Amended 1 RFQ Response Template - Mandatory Use.docx

Request for Quote Response Template Please complete this packet and attach to your Quote in OregonBuys. Quote responses are due by 1:00pm Pacific Time on December 27th, 2021.

Minimum Requirements Checklist:

· Quoted price is below the budget amount of $10,000

· Required Attachments contained in this Response Template are completed and attached with your Quote in OregonBuys

· Quote includes experience, approach, schedule of deliverables, and proposed statement of work (with schedule and agenda for facilitation) Qualifications [ 20 Points] [Describe experience with similar projects developing mission, vision, and values statements, driving engagement, making recommendations, and assisting with goalsetting. Identify key persons that would perform work for this project, their roles, and their relevant experience.]

Approach [ 50 Points] [Detail approach to mission, vision, and values statements development, future recommendations, and goalsetting processes. Include how Leadership Summit Attendees will be engaged and how consensus is reached.]

Proposed Statement of Work [ 20 Points] [Include proposed schedule of deliverables, agenda for in-person facilitation session, and sample of draft pre-work for attendees of similar nature.]

Quoted Price [ 10 Points] [Total amount for the complete body of work]

Attachment 1 Required Insurance

INSURANCE REQUIREMENTS:

Respondent shall obtain at Respondent’s expense the insurance specified in this Attachment 1 prior to performing under this Contract and shall maintain it in full force and at its own expense throughout the duration of this Contract, as required by any extended reporting period or tail coverage requirements, and all warranty periods that apply. Respondent shall obtain the following insurance from insurance companies or entities that are authorized to transact the business of insurance and issue coverage in the State of Oregon and that are acceptable to Agency. Coverage shall be primary and non-contributory with any other insurance and self-insurance, with the exception of Professional Liability and Workers’ Compensation. Respondent shall pay for all deductibles, self-insured retention, and self-insurance, if any.

WORKERS’ COMPENSATION & EMPLOYERS’ LIABILITY

All employers, including Respondent, that employ subject workers, as defined in ORS 656.027, shall comply with ORS 656.017, and provide workers' compensation insurance coverage for those workers, unless they meet the requirement for an exemption under ORS 656.126(2). Respondent shall require and ensure that each of its subcontractors complies with these requirements. If Respondent is a subject employer, as defined in ORS 656.023, Respondent shall also obtain employers' liability insurance coverage with limits not less than $500,000 each accident. If Respondent is an employer subject to any other state’s workers’ compensation law, Contactor shall provide workers’ compensation insurance coverage for its employees as required by applicable workers’ compensation laws including employers’ liability insurance coverage with limits not less than $500,000 and shall require and ensure that each of its out-of-state subcontractors complies with these requirements.

COMMERCIAL GENERAL LIABILITY:

|X| Required

Commercial General Liability Insurance covering bodily injury and property damage in a form and with coverage that are satisfactory to the State. This insurance shall include personal and advertising injury liability, products and completed operations, contractual liability coverage for the indemnity provided under this contract, and have no limitation of coverage to designated premises, project, or operation. Coverage shall be written on an occurrence basis in an amount of not less than $1,000,000.00 per occurrence. Annual aggregate limit shall not be less than $2,000,000.00.

AUTOMOBILE LIABILITY INSURANCE:

Required Not required

Automobile Liability Insurance covering Respondent’s business use including coverage for all owned, non-owned, or hired vehicles with a combined single limit of not less than $100,0000 for bodily injury and property damage. This coverage may be written in combination with the Commercial General Liability Insurance (with separate limits for Commercial General Liability and Automobile Liability). Use of personal automobile liability insurance coverage may be acceptable if evidence that the policy includes a business use endorsement is provided.

EXCESS/UMBRELLA INSURANCE:

A combination of primary and excess/umbrella insurance may be used to meet the required limits of insurance.

ADDITIONAL INSURED:

All liability insurance, except for Workers’ Compensation, Professional Liability, and Network Security and Privacy Liability (if applicable), required under this Contract must include an additional insured endorsement specifying the State of Oregon, its officers, employees and agents as Additional Insureds, including additional insured status with respect to liability arising out of ongoing operations and completed operations, but only with respect to Respondent's activities to be performed under this Contract. Coverage shall be primary and non-contributory with any other insurance and self-insurance. The Additional Insured endorsement with respect to liability arising out of your ongoing operations must be on ISO Form CG 20 10 07 04 or equivalent and the Additional Insured endorsement with respect to completed operations must be on ISO form CG 20 37 07 04 or equivalent.

