2025 Management Life Insurance.pdf

REQUEST FOR PROPOSALS

MANAGEMENT LIFE INSURANCE

SUBMISSION DEADLINE:

April 24, 2025 at 4:00 pm

DELIVER ALL PROPOSALS TO

THE DEDICATED LOCKBOX LOCATED AT:

Division of Purchasing

Raquel Tosado, Director, QPA

280 Grove Street, 1st Floor, Room 116

Jersey City, NJ 07302 https://cityofjerseycity.com/

SECTION 1: GENERAL INFORMATION & SUMMARY

1.1 Contact Person

Raquel Tosado, Director, QPA

Division of Purchasing

280 Grove Street, 1st Floor, Room 116

Jersey City, NJ 07302

201-547-5156

RTosado@jcnj.org

1.2 Procurement Process

This contract will be awarded as an "extraordinary unspecifiable services” (EUS) agreement, as defined by the Local Public Contracts law, N.J.S.A. 40A:l l-5 (1) (a) (ii), using the "fair and open" process under the "New Jersey Local Unit Pay-to-Play Law”, N.J.S.A. 19:44A-20.4 et seq.

The City Council will vote to approve a resolution awarding a contract to the Respondent whose proposal best satisfies the requirements of this Request for Proposals (RFP).

1.3 Contract Form

If selected to provide services, it is agreed and understood that the Contractor shall be bound by the requirements and terms contained in this RFP with regard to services performed, payments, indemnification, insurance, termination, and applicable licensing provisions.

It is also agreed and understood that the acceptance of the final payment by the Contractor shall be considered a release in full of all claims against the City arising out of or by reason of, the work done and materials furnished under this Contract.

1.4 Informational meeting

There will not be an informational meeting for this RFP process.

1.5 Submission deadline

Proposals must be submitted to, and be received by the Purchasing Agent, via mail or hand delivery, by 4:00 p.m. prevailing time on April 24, 2025. Proposals will not be accepted by facsimile transmission or e-mail.

1.6 Definitions

The following definitions shall apply to and are used in this Request for Proposals (RFP):

"City" - refers to the City of Jersey City.

"RFP" - refers to this Request for Proposals, including any amendments thereof or supplements thereto.

mailto:RTosado@jcnj.org

"Respondent" or "Respondents" - refers to the interested persons and/or firm(s) that submit a

Proposal.

"Contractor" - refers to the person or firm that the City awards the contract to.

1.7 Submission address: DELIVER ALL PROPOSALS TO THE DEDICATED LOCKBOX

LOCATED AT:

Division of Purchasing

Raquel Tosado, Director, QPA

280 Grove Street, 1st Floor, Room 116

Jersey City, NJ 07302

(201) 547-5156 | RTosado@jcnj.org mailto:RTosado@jcnj.org

SECTION 2: INTRODUCTION AND GENERAL INFORMATION

2.1 Introduction and Purpose

The City is currently soliciting quotes from life insurance companies to provide Life and

Accidental Death and Dismemberment Insurance for eligible management employees.

2.2 Fair and Open Process

This contract will be awarded using the "fair and open" process under the "New Jersey Local

Unit Pay-to-Play Law”, N.J.S.A. 19:44A-20.4 et seq.

The City has structured a procurement process that seeks to obtain the desired services, while establishing a competitive environment to assure that each person and/or firm is provided an equal opportunity to submit a proposal in response to the RFP. Proposals will be evaluated in accordance with the criteria set forth in Section 6 of this RFP, which will be applied in the same manner to each proposal received.

2.3 Evaluation

Proposals will be reviewed and evaluated by the City's Purchasing Agent, Business

Administrator, Assistant Business Administrator and Brokers of Record for the City. The

Proposals will be reviewed to determine if the Respondent has met the professional, administrative, and subject areas described in this RFP.

2.4 Procurement Schedule

The steps involved in the process and the anticipated completion dates are set forth in the

Procurement Schedule below. The City reserves the right to, among other things, amend, modify or alter the Procurement Schedule upon notice to all potential Respondents.

