Agenda packet — Mendota City Council, June 14, 2022 (part 1 of 2)

CITYOF MENDOTA
ooCantaloupe Center Of The World"

ROLANDO CASTRO
Mayor

JESUS MENDOZA
Mayor Pro Tem

JOSE ALONSO
JOSEPH R. RIOFRIO

OSCAR ROSALES
AGENDA

MENDOTA CITY COUNCIL
Regular City Council Meeting
CITY COUNC!L CHAMBERS
643 QUINCE STREET
June 14,2022
6:00 PM

CRISTIAN GONZALEZ
City Manager

JOHN KINSEY
City Attorney
The Mendota City Council welcomes you to its meetings, which are scheduled for the 2nd and 4th Tuesday of every month. Your interest and participation are encouraged and appreciated. Notice is hereby given that Council may discuss and/ortake action on any or all of the items listed on this agenda. Please turn your cell phones on vibrateloff while in the council chambers.

Any public writings distributed by the City of Mendota to at least a majority of the City Council regarding any item on this regular meeting agenda will be made available at the front counter at City Hall, located at 643 Quince Street Mendota, CA 93640, during normal business hours, 8 AM - 5 PM. ln compliance with the Americans with Disabilities Act, individuals requiring special assistance to participate at this meeting please contact the City Clerk at (559) 655-3291 or (559) 577-7692. Notification of at least forty-eight hours prior to the meeting will enable staff to make reasonable arrangements to ensure accessibility to the meeting.

Si necesita servicios de interpretaci6n para participar en esta reuni6n, comuniquese con la Secretaria de la Ciudad al (559) 655-3291 o (559) 577-7692 entre las 8 a.m. y las 5 p.m. de lunes a viernes. La notificaci6n de al menos veinticuatro horas antes de la reuni6n permitir6 al personal adoptar las disposiciones necesarias para garantizar su participaci6n en la reuni6n.

CALL TO ORDER

ROLL CALL

FLAG SALUTE

INVOCATION

FINALIZE THE AGENDA
Adjustments to Agenda
Adoption of final Agenda

CITIZENS' ORAL AND WRITTEN PRESENTATIONS
At this time, members of the public may address the City Council on any matter not listed on the agenda involving matters within the jurisdiction of the City Council. Please complete a "request to speak" form and limit your comments toTHREE(3)MINUTES. PleasegivethecompletedformtotheCityClerkpriortothestartofthemeeting. Allspeakers shall observe proper decorum. The Mendota Municipal Code prohibits the use of boisterous, slanderous, or profane language. All speakers must step to the podium and state their names and addresses for the record. Please watch the time.

City Council Agenda June 14,2022
1 2
1 643 Ouince Street Mendota, Calilornia 93640
Telephone: (559) 655-3291 Fresno Line: (559) 266-6456 Fax: (559) 655-4064 TDD/[TY 866-735-2919 (English) TDD/[TY 866-833-4703 (Spanish) ci.mendota.ca.us
The City ol Mendota is an equal opportunity provider and employer 1 2.
3 4

APPROVAL OF MINUTES AND NOTICE OF WAIVING OF READING

1. Minutes of the regular City Council meeting of May 24,2022. 2 Notice of waiving of the reading of all resolutions and/or ordinances introduced and/or adopted under this agenda.

CONSENT CALENDAR
Matters listed under the Consent Calendar are considered to be routine and will be enacted by one motion and one vote. There will be no separate discussion of these items. lf discussion is desired, that item will be removed from the Consent Calendar and will be epnsidered separately.

MAY 25,2022 THROUGH JUNE 8, 2022
WARRANT LIST CHECK NOS. 51800 THROUGH 51873
TOTAL FOR COUNCIL APPROVAI- = $880,315.86
Proposed adoption of Resolution No. 22-31, authorizing the City Manager to execute all necessary documents to terminate services with Administrative Solutions, lnc./Navia and to execute all documents necessary to obtain replacement services with Employer Driven lnsurance Services.

Proposed adoption of Resolution No. 22-32, adopting a list of projects for Fiscal Year 2022-2023 funded by SB1: The Road Repair and Accountability Act of 2017.

Proposed adoption of Resolution No. 22-33, awarding the construction contract for the Mendota Junior High School Safe Routes to School project to American Paving Co. in the amount of $207,622.00.

Proposed adoption of Resolution No. 22-34, approving the fireworks stand permits for 2022.

Proposed adoption of Resolution No. 22-35, approving a Procurement Policy for the City of Mendota.

Proposed adoption of Resolution No. 22-36, approving an amendment to the Fiscal Year 2021 -2022 Budget.

Proposed adoption of Resolution No. 22-37, authorizing expenditures for the materials required for the construction of the Honor Wall at the baseball fields at Rojas-Pierce Park.

5. 6.

7. I
City Council Agenda 2 June 14,2022
1 PUBLIC HEARING
Council discussion and consideration of Resolution No. 22-38, adopting a negative declaration pursuant to the California Environmental Quality Act; Resolution No. 22-39, approving an amendment to the Land Use Element of the City of Mendota General Plan Update 2005-2025; and introduction and waiver of the first reading of Ordinance No. 22-01, amending the official zoning map of the City of Mendota, all in the matter of Application No. 21-10, the Carballo (Salomon) Apartments Project (755 Marie Street; APN 013-106-15).
a. Receive report from City Planner O'Neal
b. lnquiries from City Councilto staff
c. Mayor Castro opens the public hearing
d. Once all comment has been received, Mayor Castro c/oses the public hearing
e. Councilconsiders adoption of Resolution No. 22-38 and Resolution No. 22-39 and introduction and waiver of the first reading of Ordinance No. 22- 01 BUSINESS
1 Council discussion and consideration on opening the sports fields to the public during regular park hours.
a. Receive repoft from City Manager Gonzalez
b. lnquiries from Councilto staff
c. Mayor Castro opens floor to receive any comment from the public d. Council provides direction to staff on how to proceed Council discussion and consideration of a rate for a general transactions and use tax measure ballot.
a. Receive report from Finance Director Banda
b. lnquiries from Councilto staff
c. Mayor Castro opens floor to receive any comment from the public d. Council provides direction to staff on how to proceed

3. Council discussion and consideration of Resolution No. 2240, approving and adopting the operating budget for the City of Mendota for Fiscal Year 2022-2023. a. Receive report from City Manager Gonzalez
b. lnquiies from Council to staff
c. Mayor Castro opens floor to receive any comment from the public d. Council provides input and considers Reso/ution No. 22-40 for adoption 2 City Counci! Agenda 3 June 14,2022

DEPARTMENT REPORTS AND INFORMATIONAL ITEMS
Finance Director
a) Grant Update
City Engineer
a) Update
City Attorney
a) Update
1 2.

3. 4. City Manager

MAYOR AND COUNCIL REPO AND INFORMATIONAL ITEMS
1 2
Council Member(s)
Mayor

CLOSED SESSION

CONFERENCE WTH LABOR NEGOTIATORS
Pursuant to CA Government Code SS 54954.5(0, 54957.6
a. Agency Designated Representative: Cristian Gonzalez, City Manager b. Employee Organization: Mendota Police Officers Association

CONFERENCE WITH LEGAL COUNSEL - ANTICIPATED LITIGATION
Potential initiation of litigation pursuant to paragraph (4) of subdivision (d) of Government Code section 54956.9 (two potential cases).

ADJOURNMENT

CERTIFICATION OF POSTING
I, Celeste Cabrera-Garcia, City Clerk of the City of Mendota, do hereby declare that the foregoing agenda for the Mendota City Council Regular Meeting of June 14,2022, was posted on the outside bulletin board located at City Hal!, 643 Quince Street, on Friday, June 10, 2022 at 5.00 p.m
1 1
ity Clerk
City Counci! Agenda 4
Cabrera-Garcia
June 14,2022
Minutes of City Council Meeting 1 May 24, 2022

MINUTES OF MENDOTA

REGULAR CITY COUNCIL MEETING
Regular Meeting May 24, 2022
Meeting called to order by Mayor Castro at 6:05 p.m.

A moment of silence was held for the victims of the Robb Elementary School shooting in Uvalde, Texas
Roll Call
Council Members Present: Mayor Rolando Castro, Mayor Pro Tem Jesus Mendoza and Councilors Jose Alonso and Joseph
Riofrio
Council Members Absent: Councilor Oscar Rosales
Flag salute led by Mayor Castro
Invocation led by Police Chaplain Ophelia Lugo

FINALIZE THE AGENDA

1. Adjustments to Agenda.

2. Adoption of final Agenda.

A motion was made by Mayor Pro Tem Mendoza to adopt the agenda, seconded by Councilor Riofrio; unanimously approved (4 ayes, absent: Rosales).

CITIZENS ORAL AND WRITTEN PRESENTATIONS
None offered.

