attachment_1_-_required_attachment_checklist.pdf
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- Solicitation number
- 0000040419
- Issued by
- California
About this file
This is a Required Attachment Checklist for RFP 27-3001 issued by the California Department of Social Services for a Workers Compensation Third Party Administrator contract. The checklist serves as a confirmation document that proposers must complete and submit with their bid packages to verify inclusion of all required proposal components. A complete and responsive proposal must include 17 primary attachments plus additional supporting documentation, including a proposal cover letter, minimum qualifications certification, proposal certifications, proposer and subcontractor references, cost proposal, and various state-mandated declarations and certifications.
The required attachments encompass compliance documents mandated by California state law and Department of Social Services policy, including the Bidder Declaration (GSPD-05-105), Disabled Veteran Business Enterprise declarations if applicable, Darfur Contracting Act certification, Commercially Useful Function evaluation, Civil Rights Laws certification, Iran Contracting Act certification, Contractor Certification Clause, and payee data records. Proposers must also submit copies of city or county business licenses identifying relevant locations and, critically, a Workers' Compensation Self-Insurance Administrator Certificate demonstrating authorization to provide workers' compensation claims administration services as a Third Party Administrator in California. The Target Area Contract Preference Act form and labor summary documentation are conditionally required depending on applicability to the proposer's circumstances.
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RFP 27-3001 Attachment 1 California Department of Social Services Page 1 of 2
REQUIRED ATTACHMENT CHECKLIST
Proposer’s Name:
A complete proposal or proposal package will consist of the items identified below.
Complete this checklist to confirm the items in your proposal. Place a check mark of “X” next to each item that you are submitting. For your proposal to be responsive, all required attachments must be submitted. This checklist must be returned with your bid package.
Attachment Attachment Name/Description _____ Attachment 1 Required Attachment Checklist _____ Attachment 2
Proposal Cover Letter and Statement of Intent to Meet RFP Requirements
_____ Attachment 3 Minimum Qualifications Certification _____ Attachment 4 _____ Attachment 5
Proposal/Proposer Certification Sheet Proposer References
_____ Attachment 5.1 Subcontractor References (if applicable) _____ Attachment 6 Cost Proposal _____ Attachment 7 GSPD-05-105, Bidder Declaration _____ Attachment 8 STD 843, Disabled Veteran Business Enterprise (DVBE)
Declarations (if applicable) _____ Attachment 9 DVBE Subcontractor Agreement (if applicable) _____ Attachment 10 Darfur Contracting Act Certification _____ Attachment 11 Commercially Useful Function (CUF) Evaluation Form _____ Attachment 12 California Civil Rights Laws Certification _____ Attachment 13 Iran Contracting Act Certification Form _____ Attachment 14 Contractor Certification Clause (CCC 04/2017) _____ Attachment 15 STD 204, Payee Data Record _____ Attachment 16 STD 830, Target Area Contract Preference Act (if applicable) _____ Attachment 17 DGS PD 526, Bidder’s Summary of Contract Activities and
Labor (if applicable)
Additional documentation to be submitted:
_____ Copy of City/County Business License(s) identifying the locations described in
RFP 27-3001 Attachment 1 California Department of Social Services Page 2 of 2
RFP Section C, Item 3 _____ Copy of Workers’ Compensation Self-Insurance Administrator Certificate to provide workers’ compensation claims administration services as a TPA in the State of California
REQUIRED ATTACHMENT CHECKLIST
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