7-5. Exhibit-B-2023.pdf
PDF 153 KB Posted
- Attached to
- INSURANCE BROKER & CLAIM MANAGEMENT
- Solicitation number
- 202604
- Issued by
- Erie County, New York
About this file
This is a respondent data form (Exhibit B) for the Erie County Medical Center Corporation (ECMCC) in New York, which is soliciting proposals for Insurance Broker and Claim Management services. The form requires respondents to provide comprehensive organizational information including firm name, tax payer identification, business addresses, and primary points of contact. Respondents must disclose their legal structure (corporation, LLC, partnership, or individual), state of formation, and authorization to conduct business in New York if a foreign entity. The form also requires disclosure of all directors, officers, managers, shareholders, partners, or members with their respective ownership percentages.
The form includes mandatory disclosures regarding prior contract terminations, conflicts of interest with ECMCC employees or board members, and existing business relationships with hospitals, health care systems, or health care providers in Western New York. Respondents must certify their participation in relevant procurement agreements such as New York State OGS Agreements, GSA Federal Agreements, Sourcewell, Omnia, or Premier Inc. GPO contracts. The form also provides checkboxes for respondents to identify if they hold New York State certifications as Minority Owned Business Enterprises (MBE), Women Owned Business Enterprises (WBE), or Service Disabled Veteran Owned Business Enterprises (SDVOB), with instructions to submit copies of applicable certificates with proposals. All respondents must provide an authorized signature with printed name, title, and date.
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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 .