Off-Ramp project is funded through a Transportation Improvement Board grant. Federal funding is expected, but not yet fully secured, for the Harlow Drive and Auto Center Way projects. The "Miscellaneous" project category is funded through the City's share of the state gas tax. The remaining projects in the TIP are unfunded. 181 DATE SUBMITTED: August 17, 2004 BILL # 0t'/- / ~0 AGENDA BILL CITY OF BREMERTON ~ ~ CITY COUNCIL SUBJECT: Public Heating on Ordinance Committee Meeting Date: August 25, 2004 amending BMC 3.01 Rate Table C COUNCIL MEET1NG Date: September 1 & September 9, 2004 Department: City Attorney's Office Presenter: Brett C. Vinson Phone: 473-2345 SUMMARY: The current provisions of BMC 3.01 Rate Table C relating to Community Development Fees need clarification and updating. The proposed ordinance repeals and replaces Rate Table C. ATTACHMENTS: Proposed ordinance FISCAL IMPACTS (Include Budgeted Amount): APPROVALS: DEPARTMENT DIRECTOR: CITY ATTORNEY: MAYOR:FiNANCE DIRECTOR: FISCAL/BUDGET: CONSENT AGENDA OPERATIONS: COUNCIL PRESiDENT: RECOMMENDED MOTION: 1. I move to approve the proposed ordinance on first reading repealing and replacing BMC 3.01 Rate Table C. 2. I move to pass Ordinance No. on second reading repealing and replacing BMC 3.01 Rate Table C. COUNCIL ACTION: [] Approve [] Deny [] Table [] Continue [] No Action 185 Office of the City Attorney Roger A. Lubovich, City Attorney Memorandum TO: City Council From: Brett C. Vinson ~ BO: Amendment to BMC 3.01 Rate Table C 118t9: August 26, 2004 The proposed ordinance is a housekeeping matter due to the recent adoption by the City of the Intemational Building Code. The proposed ordinance does the following: 1. Recodifies Plan Review Fees (Item No. 8) and Grading Plan Review Fees and Grading Permit Fees (Exhibit 4) that were previously contained in the UBC, 2. Makes technical corrections and electronically formats all Exhibits. It does not add to or change any fees. :[86 ORDINANCE NO. AN ORDINANCE of the City Council of the City of Bremcrton, Washington, amending Bremerton Municipal Code 3.01 Rate Table C by clarifying and establishing certain fees. WHEREAS, the current provisions of 3.01 Rate Table C of the Bremerton Municipal Code relating to Community Development Fees needs clarification and updating; WHEREAS, the City Council desires to amend the provisions of Rate Table C relating to Community Development Fees in order to provide clarity; NOW THEREFORE, THE CITY COUNCIL OF THE CITY OF BREMERTON, WASHINGTON, DOES HEREBY ORDAIN AS FOLLOWS: SECTION1. Rate Table C of Capter 3.01 of the Bremerton Municipal Code entitled "Community Development - Rate Table C" is hereby repealed in its entirety and a new Community Development - Rate Table C is hereby created to read as set forth in Exhibit A of this Ordinance. SECTION 2. Severability. If any one or more sections, subsections, or sentences of this ordinance are held to be unconstitutional or invalid, such decision shall not affect the validity of the remaining portion of this ordinance and the same shall remain in full fome and effect. SECTION3. Effective Date. This ordinance shall take effect and be in force ten (10) days from and after its passage, approval and publication as provided by law. APPROVED by the City Council the day of ., 2004 PASSED by the City Council the day of ,2004 DAREN NYGREN, Council President Approved this day of ., 2004 CARY BOZEMAN, Mayor 1 Rate Table C 187 ATTEST: APPROVED AS TO FORM: PAULA JOHNSTON, City Clerk ROGER A. LUBOVICH, City Attorney PUBLISHED the day of ., 2004 EFFECTIVE the day of _, 2004 ORDINANCE NO. R:\LEGAL\Ordinances\Community Development~R. ate Table C-2004.doc 2 Rate Table C 188 COMMUNITY DEVELOPMENT - RATE TABLE C All Rates Listed are "Not To Exceed" Fees C. DEPARTMENT OF COMMUNITY DEVELOPMENT RATE 1. SUBDIVISIONS Short $1000 + $150 per lot Long Plat $2500 + $150 per lot Final Plat $315 2. SHORELINE MASTER PROGRAM Substantial Development Permit $650 Conditional Use Permit $1750 Shoreline Variance $1750 Permit Revision $325 Shoreline Exemption $200 3. STATE ENVIRONMENTAL POLICY ACT (SEPA) Checklist $320 Environmental Impact Statement $650 + Review/Adoption additional cost of expertise 4. SITE PLAN REVIEW Four or Less Residential Units $250 Others $500 5. APPEAL To Hearing Examiner $175 6. ABATEMENTS Dangerous Building $900 + Direct Service and Supply Cost Garbage & Weed $640 + Direct Service and Supply Cost 7, BUILDING PERMIT FEES -Refer to Exhibit 1 8, PLAN REVIEW FEE 65% of the building permit fee as set forth in Exhibit 1 9. MECHANICAL PERMIT FEES -Refer to Exhibit 2 3.01 - C1 ~.8S COMMUNITY DEVELOPMENT- RATE TABLE C All Rates Listed are "Not To Exceed" Fees RATE 10. PLUMBING PERMIT FEES -Refer to Exhibit 3 11. GRADING PERMIT AND PLAN REVIEW FEES - Refer to Exhibit 4 12. ZONING ORDINANCE Ordinance Amendments Text $740 Rezone (Map Amendment) $740 Variance Administrative $325 Public Hearing/Single Famity $500 Public Hearing/Other $1750 Planned Unit Development Residential Only $1500 + $100/DU Industrial, Commercial, Mixed Use or $2500 + Other $100/DU + $100/acre Development Agreements $1600 Special Use Permit Administrative (No public hearing) $350 Hearing Examiner/SF Residential $500 Hearing Examiner/Other $1750 Non-Conforming Use Determination $275 Director's Code Interpretation $175 Zoning Verification Letter $125 13. COMPREHENSIVE PLAN Text or Map Amendment $1500 Combined Text and Map Amendment $2500 3.01 -C2 190 COMMUNITY DEVELOPMENT- RATE TABLE C All Rates Listed are "Not To Exceed" Fees EXHIBIT 2 MECHANICAL PERMIT FEES Permit Issuance and Heaters 1. For the issuance of each mechanical permit $23.50 2. For issuing each supplemental permit for which the original permit has not expired, been canceled or finaled $7.25 Unit Fee Schedule (Note: The following do not include permit-issuing fee) 1. Furnaces For the installation or relocation of each forced-air or gravity-type furnace or burner, including ducts and vents attached to such appliance, up to and including 100,000 Btu/h (29.3 kW) $14.80 For the installation or relocation of each forced-air or gravity-type furnace or burner, including ducts and vents attached to such appliance over 100,000 Btu/h (29.3 kW) $18.20 For the installation or relocation of each floor furnace, including vent $14.80 For the installation or relocation of each suspended heater, recessed wall heater or floor-mounted unit heater $14.80 2. Appliance Vents For the installation, relocation or replacement of each