3-C-DFCM Health Insurance Statement of Compliance Form, Revised 7.28.25.docx
DOCX document 78 KB Posted
- Solicitation number
- CS27023
- Issued by
- Utah
About this file
This is a Health Insurance Statement of Compliance Form issued by the Division of Facilities Construction and Management (DFCM) for the State of Utah, specifically applicable to the Zion AC Replacement project at Utah State Fairpark (Project #27071370). The form establishes compliance requirements for contractors bidding on this Stage II prequalified mechanical construction project, which involves replacing one of two LG heat pumps with a more reliable HVAC system. Only contractors who have completed Stage I prequalification and are currently listed on the DFCM Prequalified Contractors list are eligible to submit bids for this project with a construction cost estimate of $95,000.00.
The Statement of Compliance Form serves as a verification document requiring contractors to demonstrate that their health insurance offerings meet or exceed specified standards set by the State of Utah. This form is a mandatory submission component of the bidding process and ensures that all participating contractors maintain adequate health insurance coverage for their employees in accordance with state requirements. Contractors must complete and sign the revised form (dated 7.28.25) as part of their bid package to establish compliance with the health insurance provisions established by DFCM for this procurement.
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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 .