Attachment_3_Questionnaire.xlsx

Questionnaire

Firm Information

Firm Name

Address

City State Zip

FEIN

Contact Person

Email Address

Phone Number

Billing Information

Contact Person

Address

City State Zip

E-mail Address

Phone Number

Minimum Standard Requirements

i. Examiners-in-Charge, as defined by the NAIC Market Regulation Handbook, and certified by the Insurance Regulatory Examiner Society as eligible to hold the designation of Certified Insurance Examiner?

ii. Senior Examiners, as defined by the NAIC Market Regulation Handbook, and certified by the Insurance Regulatory Examiner Society as eligible to hold the designation of Accredited Insurance Examiner?

b. How many total years of experience does your firm have in conducting full scope and targeted market conduct examinations for state insurance departments?

c. How many comprehensive or targeted market conduct examinations involving workers' compensation insurance has your firm performed for state insurance departments?

d. How many comprehensive or targeted market conduct examinations of advisory and statistical organizations has your firm performed for other state insurance departments?

e. How many comprehensive market conduct examinations for state insurance departments has your firm performed in the past five years?

f. How many targeted market conduct examinations for state insurance departments has your firm performed in the past five years?

g. Provide additional details about your firm to include specialized experience with examining advisory and statistical organizations and in the area of workers' compensation insurance.

h. List all market conduct examinations of advisory organizations, statistical organizations, and workers' compensation insurance completed by your firm for state insurance departments in Florida or any other state. Please note the type of examination performed (comprehensive or targeted) and the year in which the work was performed.

i. Indicate designations attained by individuals within your firm, other than those already listed above, that will function as examiners-in-charge for market conduct examinations:

b. Does your firm agree to utilize and follow all reference materials provided by the Office?

5. Has your firm ever been sued by a regulator or receiver; or are there any lawsuits pending against your firm?

(If yes, please provide details and attach an additional sheet if necessary)

7. Disclose any immediate family members, which includes a spouse, domestic partner, or children thereof, of any person employed by the firm who will be participating in the Florida market conduct examination, who is presently employed by, or within the past six months left the employment of, any life, health, property, and casualty insurers, or their affiliates including third party administrators or managing general agents.

If the information above changes at any time during the course of an examination, the changes are required to be disclosed immediately.

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OFFICE OF INSURANCE REGULATION&12

Consultant Profile Questionnaire

Page &P of &N

Additional Contacts

Additional Contact Information

Additional Contact Person #1

Address

City State Zip

E-mail Address

Phone Number

Additional Contact Person #2

Address

City State Zip

E-mail Address

Phone Number

Additional Contact Person #3

Address

City State Zip

E-mail Address

Phone Number

OFFICE OF INSURANCE REGULATION&12

Consultant Profile Questionnaire

Page &P of &N

Standard Hourly Rates Form

Firm Information

Firm Name

FEIN

Authorized Representative

FLORIDA OFFICE OF INSURANCE REGULATION&11

&12Standard Hourly Rates

Mandatory Criteria Form

This form must be completed by the Respondent’s authorized representative. The Respondent acknowledges that the Office will rely on the representations made on this form 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 will determine the Respondent non-responsive and not evaluate 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 the Respondent will be liable for costs associated with re-procuring the services.

1. Does Respondent certify that it agrees to the terms above?

2. Does Respondent certify that the person submitting the Response is authorized to respond to this RFP on Respondent’s behalf?

4. Does Respondent certify compliance with State of Florida PUR 1001 Section 9? Click to View

5. Select “Yes” for one and select “N/A” on the others:

OR

b. Does Respondent certify that if awarded a contract, it will register with the Florida Department of State prior to execution of the Contract?

OR

c. Does Respondent certify that it is not required to register with the Florida Department of State (see applicable sections of Title XXXVI, Business Organizations, Chapters 605 through 623, F.S.)?

6. Select “Yes” for one and select “N/A” on the other:

a. Does Respondent certify that a drug-free workplace has been implemented in accordance with section 287.087, F.S.?

OR

b. Does Respondent agree to waive its right to be given preferential treatment as a drug-free workplace in the event of a tie?

7. Does Respondent agree to utilize the U.S. Department of Homeland Security’s E-Verify system to verify employment eligibility?

As the person authorized to sign the statement, I certify that this organization complies fully with the above requirements.

Dated this day of 20

Firm Name

Authorized Representative

FLORIDA OFFICE OF INSURANCE REGULATION&11

&12Mandatory Criteria https://www.dms.myflorida.com/content/download/2934/11780/PUR_1001_General_Instructions_to_Respondents.pdf Identical Tie Response Form

This form must be completed by the Respondent in the event of a tie. 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-procuring the services.

Respondents shall certify one or more of the following by checking the adjacent box(es):

C. The response is from a Florida-based business having at least one of the following characteristics: (Please provide copy of registration in state of domicile) FALSE

1. Fifty-one (51) percent of the company is owned by Floridians; or

2. Employs a workforce for this project or contract that is at least 51% Floridians; or

3. More than 51% of business assets of the company, excluding bank accounts, are located in Florida.

D. The response is from a Florida-domiciled entity; TRUE

E. The commodities used in this contract are manufactured, grown, or produced within this State; TRUE

F. The response is from a foreign manufacturer with a factory in the State employing over 200 employees working in the State; TRUE

G. The response is from a business that certified at the time of the Response that it has implemented a drug-free workplace program in accordance with section 287.087, F.S.; FALSE

H. The response is from a company that is not eligible for any of the above preferences. TRUE

As the person authorized to sign the statement, I certify that this organization complies fully with the above requirements.

Dated this day of 20

Firm Name

Authorized Representative

FLORIDA OFFICE OF INSURANCE REGULATION&12

Identical Tie Response

Notices & Acknowledgements

This notice is to make your firm aware that the Office has completed an extensive review of its financial examination processes and has implemented the following important changes. Please review and acknowledge each item below:

1. All questions regarding exam assignments or the procurement process should be directed to Exams@FLOIR.gov. Inquiries regarding the exam assignment process that are sent to other Office employees may result in the exclusion of a contractor’s proposal from subsequent exam rollouts. FALSE 0

(Initial)

TRUE

TRUE

FALSE

TRUE

FLORIDA OFFICE OF INSURANCE REGULATION&12

Contractor Notices and Required Acknowledgements

Supporting Documents

Supporting Document Check List

1. Proof of registration with the Florida Secretary of State or state of domicile (if exempt pursuant to Chapter 605 through 623, F.S.)

2. Resumes and Biographies of Examination Team Members

3. Completion of NAIC Training Documentation

4. Documents related to lawsuits or regulatory suspensions (if applicable)

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