Attachment A - Performance Work Statement.pdf

SBU - CONTRACTING AND ACQUISITIONS

Attachment A – Performance work statement

PART I - PRICE

UNLESS A WAIVER OR EXCEPTION APPLIES, PAYMENTS SUBSEQUENT TO THIS

PROCUREMENT ARE SUBJECT TO AN EXCISE TAX OF 2% PERSUANT TO 26 U.S.C.

5000C.

1. GENERAL

The Contractor shall provide On-The-Job Accidents and Accidents to and From Work Insurance services to employees of the Government of the United States of America in Belgium. The groups of employees who shall be provided with this insurance are listed in Part II - Statement of

Work paragraph 2. Eligible participants. This insurance shall be provided in accordance with Part

II - Statement of Work below and Exhibits A through C, provided as Attachment C.

Official Residence Expense (ORE) Staff are included under this contract only as a rider; the

Contractor shall bill the Chief of Mission and/or Deputy Chief of Mission (for ORE Staff) at the rates specified in Attachment B - Pricing.

2. VALUE ADDED TAX

The Government will not reimburse the Contractor for VAT under this contract. The Contractor shall not include a line for VAT on Invoices as the U.S. Embassy has a tax exemption certificate with the host government.

3. CONTRACT TYPE

This is a fixed price with economic price adjustment requirements type contract under which firm, fixed-price task orders will be issued. The fixed prices/premium rates for the On-The-Job

Accidents and Accidents to and From Work insurance services as specified in PART II -

STATEMENT OF WORK are listed in Attachment B – Pricing. The percentage used for premium calculations shall be a given percentage of the total salary amount (listed Attachment C

- Exhibits A, B, C) which the offeror will charge to insure each category of insured.

4. MINIMUM AMOUNTS

During the Base Year of the contract, and during the option year that might be exercised, the

United States Government (USG) shall place orders totaling a minimum of $5,000.00. This reflects the contract minimum guarantee for each period of performance.

5. ADMINISTRATIVE RETENTION AMOUNTS

5.1 If the Contractor requests a price adjustment under 5.4 below, the Contractor must present cost experience data that includes the retention amount. For purposes of any economic price adjustment, this retention amount is a fixed amount that is a part of the premium amounts. This retention amount will not be adjusted for any reason.

The retention amount is part of the premium and may include, but not be limited to, such costs as overhead and general and administrative costs. It will also include any profit. Essentially, it includes all costs except the actual portion of the premium intended to fund claims paid to the health care provider/claimant. Attachment B -Pricing sets forth the retention amounts per premium paid for each category of premium and for each period of performance.

NOTE TO OFFEROR: In Attachment C - Pricing, fill in the fixed annual retention amounts for each period of performance and for each category of premium. This fixed amount shall be expressed in the currency in which the premium amount is proposed. The fixed retention amount shall not be expressed in terms of a percentage of the premium.

5.4 ECONOMIC PRICE ADJUSTMENT LIFE INSURANCE PREMIUMS

5. 4.1. Premium Adjustment Based on Experience - For accident insurance, prices may be adjusted upward or downward based on the experience rating of the Mission(s) covered by this contract, and it specifically excludes all riders. No adjustment will be allowed during the first twelve months. After such time, the Contractor or the Government may request an adjustment in premiums on an annual basis. Adjustments are not retroactive to previous contract terms. Before any such adjustment is made, the Contractor agrees to provide the Government a balance sheet showing three main components for the time period: (1) receipts (premiums received) minus the retention amount, (2) number of insurance plans and (3) claims paid. The retention amount is not subject to adjustment. The Government reserves the right to have an independent third party review the balance sheet and claims and make recommendations regarding the appropriateness of the requested adjustment. Any adjustment shall be subject to mutual agreement of the parties and shall result in a written modification to the contract. The modification and corresponding adjusted prices will take effect on the date the modification is signed by the Contracting Officer.

