25EB-003S-ATTACH_10-Commercially_Useful_Function_Cert..pdf

STATE OF CALIFORNIA - DEPARTMENT OF INSURANCE

COMMERCIALLY USEFUL FUNCTION CERTIFICATION

CDI-FBMD-BMB 008 (New 05/2025)

Every certified Disabled Veteran Business Enterprise (DVBE), Small Business (SB) and Micro Business (MB) must complete this form if they will perform an element of the work.

1 CONTRACTOR NAME (Completing Form) BUSINESS NAME “or” DOING BUSINESS AS (DBA) NAME: OSDS REF # (Currently certified firms only): Expiration Date

2 COMMERCIALLY USEFUL FUNCTION (CUF)

All certified SB, MB, and/or DVBE prime contractors, subcontractors or suppliers must meet the CUF requirements under Government Code, section 14837 (d)(4) (for SB) and Military and Veterans Code, section 999(b)(S)(B) (for DVBE).

Please answer the following questions, as they apply to your company for the goods and services being acquired in this solicitation:

Mark All That Apply: DVBE SB MB 1 If awarded a contract, will your business be responsible for the execution of a distinct element of the resulting work?

Yes No

2 If awarded a contract, will your business carry out the obligation of the contract by actually performing, managing, or supervising the work involved?

Yes No

3 If awarded a contract, will you perform work that is normal for your business, service and functions? Yes No

4 If awarded a contract, will your business subcontract a portion of the work greater than would be expected by normal industry practices?

Yes No

5 If awarded a contract, will your business role be limited to that of an extra participant in a transaction, contract, or project through which funds are passed in order to obtain the appearance of SB and/or DVBE participation?

Yes No

A response of "No" in questions 1-3 or a response of "Yes" in question 4 may result in your quote being deemed non-responsive and disqualified.

3 WRITTEN STATEMENT

Provide a written statement below detailing the role, services and goods your company will provide to meet the commercially useful function requirement. At the State's option prior to award, you may be required to submit additional clarifying information.

4 AUTHORIZING SIGNATURE (REQUIRED)

The signatory of this document must be the certified business owner (or authorized representative in the case of a corporation) and as such, herby certifies under penalty of perjury under the laws of the State of California that all information provided herein is truthful and accurate.

AUTHORIZED REPRESENTATIVE SIGNATURE: TITLE:

PRINTED NAME: DATE: