1-03. N267524AN - Fillable Forms.pdf

ITN No: N267524AN – Benefits Consulting and Actuarial Services Page 1

REQUIRED SUBMITTAL CHECKLIST FORM

THE SCHOOL BOARD OF LEE COUNTY, FLORIDA

DEPARTMENT OF PROCUREMENT SERVICES

ITN No. N267524AN

Benefits Consulting and Actuarial Services

DATE SUBMITTED:

RESPONDENT NAME:

TO: The School Board of Lee County Fort Myers, Florida

I acknowledge receipt of the Proposal Submittal Requirements (Section 14) of the ITN Specifications for ITN No. N267524AN, Benefits Consulting and Actuarial Services as bound herein. I have read, understand, and agree to comply with all conditions as specified herein.

Having carefully examined the required documents, specification, plans and addenda as well as examined the existing site conditions, the undersigned proposes to furnish Services for ITN No. N267524AN, Benefits Consulting and Actuarial Services.

REQUIRED SUBMITTALS

� Watched Pre-Submission Video/Tutorial

_____Yes _____No

Euna Procurement Portal Uploads

DOCUMENT 1

PROPOSAL

� Proposer Information Sheet � Table of Contents � Letter of Transmittal � A valid insurance broker license issued by the State of Florida.

� Proof of Membership with The American Academy of Actuarial � Sunbiz – webpage and business license � Corporate Overview � Sample Contract or Agreement

DOCUMENT 2

QUESTIONAIRE

� Respond clearly and concisely to all questions

DOCUMENT 3

FINANCIAL RESPONSIBILITY

� Financial Responsibilities (Marked Confidential)

DOCUMENT 4

FILLABLE FORMS

� Required Submittal Checklist � (A) Insurance Requirements Form

� Certificate of Insurance naming School Board of Lee County as Certificate Holder

� (B) Addenda Acknowledgement Form � (C) Debarment Form � (D) Drug-Free Workplace Certification Form � (E) Public Entity Crimes Form (notarized) � (F) Emergency/Storm Related Catastrophe

Agreement � (G) Scrutinized Company Certification Form � (H) Confidential, Proprietary or Trade Secret

Acknowledgement Form

DOCUMENT 5

REFERENCES

� Three Client Reference Forms https://leeschools.bonfirehub.com/

ITN No: N267524AN – Benefits Consulting and Actuarial Services Page 2

ATTACHMENT A - INSURANCE REQUIREMENTS FORM

The School Board of Lee County Florida

Insurance Requirements

INSURANCE TYPE REQUIRED LIMITS

X 1. Workers’ Compensation Statutory Limits of Florida Statutes, Chapter 440 and all Federal Government Statutory Limits and Requirements. Policy must include Employers Liability with a limit of $500,000.00 each incident.

X 2. Commercial General Liability Bodily Injury & Property Damage (Occurrence Form) patterned after the 1995 I.S.O.

form $1,000,000.00 Single Limit Per Occurrence

X 3. Indemnification: The School Board of Lee County, Florida agrees to indemnify, only to the extent of the limits set forth in §768.28(5), Fla. Stat. and then only for the negligent or wrongful act or omission of any officer or employee acting within the scope of the officer's/employee's office or employment under circumstances in which the state or such agency or subdivision, if a private person, would be liable to the claimant. The School Board does not waive any defense of sovereign) immunity. It is further understood and agreed by the parties-to this Contract that no officer or employee may be held personally liable except as provided by §768.28(9), Fla. Stat.

X 4. Automobile Liability $1,000,000.00 Each Occurrence Owned/Non-owned/Hired Automobile Included

X 5. Other Insurance as indicated below:

a) Professional Liability $1,000,000.00

b) Builder’s Risk All projects OVER $100,000 (that will take longer than

30 days to complete) to be reviewed by the Districts Insurance Consultant and may require Builder’s Risk.

ITN No: N267524AN – Benefits Consulting and Actuarial Services Page 3

The School Board of Lee County Florida Insurance Requirements

(Continued)

X 6. Consultant shall ensure that all Subcontractors comply with the same insurance requirements that he is required to meet. The same Consultant shall provide The School Board of Lee County with certificates of insurance meeting the required insurance provisions.

X 7. The School Board of Lee County must be named as “ADDITIONAL INSURED” on the Insurance Certificate for all coverages except Workers’ Compensation and Professional Liability.

X 8. The School Board of Lee County shall be named as the Certificate Holder.

NOTE: The “Certificate Holder” should read as follows:

The School Board of Lee County, Florida Attn: Procurement Services

2855 Colonial Boulevard Fort Myers, Florida 33966

X 9. Thirty (30) Days Cancellation Notice is required.

