REQUEST FOR PROPOSALS 2015-007
for
Group Health Insurance Benefits Programs
Anaheim Transportation Network
1354 South Anaheim Boulevard
Anaheim, CA 92805
Release Date:
November 10, 2015
Proposal Due Date:
December 18, 2015
Board of Directors Consideration:
January 2016
Plan Effective Date:
April 1, 2016
An electronic copy of this RFP and attachments, if any, is available from the ATN’s website:
http://rideart.org/about-us/solicitations/. All RFP documents shall be submitted in hard copy.
ANAHEIM TRANSPORTATION NETWORK
TABLE OF CONTENTS
SECTION
I. GENERAL INFORMATION
Request for Proposal Notice
Proposal Evaluation Criteria
Conditions and Stipulations
II. AGENCY INFORMATION
Request For Medical Benefits
Contributions and Statistical Information
III. PROPOSAL FORMS
Summary of Requested Information
Medical Proposal Forms
Health Plan Organization and Benefit Questionnaire
IV. APPENDICES
Summary of Benefits – Current Plan(s)
Employee Census
SECTION I – GENERAL INFORMATION
REQUEST FOR PROPOSAL NOTICE
PROPOSAL EVALUATION CRITERIA
REQUEST FOR PROPOSAL NOTICE
Notice is hereby given that the Anaheim Transportation Network (ATN) will accept Proposals for
the following specified group insurance benefits until December 18, 2015 at 2:00 PM.
The ATN employs approximately 60 staff members, comprised of 41 full-time positions and 19 part-time team members. All full time staff members are eligible for group benefits after 60 days of employment. Approximately 50% of eligible employees choose to participate in the ATN’s group medical plan. Employees who choose not to participate in the plan are eligible to enroll during Open Enrollment period. The ATN provides group medical and dental benefits for its employees. Employees, at their own cost, may choose to enroll and their families.
The ATN pays the following of the employee’s premiums:
Employee (EE) only 21 employees
Employee and Child (EE + Child) 1 employee
Employee and Spouse (EE + Spouse) 1 employees
Employee and Family (EE + Family) 5 employees
All Proposals will be clearly identified as Insurance Proposal for the Anaheim Transportation Network (ATN). Copies of your Proposal should be forwarded to the ATN at the following address:
Anaheim Transportation Network 1354 South Anaheim Boulevard
Anaheim, CA 92805
Please note that no formal opening of the proposals will take place.
Proposals will be evaluated and the successful carrier(s) will be determined and announced at the
ATN Board of Directors meeting in January 2016. The ATN Board of Directors reserves the right
to reject any or all Proposals, waive formalities and to select the carrier and benefit options that best meet the needs of the ATN and its employees. The ATN reserves the right to select and terminate any servicing agent, agency, company or administrator.
Inquiries, clarification, or requests for Proposal forms and questionnaires by electronic mail should be directed by telephone or e-mail to the following ATN contact:
Lita Aguilar
Director of Operations and Human Resources 714-563-5287
SCOPE OF SERVICES
The scope of services may include but is not limited to the following:
1. The Contractor will provide insurance coverage fully compliant with the provision of
the United State Affordable Care Act.
2. The Contractor will provide insurance coverage for employees, spouses of employees,
employees and their children, and family coverage based on employee selection/ designation. Coverage will maximize group savings and pass that savings on to the insured. The Contractor providing a limitation on paperwork, maximizing savings to the insured on medical and pharmacy services, and provides for broad provider options will be preferred.
3. The Contractor will provide a breakdown of deductibles per individually insured by
calendar year, per family by calendar year, per hospital admission, to include the use of PPO hospitals and non-PPO hospitals, per emergency room visit, and all other preexisting condition requirements and costs. The Contractor will provide a clear statement of what procedures will not be covered and what procedures will be covered and their resulting deductibles. Additionally, any other deductibles or special clauses, constraints or requirements will be clearly stated in advance of selection of the Contractor and will remain in effect for a full calendar year upon selection of the Contractor unless changes are required by law.
4. The Contractor will provide responsive customer service in answering questions
about coverage, assisting with securing coverage, and completion of paperwork required by the ATN Director of Human Resources and the employees insured and their insured dependents.
5. The Contractor will provide for lab services.
6. The Contractor will provide for insurance that establishes a maximum out of pocket
cost per calendar year.
