Attachment 6, Vendor Certification Forms.docx
DOCX document 65 KB Posted
- Attached to
- Market Conduct Multi-State Examination
- Solicitation number
- RFP-17093
- Issued by
- Leon County, Florida
About this file
This file contains vendor certification forms for the Florida Department of Financial Services, Office of Insurance Regulation, required for participation in a Request for Proposals to conduct a multi-state market conduct examination of the National Council on Compensation Insurance, Inc. The forms establish mandatory compliance certifications that vendors must complete and submit with their proposals to be considered responsive. Respondents must certify compliance with multiple Florida Statutes requirements, including non-participation in boycotts of Israel, absence from various state scrutinized company lists, non-suspension status, E-Verify enrollment, and compliance with disclosure requirements. The certification forms include attestations regarding the vendor's business operations, legal standing, and eligibility to contract with the state.
The document specifies that submission of complete and accurate certifications is mandatory; failure to provide required certifications results in the respondent being deemed non-responsive and ineligible for award consideration. The Department reserves the right to terminate any awarded contract and hold the vendor liable for re-procurement costs if false information is discovered after award. Additional specialized attestation forms are required conditionally, including the Foreign Country of Concern Attestation Form if the contract grants access to personal identifying information, the Common Carrier Attestation Form if applicable, and a coercion for labor services affidavit for nongovernmental entities. Annual resubmission of attestation forms does not require contract amendments. All certifications must be signed by an authorized representative under penalty of perjury.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment_3_Questionnaire.xlsx | XLSX spreadsheet | |
| 2627-02 RFP OIR.pdf | ||
| Appendix B- Questions Template.xlsx | XLSX spreadsheet | |
| Q&A 10-6-26 Final.pdf |
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Text version
OFFICE OF INSURANCE REGULATION
ATTACHMENT 6
Vendor Certification Forms
By submitting this form, and the PUR 7801 which appears on the next pages, the Respondent acknowledges that the Department will rely on the representations made on this form and the PUR 7801 in making its decision of award. If the Department discovers that any of the information on this form is false prior to the award of the Contract, the Department reserves the right to deem the Respondent non-responsive and cease any consideration of its Response. If the Department discovers that any information on this form is false after the award to the Respondent is made, the Department 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.
Vendor Certification Form
I hereby certify the following on behalf of the vendor identified below:
| Customer Indicator (Required, N/A, Determined by Vendor) |
| Vendor Indicator (Certified, N/A) |
| Certification |
| Required | |
| Choose an item. | Regardless of the dollar value of the goods or services provided, in accordance with the requirements of section 287.135(5), F.S., the vendor is not participating in a boycott of Israel and is not on the State Board of Administration’s “Quarterly List of Scrutinized Companies that Boycott Israel,” available at https://www.sbafla.com/fsb/FundsWeManage/FRSPensionPlan/GlobalGovernanceMandates.aspx. |
| Required | |
| Choose an item. | If the goods or services to be provided are $1 million or more, in accordance with the requirements of section 287.135, F.S., the vendor is not on the Scrutinized Companies with Activities in Sudan List or the Scrutinized Companies with Activities in the Iran Terrorism Sectors List (collectively, “Scrutinized List of Prohibited Companies”); does not have business operations in Cuba or Syria; and is not on the State Board of Administration’s “Scrutinized List of Prohibited Companies” available under the quarterly reports section at https://www.sbafla.com/fsb/PerformanceReports.aspx. |
Form PUR 7801 (07/2024) Rule 60A-1.002, F.A.C.
| Required | |
| Choose an item. | The vendor is not on the Suspended Vendor List; it and its suppliers, subcontractors, or consultants to be utilized under the contract are not on the Convicted Vendor, Discriminatory Vendor, or Antitrust Violator Vendor Lists; and there is no pending or threatened action, proceeding, or investigation, or any other legal or financial condition, that would in any way prohibit, restrain, or diminish the vendor’s ability to satisfy the contract obligations. |
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.
| Required | |
| Certified | If the contract grants the vendor access to an individual’s personal identifying information, the vendor is not prohibited from entering into the contract pursuant to section 287.138, F.S., and has completed the Form PUR 1355, “Foreign Country of Concern Attestation Form,” available at http://www.flrules.org/Gateway/reference.asp?No=Ref-15843, and attached it hereto. |
| Determined by Vendor | |
| N/A | If the vendor is a common carrier, as defined in section 908.111, F.S., or a contracted carrier, it is not prohibited from entering into the contract pursuant to section 908.111, F.S., and has completed the Form PUR 1808, “Common Carrier or Contracted Carrier Attestation Form,” available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14614, and attached it hereto. |
| Required | |
| Choose an item. | The vendor is registered with, and uses, the E-Verify system for all newly hired employees in accordance with section 448.095, F.S.; and has not, within the last year, had a contract terminated under section 448.095(5)(c), F.S., by a public employer, contractor, or subcontractor, as defined by section 448.095(1), F.S. |
| Required | |
| Choose an item. | The vendor is in compliance with all applicable disclosure requirements set forth in section 286.101, F.S., and has not been deemed ineligible for a grant or contract funded by a state agency pursuant to section 286.101(7), F.S. |
| Required | |
| Certified | If the contract is between a nongovernmental entity and a governmental entity, in accordance with section 787.06, F.S., the vendor has completed an affidavit signed by an officer or a representative of the vendor under penalty of perjury attesting that the vendor does not use coercion for labor or services as defined in section 787.06, F.S. |
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.
FOREIGN COUNTRY OF CONCERN ATTESTATION
(PUR 1355)
This form must be completed by an officer or representative of an entity submitting a bid, proposal, or reply to, or entering into, renewing, or extending, a contract with a Governmental Entity which would grant the entity access to an individual’s Personal Identifying Information. Capitalized terms used herein have the definitions ascribed in Rule 60A-1.020, F.A.C.
__________________ is not owned by the government of a Foreign Country of Concern, is not organized under the laws of nor has its Principal Place of Business in a Foreign Country of Concern, and the government of a Foreign Country of Concern does not have a Controlling Interest in the entity.
Under penalties of perjury, I declare that I have read the foregoing statement and that the facts stated in it are true.
Printed Name:
Title:
Signature: Date:
PUR 2024
Use of Coercion for Labor and Services
Pursuant to section 787.06(14), Florida Statutes, this portion of the form must be completed by an officer or representative of the nongovernmental entity executing, renewing, or extending a contract with a governmental entity.
The entity named below does not use coercion for labor or services as defined in section 787.06, Florida Statutes.
Under penalties of perjury, I declare that I have read the foregoing statement and that the facts stated in it are true.
Entity Name:
Representative/Officer’s Printed Name:
Representative/Officer’s Title:
Signature: Date:
787.06(13) F.S.
Form PUR 2024 (07/2024)
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