4-D-DFCM Health Insurance Statement of Compliance Form, Revised 7.28.25.docx
DOCX document 78 KB Posted
- Solicitation number
- MP27005-INSPECTIONS
- Issued by
- Utah
About this file
This is a Health Insurance Statement of Compliance Form issued by the State of Utah Division of Facilities Construction and Management (DFCM) for the Convergence Hall construction project, a Code & Special Inspections Services engagement. The form serves as a compliance verification document for contractors and service providers engaged on DFCM projects, requiring attestation of health insurance coverage or exemption status. The form applies to all special inspections contractors, material testing labs, and special inspectors working on DFCM projects who must maintain current prequalification status on the DFCM Approved Special Inspection Firms, Material Testing Labs, & Special Inspectors list. Convergence Hall is a 163,000 square foot, six-story building incorporating office, maker space, retail, event, and housing room typologies at the University of Utah (USHE institution), with an estimated inspections budget of $650,000.
The Health Insurance Statement of Compliance Form requires participating contractors to certify their health insurance status as a condition of contract performance. This documentation is mandatory for all entities providing code inspection and special inspection services on the project and establishes proof of compliance with state health insurance requirements prior to contract award and throughout the term of engagement. The form's revision date of July 28, 2025, reflects current compliance standards applicable to DFCM construction projects.
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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 .