TIMELINE DATE

Issuance of Request for Proposals April 7, 2025

Receipt of Proposals April 24, 2025

Contract Effective Date July 1, 2025

2.5 Addenda or Amendments to RFP

During the period provided for the preparation of responses to the RFP, the City may issue addenda, amendments or answers to written inquiries. Those addenda will be noticed by the

City and will constitute a part of the RFP. Each Respondent is required to acknowledge receipt of addenda by executing and submitting with its Proposal the Acknowledgment of

Receipt of Addenda. The Proposal will be rejected by the City if a Respondent does not include the Acknowledgment of Receipt of Addenda. All responses to the RFP shall be prepared with full consideration of the addenda issued prior to the Proposal submission date.

All communications concerning this RFP or the RFP process shall be directed to the City's online bidding portal, Bidnet Direct. Responses to all questions will be posted on Bidnet

Direct.

Subsequent to issuance of this RFP, the City (through the issuance of addenda to all persons and/or firms that have received a copy of the RFP) may modify, supplement or amend the provisions of this RFP in order to respond to inquiries received from prospective Respondents or as otherwise deemed necessary or appropriate by (and in the sole judgment of) the City.

2.6 Rights of the City

The City reserves, holds and may exercise, at its sole discretion, the following rights and options with regard to this RFP and the procurement process in accordance with the provisions of applicable law:

• To conduct investigations of any or all of the Respondents, as the City deems necessary or convenient, to clarify the information provided as part of the Proposal and to request additional information to support the information included in any

Proposal.

• To suspend or terminate the procurement process described in this RFP at any time

(in its sole discretion.) If terminated, the City may determine to commence a new procurement process or exercise any other rights provided under applicable law without any obligation to the Respondents.

2.7 Cost of Proposal Preparation

Each Proposal and all information required to be submitted pursuant to the RFP shall be prepared at the sole cost and expense of the Respondent. There shall be no claims whatsoever against the City, its officers, officials or employees for reimbursement for the payment of costs or expenses incurred in the preparation of the Proposal or other information required by the

RFP.

2.8 Proposal evaluation

Proposals will be evaluated by the Purchasing Agent, Business Administrator, Assistant

Business Administrator, and Brokers of Record for the City, based on the specific criteria detailed in Section 6.

2.9 Written Proposal

Respondents must submit a written Proposal in a format specified by the City. The required format is detailed in Section 3.

2.10 Oral presentation

Not required for this RFP.

2.11 Additional requirements

Respondent is required to comply with requirements of P.L. 1975, c. 127, the Law Against

Discrimination and with N.J.A.C. 17:27-1.1 et seq, the Affirmative Action Rules.

A party responding to this RFP must indicate what type of business organization it is e.g., corporation, partnership, sole proprietorship, or non-profit organization. If a party is a subsidiary or direct or indirect affiliate of any other organization, it must indicate in its proposal the name of the related organization and the relationship. If a party responding to this RFP is a corporation it shall list the names of those stockholders holding 10% or more of the outstanding stock.

2.12 Disposition of RFP

Upon submission of a Proposal in response to this RFP, the Respondent acknowledges and consents to the following conditions relative to the submission and review and consideration of its Proposal:

• All Proposals shall become the property of the City and will not be returned.

• All Proposals will become public information at the appropriate time, as determined by the

City (in the exercise of its sole discretion) in accordance with law.

2.13 Open Public Records Act (OPRA) and Proprietary Information

Although Section 2.12 indicates that all Proposals will become public information, it is understood that OPRA contains exceptions for "Trade secrets and proprietary commercial or financial information obtained from any source" and "Information which, if disclosed, would give an advantage to competitors or bidders".

A Respondent may designate specific information as not subject to disclosure pursuant to the exceptions to OPRA found at N.J.S.A. 47:lA-l.l, when the Respondent has a good faith legal or factual basis for such assertion. Therefore, Respondents shall submit two (2) clearly marked versions of their Proposals. One version is to be a complete version to be used by City of evaluation.

The second version should contain redactions of legitimate "trade secrets and proprietary commercial or financial information" and/or "information which would give an advantage to competitors or bidders". This second version will be provided to persons submitting OPRA requests for information relating to this solicitation. Failure to provide two clearly marked Proposals will mean that the Respondent agrees that the single version provided does not contract trade secrets or proprietary information and may be released pursuant to OPRA requests.

