STATE OF FLORIDA

OFFICE OF INSURANCE REGULATION

APPENDIX C

Mandatory Criteria Certification Form

By submitting this form, and the PUR 7801 which appears on the next pages, the Respondent acknowledges that the Office will rely on the representations made on this form and the PUR 7801 in making its decision of award. If the Office discovers that any of the information on this form is false prior to the award of the Contract, the Office reserves the right to deem the Respondent non-responsive and cease any consideration of its Response. If the Office discovers that any information on this form is false after the award to the Respondent is made, the Office reserves the right to terminate the Contract and hold the Respondent liable for costs associated with re-procurement.

A Respondent’s failure to provide the below certification for each Certification Question and/or the PUR 7801 below will result in the Respondent being deemed non-responsive. Annual resubmissions of the following attestation forms will not require a written amendment to the Contract.

As the person authorized to sign this form, I certify that the Certification Answers provided below are accurate as to the Respondent.

Respondent Name: _____________________________________________________________________

Authorized Representative: __________________________ __________________________ ______ Printed Name Signature Date

Attachment 7, Mandatory Criteria Certification Form v2024.11.13 Page 1 of 10 Form PUR 7801 (07/2024) Rule 60A-1.002, F.A.C.

Vendor Certification Form

I hereby certify the following on behalf of the vendor identified below:

The vendor is hereby informed of the provisions of sections 287.133(2)(a), 287.134(2)(a), and 287.137(2)(a), F.S., that identify the impacts to the vendor's ability or its affiliates’ ability to respond to the competitive solicitations of a public entity; to be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with a public entity; or to transact business with a public entity if it, or its affiliates, are placed on the Convicted Vendor, Discriminatory Vendor, or Antitrust Violator Vendor Lists of the Department of Management Services. The vendor is hereby further informed of the provisions of section 287.1351, F.S., that identify the impacts to the vendor’s ability to enter into or renew a contract with an agency, as defined in section 287.012, F.S., if it is placed on the Suspended Vendor List of the Department of Management Services.

By signing below, I certify that I am authorized to complete and submit this Vendor Certification Form on behalf of the vendor.

Vendor Information Signatory

Name Signature Date

FEIN Typed or Printed Name

Title

Form PUR 7801 (07/2024) Rule 60A-1.002, F.A.C.

PUR 2024

Part B: Provision of Commodities Produced by Forced Labor

Pursuant to section 287.1346(4)(b), Florida Statutes, this portion of the form must be completed by a member of the company’s senior management, as defined in section 287.1346, F.S., when the company submits a response to a solicitation for the provision of commodities and before the company enters into or renews a contract for the provision of commodities.

I certify that to the best of my knowledge, the commodities Name of entity is offering to the Department have not been produced, in whole or in part, by forced labor.

Entity Name:

Senior Management’s Printed Name:

Senior Management member’s Title:

Signature: Date:

787.06(13) F.S.

Form PUR 2024 (07/2024) image1.png