Minutes of City Council Meeting 2 May 24, 2022

APPROVAL OF MINUTES AND NOTICE OF WAIVING OF READING

1. Minutes of the regular City Council meeting of May 10, 2022.

2. Notice of waiving of the reading of all resolutions and/or ordinances introduced and/or adopted under this agenda.

A motion was made by Councilor Riofrio to approve items 1 and 2, seconded by Mayor Pro Tem Mendoza; unanimously approved (4 ayes, absent: Rosales).

CONSENT CALENDAR

1. MAY 6, 2022 THROUGH MAY 17, 2022
WARRANT LIST CHECK NOS. 51737 THROUGH 51799
TOTAL FOR COUNCIL APPROVAL = $283,505.42

2. Proposed adoption of Resolution No. 22-30, approving the estimate and authorizing H&R Underground to proceed with recoating the influent channel walls at the Wastewater Treatment Plant Facility.

A motion was made by Councilor Riofrio to approve items 1 and 2 of the Consent Calendar, seconded by Councilor Alonso; unanimously approved (4 ayes, absent: Rosales).

BUSINESS

1. Council discussion and consideration of the Fiscal Year 2022-2023 Proposed Budget.

Mayor Castro introduced the item and City Manager Gonzalez provided the report.

Finance Director Nancy provided additional information on the item.

Discussion was held on the information provided.

Martha Cabrera – commented on the item.

Discussion was held on the information provided by Ms. Cabrera.

Brian Rickers (Aqua Natural Solutions) – commented on the item.

Discussion was held on the information provided by Mr. Rickers.

At 6:42 p.m. Councilor Riofrio left the Council Chambers and returned at 6:45 p.m.

Council provided direction to staff on suggested modifications to the draft budget.

Minutes of City Council Meeting 3 May 24, 2022

2. Council discussion and consideration on opening the sports fields to the public during regular park hours.

Mayor Castro introduced the item and City Manager Gonzalez provided the report.

Discussion was held on the item.

A motion was made by Councilor Riofrio to table the item to a future meeting agenda, seconded by Councilor Alonso; unanimously approved (4 ayes, absent: Rosales).

PUBLIC HEARING

1. Public hearing and proposed adoption of Resolution No. 22-29, confirming the diagram and authorizing the levy and collection of assessments for Landscape and Lighting Maintenance District No. 2019-01 for Fiscal Year 2022-2023.

Mayor Castro introduced the item and City Engineer Osborn provided the report.

Discussion was held on the item.

At 7:35 p.m. Mayor Castro opened the hearing the public and, seeing no one willing to comment, closed the hearing within the same minute.

A motion was made by Councilor Riofrio to adopt Resolution No. 22-29, seconded by Councilor Alonso; unanimously approved (4 ayes, absent: Rosales).

DEPARTMENT REPORTS AND INFORMATIONAL ITEMS

1. Animal Control, Code Enforcement, and Police Department a) Monthly Reports
Chief of Police Smith provided the report for the Code Enforcement Department including monthly statistics and a personnel update.

Discussion was held on code violations throughout the community.

Chief Smith provided the report for the Animal Control Department including the current capacity of the dog pound, and the status of the dog vaccination clinic.

Chief Smith provided the report for the Police Department including monthly statistics; crime trends; a drone program update; and a personnel update.

Discussion was held on the department’s monthly statistics; and Officer Gurrola being nominated for a Mother’s Against Drunk Driving award.

At 7:51 p.m. Mayor Pro Tem Mendoza left the Council Chambers.

Minutes of City Council Meeting 4 May 24, 2022

2. City Attorney
a) Update
City Attorney Kinsey provided an update on an abatement action; provide an update on pitchess motions; and requested direction from staff regarding modifying the monthly stipend for City Council Members.

Discussion was held on the information provided by City Attorney Kinsey.

Council directed staff to hold off on the item regarding modifying the monthly stipend for City Council Members.

At 7:53 p.m. Mayor Pro Tem Mendoza returned to the Council Chambers.

3. City Manager
City Manager Gonzalez reported on the 2022 ICSC Las Vegas conference that he and the Council recently attended; and provided an update on the Element 7 project.

Discussion was held on the Automatic Meter Reading project.

MAYOR AND COUNCIL REPORTS AND INFORMATIONAL ITEMS

1. Council Member(s)
Councilor Alonso shared his condolences for the victims of the mass shootings in Texas and New York and stated that he hopes legislators act on matters related to gun control.

Councilor Riofrio commented on historical acts of gun violence.

Mayor Pro Tem Mendoza commented on the mass shootings that have recently taken place and commented on the precautionary measures that local schools and the police department have in place for those types of situations.

2. Mayor
Mayor Castro commented on the devastating consequences of the mass shooting in Texas and reported on the 2022 ICSC Las Vegas conference that he recently attended.

Discussion was held on the school resource officer program.

Minutes of City Council Meeting 5 May 24, 2022

CLOSED SESSION

1. CONFERENCE WITH LABOR NEGOTIATORS
Pursuant to CA Government Code §§ 54954.5(f), 54957.6
a. Agency Designated Representative: Cristian Gonzalez, City Manager b. Employee Organization: Mendota Police Officers Association

2. CONFERENCE WITH LEGAL COUNSEL – ANTICIPATED LITIGATION Potential initiation of litigation pursuant to paragraph (4) of subdivision (d) of Government Code section 54956.9 (one potential case).

3. CONFERENCE WITH REAL PROPERTY NEGOTIATORS
a. Agency Designated Negotiator: Cristian Gonzalez, City Manager b. Negotiating Party: United Security Bank
c. Real Property Under Negotiation: 643 Quince Street, Suite B, Mendota, CA 93640
At 8:22 p.m. the Council moved into closed session.

City Attorney Kinsey left the Council Chambers following the discussion of Closed Session item 2.

At 9:12 p.m. the Council reconvened in open session and City Manager Gonzalez stated that in regard to items 1 through 3 of the Closed Session, there was no reportable action.

ADJOURNMENT
With no more business to be brought before the Council, a motion for adjournment was made at 9:13 p.m. by Councilor Alonso, seconded by Mayor Pro Tem Mendoza; unanimously approved (4 ayes, absent: Rosales).
_______________________________
Rolando Castro, Mayor
ATTEST:
_______________________________
Celeste Cabrera-Garcia, City Clerk

CITY OF MENDOTA

CASH DISBURSEMENTS
5/25/2022-6/8/2022
CK# 51800-51873
Date Check # Check Amount Vendor Department Description May 25, 2022 51800 $ 125,685.00 CITY OF MENDOTA PAYROLL GENERAL PAYROLL TRANSFER FOR 5/9/2022-5/22/2022
May 31, 2022 51801 $ 61.18 ADT SECURITY SERVICES WATER
SECURITY SERVICES FOR 6/4/22-7/3/22- WTP 1300 2ND ST.

May 31, 2022 51802 $ 28,357.91 AETNA LIFE INSURANCE COMPANY GENERAL MEDICAL INSURANCE FOR JUNE 2022
May 31, 2022 51803 $ 632.74 AFLAC GENERAL
AFLAC INSURANCE FOR THE MONTH OF MAY 2022
May 31, 2022 51804 $ 1,310.09 ALEX AUTO DIAGNOSTICS GENERAL-WATER-SEWER 2018 FORD EXPLORER PD INTER. PURGE VALVE (PD), 2007 FORD 150

SUPERCREW SPARK PLUGS, BRAKE PADS
May 31, 2022 51805 $ 291.63 CHEMSEARCH SEWER
(2) CHERRY FLOW, 5GL, NAC FE (WWTP) & FUEL CHARGE
May 31, 2022 51806 $ 2,665.92 CORE & MAIN LP WATER
(10) P24248N 1 CPXMN ANGLE METER NO LEAD (10) ANG, (4) P24258N 3/4X1 CPXMN ANGLE METR NO LEAD, (1) P14258N ANG.

