25-02 2026 Defense Panel.pdf

REQUEST FOR PROPOSALS

RFP#25-02

FUND DEFENSE PANEL

October 28, 2025 at 11:00A.M.

South Bergen Municipal Joint Insurance Fund

9 Campus Drive, Suite 216

Parsippany, NJ 07054

Executive Director: Stephen A. Sacco

LEGAL NOTICE

REQUEST FOR PROPOSAL

Notice is hereby given by the South Bergen Municipal Joint Insurance Fund (“The

FUND”) that a Request for Proposals in accord with N.J.S.A. 40A:11-1 et. Seq. will be received by the FUND on October 28, 2025 at 11:00 A.M. prevailing time conducted on electronic platform, in accord with N.J.A.C. 5:34-1 et. Seq., on

BidNet at www.bidnetdirect.com//SouthBergenJif

RFP # 25-02 DEFENSE PANEL RFP

South Bergen Municipal Joint Insurance Fund Purchasing Agent Sean P. Canning QPA

Scanning@TheCanningGroup.org 862-228-3563

Bidders must comply with the requirements of N.J.S.A. 10:5-31 et seq., and

N.J.A.C. 17:27 et. Seq., This procurement has been advertised in accordance with the “Fair and Open Basis” and nothing further shall be required under the Pay-to-Play Legislation (N.J.S.A. 19:44A-20.5).

Date: September 22, 2025 Stephen A. Sacco

Executive Director http://www.bidnetdirect.com/SouthBergenJif mailto:Scanning@TheCanningGroup.org

SEALED SUBMISSION LABEL FOR PROPOSAL

PLEASE CUT OUT THE LABEL BELOW AND TAPE TO FRONT OF SEALED SUBMISSION

***IF ELECTRONIC PROCUREMENT PLEASE FILL OUT AND UPLOAD WITH

RESPONSE****

IMPORTANT-

SEALED SUBMISSION ENCLOSED

NAME,

COMPANY &

ADDRESS:

TO:

QUALIFIED PURCHASING AGENT

SOUTH BERGEN MUNICIPAL JOINT INSURANCE

FUND

9 Campus Drive, Suite 216

Parsippany, NJ 07054

RFP 25-02 FUND DEFENSE PANEL

REQUEST FOR PROPOSALS (RFP)

FOR

DEFENSE ATTORNEY

I. PURPOSE AND INTENT

Through this Request for Proposals (RFP), the South Bergen Municipal Joint Insurance

Fund (hereinafter the “Fund”) seeks to engage a Service Provider as a member of the Fund

Defense Panel for the 2026 fund year commencing January 1, 2026 or upon appointment, whichever is later. This contract will be awarded through a Fair and Open process pursuant to NJSA 19:44A-20.5 et seq.

II. PROPOSAL SUBMISSION

Submit e-procurement response through BidNet at www.bidnetdirect.com//

SouthBergenJif

The proposal must be electronically delivered through the e procurement platform as located within the legal notice.

Faxed or E-Mailed proposals will NOT be accepted.

Any inquiry concerning this RFP should be directed in writing to:

PROCESS QUESTIONS TECHNICAL QUESTIONS

Sean P. Canning, QPA scanning@TheCanningGroup.org

862-228-3563

Jason Thorpe, Account Executive c/o PERMA South Bergen JIF jthorpe@permainc.com 201-518-7037

This Request for Proposals is to solicit professional services. All documents and information submitted in response to this solicitation shall be available to the general public as required by the New Jersey Open Public Records Act N.J.S.A. 47:1A-1 et seq. The Fund will not be responsible for any costs associated with the oral or written and/or presentation of the proposals. The Fund reserves the right to reject any and all proposals in whole or in part and waive such informalities as may be permitted by law. The Fund further reserves the right to make such investigations as it deems necessary as to the qualifications of any and all vendors submitting proposals. The fund reserves the right to negotiate contracts for such services and seek amendments to any proposal.

http://www.bidnetdirect.com/ mailto:scanning@TheCanningGroup.org mailto:jthorpe@permainc.com

III. GENERAL INFORMATION ON THE FUNCTIONS OF THE FUND

The Fund is organized pursuant to N.J.S.A. 40A: 10-36 to provide property/casualty insurance to its member local units. The Fund also provides its members with a comprehensive risk control and claims management program. The Fund is controlled by

Board of Fund Commissioners that annually elects an executive committee. The Fund is regulated by the Department of Banking and Insurance and the Department of Community

Affairs.

