1-3. Appendix B - Required Forms.pdf

Appendix B.01

CERTIFICATION OF CONTRACTOR REGARDING DEBARMENT, SUSPENSION,

AND OTHER RESPONSIBILITY MATTERS

The Contractor, _________________________, certifies to the best of its knowledge and belief, that it and its principals:

1. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency;

2. Have not within a three (3) year period preceding this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or Local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

3. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or Local) with commission of any of the offense enumerated in paragraph (2) of this certification; and

4. Have not within a three (3) year period preceding this application/proposal had one (1) or more public transactions (Federal, State, or Local) terminated for cause or default.

If the above-named Contractor is unable to certify to any of the statements in this certification, the Contractor shall attach an explanation to this certification.

The Contractor, _________________________, certifies or affirms the truthfulness and accuracy of the contents of the statements submitted on or with this certification and understands that the provision of 31 U.S.C. Section 3801 et seq. are applicable thereto.

Signature and Title of Authorized Official

Notary Public Name (Printed)

Notary Public Signature County of Expiration Date

Appendix B.02

Federal Tax Delinquency and Conviction Certification

The Contractor must complete the following two certification statements.

The Contractor must indicate its current status as it relates to tax delinquency and felony conviction by indicating in following spaces below the applicable response. The

Contractor agrees that, if awarded a contract resulting from this solicitation, it will incorporate this provision for certification in all lower tier subcontracts.

Certifications

Delinquency: The Contractor represents that it is or is not , a corporation that has any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability.

Conviction: The Contractor represents that it is or is not , a corporation that was convicted of a criminal violation under any Federal law within the preceding 24 months.

Note

If a Contractor responds in the affirmative to either of the above representations, the Contractor is ineligible to receive an award.

Term Definitions

Felony conviction: Felony conviction means a conviction within the preceding twenty-four

(24) months of a felony criminal violation under any Federal law and includes conviction of an offense defined in a section of the U.S. code that specifically classifies the offense as a felony and conviction of an offense that is classified as a felony under 18

U.S.C. § 3559.

Tax Delinquency: A tax delinquency is any unpaid Federal tax liability that has been assessed, for which all judicial and administrative remedies have been exhausted, or have lapsed, and that is not being paid in a timely manner pursuant to an agreement with the authority responsible for collecting the tax liability.

Date Signature

Company Name Title

NOTE: No award can be made without this form being completed

Appendix B.03

NON-COLLUSION AFFIDAVIT

STATE OF CALIFORNIA )

COUNTY OF ________________________________)

___________________________________________, being first duly sworn, deposes and says that he or she is of (position or title)

(the Contractor) the party making the foregoing contract that the contract price is not made in the interest of, or on behalf of, any undisclosed person, partnership, company, association, organization, or corporation; that the bid is genuine and not collusive or sham; that the Contractor, and has not directly or indirectly colluded, conspired, connived, or agreed with any Contractor or anyone else to put in a sham bid, or that anyone shall refrain from bidding; that the Contractor has not in any manner, directly or indirectly, sought by agreement, communication, or conference with anyone to fix the bid price of the Contractor or any other bidder, or to fix any overhead, profit, or cost element of the bid price, or of that of any other Contractor, or to secure any advantage against the public body awarding the contract of anyone interested in the proposed contract; that all statements contained in the bid are true; and, further, that the Contractor has not, directly or indirectly, submitted his or her bid price or any breakdown thereof, or the contents thereof, or divulged information or date relative thereto, or paid, and will not pay, any free to any corporation, partnership, company, association, organization, bid depository, or to any member or agent thereof to effectuate a collusive or sham bid.

Dated:____________________ By:_____________________

Appendix B.04

PROPOSER'S STATEMENT

REGARDING INSURANCE COVERAGE

To Be Submitted with Proposal

PROPOSER HEREBY CERTIFIES that the Proposer has reviewed and understands the insurance coverage requirements specified in the Request for Quotations (RFQ) #27-02 for Actuarial Services. Should the Proposer be awarded the contract for the work, Proposer further certifies that the Proposer can meet the specified requirements for insurance, including insurance coverage of the subcontractors, and agrees to name MST as Additional Insured for the work specified.

Name of Proposer (Person, Firm, or Corporation)

Signature of Proposer's Authorized Representative

Name & Title of Authorized Representative

Date of Signing

INSURANCE REQUIREMENTS AND LIMITS

General:

CONSULTANT, at its sole cost and expense, for the full term of this Contract (and any extensions thereof), shall obtain and maintain at minimum all of the following insurance coverage with companies qualified and approved to do business in California with an AM Best Rating of A- VII or higher.

Types of Insurance and Minimum Limits

CONSULTANT shall obtain and maintain during the term of this Contract:

(a) Worker's Compensation and Employer's Liability Insurance in conformance with the laws of the State of California (not required for CONSULTANT 's or sub-CONSULTANTs providing MST written confirmation of having no employees) with limits of not less than one million dollars ($1,000,000) each accident, $1,000,000 by disease-policy, and $1,000,000 disease-each employee.