appliance vent installed and not included in an appliance permit $7.25 3. Repairs or Additions For the repair of, alteration of, or addition to each heating appliance, refrigeration unit, cooling unit, absorption unit, or each heating, cooling, absorption or evaporative cooling system, including installation of controls regulated by the Mechanical Code $13.70 4. Boilers, Compressors and Absorption Systems For the installation or relocation of each boiler or compressor to and including 3 horsepower (10.6 kW), or each absorption system to and including 100,000 Btu/h (29.3 kW) $14.70 For the installation or relocation of each boiler or compressor over three horsepower (10.6 kW) to and including 15 horsepower (52.7 kW), or each absorption system over 100,000 Btu/h (29.3 kW) to and including 500,000 Btu/h (146.6 kW) $27.15 For the installation or relocation of each boiler or compressor over 15 horsepower (52.7 kW) to and including 30 horsepower (105.5 kW), or each absorption system over 500,000 Btu/h (146.6 kW) to and including 1,000,000 Btu/h (293.1 kW) $37.20 For the installation or relocation of each boiler or compressor over 30 horsepower (105.5 kW) to and including 50 horsepower (176 kW), or each absorption system over 1,000,000 Btu/h (293.1 kW) to and including 1,750,000 Btu/h (512.9 kW) $55.45 For the installation or relocation of each boiler or compressor over 50 horsepower (176 kW), or each absorption system over 1,750,000 Btu/h (512.9 kW) $92.65 5. Air Handlers For each air-handling unit to and including 10,000 cubic feet per minute (cfm) (4719 L/s), including ducts attached thereto Note: This fee does not apply to an air-handling unit which is a portion of a factory-assembled appliance, cooling unit, evaporative cooler or absorption unit for which a permit is required elsewhere in the Mechanical Code $10.65 For each air-handling unit over 10,000 cfm (4719 :s) $18.10 3.01 - C4 192 COMMUNITY DEVELOPMENT- RATE TABLE C All Rates Listed are "Not To Exceed" Fees 6. Evaporative Coolers For each evaporative cooler other than portable type $10.65 7. Ventilation and Exhaust For each ventilation fan connected to a single duct $7.25 For each ventilation system which is not a portion of any heating or air- conditioning system authorized by a permit $10.65 For the installation of each hood which is served by mechanical exhaust, including the ducts for such hood $10.65 8. Incinerators For the installation or relocation of each domestic-type incinerator $18.20 For the installation or relocation of each commercial or industrial-type incinerator $14.50 9. Miscellaneous For each appliance or piece of equipment regulated by the Mechanical Code but not classed in other appliance categories, or for which no other fee is listed in the table $10.65 For each gas piping system of 1 - 5 outlets $6.25 For each additional gas piping system outlet, per outlet $1.25 Other Inspections and Fees Inspections outside of normal business hours, per hour (minimum charge - two hours $49.50t Reinspection fees assessed under provisions of this chapter shall be as follows (per inspection): $49.501 Inspections for which no fee is specifically indicated, per hour (minimum charge - one-half hour) $49.50~ Additional plan review required by changes, additions or revisions to plans or to plans for which an initial review has been completed (minimum charge - one-half hour) $49.501 tOt the total hourly cost to the jurisdiction, whichever is the greatest. This cost shall include supervision, overhead, equipment, hourly wages and fringe benefits of the employees involved. 3.01 -C5 293 COMMUNITY DEVELOPMENT - RATE TABLE C All Rates Listed are "Not To Exceed" Fees EXHIBIT 3 PLUMBING PERMIT FEES Permit Issuance 1. For issuing each permit $20.00 2. For issuing each supplemental permit $10.00 Unit Fee Schedule (in addition to items 1 and 2 above) 1. For each plumbing fixture on one trap or a set of fixtures on one trap (including water, drainage piping and backflow protection therefore) $7.00 2. For each building sewer and each trailer park sewer $15.00 3. Rainwater systems - per drain (inside building) $7.00 4. For each cesspool (where permitted) $25.00 5. For each private sewage disposal system $40.00 6. For each water heater and/or vent $7.00 7. For each gas piping system of one to five outlets $5.00 8. For each additional gas piping system outlet, per outlet $1.00 9. For each industrial waste pretreatment interceptor including its trap and vent, except kitchen-type grease interceptors functioning as fixture traps $7.00 10. For each installation, alteration or repair of water piping and/or water treating equipment, each $7.00 11. For each repair or alteration of drainage or vent piping, each fixture $7.00 12. For each lawn sprinkler system on any one meter including backfiow protection devices therefore $7.00 13. For atmospheric-type vacuum breakers not included in item 12: 1 to 5 $5.00 Over 5, each $1.00 14. For each backfiow protective device other than atmospheric type vacuum breakers: 2 inch (51 mm) diameter and smaller $7.00 Over 2 inch (51 mm) diameter $15.00 15. For each graywater system $40.00 16. For initial installation and testing for a reclaimed water system $30.00~ 17. For each annual cross-connection testing of a reclaimed water system (excluding initial test ) $30.00~ 18. For each medical gas piping system serving one to five inlet(s)/outlet(s) for a specific gas $50.00 19. For each additional medical gas inlet(s)/outlet(s) $5.00 Other Inspections and Fees 1. Inspections outside of normal business hours $30.00t 2. Reinspection fee $30.00 3. Inspections for which no fee is specifically indicated $30.00~ 4. Additional plan review required by changes, additions or revisions to approved plans (minimum charge - one-half hour) $30.001 tPer hour for each hour worked or the total hourly cost to the jurisdiction, whichever is greater. This cost shall include supervision, overhead, equipment, hourly wages and fringe benefits of all the employee s involved. 