IV. MINIMUM QUALIFICATIONS

1. The responder shall demonstrate a consistent pattern of providing legal services to joint insurance or self-insured governmental entities and must quantify the results achieved.

2. The responder must demonstrate a consistent pattern of successfully controlling workers’ compensation litigation.

3. The responder must designate and provide background information on all attorneys who may be assigned to defend the Fund.

V. MANDATORY CONTENTS OF PROPOSAL

In its proposal, the responder must include the following:

1) Contact Information: Provide the name and address of the firm, the name, telephone number, fax number, and e-mail address of the individual responsible for the preparation of the proposal.

2) Compensation for FUND years awarded under this procurement will be established by the Board of Fund Commissioners at annual reorganization.”

3) A statement detailing how the responder meets minimum qualifications listed in Section

IV. List the first item followed with the specific response, followed with the next item and the response, and so on. Also include a staffing plan listing those persons who will be assigned to the engagement if selected, including the designation of the person who would be the responder’s officer responsible for all services required under the engagement. This portion of the proposal should include the relevant resume information for the individuals who will be assigned. This information shall further include, at a minimum, a description of the person’s relevant professional experience, years and type of experience, and number of years with the responder.

The responder shall also include in an addendum a copy of the data forms required by the

Department of Banking and Insurance pursuant to NJAC 11:15 – 2.6 (c) 8 a Non-

Collusion Certificate and a Disclosure of Investment Activities in Iran as attached. Also include a copy of your NJ Business Registration Certificate. If you do not already have this certificate, you can register online at https://www.nj.gov/dca/divisions/dlgs/programs/lpcl.html#1

4) A description of the responder’s experience in performing services of the type described in this RFP. Specifically identify client size and specific examples of similarities with the scope of services required under this RFP.

5) A description concerning specific and quantifiable cost savings the responder can demonstrate from similar engagements and the rational why the Fund should consider this experience when evaluating the responder’s cost proposal.

6) A description of resources of the responder (i.e., background, location, experience, staff resources, financial resources, other resources, etc.).

7) The location of the office or offices at which the responder proposes to perform services required under this RFP. Specifically, the responder must state in its proposal whether or not the responder is registered as a small business enterprise (“SBE”) with the New Jersey

Commerce and Economic Growth Commission New Jersey’s Set-Aside Program.

8) At least five references including the contact names, titles and phone numbers.

9) Any existing or potential conflicts of interest. Disclose any representation of parties or other relationships that might be considered a conflict of interest with regard to this engagement, or the Fund.

10) Contract will be in accordance with NJAC 17:44-2.2 - which requires all vendors to maintain all documentation related to the services provided for a period of five years from the date of final payment. Records to be made available to the state office of comptroller upon request.

VI. INTERVIEW & CLARIFICATION

The Fund reserves the right but has no obligation to interview any or all of the responders and the right to request clarifying information subsequent to submission of the proposal.

VII. SELECTION PROCESS AND CRITERIA

All proposals will be reviewed to determine responsiveness. Non-responsive proposals will be rejected without evaluation. For vendors that satisfy the minimum requirements, the

Fund will evaluate proposals based on the following evaluation criteria, separate or combined in some manner, and not necessarily listed in order of significance:

https://www.nj.gov/dca/divisions/dlgs/programs/lpcl.html#1

(a) The vendor’s general approach to providing the services required under this RFP.

(b) The vendor’s documented experience in successfully completing contracts of a similar size and scope to the engagement addressed by this

RFP

(c) The qualifications and experience of the vendor’s management, supervisory or other key personnel assigned to the engagement, with emphasis on documented experience in successfully completing work on contracts of similar size and scope to the services required by this RFP.

(d) The overall ability of the vendor to mobilize, undertake and successfully complete the engagement within the timeline. This criterion will include, but not be limited to, the following factors: the number and qualifications of management, supervisory and other staff proposed by the vendor to perform the services required by this RFP; the availability and commitment to the engagement of the vendor’s management, supervisory and other staff proposed; the vendor’s contract management plan, including the vendor’s contract organizational chart.

DATA FORM

(Print or Type)

Name and Address of Administrator or Servicing Organization

In connection with the above-named company, I herewith make representations and supply information about myself as hereinafter set forth. (Attach addendum or separate sheet if space hereon is insufficient to answer any question fully.) IF ANSWER IS “NONE” or

“NO EXCEPTION”, SO STATE.

1. Affiant’s Full Name:

2. Other Names Used at any Time:

3. Date of Birth: Place of Birth:

4. Social Security Number: To be supplied after confirmation of pending appointment_

5. For the last 10 years, I have lived at the following address or addresses:

ADDRESS CITY DATES

6. Schooling:

College:

Graduate:

or Professional:

Degree (List):

ATTACH LIST OF ALL EDUCATIONAL INSTITUTIONS AND LOCATION-CITY AND

STATE)

7. Member of Professional Societies or Associations (List):

8. I presently hold or have held, in the past, the following professional, occupational, and vocational licenses issued by public or governmental licensing agencies or authorities (state date license issued, issuer of license, date terminated, reason for termination):

9. Present Chief Occupation:

Position or Title:

Employer’s Name:

Address:

How long in this position?

How long with this employer? Where?

10. Other jobs, positions, directorates or officer ships concurrently held at present.

11. Complete Employment Record for Past 20 Years:

DATES EMPLOYER AND ADDRESS TITLE

12. I control directly or indirectly or own legally or beneficially 10% or more of the outstanding capital stock (in voting power) of the following companies:

12a. If any of the above stock is pledged or hypothecated in any way, please detail fully:

13. I have never been adjudicated as bankrupt, except as follows:

14. I have never been convicted or had a sentence imposed or suspended, or had pronouncement of a sentence suspended, or been pardoned for conviction of, or pleaded guilty of an nolo contendere to an information an indictment charging a felony for embezzlement, theft or larceny, mail fraud, or violating any corporate securities statute or any insurance law, nor have I been the subject of a cease and desist order or consent order of any federal or state regulatory agency, except as follows:

15 During the last 10 years, I have neither been refused a professional, occupational vocational license by any public or governmental licensing agency or regulatory authority, nor has such a license held by me ever been suspended or revoked, except as follows:

16. I have never been an officer, director, key employee or controlling stockholder of a company which, while I occupied any such position or capacity with respect to it, became insolvent or was enjoined from or ordered to cease and desist from violating any law, except as follows:

17. Neither I nor any company of which I was an officer, director or key management person at the time has ever been subject to any civil action alleging fraud, negligence or violation of any applicable racketeering statutes (state or federal), except as follows:

18. I am not and none of the employees, officers or directors of: (name of company) is an employee, officer or director of any other administrator, program manager, servicing organization or insurance producer of the Fund, nor do I or any of the employees, officers or directors of (name of company) have a direct or indirect financial interest in any other administrator, program manager, servicing organization or insurance producer of the Fund, except as follows:

18a. Any direct or indirect financial interest or any position held as employee, officer or director in any other administrator, program manager, servicing organization, or insurance producer of the Fund, as described above, has been disclosed to the Fund commissioners or executive committee, as applicable. (Yes/No)

Dated and signed this day of at

I hereby certify under penalty of perjury that the foregoing statements are true and correct to the best of my knowledge and belief and further, by the affixation of my signature hereon, I hereby give my certified consent to the New Jersey Department of Insurance to verify the representations and information supplied in response to all questions on the biographical data form, with any Federal, State, municipal or other agency which may have knowledge and/or information thereon.

