3-C-DFCM Health Insurance Statement of Compliance Form, Revised 7.28.25.docx
DOCX document 78 KB Posted
- Solicitation number
- CS27019
- Issued by
- Utah
About this file
This is a Health Insurance Statement of Compliance Form related to a Stage II Invitation to Bid issued by the State of Utah Division of Facilities Construction and Management (DFCM) for an electrical transformer and panel replacement project at Davis Technical College. The project, identified as Project #27048220, involves the replacement and relocation of selected transformers and electrical panels throughout the main building. Only contractors who have been prequalified under the Stage I Prequalification for Contractors process and appear on the DFCM Prequalified Contractors list as of the solicitation date are eligible to submit bids on this project. The construction cost estimate for this Phase 1 project is $300,000.00.
The Health Insurance Statement of Compliance Form serves as a required submission document for bidders participating in this procurement. This form, revised as of July 28, 2025, ensures that contractors demonstrate compliance with health insurance requirements established by the State of Utah for construction projects. As a prequalified Stage II bidding opportunity, this project is limited to eligible contractors who have previously completed the state's prequalification process and maintain current status on the approved contractors list.
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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 .