3-C-DFCM Health Insurance Statement of Compliance Form, Revised 7.28.25.docx
DOCX document 78 KB Posted
- Solicitation number
- DA27006
- Issued by
- 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 state and local contracting. The form, effective March 22, 2018 and revised July 28, 2025, requires contractors and subcontractors to certify that they offer qualified health insurance coverage to eligible employees and their dependents as defined under Utah Code 26B-3-909. The certification must be completed by an actuary, underwriter, or third-party administrator and signed with appropriate credentials. The compliance requirement applies to prime contractors on contracts valued at $2,000,000 or more and subcontractors on contracts valued at $1,000,000 or more. The requirement does not apply when federal funding receipt is jeopardized, in sole source contracts, or during emergency procurements.
Non-compliance with health insurance requirements carries escalating penalties beginning with a three-month suspension from state contracting on a first violation, progressing to a six-month suspension on a second violation, and potential debarment on a third or subsequent violation. Additionally, monetary penalties may be imposed up to 50 percent of the cost necessary to provide qualified health insurance coverage to non-covered eligible employees and their dependents throughout the contract duration. Contractors and subcontractors who intentionally violate the health insurance requirements are liable directly to employees for uncovered health care costs, and any intentional use of contract modifications, change orders, or multiple contracts to circumvent these requirements constitutes an infraction. For the referenced Capitol Complex Utility Plant Boiler Replacement project with a construction cost estimate of $351,000, this compliance requirement does not apply given the project cost falls below the $1,000,000 subcontractor threshold.
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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
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