3.01 -C6 194 COMMUNITY DEVELOPMENT - RATE TABLE C All Rates Listed are "Not To Exceed" Fees EXHIBIT 4 GRADING PLAN REVIEW FEES 50 cubic yards (38.2 m3) or less No fee 51 to 100 cubic yards (40 m3 to 76.5 m3) $23.50 101 to 1,000 cubic yards (77.2 m3 to 764.6 m3) $37.00 1,001 to 10,000 cubic yards (765.3 m3 to 7645.5 m3) $49.25 10,001 100,000 cubic yards (7646.3 m3 to 76,455 m3) - $49.25 for the first 10,000 cubic yards (7645.5 m3), plus $24.50 for each additional 10,000 cubic yards (7645.5 m3) or fraction thereof 100,001 to 200,000 cubic yards (76,456 m3 to 152,911 m3) - $269.75 for the first 100,000 cubic yards (76,455 m3), plus $13.25 for each additional 10,000 cubic yards (7645.5 m3) or fraction thereof 200,001 cubic yards (152,912 m3) or more - $402.25 for the first 200,000 cubic yards (152,911 m3), plus $7.25 for each additional 10,000 cubic yards (7645.5 m3) or fraction thereof Other Fees: Additional plan review required by changes, additions or revisions to approved plans (minimum charge - one-half hour) $50.50 per houri ~Or the total hourly cost to the jurisdiction, whichever is the greatest. This cost shall include supervision, overhead, equipment, hourly wages and fringe benefits of the employees involved. GRADING PERMIT FEES~ 50 cubic yards (38.2 m3) or less $23.50 51 to 100 cubic yards (40 m3 to 76.5 m3) $37.00 101 to 1,000 cubic yards (77.2 m3 to 764.6 m3) - $37.00 for the first 100 cubic yards (76.5 m3) plus $17.50 for each additional 100 cubic yards (76.5 m3) or fraction thereof 1,001 to 10,000 cubic yards (765.3 m3 to 7645.5 m3) - $194.50 for the first 1,000 cubic yards (764.6 m3), plus $14.50 for each additional 1,000 cubic yards (764.6 m3) or fraction thereof 10,001 to 100,000 cubic yards (7646.3 m~ to 76,455 m3) - $325.00 for the first 10,000 cubic yards (7645.5 m3), plus $66.00 for each additional 10,000 cubic yards (7645.5 m3) or fraction thereof 100,001 cubic yards (76,456 m3) or more - $919.00 for the first 100,000 cubic yards (76,455 m3), plus $36.50 for each additional 10,000 cubic yards (7645.5 m3) or fraction thereof Other Inspections and Fees: 1. Inspections outside of normal business hours (minimum charge - two hours) $50.50 per hour2 2. Reinspection fees assessed under provisions of this chapter shall be as follows (per inspection): $49.50 per hour2 3. Inspections for which no fee is specifically indicated (minimum charge - one-half hour) $50.50 per hour2 ~The fee for a grading permit authorizing additional work to that under a valid permit shall be the difference between the fee paid for the original permit and the fee shown for the entire project. 2Or the total hourly cost to the jurisdiction, whichever is the greatest. This cost shall include supervision, overhead, equipment, hourly wages and fringe benefits of the employees involved. 3.01 - C7 DATE SUBMITTED: August 18, 2004 BILL AGENDA BILL CITY OF BREMERTON CITY COUNCIL SUBJECT: Ordinance No. Committee Meeting Date: August 25, 2004 Amending BMC Chapters 15.01 and 15.06 COUNCIL MEETING Date: September 1, 2004 Relating to Assessments, Rates, Fees, and Department: Public Works & Charges for Water, Wastewater, and Utilities Stormwater Services. Presenter: Phil Williams Phone: 5315 SUMMARY: Engineering and Economic Services, Inc. (EES) was retained by the City to perform a cost-of-service rate study for City provided municipal utilities. The proposed ordinance incorporates amendments to Bremerton Municipal Code Chapters 15.01 and 15.06 and Appendix A of Chapter 15.06 relating to assessments, rates, fees, and charges for water, wastewater, and stormwater services recommended by EES as determined by the study. ATTACHMENTS: Proposed ordinance FISCAL IMPACTS. The Study concluded the recommended rates am required to meet O&M. capital improvements, and recover appropriate system development charges and fees for development activities. Failure to implement study recommendations will result in significant budget shortfalls. APPROVALS: DIRECTOR OF PW&U: CITY ATTORNEY: FINANCE DIRECTOR MAYOR .,~~ CONSENT AGENDA [] FISCAIdBUDGET: OPERATIONS: COUNCIL PRESIDENT: '"'-~r~.~.~x RECOMMENDED MOTION: (1) I move to approve the proposed ordinance on first reading. (2) I move to adopt Ordinance No. __ on second reading. COUNCIL ACTION: [] Approve [] Deny ~ Table [] Continue [] No Action ORDINANCE NO. AN ORDINANCE amending Chapters 15.01 and 15.06 of the Bremerton Municipal Code and Appendix A of Section 15.06 relating to assessments, rates, fees and charges for Municipal water, wastewater and stormwater services. WHEREAS, the City Council desires to amend the definition of and method for establishing certain utilities system development charges and fees set forth in Chaptersl5.01 and 15.06 of the Bremerton Municipal Code; and, WHEREAS, the City Council desires to establish system development charges and fees for the City's Stormwater Utility; and, WHEREAS, the City Council desires to amend the rates, fees and charges set forth in Appendix A of Section 15.06.015 of the Bremerton Municipal Code; NOW THEREFORE, THE CITY COUNCIL OF THE CITY OF BREMERTON, WASHINGTON, DOES HEREBY ORDAIN AS FOLLOWS: SECTION 1. Section 15.01.020 of the Bremerton Municipal Code entitled "Definitions" is hereby amended by amending certain subsections as follows: 15.01.020 DEFINITIONS. The following definitions under Section 15.010.020 are amended to read as follows: (e) (1) "Equivalent Residential Unit" (ERU) shall mean t~e ftc':.' cr ftc',;' c~aractcfisfics *'~ ............ , .... ,~ ............... r .... a umt of measurement to determine wastewater general facility charges and shall be based on 236 gallons per customer day. (g) (2) "General Facilities Charges" (GFC) shall mean the charge established to reflect the proportionate cost share for existing source, treatment, distribution, transmission, collection, interception, and storage facilities that will be paid by new customers to the City utility. (s) (17) "Stormwater system" shall mean all facilities for collecting, transporting, pumping, treating and discharging stormwater. 1 Utility Rates 197 SECTION 2. Section 15.01.030 of the Bremerton Municipal Code entitled "Utility Service Agreement" is hereby amended as follows: 15.01.030 UTILITY SERVICE AGREEMENT. (a) Each customer of the Utility and any person requesting utility service from the Utility for water, wastewater, or stormwater shall be required to make application and enter into a Utility Service Agreement, ~ .... · ~ e~,:~ A ...... * M.~nl$ ~- ~-~ 1~ ...... :g~ f~. O, .......... - ~ ..............., .............. ] ....... Agreements wk~n ........ -~ .v.