Changes to contract prices resulting from an economic price adjustment shall not be applied retroactively. Any failure to reach agreement under this clause shall be subject to the procedures in the Disputes clause.

5. 4.2. Premium Adjustment Based on Law: The rates may also be adjusted during the performance period of the contract as a result of laws enacted by the host Government, if such change in the laws has a direct impact on the cost to the Contractor to perform this contract at the rate contracted for herein. In that event, the Contracting Officer may enter into negotiations with the Contractor to modify the contract to adjust the premium rate. The Contractor agrees to provide all documentation necessary to support any requested adjustment.

5.4.2.1 Employee Pool - This clause is only in effect if the Contractor included details in its offer regarding a pooling arrangement, of which this contract is a part.

Before any adjustment is made under this price adjustment clause, the Contractor shall include in its proposal for adjustment, details setting forth how the pool impacts the request for equitable adjustment.

PART II - STATEMENT OF WORK

1. ON-THE-JOB ACCIDENTS AND ACCIDENTS TO AND FROM WORK INSURANCE

SERVICES

The Government of the United States of America requires On-The-Job Accidents and Accidents to and From Work Insurance coverage for its employees (as further described) in Belgium. The

Government has determined that such insurance coverage is a legal requirement in Belgium and that the cost of such insurance protection must be borne by the employer.

This policy covers different groups of staff members against accidents on the job and on the way to and from work. The insurance covers employees for medical expenses and continuation of pay up to the ceiling set by Belgian Law (adjusted annually) as required by the Belgian Law on

Occupational Accidents of April 10, 1971, and its amendments.

For accident insurance purposes, the word “salary” includes bonuses as required by local law.

1.1 ON-THE-JOB ACCIDENTS

The insurer agrees to insure all eligible participants (as further described) in accordance with the applicable Belgian laws.

In case of an on-the-job accident, the insurer agrees to pay to the injured person or his rightful claimants without exception or reservation, notwithstanding any forfeiture clause, all indemnification as foreseen by existing Belgian Law, until the policy comes to an end.

1.2 ACCIDENTS-TO-AND-FROM-WORK

The insurer agrees to insure all eligible participants (as further described) in accordance with the applicable Belgian laws.

In case of an accident-on-the-way-to-and-from-work, the insurer agrees to pay to the injured person or his rightful claimants without exception or reservation, notwithstanding any forfeiture clause, all indemnification as foreseen by existing Belgian Law, until the policy comes to an end.

Exhibits A thru C (Attachment C) containing the total salaries and the number of entitled employees for each category, will be used to calculate the premiums due.

Important: It is clearly understood that all claims for personal injuries resulting from an act of terrorism will also be treated as any other claim under the same terms and conditions as described above even when not explicitly mentioned in the insurer’s general conditions.

It is further understood that these terms and conditions are not limited to Belgium but applicable worldwide provided that Belgian legislation be applicable in accordance with the international treaties in force at the time the accident or incident occurred, especially, for those employees travelling outside of Belgium on an official assignment either as drivers or passengers of a US

Government vehicle or a privately-owned vehicle.

2. ELIGIBLE PARTICIPANTS

Eligible Employees - Employees, including teleworking, who are eligible participants according to the applicable Government of Belgium regulations, covered by the Belgian Social Security

System are eligible. The employees eligible for the On-The Job Accidents and Accidents to and

From Work Insurance services include the following:

• All current active employees of the United States Government, employed within the geographic boundaries of Belgium, paid under the Local Compensation Plan, and certified by the Contracting Officer.

• Foreign Service Nationals (FSNs) employed under direct hire appointments, Personal

Services Agreements (PSAs) and Personal Services Contracts (PSCs)

• Locally hired U.S. citizens employed under direct hire appointments, PSAs, and PSCs.