7. The Contractor will provide a pharmacy prescription program that maximizes the use
of discounts for both generic and brand named drugs. In addition provide information relative to prescription plans that maximize pharmacy options, an option for mail order for convenience and additional savings. The Contractor will provide specific and clear instructions on the use of the prescription program in addition to prescriptions and equipment covered and not covered and any resulting deductibles. The pharmacy prescription program may also include specific coverage from pharmacies outside of the local service area.
8. The Contractor will provide for wellness benefits
10. The Contractor may provide for Chiropractic services.
11. The Contractor will provide specifics on COBRA and will provide a Conversion of
Benefits for separating employees provided the conversion does not add to the overall cost of those employees and dependents insured remaining in the program.
12. The Contractor will provide descriptive plan materials with copies of any self-select
options and endorsements in an amount to cover every employee in the office plus ten (10) copies for the Director of Human Resources.
13. The Contractor will provide insurance that limits the amount of out-of-pocket
expenses to the employee and provides a responsive billing or accounting process.
14. The Contractor will provide dental and vision benefits.
PAYMENT
The Contractor will be paid upon submission of invoices to the appropriate contract manager as provided by any written contract.
ADDITIONAL COST
All usual and customary costs incurred as a result of providing services mentioned in Scope of Services, to include providing plan information, assisting employees with insurance questions, any required printing, mailing, date programming or reprogramming, postage and postage changes, and providing all other customer service and information to ATN RFP-2015-007 Group Health Insurance Benefits Programs will be borne by the Contractor and not subject to reimbursement by the ATN or the insured and their dependents.
TERM
The contract ATN be for a minimum of twelve (12) months. The ATN, in its sole discretion, will have the option to renew annually for an additional four (4) one-year terms for a maximum of five (5) years by agreement of both parties as specified by any written contract agreement.
RFP PROPOSAL REQUIREMENTS:
1. Insurance agents at a minimum should submit the following as a part of their proposal
and in the order presented
2. Letter of Interest stating the location and headquarters of the insurance agent’s office
to include specific statement of the services the insurance company is proposing to provide.
3. Business Credentials that provides a synopsis of the agent company’s qualifications
including capabilities of the agent; credentials of the insurance company’s management team.
4. List of Previous or Ongoing Insurance Contracts that outline experience to perform
services for a public sector employer required under the scope of services.
5. Specific Accomplishments that will demonstrate the ability of the insurance
company/insurance agent to provide services required under the scope of services.
6. Responses to the Scope of Services that demonstrates and outlines how the insurance
company/insurance agent would carry out the specific services required under the scope of services to include any enhancements that are not reflected in the scope of services. Services should include but not be limited to:
INSURER QUALIFICATIONS
1. Proposals are expected from financially sound insurers, authorized to do business in
California. Moody’s and/or A.M. Best ratings, where applicable, should be furnished for each insurer being proposed.
2. Provide descriptive materials of the plan(s) offered, listings of preferred providers (including hospitals, general practitioners and specialists).
3. State when the last provider directory was published and how often it is revised.
4. State how many primary care physicians are in the network and the percentage of
primary physicians and the percentage of the other physicians who are not accepting new patients?
5. Indicate what kind of communications is provided by the network to the Participating
providers and how often they are informed of plan changes.
7. State other plans/options network has for consideration.
8. Describe the nature and special features of the plan offered.
9. Indicate how benefits, deductible and co-payments are applied or recommended by
the plan and any required or recommended penalties or non-use of preferred providers. Specifically address how lab work will be covered or not covered.
10. Describe discounts and other pricing arrangements that the plan has negotiated with
hospitals and physicians which will provide cost reduction to the ATN. Although statewide averages are useful, it is preferred that discounts in the ATN’s local area be disclosed.
11. Managed care plans should indicate the maximum total out-of-pocket costs per plan
year per person and per family.
12. Pre-Existing Conditions -- Provide information on the extent to which pre-existing conditions are covered or not covered by your plan.
13. COBRA and Conversion Benefits
a) In addition to providing mandated COBRA benefits, proposers will make
conversion benefits available to participants entitled to continue similar coverage, without evidence of insurability, as prescribed by California law.
b) Proposers are to state if they will administer COBRA enrollments and assure
compliance with COBRA law. State separately the cost, if any, for these services.
c) Reference Listing of no fewer than four (4) references of past experience that
include at a minimum, a contact person, a company name, the services provided to that company, a phone number, and an email address.