~ ..... shall be executed prior to connection to the utility system or activation of the account. (b) The Agreement shall include the name and address of the owner and the service address of the premises served together with the service requested. The Agreement shall be signed by the owner of the property or his designated agent and shall be filed with the Department. The applicant shall pay all fees for installation of the utility service as herein provided at the time of filing. (c) The Agreement for service shall constitute a contract between the Applicant and the Department in which the applicant agrees to pay for service provided at the rate and in the manner specified. (d) The Agreement shall be effective at the time it is signed by the Director or his designee and charges for service to the premises shall be assessed from date of connection. (e) Estimated fees, assessments, and conditions quoted by the Department in writing for utility service shall become invalid after one hundred eighty (180) days from the date of the estimate unless the applicant enters into a Utility Service Agreement with the Department prior to that time. SECTION 3. Section 15.01.070 of the Bremerton Municipal Code entitled "Developer System Improvement - Agreements" is hereby amended as follows: 15.01.070 DEVELOPER SYSTEM IMPROVEMENT - AGREEMENTS. (a) A property owner or owners of any specified area situated within the Utility service area requiring utility service may petition the Department to construct public system improvements. The Department shall review the petition, and, subject to the Utility Comprehensive Plan, engineering and economic feasibility, and at the Department's option, construct the improvements upon execution of a System Improvement Agreement between the owner and the Department specifying the improvements. The estimated costs for said improvements shall be paid in full upon execution of the agreement. When completed and accepted by the Department in writing, the improvements shall become part of the Utility's system and shall be conveyed by Bill of Sale prior to service. (b) If 60% or more of the property owners of a specified area situated within the Utility service area petition the City to construct public system improvements, the City may construct said improvements upon execution of a System Improvement Agreement between the property owners and the City specifying the improvements, the terms and conditions for the improvements, and the reimbursement of all costs associated with the improvements. Reimbursement at actual cost for the improvements may be paid in full or in monthly installments plus interest at a rate set in the System Improvement Agreement with 20% of the 2 Utility Rates 198 cost due prior to installation and the balance together with interest due within thirty-six (36) months of the date from the completion and City acceptance of the improvement. (c) Deferred payments for the construction of system improvements shall be limited to system improvements and shall exclude connection fees and general facility fees. (d) The City may construct the improvements, on behalf of the property owners, utilizing City staff, negotiated contracts, or competitive bids subject to State statutes governing utility construction. (e) Property owners or developers of plats or developments shall have the option of installing the plat's interior utility system and connection to the utility system at their expense, subject to Utility Development and Construction Standards. The owner or developer shall pay 4--) charges according to the conditions of any existing reimbursement agreement for any main installed through a System Improvement Agreement. SECTION 4. Section 15.01.090 of the Bremerton Municipal Code entitled "Developer System Improvements - Reimbursement" is hereby amended as follows: 15.01.090 DEVELOPER SYSTEM IMPROVEMENTS - REIMBURSEMENT. (a) The City may enter into Agreements with property owners responsible for the installation of system improvements to provide for reimbursement to owners by others benefiting from the improvements and connecting to the improvements at a later time (latecomers). (b) Requests for reimbursement shall be made in writing prior to drafting the System Improvement Agreement and specific provisions of recovery shall be included in the Agreement. The Department shall determine the area that is subject to the cost recovery and shall identify the properties benefiting from the utility system improvements in a description or a drawing that will become part of the System Improvement Agreement. (c) Reimbursement from each benefiting property owner shall be determined by the Department as stipulated in the System Improvement Agreement. Cost recovery payments by properties benefiting from connections to developer extensions shall be collected by the City. (d) Reimbursement to the property owner constructing the improvement shall be limited to fifteen (15) years from the date of acceptance of the improvement. The City shall retain fifteen.(15) percent of the cost recovery payments for maintaining records and administration of the program and forward the remainder of the payment to the property owner who originally constructed the water, wastewater, or stormwater system improvement. SECTION 5. Section 15.06.015 of the Bremerton Municipal Code entitled "Incorporation and CPI Adjustment" is hereby amended to read as follows: 15.06.015 INCORPORATION AND CPI ADJUSTMENT. (a) Assessments, rates, fees and charges attached hereto as Appendix A and incorporated herein by this reference are hereby adopted. (b) In addition to such other changes as may be approved by City Council, commencing ..... j November 1, 2004, and in ...... j November of each successive year thereafter, the f~c:, utility rates and charge: in this section shall automatically be adjusted based 3 Utility Rates upon the most current Consumer Price Index for all Urban Consumers, Seattle, ~ T e r-:... pr~4ous-ye~, and the General Facility Charges shall be adiusted according to the most current Seattle Construction Index (SCI). SECTION 6. Section 15.06.020 of the Bremerton Municipal Code entitled "Assessments" is hereby amended to read as follows: 15.06.020 ASSESSMENTS. (a) General Facility Fcc Charge. (1) A General Facility Fee Charg$_ (GFF) (GFC) shall be charged on all new or expanded service connections to the utility system. Existing connections within the system as of the effective date of this Code shall be considered to have paid their proportionate share of the General Facility fcc Charge for existing use. (2) The calculation of the General Facility Charge for water shall be based on the meter size to be installed for a new or expanded water utility service. (3) The calculation of the General Facility fee Charge for v~,er-mad wastewater wi!! shall be based on the number of Equivalent Residential Unit(s) (ERU) served and shall be ....