3-C-DFCM Health Insurance Statement of Compliance Form, Revised 7.28.25.docx
DOCX document 78 KB Posted
- Solicitation number
- DA27002
- Issued by
- Utah
About this file
Summary
This is a Health Insurance Statement of Compliance Form issued by the State of Utah's Division of Facilities Construction and Management (DFCM) for the Utah National Guard Camp Williams Building 21 Upgrade project. The form is required for prequalified general contractors bidding on this Stage II construction project, which involves comprehensive building repairs and upgrades estimated at $2,400,000. The scope includes replacing exterior windows, storefronts, doors, roofing systems, electrical infrastructure, HVAC systems, flooring, ceiling tiles, metal soffits and gutters, latrines and shower facilities, and applying EFIS exterior wall finish to the entire building. Additionally, the project requires updating the floor plan to meet users' needs and current code requirements. Only contractors who have successfully completed Stage I Prequalification and appear on the DFCM Prequalified Contractors list as of the solicitation date are eligible to submit bids for this project.
The Health Insurance Statement of Compliance Form serves as a prerequisite compliance document that bidders must complete to demonstrate their adherence to state insurance requirements. This form is a standard requirement within DFCM's procurement process for prequalified contractors and establishes baseline eligibility criteria beyond technical and financial qualifications. The completion and submission of this form is mandatory for all bidders seeking to participate in the Stage II invitation to bid process, ensuring that only contractors meeting the state's health insurance compliance standards advance in the competitive bidding process.
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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 .