Amendment of Solicitation 19CB6022R0027 (0002).pdf

SENSITIVE BUT UNCLASSIFIED

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

1. CONTRACT ID CODE

PAGE OF PAGES

1 8

2. AMENDMENT/MODIFICATION NO.

3. EFFECTIVE DATE

See block 16C

4. REQUISITION/PURCHASE REQ. NO.

5. PROJECT NO. (If applicable)

6. ISSUED BY CODE 7. ADMINISTERED BY (If other than Item 6)

CODE

U.S. Embassy Phnom Penh #1, Street 96, Sankat Wat Phnom, Daun Penh

Phnom Pen, Cambodia

Tel: 023 728 000; Fax: 023 728 504

American Embassy Phnom Penh

General Services Office/Procurement

8. NAME AND ADDRESS OF CONTRACTOR (NO., street,city,county,State,and ZIP Code)

9a. AMENDMENT OF SOLICITATION NO.

19CB6022R0027

9b. DATED (SEE ITEM 11)

October 07, 2022

10a. MODIFICATION OF CONTRACT/ORDER NO.

10b. DATED (SEE ITEM 13)

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

[ X ] The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers [X] is extended, [] is not extended

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods: (a) By completing Items 8 and 15, and returning _______ copies of the amendment;(b) By acknowledging receipt of this amendment on each copy of the offer submitted; or(c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers.

FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE

CONTRACT ORDER NO. IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b)

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority)

E. IMPORTANT: Contractor [X] is not, [] is required to sign this document and return __ copy to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

The purpose of this amendment is to:

A. Add Exhibit E, Exhibit F, and Exhibit G into Section J – List of Exhibits/Attachments

B. Add a sub-paragraph in paragraph H.4.1 of Section H

C. Extend the closing date until January 20, 2023, at 4:00 pm, Cambodian local time.

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER (Type or print)

16A. NAME OF CONTRACTING OFFICER

Chris Berkey

15B. NAME OF CONTRACTOR/OFFEROR

BY

(Signature of person authorized to sign)

15C.DATE

SIGNED

16B. UNITED STATES OF AMERICA

BY

(Signature of Contracting Officer)

16C.DATE SIGNED

NSN 7540-01-152-8070 Standard Form 30 (revised 10/83)

Previous edition unusable Prescribed by GSA FAR (48 CFR) 53

Amendment 0002

Solicitation 19CB6022R0027

A. The solicitation is amended to incorporate Exhibit E, Exhibit F, and Exhibit G into Section J – List of

Exhibits/Attachments.

EXHIBIT E – CLAIMS/PREMIUM/NET GAIN DATA AND EMPLOYEE DATA FOR 5 YEARS

Contractual

Year

Total claims paid

(USD)

Retention amount

(USD)

Total premium paid to

Insurer (USD)

Net gain (USD)

2015-2016 $466,140.44 $157,616.16 $570,046.98 ($53,709.62)

2018-2019 $505,008.00 $111,425.08 $579,451.36 ($36,981.72)

2019-2020 $503,537.84 $111,348.12 $615,751.20 $865.24

2020-2021 $457,094.76 $123,541.08 $624,590.16 $43,954.32

2021-2022 $390,669.73 $126,928.62 $593,833.54 $76,235.19

Contractual Year Employee Spouse Children

2018-2019 564 402 676

2019-2020 550 384 636

2020-2021 569 327 691

2021-2022 577 394 692

2022-2023 586 399 691

Data for 2017 was not available due to last option year end of the previous contract and the transition period.

EXHIBIT F – HISTORY OF CATASTROPHIC CASES

Description of Illness/Accident Duration of

Hospitalization (days) Year of Illness/Accident

Type 2 diabetes mellitus 11 2019

Hemoperitoneum 12 2019

Motor-vehicle accident 19 2019

Unspecified multiple injuries 15 2018

Cutaneous abscess, furuncle and carbuncle of limb 10 2018

Pneumonia 11 2020

Atrial premature depolarization 19 2020

Placenta increta 30 2021

Pneumonia due to SARS-associated coronavirus 11 2021

Pneumonia due to SARS-associated coronavirus 10 2021

Unspecified hemorrhoids 11 2021

Melioidosis 15 2022

EXHIBIT G – HISTORY OF CLAIMS FOR OUT OF COUNTRY TREATMENT

No. Description of Illness/Accident

Country of

Service/Treatment

Taken

Total Claims

Paid

Year of Service/

Treatment

Happened

1 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $183.32 2019

2 Leukemia, unspecified THAILAND $110.54 2019

3 Other abnormal and inconclusive findings on diagnostic imaging of breast

THAILAND $862.65 2019

4 Chronic viral hepatitis B without delta-agent VIETNAM $38.00 2019

5 General examination and investigation of persons without complaint or reported diagnosis

VIETNAM $11.61 2019

6 General examination and investigation of persons without complaint or reported diagnosis

VIETNAM $56.31 2019

7 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $151.79 2019

8 Endometriosis THAILAND $49.38 2020

9 Unspecified viral hepatitis B VIETNAM $80.10 2020

10 Malignant neoplasm without specification of site THAILAND $1,882.64 2020

11 Allergic rhinitis, unspecified THAILAND $120.88 2018

12 Unspecified viral hepatitis B VIETNAM $181.14 2018

13 Polyp of cervix uteri THAILAND $119.12 2018

14 Endometriosis of ovary THAILAND $650.45 2018

15 Other specified bacterial agents as the cause of diseases classified to other chapters

THAILAND $158.28 2018

16 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $73.24 2018

17 Mastodynia THAILAND $87.91 2018

18 Mastodynia THAILAND $44.00 2018

19 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $132.66 2022

20 Allergic rhinitis, unspecified THAILAND $39.47 2022

21 Other noninfective gastroenteritis and colitis THAILAND $594.43 2022

22 Gastritis- unspecified THAILAND $18.70 2022

23 Gastritis- unspecified THAILAND $265.10 2022

24 Hypertrophy of nasal turbinates THAILAND $60.14 2022

25 Hypertrophy of nasal turbinates THAILAND $1,006.16 2022

26 Acute upper respiratory infection, unspecified THAILAND $27.70 2019

27 Other specified diseases of gallbladder THAILAND $64.38 2019

28 Low back pain THAILAND $40.71 2019

29 Allergic rhinitis, unspecified THAILAND $116.25 2019

30 Allergic rhinitis, unspecified THAILAND $85.42 2019

31 Allergic rhinitis, unspecified THAILAND $7.42 2019

32 Other hemorrhoids THAILAND $90.38 2019

33 Sialolithiasis THAILAND $1,047.33 2019

34 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $140.41 2019

35 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $107.98 2019

36 Calculus of kidney and ureter THAILAND $44.81 2019

37 Type 2 diabetes mellitus with other specified complication

THAILAND $64.70 2019

38 Other osteoporosis with pathological fracture THAILAND $207.76 2019

39 Other signs and symptoms in breast THAILAND $325.21 2019

40 Ocular pain THAILAND $22.63 2019

41 Unspecified viral hepatitis THAILAND $543.54 2019

42 Other disorders of eye and adnexa THAILAND $36.09 2019

43 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $28.78 2019

44 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $218.35 2019

45 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $143.06 2019

46 Disease of pancreas, unspecified THAILAND $230.78 2019

47 Dermatopolymyositis, unspecified THAILAND $59.18 2019

48 Acquired absence of breast and nipple THAILAND $2,395.23 2019

49 Acquired absence of breast and nipple THAILAND $32.47 2019

50 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $110.97 2019

51 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $18.66 2019

52 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $75.70 2019

53 Other signs and symptoms in breast THAILAND $149.36 2019

54 Juvenile dermatopolymyositis THAILAND $37.55 2019

55 Benign neoplasm of breast THAILAND $129.53 2019

56 Other and unspecified ovarian cysts THAILAND $147.48 2019

57 Allergic rhinitis, unspecified THAILAND $137.90 2019

58 Other and unspecified ovarian cysts THAILAND $3,162.60 2019

59 Other and unspecified ovarian cysts THAILAND $176.09 2019

60 Other specified headache syndromes VIETNAM $49.38 2019

61 Juvenile dermatopolymyositis THAILAND $49.10 2019

62 Juvenile dermatopolymyositis THAILAND $59.62 2019

63 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $54.88 2019

64 Other hemorrhoids THAILAND $35.40 2019

65 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $93.89 2019

66 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $128.15 2019

67 Juvenile dermatopolymyositis THAILAND $81.21 2019

68 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $207.26 2019

69 Allergic rhinitis, unspecified THAILAND $132.62 2019

70 Allergic rhinitis, unspecified THAILAND $130.11 2019

71 Chronic rhinitis- nasopharyngitis and pharyngitis THAILAND $36.15 2019

72 Sialolithiasis THAILAND $31.02 2019

73 Sialolithiasis THAILAND $10.50 2019

74 Sialolithiasis THAILAND $64.51 2019

75 Sialolithiasis THAILAND $6.22 2019

76 Sialolithiasis THAILAND $5.25 2019

77 Chronic sinusitis, unspecified THAILAND $22.13 2019