X 10. The Certificate must state the ITN Number and Title.

It is the responsibility of the awarded Consultant(s) to provide the District with updated copies of current Certificate of Insurance, prior to expiration any time during the awarded period.

PROPOSER’S AND INSURANCE AGENT STATEMENT:

We understand the insurance requirements contained in these specifications, and that the evidence of said insurance is required within five (5) business days of the Notice of Award of the proposal. The School Board of Lee County must be named as “ADDITIONAL INSURED” on the Insurance Certificate for Commercial General Liability and the Business Auto Liability policies. The School Board of Lee County desires proof of insurability at levels required for this proposal.

A current certificate of insurance is attached: _______YES ________ NO

Proposer Name Proposer Title

Signature of Proposer

ITN No: N267524AN – Benefits Consulting and Actuarial Services Page 4

ATTACHMENT B - ADDENDA ACKNOWLEDGEMENT FORM

It is the sole responsibility of each Proposer to ensure that all addenda released are received; that all ITB and addenda requirements have been completed and that all required submittals have been included.

The undersigned acknowledges the receipt of any addenda.

Addendum #1 Date Issued: Attached to proposal? Y N

Signature

Addendum #2 Date Issued: Attached to proposal? Y N

Addendum #3 Date Issued: Attached to proposal? Y N

Addendum #4 Date Issued: Attached to proposal? Y N

Addendum #5 Date Issued: Attached to proposal? Y N

ITN No: N267524AN – Benefits Consulting and Actuarial Services Page 5

ATTACHMENT C – DEBARMENT FORM

Certification Regarding Debarment, Suspension, Ineligibility and

Voluntary Exclusion -- Lower Tier Covered Transactions

This certification is required by the Department of Education regulations implementing Executive Order 12549, Debarment and Suspension, 34 CFR Part 85, for all lower tier transactions meeting the threshold and tier requirements stated at Section 85.110.

Instructions for Certification

1. By signing and submitting this bid, the prospective lower tier participant is providing the certification set out below.

2. The certification in this clause 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 lower tier participant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

3. The prospective lower tier participant shall provide immediate written notice to the person to which this bid is submitted if at any time the prospective lower tier participant 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," "bid," 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. You may contact the person to which this bid is submitted for assistance in obtaining a copy of those regulations.

5. The prospective lower tier participant agrees by submitting this bid 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 the department or agency with which this transaction originated.

6. The prospective lower tier participant further agrees by submitting this bid that it will include the clause titled

Certification Regarding Debarment, Suspension, Ineligibility, 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 a 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 the eligibility of its principals. Each participant may but is not required to, check the No procurement List.

8. 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.

9. 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 department or agency with which this transaction originated may pursue available remedies, including suspension and/or debarment.

Certification

(1) The prospective lower tier participant certifies, by submission of this bid, that neither it nor its principals are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department or agency.

(2) Where 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 bid.

NAME OF APPLICANT PR/AWARD NUMBER AND/OR PROJECT NAME

PRINTED NAME AND TITLE OF AUTHORIZED REPRESENTATIVE

SIGNATURE DATE

ITN No: N267524AN – Benefits Consulting and Actuarial Services Page 6

ATTACHMENT D - DRUG-FREE WORKPLACE CERTIFICATION

The undersigned Proposer, in accordance with Florida Statue 287.087 hereby certifies that does:

Name of Business

1. Publish a statement notifying employees that the unlawful manufacture, distribution, dispensing, possession, or use of a controlled substance is prohibited in the workplace and specifying the actions that will be taken against employees for violations of such prohibition.

2. Inform employees about the dangers of drug abuse in the workplace, the business’s policy of maintaining a drug-free workplace, any available drug counseling, rehabilitation, employee assistance programs and the penalties that may be imposed upon employees for drug abuse violations.

3. Give each employee engaged in providing the commodities or contractual services that are under proposal a copy of the statement specified in Paragraph 1.

4. In the statement specified in Paragraph 1, notify the employees that, as a condition of working on the commodities or contractual services that are under proposal, the employee will abide by the terms of the statement and will notify the employer of any conviction of, or plea of guilty or nolo contender to, any violation of Chapter 893 or of any controlled substance law of the United States or any state, for a violation occurring in the workplace no later than five (5) days after such conviction.

5. Impose a sanction on, or require the satisfactory participation in a drug abuse assistance or rehabilitation program if such is available in the employee’s community, by any employee who is so convicted.

