Sap-09

INTRA-AGENCY PURCHASE REQUEST

 

 

 

 

 

 

  
 

     

 

  
      

  

 

 

 

 

 

 

 

 

 

 

 

 

CABINET: Pcmonncl Cabinet
DEPARTMENT: Foerponco Health Insurance

BRANCH:
ONTACT 330130 
037;:th  
DESCRIPTION (CatalogNumbcr, ItemNumber, etc.) Quantily Unit Price Amount
Per Claim

Contract Line 0013 A80 Fees Shared Savings/Surcharge 2006 Plan Year 21.44
Contract Line 0013 A30 ?eas Shared Savings/Surcharge 2007 Plan Year 61.20
Contract Line 0013 A80 Fees Shared Saving?Surcharge 2008 Plan Year 133314
Contract Line 0013 A80 Fees Shared 2009 I?lan Year 204,504.16

MC 2 Consuii ing 50% Deposit $151,200.00

33575519. 94

SUGGESTED VENDOR: Humane:

 

 

 

 

 

Humana Contract. Please see attached documents the Contract 

 

INSTRUCT IONS: APPROVAL:

10/6234?

 

 

 

 

 

 

 

 

.
I. This form is to be used for purchasas. gin/r59
2. Submit original onfy. De Ex cutive Director Date
3. Fill in Quantity, and Unit 
4. Route to next approval area? do not hold I (It:   t' 0 234/031! 61?"
when authodzed. Executive Director Date
i
Systems Date
Omd I
Purchase Date
by nJ/?Ck.
Budget Date
x?l/?d
Agency Head orD?bsi?nc-o Date