14. Additional Information and Comments by the insurance agent/broker at their
discretion, that provides additional information deemed relevant to the evaluation of the proposal.
15. Sample Instruction Benefits Booklet and Last Provider Directory demonstrating the
same level of quality and content being proposed for this RFP.
16. Pricing that includes all pricing for all services unless otherwise stated. Insurance Agent / Company Statement of Confidentiality of Data that states a commitment to keeping data and employee information confidential and specifically addresses what procedures will be used to ensure that data / information is kept confidential and secure.
17. Expectations to carry out the terms of the vendor’s proposal.
THE ATN’S RESERVATION OF RIGHTS
1. The ATN reserves the right to reject any or all proposals, to waive any informality in
the RFP process, or to terminate the RFP process at any time, if deemed by the ATN to be in its best interests.
2. The ATN reserves the right not to award a contract pursuant to this RFP.
3. The ATN reserves the right to terminate a contract awarded pursuant to this RFP, at
any time for its convenience upon 10 days written notice to the successful proposer(s).
4. The ATN reserves the right to determine the days, hours and locations that the
successful proposer(s) will provide the services called for in this RFP. The ATN reserves the right to retain all proposals submitted and not permit withdrawal for a period of 60 days subsequent to the deadline for receiving proposals without the written consent of the ATN Contracting Officer (CO).
5. The ATN reserves the right to negotiate the fees proposed by the proposer entity.
6. The ATN reserves the right to reject and not consider any proposal that does not meet
the requirements of this RFP, including but not necessarily limited to incomplete proposals and/or proposals offering alternate or non-requested services.
7. The ATN will have no obligation to compensate any proposer for any costs incurred
in responding to this RFP.
8. Any and all agent fees will be paid by the insurance carrier.
9. The ATN Will reserve the right to at any time during the RFP or contract process to
prohibit any further participation by a proposer or reject any proposal submitted that does not conform to any of the requirements detailed herein. By accessing the nahro.economicengine.com Internet System (hereinafter, the “noted Internet System” or the “System”) and by downloading this document, each prospective proposer is thereby agreeing to abide by all terms and conditions listed within this document and within the noted Internet System, and further agrees that he/she will inform the ATN in writing within 5 days of the discovery of any item listed herein or of any item that is issued thereafter by the ATN that he/she feels needs to be addressed. Failure to abide by this time frame will relieve the ATN, but not the prospective proposer, of any responsibility pertaining to such issue.
CONFIDENTIALITY, WARRANTY AND INDEMNIFICATION
1. The CONTRACTOR agrees to exercise caution and discretion in safeguarding customer
information and data which is confidential in nature and will be required to sign a confidentiality agreement prior to receiving the ATN Employee census.
2. The CONTRACTOR will be liable for any willful and material disclosure of such
information or date in addition to being subject to criminal prosecution for violation of any applicable state or federal laws.
3. The CONTRACTOR will provide a statement of warranty that specifies the warranty of
services to be provided and any limitations therein.
4. To the fullest extent permitted by law, the CONTRACTOR Will indemnify and hold
harmless the ATN, its officers and employees from liabilities, damages, losses, and costs including but not limited to reasonable attorney fees, to the extent caused by the negligence, recklessness, or intentional wrongful conduct of the CONTRACTOR and other persons employed or utilized by the CONTRACTOR in the performance of this agreement.
CONFLICT OF INTEREST
All respondents must disclose with their proposal the name of any officer, director, or agent who is also a public officer or an employee of the ATN. Furthermore, all respondents must disclose the name of any ATN employee who owns, directly or indirectly, an interest of five percent (5%) or more in the firm or any of its branches. Furthermore, the official, prior to or at the time of submission of the proposal, must file a statement with the ATN if he/she is an employee of the ATN, disclosing his/her or spouse’s or child’s interest and the nature of the intended business.
RIGHT TO WAIVE AND REJECT
1. The ATN, in its absolute discretion, may reject any proposal of a vendor that has failed, in the opinion of the ATN, to complete or perform a ATN contracted project in a timely fashion or has failed in any other way, in the opinion of the ATN, to perform a prior contract in a satisfactory manner, and has directed the ATN Director of Finance to emphasize this condition to potential vendors.
