4-05 - Business Questionnaire.pdf
PDF 13 KB Posted
- Solicitation number
- RFP 26-19575-KM
- Issued by
- Hunt County, Texas
About this file
This is a Business Questionnaire form issued by the City of Lubbock, Texas Purchasing and Contract Management Department for use by all potential contractors and subcontractors participating in the Consulting and Broker Services for City Property and Casualty Insurance procurement. The questionnaire collects essential business information including the contractor's legal name, business address, telephone and fax numbers, business type classification, and years in operation. The form requests a brief description of materials and services to be provided. The contract opportunity involves obtaining professional property and casualty insurance consulting and broker services to manage the City's insured and self-funded programs across multiple coverage areas including Property, Auto, General Liability, Law Enforcement Liability, Employment Practices Liability, Public Officials Errors and Omissions, Airport Liability, Workers' Compensation, and Boiler & Machinery. The successful broker will be responsible for processing policy endorsements, conducting policy reviews and audits, and potentially preparing Requests for Proposals for the City's insurance needs, with coverage intended to commence on April 1, 2026, or at the next renewal date thereafter.
The questionnaire includes a comprehensive due diligence section requiring disclosure of the contractor's financial and legal standing, specifically addressing prior contract failures, pending litigation, debarment status, default history, arrearages on contracts or debts, suspension proceedings, and assessed liquidated damages or penalties. All insurance policies obtained through the successful consultant-broker must be provided net of commission to the City. The form requires certification by an owner or authorized representative through printed name, title, signature, and date. This questionnaire is a mandatory submission requirement for all bidders and must be completed as part of the proposal package for this consulting services opportunity.
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Text version
City of Lubbock, TX
Purchasing and Contract Management
Business Questionnaire
This questionnaire must be submitted for all potential Contractors and subcontractors listed on the
Schedule of Participation.
1. Name of Proposed Contractor ("Business", herein):
Doing Business As:
(other business name, if applicable)
2. Business Mailing Address:
Street Address
City State Zip Code
3. Business Telephone Number: ( ) Fax Number: ( )
4. Business Type: Individual Corporation Partnership Joint Venture
5. Number of Years in Business:
13. Please provide a brief description of your materials and/or services:
14. Is the Business a subsidiary of another entity? Yes No
15. Has the Business, or any officer or partner thereof, failed to complete a contract? Yes No
16. Is any litigation pending against the Business? Yes No
17. Has the Business ever been declared "not responsible"? Yes No
18. Has the Business been debarred, suspended, proposed for debarment, declared ineligible, voluntarily excluded or otherwise disqualified from bidding, proposing or contracting? Yes No
19. Has the Business been a defaulter, as principal, surety or otherwise? Yes No
20. Has the government or other public entity requested or required enforcement of any of its rights under a surety agreement on the basis of a default or in lieu of declaring the Business in default?
Yes No
21. Is the Business in arrears upon a contract or debt? Yes No
22. Are there any proceedings pending relating to the Business' responsibility, debarment, suspension, voluntary exclusion or qualification to receive a public contract? Yes No
23. Have liquidated damages or penalty provisions been assessed against the Business for failure to complete the work on time or for any other reason? Yes No
Printed Name: Title
Signature of Owner: Date:
File details come from the government source that posted it. Updated .