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DocuSign Envelope ID: EE765B38-37EF-4402-B4E9-8B82F98E2EE8 <br /> ORANGE COUNTY—CONTRACT CONTROL SHEET <br /> Routing Order: (1)Department, (2)IT,(3)Risk Management,(4)Financial Services,(5)Attorney,(6)Manager,(7)Clerk <br /> This Document shall accompany all contracts and shall be submitted for signature in the Routing Order specified above. If the Manager <br /> determines the contract is not appropriate for Manager approval the Manager shall submit the contract for BOCC approval. Contracts for <br /> BOCC approval must be submitted through,and complete,the routing process prior to agenda review. Contracts for legal review should <br /> be completed through the legal review process prior to being routed for signature. <br /> Deuartment <br /> Party/Vendor Name: United HealthCare Party/Vendor Contact Person: Patricia Martin Contact Phone:919-840-3106 Party/Vendor <br /> Address:3131 RDU Center Drive City Morrisville State:NC Zip:27560 Department: Amount: $1,265,095.00 Purpose:United <br /> HealthCare Application for Excess Loss Insurance Policy Budget Code(s): Vendor 4 47140 (N/A if new vendor) Vendor is a <br /> BOCC consultant? Yes ❑No® Contract Type: (Check one)New ❑ Renewal ® Amendment ❑ Effective Date 7/1/2015 <br /> Approved by Board Yes®No❑ Agenda Date:3/3/2015 Title of Contract: 1)UnitedHealthcare Stop Loss Policy and 2) <br /> UnitedHealthcare Application of Excess Loss Insurance <br /> If this is a Grant Agreement,pre-application has been approved by the Board of Commissioners Yes❑No®. If submitted for bid were <br /> bids/RFPs received Yes❑No❑ Bid/RFP number This contract has been reviewed and approved by the Department Director as to <br /> technical content: DocuSigned by: ,J(� <br /> IBA-CQ802-69FO-148F?ftJnj& f�a�,"^"(hMt,W 7/24/2015 <br /> Department Director's Signature: Date: <br /> IT Director <br /> (Applicable only to hardware/software purchases or related services)This contract has been reviewed and approved by the Information <br /> Technology Director as to technical content and information technology specifications: <br /> IT Director's Signature: Date: <br /> Risk Management <br /> Include the following coverages: ❑ CGL; ❑ Auto; ❑ WC; ❑ Professional; ❑ Property; OR No Insurance Required ❑. Hold <br /> Contract pending receipt of Certificate of Insurance ❑. With incorporation of Insurance provisions as shown,this contract is approved <br /> by the Risk Manager: DocuSigned""by: <br /> QUs& 66vvt,e 6 7/28/2015 <br /> Risk Manager's Signature: Fetes��aoo4�s__. Date: <br /> Financial Services <br /> This Contract is conditioned upon appropriation by the Board of Commissioners Yes❑No❑. A budget amendment is necessary <br /> before approval Yes❑ No❑. If budget amendment is necessary,please attach to this form. This instrument has been pre-audited in the <br /> manner required by the Local Government 7P9i2nF ROT` eM' 1 Control Act: <br /> AaVU 8/5/2015 <br /> Financial Services Director's Signature: Date: <br /> Countv Attornev <br /> Approval by Board ❑ (Contracts $90,000.00 or more for goods or services, $250,000.00 or more for construction, or any BOCC <br /> consultant contract). Approval by Manager❑ (Most other contracts$1,000 and above). Department Director approval only ❑ (Under <br /> $1,000). This contract heooimvky�ved and approved by the Attorney as to legal form and sufficiency: <br /> 1 8/5/2015 <br /> Attorney's Signature Date: <br /> Countv Manager <br /> This contract has been reviewed and is approved by the County Manager Yes❑No❑. <br /> This contract has been reviewed and is for signature by the Chair Yes❑No❑. <br /> Manager's Signature: Date: <br /> Clerk to the Board <br /> Approved by BOCC on the day of 20 . Submitted for Chair signature on the day of 20__ <br /> Clerk's Signature: Date: <br /> Revised March 2012 <br />