(Signature of Affiant)

State of

County of

Personally appeared before me the above named personally known to me, who, being duly sworn, deposes and says that affiant executed the above instrument and that the statements and answers contained therein are true and correct to the best of affiant’s knowledge and belief.

Subscribed and sworn to before me this day of .

Notary Public

My Commission Expires

(SEAL)

DATA FORM SUMMARY

YEAR

Firm Name:

Address:

Phone No. Fax. No.

1.) List all parties having or deriving any interest, right or benefit in the firm.

Name Address Interest

2.) List all senior officers and directors who will be servicing the Fund, along with a description of professional qualifications.

Name Title Qualifications

I hereby certify that the information on this disclosure is accurate and complete, and that I am an officer of the firm and am duly authorized to supply this information on behalf of the firm.

Signature: Print:

Title: Date:

EXHIBIT A

MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE

N.J.S.A. 10:5-31 et seq. (P.L.1975, c.127)

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

GOODS, GENERAL SERVICES, AND PROFESSIONAL SERVICES CONTRACTS

During the performance of this contract, the contractor agrees as follows:

The contractor or subcontractor, where applicable, will not discriminate against any employee or applicant for employment because of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. Except with respect to affectional or sexual orientation and gender identity or expression, the contractor will ensure that equal employment opportunity is afforded to such applicants in recruitment and employment, and that employees are treated during employment, without regard to their age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex.

Such equal employment opportunity shall include, but not be limited to the following: employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination;

rates of pay or other forms of compensation; and selection for training, including apprenticeship.

The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the Public Agency Compliance Officer setting forth provisions of this nondiscrimination clause.

The contractor or subcontractor, where applicable will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified applicants will receive consideration for employment without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex.

The contractor or subcontractor will send to each labor union, with which it has a collective bargaining agreement, a notice, to be provided by the agency contracting officer, advising the labor union of the contractor's commitments under this chapter and shall post copies of the notice in conspicuous places available to employees and applicants for employment.

The contractor or subcontractor, where applicable, agrees to comply with any regulations promulgated by the Treasurer pursuant to N.J.S.A. 10:5-31 et seq., as amended and supplemented from time to time and the Americans with Disabilities Act.

The contractor or subcontractor agrees to make good faith efforts to meet targeted county employment goals established in accordance with N.J.A.C. l7:27-5.2.

The contractor or subcontractor agrees to inform in writing its appropriate recruitment agencies including, but not limited to, employment agencies, placement bureaus, colleges, universities, and labor unions, that it does not discriminate on the basis of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, and that it will discontinue the use of any recruitment agency which engages in direct or indirect discriminatory practices.

The contractor or subcontractor agrees to revise any of its testing procedures, if necessary, to assure that all personnel testing conforms with the principles of job related testing, as established by the statutes and court decisions of the State of New Jersey and as established by applicable Federal law and applicable Federal court decisions.

In conforming with the targeted employment goals, the contractor or subcontractor agrees to review all procedures relating to transfer, upgrading, downgrading and layoff to ensure that all such actions are taken without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, consistent with the statutes and court decisions of the State of New Jersey, and applicable Federal law and applicable Federal court decisions.

The contractor shall submit to the public agency, after notification of award but prior to execution of a goods and services contract, one of the following three documents:

Letter of Federal Affirmative Action Plan Approval;

Certificate of Employee Information Report; or

Employee Information Report Form AA-302 (electronically provided by the Division and distributed to the public agency through the Division’s website at: http:// www.state.nj.us/treasury/contract_compliance.

The contractor and its subcontractors shall furnish such reports or other documents to the Division of Purchase & Property, CCAU, EEO Monitoring Program as may be requested by the office from time to time in order to carry out the purposes of these regulations, and public agencies shall furnish such information as may be requested by the Divisionof Purchase & Property, CCAU, EEO Monitoring Program for conducting a compliance investigation pursuant to N.J.A.C. 17:27-1.1 et seq http://www.state.nj.us/treasury/contract_compliance

NEW JERSEY ANTI-DISCRIMINATION PROVISIONS

N.J.S.A. 10:2-1 ET SEQ.