May 31, 2022 51807 $ 98.00 DEPARTMENT OF JUSTICE GENERAL (2) FINGERPRINT APPS (1) CHILD ABUSE INDEX CK, PEA (PD) May 31, 2022 51808 $ 586.33 EINERSON'S PREPRESS GENERAL-WATER-SEWER (1000) LETTERHEAD WITH 4% WATERMARK, 1000 SHEETS, 4 BOXES #10 BLACK INK NO WINDOW/ 2000 ENVELOPES
May 31, 2022 51809 $ 14,876.50 FRESNO COUNTY SHERIFF GENERAL-WATER-CFD FUND RMS JMS ACCESS FEE APRIL 2022 & DISPATCH SERVICES FOR JUNE 2022
May 31, 2022 51810 $ 717.03 FRESNO WIRE ROPE & RIGGING, INC. SEWER (1000) 316SS, (14) SPEARSNP, (12) THIMBL, (24)CLAMPS, (200) 316SS 3167X19S FOR WWTP
May 31, 2022 51811 $ 478.25 GOLDSTAR PRODUCTS, INC. SEWER (1) DIGESTIVE ENZYM POWDER- 25LB (WWTP)
May 31, 2022 51812 $ 425.30

KINGSBURG VETERINARY MANAGEMENT

LP GENERAL
(4) EUTHNASIA/IVC/SEDATION (ANIMAL CONTROL)
May 31, 2022 51813 $ 74,291.12 MID VALLEY DISPOSAL, INC. REFUSE SANITATION CONTRACT SERVICES FOR APRIL 2022
May 31, 2022 51814 $ 43,572.76 PG&E
GENERAL-WATER-SEWERSTREETS-AIRPORT
WATER DEPARTMENT UTILITIES 4/14/22-5/12/22 & CITYWIDE UTILITIES FOR 4/8/2022-5/8/2022
May 31, 2022 51815 $ 532.42 PLATT ELETRIC SUPPLY STREETS (1000) THHN 12 BLK & WHT TWIST PRO 500FT & 250PC
May 31, 2022 51816 $ 17,793.50 PROVOST & PRITCHARD
GENERAL-WATER-SEWERSTREETS
PROF. SERV. APRIL 2022 MENDOTA JR HIGH SRTS, PROFESSIONAL SER. APRIL 2022 RAILROAD CORRIDOR
May 31, 2022 51817 $ 1,431.97 PURCHASE POWER GENERAL-WATER-SEWER POSTAGE METER REFILL 5/11/22 & TRANSACTION FEE, (2)
DM300C/400C RED INK CARTRIDGE & E-Z SEAL 64OZ
May 31, 2022 51818 $ 8,832.24 SORENSEN MACHINE WORKS
GENERAL-WATER-SEWERSTREETS
MULTIPLE DEPARTMENT SUPPLIES FOR MARCH 2022 & APRIL 2022 May 31, 2022 51819 $ 160.59 USA BLUEBOOK WATER
(1) 3/8" TUBE X 3/8" TUBE X 3/8" TUBE KYNAR UNION
May 31, 2022 51820 $ 400.79 VALLEY FARM SUPPLY STORES INC. GENERAL (1) ECHO CHAIN SAW 12" (3) STIHL CHAIN LOOP 3/8"
June 1, 2022 51821 $ 841.55 JORGE URBIETA GENERAL
TD & 4850- 5/12/2022-5/15/2022
June 8, 2022 51822 $ 5,000.00 ADMINISTRATIVE SOLUTIONS - FRESNO GENERAL MEDICAL CHECK RUN 5/24/2022
June 8, 2022 51823 $ 325.20 ADT SECURITY SERVICES GENERAL-WATER-SEWER SECURITY SERVICES 6/11/22-7/12/22 CITYHALL/DMV/EDD
June 8, 2022 51824 $ 88.21 ALERT-0-LITE STREETS
(1) ASSTD CERAMIC MAGNET, 2 GAL HD COOLER, 2.5 BLK
June 8, 2022 51825 $ 691.32 AT&T GENERAL-WATER-SEWER
CITYWIDE TELEPHONE SERVICE 4/25/22-5/24/22
June 8, 2022 51826 $ 210.00 MADERA DISPOSAL SYSTEMS INC. GENERAL (6) ANIMAL CONTROL EUTHANASIA ON 4/11/22 & (15)ANIMAL CONTROL EUTHANASIA ON 4/25/22
June 8, 2022 51827 $ 100.00 MACARIO BANUELOS WATER-SEWER

DOT MEDICAL EXAM REIMBURSEMENT
June 8, 2022 51828 $ 56.91 BATTERIES PLUS BULBS SEWER
(2) 12V LEAD DURA 12-8F2
June 8, 2022 51829 $ 2,371.50 BSK ASSOCIATES WATER-SEWER

WEEKLY TREATMENT & DISTRIBUTION, WASTEWATER WEEKLY GRAB

SAMPLE, GENERAL EDT QUARTERLY SAMPLES
June 8, 2022 51830 $ 303.00 CAL VALLEY INSURANCE, INC. GENERAL-WATER-SEWER RENEWAL ERISA UP TO $500K 401(K)
June 8, 2022 51831 $ 70.09 ROLANDO CASTRO GENERAL

REIMBURSEMENT FYI AIRPORT PARKING TICKET & TAXI FARE
June 8, 2022 51832 $ 124.21 CHEMSEARCH SEWER
(3) PIT BOSS 5GL
June 8, 2022 51833 $ 146.02 COLONIAL LIFE GENERAL
LIFE INSURANCE PREMIUM FOR MAY 2022
June 8, 2022 51834 $ 944.01 CORBIN WILLITS SY'S INC. GENERAL-WATER-SEWER ACCOUNTING SOFTWARE ENHANCEMENT & SERVICE JUNE 2022
June 8, 2022 51835 $ 442.98 CROWN SERVICES CO. GENERAL-SEWER TOILET 1XWK 1000 AIRPORT BLVD BLDG #A (PD), POOL PARK, LOZANO PARK, TOILET W/SINK 1XWK 1300 2ND ST.- WWTP
June 8, 2022 51836 $ 200.00 DATA TICKET, INC. GENERAL
CITATION PROCESSING APRIL 2022 (PD)
June 8, 2022 51837 $ 1,224.72 FARMERS LUMBER AND SUPPLY CO. STREETS (1) 35' PG&E POLE- 291 MCCABE AVE., (1) 35' PG&E POLE- 449 QUINCE ST.

CITY OF MENDOTA

CASH DISBURSEMENTS
5/25/2022-6/8/2022
CK# 51800-51873
June 8, 2022 51838 $ 5,997.00 FENCE MASTERS CONTRACTORS GENERAL 50' REPLACE NEW 12' HIGH 6' HIGH 9 GAUGE & 6' HIGH 11 GAUGE

CHAIN LINK FENCE W/ COIL WIRE- VETERAN'S PARK
June 8, 2022 51839 $ 180.00

GONZALEZ TOWING, TIRE, AUTO & TRUCK

DISMANTLING WATER-SEWER

CITY CAR LOCK OUT
June 8, 2022 51840 $ 203.32 GRAINGER INC. WATER-SEWER
(2) KIT ROC 1CYL REP FOR (PRISON SITE)
June 8, 2022 51841 $ 159.05 GUTHRIE PETROLEUM INC. STREETS 2 1/5 CHEV TRACTOR HYDROLIC OIL FEE QTY:10
June 8, 2022 51842 $ 213.10 KERWEST NEWSPAPER LLDM/GENERAL (7) NOTICE OF PUBLIC HEARING REG. MEETING OF CITY COUNCIL June 8, 2022 51843 $ 240.00 LAW ENFORCEMENT GENERAL
(1000) L-9 ABANDONED VEHICLE LABEL
June 8, 2022 51844 $ 500.00 MENDOTA YOUTH RECREATION GENERAL FACILITY USE DEP. REFUND HARVEST CARIVAL 6/2/22-6/5/22
June 8, 2022 51845 $ 2,148.56 METRO UNIFORM GENERAL
(2) MENDOTA SHOULDER PATCHES, UNIFORM ITEMS D. MALDONADO, (1)SOFTSHELL JACKET, (2) FULL T-SHIRT (PD)
June 8, 2022 51846 $ 1,833.56 MUTUAL OF OMAHA GENERAL
LIFE, AD&D, LTS, & STD INSURANCE FOR JUNE 2022
June 8, 2022 51847 $ 90.00 NAVIA BENEFIT SOLUTIONS GENERAL 6-PARTICIPANT FEE POLICE- MAY 2022
June 8, 2022 51848 $ 2,500.00 NEW VISION AVIATION INC. AIRPORT PHASE 2 BROCHURE SUZANNE BERTZ-ROSA MES-C NEWTECH
(WILLIAM JOHNSON INSURANCE FOR AIRPORT)
June 8, 2022 51849 $ 895.00 NEXUS ADMINISTRATORS, INC. GENERAL-WATERT-SEWER PPA-POST CYCLE 3 RESTATEMENT
June 8, 2022 51850 $ 652.33 OFFICE DEPOT GENERAL-WATER-SEWER (1) AVERY LABELS 5160, (1) PACK OF 6 KLEENEX, PAPER, (15) ACCO PRESSTEC BINDER SIDE BOUND 11"X8 1/2, (2) DESK TRAYS, PENS June 8, 2022 51851 $ 78,161.29 PROVOST & PRITCHARD
GENERAL-WATER-SEWERSTREETS
PASS THRU-PROF SERV STEVE HAIR WESTLAND MAP-2/2022, PROF SERV ROJAS PIERCE PARK IMP MARCH 2022
June 8, 2022 51852 $ 2,406.68 RAMON'S TIRE & AUTO SERVICE SEWER-STREETS LOADER 544 J#65 TIRE, VALVE STEM, SERVICE CALL
June 8, 2022 51853 $ 370.00

RED WING BUSINESS ADVANTAGE

ACCOUNT WATER-SEWER
BOOT REPLACEMENT PER MOU FOR (J. ANGEL) & (A. SANCHEZ)
June 8, 2022 51854 $ 19,800.00 RRM DESIGN GROUP GENERAL-WATER-SEWER CITYHALL & PD STATION CONSTRUCTION DOCS. 5/18/22
June 8, 2022 51855 $ 1,131.18 SIGNMAX GENERAL
(6) 48X36 EG ALUM YEL/BLK (2) 300,(1) 290,(2) 225-PARKS June 8, 2022 51856 $ 44.68 KEVIN SMITH GENERAL
REIMBURSEMENT FOR (21) PRINTS 5X7 & (5) 8X10 PRINTS
June 8, 2022 51857 $ 355.97 UNION PACIFIC RAILROAD COMPANY STREETS PUBLIC ROADWAY ENCROACHMENT JUNE 2021
June 8, 2022 51858 $ 5,045.38 BANKCARD CENTER GENERAL-WATER-SEWER CREDIT CARD EXPENSES 4/26/22-5/24/2022 ADOBE ACROPRO SUBS, AMAZON, CHEWY DOG FOOD, NCH SOFTWARE FOR REC.

