7-5. Exhibit-B-2023.pdf
PDF 153 KB Posted
- Attached to
- OUTSIDE LEGAL/ATTORNEY SERVICES
- Solicitation number
- 202523
- Issued by
- Erie County, New York
About this file
Exhibit B is a respondent data form for Erie County Medical Center Corporation (ECMCC) in New York, requesting proposals from qualified law firms to provide outside legal and attorney services. ECMCC seeks law firms with at least eight years of experience in general civil liability defense, insurance coverage matters, and labor and employee claims. Selected firms will be responsible for defending, litigating, and providing legal advice, counsel, services, consultation, and opinions to ECMCC across these specified practice areas. Qualified law firms may apply for consideration in one or more of these areas.
The form requires respondents to provide comprehensive organizational information, including firm name, tax payer identification, principal and local office addresses, and points of contact. Respondents must disclose their legal structure, state of formation, and authorization to conduct business in New York. The form mandates disclosure of all directors, officers, managers, shareholders, partners, or members with ownership percentages. Additionally, respondents must disclose any prior contract terminations with detailed explanations, conflicts of interest involving current or former ECMCC employees or board members, and existing business relationships with hospitals, health care systems, or health care providers in Western New York. The form also requests identification of applicable certifications, including New York State OGS agreements, GSA federal agreements, and New York State Certified Minority Owned Business Enterprise (MBE), Women Owned Business Enterprise (WBE), and Service Disabled Veteran Owned Business Enterprise (SDVOB) designations, with supporting documentation required where applicable.
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Text version
EXHIBIT B RESPONDENT DATA
To facilitate correct drawing and execution of a contract for services, respondents shall supply full information concerning legal status:
Firm Name:
Tax Payer ID:
Any trade name or assumed name (“d/b/a”):
Address of Principal office:
Street:
City: State:
Zip: Phone:
Address of Local Office:
Street:
City: State:
Zip: Phone:
Point of Contact:
Please provide a point of contact(s) for any clarifying questions for your proposal submission.
Name:
Email:
Phone Number:
Name:
Email:
Phone Number:
Check one:
☐Corporation
☐Limited Liability Company
☐Partnership
☐Individual
Formed under the laws of the state of: .
If a foreign entity, state whether authorized to do business in the State of New York:
☐Yes
☐No
Names and addresses of all directors and officers (or managers if an LLC):
Names and percentage ownership interest of all shareholders, partners, or members:
Disclose whether respondent has ever had a contract terminated and if so, provide a detailed explanation of the contract and circumstances surrounding termination.
Disclose whether any shareholder, director, officer or employee is currently employed by
ECMCC, or was an employee of ECMCC during the two (2) year period preceding the date of the proposal, and if any shareholder, director, officer or employee is a member of any governing board of ECMCC or its affiliates.
Disclose any other areas that may be a potential conflict of interest.
Describe all contracts, affiliations, referral arrangements or other business relationships the respondent has with any hospital, health care system or health care provider with offices or facilities in Western New York.
Please check any/all that apply: Certification #/Contract #
☐New York State OGS Agreement
☐GSA Federal Agreement
☐Sourcewell agreement
☐Omnia Agreement
☐Premier Inc. GPO
☐NYS Certified Minority Owned Business
Enterprise (MBE) (If so, please provide a copy of the NYS Certificate with proposal)
☐NYS Certified Women Owed Business
Enterprise (WBE) (If so, please provide a copy of the NYS Certificate with proposal)
☐NYS Certified Service Disable Veteran
Owned Business Enterprise (SDVOB) (If so, please provide a copy of the NYS Certificate with proposal)
Authorized Signature
Print Name and Title
Date
File details come from the government source that posted it. Updated .