Pursuant to N.J.S.A. 10:2-1, if awarded a contract, the contractor agrees that:

a. In the hiring of persons for the performance of work under this contract or any subcontract hereunder, or for the procurement, manufacture, assembling or furnishing of any such materials, equipment, supplies or services to be acquired under this contract, no contractor, nor any person acting on behalf of such contractor or subcontractor, shall, by reason of race, creed, color, national origin, ancestry, marital status, gender identity or expression, affectional or sexual orientation or sex, discriminate against any person who is qualified and available to perform the work to which the employment relates;

b. No contractor, subcontractor, nor any person on his behalf shall, in any manner, discriminate against or intimidate any employee engaged in the performance of work under this contract or any subcontract hereunder, or engaged in the procurement, manufacture, assembling or furnishing of any such materials, equipment, supplies or services to be acquired under such contract, on account of race, creed, color, national origin, ancestry, marital status, gender identity or expression, affectional or sexual orientation or sex;

c. There may be deducted from the amount payable to the contractor by the contracting public agency, under this contract, a penalty of $50.00 for each person for each calendar day during which such person is discriminated against or intimidated in violation of the provisions of the contract; and

d. This contract may be canceled or terminated by the contracting public agency, and all money due or to become due hereunder may be forfeited, for any violation of this section of the contract occurring after notice to the contractor from the contracting public agency of any prior violation of this section of the contract.

SAMPLE CERTIFICATE OF EMPLOYEE INFORMATION REPORT

FormAA302 Rev. 11/11

STATE OF NEW JERSEY

Division of Purchase & Property

Contract Compliance Audit Unit

EEOMonitoring Program

EMPLOYEE INFORMATION REPORT

IMPORTANT-READ INSTRUCTIONSCAREFULLYBEFORECOMPLETING FORM. FAILURE TO PROPERLYCOMPLETETHEENTIRE FORM AND TOSUBMITTHEREQUIRED

$150.00FEE MA Y DELAY ISSUANCEOFYOUR CERTIFICATE. DO NOTSUBMITEEO-1 REPORTFOR SECTIONB, ITEM 11.For Instructio ns on completing the form, go to:

http://www.state.nj.us/treasury / contract comp lia nce/pdf/aa302 ins.pdf

SECTION A- COMPANY IDENTIFICATION

I. FID. NO. OR SOCIAL

SECURITY

2. TYPE OF BUSINESS

0 I. MFG O 2. SERVICE

0 4. RETAIL O 5. OTHER

O

3. WHOLESALE

3. TOTAL NO. EMPLOYEES IN THE ENTIRE

COMPANY

4. COMPANY NAME

5. STREET CITY COUNTY STATE ZIP CODE

6. NAME OF PARENT OR AFFlLIATED COMPANY (IF NON, E SO INDICATE) CITY STATE ZIP CODE

7. CHECK ONE: IS THE COMPANY: 0 SINGLE-ESTABLISHMENT EMPLOYER 0 MULTI-ESTABLISHMENT EMPLOYER

I I

9. T O TAL NUMBER OF EMPLOYEES AT ESTABLISHMENT WHICH HAS BEEN AWARDED THE CONTRACT

10. PUBLIC AGENCY AWARDING CONTRACT

CITY COUNTY STATE ZIP CODE

Official Use Onl DATE RECEIVED NAUG.DATE ASSIGNED CERTIFICATION NUMBER

SECTION B - EMPI OYMENJ DATA

11. . Reportallpetmanent, temporaryand part.timeemployeesONYOUR OWNPAYROLL. Entertheappropriatefigures onall linesand inall columns.Wherethereare no employees ina particular category, enter a zero. Include ALL employees, notjustthose in minority/non-minoritycategories, in columns1, 2, & 3. DONOTSUBMIT

AN EE0-1REPORT.