June 8, 2022 51859 $ 535.00 MARK ANTHONY DUARTE GENERAL-WATER-SERWER PEST CONTROL SERVICES CITYHALL/DMV/YOUTH CENTER 4/26/22,

TREAT GROUNDS FOR GOPHER MOUNDS ROJAS PARK
June 8, 2022 51860 $ 2,525.25 THE HOME DEPOT
GENERAL-WATER-SEWERSTREETS
MKE M18 HIGH OUTPUT BATTERY 2 PK 6.0AH, (42) 80LB SAKRETE CONCRETE MIX & PALLET FEE, (8) 1"X3/4' SHARBITE REDUCER June 8, 2022 51861 $ 460.00 THE PIN CENTER GENERAL
(200) 80TH ANNIVERSARY PINS
June 8, 2022 51862 $ 1,182.50 THE BUSINESS JOURNAL STREETS REQUEST FOR BIDS-MENDOTA JR HIGH SRTS DUE 5/26/22
June 8, 2022 51863 $ 822.79 THE CLIFFS GENERAL

HOTEL RESERVATION FOR CHIEF'S EXECUTIVE WORKSHOP
June 8, 2022 51864 $ 200.00 UNITED HEALTH CENTERS GENERAL PRE-EMPLOYMENT PHYSICAL EXAM (PD) J.SALAS
June 8, 2022 51865 $ 151.97 UNIFIRST CORPORATION GENERAL-WATER-SEWER (6) 4X6 MATS, (3) BOWL CLIP (1) MOP LARGE (1) DRY MOP
June 8, 2022 51866 $ 53.93 USA BLUEBOOK WATER
(1) CHEMTROL TRUE UNION BLEACH BALL VALVE PVP/FKM
June 8, 2022 51867 $ 150.00 VETERINARY MEDICAL CENTER GENERAL (6) CITY EUTHANASIA (ANIMAL CONTROL)
June 8, 2022 51868 $ 8,646.00 WANGER JONES HELSLEY PC ATTORNEYS GENERAL-WATER-SEWER LEGAL SERV RE: GENERAL LEGAL SERVICES 4/15/22, PASS-THRU BOCA DEL RIO LEGAL SERVICES 2/15/22
June 8, 2022 51869 $ 500.00 WESTSIDE YOUTH GENERAL

KEY DEPOSIT REIMBURSEMENT FOR SPRING CARNIVAL EVENT,
DEPOSIT REFUND FOR BASEBALL FIELD & KEY USE 3/26/22
June 8, 2022 51870 $ 405,542.65 WEST VALLEY CONSTRUCTION COMPANY WATER AUTOMATIC METER READING PROJECT APRIL 2022 PAYMENT #3
June 8, 2022 51871 $ 114.32 YONKERS & JOHNSON, INC. SEWER

83.5" OF HYD HOSE - WWTP
June 8, 2022 51872 $ 113.27 DENISE FUENTES WATER
MQ CUSTOMER REFUND FOR FUE0037
June 8, 2022 51873 $ 50.09 DENISE FUENTES WATER
MQ CUSTOMER REFUND FOR FUE0038
$ 880,315.86
1 AGENDA ITEM – STAFF REPORT
TO: HONORABLE MAYOR AND COUNCILMEMBERS
FROM: JENNIFER LEKUMBERRY, DIRECTOR OF ADMINISTRATIVE SEVICES & ASSISTANT CITY

MANAGER
VIA: CRISTIAN GONZALEZ, CITY MANAGER
SUBJECT: TERMINATION OF SERVICES WITH ASI/NAVIA AND ENGAGEMENT IN SERVICES WITH EDIS
DATE: JUNE 14, 2022
ISSUE
Shall the City Council adopt Resolution No. 22-31, transitioning from Administrative Solutions Inc. (“ASi”)/Navia to Employer Driven Insurance Services (“EDIS”) for the administration of the Consolidated Omnibus Budget Reconciliation Act (“COBRA”), Health Reimbursement Arrangement (“HRA”), and Medical Expense Reimbursement Plan (“MERP”)?

BACKGROUND
ASi/Navia is the current Third-Party Administrator (“TPA”) for the City’s COBRA, HRA and MERP. Recently Navia/ASi notified the City that they are going to be discontinuing the EOB Retrieval service effective 8/1/2022 while maintaining the same overall service fee.

Currently the EOB retrieval service is how the TPA accesses the EOBs from Aetna and processes payment for the remaining eligible amount. Without this service employees will need to obtain the EOBs and submit them to Navia/ASi themselves, likely resulting in a delayed processing period and possibly a delayed payment to the provider.

The only impact that transitioning over to EDIS would have on the employees is that they would receive new supplemental cards and a new address for claims. All of the carrier information would remain the same.

ANALYSIS
EDIS has an overall lower service fee than ASi/Navia per employee per month (“PEPM”), so the City would experience a small savings. The cost for the administration of the partial self-funding is $30/PEPM instead of $32.50/PEPM that ASi/Navia charges. The COBRA administration fee is $2/PEPM with EDIS whereas it is $1/PEPM with ASi. Therefore, for the bundled self-funding and COBRA administration it is a $1.50/ PEPM savings to transition to EDIS ($32.00 vs $33.50).

EDIS will do a claims roll-in for any claims that have not yet been paid by ASi/Navia at no additional charge. That would leave a clean transition out of ASi/Navia. 2 FISCAL IMPACT
The overall impact is a savings of $1.50 per employee and per month.

RECOMMENDATION
Staff recommends that the City Council adopt Resolution No. 22-31, authorizing the City Manager to sign all necessary documents to terminate services with ASi/Navia and to sign all documents necessary to engage in services with EDIS.

Attachment(s):

1. HRA-MERP Benefit Authorization for EDIS

2. Debit Plan Benefit Authorization for EDIS

3. Debit Card ACH Setup

4. ACH Notice and Authorization

5. COBRA Employer Set Up

6. City of Mendota Summary Plan Description (SPD)

7. Resolution No. 22-31
P.O. Box 7809, Visalia CA 93290 888-886-7973 CA Insurance License #0M76879 Group Name: _____________________
B1. HRA / MERP PLANS BENEFIT AUTHORIZATION
Health Reimbursement Arrangement or Medical Expense Reimbursement Plan Effective Date: __________________________________________ If you require a Schedule of Benefits in Spanish, please indicate # of Spanish _________ and # of English _________.

LET US KNOW WHICH HIGH DEDUCTIBLE CARRIER PLAN WE WILL CREATE YOUR HRA UNDER:

Carrier Name: Carrier Plan:

USE THIS SECTION TO TELL US WHAT YOU WOULD LIKE YOUR IN-NETWORK, SELF-FUNDED HRA / MERP BENEFITS TO BE Individual Deductible (2x)
*RX BE NE FIT
Generic / Tier 1
Office Visit Copay Brand / Tier 2
Coinsurance Non-Formulary / Tier 3
Other: Specialty / Tier 4
Embedded vs. Aggregate – Our default is to match the carrier. Please specify if you would like it to be different:

DOES YOUR HIGH DEDUCTIBLE, FULLY-INSURED CARRIER PLAN PROVIDE FIRST DOLLAR BENEFITS THAT YOU WOULD LIKE TO COVER UNDER THE HRA / MERP:

Some of the carrier plans offer first dollar benefits such as 3 office visits and/or RX coverage. If your selected carrier plan falls into this category and you intend to pay all or part of the first dollar benefit, please specify which first dollar benefit and the amount that you would like to cover. If nothing is outlined, the plan will be set with the full carrier copay (if applicable) being the member responsibility.