2. There is no obligation on the part of the ATN to award the proposal to the lowest
vendor, and the ATN reserves the right to award the proposal to the vendor submitting a responsive proposal with a resulting negotiated agreement which is most advantageous and in the best interest of the ATN, and to reject any and all proposals, or to waive any irregularity or technicality in proposals received. The ATN Will be the sole judge of the proposal and the resulting negotiated agreement that is in its best interest and its decision will be final.
3. The ATN reserves the right to waive any informalities or reject any and all proposals, in whole or part, to utilize any applicable state contracts in lieu of or in addition to this proposal and to accept the proposal that in its judgment will best serve the interest of the ATN.
4. The ATN specifically reserves the right to reject any conditional proposal and will normally reject those that made it impossible to determine the true amount of the proposal. Each item must be proposed separately and no attempt is to be made to tie any item or items to any other item or items.
DISQUALIFICATION OF VENDORS
Any of the following reasons may be considered as sufficient for the disqualification of a vendor and the rejection of his/her proposal or proposals:
1. More than one proposal for the same work from an individual, firm or corporation
under the same or different name.
2. Evidence that the vendor has a financial interest in the firm of another vendor for
the same work.
3. Evidence of collusion among vendors. Participants in such collusion will receive no
recognition as vendors for any future work of the ATN until such participant will have been reinstated as a qualified vendor.
4. Uncompleted work that in the judgment of the ATN might hinder or prevent the
prompt completion of additional work if awarded.
5. Default under previous contract.
PROPOSAL EVALUATION CRITERIA
The ATN will evaluate proposals based on the needs of the ATN and its employees. The following criteria will be used in evaluating each of the carrier responses:
1. Compliance with specifications.
2. Ability to provide comprehensive administrative support and member services to
the ATN and its covered employees and dependents.
3. Compliance with applicable State and Federal laws and regulations.
4. Financial position of insurance company, managed care organization or
5. Premium rates, retention costs, administration fees and renewal underwriting procedures.
6. Renewal rate guarantees.
7. Completion of the Rate and Benefit Proposal Forms and Questionnaires.
8. Size and location of the Medical Plan Provider Network (or Networks).
9. Nature of medical provider contracts, including provider discounts and other cost
containment methods.
10. Ability to provide the ATN with the reports requested in the proposal.
11. Ability to administer claims processing in a seamless and efficient manner.
12. The amount or type of drugs covered under the formulary.
13. The ability of the ATN to customize a benefit program that will meet the needs of
its employees.
14. Other criteria identified by the ATN as important in evaluation of submitted
proposals.
The ATN will choose the proposals that best fits its needs and the needs of its employees and dependents. The ATN is not obligated to award the contract based on cost alone.
CONDITIONS AND STIPULATIONS
You are invited to submit your Proposal for the administration of the indicated benefit plans based on the information contained in this RFP. Unless a specific note is made to the contrary, ATN will assume that Proposal conforms to the ATN’s Specifications. You are invited to ask questions during the proposal process and to seek additional information. ATN desires to maintain an interactive process and will make every effort to provide sufficient data for your response.
GENERAL CONDITIONS AND STIPULATIONS
Underwriting information pertaining to the ATN is correct and accurate to the best of our
knowledge. All providers submitting Proposals will be provided information regarding changes or additions to the underwriting data.
The ATN reserves the right to accept or reject any or all proposals and to waive formalities and select the carrier and benefit options that best meet the needs of the ATN and its employees. The ATN’s objective is to select a carrier who will provide the best possible service at the best possible cost while meeting the Request for Proposal specifications. The ATN is not obligated to award the contract based on cost alone.
Any proposed deviations to any part of these Specifications must be submitted in writing
as a part of the questionnaire, (question #1) and clearly identified in the appropriate
section of the Proposal. Any deviation deemed to be significant by the ATN will disqualify
the Proposal.
Failure to identify any such deviation(s) will not in the future accrue to the disadvantage of the ATN nor any qualified participant or dependent in any manner.
Proposals can be for one or more of the specified group benefits. However, the rate for
each benefit must be independently determined. Alternative benefit options may be considered if there would be a reduction in cost/premiums.
Provider(s) that are awarded the business will submit properly executed contracts to the
ATN within sixty (60) days of the plan effective date.
It is not the desire of the ATN or participants to be involved with the handling of claims.
Providers must specify their claims handling procedure and include a sample claim form with an example of an Explanation of Benefits.
