BPM007093_IMPAXX_Exhibits A-E.pdf

Solicitation number: BPM007093

Instructions to Offerors Mandatory Section 111 MSP Reporting Services

Industrial Commission of Arizona, Procurement Office

800 W; Washington Street Phoenix, Arizona 85007

Exhibit A

OFFER AND ACCEPTANCE FORM

SUBMISSION OF OFFER: The undersigned hereby offers and agrees to provide Mandatory Section 111

MSP Reporting Services in compliance with all terms, conditions, specifications, and amendments in the

Solicitation and any written exceptions in the Offer indicated by the latest dated version below:

Offeror company name Signature of person authorized to sign Offer Date

Address Printed name and Title

City, State, ZIP Contact name and Title

Contact emall address Contact phone number

CERTIFICATION: By signature in the above, Offeror certifies that it:

1. Will not discriminate against any employee or applicant for employment in violation of Federal Executive Order 11246, [Arizona] State Executive Orders 2023-09, 2023-01, 2009-09 or A.R.S. §§ 41-1461 through 41-1465;

2. Has not given, offered to give, nor intends to give at any time hereafter any economic opportunity, future employment, gifl, loan, gratu ity, special discount, trip, favor, or Service to a public servant in connection with the submilted offer. Failure to provide a valid signature affirming the stipulations required by this clause will result in rejection of the Offer. Signing the Offer with a false statement will void the Offer, any resulting contract, and may be subject to legal penalties under law;

3. Complies with A.R.S. § 18-132 when offering electronics or information technology products, Services, or maintenance;

4. Did not and will not involve collusion or other anti-competitive practices;

5. Is not debarred from, or otherwise prohibited from, participating in any contract awarded by federal, slate, or local government; and

6. II is __ /1s NOT __ a small business with less than 100 employees or has gross revenues of$4 million or less.

ACCEPTANCE OF OFFER

The offer is hereby accepted.

The Contractor is now bound to sell the Materials or Services listed by the attached Contract and based upon the Solicitation, including all terms, conditions, specifications, amendments, etc., and the Contractor's Offer as accepted by the State.

The Contract shall henceforth be referred to as Contract No .. _______________ _

The effective dale of the Contract is ______________ _

The Contractor is cautioned not to commence any billable work or to provide any Material or Service under this Contract until Contractor receives purchase order, contract release document, or written notice to proceed.

State of Arizona Awarded this day of 20

[Procurement Officer Name] !Procurement Officer TIiie)

Procurement officer siQnature

RFQ Template I Revision No. 5 I Revised 05-24 I Page 38 of 39

Allocation Services Inc. dba IMPAXX

300 N. Beach Street

Daytona Beach, FL 32114

Jon Gunter, Chief Executive Officer

Frank Fairchok, VP of Technology Solutions ffairchok@impaxx.com 813.650.3298

8/26/2025

X

Forced Labor of Ethnic Uyghurs Ban

Exhibit B

Mandatory Section 111 MSP Reporting Services

Industrial Commission of Arizona, Procurement Office

800 W; Washington Street Phoenix, Arizona 85007

FORCED LABOR OF ETHNIC UYGHURS BAN

Please note that if any of the following apply to the Contractor, then the Contractor shall select the "Exempt Contractor" option below:

• Contractor is a sole proprietorship;

• Contractor has fewer than ten (10) employees; OR

• Contractor is a non-profit organization.

Pursuant to A.R.S. § 35-394, written certification is required to show that the company entering into a contract with a public entity does not use the forced labor, or use any contractors, subcontractors or suppliers that use the forced labor or any goods or services produced by the forced labor or any goods or services produced by the forced labor, of ethnic Uyghurs in the People's Republic of China.

Under A.RS.§ 35-394:

1. "Company" means an organization, association, corporation, partnership, joint venture, limited partnership, limited liability partnership, limited liability company or other entity or business association, including a wholly owned subsidiary, majority-owned subsidiary, parent company or affiliate, that engages in for-profit activity and that has ten or more full-time employees.

2. "Public entity" means this State, a political subdivision of this State or an agency, board, commission or department of this State or a political subdivision of this State.

In compliance with A.R.S. § 35-394, all Contractors must select one of the following:

□ Company does not use, and agrees not to use during the term of the contract, any of the following:

• Forced labor of ethnic Uyghurs in the People's Republic of China;

• Any goods or services produced by the forced labor of ethnic Uyghurs in the People's Republic of

China; or

• Any Contractors, Subcontractors, or suppliers that use the forced labor or any goods or services produced by the forced labor of ethnic Uyghurs in the People's Republic of China.

D The Company does participate in the use of Forced Uyghurs Labor as described in A.RS. § 35-394.

D Exempt Contractor: Select all statements that apply to the Contractor:

D Contractor is a sole proprietorship;

D Contractor has fewer than ten (10) employees; and/or

D Contractor is a non-profit organization.

Company name

Address

City, State, ZIP

Signature of person authorized to sign

Printed name and Tille

Contact email address Contact phone number

RFQ Template I Revision No. 5 I Revised 05-24 I Page 39 of 39

Allocation Services Inc. dba IMPAXX

300 N. Beach Street

Daytona Beach, FL 32114

Jon Gunter, Chief Executive Officer ffairchok@impaxx.com 813.650.3298

X

Industrial Commission of AZ – BPM007093 -- Exhibit C: Criteria and Capacity -- IMPAXX

Criteria and Capacity

The offeror shall provide a narrative response to each question to demonstrate an understanding of the Scope of Work requirements.

