AttachG_FinalSubForm.pdf

PEBB Medical & Pharmacy Benefits RFP OregonBuys Bid No. S-44300-00014758 Attachment G

Attachment G Final Submission Form

PART A: Proposer information and certification

Legal Name of Proposer: ______________________________________________________________

Address: ________________________________________City, State, Zip: ______________________

State of Corporation: ________________________________Entity Type:_______________________

Contact Name: _______________________Telephone:_________________Email:________________

Oregon Business Registry Number (if required):___________________________________________

Any individual signing below hereby certifies they are an authorized representative of Proposer and that:

1. Proposer understands and accepts the requirements of this RFP. By submitting a Proposal, Proposer agrees to be bound by the Contract terms and conditions in Attachment A and as modified by any Addenda, except for those terms and conditions that PEBB has reserved for negotiation, as identified in the RFP.

2. Proposer acknowledges receipt of any and all Addenda to this RFP.

3. If awarded a Contract, Proposer agrees to perform the scope of work and meet the performance standards set forth in the final negotiated scope of work of the Contract.

4. I have knowledge regarding Proposer’s payment of taxes and by signing below I hereby certify that, to the best of my knowledge, Proposer 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.

5. Proposer does not discriminate in its employment practices with regard to race, creed, age, religious affiliation, gender, disability, sexual orientation, national origin. When awarding subcontracts, Proposer 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 business that a service-disabled veteran owns or an emerging small business. If applicable, Proposer has, or will have prior to contract execution, a written policy and practice, that meets the requirements described in ORS 279A.112 (formerly HB 3060), of preventing sexual harassment, sexual assault and discrimination against employees who are members of a protected class. PEBB may not enter into a contract with an anticipated contract price of $150,000 or more with a Proposer 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.

6. Proposer complies with ORS 652.220 and does not unlawfully discriminate against any of Proposer’s employees in the payment of wages or other compensation for work of comparable character on the basis of an employee’s membership in a protected class. “Protected class” means a group of persons distinguished by race, color, religion, sex, sexual orientation, national origin, marital status, veteran status, disability or age.

https://www.oregon.gov/DAS/Procurement/Pages/hb3060.aspx

Attachment G Contractor’s continuing compliance constitutes a material element of this Contract and a failure to comply constitutes a breach that entitles PEBB to terminate this Contract for cause.

Contractor may not prohibit any of Contractor’s employees from discussing the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person. Contractor may not retaliate against an employee who discusses the employee’s rate of wage, salary, benefits, or other compensation with another employee or another person.

7. Proposer is not engaged in the provision of broadband Internet access service, or if at any time Proposer is engaged in or may engage in the provision of broadband Internet access service Proposer is in compliance with Oregon Laws 2018, Chapter 88 (HB 4155) and applicable Public Utility Commission rules, and will remain in compliance throughout the term of the Contract.

8. Proposer and Proposer’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 lists in the System for Award Management found at:

https://www.sam.gov/

9. Proposer certifies that, to the best of its knowledge, there exists no actual or potential conflict between the business or economic interests of Proposer, 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 RFP. If any changes occur with respect to Proposer’s status regarding conflict of interest, Proposer shall promptly notify the State in writing.

10. Proposer certifies that all contents of the Proposal (including any other forms or documentation, if required under this RFP) and this Proposal Certification Sheet are truthful and accurate and have been prepared independently from all other Proposers, and without collusion, fraud, or other dishonesty.

11. Proposer understands that any statement or representation it makes, in response to this RFP, 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 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.

12. Proposer acknowledges these certifications are in addition to any certifications required in the Contract and Statement of Work in Attachment A at the time of Contract execution.

Authorized Signature Date

Printed Name and Title) https://www.treasury.gov/ofac/downloads/sdnlist.pdf https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.sam.gov%2F&data=05%7C02%7CKimberley.WISDOM%40das.oregon.gov%7C66cb231ae7934e01711708dd930da837%7Caa3f6932fa7c47b4a0cea598cad161cf%7C0%7C0%7C638828409047344090%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=IdZyl8xEvEqeWNuMxSBw%2BbWIbdZZNl0P73s2LPo7CVo%3D&reserved=0

Attachment G

Part B: Mandatory Minimum Requirements

By execution of this checklist, I, as the authorized representative of [Proposer], hereby certify that I have read, understand, and agree to the Mandatory Minimum Requirements below, and further certify to the truthfulness, completeness, and accuracy of my responses to the Mandatory Minimum Requirements.

Proposer Signature

By: ___________________________________ Date:________________________ (Authorized Signatory, Title)

Mandatory Minimum Requirements Checklist 1 Proposer agrees its Proposal is a Firm Offer and to be bound by this Proposal from the date of submission through December 31, 2029. Proposer agrees that during negotiations, PEBB may request clarification or correction of the Proposal for the purpose of evaluation. Amendments or clarifications will not affect the remainder of the Proposal, but only that portion so amended or clarified

2 If selected as an Apparent Successful Proposer (ASP), Proposer agrees to, in good faith, negotiate a Contract with PEBB by or closely around June 23, 2026.

3 Proposer is currently licensed to do business in the State of Oregon or will be by the expected Contract execution date of January 1, 2027.

4 Proposer’s Proposal is in compliance with Oregon law and the Proposer satisfies all insurance licensure requirements related to financial solvency, capital holdings, and applicable licensure types for the financial arrangements included in its Proposal.

5 Proposer has completed, obtained and performed all other registrations, filings, approvals, authorizations, consents or examinations required by any government or governmental authority for its acts contemplated by this Proposal and resulting Contract.

6 Proposer consents to PEBB investigating the references submitted by Proposer as well as those current or former customers not disclosed by Proposer and to discuss subject matter such as the Proposer’s past performance, its compliance with certain specifications and contractual obligations, its payment history regarding suppliers, sub-contractors, and workers, and any other information that may be helpful in choosing an

ASP.

7 Proposals agrees to the plan design elements and requirements within Section 3 of the Main RFP document.

8 Proposer agrees to the applicable Sample Group Benefits Contracts described in Attachment I.

9 Proposer has agreed to all of the non-negotiable provisions in the applicable Sample Group Benefits Contracts.

10 Proposer has fully responded to all items in Attachment A including providing any necessary or requested supplemental documents or information.

12 Proposer agrees to fully complete, sign, and submit an Attachment H, Disclosure Exemption Affidavit with its claimed disclosure exemptions by TBD and agrees to do so consistent with the instructions PEBB or its Consultant will provide by TBD.

14 Proposer has fully completed, signed, and submitted an Attachment E

Attachment G 15 Proposer has fully completed, signed, and submitted an Attachment F 16 Proposer has fully completed, signed, and submitted an Attachment G 17 Proposer has fully completed and submitted an Attachment N 18 Proposer has fully completed and submitted an Attachment O 19 Proposer has fully completed and submitted an Attachment R 20 Proposer has fully completed and submitted an Attachment S 21 Proposer has fully completed and submitted an Attachment T

Part C: Proposer Representations and Warranties

By execution of this checklist, I, as the authorized representative of [Proposer], hereby certify that I have read, understand, and agree to the Representations and Warranties below, and further certify to the truthfulness, completeness, and accuracy of such Representations and Warranties.

Proposer Signature

By: ___________________________________ Date:________________________ (Authorized Signatory, Title)

Representations and Warranties Checklist I (the person completing this Attachment G) am duly authorized to submit this proposal and to bind Proposer to each of the terms and provisions hereof.

Proposer possesses the established qualifications to satisfactorily perform work of the type and size included in this RFP, including compliance with all laws, rules, and regulations applicable to the performance of Proposer’s obligations hereunder.

Proposer has the skill and knowledge possessed by well-informed members of its industry, trade or profession and Proposer will apply that skill and knowledge with care and diligence to perform the work in any resulting Contract in a professional manner and in accordance with the highest standards prevalent in Proposer’s industry, trade or profession.

Proposer prepared its response to this RFP independently from all other Proposers, unless otherwise permitted by this RFP concerning subcontractors and collaborators, and without collusion, fraud, or other dishonesty

Proposer attests that no attempt has been made or shall be made by the Proposer to induce any other person or organization to submit or not submit a proposal to this

RFP.

Proposer attests that is has submitted its proposal in response to the specific language contained in the RFP, and Proposer has made no assumptions based upon either (a) verbal or written statements not contained in the RFP, or (b) any previously-issued RFP, if any.

Proposer agrees that the representations and warranties set forth in this Attachment G are in addition to, and not in lieu of, any other warranties provided.

Proposer agrees to promptly notify PEBB in writing if any of the foregoing representations or warranties will cease to be true at any time during the term of this RFP.