I

SECTION C - SIG NA TUREAND IDENTI FICATION

17. ADDRESS NO. & STREET CITY COUNTY STATE ZIP CODE PHONE (AREA CODE, NO.,EXTENSION)

JOB

CATEGORIES

ALL EMPLOYEES - M IN O RITY caaD 1 nvcc .- • •1 ~ - ••n •

COL . I

T OTAL

(Cols.2 &3)

COL. 2

MALE

COL. 3

FEMALE

MALE* *** * * ********* ** ***** FEMAL!=

'3LACK

HISPANIC

AMER.

NDIA}

ASIAN

NON

MIN.

BLACK

HISPANIC

AMER.

INDIAN

ASI AN

NON

MIN .

Officials/ Ma nag ers

Profess ionals

Technicia ns

Sa les Workers

Office & Cle rical

Craftw o rke rs

(Skilled)

Operatives

(Semi-s killed)

Laborers

(Unskilled)

Service Workers

TOTAL

Total emplo yme nt

Fro m prev io us Reoo rt (If anv)

Temporary & Part-

Time Emp lo yees The data belowshall NOT be included in the figmes for the appropriate categories above.

1 2□. H

1. Visual Survey

M □A T

2. Employment Record D 3- Other (Specify)

SECTION B OBTAINED

14 . IS THIS THE FIRST 15. IF NO, DATE LAST

OW WASINFOR ION AS TO RACE OR ETHNIC GROUP IN Employee lnfonnation REPORT SUBMITTED

Report Subm itted?

MOI DAY I YEAR 13. DATES OF PAYROLL PERIOD USED

From: To: I. YES! 2.NOI

16. NAME OF PERSON COMPLETING FORM (Print or SIGNATURE TITLE http://www.state.nj.us/treasury/contractcompliance/pdf/aa302ins.pdf

Americans with Disabilities Act of 1990

The CONTRACTOR and the OWNER do hereby agree that the provisions of Title 11 of the Americans With

Disabilities Act of 1990 (the "ACT") (42 U.S.C~ S12101 et seq.), which prohibits discrimination on the basis of disability by public entities in all services, programs, and activities provided or made available by public entities, and the rules and regulations promulgated pursuant thereunto, are made a part of this contract. In providing any act benefit, or service on behalf of the OWNER pursuant to this contract, the CONTRACTOR agrees that the performance shall be in strict compliance with the Act. In the event that the Contractor, its agents, servants, employees, or subcontractors violate or are alleged to have violated the Act during the performance of this contract, the CONTRACTOR shall defend the OWNER in any action or administrative proceeding commenced pursuant to this Act. The Contractor shall indemnify, protect, and save harmless the OWNER, its agents, servants, and employees from and against any and all suits, claims, losses, demands, or damages, of whatever kind or nature arising out of or claimed to arise out of the alleged violation. The CONTRACTOR shall, at its own expense, appear, defend, and pay any and all charges for legal services and any and all costs and other expenses arising from such action or administrative proceeding or incurred in connection therewith. In any and all complaints brought pursuant to the OWNER grievance procedure, the CONTRACTOR agrees to abide by any decision of the OWNER which is rendered pursuant to said grievance procedure. If any action or administrative proceeding results in an award of damages against the OWNER or if the OWNER must any expense to cure a violation of the ADA which has been brought pursuant to its grievance procedure, the CONTRACTOR shall satisfy and discharge the same at its OWN expense.

The OWNER shall, as soon as practicable after a claim has been made against it, give written notice thereof to the CONTRACTOR along with frill and complete particulars of the claim. if any action or administrative proceedings is brought against the OWNER or any of its agents, servants, and employees, the OWNER shall expeditiously forward or have forwarded to the CONTRACTOR every demand, complaint, notice, summons, pleading, or other process received by the OWNER or its representatives.

