2-CERTIFICATION FORM.pdf
PDF 112 KB Posted
- Solicitation number
- 1189
- Issued by
- Denton County, Texas
About this file
This certification form is a standardized document required by the City of Corinth, Texas for all respondents submitting proposals in response to the City's Request for Proposal for Health and Welfare Employee Benefits Insurance Plans covering medical, pharmacy, and dental coverage. Respondents must complete and sign the certification form to acknowledge their understanding of specifications, terms, and conditions outlined in the proposal package and to verify compliance with all applicable federal, state, and local requirements. The form requires respondents to designate an authorized representative, provide company information including principal place of business address and contact details, and initial acknowledgment of any addenda issued during the solicitation process. The City reserves the right to award multiple contracts for different coverage types, and respondents may receive awards for only one coverage area even if submitting proposals for multiple coverages. The proposal acceptance period is 120 calendar days unless otherwise noted by the respondent.
The certification form requires respondents to attest to multiple compliance requirements, including confirmation that no collusion occurred in proposal preparation, that no gratuities were offered to City officials or employees, that the firm is not debarred from federal contracts, and that the respondent does not boycott Israel, energy companies, or firearm entities as defined under Texas Government Code. Respondents must also verify they are not identified on lists maintained by the Texas Comptroller regarding contracts with foreign terrorist organizations. The form stipulates that the contract is not valid until approved by City Council and that any award letter becomes part of the final contract. Supporting documents including Medical Claims Experience, Dental Claims Experience, Provider Disruption, and Census data are available upon request from Brooke Bare, Marketing Assistant at HUB International, at brooke.bare@hubinternational.com. All respondents are responsible for monitoring the City of Corinth's Bonfire website at https://cityofcorinth.bonfirehub.com/ to download and acknowledge all required addenda prior to submission.
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CERTIFICATION FORM - Solicitation #__________
In submitting this form - signed, the respondent agrees and certifies to the following conditions:
1. The undersigned agrees that after the official opening this proposal becomes the property of the City of Corinth.
2. The undersigned affirms he/she has familiarized himself with the local conditions under which the work is to be performed; satisfied him/herself of the conditions of delivery, handling and storage of equipment and all other matters that may be incidental to the work, before submitting a proposal.
3. The undersigned agrees, if this proposal is accepted, to furnish any and all items/services upon which prices are offered, at the price(s) and upon the terms and conditions contained in the Specifications. The period for acceptance of this Proposal will be 120 calendar days unless a different period is noted by the respondent.
4. The undersigned affirms that they are duly authorized to execute this contract, that this proposal has not been prepared in collusion with any other
Respondent, nor any employee of the City of Corinth, and that the contents of this bid have not been communicated to any other respondent or to any employee of the City of Corinth prior to the official opening of this proposal.
5. The respondent certifies that no employee, representative, or agent of the firm offered or gave gratuities in any form (i.e. gifts, entertainment, etc.) to any council Member, official, or employee of the city of Corinth in order to secure favorable treatment or consideration in awarding, negotiating, amending or concluding a final agreement for this proposal. The respondent agrees that and warrants that no employee, official, or member of the City Council is, or will be, peculiarly benefited, directly or indirectly, in this proposal or any ensuing contract that may follow.
6. The respondent hereby certifies that he/she is not included on the U.S. Comptroller General’s Consolidated List of Persons or Firms currently debarred for violations of various contracts incorporating labor standards/provisions.
7. Respondent verifies that it does not Boycott Israel, and agrees that during the term of this Agreement (Contract as applicable) will not Boycott Israel as that term is defined in Texas Government Code Section 808.001, as amended. This requirement does not apply to sole proprietorships, companies with fewer than ten employees; or contracts that are less than $100,000.00.
8. Respondent affirms that is it not identified on a list created by the Texas Comptroller of Public Accounts as a company known to have contracts with or provide supplies or services to a foreign terrorist organization pursuant to Texas Government Code Chapter 2252,Subchapter F.
9. Respondent verifies that it does not boycott energy companies and will not boycott energy companies during the term of this contract, as those terms are defined by Chapter 2274, Government Code. This requirement does not apply to companies with fewer than ten full time employees; or contracts that are less than $100,000.00.
10. Company verifies that it does not have a practice, policy, guidance, or directive that discriminates against a firearm entity or firearm trade association and will not discriminate during the term of this contract against a firearm entity or firearm trade association, as those terms are defined by Chapter 2274, Government Code. This requirement does not apply to companies with fewer than ten full time employees; or contracts that are less than $100,000.00.
11. Respondent/Vendor hereby assigns to purchaser any and all claims for overcharges associated with this Contract which arise under the antitrust laws of the United States, 15 USCA Section 1 et seq., and which arise under the antitrust laws of the State of Texas, Tex. Bus. & Com. Code, Section 15.01, et seq.
12. The undersigned affirms that he/she has read and understands the specifications, terms and conditions, all exhibits and attachments contained in this proposal package.
13. The undersigned understands they are responsible for monitoring the Bonfire website at https://cityofcorinth.bonfirehub.com/to ensure they have downloaded and signed all addenda required for submission with their response.
14. The Contract is not valid until approved by Council, if applicable. When an award letter is issued, it becomes a part of this Contract.
If an addendum to this proposal is issued, acknowledge addendum by initialing beside the addendum number:
Add. No. 1 _______ Add. No. 2 ________ Add. No. 3 ________ Add. No. 4 ________ Add. No. 5_______
Company Name: _____________
Principal Place of Business Address, City, State, Zip: _____________
Principal Place of Business Phone Number:________ Fax Number: ____
AUTHORIZED REPRESENTATIVE:
Signature Date
Printed Name Title
Email Address Phone https://cityofcorinth.bonfirehub.com/
AUTHORIZED REPRESENTATIVE:
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