6. Make a good faith effort to continue to maintain a drug-free workplace through implementation of Paragraphs

1 thru 5.

As the person authorized to sign this statement, I certify that this firm complies fully with the above requirements.

Signature of Authorized Officer

Date

ITN No: N267524AN – Benefits Consulting and Actuarial Services Page 7

ATTACHMENT E - PUBLIC ENTITY CRIMES FORM

SWORN STATEMENT UNDER SECTION 287.133(3)(a), FLORIDA STATUTES, PUBLIC ENTITY CRIMES

THIS FORM MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC OR OTHER OFFICER AUTHORIZED TO ADMINISTER

OATHS.

1. This sworn statement is submitted with Invitation to Negotiate No. N267524AN for Benefits Consulting and

Actuarial Services.

2. This sworn statement is submitted by __________________________________ (Name of entity submitting sworn statement) whose business address is _____________________________________________________ and (if applicable) its Federal Employer Identification Number (FEIN) is _________________________. If the entity has no FEIN, include the Social Security Number of the individual signing this sworn statement:___________________________.

3. My name is _____________________________________ and my relationship to __________________________ (Company)

(please print name of individual signing) entity name above is ______________________________.

4. I understand that a “public entity crime” as defined in Paragraph 287.133(1)(g), Florida Statutes, means a finding of any state or federal law by a person with respect to and directly related to the transaction of business with any public entity or with an agency or political subdivision of any other state or with the United States, including, but not limited to, any bid or contract for goods or services to be provided to any public entity or an agency or political subdivision of any other state or of the United States and involving antitrust, fraud, theft, bribery, collusion, racketeering, conspiracy, or material misrepresentation.

5. I understand that “convicted” or “conviction” as defined in Paragraph 287.133(1)(b), Florida Statutes, means a violation of guilt or a conviction of a public entity crime, with or without an adjudication of guilt, in any federal or state trial court of record relating to charges brought by indictment or information after July 1, 1989, as a result of a jury verdict, nonjury trial, or entry of a plea of guilty or nolo contendere.

6. I understand that an “affiliate” as defined in Paragraph 287.133(1)(a), Florida Statutes, means:

1. A predecessor or successor of a person convicted of a public entity crime; or

2. An entity under the control of any natural person who is active in the management of the entity and who has been convicted of a public entity crime. The term “affiliate” includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in the management of an affiliate.

The ownership by one person of shares constituting a controlling interest in another person, or a pooling of equipment or income among persons when not for fair market value under an arm’s length agreement, shall be a prima facie case that one person controls another person. A person who knowingly enters into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding 36 months shall be considered an affiliate.

ITN No: N267524AN – Benefits Consulting and Actuarial Services Page 8

7. I understand that a “person” as defined in Paragraph 287.133(1)(e), Florida Statutes, means any natural person or entity organized under the laws of any state or of the United States with the legal power to enter into a binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public entity, or which otherwise transacts or applies to transact business with a public entity. The term “person” includes those officers, directors, executives, partners, shareholders, employees, members, and agents who are active in management of an entity.

8. Based on information and belief, the statement which I have marked below is true in relation to the entity submitting this sworn statement. (Please indicate which statement applies.)

_____ Neither the entity submitting this sworn statement, nor any officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management of the entity, not any affiliate of the entity have been charged with and convicted of a public entity crime subsequent to July 1, 1989.

_____The entity submitting this sworn statement, or one or more of the officers, directors, executives, partners, shareholders, employees, members, or agents who are active in management of the entity, or an affiliate of the entity has been charged with and convicted of a public entity crime subsequent to July 1, 1989, AND (Please indicate which additional statement applies.)

The person HAS __________ or HAS NOT ________ been placed on the convicted contractor list. (Please describe any action taken by or pending with the Department of Management Services concerning removal from the list.)

(Signature)

Date: _________________________________________

STATE OF_______________________________

COUNTY OF _____________________________

____________________________________APPEARED IN PERSON BEFORE ME (the undersigned authority), who is personally known to me or provided the following identification _________________________, and affixed his/her signature in the space provided above on this _______ day of _______________, 20_____.

NOTARY PUBLIC

My commission expires:

Form PUR 7068 (Rev. 11/89)

OPTIONAL ONLINE NOTARIZATION IS ACCEPTABLE

ITN No: N267524AN – Benefits Consulting and Actuarial Services Page 9

ATTACHMENT F - EMERGENCY/STORM RELATED CATASTROPHE AGREEMENT

Due to Acts of God, Acts of Terrorism or War, any Consultants working with the School District shall acknowledge and agree to the following terms and conditions. This will allow the District to obtain Federal funding if available.