(b) CONSULTANT’s vehicles used in the performance of this Contract, including owned, non-owned (e.g. owned by CONSULTANT's employees), leased or hired vehicles, shall each be covered with Commercial

Automobile, Liability Insurance using Insurance Services Office (ISO)

Business Automobile Coverage form CA 00 01 (or equivalent) in the minimum amount of one million dollars ($1,000,000) each accident for bodily injury and property damage.

(c) CONSULTANT shall obtain and maintain Commercial General Liability

Insurance coverage with coverage at least as broad as Insurance Services

Office (ISO) form CG 00 01 in the minimum amount of one million dollars

($1,000,000) per occurrence, two million dollars ($2,000,000) general aggregate, and one million dollars ($1,000,000) products and completed operations aggregate. The policy shall include a per project or per location general aggregate endorsement. If a per project/location endorsement is not available, the limit for the general aggregate shall be doubled. If

CONSULTANT maintains higher limits than the specified minimum limits, MST requires and shall be entitled to coverage for the higher limits maintained by CONSULTANT.

(d) CONSULTANT shall obtain and maintain Professional Liability insurance that insures against professional errors and omissions that may be made in performing professional services in the minimum amount of two million dollars ($2,000,000) per claim and in the aggregate. Any policy inception date, continuity date, or retroactive date must be before the effective date of the start of work, and CONSULTANT agrees to maintain continuous coverage through a period no less than three (3) years after completion of the work.

Other Insurance Provisions

(a) As to all insurance coverage required herein, any deductible or self-insured retention exceeding $5,000.00 shall be disclosed to and be subject to written approval by MST.

(b) Except Professional Liability, each insurance coverage required hereunder is to be provided as an “occurrence” form basis only.

(c) All required Automobile Liability Insurance and Commercial General

Liability Insurance shall contain the following endorsement as a part of each policy: “MST is hereby added as an additional insured as respects the operations of the named insured." The Commercial General Liability

Insurance shall be endorsed using ISO endorsement form CG 20 10 or CG

20 26 (or equivalent).

(d) All the insurance required herein shall include and contain the following clause: "It is agreed that this insurance shall not be canceled until thirty (30) days after MST shall have been given written notice of such cancellation or reduction." If a carrier will not provide the required notice of cancellation, the CONSULTANT shall provide written notice to MST of a cancellation no later than five (5) business days before cancellation.

(e) The Commercial General Liability and Automobile Liability Insurace policies shall allow and be endorsed primary coverage as respects MST and any insurance or self-insurance maintained by MST shall be excess of

CONSULTANT's insurance coverage and shall not contribute to it.

(f) All required Workers’ Compensation, Automobile Liability Insurance and

Commercial General Liability shall contain and be endorsed with a waiver of subrogation in favor of MST.

(g) CONSULTANT shall notify MST in writing at least thirty (30) days in advance of any reduction in any insurance policy required under this Contract.

(h) CONSULTANT agrees to provide MST at or before the effective date of this

Contract with a certificate of insurance of the coverage and amendatory endorsements required.

(i) If CONSULTANT, for any reason, fails to maintain insurance coverage, which is required pursuant to this Contract, the same shall be deemed a material breach of contract. MST, at its sole option, may terminate this Contract and obtain damages from the CONSULTANT resulting from said breach.

Appendix B.05

RFQ COMPLIANCE OR EXCEPTION

(Proposer must complete and submit with their proposal)

PLEASE ONLY SELECT ONE

COMPLIANCE OR EXCEPTION TO THE TERMS AND CONDITIONS OF THE RFQ

A. COMPLIANCE:

This is to certify that Proposer agrees and shall comply with the terms and conditions of the RFQ, including the Sample Contract.

Firm Name: ___________________________________________________________

Proposer Signature: _____________________________________________________

Title: _________________________________________________________________

Date: _________________________________

B. EXCEPTION:

This is to certify that Proposer takes exception to the following terms and conditions of the RFQ. Proposer must identify and list the terms and conditions by Section, page number and title. Proposer must identify what its exception is.

Firm Name: ___________________________________________________________

Proposer Signature: _____________________________________________________

Title: _________________________________________________________________

Date: _________________________________

Proposer shall list and attach to this form proposer’s exception(s):

Appendix B.06

COST PROPOSAL

Pursuant to the Notice Inviting Quotations for Request for Quotations (RFQ) #27-02, the undersigned firm submits a Quote on this Cost Proposal Form and binds itself on award by MST under this Quote to execute a Contract in accordance with its Quote, the Request for Quotations, the preceding Request for Qualifications, and the award. The RFQ, including the Notice Inviting Quotes, Technical Specifications, Sample Contract, Forms, and Addenda, if any, are made a part of this Quote and all provisions thereof are accepted, and all representations and warranties required thereby are hereby affirmed.

Grand Total Price Per Actuarial Study:____________________________

The Grand Total Price submitted with this Quote is a fixed price per actuarial study that includes the total cost for all materials, equipment, delivery charges, warranties, insurance, services, and all other costs necessary for furnishing the work under the contract for the RFQ. The Grant Total Price represents all such costs for the duration of the contract.

Company Name: _______________________

Name (Print): __________________________

Title:_________________________________

Signature: ____________________________

Date: ________________________________