It is expressly agreed and understood that any approval by the OWNER of the services provided by the

CONTRACTOR pursuant to this contract will not relieve the CONTRACTOR of the obligation to comply with the Act and to defend, indemnify, protect, and save harmless the OWNER pursuant to this paragraph.

It is further agreed and understood that the OWNER assumes no obligation to indemnify or save harmless the CONTRACTOR, its agents, servants, employees and subcontractors for any claim which may arise out of their performance of this Agreement. Furthermore, the CONTRACTOR expressly understands and agrees that the provisions of this indemnification clause shall in no way limit the CONTRACTOR'S obligations assumed in this Agreement, nor shall they be construed to relieve the CONTRACTOR from any liability, nor preclude the OWNER from taking any other actions available to it under any other provisions of the Agreement or otherwise at law.

Furthermore, the contractor expressly understands and agrees that the provisions of this indemnification clause shall in no way limit the contractor’s obligations assumed in this Agreement, nor shall they be construed to relieve the contractor from any liability, nor preclude the owner from taking any other actions available to it under any other provisions of the Agreement or otherwise at law.

New Jersey Business Registration Certification

Pursuant to N.J.S.A. 52:32-44, The South Bergen Municipal Joint

Insurance Fund (“Contracting Agency”) is prohibited from entering into a contract with an entity unless the bidder/proposer/contractor, and each subcontractor that is required by law to be named in a bid/proposal/contract has a valid Business Registration Certificate on file with the Division of Revenue and Enterprise Services within the Department of the Treasury.

Prior to contract award or authorization, the contractor shall provide the Contracting Agency with its proof of business registration and that of any named subcontractor(s).

Subcontractors named in a bid or other proposal shall provide proof of business registration to the bidder, who in turn, shall provide it to the Contracting Agency prior to the time a contract, purchase order, or other contracting document is awarded or authorized.

During the course of contract performance:

(1) the contractor shall not enter into a contract with a subcontractor unless the subcontractor first provides the contractor with a valid proof of business registration.

(2) the contractor shall maintain and submit to the Contracting Agency a list of subcontractors and their addresses that may be updated from time to time.

(3) the contractor and any subcontractor providing goods or performing services under the contract, and each of their affiliates, shall collect and remit to the Director of the Division of Taxation in the Department of the Treasury, the use tax due pursuant to the Sales and Use Tax Act, (N.J.S.A.

54:32B-1 et seq.) on all sales of tangible personal property delivered into the State. Any questions in this regard can be directed to the Division of Taxation at (609)292-6400. Form NJ-REG can be filed online at http://www.state.nj.us/treasury/revenue/busregcert.shtml.

Before final payment is made under the contract, the contractor shall submit to the Contracting Agency a complete and accurate list of all subcontractors used and their addresses.

Pursuant to N.J.S.A. 54:49-4.1, a business organization that fails to provide a copy of a business registration as required, or that provides false business registration information, shall be liable for a penalty of $25 for each day of violation, not to exceed $50,000, for each proof of business registration not properly provided under a contract with a contracting agency.

Emergency Purchases or Contracts

For purchases of an emergent nature, the contractor shall provide its Business Registration Certificate within two weeks from the date of purchase or execution of the contract or prior to payment for goods or services, whichever is earlier.

http://www.state.nj.us/treasury/revenue/busregcert.shtml

SAMPLE BUSINESS REGISTRATION CERTIFICATE

NON-COLLUSION AFFIDAVIT

SOUTH BERGEN MUNICIPAL JOINT INSURANCE FUND:

I certify that I am of the firm of the Respondent making this Proposal for the bid or proposal for the above named project, that I executed the said proposal with full authority to do so;

that said bidder has not, directly or indirectly entered into any agreement, participated in any collusion or otherwise taken any action in restraint of free, competitive bidding in connection with the above named project; and that all statements contained in said proposal and this affidavit are true, correct, and made with full knowledge that the SOUTH BERGEN MUNICIPAL JOINT INSURANCE FUND relies upon the truth of the statements contained in said Proposals and in the statements contained in this affidavit in awarding the contract for the said project.