3. LOCATION OF EMPLOYMENT

The individuals covered by 1.3. must be employed within the geographic boundaries of Belgium by:

• Foreign Agricultural Service (USDA/FAS)

• Animal and Plant Health Inspection Service of the Department of Agriculture (USDA/

APHIS)

• Federal Aviation Administration (FAA)

• the Transportation Security Administration (TSA)

• Department of Commerce (DOC)

• Office of Defense Cooperation (ODC)

• Defense Attache Office (DAO)

• Department of Homeland Security (D HS/I CE)

• Department of the Treasury (USEU

• Food and Drugs Administration (FDA)

• United States Patent and Trademark Office (USPTO)

4. PARTICIPANTS COVERED UNDER A RIDER

All current active employees of the Chief of Mission and the Deputy Chief of Mission assigned to their respective official Government residences and paid under an ORE account (separate rider). All costs for ORE employees are the responsibility of the employing officer, not the U.S.

Government.

5. INDIVIDUALS NOT ELIGIBLE FOR COVERAGE

Individuals not eligible for coverage under this contract are non-personal services contract personnel and any other individual not falling within one of the categories of employees described in this clause.

6. DEFINITIONS

ACCIDENT - Any event causing an objectively verifiable bodily injury, one cause of which is external to the insured person's organism. By extension are assimilated to accident, drowning, accidents resulting from an attempt to save persons or property in danger, accidental suffocation by gases, electrical discharge, or suffocation due to the action of toxic or corrosive substances.

COR - Contracting Officer's Representative (Human Resources Officer at post).

DEPENDENT - The employee's legal spouse or legal partner (see note below) and his/her dependent children. A dependent child is defined as a child eligible for family allowances under the Belgian Social Security system and residing with the employee (as attested by communal authorities on the "Composition of Family" (Composition de Menage/Gezinssamenstelling) form.

DISABILITY, TOTAL AND PERMANENT - A physical or mental impairment which precludes the individual from performing ordinary motor or bodily functions and which requires separation from employment.

If the impairment is the result of a previous impairment, it shall be considered a continuation of the prior impairment.

EMPLOYEE - An individual employed by the U.S. Government, under a direct-hire appointment, personal services contract, or personal services agreement, as further defined in

Section C.1.3, for On-The-Job Accidents and Accidents To and From Work Insurance. ORE Staff employed by the Chief of Mission or Deputy Chief of Mission are also included.

EMPLOYER - The United States Government or in the case of ORE the Chief of

Mission/Deputy/ Chief of Mission and Employee Association, respectively.

FMO - The Financial Management Officer or the paying office for all U.S. Government

Agencies.

GSO - General Services Officer in charge of the General Services Office at post. This officer is usually the Contracting Officer for this contract.

HOSPITAL - An institution established and operated for the care and treatment of sick and injured persons. It provides 24-hour nursing care and has diagnostic, laboratory, treatment, and surgical facilities. Any institution which does not meet this definition is not considered a hospital.

LEGAL PARTNER - Employee's legal spouse or the partner with whom he/she is legally cohabiting, who as filed a copy of the official declaration of cohabitation in accordance with article 1476 of the Civil Code to the Human Resources Office. A legal partner can be either of opposite sex or same sex.

OCCUPATIONAL ACCIDENT - Any accident taking place during and by the very fact of the execution of the employment contract or any accident taking place on the way to work, which are taken in charge of by the occupational accident Insurer.

ORE STAFF - Means Official Residence Expense (ORE) staff such as residence managers and household staff.

PAY PERIOD (PP) - A period of two weeks commencing on a Sunday and running through the

Saturday of the subsequent week. A calendar year consists of 26 pay periods.

7. KEY PERSONNEL / QUALIFICATIONS AND CAPABILITIES

Key personnel under this contract is:

Project Manager – the contractor shall provide a project manager who shall be responsible for the administration, supervision, and coordination of the contractor’s Government operations. The project manager shall be the focal point for all activities related to the performance of this contract. He/she is to be considered the Contractor's POC for the Government.

The project manager shall have good working skills in English.

During the first 90 days of performance, the Contractor shall make no substitutions of key personnel unless the substitution is required due to illness, death, or termination of employment.