Specify Carrier First Dollar Benefit(s):
______________________________________________
Amount to be covered /supplemented by HRA / MERP:
______________________________________________
DO YOU WANT TO COVER ANYTHING ADDITIONAL WITH YOUR HRA / MERP SUCH AS OUT-OF-NETWORK BENEFITS? **Out of Network Benefits: ❑ Yes ❑ No
Individual Deductible: Coinsurance Other
Combined with in-network
deductible or separate?
Would you like us to pay as allowed to the
deductible or pay as billed?
WOULD YOU LIKE TO COVER ALL OR PART OF YOUR MEMBERS OUT-OF-POCKET AFTER THE CARRIER DEDUCTIBLE? (CORRIDOR BENEFIT) Coinsurance: Copay(s): Other:

HOW WOULD YOU LIKE TO FUND YOUR MEMBER CLAIMS?
❑ Standard Funding (Include voided check)
❑ Deposit Funding (See table to the right)
❑ Level Funding (Select monthly claims amount):
 Expected Claims
 Max Claims  Other: _________
DEPOSIT FUNDING: These figures represent an amount which should provide enough funds to ensure your account does not run low while awaiting replenishment. In the event your account is not replenished in a timely fashion, we would not be able to release claims until the replenishment is received. Check should be made payable to E.D.I.S. #Enrolling Employees Deposit Amt. #Enrolling Employees Deposit Amt. 2-9 $2,500 26-40 $12,500
10-15 $5,000 41-50 $25,000
16-25 $9,000 51-99 $40,000
By signing below, you are authorizing E.D.I.S. to administer the benefits above on behalf of said employer and are agreeing to the following fees: Monthly PEPM Administrative fee (see your proposal or agent for details). One-time Set Up Fee of $500 to start the E.D.I.S. plan for the medical (waived if coming from another TPA). Annual Renewal Fee of $100 to revise and update applicable plan documents. Flat monthly billing fee of $25 (waived if enrolled in “Paperless Perks Program.”) Please complete all the information requested before signing this authorization. Please initial any changes. This is an application only, coverage and issuance of an Administrative Agreement is subject to review and approval by E.D.I.S. ___________________________________________________ __________________________________________ __________________ Officer of Company Signature Title Date
* A portion of the member’s copay at Preferred Pharmacies applies to the cost of dispensing prescriptions associated with pharmacies and your PBM. For the convenience of the drug card, the vendor charges $.50 - $.60 per submission. This fee covers the cost of the electronic submission of prescriptions. ** E.D.I.S. does not endorse or encourage the use of these benefits as they do not maximize the employer’s savings.

City of Mendota
July 1, 2022
Aetna OA Managed Choice POS Bronze 50/50 8300
Ded Plan
$0
$10
various copays
$5
$20
$50
30% up to $500
see attached schedule of benefits

ADMINISTRATIVE PLAN
X
see schedule of benefits
X
Schedule of Benefits
For
City of Mendota – Administrative Plan
with Aetna OA Managed Choice POS Bronze 50/50 8300 deductible plan Effective 07/01/2022 PENDING
The Employer’s Maximum Payment is $8,550 for individual and $17,100 for family. Any remaining balance is the member’s responsibility.

In Network Benefits under the Carrier Plan Deductible are self-funded and shared by the Member & Employer PHASE 1 – Claims applied to Carrier Deductible
BENEFIT Employee Pays Employer Pays
PHYSICIAN OFFICE VISITS $10 copay 100% after copay
SPECIALIST OFFICE VISITS $10 copay 100% after copay
X-RAY (Non-complex imaging) 0% 100%
COMPLEX IMAGING 0% 100%

INPATIENT/OUTPATIENT HOSPITAL
Hospital Services: 0% 100%
Physician & Professional Services: 0% 100%
Emergency Room: $250 copay 100% after copay
PRESCRIPTION DRUG COVERAGE (1)
*$225/$450 RX deductible applies to Tiers 2, 3 & 4
$225/$450 RX deductible
Tier 2 $20* / Tier 3 $50*
Tier 4 30% up to $500 max per fill*
100% after deductible and
copay
OUTPATIENT SURGERY 0% 100%
MENTAL HEALTH (other than SMI) *Subject to Carrier limitations Inpatient Services: 0% 100%
Outpatient Services: $10 copay 100% after copay
AMBULANCE $500 copay 100% after copay
ACUPUNCTURE SERVICES $10 copay 100% after copay
CHIROPRACTIC THERAPY $10 copay 100% after copay
PHYSICAL, OCCUPATIONAL & SPEECH THERAPY VISITS 0% 100%

DURABLE MEDICAL EQUIPMENT
(Please refer to the Evidence of Coverage for more information) 0% 100%
ALL OTHER SERVICES & SUPPLIES 0% 100%
TELADOC CONSULTATION $5 copay 100% after copay
Not subject to annual Carrier Deductible for these Benefits Employee Pays Employer Pays Carrier Pays
PHYSICIAN OFFICE VISITS $10 Carrier copay (2) $75 Carrier copay 100% after copay LAB $0 $85 Carrier copay 100% after copay
URGENT CARE $10 Carrier copay $85 Carrier copay 100% after copay PRESCRIPTION DRUG COVERAGE (1) Tier 1 $30 Tier 1 $5 Tier 1 $25 100% after copay ACUPUNCTURE SERVICES $10 Carrier copay (2) $75 Carrier copay 100% after copay ROUTINE ADULT PHYSICAL / WELL CHILD / WOMEN’S HEALTH 0% 0% 100% Phase 2 Benefits after the Carrier Deductible
Employee Pays Employer Pays Carrier Pays
MEDICAL (Refer to carrier plan summary for applicable copays) 0% 50% 50% PRESCRIPTION DRUG COVERAGE (1)
Tier 2 $100/Tier 3 $150/Tier 4 50% up to $500
Tier 2 $20 / Tier 3 $50
Tier 4 30% up to $500
max per fill
Employer pays all copay
/ coinsurance
differences
100% after copay
TOTAL OUT OF POCKET MAXIMUM Employee Family
UNDER CARRIER DEDUCTIBLE $0 $0
AFTER CARRIER DEDUCTIBLE $0 $0
TOTAL $0 $0
This is a summary of the most frequently asked-about benefits. This document is a summary of your benefits and is not meant to thoroughly explain the benefits, cost sharing, out-of-pocket maximums, exclusions, or limitations nor does it list all benefits and cost sharing. For more detailed information about the carrier benefits, please refer to your Evidence of Coverage booklet. (1) The four Rx Tiers are Tier 1) Generic Formulary; Tier 2) Brand Formulary; Tier 3) Brand Non-formulary; Tier 4) Specialty Drugs/Injectables. (2) The 1 visit limit is combined with physician office visits & acupuncture services. After the 1 visit is met (in any combination), services are subject to the carrier deductible.

UPDATED 05/05/22
AE83
P.O. Box 7809, Visalia CA 93290 888-886-7973 CA Insurance License #0M76879 Group Name: _____________________
B1. HRA / MERP PLANS BENEFIT AUTHORIZATION
Health Reimbursement Arrangement or Medical Expense Reimbursement Plan Effective Date: __________________________________________ If you require a Schedule of Benefits in Spanish, please indicate # of Spanish _________ and # of English _________.

LET US KNOW WHICH HIGH DEDUCTIBLE CARRIER PLAN WE WILL CREATE YOUR HRA UNDER:

Carrier Name: Carrier Plan:

DOES YOUR HIGH DEDUCTIBLE, FULLY-INSURED CARRIER PLAN PROVIDE FIRST DOLLAR BENEFITS THAT YOU WOULD LIKE TO COVER UNDER THE HRA / MERP:

City of Mendota
July 1, 2022
Aetna OA Managed Choice POS Bronze 50/50 8300
Ded Plan
$3750
$65
25%
$15
$50
$70
30% up to $500
see attached schedule of benefits

POLICE PLAN
X
see schedule of benefits
X
see attached schedule of benefits
Schedule of Benefits
For
City of Mendota – Police Plan
with Aetna OA Managed Choice POS Bronze 50/50 8300 deductible plan Effective 07/01/2022 PENDING
The Employer’s Maximum Payment is $3,538 (+ $600 from debit card) for individual and $7,076 for family.

Any remaining balance is the member’s responsibility.