I further warrant that no person or selling agency has been employed or retained to solicit or secure such contract upon an agreement or understanding for a commission, percentage, brokerage, or contingent fee, except bona fide employees or bona fide established commercial or selling agencies.

Signature of Representative:

Subscribed and sworn to before me this day of , 20

Print Name of

Affiant:

Notary Public of My commission expires

*This form MUST be completed, notarized and submitted with the bid document*

Disclosure Requirement

P.L. 2005, Chapter 271, Section 3 Reporting

(N.J.S.A. 19:44A – 20.27)

Any business entity that has received $50,000 or more in contracts from government entities in a calendar year will be required to file an annual disclosure report with ELEC.

The report will include certain contributions and contract information for the current calendar year.

At a minimum, a list of all business entities that file an annual disclosure report will be listed on ELEC’s website at www.elec.state.nj.us.

If you have any questions please contact ELEC at:

1-888-313-ELEC (toll free in NJ) or

609-292-8700

An analyst from ELEC’s Special Programs Section will assist you.

Initials http://www.elec.state.nj.us/

Part 2: Additional Information

Disclosure of Investment Activities in Iran

Person or Entity

Part 1: Certification

COMPLETE PART 1 BY CHECKING EITHER BOX.

Pursuant to Public Law 2012, c. 25, any person or entity that is a successful bidder or proposer, or otherwise proposes to enter into or renew a contract, must complete the certification below to attest, under penalty of perjury, that neither the person or entity, nor any parent entity, subsidiary, or affiliate is identified on the State Department of Treasury's

Chapter 25 list as a person or entity engaging in investment activities in Iran. The list is found on Treasury’s website at www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf.

The Chapter 25 list must be reviewed prior to completing the below certification. If a vendor or contractor is found to be in violation of law, action may be taken as appropriate and as may 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 certify, pursuant to Public Law 2012, c. 25, that neither the person or entity listed above, nor any parent entity, subsidiary, or affiliate thereof is listed on the N.J. Department of the

Treasury’s list of entities determined to be engaged in prohibited activities in Iran pursuant to P.L. 2012, c. 25 ("Chapter 25 List"). I further certify that I am the person listed above, or I am an officer or representative of the entity listed above and am authorized to make this certification on its behalf. I will skip Part 2 and sign and complete the Certification below.

OR

I am unable to certify as above because the person or entity and/or a parent entity, subsidiary, or affiliate thereof is listed on the N.J. Department of the Treasury’s Chapter

25 list. I will provide a detailed, accurate and precise description of the activities in Part 2 below sign and complete the Certification below.

http://www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf

PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN.

You must provide a detailed, accurate and precise description of the activities of the person or entity, or a parent entity, subsidiary, or affiliate thereof engaging in investment activates in Iran below and, if more space is needed, on additional sheets provided by you.

Part 3: Certification of True and Complete Information

I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments there to the best of my knowledge are true and complete. I attest that I am authorized to execute this certification on behalf of the above-referenced person or entity.

I acknowledge that the Fund is relying on the information contained herein and thereby acknowledge that I am under a continuing obligation from the date of this certification through the completion of any contracts with the Fund to notify the Fund in writing of any changes to the answers of information contained herein.

I acknowledge 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 recognize that I am subject to criminal prosecution under the law and that it will also constitute a material breach of my agreement(s) with the Fund and that the Fund at its option may declare any contract(s) resulting from this certification void and unenforceable.

Full Name (Print)

Title

Signature

Date

CERTIFICATION OF NON‐INVOLVEMENT IN PROHIBITED

ACTIVITIES IN RUSSIA OR BELARUS

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.

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.

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 https://pub.njleg.state.nj.us/Bills/2022/PL22/3_.PDF https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ 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).

NJ Rev. 1.22.2024

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)

PartnershipLimited 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)

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 Fund 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 Fund to notify the Fund 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, permitting the Fund to declare any contract(s) resulting from this certification void and unenforceable.

Full Name (Print): Title:

Signature: Date: