3-C-DFCM Health Insurance Statement of Compliance Form, Revised 7.28.25.docx
DOCX document 78 KB Posted
- Solicitation number
- CS27020
- Issued by
- Utah
About this file
This is a Health Insurance Statement of Compliance Form for the State of Utah's Division of Facilities Construction and Management (DFCM) related to a prequalified general contractor construction project at Davis Technical College. The document establishes compliance requirements for contractors bidding on the Main Building Glazing Replacement Phase I project (Project #27049220), which involves replacing exterior glazing and window systems in select building portions with a construction cost estimate of $265,000.00. Only contractors who have been prequalified under DFCM's Stage I Prequalification process and appear on the current DFCM Prequalified Contractors list as of the solicitation date are eligible to submit bids for this Stage II Invitation to Bid.
The Health Insurance Statement of Compliance Form requires bidding contractors to demonstrate compliance with health insurance requirements as a condition of participation in the bidding process. This compliance documentation is a prerequisite for contractors to be considered for award on DFCM construction projects and must be completed and submitted with bid packages. The form ensures that contractors meet the state's health insurance standards and regulatory requirements prior to contract execution for this Davis Technical College glazing replacement project.
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Other files
| File | Type | Posted |
|---|---|---|
| 5-3-CS27020-27049220-Approved Specs.pdf | ||
| 6-2-CS27020-27049220-Approved Plans.pdf | ||
| 4-1-CS27020-27049220-Solicitation.docx | DOCX document | |
| 1-A-DFCM General Conditions August 2020-Clean rev 07122023.pdf | ||
| 2-B-Subcontractors List Form Instructions-7.1.2021.docx | DOCX document |
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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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