The Contractor shall notify the Contracting Officer within 15 calendar days after the occurrence of any of these events and provide the information required below to the Contracting Officer at least 15 days before making any permanent substitutions.

After the first 90 days of performance, the Contractor may substitute a key person if the contractor determines that it is necessary. The Contractor shall notify the Contracting Officer of the proposed action immediately. Prior to making the substitution, the Contractor will provide the information required below to the Contracting Officer.

The Contractor shall provide a detailed explanation of the circumstances requiring the proposed substitution, a complete resume for the proposed substitute. The proposed substitute shall possess qualifications comparable to the original key person. The Contracting Officer will notify the

Contractor of its approval or disapproval of the substitution within 15 calendar days after receiving the required information. The Government will modify the contract to reflect any changes in key personnel.

8. DELIVERABLES

All reports and other deliverables required under this contract shall be delivered by email to the

COR and, if required, mailed to the following address:

U.S. EMBASSY BRUSSELS

Attn: Human Resources Officer

Regentlaan/Bd. Du Regent 27

1000 Brussels

Belgium

9. PHYSICAL AND INFORMATION SECURITY REQUIREMENTS

The contractor shall be responsible for safeguarding all government information provided for contractor use. All material /documentation produced for the USG will be the sole property of the

USG. The contractor shall not release any documents to anyone unless authorized by the USG.

10. QUALITY ASSURANCE AND SURVEILLANCE PLAN (QASP)

This plan is designed to provide an effective surveillance method to promote effective Contractor performance. The QASP provides a method for the Contracting Officer's Representative (COR) to monitor Contractor performance, advise the Contractor of unsatisfactory performance, and notify the Contracting Officer of continued unsatisfactory performance. The Contractor, not the

Government, is responsible for management and quality control to meet the terms of the contract.

The role of the Government is to conduct quality assurance to ensure that contract standards are achieved.

Performance Objective

PWS

Paragraph Performance Threshold

Services

1 to 14

All required services are performed and no more than

Performs all the insurance services set forth in the Performance Work

Statement (PWS) one (1) customer complaint is received per month

Timely payment of benefits (within

14 calendar days from the date the claim is submitted to the Contractor)

No more than one (1) customer complaint is received per month

No incorrectly denied claims. 1 to 14 No more than one (1) customer complaint is received per month.

Surveillance. The COR will receive and document all complaints from Government personnel regarding the services provided. If appropriate, the COR will send the complaints to the

Contractor for corrective action.

Standard. The performance standard is that the Government receives no more than one (1) customer complaint per month. The COR shall notify the Contracting Officer of the complaints so that the Contracting Officer may take appropriate action to enforce the inspection clause (FAR

52.246-4, Inspection of Services – Fixed Price (AUG 1996) or the appropriate Inspection of

Services clause), if any of the services exceed the standard.

Procedures:

a) If any Government personnel observe unacceptable services, either incomplete work or required services not being performed, they should immediately contact the COR.

b) The COR will complete appropriate documentation to record the complaint.

c) If the COR determines the complaint is invalid, the COR will advise the complainant.

The COR will retain the annotated copy of the written complaint for his/her files.

d) If the COR determines the complaint is valid, the COR will inform the Contractor and give the Contractor additional time to correct the defect, if additional time is available.

The COR shall determine how much time is reasonable.

e) The COR shall, as a minimum, orally notify the Contractor of any valid complaints.

f) If the Contractor disagrees with the complaint and challenges the validity of the complaint, the Contractor will notify the COR. The COR will review the matter to determine the validity of the complaint.

g) The COR will consider complaints as resolved unless notified otherwise by the complaint.

h) Repeat customer complaints are not permitted for any services. If a repeat customer complaint is received for the same deficiency during the service period, the COR will contact the Contracting Officer for appropriate action under the Inspection clause.

11. ORDERING PROCEDURES

The Government will issue a task order after contract award to identify all employees to be covered by the insurance described in this contract and the coverage selected by each employee.