78 Allergic rhinitis, unspecified THAILAND $113.63 2019

79 Tear of meniscus, current VIETNAM $31.39 2019

80 Sialolithiasis THAILAND $50.67 2019

81 Arthritis, unspecified THAILAND $68.46 2019

82 Tear of meniscus, current VIETNAM $2,927.37 2019

83 Juvenile dermatopolymyositis THAILAND $39.81 2019

84 Benign neoplasm of unspecified breast THAILAND $75.42 2019

85 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $325.85 2019

86 Acute sinusitis, unspecified THAILAND $23.10 2019

87 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $110.78 2019

88 Essential (primary) hypertension THAILAND $151.83 2019

89 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $185.86 2019

90 Endometriosis of ovary AUSTRALIA $3,935.64 2019

91 Tear of meniscus, current VIETNAM $43.53 2019

92 Endometriosis of ovary AUSTRALIA $64.36 2019

93 Juvenile dermatopolymyositis THAILAND $156.80 2019

94 Pain in unspecified foot THAILAND $85.64 2019

95 Chronic viral hepatitis B without delta-agent THAILAND $1,671.61 2018

96 Other and unspecified dermatitis THAILAND $8.46 2018

97 Unspecified hemorrhoids SINGAPORE $256.78 2018

98 Acute sinusitis, unspecified SINGAPORE $342.50 2018

99 Dermatopolymyositis THAILAND $128.98 2018

100 Benign neoplasm of breast THAILAND $48.18 2018

101 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $80.65 2018

102 Myopia THAILAND $42.84 2018

103 Myopia THAILAND $59.56 2018

104 Low back pain THAILAND $274.19 2018

105 Myopia THAILAND $35.68 2018

106 Myopia THAILAND $25.76 2018

107 Unspecified lump in breast VIETNAM $12.10 2019

108 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $40.00 2018

109 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $278.96 2018

110 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $64.96 2018

111 Nonsuppurative otitis media, unspecified THAILAND $110.69 2018

112 Cholesterolosis of gallbladder THAILAND $161.25 2018

113 Other and unspecified ovarian cysts THAILAND $46.96 2019

114 Benign neoplasm of ovary THAILAND $76.00 2019

115 Other postprocedural states THAILAND $373.21 2019

116 Hyperlipidaemia, unspecified THAILAND $213.86 2019

117 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $45.67 2019

118 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $257.99 2019

119 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $45.67 2019

120 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $312.66 2019

121 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $92.49 2020

122 Juvenile dermatopolymyositis THAILAND $48.56 2020

123 Juvenile dermatopolymyositis THAILAND $66.50 2020

124 Neuralgia and neuritis, unspecified THAILAND $58.84 2020

125 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $233.82 2020

126 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $394.12 2020

127 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $26.36 2020

128 Myositis THAILAND $116.94 2020

129 Other signs and symptoms in breast THAILAND $69.38 2019

130 Other signs and symptoms in breast THAILAND $25.44 2019

131 Unspecified abdominal pain THAILAND $31.56 2019

132 Angina pectoris VIETNAM $81.46 2019

133 Arthritis, unspecified THAILAND $205.72 2020

134 Keratoconus THAILAND $25.65 2021

135 Keratoconus THAILAND $142.38 2021

136 Hyperplasia of prostate THAILAND $32.68 2021

137 Malignant neoplasm of hepatic flexure THAILAND $2,706.81 2021

138 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $272.82 2022

139 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $176.11 2022

140 Juvenile dermatopolymyositis THAILAND $107.46 2022

141 Juvenile dermatopolymyositis THAILAND $228.80 2022

142 Glaucoma THAILAND $52.76 2022

143 Keratoconus THAILAND $3,296.87 2022

144 Pain in left shoulder THAILAND $203.69 2022

145 Observation for suspected disease or condition, unspecified

THAILAND $104.41 2022

146 Other intervertebral disc degeneration- lumbar region

THAILAND $30.20 2022

147 Other intervertebral disc degeneration- lumbar region

THAILAND $262.48 2022

148 Occlusion and stenosis of carotid artery THAILAND $139.75 2022

149 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $229.87 2022

150 Nontoxic single thyroid nodule THAILAND $199.62 2022

151 General examination and investigation of persons without complaint or reported diagnosis

THAILAND $65.07 2022

152 Cervicalgia THAILAND $346.57 2022

153 Irritable bowel syndrome with diarrhea SINGAPORE $134.31 2022

154 Irritable bowel syndrome with diarrhea SINGAPORE $541.84 2022

155 Unspecified lump in breast SINGAPORE $20.00 2022

156 Unspecified lump in breast SINGAPORE $24.00 2022

157 Unspecified lump in breast SINGAPORE $20.00 2022

158 Hyperplasia of prostate THAILAND $2,460.79 2022

159 Gastritis- unspecified THAILAND $683.82 2022

160 Cervicalgia THAILAND $15.46 2022

161 Cervicalgia THAILAND $42.74 2022

162 Cervicalgia THAILAND $111.89 2022

163 Juvenile dermatopolymyositis THAILAND $89.78 2022

164 Vaccine or biological substance, unspecified causing adverse effects in therapeutic use

THAILAND $8.32 2022

165 Juvenile dermatopolymyositis THAILAND $264.00 2022

B. Add a sub-paragraph (6) into (b) Medical Insurance Claims, of paragraph H.4.1 as follows:

(6) The contractor at its own discretion may propose E-claiming system to process and administer claims.

It is at contractor’s responsibility for the setup and maintenance of the system.

C. The closing date is extended until January 20, 2023 at 4:00 pm, Cambodian local time.