The Provider(s) awarded the business Will be required to provide ATN-specific loss data
(i.e. premium / claims and utilization data) at least annually. After the first renewal, paid claims and utilization data covering at least a twelve (12) month period must be provided to the ATN prior to or concurrent with any subsequent rate adjustment.
Employees (and their dependents) that terminate their employment for any reason must
be given the option to continue or convert their insurance to individual contracts without evidence of insurability per state mandates and federal COBRA regulations. Such coverage will not be contingent upon the ATN’s coverage continuing with the Provider.
All Providers must be in full compliance with State of California and Federal requirements
relating to the requested coverage or administration of or insuring of such benefits, including all applicable laws and regulations.
Any and all legislative mandates that apply to the State of California. Failure to include
any such benefits in the Proposal will not accrue to the detriment of the ATN nor any employee or any dependent in any manner.
Agents will clearly identify the carrier in the Proposal being submitted. Carriers should
record or to go direct through the insurance carrier. The ATN reserves the right to select and terminate any servicing agent, agency, company or administrator.
Comprehensive benefit brochures and provider directories must be made available to
each covered participant at enrollment. Individual certificates, member cards or other pertinent information must be provided no later than 30 days after the effective date or delivery of enrollment data.
A servicing representative must be available to the ATN on an on-going basis.
Representatives must be available at the initial open enrollment meetings to explain the plan and enroll ATN employees.
COVERAGE CONDITIONS AND STIPULATIONS
Coverage under the accepted plan will be from April 1, 2016 through December 31, 2016,
with calendar year renewals thereafter. ATN has the right to renew for up to four (4) additional years based on the one-year option commencing January 2017 through December 2020. The carrier has the right to amend rates at the beginning of the next plan period subject to at least forty-five (45) days written notice, prior to the effective date of the change.
Multiple year fees and/or rate guarantees are encouraged.
ELIGIBILITY AND ENROLLMENT CONDITIONS AND STIPULATIONS
Enrolled participants will be immediately eligible for the plan upon its effective date. Eligible participants hired after the effective date will become eligible 60 days after hire date. Any employee absent from work due to illness or injury on the date coverage would otherwise become effective Will, upon return to work, have coverage retroactive to the effective date.
Employees eligible to participate in the plan are permanent employees whose usual work
schedule is 30hours per week. These employees are eligible for employer contribution.
Employees who do not enroll within thirty-one (31) days of the eligibility date may be required to submit evidence of insurability for themselves and dependents, as applicable.
When two employees of the ATN are married and one is enrolled as a dependent under
the other employee’s policy, the employee enrolled as a dependent Will be allowed to enroll as a single covered employee without waiting periods, evidence of insurability provided the reason for the enrollment is one of the following:
Termination of the employment of the spouse
Death of the spouse
occurrence.
When an employee's spouse and dependents are not covered as dependents under this
plan, due to coverage at his/her own place of employment, such dependents may apply for coverage upon termination of employment or loss of coverage with current employer. Validation of such application must be completed within thirty-one (31) days.
A spouse, eligible dependents include unmarried natural children, stepchildren, legally
adopted children, and permanent foster children, or any other child who is related to the eligible employee by blood or marriage and who resides with the employee in a normal parent/child relationship, age 26 or younger who are dependent upon the employee for support.
Unmarried dependent children beyond the age of 18 will have coverage extended:
To age 26if a full-time student; or
SECTION II – ATN INFORMATION
Request for Medical Benefits
Contribution and Statistical Information
REQUEST FOR MEDICAL BENEFITS
Funding Requested: Fully-Insured
The ATN currently offers its employees a major medical plan through Kaiser Permanente. It is the intent of the ATN to continue offering at least four (4) of plan options. The ATN may consider offering additional plan options alongside the existing plans.
In addition to the current benefit plan, summary of benefits included on Page #19, the ATN wishes to receive Proposals for the following plan options:
Comprehensive Major Medical & Dental Plan
Plan Type Deductible Coinsurance Out-of Pocket Maximum (Single/Family)
Comp. Maj. Med. $___/$___
Comp. Maj. Med. $___/$___
Comp. Maj. Med. $___/$___
PPO, POS and Managed Care Plans
Plan Type Office Co-Pay Drug Co-Pay In-Patient Hospital Co-Insurance Individual In-Network Maximum Individual Out-Network Maximum Dental Coverage PPO PPO POS POS MCO
NOTE: If you are unable to provide a quote for a plan that meets these exact requirements, the ATN would entertain quotes for the plan option that most closely matches the benefit levels outlined above.