If any changes need to be made to the coverage listing, the contracting officer will issue a new task order or a modification to the existing one. This new task order will include all changes made since the previous task order was issued and will include any increase or decrease in necessary funding. The changes to the list of eligible individuals will supersede the initial list provided under prior task orders without prejudice to the ineligibility clause.

The ORE staff, EA employees under separate riders are not included under the task orders issued by the Contracting Officer. Because their coverage is under a rider, their employer is responsible for directly interacting with the Contractor to order any coverage for their employees. When contacted by the employer, the Contractor shall advise the employer of the paperwork and payment that will be necessary to order coverage for the identified individuals. Because more than one employer may have ORE staff, the Contractor may be contacted by more than one employer (typically the Chief of Mission and Deputy Chief of Mission).

12. CONTRACTOR RESPONSIBILITY IN CLAIMS AND REIMBURSEMENT TO

CLAIMANTS

General. The Contractor shall be responsible for all planning, estimating, programming, project management, scheduling, dispatching, supervision, and inspection of work. The Contractor shall maintain his own reference library of technical reference works and local laws and regulations, including current tariffs and registries. The Contractor shall treat the information provided by the

Embassy concerning employee' personal data, medical information, and salaries as highly sensitive and not divulge any employee information to unauthorized persons. The Contractor shall establish procedures for handling medical insurance claims as follows:

a) Administrative Records

1. The contractor shall maintain insurance files for each eligible employee including receipts and proof of paid claims, requests for claim reimbursements, and accounting of paid benefits.

2. The contractor shall provide the COR with the necessary claim forms for each type of benefit that can be claimed under the contract. These forms shall specify a list of documents required to be appended to each claim and otherwise provide instructions for claim filing.

3. The contractor shall use the English spelling of the employees' names in all transactions

4. The Contractor shall process employee claims within two (2) weeks from receipt of the claim.

b) Insurance Claims – Settlement of insurance shall be completed as follows:

1. All claims shall be submitted directly to the Contractor by employees.

2. The Contractor shall date stamp and screen all claims submitted on the day of receipt. If there are any missing documents or information thereby disallowing said claim to be payable, the

Contractor shall notify the employee within two days, with a copy to the COR (if notification is written).

3. The Contractor shall settle the claims no later than two weeks from the date the claim is submitted to the Contractor.

4. Settlement shall be by bank transfer in the name of the employee for each claim submitted.

Each payment shall be accompanied by a form providing details of the amount reimbursed with an explanation of deductions, if any.

13. REPORT REQUIREMENTS

All claims shall be timely uploaded to an online portal, provided by the insurer and used by both

US Embassy HR employees and the insurer’s employees.

The portal is used:

• to open a file whenever an employee had an accident on the job

• for communication between Insurer and US Embassy HR whenever extra information is requested;

• to update when an employee’s sick leave has extended;

• to update when an employee has started working again;

• to share all sick leave certificates, pay slips, other documents;

The USG employees will not have access to the online portal, communication between the insurer and the employee will be carried out through postal mail.

14. MISCELLANEOUS CONTRACTOR REQUIREMENTS

General. The Contractor shall take all such steps as are necessary, and obtain and pay for all permits, taxes and fees as are required by the Belgian government to establish and/or operate a commercial venture locally. A contract with the U.S. Government conveys no special privileges or immunities to the Contractor. The Contractor is an independent commercial concern and not a part of the U.S. mission. The Contractor's employees are not U.S. Government employees.

Registration of this contract with the Belgian government, if required by law, will be the sole responsibility of the Contractor, and any fees, taxes, or other duties shall be payable by the

Contractor without recourse to the Government of the amounts thereof.

Licenses and Local Laws. The Contractor shall possess all permits, licenses, and any other appointments required for the prosecution of work under this contract, all at no additional cost to the Government. The Contractor shall perform this contract in accordance with local laws.

End of “Attachment A - Performance work statement”