In Network Benefits under the Carrier Plan Deductible are self-funded and shared by the Member & Employer PHASE 1 – Claims applied to Carrier Deductible
BENEFIT Employee Pays Employer Pays
DEDUCTIBLE $3,750* Individual / $7,500 Family $600 Employee*/$0 Family PHYSICIAN OFFICE VISITS deductible waived $65 copay 100% after copay SPECIALIST OFFICE VISITS deductible waived $65 copay 100% after copay X-RAY (Non-complex imaging) 25% 75%
COMPLEX IMAGING 25% 75%

INPATIENT/OUTPATIENT HOSPITAL
Hospital Services: 25% 75%
Physician & Professional Services: 25% 75%
Emergency Room: 50% 50%
PRESCRIPTION DRUG COVERAGE (1)
*$225/$450 RX deductible applies to Tiers 2, 3 & 4
$225/$450 RX deductible
Tier 2 $50 / Tier 3 $70
Tier 4 30% up to $500 max per fill
100% after deductible and
copay
OUTPATIENT SURGERY 25% 75%
MENTAL HEALTH (other than SMI) *Subject to Carrier limitations Inpatient Services: 25% 75%
Outpatient Services: deductible waived $65 copay 100% after copay AMBULANCE 25% 75%
ACUPUNCTURE SERVICES deductible waived $65 copay 100% after copay CHIROPRACTIC THERAPY deductible waived 50% 50%
PHYSICAL, OCCUPATIONAL & SPEECH THERAPY VISITS 25% 75%

DURABLE MEDICAL EQUIPMENT
(Please refer to the Evidence of Coverage for more information) 50% 50%
ALL OTHER SERVICES & SUPPLIES 25% 75%
TELADOC CONSULTATION $5 copay 100% after copay
Not subject to annual Carrier Deductible for these Benefits Employee Pays Employer Pays Carrier Pays
PHYSICIAN OFFICE VISITS $60 Carrier copay (2) $25 Carrier copay 100% after copay LAB $75 Carrier copay $10 Carrier copay 100% after copay URGENT CARE $65 Carrier copay $30 Carrier copay 100% after copay PRESCRIPTION DRUG COVERAGE (1) Tier 1 $30 Tier 1 $15 Tier 1 $15 100% after copay ACUPUNCTURE SERVICES $60 Carrier copay (2) $25 Carrier copay 100% after copay ROUTINE ADULT PHYSICAL / WELL CHILD / WOMEN’S HEALTH 0% 0% 100% Phase 2 Benefits after the Carrier Deductible
Employee Pays Employer Pays Carrier Pays
MEDICAL (Refer to carrier plan summary for applicable copays) 25% 25% 50% PRESCRIPTION DRUG COVERAGE (1)
Tier 2 $100/Tier 3 $150/Tier 4 50% up to $500
Tier 2 $50 / Tier 3 $70
Tier 4 30% up to $500
max per fill
Employer pays all copay
/ coinsurance balances
100% after copay
TOTAL OUT OF POCKET MAXIMUM Employee Family
UNDER CARRIER DEDUCTIBLE $4,287* $9,774
AFTER CARRIER DEDUCTIBLE $ 125 $ 250
TOTAL $4,412 $10,024
This is a summary of the most frequently asked-about benefits. This document is a summary of your benefits and is not meant to thoroughly explain the benefits, cost sharing, out-of-pocket maximums, exclusions, or limitations nor does it list all benefits and cost sharing. For more detailed information about the carrier benefits, please refer to your Evidence of Coverage booklet. (1) The four Rx Tiers are Tier 1) Generic Formulary; Tier 2) Brand Formulary; Tier 3) Brand Non-formulary; Tier 4) Specialty Drugs/Injectables. (2) The 1 visit limit is combined with physician office visits & acupuncture services. After the 1 visit is met (in any combination), services are subject to the carrier deductible.
*Employees Only are to use their debit card in conjunction with this plan to fund the first $600 of the HRA Individual deductible. The out of pocket in phase 1 is the total out of pocket ($4,887) minus the $600 debit allotment given to the Employees ($4,887-$600=$4,287). UPDATED 05/05/22 AE83
P.O. Box 7809, Visalia CA 93290 888-886-7973 CA Insurance License #0M76879 Group Name: _____________________
C1. DEBIT CARD PLAN SETUP & BENEFIT AUTHORIZATION
Tell us what benefits are approved for reimbursement on the Wex Health Card with E.D.I.S.

Effective Date: __________________________________________ Employer Name as it should be printed
on debit card – 26 character maximum | | | | | | | | | | | | | | | | | | | | | | | | | If you require a Schedule of Benefits in Spanish, please indicate # of Spanish _________ and # of English _________.

LET US KNOW WHICH HIGH DEDUCTIBLE CARRIER PLAN WE WILL CREATE YOUR HRA / MERP UNDER:

Carrier Name: Carrier Plan:

USE THIS SECTION TO TELL US WHAT YOU WOULD LIKE YOUR SELF-FUNDED HRA / MERP BENEFITS TO BE:

BENEFITS: ❑ Medical ❑ Pharmacy ❑ Dental ❑ Vision
Card will cover 100% up to $ ___________________ per calendar year. Includes all carrier’s copays and deductibles.

Optional Benefit: ❑ Deductible Amount: $________________ EXCEPTIONS: List all benefits that do not apply to the debit card. Any exceptions to the 100% benefit may cause misuse of the debit card.

E.D.I.S. is not responsible for misuse of the debit card.

1. 2.

Out-of-Network: ❑ Yes ❑ No After carrier deductible: ❑ Yes ❑ No

RULES OF THE ROAD FOR THE EMPLOYEE

1. Cards are sent to the employee’s address from the debit card vendor and may take up to 10 days following the members being loaded

2. Copies of all receipts and statements of charges should be uploaded to the E.D.I.S. Debit Card Mobile App/Wex Portal, FAX’ed, emailed, or mailed to E.D.I.S. within 10 days from the date of service, or of a request from the employer and/or E.D.I.S.

3. It is the member’s responsibility to ensure the debit card is used only for the benefits outlined in the Schedule of Benefits provided by E.D.I.S. Failure to send in your receipts and statements (if requested) or the misuse of the debit card will require the debit card to be made inactive.

4. Termination of an employee’s debit card will be on the next business day of notice from the employer. Benefits will remain in effect until the end of the month.

Employees will need to pay for services up front and submit a receipt for reimbursement.

FUNDING / COLLATERAL AMOUNT
Your funds will be pulled daily or weekly by the bank depending on which option you select. Your initial Pre-Fund Collateral will depend on the daily or weekly selection and is outlined below:
- Daily ACH Debit, initiated by Bank – 3% of annual liability required up front. OR - Weekly ACH Debit, initiated by Bank – 5% of annual liability required up front.

SMALL CLIENT SET UP: In the event that calculated funding amount (based on the annual benefit amount elections) for the desired replenishment op tion is less than the required minimum of $2,500, the funding amount will be the lesser of $500 or $100 per participant for clients with 1-5 cardholders or the greater of $500 or 3% for clients with 6 or more cardholders; however, the Client must use daily ACH debit replenishment.

WEEKLY REPLENISHMENT: The minimum funding for weekly replenishment is the greater of $2,500 or the calculated amount associated with the selected replenishment option.

COLLATORAL TRUE-UP: As per the bank contract, you agree to fund the Collateral Account in an amount reasonably required by Bank (the “Funding Amount”), as indicated by the deposit account agreement, by applying the initial collateral rate to the annual aggregate election amount that will be loaded onto the Cards. In order to maintain the Funding Amount there will be an annual “true up” or audit of the account. This may require adding additional funds as necessary to replace amounts settled by Bank if your number of enrolled employees grows beyond the initial number. The bank will notify E.D.I.S. of the true up requirements if more collateral is required, or if collateral should be returned due to a decrease in the number of enrolled employees. If the collateral account is not kept at the required minimums each year, the bank may choose to suspend the cards and/or close the account altogether for its protection.

SUBSTANTIATION
❑ E.D.I.S. is to substantiate according to the IRS agreement ❑ We choose to opt out of claims substantiation and agree to sign a hold harmless agreement releasing E.D.I.S. and their vendor(s) of any substantiation requirements set by the IRS. Upon receipt of this setup form, we will return the hold harmless to you for signature.

There is a monthly PEPM administration fee (see your proposal or agent for details) in addition to the Monthly Debit Card Fee of $2.00 PEPM, there is a one-time set up fee of $500 to start the E.D.I.S. plan for medical (waived if coming from another TPA) and there is a $100 renewal fee that will be charged each year. There is a $5 pass through fee to replace a lost or stolen debit card.

Please complete all the information requested before signing this authorization. Please initial any changes to this authorization and note this is an application only.

Coverage and the issuance of an Administration Agreement is subject to review and approval by E.D.I.S. Benefit changes may only be made at the group’s carrier and or E.D.I.S.’s anniversary date. All banking will be handled between the bank and the client and funds will not be run through E.D.I.S.

By signing this form, you agree to all the terms and conditions of the WEX Health Card™ and E.D.I.S. Employer Driven Insurance Services™. ________________________________________________________ ___________________________________________ ______________________ Officer of Company Signature Title Date
City of Mendota
POLICE PLAN July 1, 2022
C i t y o f M e n d o t a
Aetna
OA Managed Choice POS Bronze 50/50 8300 deductible
plan
X X
600
X

AUTHORIZATION FOR ACH DEBITS / CREDITS
________________________________________________________ Depositor Name as Shown on Bank Records
________________________________________________________ Checking Account Number/ Transit Routing Number
(A voided check or spec sheet must be attached for this account) TO: ____________________________________________________ ________________________________________________________ (Bank Address: Street, Box #, City, State and Zip Code) Depositor authorizes The Bancorp Bank to present automated debits and credits to and from the above listed account as required to perform their responsibilities related to processing Depositor’s benefit program. This authorization will remain in effect until revoked by Depositor in writing and until you actually receive such notice Depositor agrees that you shall be fully protected in honoring any such ACH transaction.