CONTRIBUTIONS AND STATISTICAL INFORMATION
Medical Premium Contribution
ATN currently contributes the entire cost of the employee’s plan premium. ATN does not contribute to the
dependent/family coverage. Cost associated with the dependent coverage is deducted through payroll deduction from the employee’s paycheck.
ATN does not contribute towards the retiree’s plan premium.
Current Medical Rates - CUSTOMIZABLE
Plan Single Family
Early Retiree (Single/Family)
65+ Retiree (Single/Family)
Premium History & Employee Census
Attachment 1
PARTICIPANT BREAKDOWN
Attachment 2
Plan Single EE+Spouse EE+ Child Family COBRA Total
Attachment 1
Attachment
Attachment 3
CIVIL RIGHTS REQUIREMENTS
Bidder’s Name: ______________________________ Hereby certifies that:
(1) Nondiscrimination - In accordance with Title VI of the Civil Rights Act, as amended, 42U.S.C. Section 2000d, section 303 of the Age Discrimination Act of1975, as amended,42 U.S.C. Section 6102, section 202 of the Americans with Disabilities Act of 1990, 42U.S.C. Section 12132, and Federal transit law at 49 U.S.C. Section 5332, the Successful Bidder agrees that it will not discriminate against any employee or applicant for employment because of race, color, creed, national origin, sex, age, or disability. In addition, t1ie Successful Bidder agrees to comply with applicable Federal implementing regulations and other implementing requirements FTA may issue.
(2) Equal Employment Opportunity - The following equal employment opportunity requirements apply to the underlying contract:
(a) Race, Color, Creed, National Origin, Sex - In accordance with Title VII of the Civil Rights Act, as amended, 42 U.S.C. Section 2000e, and Federal transit laws at 49 U.S.C. Section 5332, the Successful Bidder agrees to comply with all applicable equal employment opportunity requirements of U.S. Department of Labor (U.S.DOL) regulations, "Office of Federal Contract Compliance Programs, Equal Employment Opportunity, Department of Labor," 41 C.F.R. Parts 60 et seq., (which implement Executive Order No. 11246, "Equal Employment Opportunity," as amended by Executive Order No. 11375, "Amending Executive Order 11246 Relating to Equal Employment Opportunity," 42 U.S.C. Section 2000e note), and with any applicable Federal statutes, executive orders, regulations, and Federal policies that may in the future affect construction activities undertaken in the course of the Project. The Successful Bidder agrees to take affirmative action to ensure that applicants are employed, and that employees are treated during employment, without regard to their race, color, creed, national origin, sex, or age. Such action shall include, but not be limited to, the following: employment, upgrading, demotion or transfer, recruitment or recruitment advertising, layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. In addition, the Successful Bidder agrees to comply with any implementing requirements FTA may issue.
(b) Age - In accordance with section 4 of the Age Discrimination in Employment Act of 1967, as amended, 29 U.S.C. Section 623 and Federal transit law at 49 U.S.C. Section 5332, the Successful Bidder agrees to refrain from discrimination against present and prospective employees for reason of age. In addition, the Successful Bidder agrees to comply with any implementing requirements FTA may issue.
(c) Disabilities- In accordance with section 102 of the Americans with Disabilities Act, as amended, 42 U.S.C. Section 12112, the Successful Bidder agrees that it will comply with the requirements of U.S. Equal Employment Opportunity Commission, "Regulations to Implement the Equal Employment Provisions of the Americans with Disabilities Act," 29 C.F.R. Part 1630, pertaining to employment of persons with disabilities. In addition, the Successful Bidder agrees to comply with any implementing requirements FTA may issue.
(3) The Successful Bidder also agrees to include these requirements in each subcontract financed in whole or in part with Federal assistance provided by FTA, modified only if necessary to identify the affected parties.
I am authorized to make this verification on behalf of the supplier. The statements in the foregoing document are true of my own knowledge, except as to matters which are therein stated on information and belief, and as those matters I believe them to be true. I declare under the penalty of perjury that the foregoing is true and correct.