Question 1: How many years of experience do you have in Mandatory Section 111 MSP Reporting Services?

Offerors response:

While IMPAXX has been performing Section 111 Reporting for our customers for six years, our 111 Reporter platform has been querying and reporting to CMS for sixteen years. IMPAXX has also provided consulting services to its customers for Section 111 Reporting since the inception of live reporting to CMS in 2010.

Question 2: List three (3) projects or jobs of similar size and scope of work with Mandatory Section 111 MSP Reporting Services.

Offerors response:

IMPAXX performs Section 111 Reporting services to customers of all sizes, with some having only a handful of claims and others with hundreds of thousands of claims. We report for individual Responsible Reporting Entities (RREs), third party claim administrators (TPAs) that manage many RREs, and insurance carriers.

IMPAXX submitted a question to the Industrial Commission of Arizona’s Procurement Office to understand the scope of the reporting for this RFQ. The response indicated there was a single RRE ID for workers’ compensation and the monthly average of queried claims is 24. Many of our customers in this size range decide against an electronic data interchange (EDI) and opt to use our web portal to enter the claim data. However, as the RFQ document shows the desire to have an EDI connection to File Handler, here are three examples of the smaller volume EDI customer setups we have in production:

1. Government Risk Pool: With an active claim count of 100, this agency is connected to our 111 Reporter platform with an integration in their Origami claim system. Our system receives weekly text files from the built-in Origami specification and returns response files with validation and other CMS data to update the claims in Origami.

2. County Agency: With an active claim count of 4,000 claims, this agency is connected to our 111 Reporter platform with an integration into their KlearAI claim system. The agency had KlearAI build functionality to one of our text-based specifications that exchanges data and responses on a weekly basis.

Industrial Commission of AZ – BPM007093 -- Exhibit C: Criteria and Capacity -- IMPAXX

3. State Property Insurer: This state agency only has a few dozen new claims each year and chose to use the self-service web portal of our 111 Reporter platform. As new claimants are identified, an employee of the agency creates the claim record in our system but only adds the query related fields – first and last name, date of birth, gender and Social Security Number. This allows the records to be queried each month, and, if any are returned as a positive beneficiary, the employee adds the reporting-related data fields via the portal. 111 Reporter has built in reports and notification functionality to keep this agency on track with Section 111 Reporting.

Question 3: What year did you start using the reporting services for Mandatory Section 111 MSP Reporting Services?

Offerors response:

IMPAXX started production reporting to CMS in the first quarter of 2020. However, our 111 Reporter platform, provided through our software partner, has reported for thousands of RREs since 2010.

Instructions to Offerers Exhibit D

Mandatory Section 111 MSP Reporting Services

Industrial Commission of Arizona, Procurement Office

Phoenix, Arizona 85007

Primary Point of Contact. The selected vendor(s) shall provide a point of contract for each key section that is involved in the Mandatory Section 111 MSP Reporting Services.

This will allow the ICA to convey communication in a timely manner.

Vendor Point of Contact

1) Name

Phone Number

Cell Phone _____________________ __ _ email _______________________ _

2) Name

Phone Number

Cell Phone _______________________ _ email ------------------------

3) Name

Phone Number

Cell Phone email------------ ------------

Frank Fairchok

Casey Bell

813.650.3298 ffairchok@impaxx.com cbell@impaxx.com

Melissa Perdew

714.497.7211

949.282.7651 mperdew@impaxx.com

443.393.4899

Reference Document Exhibit E

Mandatory Section 111 MSP Reporting Services

Industrial Commission of Arizona, Procurement Office

Phoenix, Arizona 85007

References: The State intends to conduct reference checks provided by Offerers. Offerors shall provide at least three

(3) client references for assignments that replicate or mirror the requirements of this RFQ, if references are unresponsive, the agency may require you to give additional references.

Client Company/Address Contact Begin Date End Date

X X X X

Phone Number Email Address

X X

Event Scope and deliverables, include number of resources engaged in project, timeline of project (major milestones)

X

List job positions provided and technologies utilized to supplement services.

X

D Client Company/Address

X

Phone Number

X

Contact

X

Email Address

X

Begin Date End Date

X X

Event Scope and deliverables, include number of resources engaged in project, timeline of project (major milestones)

X

List job positions provided and technologies utilized to supplement services.

X

Client Company/Address Contact

X X

Phone Number Email Address

X X

Begin Date End Date

X X

Event Scope and deliverables, include number of resources engaged in project, timeline of project(major milestones)

X

List job positions provided and technologies utllized to supplement services.

X

Cobb County School District

Penny Niles

2021 Present

770.426.3357 daisy.james@cobbk12.org

Bath Iron Works

Daisy James

2020 Present

207.442.1664 penny.niles@gdbiw.com

Jared PaytonMEMIC

Three-year terms (renewed), Section 111 Reporting Services

111 Reporter web-based reporting tool

Section 111 Reporting and MSP compliance services

207.791.3510 jpayton@memic.com

Section 111 Reporting and MSP compliance services

Present

111 Reporter web-based reporting tool

111 Reporter web-based reporting tool