The City reserves the right to review information designated as proprietary or confidential and will advise the Respondent if any redactions appear inconsistent with OPRA.

The City will not honor any attempt by a Respondent to designate its entire Proposal as proprietary, confidential and/or to claim copyright protection for its entire proposal. In the event of any challenge to the Respondent's assertion of confidentiality with which the City does not concur, the Respondent shall be solely responsible for defending its designation.

SECTION 3: WRITTEN PROPOSAL FORMAT

Proposals must address all information requested in this RFP. Proposals which in the judgment of the City fail to meet the requirements of the RFP or which are in any way conditional, incomplete, obscure, contain additions or deletions from requested information, or errors may be rejected.

3.1 Mandatory Information

The following information should be provided by your organization as part of the RFP response

- due by April 21, 2025.

• Provide rates for a July 1, 2025, effective date with a second-year rate guarantee (if applicable).

• Match current plan designs that are in place today for all lines of coverage.

• If there are any discrepancies from the current plan design/provisions, please detail them to us (otherwise we will assume you can match the current from a plan design and provision perspective).

• Provide information on any of your ''value added" services that are included into the Life and AD&D policy.

It is important to note that pursuant to N.J.S.A. 40A:5-16, the City is prohibited from paying for goods or services before they have been provided. Therefore, any proposals which specify payment upon contract signing will be deemed unresponsive and rejected.

SECTION 4: SCOPE OF SERVICES

See the Schedule of Insurance below.

SCHEDULE OF

INSURANCE

The amount of an Insured Person's insurance is determined from the following table. The initial amount of coverage is the amount which applies to an Insured Person's Classification on the date his coverage becomes effective. Such coverage may increase in amount in accordance with the table. Any such increase will be effective on:

(1) The first day of the Insurance Month which coincides with or follows the date on which the Insured Person becomes eligible for the increase, provided such Insured Person is actively at work (includes vacation time) on that day; or

(2) The day the Insured Persons resumes active work if not actively at work on the day of the increase otherwise would have been effective.

An Insured Person's coverage may decrease because of retirement, reaching a specified age, or in accordance with the table. Any such decrease will be effective on the first day of the

Insurance Month coinciding with or following the date the condition for reduction is reached.

The Accidental Death and Dismemberment coverage will not decrease on or after the date of a covered injury.

TABLE OF INSURANCE

Insurance Class Classification of

Insured Persons

Basic Life Insurance Basic ADD Insurance

1 Full-time employees The amount of insurance is equal to three (3) times the

Insured Person’s annual earnings rounded to the next higher $1000, with a maximum of

$425,000

The amount of insurance is equal to three (3) times the

Insured Person’s annual earnings rounded to the next higher $1000, with a maximum of

$425,000

The Basic Life Insurance and Basic Accidental Death and Dismemberment Insurance will reduce 35% on the Insured Person's 65th birth date and will reduce an additional 15% on the

Insured Person's 70th birth date.

All of the insurance provided under the Group Policy will terminate on the Insured Person's date of retirement.

DATE OF RETIREMENT means the effective date of the Insured Person's retirement pension benefits under any plan which the Policyholder sponsors, makes, or has made contributions.

All providers will be required to accept copies of the employees' current beneficiary cards on file.

SECTION 5: PROPOSAL SUBMISSION REQUIREMENTS

To be responsive, Proposals must provide all requested information and must be in strict conformance with the instructions set forth herein. Proposals and all related information must be bound, signed, and acknowledged by the Respondent.

5.1 Number of copies

RESPONDENTS MUST PROVIDE: 1 SIGNED ORIGINAL, 2 COPIES OF THEIR

PROPOSAL OF WHICH 1 MUST BE UNBOUND (FOR PHOTOCOPYING/SCANNING

PURPOSES), 1 REDACTED VERSION, AND A DIGITAL COPY OF THE ORIGINAL

ON A THUMB DRIVE.

