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5452 - Amendment 2 Executed Docusign City Council Transmittal Coversheet File Name Purchasing Contact City Council Target Date Granicus # Ordinance # DocuSign Envelope ID: 06BBB439-BF51-49EA-9D00-281AED251ACE Karen Smith RFP 5452 Amendment 2 - Clear Risk 12-13-16 Contract 5452, Amendment 2 December 13, 2016 City of Denton, TX 601 E. Hickory, Suite A Denton, Texas USA, 76205 Attention: Howard Martin, Interim City Manager RE: Amendment 2 of the ClearRisk Claims Service Agreement 5452 Dear Mr. Payne, This is to confirm our agreement concerning the Amendment 2 of the ClearRisk Claims Services Agreement effective since January 9th, 2014 (Contract 5452) and entered into with ClearRisk, Inc. (“ClearRisk”), a copy of which is attached hereto for easy reference (the “Service Agreement”) for the same price and term of one (1) year, from January 9th, 2017 to January 9th, 2018. Please note: ClearRisk is initiating a 12.5% increase in 2017 on all annual user licenses and web form fees. This is ClearRisk’s first price increase. However, ClearRisk would like to take this opportunity to extend the term from the initially agreed upon one (1) year renewal term to a three (3) year renewal term (the “Extended Term”). This allows the City of Denton, TX to benefit in a price freeze for the duration of the extended term and not be affected by the 2017 price increase. Any additional user licenses or web forms not currently under contract would also benefit from this price freeze. The total contract shall not-to-exceed $99,000. All the terms and conditions of the Service Agreement shall continue to govern the services rendered by you to ClearRisk during the Extended Term. If the above provisions are acceptable by you, please print and sign two copies of this letter in the space provided below and return one to the undersigned. Sincerely, Craig Rowe CEO & Founder, ClearRisk, Inc. DocuSign Envelope ID: 06BBB439-BF51-49EA-9D00-281AED251ACE Contract 5452, Amendment 2 Certificate of Interested Parties Electronic Filing In 2015, the Texas Legislature adopted House Bill 1295, which added section 2252.908 of the Government Code. The law states that the City may not enter into this contract unless the Contractor submits a disclosure of interested parties (Form 1295) to the City at the time the Contractor submits the signed contract. The Texas Ethics Commission has adopted rules requiring the business entity to file Form 1295 electronically with the Commission. Contractor will be required to furnish an original notarized Certificate of Interest Parties before the contract is awarded, in accordance with Government Code 2252.908. The contractor shall: 1. Log onto the State Ethics Commission Website at : https://www.ethics.state.tx.us/whatsnew/elf_info_form1295.htm 2. Register utilizing the tutorial provided by the State 3. Print a copy of the completed Form 1295 4. Enter the Certificate Number on page 3 of this amendment. 5. Sign and notarize the Form 1295 6. Email the notarized form to purchasing@cityofdenton.com with the contract number in the subject line. (EX: Contract 1234 – Form 1295) The City must acknowledge the receipt of the filed Form 1295 not later than the 30th day after Council award. Once a Form 1295 is acknowledged, it will be posted to the Texas Ethics Commission’s website within seven business days. DocuSign Envelope ID: 06BBB439-BF51-49EA-9D00-281AED251ACE Contract 5452, Amendment 2 Read and Accepted on ___________________________________ ClearRisk, Inc. _______________________________________ Name: Craig Rowe Title: CEO _____________________________________________ TEXAS ETHICS COMMISSION CERTIFICATE NUMBER City of Denton, TX _______________________________________ Howard Martin Interim City Manager Attest: Jennifer Walters, City Secretary _______________________________________________ Approved as to Legal Form: Anita Burgess, City Attorney ___________________________________________________________ DocuSign Envelope ID: 06BBB439-BF51-49EA-9D00-281AED251ACE 2016-142707 December 13, 2016 Exhibit CONFLICT OF INTEREST QUESTIONNAIRE - FORM CIQ For vendor or other person doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local government entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. 1 Name of vendor who has a business relationship with local governmental entity. 2 Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information in this section is being disclosed. Name of Officer This section, (item 3 including subparts A, B, C & D), must be completed for each officer with whom the vendor has an employment or other business relationship as defined by Section 176.001(1-a), Local Government Code. Attach additional pages to this Form CIQ as necessary. A. Is the local government officer named in this section receiving or likely to receive taxable income, other than investment income, from the vendor? Yes No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer named in this section AND the taxable income is not received from the local governmental entity? Yes No C. Is the filer of this questionnaire employed by a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership of one percent or more? Yes No D. Describe each employment or business and family relationship with the local government officer named in this section. 