3-C-DFCM Health Insurance Statement of Compliance Form, Revised 7.28.25.docx
DOCX document 78 KB Posted
- Solicitation number
- CS26050
- 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), effective March 22, 2018 and revised July 28, 2025. The form pertains to the Willard Bay Marina Levee Repair project (Project #26228510) managed by the Department of Natural Resources/State Parks, with a construction cost estimate of $375,000. The scope of work includes MSE (Mechanically Stabilized Earth) Panel Retaining Wall Construction, rip rap installation, and repairs to a damaged parking lot once stabilized. The form requires certification by a qualified actuary, underwriter, or third-party administrator that the employer contractor maintains an offer of qualified health insurance coverage as defined in Utah Code 26B-3-909 for eligible employees and their dependents.
The Health Insurance Statement of Compliance applies to prime contractors and design professionals when contracts are $2,000,000 or more in aggregate value, and to subcontractors and subconsultants when agreements are $1,000,000 or more. The requirement does not apply if compliance jeopardizes receipt of federal funds, if the contract is sole source, or if it is an emergency procurement. Non-compliance penalties escalate progressively, including three-month suspension on first violation, six-month suspension on second violation, potential debarment on third or subsequent violations, and monetary penalties up to 50 percent of the cost to purchase qualified health insurance coverage. Contractors who intentionally violate the requirement are liable to eligible employees for health care costs that would have been covered, and intentional use of change orders, contract modifications, or multiple contracts to circumvent requirements constitutes an infraction.
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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 .