~;~ ~-'~ ....... '~ ~ · -er ..................... omputed as follows. Single Family Residence 1 ERU/Unit Duplex (two units) Twc unit: 1 ERU/Unit Multi-family (3 or more units) .4 0.65 ERU/Unit Mobile Home Space in Mobile Home Park 0.65 ERU per space (Common building at additional commercial rate and laundry areas at laundry rate.) Recreational Vehicle Waste Dumping Station 0.65 ERU per station Schools 0.030 ERU per student capacity Churches (School uses at additional per student 0.65 ERU per 100 capacity rate.) seats Hospitals - General I ERU per bed Convalescent Hospitals 0.50 ERU per bed Residential Care/Boarding Facilities 0.25 ERU per bed 4 Utility Rates 299 Hotels and Motels (Additional charges for 0.25 ERU per room restaurant or tavern at restaurant or tavern rate, or motel unit laundry areas at laundry rates, and meeting room areas with fixtures at commercial rate.) Food Preparation and/or Serving Areas 0.15 ERU per 100 square feet Vehicle Wash Self-Service Vehicle Wash 1. t7 ERU per bay Full-Service Vehicle Wash 15.66 ERU per bay All Other Vehicle Washes See Wet Industrial Laundries & Laundromats 0.30 ERU per 100 square feet Industrial Laundries See Wet Industrial Remodels of the above-listed, which result in no increase in the units on which the charge for a new building is calculated, the ERU for the remodel will be calculated on the basis of the fixtures added using the amounts in the Commercial Section. Commercial, Office, & Dry Industrial Charge for each plumbing fixture to be installed. Bathtub w/or w/o shower 0.13 ERU Dental unit or cuspidor 0.1 ERU Dishwasher 0.1 ERU Disposal 0.1 ERU Drinking Fountain 0.05 ERU Floor Drain 0.01 ERU Fountain/Backwash 0.1 ERU Kitchen Sink 0.08 ERU Laundry Tray 0.08 ERU Lavatory 0.05 ERU Service Sink 0.08 ERU Shower (each head) 0.13 ERU Swimming Pool/Backwash 0.1 ERU Urinal 0.17 ERU Urinal Trough (for each 2-foot section) 0.17 ERU Wash Sink (for each set of faucets) 0.08 ERU Washing Machine 0.07 ERU 5 Utility Rates 201 Water Closet 0.33 ERU Wet Industrial To be deter- mined on an individual basis by the City utilizing the formula listed below GFC = (G.P.D./236) x SRF x F G.P.D. = Anticipated volume of discharge to sewer in gallons per day. SFR = Current General Facility Charge for a single family residential unit. F = Extra strength factor, whole number multiplier derived for every 330 my/1 of biochemical oxygen demand or suspended solids, or fraction thereof, in excess of the first 330 mg/1 of biochemical oxygen demand or suspended solids. Example: Factor Range 1 0-330 2 331- 660 3 661- 990 (continues per 300 increment) Undefined Building and Sewer Use To be deter- mined on an individual basis by the City. 6 Utility Rates Additional Loading or Change of Use Determined on basis of additional loading or new use for entire facility less credit for former use. No refunds if new use is less than former use. (4) The following are the definitions of the classifications used in establishing the ERUs. "Church" is defined as a building or structure whose principal use is for worship and in which the incidental use for school or recreational purposes is less than 12 hours per week. Church buildings used for school purposes in excess of 12 hours per week shall be charged the GFC per student capacity in addition to the charge per 100 seats as a church. "Commercial building" is defined as a building used for conducting of wholesale or retail trade. Dry industrial buildings or structures are those buildings or structures housing light industrial activities where use of water and subsequent discharge of sewer does not occur in connection with the industrial process. Warehouses and other storage buildings with sewer connections are classified as dry industrial buildings. "Convalescent hospital" (or rest home) is defined as a building or structure used for housing of persons convalescing from illness or injury or persons requiring close personal care. No additional charge shall be made for laundry or food and drink preparation and serving facilities included in the convalescent hospitals. "Food preparation and serving facility," includes restaurants, taverns, delicatessens, and wholesale and retail bakeries, but does not include canneries, dairies, cheese factories, packing houses and similar facilities, which shall be classified as "Wet Industrial" under the paragraph addressing wet industrial. "General hospital" is defined as a building or structure used for the temporary housing of ill or iniured persons and containing facilities for medical and surgical treatment of such persons. No additional charge shall be made for laundry and food and drink preparation and serving facilities included in hospitals. "Hotel" (or motel) is defined as a building or group of buildings used for temporary housing of persons containing rooms or units intended for the use of transient persons. Those areas within hotels and motels to be used for commercial preparation of and serving of food and drink shall be charged at the rate for food preparation and/or serving. Commercial areas within hotels and motels, including convention facilities and other such common areas other than lobby areas, shall be charged at the rate for commercial and dry industrial areas. Areas used for laundry facilities in hotels and motels shall be charged at the rate for laundries and Laundromats. Such additional 7 Utility Rates 203 charges for food and drink, commercial areas and laundry shall be in addition to the charge per room or motel unit. "Industrial laundry" is defined as a building or structure or parts of buildings and structures used for housing and operating laundry equipment for the large scale washing of uniforms, towels, linens, etc. The anticipated volume and strength of the sewage to be generated fi.om an industrial laundry would be considerably more than that from a commercial laundry or Laundromat. Industrial laundries shall be classified as "Wet Industrial" under the paragraph addressing wet industrial. "Laundry" and "Laundromat" is defined as a commercial building and structure, or parts of commemial buildings and structures used for housing and operating laundry equipment by the general public to wash clothes and linens for personal use. "Multi-family residence" shall be defined as a building or a group of buildings housing three or more families, living independently of each other, a family being defined as one or more person