CONDITIONS FOR EMERGENCY / HURRICANE OR DISASTER

It is hereby made a part of this Invitation to Negotiate that before, during and after a public emergency, disaster, hurricane, flood or acts of God that the municipal government, through the School District of Lee County, shall require a "first priority" basis for goods and services. It is vital and imperative that the majority of citizens are protected from any emergency situation, which threatens public health and safety, as, determined by the School District of Lee County. Consultant agrees to rent/sell/lease all goods and services to the School District of Lee County or other government entity as opposed to a private citizen, on a first priority basis. The District expects to pay a fair and reasonable price for all products in the event of a disaster, emergency or hurricane. Consultant shall furnish a “24-hour” phone number in the event of such an emergency.

I hereby understand and agree to the above statement:

(Signature) (Print Name) (Title)

Emergency Telephone Number:

Home Telephone Number:

Cellular Phone Number:

ITN No: N267524AN – Benefits Consulting and Actuarial Services Page 10

ATTACHMENT G - SCRUTINIZED COMPANY CERTIFICATION FORM

I hereby swear or affirm that as of the date below this company is not listed on a Scrutinized Companies list created pursuant to 215.4725, 215.473, or 287.135, Florida Statutes. Pursuant to 287.135, Florida Statutes I further affirm that:

1. This company is not participating in a boycott of Israel such that it is not refusing to deal, terminating business activities, or taking other actions to limit commercial relations with Israel, or persons or entities doing business in Israel or in Israeli-controlled territories, in a discriminatory manner.

1. This Company does not appear on the Scrutinized Companies with Activities in Sudan List where the State Board of Administration has established the following criteria:

a. Have a material business relationship with the government of Sudan or a government-created project involving oil related, mineral extraction, or power generation activities, or

b. Have a material business relationship involving the supply of military equipment, or

c. Impart minimal benefit to disadvantaged citizens that are typically located in the geographic periphery of Sudan, or

d. Have been complicit in the genocidal campaign in Darfur.

2. This Company does not appear on the Scrutinized Companies with Activities in the Iran Petroleum Energy Sector List where the State Board of Administration has established the following criteria:

a. Have a material business relationship with the government of Iran or a government-created project involving oil related or mineral extraction activities, or

b. Have made material investments with the effect of significantly enhancing Iran‘s petroleum sector.

3. This Company is not engaged in business operations in Cuba or Syria.

Company Name:

Signature of Authorized Representative:

Date:

Name and Title:

ITN No: N267524AN – Benefits Consulting and Actuarial Services Page 11

ATTACHMENT H – CONFIDENTIAL, PROPRIETARY OR TRADE SECRET ACKNOWLEDGEMENT FORM

As specified in the General Conditions:

Confidential, Proprietary or Trade Secret: All responses received in response to this solicitation shall be considered a public record pursuant to Chapter 119 Florida Statutes disclosure and will not be confidential with the exception of financial statements.

a) Redacted Copies: If the Proposer considers any portion of the documents, data or records submitted in response to this solicitation to be confidential, trade secret or otherwise not subject to disclosure pursuant to Chapter 119 Florida Statutes, the Florida Constitution or other authority, the Proposer must also simultaneously provide the School District with a separate redacted electronic copy of its proposal.

b) The redacted copies shall contain the School District’s solicitation name, number, and the name of Proposer on the cover, and shall be clearly titled “Redacted Copy.” The Redacted Copies shall be provided to the School District at the same time Proposer submits its response to the solicitation and must only exclude or obliterate those exact portions which are claimed confidential, proprietary, or trade secret.

c) Proposer shall be responsible for defending its determination that the redacted portions of its response are confidential, trade secret or otherwise not subject to disclosure. Further, Proposer shall protect, defend and indemnify the School District for any and all claims from or relating to Proposers determination that the redacted portions of its response are confidential, proprietary, trade secret or otherwise not subject to disclosure.

d) If the Proposer fails to submit Redacted Copies with its response, the Department is authorized to produce the entire documents, data or records submitted by Proposer in response to a public records request for these records.

e) Public Meetings/Evaluations: All evaluations of solicitations are subject to discussion at public meetings. If during the course of the evaluation, pertinent facts cannot be disclosed or discussed in a public forum due to the Proposer’s designating such materials as confidential, the Proposer’s response may be deemed non-responsive and rejected from further consideration of award and any rights to protest is thereby waived.

I have read and acknowledge the conditions as listed above in regards to confidential, propriety or trade secrets.

Name:______________________________________

Company Name:______________________________

Title:_______________________________________

Date: ______________________________________