3-C-DFCM Health Insurance Statement of Compliance Form, Revised 7.28.25.docx
DOCX document 78 KB Posted
- Solicitation number
- CS26071
- Issued by
- Davis County, Utah
About this file
This is a Health Insurance Statement of Compliance Form issued by the State of Utah's Division of Facilities Construction and Management (DFCM) for use in connection with state and local construction contracts. The form requires certification by an actuary or underwriter that the contractor or subcontractor maintains qualified health insurance coverage for eligible employees and their dependents, as defined under Utah Code 26B-3-909. The compliance requirement applies to prime contractors and design professionals on contracts valued at $2,000,000 or more in the aggregate, and to subcontractors and subconsultants on contracts valued at $1,000,000 or more in the aggregate. The requirement does not apply if compliance would jeopardize receipt of federal funds, if the contract is a sole source procurement, or if the contract is an emergency procurement.
Non-compliance with the health insurance requirement carries significant penalties, including three-month suspension from state contracting for a first violation, six-month suspension for a second violation, and potential debarment for a third or subsequent violation. Contractors may also face monetary penalties of up to fifty percent of the cost necessary to purchase qualified health insurance coverage for non-compliant employees, and contractors are liable to eligible employees for uncovered health care costs. Additionally, intentional circumvention of the requirements through change orders, modifications, or multiple contracts is classified as an infraction. The form, effective March 22, 2018 and revised July 28, 2025, requires the actuary or underwriter to certify compliance as of a specified date and provide credentials and company information.
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Text version
HEALTH INSURANCE STATEMENT OF COMPLIANCE
Effective March 22, 2018 (Revised July 28, 2025)
EMPLOYER: Contractor / Company Name
The undersigned is (check applicable box):
☐ An actuary selected by the Employer or the Employer’s insurer.
☐ An underwriter responsible for developing the Employer’s employer group’s premium rates.
☐ An actuary or underwriter selected by a third party administrator as defined in Utah Code § 31A-1-301 for an employee welfare benefit plan described in Utah Code § 63A-5b-607(1)(d)(ii).
The undersigned hereby certifies that as of Click to enter a date the Employer makes and maintains an offer of “qualified health insurance coverage” as that term is defined in Utah Code § 26B-3-909 for the Employer’s eligible employees and the eligible employees’ dependents.
Actuary/Underwriter:
Signature
Please type/print name clearly
Credentials:
Company:
Applies to: (i) a prime contractor (and design professional) if the prime contract (or design professional contract) is in the aggregate amount of $2,000,000 or more; and (ii) a subcontractor (and subconsultant of a design professional) if the subcontract (or subconsultant agreement) is in the aggregate amount of $1,000,000 or more.
Does not apply: (i) if application jeopardizes DFCM’s receipt of federal funds; (ii) if the contract is a sole source contract; or (iii) if the contract is an emergency procurement.
Penalties for non-compliance: Penalties may include: (i) a three-month suspension of the contractor or subcontractor from entering into future contracts with the state upon a first violation; (ii) a sixth-month suspension of the contractor or subcontractor from entering into future contracts with the state upon a second violation; (iii) an action for debarment of the contractor or subcontractor upon a third or subsequent violation; and (iv) monetary penalties which may not exceed 50% of the amount necessary to purchase qualified health insurance coverage for eligible employees and the dependents of eligible employees of the contractor or subcontractor who were not offered qualified health insurance coverage during the duration of the contract. A contractor or subcontractor who intentionally violates Utah Code § 63A-5b-607 is liable to an eligible employee for health care costs that would have been covered by qualified health insurance coverage. A person who intentionally uses change orders, contract modifications or multiple contracts to circumvent the requirements of Utah Code § 63A-5b-607 is guilty of an infraction.
DFCM Health Insurance Statement Of Compliance Form, 3.22.2018 (Revised 7.28.2025) image1.png
File details come from the government source that posted it. Updated .