Att_D_VISS Past Performance Questionnaire_Clean.docx

Vision Insurance

RFQ# 2031JW26Q00058

ATTACHMENT D

PAST PERFORMANCE QUESTIONNAIRE

To Quoter:

Please provide this Past Performance Questionnaire package to each of your “Reference” government / commercial contracting offices according to the instructions in Section E, subsection 2.2.1(3) of the Request for Quote (RFQ).

To Quoter’s Reference:

The Office of the Comptroller of the Currency (OCC) Administrative Office – Acquisitions Management (AQM) requests your assistance in providing past performance information on the Contractor (a prospective “Quoter” under our RFQ) and corresponding contract listed herein. Please complete this Questionnaire in accordance with the instructions set forth immediately below.

AQM agrees to protect your information as For Official Use Only/Procurement Sensitive Information consistent with the Federal Acquisition Regulation (FAR) 3.104, as noted in the header on each page of the Questionnaire package.

Instructions for Quoter’s Reference:

1. If you are providing a reference based upon a Federal Government contract, then please complete the attached Past Performance Questionnaire regarding the Quoter based upon your most recent Contractor Performance Assessment Report (CPAR) prepared in accordance with FAR 42.15; provided, you do not actually enter your CPARs into the Contractor Performance Assessment Reporting System (CPARS). Alternatively, if you are providing a reference as a non-federal Government entity, then please proceed with completing this past performance questionnaire.

NOTE (FOR FEDERAL GOVERNMENT AGENCIES): If your office enters its CPARs into CPARS, please advise the AQM contact to that effect rather than completing this Questionnaire. This will enable AQM to retrieve your latest CPAR for the Quoter on-line directly from CPARS.

2. Please use the attached Rating Instruction (or the equivalent you use in producing CPARs) in providing the rating assessments that best describe the Contractor’s performance on your contract.

3. Please send a copy of the completed Questionnaire directly to the AQM contact by email to be received timely no later than 12:00 PM ET on Thursday, June 4, 2026.

AQM Contacts

REFERENCE’S RATING INSTRUCTIONS

Please provide your assessment of each factor rated in the Questionnaire by using the following rating scale and corresponding definitions (or the equivalent you use in producing your CPARs, as may be appropriate in each case.

1. Rating Scale:

· Excellent – Performance meets contractual requirements and exceeds many requirements to the Government’s benefit.

· Good – Performance meets contractual requirements and exceeds some to the Government’s benefit.

· Satisfactory – Performance meets contractual requirements.

· Poor – Performance meets contractual requirements with significant Government oversight resulting from several issues that required corrective action.

· Unsatisfactory – Performance does not meet contractual requirements and recovery is not likely in a timely manner.

· Not Applicable (N/A) – Unable to provide a score. Performance in this area not applicable to effort assessed.

PAST PERFORMANCE QUESTIONNAIRE FOR RFQ 2031JW26Q00058 for VISION INSURANCE

TO BE COMPLETED BY THE QUOTER’S REFERENCE

1. Quoter (Contractor)/Division: ____________________________________________________ Street Address: ___________________________________________________________________ City, State, Zip: ___________________________________________________________________ Province/Country: ________________________________________________________________ CAGE Cade: ______________________________________________________________________ UEID Number: ______________________________________________________________ NAICS Code: ______________________________________________________________________

3. Period of Performance Assessed: ________________________________________________

4. Contract#: ________________ Order # _______________ (if applicable) 5. Location of Contractor Performance: _________________________________________________

6. Reference Contracting Office/Code: ____________________________________________________

7. Contracting Officer (Name/Phone): _____________________________________________________

8. Contract Award Date/Effective Date: ____________________________________________________

9. Contract Completion Date: ____________________________________________________________

10. Contract Awarded Dollar Value: _______________________________________________________

11. Contract Current Dollar Value: ________________________________________________________

12. Basis for Contract Award (check all that apply):

___ Negotiated ___ Competitive ___ Non-Competitive

13. Type of Contract (check the one that applies):

___ Firm Fixed Priced (FFP) ___ Cost Plus Fixed Fee (CPFF) ___ Time and Material (T&M) ___ CPFF (Level of Effort) ___ Combined (Hybrid) ___ Labor Hour (LH)

14. Key Subcontractors (list as needed):

Subcontractor Name: ________________________________________________________________ Cage Code: __________________________________ UEID Number: ___________________________________

15. Program/Project Title: _____________________________________________________

16. Contract Effort Description: __________________________________________________________________________________________________________________________________________________________________________

· Does this contract include a subcontracting plan? ___ Yes ___ No ___ N/A

· Subcontracting under this contract is covered by a [comprehensive] [commercial] [N/A] (select one) Small Business subcontracting plan.

· Date of latest Subcontracting Report/Summary Subcontracting Report: _____

FACTORS RATED (1-4):

1. Quality of Product or Service – Assess the Contractor’s conformance to contract requirements, specification, quality, and standards of good workmanship (e.g., commonly accepted technical, professional standards).

___Excellent ___ Good ___Satisfactory___ Poor ___ Unsatisfactory ___N/A

Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Timeliness (Schedule Performance) – Assess the Contractor’s timeliness against the completion of the contract, task orders, milestones, delivery schedules, and administrative requirements (e.g. effort that contribute to or effect the schedule variance).

___Excellent ___ Good ___ Satisfactory___ Poor ___ Unsatisfactory ___ N/A

Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Business Relations – Assess the integration and coordination of all activity needed to execute the contract, specifically the timeliness, completeness, and quality of problem identification, corrective action plans, quote submissions, the Contractor’s history or reasonable and cooperative behavior, customer satisfaction, timely award and management of subcontract. Include the adequacy of the Contractor’s accounting, billing, estimating systems and the and management of subcontractors, including subcontractor costs.

___ Excellent ___ Good ___ Satisfactory ___ Poor ___ Unsatisfactory ___ N/A

Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Problem Resolution (Management of Key Personnel) – Assess the completeness, timelines, and quality of problem identification, corrective action plans, quote submissions. The Contractor’s performance in selecting, retaining, supporting, and replacing, when necessary, key personnel. The Contractor’s history of reasonable and cooperative behavior, and customer satisfaction.

___ Excellent ___ Good ___ Satisfactory___ Poor ___ Unsatisfactory ___ N/A

Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

OTHER AREAS ASSESSED (1-4):

1. Has the Contractor been given a cure notice(s), show cause notices(s), suspension of progress payments, or letter(s) of direction, etc.?

___ Yes ___ No ___ N/A

Comments: ___________________________________________________________________________

2. If applicable, do you intend to exercise the option on this contract?

___ Yes ___ No ___ N/A

3. Recommendation: Given what you know today about the Contractor’s ability to execute what they promised in the quote, would you still award to them today if you had a choice?

___ Yes ___ No

Comments: ___________________________________________________________________________

4. Please provide any additional comments concerning the past performance of the Contractor.

Comments: ___________________________________________________________________________

Procurement Sensitive Information See FAR 3.104