WAIVER OF SUBROGATION:

Respondent shall waive rights of subrogation which Respondent or any insurer of Respondent may acquire against the Agency or State of Oregon by virtue of the payment of any loss. Respondent will obtain any endorsement that may be necessary to affect this waiver of subrogation, but this provision applies regardless of whether or not the Agency has received a waiver of subrogation endorsement from the Respondent or the Respondent’s insurer(s).

TAIL COVERAGE:

If any of the required insurance is on a claims made basis and does not include an extended reporting period of at least 24 months, Respondent shall maintain either tail coverage or continuous claims made liability coverage, provided the effective date of the continuous claims made coverage is on or before the effective date of this Contract, for a minimum of 24 months following the later of (i) Respondent’s completion and Agency’s acceptance of all Services required under this Contract, or, (ii) Agency or Respondent termination of this Contract, or, iii) The expiration of all warranty periods provided under this Contract.

CERTIFICATE(S) AND PROOF OF INSURANCE:

Respondent shall provide to Agency Certificate(s) of Insurance for all required insurance before delivering any Goods and performing any Services required under this Contract. The Certificate(s) shall list the State of Oregon, its officers, employees and agents as a Certificate holder and as an endorsed Additional Insured. The Certificate(s) shall also include all required endorsements or copies of the applicable policy language effecting coverage required by this Contract. If excess/umbrella insurance is used to meet the minimum insurance requirement, the Certificate of Insurance must include a list of all policies that fall under the excess/umbrella insurance. As proof of insurance Agency has the right to request copies of insurance policies and endorsements relating to the insurance requirements in this Contract.

NOTICE OF CHANGE OR CANCELLATION:

The Respondent or its insurer must provide at least 30 days’ written notice to Agency before cancellation of, material change to, potential exhaustion of aggregate limits of, or non-renewal of the required insurance coverage(s).

INSURANCE REQUIREMENT REVIEW:

Respondent agrees to periodic review of insurance requirements by Agency under this Contract and to provide updated requirements as mutually agreed upon by Respondent and Agency.

STATE ACCEPTANCE:

All insurance providers are subject to Agency acceptance. If requested by Agency, Respondent shall provide complete copies of insurance policies, endorsements, self-insurance documents and related insurance documents to Agency’s representatives responsible for verification of the insurance coverages required under this Attachment 1.

Attachment 2

RESPONDENT INFORMATION AND CERTIFICATION SHEET

Respondent Name (printed):

Address:

City, State, Zip:

Respondent Contact Person:

Telephone:

Email:

State of Incorporation:

Entity Type:

Oregon Secretary of State Business Registry Number (if required):

Any individual signing below hereby certifies he/she is an authorized representative of Respondent and that:

1. Respondent understands and accepts the requirements of this RFQ. By submitting a Quote, Respondent agrees to be bound by the Contract/Price Agreement terms and conditions in Attachment A, as modified by Bid Amendment(s), if any.

2. Respondent acknowledges receipt of any and all Bid Amendments to this RFQ.

3. If awarded a Contract/Price Agreement, Respondent agrees to comply with all provisions of the RFQ and meet the performance standards set forth in the Contract/Price Agreement.

4. Respondent has no undisclosed liquidated and delinquent debt owed to the State or any department or agency of the State.

5. I have knowledge regarding Respondent’s payment of taxes and by signing below I hereby certify, to the best of my knowledge, Respondent is not in violation of any tax laws of the state or a political subdivision of the state, including, without limitation, ORS 305.620 and ORS chapters 316, 317 and 318.

6. Respondent does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Respondent does not discriminate against any business certified under ORS 200.055 as a disadvantaged business enterprise, a minority-owned business, a woman-owned business, a service-disabled veteran owned business, or an emerging small business. If applicable, Respondent has, or will have prior to contract execution, a written policy and practice, that meets the requirements described in ORS 279A.112, of preventing sexual harassment, sexual assault and discrimination against employees who are members of a protected class. Agency may not enter into a contract with an anticipated contract price of $150,000 or more with a Respondent that does not certify it has such a policy and practice. See https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx for additional information and sample policy template.

7. Respondent and Respondent’s employees, agents, and subcontractors are not included on:

A. the “Specially Designated Nationals and Blocked Persons” list maintained by the Office of Foreign Assets Control of the United States Department of the Treasury found at: https://www.treasury.gov/ofac/downloads/sdnlist.pdf, or B. the government wide exclusions list in the System for Award Management found at: https://www.sam.gov/portal/SAM/#1

8. Respondent certifies to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Respondent, its employees, or its agents, on the one hand, and the business or economic interests of the State, on the other hand, arising out of, or relating in any way to, the subject matter of the RFQ. If any changes occur with respect to Respondent’s status regarding conflict of interest, Respondent shall promptly notify the State in writing.