Executed on _____________________________________ at _________________, California
Date City
Signature:______________________________
Printed Name:___________________________
BIDDER’S CERTIFICATION OF ENERGY CONSERVATION, AIR QUALITY, AND CLEAN WATER COMPLIANCE
Company Name:____________________________________________________
The third party contractor named above hereby certifies compliance with the requirements listed below and regulations issued by the Environmental Protection Agency (EPA), Federal Highway Administration, Federal Transit Administration (FTA) and other agencies of the Federal Government as well as future regulations, guidelines, standards, orders, directives or other requirements that may affect this procurement contract.
The above named contractor will:
1. Comply with all applicable standards, orders, or regulation pursuant to the Clean Air Act, as
amended, 42 U.S.C., and 7401 et seq.
2. Comply with all applicable standards, orders, or regulations issued pursuant to the Federal Water
Pollution Control Act, as amended, 33 U.S.C., 1251 et seq.
3. Comply with mandatory standards and policies relating to energy efficiency, which are contained
in the state energy conservation plan issued in compliance with the Energy Policy and Conservation Act.
CERTIFICATION:
I, the official named below, hereby swear that I am duly authorized legally to bind the Bidder or grant recipient to the above-described certification. I am fully aware that this certification executed on the date and in the county below, is made under penalty of perjury under the laws of the State of California.
Company Name: ________________________________
Official’s Name: ____________________________________________ Title:______________________________ Date:___________________
CERTIFICATION OF RESTRICTIONS ON LOBBYING
I, hereby certify on behalf of ________________________________ that:
(1) No Federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with the awarding of any Federal contract, the making of any Federal grant, the making of any Federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal contract, grant, loan or cooperative agreement.
(2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any Federal agency, a Member of Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this Federal contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying", in accordance with its instructions as amended by "Government wide Guidance for New Restrictions on Lobbying,61 CFR 1413.
(3) The undersigned shall require that the language of this certification be included in the award documents for all sub-awards at all tiers (including sub-contracts, subgrants, Contracts under grants, loans, and cooperative agreements) which exceed $100,000 and that all such sub-recipients shall certify and disclose accordingly.
This certification is a material representation of fact upon which reliance was placed when this transaction was made or entered into. Submission of this certification is a prerequisite for making or entering into this transaction imposed by 31 U.S.C. 1352 (as amended by the Lobbying Disclosure Act of 1995). Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
The Successful Bidder certifies or affirms the truthfulness and accuracy of each statement of its certification and disclosure, if any. In addition, the Successful Bidder understands and agrees that the provisions of 31 U.S.C. A 3801, et seq., apply to this certification and disclosure, if any.
Certificate of Non-Compliance
The bidder hereby certifies that it cannot comply with the requirements of 49 U.S.C. Section 5323(U)(2)(C) and Section 165(b)(3) of the Surface Transportation Assistance Act of 1982, as amended, but may qualify for an exception to the requirements consistent with 49 U.S.C. Sections 5323U)(2)(B) or (j)(2)(D), Sections 165(b)(2) or (b)(4) of the Surface Transportation Assistance Act, as amended, and regulations in 49 C.F.R. 661.7.
Date:_______________________________ Signature:______________________________
STATE OF CALIFORNIA DRUG FREE WORKPLACE CERTIFICATION
Company/Organization Name:________________________________________________
The Bidder named above hereby certifies compliance with U.S. DOT regulations 49 CFR Part 29, Subpart F and Government Code Section 8355 in matters relating to providing a drug-free workplace. The above named Bidder or grant recipient will:
1. Publish a statement notifying employees that unlawful manufacture, distribution, dispensation,
possession, or use of a controlled substance is prohibited and specifying actions to be taken against employees for violations of the prohibition.
2. Establish an on-going Drug-Free Awareness Program as required to inform employees about all the following:
a. The dangers of drug abuse in the workplace,
b. The person's or organization's policy of maintaining a drug-free workplace,
c. Any available drug counseling, rehabilitation, and employee assistance programs,
d. Penalties that may be imposed upon employees for drug abuse violations occurring in
the workplace.
3. Every employee who works on the proposed contract or grant will receive a copy of the
company's drug-free policy statement.
4. Notify each employee that as a condition of employment financed with Federal assistance
provided in the proposed contract, the employee will be required to:
a. Abide by the terms of the company's policy statement, and
b. Notify the employer (Bidder) in writing of any conviction for a violation of a criminal drug
statute occurring in the workplace no later than five (5) calendar days after that conviction.
