2-PD 1.1 Attachment A- Proposal Submittal Form.docx
DOCX document 31 KB Posted
- Attached to
- Health and Pharmacy Benefits
- Solicitation number
- RFP 26-008
- Issued by
- Williamson County, San Antonio City, Texas
About this file
This is a Solicitation Submittal Form from the City of Round Rock, Texas, for a Request for Proposals (RFP) related to Health and Pharmacy Benefits administration services. The City seeks proposals from firms experienced in providing comprehensive health benefits and prescription drug claims services, including enhanced program recommendations, options, and alternatives through internal or external sources. The City currently outsources health, dental, vision, and prescription drug claims benefit administration services to United Healthcare as a Third-Party Administrator serving approximately 2,400 active employees, retirees, and dependents. The City operates on a fiscal year of October 1st through September 30th, with a benefits plan year running January 1st through December 31st and open enrollment occurring each October. Respondents must complete, sign, and upload this form with their submittal in the City's Bonfire portal, with failure to do so resulting in potential disqualification.
By submitting a response, respondents certify that all statements, pricing, and information are current, complete, and accurate, and agree that the City's Definitions and Standard Terms and Conditions in effect at the time of solicitation release shall govern the resulting contract unless specifically provided otherwise. Respondents must also confirm they have not offered any economic opportunity, employment, gift, loan, gratuity, discount, or favor to any City employee or evaluator in connection with their submittal. The signatory must be authorized to represent and bind the responding company. Supplemental Terms and Conditions applicable to this solicitation are available on the City's website at https://www.roundrocktexas.gov/city-businesses/solicitations/.
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Text version
ATTACHMENT A
SOLCITATION SUBMITTAL FORM AND EXECUTION
City of Round Rock Name of Solicitation RFP No. XX-XXX Class/Item: ###-## / ###-##
MONTH & YEAR
NOTE: RESPONDENTS SHALL COMPLETE, SIGN, AND UPLOAD THIS ATTACHMENT WITH THEIR SUBMITTAL IN BONFIRE. FAILURE TO DO SO MAY RESULT IN DISQUALIFICATION OF THE SUBMITTAL.
By signature hereon, the Respondent certifies that:
All statements, pricing and information prepared and submitted to the City’s Bonfire portal in response to this solicitation are current, complete, and accurate.
He/she has not given, offered to give, nor intends to give at any time hereafter, any economic opportunity, future employment, gift, loan gratuity, special discount, trip, favor, or service to a City employee, evaluator, or evaluating entity in connection with the submitted response. Signing the Execution of Solicitation Submittal Form with a false statement shall void the submitted offer or any resulting contracts.
Respondent represents and warrants that the individual signing this Execution of Solicitation Submittal Form is authorized to sign this document, represent the Respondent and to bind the Respondent under any contract resulting from this submittal.
RESPONDENT (COMPANY):
SIGNATURE (INK/DIGITAL):
NAME (TYPED/PRINTED):
TITLE:
DATE:
STREET:
CITY/STATE/ZIP:
TELEPHONE & FAX NO.:
E-MAIL ADDRESS:
FEDERAL TAX IDENTIFICATION NUMBER (FIN):
By submitting a response to this solicitation, the Respondent agrees that the City’s Definitions and Standard Terms and Conditions, in effect at the time of release of the solicitation, shall govern unless specifically provided otherwise in a separate agreement or on the face of a purchase order. In addition, the Supplemental Terms and Conditions listed in Section III, shall also be enforced as part of the contract, and can be obtained from the City’s website at: https://www.roundrocktexas.gov/city-businesses/solicitations/
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