9. Respondent certifies all contents of its Quote (including any other forms or documentation, if required under this RFQ), and this Quote Cover Sheet are truthful and accurate and have been prepared independently from all other Respondents, and without collusion, fraud, or other dishonesty.

10. Respondent understands any statement or representation made in response to this RFQ, if determined to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" {as defined by the Oregon False Claims Act, ORS 180.750(1)}, made under Contract/Price Agreement being a "false claim" {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

11. Respondent acknowledges these certifications are in addition to any certifications required in the Contract/Price Agreement at the time of execution.

Authorized Signature

Date

(Printed Name and Title)

Email Address

Attachment 3 Independent Respondent Contractor Certification Respondent certifies the following:

Respondent Signature: Date:

Attachment 4 Executive Order 21-29 Vaccination Compliance Form

On August 13, 2021, Governor Kate Brown signed Executive Order (EO) 21-29. The purpose of the EO is to protect state workers, their coworkers and the public that relies on state services from the effects of COVID-19. This EO requires, in part, that Executive Branch state agencies have documentation that all workers are in compliance with the requirements of the EO. Per section 1.f., a Worker is an individual who is not employed by the state of Oregon but is engaged to provide goods or services to the Executive Branch through any formal or informal agreement; and where the goods or services are performed in person and on site at an Executive Branch worksite.

The purpose of this form is to document compliance with EO 21-29. If you fail to submit this signed document, you, your employees, and your subcontractors may be denied access to the worksite. A failure to comply with EO 21-29 may be a breach of contract and could result in termination of the contract.

The undersigned also understands that any statement or representation it makes, to be false or fraudulent, a misrepresentation, or inaccurate because of the omission of material information could result in a "claim" {as defined by the Oregon False Claims Act, ORS 180.750(1)}, being a "false claim" {ORS 180.750(2)} subject to the Oregon False Claims Act, ORS 180.750 to 180.785, and to any liabilities or penalties associated with the making of a false claim under that Act.

Secretary of State has determined that (Enter Respondent name here). has Workers at the address 1300 Broadway St NE, Salem, Oregon 97301 under Contract number (to be entered by Agency at contract award) By checking the box below, I declare that the following statement is true:

I have documentation confirming all Workers from my company who work onsite at the above listed worksite are fully vaccinated against COVID-19, as required by EO 21-29.

I have documentation confirming that all Workers from my company who work onsite at the above listed worksite are either fully vaccinated against COVID-19 or have an approved medical exception or have an approved religious exception, as required by EO 21-29. I have a written accommodation plan for each approved exception.

I do not have documentation confirming that all Workers at the above listed are in compliance with EO 21-29 I decline to respond I acknowledge that substitute, replacement, additional or new Workers are subject to this EO-21-29 and I will maintain documentation confirming compliance with EO 21-29 during the term of this contract or the duration of EO 21-29 whichever first expires or terminates.

By signature below, the undersigned Authorized Representative on behalf of Respondent certifies to the best of his or her knowledge and belief that the responses provided on this form are complete, accurate, and not misleading.

Signature: Printed Name:

Date: Title:

Attachment 5

RESPONSIBILITY INQUIRY

Agency will determine responsibility of a Respondent prior to award and execution of a Contract. In addition to this form, Agency may notify Respondent of other documentation required, which may include but is not limited to recent profit-and-loss history, current balance statements and cash flow information, assets-to-liabilities ratio, including number and amount of secured versus unsecured creditor claims, availability of short and long-term financing, bonding capacity, insurability, credit information, materials and equipment, facility capabilities, personnel information, record of performance under previous contracts, etc. Failure to promptly provide requested information or clearly demonstrate responsibility may result in an Agency finding of non-responsibility and rejection.

1. Does Respondent have available the appropriate financial, material, equipment, facility and personnel resources and expertise, or ability to obtain the resources and expertise, necessary to demonstrate the capability of Respondent to meet all contractual responsibilities? YES ☐ / NO ☐.

Within the last five years, how many contracts of a similar nature has Respondent completed that, to the extent that the costs associated with and time available to perform the contract remained within Respondent′s control, Respondent stayed within the time and budget allotted, and there were no contract claims by any party? Number: ____ How many contracts did not meet those standards? Number: ____ If any, please explain.