4 I have no Conflict of Interest to disclose. 5 Signature of vendor doing business with the governmental entity Date DocuSign Envelope ID: 06BBB439-BF51-49EA-9D00-281AED251ACE 1 12/6/2016 Certificate Of Completion Envelope Id: 06BBB439BF5149EA9D00281AED251ACE Status: Completed Subject: City Council Docusign Item - 5452 Amendment 2 Source Envelope: Document Pages: 5 Signatures: 5 Envelope Originator: Certificate Pages: 6 Initials: 0 Karen E. Smith AutoNav: Enabled EnvelopeId Stamping: Enabled Time Zone: (UTC-06:00) Central Time (US & Canada) karen.smith@cityofdenton.com IP Address: 129.120.6.150 Record Tracking Status: Original 12/2/2016 1:15:12 PM Holder: Karen E. Smith karen.smith@cityofdenton.com Location: DocuSign Signer Events Signature Timestamp Karen E. Smith karen.smith@cityofdenton.com Assistant Purchasing Manager City of Denton Security Level: Email, Account Authentication (Optional) Completed Using IP Address: 129.120.6.150 Sent: 12/2/2016 1:22:17 PM Viewed: 12/2/2016 1:22:26 PM Signed: 12/2/2016 1:22:58 PM Electronic Record and Signature Disclosure: Not Offered via DocuSign ID: Craig Rowe crowe@clearrisk.com Security Level: Email, Account Authentication (Optional) Using IP Address: 99.234.101.40 Sent: 12/2/2016 1:22:59 PM Resent: 12/6/2016 7:56:00 AM Viewed: 12/5/2016 7:23:48 AM Signed: 12/6/2016 8:05:30 AM Electronic Record and Signature Disclosure: Accepted: 12/5/2016 7:23:48 AM ID: 68bab2ae-ff45-4433-bb17-1e23d9f22a29 John Knight john.knight@cityofdenton.com Deputy City Attorney City of Denton Security Level: Email, Account Authentication (Optional) Using IP Address: 129.120.6.150 Sent: 12/6/2016 8:05:33 AM Viewed: 12/6/2016 11:54:38 AM Signed: 12/6/2016 11:55:27 AM Electronic Record and Signature Disclosure: Not Offered via DocuSign ID: Julia Winkley julia.winkley@cityofdenton.com Contracts Administration Supervisor City of Denton Security Level: Email, Account Authentication (Optional) Completed Using IP Address: 129.120.6.150 Sent: 12/6/2016 11:55:29 AM Viewed: 12/6/2016 1:40:33 PM Signed: 12/14/2016 10:43:06 AM Electronic Record and Signature Disclosure: Not Offered via DocuSign ID: Signer Events Signature Timestamp Howard Martin howard.martin@cityofdenton.com Interim City Manager City of Denton Security Level: Email, Account Authentication (Optional) Using IP Address: 129.120.6.150 Sent: 12/14/2016 10:43:10 AM Viewed: 12/20/2016 9:52:49 AM Signed: 12/20/2016 9:53:08 AM Electronic Record and Signature Disclosure: Not Offered via DocuSign ID: Jennifer Walters jennifer.walters@cityofdenton.com City Secretary City of Denton Security Level: Email, Account Authentication (Optional) Using IP Address: 129.120.6.150 Sent: 12/20/2016 9:53:09 AM Viewed: 12/21/2016 9:38:37 AM Signed: 12/21/2016 9:38:50 AM Electronic Record and Signature Disclosure: Not Offered via DocuSign ID: In Person Signer Events Signature Timestamp Editor Delivery Events Status Timestamp Agent Delivery Events Status Timestamp Intermediary Delivery Events Status Timestamp Certified Delivery Events Status Timestamp Carbon Copy Events Status Timestamp Julia Winkley julia.winkley@cityofdenton.com Contracts Administration Supervisor City of Denton Security Level: Email, Account Authentication (Optional) Sent: 12/6/2016 8:05:31 AM Viewed: 12/6/2016 8:22:36 AM Electronic Record and Signature Disclosure: Not Offered via DocuSign ID: Sherri Thurman sherri.thurman@cityofdenton.com Security Level: Email, Account Authentication (Optional) Sent: 12/6/2016 8:05:31 AM Electronic Record and Signature Disclosure: Not Offered via DocuSign ID: Jane Richardson jane.richardson@cityofdenton.com Security Level: Email, Account Authentication (Optional) Sent: 12/14/2016 10:43:08 AM Viewed: 12/14/2016 11:33:19 AM Electronic Record and Signature Disclosure: Not Offered via DocuSign ID: Robin Fox Robin.fox@cityofdenton.com Security Level: Email, Account Authentication (Optional) Sent: 12/14/2016 10:43:08 AM Carbon Copy Events Status Timestamp Electronic Record and Signature Disclosure: Accepted: 10/9/2015 1:39:51 PM ID: 04463961-03db-4c4d-9228-d660d6146ed6 Jennifer Bridges jennifer.bridges@cityofdenton.com Procurement Assistant City of Denton Security Level: Email, Account Authentication (Optional) Sent: 12/21/2016 9:38:52 AM Viewed: 12/28/2016 3:07:05 PM Electronic Record and Signature Disclosure: Not Offered via DocuSign ID: Jane Richardson jane.richardson@cityofdenton.com Security Level: Email, Account Authentication (Optional) Sent: 12/21/2016 9:38:53 AM Electronic Record and Signature Disclosure: Not Offered via DocuSign ID: Scott Payne scott.payne@cityofdenton.com Security Level: Email, Account Authentication (Optional) Sent: 12/21/2016 9:38:54 AM Viewed: 12/21/2016 9:40:54 AM Electronic Record and Signature Disclosure: Not Offered via DocuSign ID: Notary Events Timestamp Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 12/21/2016 9:38:54 AM Certified Delivered Security Checked 12/21/2016 9:38:54 AM Signing Complete Security Checked 12/21/2016 9:38:54 AM Completed Security Checked 12/21/2016 9:38:54 AM Electronic Record and Signature Disclosure ELECTRONIC RECORD AND SIGNATURE DISCLOSURE From time to time, City of Denton (we, us or Company) may be required by law to provide to you certain written notices or disclosures. 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