25-84131500-ITN DFS BOR Attachment R Notice of Conflict.pdf
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- Attached to
- Insurance Broker of Record - Reinsurance Broker for Property and Casualty lines, Risk Management and
- Solicitation number
- ITN-13124
- Issued by
- St. Johns County, Florida
About this file
Attachment R is a Notice of Conflict of Interest form for Invitation to Negotiate (ITN) No. 25-84131500-ITN, issued by the Florida Department of Management Services on behalf of the Department of Financial Services' Division of Risk Management. The form requires potential respondents to disclose any conflicts of interest, specifically identifying any corporate officers, directors, or agents who are currently state employees, or current state employees who own a 5% or more interest in the responding company. The form is designed to ensure transparency and compliance with Chapter 112 of the Florida Statutes during the solicitation process.
The document provides a standard template for vendors to declare potential conflicts of interest, with blank spaces for listing individuals who might represent a conflict. Respondents are instructed to write "N/A" if no conflicts exist. The form requires the signature of the respondent's authorized representative, along with a printed name and date, to formally attest to the accuracy of the conflict of interest disclosure.
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Text version
ITN No.: 25-84131500-ITN
ITN No.: 25-84131500-ITN
Attachment R
NOTICE OF CONFLICT OF INTEREST
Respondent (Vendor) Name: ______________________________________________
For the purpose of participating in the solicitation process and complying with the provisions of Chapter 112, F.S., the company states the following conflict(s) of interest exists as noted below (if none, write N/A in the applicable section(s) below):
The persons listed below are corporate officers, directors, or agents of the Respondent and are also currently employees of the State or one of its agencies:
The persons listed below are current employees of the State or one of its agencies who own an interest of five percent (5%) or more in the Respondent:
Signature of Respondent’s Authorized Representative
Authorized Representative’s Printed Name
Date
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