5.2 Proposal format

To facilitate a timely and comprehensive evaluation of all submitted Proposals, it is essential that all Respondents adhere to the required response format. The City requires a standard format for all Proposals submitted to ensure that clear, concise, and complete statements are available from each Respondent in response to requirements. The required format is detailed in Section 3.

The City is not under any obligation to search for clarification through additional or unformatted information submitted as a supplement to the formatted response. Where a Proposal contains conflicting information, the City, at its option, may either request clarification or may consider the information unresponsive.

5.3 Submission deadline

Proposals must be received by the City no later than 4:00 p.m. prevailing time on April 24, 2025 and must be mailed or hand-delivered.

SECTION 6: PROPOSAL EVALUATION

The City's objective in soliciting Proposals is to enable it to select a Contractor that will provide high-quality and cost-effective rates to the City.

6.1 Evaluation methodology

Proposals will be evaluated by the Purchasing Agent, Business Administrator, Assistant Business

Administrator and Brokers of Record for the City on the basis of which is the most advantageous, and this evaluation will consider the following:

a. Items listed under section 3.1.

b. Prior experience with similar cities

The City does not wish to educate its Contractor as to the workings (both operational and statutory) of municipal government. As a result, Proposals should include references from cities of similar size (approximately 356 management employees) and should include contact information for those entities.

c. Commitment to diversity

While the inclusion of Minority-Owned, Woman-Owned, Disadvantaged Business

Enterprise(s), and/or Emerging Small Business Enterprise(s) is not strictly required, the city strongly encourages participation of M/W/DBE and ESBE firms as prime or subcontractors. If included on the team, the firm’s M/W/DBE or ESBE certification, participating staff from the M/W/DBE and/or ESBE, and specific tasks to be performed by the M/W/DBE and/or ESBE should be included in this section.

6.2 Oral Presentation Guidelines

Not required for this RFP

6.3 Final evaluation

The City will select the most advantageous Proposal based on all of the evaluation factors set forth in this RFP and make the award in the best interest of the City. Each Proposal must satisfy the objectives and requirements detailed in this RFP. The Contractor shall be determined by an evaluation of the total content of the Proposal submitted. The City shall not be obligated to explain the results of the evaluation process to any Respondent.

6.4 Contract award

A contract will be awarded as an "extraordinary unspecifiable services” (EUS) agreement, as defined by the Local Public Contracts Law, N.J.S.A. 40A:11-5 (1) (a)_ (ii), pursuant to the "fair and open" provisions of the "New Jersey Local Unit Pay-to-Play Law”, N.J.S.A. 19:44A-20.4 et seq.

The Municipal Council will vote to accept the proposal of a Respondent within 30 days of the receipt of the Proposals.

SECTION 7: GENERAL TERMS AND CONDITIONS

The following are general terms and conditions which may or may not be explained elsewhere in this RFP.

7.1 City's right to reject

The City reserves the right to reject any or all Proposals, if necessary, or to waive any informalities in the Proposals, and, unless otherwise specified by the Respondent, to accept any item, items or services in the Proposal should it be deemed in the best interest of the City.

7.2 Original/Authorized signatures

Each Proposal and all required forms must be signed in ink by a person authorized to do so.

7.3 Delivery of proposals

Proposals may be hand delivered or mailed consistent with the provisions of the legal notice to

Respondents. In the case of mailed Proposals, the City assumes no responsibility for Proposals received after the designated date and time and will return late proposals unopened. Proposals will not be accepted by facsimile or e-mail.

7.4 Business Registration Certificate

P.L. 2004, c. 57 (Chapter 57) amends and supplements the business registration provisions of

N.J.S.A. 52:32-44, which imposes certain requirements upon a business competing for or entering into a contract with a local contracting agency whose contracting activities are subject to the requirements of the Local Public Contracts Law (N.J.S.A. 40A:11-2).

Respondents are required to comply with the requirements of P.L. 2004, c. 57 (Chapter 57) which include submitting a copy of their Business Registration Certificate (BRC), issued by the NJ

Department of the Treasury.

7.5 Compliance with the Americans with Disabilities Act of 1990

Discrimination on the basis of disability in contracting for the purchase of goods and services is prohibited. Respondent is required to read the Americans with Disabilities language that is included as Appendix A in the separately attached forms and agree that the provisions of Title

II of the Act are made a part of the contract. The Respondent is obligated to comply with the

Act and to hold the owner harmless.

7.6 Clarification of RFP

Should any difference arise as to the meaning or intent of this RFP, the City's Business

Administrator's decision shall be final and conclusive.

7.7 Indemnification

The Contractor agrees to protect, defend and save harmless the City against damage for payment for the use of any patented material process, article or devise that may enter into the manufacture, construction or form a part of the work covered by either order or contract and further agrees to indemnify and save harmless the City from suits or actions of every nature and description brought against it for, or on account of, any injuries or damages received or sustained by any party or parties by, or from, any of the acts of the Contractor , its servants or agents.

7.8 Insurance requirements

The Contractor shall maintain sufficient insurance to protect against all claims under

Workmen's Compensation, General Liability, Automobile Liability, and Professional

Liability and shall be subject to approval for adequacy of protection. Certificates of such insurance, naming the City as an additional insured, when possible, shall be provided.

Insurance requirements are as follows:

a) Commercial General Liability in the amount of $1,000,000 per occurrence and $2,000,000 in aggregate including Products & Completed Operations coverage.

b) Workmen’s Compensation Insurance with NJ statutory limits and Employer’s Liability in the amount of $1,000,000.

c) Automobile Liability in the amount of $1,000,000 combined single limit.

d) Professional Liability Insurance in $2,000,000 per occurrence and in aggregate.

e) Cyber Liability in the amount of $2,000,000 each incident and in aggregate.

Certificate of Insurance

Certificate of Insurance (COI) verifying evidence of such insurance to be provided prior to the execution of the contract. Where applicable all COI shall name “City of Jersey City, its officers and employees as an additional insured on a primary, noncontributory basis”. All Certificates shall bear the City Project Name and Number if applicable.

Coverage Effective Period

The insurance policies required shall be kept in force for the period specified below:

• General Liability, Automobile Liability, and Workers’ Compensation policies shall be kept in force until the submission of the Contractor’s final invoice.

• Professional Liability coverage must be effective retroactive to the earlier of the date of the Agreement of the date of a Notice-to-Proceed and policy shall be kept in force until at least three (3) years after completion of this Contract/Project or, if said coverage is not commercially available for such term, then for such term as is commercially available.

7.9 Compliance with Equal Employment Opportunity/Affirmative Action Plan

a) If the agreement exceeds $44,000.00 it shall also be subject to the provisions of N.J.S.A.

10:5-31 et seq. and N.J.A.C. 17:27 et seq. (Equal Employment Opportunity/Affirmative

Action Provisions).

Respondents are required to comply with the requirements of N.J.S.A. 10:5-31 et seq. and

N.J.A.C. 17:27 et seq.

b) This Agreement shall not become effective, and Contractor shall provide no services under this Agreement until it has complied with the Equal Employment Opportunity/Affirmative

Action provisions. The mandatory Equal Employment Opportunity/Affirmative Action

Language, Exhibit A, summarizes the full, required regulatory text.

Exhibit A and additional EEO/AA mandatory languages and forms are attached under separate cover and incorporated herein. For information on EEO/AA requirements and forms only, please contact:

Jeana F. Abuan, Department of Administration, Office of Tax Abatement & Compliance

Director, Public Agency Compliance Officer (P.A.C.O)

280 Grove Street, Lower Level, Room 109A

Jersey City NJ 07302

(201) 547- 4538 or (201) 547-4946

E-mail Address: abuanj@jcnj.org

7.10 City of Jersey City Lobbyist Disclosure Ordinance

The contract will be awarded in accordance with the City of Jersey City's Disclosure of

Lobbyist Representative Status Ordinance §3-9.1 et seq. adopted on June 12, 2002. The

Contractor will be required to certify that the Contractor either did not retain the services of a lobbyist to lobby on behalf of the Contractor for the award this contract, or if a lobbyist was retained by the Contractor for such purposes, the Contractor’s lobbyist prior to commencing his/her lobbying activities, shall have filed a notice of lobbyist representative status form with the City Clerk. The Contractor whose lobbyist failed to comply with the provisions of

Ordinance §3-9.1 et seq, following notice and an opportunity to be heard, shall be disqualified from entering into contracts with the City for a period of two (2) years for each violation.

7.11 Term of Contract

The initial term of the agreement will be for one (1) year effective July 1, 2025, with a termination date of June 30, 2026, pursuant to a resolution of the Municipal Council awarding the contract.

a) Respondents shall provide a three (3) year premium schedule with the City of Jersey City having options to renew the contract for two (2) additional one (1) year terms, at one-year intervals from the effective date.

b) In the event the Contractor desires to affect an assignment, it will notify the City in writing of the proposed date of t h e assignment and the name and address of the assignee.

The assignment may thereafter be affected unless the City notifies the Contractor of its objections in writing within thirty (30) days following receipt of such notice of assignment. The assignee must provide the same information and format as required in this request for proposals.

c) Notwithstanding anything to the contrary herein contained, this agreement may be terminated by the City without cause at any time for any reason upon thirty (30) days' notice given in writing to the Contractor.

If additional funds for this agreement are not appropriated and made available in the City's

Calendar year 2025 budget, or in subsequent calendar years, this agreement will terminate upon the expenditure of the funds authorized by purchase order.

7.12 Payment Process

The City agrees to make monthly payments to the Contractor via partial payments. Compensation shall be payable upon the submission of invoices to the Office of Employee Benefits based on the number of enrollees each month. The Contractor understands that each invoice must be submitted to the governing body of the City for approval before payment. The governing body meets on the second and the fourth Wednesday of each month. However, the governing body meets one time in the months of July, August, and December. A thirty (30) day grace period shall be granted to the

City to pay any and all fees necessary.

The Contractor’s final invoice may be submitted after the Office of Employee Benefits and the

Contractor agrees that all of the services required under this Agreement have been delivered and are acceptable.

CITY OF JERSEY CITY REQUEST FOR PROPOSALS

PURPOSE: MANAGEMENT LIFE INSURANCE DUE DATE: April 24, 2025

CITY OF JERSEY CITY

PROJECT: MANAGEMENT LIFE INSURANCE

(an individual)

The undersigned is (a corporation) under the laws

(a partnership)

Of the State of having offices at and submits this proposal in response to the City's RFP.

Signed: _______________________________________________________

Name: _______________________________________________________

Title: ________________________________________________________

Company: ____________________________________________________

Address: _____________________________________________________

SECTION 8: REQUIRED ADMINISTRATIVE FORMS

PROJECT: MANAGEMENT LIFE INSURANCE 2025

RESPONDENT: __________________________________________________________

Please place the checklist and the required forms at the front of your proposal.

RESPONDENT=S CHECKLIST

Item

Respondent

Initials

Purchasing

Review

*Acknowledgment of Receipt of Addenda

*Statement of Ownership Disclosure

Mandatory Affirmative Action Language (Exhibit A)

Non-Collusion Affidavit (Notarized)

Americans with Disabilities Act (Appendix A)

With Proposal or after notification of award, but prior to signing a contract, submit photo copy of one of the following three documents:

1. A valid letter that the contractor is operating under an existing Federally approved or sanctioned affirmative action program (good for one year from the date of the letter); or

2. Unexpired Certificate of Employee Information

Report; or

3. Employee Information Report (Form AA302) if first time doing business with

Jersey City.

Supplier Diversity Questionnaire

Business Registration Certificate

Certification of Non-Involvement in Prohibited Activities in Russia or Belarus

Original signature(s) on all required forms

*A Proposer’s failure to include these forms with its proposal will result in the rejection of the proposal.

https://cityofjerseycity.com/

STATEMENT OF OWNERSHIP DISCLOSURE

N.J.S.A. 52:25-24.2 (P.L. 1977, c.33, as amended by P.L. 2016, c.43)

This statement shall be completed, certified to, and included with all bid and proposal submissions. Failure to submit the required information is cause for automatic rejection of the bid or proposal.

Name of Organization:_________________________________________________________________

Organization Address:_________________________________________________________________

Part I Check the box that represents the type of business organization:

Sole Proprietorship (skip Parts II and III, execute certification in Part IV)

Non-Profit Corporation (skip Parts II and III, execute certification in Part IV)

For-Profit Corporation (any type) Limited Liability Company (LLC)

Partnership Limited Partnership Limited Liability Partnership (LLP)

Other (be specific): ______________________________________________

Part II

The list below contains the names and addresses of all stockholders in the corporation who own 10 percent or more of its stock, of any class, or of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be. (COMPLETE

THE LIST BELOW IN THIS SECTION)

OR

No one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no individual partner in the partnership owns a 10 percent or greater interest therein, or no member in the limited liability company owns a 10 percent or greater interest therein, as the case may be. (SKIP TO PART IV)

(Please attach additional sheets if more space is needed):

Name of Individual or Business Entity Address

Part III DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS

OR LLC MEMBERS LISTED IN PART II

If a bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10 percent or greater beneficial interest in the publicly traded parent entity as of the last annual federal Security and Exchange Commission (SEC) or foreign equivalent filing, ownership disclosure can be met by providing links to the website(s) containing the last annual filing(s) with the federal Securities and Exchange Commission (or foreign equivalent) that contain the name and address of each person holding a 10% or greater beneficial interest in the publicly traded parent entity, along with the relevant page numbers of the filing(s) that contain the information on each such person. Attach additional sheets if more space is needed.

Website (URL) containing the last annual SEC (or foreign equivalent) filing Page #’s

Please list the names and addresses of each stockholder, partner or member owning a 10 percent or greater interest in any corresponding corporation, partnership and/or limited liability company (LLC) listed in Part II other than for any publicly traded parent entities referenced above. The disclosure shall be continued until names and addresses of every noncorporate stockholder, and individual partner, and member exceeding the 10 percent ownership criteria established pursuant to N.J.S.A. 52:25-24.2 has been listed. Attach additional sheets if more space is needed.

Stockholder/Partner/Member and Corresponding Entity Listed in Part II

Address

Part IV Certification

I, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I acknowledge: that I am authorized to execute this certification on behalf of the bidder/proposer; that the CITY OF JERSEY CITY is relying on the information contained herein and that I am under a continuing obligation from the date of this certification through the completion of any contracts with the CITY OF JERSEY CITY to notify the CITY OF JERSEY CITY in writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the, CITY OF JERSEY CITY to declare any contract(s) resulting from this certification void and unenforceable.

Full Name (Print): Title:

Signature: Date:

THE CITY OF JERSEY CITY IS AN AFFIRMATIVE ACTION & EQUAL OPPORTUNITY EMPLOYER AND COMPLIES WITH ALL

LOCAL, STATE AND FEDERAL LAWS AND REGULATIONS IN EMPLOYMENT AND CONTRACTING.

SUPPLIER DIVERSITY BIDDER QUESTIONNAIRE

The City of Jersey City is committed to ensuring that its utilization of vendors reflects the diversity of its community. Please complete this form to assist us with monitoring our supplier diversity performance.

Business Name: ________________________________________________________________

Address: ________________________________________________________________

Phone: ________________________________________________________________

Email: ________________________________________________________________

Contact Name: ________________________________________________________________

Please indicate if your business qualifies as any of the following: (See definitions for clarification)

� Minority Owned

� Woman Owned

� Veteran Owned

� Disability Owned

� Lesbian, Gay, Bisexual, Transgender Owned

� None

Please indicate if your business is currently certified by an authorized certifying body as any of the following:

� Minority Business Enterprise

� Woman Business Enterprise

� Veteran Business Enterprise

� Disability Owned Business Enterprise

� Lesbian, Gay, Bisexual, Transgender Business Enterprise

� Disadvantaged Business Enterprise

� Small Business Enterprise

� None

THE CITY OF JERSEY CITY IS AN AFFIRMATIVE ACTION & EQUAL OPPORTUNITY EMPLOYER AND COMPLIES WITH ALL

LOCAL, STATE AND FEDERAL LAWS AND REGULATIONS IN EMPLOYMENT AND CONTRACTING.

SUPPLIER DIVERSITY DEFINITIONS

Minority Owned- a business which is a sole proprietorship, partnership or corporation at least 51% of which is owned and controlled by persons who are African American, Hispanic, Asian American, American Indian or Alaskan Native, defined as follows:

African American: a person having origins in any of the black racial groups of Africa.

Hispanic: a person of Mexican, Puerto Rican, Central or South American or other non-European Spanish culture or origin regardless of race.

Asian: a person having origins in any of the original peoples of the Far East, South East Asia, Indian subcontinent, Hawaii or the Pacific Islands.

American Indian or Alaskan Native: a person having origins in any of the original peoples of North America and who maintains cultural identification through tribal affiliation or community recognition.

Woman Owned- a business which is a sole proprietorship, partnership or corporation at least 51% of which is owned and controlled by a woman or women.

Veteran Owned- a business which is a sole proprietorship, partnership or corporation at least 51% of which is owned and controlled by a person or persons who are veterans.

"Veteran" means any citizen and resident of this State now or hereafter honorably discharged or released under honorable circumstances who served in any branch of the Armed Forces of the United States or a Reserve component thereof for at least 90 days and shall include disabled veterans.

Disability Owned- a business which is a sole proprietorship, partnership or corporation at least 51% of which is owned and controlled by a person or persons with a disability.

Lesbian, Gay, Bisexual, Transgender Owned- a business which is a sole proprietorship, partnership or corporation at least 51% of which is owned and controlled by an LGBT person or persons.

CERTIFICATION OF NON‐INVOLVEMENT IN

PROHIBITED ACTIVITIES IN RUSSIA OR BELARUS

NJ Rev. 1.22.2024

Pursuant to N.J.S.A. 52:32-60.1, et seq. (L. 2022, c. 3) any person or entity (hereinafter “Vendori”) that seeks to enter into or renew a contract with a State agency for the provision of goods or services, or the purchase of bonds or other obligations, must complete the certification below indicating whether or not the Vendor is identified on the Office of Foreign Assets Control (OFAC) Specially Designated Nationals and Blocked Persons list, available here:

https://sanctionssearch.ofac.treas.gov/. If the Department of the Treasury finds that a Vendor has made a certification in violation of the law, it shall take any action as may be appropriate and provided by law, rule or contract, including but not limited to, imposing sanctions, seeking compliance, recovering damages, declaring the party in default and seeking debarment or suspension of the party.

I, the undersigned, certify that I have read the definition of “Vendor” below, and have reviewed the Office of Foreign Assets Control (OFAC) Specially Designated Nationals and Blocked Persons list, and having done so certify:

(Check the Appropriate Box)

A.

That the Vendor is not identified on the OFAC Specially Designated Nationals and Blocked Persons list on account of activity related to Russia and/or Belarus.

OR

B.

That I am unable to certify as to “A” above, because the Vendor is identified on the OFAC Specially Designated Nationals and Blocked Persons list on account of activity related to Russia and/or Belarus.

OR

C.

That I am unable to certify as to “A” above, because the Vendor is identified on the OFAC Specially Designated Nationals and Blocked Persons list. However, the Vendor is engaged in activity related to Russia and/or Belarus consistent with federal law, regulation, license or exemption. A detailed description of how the Vendor’s activity related to Russia and/or Belarus is consistent with federal law is set forth below.

(Attach Additional Sheets If Necessary.)

Signature of Vendor’s Authorized Representative Date

Print Name and Title of Vendor’s Authorized Representative Vendor’s FEIN

Vendor’s Name Vendor’s Phone Number

Vendor’s Address (Street Address) Vendor’s Fax Number

Vendor’s Address (City/State/Zip Code) Vendor’s Email Address i Vendor means: (1) A natural person, corporation, company, limited partnership, limited liability partnership, limited liability company, business association, sole proprietorship, joint venture, partnership, society, trust, or any other nongovernmental entity, organization, or group; (2) Any governmental entity or instrumentality of a government, including a multilateral development institution, as defined in Section 1701(c)(3) of the International Financial Institutions Act, 22 U.S.C. 262r(c)(3); or (3) Any parent, successor, subunit, direct or indirect subsidiary, or any entity under common ownership or control with, any entity described in paragraph (1) or (2).