living as a single housekeeping unit or household sewer service being provided through not more than one sewer connection. Common buildings in an apartment house complex requiring sewer service shall be charged as commercial buildings and that portion of buildings housing common laundry facilities shall be charged as laundries and Laundromats. "Mobile Home Park," (including travel trailer parks) is defined as any area or tract of land having a sewer connection, and where sewerage collection pipes are extended to two or more spaces occupied by, or intended to be occupied by a mobile home, travel trailer, or motor home which are defined as a vehicle with our without motive power which is designed, used, or intended for use as a place of human habitation, or as eating, sleeping, or living quarters or any combination thereof. A mobile home space is defined as the individual location having a sewer hookup for each such vehicle. For purposes of determining the GFCs for mobile home parks' common buildings, such as recreation halls, etc., shall be charged as commercial buildings. Buildings housing laundry facilities shall be charged as laundries and Laundromats and food or drink service buildings shall be charged a food preparation and/or serving. "Recreational Vehicle Waste Dumping Station" is defined as a building or structure used for the dumping of sanitary sewer wastes from recreational vehicle holding tanks. Includes gray water from sinks and showers. (This excludes an individual collector installed by a homeowner for his/her own use.) "Residential Care/Boarding Facility" is defined as a residential building or structure used for housing of persons requiring either long-term supervision and general care, or any type of dependency recovery. No additional charge shall be made for laundry or food and drink preparation and serving facilities included in the Residential Care/Boarding Facilities. "School" is defined as a building or group of buildings used for school purposes more than 12 hours per week, involving assemblage for instruction, education, or recreation. Schools may be public or private. 8 Utility Rates 204 "Single family residence" shall be defined as a building containing one kitchen, designed and/or used to house not more than one family, including all necessary employees of such family, such building having a single sewer service connection. Mobile homes occupying a separate lot and providing permanent housing with a separate sewer connected shall be classified as a single- family residence. "Undefined buildings" and" undefined sewer use" are those not defined in Section (a)(4). "Vehicle wash" is defined as a commercial building or structure used for washing vehicles. Self- service vehicle washes are coin-operated facilities serving the general public that require the customer to wash the vehicle. Full-service vehicle washes are facilities serving the general public, wherein the vehicle is washed for the customer, either automatically or by attendant~. All other vehicle and parts washing or steam cleaning facilities that discharge to the sanitary sewer will be reviewed on a case-by-case basis. "Wet industrial" is defined as a building or structure housing industrial activities where the use of water and subsequent discharge to the sewer occurs in connection with an industrial process. Facilities with a discharge of 200,000 gallons per day or greater are considered wet industrial. Other facilities that discharge less than 200,000 gallons per day, and whose anticipated strength of the sewage to be generated fi.om the facility is greater than domestic sewage strengths may also be considered wet industrial. Those facilities will be reviewed on a case-by-case basis. The anticipated volume and strength of sewage from an average single-family residence shall be considered when calculating GFCs. (5) Additional loading or change of use is defined as an increased demand for wastewater treatment from an existing wet industrial building or structure. The additional loading may be the result of replacement or addition to an existing structure or facility, a change in use, or a fifteen percent (15%) or greater increase above the permitted volume or character of the wastewater constituents being discharged. (6) ERUs shall be determined on the basis of the number of single family residence equivalent units with the additional loading or the new use with credit being given for the number of single family residence equivalent units of the original facility. No refund will be given if the change of use results in a decreased sewer loading. Any addition to an existing single family residence which does not result in an additional dwelling will be exempt from additional charge. (7) The calculation for General Facility Charges for stormwater shall be based on the number of Impervious Surface Units (ISUs) as defined in BMC 15.01.020.. The number of ISUs charged shall be based on the total impervious area divided by the amount of impervious area in an ISU. However, all single-family residential parcels as defined in BMC 15.01.020 shall be one (1) ISU. For commercial developments, wherein the City requires that the development provide for onsite detention, the ISUs charged shall be based on the number of acres (5.4 ISUs per acre). 9 Utility Rates 205 (8) Tk: GFF For non-city residents, all GFCs shall be assessed and paid at the time of execution of the Utility Service Agreement and prior to occupancy of the new or expanded facilities and shall be in addition to rates and other fees, assessments, and charges established for utility service. For city residents, twenty-five percent (25%) of all GFCs shall be paid at the time of issuance of a development (grade and fill) permit and the remaining balance, in addition to rates and other fees, assessments, and charges established for utility service, shall be paid at the time of execution of the Utility Service Agreement. FFF. · . (b){q0 Connection/Inspection Fee. A connection/inspection fee shall be charged for all service connections to the utility system. Additional fees may be charged ifa reinspection is required as a result of the property owner/developer's failure to comply with the correction notice from a prior inspection, inaccessibility of facilities for scheduled inspections, or an unsafe site. The connection/inspection fee or deposit shall be assessed and paid at the time of execution of the Utility Service Agreement P ...... +:~-~: ..... ,:^- c~ ~.. ~ ~h .... ~ c~. ~. .... ~,~ 10 Utility Rates 206 (c) Change in class of service or ERU assignment. When a change occurs which would place the customer in a different class of service or change the ERU assignment from that on which general facility charges have been paid, an additional general facility charge shall be charged. The additional fee shall be the difference between the general facility charge, calculated at the current rates, based on the current class of service and ERU assignment, and the general facility charge that has already been paid. {d) Wastewater connection agreement. A wastewater connection agreement may be executed between the City of Bremerton and a user who desires to obtain wastewater service for an existing residential or nonresidential stmctare connected to a septic system. The wastewater connection agreement, negotiated on a case- by- case basis, will allow the user to make payments on any connection fee in excess of $5,000 over a period of time ranging from one to five ,/ears. {e) Capital reserves. The general facility funds collected under this chapter shall be deposited in the utilities capital reserve fund and used only for utility system capital improvements. SECTION 7. Appendix A to Section 15.06.015(a) is hereby amended to read as stated in Exhibit A attached hereto. SECTION 8. Severabilitv. If any one or more sections, subsections, or sentences of this Ordinance are held to be unconstitutional or invalid, such decision shall not affect the validity of the remaining portion of this Ordinance and the same shall remain in full force and effect. SECTION 9. Effective Date. This ordinance shall take effect and be in force ten (10) days from and after its passage, approval and publication as provided by law. The rates, fees and charges as set forth within Appendix A of this Ordinance shall take effect on November 1, 2004. APPROVED by the City Council the day of ., 2004 PASSED by the City Council the day of ., 2004 DAREN NYGREN, Council President Approved this day of ., 2004 CARY BOZEMAN, Mayor ATTEST: APPROVED AS TO FORM: PAULA JOHNSTON, City Clerk ROGER A. LUBOVICH, City Attorney 11 Utility Rates 207 PUBLISHED the day of ., 2004 EFFECTIVE the day of ,2004 ORDINANCE NO. R:\LEGAL\Ordinances~Public Works & UtilitiesX2004 Rate Ordinance - 08-16-04 - Final2.doc 12 Utility Rates 208 Appendix A ASSESSMENTS, RATES, FEES, AND CHARGES EFFECTIVE NOVEMBER 1, 2004 Within Outside City Limits City Limits GENERAL FACILITY CHARGES Water (per Meter Size) 5/8" x3/4" $ 2,300.00 $ 2,300.00 1" $ 5,750.00 $ 5,750.00 I 1/2" $ 11,500.00 $ 11,500.00 2" $ 18,400.00 $ 18,400.00 Greater than 2" Calculated based on usage Calculated based an usage Wastewater (per ERU) $ ?.9.!2 $ 3,482.00 $ 2?6.75 $ 3,482.00 Stormwater (per ISU) $ 933.00 $ 933.00 Per Front F~t $ 20?,2 $ 20.62 OffP. eadP. ate $ !,92!.99 $ !,53!.50 Per Frent Feet $ 25.52 $ 32.29 OffRc, ad P, atc $ 1,276.25 $ ...... 38 CONNECTION/INSPECTION FEES Water 5/8"x3/4" $ 1,5277.2 $ 1,715.00 $ 2,291.12 $ 2,572.50 1" $ !,53!.50 $ 1,848.00 $ 2,297.25 $ 2,772.00 1 I/2" $ 2,27a..S5 $ 2,899.00 $ 2,562.27 $ 4,348.50 2" $ ,~ ~-r~n'~ $ 3,682.00 $~,,~'~":.v.,,~A $ 5,523.00 Greater than 2" Actual Time & Materials 150% of Actual Time & Materials Field Inspection Fees Water main extensions (per foot) $ !.02 $ 1.10 $ 1.53 $ 1.65 but not less than: $ ~.087.0 $ 410.00 $ 612.60 $ 615.00 Pump Station $ 526.02 $ 540.00 $ $0~..0~. $ 810.00 Miscellaneous (per hour) $ ~.2.$~° $ 45.00 $ 6~..32 $ 67.50 Wastewater Lateral Connection at P/L $ a. 2.gg $ 45.00 $ 6n..32 $ 67.50 Lateral Connection at Main $ 268.0! $ 270.00 $ ~.02.02 $ 405.00 Conveyance Facility Ext. (Per Foot) $ !.22 $ 1.50 $ !.99 $ 2.25 but not less than: $ 22!.fi2 $ 325.00 $ ~.E2A2 $ 487.50 Pump Station $ 526.03 $ 540.00 $ °~9a..Oa. $ 810.00 Miscellaneous (per hour) $ '1.2.88 $ 45.00 $ fi'1.32 $ 67.50 1 of 8 209 EXHIBIT A Within Outside City Limits City Limits RETAIL WATER SERVICE RATES General Service - Monthly Service Charge Meter Size 5/8" x 3/4" $ 5.2! $ 8.02 $ 7.95 $ 12.03 1" $ 6.07 $ 9.17 $ 9.09 $ 13.76 I 1/2" $ g.52 $ 13.03 $ !2.97 $ 19.55 2" $ !!.59 $ 17.50 $ !7.% $ 26.25 3" $ 22.,ru3 $ 33.22 $ 32.92 $ 49.83 4" $ ~9.91 $ 61.82 $ 51.52 $ 92.73 6" $ P. 5.29 $ 219.39 $ 2!7.93 $ 329.09 8" $ 539.25 $ 800.69 $ 795.11 $ 1,201.04 10" $ !,893.!9 $ 2,858.72 $ 2,839.75 $ 4,288.08 12" $ 7,11°,,.87 $ 10,749.49 $ 19,578.22 $ 16,124.24 Residential Commodity Charge (per HCF) 0- 10HCF/Month $ 9.77 $ 0.87 $ 1.15 $ 1.31 Over 10 HCF/Month $ 0.97 $ 1.46 Non - Residential Commodity Charge (per HCF) $ 0.94 $ 1.41 Fire Protection - Monthly Service Charge Service Size 1" $ 19.52 $ 13.67 $ 15.83 $ 20.51 1 1/2" $ 15.82 $ 20.57 $ 23.59 $ 30.86 2" $ 29.57 $ 26.75 $ 39.83 $ 40.12 3" $ 22.67 $ 29.47 $ 3~.~ $ 44.20 4" $ 2~.7! $ 32.12 $ 37.01 $ 48.18 6" $ 29.82 $ 40.08 $ ~.5.20 $ 60.13 8" $ 41.04 $ 53.36 $ 5!.57 $ 80.04 I0" $ 57.52 $ 74.79 $ 8d.33 $ t12.19 12" $ E2.21 $ 106.91 $ 123.21 $ 160.37 Commodity Charge (per HCF) $ 1.53 $ 1.88 $ 2.20 $ 2.82 - For Usage Other Than Firefighting Low-Income Senior and Low-Income Disabled Citizen - Monthly Service Charge Base Charge (per account) $ 5.3! $ 8.02 $ 7.95 $ 12.03 Commodity Charge 0 - 5 HCF/Month No Charge No Charge 5 - 10 HCF/Month $ 0.87 $ 1.3l Over lOHCF/Month $ 0.77 $ 0.97 $ 1.15 $ 1.46 Temporary/Construction Meter 1" Meter Deposit $ 192.10 $ 105.00 $ !92.19 $ 105.00 Base Fee (per month) $ 5.97 $ 9.17 $ 9.99 $ 13.76 Set Up Fee $ 79.d~. $ 90.00 $ ! ! 9.~.5 $ 90.00 Hydrant meter (3" Meter) Deposit $ 510.50 $ 510.00 $ 5!0.59 $ 510.00 Base Fee (per month) $ 19.99 $ 33.22 $ 28.5~. $ 49.83 Set Up Fee $ 79.5! $ 90.00 $ 119.% $ 90.00 Equipment Loss/Damage Actual Time & Materials 150% of Actual Time & Materials Commodity Charge (perHCF) $ 9.77 $ 0.94 $ 1.15 $ 1.41 2of8 2']0 Within Outside City Limits City Limits RETAIL WATER SERVICE RATES (cont'd) City Government Water Services Monthly Fixed Charge Parks Department $ 2,000.00 Commodity Charge (per HCF) $ 30f8 211 Within Outside City Limits City Limits RETAIL WASTEWATER SERVICE RATES Monthly Service Charge Single Family Base Charge (per account) $ !!.Eh. $ 18.12 $ !2.58 $ 20.84 Commodity Charge (per HCF) $ 3.68 $ 4.24 Duplex on 1 Meter or 2 Bldgs on l Meter Base Charge (per unit) $ 9.99 $ 14.37 $ 10.°,,2 $ 16.53 Commodity Charge (per HCF) $ 3.68 $ 4.24 Multi - Family Base Charge (per unit) $ 9.29 $ 14.37 $ 19.g2 $ 16.53 Commodity Charge (per HCF) $ 3.68 $ 4.24 Commercial I Base Charge (per account) $ 17.5! $ 26.79 $ 20.!6 $ 30.81 Commodity Charge (per HCF) $ 3.78 $ 4.34 Commercial II BaseCharge (per account) $ !7.