Depositor agrees that your treatment of each such ACH transaction and your rights in respect to it shall be the same as if it were a check signed by Depositor.

I authorize payments to be withdrawn daily or weekly as needed. (Please circle one) Dated this _____ day of __________, 20_____.
________________________________________________________ Signature of Depositor in Agreement with Bank Records
Please update your ACH filter (on the above reference account) to grant access to The Bancorp Bank. The Bancorp Bank identification number is: 1050006509.

City of Mendota
The Bancorp Bank Payment Solutions Group
Payment Solutions Group Internet Banking Enrollment Form Note: Payment Solutions Group Client Internet Banking access is restricted to “View Only” status. With the exception of password changes for normal business purposes, no other changes may be made to the accounts listed below.

Electronic monthly statements are also offered through this application; please enroll online to discontinue paper statements mailed each month.

Section A- Company Information
Company Name: ____________________________________________ Company Address: ____________________________________________ City: ____________________________________________
State: ____________________
Zip: ___________________
Section B- DDA accounts to view (to be completed by Bank).

DDA Account Number:___________________ DDA Account Number: ____________________ Section C- Security Question:

As a default for corporate users, the Security Question used to authenticate access for password changes will reference your Tax ID number. Please list your company’s Tax ID number in the space below:

Tax ID Number: __________________________
Section D- Please date, sign, and return this form to your Benefits Administrator to initiate Internet Banking view access – this user will be set up as the ADMIN user for the application with the ability to set up subsequent users:

Access Requested by: __________________________ Phone Number:_______________________ E-Mail Address________________________________________
(Once the configuration has been completed, the user id and password will be e-mailed to the above.) By signing this form, I certify that I am authorized by my company to request The Bancorp Bank Internet Banking view-only access. I also certify that any additional individuals that I, as Company Administrator, grant access to view account information will adhere to The Bancorp Bank Internet Banking Terms and Conditions of Use policy and will not disseminate or share the account password(s) with unauthorized personnel. Failure of any person(s) to adhere to The Bancorp Bank Internet Banking Terms and Conditions of Use, Privacy Policy, and Security Policy may result in Internet Banking access revocation.

Online access accounts are reviewed every month. After 6 months of inactivity on the online access account, your access will be terminated and you will need to contact your TPA to reinstate your online access.

Signature: _____________________________________
Print Name: _____________________________________
Title: ___________________________________________
Date: ____________
City of Mendota
643 Quince St
Mendota
CA
93640
94-6000369
Cristian Gonzalez (559) 655-3291
[email protected]
Cristian Gonzalez
City Manager
The Bancorp Bank Payment Solutions Group
Deposit Account Agreement
This Deposit Account Agreement, dated as of _____________, is between The Bancorp Bank, located at 6100 S. Old Village Place, Sioux Falls, South Dakota (“Bank”) and ____________________________________________________(Company Name and DBA), located at ____________________________________________________________________________ (“Client”). Company TAX ID Number _________________________________. Please ensure that this is the Legal Business Name/DBA and Address of Entity (This must coincide with the name on the IRS documentation also required) Recitals
Client provides employee benefit plan participants the ability to access their benefit accounts electronically through a stored value card (“Card”) similar to a debit card transaction. Bank is a member of Visa / MasterCard and is in the business of issuing cards and establishing accounts for the settlement of card transactions.

Client is establishing a non-interest bearing deposit account (the “Collateral Account”) for the purpose of enabling Bank to settle Card transactions in a timely manner.

WEX Health and E.D.I.S. (Partner) have entered into an agreement to provide Card services to employers such as Client.

Purpose
Bank and Client enter into this Deposit Account Agreement to provide the following:

1. The Client will have no access to the funds deposited into the Collateral Account until their return by the Bank pursuant to the terms of Paragraph 3 or 4 below.

2. The Client authorizes the Bank to use funds in the Collateral Account only for the purposes of settling Card transactions and paying fees debited from cardholders’ accounts, both further limited to Cards issued to Client participants.

3. 120 days following the deactivation of all Cards associated with Client, Bank will return all remaining Client funds in the Collateral Account.

4. As collateral for the Client’s obligations to the Bank, the Client hereby grants to the Bank a first priority security interest in all funds held in the Collateral Account.

5. View-only access to the Collateral Account information is granted to WEX Health and Partner for the purpose of assisting the Bank and Client in resolving any relevant banking questions that may arise.

6. Bank will provide Client monthly statements of Collateral Account activity.

7. This Agreement shall be interpreted and governed in accordance with the laws of Delaware.

8. Client agrees to fund the Collateral Account in an amount reasonably required by Bank (the “Funding Amount”), as indicated by the following table, by applying the initial collateral rate to the annual aggregate election amount that will be loaded onto the Cards. Client will maintain the Funding Amount by periodically transferring additional funds as necessary to replace amounts settled by Bank. Please select one of the following replenishment options.

Select
one
Replenishment Option
Initial
Collateral
Rate
Daily ACH Debit, initiated by Bank 3%
Weekly ACH Debit, initiated by Bank 5%
Weekly ACH Credit, initiated by Client 7%
Weekly Wire, initiated by Client 6%
City of Mendota
643 Quince St, Mendota, CA 93640
94-6000369
X
Please indicate the expected number of monthly replenishment transactions and estimated monthly replenishment amounts, based on your replenishment option above and annual elections.

Circle One # of Transactions
(monthly)
Select
one
Expected dollar of transactions
(monthly)
Select
one
ACH/Wire 1-10 $ 1.00 - $ 2,500.00
ACH/Wire 10-20 $ 2,500.00 - $ 5,000.00
ACH /Wire 20+ $ 5,000.00 +
If utilizing Weekly ACH Credit or Wire replenishment, funds are required to be deposited into the Collateral Account by end of business each Tuesday for the previous Monday through Sunday settlement week.

SMALL CASE CLIENT SET UP: In the event that calculated Funding Amount (based on the annual benefit account elections) for the desired replenishment option is less than the required minimum $2,500, the Funding Amount will be the lesser of $500 or $100 per participant for clients with 1-5 cardholders or the greater of $500 or 3% for clients with 6 or more cardholders; however, the Client must use Daily ACH Debit replenishment.

WEEKLY REPLENISHMENT: The minimum funding for weekly replenishment is the greater of $2,500 or the calculated amount associated with the selected replenishment option.

Client agrees that its failure to maintain the Funding Amount as required may result in Cards being suspended until the account is properly funded. If using one of the ACH Debit replenishment options, the attached Authorization for ACH Debits / Credits must be completed and returned with a copy of a voided check or spec sheet.

9. Client may request that the Funding Amount be reduced to take into account events such as a reduction in workforce resulting in a significant decrease in the number of Client’s Cards. Bank will not unreasonably refuse to adjust the Funding Amount and return any difference to Client.

10. Legal Entity Type (i.e. Corporation, Limited Partnership, Partnership, Sole Proprietorship, Trust, etc.):
________________________________________________________ Please print

11. Industry Type (North American Industry Classification System (NAICS): i.e. Manufacturing, Retail, Construction, Commercial Banking, Finance and Insurance, Educational Services, Food Services, Transportation, etc.) ________________________________________________________ Please print

12. Additional authorized account signors, if necessary:

Signature: ___________________________ Signature: __________________________ Printed Name: _______________________ Printed Name: _______________________ Title: ______________________________ Title: ______________________________ DOB ___________SS#_________________ DOB: ______________SS#_____________ *** Please return the signed agreement with a copy of your IRS Form SS4 (EIN Assignment Letter). Agreements submitted without the documentary evidence may be delayed.

Additional documentation may be requested to verify business address and/or business name. You will be contacted by a Bank representative if any additional documentation is required.

The parties have executed this Agreement as of the date written above.

Client: The Bancorp Bank:

Signature: ______________________________ Signature: ____________________________ Printed Name: __________________________ Name: _______________________________ Title: _________________________________ Title: ________________________________ DOB: ______________SS#________________
Telephone Number: ______________________
Email Address: ________________________
Government Entity
Municipality
Cristian Gonzalez
City Manager
(559) 655-3291
[email protected]
0 X X

CERTIFICATION OF BENEFICIAL OWNER(S)
Persons opening an account of behalf of a legal entity must provide the following information:
a. Name and Title of Natural Person Opening Account:
________________________________________________________________________________ b. Name and Address of Legal Entity for Which the Account is Being Opened:
_________________________________________________________________________________ Note: Section C (only) is not applicable for Publicly Traded Companies or Non-Government Organizations (i.e. non-profit charities and religious organizations such as churches). c. The following information for each individual, if any, who, directly or indirectly, through any contract, arrangement, understanding, relationship or otherwise, owns 25 percent or more of the equity interests of the legal entity listed above:
(If no individual meets this definition, please write “Not Applicable.”) Name Date
of
Birth
Address For U.S.