5. Notify FTA in writing, within in ten (10) calendar days after receiving notice required by
paragraph 4 (ii) from an employee or otherwise receiving actual notice of that conviction. The Bidder, as employer of any convicted employee, must provide notice, including position title, to every project officer or other designee on whose project activity the convicted employee was working. Notice shall include the identification number(s) of each affected vehicle and related equipment and accessories.
6. Taking one of the following actions within thirty (30) calendar days of receiving notice under
paragraph 4 (b) with respect to any employee who is convicted:
a. Taking appropriate personnel action against that employee, up to an including termination,
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b. Requiring the employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or local health, law enforcement, or other appropriate agency; and
c. Making a good faith effort to continue to maintain a drug-free workplace through
implementation of Paragraph 1,2,3,4,5, and 6 of this certification. The Bidder agrees to maintain a list identifying its headquarters location and each workplace it maintains in which activities provided by this contract are conducted, and make that list readily accessible to the State Department of Transportation.
CERTIFICATION
I, the official named below, hereby swear that I am duly authorized legally to bind the Bidder or grant recipient to the above-described certification. I am fully aware that this certification executed on the date and in the county below, is made under penalty of perjury under the laws of the State of California.
Date:________________________ Signature:_____________________________
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CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY AND VOLUNTARY EXCLUSION LOWER TIER COVERED TRANSACTIONS
The Contractor is required to comply with 49 CFR 29, Subpart C and must include the requirement to comply with 49 CFR 29, Subpart C in any lower tier covered transaction it enters into.
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this Proposal, the prospective recipient of Federal assistance funds is providing the certification as set out below.
2. The certification in this class is a material representation of fact upon which reliance was placed when this transaction was entered into. If it is later determined that the prospective recipient of Federal assistance funds knowingly rendered an erroneous certification, in addition to other remedies available to procuring agency, the Federal Government, and/or the Department of Labor (DOL) may pursue available remedies, including suspension and/or debarment.
3. The prospective recipient of Federal assistance funds shall provide immediate written notice to the person to whom this proposal is submitted if at any time the prospective recipient of Federal assistance funds learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances.
4. The terms "covered transaction," "debarred," "suspended," "ineligible," "lower tier covered transaction," "participant," "person," "primary covered transaction," "principal," "proposal," and "voluntarily excluded", as used in this clause, have the meanings set out in the Definitions and Coverage sections of rules implementing Executive Order
12549.
5. The prospective recipient of Federal assistance funds agrees by submitting this Proposal that, should the proposed covered transaction be entered into, it shall not knowingly enter into any lower tier covered transaction with a person who is debarred, suspended, declared ineligible, or voluntarily excluded from participation in this covered transaction, unless authorized by DOL. 6. The prospective recipient of Federal assistance funds further agrees by submitting this Proposal that
it will include the clause titled "Certification Regarding Debarment, Suspension, Ineligible and Voluntary Exclusion - Lower Tier Covered Transactions," without modification, in all lower tier covered transactions and in all solicitations for lower tier covered transactions.
7. A participant in a covered transaction may rely upon a certification of prospective participant in a
lower tier covered transaction that it is not debarred, suspended, ineligible, or voluntarily excluded from the covered transaction, unless it knows that the certification is erroneous. A participant may decide the method and frequency by which it determines
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8. The eligibility of its principals. Each participant may but is not required to check the List of Parties
Excluded from Procurement or Non-procurement Programs.
9. Nothing contained in the foregoing shall be construed to require establishment of a system of
records in order to render in good faith the certification required by this clause. The knowledge and information of a participant is not required to exceed that which is normally possessed by a prudent person in the ordinary course of business dealings.
10.Except for transactions authorized under paragraph 5 of these instructions, if a participant in a
covered transaction knowingly enters into a lower tier covered transaction with a person who is suspended, debarred, ineligible, or voluntarily excluded from participation in this transaction, in addition to other remedies available to the Federal Government; the DOL may pursue available remedies, including suspension and/or debarment.
By signing and submitting the proposal, the Bidder certifies as follows: (1) The lower tier participant certifies, by submission of this proposal, that neither it, nor its principals as defined at 49 CFR Part 29.995 or affiliates, as defined by 49CFR 29.905, are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction as defined by 49 CFR 29.904, or by any Federal department or agency. (2) When the prospective lower tier participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to this proposal.
Name and Title of Authorized Representative
Signature