~2 $ 27.26 $ 20.52 $ 31.35 Commodity Charge (per HCF) $ 5.92 $ 6.81 Commercial III Base Charge (per account) $ 17.66 $ 27.02 $ 20.22 $ 31.07 Commodity Charge (per HCF) $ 4.85 $ 5.57 Low-Income Senior and Low-Income Disabled Citizen Base Charge (per account) $ 7.25 $ 11.25 $ g.~.7 $ 12.94 Commodity Charge (per HCF) 0 - 5 HCFfMonth No charge No charge Over 5 HCF/Month $ 3.68 $ 4.24 Septage Disposal (PerGallonofTankCapacity) $ 9.!2 $ 0.15 $ 9.!9 $ 0.15 4of8 212 .Within Outside City Limits City Limits RETAIL STORMWATER RATES Monthly Service Charge Single Family / Duplex Base Charge (per account) $ n,.59 $ 5.97 N/A Exception: Duplex w/2 Meters (per account) $ 2.55 $ 2.99 N/A Multi - Family Base Charge (per ISU) $ A.59 $ 5.97 N/A Commercial Base Charge (per ISU) $ ~.~59 $ 5.97 N/A Public School Districts (per account) $ n,.59 $ 5.97 N/A Low-Income Senior and Low-Income Disabled Citizen Base Charge (per account) $ 2.~~. $ 3.65 N/A Multi - Family & Commercial Rate Adjustment Water Quality (per ISU) $ ~v.~.~f'~ ~ ~ $ (0.66) N/A Water Quantity (perlSU) $ ~..~ nax $ (1.99) N/A Stormwater Penalty New Multi - Family & Commercial development without on-site detention Charge (per ISU) $ 1.02 $ 1.33 N/A IMPROPER STORMWATER INFLOW RATES The following rates are established for Improper Stormwater Inflow, based upon the stormwater ISU for each lot and adjusted annually on the following schedule: EFFECTIVE DATE RATE May 1, 2004 75% Stormwater Fee for Property May 1, 2005 100% Stormwater Fee for Property After May 1, 2005, the Improper Stormwater Inflow Rate will remain at 100% of the Stormwater Fee for a property unless otherwise modified by the City Council. The fees shall be deposited in the Wastewater Fund (451). 5 of 8 Within Outside City Limits City Limits MISCELLANEOUS FEES AND CHARGES Park Reservation Fee $ 30.53 $ 30.00 $ 2@.63 $ 30.00 (non-refundable) Office Services New Account (includes water turn-on) $ 20.00 $ 20.00 Account Maintenance $ 5.!1 $ 5.00 $ 5.1l $ 5.00 Past Due Notice $ 2.55 $ 2.50 $ 2.55 $ 2.50 Lien Recovery Charge $ 102.10 $ 100.00 $ !02.10 $ 100.00 Duplicate Bill Charge $ 1.02 $ 1.00 $ 1.02 $ 1.00 Close AccounffMeter Read/Water Service Turn- off $ 25.00 $ 20.00 $ 25.00 $ 20.00 Field Services Pavement Restoration Charge (refundable, if assessed and not required) Asphalt Patch $ 694.00 $ 1,041.00 Concrete Patch $ 894.00 $ 1,341.00 Asphalt Trench $ 8!5.80 $ 817.00 $ !,225.20 $ 1,225.50 Concrete Trench $ 2,?.8.20 $ 2,348.00 $ 3,522.~5 $ 3,522.00 County Road Permit N/A Cost Wet Tapping (Water Main Only)* 8" and smaller - excl excavation & backfill $ !,995.02 $ 2,852.00 $ 2,992.55 $ 4,278.00 8" and smaller- service toproperty line $ 2,5g5.77 $ 5,746.00 $ 5,279.55 $ 8,6t9.00 8" and :m,x!!cr ta~ cn!y $ ~.90.08 $ 725.12 Greater than 8"x 8" Actual Time & Materials 150% of Actual Time & Materials *Does Not Include Pavement Restoration Charge Fire Hydrant Installation $ n.,0E7.05 $ 5,12 I. ! 1 Actual Time & Materials 150% of Actual Time & Materials Water Meter Reinstallation 3/4" & 1" $ 50.24 $ 68.00 $ 50.24 $ 68.00 1-1/2" & 2" $ 9~..95 $ 108.00 $ ?..95 $ 108.00 3" and greater Time & Materials Time & Materials Water Meter Reactivation $ n. 2.S8 $ 48.00 $ ~2.85 $ 48.00 Water Meter Tampering Tampering Removal $ 13n..77 $ 173.00 $ !?..77 $ 173.00 Tampering Reinstallation Time & Materials Time & Materials Cross-Connection Control Inspection $ ~2.~°,. $ 45.00 $ ~2.88 $ 45.00 Fire Service - Detector, Meter & MXU $ 2!5.5 ! $ 397.75 $ 3 !5.5! $ 397.75 Storz Adapter $ 23!.77 $ 236.00 $ 231.77 $ 236.00 6of8 Within Outside City Limits Cit~ Limits MISCELLANEOUS (cont'd) Water Service Turn-off/Turn-on (Customer Request) Regular Hours $ 20.00 $ 20.00 AflerHours $ 197.2! $ 150.00 $ !97.2! $ 150.00 Delinquency Notice $ 19.72 $ 10.00 $ 19.72 $ 10.00 Water Service Turn-off/Turn-on (Delinquent Accounts) Regular Hours $ 42.88 $ 45.00 $ ~2.88 $ 45.00 After Hours $ 197.2! $ 150.00 $ 197.21 $ 150.00 Flow and Pressure Test (Uncertified) 3/4" & 1" meters only $ ~2.88 $ 48.00 $ ~,2.88 $ 48.00 1-1/2" & 2" meters only $ 85.76 $ 87.00 $ E5.76 $ 87.00 Larger than 2" Time & Materials Time & Materials Utility Plant Locates Regular Hours N/C N/C After Hours $ 197.21 $ 150.00 $ !97.2! $ 150.00 Emergency N/C N/C Meter Test Fee (based on meter size) 3/4" & 1" $ 94.95 $ 108.00 $ 9~.95 $ 108.00 14/2" &2" $ 152.15 $ 148.00 $ !52.!5 $ 148.00 3" or greater Time & Materials Time & Materials Engineering Services* Plan Check Fees Main Extensions: per foot $ 0.22 $ 0.25 $ 0.?. $ 0.38 BUT not less than $ 2!n...n..! $ 214.00 $ 221.62 $ 321.00 (Includes hydrants and appurtenances and connection to water system) Pump Stations $ 526.02 $ 536.00 $ 80~.0~, $ 804.00 Fireline Extension $ 85.76 $ 86.00 $ !28.65 $ 129.00 Irrigation Systems $ 85.76 $ 86.00 $ 12°,,.65 $ 129.00 System Connections $ g5.76 $ 86.00 $ 128.65 $ 129.00 Miscellaneous (perhour) $ 42.88 $ 45.00 $ 6~.22 $ 67.50 * Fees include original review and one resubmittal review. Additional reviews will be charged at miscellaneous hourly rate (above). 7of8 £'15 Within Outside City Limits City Limits MISCELLANEOUS (cont'd) Storm Drainage Plan Review Fees ** Preliminary Drainage Plans Residential Development $ 22 !.E2 $ 332.00 N/A Non-Residential Development $ 229.73 $ 230.00 N/A Plus perlSU $ !0.2! $ 10.00 Final Detailed Drainage Plans Residential Development (per lot) 0 - 20 Lots $ 25.7~. $ 36.00 N/A 21 - 50 Lots $ 25.52 $ 26.00 N/A 51 - 100 Lots $ 22.97 $ 23.00 N/A 100+ Lots $ 20?.2 $ 20.00 N/A Minimum Charge $ 255.25 $ 255.00 N/A Non-Residential Development per ISU $ 207.2 $ 20.00 N/A Minimum Charge $ 29~.2@ $ 306.00 N/A Resubmittal Fees First Resubmittal No Charge N/A Subsequent Resubmittal $ 255.25 $ 255.00 N/A Storm Drainage Inspection Fees ** Residential Development (per lot) $ 15.22 $ 15.00 N/A Non-ResidentialDevelopment (per ISU) $ 15.22 $ 15.00 N/A Minimum Charge $ 152.15 $ 153.00 N/A Conveyance Fac. Ext. (per foot) $ 0.77 $ 0.80 N/A Minimum Charge $ ~0~.20 $ 306.00 N/A Unscheduled Inspections* (per site visit) $ n. 2.88 $ 45.00 N/A *(Unscheduled inspections shall be tracked through the course of a project and billed after the final site inspection. Fees for unscheduled inspections shall be paid prior to final occupancy approval.) ** Does not apply to single family residence or duplex construction on an existing established lot. Utility/Lien Search Fee (Manual)* $ 30.00 $ 30.00 *Search per parcel 8of8