Persons: Social
Security
Number
For Foreign Persons: Passport
Number and Country of
Issuance, or other similar
identification number*
Percentage
of
Ownership
d. The following information for one individual with significant responsibility for managing the legal entity listed above, such as:
 An executive officer or senior manager (e.g., Chief Executive Officer, Chief Financial Officer, Chief Operating Officer, Managing Member, General Partner, President, Vice President, Treasurer): or  Any other individual who regularly performs similar functions. (i.e. account signer) (If appropriate, an individual listed under section (c) above may also be listed in this section (d)).

Name Date of
Birth
Address For U.S.

Persons:

SSN
For Foreign Persons: Passport
Number and Country of
Issuance, or other similar
identification number
Percentage
of
Ownership
I, _________________________________ (name of person opening account), hereby certify, to the best of my knowledge, that the information provided above is complete and correct.

Signature: _____________________________________________________ Date: _______________ Company Tax ID Number: ____________________ Stock Symbol if Publicly Traded: __________________ * In lieu of a passport number, foreign persons may also provide an alien identification card number, or number and country of issuance of any other government-issued document evidencing nationality or residence and bearing a photograph or similar safeguard.

Cristian Gonzalez, City Manager
City of Mendota, 643 Quince St, Mendota, CA 93640
not applicable
Cristian Gonzalez
94-6000369
Cristian Gonzalez 643 Quince St,
Mendota, CA 93640
0%

ACH NOTICE AND AUTHORIZATION
AUTHORIZATION AGREEMENT FOR E.D.I.S. TRANSATIONS (ACH CREDITS) Company Name City of Mendota
Company Tax ID# 94-6000369
I hereby authorize E.D.I.S. to initiate debit or credit entries to my Checking Account indicated below at the depository financial institution named below, hereafter called DEPOSITORY, and to debit or credit the same to such account. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. Law.

Depository (Bank) Name ___________________________________________ Branch __________________________________________________________ City _______________________, State ____________ Zip ________________ Account Type: (Circle One) Checking Savings
Routing Account Number ___________________________________________ Checking Account Number __________________________________________ This authorization is to remain in force and effect until E.D.I.S. has received written notification from me of its termination in such time and in such manner as to afford E.D.I.S. and DEPOSITORY a reasonable opportunity to act on it.

Name Cristian Gonzalez
(Authorized signer on Business Checking Account)
Date __________________________________________
Signature ________________________________________________________ Select one or both:

Claims funding - E.D.I.S. will debit your designated account to fund all current or past due claim funds.

Admin Fees/Premium - E.D.I.S. will debit your designated account to fund all current or past due fees.

As an Employer, your “Finance Contact” will be contacted via email notifying him or her in 2 business days prior to debiting your account. Groups will be debited around the 1st of each billing month.

Groups will be charged $25.00 for each returned ACH due to incorrect account information or insufficient funds.

Employer may revoke debit authorization only by written notice. Revocation must be mailed or faxed 10 business days prior to desired date: E.D.I.S., P.O. Box 7809, Visalia, CA 93290 or FAX (559) 733-1314.

CA Insurance License #0M76879

COBRA/CAL-COBRA ENROLLMENT CHECK LIST
The following preliminary list of information must be received in our office by the end of the current month for a first of the month following effective date.

Set Up Form & Service Agreement:

1. Effective date to be the first of the month following submission of all information requested.

2. Set Up Form must be completed in full.

2. Service Agreement must be signed and dated by an authorized Officer of the Company.

Carrier and Plan Information:

1. Carrier and Plan Information Form-Please complete this form for each employer-sponsored group health plan subject to COBRA.

2. Attach a copy of the current rate sheet for each plan.

3. Attach a complete copy of last monthly premium billing statement for each plan.

4. Attach a complete copy of the Plan Document/Certificate of Coverage for each plan.

5. Current COBRA/CAL-COBRA Participants Form (if applicable).

6. Current COBRA/CAL-COBRA Qualifier Form (if applicable).

Additional Information Required For Clients For Whom E.D.I.S. Does Not Administer Benefits

1. An initial set-up fee in the amount of $100.00 made payable to E.D.I.S.

2. For group billing purposes, we will need a group census (preferably an Excel spread sheet) of the active employees who are enrolled in one or more or the employer-sponsored health plan coverages. Must include name, address, social security number, and date of birth for each employee. Plan enrollment and dependent information also needed. *************************************************************************************************************** Return your completed forms to:

Email: [email protected]
Mail: PO Box 7809
Visalia, CA 93290
Physical: 5429 Avenida de los Robles, Suite A
Visalia, CA 93291
Fax: (559) 733-2325
Thank you for the confidence you have placed in us by allowing us to assist your client in the administration of COBRA or CAL-COBRA.

CA Insurance License #0M76879

COBRA SET UP FORM
Section A – Employer Information
Company Name DBA (Doing Business As) Federal Tax ID Number (FEIN) Address Requested Effective Date
City State Zip Nature of Business
Section B – Contact Information
Contact Type Contact Name Title Phone Fax Email Address

1. Executive

2. Primary COBRA

3. Primary Billing

4. Other
The above named contacts identifies all individuals to whom E.D.I.S. may provide/disclose protected health information (PHI) in the performance of its duties as set forth in the Confidentiality Exhibit of the Administrative Services Agreement (Client may use additional pages if needed, provided they reference the Confidentiality Exhibit and the effective date). E.D.I.S. will assume that this list is exhaustive and that any individual not provided in this list is not authorized to receive PHI from E.D.I.S. unless subsequently named in writing by an existing HIPAA authorized contact of the Client.

Section C – General Information
Number Of Employees Eligible For Benefits Number Of Employees Covered By Benefits Number Of Current COBRA Continuants Number Of Employees Terminated In The Last 60 Days Do you offer a Health Flexible Spending Account (FSA)? Yes No If eligible, a participant may continue a health FSA through COBRA Do you offer a Health Reimbursement Arrangement (HRA) or Medical Expense Reimbursement Plan (MERP)? Yes No If eligible, a participant may continue an HRA or MERP through COBRA Do you want to charge the allowable 150% for COBRA participants on the 11-month disability extension? Yes No COBRA allows an employer to charge 150% of the applicable premium for COBRA continuation coverage during the 11-month disability extension period that is available to individuals that meet certain requirements. To qualify for the additional 11 months of COBRA continuation coverage, the qualified beneficiary must:
 Have a ruling from the Social Security Administration that he or she became disabled prior to or within the first 60 days of COBRA continuation coverage
 Send the plan a copy of the Social Security ruling letter within 60 days of receipt or (if later) the date of the qualifying event or date of coverage loss following the qualifying event, but prior to expiration of the 18-month period of coverage.

If these requirements are met, the entire family qualifies for an additional 11 months of COBRA continuation coverage.

Section D – Eligibility Reporting
Would you like E.D.I.S. to send termination notices to your carriers? If yes, please fill out the appropriate contact information on the Carrier and Plan Information Form for each plan. Yes No Section E – Employer Representative – Form completed by:

Name Title Date
City of Mendota 94-6000369
643 Quince St July 1, 2022
Mendota CA 93640 municipality
Cristian Gonzalez City Manager (559) 655-3291 [email protected] same as executive contact
same as executive contact
44 3
40 0
0 0
0 0
Cristian Gonzalez City Manager
CA Insurance License #0M76879

CARRIER AND PLAN INFORMATION FORM
Please complete a copy of this form for each employer sponsored group benefit plan (including FSA, HRA and MERP) which is subject to COBRA. Use a separate form for each plan with a unique set of rates and/or group number.

Section A – Plan Information
IMPORTANT: Missing or incomplete fields will cause a delay in the implementation process and may cause a loss of the desired effective date.

Company Name Carrier Name Group Number Plan Name
Is there a waiting period? If yes, how long? Following the waiting period, coverage is effective:

Yes No ____ Days ____
Months Immediately Next Day First of the Month Other (specify) _________ Upon termination, coverage ceases Number of employees covered on plan Date of termination Day following termination End of month Other (specify) ________ Dependent Child Age Limit Full-time Student Age Limit What is the billing effective date for newly added dependents due to birth or adoption? Date of event ____ Days following event
First of month First of following month
Coverage Type (select only one)
Medical Dental Vision RX Health FSA HRA MERP Other (specify) ____________________________________ Type of Plan Plan Effective Dates Open Enrollment Dates HMO PPO POS Indemnity Other (specify) ___________ _______ through _______ _______ through _______ Is this plan bundled or combined with any other plans for COBRA purposes? Yes No When plans are bundled for COBRA purposes, an individual electing COBRA coverage for a particular plan is, by default, also electing coverage under the other bundled plan(s). For example, if you require an employee to first elect medical coverage in order to elect dental coverage, those plans are bundled.