6-Attachment 9 - Certification re Debarment Suspension.pdf
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- Solicitation number
- RFP-2026-004
- Issued by
- Milwaukee County, Mattoon Village, Wisconsin
About this file
This is a Certification Regarding Debarment and Suspension document for Milwaukee County, Wisconsin's Request for Proposal to provide Basic Life Insurance and Optional Life Insurance Program administration and coverage services. The County seeks qualified and experienced firms to deliver comprehensive insurance coverage and full administrative services for its life insurance programs. The contract is structured with an initial three-year term followed by renewal options, with Willis Towers Watson Midwest, Inc. serving as the County's Broker of Record.
The certification requires applicants to attest that their principals, owners, officers, shareholders, key employees, directors, and member partners are not presently debarred, suspended, proposed for debarment, or otherwise ineligible for covered transactions by any Federal department or agency. Applicants must also confirm they have not been convicted of fraud or criminal offenses related to public transactions within the preceding three years, are not currently indicted for such offenses, and have not had public transactions terminated for cause or default within the same three-year period. The document requires authorized signature, date, printed name, title, and company information from the applicant.
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Text version
ATTACHMENT 9
CERTIFICATION REGARDING
DEBARMENT AND SUSPENSION
The applicant certifies to the best of its knowledge and belief that its principals, owners, officers, shareholders, key employees, directors and member partners: (1) are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from covered transactions by any Federal department or agency; (2) have not within a three-year period preceding the date of this proposal been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) transaction or contract under a public transaction, violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (3) are not presently indicted for or otherwise criminally charged by a governmental entity
(Federal, State or local) with commission of any of the offenses enumerated in (2) of this certification; and (4) have not within a three-year period preceding the date of this proposal had one or more public transactions (Federal, State or local) terminated for cause or default.
Authorized Signature: Date:
Printed Name: Title:
Company:
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