Response:

Within the last three years has Respondent (incl. a partner or shareholder owning 10% or more of Respondent’s firm) or a major subcontractor (receiving 10% or more of a total contract amount) been criminally or civilly charged, indicted or convicted in connection with:

obtaining, attempting to obtain, or performing a public (Federal, state, or local) contract or subcontract, violation of federal or state antitrust statutes relating to the submission of bids or Quotes, or embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, tax evasion, or receiving stolen property? YES ☐ / NO☐.

If "YES," indicate the jurisdiction, date of indictment, charge or judgment, and names and summary of charges in the response field below.

Response:

Within the last three years, has Respondent had:

any contracts terminated for default by any government agency, or any lawsuits filed against it by creditors or involving contract disputes? YES ☐ / NO☐.

If "YES," please explain. (With regard to judgments, include jurisdiction and date of final judgment or dismissal.)

Response:

Does Respondent have any outstanding or pending judgments against it? YES ☐ / NO☐.

Is Respondent experiencing financial distress or having difficulty securing financing? YES ☐ / NO☐.

Does Respondent have sufficient cash flow to fund day-to-day operations throughout the proposed contract period? YES ☐ / NO☐ If "YES” on the first question or second question, or “NO” on the third question, please provide additional details.

Response:

Within the last three years, has Respondent filed a bankruptcy action, filed for reorganization, made a general assignment of assets for the benefit of creditors, or had an action for insolvency instituted against it? YES ☐ / NO☐.

If "YES," indicate the filing dates, jurisdictions, type of action, ultimate resolution, and dates of judgment or dismissal, if applicable.

Response:

Does Respondent have all required licenses, insurance and/or registrations, if any, and is Respondent legally authorized to do business in the State of Oregon? YES ☐ /NO☐.

If "NO," please explain.

Response:

Pay Equity Certificate. This certificate is required if Respondent employs 50 or more full-time workers, and the prospective contract price is estimated to exceed $500,000. [This requirement does not apply to architectural, engineering, photogrammetric mapping, transportation planning or land surveying and related services contracts.] Does a current authorized representative of Respondent possess an unexpired Pay Equity Certificate issued by the Department of Administrative Services? YES ☐ / NO ☐ / N/A☐. [If the certificate was provided with the Bid or Quote submitted for a solicitation related to the prospective contract, then it is not necessary to resubmit it. Just indicate “see Bid” or “see Quote” in the response field. Otherwise, if applicable, submit a copy of the certificate with this form.] Response:

AUTHORIZED SIGNATURE

By signature below, the undersigned Authorized Representative on behalf of Respondent certifies to the best of his or her knowledge and belief that the responses provided on this form are complete, accurate, and not misleading.

Project Name: Leadership Summit Group Facilitation

Authorized Signature Date Print Name Title

Attachment 6

CERTIFIED DISADVANTAGED BUSINESS OUTREACH PLAN

Respondent Name:

Date:

Contact Name:

Telephone:

Email:

“Certified Firm” means a small business certified under ORS 200.055 by the Oregon Certification Office for Business Inclusion and Diversity (COBID) as minority-owned businesses, woman-owned businesses, businesses that service-disabled veterans own, and emerging small businesses.

Certified Firms must have an equal opportunity to participate in the performance of contracts financed with state funds. By submitting its offer, Respondent certifies that it has taken, and if there are further opportunities, will take reasonable steps to ensure that Certified Firms are provided an equal opportunity to compete for and participate in the performance of any subcontracts resulting from this procurement.

The information submitted in response to this clause will not be considered in any scored evaluation.

1. Is Respondent an Oregon certified firm?

Yes ☐No ☐ If yes, indicate all certification type(s): DBE ☐ MBE ☐WBE ☐ SDV ☐ESB ☐and supply Oregon State Certification Number: __________________________

2. Include a list of Certified Firms that Respondent has had a contractual relationship with within the last two years.

3. Include a list of firms that Respondent has had a contractual relationship with within the last two years that are not Certified Firms but may be minority-owned, woman-owned, service-disabled veteran-owned or emerging small businesses.

4. Does Respondent foresee any subcontracting opportunities for this procurement?

Yes ☐ No ☐ If no, do not complete the rest of this form and submit this first page with your Quote.

If yes, please complete the following pages and submit all pages with your Quote.

Certified Disadvantaged Business Outreach Plan

5. Describe the steps Respondent will take to solicit Certified Firms for subcontracting opportunities if awarded a contract from this procurement.

6. Describe the subcontracting opportunities and the approximate dollar value of each that may be available, if awarded a Contract.

7. Would Respondent be willing to report the identity of each subcontractor and the value of each subcontract to COBID if awarded a Contract from this procurement?